Antegrade femoral nailing in the lateral decubitus position: a case series, technical tips and review of literature.

BACKGROUND: Femoral intramedullary nailing is traditionally performed with the patient supine on a fracture table. We aimed to describe a case series of femoral intramedullary nailing for fracture in the lateral position, with discussion of the operative technique. METHODS: A retrospective analysis identified 52 patients who underwent femoral intramedullary nailing performed in a lateral position without traction over a 5-year period at a single level 1 trauma center. Medical records were reviewed for demographics, blood loss including need for transfusion, operative duration, complications, length of stay, fracture union, re-operation and death. RESULTS: There were 24 subtrochanteric, 16 peri-trochanteric and 12 diaphyseal femoral fractures. Mean operative time was 136.2 ± 101.4 min with a mean estimated blood loss of 372.5 ± 349.6 ml. Seventeen patients required blood transfusion. Mean length of stay was 10.3 ± 8.1 days. There were 3 (5.8%) surgical (compartment syndrome, infection and retained drain) and 12 (23.1%) medical complications, with a 30-day mortality rate of 3.8% (2). Mean follow-up was 9.9 ± 8.7 months. The union rate was 94.2% (49) and 3.8% (2) patients required revision fixation (hardware exchange for irritation and exchange nailing for non-union). Discharge destination was home, rehabilitation center and specialized nursing facility in 21 (40.4%), 16 (30.8%) and 15 (28.8%) patients, respectively. DISCUSSION AND CONCLUSION: Femoral intramedullary nailing in the lateral decubitus position is a useful technique of managing peri-trochanteric, subtrochanteric and diaphyseal femoral fractures. We describe a known technique with technical tips, which has distinct advantages over traditional supine positioning especially in certain patient and fracture types. In addition, operative times, blood loss, length of stay, revision and outcomes were comparable to the literature.

Web-based training intervention to increase physical activity level and improve health for adults with intellectual disability.

BACKGROUND: Individuals with intellectual disability (ID) are less physically active, have a higher body mass index (BMI) and are at greater risk for cardiovascular diseases (CVDs) than people without ID. The purpose of the study was to explore the effectiveness of a web-based training programme, consisting of 150 min of activity per week, on the health of people with ID. METHOD: Participants with ID living in supported accommodation (n = 28, 48% female, age = 36.4 ± 9.56 years) participated in a web-based training programme, consisting of a combination of exercises (endurance, strength balance and flexibility) of moderate intensity, 50 min, three times per week for 12 weeks. The body composition and waist circumference (WC) were measured, and questionnaires were used to assess enjoyment, quality of life (QoL) and physical activity (PA) level. Descriptive statistics and pairwise comparison pre and post intervention were carried out. RESULTS: A total of 22 out of 28 participants completed the 12-week training intervention with 83% mean attendance of training sessions. The intensity of the PA level increased and a decrease in fat mass of 1.9 ± 2.4 kg, P < 0.001 and WC of 3 ± 5 cm, P = 0.009 were observed. Enjoyment of training sessions was 3.9 out of 5, and no differences in QoL were found. CONCLUSION: A web-based training programme is an effective tool for improving health parameters of people with ID and offers a new way for caregivers to enhance the PA for the target group.

Lichen Sclerosis is Associated With a High Rate of Local Failure After Radio(chemo)therapy for Vulvar Cancer.

AIMS: Radio(chemo)therapy plays an important role in the treatment of vulvar cancer, either as postoperative treatment or as definitive treatment in patients who present with inoperable disease. Only limited data are available regarding outcome after modern state of the art radio(chemo)therapy and more information regarding prognostic factors are warranted. The aim of this study was to evaluate disease outcomes after radio(chemo)therapy in patients with vulvar cancer with special emphasis on the impact of lichen sclerosis on local control. MATERIALS AND METHODS: All consecutive patients (n = 109) from the western half of Denmark who were treated with definitive (n = 52) or postoperative (n = 57) radio(chemo)therapy between January 2013 and January 2020 were included. Local control, cause-specific survival and overall survival, as well as morbidity, were analysed using Kaplan-Meier statistics. Prognostic factors for local control were analysed in univariate and multivariate analysis. RESULTS: At a median follow-up of 35 (4-95) months, 46 (42.0%) patients were diagnosed with recurrence. Eighty per cent of the recurrences were located to the vulva region, leading to a 5-year local control of 58.9% (confidence interval 47.9-69.9). Cause-specific survival was 62.9% (confidence interval 53.1-72.7), whereas overall survival was 58.0% (confidence interval 47.6-68.5). Grade 3-4 morbidity was diagnosed in 10 (9%) patients. Lichen sclerosis (hazard ratio 3.89; confidence interval 1.93-7.79) was an independent risk factors for local recurrence. Patients without lichen sclerosis had a 5-year local control rate of 83.6% (confidence interval 67.2-99.0) and 62.6% (confidence interval 43.2-82.0) after postoperative and definitive radio(chemo)therapy, respectively. In patients with lichen sclerosis, the local control rate was 44.0% (confidence interval 19.3-69.0) and 17.6% (confidence interval 0-30.0) after postoperative and definitive radio(chemo)therapy, respectively. CONCLUSION: Radio(chemo)therapy plays an important role in the treatment of vulvar cancer. However, despite dose escalation, a substantial proportion of patients experienced local relapse. Pre-existing lichen sclerosis seems to have a significant impact on the risk of recurrence. This should influence surveillance programmes for these patients.

The nature and importance of women's goals for immediate and delayed breast reconstruction.

OBJECTIVES: Increasingly, women undergo breast reconstruction (BR) surgery to restore health-related and psychosocial quality of life after mastectomy. Most research focuses on BR outcomes rather than women's pre-surgical expectations of, and goals for, immediate (IBR) or delayed (DBR) procedures, yet such information could support women's decision-making. This study aimed to investigate women's BR goals, whether they differed according surgery timing (IBR or DBR), and the importance women placed on them. METHODS: Seventy-six women considering DBR (n = 50) or IBR (n = 26) at a UK hospital were encouraged to clarify their BR goals and rate the importance of achieving each one. Content analysis categorised and counted the frequency of the goals they reported. RESULTS: Fifteen goal categories (7 surgical, e.g. scarring; 8 psychosocial/lifestyle, e.g. feeling feminine) were identified. Many (e.g. scarring, intimacy) were reported by a similar percentage of women in each surgical group, however, differences were identified (e.g. breast sensation was not mentioned by women considering IBR). Women reported more psychosocial (n = 206) than surgical goals (n = 160). Further, an independent t-tests revealed that women in both groups placed significantly more importance on the psychosocial (M = 9.4) than surgical goals (M = 8.5). CONCLUSIONS: This study highlights the variety of goals women have for BR, the importance they attach to them, and differences and similarities between those seeking IBR and DBR. Future research should consider whether BR goals are met, how goal achievement influences satisfaction with outcome over time and how best to incorporate goals into pre-surgical treatment decision-making.

PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction.

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients' goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Measurement of the Spectral Shape of the ß-Decay of

We report on a comparison between the theoretically predicted and experimentally measured spectra of the first-forbidden nonunique ß-decay transition ^{137}Xe(7/2^{-})→^{137}Cs(7/2^{+}). The experimental data were acquired by the EXO-200 experiment during a deployment of an AmBe neutron source. The ultralow background environment of EXO-200, together with dedicated source deployment and analysis procedures, allowed for collection of a pure sample of the decays, with an estimated signal to background ratio of more than 99 to 1 in the energy range from 1075 to 4175 keV. In addition to providing a rare and accurate measurement of the first-forbidden nonunique ß-decay shape, this work constitutes a novel test of the calculated electron spectral shapes in the context of the reactor antineutrino anomaly and spectral bump.

Outcome following local excision of T1 anal cancers-a systematic review.

PURPOSE: In most cases, squamous cell carcinoma of the anus (SCCA) is treated with chemo-radiotherapy preserving sphincter function and offering good long-term survival and low recurrence rates. However, chemo-radiotherapy has several side effects: dyspareunia, impotence, fecal incontinence, pain, and skin symptoms. Small/T1 tumors, without metastatic disease, can be treated with local excision alone. We aimed to systematically review the literature regarding outcome following local excision of T1 SCCA. METHODS: PubMed and Embase databases were searched for studies that investigated outcome following local excision of SCCA. RESULTS: Twenty-three studies were included. Twenty of the studies were retrospective, and three studies included more than 100 patients. Most of the studies were published before the 1980s. Overall there was great heterogeneity and missing data across the included studies when comparing patient demographics, resection margins, definitions on tumor location, and outcome. Overall 5-year survival was 69% (95% CI 66-72) following local excision. Overall 5-year recurrence was 37% (95% CI 30-45) following local excision. No complications were reported following local excision. CONCLUSION: The current literature on outcome following local excision of T1 anal cancers consists predominantly of smaller, retrospective, and heterogenous studies. Overall 5-year survival is acceptable, but worse than following chemo-radiation therapy. However, local excision seems to have no or only few minor complications. Recurrence rates are high. Therefore, a thorough follow-up program is needed when performing local excision as primary treatment for T1 SCCA. There is an evident need for further studies.

[Nocebo, informed consent and doctor-patient communication]. / Nocebo, Aufklärung und Arzt-Patienten-Kommunikation.

Negative previous experiences (conditioning), observational learning and expectations can trigger nocebo effects. They are responsible for a substantial proportion of the side effects of medical treatment, and are induced primarily by risk information for informed consent. This has been demonstrated in studies on patient groups with or without modified medical information. Drug trials in the field of neurology and psychiatry have regularly revealed side effects and drop-out also in placebo groups. The underlying neurobiological mechanisms were experimentally investigated especially for nocebo-induced hyperalgesia, whereby the specifically involved regions of the brain could be identified by functional imaging as well as changes in the dopamine, endorphin and cholecystokinin systems. Nocebo effects are specific, i.e. they are closely related to patient information and can induce or aggravate exactly the symptoms addressed. Nevertheless, informed consent is an essential part of doctor-patient communication; however, information on risks can be markedly less damaging when unnecessary repetitions are avoided, misunderstandings are recognized or resolved and several different options are given. In addition, risks should always be named together with positive aspects, such as the advantages of the appropriate treatment, the prophylactic measures applied or the early detection and treatment of developing side effects. The best protection against harm caused by information on risks is a trustful doctor-patient relationship. Poor knowledge of nocebo effects or lack of countermeasures constitute a serious threat to patients and according to the current state of knowledge could be rated as medical malpractice.

Search for Neutrinoless Double-ß Decay with the Complete EXO-200 Dataset.

A search for neutrinoless double-ß decay (0νßß) in ^{136}Xe is performed with the full EXO-200 dataset using a deep neural network to discriminate between 0νßß and background events. Relative to previous analyses, the signal detection efficiency has been raised from 80.8% to 96.4±3.0%, and the energy resolution of the detector at the Q value of ^{136}Xe 0νßß has been improved from σ/E=1.23% to 1.15±0.02% with the upgraded detector. Accounting for the new data, the median 90% confidence level 0νßß half-life sensitivity for this analysis is 5.0×10^{25} yr with a total ^{136}Xe exposure of 234.1 kg yr. No statistically significant evidence for 0νßß is observed, leading to a lower limit on the 0νßß half-life of 3.5×10^{25} yr at the 90% confidence level.

Human walk-to-run transition in the context of the behaviour of complex systems.

This study had two main aims: 1) to investigate if the walk-to-run (WR-) transition occurs when the speed of locomotion is kept constant below the WR-transition speed (speed clamp) and the stride rate is increased monotonously using a metronome and 2) to investigate if diversion of attention and awareness from the locomotion process influences the position of the WR-transition in stride rate, stride length, and locomotion speed (SrSlLs) space. Eighteen healthy individuals (13 men and 5 women) were recruited (age: 23.9 ±â€¯1.5 years, height: 1.77 ±â€¯0.10 m and body mass: 77.3 ±â€¯12.8 kg). Stride-by-stride stride rates, stride lengths, locomotion speeds, and duty factors were determined on a treadmill in 4 different tests: 1) reference WR-transition, 2) preferred walking speed, 3) dual-task test including arithmetic calculations and 4) four speed clamp bouts with different initial velocities. Walk-to-run transitions were elicited in all participants in the speed clamp bouts. When the stride rate ramp was clamped at preferred walking speed the WR-transition stride rate was not significantly different from the WR-transition stride rate during the reference test (t = 2.2, p = 0.312). However, in the SrSlLs space the speed clamp WR-transitions all deviated from the position of the reference WR-transition. Additionally, it was demonstrated that intensive attentional diversion using a dual-task paradigm had very little influence on the position of the WR-transition in the SrSlLs space. It is argued that these observations can be explained in the context of the behavior of complex systems.

Advances in Semiochemical Repellents to Mitigate Host Mortality From the Spruce Beetle (Coleoptera: Curculionidae).

We tested 3-methyl-2-cyclohexen-1-one (MCH) and novel semiochemicals as potential spruce beetle (Dendroctonus rufipennis Kirby) (Coleoptera: Curculionidae, Scolytinae) repellents over multiple years in Utah and Colorado trapping bioassays. MCH is a known spruce beetle repellent and our testing revealed Acer kairomone blend (AKB) and isophorone plus sulcatone as repellents. We subsequently tested these semiochemicals for area and single tree protection to prevent spruce beetle attacks at locations in Utah, Colorado, Wyoming, New Mexico, and Alaska. Individual tree protection trials found MCH-AKB provided significant protection against spruce beetle attacks in the southern Rocky Mountains but not in Alaska. Adding sulcatone or doubling MCH-AKB pouches did not further enhance protection. A degree of protection was extended to spruce at least 10 m distant from the repellents, including in Alaska. Tree diameter was not a significant covariate among treated trees but was positively correlated with the probability of infestation for surrounding spruce. In area protection trials, spruce in control plots were 2.4 times more likely to be in a higher severity attack class compared with spruce in plots treated with MCH-AKB pouches deployed at 30 sets per hectare. Tree diameter had a significant, positive relationship to the probability of infestation. We found MCH-AKB to offer a high degree of protection against beetle attack in Engelmann spruce (Picea engelmannii Parry ex Engelm.) (Pinales: Pinaceae) (Picea engelmannii Parry ex Engelm.) (Pinales: Pinaceae), especially for single tree protection (66% of control trees were strip- or mass-attacked compared with 6% of repellent-treated trees). AKB requires registration and labeling, however, before this economical and environmentally benign semiochemical can be used operationally.

[Cell salvage : Scientific evidence, clinical practice and legal framework]. / Maschinelle Autotransfusion : Wissenschaftliche Evidenz, klinische Praxis und rechtliche Rahmenbedingungen.

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

A framework for exposure characterization and gamma dosimetry at the NMBU FIGARO irradiation facility.

PURPOSE: The FIGARO low dose 60Co gamma irradiation facility at the Norwegian University of Life Sciences, Ås, Norway, is dedicated to the study of effects on living organisms from acute or chronic ionizing radiation exposures, either alone or in combination with other stressors such as UV radiation, metals or radionuclides. Here, we present a framework of working guidelines and computer software for characterization of absorbed dose rates and accumulated doses to organisms exposed within the continuous gamma field at FIGARO. The aims of the framework are to ensure gamma exposures are well characterized, that results from exposures are correctly interpreted in terms of absorbed dose rates and accumulated doses, and that sufficient information is available so that exposures can be reproduced later or at other facilities. METHODS: The software of the framework includes a Geant4 application for Monte Carlo radiation transport simulations and tools for dose planning, recording and reporting. The working guidelines are prepared for expert users who provide simulated, calculated or estimated absorbed dose rates and for regular users who conduct exposure experiments and are responsible for record keeping. To demonstrate the developed framework, we use a case study where 14 freshwater microcosms are exposed to four levels of gamma dose rates at FIGARO. CONCLUSION: The framework guides users towards good dosimetry practices. Lessons learned could be transferable to other gamma irradiation facilities.

Search for Neutrinoless Double-Beta Decay with the Upgraded EXO-200 Detector.

Results from a search for neutrinoless double-beta decay (0νßß) of ^{136}Xe are presented using the first year of data taken with the upgraded EXO-200 detector. Relative to previous searches by EXO-200, the energy resolution of the detector has been improved to σ/E=1.23%, the electric field in the drift region has been raised by 50%, and a system to suppress radon in the volume between the cryostat and lead shielding has been implemented. In addition, analysis techniques that improve topological discrimination between 0νßß and background events have been developed. Incorporating these hardware and analysis improvements, the median 90% confidence level 0νßß half-life sensitivity after combining with the full data set acquired before the upgrade has increased twofold to 3.7×10^{25} yr. No statistically significant evidence for 0νßß is observed, leading to a lower limit on the 0νßß half-life of 1.8×10^{25} yr at the 90% confidence level.

Effect of participation in a park-based afterschool program on cardiovascular disease risk among severely obese youth.

OBJECTIVES: The prevalence of severe obesity in youth is rising, despite reports of obesity rates stabilizing overall. While reports on treatment outcomes for youth with severe obesity (bariatric surgery, behavioral and pharmacological treatments) exist, very few community-based programs have reported changes in health outcomes in this population. We assessed changes in cardiovascular health risk profiles among racial/ethnic minority youth with severe obesity who participated in Fit2Play™, a park-based afterschool health promotion program. STUDY DESIGN: A longitudinal cohort study. METHODS: Children aged 6-14 years (N = 1546, 51% Hispanic, 44% non-Hispanic black) who participated in the Fit2Play™ in one of 34 urban park sites for one school year over five separate school years (2010-2015) had height, weight, four-site skinfold thicknesses, systolic blood pressure (SBP)/diastolic blood pressure (DBP), fitness tests, and a health/wellness knowledge test collected at the beginning and end of the school year. Two-level repeated measures mixed models examined changes in cardiovascular health outcomes (body mass index [BMI], skinfold thickness, systolic/diastolic blood pressure percentile [SBPP/DBPP], cardiorespiratory fitness [PACER]) in youth with severe obesity over 1- and 2-year follow-up. RESULTS: Compared with baseline, BMI decreased 13% (incidence rate ratio [IRR] 95% confidence interval [CI]: 0.83-0.90), sumof skinfold thicknesses decreased 5% (IRR 95% CI: 0.91-0.99), SBPP decreased 5% (IRR 95% CI: 0.90-0.99), DBPP decreased 19% (IRR 95% CI: 0.77-0.86), and PACER scores increased 12% (IRR 95% CI: 1.0-1.27) after two years of participation in the Fit2Play™ program. CONCLUSIONS: Findings here support community/park-based youth programs as effective and accessible treatment options for reducing cardiovascular disease risk among youth with severe obesity.

Eccentric exercise induces spatial changes in the mechanomyographic activity of the upper trapezius muscle.

In this study, we hypothesized that the recordings of multichannel mechanomyography (MMG) of the upper trapezius muscle would reveal spatially dependent manifestations in the presence of delayed onset muscle soreness occurring 24 hours after eccentric exercise (ECC). Sixteen participants performed high-intensity eccentric exercises (5 sets of 10 eccentric contractions at 100% of max elevation force) targeting the upper trapezius on their dominant side. Twelve accelerometers were attached to record MMG activity during submaximal exercise consisting of static and dynamic arm flexion and abduction. Measurements were taken before and 24 hours after ECC. Average rectified value (ARV), percentage of determinism (% DET), and recurrence (% REC) of the MMG signals were computed to estimate the level of muscular activity and the magnitude of regularity of the MMG. The ARV, % REC, and % DET maps revealed heterogeneous MMG activity of the upper trapezius 24 hours after ECC when compared with before. Increased ARV, % REC, and % DET were found 24 hours after ECC when compared with before. The study provides new key information on how a single muscle responds to ECC. Our findings suggest that multichannel MMG and nonlinear analyses may detect muscular and musculo-tendinous alterations due to ECC.

Evidence for a Prepupal Diapause in the Mountain Pine Beetle (Dendroctonus ponderosae).

Dormancy strategies, including diapause and quiescence, enable insects to evade adverse conditions and ensure seasonally appropriate life stages. A mechanistic understanding of a species' dormancy is necessary to predict population response in a changing climate. Climate change is influencing distribution patterns and population success of many species, including Dendroctonus ponderosae Hopkins (Coleoptera: Curculionidae: Scolytinae), the most important mortality agent of pines in western North America. Diapause is considered absent in D. ponderosae, and quiescence in the final larval stage prior to pupation (i.e., prepupal) is considered the main dormancy strategy. We evaluated if a facultative diapause in the prepupal stage, rather than a pupation threshold ~15°C (i.e., quiescence), could describe pupation patterns in two latitudinally separated D. ponderosae populations in the western United States. We hypothesized that if pupation occurs at lower temperatures than previously described, and if significant prepupal developmental delays occur, diapause is a likely physiological mechanism. Although there was considerable variation within and between populations, pupation occurred below the previously established threshold suggesting a prepupal facultative diapause that is induced when late instars experience cool temperatures. Individuals that pupated at temperatures below 15°C also had developmental delays, relative to development at warmer temperatures, consistent with diapause development. Pupation patterns differed between populations wherein diapause was induced at cooler temperatures and diapause development was shorter in southern compared with northern D. ponderosae. Recognition of a facultative diapause that varies among and between populations is critical for making predictions about future population response and range expansion in a changing climate.

Hybridization of Subgap States in One-Dimensional Superconductor-Semiconductor Coulomb Islands.

We present measurements of one-dimensional superconductor-semiconductor Coulomb islands, fabricated by gate confinement of a two-dimensional InAs heterostructure with an epitaxial Al layer. When tuned via electrostatic side gates to regimes without subgap states, Coulomb blockade reveals Cooper-pair mediated transport. When subgap states are present, Coulomb peak positions and heights oscillate in a correlated way with magnetic field and gate voltage, as predicted theoretically, with (anti)crossings in (parallel) transverse magnetic field indicating Rashba-type spin-orbit coupling. Overall results are consistent with a picture of overlapping Majorana zero modes in finite wires.