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Objectives: The combination of broad conditional applicability and ease of data collection make some general risk scores an attractive tool for clinical decision making under acute care conditions. To date, general risk scores have demonstrated moderate levels of accuracy for key outcomes, but there are no definitive general scores integrated universally into prehospital care. The objective of our study was to demonstrate a relationship between the revised trauma score (RTS) and prehospital lifesaving interventions (LSI) and downstream hospital mortality among a large, diverse, multi-year cohort of critical care transport patients. We hypothesized that the RTS is associated with mortality and prehospital LSI generally across all conditions, including non-trauma., Methods: We conducted a retrospective observational study using a pre-established cohort of sequentially enrolled patients from a regional air medical service between the years 2012 and 2021. Pediatric patients, non-transports, and those transported to hospitals outside the regional health system were excluded from the study. Both trauma and non-trauma patients were included in this study. We performed logistic regressions to evaluate the association between RTS and the outcomes of LSI and hospital mortality, while controlling for age, sex, and medical category. Graphs were constructed to plot RTS against prehospital LSI and survival percentage., Results: Our final patient cohort was 62,424 patients. 58.4% of all patients required a prehospital LSI. Non-trauma cases made up 69.7% of the patient population. The Revised Trauma Score was inversely proportional with both prehospital LSI and mortality. The logistic regression model yielded an odds ratio (OR) of 0.55 (95% CI 0.54 - 0.56) for the association between RTS and death. Additionally, when the components of RTS were associated with mortality, they each showed a statistically significant OR. The Revised Trauma Score was also associated with prehospital LSI (OR 0.10; 95% CI 0.03 - 0.33)., Conclusions: In a large helicopter EMS cohort of both trauma and non-trauma patients, the RTS was inversely associated with prehospital LSI and hospital mortality. The generalized utility of RTS demonstrated in our study warrants further investigation of this measure as a broader triage tool.

Objective: The epidemiology accompanying helicopter emergency medical services (HEMS) transport has evolved as agencies have matured and become integrated into regionalized health systems, as evidenced primarily by nationwide systems in Europe. System-level congruence between Europe and the United States, where HEMS is geographically fragmentary, is unclear. In this study, we provide a temporal, epidemiologic characterization of the largest standardized private, nonprofit HEMS system in the United States, STAT MedEvac., Methods: We obtained comprehensive timing, procedure, and vital signs data from STAT MedEvac prehospital electronic patient care records for all adult patients transported to UPMC Health System hospitals in the period of January 2012 through October 2021. We linked these data with hospital electronic health records available through June 2018 to establish length of stay and vital status at discharge., Results: We studied 90,960 transports and matched 62.8% (n = 57,128) to the electronic health record. The average patient age was 58.6 years ( 19 years), and most were male (57.9%). The majority of cases were interfacility transports (77.6%), and the most common general medical category was nontrauma (72.7%). Sixty-one percent of all patients received a prehospital intervention. Overall, hospital mortality was 15%, and the average hospital length of stay (LOS) was 8.8 days ( 10.0 days). Observed trends over time included increases in nontrauma transports, level of severity, and in-hospital mortality. In multivariable models, case severity and medical category correlated with the outcomes of mortality and LOS., Conclusion: In the largest standardized nonprofit HEMS system in the United States, patient mortality and hospital LOS increased over time, whereas the proportion of trauma patients and scene runs decreased., Competing Interests: Declaration of Competing Interest The author(s) have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to test the effect of a 30-minute nap versus a 2-hour nap opportunity taken during a simulated night shift on performance, fatigue, sleepiness, mood, and sleep at the end of shift and during post-night shift recovery., Methods: We conducted a randomized crossover trial of three nap conditions (30-minute, 2-hour, and no-nap) during 12-hour simulated night shifts. We tested for differences in performance, fatigue, sleepiness, mood, and sleep during in-lab and at-home recovery. Performance was measured with the Brief Psychomotor Vigilance Test (PVT-B). Subjective ratings were assessed with single-item surveys., Results: Twenty-eight individuals consented to participate [mean age 24.4 (standard deviation 7.2) years; 53.6% female; 85.7% Emergency Medical Services clinicians]. PVT-B false starts at the end of the 12-hour night shift (at 07:00 hours) and at the start of in-lab recovery (08:00 hours) were lower following the 2-hour nap versus other conditions (P<0.05). PVT-B response time at +0 minutes post-recovery nap was poorer compared to pre-recovery nap for the no-nap condition (P=0.003), yet not detected for other nap conditions (P>0.05). Sleepiness, fatigue, and some mood states were lower at most hourly assessments during the in-lab recovery period following the 2-hour nap condition compared to the other conditions. Sleep during recovery did not differ by duration of night shift nap., Conclusions: A 2-hour nap opportunity versus a 30-minute or no-nap opportunity is beneficial for performance, alertness, and mood post-night shift. No differences were detected in sleep during recovery.

Objective: Blunting of the sleep-related dip in blood pressure (BP) has been linked to numerous cardiovascular outcomes including myocardial infarction. Blunting of BP dipping occurs during night shift work and previous research suggest that a 60-min or longer on-shift nap is needed to restore normal/healthy BP dipping. We sought to determine the effect of different durations of napping on BP during and following simulated night shifts. We hypothesized that the greatest benefit in terms of restoration of normal BP dipping during night shift work would be observed during a longer duration nap versus a shorter nap opportunity., Methods: We used a randomized crossover laboratory-based study design. Participants consented to complete three separate 72-hr conditions that included a 12-hr simulated night shift. Nap conditions included a 30-min and 2-hr nap compared to a no-nap condition. Ambulatory BP monitoring was assessed hourly and every 10-30 mins during in-lab naps. Blunted BP dipping during in-lab naps was the primary outcome. Goal enrollment of 25 (35 with attrition) provided 80% power to detect a mean difference of 5 mmHg in BP between nap conditions., Results: Of the 58 screened, 28 were consented, and 26 completed all three 72-hr conditions. More than half (53.6%) were female. Mean age was 24.4 years (SD7.2). Most (85.7%) were certified as emergency medical technicians or paramedics. The mean percentage dip in systolic BP (SBP) and diastolic BP (DBP) did not differ between the 30-min and 2-hr nap conditions ( p  > 0.05), yet a greater proportion of participants experienced a 10-20% dip in SBP or DBP during the 2-hr nap versus the 30-min nap ( p  < 0.05). For every additional minute of total sleep during the 30-min nap, the percentage of SBP dip improved by 0.60%, and the percentage of DBP dip improved by 0.68% ( p < 0.05). These improvements approximate to a 6% per minute relative advancement toward normal/healthy BP dipping., Conclusions: Restoration of a normal/healthy dip in BP is achievable during short and long duration nap opportunities during simulated night shift work. Our findings support the hypothesis that BP dipping is more common during longer 2-hr versus shorter 30-min naps., Trial Registration: ClinicalTrials.gov, NCT04469803. Registered on 9 July 2020.

Objective: We sought to test the effects of different duration naps on post-nap cognitive performance during simulated night shifts., Methods: We used a randomized laboratory-based crossover trial design with simulated 12-hr night shifts and each participant completing three conditions of 72 hrs each (Clinicaltrials.gov; registration # NCT04469803). The three conditions tested included no-nap, a 30-min nap opportunity, and a 2-hr nap opportunity. Naps occurred at 02:00 hrs. Cognitive performance was assessed with the Brief 3-min Psychomotor Vigilance Test (PVT-B). Four PVT-B measures include: reaction time (RT in milliseconds (ms)), lapses (RT > 355 ms), false starts (reactions before stimulus or RT <100 ms), and speed (1,000/RT). The PVT-B was performed at the start of the simulated night shift (19:00), end of shift (07:00), pre-nap (02:00), and at 0 mins, 10 mins, 20 mins, and 30 mins following the 30-min and 2-hr nap conditions. Simultaneously, participants reported subjective ratings of fatigue and other constructs., Results: Twenty-eight (15 female), mostly certified emergency medical technicians or paramedics, consented to participate. For all three conditions, looking within condition, PVT-B lapse performance at the end of the 12-hr simulated night shift (at 07:00) was poorer compared to shift start ( p  < 0.05). Performance on PVT-B speed, RT, and false starts were poorer at shift end than shift start for the no-nap and 30-min nap conditions ( p  < 0.05), but not for the 2-hr nap condition ( p  > 0.05). Compared to pre-nap measures, performance on the PVT-B assessed at 0 mins post-nap showed significant performance declines for lapses and speed for both the 30-min and 2-hr nap conditions ( p  < 0.05), but not at 10, 20, or 30 mins post-nap. After waking from the 2-hr on-shift nap opportunity (at 0 mins), participants rated sleepiness, difficulty with concentration, and alertness poorer than pre-nap ( p  < 0.05). Participants in the 30-min nap condition rated alertness poorer immediately after the nap (at 0 mins) compared to pre-nap ( p  < 0.05)., Conclusions: While sleep inertia was detectable immediately following short 30-min and long 2-hr nap opportunities during simulated night shift work, deficits in cognitive performance and subjective ratings quickly dissipated and were not detectable at 10-30 mins post-nap.

Introduction: Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival., Methods: We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models., Results: 17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution., Conclusion: Severity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care., (Copyright © 2022 Elsevier B.V. All rights reserved.)

We performed a systematic review of four databases to determine if the evidence supports a short or long duration nap during night shifts to mitigate fatigue, and/or improve health, safety, or performance for emergency services and public safety personnel (PROSPERO CRD42020156780). We focused on experimental research and evaluated the quality of evidence with the grading of recommendations, assessment, development, and evaluation (GRADE) framework. We used the Cochrane Collaboration's risk of bias tool to assess bias and reported findings using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Our search yielded n = 10,345 records and n = 44 were reviewed in full-text. Inter-rater agreement during screening was substantial (Kappa = 0.66). We retained n = 11 publications, reporting on n = 7 experimental studies with a cumulative sample size of n = 140. We identified wide variation in study design, napping interventions (i.e., timing, placement, and duration), and outcomes. We identified mixed findings comparing brief, moderate, and long duration naps on outcomes of interest. All seven studies presented serious risk of bias and the quality of evidence was rated as low. Based on the best available evidence, decisions regarding nap duration during night shift work should be based on time (post-nap) and outcome., Competing Interests: Conflicts of interest The authors do not have any conflicts of interest to disclose., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Membranous nephropathy (MN) is an autoimmune disease caused by autoantibodies against the podocyte antigens phospholipase A 2 receptor 1 (PLA 2 R1) and thrombospondin type 1 domain containing protein 7A (THSD7A) in 80% and 2-3% of patients, respectively. THSD7A antibodies are considered to be pathogenic and highly specific for MN patients. Using an indirect immunofluorescence test (IIFT) we detected THSD7A-antibodies (titre 1:10) in the serum of a patient with high proteinuria who, however, in the kidney biopsy was diagnosed with diabetic nephropathy and MN was excluded as a possible cause of proteinuria. Different immunofluorescence assays and Western blot techniques using recombinant THSD7A (rTHSD7A) or THSD7A from different human tissues revealed that the circulating THSD7A-autoantibodies were only of the IgG3 subclass. The patient serum reacted exclusively with rTHSD7A and only when the antigen was present in reducing Western blot conditions, or on formaldehyde-fixed cells for the IIFT. Our findings show for the first time the existence of circulating THSD7A-antibodies recognizing denatured/reduced rTHSD7A, which do not react with glomerular THSD7A in vivo and are thus presumptively non-pathogenic. As a consequence, kidney biopsy or Western blot analyses of THSD7A under non-reducing conditions should be performed to confirm the diagnosis of THSD7A-associated MN, especially in cases with low THSD7A-antibody levels in the IIFT., (© 2021. The Author(s).)

The present paper provides a detailed historical and numerical analysis of the processes regarding body procurement in a particular German anatomical institute, namely, the Dr. Senckenbergische Anatomie (DSA) in Frankfurt am Main. It covers the period from 1946 to 1980; i.e. the transitional phase during which unclaimed corpses were replaced by corpses stemming from body donors. The DSA is fortunate to possess the complete set of records spanning that period. Thus, we cannot only document the (failed) organizational and political efforts of the local anatomists and governmental agencies to uphold the unclaimed body system of old, but we can also present rather detailed data regarding the genesis of the system of body donations. In particular, we will provide evidence that this system was more or less self-generating, and that its emergence was not actively propagated by the local anatomists. Instead, it was triggered by both the media and by the donors themselves, with the latter acting as multipliers. In addition we provide, for the first time, data on the efficacy (in terms of "file corpses" vs. real corpses in anatomy) of a body donation system in Germany., (Copyright © 2021 Elsevier GmbH. All rights reserved.)

Background: There is an emerging body of evidence that links exposure to shift work to cardiovascular disease (CVD). The risk of coronary events, such as myocardial infarction, is greater among night shift workers compared to day workers. There is reason to believe that repeated exposure to shift work, especially night shift work, creates alterations in normal circadian patterns of blood pressure (BP) and heart rate variability (HRV) and that these alterations contribute to increased risk of CVD. Recent data suggest that allowing shift workers to nap during night shifts may help to normalize BP and HRV patterns and, over time, reduce the risk of CVD. The risk of CVD related to shift work is elevated for emergency medical services (EMS) shift workers due in part to long-duration shifts, frequent use of night shifts, and a high prevalence of multiple jobs., Methods: We will use a randomized crossover trial study design with three study conditions. The targeted population is comprised of EMS clinician shift workers, and our goal enrollment is 35 total participants with an estimated 10 of the 35 enrolled not completing the study protocol or classified as lost to attrition. All three conditions will involve continuous monitoring over 72 h and will begin with a 36-h at-home period, followed by 24 total hours in the lab (including a 12-h simulated night shift), ending with 12 h at home. The key difference between the three conditions is the intra-shift nap. Condition 1 will involve a simulated 12-h night shift with total sleep deprivation. Condition 2 will involve a simulated 12-h night shift and a 30-min nap opportunity. Condition 3 will involve a simulated 12-h night shift with a 2-h nap opportunity. Our primary outcomes of interest include blunted BP dipping and reduced HRV as measured by the standard deviation of the inter-beat intervals of normal sinus beats. Non-dipping status will be defined as sleep hours BP dip of less than 10%., Discussion: Our study will address two indicators of cardiovascular health and determine if shorter or longer duration naps during night shifts have a clinically meaningful impact., Trial Registration: ClinicalTrials.gov NCT04469803 . Registered on 9 July 2020.

Introduction: Public access defibrillation (PAD) programs seek to optimize locations of automated external defibrillators (AEDs) to minimize the time from out-of-hospital cardiac arrest (OHCA) recognition to defibrillation. Most PAD programs have focused on static AED (S-AED) locations in high traffic areas; pervasive electronic data infrastructure incorporating real-time geospatial data opens the possibility for AED deployment on mobile infrastructure for retrieval by nearby non-passengers. Performance characteristics of such systems are not known. Hypothesis: We hypothesized that publicly accessible AEDs located on buses would increase publicly accessible AED coverage and reduce AED retrieval time relative to statically located AEDs. Methods: S-AED sites in Pittsburgh, PA were identified and consolidated to 1 AED per building for analysis ( n  = 582). Public bus routes and schedules were obtained from the Port Authority of Allegheny County. OHCA locations and times were obtained from the Pittsburgh site of the Resuscitation Outcomes Consortium. Two simulations were conducted to assess the characteristics and impact of AEDs located on buses. In Simulation #1, geographic coverage area of AEDs located on buses (B-AEDs) was estimated using a 1/8th mile (201 m) retrieval radius during weekday, Saturday and Sunday periods. Cumulative geographic coverage across each period of the week was compared to S-AED coverage and the added coverage provided by B-AEDs was calculated. In Simulation #2, spatiotemporal event coverage was estimated for historical OHCA events, assuming constraints designed to reflect real world AED retrieval scenarios. Event coverage and AED retrieval time were compared between B-AEDs and S-AEDs across periods of the week and residential/nonresidential spatial areas. Results: Cumulative geographic coverage by S-AEDs was 23% across all periods, assuming uniform access hours. B-AEDs alone versus B-AEDs + S-AEDs covered 20% vs. 34% (weekday), 14% + 30% (Saturday), and 10% + 28% (Sunday). There was no statistically significant difference in 3-minute historical AED accessibility between only B-AEDs and only S-AEDs in standalone deployments (12% vs. 14%). However, when allowing for retrieval of either type of AED in the same scenario, event coverage was improved to 22% ( p  < 0.001). Conclusion: Deployment of B-AEDs may improve AED coverage but not as a standalone deployment strategy.

On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers. The injured had wounds often seen in war-settings, with the signature of high velocity weaponry. We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.

Persistent topological defects and textures are particularly dramatic consequences of superfluidity. Among the most fascinating examples are the singular vortices arising from the rotational symmetry group SO(3), with surprising topological properties illustrated by Dirac's famous belt trick. Despite considerable interest, controlled preparation and detailed study of vortex lines with complex internal structure in fully three-dimensional spinor systems remains an outstanding experimental challenge. Here, we propose and implement a reproducible and controllable method for creating and detecting a singular SO(3) line vortex from the decay of a non-singular spin texture in a ferromagnetic spin-1 Bose-Einstein condensate. Our experiment explicitly demonstrates the SO(3) character and the unique spinor properties of the defect. Although the vortex is singular, its core fills with atoms in the topologically distinct polar magnetic phase. The resulting stable, coherent topological interface has analogues in systems ranging from condensed matter to cosmology and string theory.

Introduction: Opioid-related overdoses have been steadily increasing over the past decade in the United States. Naloxone is used by first responders to revive overdose victims, but results may be improved by increasing access to and usage of naloxone by bystanders. Automated External Defibrillators (AEDs) are pervasive, recognizable, and publicly accessible. Co-locating naloxone kits with AEDs could increase public naloxone access and usage. However, the impact of co-locating naloxone kits with AEDs is not known., Objectives: We sought to evaluate the impact of co-locating naloxone kits with AEDs in a simulation study centered on Allegheny County, Pennsylvania., Methods: Naloxone administration frequency (N = 3,650) at the zip-code level from March 2016 to March 2017 was provided by the Allegheny County Health Department. AED point locations (N = 1,653) were obtained from the University of Pittsburgh's Resuscitation Logistics and Informatics Venture. Zip-code level geospatial analyses were conducted using QGIS and STATA to determine the correlation between AED count and naloxone administrations. AED naloxone kit (N-AED) coverage, based on a maximum "walking-distance" radius of 200 m, was estimated at a zip-code level using the QGIS buffer tool and a custom MATLAB script. Potential impact of N-AEDs was estimated assuming uniform spatial distribution of naloxone administrations., Results: The median (IQR) AED coverage based on a 200 m access radius per zip code was 4% (0-7). The median (IQR) number of naloxone administrations per zip code was 27(7-55). A total of 82 zip codes had data for both AED locations and naloxone administrations. The correlation between number of AEDs and naloxone administrations per zip code was 0.20. Overall, 16% of naloxone administrations were estimated to be covered by an N-AED., Conclusion: Using these limited methods, co-locating naloxone with AEDs is not likely to have a standalone impact on preventing overdose fatalities.

Introduction: Optimizing placement of Automated External Defibrillators (AED) can increase survival after an out-of-hospital cardiac arrest (OHCA). Using postal collection boxes (PCB) as locations for AEDs could potentially enhance accessibility and streamline maintenance. In this study, we modeled the hypothetical effects of deploying AEDs at PCB locations., Hypothesis: We hypothesized that PCB-AEDs would increase AED coverage overall and in residential areas, and reduce the distance from OHCA to an AED., Methods: AEDs in Pittsburgh, PA were identified by the University of Pittsburgh Resuscitation Logistics and Informatics Venture (n=747). PCB locations were obtained from the United States Postal Service (n=479). OHCA locations from 2009 to 2014 were obtained from the Pittsburgh site of the Resuscitation Outcomes Consortium. AED coverage assuming a ¼ mile radius around each AED was estimated for known AEDs, PCB-AEDs (hypothetical AED locations), and known AEDs augmented by PCB-AEDs, both overall and for residential and non-residential zones. Linear distance from each OHCA to the nearest AED was calculated and compared between the sets., Results: The set of known AEDs augmented with PCB-AEDs covered more of the city overall (55% vs 30%), as well as greater proportions of residential (62% vs 27%) and non-residential areas (45% vs 30%). The median distance from OHCA to AED was significantly shorter when known AEDs were augmented with PCB-AEDs (0.12mi vs 0.32mi; p=0.001)., Conclusion: Augmenting existing publicly accessible AEDs with AEDs deployed at PCBs can increase AED spatial coverage in both residential and non-residential areas, and reduce the distance from AED to OHCA., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To describe how computer-assisted presentation of case data can lead experts to infer machine-implementable rules for case definition in electronic health records. As an illustration the technique has been applied to obtain a definition of acute liver dysfunction (ALD) in persons with inflammatory bowel disease (IBD)., Methods: The technique consists of repeatedly sampling new batches of case candidates from an enriched pool of persons meeting presumed minimal inclusion criteria, classifying the candidates by a machine-implementable candidate rule and by a human expert, and then updating the rule so that it captures new distinctions introduced by the expert. Iteration continues until an update results in an acceptably small number of changes to form a final case definition., Results: The technique was applied to structured data and terms derived by natural language processing from text records in 29,336 adults with IBD. Over three rounds the technique led to rules with increasing predictive value, as the experts identified exceptions, and increasing sensitivity, as the experts identified missing inclusion criteria. In the final rule inclusion and exclusion terms were often keyed to an ALD onset date. When compared against clinical review in an independent test round, the derived final case definition had a sensitivity of 92% and a positive predictive value of 79%., Conclusion: An iterative technique of machine-supported expert review can yield a case definition that accommodates available data, incorporates pre-existing medical knowledge, is transparent and is open to continuous improvement. The expert updates to rules may be informative in themselves. In this limited setting, the final case definition for ALD performed better than previous, published attempts using expert definitions., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Blood serum serves as a chemoattractant towards which cancer cells migrate and invade, facilitating their intravasation into microvessels. However, the actual molecules towards which the cells migrate remain elusive. This modified invasion assay has been developed to identify targets which drive cell migration and invasion. This technique compares the invasion index under three conditions to determine whether a specific hormone, growth factor, or cytokine plays a role in mediating the invasive potential of a cancer cell. These conditions include i) normal fetal bovine serum (FBS), ii) charcoal-stripped FBS (CS-FBS), which removes hormones, growth factors, and cytokines and iii) CS-FBS + molecule (denoted "X"). A significant change in cell invasion with CS-FBS as compared to FBS, indicates the involvement of hormones, cytokines or growth factors in mediating the change. Individual molecules can then be added back to CS-FBS to assay their ability to reverse or rescue the invasion phenotype. Furthermore, two or more factors can be combined to evaluate the additive or synergistic effects of multiple molecules in driving or inhibiting invasion. Overall, this method enables the investigator to determine whether hormones, cytokines, and/or growth factors play a role in cell invasion by serving as chemoattractants or inhibitors of invasion for a particular type of cancer cell or a specific mutant. By identifying specific chemoattractants and inhibitors, this modified invasion assay may help to elucidate signaling pathways that direct cancer cell invasion.

Acute kidney injury (AKI) is characterized by the acute nature and the inability of kidneys to maintain fluid homeostasis as well as adequate electrolyte and acid-base balance, resulting in an accumulation of nitrogenous waste and elevation of serum blood urea nitrogen and creatinine values. Acute kidney injury may be a single isolated event, yet oftentimes, it results from an acute chronic kidney disease. It is critical to seek out the etiology of AKI and to promptly manage the underlying chronic kidney disease to prevent comorbidities and mortality that may ensue. We described a case of a 16-year-old adolescent girl with Down syndrome who presented with AKI and electrolyte aberrance.Abdominal and renal ultrasounds demonstrated a significantly dilated bladder as well as frank hydronephrosis and hydroureter bilaterally. Foley catheter was successful in relieving the obstruction and improving her renal function. However, a magnetic resonance imaging was pursued in light of her chronic constipation and back pain, and it revealed a structural defect (tethered cord) that underlies a chronic process that was highly likely contributory to her AKI. She was managed accordingly with a guarded result and required long-term and close monitoring.

Background: Nondiarrheal or Streptococcus pneumoniae-related hemolytic uremic syndrome (HUS) represents a heterogeneous group of disorders. This study was performed to: (1) describe the current incidence, causes, demographic features, hospital courses, and short-term outcomes of non-enteropathic HUS; (2) compare findings in patients with non-enteropathic HUS with those obtained from a contemporaneous cohort of children with enteropathic or diarrhea-associated HUS (D+ HUS) diagnosed and treated at the same clinical sites; and (3) identify clinical or laboratory features that differentiate these 2 groups and predict disease severity and the short-term outcome in patients with non-enteropathic HUS., Methods: Data were collected from patients screened between 1997 and 2001 for enrollment in a multicenter trial of SYNSORB Pk (SYNSORB Biotech Inc, Calgary, Alberta, Canada) in D+ HUS, but who were ineligible because of lack of a diarrhea prodrome. The following features were recorded: age; sex; ethnicity; prodromal symptoms; cause; nadir values for hemoglobin, hematocrit, and platelet count; use of dialysis; and length of hospitalization., Results: Twenty-seven of 247 children with HUS had non-enteropathic HUS (11%). Twenty-four patients (15 boys, 9 girls), whose medical records were complete and available for review, comprise the study cohort. Mean age at onset was 4.2 +/- 0.9 (SE) years. Infection caused by S pneumoniae was diagnosed in 9 patients (38%). Dialysis was performed in 17 patients (71%) for 40 +/- 27 days. Median length of hospitalization was 22 days (range, 2 to 71 days). Children with S pneumoniae-related HUS had a longer hospital stay than those with other causes of non-enteropathic HUS, but all patients with S pneumoniae-related HUS recovered kidney function. Dialysis therapy was required more often (17 of 24 versus 59 of 145 children; P = 0.025) and hospital stays were longer (median, 22 versus 9 days; P = 0.002) in children with non-enteropathic HUS compared with patients with D+ HUS who were enrolled in the SYNSORB Pk clinical trial., Conclusion: (1) The incidence of non-enteropathic HUS is approximately one tenth that of D+ HUS; (2) patients with non-enteropathic HUS require dialysis therapy more often and are hospitalized more than twice as long during the acute episode compared with those with D+ HUS; (3) infection caused by S pneumoniae accounts for nearly 40% of cases of non-enteropathic HUS; and (4) although S pneumoniae-related HUS is associated with a less favorable short-term course than other types of non-enteropathic HUS or D+ HUS, the long-term prognosis for recovery of renal function appears to be good in these patients.

Objective: More than half of the children diagnosed with nephrotic syndrome will have relapses. These can be infrequent relapses (IRs: <2 in 6 months or <3 in a year) or frequent relapses (FRs: >2 in 6 months or >3 in a year). Patients who relapse while on alternate day steroids or within 1 month of discontinuation of steroid therapy are considered steroid-dependent (SD; J Pediatr. 1982; 101:514-518). Patients with an IR course have a better long-term prognosis, and many of them have minimal-change disease without mesangial hypercellularity or sclerosis. The purpose of our study was to identify factors at initial presentation that could predict the relapse pattern in the first year after diagnosis, without taking into consideration the histopathology found on renal biopsy., Design: We analyzed the medical records of children who were seen by us before March 1997 and followed for at least 1 year. Variables selected in the study were age, sex, race, presence or absence of hematuria, and days to remission (defined as protein-free) at the initial presentation, because they could relate to the pattern of relapses (ie, IR, FR, and SD)., Results: Of 70 patients, 14 were excluded because of insufficient data. There were 38 males (67.9%) and 18 females (32.1%), giving a male:female ratio of 1.8:1. Median age at presentation was 3.25 years (range: 1.5-13), and 76.9% were white, 8.9% black, 7.1% Hispanic, and 7.1% other. Of all the patients, 23 were IR (41.1%), 9 were FR (16.1%), and 24 were SD (42. 9%). Median days to remission were 10 (range: 2-60), on Prednisone 60 mg/M(2) daily. Hematuria was present initially in 26 patients (46. 4%), and absent in 30 (53.6%). Age, sex, race, and hematuria, as independent variables, were not predictors of relapses in the first year. However, using a stratified analysis based on the presence or absence of hematuria, we found that if the remission occurred within the first week of therapy, the patients without hematuria were more likely to be IR. The sensitivity and specificity of this finding were 67% and 89%, respectively, with a positive predictive value of 94%., Conclusion: We conclude that of all the presenting features, the rapidity of initial response to steroid therapy combined with the presence of hematuria, could predict future relapses and should be well documented.

Purpose: The case of a 4-year-old boy with hemophilia B with inhibitor who developed nephrotic syndrome is described. The possible association between factor IX therapy and nephrotic syndrome in patients with hemophilia B is discussed., Patient and Methods: A chart review of a 4-year-old boy with hemophilia B and an inhibitor who developed nephrotic syndrome with transient hypocomplementemia was performed. In addition, a literature search was undertaken to determine the prevalence of this association and possible etiologic factors., Results: Although the nephrotic syndrome was resistant to steroid therapy and Bebulin (Osterreichisches Institut für Haemoderivate Ges.M.B.H., Subsidiary of Immuno AG, Vienna, Austria) infusions were continued, the edema resolved and proteinuria decreased. Seven month later, proteinuria, accompanied by transient hypocomplementemia, increased again. A rise in factor IX inhibitor level was observed. The patient received no immunosuppressive therapy, and exhibited a continuous decrease in urinary protein excretion over the following months., Discussion: A discussion about possible differential diagnoses and a review of the literature are presented.

Cementifying fibroma is a benign fibro-osseous lesion that may occur in either the mandible or the maxilla, with a predilection for the mandible. In the patient described, a recurrent mandibular cementifying fibroma was successfully resected, with microsurgical preservation of the inferior alveolar nerve and immediate reconstruction via an autogenous iliac bone graft.

Simultaneous comparisons were made between a freezing-tolerant, cold-acclimating (CA) wild potato species (Solanum commersonii) and a freezing-sensitive, nonacclimating (NA) cultivated species (Solanum tuberosum). Comparative studies allowed differentiation of plasma membrane lipid changes associated with increased freezing tolerance following CA from lipid changes that can result from metabolic adjustment to reduced temperature during CA. Following CA treatment lipid changes found in both the NA and CA species included a decrease in palmitic acid, an increase in unsaturated to saturated fatty acid ratio, an increase in free sterols, an increase in sitosterol, and a slight decrease in cerebrosides. Lipid changes detected only in the acclimating species included an increase in phosphatidylethanolamine, a decrease in sterol to phospholipid ratio, an increase in linoleic acid, a decrease in linolenic acid, and an increase in acylated steryl glycoside to steryl glycoside ratio. These changes were either absent or opposite in the NA species, suggesting an association of these lipid changes with CA. Furthermore, the lipid changes associated with increased freezing tolerance during CA were distinct from lipid differences between the two species in the NA state.

Frost or winter survival is regarded as a complex trait with polygenic inheritance. Two major components of this survival in crop plants are freezing tolerance in the nonacclimated state and cold acclimation capacity. To date researchers have not distinguished the two components as separate heritable traits. The mode of inheritance of these two traits was investigated in F1 and backcross populations of two wild diploid potato species (Solanum commersonii and Solanum cardiophyllum) exhibiting extremes of freezing tolerance and acclimation capacity. Precise assessment of these two traits allowed distinction of small but significant differences among genotypes. The two traits were not correlated in segregating populations, suggesting independent genetic control. Analyses of generation means indicate that all of the variance for acclimation capacity and a major proportion of the variance for the nonacclimated freezing tolerance can be best explained by an additive-dominance model with both traits being partially recessive. Recovery of parental phenotypes in limited populations suggests that both traits are controlled by relatively few genes. To our knowledge this is the first study demonstrating independent genetic control of the two main traits associated with frost or winter survival. Our results show that it should be possible to incorporate these traits from wild germ plasm into cultivated crop plants by independent selection. These results help explain the lack of progress in improving winter survival through field selection. Furthermore, our study demonstrates relative simplicity of the inheritance of cold acclimation, thus providing avenues for understanding the link between biochemical and genetic aspects of low-temperature stress in crop plants.

Postoperative pharyngocutaneous fistula is not an uncommon complication. Although the frequency of postoperative fistulae has decreased with the use of perioperative broad-spectrum antibiotics, it remains a complication with significant morbidity and expense. We present an animal model for postoperative pharyngocutaneous fistulae based on increasing wound tension. The New Zealand white rabbit was used to assess the rate of wound breakdown in the thyrohyoid membrane. The animals were assigned to one of seven groups according to the width of tissue resected. After tissue resection, the pharyngeal wounds were repaired, as were the overlying skin wounds. Animals were monitored postoperatively up to 14 days, at which time they were killed and underwent autopsy. Statistically significant results were achieved that demonstrate an increasing incidence of pharyngeal wound breakdown associated with increasing width of tissue resected and, therefore, closure tension. The procedure and results will be presented in detail. We propose that this model may be used to assess postoperative wounds as well as substances or methods touted as promoters of wound healing.

Vestibular dysfunction has many etiologies. Symptoms including vertigo and imbalance may severely hamper life-style, causing the afflicted individual to seek medical attention. For many patients with vestibular complaints a cure is not available. However, the physician is often called upon to relieve incapacitating symptoms. The purpose of this article is to discuss vestibular rehabilitation as a therapeutic modality for patients with chronic vestibular dysfunction.

Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.

A 19-month-old boy with AIDS developed clinically unexplainable proteinuria. Biopsied renal tissue was examined by light microscopy, transmission electron microscopy, and immunofluorescence. Findings included an increase of mesangial matrix with occasional nodular sclerosis, mesangial hypercellularity, and glomerular deposits of kappa and lambda light chains. There were deposits of kappa, but not lambda, light chains in the arteriolar walls, and around the tubular and interstitial capillary basement membranes. Quantitative urinary immunoelectrophoresis revealed an extremely high urinary concentration of kappa light chain. These changes are diagnostic of light chain nephropathy. The rarity of light chain nephropathy in childhood and its occurrence in a patient with AIDS make this case unusual.

Traumatic perforations of the tympanic membrane are not uncommon injuries. The various etiologies of this injury along with the appropriate evaluation will be discussed. The goal of this review is to enhance the nonotolaryngologist's knowledge of this condition and its treatment.

Macroglossia is defined as a resting tongue that protrudes beyond the teeth or alveolar ridge. Complications of macroglossia include articulation errors, mandibular deformities, deglutition difficulties, and airway obstruction. Etiologies include hypothyroidism, the Beckwith-Wiedemann syndrome, lymphangiomatosis, and amyloidosis. Surgical correction of this condition at an early age may prevent or minimize the maxillofacial deformities and speech defects.

Compensatory renal hypertrophy was studied in fetal lambs during midgestation. Functional adaptation was correlated with anatomica and biochemical changes by measuring glomerular filtration and clearance of para-amino hippurate (PAH). Normal intrauterine body growth and kidney growth by changes in RNA and DNA over a 72-hr period were studied in twin fetuses. Seventy-two hr after left uninephrectomy in single fetuses, there was a significant increase in weight of the renoprival right kidney as well as a significant increase in renal cortical content of RNA and DNA. The rate of increase in RNA was greater than the increase in DNA. Preliminary studies suggest that an increase in renal function parallels renal hypertrophy in fetal lambs.