Automated end-to-side anastomosis to the middle cerebral artery: a feasibility study

The treatment of complex cerebrovascular or skull base pathological conditions necessitates a microsurgical blood flow preservation or augmentative revascularization procedure as either an adjunctive safety measure or a definitive treatment. The brain is susceptible to ischemia, and procedure-related risks can be minimized by the reduction of occlusion time or the use of a nonocclusive technique. The authors therefore analyzed the feasibility of an automatic device (C-Port xA, Cardica) designed for constructing an end-to-side anastomosis with or without flow interruption for a middle cerebral artery (MCA) bypass in a human cadaveric model and in an in vivo craniotomy simulation model.

Application of ultra high performance concrete (UHPC) as a thin-bonded overlay for concrete bridge decks

As transportation infrastructure across the globe approaches the end of its service life, new innovative materials and applications are needed to sustainably repair and prevent damage to these structures. Bridge structures in the United States in particular are at risk as a large percentage will be reaching their design service lives in the coming decades. Superstructure deterioration occurs due to a variety of factors, but a major contributor comes in the form of deteriorating concrete bridge decks. Within a concrete bridge deck system, deterioration mechanisms can include spalling, delaminations, scaling from unsuitable material selection, freeze-thaw damage, and corrosion of reinforcing steel due to infiltration of chloride ions and moisture. This thesis presents findings pertaining to the feasibility of using UHPC as a thin-bonded overlay on concrete bridge decks, specifically in precast bridge deck applications where construction duration and traffic interruption can be minimized, as well as in cast-in-place field applications. UHPC has several properties that make it a desirable material for this application. These properties include post-cracking tensile capacity, high compressive strength, high resistance to environmental and chemical attack, negligible permeability, negligible dry shrinkage when thermally cured, and the ability to self consolidate. The compatibility of this bridge deck overlay system was determined to minimize overlay thickness and dead load without sacrificing bond integrity or lose of protective capabilities. A parametric analysis was conducted using a 3D finite element model of a simply supported bridge under HS-20 truck and overload. Experimental tests were conducted to determine the net effect of UHPC volume change due to restrained shrinkage and tensile creep relaxation. The combined effects from numerical models and test results were then considered in determining the optimum overlay thickness for cast-in-place and precast applications.

Effects of Chemical Deicers on Amphibian Communites

Roads and highways present a unique challenge to wildlife as they exhibit substantial impacts on the surrounding ecosystem through the interruption of a number of ecological processes. With new roads added to the national highway system every year, an understanding of these impacts is required for effective mitigation of potential environmental impacts. A major contributor to these negative effects is the deposition of chemicals used in winter deicing activities to nearby surface waters. These chemicals often vary in composition and may affect freshwater species differently. The negative impacts of widespread deposition of sodium chloride (NaCl) have prompted a search for an `environmentally friendly' alternative. However, little research has investigated the potential environmental effects of widespread use of these alternatives. Herein, I detail the results of laboratory tests and field surveys designed to determine the impacts of road salt (NaCl) and other chemical deicers on amphibian communities in Michigan's Upper Peninsula. Using larval amphibians I demonstrate the lethal impacts of a suite of chemical deicers on this sensitive, freshwater species. Larval wood frogs (Lithobates sylvatica) were tolerant of short-term (96 hours) exposure to urea (CH4N2O), sodium chloride (NaCl), and magnesium chloride (MgCl2). However, these larvae were very sensitive to acetate products (C8H12CaMgO8, CH3COOK) and calcium chloride (CaCl2). These differences in tolerance suggest that certain deicers may be more harmful to amphibians than others. Secondly, I expanded this analysis to include an experiment designed to determine the sublethal effects of chronic exposure to environmentally realistic concentrations of NaCl on two unique amphibian species, L. sylvatica and green frogs (L. clamitans). L. sylvatica tend to breed in small, ephemeral wetlands and metamorphose within a single season. However, L. clamitans breed primarily in more permanent wetlands and often remain as tadpoles for one year or more. These species employ different life history strategies in this region which may influence their response to chronic NaCl exposure. Both species demonstrated potentially harmful effects on individual fitness. L. sylvatica larvae had a high incidence of edema suggesting the NaCl exposure was a significant physiologic stressor to these larvae. L. clamitans larvae reduced tail length during their exposure which may affect adult fitness of these individuals. In order to determine the risk local amphibians face when using these roadside pools, I conducted a survey of the spatial distribution of chloride in the three northernmost counties of Michigan. This area receives a relatively low amount of NaCl which is confined to state and federal highways. The chloride concentrations in this region were much lower than those in urban systems; however, amphibians breeding in the local area may encounter harmful chloride levels arising from temporal variations in hydroperiods. Spatial variation of chloride levels suggests the road-effect zone for amphibians may be as large as 1000 m from a salt-treated highway. Lastly, I performed an analysis of the use of specific conductance to predict chloride concentrations in natural surface water bodies. A number of studies have used this regression to predict chloride concentrations from measurements of specific conductance. This method is often chosen in the place of ion chromatography due to budget and time constraints. However, using a regression method to characterize this relationship does not result in accurate chloride ion concentration estimates.

A new surgical approach for exclusion of renal artery aneurysms avoiding organ ischemia

INTRODUCTION: Surgical treatment of renal artery aneurysms is inevitably associated with temporary renal artery occlusion and risk of ischemic injury. We present a technique for renal artery grafting and aneurysm exclusion without interrupting renal blood flow. REPORT: A symptomatic renal artery aneurysm was bypassed with a venous graft between the abdominal aorta and the very distal renal artery utilizing a distal anastomotic device without interruption of renal blood flow. The aneurysm was then excluded by means of hemostatic clips. CONCLUSION: The presented surgical technique offers the major advantage of avoiding organ ischemia and accelerating the surgical procedure.

Comparison of drug retention rates and causes of drug discontinuation between anti-tumor necrosis factor agents in rheumatoid arthritis

OBJECTIVE: Tumor necrosis factor (TNF) inhibitors have revolutionized the treatment of severe rheumatoid arthritis (RA), yet drug discontinuation is common. The aim of this study was to compare treatment retention rates and specific causes of anti-TNF discontinuation in a population-based RA cohort. METHODS: All patients treated with etanercept, infliximab, or adalimumab within the Swiss Clinical Quality Management RA cohort between 1997 and 2006 were included in the study. Causes of treatment discontinuation were broadly categorized as adverse events (AEs) or nontoxic causes, and further subdivided into specific categories. Specific causes of treatment interruption were analyzed using a Cox proportional hazards model and adjusted for potential confounders. RESULTS: A total of 2,364 anti-TNF treatment courses met the inclusion criteria. Treatment discontinuation was reported 803 times: 309 with etanercept, 249 with infliximab, and 245 with adalimumab. Drug inefficacy represented the largest single cause of treatment discontinuation (55.8% of cases). The median time of receiving anti-TNF therapy was 37 months, but discontinuation rates differed between the 3 anti-TNF agents (P < 0.001), with shorter retention rates for infliximab (hazard ratio [HR] 1.24, 99% confidence interval [99% CI] 1.01-1.51). The specific causes of treatment discontinuation revealed an increased risk of AEs with infliximab (HR 1.4, 99% CI 1.003-1.96), mostly due to an increased risk of infusion or allergic reactions (HR 2.11, 99% CI 1.23-3.62). Other discontinuation causes were equally distributed between the anti-TNF agents. CONCLUSION: In this population, infliximab was associated with higher overall discontinuation rates compared with etanercept and adalimumab, which is mainly due to an increased risk of infusion or allergic reactions.

Herman D. Stein

Herman Stein, President of the International Association of Schools of Social Work from 1968 - 1976, has for more than sixty years excelled as an educator, scholar, internationalist, university administrator, and leader in a variety of professional associations. From almost the beginning of his career, the world has been the stage on which he has played those many roles, all of them with an abundance of talent. In fact, while he was in the graduate program of what is now the Columbia University School of Social Work, he had to decide whether to become a social worker or an actor. As an undergraduate he became involved in student theatrical productions, where he teamed up with the famous comedian, Danny Kaye, who became a life-long companion and friend. At the end of Steins first year in the social work program, he was invited to join an off-Broadway variety show that helped to launch Kaye on his meteoric rise on both stage and screen. "If I´d joined," Stein has said, "the theater probably was going to be where I would make my career as a character actor." Fortunately for social work and social work education, he chose instead to continue his studies at the School of Social Work, from which he received his master's degree in 1941 and the doctoral degree in 1958. While the world has been his stage, education has been at the heart of his manifold activities. Following a period of direct service practice as a caseworker in a well-known private agency in New York City, he was recruited by the Columbia School of Social Work in 1945 as a faculty member. With an interruption for a significant overseas assignment from 1947 to 1950, he continued at Columbia for another fourteen years, rising through all professorial ranks to Professor and Director of the School's Research Center.

Ansätze zur Ermittlung und Reduktion nichtproduktiver Zeiten an Tiefbohranlagen

Aufgrund der hohen Kosten für Tiefbohrungen ist eine wirtschaftliche Stromerzeugung aus der tiefen Geothermie derzeit nur bedingt möglich. Da die Herstellkosten einer Tiefbohrung direkt von der Herstellzeit abhängig sind, wird eine Optimierung der nichtproduktiven Prozesse angestrebt. Vorrangig sind die Prozesse zu betrachten und zu optimieren, durch die eine Unterbrechung des Bohrens auftritt. Dies ist hauptsächlich beim Transport der Rohre zwischen Lager und Arbeitsplattform sowie bei den Verschraubungsprozessen der Rohre der Fall. Im Rahmen dieses Beitrags werden Konzepte zur Umgestaltung dieser Prozesse und Bewegungsabläufe an Tiefbohranlagen entwickelt und auf ihr zeitliches Einsparpotential untersucht.

Sonication: a valuable technique for diagnosis and treatment of periprosthetic joint infections

BACKGROUND Periprosthetic joint infection (PJI) is the most severe complication, following joint arthroplasty. Identification of the causal microbial factor is of paramount importance for the successful treatment. PURPOSE The aim of this study is to compare the sonication fluid cultures derived from joint prosthetic components with the respective periprosthetic tissue cultures. METHODS Explanted prosthesis components for suspected infection were placed into a tank containing sterile Ringer's solution and sonicated for 1 minute at 40 kHz. Sonication fluid cultures were examined for 10 days, and the number and identity of any colony morphology was recorded. In addition, periprosthetic tissue specimens (>5) were collected and cultured according to standard practice. The duration of antimicrobial interruption interval before culture sampling was recorded. RESULTS Thirty-four patients composed the study group. Sonication fluid cultures were positive in 24 patients (70.5%). Sixteen of thirty four periprosthetic tissue cultures (47.1%) were considered positive, all revealing the same microbial species with the respective sonication fluid cultures: 3 tissue samples showed polymicrobial infection. All tissue cultures were also found positive by the sonication fluid culture. CONCLUSIONS Sonication fluid cultures represent a cheap, easy, accurate, and sensitive diagnostic modality demonstrating increased sensitivity compared to periprosthetic tissue cultures (70.5 versus 47.1%).

Towards a Hybrid Method to Categorize Interruptions and Activities in Healthcare

Objective Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular and for improving healthcare quality and patient safety in general. Method The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. Results The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. Conclusions Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Interruptions in Workflow for RNs in a Level One Trauma Center

An understanding of interruptions in healthcare is important for the design, implementation, and evaluation of health information systems and for the management of clinical workflow and medical errors. The purpose of this study is to identify and classify the types of interruptions experienced by Emergency Department(ED) nurses working in a Level One Trauma Center. This was an observational field study of Registered Nurses (RNs) employed in a Level One Trauma Center using the shadowing method. Results of the study indicate that nurses were both recipients and initiators of interruptions. Telephones, pagers, and face-to-face conversations were the most common sources of interruptions. Unlike other industries, the healthcare community has not systematically studied interruptions in clinical settings to determine and weigh the necessity of the interruption against their sometimes negative results such as medical errors, decreased efficiency, and increased costs. Our study presented here is an initial step to understand the nature, causes, and effects of interruptions, thereby improving both the quality of healthcare and patient safety. We developed an ethnographic data collection technique and a data coding method for the capturing and analysis of interruptions. The interruption data we collected are systematic, comprehensive, and close to exhaustive. They confirmed the findings from earlier studies by other researchers that interruptions are frequent events in critical care and other healthcare settings. We are currently using these data to analyze the workflow dynamics of ED clinicians, to identify the bottlenecks of information flow, and to develop interventions to improve the efficiency of emergency care through the management of interruptions.

Towards a hybrid method to categorize interruptions and activities in healthcare.

OBJECTIVE: Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD: The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS: The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS: Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Interruptions in workflow for RNs in a Level One Trauma Center.

An understanding of interruptions in healthcare is important for the design, implementation, and evaluation of health information systems and for the management of clinical workflow and medical errors. The purpose of this study is to identify and classify the types of interruptions experienced by ED nurses working in a Level One Trauma Center. This was an observational field study of Registered Nurses employed in a Level One Trauma Center using the shadowing method. Results of the study indicate that nurses were both recipients and initiators of interruptions. Telephone, pagers, and face-to-face conversations were the most common sources of interruptions. Unlike other industries, the outcomes caused by interruptions resulting in medical errors, decreased efficiency and increased cost have not been systematically studied in healthcare. Our study presented here is an initial step to understand the nature, causes, and effects of interruptions, and to develop interventions to manage interruptions to improve healthcare quality and patient safety. We developed an ethnographic data collection technique and a data coding method for the capturing and analysis of interruptions. The interruption data we collected are systematic, comprehensive, and close to exhaustive. They confirmed the findings from early studies by other researchers that interruptions are frequent events in critical care and other healthcare settings. We are currently using these data to analyze the workflow dynamics of ED clinicians, identify the bottlenecks of information flow, and develop interventions to improve the efficiency of emergency care through the management of interruptions.

Dual Targeting of Tumor Angiogenesis and Chemotherapy by Endostatin- Cytosine Deaminase-Uracil PhosphoribosylTransferase

Antiangiogenesis is a promising anti-tumor strategy through inhibition tumor vascularformation to suppress tumor growth. Targeting specific VEGF/R has been showntherapeutic benefits in many cancer types and become a first approvedantiangiogenic modalities by Food and Drug Administration (FDA) in United States.However, interruption of homeostasis in normal tissues that is likely due to theinhibition of VEGF/R signaling pathway induces unfavorable side effects. Moreover,cytostatic nature of antiangiogenic drugs frequently causes less tumor cell specifickilling activity, and cancer cells escaped from cell death induced by these drugseven gain more malignant phenotypes, resulting in tumor invasion and metastasis.To overcome these issues, we developed a novel anti-tumor therapeutic EndoCDfusion protein which linked endostatin (Endo) to cytosine deaminase-uracilvphosphoribosyl transferase (CD). Endo targets unique tumor endothelial cells toprovide tumor-specific antiangiogenesis activity and also carries CD to the localtumor area, where it serves nontoxic prodrug 5-fluorocytosine (5-FC) enzymaticconversion reaction to anti-metabolite chemotherapy drug 5-fluorouracil (5-FU). Wedemonstrated that 5-FU concentration was highly increased in tumor sites, resultingin high level of endothelial cells and tumor cells cytotoxic efficacy. Furthermore,EndoCD/5-FC therapy decreased tumor growth and colorectal liver metastasisincident compared with bevacizumab/5-FU treatment in human breast and colorectalliver metastasis orthotropic animal models. In cardiotoxicity safety profile,EndoCD/5-FC is a contrast to bevacizumab/5-FU; lower risk of cardiotoxicityinduction or heart function failure was found in EndoCD/5-FC treatment thanbevacizumab/5-FU does in mice. EndoCD/5-FC showed more potent therapeuticefficacy with high safety profile and provided stronger tumor invasion or metastasisinhibition than antiangiogenic drugs. Together, EndoCD fusion protein with 5-FCshowed dual tumor targeting activities including antiangiogenesis and tumor localchemotherapy, and it could serve as an alternative option for antiangiogenic therapy.

Pathophysiologie des Schmerzes und Neuraltherapie

Die Neuraltherapie nach Huneke ist eine Injektionsbehandlung, welche Lokalanästhetika zur Diagnostik und Therapie einsetzt. Je nach Situation erfolgt der Reiz (und/oder die Unterbrechung einer pathologischen Belastung) im Bereiche der Segmentreflektorik oder über das sogenannte Störfeld. Dieses kann ausserhalb jeder segmentalen Ordnung eine Erkrankung oder ein Schmerzbild auslösen und unterhalten. Mit der Neuraltherapie werden gezielt autoregulatorische Mechanismen des Vegetativums (insbesondere des Sympathikus) angesprochen. Theoretische Grundlagen hierzu sind Erkenntnisse aus der Neurophysiologie und der Modernen Physik.

Regorafenib as second-line therapy for intermediate or advanced hepatocellular carcinoma: Multicentre, open-label, phase II safety study

PURPOSE: We assessed the safety of the multikinase inhibitor regorafenib in patients with hepatocellular carcinoma (HCC) that had progressed following first-line sorafenib. PATIENTS AND METHODS: Thirty-six patients with Barcelona Clinic Liver Cancer stage B or C HCC and preserved to mildly impaired liver function (Child-Pugh class A) received regorafenib 160 mg once daily in cycles of 3 weeks on/1 week off treatment until disease progression, unacceptable toxicity, death or patient/physician decision to discontinue. The primary end-point was safety; secondary end-points included efficacy (including time to progression and overall survival). RESULTS: The median treatment duration was 19.5 weeks (range 2-103). At data cutoff, three patients remained on treatment. Reasons for discontinuation were adverse events (n=20), disease progression (n=10), consent withdrawal (n=2) and death (n=1). Seventeen patients required dose reductions (mostly for adverse events [n=15]); 35 patients had treatment interruption (mostly for adverse events [n=32] or patient error [n=11]). The most frequent treatment-related adverse events were hand-foot skin reaction (any grade n=19; grade ≥3 n=5), diarrhoea (n=19; n=2), fatigue (n=19; n=6), hypothyroidism (n=15; n=0), anorexia (n=13; n=0), hypertension (n=13; n=1), nausea (n=12; n=0) and voice changes (n=10; n=0). Disease control was achieved in 26 patients (partial response n=1; stable disease n=25). Median time to progression was 4.3 months. Median overall survival was 13.8 months. CONCLUSION: Regorafenib had acceptable tolerability and evidence of antitumour activity in patients with intermediate or advanced HCC that progressed following first-line sorafenib.