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There has been little reported on the transoral reconstructive options following salvage transoral robotic surgery. This paper describes the facial artery musculomucosal flap as a method to introduce vascularised tissue to a previously irradiated resection bed.
A facial artery musculomucosal flap was used to reconstruct the lateral pharyngeal wall in 13 patients undergoing salvage transoral robotic surgery for oropharyngeal squamous cell carcinoma. Outcomes recorded include flap and donor site complications, length of stay, and swallowing and speech outcomes.
There were no immediate or late flap complications, or cases of delayed wound healing in this series. There were two facial artery musculomucosal related complications requiring surgical management: one bleed from the facial artery musculomucosal donor site and one minor surgical revision. Healing of the flap onto the resection bed was successful in all cases.
The facial artery musculomucosal flap provides a suitable transoral local flap option for selected patients undergoing salvage transoral robotic surgery for oropharyngeal malignancies.
The flora of Mediterranean ecosystems contains families with species having fully and under-developed embryos in their seeds. After-ripening for physiological dormancy release and smoke influence germination in many species. We investigated how after-ripening and embryo growth interact with smoke to influence the temporal dynamics of seedling emergence among fire ephemerals. Seeds were placed in the field and under standardized (50% relative humidity, 30°C) laboratory conditions to test the effects of summer conditions on physiological dormancy loss. Germination was tested with water or smoke compounds (smoke water, KAR1) at a simulated autumn/winter temperature (18/7°C). The timing and amount of seedling emergence with smoke was observed for seeds exposed to near-natural conditions. During summer, physiological dormancy was broken in all species, enabling germination at autumn/winter but not summer temperatures; no embryo growth occurred in seeds with under-developed embryos. At the start of the wet season, seedling emergence from seeds with fully developed embryos occurred earlier than from seeds with under-developed embryos. In a non-consistent manner among our study species, smoke and smoke compounds influenced the rate of embryo growth and amount of germination. Effects of smoke were noticeable in terms of number of emergents in the first emergence season. Among ecologically similar species, we have shown (1) that both thermal and embryo traits exclude germination in the summer, (2) how embryo size influences the timing of seedling emergence in autumn–winter, and (3) a reduced requirement for smoke in the second emergence season after a fire with a shift to reliance on seasonal cues for emergence.
Chronic spontaneous urticaria (CSU) has been associated with depression and can have an impact on quality of life. Therefore, researchers have suggested the potential utility of psychological interventions for targeting depression among CSU patients. Psychological interventions that may hold the most promise are those that are brief and easily transportable, such as brief behavioural activation treatment for depression. We report results of a preliminary investigation of an uncontrolled open trial of a one-session behavioural activation treatment for depression designed for patients with CSU (BATD-CSU) at a university-based allergy and immunology clinic. Participants were 11 females with chronic, poorly controlled urticaria and symptoms of depression. Following the completion of pretreatment questionnaires, participants were administered BATD-CSU primarily by non-mental health professionals trained and supervised in its delivery. One month post-BATD-CSU, participants completed follow-up questionnaires. Participants exhibited significant reductions in depression severity, avoidance/rumination, and work/school impairment. BATD-CSU was also associated with improvements in urticaria control one month post-treatment. Moreover, five of nine patients reported reliable and clinically significant improvement on at least one outcome. Results demonstrate that BATD-CSU may have benefits for CSU patients even when consisting of one session and delivered by professionals with limited background in psychological interventions, thus speaking to its feasibility and transportability.
There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal.
Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12).
In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%).
PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.
Evidence in support of the Developmental Origins of Health and Disease (DOHaD) hypothesis has reached the level where it can appropriately be used to inform practice. DOHaD informed interventions supporting primary noncommunicable disease risk reduction should target the pre- and periconceptional periods, pregnancy, lactation, childhood and adolescence. Such interventions are dependent on a health workforce (including dietitians, nurses, midwives, doctors, and nutrition teachers), that has a deep understanding of DOHaD concepts. This study assessed development of awareness of DOHaD concepts during undergraduate health professional training programs. Using a cross-sectional design, a standardized questionnaire was completed by Year 1–4 undergraduate students studying nutrition in Japan (n=309) and Year 1–3 nursing students in New Zealand (n=151). On entry to undergraduate study, most students had no awareness of the terms ‘DOHaD’ or ‘First 1000 Days’. While awareness reached 60% by Year 3 in courses that included DOHaD-related teaching, this remains inadequate. More than 95% of Year 1 undergraduates in both countries demonstrated an appreciation of associations between maternal nutrition and fetal health. However, awareness of associations between parental health status and/or nutritional environment and later-life health was low. While levels of awareness increased across program years, overall awareness was less than optimal. These results indicate evidence of some focus on DOHaD-related content in curricula. We argue that DOHaD principles should be one pillar around which health training curricula are built. This study indicates a need for the DOHaD community to engage with faculties in curriculum development.
On a visit to Malta in 1838, Queen Adelaide expressed severe disappointment that the British colony did not possess a purpose-built Anglican place of worship. She determined to fund the building of one at her personal expense and within six years the grandiose neoclassical church of St Paul's, Valletta, was completed. This imposing structure occupied an ambiguous position in a colony where the British government was pledged to maintain Roman Catholicism. St Paul's was ostensibly intended for the existing Anglican population in Malta. However, the church was perceived by both evangelicals and Roman Catholics as a potential instrument of propagating Protestantism. In examining the basis for these perceptions, this article suggests that St Paul's was part of a larger effort, driven by high church clergy connected with the Society for Promoting Christian Knowledge (SPCK), to influence the Maltese towards greater sympathy with the Anglican tradition, while avoiding overt proselytizing. The concomitant establishment of the diocese of Gibraltar in 1842 was, it is argued, key to this enterprise. The analysis advanced here has important implications for our understanding of Anglicanism in an imperial context, the contribution of royal patronage to this process and the conflict between religious and governmental imperatives.
Introduction: Pediatric musculoskeletal (MSK) image interpretation has been identified as a knowledge gap among emergency medicine trainees. The main objective of this study was to implement a validated on-line pediatric MSK radiograph interpretation system with a performance-based competency endpoint into pediatric emergency fellowship programs and examine the number of cases needed to achieve a competency threshold of 80% accuracy, sensitivity and specificity. We further determined proportion who successfully achieved competency in a given module and the change in accuracy from baseline to competency. Methods: This was a prospective cohort multi-centre study. There were seven MSK radiograph modules, each containing 200-400 cases (demo-https://imagesim.com/course-information/demo/). Thirty-seven pediatric emergency medicine fellows participated for 12 months. Participants did cases until they reached competency, defined as at least 80% accuracy, sensitivity and specificity. We calculated the overall and per module median number of cases required to achieve competency, proportion of participants who achieved competency, median time on case, and the mean change in accuracy from baseline to competency. Results: Overall, the median number of cases required to achieve competency was 76 (min 54, max 756). Between different body parts, there was a significant difference in the median number of cases needed to achieve competency, p <0.0001, with ankle and knee being among the most challenging modules. Proportions of those who started a module and completed it to competency varied significantly, and ranged from 32.4% in the ankle module to 97.1% in the forearm/hand, p<0.0001. The overall median time on each case was 34.1 (min 7.6, max 89.5) seconds. The overall change in accuracy from baseline to 80% competency was 13.5% (95% CI 12.1, 14.8), with the respective Cohens effect size of 1.98. The change in accuracy was different between modules, p=0.001, with post-hoc analyses demonstrating that the ankle/foot radiograph module had a greater increase in accuracy relative to elbow (p=0.009) and pelvis/femur (p=0.006). Conclusion: It was feasible for pediatric emergency medicine fellows to complete each learning pediatric MSK learning module to competency within approximately one hour, with the exception of the ankle module. Learners who completed the modules to competency demonstrated very significant increases in interpretation skill.
Rib bone biopsy samples are often used to estimate changes in skeletal mineral reserves in cattle but differences in sampling procedures and the bone measurements reported often make interpretation and comparisons among experiments difficult. ‘Full-core’ rib bone biopsy samples, which included the external cortical bone, internal cortical bone and trabecular bone (CBext, CBint and Trab, respectively), were obtained from cattle known to be in phosphorus (P) adequate (Padeq) or severely P-deficient (Pdefic) status. Experiments 1 and 2 examined growing steers and Experiment 3 mature breeder cows. The thickness of cortical bone, specific gravity (SG), and the amount and concentration of ash and P per unit fresh bone volume, differed among CBext, CBint and Trab bone. P concentration (mg/cc) was closely correlated with both SG and ash concentrations (pooled data, r=0.99). Thickness of external cortical bone (CBText) was correlated with full-core P concentration (FC-Pconc) (pooled data, r=0.87). However, an index, the amount of P in CBext per unit surface area of CBext (PSACB; mg P/mm2), was more closely correlated with the FC-Pconc (pooled data, FC-Pconc=37.0+146×PSACB; n=42, r=0.94, RSD=7.7). Results for measured or estimated FC-Pconc in 10 published studies with cattle in various physiological states and expected to be Padeq or in various degrees of Pdefic status were collated and the ranges of FC-Pconc indicative of P adequacy and P deficiency for various classes of cattle were evaluated. FC-Pconc was generally in the range 130 to 170 and 100 to 120 mg/cc fresh bone in Padeq mature cows and young growing cattle, respectively. In conclusion, the FC-Pconc could be estimated accurately from biopsy samples of CBext. This allows comparisons between studies where full-core or only CBext biopsy samples of rib bone have been obtained to estimate changes in the skeletal P status of cattle and facilitates evaluation of the P status of cattle.
Lymphatic filariasis is a neglected tropical disease caused by roundworm parasites such as Brugia malayi that spread via a mosquito vector. In vitro culture of these parasites provides controlled conditions to understand parasite biology and provides a cheaper way to screen potential micro- and macrofilaricides. Published studies have used a wide array of approaches and metrics regarding in vitro cultures of B. malayi; as a result, drawing comparisons and identifying the reasons why inability to reproduce outcomes are difficult. This study sought to determine conditions that ensure reproducible outcomes and used evaluation metrics that are easily measured and can be automated to ensure objectivity. We found culturing B. malayi third-stage larvae (L3) in endothelial basal media supplemented with 20% fetal bovine serum and 75 µm ascorbic acid in a temperature- and humidity-controlled incubator produced better survival and molting rates as well as longer and more motile parasites than previously reported. The benefit of ascorbic acid seemed to be unique to L3 parasites, as the addition of ascorbic acid to adult parasites had no significant impact on survival or motility. The methods reported in this study will help in designing experiments for both parasite behaviour studies and drug screening applications for disease eradication.
Alzheimer's disease has become an important public health burden for older adults. Clinicians face a challenging task to efficiently evaluate cognition in dementia in clinical settings. We sought to assess the validity and inter-correlations of brief cognitive assessments in a cohort of severely demented patients.
In total, 49 individual patients (N = 49) ranging in age from 62 to 97 years old were included in this performance improvement project. Over the course of two–three sessions, five cognitive instruments were administered to each patient: Severe Impairment Battery (SIB), Severe Impairment Battery-8 (SIB-8), Mini Mental State Examination (MMSE), Severe Mini Mental State Examination (sMMSE) and Brief Interview of Mental Status (BIMS). We sought to assess patient factors that might have been barriers to optimal performance on cognitive/functional tests. Researchers assessed her impression of the participants’ difficulty comprehending instructions, distractibility, apparent fatigue, and frustration, which were the four barriers rated.
Data were analyzed for 49 patients from the inpatient dementia unit with a total of 51 samples. All of the inter-correlations between the five cognitive instruments had Spearman coefficients of (rs) > 0.7 and were statistically significant with p < 0.001. The SIB-8 and sMMSE were positively correlated with the SIB. The perceived barrier scores ranged from 0- no issue to 1-mild issue on all five cognitive instruments.
Brief cognitive tests designed for severe dementia such as the SIB-8 and sMMSE have been evaluated in this project to be shorter in administration duration and highly correlated with gold standard instruments: the SIB and MMSE.
Direct extension of an intracranial meningioma to involve the temporal bone is rare. Recognised sites of origin and routes of access to the middle ear and labyrinthine apparatus have been described. Direct spread through the temporal bone to primarily involve the external auditory canal has not been widely reported in the literature.
This paper discusses clinical and radiological findings in three cases of temporal bone meningioma presenting as masses within the external auditory canal.
Diagnosing temporal meningioma can be challenging because of its rarity and the often non-specific clinical and histological findings. It is important for both the surgeon and radiologist to be aware of the diagnosis and its related imaging findings in order to facilitate a timely diagnosis.
Introduction: Gingivostomatitis is a common, painful pediatric presentation, and yet, few studies are available to guide management. We aimed to describe pediatric emergency physicians’ current practice patterns, with respect to analgesic use in children with acute gingivostomatitis. Methods: A national survey was conducted at all 15 national academic pediatric centres. Electronic surveys were distributed to pediatric emergency physicians using a modified Dillman protocol; non-respondents received paper surveys via post. Data were collected regarding demographics, clinical behaviour, knowledge, perceived barriers and factors that influence practice. Results: Overall response rate was 74% (150/202). Most physicians preferred the combination of acetaminophen and ibuprofen (72%) to either agent alone (ibuprofen 19%, acetaminophen 7%). The preferred second-line analgesics were oral morphine (48%, 72/150) and compounded topical formulas (42%, 64/150). The most commonly cited compounded agent was Benadryl plus Maalox (23%, 35/150). Clinical experience with a medication appeared to be the greatest influence on practice patterns; with 52% (78/149) ‘strongly agreeing’ that this was a factor. The most commonly cited barrier to adequate analgesia was difficulty in administration of topical or oral medication to children. Conclusion: As with many other painful conditions, acetaminophen and ibuprofen are reported to be used most frequently. However, oral morphine and topical compounded agents were also frequently prescribed. Regardless of patient age, physicians preferred oral morphine as a second-line agent to treat pain from severe gingivostomatitis. Future research should focus on determining which analgesic and route (oral or topical) is the most effective and best-tolerated choice.
The 2012 West Nile virus (WNV) epidemic was the largest since 2003 and the North Texas region was the most heavily impacted. We conducted a serosurvey of blood donors from four counties in the Dallas–Fort Worth area to characterize the epidemic. Blood donor specimens collected in November 2012 were tested for WNV-specific antibodies. Donors positive for WNV-specific IgG, IgM, and neutralizing antibodies were considered to have been infected in 2012. This number was adjusted using a multi-step process that accounted for timing of IgM seroreversion determined from previous longitudinal studies of WNV-infected donors. Of 4971 donations screened, 139 (2·8%) were confirmed WNV IgG positive, and 69 (1·4%) had IgM indicating infection in 2012. After adjusting for timing of sampling and potential seroreversion, we estimated that 1·8% [95% confidence interval (CI) 1·5–2·2] of the adult population in the Dallas–Fort Worth area were infected during 2012. The resulting overall estimate for the ratio of infections to reported WNV neuroinvasive disease (WNND) cases was 238:1 (95% CI 192–290), with significantly increased risk of WNND in older age groups. These findings were very similar to previous estimates of infections per WNND case, indicating no change in virulence as WNV evolved into an endemic infection in the United States.
We present the first snow/ice chemistry and ice radar results ever collected from South Georgia as part of an initial reconnaissance with the ultimate goal of assessing the feasibility of a South Georgia ice core to reconstruct past climate in the South Atlantic. South Georgia is well situated to capture a record of past atmospheric chemical composition over the South Atlantic and of past variability in the position and intensity of the austral westerlies. The question is how well preserved an ice core record can be recovered from a region experiencing accelerated melting? The results presented in this paper offer only a preliminary step in determining the feasibility of future deep ice coring on South Georgia. However, this initial reconnaissance does provide some basic information including: the chemistry of the atmosphere over South Georgia relative to other Southern Hemisphere ice coring sites; the potential for preservation of ‘annual layers’ in old ice on the island; a possible age for deep ice in the region; and an estimate of glacier health in the lower elevation regions of the island.
We present initial results of a new campaign of simulations focusing on the interaction of planetary winds with stellar environments using Adaptive Mesh Refinement methods. We have confirmed the results of Stone & Proga (2009) that an azimuthal flow structure is created in the planetary wind due to day/night temperatures differences. We show that a backflow towards the planet will occur with a strength that depends on the escape parameter. When a stellar outflow is included, we see unstable bow waves forming through the outflow's interaction with the planetary wind.
The Near Infrared Imager and Slitless Spectrograph (NIRISS) aboard the James Webb Space Telescope (JWST) will offer wide-field slitless spectroscopy (WFSS) with a resolving power R = 150 at wavelengths from 0.8 to 2.25 microns. In this band, NIRISS will be sensitive to Lyman α emission lines and continuum breaks in the spectra of galaxies with redshifts 6 < z < 17, allowing it to probe the first stars and ionizing sources in the early universe. NIRISS observations of the high-redshift universe will provide a wealth of information on foreground objects, creating a unique library of optical emission-line spectra from the faintest galaxies at lower redshifts. To explore its ability to identify and characterize galaxies at all redshifts, we have modeled a NIRISS observation of a massive strong-lensing galaxy cluster and analyzed the synthetic images using standard software tools. Our simulations demonstrate that WFSS with NIRISS will provide a powerful tool for the exploration of galaxies near and far.
African swine fever virus (ASFV) continues to cause outbreaks in domestic pigs and wild boar in Eastern European countries. To gain insights into its transmission dynamics, we estimated the pig-to-pig basic reproduction number (R0) for the Georgia 2007/1 ASFV strain using a stochastic susceptible-exposed-infectious-recovered (SEIR) model with parameters estimated from transmission experiments. Models showed that R0 is 2·8 [95% confidence interval (CI) 1·3–4·8] within a pen and 1·4 (95% CI 0·6–2·4) between pens. The results furthermore suggest that ASFV genome detection in oronasal samples is an effective diagnostic tool for early detection of infection. This study provides quantitative information on transmission parameters for ASFV in domestic pigs, which are required to more effectively assess the potential impact of strategies for the control of between-farm epidemic spread in European countries.
Histiocystic sarcoma is a rare, but aggressive tumour that often involves extranodal sites. Histiocystic sarcoma is recognised by the World Health Organization as one of six subtypes of dendritic cell neoplasms. Diagnosis is difficult due to overlapping immunohistochemistry with other dendritic cell neoplasms. The optimal roles for chemotherapy, radiotherapy and surgery in the treatment of histiocytic sarcoma remain unknown.
We report a case of a patient with histiocytic sarcoma diagnosed after excisional biopsy and immunohistochemistry testing.
The patient underwent external beam radiation therapy (EBRT). After 18 Gray (Gy), the 8 cm lesion had regressed to ~5 cm in diameter. The treatments were continued to a total dose of 45 Gy with the lesion regressing to less than a centimeter by the end of treatment. Local control was maintained but the patient died of acute myelogenous leukemia 5 months after her treatment.
This case suggests that histicytic sarcomas can be controlled locally with EBRT.