Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates: Lessons Learned

Abstract Purpose: We sought to characterize our recent experience with thoracoscopic congenital diaphragmatic hernia (CDH) repair and identify patient selection factors. Methods: We reviewed the medical records of full-term neonatal (<1 month of age) patients who underwent thoracoscopic CDH repair between 2004 and 2008 (n=15). We obtained data on prenatal diagnosis, characteristics of the CDH and repair, complications, and outcome. Results: All patients were stabilized preoperatively and underwent repair at an average of 5.7+/-1.3 days. Six patients were prenatally diagnosed, including the 5 inborn. Thirteen defects were left-sided. All were intubated shortly after birth and 2 required extracorporeal membrane oxygenation (ECMO). Twelve of 15 (80%) patients underwent successful thoracoscopic primary repair, including 1 of the patients who required ECMO prior to repair. Conversion to open repair occurred in 3 of 15 (20%) patients because of the need for patch closure or intraoperative instability. Among those converted to open, all had left-sided CDH defects and 3 had stomach herniation (of 5 such patients). Patients spent an average of 6.9+/-1.0 days on the ventilator following repair. The average time until full-enteral feeding was 16.7+/-2.25 days, and average length of hospital stay was 23.8+/-2.73 days. All patients survived to discharge, and average length of follow-up was 15.3+/-3.6 months. Conclusions: Thoracoscopic repair of CDH is a safe, effective strategy in patients who have undergone prior stabilization. Stomach herniation is associated with, but does not categorically predict, conversion to open repair. ECMO use prior to repair should not be an absolute contraindication to thoracoscopic repair.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78119/1/lap.2009.0129.pd

D’Agents: Security in a Multiple-Language, Mobile-Agent System

Abstract. Mobile-agent systems must address three security issues: protecting an individual machine, protecting a group of machines, and protecting an agent. In this chapter, we discuss these three issues in the context of D’Agents, a mobile-agent system whose agents can be written in Tcl, Java and Scheme. (D’Agents was formerly known as Agent Tcl.) First we discuss mechanisms existing in D’Agents for protecting an individual machine: (1) cryptographic authentication of the agent’s owner, (2) resource managers that make policy decisions based on the owner’s identity, and (3) secure execution environments for each language that enforce the decisions of the resource managers. Then we discuss our planned market-based approach for protecting machine groups. Finally we consider several (partial) solutions for protecting an agent from a malicious machine.

Slate Literary Magazine, 2012-2013

Trinity College\u27s Literary Magazine - student works.https://digitalrepository.trincoll.edu/slate/1000/thumbnail.jp

Regulating Assisted Reproduction in Canada, Switzerland, and the USA: Comparing the Judicialization of Policy-making

This article analyses the extent to which courts shape policies for assisted reproduction. While the USA is considered to be the most litigious country, Canada has observed a growing involvement of the courts from the 1980’s onward, and Switzerland is characterized by a modest degree of judicialization. Based on national patterns, we would expect litigation and court impact to vary across these three countries. As this paper demonstrates, policy-process specific variables such as the structure of policy conflicts, the novelty of regulation, self-regulation by key stakeholders, and the policies in place better explain the variation in the judicialization of policy-making

Activism and Legitimation in Israel's Jurisprudence of Occupation

Colonial law need not exclude the colonized in order to subordinate them, and ‘activist’ courts can advance the effect of subordination no less than ‘passive’ courts. As a case study, this article examines the jurisprudential legacy of the Israeli Supreme Court in the context of the prolonged Israeli occupation of Palestine. Applying insights from legal realist, law and society, and critical legal studies scholarship, the article questions the utility of using the activist and passive labels. It illustrates how the Israeli activist court, through multiple legal and discursive moves, has advanced and legitimated the colonization of Palestine; that the court is aware of its role; and that arguments that focus on the court’s informal role do not mitigate this legitimating effect. Unlike other scholars, the article shows that the Israeli court’s role—by extending the power of judicial review to the military’s actions in the occupied areas—is neither novel nor unique or benevolent, as the British colonization of India and the US colonization of Puerto Rico show

Is the Rule of Law an Antidote for Religious Tension? The Promise and Peril of Judicializing Religious Freedom

Although “rule of law” is often regarded as a solution for religious conflict, this article analyzes the role of legal processes and institutions in hardening boundaries and sharpening antagonisms among religious communities. Using case studies from Sri Lanka, India, Malaysia, and Pakistan, we highlight four specific mechanisms through which legal procedures, structures, and instruments can further polarize already existing religious conflicts. These mechanisms include the procedural requirements and choreography of litigation (Sri Lanka), the strategic use of legal language and court judgments by political and socioreligious groups (India), the activities of partisan activists who mobilize around litigation (Malaysia), and the exploitation of “public order” laws in contexts framed by antagonism targeting religious minorities (Pakistan)

Infants with esophageal atresia and right aortic arch: Characteristics and outcomes from the Midwest Pediatric Surgery Consortium

Purpose Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF. Methods A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up. Results In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54–2.65) vs. 2.57 kg (2.00–3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32–37) vs. 37 weeks (35–39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p  0.29). Conclusion RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach

The effect of perfluorocarbon vapour on the measurement of respiratory tidal volume during partial liquid ventilation

During partial liquid ventilation perfluorocarbon vapour is present in the exhaled gases. The volumes of these gases are measured by pneumotachometers. Error in measuring tidal volumes will give erroneous measurement of lung compliance during partial liquid ventilation. We aim to compare measured tidal volumes with and without perfluorocarbon vapour using tidal volumes suitable for use in neonates. Tidal volumes were produced with a 100 ml calibration syringe from 20 to 100 ml and with a calibrated Harvard rodent ventilator from 2.5 to 20 ml. Control tidal volumes were drawn from a humidifier chamber containing water vapour and the PFC tidal volumes were drawn from a humidifier chamber containing water and perfluorocarbon (FC-77) vapour. Tidal volumes were measured by a fixed orifice, target, differential pressure flowmeter (VenTrak) or a hot-wire anenometer (Bear Cub) placed between the calibration syringe or ventilator and the humidifier chamber. All tidal volumes measured with perfluorocarbon vapour were increased compared with control (ANOVA p < 0.001 and post t-test p < 0.0001). Measured tidal volume increased from 7 to 16% with the fixed orifice type flow-meter, and from 35 to 41% with the hot-wire type. In conclusion, perfluorocarbon vapour flowing through pneumotachometers gives falsely high tidal volume measurements. Calculation of lung compliance must take into account the effect of perfluorocarbon vapour on the measurement of tidal volume

Demographic, clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO Registry

OBJECTIVES: The Digital Ulcers Outcome (DUO) Registry was designed to describe the clinical and antibody characteristics, disease course and outcomes of patients with digital ulcers associated with systemic sclerosis (SSc). METHODS: The DUO Registry is a European, prospective, multicentre, observational, registry of SSc patients with ongoing digital ulcer disease, irrespective of treatment regimen. Data collected included demographics, SSc duration, SSc subset, internal organ manifestations, autoantibodies, previous and ongoing interventions and complications related to digital ulcers. RESULTS: Up to 19 November 2010 a total of 2439 patients had enrolled into the registry. Most were classified as either limited cutaneous SSc (lcSSc; 52.2%) or diffuse cutaneous SSc (dcSSc; 36.9%). Digital ulcers developed earlier in patients with dcSSc compared with lcSSc. Almost all patients (95.7%) tested positive for antinuclear antibodies, 45.2% for anti-scleroderma-70 and 43.6% for anticentromere antibodies (ACA). The first digital ulcer in the anti-scleroderma-70-positive patient cohort occurred approximately 5 years earlier than the ACA-positive patient group. CONCLUSIONS: This study provides data from a large cohort of SSc patients with a history of digital ulcers. The early occurrence and high frequency of digital ulcer complications are especially seen in patients with dcSSc and/or anti-scleroderma-70 antibodies