A Novel Cooling Device for Kidney Transplant Surgery.

Background: Prolonged warm ischemia time (WIT) in kidney transplantation is associated with numerous adverse outcomes including delayed graft function and decreased patient and graft survival. Circumventing WIT lies in maintaining renal hypothermia and efficiently performing the vascular anastomosis during this portion of the procedure. Although numerous methods of intra-operative renal cooling have been proposed, most suffer from practical limitations, and none have been widely adopted. Herein we describe a novel device specifically designed to maintain renal hypothermia during kidney transplant surgery.Methods: Aluminum tubing was organized in a serpentine pattern to create a malleable, form-fitting cooling jacket to manipulate renal allografts during transplant surgery. Adult porcine kidneys were used to test the device with 4°C saline as coolant. Kidneys were placed at 24°C; surface and core temperatures were monitored using implanted thermocouples. Anastomosis of porcine kidney vessels to GORE-TEX® vascular grafts in an ex-vivo operative field was performed to assess the functionality of the device.Results: The device maintained surface and core graft temperatures of ≤5°C after 60 minutes of WIT. Furthermore, the device provided hands-free retraction and support for the allograft. We found that ex-vivo anastomosis testing was enhanced by the presence of the cooling jacket.Conclusions: This proof-of-concept study demonstrated that our novel device is a practical tool for renal transplantation and can maintain sufficiently cool graft temperatures to mitigate WIT in an ex-vivo setting. This device is the first of its kind and has the potential to improve kidney transplant outcomes by eliminating WIT during graft implantation.

Assessing the potential of quantitative 2D HSQC NMR in 13C enriched living organisms.

In vivo Nuclear Magnetic Resonance (NMR) spectroscopy has great potential to interpret the biochemical response of organisms to their environment, thus making it an essential tool in understanding toxic mechanisms. However, magnetic susceptibility distortions lead to 1D NMR spectra of living organisms with lines that are too broad to identify and quantify metabolites, necessitating the use of 2D 1H-13C Heteronuclear Single Quantum Coherence (HSQC) as a primary tool. While quantitative 2D HSQC is well established, to our knowledge it has yet to be applied in vivo. This study represents a simple pilot study that compares two of the most popular quantitative 2D HSQC approaches to determine if quantitative results can be directly obtained in vivo in isotopically enriched Daphnia magna (water flea). The results show the perfect-HSQC experiment performs very well in vivo, but the decoupling scheme used is critical for accurate quantitation. An improved decoupling approach derived using optimal control theory is presented here that improves the accuracy of metabolite concentrations that can be extracted in vivo down to micromolar concentrations. When combined with 2D Electronic Reference To access In vivo Concentrations (ERETIC) protocols, the protocol allows for the direct extraction of in vivo metabolite concentrations without the use of internal standards that can be detrimental to living organisms. Extracting absolute metabolic concentrations in vivo is an important first step and should, for example, be important for the parameterization as well as the validation of metabolic flux models in the future.

Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital.

BACKGROUND: Frequent pages can disrupt workflow, interrupt patient care, and may contribute to physician burnout. We hypothesized that paging volumes followed consistent temporal trends, regardless of the medical or surgical service, reflecting systems based issues present in our hospitals. METHODS: A retrospective review of the hospital paging systems for 4 services at The Ottawa Hospital was performed. Resident paging data from April 1 to July 31, 2018 were collected for services with a single primary pager number including orthopaedic surgery, general surgery, neurology, and neurosurgery. Trends in paging volume during the 4-month period were examined. Variables examined included the location of origin of the page (emergency room vs. inpatient unit), and day/time of the page. RESULTS: During the study period, 25,797 pages were received by the 4 services, averaging 211 (± Standard Deviation (SD) 12) pages per day. 19,371 (75%) pages were from in-patient hospital units, while 6426 (24%) were pages from the emergency room. The median interval between pages across all specialties was 22:30 min. Emergency room pages peaked between 16:30 and 20:00, while in-patient units peaked between 17:30 and 18:30. CONCLUSIONS: Each service experienced frequent paging with similar patterns of marked increases at specific times. This study identifies areas for future study about what the factors are that contribute to the paging patterns observed.

Optimal control RF pulses for excitation and suppression of NMR signals in a conductive medium.

In this work, optimal control theory was used to design efficient excitation schemes in highly conductive materials, where both the radio frequency field strength and phase vary as a function of penetration depth. A pulse was designed to achieve phase alignment between signals at different depths within the conductor and thus to obtain higher signals from that region. In addition, an efficient suppression pulse was designed by insuring mutual suppression between the signals from various depths in the sample. The performance of the new approach was demonstrated experimentally for a bulk lithium sample for the excitation problem and for a biphasic metal/liquid sample for the selective suppression pulse.

Next-generation heteronuclear decoupling for high-field biomolecular NMR spectroscopy.

Ultra-high-field NMR spectroscopy requires an increased bandwidth for heteronuclear decoupling, especially in biomolecular NMR applications. Composite pulse decoupling cannot provide sufficient bandwidth at practical power levels, and adiabatic pulse decoupling with sufficient bandwidth is compromised by sideband artifacts. A novel low-power, broadband heteronuclear decoupling pulse is presented that generates minimal, ultra-low sidebands. The pulse was derived using optimal control theory and represents a new generation of decoupling pulses free from the constraints of periodic and cyclic sequences. In comparison to currently available state-of-the-art methods this novel pulse provides greatly improved decoupling performance that satisfies the demands of high-field biomolecular NMR spectroscopy.

Budesonide Orodispersible Tablet for the Treatment of Refractory Esophageal Lichen Planus.

Esophageal lichen planus is an uncommon but highly morbid condition where effective treatments are limited. Diagnosis may be challenging and requires a high degree of clinical suspicion considering endoscopic, histopathological, esophageal, and extraesophageal manifestations. We describe a severe case of esophageal lichen planus and recurrent esophageal stricture that was refractory to acid suppression, local and systemic steroid formulations, and dilatation. We present the first reported use of budesonide orodispersible tablet for this condition, including the excellent clinical, endoscopic, and histopathological response.

Septic and febrile kidney stone presentations during the COVID-19 pandemic What is the effect of reduced access to care during pandemic restrictions?

INTRODUCTION: During the early stages of the COVID-19 pandemic, hospitals shifted their resources and focus toward COVID-19 care and non-deferrable conditions. Renal colic is one of the most common urologic presentations to the emergency department (ED ). In our study, we examined whether there was an increase in septic/febrile stone presentations to the ED requiring ureteral stent insertion after the public health restrictions during the COVID-19 pandemic. METHODS: We carried out a retrospective cohort study and reviewed charts of septic/febrile stone patients requiring ureteral stent insertion from January 1, 2019, to March 16, 2020 (pre-COVID) and July 1, 2020, to December 31, 2021 (intra-COVID) at the Queen Elizabeth II Health Sciences Centre in Halifax, NS. The incidence of septic/febrile stone presentation, baseline characteristics, and perioperative outcomes were captured. RESULTS: There were 54 patients in the pre-COVID group and 74 patients in the intra- COVID group. There were no statistically significant differences found in baseline or stone characteristics between the two groups (p>0.05). Patients in the intra-COVID group were found to have a longer presentation to operating room time when compared to the pre- COVID cohort (U=961.00, p=0.04). The intra-COVID group had 20 more cases of septic stone presentations compared to the pre-COVID group at the 15-month mark (pre-COVID, n=54; intra-COVID, n=74). CONCLUSIONS: We found increased time to operative intervention in the intra-COVID cohort compared to the pre-COVID cohort. The overall number of urgent and/or critically ill ureteric stone patients increased between cohorts but was not statistically significant.

Localization dynamics of fluids in random confinement.

The dynamics of two-dimensional fluids confined within a random matrix of obstacles is investigated using both colloidal model experiments and molecular dynamics simulations. By varying fluid and matrix area fractions in the experiment, we find delocalized tracer particle dynamics at small matrix area fractions and localized motion of the tracers at high matrix area fractions. In the delocalized region, the dynamics is subdiffusive at intermediate times, and diffusive at long times, while in the localized regime, trapping in finite pockets of the matrix is observed. These observations are found to agree with the simulation of an ideal gas confined in a weakly correlated matrix. Our results show that Lorentz gas systems with soft interactions are exhibiting a smoothening of the critical dynamics and consequently a rounded delocalization-to-localization transition.

An atypical case of progressive multifocal leukoencephalopathy in a patient with high grade B-cell lymphoma causing diagnostic delay.

Progressive multifocal leukoencephalopathy (PML) is a rare disease of the central nervous system caused by opportunistic infection with JC virus. It presents in patients who are immunocompromised, and diagnosis is made by correlating clinical findings and radiological changes with the detection of JC virus in cerebrospinal fluid. Rarely, a brain biopsy is needed. A 72 year old with high grade B-cell lymphoma developed right arm weakness and limb ataxia shortly after his diagnosis. CNS involvement was excluded with a normal CT head, MRI brain/spine, and CSF examination. A paraneoplastic cause was suspected, and he received 5 cycles of Rituximab-containing chemotherapy to a complete metabolic remission. His neurology evolved during treatment despite serial MRI and CSF examination remaining normal. CSF and serum were both negative for JC virus by PCR. Following completion of chemotherapy, he deteriorated acutely with seizures and personality changes. It was only at this point that a repeat MRI showed new multiple scattered ring enhancing lesions within both cerebral hemispheres. The patient underwent a brain biopsy confirming JC virus positive-PML by immunohistochemistry and passed away one month later. This case illustrates the diagnostic challenges associated with PML and had several atypical features which led to diagnostic delay, specifically the onset of symptoms before starting immunochemotherapy, and the lack of radiological change despite evolving neurology. The eventual MRI abnormalities were not altogether classical for PML which, coupled with the JC-negativity in CSF and serum, meant a brain biopsy was required to reach the diagnosis.

The Impact of Combined Warm and Cold Ischemia Time on Post-transplant Outcomes.

Background: Prolonged warm ischemia time (WIT) and cold ischemia time (CIT) are independently associated with post-transplant graft failure; their combined impact has not been previously studied. We explored the effect of combined WIT/CIT on all-cause graft failure following kidney transplantation. Methods: The Scientific Registry of Transplant Recipients was used to identify kidney transplant recipients from January 2000 to March 2015 (after which WIT was no longer separately reported), and patients were followed until September 2017. A combined WIT/CIT variable (excluding extreme values) was separately derived for live and deceased donor recipients using cubic splines; for live donor recipients, the reference group was WIT 10 to <23 minutes and CIT >0 to <0.42 hours, and for deceased donor recipients the WIT was 10 to <25 minutes and CIT 1 to <7.75 hours. The adjusted association between combined WIT/CIT and all-cause graft failure (including death) was analyzed using Cox regression. Secondary outcomes included delayed graft function (DGF). Results: A total of 137 125 recipients were included. For live donor recipients, patients with prolonged WIT/CIT (60 to ≤120 minutes/3.04 to ≤24 hours) had the highest adjusted hazard ratio (HR) for graft failure (HR = 1.61, 95% confidence interval [CI] = 1.14-2.29 relative to the reference group). For deceased donor recipients, a WIT/CIT of 63 to ≤120 minutes/28 to ≤48 hours was associated with an adjusted HR of 1.35 (95% CI = 1.16-1.58). Prolonged WIT/CIT was also associated with DGF for both groups although the impact was more driven by CIT. Conclusions: Combined WIT/CIT is associated with graft loss following transplantation. Acknowledging that these are separate variables with different determinants, we emphasize the importance of capturing WIT and CIT independently. Furthermore, efforts to reduce WIT and CIT should be prioritized.

Contexte: La période prolongée d'ischémie à chaud (WIT­warm ischemia time) et la période prolongée d'ischémie à froid (CIT­cold ischemia time) ont été associées de façon indépendante à une défaillance du greffon post-transplantation, mais leur effet combiné n'a jamais été étudié. Nous avons examiné l'effet combiné WIT/CIT sur la défaillance du greffon toutes causes confondues après une transplantation rénale. Méthodologie: Le Scientific Registry of Transplant Recipients a été utilisé pour identifier les receveurs d'une greffe de rein entre janvier 2000 et mars 2015 (date après laquelle la WIT n'a plus été rapportée séparément). Les patients ont été suivis jusqu'en septembre 2017. Une variable combinée WIT/CIT (excluant les valeurs extrêmes) a été dérivée de façon isolée pour les donneurs vivants et les donneurs décédés à l'aide d'une fonction spline cubique. La WIT du groupe référence pour les donneurs vivants se situait entre 10 et <23 minutes, et la CIT entre 0 et <0,42 heure; pour les donneurs décédés, la WIT se situait entre 10 et <25 minutes, et la CIT entre 1 et <7,75 heures. L'association corrigée entre une combinaison WIT/CIT et la défaillance du greffon toutes causes confondues (y compris le décès) a été analysée à l'aide de la régression de Cox. Les résultats secondaires incluaient une reprise retardée de la fonction du greffon (RRFG). Résultats: Un total de 137 125 receveurs d'un rein a été inclus. Dans le groupe des receveurs d'un organe provenant d'un donneur vivant, les patients avec une WIT/CIT prolongée (60 à ≤120 minutes/3,04 à ≤24 heures) présentaient un risque relatif corrigé plus élevé de défaillance du greffon (RRc: 1,61; IC 95 %: 1,14-2,29) par rapport au groupe de référence. Dans le groupe des receveurs d'un organe provenant d'un donneur décédé, une combinaison WIT/CIT de 63 à ≤120 minutes/28 à ≤48 heures a été associée à un RRc de 1,35 (IC 95 %: 1,16-1,58). La WIT/CIT prolongée a également été associée à une RRFG pour les deux groupes, bien que cet effet ait été davantage influencé par la CIT. Conclusion: La combinaison WIT/CIT est associée à la perte du greffon après la transplantation. Sachant qu'il s'agit de variables distinctes avec des déterminants différents, nous soulignons l'importance de rapporter la WIT et la CIT de façon indépendante. Qui plus est, les efforts visant à réduire la WIT et la CIT devraient être prioritaires.

Spontaneous, atraumatic hydrocele rupture: A case report.

There is little information in the literature on the management and prognosis of ruptured hydroceles. We present a case report of spontaneous, atraumatic left hydrocele rupture in a 64-year-old male. His hydrocele was initially diagnosed as non-complex and appeared to have ruptured spontaneously three years after initial onset. On follow-up in clinic, mild re-accumulation of fluid was observed, and no pain was reported by the patient. Post-rupture fluid re-accumulation was minimal in our patient but there is potential for significant fluid re-accumulation based on other reports of ruptured hydroceles.

Effect of Tranexamic Acid on Bleeding Outcomes After Percutaneous Nephrolithotomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Purpose: We performed a systematic review and meta-analysis of the literature to evaluate the efficacy of the routine use of tranexamic acid (TXA) during percutaneous nephrolithotomy (PCNL). Methods: This systematic review was conducted following the updated reporting guidelines from PRISMA 2020. Results: In total, 275 titles and abstracts were reviewed, of which 20 were screened to be eligible for full text review. Of these 20 articles, 11 were selected for inclusion after full article evaluations. Seven of these 11 studies were seen as having a low risk of bias with a Jadad score of ≥3. These studies were included for data extraction. Once data were extracted, 964 patients were included. The primary outcome, blood transfusion rate, showed significant reduction with a ratio for transfusion rate of 0.34 [95% confidence interval (CI) (0.19 to 0.61), z = 3.61, p = 0.0003]. Mean hemoglobin (Hgb) drop and operative time were both shown to be reduced with the use of TXA. The mean difference for Hgb drop was -0.86 [95% CI (-1.26 to -0.46), z = 4.23, p < 0.0001]. Reduction in operative time showed a mean difference of -8.45 minutes [95% CI (-15.04 to -1.86), z = 2.51, p = 0.01]. Stone clearance was not shown to differ significantly between experimental and control groups, with a risk ratio of 1.28 [95% CI (0.89 to 1.84), z = 1.31, p = 0.19]. Conclusions: This meta-analysis revealed that the routine use of TXA at time of PCNL reduces the rates of blood transfusion, mean Hgb drop, and operative time. With the low cost of TXA and strong safety profile, stronger consideration should be given to the routine use of TXA during PCNL by endoscopic surgeons.

Fenretinide promotes functional recovery and tissue protection after spinal cord contusion injury in mice.

The inflammatory response is thought to contribute to secondary damage after spinal cord injury (SCI). Polyunsaturated fatty acids (PUFAs) play an important role in the onset and resolution of inflammation. Arachidonic acid (AA), an omega-6 PUFA, contributes to the initiation of inflammatory responses, whereas docosahexaenoic acid (DHA), an omega-3 PUFA, has antiinflammatory effects. Therefore, decreasing AA and increasing DHA levels after SCI might be expected to attenuate inflammation after SCI and promote tissue protection and functional recovery. We show here that daily oral administration of fenretinide after spinal cord contusion injury led to a significant decrease in AA and an increase in DHA levels in plasma and injured spinal cord tissue. This was accompanied by a significant reduction in tissue damage and improvement in locomotor recovery. Fenretinide also reduced the expression of proinflammatory genes and the levels of oxidative stress markers after SCI. In addition, in vitro studies demonstrated that fenretinide reduced TNF-alpha (tumor necrosis factor-alpha) expression by reactive microglia. These results demonstrate that fenretinide treatment after SCI can reduce inflammation and tissue damage in the spinal cord and improve locomotor recovery. These beneficial effects may be mediated via the ability of fenretinide to modulate PUFA homeostasis. Since fenretinide is currently in clinical trials for the treatment of cancers, this drug might be a good candidate for the treatment of acute SCI in humans.

Supercooled dynamics of grain boundary particles in two-dimensional colloidal crystals.

We experimentally investigate the dynamics of particles constituting grain boundaries in a two-dimensional colloidal crystal, using video-microscopy. A clear plateau in the mean square displacement of the grain boundary particles is found, followed by an upswing indicative of cage breaking. The van Hove correlation functions and the non-Gaussian parameter show that grain boundary particle dynamics are highly heterogeneous. Furthermore, we identified clusters of cooperatively moving particles and analyzed the time-dependence of the weight-averaged mean cluster size. We find good correlation between the behavior of the mean square displacement, and the time dependence of the non-Gaussian parameter and the cluster size, as also reported for various supercooled systems. Our results therefore provide experimental support for the similarity between particle dynamics in grain boundaries and in supercooled liquids as suggested by recent computer simulations.

Urolithiasis in the elderly.

OBJECTIVES: Urolithiasis is an increasing problem in patients ≥ 80 years. Our objective was to compare patients ≥ 80 years with urolithiasis to a younger cohort in terms of presentation and management. METHODS: Patients referred to a tertiary care stone clinic for management of urolithiasis over a 5 year period were reviewed. Data collected on clinical parameters for patients ≥ 80 years were compared with a random sample of those < 80 years. RESULTS: There were 26 patients ≥ 80 years and 102 in the sample < 80 years; mean age was 83.5 ± 0.6 and 50.1 ± 1.3 years, respectively. The older group had more comorbidities. The presenting complaint was more often flank pain in younger patients. Patients ≥ 80 years had larger stones. Early ureteric stent insertion was more likely in the elderly compared with the younger group (27% versus 7%, p < 0.01). Definitive therapy for patients ≥ 80 years was most often percutaneous nephrolithotomy (PCNL) (23%) compared with only 9% in the younger group. In contrast, the most common definitive treatment modality used for patients < 80 years was extracorporeal shock wave lithotripsy (ESWL) (35% versus 8%, p < 0.01). There was no difference in intraoperative complications. Thirty nine percent of the older group was managed as outpatients. More of the older group had postoperative complications but all were minor. CONCLUSION: Urolithiasis in the elderly is challenging to treat because they have more comorbidities and are less likely to present with classic symptoms of renal colic. This may lead to later presentation with larger and more complex stone disease. Early ureteric stent is often required and definitive PCNL is more likely than in the younger cohort. Despite these issues most can be treated safely and often as an outpatient.

Technology readiness of medical students and the association of technology readiness with specialty interest.

BACKGROUND: Technology readiness (TR) is a construct which characterizes an individual's propensity to utilize new technology. Despite increased technology use in healthcare, limited data exists on medical student TR and the relation of TR with specialty interest. This study assesses the TR of 2nd year medical students and its association with specialty interest. METHODS: Respondents completed a survey assessing their most preferred specialty, specialty interests, and technology readiness using a 5-point Likert scale. Using Chi-square analysis, we examined the relation between demographics, TR, and specialty interest. RESULTS: This study obtained a 45.7% (n = 53/116) response rate demonstrating that 79.2% (n = 42/53) of students were "technology ready." Male students were more likely to be technology ready (95.2%, n = 20/21, vs 68.8%, n = 22/32, p = 0.02) when compared to female students. Technology ready students were associated with being more interested in "Technology-Focused" specialties compared to students who were not technology ready (88.5%, n = 23/26 vs 70.4%, n = 19/27, p = 0.104). CONCLUSIONS: As a cohort, most medical students were technology ready. It is inconclusive if technology ready students are more likely to be interested in technology-focused specialties due to the limited sample size of this study, although with an increased sample size, an improved understanding on technology readiness and its potential impact on student specialty interest may be obtained. Furthermore, knowledge of TR may aid in developing targeted technology-based education programs and in improving remedial approaches for students who are less comfortable with new technology.

CONTEXTE: La réceptivité aux technologies (RT) renvoie à la tendance qu'a un individu à utiliser une nouvelle technologie. Malgré l'utilisation accrue des technologies dans le domaine des soins de santé, il existe peu de données sur la RT des étudiants en médecine et sur la relation entre cette réceptivité et leur intérêt envers les diverses spécialités. La présente étude évalue la RT des étudiants en médecine de 2e année et le rapport entre celle-ci et leur intérêt envers certaines spécialités. MÉTHODES: Les répondants au sondage ont été interrogés sur leur spécialité préférée, sur leurs intérêts envers les diverses spécialités et sur leur réceptivité aux technologies. Leurs réponses ont été évaluées à l'aide d'une échelle de Likert à 5 points. En utilisant l'analyse du Chi carré, nous avons examiné la relation entre la démographie, la RT et les intérêts de spécialité. RÉSULTATS: Cette étude a obtenu un taux de réponse de 45,7 % (n = 53/116), montrant que 79,2 % (n = 42/53) des étudiants sont prêts pour l'utilisation des technologies. Cette tendance est davantage présente chez les étudiants de sexe masculin (95,2 %, n = 20/21, comparé à 68,8 %, n = 22/32, p = 0,02 pour les étudiantes). Les étudiants qui sont réceptifs aux technologies ont plus tendance que leurs homologues qui le sont moins à s'intéresser aux spécialités « axées sur la technologie ¼ (88,5 %, n = 23/26, comparé à 70,4 %, n = 19/27, p = 0,104). CONCLUSIONS: La plupart des étudiants de la cohorte étudiée étaient réceptifs aux technologies. En raison de la taille limitée de l'échantillon de l'étude, on ne peut pas conclure que les étudiants qui sont réceptifs aux technologies sont plus susceptibles de s'intéresser aux spécialités axées sur la technologie. Des recherches fondées sur un échantillon élargi nous aideraient à mieux comprendre la réceptivité aux technologies et son impact potentiel sur les intérêts des étudiants envers les diverses spécialités. De surcroît, ces connaissances peuvent contribuer à l'élaboration de programmes d'enseignement axés sur la technologie et de mesures d'aide au profit des étudiants qui sont moins à l'aise avec les nouvelles technologies.

A randomised study of comfort during bronchoscopy comparing conscious sedation and anaesthetist-controlled general anaesthesia, including the utility of bispectral index monitoring.

BACKGROUND: The difference in patient comfort with conscious sedation versus general anaesthesia for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with conscious sedation is noninferior to general anaesthesia. METHODS: 96 subjects were randomised to receive conscious sedation or general anaesthesia for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included willingness to undergo a repeat procedure if necessary and level of sedation assessed clinically and by bispectral index (BIS) monitoring. RESULTS: There was no significant difference between subject comfort scores (difference -0.01, 95% CI -0.63-0.61 on a 10-point scale; p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, 95% CI -4.8-15.5%; p=0.37). Deeper levels of sedation in the general anaesthesia cohort was confirmed with both clinical and BIS monitoring. There was no significant difference in diagnostic accuracy (conscious sedation 93.9%, 95% CI 80.4-98.3% versus general anaesthesia 86.5%, 95% CI 72.0-94.1%; p=0.43). There were more complications (29.6%, 95% CI 18.2-44.2% versus 6.1%, 95% CI 2.1-16.5%; p<0.01) in the general anaesthesia group. There was no relationship between high BIS scores and subject discomfort. BIS levels <40 during a procedure were associated with increased complications. CONCLUSION: Conscious sedation is not inferior to general anaesthesia in providing patient comfort during bronchoscopy, despite lighter sedation, and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.

Grain-boundary fluctuations in two-dimensional colloidal crystals.

We study grain-boundary fluctuations in two-dimensional colloidal crystals in real space and time using video microscopy. The experimentally obtained static and dynamic correlation functions are very well described by expressions obtained using capillary wave theory. This directly leads to values for the interfacial stiffness and the interface mobility, the key parameters in curvature-driven grain-boundary migration. Furthermore, we show that the average grain-boundary position exhibits a one-dimensional random walk as recently suggested by computer simulations [Z. T. Trautt, M. Upmanyu, and A. Karma, Science 314, 632 (2006)]. The interface mobility determined from the mean-square displacement of the average grain-boundary position is in good agreement with values inferred from grain-boundary fluctuations.

"Between a Rock and a Hard Place": A Case Report of Stone Fragment Impaction Causing a Retained Ureteroscope Requiring Open Surgical Intervention.

Background: Ureteroscopy is frequently used for small renal and ureteral calculi. Rarely cases have been reported of retained ureteroscopes as a complication. With the limited number of cases, it is important to add these to the literature to mitigate the future risk from this complication that can lead to significant morbidity. We present our unique experience with a retained ureteroscope requiring open surgical intervention. Case Presentation: Our case is a 65-year-old female undergoing ureteroscopy for a 2 cm right ureteropelvic junction obstructing stone. After laser lithotripsy, there was significant buildup of stone debris distally along the ureteroscope. Conservative measures failed to remove the ureteroscope, so an open surgical approach was taken. The ureteroscope was removed, and a ureteral reimplant was performed. Postoperative CT shows residual hydronephrosis, but there is no obstruction seen on renal Lasix scan. Conclusions: This is a rare, but real, complication that urologists must be aware of. Preventive measures with pre-stenting early intraoperative stenting, using a ureteral access sheath, or using a single-use flexible ureteroscope could be considered especially when treating larger stones endoscopically.