Outcomes in patients ≥ 80 years with a diagnosis of a hepatopancreaticobiliary (HPB) malignancy.

Older patients are underrepresented in oncological clinical trials. The incidence of hepatopancreaticobiliary (HPB) malignancies is higher in older patients, but data on outcomes are lacking. This study assessed patient outcomes in those < 80 and ≥ 80 years with a HPB malignancy seen at a tertiary referral centre, The Christie NHS Foundation Trust. Data on patients with a HPB malignancy were collected retrospectively between 2012 and 2017 via on-line case-note review. Survival was calculated using the Kaplan-Meier method and prognostic factors using log-rank analysis. Of 1421 patients, 10% were ≥ 80 years. Of patients < 80 and ≥ 80 years, 56% and 57% had pancreas cancer, 39% and 36% biliary tract cancer, and 5% and 7% had hepatocellular carcinoma, respectively. Amongst patients ≥ 80 years, 75% had an Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2. Patients ≥ 80 years had higher rates of comorbidity; 28% received systemic anti-cancer therapy (SACT), compared with 62% of patients < 80 years. Best supportive care (BSC) was instituted in 44% of older patients, compared with 13% in those < 80 years. Of patients ≥ 80 years who received SACT, 82% received monotherapy. Median overall survival (OS) for patients receiving palliative SACT was 10.07 months (95% CI 8.89-11.08) and 10.10 months (95% CI 6.30-12.30) in patients < 80 and ≥ 80 years, respectively, p 0.41; ECOG PS (p < 0.001) was prognostic for OS in older patients but Adult Comorbidity Evaluation-27 comorbidity score (p = 0.07, when comparing groups of ACE score ≤ 1 and > 1) was not. Baseline factors were similar in both age cohorts, but more comorbidities were present in older patients. Older patients were less likely to receive SACT, but when they did, they had an equivalent benefit in OS to younger patients.

Young Accreting Compact Objects in M31: The Combined Power of NuSTAR, Chandra, and Hubble.

We present 15 high-mass X-ray binary (HMXB) candidates in the disk of M31 for which we are able to infer compact object type, spectral type of the donor star, and age using multiwavelength observations from NuSTAR, Chandra, and the Hubble Space Telescope. The hard X-ray colors and luminosities from NuSTAR permit the tentative classification of accreting X-ray binary systems by compact object type, distinguishing black hole from neutron star systems. We find hard-state black holes, pulsars, and non-magnetized neutron stars associated with optical point-source counterparts with similar frequency. We also find nine non-magnetized neutron stars coincident with globular clusters and an equal number of pulsars with and without point-source optical counterparts. We perform spectral energy distribution (SED) fitting for the most likely optical counterparts to the HMXB candidates, finding seven likely high-mass stars and one possible red helium-burning star. The remaining seven HMXB optical counterparts have poor SED fits, so their companion stars remain unclassified. Using published star formation histories, we find that the majority of HMXB candidates-X-ray sources with UV-bright point-source optical counterpart candidates-are found in regions with star formation bursts less than 50 Myr ago, and three are associated with young stellar ages (<10Myr). This is consistent with similar studies of HMXB populations in the Magellanic Clouds, M33, NGC 300, and NGC 2403.

Dectin-2 sensing of house dust mite is critical for the initiation of airway inflammation.

How the immune system senses aeroallergens and triggers an aberrant inflammation is poorly understood. Dectin-2 is a house dust mite (HDM)-sensing pattern recognition receptor. In a 3-week mouse model of repeated intranasal HDM challenge, anti-Dectin-2 potently attenuated the characteristic allergic inflammation and airway hyper-responsiveness. Anti-Dectin-2 also prevented neutrophil influx following a single HDM challenge. Interestingly, cysteinyl leukotrienes, but not chemokine and cytokine levels were inhibited by anti-Dectin-2 in this acute model, and in ex vivo challenge of cultured alveolar macrophages with HDM. Furthermore in the single-challenge model, zileuton, an inhibitor of leukotriene production, produced a similar effect as Dectin-2 blockade. Together these data suggest alveolar macrophage sensing of HDM by Dectin-2 elicits the production of cysteinyl leukotrienes, and this axis is key for the initiation of airway inflammation to this aeroallergen. Finally, we found Dectin-2-positive infiltrating cells present in bronchial biopsies from asthmatic subjects.

A paramedic study comparing the use of the Airtraq, Airway Scope and Macintosh laryngoscopes in simulated prehospital airway scenarios.

In a randomised, cross-over study, we compared the use of the Airtraq , Airway Scope and Macintosh laryngoscopes by paramedics for tracheal intubation in three simulated prehospital scenarios. Fifty-four paramedics were invited to take part. When evaluated in a difficult airway manikin, median IQR [range] time to intubation with the Airtraq (21 (16-37 [6-80] s) and Airway Scope (16 (5-75 [12-23] s) was shorter than that with the Macintosh laryngoscope (39 (25-54 [7-120] s; p < 0.0001). The success rate within 30 s was greater with the Airtraq (61%) and Airway Scope (93%) than with the Macintosh laryngoscope (22%; p < 0.0001). When used for a standard intubation and in the sitting position, we found minimal differences among the three laryngoscopes. We conclude that the Airway Scope and Airtraq have significant advantages over the Macintosh laryngoscope and that of the two, the Airway Scope is the more effective device to use in the prehospital environment.

A history of James Craig's hall for the Royal College of Physicians of Edinburgh.

The architectural history of the College's George Street hall, completed in 1781, has commonly been overlooked because it was demolished and deemed to have been a disappointment to both its owners and its architect, James Craig. This article reassesses the College's ambitions and Craig's efforts to match them, by accounting for the number of drawings which were made for the site and building, Craig's sources of inspiration and the building's appearance and influence. The paper reveals that the hall was actually intended to be part of a larger complex of buildings and rival Register House as the New Town's most impressive public edifice. The building has not been examined in this way before, and Craig's use of his library, drawing equipment and knowledge of London's architects and architecture are discussed to offer insight into his personal vision for the hall's appearance and meaning.

Environmental prevalence and persistence of Salmonella spp. in outdoor swine wallows.

Swine can harbor Salmonella in their gastrointestinal tracts. It has been estimated that up to 48% of the U.S. swine herd may carry Salmonella. Housing sows in farrowing stalls has become controversial due to animal welfare-based criticisms. An alternative production system is to keep sows outdoors on pasture with access to individual farrowing huts. This study was designed to determine the effects of two production systems on indicator bacteria and Salmonella of sows housed indoors in farrowing stalls (n = 52) compared to sows housed outdoors (n = 52) in English style huts. Each farrowing radial contained one wallow, from which mud (n = 290) and water (n = 290) samples were collected weekly. All samples were analyzed for generic E. coli, coliforms and Salmonella. No differences (p > 0.05) were detected in Salmonella, generic E. coli and coliform populations between indoor farrowing stalls and outdoor farrowing huts. However, all 8 outdoor wallows contained Salmonella spp. at some point during the study (n = 49 Salmonella isolates). Salmonella genotypes persisted within some wallows for >5 months, and genetically indistinguishable Salmonella isolates were found in multiple wallows. Salmonella isolated from outdoor sow feces were genetically indistinguishable by PFGE from Salmonella isolated from wallows (n = 33) throughout the study, indicating that pathogenic bacteria were cycling between swine and their environment. In conclusion, the role of wallows in disseminating Salmonella within an outdoor swine herd appears to be significant.

Treatment of hand and wrist pain. A randomized clinical trial of high voltage pulsed, direct current built into a wrist splint.

To determine the effectiveness of high voltage pulsed current (HVPC) in reducing chronic hand edema, 120 individuals were randomly assigned to one of two treatment groups. Group I clients were given an appropriate sized wrist splint, incorporating an energized, high voltage pulsed unit. Group II clients were given an identical splint with a non-energized unit. Each client received daily treatments at the worksite consisting of 30 minute sessions totaling 20 treatments during a 35 day period. Pre-treatment and post-treatment evaluations included measurements of pain, grip strength, and edema volume; repetitive task testing; and Semmes-Weinstein Monofilament sensory testing. In the energized group, post-treatment evaluation showed statistically significant decreases in the amount of stimulation required to stimulate the median nerve and the amount of hand edema and pain. The energized group also had improved repetitive task times. None of these improvements occurred in the non-energized group. Based on these results, HVPC appears to be an effective method for minimizing the severity of repetitive stress injuries of the wrist.

Distribution of collagens and glycosaminoglycans in the joint capsule of the proximal interphalangeal joint of the human finger.

BACKGROUND: The capsule of the proximal interphalangeal joint consists of the central slip of the extensor tendon dorsally, the collateral ligaments at the sides and the palmar ligament ventrally. Fibrocartilaginous menisci have been reported extending into the joint cavity and the central slip has a sesamoid fibrocartilage articulating with the proximal phalanx. This study relates ECM composition in the joint capsule to function. METHODS: Each part of the capsule from 24 fingers amputated because of trauma, carcinoma, isthaemia, fixed-flexion deformities or Dupuytren's contracture, was dissected out. Sections were prepared for routine histology or immunolabelled with a panel of monoclonal and polyclonal antibodies against collagens and glycosaminoglycans using the avidin/biotin/peroxidase procedure. RESULTS: All parts of the capsule consistently labelled for types I, III and VI collagens and for dermatan and keratan sulphate, though labelling was more pericellular in fibrocartilaginous regions. In contrast, only certain regions of the capsule in some fingers labelled for type II collagen, chondroitin 4 or 6 sulphate. The sesamoid fibrocartilage in the central slip showed the greatest degree of fibrocartilage differentiation, especially in fixed-flexion deformity fingers, and the palmar ligament the least. CONCLUSIONS: The immunolabelling patterns suggest that there is an ordered sequence of matrix changes accompanying fibrocartilage differentiation. Chondroitin sulphate-containing proteoglycans accumulate first, and type II collagen appears later. The presence or absence of type II collagen probably relates to different levels of compressive loading. No fibrocartilaginous menisci were found in normal joints and those described previously are regarded as synovial folds.

High resolution magnetic resonance imaging of the proximal interphalangeal joints. Correlation with histology and production of a three-dimensional data set.

The magnetic resonance imaging appearance of the proximal interphalangeal joints of cadavers was correlated with histology of the same specimen allowing many small-scale features to be identified that might otherwise have been misinterpreted. It enabled the magnetic resonance signal to be understood at a tissue and cellular level, allowing identification of synovial folds extending from the extensor tendon and volar plate, the entheses of the proper collateral ligament, the epitenon of the flexor tendons and the presence of osteophytes and sites of cartilage erosion. The main difficulties in matching two-dimensional magnetic resonance images with histology were the differing section thicknesses of the two methods and shrinkage of histological specimens. There are many advantages in producing high resolution three-dimensional datasets-the magnetic resonance section thickness is reduced and the individual components of the joint can be viewed simultaneously in two or more planes. A unique magnetic resonance atlas of three dimensional joint structure is presented.

Acquired esotropia due to Arnold-Chiari I malformation.

OBJECTIVE: Diplopia is not frequently associated with Arnold-Chiari I malformation. We reviewed our cases of Arnold-Chiari I malformation in which acquired esotropia with diplopia was the main neuro-ophthalmologic finding early in the clinical course. MATERIALS AND METHODS: Five patients were studied, all female, ranging in age from 17 to 36 years, who were treated by the neuro-ophthalmology service of urban teaching hospitals. Eye movement recordings using magnetic search coil technique were performed in two patients. RESULTS: All patients reported onset of horizontal diplopia due to acquired esotropia as an initial manifestation of the Arnold-Chiari I malformation. All had full abduction of each eye. In addition, all five had gaze-evoked nystagmus, two skew deviations, and one bilateral internuclear ophthalmoparesis. Oculography in two patients showed normal abducting saccadic peak velocities. This supports divergence palsy as a mechanism of acquired esotropia and provides evidence against subtle sixth nerve palsy in these patients. Four patients underwent neurosurgical decompression of their Chiari malformations, and neuro-ophthalmologic signs and symptoms improved in all. CONCLUSIONS: Acquired esotropia, often in association with other eye movement abnormalities, may be an early sign of Arnold-Chiari I malformation. This quantitative study indicates that divergence palsy is the cause of esotropia in some patients. Neurosurgical suboccipital and upper cervical decompression may lead to improvement or resolution of diplopia.

Topical treatment of periocular capillary hemangioma.

Five patients with vision-threatening periocular capillary hemangiomas were treated with topical clobetasol propionate cream. Two received steroid eye drops. All experienced a decrease in the size of their hemangioma. Topical treatment of periocular capillary hemangioma appears to be well tolerated and, in selected cases, may eliminate the need for intralesional injection of corticosteroids.

Visual loss due to progressive multifocal leukoencephalopathy in a heart transplant patient.

A 59-year-old male heart transplant recipient experienced progressive visual loss following routine cataract surgery with intraocular lens implantation. Cranial magnetic resonance (MR) imaging suggested and brain biopsy confirmed the cause to be progressive multifocal leukoencephalopathy (PML). The patient died 2 months following cataract surgery. This case illustrates that visual failure may be the initial manifestation of PML, and the ophthalmologist should be aware of this central demyelinating disorder when dealing with immunocompromised patients.

Dry-heat destruction of lipopolysaccharide: mathematical approach to process evaluation.

A mathematical model was developed to estimate the number of logarithmic cycles (LDec) of lipopolysaccharide concentration destroyed by a dry-heat sterilization process. The LDec values calculated from the mathematical model agreed well with those obtained from the destruction of lipopolysaccharide by a dry-heat treatment. A discussion of how the mathematical model may be used to evaluate a dry-heat sterilization cycle is presented. This mathematical model and the dry-heat destruction curves indicated existence of a maximum LDec value at each temperature. The implications of this finding are discussed.

Evaluation of acceptance criteria for particulate limits for small-volume parenteral products.

The precision of and correlation between the USP membrane filtration-microscopic method and the instrumental method for sizing and quantifying particulate matter in small-volume parenteral products were determined using simulated products. The total variance for the instrumental counts was lower than the USP method for all products in the 10--25-mum particle range and for most products in the greater than or equal to 25--50-mum range. A linear relationship between the instrumental counts and the USP counts was demonstrated for the 10--25-mum particle range. However, the instrumental reading was higher than the USP method for counts of 10 or more particles/ml. The instrumental and the USP methods failed to correlate on particulate sizes greater than 25 mum. The content of particulate matter in over 100 small-volume parenteral products was sized and quantified by the USP and the instrumental methods. From the instrumental data, a statistical treatment for the analysis of particulate data is presented as an objective method of evaluating acceptance criteria on particulate matter in small-volume parenteral products.