Focusing of a Rydberg Positronium Beam with an Ellipsoidal Electrostatic Mirror.

Slow atoms in Rydberg states can exhibit specular reflection from a cylindrical surface upon which an azimuthally periodic potential is imposed. We have constructed a concave mirror of this type, in the shape of a truncated oblate ellipsoid of revolution, which has a focal length of (1.50±0.01) m measured optically. When placed near the center of a long vacuum pipe, this structure brings a beam of n=32 positronium (Ps) atoms to a focus on a position sensitive detector at a distance of (6.03±0.03) m from the Ps source. The intensity at the focus implies an overall reflection efficiency of ∼30%. The focal spot diameter (32±1) mm full width at half maximum is independent of the atoms' flight times from 20 to 60 µs, thus indicating that the mirror is achromatic to a good approximation. Mirrors based on this principle would be of use in a variety of experiments, allowing for improved collection efficiency and tailored transport or imaging of beams of slow Rydberg atoms and molecules.

Pre-eclampsia and acute pulmonary embolism-the importance of making a differential diagnosis: a case report.

We describe the case of a 41-year-old pregnant patient who presented at 38 weeks of gestation for an urgent cesarean section, with new onset of pre-eclampsia as the initial diagnosis. The intraoperative course was complicated by seizures and hemodynamic collapse. Initially, the presentation of seizure pointed to pre-eclampsia/eclampsia; however, with careful consideration of each event as it occurred, the correct diagnosis was later determined to be pulmonary embolism and stroke. This case illustrates the importance of considering multiple possible etiologies, even when a particular diagnosis seems obvious.

Prospective Evaluation of the Effect of Thigh Dissection for Removal of Transobturator Mid Urethral Slings on Refractory Thigh Pain.

PURPOSE: Transobturator slings have higher rates of de novo neurologic symptoms than retropubic slings, most commonly related to the thigh. Cases refractory to conservative management may require removal of the thigh portion of the sling. In this series we prospectively examine the effect of thigh dissection with mesh removal on refractory thigh pain. MATERIALS AND METHODS: All thigh dissections for refractory neurologic symptoms after transobturator sling placement were followed prospectively from October 2012 to October 2015. Patients were assessed preoperatively, with a pain score using a visual analog scale, and postoperatively with a global response assessment. RESULTS: A total of 12 thigh dissections were performed from October 2012 to October 2015 in 8 patients. Mean (±SD) time from original mesh placement to presentation was 2.7 (±1.5) years. Average preoperative pain score was 7.9 (±1.7) out of 10, with pain in the thigh in all patients. Seven cases involved unilateral thigh dissection and 1 had concomitant bilateral thigh dissection. Five patients underwent concurrent transvaginal excision. On postoperative evaluation the average global response rating was 1.6, with 1 defined as very much better and 2 defined as much better. Of the 8 patients 3 went on to have the contralateral side done with an average global response rating of 1.3 (±0.6). One patient underwent further treatment for stress urinary incontinence with placement of a retropubic mid urethral sling. CONCLUSIONS: Our prospective series supports the use of thigh dissection in patients with refractory neurologic symptoms after transobturator sling placement. The procedure can be performed safely with positive outcomes for the patient.

Angle-Resolved Spectroscopy of Positronium Emission from a Cu(110) Surface.

The affinity A_{Ps} of positronium (Ps) atoms for a metal is the negative of the maximum kinetic energy with which Ps is emitted into vacuum when thermalized positrons in a metal encounter the surface. When this quantity is measured by ground state Ps time of flight (TOF), the precision is severely limited by the short triplet state lifetime of 142 ns. By quickly converting the emitted Ps atoms into long-lived Rydberg states, we are able to dramatically increase the TOF to allow precision measurements of A_{Ps}. From our measurements made on a Cu(110) sample at T=128 K, we find A_{Ps}(128 K)=(-2.476±0.010_{stat}±0.013_{syst}) eV, compared with the result A_{Ps}(128 K)=(-2.545±0.010_{num}±0.010_{syst}) eV found using highly accurate generalized gradient approximations for both electrons and positrons within density functional theory. Such precision opens up opportunities in the quest for an improved density functional.

Monoenergetic positronium emission from metal-organic framework crystals.

Recently it has been discovered that positronium (Ps), after forming in metal-organic framework (MOF) crystals, is emitted into vacuum with a high efficiency and low energy that can only be explained by its propagating as delocalized Bloch states. We show that the Ps atoms are emitted from MOFs in a series of narrow energy peaks consistent with Ps at Bloch-state energy minima being emitted adiabatically into the vacuum. This implies that the Ps emission energy spectra can be directly compared with calculations to obtain detailed information about the Ps band structure in the MOF crystal. The narrow energy width of the lowest energy Ps peak from one MOF sample (2-Methylimidazole zinc salt ZIF-8) suggests it originates from a polaronic Ps surface state. Other peaks can be assigned to Ps with an effective mass of about twice that of bare Ps. Given the immense catalog of available MOF crystals, it should be possible to tune the Ps properties to make vastly improved sources with high production efficiency and a narrow energy spread, for use in fundamental physics experiments.

Fecal incontinence: the role of the urologist.

Fecal incontinence is the involuntary loss of solid or liquid stool. While the true prevalence of fecal incontinence is difficult to discern, it is estimated that almost 9 % of non-institutionalized women in the US experience this condition. Disorders leading to fecal urgency alone are usually related to rectal storage abnormalities while incontinence is often a result of anatomic or neurologic disruption of the anal sphincter complex. Many risk factors exist for fecal incontinence and include female sex, increasing age, higher body mass index (BMI), limited physical activity, smoking, presence of neuropsychiatric conditions, higher vaginal parity and history of obstetrical trauma, presence of chronic diarrhea and irritable bowel syndrome, or history of rectal surgery, prostatectomy and radiation. Evaluation of fecal incontinence involves a careful patient history and focused physical exam. Diagnostic tests include endorectal ultrasonography, anal manometry, anal sphincter electromyography, and defecography. Treatment strategies include behavioral, medical and surgical therapies as well as neuromodulation. Treatment is based on the presumed etiology of the condition and a multi-modal approach is often necessary to achieve the maximum benefit for patients.

Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first-line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.

Surgical techniques for pelvic floor reconstruction: review of the recent literature.

The number of women who will undergo pelvic organ prolapse repair is predicted to increase by almost 50% by 2050. Surgeons need updated knowledge and mastery of pelvic floor reconstruction in order to meet the rising demand for services. This review provides an update on the evidence for the various surgical techniques for anterior, posterior, and apical pelvic organ prolapse, specifically focusing on randomized trials within the last ten years.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT: The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE: To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION: PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS: Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS: Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY: In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

What are the best outcome measures when assessing treatments for LUTD?--achieving the most out of outcome evaluation: ICI-RS 2011.

A think tank was convened at the third ICI-RS meeting held in the UK, June 2011, to consider the best outcome measures when assessing treatments for lower urinary tract dysfunction (LUTD). Given the vast array of measures available a focus on questionnaires was decided upon, which continued to highlight a plethora of available tools. The decision was therefore taken to approach this topic from an alternative perspective and instead ask the audience of gathered experts in this field to consider, "What we need to ask as a minimum in order to capture the most fundamental parameters when evaluating new treatments for LUTD?" Discussions highlighted the need for inclusion of a global measure in all outcome evaluations in order to increase comparability between different treatment evaluations and different populations. More specific categories of evaluation identified were: treatment satisfaction, symptom quantification, health related quality of life and adverse events. Further optional components were identified for inclusion where relevant, such as health economic, goal setting and psychosocial evaluation. A "Minimum Outcome Set for Testing (MOST)" was therefore proposed by selecting a health outcome measure from each category while not being prescriptive about specific outcome measurement selection. The 'MOST' toolkit is therefore proposed to promote standardized evaluation in this field and represents a useful starting point for further consideration of this concept.

Trospium chloride has no effect on memory testing and is assay undetectable in the central nervous system of older patients with overactive bladder.

BACKGROUND: Muscarinic receptors in the brain play an important role in cognitive function, especially memory, and there is growing awareness that specific antimuscarinic drugs for overactive bladder (OAB) may have adverse central nervous system (CNS) effects. Selection of an antimuscarinic OAB drug with reduced potential for CNS effects could be especially beneficial in the elderly people, in whom even the modest cognitive impairment may negatively affect independence. PURPOSE: The purpose of the study is to determine if trospium chloride is assay detectable in the CNS of older adults with OAB and to assess whether deterioration of memory occurs in these individuals. METHODS: Twelve cognitively intact older adults (>or=65-75 years old) with OAB were given extended-release trospium chloride 60 mg once daily over a 10-day period to achieve plasma steady-state levels. Standardised memory testing (Hopkins Verbal Learning Test-Revised and Brief Visuospatial Memory Test-Revised) was performed predose and postdose. Cerebrospinal spinal fluid (CSF) and plasma samples were drawn on day 10 and assayed for trospium chloride. Predose (day 0) and postdose (day 10) results on the memory tests were compared using a reliable change index to assess a meaningful change in learning or memory. RESULTS: Trospium chloride levels in all the CSF samples (n = 72) of all participants were assay undetectable (<40 pg/ml) on day 10 at steady-state peak plasma concentration concurrent with measureable peak plasma values (C(max) = 925 pg/ml). Repeat memory testing revealed no significant net drug effect on learning or recall. CONCLUSIONS: This is the first study to investigate for the presence of an OAB antimuscarinic in the human brain, performed by assaying for concentrations of trospium chloride and correlating with simultaneous clinical cognitive safety measures. The results of both pharmacological and neuropsychological testing support the hypothesis of a lack of detectable CNS penetration for the quaternary amine trospium chloride.

Transvaginal sacrospinous rectopexy: initial clinical experience.

BACKGROUND: There is a wide range of surgical procedures available to treat rectal prolapse that differ in approach as well as in principle. The current perineal approaches available involve mucosal or full thickness resection. There are currently no accepted procedures combining rectal fixation without resection using the perineal approach. We present our initial report of transvaginal sacrospinous rectopexy for the treatment of rectal prolapse. METHODS: A longitudinal incision was made in the posterior wall of the vagina. The rectum and sacrospinous ligament were identified. Two sutures were placed in the sacrospinous ligament and brought through a piece of Surgisis mesh previously anchored to the anterior surface of the rectum. This was performed bilaterally. These sutures were tied to complete the rectal suspension, and the posterior wall of the vagina was closed. RESULTS: Transvaginal sacrospinous rectopexy was performed in all seven cases. In the first two cases, a Delorme procedure was performed concurrently. Two patients had rubber band ligation for symptomatic internal hemorrhoids, one patient had a sphincter plication, and one patient had an anal encirclement procedure with Surgisis. Six of the seven patients had concomitant urologic procedures. The average operative time was 163 min, and the average blood loss was 107 mL. None of the cases required conversion to an open procedure. There was one full thickness recurrence at 18 weeks. CONCLUSION: Transvaginal sacrospinous rectopexy is a safe, minimally invasive, technically feasible technique for the treatment of rectal prolapse.

Human pancreatic islets in culture: effects of supplementing the medium with homologous and heterologous serum.

Islets of Langerhans, isolated from the human fetal pancreas and cultured in media supplemented with serums from human umbilical cord or adult donors, remained intact, free-floating, and functional for 2 to 5 months. Substitution of fetal calf serum for the human serum usually resulted in attachment of islets, monolayer formation, and relatively early (3 weeks) functional arrest.

Renin-angiotensin role in thirst: paradoxical enhancement of drinking by angiotensin converting enzyme inhibitor.

A competitive angiotensin converting enzyme antagonist SQ 20, 881 (SQ), was used to examine the role of the renin-angiotensin system in putative renin-dependent thirst in the albino rat. Significant enhancement of "renin-dependent" as well as renin-independent drinking was observed in the presence of peripheral SQ. Intraventricular SQ obviated this enhancement of drinking but did not affect the water intake caused by the original stimulus itself, whereas it sharply reduced drinking evoked by peripheral renin in nephrectomized rats. Prior renin depletion likewise had no influence on so-called renin-dependent thirst.

Confocal scanning optical microscopy of a 3-million-year-old Australopithecus afarensis femur.

Portable confocal scanning optical microscopy (PCSOM) has been specifically developed for the noncontact and nondestructive imaging of early human fossil hard tissues, which here we describe and apply to a 3-million-year-old femur from the celebrated Ethiopian skeleton, "Lucy," referred to Australopithecus afarensis. We examine two bone tissue parameters that demonstrate the potential of this technology. First, subsurface reflection images from intact bone reveal bone cell spaces, the osteocyte lacunae, whose density is demonstrated to scale negatively with body size, reflecting aspects of metabolism and organismal life history. Second, images of a naturally fractured cross section near to Lucy's femoral mid-shaft, which match in sign those of transmitted circularly polarized light, reveal relative collagen fiber orientation patterns that are an important indicator of femoral biomechanical efficacy. Preliminary results indicate that Lucy was characterized by metabolic constraints typical for a primate her body size and that in her femur she was adapted to habitual bipedalism. Limitations imposed by the transport and invasive histology of unique or rare fossils motivated development of the PCSOM so that specimens may be examined wherever and whenever nondestructive imaging is required.

Fluorescence-guided stereotactic biopsy: a proof-of-concept study.

OBJECTIVEAccurate histopathological diagnoses are often necessary for treating neuro-oncology patients. However, stereotactic biopsy (STB), a common method for obtaining suspicious tissue from deep or eloquent brain regions, fails to yield diagnostic tissue in some cases. Failure to obtain diagnostic tissue can delay initiation of treatment and may result in further invasive procedures for patients. In this study, the authors sought to determine if the coupling of in vivo optical imaging with an STB system is an effective method for identification of diagnostic tissue at the time of biopsy.METHODSA minimally invasive fiber optic imaging system was developed by coupling a 0.65-mm-diameter coherent fiber optic fluorescence microendoscope to an STB system. Human U251 glioma cells were transduced for stable expression of blue fluorescent protein (BFP) to produce U251-BFP cells that were utilized for in vitro and in vivo experiments. In vitro, blue fluorescence was confirmed, and tumor cell delineation by fluorescein sodium (FNa) was quantified with fluorescence microscopy. In vivo, transgenic athymic rats implanted with U251-BFP cells (n = 4) were utilized for experiments. Five weeks postimplantation, the rats received 5-10 mg/kg intravenous FNa and underwent craniotomies overlying the tumor implantation site and contralateral normal brain. A clinical STB needle containing our 0.65-mm imaging fiber was passed through each craniotomy and images were collected. Fluorescence images from regions of interest ipsilateral and contralateral to tumor implantation were obtained and quantified.RESULTSLive-cell fluorescence imaging confirmed blue fluorescence from transduced tumor cells and revealed a strong correlation between tumor cells quantified by blue fluorescence and FNa contrast (R2 = 0.91, p < 0.001). Normalized to background, in vivo FNa-mediated fluorescence intensity was significantly greater from tumor regions, verified by blue fluorescence, compared to contralateral brain in all animals (301.7 ± 34.18 relative fluorescence units, p < 0.001). Fluorescence intensity measured from the tumor margin was not significantly greater than that from normal brain (p = 0.89). Biopsies obtained from regions of strong fluorescein contrast were histologically consistent with tumor.CONCLUSIONSThe authors found that in vivo fluorescence imaging with an STB needle containing a submillimeter-diameter fiber optic fluorescence microendoscope provided direct visualization of neoplastic tissue in an animal brain tumor model prior to biopsy. These results were confirmed in vivo with positive control cells and by post hoc histological assessment. In vivo fluorescence guidance may improve the diagnostic yield of stereotactic biopsies.

Epithelioid glioblastoma presenting as aphasia in a young adult with ovarian cancer: A case report.

Our patient's clinical history and preoperative radiographic evaluation suggested central nervous system (CNS) metastatic disease. Ultimately, final pathology revealed epithelioid glioblastoma (eGBM), a newly classified CNS primary tumor. This reinforces the importance of direct tissue sampling and including eGBM on the differential for young patients with histories of systemic cancer presenting with new CNS lesions.

The cardiothoracic ratio in AGA and SGA very low birth weight newborn infants.

BACKGROUND: Cardiothoracic (CT) ratio is a common measurement used to assess heart size in chest radiographs of pediatric patients, but no recent studies have analyzed the standards for CT ratios in very low birth weight (VLBW) infants. OBJECTIVE: The aim of this study was to provide improved standards for CT ratios measured from chest radiographs of VLBW (<1500 g) infants, and to compare CT ratios between small for gestational age (SGA) and appropriate for gestational age (AGA) infants in this population. DESIGN/METHODS: Among VLBW infants admitted to the Jacobi Medical Center NICU from 2002 to 2004, CT ratios were calculated from anteroposterior supine chest radiographs taken of 54 VLBW infants (18 SGA and 36 AGA group-matched on the basis of birthweight and sex) during the first 24 h of life. RESULTS: There were no significant differences between the two groups with respect to birthweight, sex, 1-min Apgar score, 5-min Apgar score, intubation status and degree of inspiration. Median GA of the SGA infants was significantly greater than the AGA infants (30 and 27 weeks, respectively; P<0.001). CT ratios among SGA infants were significantly larger than those among AGAs. Using the widest internal width of the bony thorax, the mean CT ratio among SGA and AGA infants was 0.523 and 0.479, respectively (P=0.00102). CONCLUSIONS: VLBW SGA infants have larger CT ratios than VLBW AGA infants, suggesting that existing standards for normal CT ratios may be inappropriate for use among SGA infants.

Methylation of the hMLH1 promoter correlates with lack of expression of hMLH1 in sporadic colon tumors and mismatch repair-defective human tumor cell lines.

Somatic mutations in DNA mismatch repair genes have been observed in sporadic tumors as well as cell lines and xenografts derived from such tumors implicating genetic defects of mismatch repair genes in the development of such tumors. However, the proportion of sporadic tumors in which mismatch repair genes have been inactivated has not been determined accurately. We have analyzed 66 sporadic colorectal tumors for the expression of hMLH1 by immunohistochemistry and identified 4 tumors that do not express hMLH1. These four colorectal tumors, a colon tumor cell line (SW48) and an endometrial tumor cell line (AN3CA), did not express hMLH1, despite the absence of mutations in its coding sequence. Cytosine methylation of the hMLH1 promoter region was found in these four colorectal tumors, whereas cytosine methylation of the hMLH1 promoter region was absent in adjacent normal tissue or in nine tumors that expressed hMLH1. In addition, cytosine methylation of the hMLH1 promoter region was observed in the SW48 and AN3CA cell lines that do not express hMLH1 but not in four tumor cell lines known to express hMLH1 mRNA. Our data indicate that DNA methylation is likely to be a common mode of mismatch repair gene inactivation in sporadic tumors.