Single-Step Protocol for Isolating the Recombinant Extracellular Domain of the Luteinizing Hormone Receptor from the Ovis aries Testis.

The luteinizing hormone receptor (LHR) is a glycoprotein member of the G protein-coupled receptors superfamily. It participates in corpus luteum formation and ovulation in females and acts in testosterone synthesis and spermatogenesis in males. In this study, we extracted RNA from sheep testicles and synthetized the cDNA to amplify the gene lhr-bed. This gene consists of 762 bp and encodes 273 amino acids of the extracellular domain of LHR. The lhr-bed was cloned into pJET1.2/blunt, then subcloned into pCOLD II, and finally, transformed in E. coli BL21 (DE3) cells. Because the induced rLHR-Bed protein was found in the insoluble fraction, we followed a modified purification protocol involving induction at 25 °C, subjection to denaturing conditions, and on-column refolding to increase solubility. We confirmed rLHR-Bed expression by means of Western blot and mass spectrometry analysis. It is currently known that the structure stem-loop 5'UTR on pCOLD II vector is stable at 15 °C. We predicted and obtained RNAfold stability at 25 °C. We successfully obtained the recombinant LHR extracellular domain, with protein yields of 0.2 mg/L, and purity levels of approximately 90%, by means of a single chromatographic purification step. The method described here may be used to obtain large quantities of rLHR-Bed in the future.

Revisional Roux-en-Y gastric bypass after failed gastric banding: a case-matched study.

BACKGROUND: Revisional surgery is technically demanding and is usually associated with higher intraoperative and perioperative risks than primary procedures. The objective of this study is to compare outcomes of patients who had gastric bypass procedures performed as a rescue procedure for failed gastric banding, with those who had a primary gastric bypass. MATERIALS AND METHODS: The group of patients undergoing revisional gastric bypass for failed gastric band was matched in a 1:2 ratio with control patients who underwent a primary RYGB, based on gender, score, preoperative body mass index, and comorbidities. Data were retrospectively retrieved. RESULTS: Thirty one (33.3%) patients underwent band removal and gastric bypass (group A) and 62 (66.6%) only primary gastric bypass (group B). Nonsignificant differences were seen in operative time, operative bleeding, or length of stay. Complications were more frequent in group A. Postoperative weight at 12-month follow-up was greater in group A, however, not statistically significant. Changes in weight, both absolute, and percentage were not different between groups. This observation was also true for BMI, in which no significant differences were seen. Overall, mean follow-up was 16 ± 3.2 months. CONCLUSION: Gastric bypass can be performed as revisional bariatric surgery, with low complication rates and acceptable outcomes, though not with the same safety as a primary procedure. Gastric bypass is a satisfactory option for patients with a failed gastric band.

Use of the self-reported critical view of safety in laparoscopic cholecystectomy during residency.

BACKGROUND: Even though the goal of safely performing cholecystectomy is already a priority in general surgical training programs, we aimed to study how many residents and attendings reached the critical view of safety (CVS) in laparoscopic cholecystectomy. MATERIALS AND METHODS: Retrospective review of prospectively collected data of all patients with biliary surgical conditions, which underwent laparoscopic cholecystectomy and their corresponding postoperative notes with self-reported CVS from May 2019 to May 2020 in an academic hospital. Comparisons of operative variables between postgraduate year and attendings were made. RESULTS: Laparoscopic cholecystectomy was performed in 126 elective cases (62.6%) and 75 (37.3%) emergency cases. On 105 (83.3%) of the elective cases and on 54 (66.7%) emergency cases, a CVS was successfully performed. PGY3 and PGY5 had higher odds of achieving CVS compared to attendings OR 6.09 (95% CI 2.05 to 8.07) and 4.51 (95% CI 1.0 to 10.20), respectively. Overall, attendings had decreased odds ratio of achieving CVS of 0.488 when compared to all residents. Elective procedures had increased odds ratios of achieving CVS of 3.44 (95% CI 1.52 to 7.74). On elective cases, attendings performed significantly faster procedures when compared to PGY2-4, but not PGY5. No differences were seen between operative speeds between PGY. Third-year residents were identified as having the highest frequency of CVS; however, these differences were not statistically significant. In emergency cases, blood loss, operative time, CVS, and bile duct injuries revealed non-significant differences between operators. CONCLUSION: CVS was reached significantly more often in elective than in emergency surgeries. There is still a lack of residents and attending surgeons who still failed to complete CVS during LC, highlighting the need for further education. Future studies should be attempted to repeat this study with a larger sample size and multiple coaching sessions to determine long-term efficacy.

Esophageal Duplication Cysts in 97 Adult Patients: A Systematic Review.

BACKGROUND: Esophageal duplication cysts are a rare congenital cystic malformation from faulty intrauterine recanalization of the esophagus during the 4-8th weeks of development. They account for 20% of all gastrointestinal duplication cysts and commonly involve the distal esophagus. Presenting symptoms may be related to size and location. MATERIALS AND METHODS: Following the PRISMA guidelines, a systematic review was performed by searching published literature in various databases. Data from 97 reported case reports were pooled to present a descriptive and statistical analysis. RESULTS: Patient population was composed of 51(52.5%) males and 46 (47.5%) females, and mean ages was 42.3 years (18-77). Distal cysts were the most prevalent. Seventy-nine (81.4%) patients were symptomatic; common symptoms included dysphagia, chest pain, cough and weight loss. Fifteen (15.5%) patients were treated conservatively and 75 (84.5%) by surgical treatment, among them thoracotomy in 30 (30.9%) patients and VATS in 17 (17.5%) patients. Mean length of hospital stay was 8.6 days (range: 1-26 days). One fatality was registered. Location, unlike size, was not found to influence presenting symptoms or treatment employed. Frequency of conservative treatment was not significantly different between symptomatic and asymptomatic patients. Open approaches were associated with longer stays than their minimally invasive counterparts. CONCLUSION: Esophageal duplication cysts remain rare in adults and are frequently located in the distal esophagus. Larger cysts are more likely to cause symptoms. Various surgical techniques may successfully be employed in the treatment of this pathology. Minimally invasive procedures have a shorter hospital stay.

MIS-Like Structures with Silicon-Rich Oxide Films Obtained by HFCVD: Their Response as Photodetectors.

MIS-type structures composed of silicon-rich oxide (SRO), thin films deposited by hot filament chemical vapor deposition (HFCVD), show interesting I-V and I-t properties under white light illumination and a response as photodetectors. From electrical measurements, it was found that at a reverse bias of -4 V, the illumination current increased by up to three orders of magnitude relative to the dark current, which was about 82 nA, while the photogenerated current reached a value of 25 µA. The reported MIS structure with SRO as the dielectric layer exhibited a hopping conduction mechanism, and an ohmic conduction mechanism was found with low voltage. I-t measurements confirmed the increased photogenerated current. Furthermore, the MIS structure, characterized by current-wavelength (I-λ) measurements, exhibited a maximum responsivity value at 254 mA/W, specific detectivity (D*) at 2.21 × 1011 cm Hz1/2 W-1, and a noise equivalent power (NEP) of 49 pW at a wavelength of 535 nm. The structure exhibited good switching behavior, with rise and fall times between 120 and 150 ms, respectively. These rise and decay times explain the generation and recombination of charge carriers and the trapping and release of traps, respectively. These results make MIS-type structures useful as photodetectors in the 420 to 590 nm range.

Modeling human pollution in water bodies using somatic coliphages and bacteriophages that infect Bacteroides thetaiotaomicron strain GA17.

The ability to detect human fecal pollution in water is of great importance when assessing the associated health risks. Many microbial source tracking (MST) markers have been proposed to determine the origin of fecal pollution, but their application remains challenging. A range of factors, not yet sufficiently analyzed, may affect MST markers in the environment, such as dilution and inactivation processes. In this work, a statistical framework based on Monte Carlo simulations and non-linear regression was used to develop a classification procedure for use in MST studies. The predictive model tested uses only two parameters: somatic coliphages (SOMCPH), as an index of general fecal pollution, and human host-specific bacteriophages that infect Bacteroides thetaiotaomicron strain GA17 (GA17PH). Taking into account bacteriophage dilution and differential inactivation, the threshold concentration of SOMCPH was calculated to be around 500 PFU/100 mL for a limit of detection of 10 PFU/100 mL. However, this threshold can be lowered by increasing the analyzed volume sample, which in turn lowers the limit of detection. The resulting model is sufficiently accurate for application in practical cases involving MST and could be easily used with markers other than those tested here.

Camera-LiDAR Multi-Level Sensor Fusion for Target Detection at the Network Edge.

There have been significant advances regarding target detection in the autonomous vehicle context. To develop more robust systems that can overcome weather hazards as well as sensor problems, the sensor fusion approach is taking the lead in this context. Laser Imaging Detection and Ranging (LiDAR) and camera sensors are two of the most used sensors for this task since they can accurately provide important features such as target´s depth and shape. However, most of the current state-of-the-art target detection algorithms for autonomous cars do not take into consideration the hardware limitations of the vehicle such as the reduced computing power in comparison with Cloud servers as well as the reduced latency. In this work, we propose Edge Computing Tensor Processing Unit (TPU) devices as hardware support due to their computing capabilities for machine learning algorithms as well as their reduced power consumption. We developed an accurate and small target detection model for these devices. Our proposed Multi-Level Sensor Fusion model has been optimized for the network edge, specifically for the Google Coral TPU. As a result, high accuracy results are obtained while reducing the memory consumption as well as the latency of the system using the challenging KITTI dataset.

Exploring a Novel Multiple-Query Resistive Grid-Based Planning Method Applied to High-DOF Robotic Manipulators.

The applicability of the path planning strategy to robotic manipulators has been an exciting topic for researchers in the last few decades due to the large demand in the industrial sector and its enormous potential development for space, surgical, and pharmaceutical applications. The automation of high-degree-of-freedom (DOF) manipulator robots is a challenging task due to the high redundancy in the end-effector position. Additionally, in the presence of obstacles in the workspace, the task becomes even more complicated. Therefore, for decades, the most common method of integrating a manipulator in an industrial automated process has been the demonstration technique through human operator intervention. Although it is a simple strategy, some drawbacks must be considered: first, the path's success, length, and execution time depend on operator experience; second, for a structured environment with few objects, the planning task is easy. However, for most typical industrial applications, the environments contain many obstacles, which poses challenges for planning a collision-free trajectory. In this paper, a multiple-query method capable of obtaining collision-free paths for high DOF manipulators with multiple surrounding obstacles is presented. The proposed method is inspired by the resistive grid-based planner method (RGBPM). Furthermore, several improvements are implemented to solve complex planning problems that cannot be handled by the original formulation. The most important features of the proposed planner are as follows: (1) the easy implementation of robotic manipulators with multiple degrees of freedom, (2) the ability to handle dozens of obstacles in the environment, (3) compatibility with various obstacle representations using mathematical models, (4) a new recycling of a previous simulation strategy to convert the RGBPM into a multiple-query planner, and (5) the capacity to handle large sparse matrices representing the configuration space. A numerical simulation was carried out to validate the proposed planning method's effectiveness for manipulators with three, five, and six DOFs on environments with dozens of surrounding obstacles. The case study results show the applicability of the proposed novel strategy in quickly computing new collision-free paths using the first execution data. Each new query requires less than 0.2 s for a 3 DOF manipulator in a configuration space free-modeled by a 7291 × 7291 sparse matrix and less than 30 s for five and six DOF manipulators in a configuration space free-modeled by 313,958 × 313,958 and 204,087 × 204,087 sparse matrices, respectively. Finally, a simulation was conducted to validate the proposed multiple-query RGBPM planner's efficacy in finding feasible paths without collision using a six-DOF manipulator (KUKA LBR iiwa 14R820) in a complex environment with dozens of surrounding obstacles.

Synthesis and Two-Dimensional Chiral Surface Self-Assembly of a π-Conjugated System with Three-Fold Symmetry: Benzotri(7-Azaindole).

The synthesis of a novel expanded π-conjugated system, namely benzotri(7-azaindole), BTAI, is reported. Its C3h symmetry along with the integration of six complementary donor and acceptor N-H⋅⋅⋅N hydrogen bonds in the conjugated structure promote the 2D self-assembly on Au(111) over extended areas. Besides, a perfect commensurability with the gold lattice endows the physisorbed molecular film with a remarkable stability. The structural features of BTAI result in two levels of surface chirality: Firstly, the molecules become chiral upon adsorption on the surface. Then, due to the favorable N-H⋅⋅⋅N hydrogen bond-directed self-assembly, along with the relative molecular rotation with respect to the substrate, supramolecular chirality manifests in two mirror enantiomorphous domains. Thus, the system undergoes spontaneous chiral resolution. LEED and STM assisted by theoretical simulations have been employed to characterize in detail these novel 2D conglomerates with relevant chiral properties for systems with C3h symmetry.

No surviving evolved companions of the progenitor of SN 1006.

Type Ia supernovae are thought to occur when a white dwarf made of carbon and oxygen accretes sufficient mass to trigger a thermonuclear explosion. The accretion could be slow, from an unevolved (main-sequence) or evolved (subgiant or giant) star (the single-degenerate channel), or rapid, as the primary star breaks up a smaller orbiting white dwarf (the double-degenerate channel). A companion star will survive the explosion only in the single-degenerate channel. Both channels might contribute to the production of type Ia supernovae, but the relative proportions of their contributions remain a fundamental puzzle in astronomy. Previous searches for remnant companions have revealed one possible case for SN 1572 (refs 8, 9), although that has been questioned. More recently, observations have restricted surviving companions to be small, main-sequence stars, ruling out giant companions but still allowing the single-degenerate channel. Here we report the results of a search for surviving companions of the progenitor of SN 1006 (ref. 14). None of the stars within 4 arc minutes of the apparent site of the explosion is associated with the supernova remnant, and we can firmly exclude all giant and subgiant stars from being companions of the progenitor. In combination with previous results, our findings indicate that fewer than 20 per cent of type Ia supernovae occur through the single-degenerate channel.

Chemistry below graphene: decoupling epitaxial graphene from metals by potential-controlled electrochemical oxidation.

While high-quality defect-free epitaxial graphene can be efficiently grown on metal substrates, strong interaction with the supporting metal quenches its outstanding properties. Thus, protocols to transfer graphene to insulating substrates are obligatory, and these often severely impair graphene properties by the introduction of structural or chemical defects. Here we describe a simple and easily scalable general methodology to structurally and electronically decouple epitaxial graphene from Pt(111) and Ir(111) metal surfaces. A multi-technique characterization combined with ab-initio calculations was employed to fully explain the different steps involved in the process. It was shown that, after a controlled electrochemical oxidation process, a single-atom thick metal-hydroxide layer intercalates below graphene, decoupling it from the metal substrate. This decoupling process occurs without disrupting the morphology and electronic properties of graphene. The results suggest that suitably optimized electrochemical treatments may provide effective alternatives to current transfer protocols for graphene and other 2D materials on diverse metal surfaces.

Use of non-linear mixed-effects modelling and regression analysis to predict the number of somatic coliphages by plaque enumeration after 3 hours of incubation.

The present study aimed to establish the kinetics of the appearance of coliphage plaques using the double agar layer titration technique to evaluate the feasibility of using traditional coliphage plaque forming unit (PFU) enumeration as a rapid quantification method. Repeated measurements of the appearance of plaques of coliphages titrated according to ISO 10705-2 at different times were analysed using non-linear mixed-effects regression to determine the most suitable model of their appearance kinetics. Although this model is adequate, to simplify its applicability two linear models were developed to predict the numbers of coliphages reliably, using the PFU counts as determined by the ISO after only 3 hours of incubation. One linear model, when the number of plaques detected was between 4 and 26 PFU after 3 hours, had a linear fit of: (1.48 × Counts3 h + 1.97); and the other, values >26 PFU, had a fit of (1.18 × Counts3 h + 2.95). If the number of plaques detected was <4 PFU after 3 hours, we recommend incubation for (18 ± 3) hours. The study indicates that the traditional coliphage plating technique has a reasonable potential to provide results in a single working day without the need to invest in additional laboratory equipment.

Outcome of Recipients of Hematopoietic Stem Cell Transplants Who Require Intensive Care Unit Support: A Single Institution Experience.

Admission to the intensive care unit (ICU) of a patient who has been grafted with hematopoietic stem cells is a serious event, but the role of the ICU in this setting remains controversial. Data were analyzed from patients who underwent autologous or allogeneic bone marrow transplantation at the Centro de Hematología y Medicina Interna de Puebla, México, between May 1993 and October 2014. In total, 339 patients were grafted: 150 autografts and 189 allografts; 68 of the grafted patients (20%) were admitted to the ICU after transplantation: 27% of the allografted and 11% of the autografted patients (p = 0.2). Two of 17 autografted patients (12%) and 5 of 51 allografted patients (10%) survived. All patients who required insertion of an endotracheal tube died, whereas 7 of 11 patients without invasive mechanical ventilation survived (p = 0.001). Only 10% of the grafted patients survived their stay in the ICU; this figure is lower than those reported from other centers and may reflect several facts, varying from the quality of the ICU support to ICU admission criteria to the initial management of all the grafts in an outpatient setting, which could somehow delay the arrival of patients to the hospital.

Vacancy formation on C60/Pt (111): unraveling the complex atomistic mechanism.

The interaction of fullerenes with transition metal surfaces leads to the development of an atomic network of ordered vacancies on the metal. However, the structure and formation mechanism of this intricate surface reconstruction is not yet understood at an atomic level. We combine scanning tunneling microscopy, high resolution and temperature programmed-x-ray photoelectrons spectroscopy, and density functional theory calculations to show that the vacancy formation in C60/Pt(111) is a complex process in which fullerenes undergo two significant structural rearrangements upon thermal annealing. At first, the molecules are physisorbed on the surface; next, they chemisorb inducing the formation of an adatom-vacancy pair on the side of the fullerene. Finally, this metastable state relaxes when the adatom migrates away and the vacancy moves under the molecule. The evolution from a weakly-bound fullerene to a chemisorbed state with a vacancy underneath could be triggered by residual H atoms on the surface which prevent a strong surface-adsorbate bonding right after deposition. Upon annealing at about 440 K, when all H has desorbed, the C60 interacts with the Pt surface atoms forming the vacancy-adatom pair. This metastable state induces a small charge transfer and precedes the final adsorption structure.

Fullerenes from aromatic precursors by surface-catalysed cyclodehydrogenation.

Graphite vaporization provides an uncontrolled yet efficient means of producing fullerene molecules. However, some fullerene derivatives or unusual fullerene species might only be accessible through rational and controlled synthesis methods. Recently, such an approach has been used to produce isolable amounts of the fullerene C(60) from commercially available starting materials. But the overall process required 11 steps to generate a suitable polycyclic aromatic precursor molecule, which was then dehydrogenated in the gas phase with a yield of only about one per cent. Here we report the formation of C(60) and the triazafullerene C(57)N(3) from aromatic precursors using a highly efficient surface-catalysed cyclodehydrogenation process. We find that after deposition onto a platinum (111) surface and heating to 750 K, the precursors are transformed into the corresponding fullerene and triazafullerene molecules with about 100 per cent yield. We expect that this approach will allow the production of a range of other fullerenes and heterofullerenes, once suitable precursors are available. Also, if the process is carried out in an atmosphere containing guest species, it might even allow the encapsulation of atoms or small molecules to form endohedral fullerenes.

[Evolution of endovascular treatment compared with medical and surgical treatment in patients with aortic syndrome type B]. / Evolución del tratamiento endovascular comparado con el tratamiento médico y el quirúrgico en pacientes con síndrome aórtico agudo de tipo B.

INTRODUCTION: Surgical treatment is accepted as conventional treatment of patients with acute aortic syndrome associated to ischemic complications. Promising results of thoracic endovascular aortic repair (TEVAR) has expanded its indication to a variety of thoracic aorta pathologies. OBJECTIVES: The objective of this study was to evaluate the safety and efficacy of TEVAR during the in-hospital period and at mid-term follow-up, and compare with medical and surgical treatment in patients who presented with acute aortic syndrome (AAS) type B. MATERIAL AND METHODS: Of 113 patients that fulfilled the inclusion criteria, 58 underwent endovascular treatment (Group 1), 34 had medical treatment (Group 2), and 21 had surgical treatment (Group 3). RESULTS: Global and cardiovascular in-hospital mortality was superior in Group 3 (p = 0.0001). Mean follow-up was 30.4 ± 12.2 months. The survival rate free from cardiovascular death was 92.5, 60.5, and 42.9, in Group 1, 2, and 3, respectively, at 36 months. CONCLUSIONS: Our results suggest that endovascular treatment is feasible, safe, and associated with a reduction of in-hospital and mid-term major adverse cardiovascular events, and superior survival rate compared with surgical and medical treatment.

Exploring plastic biofilm formation and Escherichia coli colonisation in marine environments.

Microorganisms, including potential pathogens, can colonise plastic surfaces in aquatic environments. This study investigates the colonisation of plastic pellets by Escherichia coli (E. coli) as a proxy for faecal pathogens in aquatic environments. Plastic pellets from a polluted beach were placed in seawater aquaria spiked with E. coli. Diverse bacteria, primarily from the Proteobacteria phylum, rapidly colonised the pellets within 24 h, with notable species known for plastic or hydrocarbon degradation. Over 26 days, biofilms formed on the plastic surfaces, reaching bacterial populations of up to 6.8·105 gene copies (gc) of the 16S rRNA mm-2. E. coli, was detected in the pellets for up to 7 days using culture methods, exhibiting varying attachment densities regardless of source or environmental factors. The study highlights plastic biofilms as reservoirs for E. coli, contributing to the survival and persistence of faecal bacteria in aquatic systems. These findings deepen our understanding of the risks associated with plastic pollution in marine settings, offering insights into the behaviour of faecal indicators and their implications for water quality assessments, while providing valuable information on potential pathogen dissemination within plastic-associated microbial communities.

Structural Defects on Graphene Generated by Deposition of CoO: Effect of Electronic Coupling of Graphene.

Understanding the interactions in hybrid systems based on graphene and functional oxides is crucial to the applicability of graphene in real devices. Here, we present a study of the structural defects occurring on graphene during the early stages of the growth of CoO, tailored by the electronic coupling between graphene and the substrate in which it is supported: as received pristine graphene on polycrystalline copper (coupled), cleaned in ultra-high vacuum conditions to remove oxygen contamination, and graphene transferred to SiO2/Si substrates (decoupled). The CoO growth was performed at room temperature by thermal evaporation of metallic Co under a molecular oxygen atmosphere, and the early stages of the growth were investigated. On the decoupled G/SiO2/Si samples, with an initial low crystalline quality of graphene, the formation of a CoO wetting layer is observed, identifying the Stranski-Krastanov growth mode. In contrast, on coupled G/Cu samples, the Volmer-Weber growth mechanism is observed. In both sets of samples, the oxidation of graphene is low during the early stages of growth, increasing for the larger coverages. Furthermore, structural defects are developed in the graphene lattice on both substrates during the growth of CoO, which is significantly higher on decoupled G/SiO2/Si samples mainly for higher CoO coverages. When approaching the full coverage on both substrates, the CoO islands coalesce to form a continuous CoO layer with strip-like structures with diameters ranging between 70 and 150 nm.

Anaphylaxis diagnosis and treatment at an emergency department in Puerto Rico.

OBJECTIVE: Anaphylaxis is a severe, potentially life-threatening systemic allergic reaction. Most cases of anaphylaxis are encountered and managed at Emergency Departments (ED). We aimed to evaluate all cases of anaphylaxis and of acute allergic reactions presenting to the ED of the Veterans Affairs Caribbean Healthcare System (VACHS) to assess each patient's presentation, the possible cause of that individual's allergic reaction or anaphylaxis, and the treatment or treatments that that person received. METHODS: We conducted a retrospective review of all of the cases seen at the ED from July 2007 through July 2009 in which a diagnosis of either anaphylaxis (ICD-9-CM 995.0) or allergic reaction (ICD-9-CM 995.3) was made. We reviewed the diagnosis of each case using the anaphylaxis guidelines and compared the presentations, causes, treatments, and outcomes of patients with recognized or unrecognized anaphylaxis. RESULTS: The study included 135 adults. Six patients (4.4%) were diagnosed with anaphylaxis and 129 patients (95.6%) were found to have been suffering from allergic reactions. Among the patients diagnosed with allergic reactions, 25 (23%) met the diagnostic criteria for anaphylaxis but were not recognized as having experienced it. The most common causes for anaphylaxis were food (41.9%), medication (38.7%), and insect bites or stings (12.9%); in 12.9% of the cases, a cause could not be determined. There were no statistically significant differences between groups in terms of demographics, causes, or symptoms. Significant differences were found in patient vital signs upon ED arrival. There was under-treatment, particularly among subjects with unrecognized anaphylaxis. Only 67% of recognized and 4% of unrecognized anaphylaxis were treated with epinephrine (p<0.001). It was more likely for subjects whose anaphylaxis was recognized to be admitted than was the case for patients whose anaphylaxis went unrecognized or who were merely suffering from allergic reactions (p<0.001). CONCLUSION: Anaphylaxis is under-diagnosed and under-treated in ED patients receiving care at the VACHS. There is a need to improve anaphylaxis recognition and treatment in the ED setting and, in addition, to better identify barriers to optimal health care.