At the Cleveland Clinic Foundation, RN first assistants (RNFAs) have replaced inexperienced interns and rotating general surgery residents as surgical first assistants. Their new role includes ...harvesting inferior epigastric arteries (IEAs) for coronary artery bypass procedures. The RNFAs remove the IEAs through paramedian incisions that extend from below the umbilicus to the groin, dissect the IEAs as pedicles, and complete wound closure. This is one example of the expanded role of RNFAs during complex surgical procedures.
A number of ecological models have been developed to provide an understanding of the various biotic and abiotic components required to conserve biodiversity and to reconcile objectives and methods ...between those interested in the conservation of species (e.g., population management) and those advocating the conservation of spaces (e.g., protected areas). One of the better known efforts-pioneered in the Pacific Northwest of the United States-is a hierarchical ecological framework that separates biodiversity into compositional, structural, and functional attributes at the genetic, population, community-ecosystem, and landscape levels of organization. We present an adaptation of this terrestrial framework consistent with the ecological function of marine environments. Our adaptation differs in its treatment of the community and ecosystem levels of organization. In our marine framework, the community level denotes predominantly the biotic community components of biodiversity, and the ecosystem level-consistent with marine terminology-denotes predominantly physical and chemical components. The community and ecosystem levels are further separated into those attributes based on ecological structures such as depth or species richness and those based on ecological processes such as water motion or succession. The distinction between the biotic (genetic, population, and community) and abiotic (ecosystem) is required because the biological components of biodiversity such as competition or predation are often more difficult to observe than the abiotic components such as upwellings, substratum, or temperature. As a result, efforts to conserve marine biodiversity are often dependent on the observable abiotic (ecosystem) components, which can be used as surrogates for the identification and monitoring of biotic (community) components. We used our hierarchical framework to identify and suggest how conservation strategies could be implemented in marine environments depending on whether existing data are to be used or new data are to be collected.
While pancreatic cancer (PC) survival rates have recently shown modest improvement, the disease remains largely incurable. Early detection of pancreatic cancer may result in improved outcomes and ...therefore, methods for early detection of cancer, even premalignant lesions, may provide more favorable outcomes. Pancreatic intraepithelial neoplasias (PanINs) have been identified as premalignant precursor lesions to pancreatic cancer. However, conventional imaging methods used for screening high-risk populations do not have the sensitivity to detect PanINs. Here, we have employed hyperpolarized metabolic imaging in vivo and nuclear magnetic resonance (
H-NMR) metabolomics ex vivo to identify and understand metabolic changes, towards enabling detection of early PanINs and progression to advanced PanINs lesions that precede pancreatic cancer formation. Progression of disease from tissue containing predominantly low-grade PanINs to tissue with high-grade PanINs showed a decreasing alanine/lactate ratio from high-resolution NMR metabolomics ex vivo. Hyperpolarized magnetic resonance spectroscopy (HP-MRS) allows over 10,000-fold sensitivity enhancement relative to conventional magnetic resonance. Real-time HP-MRS was employed to measure non-invasively changes of alanine and lactate metabolites with disease progression and in control mice in vivo, following injection of hyperpolarized 1-
C pyruvate. The alanine-to-lactate signal intensity ratio was found to decrease as the disease progressed from low-grade PanINs to high-grade PanINs. The biochemical changes of alanine transaminase (ALT) and lactate dehydrogenase (LDH) enzyme activity were assessed. These results demonstrate that there are significant alterations of ALT and LDH activities during the transformation from early to advanced PanINs lesions. Furthermore, we demonstrate that real-time conversion kinetic rate constants (k
and k
) can be used as metabolic imaging biomarkers of pancreatic premalignant lesions. Findings from this emerging HP-MRS technique can be translated to the clinic for detection of pancreatic premalignant lesion in high-risk populations.
The TeV extragalactic sky is dominated by blazars, radio-loud active galactic nuclei with a relativistic jet pointing towards the Earth. Blazars show variability that can be quite exceptional both in ...terms of flux (orders of magnitude of brightening) and time (down to the minute timescale). This bright flaring activity contains key information on the physics of particle acceleration and photon production in the emitting region, as well as the structure and physical properties of the jet itself. The TeV band is accessed from the ground by Cherenkov telescopes that image the pair cascade triggered by the interaction of the gamma ray with the Earth's atmosphere. The Cherenkov Telescope Array (CTA) represents the upcoming generation of imaging atmospheric Cherenkov telescopes, with a significantly higher sensitivity and larger energy coverage with respect to current instruments. It will thus provide us with unprecedented statistics on blazar light-curves and spectra. In this contribution we present the results from realistic simulations of CTA observations of bright blazar flares, taking as input state-of-the-art numerical simulations of blazar emission models and including all relevant observational constraints.
Several medications have individually been shown to reduce mortality in patients with acute coronary syndromes (ACS), but data on long-term outcomes related to the use of combinations of these ...medications are limited. For 2,684 consecutive patients admitted with ACS from January 1999 and January 2007, a composite score was calculated correlating with the use upon discharge of indicated evidence-based medications (EBMs): aspirin, β blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents. Multivariate models were used to examine the impact of EBM score on 2-year events with adjustment for components of the Global Registry of Acute Coronary Events (GRACE) risk score, thienopyridine use, and year of discharge. Women were older, had more co-morbidities, and were less likely to receive all 4 EBMs (53% vs 64%, p < 0.0001) than men. Patients who received all 4 indicated EBMs had a significant 2-year survival benefit compared to patients who received ≤1 EBM (odds ratio 0.25, 95% confidence interval 0.15 to 0.41), which was observed when men and women were examined separately (for men, odds ratio 0.22, 95% confidence interval 0.11 to 0.44; for women, odds ratio 0.3, 95% confidence interval 0.15 to 0.63). A modest benefit, in terms of cardiovascular disease events (myocardial infarction, rehospitalization, stroke, and death), was observed only for men who received all 4 EBMs. In conclusion, a combination of cardiac medications at the time of ACS discharge is strongly associated with 2-year survival in men and women, suggesting that discharge is an important time to prescribe secondary preventative medications.
The therapeutic gold standard of muscle-invasive tumour stages is radical cystectomy (RC), but there are still conflicting reports about associated morbidity and mortality and the oncologic benefit ...of RC in elderly patients. The aim of the present study was the comparison of overall (OS) and cancer-specific survival (CSS) in patients <75 and >75 years of age (median follow-up was 42 months).
Clinical and histopathological data of 2,483 patients with urothelial carcinoma and consecutive RC were collated. The study group was dichotomized by the age of 75 years at RC. Statistical analyses comprising an assessment of postoperative mortality within 90 days, OS and CSS were assessed. Multivariate logistic regression and survival analyses were performed.
The 402 patients (16.2%) with an age of ≥75 years at RC showed a significantly higher local tumour stage (pT3/4 and/or pN+) (58 vs 51%; p=0.01), higher tumour grade (73 vs 65%; p=0.003) and higher rates of upstaging in the RC specimen (55 vs 48%; p=0.032). Elderly patients received significantly less often adjuvant chemotherapy (8 vs 15%; p<0.001). The 90-day mortality was significantly higher in patients ≥75 years (6.2 vs 3.7%; p=0.026). When adjusted for different variables (gender, tumour stage, adjuvant chemotherapy, time period of RC), only in male patients and locally advanced tumour stages was an association with 90-day mortality noticed. The multivariate analysis showed that patients ≥75 years of age have a significantly worse OS (HR=1.42; p<0.001) and CSS (HR=1.27; p=0.018).
An age of ≥75 years at RC is associated with a worse outcome. Prospective analyses including an assessment of the role of comorbidity and possibly age-dependent tumour biology are warranted.
Dwarf spheroidal galaxies of the Local Group are close satellites of the Milky Way characterized by a large mass-to-light ratio and are not expected to be the site of nonthermal high-energy gamma-ray ...emission or intense star formation. Therefore they are among the most promising candidates for indirect dark matter searches. During the last years the High Energy Stereoscopic System (H.E.S.S.) of imaging atmospheric Cherenkov telescopes observed five of these dwarf galaxies for more than 140 hours in total, searching for TeV gamma-ray emission from annihilation of dark matter particles. The new results of the deep exposure of the Sagittarius dwarf spheroidal galaxy, the first observations of the Coma Berenices and Fornax dwarves and the reanalysis of two more dwarf spheroidal galaxies already published by the H.E.S.S. Collaboration, Carina and Sculptor, are presented. In the absence of a significant signal new constraints on the annihilation cross section applicable to weakly interacting massive particles (WIMPs) are derived by combining the observations of the five dwarf galaxies. The combined exclusion limit depends on the WIMP mass and the best constraint is reached at 1-2 TeV masses with a cross-section upper bound of ~ 3.9 x 10 super(-24) cm super(3) s super(-1) at a 95% confidence level.
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