Therapeutic upper gastrointestinal endoscopy in children : An audit of 443 procedures and literature review

The safety, effectiveness and capabilities of therapeutic upper fibreoptic endoscopy in children undergoing therapeutic endoscopic procedures (n = 443) was studied. Therapy for gastrointestinal bleeding formed the major group (injection sclerotherapy for varices, n = 197 procedures; thermocoagulation for haemorrhagic gastritis, n = 1; and photocoaulation for Dieulafoy's disease, n = 1). Sclerotherapy was 97% effective in controlling acute bleeding and 84% effective in obliterating varices with no serious complications or deaths. Oesophageal dilatations for surgical, caustic, congenital and peptic strictures and achalasia (n = 193) were performed with no oesophageal perforations or deaths. Foreign bodies were retrieved (n = 34) with no failures or complications. Percutaneous endoscopic gastrostomy was performed (n = 11) with one failure, proceeding to an unsuccessful surgical gastrostomy. Miscellaneous procedures included endoscopic transpyloric tube placement (n = 5) and endoscopic diathermy of pyloric web (n = 1). Therapeutic fibreoptic endoscopy is therefore concluded to be safe and effective in children, replacing rigid oesophagoscopy and some traditional surgical approaches.

The hemodynamic effects of in-tandem carotid artery stenosis: Implications for carotid endarterectomy

Objectives: It remains controversial whether patients with severe disease of the internal carotid artery and a coexisting stenotic lesion downstream would benefit from a carotid endarterectomy (CEA) of the proximal lesion. The aim of this study was to simulate the hemodynamic and wall shear effects of in-tandem internal carotid artery stenosis using a computational fluid dynamic (CFD) idealized model to give insight into the possible consequences of CEA on these lesions. Methods: A CFD model of steady viscous flow in a rigid tube with two asymmetric stenoses was introduced to simulate blood flow in arteries with multiple constrictions. The effect of varying the distance between the two stenoses, and the severity of the upstream stenosis on the pressure and wall shear stress (WSS) distributions on the second plaque, was investigated. The influence of the relative positions of the two stenoses was also assessed. Results: The distance between the plaques was found to have minimal influence on the overall hemodynamic effect except for the presence of a zone of low WSS (range -20 to 30 dyne/cm2) adjacent to both lesions when the two stenoses were sufficiently close (<4 times the arterial diameter). The upstream stenosis was protective if it was larger than the downstream stenosis. The relative positions of the stenoses were found to influence the WSS but not the pressure distribution. Conclusions: The geometry and positions of the lesions need to be considered when considering the hemodynamic effects of an in-tandem stenosis. Low WSS is thought to cause endothelial dysfunction and initiate atheroma formation. The fact that there was a flow recirculation zone with low WSS in between the two stenoses may demonstrate how two closely positioned plaques may merge into one larger lesion. Decision making for CEA may need to take into account the hemodynamic situation when an in-tandem stenosis is found. CFD may aid in the risk stratification of patients with this problem.

The impact of wall shear stress and pressure drop on the stability of the atherosclerotic plaque

Rupture of vulnerable atheromatous plaque in the carotid and coronary arteries often leads to stroke and heart attack respectively. The mechanism of blood flow and plaque rupture in stenotic arteries is still not fully understood. A three dimensional rigid wall model was solved under steady state conditions and unsteady conditions by assuming a time-varying inlet velocity profile to investigate the relative importance of axial forces and pressure drops in arteries with asymmetric stenosis. Flow-structure interactions were investigated for the same geometry and the results were compared with those retrieved with the corresponding 2D cross-section structural models. The Navier-Stokes equations were used as the governing equations for the fluid. The tube wall was assumed hyperelastic, homogeneous, isotropic and incompressible. The analysis showed that the three dimensional behavior of velocity, pressure and wall shear stress is in general very different from that predicted by cross-section models. Pressure drop across the stenosis was found to be much higher than shear stress. Therefore, pressure may be the more important mechanical trigger for plaque rupture other than shear stress, although shear stress is closely related to plaque formation and progression.

Miniscleral lens wear influences corneal curvature and optics

Purpose Transient changes in corneal topography associated with soft and conventional or reverse geometry rigid contact lens wear have been well documented; however, only a few studies have examined the influence of scleral contact lens wear upon the cornea. Therefore, in this study, we examined the influence of modern miniscleral contact lenses, which land entirely on the sclera and overlying tissues, upon anterior corneal curvature and optics. Methods Anterior corneal topography and elevation data were acquired using Scheimpflug imaging (Pentacam HR, Oculus) immediately prior to and following 8 hours of miniscleral contact lens wear in 15 young healthy adults (mean age 22 ± 3 years, 8 East Asian, 7 Caucasian) with normal corneae. Corneal diurnal variations were accounted for using data collected on a dedicated measurement day without contact lens wear. Corneal clearance was quantified using an optical coherence tomographer (RS-3000, Nidek) following lens insertion and after 8 hours of lens wear. Results Although corneal clearance was maintained throughout the 8 hour lens wear period, significant corneal flattening (up to 0.08 ± 0.04 mm) was observed, primarily in the superior mid-peripheral cornea, which resulted in a slight increase in against-the-rule corneal astigmatism (mean +0.02/-0.15 x 94 for an 8 mm diameter). Higher order aberration terms of horizontal coma, vertical coma and spherical aberration all underwent significant changes for an 8 mm corneal diameter (p ≤ 0.01), which typically resulted in a decrease in RMS error values (mean change in total higher order RMS -0.035 ± 0.046 µm for an 8 mm diameter). There was no association between the magnitude of change in central or mid-peripheral corneal clearance during lens wear and the observed changes in corneal curvature (p > 0.05). However, Asian participants displayed a significantly greater reduction in corneal clearance (p = 0.04) and greater superior-nasal corneal flattening compared to Caucasians (p = 0.048). Conclusions Miniscleral contact lenses that vault the cornea induce significant changes in anterior corneal surface topography and higher order aberrations following 8 hours of lens wear. The region of greatest corneal flattening was observed in the superior-nasal mid-periphery, more so in Asian participants. Practitioners should be aware that corneal measurements obtained following miniscleral lens removal may mask underlying corneal steepening.

Trends in US contact lens prescribing 2002-2014

Purpose To document contact lens prescribing patterns in the United States between 2002 and 2014. Methods A survey of contact lens prescribing trends was conducted each year between 2002 and 2014, inclusive. Randomly selected contact lens practitioners were asked to provide information relating to 10 consecutive contact lens fits between January and March each year. Results Over the 13-year survey period, 1650 survey forms were received from US practitioners representing details of 7702 contact lens fits. The mean (±SD) age of lens wearers was 33.6 (±15.2) years, of whom 65.2% were female. Rigid lens new fits decreased from 13.0% in 2002 to 9.4% in 2014. Across this period, silicone hydrogels have replaced mid water contact lens hydrogels as the soft lens material of choice. Toric lenses represented about 25 to 30% of all soft lens fits. Multifocal soft lenses are generally preferred to monovision. Daily disposable lens fits have recently increased, and in 2014, they represented 27.1% of all soft lens fits. Most lenses are prescribed on 1 to 2 weekly or monthly lens replacement regimen. Extended wear remains a minority lens wearing modality. The vast majority of those wearing reusable lenses use multipurpose lens care solutions. Lenses are mostly worn 7 d/wk. Conclusions This survey has revealed prescribing trends and preferences in the United States over the past 13 years.

Nonparametric traversability estimation in partially occluded and deformable terrain

Terrain traversability estimation is a fundamental requirement to ensure the safety of autonomous planetary rovers and their ability to conduct long-term missions. This paper addresses two fundamental challenges for terrain traversability estimation techniques. First, representations of terrain data, which are typically built by the rover’s onboard exteroceptive sensors, are often incomplete due to occlusions and sensor limitations. Second, during terrain traversal, the rover-terrain interaction can cause terrain deformation, which may significantly alter the difficulty of traversal. We propose a novel approach built on Gaussian process (GP) regression to learn, and consequently to predict, the rover’s attitude and chassis configuration on unstructured terrain using terrain geometry information only. First, given incomplete terrain data, we make an initial prediction under the assumption that the terrain is rigid, using a learnt kernel function. Then, we refine this initial estimate to account for the effects of potential terrain deformation, using a near-to-far learning approach based on multitask GP regression. We present an extensive experimental validation of the proposed approach on terrain that is mostly rocky and whose geometry changes as a result of loads from rover traversals. This demonstrates the ability of the proposed approach to accurately predict the rover’s attitude and configuration in partially occluded and deformable terrain.

"It's not the Jedi way!": Moral ambivalence and delivering the 'good' in Star Wars

This article examines the nature of good and evil through the prism of Star Wars, arguing that the ostensible dichotomy between the ‘good’ Jedi and the ‘evil’ Sith is false, and instead both the Jedi and the Sith engage in violence, which is evil. Anakin Skywalker then arrives as the Christ-figure who becomes evil and ‘dies’ to destroy the old rigid law of the letter adhered to by the Jedi, before resurrecting and sacrificing himself to defeat the Sith transgressors. As Milbank argues, the act of selfless love by Anakin as the Christ-figure therefore produces the good, the end of violent conflict which is ontological peace, and institutes the law of love which leads to life and peace.

Shear tests of rivet fastened rectangular hollow flange channel beams

The intermittently rivet fastened Rectangular Hollow Flange Channel Beam (RHFCB) is a new cold-formed hollow section proposed as an alternative to welded hollow flange channel beams. It is a monosymmetric channel section made by intermittently rivet fastening two torsionally rigid rectangular hollow flanges to a web plate. This process enables the end users to choose an effective combination of different web and flange plate sizes to achieve optimum design capacities. Recent research studies focused mainly on the shear behaviour of the most commonly used lipped channel beam and welded hollow flange beam sections. However, the shear behaviour of rivet fastened RHFCB has not been investigated. Therefore a detailed experimental study involving 24 shear tests was undertaken to investigate the shear behaviour and capacities of rivet fastened RHFCBs. Simply supported test specimens of RHFCB with aspect ratios of 1.0 and 1.5 were loaded at mid-span until failure. Comparison of experimental shear capacities with corresponding predictions from the current Australian cold-formed steel design rules showed that the current design rules are very conservative for the shear design of rivet fastened RHFCBs. Significant improvements to web shear buckling occurred due to the presence of rectangular hollow flanges while considerable post-buckling strength was also observed. Such enhancements to the shear behaviour and capacity were achieved with a rivet spacing of 100 mm. Improved design rules were proposed for rivet fastened RHFCBs based on the current shear design equations in AISI S100 and the direct strength method. This paper presents the details of this experimental investigation and the results.

Mechanical properties and damage tolerance of Y2SiO5

Y2SiO5 has potential applications as functional-structural ceramic and environmental/thermal barrier coating material. As an important grain-boundary phase in the sintered Si3N4, it also influences the mechanical and dielectric performances of the host material. In this paper, we present the mechanical properties of Y2SiO5 including elastic moduli, hardness, strength and fracture toughness, and try to understand the mechanical features from the viewpoint of crystal structure. Y2SiO5 has low shear modulus, low hardness, as well as high capacity for dispersing mechanical damage energy and for resisting crack penetration. Particularly, it can be machined by cemented carbides tools. The crystal structure characteristics of Y2SiO5 suggest the low-energy weakly bonded atomic planes crossed only by the easily breaking Y-O bonds as well as the rotatable rigid SiO4 tetrahedra are the origins of low shear deformation, good damage tolerance and good machinability of this material. TEM observations also demonstrate that the mechanical damage energy was dispersed in the form of the micro-cleavages, stacking faults and twins along these weakly bonded atomic planes, which allows the "microscale-plasticity" for Y2SiO5.