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Background and Objectives: A recognized gap exists between primary care physicians' training in musculoskeletal (MSK) medicine and the burden of MSK complaints in primary care. Family medicine interns often lack adequate baseline MSK physical exam skills, which prompted a proposal to introduce a fourth-year preceptorship to reinforce MSK education. The aim of this study was to prioritize the most important elements to include in this new clinical rotation., Methods: We employed a three-round, modified Delphi method to derive consensus. Eleven panelists with experience and expertise in MSK training, medical education, or both generated a list of 118 elements. Each panelist then ranked each element by level of importance, and we reviewed the results. The ranking process was repeated two more times with a goal of achieving consensus., Results: Seventy-seven curricular elements (topics, skills, experiences) achieved consensus recommendation by being ranked either "fairly important" or "very important" for inclusion in the curriculum. Twenty-eight items were unanimously ranked "very important," 42 received a mix of "very important" and "fairly important" rankings, and seven received unanimous ranking of "fairly important." Three items were unanimously ranked "neither important nor unimportant.", Conclusions: Longitudinal repetition of physical exam skills, reinforcement of relevant anatomy, and incorporation of specific frameworks for approaching MSK care are important components. Physical examination of the shoulder, knee, back, and hip are especially meaningful clinically.

This study investigates the use of six plant-based coagulants - Acacia erioloba , Ricinodendron rautanenii , Schinziophyton rautanenii , Peltophorum africanum , Delonix regia , and Maerua angolensis for the removal of turbidity from wastewater effluent. The coagulants were characterized using Scanning Electron Microscopy (SEM) to determine morphological structure, X-ray fluorescence (XRF) to assess chemical composition, and X-ray diffraction to analyse the molecular structure. The coagulation process was evaluated using jar tests with varying coagulant dosages and pH levels. SEM images revealed irregular, rough surfaces, with all materials being amorphous and non-crystalline. Significant levels of essential elements, including iron (Fe), calcium (Ca), sulphur (S), and potassium (K) were revealed. Turbidity removal efficiency fluctuated with pH, showing optimal results under alkaline conditions. Notably, strong negative correlations between pH and turbidity were observed for all coagulants except Peltophorum africanum at a dosage of 20 g/L. Doubling the coagulant volume achieved turbidity reductions between 59% and 92.24%, except for Acacia erioloba and Ricinodendron rautanenii at a dosage of 40 g/L, which showed increased turbidity. The study also employed machine learning techniques to analyse the data and predict the most effective coagulant dosage under different pH conditions. These findings suggest that plant-based coagulants could be viable alternatives to chemical coagulants, with machine learning providing accurate predictions of coagulation performance. Further research is recommended to explore the capabilities of these natural coagulants fully.

The purpose of the preparticipation physical evaluation (PPE) is to promote safe participation in sport and to restrict participation only when necessary for the safety of the athlete. Based on expert opinion, this tool is considered standard of care. Six stakeholder professional societies collaboratively published the Preparticipation Physical Evaluation Monograph to guide a more useful experience for both examiners and athletes. The PPE uses systems-based history-taking and physical examinations to determine medical eligibility for participation in sport., Competing Interests: Disclosure The authors do not have any commercial or financial conflicts of interest or any funding sources to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In this study, water treatment sludge was investigated through batch modes for the treatment of saline water to meet livestock drinking consents. The water quality was assessed using water quality index (WQI).The kinetic data was best described by the Pseudo - Second - Order model and the equilibrium isotherm by the Freundlich model. The maximum removal efficiency was 51.5 ± 0.65%, 22.6 ± 0.5% and 100% for Sulphates (SO 4 2- ), Chloride (Cl - ), and Nitrates (NO 3 - ), respectively. The maximum removal efficiency of sodium (Na) and nickel (Ni) was 100% each at 0.4g dose and that of manganese (Mn) was 87.5% at 1.2g dose. The effect of temperature revealed that the adsorption capacity for anions, decreased with increasing temperature, whereas for the cations the adsorption capacities increased with increasing temperature. The water treatment sludge reduced the total dissolved solids (TDS) and electrical conductivity (EC) from the initial values of 19600 mgL -1 and 38900 μScm -1 to 98 mgL -1 and 1728 μScm -1 ,respectively. The Water Quality Indices were 37.35 and 7.57, before and after treatment, respectively. Water treatment sludge can be used for the pre-treatment process before using conventional treatment technologies. Pilot scale investigations should be conducted before field trials., (© 2023 The Authors.)

Background: People who inject drugs (PWID) are disproportionately affected by HIV despite the availability of multiple efficacious biomedical prevention interventions including oral pre-exposure prophylaxis (PrEP). Little is known about the knowledge, acceptability, and uptake of oral PrEP among this population in Kenya. To inform the development of oral PrEP uptake optimization interventions for PWID in Kenya, we conducted a qualitative assessment to establish oral PrEP awareness and willingness to take PrEP by this group in Nairobi City., Methodology: Guided by the Capability, Opportunity, Motivation, and Behaviour (COM-B) model of health behavior change, we conducted 8 focus group discussions (FGDs) among randomly constituted samples of PWID in four harm reduction drop-in centers (DICs) in Nairobi in January 2022. The domains explored were: perceived risks (behaviour), oral PrEP awareness and knowledge (capability), motivation to use oral PrEP (behaviour), and perceptions on community uptake (motivation and opportunity). Completed FGD transcripts were uploaded to Atlas.ti version 9 and thematic analysis was conducted through an iterative process of review and discussion by two coders., Findings: There was a low level of oral PrEP awareness with only 4 of the 46 PWID having heard of PrEP; only 3 out of 46 participants had ever used oral PrEP and 2 out of 3 were no longer using it, indicating a low capacity to make decisions on oral PrEP. Most study participants were aware of the risk posed by unsafe drug injection and expressed willingness to take oral PrEP. Nearly all participants demonstrated low understanding of the role oral PrEP plays in complementing condoms in HIV prevention, presenting an opportunity for awareness creation. While the PWID were eager to learn more about oral PrEP, they favored DICs as places where they would like to obtain information and oral PrEP if they chose to use it, identifying an opportunity for oral PrEP programming interventions., Conclusion: Creation of oral PrEP awareness among PWID in Kenya is likely to improve uptake since the PWID are receptive. Oral PrEP should be offered as part of combination prevention approaches, and effective messaging through DICs, integrated outreaches, and social networks are recommended to mitigate displacement of other prevention and harm reduction practices by this population., Trial Registration: ClinicalTrials.gov Protocol Record STUDY0001370., Competing Interests: Competing interests The authors declare that they have no competing interests.

The adsorption of copper, iron and nickel ions from an aqueous solution using Makoro granite clay brick waste through batch and fixed - bed column modes was investigated. The adsorbent was characterised using X-Ray Fluorescence, X-Ray Diffraction (XRD), Thermogravimetric Analysis, and Scanning Electron Microscopy (SEM). XRD results revealed crystalline peaks of Quartz (51.28 %) and mullite (23.40%) in fresh and loaded adsorbent with unnotable changes before and after adsorption. SEM images indicate the presence of micro pores and irregularly distributed surfaces. Batch kinetic maximum adsorption capacities for iron, copper, and nickel are 7.60, 6.70 and 6.20 mg g -1 media respectively with 60 min as the optimum time. The maximum adsorption capacities at adsorbent dosage of 5 g L -1 were 10.0, 7.60 and 7.20 mg L -1 for iron, copper and nickel ions. The corresponding adsorption capabilities from the fixed-bed column reactor were 2.23, 2.22 and 0.74 mg g -1 media respectively. The thermodynamics parameters of enthalpy change (ΔH) were 5.21, 9.32 and 5.22 kJ mol -1 respectively for Copper, iron and nickel ions and the corresponding entropy change (ΔS) were -0.04, -0.05 and -0.03 kJmol -1 K -1 respectively and the process being non-spontaneous and exothermic. Thomas and Yoon-Nelson models yielded similar low coefficient of determination (R 2 ) values (0.06 and 0.07) for copper and iron ions. Further investigations such as the use of real wastewater, competition of anions and further media characterisation and modifications are recommended., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s).)

Background: The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients., Methods: The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected., Results: Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038)., Conclusions: Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology., Competing Interests: Conflicts of interest and sources of funding: M.W.W. was a paid speaker for LifeCell and previous owner of SPY Elite at the time of data collection. This was more than 36 months before submission for publication., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Water treatment sludge have shown promising results as adsorbent for phosphorus and sulphate removal from real wastewater. The study was conducted through batch kinetics and equilibrium isotherm modes. The chemical composition reveal that aluminium compounds were dominant in the fresh sludge and aluminium phosphates were also observed in the used sludge. The results reveal that Manganese was leached from the material at all pH values investigated with the highest level observed at pH 2 and all concentrations higher than the national standard of discharge into the relevant environment. The point of zero charge of the adsorbent was pH 8.04 and high adsorption capacities for both sulphate and phosphate ions were observed at pH values lower than this point. Batch kinetic results revealed 96.0 ± 3.0% sulphates removal in the first 30 min whereas the highest phosphates removal was 88.0 ± 4.0% attained at 300 min of the experiment. Pseudo - second order reaction fitted the data better than Pseudo-first order reaction. The percentage removal of sulphates was observed decreasing with increasing adsorbent dose after 2.4 g dose but removal increased with increasing media dosage for phosphorus. The equilibrium data was better described by Freundlich isotherm with constants relating to adsorption capacities being 6.76 and 6.2 L g -1 respectively, for sulphates and phosphates adsorption. The adsorption capacity of phosphates was observed decreasing with increasing temperature, but the results were not conclusive in the case of sulphates. The results reveal that copper, nickel, and zinc have affinity for sulphates. The water treatment sludge can be used for phosphate and sulphate removal from wastewater though the leachability of manganese is a concern. Further investigations through fixed bed columns will need to be investigated before field trials. In conclusion, the sludge can be used as adsorbent for phosphorus and sulphates removal from wastewater through filtration and onsite treatment methods such as vertical or horizontal flow wetland systems. The success of the adsorbent will reduce the costs associated with its disposal which can also lead to leachability of metals into the environment with time., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Shortage of water for agriculture has resulted in the need to explore the use of wastewater for irrigation, however this can pose a health problem to the people emanating from the produced food as a result of the accumulation of pollutants. The purpose of this research was to investigate the accumulation of some heavy metals and bacteriological indicators in the different parts of spinach vegetable irrigated with secondary wastewater effluent treated through a pilot filtration system. There was a variation of heavy metals accumulation in the roots, stem and leafy parts of the vegetable. Bioaccumulation factors of some metals were greater than 1 in the roots and stems but not in the leaves. Three heavy metals being copper, iron and zinc revealed high translocation factors in the stems than leaves; whereas arsenic, chromium, nickel, manganese and lead had high translocation factors in the leaves than stems. Health index coefficients in the stem during the first, second and third months were 2.33, 0.18 and 3.57 respectively, and corresponding values in the leaves were 0.68, 0.09 and 6.75 if consumed by adults. The health index values greater than 1 in children were 2.68 in the stem during the first month and then 4.1 and 7.76 in the stem and leaves during the third month for spinach consumed by children. There was no bacteriological indicators detected in the aboveground parts of the vegetable. To conclude, irrigation of vegetables should be practiced using secondary treated wastewater and monitoring over time intervals in order to safe guard human health., (© 2020 The Author(s).)

Slow sand filtration has been used for decades for the removal of pathogens from water. A combination of roughing and slow sand filters has been evaluated for the removal of pathogen indicators from secondary effluent. The filter system was modified with the addition of slag and coal clinker ash. The filter system reached up to 100% removal of faecal coliforms, faecal streptococci, Escherichia coli and total coliforms after 17 weeks of treatment. Log reductions ranged between 0.0-4.1, 1.33-2.0, 1.34-2.37 and 1.4-4.5 for E. coli , faecal streptococci, faecal coliforms and total coliforms respectively. There was no strong correlation between pH and the bacterial counts as correlation coefficients were -0.15, 0.15, 0.38 and -0.07 in respect to E. coli , faecal coliforms, faecal streptococci and total coliforms. The correlation coefficients for temperature were -0.18, -0.14, 0.10, and -0.39 for E. coli , faecal coliforms, faecal streptococci and total coliforms respectively, suggesting that temperature did not influence the bacterial removal efficiency. For turbidity, the correlation coefficients were 0.64, 0.70, 0.68 and -0.06 respectively, for E. coli , faecal coliforms, faecal streptococci and total coliforms. Only total coliforms had no correlation with turbidity. There was a significant difference between effluent from holding tank and slow sand filter as p values of 0.008, 0.0006, 0.00000, and 0.00008 were observed for faecal coliforms, faecal streptococci, E. coli and total coliforms counts, respectively. The results obtained indicate that the combination of roughing and slow sand filters can successfully reduce microorganisms from secondary wastewater.

South Texas has experienced local transmission of Zika virus and of other mosquito-borne viruses such as chikungunya virus and dengue virus in the last decades. Using a mosquito surveillance program in the Lower Rio Grande Valley (LRGV) and San Antonio, TX, from 2016 to 2018, we detected the presence of an insect-specific virus, cell fusing agent virus (CFAV), in the Aedes aegypti mosquito population. We tested 6,326 females and 1,249 males from the LRGV and 659 females from San Antonio for CFAV by RT-PCR using specific primers. Infection rates varied from 0 to 261 per 1,000 mosquitoes in the LRGV and 115 to 208 per 1,000 in San Antonio depending on the month of collection. Infection rates per 1,000 individuals appeared higher in females collected from BG Sentinel 2 traps compared to Autocidal Gravid Ovitraps, but the ratio of the percentage of infected pools did not differ by trap type. The natural viral load in individual males ranged from 1.25 x 10 2 to 5.50 x 10 6 RNA copies and in unfed females from 5.42 x 10 3 to 8.70 x 10 6 RNA copies. Gravid females were found to harbor fewer viral particles than males and unfed females.

This study investigated the use of copper smelter slag for the removal of phosphorus from secondary wastewater effluent through batch tests. The media was physically and chemically characterized and showed presence of Fe 2 O 3 (45.22%), SiO 2 (14.98%), Al 2 O 3 (3.21%), CaO (1.99%), SO 3 (1.77%) and MgO (1.33%). Scanning electron microscopy monographs revealed smooth and flat surface and no heterogeneity on the surface of the slag with visible micro pores before the experiment and less visible after the experiment. The point of zero charge of the media was 5.0. Equilibrium was reached after 4 h at 29.5 ± 0.71% phosphorus removal efficiency and media dosage of 0.4/100 mL. The kinetic data was best described by Pseudo second order equation. More than one mechanisms were involved in the adsorption of phosphorus onto copper smelter slag as suggested by multi-linearity of intra particle diffusion model. Ninety seven percent (97.5 ± 0.0%) removal efficiency was achieved at an equilibrium dosage of 160 gL -1 . The equilibrium isotherm was described better by Langmuir equation with observed maximum adsorption capacity of 0.16 mg P g -1 media and the experimental maximum adsorption capacity was 0.26 mg P g -1 media. Regeneration studies showed low performance with maximum efficiency of 11.7% revealed during the first regeneration trial therefore low practical benefits. Copper smelter slag is a poor adsorbent for phosphorus and further studies on the media should be conducted., (© 2020 The Authors.)

Background:  Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases., Methods:  We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance., Results:  Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications ( p  = 0.051) and flap-specific complications ( p  = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance., Conclusion:  Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Anatomical variations in perforator arrangement may impair the surgeon's ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap., Methods: A single surgeon's experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange ("APEX") arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion., Results: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps., Conclusions: This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required., Clinical Question/level of Evidence: Therapeutic, III.

Background: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women (aged 65 years or older). However, many surgeons anecdotally believe that surgery in elderly patients is inherently dangerous, or at least prone to more complications., Methods: The authors conducted a retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (65 years or older) and a nonelderly cohort (younger than 65 years). Cohort was the primary predictor variable. Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap reexploration. Secondary outcomes such as wound healing problems, seroma, and others were also assessed., Results: There were 285 flaps in the nonelderly cohort and 54 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts. Breast wound dehiscence was significantly higher in the elderly cohort (p < 0.01). On logistic regression, being elderly was seen as a significant risk factor for complete flap loss (OR, 10.92; 95 percent CI, 0.97 to 122.67; p = 0.05). The overall success rate for the nonelderly cohort was 99.6 percent, whereas the success rate for the nonelderly cohort was 96.3 percent., Conclusions: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients., Clinical Question/level of Evidence: Risk, II.

Background: When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle., Methods: Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively., Results: Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation., Conclusion: The creation of central under flap pocket technique allows for safe, effective, and expedient delayed implant augmentation of perforator flap breast reconstruction., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supermassive black holes in galaxy centres can grow by the accretion of gas, liberating energy that might regulate star formation on galaxy-wide scales. The nature of the gaseous fuel reservoirs that power black hole growth is nevertheless largely unconstrained by observations, and is instead routinely simplified as a smooth, spherical inflow of very hot gas. Recent theory and simulations instead predict that accretion can be dominated by a stochastic, clumpy distribution of very cold molecular clouds--a departure from the 'hot mode' accretion model--although unambiguous observational support for this prediction remains elusive. Here we report observations that reveal a cold, clumpy accretion flow towards a supermassive black hole fuel reservoir in the nucleus of the Abell 2597 Brightest Cluster Galaxy (BCG), a nearby (redshift z = 0.0821) giant elliptical galaxy surrounded by a dense halo of hot plasma. Under the right conditions, thermal instabilities produce a rain of cold clouds that fall towards the galaxy's centre, sustaining star formation amid a kiloparsec-scale molecular nebula that is found at its core. The observations show that these cold clouds also fuel black hole accretion, revealing 'shadows' cast by the molecular clouds as they move inward at about 300 kilometres per second towards the active supermassive black hole, which serves as a bright backlight. Corroborating evidence from prior observations of warmer atomic gas at extremely high spatial resolution, along with simple arguments based on geometry and probability, indicate that these clouds are within the innermost hundred parsecs of the black hole, and falling closer towards it.

The eclipses of certain types of binary millisecond pulsars (i.e. 'black widows' and 'redbacks') are often studied using high-time-resolution, 'beamformed' radio observations. However, they may also be detected in images generated from interferometric data. As part of a larger imaging project to characterize the variable and transient sky at radio frequencies <200 MHz, we have blindly detected the redback system PSR J2215+5135 as a variable source of interest with the Low-Frequency Array (LOFAR). Using observations with cadences of two weeks - six months, we find preliminary evidence that the eclipse duration is frequency dependent (∝ν -0.4 ), such that the pulsar is eclipsed for longer at lower frequencies, in broad agreement with beamformed studies of other similar sources. Furthermore, the detection of the eclipses in imaging data suggests an eclipsing medium that absorbs the pulsed emission, rather than scattering it. Our study is also a demonstration of the prospects of finding pulsars in wide-field imaging surveys with the current generation of low-frequency radio telescopes.

Due to their steep spectra, low-frequency observations of Fanaroff-Riley type II (FR II) radio galaxies potentially provide key insights in to the morphology, energetics and spectrum of these powerful radio sources. However, limitations imposed by the previous generation of radio interferometers at metre wavelengths have meant that this region of parameter space remains largely unexplored. In this paper, the first in a series examining FR IIs at low frequencies, we use LOFAR (LOw Frequency ARray) observations between 50 and 160 MHz, along with complementary archival radio and X-ray data, to explore the properties of two FR II sources, 3C 452 and 3C 223. We find that the morphology of 3C 452 is that of a standard FR II rather than of a double-double radio galaxy as had previously been suggested, with no remnant emission being observed beyond the active lobes. We find that the low-frequency integrated spectra of both sources are much steeper than expected based on traditional assumptions and, using synchrotron/inverse-Compton model fitting, show that the total energy content of the lobes is greater than previous estimates by a factor of around 5 for 3C 452 and 2 for 3C 223. We go on to discuss possible causes of these steeper-than-expected spectra and provide revised estimates of the internal pressures and magnetic field strengths for the intrinsically steep case. We find that the ratio between the equipartition magnetic field strengths and those derived through synchrotron/inverse-Compton model fitting remains consistent with previous findings and show that the observed departure from equipartition may in some cases provide a solution to the spectral versus dynamical age disparity.

Cosmic rays are the highest-energy particles found in nature. Measurements of the mass composition of cosmic rays with energies of 10(17)-10(18) electronvolts are essential to understanding whether they have galactic or extragalactic sources. It has also been proposed that the astrophysical neutrino signal comes from accelerators capable of producing cosmic rays of these energies. Cosmic rays initiate air showers--cascades of secondary particles in the atmosphere-and their masses can be inferred from measurements of the atmospheric depth of the shower maximum (Xmax; the depth of the air shower when it contains the most particles) or of the composition of shower particles reaching the ground. Current measurements have either high uncertainty, or a low duty cycle and a high energy threshold. Radio detection of cosmic rays is a rapidly developing technique for determining Xmax (refs 10, 11) with a duty cycle of, in principle, nearly 100 per cent. The radiation is generated by the separation of relativistic electrons and positrons in the geomagnetic field and a negative charge excess in the shower front. Here we report radio measurements of Xmax with a mean uncertainty of 16 grams per square centimetre for air showers initiated by cosmic rays with energies of 10(17)-10(17.5) electronvolts. This high resolution in Xmax enables us to determine the mass spectrum of the cosmic rays: we find a mixed composition, with a light-mass fraction (protons and helium nuclei) of about 80 per cent. Unless, contrary to current expectations, the extragalactic component of cosmic rays contributes substantially to the total flux below 10(17.5) electronvolts, our measurements indicate the existence of an additional galactic component, to account for the light composition that we measured in the 10(17)-10(17.5) electronvolt range.

Signaling pathways involving nuclear receptors (NRs), their ligands and coregulators, regulate tissue-specific transcriptomes in diverse processes, including development, metabolism, reproduction, the immune response and neuronal function, as well as in their associated pathologies. The Nuclear Receptor Signaling Atlas (NURSA) is a Consortium focused around a Hub website (www.nursa.org) that annotates and integrates diverse 'omics datasets originating from the published literature and NURSA-funded Data Source Projects (NDSPs). These datasets are then exposed to the scientific community on an Open Access basis through user-friendly data browsing and search interfaces. Here, we describe the redesign of the Hub, version 3.0, to deploy "Web 2.0" technologies and add richer, more diverse content. The Molecule Pages, which aggregate information relevant to NR signaling pathways from myriad external databases, have been enhanced to include resources for basic scientists, such as post-translational modification sites and targeting miRNAs, and for clinicians, such as clinical trials. A portal to NURSA's Open Access, PubMed-indexed journal Nuclear Receptor Signaling has been added to facilitate manuscript submissions. Datasets and information on reagents generated by NDSPs are available, as is information concerning periodic new NDSP funding solicitations. Finally, the new website integrates the Transcriptomine analysis tool, which allows for mining of millions of richly annotated public transcriptomic data points in the field, providing an environment for dataset re-use and citation, bench data validation and hypothesis generation. We anticipate that this new release of the NURSA database will have tangible, long term benefits for both basic and clinical research in this field.

Background: Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy., Methods: A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope., Results: Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy., Conclusions: The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy., Clinical Question/level of Evidence: Therapeutic, IV.

We present measurements of radio emission from cosmic ray air showers that took place during thunderstorms. The intensity and polarization patterns of these air showers are radically different from those measured during fair-weather conditions. With the use of a simple two-layer model for the atmospheric electric field, these patterns can be well reproduced by state-of-the-art simulation codes. This in turn provides a novel way to study atmospheric electric fields.

High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.

Background: The deep inferior epigastric artery perforator (DIEP) free flap is the optimal autogenous reconstructive technique in many patients undergoing postmastectomy. Our aim was to evaluate the standard DIEP free flap design in relation to the dominant perforating vessels using computed tomography angiography (CTA)., Methods: We retrospectively reviewed CTAs from 75 patients who had undergone perforator flap reconstruction within the past year. Locations of the largest perforator with a minimum diameter of 2.0 mm piercing the anterior rectus fascia were recorded., Results: Of 150 hemiabdomens reviewed, 146 (97.3%) had a dominant perforator. The median location for the dominant perforator was 3.3 cm lateral and 0.9 cm below the umbilicus. One hundred twenty-one (83%) of the dominant perforators arose within 3 cm of the umbilicus. One hundred one (69%) arose at or below the level of the umbilicus. Forty-five (31%) arose above the level of the umbilicus. Thirteen (9%) arose more than 2 cm above the umbilicus., Conclusions: The standard DIEP flap design incorporates most of the dominant perforating vessels. However, a significant number of perforators arise at or above the umbilicus, which would be near the edge or out of the standard design of the DIEP. Our findings support the use of preoperative CTA in the evaluation of patients undergoing DIEP free flap reconstruction. Modification of flap design to include the dominant perforating vessels should be considered when the dominant vessel is outside the standard design of the DIEP.

Background: Complex osteocutaneous maxillofacial reconstruction requiring multiple free flaps and with an extensive zone of injury can be fraught with complications and difficulty. Often, the remnants of native mandible are malpositioned and the skeletal structure of the upper face is distorted. The authors seek to extend the use of virtual planning to complex maxillofacial reconstruction by presenting their early experience in these difficult patients., Methods: A retrospective chart review of 10 consecutive patients who underwent complex maxillofacial reconstruction using virtual surgical planning was undertaken. The authors define complex maxillofacial reconstruction as that requiring an osteocutaneous flap in which multiple osteotomies were required in addition to at least one of the following: need for multiple free flaps, history of osteoradionecrosis, and ballistic injury. Synthes Proplan CMF surgical planning was performed using computed tomographic scanning of the maxillofacial area and the donor site. Jigs and cutting guides were created and plates were prebent. The flap was harvested and osteotomized using the jigs and inset. Postoperative computed tomographic scanning was performed to evaluate the reconstruction., Results: Ten consecutive patients who met the criteria underwent review. There were no intraoperative complications. Postoperative computed tomographic scans showed excellent contour of the osseous flaps. All patients had functional mandibular range of motion., Conclusions: Use of virtual surgical planning allows for complex maxillofacial reconstruction with multiple simultaneous free flaps to be performed reliably and successfully. The use of prefabricated jigs and precontoured plates eases osteocutaneous flap molding and inset, allowing for a more complex procedure to be successful.

Pulsars emit from low-frequency radio waves up to high-energy gamma-rays, generated anywhere from the stellar surface out to the edge of the magnetosphere. Detecting correlated mode changes across the electromagnetic spectrum is therefore key to understanding the physical relationship among the emission sites. Through simultaneous observations, we detected synchronous switching in the radio and x-ray emission properties of PSR B0943+10. When the pulsar is in a sustained radio-"bright" mode, the x-rays show only an unpulsed, nonthermal component. Conversely, when the pulsar is in a radio-"quiet" mode, the x-ray luminosity more than doubles and a 100% pulsed thermal component is observed along with the nonthermal component. This indicates rapid, global changes to the conditions in the magnetosphere, which challenge all proposed pulsar emission theories.

Free fibula transfer has become the workhorse in mandibular reconstruction. Total mandibular reconstruction is an uncommon procedure with added complexity. Numerous techniques have been described for such reconstruction, many requiring a temporomandibular joint prosthesis. We present a novel method where simultaneous bilateral free fibula transfer utilizing preoperative virtual surgical planning was used to produce a total autogenous reconstruction. The virtual surgical planning allows to effectively quantify the bone stock required preoperatively and facilitates intraoperative modeling of the fibula. Therefore, a more anatomically correct reconstruction is obtained resulting in improved functional and aesthetic outcomes.

Composite defects of the fronto-orbital region represent a reconstructive challenge. Total autogenous reconstruction requires a thin pliable skin flap along with a bony component that can be osteotomized predictably. The thoracodorsal artery perforator/scapular bone chimeric flap provides a reliable single-stage method to cover difficult composite forehead defects where local options are unsuitable or have been exhausted. We present a patient with a traumatic fronto-orbital defect that has been successfully reconstructed using this flap. The report of this case illustrates well the versatility of the subscapular system as a donor site for difficult composite posttraumatic defects where tissue components need to be inset in a complex three-dimensional fashion.

Hydroxyapatite cement has become a popular alternative to bone grafts in reconstructing the calvarium. Although animal studies have shown promising results with use of hydroxyapatite, human clinical studies have shown mixed results including significant rates of infection. This is a retrospective chart review during a 7-year period (1997-2003) of 20 patients who underwent secondary forehead cranioplasty with hydroxyapatite cement (Norian Craniofacial Reconstruction System). Basic demographics including age, sex, and diagnosis were identified. Characteristics of the defects were recorded including size, location, and depth (full versus partial thickness). The volume of hydroxyapatite and any adjunctive procedures were identified. The postoperative course was analyzed for length of follow-up and the presence of infections.Twenty patients were identified in which Norian had been used and 3 patients were lost to follow-up. Secondary forehead asymmetry was the most common presentation. The mean volume of hydroxyapatite used was 24.4 mL. All patients had initially acceptable aesthetic results. Of the 17 patients, 10 (59%) ultimately had infectious complications. Infection occurred on a mean of 17.3 months after surgery (range, 4 mo to 4 y), and the mean amount of hydroxyapatite used was 32.5 mL (infections) versus 14.3 mL (no infections). Of the 10 patients with complications, 9 required surgical debridement and subsequent delayed reconstruction. Although hydroxyapatite cement can yield excellent aesthetic results, its use in secondary reconstruction has yielded unacceptably high infection rates leading to discontinuation of its use in this patient population.

High velocity injuries have traditionally been covered with free muscle flaps. We sought to evaluate the utility of the anterolateral thigh flap (ALT) flap as a primary choice in reconstructing traumatic injuries in Western patients.A retrospective chart review was conducted of 122 patients treated at the R Adams Cowley Shock Trauma Center and at the Louisiana State University Trauma Center. Data collected included defect size, donor site location, flap composition and size, number of anastamoses, number of perforators, donor site closure, and complications.A total of 127 ALT flap reconstructions were performed. About 74% involved the lower extremity, 12% head and neck, 11% upper extremity, 2% abdomen, <1% chest, and <1% pelvis. The success rate was 96% with 3 total flap failures and 2 partial flap failures. Average follow-up was 9.3 months.The results of this review confirm that the ALT flap is a reliable, versatile tool for managing composite traumatic injuries.

The inferior gluteal artery perforator (IGAP) free flap represents an alternative technique for autogenous breast reconstruction in patients with insufficient abdominal donor tissue. Historically, patients underwent a staged approach for bilateral breast reconstruction with the IGAP because it is technically demanding and can be time consuming. The bilateral simultaneous IGAP can be performed effectively with 2 microsurgeons operating together. This is a retrospective study of 22 patients (44 flaps) who underwent bilateral breast reconstruction with bilateral IGAP flaps in one operation between January 2005 and December 2007. The following parameters were evaluated and compared to our published data with unilateral IGAP flap reconstruction: operating time, blood loss, flap weight, hospital length of stay, and perioperative complications. A follow-up patient survey was also conducted to gauge patient's satisfaction with the donor site and procedure. The flap survival rate was 100%. Complications included 1 patient with 1 flap with partial fat necrosis, 2 patients who required reoperation for venous congestion, 1 patient with a hematoma, 2 patients with delayed buttock wound healing, 2 patients requiring resuturing for buttock wound dehiscence, and 1 patient with resolved paresthesias. The majority of patients were satisfied with the procedure and donor site. In this study, we detail our experience with the inferior gluteal region as a reliable source of donor tissue and the simultaneous bilateral IGAP flap as an efficient method of breast reconstruction.

Aedes densonucleosis virus (family Parcoviridae, genus Brevidensovirus, AeDNV) is a mosquito pathogen that increases Aedes aegypti larval mortality and reduces adult life span. We conducted three laboratory population cage trials, each lasting 16-25 wk. We tested two broad hypotheses. First, Ae. aegypti raised in containers seeded with 10(8) AeDNV genome equivalents/ml (geq/ ml), a concentration feasible for field application, increase AeDNV to concentrations that cause significant adult and larval mortality. Second, infected female mosquitoes disperse AeDNV to uninfected larval habitats. In hypothesis 1, we addressed the rate at which infected larvae secrete virus, how AeDNV titers change in seeded containers over time, whether AeDNV decays over time, and whether AeDNV exposed populations are reduced. In hypothesis 2, we monitored AeDNV concentrations in novel containers after oviposition by infected females. Both hypotheses were supported. Larvae increased AeDNV, secreting virus at a rate of 2.14 x 10(6) geq/larva/d when exposed to 10(8) geq/ml. AeDNV titers reached an asymptote of 10(10) geq/ml by week 10 in seeded containers. AeDNV decayed by 1 log every 4 d as indicated by a reduction in larval mortality. Adult population size was reduced in treated populations. Infected females dispersed AeDNV to novel containers, with titers reaching 10(8) geq/ml. The parameters were used in a Leslie-Lewis matrix model. This model predicted that AeDNV negatively affects Ae. aegypti densities and population structure and thus vectorial capacity.

Most of the baryons in galaxy clusters reside between the galaxies in a hot, tenuous gas. The densest gas in their centres should cool and accrete onto giant central galaxies at rates of 10-1,000 solar masses per year. No viable repository for this gas, such as clouds or new stars, has been found. New X-ray observations, however, have revealed far less cooling below X-ray temperatures than expected, altering the previously accepted picture of cooling flows. As a result, most of the gas must be heated to and maintained at temperatures above approximately 2 keV (ref. 3). The most promising heating mechanism is powerful radio jets emanating from supermassive black holes in the central galaxies of clusters. Here we report the discovery of giant cavities and shock fronts in a distant (z = 0.22) cluster caused by an interaction between a radio source and the hot gas surrounding it. The energy involved is approximately 6 x 10(61) erg, the most powerful radio outburst known. This is enough energy to quench a cooling flow for several Gyr, and to provide approximately 1/3 keV per particle of heat to the surrounding cluster.

Radiation therapy prevents heterotopic ossification after cemented total hip arthroplasty, but its effect on the fixation of porous-coated devices is not known. The purpose of this study was to determine the effect of irradiation on the pullout strength of a porous implant in the canine model. A custom-designed titanium fiber metal-coated cylinder was implanted into the distal femurs of 12 dogs. One femur of each dog was irradiated with 10 Gy, given in four 2.5-Gy daily fractions beginning one day after surgery. Serial bone scans were performed at one, two, four, and six weeks postoperatively. At six weeks, the femurs were harvested, and eight were randomly selected for mechanical testing. Scintigraphic evaluation showed a significant reduction in uptake at one and two weeks in the irradiated limb, but this had returned to normal at four and six weeks. The failure to pullout was significantly less in the irradiated limb compared with the control limb six weeks postoperatively. In this canine model, the pullout strength of the titanium fiber implant was significantly reduced by a dose of radiation commonly used in the prevention of heterotopic ossification. If irradiation is chosen for prophylaxis, either the porous implant should be adequately shielded or a cemented implant should be utilized.