Preserving arteriovenous fistula outcomes during surgical training

PURPOSE: Arteriovenous fistulae (AVFs) are the preferred option for vascular access, as they are associated with lower mortality in hemodialysis patients than in those patients with arteriovenous grafts (AVGs) or central venous catheters (CVCs). We sought to assess whether vascular access outcomes for surgical trainees are comparable to fully trained surgeons.

METHODS: A prospectively collected database of patients was created and information recorded regarding patient demographics, past medical history, preoperative investigations, grade of operating surgeon, type of AVF formed, primary AVF function, cumulative AVF survival and functional patency.

RESULTS: One hundred and sixty-two patients were identified as having had vascular access procedures during the 6 month study period and 143 were included in the final analysis. Secondary AVF patency was established in 123 (86%) of these AVFs and 89 (62.2%) were used for dialysis. There was no significant difference in survival of AVFs according to training status of surgeon (log rank x2 0.506 p=0.477) or type of AVF (log rank x2 0.341 p=0.559). Patency rates of successful AVFs at 1 and 2 years were 60.9% and 47.9%, respectively.

CONCLUSION: We have demonstrated in this prospective study that there are no significant differences in outcomes of primary AVFs formed by fully trained surgeons versus surgical trainees. Creation of a primary AVF represents an excellent training platform for intermediate stage surgeons across general and vascular surgical specialties.

Two-year survival of ART restorations placed in elderly patients: A randomised controlled clinical trial

OBJECTIVES: Older dentate adults are a high caries risk group who could potentially benefit from the use of the atraumatic restorative treatment (ART). This study aimed to compare the survival of ART and a conventional restorative technique (CT) using rotary instruments and a resin-modified glass-ionomer for restoring carious lesions as part of a preventive and restorative programme for older adults after 2 years.

METHODS: In this randomised controlled clinical trial, 99 independently living adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations. The survival of restorations was assessed by an independent and blinded examiner 6 months, 1 year and 2 years after restoration placement.

RESULTS: Ninety-six (67.6%) and 121 (76.6%) restorations were assessed in the ART and CT groups, respectively, after 2 years. The cumulative restoration survival percentages after 2 years were 85.4% in the ART and 90.9% in the CT group. No statistically significant between group differences were detected (p=0.2050, logistic regression analysis).

CONCLUSIONS: In terms of restoration survival, ART was as effective as a conventional restorative approach to treat older adults after 2 years. This technique could be a useful tool to provide dental care for older adults particularly in the non-clinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL SIGNIFICANCE: The results of this study show that ART presented survival rates similar to conventional restorations in older adults. ART appears to be a cost-effective way to provide dental care to elderly patients, particularly in out of surgery facilities, such as nursing homes.

Generalized Selection Combining for Cognitive Relay Networks over Nakagami-m Fading

We consider transmit antenna selection with receive generalized selection combining (TAS/GSC) for cognitive decodeand-forward (DF) relaying in Nakagami-m fading channels. In an effort to assess the performance, the probability density function and the cumulative distribution function of the endto-end SNR are derived using the moment generating function, from which new exact closed-form expressions for the outage probability and the symbol error rate are derived. We then derive a new closed-form expression for the ergodic capacity. More importantly, by deriving the asymptotic expressions for the outage probability and the symbol error rate, as well as the high SNR approximations of the ergodic capacity, we establish new design insights under the two distinct constraint scenarios: 1) proportional interference power constraint, and 2) fixed interference power constraint. Several pivotal conclusions are reached. For the first scenario, the full diversity order of the
outage probability and the symbol error rate is achieved, and the high SNR slope of the ergodic capacity is 1/2. For the second scenario, the diversity order of the outage probability and the symbol error rate is zero with error floors, and the high SNR slope of the ergodic capacity is zero with capacity ceiling.

Are the differences in adulthood ill-health across the North-South divide and between Scotland and England also evident in early childhood health indicators?

Regional differences in adult morbidity and mortality within England (i.e., north-south divide or gradient) and between England and Scotland (i.e., Scottish effect) are only partly explained by adult levels of socioeconomic status or risk factors. This suggests variation in early life, and is supported by the fetal origins and life-course literature which posits that birth outcomes and subsequent, cumulative exposures influence adult health. However, no studies have examined the north-south gradient or Scottish effect in health in the earliest years of life. The aims of the study were: i) to examine health indicators in English and Scottish children at birth and age three to establish whether regional differences exist; and ii) to establish whether observed changes in child health at age three were attributable to birth and/or early life environmental exposures. Respondents included 10,639 biological Caucasian mothers of singleton children recruited to the Millennium Cohort Study (MCS) in the year 2000. Outcome variables were: gestational age and birth weight, and height, body mass index (BMI), and externalising behavioural problems at age three. Region/country was categorised as: South (reference), Midlands, North (England), and Scotland. Respondents provided information on child, maternal, household, and socioeconomic characteristics. Results indicated no significant regional variations for gestational age or birth weight. At age three there was a north-south gradient for externalising behaviour and a north-south divide in BMI which attenuated on adjustment. However, a north-south divide in height was not fully explained by adjustment. There was also evidence of a ‘Midlands effect’, with increased likelihood of shorter stature and behaviour problems. Results showed a Scottish effect for height and BMI in the unadjusted models, and height in the adjusted model, but a decreased likelihood of behaviour problems. Findings indicated no regional differences in health at birth, but some regional variation at age three supports the cumulative life-course model.

Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation

PURPOSE: To investigate the effects of using volumetric modulated arc therapy (VMAT) and/or voluntary moderate deep inspiration breath-hold (vmDIBH) in the radiation therapy (RT) of left-sided breast cancer including the regional lymph nodes.

MATERIALS AND METHODS: For 13 patients, four treatment combinations were compared; 3D-conformal RT (i.e., forward IMRT) in free-breathing 3D-CRT(FB), 3D-CRT(vmDIBH), 2 partial arcs VMAT(FB), and VMAT(vmDIBH). Prescribed dose was 42.56 Gy in 16 fractions. For 10 additional patients, 3D-CRT and VMAT in vmDIBH only were also compared.

RESULTS: Dose conformity, PTV coverage, ipsilateral and total lung doses were significantly better for VMAT plans compared to 3D-CRT. Mean heart dose (D(mean,heart)) reduction in 3D-CRT(vmDIBH) was between 0.9 and 8.6 Gy, depending on initial D(mean,heart) (in 3D-CRT(FB) plans). VMAT(vmDIBH) reduced the D(mean,heart) further when D(mean,heart) was still >3.2 Gy in 3D-CRT(vmDIBH). Mean contralateral breast dose was higher for VMAT plans (2.7 Gy) compared to 3DCRT plans (0.7 Gy).

CONCLUSIONS: VMAT and 3D-CRT(vmDIBH) significantly reduced heart dose for patients treated with locoregional RT of left-sided breast cancer. When Dmean,heart exceeded 3.2 Gy in 3D-CRT(vmDIBH) plans, VMAT(vmDIBH) resulted in a cumulative heart dose reduction. VMAT also provided better target coverage and reduced ipsilateral lung dose, at the expense of a small increase in the dose to the contralateral breast.

Net energy analysis of a solar combi system with Seasonal Thermal Energy Store

EU targets require nearly zero energy buildings (NZEB) by 2020. However few monitored examples exist of how NZEB has been achieved in practise in individual residential buildings. This paper provides an example of how a low-energy building (built in 2006), has achieved nearly zero energy heating through the addition of a solar domestic hot water and space heating system (“combi system”) with a Seasonal Thermal Energy Store (STES). The paper also presents a cumulative life cycle energy and cumulative life cycle carbon analysis for the installation based on the recorded DHW and space heating demand in addition to energy payback periods and net energy ratios. In addition, the carbon and energy analysis is carried out for four other heating system scenarios including hybrid solar thermal/PV systems in order to obtain the optimal system from a carbon efficiency perspective.

Validation of non‑stationary precipitation series for site‑specific impact assessment: comparison of two statistical downscaling techniques

Statistical downscaling (SD) methods have become a popular, low-cost and accessible means of bridging the gap between the coarse spatial resolution at which climate models output climate scenarios and the finer spatial scale at which impact modellers require these scenarios, with various different SD techniques used for a wide range of applications across the world. This paper compares the Generator for Point Climate Change (GPCC) model and the Statistical DownScaling Model (SDSM)—two contrasting SD methods—in terms of their ability to generate precipitation series under non-stationary conditions across ten contrasting global climates. The mean, maximum and a selection of distribution statistics as well as the cumulative frequencies of dry and wet spells for four different temporal resolutions were compared between the models and the observed series for a validation period. Results indicate that both methods can generate daily precipitation series that generally closely mirror observed series for a wide range of non-stationary climates. However, GPCC tends to overestimate higher precipitation amounts, whilst SDSM tends to underestimate these. This infers that GPCC is more likely to overestimate the effects of precipitation on a given impact sector, whilst SDSM is likely to underestimate the effects. GPCC performs better than SDSM in reproducing wet and dry day frequency, which is a key advantage for many impact sectors. Overall, the mixed performance of the two methods illustrates the importance of users performing a thorough validation in order to determine the influence of simulated precipitation on their chosen impact sector.

When opportunity matters: Comparing the risk taking attitudes of prisoners and recently released ex-prisoners

Risk-taking tendencies and environmental opportunities to commit crime are two key features in understanding criminal behavior. Upon release from prison, ex-prisoners have a much greater opportunity to engage in risky activity and to commit criminal acts. We hypothesized that ex-prisoners would exhibit greater risk-taking tendencies compared to prisoners who have fewer opportunities to engage in risky activity and who are monitored constantly by prison authorities. Using cumulative prospect theory to compare the risky choices of prisoners and ex-prisoners our study revealed that ex-prisoners who were within 16 weeks of their prison release made riskier choices than prisoners. Our data indicate that previous studies comparing prisoners behind bars with nonoffenders may have underestimated the risk-taking tendencies of offenders. The present findings emphasize the central role played by risk-taking attitudes in criminal offending and highlight a need to examine offenders after release from prison.

On the Multivariate Gamma-Gamma (ΓΓ) Distribution with Arbitrary Correlation and Applications in Wireless Communications

The statistical properties of the multivariate GammaGamma (ΓΓ) distribution with arbitrary correlation have remained unknown. In this paper, we provide analytical expressions for the joint probability density function (PDF), cumulative distribution function (CDF) and moment generation function of the multivariate ΓΓ distribution with arbitrary correlation. Furthermore, we present novel approximating expressions for the PDF and CDF of the su m of ΓΓ random variables with arbitrary correlation. Based on this statistical analysis, we investigate the performance of radio frequency and optical wireless communication systems. It is noteworthy that the presented expressions include several previous results in the literature as special cases.

Zooming In on the Progenitors of Superluminous Supernovae With the HST

We present Hubble Space Telescope (HST) rest-frame ultraviolet imaging of the host galaxies of 16 hydrogen-poor superluminous supernovae (SLSNe), including 11 events from the Pan-STARRS Medium Deep Survey. Taking advantage of the superb angular resolution of HST, we characterize the galaxies' morphological properties, sizes, and star formation rate (SFR) densities. We determine the supernova (SN) locations within the host galaxies through precise astrometric matching and measure physical and host-normalized offsets as well as the SN positions within the cumulative distribution of UV light pixel brightness. We find that the host galaxies of H-poor SLSNe are irregular, compact dwarf galaxies, with a median half-light radius of just 0.9 kpc. The UV-derived SFR densities are high ([Sigma(SFR)] similar or equal to 0.1M(circle dot) yr(-1) kpc(-1)), suggesting that SLSNe form in overdense environments. Their locations trace the UV light of their host galaxies, with a distribution intermediate between that of long-duration gamma-ray bursts (LGRBs; which are strongly clustered on the brightest regions of their hosts) and a uniform distribution (characteristic of normal core-collapse SNe), though cannot be statistically distinguished from either with the current sample size. Taken together, this strengthens the picture that SLSN progenitors require different conditions than those of ordinary core-collapse SNe to form and that they explode in broadly similar galaxies as do LGRBs. If the tendency for SLSNe to be less clustered on the brightest regions than are LGRBs is confirmed by a larger sample, this would indicate a different, potentially lower-mass progenitor for SLSNe than LRGBs.

Long-Term Follow-Up of a Large Active Surveillance Cohort of Patients With Prostate Cancer

PURPOSE: Active surveillance is increasingly accepted as a treatment option for favorable-risk prostate cancer. Long-term follow-up has been lacking. In this study, we report the long-term outcome of a large active surveillance protocol in men with favorable-risk prostate cancer.

PATIENTS AND METHODS: In a prospective single-arm cohort study carried out at a single academic health sciences center, 993 men with favorable- or intermediate-risk prostate cancer were managed with an initial expectant approach. Intervention was offered for a prostate-specific antigen (PSA) doubling time of less than 3 years, Gleason score progression, or unequivocal clinical progression. Main outcome measures were overall and disease-specific survival, rate of treatment, and PSA failure rate in the treated patients.

RESULTS: Among the 819 survivors, the median follow-up time from the first biopsy is 6.4 years (range, 0.2 to 19.8 years). One hundred forty-nine (15%) of 993 patients died, and 844 patients are alive (censored rate, 85.0%). There were 15 deaths (1.5%) from prostate cancer. The 10- and 15-year actuarial cause-specific survival rates were 98.1% and 94.3%, respectively. An additional 13 patients (1.3%) developed metastatic disease and are alive with confirmed metastases (n = 9) or have died of other causes (n = 4). At 5, 10, and 15 years, 75.7%, 63.5%, and 55.0% of patients remained untreated and on surveillance. The cumulative hazard ratio for nonprostate-to-prostate cancer mortality was 9.2:1.

CONCLUSION: Active surveillance for favorable-risk prostate cancer is feasible and seems safe in the 15-year time frame. In our cohort, 2.8% of patients have developed metastatic disease, and 1.5% have died of prostate cancer. This mortality rate is consistent with expected mortality in favorable-risk patients managed with initial definitive intervention.

HD Laser scanning for the evaluation of salt decay laboratory simulations of building limestone

Laboratory salt decay simulations are a well established method to assess the relative durability of stone. There is still, however, very much scope to implement improved monitoring techniques to investigate the changes experienced by the materials during these experiments. Non-destructive techniques have acquired over recent decades a preferential status for monitoring change samples during salt decay tests, as they allow cumulative tests on each sample. The development of HD laser scanning permits detailed mapping of surface changes and, therefore, constitutes an effective technique to monitor non-destructively surface changes in tested samples as an alternative to other monitoring techniques such as traditional weight loss strategies that do not permit any degree of spatial differentiation that can be related, for example, to underlying stone properties.

Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey

OBJECTIVES: The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences.

DESIGN: A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer.

PARTICIPANTS: 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden.

PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate.

RESULTS: 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables.

CONCLUSIONS: We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.

Concussion and Brain Injury in Contact Sport: Legal Implications

A concussed participant leaving the field of play is one of the most worrying sights in sport. It is also one that might have serious legal implications for sports governing bodies. Over the past number of years, a major class action suit has rumbled through the US courts as taken against that country's biggest professional sport, the National Football League. The NFL is at present attempting to settle the lawsuit from more than 4,500 retired players who claim that the NFL knew for decades about the chronic health risks associated with cumulative concussions in American football but failed to warn players or take preventative steps. Testimony from retired NFL players has revealed stories of chronic headaches, Alzheimer-like forgetfulness, altered personalities and sometimes a downward spiral into depression, violence and suicide. Medical research is suggesting that professional American football players are three times more likely to die as a result of certain neurodegenerative diseases than the general population. This paper notes that the concerns about concussion are not confined to the NFL and extend to contact sport more widely and notably rugby union. This paper also assesses the reaction of leading sports governing bodies globally to the recorded medical risks and accompanying legal vulnerabilities.

Identification and output tracking control of Hammerstein systems through wireless networks

his paper investigates the identification and output tracking control of a class of Hammerstein systems through a wireless network within an integrated framework and the statistic characteristics of the wireless network are modelled using the inverse Gaussian cumulative distribution function. In the proposed framework, a new networked identification algorithm is proposed to compensate for the influence of the wireless network delays so as to acquire the more precise Hammerstein system model. Then, the identified model together with the model-based approach is used to design an output tracking controller. Mean square stability conditions are given using linear matrix inequalities (LMIs) and the optimal controller gains can be obtained by solving the corresponding optimization problem expressed using LMIs. Illustrative numerical simulation examples are given to demonstrate the effectiveness of our proposed method.