Case report of large solitary skull base metastasis from renal cell carcinoma as initial clinical presentation: Radiological findings and differentials.

A 58-year-old male with good past health presented with headache and visual disturbance for 1 month. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed, showing a large aggressive midline mass with epicenter at the skull base and sellar-suprasellar region. There was marked heterogenous enhancement and intratumoral calcifications. It demonstrated clivus erosion, sphenoid sinus invasion, cavernous sinus invasion and optic chiasm compression. The imaging features were considered to be consistent with clival chordoma and the patent underwent emergent endoscopic transsphenoidal surgical excision. The difficult operation found an unexpected highly vascularized tumor and histopathology of the excision showed clear cell renal cell carcinoma metastasis. Subsequent work up of the patient with positron emission tomography-computed tomography (PET-CT) confirmed suspicion of the primary tumor, arising from left kidney. This case demonstrates an underestimated differential diagnosis of a large aggressive skull base mass as the first initial clinical presentation of metastatic disease.

Direct Carotid Puncture for Mechanical Thrombectomy in Acute Ischemic Stroke: Literature Review and a Single-Center Experience.

BACKGROUND: Endovascular thrombectomy (EVT) for acute ischemic stroke via direct carotid puncture (DCP) has been commonly reported as case reports and series in the literature. However, the reported procedural risk and therapeutic outcome associated with this approach were variable. In this study, we aim to establish the role and safety profile of this alternative access technique by describing our single-center experience and conducting a comprehensive review of the literature. METHODS: We conducted a retrospective review of consecutive patients at our center with large vessel occlusion (LVO) treated between 2018 and 2020 with DCP access. In addition, a literature review of studies published from 2012-2021 following PRISMA guidelines was conducted. RESULTS: During the 3-year period, 11 patients with LVO were treated with EVT using DCP technique in our local cohort. A total of 216 cases were found in the literature search. A combined total of 227 cases were reviewed separately and collectively. Combining the data, DCP access was successfully achieved in 93.3% of the cases; 76.6% achieved satisfactory recanalization (mTICI ≥2b). DCP-related complications were seen in 20.3% of cases. A total of 32.4% patients were functionally independent (mRS ≤2) upon follow-up. CONCLUSIONS: Results from the literature review and our experience illustrate DCP as a feasible approach for EVT. The role of DCP as a bailout is iterated despite a higher complication risk, which may be imperative in low-volume stroke centers. Further studies to evaluate the role of DCP as a primary vascular access technique for EVT in selected cases could be explored.

Traffic speeds associated with implementation of 80 mph speed limits on West Texas rural interstates.

PROBLEM: In 2006 Texas raised the daytime speed limit for passenger vehicles on segments of I-10 and I-20 from 75 to 80 mph. METHODS: Traffic speeds were measured before and 3, 12, and 16 months after the limit was changed. RESULTS: During the 16-month period following the speed limit increase, mean speeds of passenger vehicles on I-20 increased by 9 mph relative to the comparison road, where no speed limit change occurred and traffic speeds declined. On I-10 mean speeds increased by 4 mph relative to the comparison road. Limiting the analysis to the month before the speed limit change and 1 year later, the proportion of drivers exceeding 80 mph was 18 times higher on I-20 and 2 times higher on I-10. DISCUSSION: The smaller speed increases on I-10 may be related to its proximity to the U.S. border with Mexico. Highly visible border patrol activity coincided with posting of the higher speed limit. Long-term monitoring in other states suggests that traffic speeds in Texas are likely to continue to increase. IMPACT ON INDUSTRY: The present study adds to the wealth of evidence that increased speed limits lead to increased travel speeds. The primary countermeasures to reduce the risk of speed-related crashes include highly visible police traffic enforcement and the use of speed cameras accompanied by publicity.

Undercounting of large trucks in federal and state crash databases: Extent of problem and how to improve accuracy of truck classifications.

OBJECTIVE: Prior research suggested that single-unit trucks are undercounted when using vehicle body codes in the Fatality Analysis Reporting System (FARS). This study explored the extent of the misclassification and undercounting problem for crashes in FARS and state crash databases. METHODS: Truck misclassifications for fatal crashes were explored by comparing the Trucks Involved in Fatal Accidents (TIFA) database with FARS. TIFA used vehicle identification numbers (VINs) and survey information to classify large trucks. This study used VINs to improve the accuracy of large truck classifications in state crash databases from 5 states (Delaware, Maryland, Minnesota, Nebraska, and Utah). RESULTS: The vehicle body type codes resulted in a 19% undercount of single-unit trucks in FARS and a 23% undercount of single-unit trucks in state databases. Tractor-trailers were misclassified less often. Misclassifications occurred most frequently among single-unit trucks in the weight classes of 10,001-14,000 pounds. CONCLUSIONS: The amount of misclassification of large trucks is large enough to potentially affect federal and state decisions on traffic safety. Using information from VINs results in more complete and accurate counts of large trucks involved in crashes. The National Transportation Safety Board recommended actions to improve federal and state crash data.

(1)H, (13)C and (15)N resonance assignments of the RodA hydrophobin from the opportunistic pathogen Aspergillus fumigatus.

Hydrophobins are fungal proteins characterised by their amphipathic properties and an idiosyncratic pattern of eight cysteine residues involved in four disulphide bridges. The soluble form of these proteins spontaneously self-assembles at hydrophobic/hydrophilic interfaces to form an amphipathic monolayer. The RodA hydrophobin of the opportunistic pathogen Aspergillus fumigatus forms an amyloid layer with a rodlet morphology that covers the surface of fungal spores. This rodlet layer bestows hydrophobicity to the spores facilitating their dispersal in the air and rendering the conidia inert relative to the human immune system. As a first step in the analysis of the solution structure and self-association of RodA, we report the (1)H, (13)C and (15)N resonance assignments of the soluble monomeric form of RodA.

Physician accessibility: an urban case study of pediatric providers.

Social disparity in the spatial distribution of healthcare providers in urban areas is a recognized problem. However, efforts to quantify the problem have been hampered by a lack of satisfactory measurements and methods. We revive and enhance a strategy based on provider density, proposed nearly three decades ago. The method avoids the border-crossing problem associated with provider-population ratios, yet reports spatial accessibility in intuitive units that are easily compared across diverse populations and geographies. We find racial and socioeconomic disparities in our case city, Washington, DC, despite a citywide overabundance of primary care providers for children.

SAOS-2 osteosarcoma cells bind fibroblasts via ICAM-1 and this is increased by tumour necrosis factor-α.

We recently reported exchange of membrane and cytoplasmic markers between SAOS-2 osteosarcoma cells and human gingival fibroblasts (h-GF) without comparable exchange of nuclear markers, while similar h-GF exchange was seen for melanoma and ovarian carcinoma cells. This process of "cellular sipping" changes phenotype such that cells sharing markers of both SAOS-2 and h-GF have morphology intermediate to that of either cell population cultured alone, evidencing increased tumour cell diversity without genetic change. TNF-α increases cellular sipping between h-GF and SAOS-2, and we here study binding of SAOS-2 to TNF-α treated h-GF to determine if increased cellular sipping can be accounted for by cytokine stimulated SAOS-2 binding. More SAOS-2 bound h-GF pe-seeded wells than culture plastic alone (p<0.001), and this was increased by h-GF pre-treatment with TNF-α (p<0.001). TNF-α stimulated binding was dose dependent and maximal at 1.16 nM (p<0.05) with no activity below 0.006 nM. SAOS-2 binding to h-GF was independent of serum, while the lipopolysaccharide antagonist Polymyxin B did not affect results, and TNF-α activity was lost on boiling. h-GF binding of SAOS-2 started to increase after 30min TNF-α stimulation and was maximal by 1.5 hr pre-treatment (p<0.001). h-GF retained maximal binding up to 6 hrs after TNF-α stimulation, but this was lost by 18 hrs (p<0.001). FACS analysis demonstrated increased ICAM-1 consistent with the time course of SAOS-2 binding, while antibody against ICAM-1 inhibited SAOS-2 adhesion (p<0.04). Pre-treating SAOS-2 with TNF-α reduced h-GF binding to background levels (p<0.003), and this opposite effect to h-GF cytokine stimulation suggests that the history of cytokine exposure of malignant cells migrating across different microenvironments can influence subsequent interactions with fibroblasts. Since cytokine stimulated binding was comparable in magnitude to earlier reported TNF-α stimulated cellular sipping, we conclude that TNF-α stimulated cellular sipping likely reflects increased SAOS-2 binding as opposed to enhanced exchange mechanisms.

Characteristics of interstate motorcoach carriers with elevated rates of crashes and inspection violations.

Widely-publicized fatal motorcoach crashes have caused public concern about their safety. This study estimated crash and violation rates among interstate motorcoach carriers based on 2005-2011 data obtained from the Federal Motor Carrier Safety Administration (FMCSA). Motorcoach carriers with relatively high crash and violation rates were compared with those with better safety records. The principal component analysis produced three orthogonal factors that captured the majority (63 percent) of the total variance in the data set. Motorcoach carriers operating 10 or fewer motorcoaches were more likely to be classified in both the high crash rate and the high inspection and violation rates group. Those carriers with 10 or fewer years in business were more likely to be classified in the high inspection and violation rates group. The vast majority of motorcoach carriers with problematic safety records were non-scheduled route providers (charters). Scheduled-service motorcoach carriers identified as providing at least occasional curbside service, defined as picking up or dropping off passengers at a place other than a traditional terminal at the origin or destination, had an increased risk of involvement in fatal crashes compared with other scheduled-service carriers (1.4 per 100 vehicles, 95% C.I.: 0.1-2.7 versus 0.2, 95% C.I.: 0.0-0.5). The data did not indicate whether crashes or violations occurred during the trips where curbside service was provided. These findings suggest that FMCSA and the states need to have the resources necessary for close monitoring of motorcoach carriers, particularly high-risk ones such as small and less experienced motorcoach carriers.

Safety challenges and oversight in the motorcoach industry: attitudes and perceptions of drivers, roadside inspectors, and federal investigators.

Interstate motorcoach travel has been the fastest-growing transportation mode in recent years. To identify challenges to monitoring compliance with motorcoach safety regulations and to examine factors affecting safety, four focus groups with a total of 32 participants were conducted during 2011, one with federal safety investigators, one with state motor carrier inspectors, and two with motorcoach drivers. Investigators and inspectors expressed concern about falsified logbooks, inadequate sleep among motorcoach drivers, hazards from speeding motorcoaches, practices by motorcoach carriers to mask ownership and avoid oversight, and difficulties keeping up with rapid motorcoach industry growth. Drivers described problems with getting sufficient sleep, pressure to drive longer than permitted, and fears of motor carriers giving them less work if they turned down driving jobs. Drivers said that driving 72-74 mph was acceptable in light traffic. To help assess workload among personnel performing safety oversight, data on numbers of motor carriers, commercial motor vehicles, federal investigators, and state inspectors were obtained from the Federal Motor Carrier Safety Administration (FMCSA). The data suggested a heavy workload (2.13 inspectors per 1,000 commercial motor vehicles). The focus groups of inspectors, investigators, and drivers indicated the existence of serious motorcoach safety problems, provided insight about the multiple factors contributing to them, and described major obstacles to effective safety oversight. The qualitative nature of focus group research means that these notable findings will need to be measured using other methods such as surveys and observational studies.

Declines in fatal crashes of older drivers: changes in crash risk and survivability.

OBJECTIVES: Previous research has found that older driver fatal crash involvement rates per licensed driver declined substantially in the United States during 1997-2006 and declined much faster than the rate for middle-age drivers. The current study examined whether the larger-than-expected decline for older drivers extended to nonfatal crashes and whether the decline in fatal crash risk reflects lower likelihood of crashing or an improvement in survivability of the crashes that occur. METHODS: Trends in the rates of passenger vehicle crash involvements per 100,000 licensed drivers for drivers 70 and older (older drivers) were compared with trends for drivers ages 35-54 (middle-age drivers). Fatal crash information was obtained from the Fatality Analysis Reporting System for years 1997-2008, and nonfatal crash information was obtained from 13 states with good reporting information for years 1997-2005. Analysis of covariance models compared trends in annual crash rates for older drivers relative to rates for middle-age drivers. Differences in crash survivability were measured in terms of the odds of fatality given a crash each year, and the historical trends for older versus middle-age drivers were compared. RESULTS: Fatal crash involvement rates declined for older and middle-age drivers during 1997-2008 (1997-2005 for the 13 state subsample), but the decline for drivers 70 and older far exceeded the decline for drivers ages 35-54 (37 versus 23 percent, nationally; 22 versus 1 percent, 13 states). Nonfatal injury crash involvement rates showed similarly larger-than-expected declines for older drivers in the 13 state subsample, but the differences were smaller and not statistically significant (27 percent reduction for older drivers versus 16 percent for middle-age drivers). Property-damage-only crash involvement rates declined for older drivers (10 percent) but increased for middle-age drivers (1 percent). In 1997, older drivers were 3.5 times more likely than middle-age drivers to die in police-reported crashes (6.2 versus 1.8 deaths per 1000 crashes), but this difference was reduced during the 9-year study period to 2.9 times, as the rate of older drivers dying in a crash declined (5.5 deaths per 1000 crashes in 2005) and the death risk remained relatively stable for middle-age drivers. CONCLUSIONS: Contrary to expectations based on increased licensure and travel by older drivers, their fatal crash risk has declined during the past decade and has declined at a faster rate than for middle-age drivers. The decreased risk for older drivers appears to extend not only to nonfatal injury crashes but also to property-damage-only crashes, at least as reported to police in the 13 states included in the nonfatal injury analysis. Although insurance collision data suggest that overall crash risk of older drivers may not be changing relative to middle-age drivers, the current analysis indicates that the reduced fatality risk of older drivers reflects both less likelihood of being involved in a police-reported crash and greater likelihood that they will survive when they do crash.

Optimizing secondary prevention: Statin prescribing across East and West London in accordance with NICE guidelines.

OBJECTIVES: Statins are a well-known primary and secondary prevention drug for cardiovascular disease and NICE guidelines have been issued to identify key indicators for their use. An audit looking into statin prescribing for medical inpatients was carried out in two geographically distinct London hospitals. DESIGN: A prospective inpatient audit of medical prescription charts was performed. Blood results were reviewed for the inpatients during their admission to identify any contraindications for statin usage (rhabdomyolysis). The medical notes were also reviewed for patient refusal of statin therapy. SETTING: The study was carried out at two distinct hospitals in London. Whipps Cross University Hospital (WCUH) and Chelsea & Westminster Hospital (CWH) are located in East London and West London, respectively. Acute medical, surgical, obstetrics and gynaecology, paediatric and palliative wards were excluded. PARTICIPANTS: A total of 309 inpatient medical notes and prescription chart data were collected from WCUH (n = 211) and CWH (n = 98). MAIN OUTCOME MEASURES: High percentage of hospitalized patients are not prescribed statins despite clear clinical indications for their use. Regardless of geographical and socioeconomic factors between hospitals, statin prescribing remains suboptimal. RESULTS: The patient demographics in both hospitals were very similar; the mean age at WCUH was 78 ± 15 1SD while at CWH the mean age was 74 ± 15 1SD. The results showed that approximately one-third of patients (30% at WCUH and 33% at CWH) had at least one indication for statin therapy according to NICE guidelines and yet they were not prescribed a statin. Ten percent of patients at WCUH and 13% of patients at CWH had ischaemic heart disease (IHD) and yet were not prescribed statins. CONCLUSION: Statin prescription is often overlooked in secondary care with patients being discharged without the appropriate assessment (NICE guidelines), which subsequently means repeat prescriptions are not provided by the GP. This study is the first to show that this problem is not due to resources or geography, but is inherent within the NHS system. Consequently, a revised prescription chart checking system has been suggested for pharmacists and junior doctors.

Creating a geospatial database of risks and resources to explore urban adolescent substance use.

This article illustrates the methodology of creating a comprehensive geospatial database in order to systematically understand the social ecology of risk and protection for urban youth. The challenges and future opportunities involved with this complex work were reviewed, and specific examples were provided to guide researchers. Data were collected from a Washington, DC adolescent substance abuse treatment sample to construct a geospatial database to evaluate urban youths' social environmental risk and resources. A geographic information systems (GIS) approach was adopted to integrate a large array of variables at different levels of geography. For example, risk factors included proximity to crime hotspots, and other known potential establishments with negative influence (such as liquor stores). We also used GIS to assess the subjects' accessibility to protective resources such as public libraries, recreational, parks, and police stations. Unique to our method was the collecting and mapping of each teen's activity locations (places they typically frequent). These data form "risk and protection exposure" estimates for each teen. Finally, we illustrated the specific methods for creating a dynamic geospatial database for urban youth and present future analytical approaches and challenges with these type of data.

Exploring the declines in older driver fatal crash involvement.

The number of drivers 70 and older is growing at a fast pace, and older drivers are keeping their licenses longer and driving more. Despite these trends, older driver crash deaths and fatal crash involvements declined steadily during the decade 1997-2006 following an upward trend for many years. The present study explored various facets of the decline in older driver fatal crash involvement during 1997-2006. Declines in the rates of older driver fatal crashes were found per licensed driver and per population during 1997-2006; crash involvement per mile traveled also declined during 1995-2001. Relative to drivers aged 35-54, driver fatal crash involvement rates declined at significantly faster rates for drivers 70 and older, and an even more substantial decline was experienced by drivers 80 and older. Especially notable were greater declines in fatal crash involvement rates for intersection crashes and two-vehicle crashes among older drivers relative to drivers aged 35-54; such crash types have accounted for disproportionate numbers of crashes among older drivers in the past.

Substance use, social networks, and the geography of urban adolescents.

This article demonstrates a research strategy and prevention methodology for substance using urban youth that incorporates individual, social, and geographical parameters to systematically understand the ecology of risk and protection for urban youth. The primary goal of this study was to describe and analyze substance using and nonusing urban adolescents' social networks; risky and protective settings where they socialize; and the relationship to health outcomes such as substance use, depression, and stress. Geographic Information Systems (GIS) derived spatial relationships and analyses between the specific locations where the teens are active, their subjective ratings of these locations, and objective environmental risk data. These social network and GIS data were merged to form a detailed description and analysis of the social ecology of urban adolescent substance use. A case study was constructed to illustrate the methodology of creating a three-dimentional ecological profile that helps explain these relationships and provides preventive applications. Linear distances were computed between the homes of the users and the risky and safe places that they identified. On average, the distance between users' homes and their identified safe places was three times the distance between their homes and their identified risky places. This study provides support for understanding urban adolescent substance use through the detailed and multiple dimensional analysis of teens' social ecologies.