Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis

Objective Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis. Study Design Retrospective cohort study. Methods History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache. Results Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy. Conclusion Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes. Level of Evidence4. Laryngoscope, 127:1011-1016, 201

Disposal of Household Wastewater in Soils of High Stone Content (1981-1983)

Four experimental filter fields were constructed with built-in monitoring equipment in Nixa soils. These soils contain many chert fragments and a fragipan about 60 cm below the soil surface. The fragipan restricts downward movement of water and is the designlimitingfeature. The four filter fields were: 1. A standard filter field, 76 cm deep. The bottom of the trench was in the fragipan. 2. A modified standard filter field, 30 cm deep. The bottom of the trench was above the fragipan. 3. A modified pressure filter field, 40 cm deep. The bottom of the trench was above the fragipan. In addition, a pressure-distribution system was used to insure uniform distribution of effluent in the trench. Inadvertently, this field was installed in a different soil, and the results cannot be compared directly with the other three. 4. Another modified pressure filter field with the bottom of the trench only 6 cm below the soil surface. Observation of these systems confirms that placing filter fields higher in the soil above the hydraulically limiting horizon results in improved hydraulic performance. The presence of the fragipan amplified the adverse effects attributable to climatic stress. The seepage beds which are higher in the soil profile are able to handle the effluent load and climate load with less danger of surfacing

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program

Introduction: Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures. Methods: We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation. Results: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45–63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32–51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period. Conclusion: Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes

3-PG Productivity Modeling of Regenerating Amazon Forests: Climate Sensitivity and Comparison with MODIS-Derived NPP

Potential forest growth predicted by the Physiological Principles in Predicting Growth (3-PG) model was compared for forest and deforested areas in the Legal Amazon to assess potential differing regeneration associated with climate. Historical deforestation and regeneration have occurred in environmentally marginal areas that influence regional carbon sequestration estimates. Effects of El Niño–induced drought further reduce simulated production by decreasing soil water availability in areas with shallow soils and high transpiration potential. The model was calibrated through comparison of literature biomass and with satellite-based estimates. Net primary productivity (NPP) for mature Amazonian forests from the 3-PG model was positively correlated (r 2 = 0.77) with a Moderate Resolution Imaging Spectroradiometer (MODIS)-derived algorithm, though with some bias. Annual total NPP for the study area using a 1961–90 average climatology was 4.6 Pg C yr−1, which decreased to 4.2 Pg C yr−1 when simulated with climate from the severe 1997/98 El Niño event. From a regional analysis, results showed that biomass accumulation is almost entirely controlled by the availability of soil water. Also, areas currently forested in the eastern Amazon are more sensitive to extreme El Niño–induced drought than southern areas with the greatest deforestation extent

In the Supreme Court of the United States Barbara Grutter, Petitioner, v. Lee Bollinger, et al., Respondents. On Writ of Certiorari to the United States Court of Appeals for the Sixth Circuit

Brief of the University of Michigan Asian Pacific American Law Students Association, the University of Michigan Black Law Students\u27 Alliance, the University of Michigan Latino Law Students Association, and the University of Michigan Native American Law Students Association as Amici Curiae in Support of Respondent

In the Supreme Court of the United States Barbara Grutter, Petitioner, v. Lee Bollinger, et al., Respondents. On Writ of Certiorari to the United States Court of Appeals for the Sixth Circuit

Brief of the University of Michigan Asian Pacific American Law Students Association, the University of Michigan Black Law Students\u27 Alliance, the University of Michigan Latino Law Students Association, and the University of Michigan Native American Law Students Association as Amici Curiae in Support of Respondent

A Flagellar A-Kinase Anchoring Protein with Two Amphipathic Helices Forms a Structural Scaffold in the Radial Spoke Complex

A-kinase anchoring proteins (AKAPs) contain an amphipathic helix (AH) that binds the dimerization and docking (D/D) domain, RIIa, in cAMP-dependent protein kinase A (PKA). Many AKAPs were discovered solely based on the AH–RIIa interaction in vitro. An RIIa or a similar Dpy-30 domain is also present in numerous diverged molecules that are implicated in critical processes as diverse as flagellar beating, membrane trafficking, histone methylation, and stem cell differentiation, yet these molecules remain poorly characterized. Here we demonstrate that an AKAP, RSP3, forms a dimeric structural scaffold in the flagellar radial spoke complex, anchoring through two distinct AHs, the RIIa and Dpy-30 domains, in four non-PKA spoke proteins involved in the assembly and modulation of the complex. Interestingly, one AH can bind both RIIa and Dpy-30 domains in vitro. Thus, AHs and D/D domains constitute a versatile yet potentially promiscuous system for localizing various effector mechanisms. These results greatly expand the current concept about anchoring mechanisms and AKAPs

Antiretroviral Drug Resistance Testing in Adult HIV-1 Infection: 2008 Recommendations of an International AIDS Society-USA Panel

Resistance to antiretroviral drugs remains an important limitation to successful human immunodeficiency virus type 1 (HIV-1) therapy. Resistance testing can improve treatment outcomes for infected individuals. The availability of new drugs from various classes, standardization of resistance assays, and the development of viral tropism tests necessitate new guidelines for resistance testing. The International AIDS Society-USA convened a panel of physicians and scientists with expertise in drug-resistant HIV-1, drug management, and patient care to review recently published data and presentations at scientific conferences and to provide updated recommendations. Whenever possible, resistance testing is recommended at the time of HIV infection diagnosis as part of the initial comprehensive patient assessment, as well as in all cases of virologic failure. Tropism testing is recommended whenever the use of chemokine receptor 5 antagonists is contemplated. As the roll out of antiretroviral therapy continues in developing countries, drug resistance monitoring for both subtype B and non-subtype B strains of HIV will become increasingly importan