Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

Driver Safety in Far-side and Far-oblique Crashes: A Study of Patrol Vehicles in the United States of America

The dissertation titled "Driver Safety in Far-side and Far-oblique Crashes" presents a novel approach to assessing vehicle cockpit safety by integrating Human Factors and Applied Mechanics. The methodology of this approach is aimed at improving safety in compact mobile workspaces such as patrol vehicle cockpits. A statistical analysis performed using Michigan state's traffic crash data to assess various contributing factors that affect the risk of severe driver injuries showed that the risk was greater for unrestrained drivers (OR=3.38, p<0.0001) and for incidents involving front and far-side crashes without seatbelts (OR=8.0 and 23.0 respectively, p<0.005). Statistics also showed that near-side and far-side crashes pose similar threat to driver injury severity. A Human Factor survey was conducted to assess various Human-Machine/Human-Computer Interaction aspects in patrol vehicle cockpits. Results showed that tasks requiring manual operation, especially the usage of laptop, would require more attention and potentially cause more distraction. A vehicle survey conducted to evaluate ergonomics-related issues revealed that some of the equipment was in airbag deployment zones. In addition, experiments were conducted to assess the effects on driver distraction caused by changing the position of in-car accessories. A driving simulator study was conducted to mimic HMI/HCI in a patrol vehicle cockpit (20 subjects, average driving experience = 5.35 years, s.d. = 1.8). It was found that the mounting locations of manual tasks did not result in a significant change in response times. Visual displays resulted in response times less than 1.5sec. It can also be concluded that the manual task was equally distracting regardless of mounting positions (average response time was 15 secs). Average speeds and lane deviations did not show any significant results. Data from 13 full-scale sled tests conducted to simulate far-side impacts at 70 PDOF and 40 PDOF was used to analyze head injuries and HIC/AIS values. It was found that accelerations generated by the vehicle deceleration alone were high enough to cause AIS 3 - AIS 6 injuries. Pretensioners could mitigated injuries only in 40 PDOF (oblique) impacts but are useless in 70 PDOF impacts. Seat belts were ineffective in protecting the driver's head from injuries. Head would come in contact with the laptop during a far-oblique (40 PDOF) crash and far-side door for an angle-type crash (70 PDOF). Finite Element analysis head-laptop impact interaction showed that the contact velocity was the most crucial factor in causing a severe (and potentially fatal) head injury. Results indicate that no equipment may be mounted in driver trajectory envelopes. A very narrow band of space is left in patrol vehicles for installation of manual-task equipment to be both safe and ergonomic. In case of a contact, the material stiffness and damping properties play a very significant role in determining the injury outcome. Future work may be done on improving the interiors' material properties to better absorb and dissipate kinetic energy of the head. The design of seat belts and pretensioners may also be seen as an essential aspect to be further improved.

Improving Conditions of Latino Children Brightens the Future of America

An introduction to the inaugural issue of the Journal of Applied Research on Children.

An exploratory investigation of America's most costly delinquents: Juvenile firesetters

This study focused on the instruments that are currently being used by fire department personnel to identify and classify juvenile firesetters, these instruments, as published by the Federal Emergency Management Agency (F.E.M.A.) have never been empirically validated as to their ability to discriminate between first time and multiple firesetters and to predict the degree of risk for future firesetting by juveniles that come to the attention of authorities for firesetting behaviors. The study was descriptive in nature and not designed to test the validity of these instruments. The study was designed to test the ability of the instruments to discriminate between first time and multiple firesetters and to categorize known firesetters, based on the motive for firesetting, as to their degree or risk for future firesetting.^ The results suggest that the F.E.M.A. instruments are of little use in discriminating between first time and multiple firesetters. The F.E.M.A. instruments were not able to categorize juvenile firesetters as to their potential risk for future firesetting. A subset of variables from the F.E.M.A. instruments was identified that may be useful in discriminating between youth that are troubled firesetters and those that are not. ^

Diagnosis and Treatment of Venous Malformations Consensus Document of the International Union of Phlebology (IUP): updated 2013

Venous malformations (VMs) are the most common vascular developmental anomalies (birth defects) . These defects are caused by developmental arrest of the venous system during various stages of embryogenesis. VMs remain a difficult diagnostic and therapeutic challenge due to the wide range of clinical presentations, unpredictable clinical course, erratic response to the treatment with high recurrence/persistence rates, high morbidity following non-specific conventional treatment, and confusing terminology. The Consensus Panel reviewed the recent scientific literature up to the year 2013 to update a previous IUP Consensus (2009) on the same subject. ISSVA Classification with special merits for the differentiation between the congenital vascular malformation (CVM) and vascular tumors was reinforced with an additional review on syndrome-based classification. A "modified" Hamburg classification was adopted to emphasize the importance of extratruncular vs. truncular sub-types of VMs. This incorporated the embryological origin, morphological differences, unique characteristics, prognosis and recurrence rates of VMs based on this embryological classification. The definition and classification of VMs were strengthened with the addition of angiographic data that determines the hemodynamic characteristics, the anatomical pattern of draining veins and hence the risk of complication following sclerotherapy. The hemolymphatic malformations, a combined condition incorporating LMs and other CVMs, were illustrated as a separate topic to differentiate from isolated VMs and to rectify the existing confusion with name-based eponyms such as Klippel-Trenaunay syndrome. Contemporary concepts on VMs were updated with new data including genetic findings linked to the etiology of CVMs and chronic cerebrospinal venous insufficiency. Besides, newly established information on coagulopathy including the role of D-Dimer was thoroughly reviewed to provide guidelines on investigations and anticoagulation therapy in the management of VMs. Congenital vascular bone syndrome resulting in angio-osteo-hyper/hypotrophy and (lateral) marginal vein was separately reviewed. Background data on arterio-venous malformations was included to differentiate this anomaly from syndrome-based VMs. For the treatment, a new section on laser therapy and also a practical guideline for follow up assessment were added to strengthen the management principle of the multidisciplinary approach. All other therapeutic modalities were thoroughly updated to accommodate a changing concept through the years.

On "Renaissance" and "culture" and their Jewish applications : presitential address to the Union of Jewish Literary Societies by the Chief Rabbi, Monday, March 1st, 5675 - 1915 at University College, London

[Joseph Herman Hertz]

The voice of America on Kishineff

ed. by Cyrus Adler

The Jews in the making of America

by George Cohen