PFO closure vs. medical therapy in cryptogenic stroke or transient ischemic attack: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: This study aims to assess whether patent foramen ovale (PFO) closure is superior to medical therapy in preventing recurrence of cryptogenic ischemic stroke or transient ischemic attack (TIA). METHODS: We searched PubMed for randomized trials which compared PFO closure with medical therapy in cryptogenic stroke/TIA using the items: "stroke or cerebrovascular accident or TIA" and "patent foramen ovale or paradoxical embolism" and "trial or study". RESULTS: Among 650 potentially eligible articles, 3 were included including 2303 patients. There was no statistically significant difference between PFO-closure and medical therapy in ischemic stroke recurrence (1.91% vs. 2.94% respectively, OR: 0.64, 95%CI: 0.37-1.10), TIA (2.08% vs. 2.42% respectively, OR: 0.87, 95%CI: 0.50-1.51) and death (0.60% vs. 0.86% respectively, OR: 0.71, 95%CI: 0.28-1.82). In subgroup analysis, there was significant reduction of ischemic strokes in the AMPLATZER PFO Occluder arm vs. medical therapy (1.4% vs. 3.04% respectively, OR: 0.46, 95%CI: 0.21-0.98, relative-risk-reduction: 53.2%, absolute-risk-reduction: 1.6%, number-needed-to-treat: 61.8) but not in the STARFlex device (2.7% vs. 2.8% with medical therapy, OR: 0.93, 95%CI: 0.45-2.11). Compared to medical therapy, the number of patients with new-onset atrial fibrillation (AF) was similar in the AMPLATZER PFO Occluder arm (0.72% vs. 1.28% respectively, OR: 1.81, 95%CI: 0.60-5.42) but higher in the STARFlex device (0.64% vs. 5.14% respectively, OR: 8.30, 95%CI: 2.47-27.84). CONCLUSIONS: This meta-analysis does not support PFO closure for secondary prevention with unselected devices in cryptogenic stroke/TIA. In subgroup analysis, selected closure devices may be superior to medical therapy without increasing the risk of new-onset AF, however. This observation should be confirmed in further trials using inclusion criteria for patients with high likelihood of PFO-related stroke recurrence.

Wound infection after excision and primary midline closure for pilonidal disease: risk factor analysis to improve patient selection.

BACKGROUND: Excision and primary midline closure for pilonidal disease (PD) is a simple procedure; however, it is frequently complicated by infection and prolonged healing. The aim of this study was to analyze risk factors for surgical site infection (SSI) in this context. METHODS: All consecutive patients undergoing excision and primary closure for PD from January 2002 through October 2008 were retrospectively assessed. The end points were SSI, as defined by the Center for Disease Control, and time to healing. Univariable and multivariable risk factor analyses were performed. RESULTS: One hundred thirty-one patients were included [97 men (74%), median age = 24 (range 15-66) years]. SSI occurred in 41 (31%) patients. Median time to healing was 20 days (range 12-76) in patients without SSI and 62 days (range 20-176) in patients with SSI (P < 0.0001). In univariable and multivariable analyses, smoking [OR = 2.6 (95% CI 1.02, 6.8), P = 0.046] and lack of antibiotic prophylaxis [OR = 5.6 (95% CI 2.5, 14.3), P = 0.001] were significant predictors for SSI. Adjusted for SSI, age over 25 was a significant predictor of prolonged healing. CONCLUSION: This study suggests that the rate of SSI after excision and primary closure of PD is higher in smokers and could be reduced by antibiotic prophylaxis. SSI significantly prolongs healing time, particularly in patients over 25 years.

Use of a ventricular septal defect occluder for apical closure in transapical aortic valve replacement.

During transapical transcatheter aortic valve replacement (TA-TAVR), the apical closure remains a challenge for the surgeon, having the risk for ventricular tear and massive bleeding. Apical closure devices are already under clinical evaluation, but only a few can lead to a full percutaneous TA-TAVR. We describe the successful use of a 9-mm myocardial occluder (ventricular septal defect occluder) that was used to seal the apex after a standard TA-TAVR (using the Sapien XT 23-mm transcatheter valve and the Ascendra + delivery system). The placement of the nonmodified myocardial occluder was performed through the Ascendra + delivery system, with a very small amount of blood loss and an acceptable sealing of the apical tear. This approach is feasible and represents a further step toward true-percutaneous transapical heart valve procedures. Modified apical occluders are under evaluation in animal models.

Apical access and closure devices for transapical transcatheter heart valve procedures.

The majority of transcatheter aortic valve implantations, structural heart procedures and the newly developed transcatheter mitral valve repair and replacement are traditionally performed either through a transfemoral or a transapical access site, depending on the presence of severe peripheral vascular disease or anatomic limitations. The transapical approach, which carries specific advantages related to its antegrade nature and the short distance between the introduction site and the cardiac target, is traditionally performed through a left anterolateral mini-thoracotomy and requires rib retractors, soft tissue retractors and reinforced apical sutures to secure, at first, the left ventricular apex for the introduction of the stent-valve delivery systems and then to seal the access site at the end of the procedure. However, despite the advent of low-profile apical sheaths and newly designed delivery systems, the apical approach represents a challenge for the surgeon, as it has the risk of apical tear, life-threatening apical bleeding, myocardial damage, coronary damage and infections. Last but not least, the use of large-calibre stent-valve delivery systems and devices through standard mini-thoracotomies compromises any attempt to perform transapical transcatheter structural heart procedures entirely percutaneously, as happens with the transfemoral access site, or via a thoracoscopic or a miniaturised video-assisted percutaneous technique. During the past few years, prototypes of apical access and closure devices for transapical heart valve procedures have been developed and tested to make this standardised successful procedure easier. Some of them represent an important step towards the development of truly percutaneous transcatheter transapical heart valve procedures in the clinical setting.

The application of the structural correlation method to determine the reaction coordinate for a putative ring closure reaction

The cr ystal structure of the compound 2-benzoylethylidene-3-(2,4- dibromophenyl)-2,3-dihydro-5-phenyl-l,3,4-thiadiazole* C23H16Br2NZOS (BRMEO) has been determined by using three dimensiona l x-ray diffraction data. The crys tal form is monoclinic, space group P21/c, a = 17.492(4), o -.t' 0 R 0 b =: 16.979(1), c = 14.962(1) A, "X. =o= 90 ',= 106.46(1) , z = 8, graphite-monochromatized Mo~ rad iation, Jl= 0.710J3~, D = 1.62g/cc and o D = 1.65g/cc. The data were col lected on ~ Nonius CAD-4 c diffractometer. The following atoms were made anisotropic: Br, S, N, 0, C7, and C14-C16 for each i ndependent molecu le ; the rest were left isotropic. For 3112 independent refl ec tions with F > 6G\F), R == 0.057. The compound has two independent molecules within the asymmetric unit. Two different conformers were observed which pack well together. /l The S---O interaction distances of 2.493(6) and 2 . 478(7) A were observed for molecules A and B respectively. These values are consistent with earlier findings for 2-benzoylmethylene-3-(2,4-dibromophenyl)- ~~ 2,3-dihydro-5-phenyl-l,3,4-thiadiazole C22H14Br2N20S (BRPHO) and 2-benzoylpropylidene-3-(2,4-dibromophenyl)-2,3-dihydroiii ,'r 5-phenyl-l,3,4-thiadiazole C24H18Br2N20S (BRPETO ) where S---O distances are l ess than the van der Waals (3.251\) but greater than those expected for () a single bond (1.50A). From the results and the literature it appears obvious that the energy/reaction coordinate pathway has a minimum between the end structures (the mono- and bicyclic compounds). * See reference (21) for nomenclature.

The relationship between stem-form, stand-closure and site -conditions : the influence of environmental conditions on tree allometry and forest structure in west-central Alberta

Changes in the configuration of a tree stern result insignificant differences in its total volume and in the proportion of that volume that is merchantable timber. Tree allometry, as represented by stem-fo~, is the result of the vertical force of gravity and the horizontal force of wind. The effect of wind force is demonstrated in the relationship between stem-form, standclosure and site-conditions. An increase in wind force on the individual tree due to a decrease in stand density should produce a more tapered tree. The density of the stand is determined by the conditions that the trees are growing under. The ability of the tree to respond to increased wind force may also be a function of these conditions . This stem-form/stand-closure/site-conditions relationship was examined using a pre-existing database from westcentral Alberta. This database consisted of environmental, vegetation, soils and timber data covering a wide range of sites. There were 653 sample trees with 82 variables that formed the basis of the analysis. There were eight tree species consisting of Pinus contorta, Picea mariana, Picea engelmannii x glauca, Abies lasiocarpa, Larix laricina, Populus tremuloides, Betula papyrifera and Populus balsamifera plus a comprehensive all-species data set. As the actual conformation of the stern is very individual, stem-fo~was represented by the diameter at breast height to total height r~tio. The four stand-closure variables, crown closure, total basal area, total volume and total number of stems were reduced to total basal area and total number of stems utilizing a bivariate correlation matrix by species. Site-conditions were subdivided into macro, meso and micro variables and reduced in number 3 using cross-tabulations, bivariate correlation and principal components analysis as screening tools. The stem-fo~/stand-closure relationship was examined using bivariate correlation coefficients for stem-fo~ with total number of stems and stem-fo~ with total basal area. The stem-fo~/site-conditions and the stand-closure/site- conditions relationships were examined using multiple correlation coefficients. The stem-form/stand-closure/site-conditions relationship was examined using multiple correlation coefficients in separate analyses for both total number of stems and total basal area. An increase in stand-closure produced a decrease in stem-form for both total number of stems and total basal area for most species. There was a significant relationship between stem-form and site-conditions and between stand-closure and site-conditions for both total number of stems and total basal area for most species. There was a significant relationship between the stemform and site-conditions, including the stand-closure, for most species; total number of stems was involved independently of the site-conditions in the prediction of stem-form and total basal area was not. Larix laricina and Betula papyrifera were the exceptions to the trends observed with most species. The influence of both stand-closure (total number of stems in particular) and site-conditions (elevation in particular) suggest that forest management practices should include these- ecological parameters in determining appropriate restocking levels.

Cognitive set, absorption, and achievement as moderators of the perceptual closure effect in picture priming /

The present study examined individual differences in Absorption and fantasy, as well as in Achiievement and achievement striving as possible moderators of the perceptual closure effect found by Snodgrass and Feenan (1990). The study also examined whether different instructions (experiential versus instrumental) interact with the personality variables to moderate the relationship between priming and subsequent performance on a picture completion task. 1 28 participants completed two sessions, one to fill out the MPQ and NEO personality inventories and the other to complete the experimental task. The experimental task consisted of a priming phase and a test phase, with pictures presented on a computer screen for both phases. Participants were shown 30 pictures in the priming phase, and then shovm the 30 primed pictures along with 30 new pictures for the test phase. Participants were randomly assigned to receive one of the two different instruction sets for the task. Two measures of performance were calculated, most fragmented measure and threshold. Results of the present study confirm that a five-second exposure time is long enough to produce the perceptual closure effect. The analysis of the two-way interaction effects indicated a significant quadratic interaction of Absorption with priming level on threshold performance. The results were in the opposite direction of predictions. Possible explanations for the Absorption results include lack of optimal conditions, lack of intrinsic motivation and measurement problems. Primary analyses also revealed two significant between-subject effects of fantasy and achievement striving on performance collapsed across priming levels. These results suggest that fantasy has a beneficial effect on performance at test for pictures primed at all levels, whereas achievement striving seems to have an adverse effect on performance at test for pictures primed at all levels. Results of the secondary analyses with a revised threshold performance measure indicated a significant quadratic interaction of Absorption, condition and priming level. In the experiential condition, test performance, based on Absorption scores for pictures primed at level 4, showed a positive slope and performance for pictures primed at levels 1 and 7 based on Absorption showed a negative slope. The reverse effect was found in the instrumental condition. The results suggest that Absorption, in combination with experiential involvement, may affect implicit memory. A second significant result of the secondary analyses was a linear three-way interaction of Achievement, condition and priming level on performance. Results suggest that as Achievement scores increased, test performance improved for less fragmented primed pictures in the instrumental condition and test performance improved for more highly fragmented primes in the experiential condition. Results from the secondary analyses suggest that the revised threshold measure may be more sensitive to individual differences. Results of the exploratory analyses with Openness to Experience, Conscientiousness and agentic positive emotionality (PEM-A) measures indicated no significant effects of any of these personality variables. Results suggest that facets of the scales may be more useful with regard to perceptual research, and that future research should examine narrowly focused personality traits as opposed to broader constructs.

The impact of wine closure and packaging type, and light and temperature exposure on the concentration of 3-alkyl-2 -methoxypyrazines and other key constituents of wine

3-alkyl-2-methoxypyrazines (MPs) are grape- and insect-derived odor-active compounds responsible for vegetative percepts that are detrimental to wine quality when elevated. This study tested both the effect of closure/packaging types and light/temperature storage conditions on MPs (isopropyl-, secbutyl-, and isobutyl-MP) in wine. An MP-emiched wine rapidly (after 140 hours) and significantly decreased in MP concentration after natural and synthetic cork contact (immersion of closures in wine). This decrease was greatest with synthetic closures (70% - 89% reduction) and secbutyl-MP. Subsequently storage trials tested the effects of commercial closure/packaging options (natural cork, agglomerate cork, synthetic corks, screwcaps and TetraPak® cartons) on MPs in MP-emiched Riesling and Cabernet Franc over 18 months. Regardless of packaging, isobutyl-MP was the most altered from bottling. Notably, all MP levels tended to decrease to the greatest extent in TetraPak® cartons (~34% for all MPs) and there was evidence of contribution ofisoproyl- and secbutyl-MP from cork-based closures (i.e. ~30% increase in secbutyl-MP after 6 months) or from an unidentified wine constituent. To test the effects of various light/temperature conditions (light exposed at ambient temperature in three different bottle hues, light excluded at ambient temperature and light excluded at a "cellar" temperature (14°C)), MP-emiched Riesling and Cabernet Franc were also analyzed for MP concentrations over 12 months. MPs did not vary consistently with light or temperature. Other odorants and physico-chemical properties were tested in all wines during storage trials and closely agree with previous literature. These results provide novel insights into MPs during ageing, interactions with packaging and storage conditions, and assist in the selection of storage conditions/packaging for optimal wine quality.

Wage Flexibility and Contract Structure in Germany

In this paper, we look at how labor market conditions at different points during the tenure of individuals with firms are correlated with current earnings. Using data on individuals from the German Socioeconomic Panel for the 1985-1994 period, we find that both the contemporaneous unemployment rate and prior values of the unemployment rate are significantly correlated with current earnings, contrary to results for the American labor market. Estimated elasticities vary between 9 and 15 percent for the elasticity of earnings with respect to current unemployment rates, and between 6 and 10 percent with respect to unemployment rates at the start of current firm tenure. Moreover, whereas local unemployment rates determine levels of earnings, national rates influence contemporaneous variations in earnings. We interpret this result as evidence that German unions do, in fact, bargain over wages and employment, but that models of individualistic contracts, such as the implicit contract model, may explain some of the observed wage drift and longer-term wage movements reasonably well. Furthermore, we explore the heterogeneity of contracts over a variety of worker and job characteristics. In particular, we find evidence that contracts differ across firm size and worker type. Workers of large firms are remarkably more insulated from the job market than workers for any other type of firm, indicating the importance of internal job markets.

A Study of Closure and Fuzzy Closure Spaces with Reference to H-Closedness and Convexity

Department of Mathematics, Cochin University of Science and Technology.

Closure of the Monte Carlo dynamical equation in the spherical Sherrington-Kirkpatrick model

We study the analytical solution of the Monte Carlo dynamics in the spherical Sherrington-Kirkpatrick model using the technique of the generating function. Explicit solutions for one-time observables (like the energy) and two-time observables (like the correlation and response function) are obtained. We show that the crucial quantity which governs the dynamics is the acceptance rate. At zero temperature, an adiabatic approximation reveals that the relaxational behavior of the model corresponds to that of a single harmonic oscillator with an effective renormalized mass.

Operational Flexibility: A Model for Effective Project Management

The aim of this study is to investigate the role of operational flexibility for effective project management in the construction industry. The specific objectives are to: a) Identify the determinants of operational flexibility potential in construction project management b) Investigate the contribution of each of the determinants to operational flexibility potential in the construction industry c) Investigate on the moderating factors of operational flexibility potential in a construction project environment d) Investigate whether moderated operational flexibility potential mediates the path between predictors and effective construction project management e) Develop and test a conceptual model of achieving operational flexibility for effective project management The purpose of this study is to findout ways to utilize flexibility inorder to manage uncertain project environment and ultimately achieve effective project management. In what configuration these operational flexibility determinants are demanded by construction project environment in order to achieve project success. This research was conducted in three phases, namely: (i) exploratory phase (ii) questionnaire development phase; and (iii) data collection and analysis phase. The study needs firm level analysis and therefore real estate developers who are members of CREDAI, Kerala Chapter were considered. This study provides a framework on the functioning of operational flexibility, offering guidance to researchers and practitioners for discovering means to gain operational flexibility in construction firms. The findings provide an empirical understanding on kinds of resources and capabilities a construction firm must accumulate to respond flexibly to the changing project environment offering practitioners insights into practices that build firms operational flexibility potential. Firms are dealing with complex, continuous changing and uncertain environments due trends of globalization, technical changes and innovations and changes in the customers’ needs and expectations. To cope with the increasingly uncertain and quickly changing environment firms strive for flexibility. To achieve the level of flexibility that adds value to the customers, firms should look to flexibility from a day to day operational perspective. Each dimension of operational flexibility is derived from competences and capabilities. In this thesis only the influence on customer satisfaction and learning exploitation of flexibility dimensions which directly add value in the customers eyes are studied to answer the followingresearch questions: “What is the impact of operational flexibility on customer satisfaction?.” What are the predictors of operational flexibility in construction industry? .These questions can only be answered after answering the questions like “Why do firms need operational flexibility?” and “how can firms achieve operational flexibility?” in the context of the construction industry. The need for construction firms to be flexible, via the effective utilization of organizational resources and capabilities for improved responsiveness, is important because of the increasing rate of changes in the business environment within which they operate. Achieving operational flexibility is also important because it has a significant correlation with a project effectiveness and hence a firm’s turnover. It is essential for academics and practitioners to recognize that the attainment of operational flexibility involves different types namely: (i) Modification (ii) new product development and (iii) demand management requires different configurations of predictors (i.e., resources, capabilities and strategies). Construction firms should consider these relationships and implement appropriate management practices for developing and configuring the right kind of resources, capabilities and strategies towards achieving different operational flexibility types.

Type 2 diabetes; elderly; cognitive deficit; cognitive flexibility; executive functions Resumen

Through meditation, people become aware of what happens in the body and mind, accepting the present experiences as they are and getting a better understanding of the true nature of things. Meditation practices and its inclusion as an intervention technique, have generated great interest in identifying the brain mechanisms through which these practices operate. Different studies suggest that the practice of meditation is associated with the use of different neural networks as well as changes in brain structure and function, represented in higher concentration of gray matter structures at the hippocampus, the right anterior insula, orbital frontal cortex (OFC) and greater involvement of the anterior cingulate cortex (ACC). These and other unrelated studies, shows the multiple implications of the regular practice of mindfulness in the structures and functions of the brain and its relation to certain observable and subjective states in people who practice it. Such evidence enabling the inclusion of mindfulness in psychological therapy where multiple applications have been developed to prove its effectiveness in treating affective and emotional problems, crisis management, social skills, verbal creativity, addiction and craving management, family and caregivers stress of dementia patients and others. However, neuropsychological rehabilitation has no formal proposals for intervention from these findings. The aim of this paper is to propose use of Mindfulness in neuropsychological rehabilitation process, taking the positions and theory of A.R. Luria.