Application of creeping flow through a linearly absorbing slit filled with porous medium to diseased renal tubules.

In this paper, we have discussed the flow of a Newtonian fluid through a slit filled with porous medium and linearly reabsorbing porous walls. The study is motivated by fluid flow in diseased renal tubules in a kidney. Due to diseases, some fibrous material, fatty substances and solid waste particles, etc., may get suspended in tubule channel as well as on the pores of the wall, resulting in the porous filling in the slit and biofouling, respectively. In this study, the absorption at the wall is assumed to follow a linear pattern and the fluid is assumed to be entering the channel at a prescribed initial flow rate. The problem of the two-dimensional fluid flow is formulated using stream function, and inverse solution method is applied to obtain an exact solution of the fourth-order compatibility equation. Some special cases are also deduced from the obtained results and compared with available results from literature. Expressions for various physically relevant quantities like fluid velocities, volume flow rate, fractional reabsorption, leakage flux and pressure distribution are obtained. The results are used to demonstrate how medium porosity and biofouling parameter may affect average pressure differences in the renal tubules of a rat kidney. Finally, the results are presented graphically and effects of changing various parameters on the flow are analysed. We have also deduced some special cases when the wall reabsorption is uniform, and when there is no medium porosity. We have shown these special cases match with the already present results in the literature.

Beware of the hot swollen calf following knee replacement surgery: it might not be a deep vein thrombosis.

We report the case of a 77-year-old woman who presented with a 10-day history of increasing swelling and erythema of her right calf and popliteal areas 12 years after bilateral total knee replacements. Deep venous thrombosis (DVT), cellulitis or possible deep sepsis as a result of the knee replacement were the initial differential diagnoses. Due to clinical deterioration, exploration and radical debridement were performed and a 1.5 L collection of pus was identified through a small posteromedial proximal tibial bone defect adjacent to the tibial component, extending between gastrocnemius, soleus and into the distal calf. The procedure was extended to a first stage revision (complete implant and cement removal). Although leg swelling is common in joint infections secondary to knee swelling as a result of the inflammation, synovitis and/or knee effusion response, this case highlights the need to consider additional pathology such as deep abscess formation or DVT in these types of presentations.

Design, synthesis, crystal structures and anticancer activity of 4-substituted quinolines to target PDK1.

The induced fit docking of anilino quinoline scaffold results in the required hydrogen bonding interactions with amino acid residues in the orthosteric site of 3 Phosphoinositide dependent kinase (PDK1). The rational design of 4-substituted amino quinolines is carried out and eight compounds are synthesized. Four crystal structures are determined and their binding mode with adenosine triphosphate (ATP) site of PDK1 is analyzed. The anticancer activity in A549 cell lines of the test compounds by MTT assay resulted in an inhibitor with IC50 value of 0.96 µM which is less than the pemetrexed, a marketed lung cancer drug.

Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry.

BACKGROUND: The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM). METHODS: Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR. RESULTS: This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery. CONCLUSIONS: NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.

Selection and validation of appropriate reference genes for quantitative real-time PCR analysis in Salvia hispanica.

Quantitative real-time polymerase chain reaction (qRT-PCR) has become the most popular choice for gene expression studies. For accurate expression analysis, it is pertinent to select a stable reference gene to normalize the data. It is now known that the expression of internal reference genes varies considerably during developmental stages and under different experimental conditions. For Salvia hispanica, an economically important oilseed crop, there are no reports of stable reference genes till date. In this study, we chose 13 candidate reference genes viz. Actin11 (ACT), Elongation factor 1-alpha (EF1-α), Eukaryotic translation initiation factor 3E (ETIF3E), alpha tubulin (α-TUB), beta tubulin (ß-TUB), Glyceraldehyde 3-phosphate dehydrogenase (GAPDH), Cyclophilin (CYP), Clathrin adaptor complex (CAC), Serine/threonine-protein phosphatase 2A (PP2A), FtsH protease (FtsH), 18S ribosomal RNA (18S rRNA), S-adenosyl methionine decarboxylase (SAMDC) and Rubisco activase (RCA) and the expression levels of these genes were assessed in a diverse set of tissue samples representing vegetative stages, reproductive stages and various abiotic stress treatments. Two of the widely used softwares, geNorm and Normfinder were used to evaluate the expression stabilities of these 13 candidate reference genes under different conditions. Results showed that GAPDH and CYP expression remain stable throughout in the different abiotic stress treatments, CAC and PP2A expression were relatively stable under reproductive stages and α-TUB, PP2A and ETIF3E were found to be stably expressed in vegetative stages. Further, the expression levels of Diacylglycerol acyltransferase (DGAT1), a key enzyme in triacylglycerol synthesis was analyzed to confirm the validity of reference genes identified in the study. This is the first systematic study of selection of reference genes in S. hispanica, and will benefit future expression studies in this crop.

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement.

PURPOSE: To develop an atlas for oncoplastic surgery (OPS) with template dissection techniques via anatomically ideal incisions for breast conservation surgery. The evolution of breast conservation techniques has evolved from placing an incision directly over the lesion to the incorporation of a thoughtful decision making process utilizing oncoplastic surgical (OPS) techniques to combining OPS with incision placement in anatomically advantageous sites. The high survival rates of breast cancer and effect of breast surgery on quality of life reinforce emphasis of optimal oncologic as well as aesthetic outcome. OPS results in greater patient satisfaction, fewer surgeries, and is oncologically safe. Today's breast surgeon is tasked with optimizing both oncologic and aesthetic outcomes. METHODS: Presentation of reproducible dissection techniques and incision placement strategies to afford surgeons a step-by-step approach of OPS via anatomically ideal incisions in breast conservation surgery. RESULTS: Demonstration of reproducible techniques to facilitate the decision making process of optimal breast conservation surgery, eliminate knowledge gaps for surgeons, optimize outcome for individuals undergoing breast conservation surgery, and decrease disparity of care. CONCLUSION: Adoption of OPS techniques utilizing an anatomically ideal incision in breast conservation surgery is a feasible and reproducible practice for breast surgeons. Application of these techniques results in maintained optimal shape, size, and contour without the typical overlying skin envelope scars. OPS techniques performed under the skin envelope result in expected OPS oncologic and aesthetic outcomes with the addition of the resulting scar(s) in anatomically discrete position(s).

Longitudinal Hypertension Outcomes at Four Student-Run Free Clinic Sites.

BACKGROUND AND OBJECTIVES: Student-Run Free Clinics (SRFCs) play a significant role in medical education yet there is minimal information about patient outcomes over time in this setting. The purpose of this study was to assess longitudinal outcomes of hypertension management during routine care at four SRFC sites, while comparing control rates with national standards, and examining for characteristics independently associated with uncontrolled hypertension. METHODS: The authors conducted a retrospective medical record review of visits from January 2004 through April 2016 with an initial visit for hypertension and a follow-up visit 9 to 15 months later. Hypertension control was analyzed using descriptive statistics, paired t tests, logistic regression, and a longitudinal linear mixed-effects model. RESULTS: This study included 496 patients and 4,798 visits. The mean age was 50.9 (SD 10.8) years old, 71.2% (346) were Latinos, 63.3% (314) were Spanish speaking, and 15.5% (72) were homeless. Mean blood pressure was reduced from 141.6 (SD 21.8)/85.1 (SD 13.2) to 132.1 (SD 17.3)/79.4 (SD10.8), a decrease of 9.5 (CI 7.4, 11.5)/5.7 (CI 4.4, 7.0) mmHg. Blood pressure was significantly reduced within the first month of treatment, and this reduction was sustained throughout the follow-up period. Using the National Health and Nutrition Examination Survey (NHANES) definition (<140/<90), blood pressure was controlled in 59.7% (296/496) of patients. No significant differences in control were noted based on gender, ethnicity, language, housing status, or clinic site. CONCLUSIONS: SRFCs can provide effective long-term hypertension management and achieve rates of control that exceed national averages despite serving those least likely to be controlled.

Investment Success in Public Health: An Analysis of the Cost-Effectiveness and Cost-Benefit of the Global Programme to Eliminate Lymphatic Filariasis.

Background: It has been estimated that $154 million per year will be required during 2015-2020 to continue the Global Programme to Eliminate Lymphatic Filariasis (GPELF). In light of this, it is important to understand the program's current value. Here, we evaluate the cost-effectiveness and cost-benefit of the preventive chemotherapy that was provided under the GPELF between 2000 and 2014. In addition, we also investigate the potential cost-effectiveness of hydrocele surgery. Methods: Our economic evaluation of preventive chemotherapy was based on previously published health and economic impact estimates (between 2000 and 2014). The delivery costs of treatment were estimated using a model developed by the World Health Organization. We also developed a model to investigate the number of disability-adjusted life years (DALYs) averted by a hydrocelectomy and identified the cost threshold under which it would be considered cost-effective. Results: The projected cost-effectiveness and cost-benefit of preventive chemotherapy were very promising, and this was robust over a wide range of costs and assumptions. When the economic value of the donated drugs was not included, the GPELF would be classed as highly cost-effective. We projected that a typical hydrocelectomy would be classed as highly cost-effective if the surgery cost less than $66 and cost-effective if less than $398 (based on the World Bank's cost-effectiveness thresholds for low income countries). Conclusions: Both the preventive chemotherapy and hydrocele surgeries provided under the GPELF are incredibly cost-effective and offer a very good investment in public health.

A rare endocrine cause of electrical storm - a case report.

Sheehan's syndrome, also called Simmond's syndrome, postpartum apoplexy, postpartum pituitary necrosis, and postpartum panhypopituitary syndrome, is the name given to postpartum hypopituitarism. The syndrome is caused by an infarction in the adenohypophysis, usually precipitated by massive uterine haemorrhage and hypovolemic shock during or after childbirth. Extensive destruction of pituitary cells results in varying degree of hypopituitarism. Acute loss of adenohypophysis function can be fatal without glucocorticoid and thyroid replacement therapy and survivors will require life time hormonal replacement therapy. Most cases present in the postpartum period with lactation failure or after months to years after the delivery. In many affected women, anterior pituitary dysfunction is not diagnosed for many years. Dyselectrolytemia is one of a common presentation in Sheehan's syndrome. Herein, we report a case of a 35-year old female with a history of obstetric hysterectomy 2 years ago in view of severe postpartum haemorrhage with history of failure of lactation and three episodes of syncope since last 1½ years and now presented with polymorphic ventricular tachycardia which required DC cardioversion. She was referred as a case of long QT syndrome. On investigating further, she had hypokalaemia secondary to hypopituitarism due to Sheehan's syndrome.

Medical Student Perceptions of the Learning Environment: Learning Communities Are Associated With a More Positive Learning Environment in a Multi-Institutional Medical School Study.

PURPOSE: Many medical schools have implemented learning communities (LCs) to improve the learning environment (LE) for students. The authors conducted this study to determine whether a relationship exists between medical student perceptions of the LE and presence of LCs during the preclerkship years. METHOD: Students from 24 schools participating in the American Medical Association Learning Environment Study completed the 17-item Medical Student Learning Environment Survey (MSLES) at the end of their first and second years of medical school between 2011 and 2013. Mean total MSLES scores and individual item scores at the end of the first and second years in schools with and without LCs were compared with t tests, and effect sizes were calculated. Mixed-effects longitudinal models were used to control for student demographics and random school and student effects on the relationship between LC status and MSLES score. RESULTS: A total of 4,980 students (81% of 6,148 matriculants) from 18 schools with LCs and 6 without LCs participated. Mean [SD] MSLES scores were significantly higher in LC schools compared with non-LC schools at the end of year one (3.72 [0.44] versus 3.57 [0.43], P < .001) and year two (3.69 [0.49] versus 3.42 [0.54], P < .001). The effect size increased from 0.35 (small) at the end of year one to 0.53 (medium) at the end of year two. CONCLUSIONS: This large multi-institutional cohort study found that LCs at medical schools were associated with more positive perceptions of the LE by preclerkship students.

Abnormal trigeminal sensory processing in obese mice.

Obesity is associated with several pain disorders including headache. The effects of obesity on the trigeminal nociceptive system, which mediates headache, remain unknown. We used 2 complementary mouse models of obesity (high-fat diet and leptin deficiency) to examine this. We assessed capsaicin-induced nocifensive behavior and photophobia in obese and control mice. Calcium imaging was used to determine the effects of obesity on the activity of primary trigeminal afferents in vitro. We found that obese mice had a normal acute response to a facial injection of capsaicin, but they developed photophobic behavior at doses that had no effect on control mice. We observed higher calcium influx in cultured trigeminal ganglia neurons from obese mice and a higher percentage of medium to large diameter capsaicin-responsive cells. These findings demonstrate that obesity results in functional changes in the trigeminal system that may contribute to abnormal sensory processing. Our findings provide the foundation for in-depth studies to improve the understanding of the effects of obesity on the trigeminal system and may have implications for the pathophysiology of headache disorders.

Exploring triacylglycerol biosynthetic pathway in developing seeds of Chia (Salvia hispanica L.): a transcriptomic approach.

Chia (Salvia hispanica L.), a member of the mint family (Lamiaceae), is a rediscovered crop with great importance in health and nutrition and is also the highest known terrestrial plant source of heart-healthy omega-3 fatty acid, alpha linolenic acid (ALA). At present, there is no public genomic information or database available for this crop, hindering research on its genetic improvement through genomics-assisted breeding programs. The first comprehensive analysis of the global transcriptome profile of developing Salvia hispanica L. seeds, with special reference to lipid biosynthesis is presented in this study. RNA from five different stages of seed development was extracted and sequenced separately using the Illumina GAIIx platform. De novo assembly of processed reads in the pooled transcriptome using Trinity yielded 76,014 transcripts. The total transcript length was 66,944,462 bases (66.9 Mb), with an average length of approximately 880 bases. In the molecular functions category of Gene Ontology (GO) terms, ATP binding and nucleotide binding were found to be the most abundant and in the biological processes category, the metabolic process and the regulation of transcription-DNA-dependent and oxidation-reduction process were abundant. From the EuKaryotic Orthologous Groups of proteins (KOG) classification, the major category was "Metabolism" (31.97%), of which the most prominent class was 'carbohydrate metabolism and transport' (5.81% of total KOG classifications) followed by 'secondary metabolite biosynthesis transport and catabolism' (5.34%) and 'lipid metabolism' (4.57%). A majority of the candidate genes involved in lipid biosynthesis and oil accumulation were identified. Furthermore, 5596 simple sequence repeats (SSRs) were identified. The transcriptome data was further validated through confirmative PCR and qRT-PCR for select lipid genes. Our study provides insight into the complex transcriptome and will contribute to further genome-wide research and understanding of chia. The identified novel UniGenes will facilitate gene discovery and creation of genomic resource for this crop.

Longitudinal hyperlipidemia outcomes at three student-run free clinic sites.

BACKGROUND AND OBJECTIVES: Student-run free clinics (SRFC) aim to improve health outcomes of vulnerable populations by providing care to those who have difficulty accessing the traditional health care safety net. Reducing low density lipoprotein (LDL) is known to improve health outcomes, yet uninsured patients remain especially susceptible to poor control. This study describes hyperlipidemia control over time among patients who received care at three University of California San Diego Student-Run Free Clinic Project (SRFCP) sites. METHODS: The authors performed a retrospective review of clinic visits from August 2006--November 2010 from three sites of the SRFCP. Patients with a new diagnosis of hyperlipidemia, a baseline LDL level, and at least one follow-up LDL drawn between 6 weeks and 18 months were included in this study (n=96). Hyperlipidemia control was analyzed using descriptive statistics, Fisher's exact tests, paired t tests, and binary logistic regression. RESULTS: At the last visit, 58.3% (56/96) of patients had achieved LDL goal. LDL decreased from a baseline mean of 135.8 mg/dL to 101.3mg/dL among the cohort (P<.001). Statins were used in 86.5% (83/96) of patients. No significant differences were noted when stratified by language, gender, diabetes comorbidity, homelessness, or clinic site. When comparing Hispanics and Caucasians only, Hispanic patients had better LDL control than Caucasians. CONCLUSIONS: This study demonstrates that a SRFC can effectively manage hyperlipidemia over time, and rates of control can exceed national standards.

Knee arthroplasty with a medial rotating total knee replacement. Midterm clinical findings: a district general experience of 38 cases.

BACKGROUND: The Medial Rotating Knee replacement (MRK) was first used in 1994, reporting high rates of satisfaction. It is designed to replicate natural knee kinematics and improve stability and function. There are limited studies on the mid-term clinical outcomes, in particular in a district general hospital (DGH) environment. This is the first study that we are aware of that evaluates the learning curve of the implementation of this knee system in this environment. PATIENTS/METHOD: Between 2007 and 2009 we performed 38 consecutive MRK replacements (MAT ORTHO, UK) in 36 patients. The mean follow-up was four years. Patients were evaluated clinically, using OKS and patient questionnaire and radiographically (good/acceptable/poor) to assess outcome. RESULTS: Mean age was 73.0 years. Mean pre-operative OKS was 17.7 (range 8-29), which rose to 38.1 (range 23-48) at latest follow up (p<0.005). Overall 71% of the patients were either satisfied (29%) or very satisfied (42%). 81% felt an improvement of the ability to go up or down stairs and 92% felt stable. All poor radiographic and the majority of acceptable outcomes were experienced in the first 50% of cases. CONCLUSION: The MRK can be successfully implanted in a DGH environment. It improves pain and function comparably to standard TKRs, however, subjective improvement may be higher. Radiographic evaluation shows an acceptable learning curve. LEVEL OF EVIDENCE: Level IV case series.

The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care.

METHODS: The authors designed a survey instrument to examine the effect of involvement in a student-run free clinic project (SRFCP) on medical student self-reported attitudes toward the underserved and interest in primary care. From 2001-2010, first-and second-year medical students in an introductory service-learning elective course rated each of 15 statements on a seven-point Likert scale pre/post survey. Wilcoxon's signed rank test was performed on all matched pairs and an intent-to-treat analysis included unmatched pairs. RESULTS: The response rate was 97.9%, with 914 of 934 students enrolled participating. Significant increases were seen in each of the 15 items in matched pre/post survey pairs, N = 433 (47.4%), or with an intent-to-treat analysis, N = 914 (p ≤ .002 for all). CONCLUSIONS: This study found that medical student involvement in a SRFCP improved student knowledge, skills, attitudes and self-efficacy with the underserved, interest in work with the underserved after graduation, and interest in primary care.

5-Year cost/benefit analysis of revision of failed unicompartmental knee replacements (UKRs); not "just" a primary total knee replacement (TKR).

BACKGROUND: A number of studies suggest that one advantage of a unicompartmental knee replacement (UKR) is ease of revision to a total knee replacement (TKR). We aimed to perform a cost/benefit analysis of patients undergoing this procedure at our centre to evaluate its economic viability. METHODS: From our own prospective joint replacement database we identified 812 consecutive tibio-femoral UKRs performed (1994-2007) of which 23 were revised to TKR (2005-2008). These were then matched to a cohort of primary TKRs (42 patients). Data were collected regarding patient demographics, cost of surgery, clinical outcome (OKS) and follow-up costs at five years. RESULTS: There was no significant difference in implant costs or in length of stay, however tourniquet time was significantly higher in the revision group (average 93 min (UKR) vs 75 min (TKR) p<0.0001). At five years there was no significant difference in clinical outcome between the revision UKR and primary TKR groups, mean OKS 27 and 32 respectively (p=0.20). The revision group had a greater complication and revision rate, attending significantly more follow-up appointments (average 6 (UKR) vs 2 (TKR) p<0.0001) and consultant appointments (average 4 (UKR) vs 0.4 (TKR) p<0.0001). This was translated to significantly higher follow-up costs. CONCLUSION: Revision of UKR to TKR is not universally a straightforward procedure comparable to a standard primary replacement. Despite cost of components not being significantly higher than primary TKR there are multiple hidden follow-up costs. The clinical outcomes are however similar at 5 years.

Clinical outcomes of diabetic patients at a student-run free clinic project.

OBJECTIVES: Our objective was to determine if the quality of care of diabetic patients at a Student-Run Free Clinic Project (SRFCP) meets the standard of care, is comparable with other published outcomes, and whether pertinent diabetic clinical indicators improve over time. METHODS: The authors conducted a retrospective chart review of diabetic patients at three University of California-San Diego (UCSD) SRFCP sites from December 1, 2008 to December 1, 2009 (n=182), calculated the percentage who received recommended screening tests, percent at goal, and compared these to published outcomes using Fisher's exact tests. Baseline measures were compared to most recent values using paired t tests. RESULTS: The percentage of patients who received recommended screening tests (process measures) was blood pressure (BP) 100%, HbA1c 99.5%, creatinine 99.5%, LDL 93%, HDL and triglycerides 88%, microalbumin/creatinine ratio 80%, and ophthalmology exam 32%. Intermediate outcomes included: 70% of patients were at LDL goal <100, 70% had microalbumin/creatinine ratio <30, 61% of males were at HDL goal %gt;40, 47% of females at HDL goal>50, 52% with triglycerides <150, 45% had BP <130/80, and 30% of patients had HbA1c <7. Mean HbA1c, LDL, HDL, triglycerides and blood pressure improved significantly over time. CONCLUSIONS: Diabetic patients at UCSD SRFCP reached goals for both process measures and intermediate outcomes at rates that meet or exceed published outcomes of insured and uninsured diabetics on nearly all measures, with the exception of ophthalmology screening. Glycemic control, cholesterol levels, and blood pressure improved significantly during care at the UCSD SRFCP.

Medical student perceptions of the educational value of a student-run free clinic.

BACKGROUND AND OBJECTIVES: Many medical schools have student-run free clinics (SRFCs), yet their educational value has not been well studied. We performed a one-time cross-sectional survey to assess medical student perceptions of the educational value of an SRFC at their institution. METHODS: The authors designed and validated a survey instrument including six statements on a 5-point Likert-scale. The questionnaire was distributed from February through May 2010 to all students enrolled at the University of California San Diego (UCSD) School of Medicine as part of a larger yearly, anonymous, internet-based survey regarding their experiences at the institution. RESULTS: The response rate was 66.5% with 347 of 522 eligible students participating. Ninety percent agreed or strongly agreed that the SRFC was a valuable educational experience, mean score: 4.51 on a scale of 5. Eighty-two percent agreed or strongly agreed that the teaching was excellent, mean score: 4.23. Students agreed or strongly agreed that the SRFC improved attitudes toward working with underserved patients (72%, mean score 3.99), helped students stay connected to sense of purpose, (71%, mean score 3.98), improved overall sense of well-being (67%, mean score 3.88), and influenced their decision to come to UCSD (52%, mean score 3.37). Eighty-four percent of qualitative responses in a free text comment box were positive (46 of 55). CONCLUSIONS: To the authors' knowledge, this is the first study to report the perceptions of an entire medical student body of a SRFC at their institution. The majority felt that this was a valuable educational experience.