Successful therapy for a patient with an infected ascending aortic graft and sternal osteomyelitis without graft removal.

Objective: Following open-heart surgery, sternal osteomyelitis or infection of the graft may be a serious complication with high mortality rates. The recommended treatment of an infected graft is its explantation. Because of the poor performance status of the patient, this may not always be an option. We report a successful treatment concept without removal of the infected graft. Methods: The infected ascending aortic graft and the remaining sternum of a critically ill 60-year-old man were covered with a bilateral pectoralis muscle flap. Results: Postoperatively, the laboratory test values normalized and the patient was discharged 1 month after the intervention. One year after surgery, the patient was in good condition and the examination showed no signs of infection. Conclusion: The thus demonstrated treatment concept with insertion of well-vascularized tissues in combination with a specific antibiotic regime in our hands proved to be an additional option for the successful management of life-threatening infections of a sternal osteomyelitis in combination of an infected aortic graft.

Use of unmodified starches and partial removal of serum to improve Granada medium stability

The use of 1% unmodified rice starch and 1% horse serum instead of 2% soluble starch and 5% serum in Granada medium is described. These components result in a medium of increased stability, preventing spoilage after a few days of storage at room temperature

Antibiotic lock technique combined with systemic antimicrobial therapy for management of port-related bloodstream infections in onco-haematological patients without catheter removal

Background : Port-related bloodstream infection (PRBSI) is a common complication associated with long-term use of ports systems. Systemic antimicrobial therapy (ST) and removal of the device is the standard management of PRBSI. However, a conservative management combining ST with antibiotic lock therapy (ALT) without port removal has been suggested as an alternative management option for infections due to gram-positive skin colonizers with low virulence.¦Objectives : i) to assess the frequency of management of PRBSI in onco-hematological patients by combining the ALT with ST, without catheter removal and ii) to analyze the efficacy of such an approach.¦Methods : Retrospective observational study over a 6-year period between 2005 and 2010, including patients who where diagnosed with PRBSI and who were treated with ST and ALT. PRBSI diagnosis consisted in clinical signs of bacteremia with blood cultures positive for gram-positive skin colonizers. The primary endpoint was failure to cure the PRBSI.¦Results : 61 port infections were analysed, of which 23 PRBSI met the inclusion criteria. All the patients were suffering from haematological conditions and 75% were neutropenic at the time of PRBSI diagnosis. S. epidermidis was responsible for 91% of PRBSI (21/23). The median duration of ST was 14 days (range 7-35) and the median duration of ALT was 15 days (range 8-41). Failure to cure the PRBSI requiring port removal was observed in 4 patients, but was not associated with severe infectious complications. Kaplan-Meier analysis showed a success rate in port salvage at day 180 (6 months) of 78% (95%CI 59-97%).¦Conclusion : The success rate observed in the present study suggests that combining ST and ALT is an effective option to conservatively treat PRBSI caused by pathogens of low virulence such as S. epidermidis.

Late removal of retrievable caval filters.

The advent of retrievable caval filters was a game changer in the sense, that the previously irreversible act of implanting a medical device into the main venous blood stream of the body requiring careful evaluation of the pros and cons prior to execution suddenly became a "reversible" procedure where potential hazards in the late future of the patient lost most of their weight at the time of decision making. This review was designed to assess the rate of success with late retrieval of so called retrievable caval filters in order to get some indication about reasonable implant duration with respect to relatively "easy" implant removal with conventional means, i.e., catheters, hooks and lassos. A PubMed search (www.pubmed.gov) was performed with the search term "cava filter retrieval after 30 days clinical", and 20 reports between 1994 and 2013 dealing with late retrieval of caval filters were identified, covering approximately 7,000 devices with 600 removed filters. The maximal duration of implant reported is 2,599 days and the maximal implant duration of removed filters is also 2,599 days. The maximal duration reported with standard retrieval techniques, i.e., catheter, hook and/or lasso, is 475 days, whereas for the retrievals after this period more sophisticated techniques including lasers, etc. were required. The maximal implant duration for series with 100% retrieval accounts for 84 days, which is equivalent to 12 weeks or almost 3 months. We conclude that retrievable caval filters often become permanent despite the initial decision of temporary use. However, such "forgotten" retrievable devices can still be removed with a great chance of success up to three months after implantation. Conventional percutaneous removal techniques may be sufficient up to sixteen months after implantation whereas more sophisticated catheter techniques have been shown to be successful up to 83 months or more than seven years of implant duration. Tilting, migrating, or misplaced devices should be removed early on, and replaced if indicated with a device which is both, efficient and retrievable.

Guidleines for Removal of Traffic Control Devices in Rural Areas, October 2005

It is commonly regarded that the overuse of traffic control devices desensitizes drivers and leads to disrespect, especially for low-volume secondary roads with limited enforcement. The maintenance of traffic signs is also a tort liability concern, exacerbated by unnecessary signs. The Federal Highway Administration’s (FHWA) Manual on Uniform Traffic Control Devices (MUTCD) and the Institute of Transportation Engineer’s (ITE) Traffic Control Devices Handbook provide guidance for the implementation of STOP signs based on expected compliance with right-of-way rules, provision of through traffic flow, context (proximity to other controlled intersections), speed, sight distance, and crash history. The approach(es) to stop is left to engineering judgment and is usually dependent on traffic volume or functional class/continuity of system. Although presently being considered by the National Committee on Traffic Control Devices, traffic volume itself is not given as a criterion for implementation in the MUTCD. STOP signs have been installed at many locations for various reasons which no longer (or perhaps never) met engineering needs. If in fact the presence of STOP signs does not increase safety, removal should be considered. To date, however, no guidance exists for the removal of STOP signs at two-way stop-controlled intersections. The scope of this research is ultra-low-volume (< 150 daily entering vehicles) unpaved intersections in rural agricultural areas of Iowa, where each of the 99 counties may have as many as 300 or more STOP sign pairs. Overall safety performance is examined as a function of a county excessive use factor, developed specifically for this study and based on various volume ranges and terrain as a proxy for sight distance. Four conclusions are supported: (1) there is no statistical difference in the safety performance of ultra-low-volume stop-controlled and uncontrolled intersections for all drivers or for younger and older drivers (although interestingly, older drivers are underrepresented at both types of intersections); (2) compliance with stop control (as indicated by crash performance) does not appear to be affected by the use or excessive use of STOP signs, even when adjusted for volume and a sight distance proxy; (3) crash performance does not appear to be improved by the liberal use of stop control; (4) safety performance of uncontrolled intersections appears to decline relative to stop-controlled intersections above about 150 daily entering vehicles. Subject to adequate sight distance, traffic professionals may wish to consider removal of control below this threshold. The report concludes with a section on methods and legal considerations for safe removal of stop control.

Purification of recombinant proteins by chemical removal of the affinity tag.

The efficient removal of a N- or C-terminal purification tag from a fusion protein is necessary to obtain a protein in a pure and active form, ready for use in human or animal medicine. Current techniques based on enzymatic cleavage are expensive and result in the presence of additional amino acids at either end of the proteins, as well as contaminating proteases in the preparation. Here we evaluate an alternative method to the one-step affinity/protease purification process for large-scale purification. It is based upon the cyanogen bromide (CNBr) cleavage at a single methionine placed in between a histidine tag and a Plasmodium falciparum antigen. The C-terminal segment of the circumsporozoite polypeptide was expressed as a fusion protein with a histidine tag in Escherichia coli purified by Ni-NAT agarose column chromatography and subsequently cleaved by CNBr to obtain a polypeptide without any extraneous amino acids derived from the cleavage site or from the affinity purification tag. Thus, a recombinant protein is produced without the need for further purification, demonstrating that CNBr cleavage is a precise, efficient, and low-cost alternative to enzymatic digestion, and can be applied to large-scale preparations of recombinant proteins.

Development and use of a high-fidelity simulator for fetal endotracheal balloon occlusion (FETO) insertion and removal.

Objectives The objective of this article is to describe the development of an anatomically accurate simulator in order to aid the training of a perinatal team in the insertion and removal of a fetal endoscopic tracheal occlusion (FETO) balloon in the management of prenatally diagnosed congenital diaphragmatic hernia. Methods An experienced perinatal team collaborated with a medical sculptor to design a fetal model for the FETO procedure. Measurements derived from 28-week fetal magnetic resonance imaging were used in the development of an anatomically precise simulated airway within a silicone rubber preterm fetal model. Clinician feedback was then used to guide multiple iterations of the model with serial improvements in the anatomic accuracy of the simulator airway. Results An appropriately sized preterm fetal mannequin with a high-fidelity airway was developed. The team used this model to develop surgical skills with balloon insertion, and removal, and to prepare the team for an integrated response to unanticipated delivery with the FETO balloon still in situ. Conclusions This fetal mannequin aided in the ability of a fetal therapy unit to offer the FETO procedure at their center for the first time. This model may be of benefit to other perinatal centers planning to offer this procedure.

Effects of the removal of shelterwood on the foliar nutrient conceentrations of Norway spruce (Picea abies(L.)Karst.) on drained peatlands

Tiivistelmä: Neulasten pääravinnepitoisuuksien muutokset turvekankaan alikasvoskuusikossa ylispuuhakkuun jälkeen

Effects of convection on the removal of the multiplicity of stable states in one-dimensional vertical models

Here I develop a model of a radiative-convective atmosphere with both radiative and convective schemes highly simplified. The atmospheric absorption of radiation at selective wavelengths makes use of constant mass absorption coefficients in finite width spectral bands. The convective regime is introduced by using a prescribed lapse rate in the troposphere. The main novelty of the radiative-convective model developed here is that it is solved without using any angular approximation for the radiation field. The solution obtained in the purely radiation mode (i. e. with convection ignored) leads to multiple equilibria of stable states, being very similar to some results recently found in simple models of planetary atmospheres. However, the introduction of convective processes removes the multiple equilibria of stable states. This shows the importance of taking convective processes into account even for qualitative analyses of planetary atmosphere

Identification and removal of low-complexity sites in allele-specific analysis of ChIP-seq data.

MOTIVATION: High-throughput sequencing technologies enable the genome-wide analysis of the impact of genetic variation on molecular phenotypes at unprecedented resolution. However, although powerful, these technologies can also introduce unexpected artifacts. Results: We investigated the impact of library amplification bias on the identification of allele-specific (AS) molecular events from high-throughput sequencing data derived from chromatin immunoprecipitation assays (ChIP-seq). Putative AS DNA binding activity for RNA polymerase II was determined using ChIP-seq data derived from lymphoblastoid cell lines of two parent-daughter trios. We found that, at high-sequencing depth, many significant AS binding sites suffered from an amplification bias, as evidenced by a larger number of clonal reads representing one of the two alleles. To alleviate this bias, we devised an amplification bias detection strategy, which filters out sites with low read complexity and sites featuring a significant excess of clonal reads. This method will be useful for AS analyses involving ChIP-seq and other functional sequencing assays.