Learning curve and period of experience required for the competent diagnosis of acute appendicitis using abdominal computed tomography: a prospective observational study

Objective To assess the learning curve of novice residents in diagnosing acute appendicitis using abdominal computed tomography (CT) scans. Methods This prospective observational study was conducted within a 4-month period from March 1 to June 30, 2015. After CT scans for right lower quadrant pain or similar acute abdomen were evaluated, postgraduate year 1 (PGY-1) residents completed an interpretation checklist. The primary outcome was evaluation of the learning curve for competent CT scan interpretation under suspicion of acute appendicitis. Secondary outcomes were cumulative numbers of accurate abdominal CT interpretations regardless of initial clinical impression and training period. Results PGY-1 residents recorded a total of 230 interpretation checklists. There were 53, 51, 46, 44, and 36 checklists recorded by individual residents and 92, 92, 91, 91, and 61 respective training days in the emergency department, excluding rotation periods in other departments. After 16 to 20 interpretations of abdominal CT scans performed under suspicion of acute appendicitis, the residents could diagnose acute appendicitis with more than 95% accuracy. Overall, the sensitivity and specificity for diagnosing acute appendicitis were 97% (95% confidence interval, 94 to 100) and 83% (95% confidence interval, 80 to 87), respectively. After 61 to 80 abdominal CT interpretations regardless of suspicion of acute appendicitis and after 41 to 50 days in training, PGY-1 emergency department residents could diagnose acute appendicitis with more than 95% accuracy. Conclusion PGY-1 residents require 16 to 20 checklist interpretations to acquire acceptable abdominal CT interpretation. After performing 61 to 80 CT scans regardless of suspicion of acute appendicitis, they could diagnose acute appendicitis with acceptable accuracy

Ilizarov Treatment of Congenital Pseudarthrosis of the Tibia: A Multi-Targeted Approach Using the Ilizarov Technique

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopaedics. The treatment goals are osteosynthesis, stabilization of the ankle mortise by fibular stabilization, and lower limb-length equalization. Each of these goals is difficult to accomplish but regardless of the surgical options, the basic biological considerations are the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation, and the correction of any angular deformity. The Ilizarov method is certainly valuable for the treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. Leg-length discrepancy can be managed by proximal tibial lengthening using distraction osteogenesis combined with or without contralateral epiphysiodesis. However, treatment of CPT is fraught with complications due to the complex nature of the disease, and failure is common. Residual challenges, such as refracture, growth disturbance, and poor foot and ankle function with stiffness, are frequent and perplexing. Refracture is the most common and serious complication after primary healing and might result in the re-establishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. This review describes a multi-targeted approach for tackling these challenges, which utilizes the Ilizarov technique in atrophic-type CPT

High blood viscosity in acute ischemic stroke

BackgroundThe changes in blood viscosity can influence the shear stress at the vessel wall, but there is limited evidence regarding the impact on thrombogenesis and acute stroke. We aimed to investigate the effect of blood viscosity on stroke and the clinical utility of blood viscosity measurements obtained immediately upon hospital arrival.MethodsPatients with suspected stroke visiting the hospital within 24 h of the last known well time were enrolled. Point-of-care testing was used to obtain blood viscosity measurements before intravenous fluid infusion. Blood viscosity was measured as the reactive torque generated at three oscillatory frequencies (1, 5, and 10 rad/sec). Blood viscosity results were compared among patients with ischemic stroke, hemorrhagic stroke, and stroke mimics diagnosed as other than stroke.ResultsAmong 112 enrolled patients, blood viscosity measurements were accomplished within 2.4 ± 1.3 min of vessel puncture. At an oscillatory frequency of 10 rad/sec, blood viscosity differed significantly between the ischemic stroke (24.2 ± 4.9 centipoise, cP) and stroke mimic groups (17.8 ± 6.5 cP, p < 0.001). This finding was consistent at different oscillatory frequencies (134.2 ± 46.3 vs. 102.4 ± 47.2 at 1 rad/sec and 39.2 ± 11.5 vs. 30.4 ± 12.4 at 5 rad/sec, Ps < 0.001), suggesting a relationship between decreases in viscosity and shear rate. The area under the receiver operating curve for differentiating cases of stroke from stroke mimic was 0.79 (95% confidence interval, 0.69–0.88).ConclusionPatients with ischemic stroke exhibit increases in whole blood viscosity, suggesting that blood viscosity measurements can aid in differentiating ischemic stroke from other diseases

Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Discutindo a educação ambiental no cotidiano escolar: desenvolvimento de projetos na escola formação inicial e continuada de professores

A presente pesquisa buscou discutir como a Educação Ambiental (EA) vem sendo trabalhada, no Ensino Fundamental e como os docentes desta escola compreendem e vem inserindo a EA no cotidiano escolar., em uma escola estadual do município de Tangará da Serra/MT, Brasil. Para tanto, realizou-se entrevistas com os professores que fazem parte de um projeto interdisciplinar de EA na escola pesquisada. Verificou-se que o projeto da escola não vem conseguindo alcançar os objetivos propostos por: desconhecimento do mesmo, pelos professores; formação deficiente dos professores, não entendimento da EA como processo de ensino-aprendizagem, falta de recursos didáticos, planejamento inadequado das atividades. A partir dessa constatação, procurou-se debater a impossibilidade de tratar do tema fora do trabalho interdisciplinar, bem como, e principalmente, a importância de um estudo mais aprofundado de EA, vinculando teoria e prática, tanto na formação docente, como em projetos escolares, a fim de fugir do tradicional vínculo “EA e ecologia, lixo e horta”.Facultad de Humanidades y Ciencias de la Educació

Analysis of Groundwater Level Variations Caused by the Changes in Groundwater Withdrawals Using Long Short-Term Memory Network

To properly manage the groundwater resources, it is necessary to analyze the impact of groundwater withdrawal on the groundwater level. In this study, a Long Short-Term Memory (LSTM) network was used to evaluate the groundwater level prediction performance and analyze the impact of the change in the amount of groundwater withdrawal from the pumping wells on the change in the groundwater level in the nearby monitoring wells located in Jeju Island, Korea. The Nash&ndash;Sutcliffe efficiency between the observed and simulated groundwater level was over 0.97. Therefore, the groundwater prediction performance of LSTM was remarkably high. If the groundwater level is simulated on the assumption that the future withdrawal amount is reduced by 1/3 of the current groundwater withdrawal, the range of the maximum rise of the groundwater level would be 0.06&ndash;0.13 m compared to the current condition. In addition, assuming that no groundwater is taken, the range of the maximum increase in the groundwater level would be 0.11&ndash;0.38 m more than the current condition. Therefore, the effect of groundwater withdrawal on the groundwater level in this area was exceedingly small. The method and results can be used to develop new groundwater withdrawal sources for the redistribution of groundwater withdrawals

Behavior of framed modular building system with double skin steel panels

A new type of lateral force-resisting system, a framed modular building with double skin steel panels of slender thin steel plates is presented. Modular construction leads to faster construction, improved quality and reduced resources and waste. A steel panel strengthened framed modular system is developed for the lateral load resisting system instead of in situ concrete core walls. The proposed double skin steel panel systems showed moderate ductility and energy dissipation due to their post-buckling strength. Full-scale experiments on a framed modular system with double skin steel panels were conducted. The test of the frame with steel panel systems showed that all steel panel systems reached a yielding point before the frame structure started to yield, so that severe damage to the frame as a primary structure was controlled. Also, the steel panel systems increased the initial lateral stiffness of the total system and maintained the elastic range of the panels up to near the yielding point of plates without local buckling driven from its shear behavior. By rigid-plastic analysis, the post-buckling strength of thin plates under in-plane bending was predicted and compared with experimental results. Based on the experimental data of the panels, the analytic model of these panel systems was constructed and compared with the experimental results of frames with double skin steel panel systems. (C) 2011 Elsevier Ltd. All rights reserved.MAZZONI S, 2006, OPENSEES COMMAND LANMATTEIS GD, 2005, ENG STRUCTURES, V27HITAKA T, 2003, J STRUCTURAL ENG ASC, V129XIAO LZ, 2003, PROGR STRUCTURAL ENG, V5, P252GIONCU V, 2002, DUCTILITY SEISMIC REASTANEHASL A, 2001, SEISMIC BEHAV DESIGNMATTEIS GD, 2000, J CONSTRUCTIONAL STE, V53GALAMBUS TV, 1998, GUIDE STABILITY DESIPark MS, 1996, THIN WALL STRUCT, V25, P185CACCESE V, 1996, J STRUCTURAL ENG ASC, V119NAKASHIMA M, 1995, J STRUCTURAL ENG ASC, V121GRZEBIETA RH, 1994, P 6 INT S TUB STRUCT, P255ELGAALY M, 1993, J STRUCTURAL ENG ASC, V119HILL R, 1986, J MECH PHYS SOLIDS, V34, P511KECMAN D, 1983, INT J MECH SCI, V25, P623EASLEY JT, 1969, J STRUCT DIV ASCE, V95, P1497

&quot;4-in-1 Osteosynthesis&quot; for Atrophic-type Congenital Pseudarthrosis of the Tibia

Background: According to the authors&apos; multi-targeted, fibular status-based algorithmic approach using the Ilizarov technique, ankle stabilization by end-to-end osteosynthesis of the fibula is advocated for mild (type B1), &quot;4-in-1 osteosynthesis&quot; in which all 4 proximal and distal segments of the tibia and fibula are placed in 1 healing mass for moderate (type B2), and distal tibiofibular (TF) fusion for severe (type B3) fibular pseudarthrosis in association with atrophic-type congenital pseudarthrosis of the tibia (CPT). This report describes the indications, operative technique, and outcomes of &quot;4-in-1 osteosynthesis&quot; for atrophic-type CPT associated with type B2 fibular pseudarthrosis. Methods: Thirteen patients presented with atrophic-type CPT associated with type B2 fibular pseudarthrosis underwent Ilizarov osteosynthesis between 1989 and 2007 for atrophic-type CPT. To validate the efficacy of &quot;4-in-1 osteosynthesis&quot; in these patients, fracture risk and ankle function were compared between 2 groups of type B2 patients, namely, 8 patients (mean age, 6.3 y) who underwent &quot;4-in-1 osteosynthesis&quot; according to our current protocol (Group I), and 5 patients (mean age, 3.2 y) treated by other techniques (3 distal TF fusion, 2 failed end-to-end osteosynthesis) during the learning period (Group II). Results: No refracture occurred in Group I, whereas refracture occurred in all except 1 in Group II. Ankles were eventually stabilized by distal TF fusion in all patients in Group II. The Kaplan-Meier method revealed a refracture-free cumulative survival rate of 100% in Group I, whereas in Group II, it dropped progressively and reached 60% at 1.8 years and 20% at 2.7 years. No significant difference in ankle function was evident between the 2 groups (american orthopaedic foot and ankle society (AOFAS) score, 89.25 +/- 7.25 after 7.4 y of follow-up in Group I, and 84.6 +/- 9.53 after 13 y of follow-up in Group II). Conclusions: It is imperative that fibular status be evaluated carefully to enable the planning of the most effective, safe, practical treatment. &quot;4-in-1 osteosynthesis,&quot; which is primarily considered for bony union with a large cross-sectional area and ankle stabilization, seems to be a better choice for atrophic-type CPT associated with type B2 fibular pseudarthrosis, in which end-to-end osteosynthesis of the fibula often fails. Level of Evidence: Level III, Retrospective comparative study.N