NMS, and Why We Should Call It (Malignant) Catatonia

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A 53-year-old otherwise healthy woman presents with a 2-year history of intermittent fecal incontinence. Because of embarrassment, she has curtailed her social and professional activities. Physical activity often precipitates an episode, and she wears absorbent pads. She has occasional urinary incontinence when she coughs or sneezes. There is no history of gastrointestinal or rectal surgery and no neurologic symptoms. Physical examination reveals no perianal deformity or rectal prolapse. The tone of the anal canal is adequate, whereas contractions of the anal sphincter muscle and the puborectalis muscle are weak. On the patient's bearing down, there is no rectal prolapse, and the perineal descent is approximately 2 cm. How should she be evaluated and treated? The Cl inic a l Probl e m Fecal incontinence is a devastating nonfatal illness, resulting in considerable embarrassment and anxiety in those who have it. It affects 2 to 17% of people living in the community and almost half of all nursing home residents. 1 Many affected persons do not voluntarily report fecal incontinence to their physicians and must be asked about it directly. 2 The prevalence of fecal incontinence is increased among women, the elderly, persons with poor health status or physical limitations, and those residing in nursing homes. 2 Other risk factors associated with fecal incontinence in adults include rectal radiation therapy (e.g., for prostate cancer), pregnancy, injury to the sphincter or nerve damage associated with vaginal delivery, anorectal surgical procedures (e.g., sphincterotomy for anal fissures), diarrhea alone or in association with the irritable bowel syndrome, and fecal impaction. Neurologic conditions (e.g., stroke, multiple sclerosis, spinal cord injury, and Parkinson's disease) and diabetes are also risk factors. Continence relies on the appropriate functioning of the puborectalis muscle and the internal and external anal sphincter muscles, which encircle the anal canal S t r ategie s a nd E v idence Evaluation A detailed history should be taken to assess the frequency, severity, and nature of the incontinence and the effect of incontinence on the quality of the patient's life, including an assessment of the patient's ability to leave the house for work and social activities. Patients are particularly anxious about the unpredictability of episodes of fecal incontinence and often alter their social and professional activities to avoid embar

An analysis of the XOR dynamic problem generator based on the dynamical system

This is the post-print version of the article - Copyright @ 2010 Springer-VerlagIn this paper, we use the exact model (or dynamical system approach) to describe the standard evolutionary algorithm (EA) as a discrete dynamical system for dynamic optimization problems (DOPs). Based on this dynamical system model, we analyse the properties of the XOR DOP Generator, which has been widely used by researchers to create DOPs from any binary encoded problem. DOPs generated by this generator are described as DOPs with permutation, where the fitness vector is changed according to a permutation matrix. Some properties of DOPs with permutation are analyzed, which allows explaining some behaviors observed in experimental results. The analysis of the properties of problems created by the XOR DOP Generator is important to understand the results obtained in experiments with this generator and to analyze the similarity of such problems to real world DOPs.This work was supported by Brazil FAPESP under Grant 04/04289-6 and by UK EPSRC under Grant EP/E060722/2

Ventricular pacing or dual-chamber pacing for sinus-node dysfunction

BACKGROUND Dual-chamber (atrioventricular) and single-chamber (ventricular) pacing are alternative treatment approaches for sinus-node dysfunction that causes clinically significant bradycardia. However, it is unknown which type of pacing results in the better outcome. METHODS We randomly assigned a total of 2010 patients with sinus-node dysfunction to dual-chamber pacing (1014 patients) or ventricular pacing (996 patients) and followed them for a median of 33.1 months. The primary end point was death from any cause or nonfatal stroke. Secondary end points included the composite of death, stroke, or hospitalization for heart failure; atrial fibrillation; heart-failure score; the pacemaker syndrome; and the quality of life. RESULTS The incidence of the primary end point did not differ significantly between the dual-chamber group (21.5 percent) and the ventricular-paced group (23.0 percent, P=0.48). In patients assigned to dual-chamber pacing, the risk of atrial fibrillation was lower (hazard ratio, 0.79; 95 percent confidence interval, 0.66 to 0.94; P=0.008), and heart-failure scores were better (P CONCLUSIONS In sinus-node dysfunction, dual-chamber pacing does not improve stroke-free survival, as compared with ventricular pacing. However, dual-chamber pacing reduces the risk of atrial fibrillation, reduces signs and symptoms of heart failure, and slightly improves the quality of life. Overall, dual-chamber pacing offers significant improvement as compared with ventricular pacing

Intraoperative high resolution duplex imaging during carotid endarterectomy: Which abnormalities require surgical correction?

Objectives:This study evaluates high resolution, duplex ultrasound imaging for quality control of carotid endarterectomy in order to determine which technical factors were linked to residual stenosis and to define duplex criteria for reexploration.Design, material and methods:A consecutive series of 100 patients undergoing carotid endarterectomy were evaluated. Duplex imaging was performed prior to wound closure and repeated at 6–8 weeks postoperatively. Stenoses were classified as non-significant, moderate or severe based on duplex criteria. Intimal flaps, shelves, kinks, clamp damage and fronds were identified by ultrasound imaging.Results:Five moderate stenoses were noted in the proximal endarterectomy site (PES), and at follow-up three had resolved. Adherent fronds were detected in 83% of vessels and resolved in all but three cases. At the distal endarterectomy site there were 10 severe and 12 moderate stenoses. Intimal flaps were associated with an increased incidence of residual stenosis (p = 0.010).Conclusions:We conclude that severe stenoses with an intimal flap should be corrected immediately. Further data is required to establish the significance of kinks. Residual intimal flaps in the PES appear to remodel. The role of completion duplex may lie in the modification of surgical technique to eradicate anatomical and haemodynamic imperfections

Critical Susceptibility Exponent Measured from Fe/W(110) Bilayers

The critical phase transition in ferromagnetic ultrathin Fe/W(110) films has been studied using the magnetic ac susceptibility. A statistically objective, unconstrained fitting of the susceptibility is used to extract values for the critical exponent (gamma), the critical temperature Tc, the critical amplitude (chi_o) and the range of temperature that exhibits power-law behaviour. A fitting algorithm was used to simultaneously minimize the statistical variance of a power law fit to individual experimental measurements of chi(T). This avoids systematic errors and generates objective fitting results. An ensemble of 25 measurements on many different films are analyzed. Those which permit an extended fitting range in reduced temperature lower than approximately .00475 give an average value gamma=1.76+-0.01. Bilayer films give a weighted average value of gamma = 1.75+-0.02. These results are in agreement with the -dimensional Ising exponent gamma= 7/4. Measurements that do not exhibit power-law scaling as close to Tc (especially films of thickness 1.75ML) show a value of gamma higher than the Ising value. Several possibilities are considered to account for this behaviour.Comment: -Submitted to Phys. Rev. B -Revtex4 Format -6 postscript figure

Analytic and Asymptotic Methods for Nonlinear Singularity Analysis: a Review and Extensions of Tests for the Painlev\'e Property

The integrability (solvability via an associated single-valued linear problem) of a differential equation is closely related to the singularity structure of its solutions. In particular, there is strong evidence that all integrable equations have the Painlev\'e property, that is, all solutions are single-valued around all movable singularities. In this expository article, we review methods for analysing such singularity structure. In particular, we describe well known techniques of nonlinear regular-singular-type analysis, i.e. the Painlev\'e tests for ordinary and partial differential equations. Then we discuss methods of obtaining sufficiency conditions for the Painlev\'e property. Recently, extensions of \textit{irregular} singularity analysis to nonlinear equations have been achieved. Also, new asymptotic limits of differential equations preserving the Painlev\'e property have been found. We discuss these also.Comment: 40 pages in LaTeX2e. To appear in the Proceedings of the CIMPA Summer School on "Nonlinear Systems," Pondicherry, India, January 1996, (eds) B. Grammaticos and K. Tamizhman

Comparison of Intermediate-Dose Methotrexate with Cranial Irradiation for the Post-Induction Treatment of Acute Lymphocytic Leukemia in Children

Abstract We compared two regimens with respect to their ability to prolong disease-free survival in 506 children and adolescents with acute lymphocytic leukemia. All responders to induction therapy were randomized to treatment with 2400 rad of cranial irradiation plus intrathecal methotrexate or to treatment with intermediate-dose methotrexate plus intrathecal methotrexate, as prophylaxis for involvement of the central nervous system and other sanctuary areas. Patients were then treated with a standard maintenance regimen. Complete responders were stratified into either standard-risk or increased-risk groups on the basis of age and white-cell count at presentation. Among patients with standard risk, hematologic relapses occurred in 9 of 117 given methotrexate and 24 of 120 given irradiation (P\u3c0.01). The rate of Central-nervous-system relapse was higher in the methotrexate group (23 of 117) than in the irradiation group (8 of 120) (P = 0.01). Among patients with increased risk, radiation offered greater protection to the central nervous system than methotrexate (P = 0.03); there was no difference in the rate of hematologic relapse. In both risk strata the frequency of testicular relapse was significantly lower in the methotrexate group (1 patient) than the radiation group (10 patients) (P = 0.01). Methotrexate offered better protection against systemic relapse in standard-risk patients and better protection against testicular relapse overall, but it offered less protection against relapses in the central nervous system than cranial irradiation. (N Engl J Med. 1983; 308:477–84.

Superfluid toroidal currents in atomic condensates

The dynamics of toroidal condensates in the presence of condensate flow and dipole perturbation have been investigated. The Bogoliubov spectrum of condensate is calculated for an oblate torus using a discrete-variable representation and a spectral method to high accuracy. The transition from spheroidal to toroidal geometry of the trap displaces the energy levels into narrow bands. The lowest-order acoustic modes are quantized with the dispersion relation $\omega \sim |m| \omega_s$ with $m=0,\pm 1,\pm 2, ...$. A condensate with toroidal current $\kappa$ splits the $|m|$ co-rotating and counter-rotating pair by the amount: $\Delta E \approx 2 |m|\hbar^2 \kappa < r^{-2}>$. Radial dipole excitations are the lowest energy dissipation modes. For highly occupied condensates the nonlinearity creates an asymmetric mix of dipole circulation and nonlinear shifts in the spectrum of excitations so that the center of mass circulates around the axis of symmetry of the trap. We outline an experimental method to study these excitations.Comment: 8 pages, 8 figure

Singular Casimir Elements of the Euler Equation and Equilibrium Points

The problem of the nonequivalence of the sets of equilibrium points and energy-Casimir extremal points, which occurs in the noncanonical Hamiltonian formulation of equations describing ideal fluid and plasma dynamics, is addressed in the context of the Euler equation for an incompressible inviscid fluid. The problem is traced to a Casimir deficit, where Casimir elements constitute the center of the Lie-Poisson algebra underlying the Hamiltonian formulation, and this leads to a study of the symplectic operator defining the Poisson bracket. The kernel of the symplectic operator, for this typical example of an infinite-dimensional Hamiltonian system for media in terms of Eulerian variables, is analyzed. For two-dimensional flows, a rigorously solvable system is formulated. The nonlinearity of the Euler equation makes the symplectic operator inhomogeneous on phase space (the function space of the state variable), and it is seen that this creates a singularity where the nullity of the symplectic operator (the "dimension" of the center) changes. Singular Casimir elements stemming from this singularity are unearthed using a generalization of the functional derivative that occurs in the Poisson bracket