Towards a fuller assessment of benefits to children's health of reducing air pollution and mitigating climate change due to fossil fuel combustion.

BACKGROUND: Fossil fuel combustion by-products, including particulate matter (PM2.5), polycyclic aromatic hydrocarbons (PAH), nitrogen dioxide (NO2) and carbon dioxide (CO2), are a significant threat to children's health and equality. Various policies to reduce emissions have been implemented to reduce air pollution and mitigate climate change, with sizeable estimated health and economic benefits. However, only a few adverse outcomes in children have been considered, resulting in an undercounting of the benefits to this vulnerable population. OBJECTIVES: Our goal was to expand the suite of child health outcomes addressed by programs to assess health and economic benefits, such as the Environmental Protection Agency (EPA) Benefits Mapping and Analysis Program (BenMAP), by identifying concentration-response (C-R) functions for six outcomes related to PM2.5, NO2, PAH, and/or PM10: preterm birth (PTB), low birthweight (LBW), autism, attention deficit hyperactivity disorder, IQ reduction, and the development of childhood asthma. METHODS: We conducted a systematic review of the literature published between January 1, 2000 and April 30, 2018 to identify relevant peer-reviewed case-control and cohort studies and meta-analyses. In some cases meta-analyses were available that provided reliable C-R functions and we assessed their consistency with subsequent studies. Otherwise, we reviewed all eligible studies published between our search dates. RESULTS: For each pollutant and health outcome, we present the characteristics of each selected study. We distinguish between C-R functions for endpoints having a causal or likely relationship (PTB, LBW, autism, asthma development) with the pollutants for incorporation into primary analyses and endpoints having a suggestive causal relationship with the pollutants (IQ reduction, ADHD) for secondary analyses. CONCLUSION: We have identified C-R functions for a number of adverse health outcomes in children associated with air pollutants largely from fossil fuel combustion. Their incorporation into expanded assessments of health benefits of clean air and climate mitigation policies will provide an important incentive for preventive action.

Robotic uterine-sparing vesicovaginal fistula repair.

INTRODUCTION AND HYPOTHESIS: The objective was to describe a technique for the robotic repair of complex vesicovaginal fistula (VVF) with uterine preservation. METHODS: From 2015 to 2017, two patients underwent the procedure. Following placement of the patient in the lithotomy position, catheterization of the fistulous tract and laparoscopic omental harvesting is performed. Then, the robotic system is docked. A transverse incision was made in the peritoneum above the uterus was made to provide access to the bladder, the uterus is mobilized, and a cystotomy is performed to identify the structures. Subsequently, the cystotomy is extended toward the fistulous tract, the plane between the organs is dissected to proceed with the vaginal closure, the vagina is closed, the omental flap is interposed, and the bladder is closed. RESULTS: Mean operative time (OT) was 219 min. Mean estimated blood loss (EBL) was 75 ml. One of the patients had an intraoperative cervix canal injury that was identified and repaired. The postoperative course was uneventful, and the mean length of hospital stay (LOS) was 1 day. A mean follow-up of 17 (±9.89) months showed no recurrence at cystoscopy or imaging evaluation. CONCLUSIONS: Uterine-sparing VVF repair is feasible and safe. More studies are needed to assess equivalence compared with other procedures.

Comparing Fullerenes by Spectral Moments.

Suppose G is a graph, A(G) its adjacency matrix, and µ1(G)≤(G)µ2(G)≤ ... ≤ µ(n)(G)are eigenvalues of A(G). The numbers S(k)(G) = Σ(i) n = 1 µ(i)k (G), 0 ≤ k ≤ n -1 are said to be the k-th spectral moment of G and the sequence S(G) = (S0(G), S1 (G),..., S(n-1)(G)is called the spectral moments sequence of G. Suppose G1 and G2 are graphs. If there exists an integer k, 1 ≤ k ≤ n - 1, such that for each i, 0 ≤ i ≤ k - 1, S(i) (G1) = S(i)(G2) and S(k)(G1) < S(k)(G2) then we write G1 -<(s) G2. The aim of this paper is order some classes of fullerene graphs with respect to the S-order.

Combination therapy - deferasirox and deferoxamine - in thalassemia major patients in emerging countries with limited resources.

BACKGROUND: The problem of iron-overload observed in thalassemia patients can be overcome using chelating agents such as deferiprone (Ferroprox(®) ), deferasirox (Exjade(®) ) and deferoxamine (Desferal(®) ). Although these drugs can be used as monotherapy, combined therapy, especially deferiprone with deferoxamine, has led to promising outcomes in various studies. METHODS AND MATERIALS: In this quasi-experimental study, serum ferritin levels were evaluated in 32 ß-thalassemia major patients with severe iron overload before and after receiving combined deferasirox (30-40 mg kg(-1) day(-1) ) and deferoxamine (40-50 mg kg(-1) day(-1) ) 2 days a week. This study was conducted from September 2012 to September 2013 in Southern Iran. RESULTS: The mean of serum ferritin levels significantly reduced from 4031 ± 1955 to 2416 ± 1653 ng mL(-1) after 12 months of therapy (P < 0·001). Echocardiograph findings showed significant improvement 1year after end of the study (P < 0·001). No drug toxicity was observed by monitoring serum creatinine, liver enzymes and blood urea nitrogen (BUN) during the study period. We observed no correlation between mean serum ferritin change and age (P = 0·87). In addition, the mean serum ferritin change did not differ between male and female thalassemia patients (P = 0·454). No difference in mean serum ferritin change was observed between patients who had undergone splenectomy compared to those who had not done so (P = 0·307). CONCLUSION: The study suggests that combination chelating therapy with deferasirox and deferoxamine can effectively reduce iron burden in ß-thalassemia major patients with heavy iron overload without any significant complications.

New trends in methyl salicylate sensing and their implications in agriculture.

Methyl salicylate (MeSal) is an organic compound present in plants during stress events and is therefore a key marker for early plant disease detection. It has usually been detected by conventional methods that require bulky and costly equipment, such as gas chromatography or mass spectrometry. Currently, however, chemical sensors provide an alternative for MeSal monitoring, showing good performance for its determination in the vapour or liquid phase. The most promising concepts used in MeSal determination include sensors based on electrochemical and conductometric principles, although other technologies based on mass-sensitive, microwave, or spectrophotometric principles also show promise. The receptor elements or sensitive materials are shown to be part of the key elements in these sensing technologies. A literature survey identified a significant contribution of bioreceptors, including enzymes, odourant-binding proteins or peptides, as well as receptors based on polymers or inorganic materials in MeSal determination. This work reviews these concepts and materials and discusses their future prospects and limitations for application in plant health monitoring.

Is video-assisted thoracoscopic surgery superior to limited axillary thoracotomy in the management of spontaneous pneumothorax?

OBJECTIVE: To evaluate bullectomy and pleurectomy in the treatment of spontaneous pneumothorax (PNO) using video-assisted thoracoscopic surgery (VATS), and to compare the outcome with that of the same procedure performed using limited axillary thoracotomy (LAT). DESIGN: A retrospective case series with patient follow-up. SETTING: A Canadian tertiary care hospital. PATIENTS: The medical records of all patients with a spontaneous PNO treated by either VATS or LAT at the Ottawa Hospital - General Campus, Ottawa, Ontario, between April 1993 and August 1999 were reviewed, and the patients were subsequently interviewed. MAIN OUTCOME MEASURES: Operative details (length of operation, operative complications); postoperative details (duration of chest tube, length of hospital stay, duration of analgesia, pain, time missed from work, complications, recurrence rate); and cost (hospital and operative, socioeconomic [time missed from work]). RESULTS: Fifty patients were identified who had had surgical treatment of a spontaneous PNO. Twenty-eight patients were treated by LAT and 22 underwent VATS. The median length of follow-up was 44.6 months (range four to 81.5 months). Three patients developed a recurrent PNO - two patients after LAT and one patient after VATS. No difference was found between the two groups in the operating time or in the amount of pain experienced immediately after surgery. However, patients who underwent VATS had a shorter length of stay (P=0.002) and a shorter requirement for analgesics postoperatively (P=0.03). Overall, the total cost of VATS was no different than that for LAT; however, in terms of socioeconomic costs, patients in the VATS group missed significantly less time from work postoperatively (P=0.02). CONCLUSIONS: VATS offers a cost effective and better tolerated procedure for the management of spontaneous PNO than the time-honoured open technique.

Rectal hyposensitivity is uncommon and unlikely to be the central cause of obstructed defecation in patients with high-grade internal rectal prolapse.

BACKGROUND: There are several causes of obstructed defecation one of which is thought to be internal rectal prolapse. Operations directed at internal prolapse, such as laparoscopic ventral rectopexy, may improve obstructed defecation symptoms significantly. It is not clear whether the obstructed defecation with internal prolapse is a mechanical phenomenon or whether it results changes in rectal sensitivity. This study aimed to evaluate rectal sensory function in patients with obstructed defecation and high-grade internal rectal prolapse. METHODS: This study represents a retrospective review of a prospectively collected database of patients attending a tertiary referral pelvic floor unit. Patients with high-grade (recto-anal) intussusception formed the basis of this study. Rectal sensory function was determined by intrarectal balloon inflation. Three parameters (sensory threshold, urge to defecate and maximum tolerated volumes) were recorded. Abnormal sensitivity was defined as partial (one or two parameters abnormal) or total (all three abnormal). KEY RESULTS: Four hundred and eight patients with high-grade internal rectal prolapse both with and without obstructed defecation symptoms were studied. Two hundred and forty one (59%) had normal sensation. Eighteen (4%) had total hyposensitivity and three (1%) total hypersensitivity. A further 96 (24%) had partial hyposensitivity whilst 50 (12%) had partial hypersensitivity. Neither hypersensitivity nor hyposensitivity differed between patients with and without symptoms of obstructed defecation. CONCLUSIONS & INFERENCES: Rectal hyposensitivity is relatively uncommon in patients with high-grade internal rectal prolapse and obstructed defecation. Internal rectal prolapse may cause obstructed defecation through a mechanical process. It does not appear that rectal hyposensitivity plays a significant part in the pathological process.

Incidentally detected stenoses proximal to grafts originating below the common femoral artery: do they affect graft patency or warrant repair in asymptomatic patients?

OBJECTIVE: Stenoses in infrageniculate arteries proximal to a lower extremity vein graft may reduce flow velocity through the bypass graft and are thought to predispose to graft occlusion. Repair of these lesions has been recommended to preserve graft function. This study was undertaken to better define the natural history of grafts below inflow lesions and to evaluate the necessity of repair to preserve graft patency. METHODS: From 1994 through 1999, patients undergoing lower extremity vein grafts by a single surgeon at a university hospital and an affiliated teaching hospital were placed in a prospective protocol for proximal infrageniculate native artery and graft surveillance through use of duplex scanning. The records of those patients with grafts originating distal to the common femoral artery were evaluated; they form the basis for this report. Arteriograms were obtained before bypass grafting, and no patient had a stenosis greater than 50% diameter reduction proximal to the graft origin. Follow-up scans were obtained from the common femoral artery through the graft and outflow artery. The peak systolic velocity and velocity ratio in an infrageniculate native artery proximal to the graft origin were recorded, as were the location and the time interval since the bypass graft. Repair of these proximal lesions was not performed during the course of this study. Revision of the bypass graft or its anastomoses was undertaken according to preestablished duplex scan criteria. RESULTS: During this time, 288 autogenous infrainguinal bypass grafts were performed, of which 159 originated below the common femoral artery; of these, 74 were from the superficial femoral artery, 29 from the profunda femoris artery, 49 from the popliteal artery, and 7 from a tibial artery. The maximum peak systolic velocity proximal to the graft origin was more than 250 in 38 arteries (25%) and more than 300 in 26 arteries (16%). The velocity ratio was 3.0 or more in 32 arteries at the same location as the peak systolic velocity and 3.5 or more in 23 arteries (15%), confirming hemodynamically significant stenoses at these sites. The location of peak systolic velocity was the common femoral artery in 81 patients (51%), the superficial femoral artery in 50 (31%), the popliteal artery in 22 (14%), and a tibial artery in 6 (4%). Follow-up ranged from 8 to 60 months (mean, 35 months). During follow-up, 19 patients died, 18 with patent grafts. Overall, nine grafts occluded. One of the occluded grafts had a velocity ratio greater than 3.0; this may have contributed to graft thrombosis. The other occlusions resulted from an unrepaired graft lesion in 2 patients, graft infection in 2 patients, and graft ligation necessitated by below-knee amputation in 2 patients. No cause for the occlusion could be identified in two of the grafts (neither had evidence of proximal arterial stenosis). Assisted primary patency rates were 95% and 91% at 3 and 5 years, respectively. CONCLUSIONS: For grafts originating distal to the common femoral artery, stenoses proximal to the graft do not affect bypass graft patency and do not require repair to prevent graft occlusion. Surveillance of these lesions may therefore be unnecessary, inasmuch as the repair of proximal lesions should not be undertaken to preserve graft function.

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing.

OBJECTIVE: The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. METHODS: A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. RESULTS: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P <.002), a palpable pedal pulse (85% healed vs 42%, P <.0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P <.02), and the number of patent tibial arteries after bypass to the ankle (P <.0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. CONCLUSIONS: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.