Telementoring during endovascular treatment of abdominal aortic aneurysms: a prospective study.

PURPOSE: To explore the use of telementoring for distant teaching and training in endovascular aortic aneurysm repair (EVAR). METHODS: According to a prospectively designed study protocol, 48 patients underwent EVAR: the first 12 patients (group A) were treated at a secondary care center by an experienced interventionist, who was training the local team; a further 12 patients (group B) were operated by the local team at their secondary center with telementoring by the experienced operator from an adjacent suite; and the last 24 patients (group C) were operated by the local team with remote telementoring support from the experienced interventionist at a tertiary care center. Telementoring was performed using 3 video sources; images were transmitted using 4 ISDN lines. EVAR was performed using intravascular ultrasound and simultaneous fluoroscopy to obtain road mapping of the abdominal aorta and its branches, as well as for identifying the origins of the renal arteries, assessing the aortic neck, and monitoring the attachment of the stent-graft proximally and distally. RESULTS: Average duration of telementoring was 2.1 hours during the first 12 patients (group B) and 1.2 hours for the remaining 24 patients (group C). There was no difference in procedural duration (127+/-59 minutes in group A, 120+/-4 minutes in group B, and 119+/-39 minutes in group C; p=0.94) or the mean time spent in the ICU (26+/-15 hours in group A, 22+/-2 hours in group B, and 22+/-11 hours for group C; p=0.95). The length of hospital stay (11+/-4 days in group A, 9+/-4 days in group B, and 7+/-1 days in group C; p=0.002) was significantly different only for group C versus A (p=0.002). Only 1 (8.3%) patient (in group A: EVAR performed by the experienced operator) required conversion to open surgery because of iliac artery rupture. This was the only conversion (and the only death) in the entire study group (1/12 in group A versus 0/36 in groups B + C, p=0.31). CONCLUSIONS: Telementoring for EVAR is feasible and shows promising results. It may serve as a model for development of similar projects for teaching other invasive procedures in cardiovascular medicine.

Yhdyskuntajätevesien yhteispuhdistus sellu- ja paperitehtaan aktiivilietelaitoksessa

Työn tavoitteena on ollutselvittää kustannukset, joita syntyy, jos Kuusankosken kaupungin puhdistamolta johdetaan jätevedet UPM-Kymmene Oyj:n Kymin aktiivilietelaitokselle puhdistettaviksi, ja kustannukset, joita aiheutuu kaupungin puhdistamon laajentamisesta typenpoistoon sopivaksi sekä verrata näiden hankkeiden kustannuksia. Työssä selvitetään myös muutokset, joita yhteispuhdistukseen siirtymisestä aiheutuu Kymin aktiivilietelaitokselle ja miten jätevesikuormitus Kymijokeen muuttuu. Lisäksi työssäon tarkasteltu yhdyskuntajätevedenpuhdistamoilta tuotujen lietteiden vaikutustaKymin aktiivilietelaitoksen toimintaan ja luotu katsaus käytössä olevien metsäteollisuusyritysten ja kaupunkien yhteispuhdistamojen toimintaan Raumalla ja Grand Rapids:ssa. Yhdyskuntajätevesien yhteispuhdistuksesta sellu- ja paperitehtaan aktiivilietelaitoksessa on saatu hyviä kokemuksia Raumalta. Kokonaistyppikuormitus Rauman merialueelle on puolittunut ja lisäksi fosfori- ja BOD-kuormitukset ovat vähentyneet. Ravinteiden tarve puhdistamolla on kuitenkin ennakoitua suurempija ravinteiden kulutusta voidaan selittää monella tekijällä mm. lämpötilan laskulla ja lietekuorman lisääntymisellä. Kymin puhdistamolle on tuotu Akanojan puhdistamon ylijäämäliete vuodesta 1996 lähtien. Vuoden 2004 marras- ja joulukuussa suoritetussa kokeilussa Kymin puhdistamolle tuotiin Akanojan lietteiden lisäksi osa Kouvolan puhdistamolla syntyneistä lietteistä. Kokeilun perusteella voidaan todeta, että yhdyskuntajätevesilietteiden tuonnilla voidaan korvata puhdistamolla tarvittavia ravinteita. Uusi jätteenpolttodirektiivi tuskin aiheuttanee ongelmia poltettaessa voimalaitoksella ylijäämälietettä, joka sisältää myös yhdyskuntajätevesistä peräisin olevaa lietettä. Kymin aktiivilietelaitoksen lämpötila tulee laskemaan yhteispuhdistukseen siirryttäessä viileiden yhdyskuntajätevesien vaikutuksesta. Yhteispuhdistustilanteessa Kuusankosken keskustan jokialueen bakteeritilanteeseen ei ole todennäköisesti tulossa muutosta, mutta virustilanteen muuttuminen voi olla mahdollista. Yhteispuhdistukseen siirryttäessä Kymin puhdistamon kapasiteettia tarvitsee kasvattaa ainoastaan jälkiselkeytyksen suhteen. Yhteispuhdistustilanteessa jätevesikuormitus Kymijokeen tulee pienenemään erityisesti typen osalta ja myös BOD- ja fosforikuormat pienenevät. COD-kuormitus pysyy lähes ennallaan ja kiintoainekuorma saattaa lisääntyä hiukan. Yhteispuhdistustilanteessa Kymijokeen aiheutuu jätevesikuormitusta myös ohituksista, kun yhdyskuntajätevesimäärä ylittää hetkellisesti esimerkiksi rankkasateen sattuessa mitoitusvirtaamansa arvon. Investointikustannukseksi, Kuusankosken kaupungin puhdistamon muuttamisesta typenpoistoon sopivaksi, arvioitiin mitoitusvirtaamasta riippuen 3 210 000 ¤ tai 2 460 000 ¤. Yhteispuhdistukseen siirtyminen aiheuttaa kaupungille n. 3 755 000 ¤ investointikustannuksen ja Kymin puhdistamolle n. 365 000 ¤. Investointikustannuksiltaan yhteispuhdistukseen siirtyminen tulee kaupungille kalliimmaksi mutta pitkällä aikavälillä tarkasteltuna edullisempi vaihtoehto Kuusankosken kaupungin kannalta on siirtyminen yhteispuhdistukseen.

Vorapaxar in the secondary prevention of atherothrombotic events.

BACKGROUND: Thrombin potently activates platelets through the protease-activated receptor PAR-1. Vorapaxar is a novel antiplatelet agent that selectively inhibits the cellular actions of thrombin through antagonism of PAR-1. METHODS: We randomly assigned 26,449 patients who had a history of myocardial infarction, ischemic stroke, or peripheral arterial disease to receive vorapaxar (2.5 mg daily) or matching placebo and followed them for a median of 30 months. The primary efficacy end point was the composite of death from cardiovascular causes, myocardial infarction, or stroke. After 2 years, the data and safety monitoring board recommended discontinuation of the study treatment in patients with a history of stroke owing to the risk of intracranial hemorrhage. RESULTS: At 3 years, the primary end point had occurred in 1028 patients (9.3%) in the vorapaxar group and in 1176 patients (10.5%) in the placebo group (hazard ratio for the vorapaxar group, 0.87; 95% confidence interval [CI], 0.80 to 0.94; P<0.001). Cardiovascular death, myocardial infarction, stroke, or recurrent ischemia leading to revascularization occurred in 1259 patients (11.2%) in the vorapaxar group and 1417 patients (12.4%) in the placebo group (hazard ratio, 0.88; 95% CI, 0.82 to 0.95; P=0.001). Moderate or severe bleeding occurred in 4.2% of patients who received vorapaxar and 2.5% of those who received placebo (hazard ratio, 1.66; 95% CI, 1.43 to 1.93; P<0.001). There was an increase in the rate of intracranial hemorrhage in the vorapaxar group (1.0%, vs. 0.5% in the placebo group; P<0.001). CONCLUSIONS: Inhibition of PAR-1 with vorapaxar reduced the risk of cardiovascular death or ischemic events in patients with stable atherosclerosis who were receiving standard therapy. However, it increased the risk of moderate or severe bleeding, including intracranial hemorrhage. (Funded by Merck; TRA 2P-TIMI 50 ClinicalTrials.gov number, NCT00526474.).

The Role of Information in Contemporary Migration. More Sources but Less Informed

La migració internacional contemporània és integrada en un procés d'interconnexió global definit per les revolucions del transport i de les tecnologies de la informació i la comunicació. Una de les conseqüències d'aquesta interconnexió global és que les persones migrants tenen més capacitat per a processar informació tant abans com després de marxar. Aquests canvis podrien tenir implicacions inesperades per a la migració contemporània pel que fa a la capacitat de les persones migrants per a prendre decisions més informades, la reducció de la incertesa en contextos migratoris, el desdibuixament del concepte de distància o la decisió d'emigrar cap a llocs més llunyans. Aquesta recerca és important, ja que la manca de coneixement sobre aquesta qüestió podria contribuir a fer augmentar la distància entre els objectius de les polítiques de migració i els seus resultats. El paper que tenen els agents de la informació en els contextos migratoris també podria canviar. En aquest escenari, perquè les polítiques de migració siguin més efectives, s'haurà de tenir en compte la major capacitat de la població migrant de processar la informació i les fonts d'informació en què es confia. Aquest article demostra que l'equació més informació equival a més ben informat no es compleix sempre. Fins i tot en l'era de la informació, les fonts no fiables, les expectatives falses, la sobreinformació i els rumors encara són presents en els contextos migratoris. Tanmateix, defensem l'argument que aquests efectes no volguts es podrien reduir complint quatre requisits de la informació fiable: que sigui exhaustiva, que sigui rellevant, que s'hi confiï i que sigui actualitzada.

Independent sources of condition dependency and multiple pathways determine a composite trait: lessons from carotenoid-based plumage colouration.

Many colour ornaments are composite traits consisting of at least four components, which themselves may be more complex, determined by independent evolutionary pathways, and potentially being under different environmental control. To date, little evidence exists that several different components of colour elaboration are condition dependent and no direct evidence exists that different ornamental components are affected by different sources of variation. For example, in carotenoid-based plumage colouration, one of the best-known condition-dependent ornaments, colour elaboration stems from both condition-dependent pigment concentration and structural components. Some environmental flexibility of these components has been suggested, but specifically which and how they are affected remains unknown. Here, we tested whether multiple colour components may be condition dependent, by using a comprehensive 3 × 2 experimental design, in which we carotenoid supplemented and immune challenged great tit nestlings (Parus major) and quantified effects on different components of colouration. Plumage colouration was affected by an interaction between carotenoid availability and immune challenge. Path analyses showed that carotenoid supplementation increased plumage saturation via feather carotenoid concentration and via mechanisms unrelated to carotenoid deposition, while immune challenge affected feather length, but not carotenoid concentration. Thus, independent condition-dependent pathways, affected by different sources of variation, determine colour elaboration. This provides opportunities for the evolution of multiple signals within components of ornamental traits. This finding indicates that the selective forces shaping the evolution of different components of a composite trait and the trait's signal content may be more complex than believed so far, and that holistic approaches are required for drawing comprehensive evolutionary conclusions.

Chiasmatic infiltration secondary to late malignant transformation of retinoma.

PURPOSE: To report the lethal course of malignant transformation of retinoma in an adult. METHODS: Case report. A 40-year-old patient presented with retinoma in his right eye and retinoblastoma in his left eye. Enucleation was recommended but refused and the patient received whole eye radiotherapy elsewhere. Five years later he presented again, with temporal hemianopsia of the left eye secondary to chiasmatic invasion. RESULTS: Diagnosis of retinoblastoma infiltration was confirmed by stereotactic biopsy of the chiasmatic lesion. Treatment with intravenous and intrathecal chemotherapy led to partial remission, and was followed by stereotactic irradiation of the chiasmatic mass and right optic nerve. The left eye was enucleated. Death occurred one year later due to cerebrospinal fluid metastases. CONCLUSION: Extraocular extension of retinoblastoma diagnosed in adulthood has never, to our knowledge, been reported. This case stresses the importance of lifelong retinoma monitoring and the necessity for radical treatment in the event of malignant transformation.

The Effect of Switching Ranibizumab to Aflibercept in Refractory Cases of Macular Edema Secondary to Ischemic Central Vein Occlusion.

Background: Macular edema resulting from central retinal vein occlusion is effectively treated with anti-vascular endothelial growth factor injections. However, some patients need monthly retreatment and still show frequent recurrences. The purpose of this study was to evaluate the visual and anatomic outcomes of refractory macular edema resulting from ischemic central retinal vein occlusion in patients switched from ranibizumab to aflibercept intravitreal injections. Patients and Methods: We describe a retrospective series of patients followed in the Medical Retina Unit of the Jules Gonin Eye Hospital for macular edema due to ischemic central retinal vein occlusion, refractory to monthly retreatment with ranibizumab, and changed to aflibercept. Refractory macular edema was defined as persistence of any fluid at each visit one month after last injection during at least 6 months. All patients had to have undergone pan-retinal laser scan. Results: Six patients were identified, one of whom had a very short-term follow-up (excluded from statistics). Mean age was 57 ± 12 years. The mean changes in visual acuity and central macular thickness from baseline to switch were + 20.6 ± 20.3 ETDRS letters and - 316.4 ± 276.6 µm, respectively. The additional changes from before to after the switch were + 9.2 ± 9.5 ETDRS letters and - 248.0 ± 248.7 µm, respectively. The injection intervals could often be lengthened after the switch. Conclusions: Intravitreal aflibercept seems to be a promising alternative treatment for macular edema refractory to ranibizumab in ischemic central retinal vein occlusion.

Using a blog to create and support a Community of Inquiry in Secondary Education

Understanding how blogs can support collaborative learning is a vital concern for researchers and teachers. This paper explores how blogs may be used to support Secondary Education students’ collaborative interaction and how such an interaction process can promote the creation of a Community of Inquiry to enhance critical thinking and meaningful learning. We designed, implemented and evaluated a science case-based project in which fifteen secondary students participated. Students worked in the science blogging project during 4 months. We asked students to be collaboratively engaged in purposeful critical discourse and reflection in their blogs in order to solve collectively science challenges and construct meaning about topics related to Astronomy and Space Sciences. Through student comments posted in the blog, our findings showed that the blog environment afforded the construction of a Community of Inquiry and therefore the creation of an effective online collaborative learning community. In student blog comments, the three presences for collaborative learning took place: cognitive, social, and teaching presence. Moreover, our research found a positive correlation among the three presences –cognitive, social and teaching– of the Community of Inquiry model with the level of learning obtained by the students. We discuss a series of issues that instructors should consider when blogs are incorporated into teaching and learning. We claim that embedded scaffolds to help students to argue and reason their comments in the blog are required to foster blog-supported collaborative learning.