Special Situations in the Management of Diverticular Disease.

Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation. 2 It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circumstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circumstances.

Chemical Differentiation of Osseous, Dental, and Non-skeletal Materials in Forensic Anthropology using Elemental Analysis.

Forensic anthropologists are generally able to identify skeletal materials (bone and tooth) using gross anatomical features; however, highly fragmented or taphonomically altered materials may be problematic to identify. Several chemical analysis techniques have been shown to be reliable laboratory methods that can be used to determine if questionable fragments are osseous, dental, or non-skeletal in nature. The purpose of this review is to provide a detailed background of chemical analysis techniques focusing on elemental compositions that have been assessed for use in differentiating osseous, dental, and non-skeletal materials. More recently, chemical analysis studies have also focused on using the elemental composition of osseous/dental materials to evaluate species and provide individual discrimination, but have generally been successful only in small, closed groups, limiting their use forensically. Despite significant advances incorporating a variety of instruments, including handheld devices, further research is necessary to address issues in standardization, error rates, and sample size/diversity.

Outcomes after abdominal aortic aneurysm repair requiring a suprarenal cross-clamp.

OBJECTIVE: The objective of this study was to analyze the early and late outcomes of patients who require a suprarenal aortic cross-clamp during elective open repair of an abdominal aortic aneurysm (AAA). METHODS: Patients from 1998 to 2012 who required a suprarenal aortic cross-clamp during elective open AAA repair were reviewed. Data abstracted included demographics and comorbidities; preoperative, perioperative, and late renal function; late interventions related to AAA repair; and late mortality. A decrease in renal function was defined as a >30% decline in estimated glomerular filtration rate (eGFR) compared with the preoperative value. Primary outcomes included renal function, intervention-free survival, and overall survival. RESULTS: During the study period, 211 patients underwent open elective or urgent AAA repair; 69 required a suprarenal cross-clamp. The mean age was 71 years, and 80% were men. The mean preoperative creatinine concentration was 1.2 mg/dL, and the mean preoperative eGFR was 66 mL/min/1.73 m2. Location of the aortic cross-clamp was suprarenal (37), supramesenteric (21), and supraceliac (11). Perioperatively, 21 patients (30%) experienced a significant decrease in eGFR; four patients required hemodialysis. Six patients had full recovery of renal function by discharge. Perioperative morbidity and mortality were 35% and 4%, respectively. At a mean follow-up of 3 years, seven patients had an eGFR significantly less than the preoperative value. Late interventions related to the AAA repair were required in eight patients. Indications included wound complication (3), anastomotic aneurysm (2), incisional hernia (1), anastomotic graft stenosis (1), and proximal aortic dilation (1). Overall 5-year intervention-free survival was 62% and overall survival 77%. Intervention-free survival was enhanced by antiplatelet use (P = .04), whereas overall survival was decreased by chronic obstructive pulmonary disease (P = .003) and perioperative pneumonia (P = .001). CONCLUSIONS: More than a quarter of patients requiring a suprarenal cross-clamp during open AAA repair experience renal dysfunction. Late graft-related complications are few, with preoperative and perioperative pulmonary function negatively affecting overall patient survival.

Basic data related to thrombolytic therapy for acute venous thrombosis.

BACKGROUND: Treatment guidelines for thrombolysis in iliofemoral deep venous thrombosis (DVT) are based on a limited number of observational and prospective studies. The acute venous thrombosis: thrombus removal with adjunctive catheter-directed thrombolysis (ATTRACT) trial will be the first large, multicenter randomized control trial to evaluate the relative advantages of several current treatment strategies. The objective of this study was to summarize the existing data that inform the use of catheter-directed thrombolysis (CDT) or pharmacomechanical thrombectomy in the management of acute iliofemoral DVT. METHODS: A search of the current literature was done using PubMed, Ovid, and Cochrane databases for all available articles published up to December 2013. RESULTS: Of those studies, which included at least 25 patients, 19 case series were identified from 1996 to 2012. Treatment groups included anticoagulation, surgical thrombectomy, pharmacomechanical thrombectomy, and CDT. Cases observed in each ranged from 26 to 101. Three studies were identified which derived data from national multicenter registries. Only 2 randomized control trials were identified from 2002 to 2012. Both support the use of CDT over anticoagulation alone for treatment of iliofemoral DVT. CONCLUSIONS: Present treatment guidelines for acute iliofemoral DVT have been in flux and are derived from a relatively small amount of clinical data. They are summarized here in anticipation of results from the ongoing ATTRACT trial.

Detecting Chemical Vapor Diffusion through Firefighter Turnout Gear.

Firefighters are exposed to burning materials that may release toxic partial combustion and pyrolysis products into the environment, including compounds listed as priority pollutants by the United States Environmental Protection Agency (EPA). A novel passive sampling dosimeter device containing firefighter turnout gear as a diffusion membrane and an activated charcoal strip (ACS) for volatile analyte collection was designed and used to monitor potential exposures of firefighters to volatile organic compounds. Solvent extracts from the ACS and turnout gear diffusion layer were analyzed using Gas Chromatography-Mass Spectrometry (GC-MS) to determine the diffusion of compounds from burned substrates through firefighter turnout gear and compound adsorption to the turnout gear. The compounds in these samples were identified using target factor analysis (TFA). An activated carbon layer (ACL) was added to the dosimeter between the turnout gear and the ACS. The presence of combustion and pyrolysis compounds identified on the ACS in the dosimeter was reduced.

Nd:YAG-CO(2) double-pulse laser induced breakdown spectroscopy of organic films.

Laser-induced breakdown spectroscopy (LIBS) using double-pulse irradiation with Nd:YAG and CO(2) lasers was applied to the analysis of a polystyrene film on a silicon substrate. An enhanced emission signal, compared to single-pulse LIBS using a Nd:YAG laser, was observed from atomic carbon, as well as enhanced molecular emission from C(2) and CN. This double-pulse technique was further applied to 2,4,6-trinitrotoluene residues, and enhanced LIBS signals for both atomic carbon and molecular CN emission were observed; however, no molecular C(2) emission was detected.

Differential absorption lidar CO2 laser system for remote sensing of TATP related gases.

A CW tunable 10.6 microm CO(2) laser differential absorption lidar (DIAL) system has been developed, for the first time to our knowledge, for the remote sensing of triacetone triperoxide (TATP) gas vapors, which have strong absorption lines at several wavelengths, including 3.3, 8.3, and 10.6 microm. The DIAL laser beam was transmitted through an enclosed absorption cell containing TATP or SF(6), and backscattered returns were measured from a retroreflector array target at ranges of 5-100 m. DIAL sensitivity for the detection of TATP was about 0.5 ng/microl [52 parts in 10(6)(ppm)] for a 0.3 m path.

Misidentification of vagus nerve stimulator for intravenous access and other major adverse events.

The vagus nerve stimulator has become a standard modality for intractable pediatric epilepsy. We reviewed our experience with major adverse events, after accidental puncture of a stimulator wire by an emergency room physician seeking intravenous access to treat status epilepticus. The Children's National Medical Center database was reviewed for patients undergoing vagus nerve stimulator placement between January 1988 and June 2006. Patient characteristics, duration of therapy, and treatment-limiting adverse events were noted. Of 62 patients implanted over 8 years, 22 (35%) had adverse events which led to a change in therapy. Adverse events included prominent drooling, coughing, throat discomfort, dysphagia, wound infection, difficulty breathing, vomiting, vocal-cord weakness, lead failure, and iatrogenic (piercing of wire; surgical clipping of wire during revision). Eight patients required nonroutine surgical intervention (13%). There were two unusual case presentations. In a 13-year-old boy with status epilepticus at an outlying emergency department, the stimulator line was pierced in search of intravenous access. In a 25-year-old housepainter, neck paresthesias upon right lateral neck turning were attributed to insufficient strain relief. Treatment-limiting adverse events occurred in approximately one-third of patients. Unanticipated adverse events included misidentification of the wire for intravenous access, clipping of the wire during surgical dissection, and cervical dysesthesias associated with head-turning.

A Comprehensive Study of the Alteration of Ignitable Liquids by Weathering and Microbial Degradation.

The differing effects of weathering and microbial degradation are described here in a comprehensive study that involved 50 different ignitable liquids from the Ignitable Liquids Database and Reference Collection. Examples of ignitable liquid residues from each of the main classes established by the American Society of Testing and Materials are presented. Weathering was accomplished via evaporation, whereas microbial degradation was carried out on soil at room temperature for periods of up to 21 days. Major trends included the rapid degradation of long n-alkanes and monosubstituted alkyl benzenes (e.g., toluene, ethylbenzene, and propylbenzene). Surprisingly, some longer branched alkanes (e.g., trimethyloctanes) were also susceptible to microbial attack. Although all ignitable liquids examined suffered at least to some extent from microbial degradation, gasoline, petroleum distillates, and oxygenates were the most susceptible. Isoparaffinic and naphthenic-paraffinic products were the most resistant to microbial degradation.

Performance testing of commercial containers for collection and storage of fire debris evidence.

Fire debris evidence may contain ignitable liquid residues valuable in the investigation of a potential arson scene. The ability to obtain evidence containers that are contaminant-free and vapor-tight is essential to the analysis and storage of fire debris evidence. Commercial containers such as metal "paint" cans, glass mason jars, and polymer bags are often employed as fire debris evidence containers. The purpose of this research was to determine which of these three types of containers provided the most vapor-tight seal for the prevention of ignitable liquid vapor loss and to assess the potential for cross-contamination. Leak rates for each type of container were measured under controlled conditions. Simple mixtures of hydrocarbons were utilized in these experiments. Leak rates were determined based on the amounts of hydrocarbon recovered from activated charcoal located outside the test container and within a secondary container. Quantitation of the hydrocarbons recovered from activated charcoal was calculated using external standard calibration curves following analysis by gas chromatography-mass spectrometry. The results demonstrated that glass jars had the fastest leak rate followed by metal paint cans and properly heat-sealed polymer bags with the slowest leak rate. Each container exhibited a different leak mechanism, which resulted in an observable effect on the composition of hydrocarbons lost from the container. Hydrocarbon transfer from one container to another is also demonstrated. This study presents results that reveal the most vapor-tight container to be a properly heat-sealed copolymer bag.

Characterization of automobile float glass with laser-induced breakdown spectroscopy and laser ablation inductively coupled plasma mass spectrometry.

A comparative analysis of the discriminating power of laser-induced breakdown spectroscopy (LIBS) and laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS), each coupled with refractive index (RI) measurements, is presented for a study of 23 samples of automobile float glass. Elemental emission intensity ratios (LIBS) and elemental concentration ratios (LA-ICP-MS) and their associated confidence intervals were calculated for each float glass sample. The ratios and confidence intervals were used to determine the discrimination power of each analytical method. It was possible to discriminate 83% of the glass samples with 99% confidence based on LIBS spectra alone, and 96-99% of the samples could be discriminated based on LIBS spectra taken in conjunction with RI data at the same confidence level. LA-ICP-MS data allowed for 100% discrimination of the samples without the need for RI data. The results provide evidence to support the use of LIBS combined with RI for forensic analysis of float glass in laboratories that do not have access to LA-ICP-MS.

Electrorheological analysis of nano laden suspensions.

The synthesis and characterization of Pb3O2Cl2 nanowires and the electrorheological (ER) properties of carbon nanofiber (CNF), carbon nanotube (CNT) and Pb3O2Cl2 nanowire (NW) laden suspensions is presented. The ER properties were investigated through oscillatory shear experiments. The viscoelastic response in the presence of dc electric fields was analyzed. Actuation behavior for the CNF and NW laden suspensions was observed at low voltages and low concentration of the reinforcements (0.05 wt%). In the case of the CNT laden suspensions, an effect was observed at a concentration of 0.0125 wt%. Positive and negative electrorheological behaviors were observed due to differences in electrical conductivity and polarization mechanisms.

Assessing evidentiary value in fire debris analysis by chemometric and likelihood ratio approaches.

Results are presented from support vector machine (SVM), linear and quadratic discriminant analysis (LDA and QDA) and k-nearest neighbors (kNN) methods of binary classification of fire debris samples as positive or negative for ignitable liquid residue. Training samples were prepared by computationally mixing data from ignitable liquid and substrate pyrolysis databases. Validation was performed on an unseen set of computationally mixed (in silico) data and on fire debris from large-scale research burns. The probabilities of class membership were calculated using an uninformative (equal) prior and a likelihood ratio was calculated from the resulting class membership probabilities. The SVM method demonstrated a high discrimination, low error rate and good calibration for the in silico validation data; however, the performance decreased significantly for the fire debris validation data, as indicated by a significant increase in the error rate and decrease in the calibration. The QDA and kNN methods showed similar performance trends. The LDA method gave poorer discrimination, higher error rates and slightly poorer calibration for the in silico validation data; however the performance did not deteriorate for the fire debris validation data.

Assessing the evidentiary value of smokeless powder comparisons.

Gas chromatography-electron ionization-mass spectrometry (GC-EI-MS) and physical characteristics data for 726 smokeless reloading powders were analyzed by pairwise comparisons of samples comprising the same product and different products. Pairwise comparisons were restricted to samples having matching kernel shape, color, presence or absence of a perforation and measurements. Discrete results were analyzed for same and different products having matching chemical composition determined from a list of 13 organic components. A continuous score-based likelihood ratio was determined for same and different product comparisons using the Fisher transform of the Pearson correlation between the total ion spectra of the compared samples. Probability distributions for same product and different product comparisons appeared bimodal and were modeled with kernel density distributions. In the discrete and continuous data comparisons, the likelihood ratios for probabilities conditioned on same shape, color, presence/absence of perforation and size were found to provide relatively limited support for either the proposition of same product or different product. Further restricting the pairwise comparisons to samples belonging to the same cluster, as determined by agglomerative hierarchical cluster analysis, provided probability distributions for same product and different product comparisons that were more normal, but did not improve the resulting likelihood ratios. These results inform the forensic analyst regarding the evidentiary value of database search results and direct comparisons of recovered and control samples of smokeless powders.

Adsorption saturation and chromatographic distortion effects on passive headspace sampling with activated charcoal in fire debris analysis.

Distortion of the chromatographic profile obtained for hydrocarbons that have been sampled by adsorption onto activated charcoal is a well-known phenomenon. The work reported here helps to better define the causes of chromatographic profile distortion and offers a potential method to avoid chromatographic distortion in some cases through a subsampling technique. The recovery of hydrocarbons from an equimolar mixture was investigated to determine the influence of hydrocarbon concentration on the molar ratios of recovered components. In a one-quart container, hydrocarbon volumes as small as 24 microL (liquid) were sufficient to saturate the surface area available for adsorption on a 99.0 mm2 square of activated charcoal, resulting in significant distortions in the molar ratio and the chromatographic profile of the recovered hydrocarbons. Passive headspace sampling of a similarly small volume of unweathered gasoline spiked onto carpet padding resulted in a significant distortion of the chromatographic profile. The chromatographic profile of the recovered hydrocarbons closely resembled 75% weathered gasoline. Heating the container spiked with unweathered gasoline to evenly distribute the components and then removing a subsample of the carpet padding to a second container for passive headspace analysis greatly reduced the amount of distortion in the resulting chromatogram.

Inverse Opal Nanocrystal Superlattice Films.

We describe the single-step self-organization of nanocrystal superlattice films infused with spatially ordered arrays of micrometer-size pores. In a humid atmosphere, water droplets condense on the surface of evaporating thin-film solutions of nanocrystals. Nanocrystals coated with the appropriate ligands stabilize the water droplets, allowing them to grow to uniform size and ultimately pack into very ordered arrays. The droplets provide a temporary template that casts an ordered macroporous nanocrystal film. This process could serve as a reliable bottom-up self-assembly approach for fabricating two-dimensional waveguides with tunable optical properties for single-chip integration of photonic and electronic technologies.

Preliminary validation of handheld X-ray fluorescence spectrometry: distinguishing osseous and dental tissue from nonbone material of similar chemical composition.

One of the tasks of a forensic anthropologist is to sort human bone fragments from other materials, which can be difficult when dealing with highly fragmented and taphonomically modified material. The purpose of this research is to develop a method using handheld X-ray fluorescence (HHXRF) spectrometry to distinguish human and nonhuman bone/teeth from nonbone materials of similar chemical composition using multivariate statistical analyses. The sample materials were derived primarily from previous studies: human bone and teeth, nonhuman bone, nonbiological materials, nonbone biological materials, and taphonomically modified materials. The testing included two phases, testing both the reliability of the instrument and the accuracy of the technique. The results indicate that osseous and dental tissue can be distinguished from nonbone material of similar chemical composition with a high degree of accuracy (94%). While it was not possible to discriminate rock apatite and synthetic hydroxyapatite from bone/teeth, this technique successfully discriminated ivory and octocoral.

Chemical Differentiation of Osseous and Nonosseous Materials Using Scanning Electron Microscopy-Energy-Dispersive X-Ray Spectrometry and Multivariate Statistical Analysis.

Identification of osseous materials is generally established on gross anatomical features. However, highly fragmented or taphonomically altered materials may be problematic and may require chemical analysis. This research was designed to assess the use of scanning electron microscopy-energy-dispersive X-ray spectrometry (SEM/EDX), elemental analysis, and multivariate statistical analysis (principal component analysis) for discrimination of osseous and nonosseous materials of similar chemical composition. Sixty samples consisting of osseous (human and nonhuman bone and dental) and non-osseous samples were assessed. After outliers were removed a high overall correct classification of 97.97% was achieved, with 99.86% correct classification for osseous materials. In addition, a blind study was conducted using 20 samples to assess the applicability for using this method to classify unknown materials. All of the blind study samples were correctly classified resulting in 100% correct classification, further demonstrating the efficiency of SEM/EDX and statistical analysis for differentiation of osseous and nonosseous materials.

Class-conditional feature modeling for ignitable liquid classification with substantial substrate contribution in fire debris analysis.

Forensic chemical analysis of fire debris addresses the question of whether ignitable liquid residue is present in a sample and, if so, what type. Evidence evaluation regarding this question is complicated by interference from pyrolysis products of the substrate materials present in a fire. A method is developed to derive a set of class-conditional features for the evaluation of such complex samples. The use of a forensic reference collection allows characterization of the variation in complex mixtures of substrate materials and ignitable liquids even when the dominant feature is not specific to an ignitable liquid. Making use of a novel method for data imputation under complex mixing conditions, a distribution is modeled for the variation between pairs of samples containing similar ignitable liquid residues. Examining the covariance of variables within the different classes allows different weights to be placed on features more important in discerning the presence of a particular ignitable liquid residue. Performance of the method is evaluated using a database of total ion spectrum (TIS) measurements of ignitable liquid and fire debris samples. These measurements include 119 nominal masses measured by GC-MS and averaged across a chromatographic profile. Ignitable liquids are labeled using the American Society for Testing and Materials (ASTM) E1618 standard class definitions. Statistical analysis is performed in the class-conditional feature space wherein new forensic traces are represented based on their likeness to known samples contained in a forensic reference collection. The demonstrated method uses forensic reference data as the basis of probabilistic statements concerning the likelihood of the obtained analytical results given the presence of ignitable liquid residue of each of the ASTM classes (including a substrate only class). When prior probabilities of these classes can be assumed, these likelihoods can be connected to class probabilities. In order to compare the performance of this method to previous work, a uniform prior was assumed, resulting in an 81% accuracy for an independent test of 129 real burn samples.

N1-substituent effects in the selective delivery of polyamine conjugates into cells containing active polyamine transporters.

Several N(1)-arylalkylpolyamines containing various aromatic ring systems were synthesized as their respective HCl salts. The N(1)-substituents evaluated ranged in size from N(1)-benzyl, N(1)-naphthalen-1-ylmethyl, N(1)-2-(naphthalen-1-yl)ethyl, N(1)-3-(naphthalen-1-yl)propyl, N(1)-anthracen-9-ylmethyl, N(1)-2-(anthracen-9-yl)ethyl, N(1)-3-(anthracen-9-yl)propyl, and pyren-1-ylmethyl. The polyamine architecture was also altered and ranged from diamine to triamine and tetraamine systems. Biological activities in L1210 (murine leukemia), Chinese hamster ovary (CHO), and CHO's polyamine transport-deficient mutant (CHO-MG) cell lines were investigated via IC(50) cytotoxicity determinations. K(i) values for spermidine uptake were also determined in L1210 cells. The size of the N(1)-arylalkyl substituent as well as the polyamine sequence used had direct bearing on the observed cytotoxicity profiles. N(1)-Tethers longer than ethylene showed dramatic loss of selectivity for the polyamine transporter (PAT) as shown in a CHO/CHO-MG cytotoxicity screen. In summary, there are clear limits to the size of N(1)-substituents, which can be accommodated by the polyamine transporter. A direct correlation was observed between polyamine-conjugate uptake and cytotoxicity. In this regard, a cytotoxicity model was proposed, which describes a hydrophobic pocket of set dimensions adjacent to the putative PAT polyamine-binding site.