Frequency of retinal detachments in dogs after prophylactic transpupillary retinopexy.

PURPOSE: To evaluate the frequency of retinal detachments following prophylactic transpupillary retinopexy (PTPRP). METHODS: The medical records of dogs that received a PTPRP between 2014 and 2022 were retrospectively analyzed for age, sex, breed, reason for retinopexy, laser power setting, number of retinal burns, follow-up duration, and outcome. Laser power settings were increased until retinal burns could be visualized and were made 360° in a double row in the peripheral retina. RESULTS: Fifty-seven cases (75 eyes), 28 males and 29 females, had PTPRP performed. The median age was 8 years (4 months-14 years) with Shih tzu (n = 12), Bichon (n = 5), Miniature Poodle (n = 5), and Yorkie (n = 4) being the most common breeds. PTPRP were performed due to severe vitreal degeneration (n = 66), retinal detachment in the contralateral eye (n = 25), capsular tear with escaped lens material during phacoemulsification (n = 6), intracapsular lens extraction (n = 2), and lens luxation during phacoemulsification (n = 3). The median power setting, number of retinal burns, and follow-up time were 300 mW (201-595 mW), 210 burns (35-921 burns), and 473 days (14-1862 days), respectively. Additionally, five patients had a barrier-pexy performed in the contralateral eye, due to partial detachment. Retinal detachment occurred in 3/75 (4.0%) of eyes that received a PTPRP at the final examination. Of the patients with a detachment in the contralateral eye (n = 25), no detachment was noted at the last follow-up examination. Two partial detachments that had barrier-pexies had progressed at the final examination. CONCLUSIONS: These results demonstrate that PTPRP may be beneficial in decreasing the risk of retinal detachment in selected cases.

Metagenome-assembled genomes of an acid-tolerant nitrifying bacterial community isolated from a bioreactor used in ammonium scrubbers at animal-rearing facilities.

We report 12 metagenome-assembled genomes (MAGS) of a bioreactor community of acid-tolerant nitrifying bacteria. The MAGS include autotrophs in the Nitrospira genus and heterotrophs in the Xanthomonadales, Ktedonobacterales, Cytophagales, Burkholderiales, and Hyphomicrobiales. These taxonomic and genomic data provide insights into the core community members required for nitrification at low pH.

Necrotizing Pneumonia, a Skeletal Muscle Lesion, and a Fungating Duodenal Mass: An Atypical Presentation of Rapidly Progressing Lung Adenocarcinoma.

Lung adenocarcinoma, the predominant subtype of non-small cell lung cancer, typically metastasizes to common sites such as the liver and adrenal glands. However, rare instances involve skeletal muscle metastasis. We present a case of a 45-year-old female with a medical history of hypertension, epilepsy, and fibromyalgia, who presented to the emergency department with hemoptysis and multifocal pain. Chest imaging revealed a cavitary lesion which appeared to be necrotizing pneumonia. Further investigations uncovered a fluid collection in the left thigh, which would be identified as poorly differentiated carcinoma. Subsequent testing identified the lung as the primary source of metastasis. Despite radiation treatment, the patient's condition deteriorated over the next 50 days, highlighting the aggressive nature of the disease.

Lipid emulsion therapy during management of the critically-ill poisoned patient: a prospective cohort study.

BACKGROUND: Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. METHODS: We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. RESULTS: We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. CONCLUSION: Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion.

Clinical description with magnetic resonance appearance of a high-grade undefined optic nerve glioma with intracranial extension.

A 4-year-old mixed-breed dog was presented for hyphema and glaucoma of the right eye. Enucleation of the right globe was carried out, and histopathology examination revealed an optic nerve glioma with incomplete surgical margins. At 8 wk after surgery, the dog had depressed mentation and a diminished pupillary light reflex of the left eye. Magnetic resonance imaging revealed an irregular, heterogeneously T2 hyperintense/T1 isointense mass in the region of the optic chiasm. Compression of the rostral thalamus was present, with effacement of the pituitary gland and involvement of the right orbit. The dog was euthanized 4.5 mo after initial presentation. An undefined glioma of the right optic nerve with extension to the diencephalon was diagnosed on necropsy. Key clinical message: Although rare, intraocular glioma is a differential diagnosis for hyphema, glaucoma, and retinal detachment. Magnetic resonance imaging should be considered in cases of intraocular neoplasia, notably in those with incomplete surgical margins of the optic nerve.

Description clinique avec aspect en résonance magnétique d'un gliome indéfini de haut grade du nerf optique avec extension intracrânienne. Un chien de race croisé âgé de 4 ans a été présenté pour un hyphéma et un glaucome de l'œil droit. Une énucléation du globe droit a été réalisée et l'examen histopathologique a révélé un gliome du nerf optique aux marges chirurgicales incomplètes. Huit semaines après la chirurgie, le chien avait une diminution du processus mental et un réflexe pupillaire à la lumière diminué de l'œil gauche. L'imagerie par résonance magnétique a révélé une masse irrégulière hétérogène hyperintense T2/T1 isointense dans la région du chiasma optique. Une compression du thalamus rostral était présente, avec effacement de l'hypophyse et atteinte de l'orbite droite. Le chien a été euthanasié 4,5 mois après la présentation initiale. Un gliome indéfini du nerf optique droit avec extension au diencéphale a été diagnostiqué à l'autopsie.Message clinique clé:Bien que rare, le gliome intraoculaire est un diagnostic différentiel pour l'hyphéma, le glaucome et le décollement de la rétine. L'imagerie par résonance magnétique doit être envisagée en cas de néoplasie intraoculaire, notamment chez ceux dont les marges chirurgicales du nerf optique sont incomplètes.(Traduit par Dr Serge Messier).

Effects of corneoconjunctival transposition, posterior lamellar keratoplasty and modified deep lamellar endothelial keratoplasty on streak retinoscopy in equine cadaver eyes.

OBJECTIVE: Evaluate the effects of corneoconjunctival transposition (CCT), posterior lamellar keratoplasty (PLK) and modified deep lamellar endothelial keratoplasty (DLEK) on streak retinoscopy in equine cadaver eyes. METHODS: Intraocular pressure (IOP) was maintained at 25 ± 3 mmHg in 35 equine cadaver eyes. Streak retinoscopy was performed prior to (NO VISCO) and following (VISCO) intracameral injection of 1.0 ml of viscoelastic. Following optical coherence tomography (OCT), an axial CCT [n = 11] or PLK [n = 12], or peripheral DLEK [n = 12] was performed. Streak retinoscopy and OCT were repeated postoperatively. RESULTS: Postsurgical net meridional and spherical refraction for CCT [Horizontal (H): 3.4 (95% CI 2.4-4.4) diopters (D), p < .001, Vertical (V): 3.5 (95% CI 2.7-4.4) D, p < .001, Spherical: 3.5 (95% CI 2.6-4.3) D, p < .001] and PLK [H: 3.2 (95% CI 2.2-4.1) D, p < .001, V: 2.8 (95% CI 2.0-3.6) D, p < .001, Spherical: 3.0 (95% CI 2.2-3.8) D, p < .001] were significantly increased from presurgical (VISCO) values. No difference between presurgical (VISCO) and postsurgical values were identified for the DLEK. Postoperative OCT revealed space between anterior and posterior corneal grafts and corneal undulation associated with suture placement. CONCLUSION: Meridional and spherical refraction had a hyperopic shift following CCT and PLK, with a significantly higher value in the vertical meridian for the CCT. Pre- and postoperative refraction was not significantly different for the DLEK. This supports that the DLEK has a lesser effect on immediate postoperative refraction compared with CCT or PLK.

Transcatheter Edge-to-Edge Repair of Systemic Tricuspid Valve in Extracardiac Fontan Circulation: First in Human.

Transcatheter edge-to-edge valve repair can improve clinical outcomes in otherwise high-risk surgical patients. This is a first-in-human procedure outlining transcatheter edge-to-edge valve repair of a systemic tricuspid valve in an extracardiac Fontan patient born with hypoplastic left heart syndrome with prohibitive surgical risk. (Level of Difficulty: Advanced.).

Clinical and pathologic evaluation of chorioretinal lesions in wild owl species.

OBJECTIVE: Investigate histopathology and spectral-domain optical coherence tomography (OCT) imaging of wild owls with chorioretinitis and identify any potential correlation with an infectious etiology. MATERIALS AND METHODS: Ophthalmic examination and retinal OCT imaging were performed on fifteen great horned (Strix varia) and barred (Bubo virginianus) owls (30 eyes) with chorioretinitis and five owls with normal eyes (10 eyes). Testing to investigate the presence of potential infectious diseases included a complete blood count, biochemistry, protein electrophoresis, West Nile virus (WNV) plaque reduction neutralization test, Toxoplasma gondii modified direct agglutination test, WNV RT-PCR, and Avian Influenza RT-PCR. A necropsy was performed on all owls, including ocular histopathology. RESULTS: Fundus lesions included retinal detachment (7/15 owls), depigmented lesions (12/15), pigment clumping (8/15), and retinal tear (4/15). All birds were negative for WNV and Avian Influenza on RT-PCR. Of the owls with chorioretinitis, 3/15 were seropositive for WNV and 7/15 for T. gondii. Optical coherence tomography of 25/30 affected eyes revealed outer retinal lesions (19/25 eyes), retinal detachment (16/25), and retinal tears (3/25). Histopathological examination revealed outer nuclear layer atrophy (19/30 eyes), retinal detachment (18/30), retinal tears (7/30), suprachoroidal hemorrhage (12/30), scleral rupture (3/30), and ossicle fracture (3/30). CONCLUSIONS: Although 20% of birds were seropositive for WNV and 46.6% for T. gondii, histopathologic findings supported that the posterior segment lesions in the study group were likely due to blunt ocular trauma rather than an infectious etiology. The results of OCT imaging and histopathology documented retinal changes most consistent with blunt ocular trauma.

Comparison of image quality of corneal and retinal optical coherence tomography using sedation and general anesthesia protocols with or without retrobulbar anesthesia in horses.

OBJECTIVE: To compare image quality and acquisition time of corneal and retinal spectral domain optical coherence tomography (SD-OCT) under 3 different sedation-anesthesia conditions in horses. ANIMALS: 6 middle-aged geldings free of ocular disease. PROCEDURES: 1 randomly selected eye of each horse was evaluated via SD-OCT under the following 3 conditions: standing sedation without retrobulbar anesthetic block (RB), standing sedation with RB, and general anesthesia with RB. Five regions of interest were evaluated in the cornea (axial and 12, 3, 6, and 9 o'clock positions) and fundus (optic nerve head). Three diagnostic scans of predetermined quality were obtained per anatomical region. Image acquisition times and total scans per site were recorded. Corneal and retinal SD-OCT image quality was graded on a subjective scale from 0 (nondiagnostic) to 4 (excellent). RESULTS: Mean values for the standing sedation without RB, standing sedation with RB, and general anesthesia conditions were 24, 23, and 17, respectively, for total cornea scan attempts; 23, 19, and 19 for total retina-scan attempts; 14.6, 13.2, and 9.2 minutes for total cornea scan time; 19.1, 9.2, and 13.0 for total retina scan time; 2.0, 2.3, and 2.5 for cornea grade; and 2.7, 2.9, and 2.5 for retina grade. CONCLUSIONS AND CLINICAL RELEVANCE: The RB facilitated globe akinesia and improved the percentage of scans in frame and region of interest accuracy for retinal imaging via OCT in horses. Retrobulbar blocks improved clinical image acquisition while minimizing motion artifact.

Scoping review of head and neck neoplasms presenting with obstructive sleep apnoea: the importance of flexible nasendoscopy.

BACKGROUND: Obstructive sleep apnoea (OSA) can be caused by neoplasms involving the upper aerodigestive tract. Currently, many of these patients have this diagnosis missed, as most adults diagnosed with OSA do not undergo adequate head and neck examination including flexible nasendoscopy. We performed a review of the literature to shed light on this phenomenon and outline the pathologies and issues surrounding this sub-population of patients diagnosed with OSA. METHODS: A scoping review of the literature was conducted on head and neck neoplasms presenting with OSA. Data were extracted on demographics, clinical presentation, histopathology, treatment and patient outcomes. RESULTS: Sixty-seven articles were included, describing 79 patients. Mean age was 45.8 years, and 77.2% were male. Symptoms of OSA were present for an average of 29.2 months before a diagnosis of causative neoplasm was made. Forty-two different benign and malignant histopathological entities were reported. At diagnosis, the causative pathology of 100% of patients was visible on head and neck examination including flexible nasendoscopy, while only 53.2% were visible on trans-oral examination. One-third of patients had commenced inappropriate treatment for OSA, including three who had undergone sleep surgical procedures. The majority of patients were treated with surgery alone (72.2%). CONCLUSION: Although rare, neoplasms of the upper aerodigestive tract should be considered as a cause of OSA, especially in patients experiencing other symptoms in addition to the typical symptoms of OSA. They should particularly be considered in patients with comparatively lower body mass index or those with worsening OSA without an apparent cause identified.

Corneoconjunctival transposition with and without ACell® for deep corneal ulcer repair in 18 dogs.

OBJECTIVE: To document a case series using corneoconjunctival transposition (CCT) surgery with and without bioscaffolding matrix (ACell® ) to repair deep corneal ulcers and perforations in dogs. ANIMALS STUDIED: Eighteen dogs of various breeds that presented with deep or perforating corneal ulcers. PROCEDURES: Corneoconjunctival transposition grafts with or without ACell® were sutured using a simple interrupted 8-0 or 9-0 polyglactin 910 pattern. RESULTS: A total of eighteen dogs (19 eyes) were diagnosed with deep corneal ulcers (n = 7) and perforating corneal ulcers (n = 12). A CCT was performed in all eyes, with ten of them additionally receiving an ACell® graft. The majority of lesions were located axially in 14/19 (81%) eyes. Grafts were harvested from dorsal (n = 8), temporal (n = 5), ventral (n = 4), or nasal (n = 2) quadrants. Brachycephalic breeds (13/18) were over-represented. Keratoconjunctivitis sicca was present in 10/19 eyes (52.6%). Bacterial isolates were cultured from 8/19 eyes. Post-operative therapy included topical antibiotics, plasma, cycloplegics, oral antibiotics, and oral nonsteroidal anti-inflammatory drugs. CCT integration with and without ACell® occurred at a median of 20 days (range 7-38 days) post-operatively with no significant difference between groups. Median follow-up time was 188 days. Short-term post-operative complications included granulation tissue formation (19/19), corneal edema (4/19), graft retraction (4/19), and anterior synechia (1/19). Long-term complications in 14 eyes with follow-up >30 days included superficial corneal pigmentation (6/14) and epithelial inclusion cysts (5/14). Two eyes were nonvisual at last follow-up due to cataract formation. CONCLUSIONS: Corneoconjunctival transposition with ACell® can be utilized for corneal ulcer repair in dogs.

Surgical excision of iridociliary tumors using a postero-anterior cyclo-iridectomy and thermocautery in two dogs.

OBJECTIVE: To report the surgical excision of an iridociliary adenoma and iridal melanocytoma using a postero-anterior cyclo-iridectomy in two dogs. PROCEDURE: A 7 year old neutered male English springer spaniel (case 1) and a 7 year old neutered male Labrador mix (case 2) were presented for evaluation of an intrairidal mass OS. RESULTS: Complete ophthalmic examination revealed a large, dorsonasal, well-demarcated, intrairidal mass OS. A tan to pink intrairidal mass extending into the iridocorneal angle (case 1) and a pigmented intrairidal mass (case 2) were present. B-mode ultrasonography showed a focal, soft tissue, homogenous mass within the uvea adjacent to and contacting the lens. Neither pars plana involvement nor vitreal extension was present. A postero-anterior cyclo-iridectomy was performed through a polyhedral scleral flap. Thermocautery was used to complete the cyclo-iridectomy (case 1) and partial iridectomy (case 2) to excise the mass en bloc. Histopathology revealed a completely excised iridociliary adenoma (case 1) and iris melanocytoma (case 2). The surgery sites healed without complication. Mild uveitis (cases 1 and 2), scant vitreal hemorrhage (case 1), and mild hyphema (case 2) were present three days postoperatively but had resolved ten days postoperatively. The patients remain visual twenty-two months (case 1) and seven months (case 2) postoperatively with a normal intraocular examination other than an iridal defect and mild dorsonasal lens capsular opacities. CONCLUSIONS: The surgical approach described in these cases is utilized in physician-based medicine. This approach and the use of thermocautery provide a viable surgical option for excision of large iridociliary tumors in dogs.

Preliminary report of postoperative complications of phacoemulsification in Pugs: A multicenter retrospective study of 32 cases.

OBJECTIVE: To compare complication rates and visual outcomes following phacoemulsification in Pugs versus dogs of other breeds. ANIMALS STUDIED: Thirty-two pure-bred Pugs (55 eyes) and 32 dogs of other breeds (56 eyes) undergoing phacoemulsification. PROCEDURES: Multi-institutional retrospective medical record review of perioperative factors, postoperative complications, and visual outcomes. The reference population of dogs of varying breeds included surgical cases following each Pug case at the same institutions. Perioperative risk factors and postoperative complication rates were compared between the two populations. RESULTS: Pigmentary keratitis and diabetes mellitus were the most common preoperative comorbidities, found in 75% (P < .001) and 72% (P = .12) of Pugs, respectively. No perioperative factors were significantly associated with postoperative complications in Pugs. Postoperative complication rates were similar between groups; however, the most common complication in Pugs was corneal ulceration (15% of operated eyes), whereas glaucoma was most common in the reference population (13% of operated eyes). Three months postoperatively, vision was preserved in 91% of eyes of Pugs (50/55) and 95% of the reference population (53/56). One year postoperatively, 80% (32/40) of Pug eyes and 82% (28/34) of eyes in the reference population remained sighted. CONCLUSIONS: Comorbidities and complications of cataract surgery in Pugs of this study demonstrate a predisposition for corneal disease. This highlights the importance of preoperative evaluation of factors associated with PK and corneal clarity, and postoperative monitoring for corneal ulceration in this breed.

Use of the GORE® CARDIOFORM Septal Occluder for percutaneous closure of secundum atrial septal defects: Results of the multicenter U.S. IDE trial.

OBJECTIVE: To evaluate safety and efficacy of the GORE® CARDIOFORM Septal Occluder for percutaneous transcatheter closure of ostium secundum atrial septal defects. BACKGROUND: The GORE® CARDIOFORM septal occluder is a double-disc, low profile, soft, conformable device, with distinct advantages over the GORE® HELEX® Septal Occluder. METHODS: Subjects were enrolled in this single arm prospective study from 21 U.S. sites, and followed for 3 years. Primary endpoint was 6 month composite clinical success, comprised of technical success (implantation and retention of device), closure success (normalization of right heart size), no 30 day serious adverse events, and no device embolization or reintervention. Secondary endpoints included technical success, procedure success (technical success and ≤ 2 mm residual shunt at procedure conclusion), closure success (clinically insignificant or no residual shunt), and safety (freedom from 30 day serious adverse events and 6-month device events). RESULTS: Between October 2012 and May 2015, 50 pivotal and 350 continued access subjects underwent attempted transcatheter GORE® CARDIOFORM Septal Occluder implantation. Median age was 6.9 years, and mean static defect diameter 9.7 ± 3.1 mm. Device placement was achieved in 93.5% (374/400). Composite clinical success was 90.2% and clinical closure success was 98.8% at 6 months. Freedom from serious adverse events was 98.3% at 30 days, with no device embolizations or reinterventions through 6 months. CONCLUSIONS: The GORE® CARDIOFORM Septal Occluder has high composite clinical success and safety, performing well in defects ≤17 mm by stop flow stretched diameter. Single, multifenestrated, and deficient retroaortic tissue defects were well represented and successfully treated.

Outcomes of dental and craniofacial osseointegrated implantation in head and neck cancer patients.

BACKGROUND: Treatment of head and neck cancer may result in disfiguring and debilitating anatomical changes. Osseointegrated implants may be used in these patients to facilitate attachment of implant-retained dentures or cosmetic prostheses. METHODS: A retrospective audit was performed, reviewing the treatment of patients who received dental or craniofacial osseointegrated implants during treatment of head and neck cancer. RESULTS: One hundred sixty implants were inserted in 54 patients with oral, nasal, orbital, or auricular defects. Overall, 85% of implants were successful after mean follow-up of 25.7 months. The brand of implant used was shown to impart a statistically significant implant survival difference, and orbital implants had poorer survival compared to nonorbital implants. There was a statistical insignificant implant survival advantage in both nonsmokers and patients who did not undergo radiotherapy. CONCLUSIONS: Dental and craniofacial osseointegrated implants may be reliably used in patients with head and neck cancer. However, further research is required to clarify the role of smoking in osseointegrated implant failure.

Longitudinal Associations of Sleep Duration, Morning and Evening Cortisol, and BMI During Childhood.

OBJECTIVE: This study aimed to examine associations between sleep duration, BMI, and cortisol levels across childhood. METHODS: Participants included 361 children adopted domestically in the United States. Random-intercept cross-lagged panel models tested for between-person and bidirectional within-person associations of sleep duration, BMI, and morning and evening cortisol at age 4.5 to 9 years. RESULTS: Sleep duration and BMI were stable during childhood, inversely associated at the between-person level, and unrelated to morning or evening cortisol. BMI at age 6 years predicted longer sleep duration and lower evening cortisol at age 7 years, and lower morning cortisol at age 7 years predicted higher BMI at age 9 years within individuals. CONCLUSIONS: The association between sleep and BMI is more likely a stable between-person phenomenon rather than a unidirectional association that develops within individuals over time.

Balloon Angioplasty and Stenting for Unilateral Branch Pulmonary Artery Stenosis Improve Exertional Performance.

OBJECTIVES: This study sought to determine whether pulmonary artery intervention in patients with unilateral proximal pulmonary artery stenosis (PAS) improves exercise capacity, abnormal ventilatory response to exercise, and symptoms. BACKGROUND: Stenosis of the branch pulmonary arteries results in pulmonary blood flow maldistribution (PBFM). The resulting ventilation-perfusion mismatch is associated with an increased ventilatory response to exercise and decreased exercise capacity. It is unclear if technical success in relieving branch PAS translates to clinical improvement in exercise capacity and ventilatory response. METHODS: Twenty patients with biventricular circulation and a minimum 10% PBFM who underwent transcatheter relief of PAS were enrolled in a multi-institutional prospective cohort study. Pre- and post-procedure assessment of the degree of PBFM, exercise capacity, ventilatory response to exercise, and subjective assessment of breathlessness were collected and analyzed. RESULTS: Technical success was achieved in all patients with significant angiographic improvement in minimal lumen diameter (p = 0.001) and peak gradient (p = 0.001). Median PBFM improved (19.5% [range 12.0% to 31.0%] before vs. 7.0% [range 0% to 33.0%] after; p = 0.003). Exercise capacity was low at baseline and improved significantly post-intervention; percent predicted peak oxygen consumption improved from 70% (range 45% to 96%) to 83% (range 47% to 121%) (p = 0.02). Percent predicted oxygen pulse improved (p = 0.02). Ventilatory response to exercise improved; ventilatory equivalent of carbon dioxide slope post-intervention decreased to 29.3 versus 32.5 pre-intervention (p = 0.01). Subjective assessment of dyspnea improved. Five patients with minimal improvement in PBFM also showed minimal improvement in exercise parameters. CONCLUSIONS: Successful relief of unilateral branch PAS results in significant improvements in exercise capacity, ventilatory efficiency, and symptoms.

A nursing solution to primary care delivery shortfall.

Many countries project that they will have difficulty to meet their demand for primary care based on an inadequate supply of primary care doctors. There are many reasons for this, and they tend to vary by country. The policy options available to these countries are to increase the number of local primary care doctors, recruit doctors from other countries, ration primary care, shift more primary care to specialists, or authorize other disciplines to provide primary care. This article examines lessons learned in the United States over the past 50 years and proposes that expanding the use of nurse practitioners is the best solution when measured by feasibility, costs, ethics, and scope of the care delivered. Using nurse practitioners trained in country meets the World Health Organization global code of practice regarding the international recruitment of health personnel.