Reflecting on an anniversary. The 1970 SS Arrow oil spill in Chedabucto Bay, Nova Scotia, Canada.

Fifty years ago, the tanker SS Arrow ran aground in Chedabucto Bay on the east coast of Canada, causing a massive spill of Bunker C oil in winter conditions. This article reflects on this anniversary, briefly describing the spill response and the considerable follow-up research over five decades on the fate and effects of oils spilled in northern cold marine waters. Importantly, the spill led to considerable work in Canada on spill control and bioremediation measures, and advice about oil spills as a marine pollutant of global importance.

Assessing the role of ketogenic dietary therapy in ring chromosome 20 syndrome: A patient-led approach.

Ring chromosome 20 syndrome (r(20)) is an ultra-rare disease characterized by drug-refractory epilepsy, cognitive impairment, and behavioral problems. Nonpharmacological treatments alongside antiepileptic drugs early after diagnosis may help reduce seizure frequency and preserve cognition. Ketogenic dietary therapy (KDT) has benefitted children with complex, refractory epilepsies, but its efficacy in r(20) is unknown. We assessed clinical prescription, implementation, and patient experience of KDT in r(20) through online surveys and a workshop. Forty-two patients, families, carers, and 23 healthcare professionals completed the surveys. While nearly all patients were familiar with KDT, only half had tried it. Significant improvement in seizure activity, cognition, and alertness was reported; side effects were typically mild but with one report of increased seizure frequency. A high rate of co-morbidity, older age at presentation, behavioral problems, and cognitive impairment can make implementing KDT in r(20) challenging. In the UK, NHS KDT services are predominantly available to pediatric patients, with very limited adult access. A health economic analysis illustrating reduced acute care costs or improved quality of life may support more widespread KDT implementation. Growing evidence supports KDT as an effective and safe intervention, but further research is needed to understand the mechanisms of r(20) and its interaction with ketosis.

Anatomic versus physiologic assessment of coronary artery disease. Role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making.

Angiographic severity of coronary artery stenosis has historically been the primary guide to revascularization or medical management of coronary artery disease. However, physiologic severity defined by coronary pressure and/or flow has resurged into clinical prominence as a potential, fundamental change from anatomically to physiologically guided management. This review addresses clinical coronary physiology-pressure and flow-as clinical tools for treating patients. We clarify the basic concepts that hold true for whatever technology measures coronary physiology directly and reliably, here focusing on positron emission tomography and its interplay with intracoronary measurements.

Intraosseous line placement for antidote injection by first responders and receivers wearing personal protective equipment.

STUDY OBJECTIVE: Early antidotal therapy may be lifesaving in hazardous materials victims. Intravenous line placement is difficult while wearing personal protective equipment (PPE). We assessed the ability of protected, experienced first responders and limited-experience first receivers to place intraosseous (IO) lines for antidote administration. METHODS: Six first responders donned 4 (A, B, C, and D) and 12 first receivers donned 2 (C and D) United States Environmental Protection Agency PPE levels in random order and then placed IO lines in 1 of 4 anatomical sites in 12 anesthetized Spanish goats. Observers timed interventions until bolus injection of isotonic sodium chloride solution. RESULTS: First responders placed IO lines successfully in 100% of cases. The median (interquartile range) times to completion (in seconds) were as follows: level A, 43.5 (23.0); B, 45.0 (29.0); C, 40.0 (15.0); D, 30.0 (17.0). First receivers placed IO lines successfully in 91% of cases. The median (interquartile range) times to completion (in seconds) were as follows: level C, 42.0 (19.5); D, 37.0 (11.0). There were no significant differences in time to completion among PPE levels (overall or pairwise) or between operator groups. Two (4%) of 48 line placements resulted in recognized extravasation due to penetration of the opposite cortex. Infusions were completed successfully. CONCLUSION: Hazardous materials first responders and receivers can effectively place IO lines in a goat while wearing PPE. Intraosseous lines may facilitate earlier administration of antidotes in hazardous materials victims.

Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study.

STUDY DESIGN: Retrospective, multicenter study of robotically-guided spinal implant insertions. Clinical acceptance of the implants was assessed by intraoperative radiograph, and when available, postoperative computed tomography (CT) scans were used to determine placement accuracy. OBJECTIVE: To verify the clinical acceptance and accuracy of robotically-guided spinal implants and compare to those of unguided free-hand procedures. SUMMARY OF BACKGROUND DATA: SpineAssist surgical robot has been used to guide implants and guide-wires to predefined locations in the spine. SpineAssist which, to the best of the authors' knowledge, is currently the sole robot providing surgical assistance in positioning tools in the spine, guided over 840 cases in 14 hospitals, between June 2005 and June 2009. METHODS: Clinical acceptance of 3271 pedicle screws and guide-wires inserted in 635 reported cases was assessed by intraoperative fluoroscopy, where placement accuracy of 646 pedicle screws inserted in 139 patients was measured using postoperative CT scans. RESULTS: Screw placements were found to be clinically acceptable in 98% of the cases when intraoperatively assessed by fluoroscopic images. Measurements derived from postoperative CT scans demonstrated that 98.3% of the screws fell within the safe zone, where 89.3% were completely within the pedicle and 9% breached the pedicle by up to 2 mm. The remaining 1.4% of the screws breached between 2 and 4 mm, while only 2 screws (0.3%) deviated by more than 4 mm from the pedicle wall. Neurologic deficits were observed in 4 cases yet, following revisions, no permanent nerve damage was encountered, in contrast to the 0.6% to 5% of neurologic damage reported in the literature. CONCLUSION: SpineAssist offers enhanced performance in spinal surgery when compared to free-hand surgeries, by increasing placement accuracy and reducing neurologic risks. In addition, 49% of the cases reported herein used a percutaneous approach, highlighting the contribution of SpineAssist in procedures without anatomic landmarks.

Survey of polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and non-ortho-polychlorinated biphenyls in U.S. meat and poultry, 2007-2008: effect of new toxic equivalency factors on toxic equivalency levels, patterns, and temporal trends.

A statistically based survey of dioxins and dioxin-like compounds in domestic meat and poultry was conducted by the U.S. Department of Agriculture (USDA) from September 2007 to September 2008. Seventeen toxic polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and four non-ortho-polychlorinated biphenyls (no-PCBs) were measured in 510 beef (steer/heifer), market hog, young turkey, and young chicken samples. The results of the survey showed the sum of PCDD/F and no-PCB toxic equivalencies (sum-TEQs) ranging from not detected to 4.5 pg/g of lipid. Mean sum-TEQ levels for beef, turkey, chicken, and pork were 0.66, 0.61, 0.17, and 0.16 pg/g of lipid, respectively. To compare the new survey data with data from previous USDA surveys in the mid-1990s and 2002-2003, TEQs from all data sets were calculated using the most recent 2005 toxic equivalency factors (TEFs). The results of the recalculation on the older survey data was a small increase (4-13%) in mean TEQs for the mid-1990s data, which initially used pre-1994 TEFs, and a small decrease (2-4%) for the 2002-2003 data, which initially used 1998 TEFs. A comparison of the three surveys indicates declining TEQ trends in all slaughter classes over the 10 year period; however, the congener patterns remain relatively constant between 2002 and 2008, indicating similar animal exposures to dioxins and dioxin-like compounds during these time periods. Several samples from the 2008 survey with the highest TEQ values are undergoing follow-up investigations to determine possible sources that may be contributing to these levels.

Hot flashes in patients with hypogonadism and low serum gonadotropin levels.

OBJECTIVE: To augment the number of cases in the literature describing patients with hot flashes due to hypopituitarism or hypothalamic hypogonadism. METHODS: We reviewed medical records for hot flashes in our patients with low sex hormone levels and low or inappropriately normal gonadotropin levels, and we inquired about hot flashes in new patients with these hormone patterns. A comprehensive literature review on this subject was also completed. RESULTS: In our medical records, we found 14 patients with hot flashes, low sex hormone levels, and low or inappropriately normal gonadotropin levels. In this group of patients, 10 had hypopituitarism and 6 had hypothalamic hypogonadism; 2 patients had both conditions. Hormone replacement therapy successfully relieved or substantially decreased the hot flashes in all 8 patients treated. A review of the literature revealed 17 patients with hot flashes and hypopituitarism and another 5 patients with hypothalamic hypogonadism. CONCLUSION: Hot flashes as a manifestation of low sex hormone levels and associated with low or inappropriately normal gonadotropin levels occur in patients with hypopituitarism and hypothalamic hypogonadism. Sex hormone replacement therapy alleviates the symptoms.

Immobilization-related hypercalcemia after renal failure in burn injury.

OBJECTIVE: To describe a patient with hypercalcemia presumably due to immobilization in the setting of burn injury and acute renal failure. METHODS: We present a case report of a man who sustained a severe burn injury and then had renal failure and hypercalcemia. An additional series of patients with burns and immobilization was assessed for the presence of hypercalcemia. RESULTS: In a 43-year-old man with burns on 65% of his body surface area, acute renal failure developed. Renal function failed to return, and he continued to require hemodialysis. Because of the severity and extensiveness of his burns, he remained immobilized. Serum calcium levels were low during the early part of the hospitalization. On the 57th day, generalized tonic-clonic seizures developed, and he was found to have a high ionized calcium level (1.41 mmol/L). Low values were recorded for intact parathyroid hormone (2 pg/mL), 25-hydroxyvitamin D (5 ng/mL), and 1,25-dihydroxyvitamin D (4 pg/mL). Persistent and recurrent hypercalcemia eventually responded to pamidronate and calcitonin. Other than immobilization, we could identify no predisposing factors such as confounding illnesses or medications that could have caused the hypercalcemia. A review of serum ionized calcium levels in 50 consecutive patients admitted to a burn unit and immobilized for at least 20 days failed to reveal any episodes of persistent hypercalcemia. CONCLUSION: In our patient with burns and renal failure, symptomatic hypercalcemia was most likely attributable to prolonged immobilization. As patients with catastrophic illnesses survive for longer periods, additional problems such as hypercalcemia from immobilization may occur.