A Biliary Endoprosthesis Functioning After Six Years

The functional lifetime for biliary endoprostheses has typically been 7 months. When combined with sphincterotomy for common bile duct stones, it affords an alternative to surgery in high risk patients. Biliary endoprostheses often require replacement in these patients, though recent reports suggest they are functioning longer. We present an 85-year-old asymptomatic woman with a 6-year-old biliary endoprosthesis, believed to be the longest functioning stent reported in the literature

Endoscopic Retrograde Cholangiopancreatography Treatment of Cholecystitis: Possible? Yes; Practical??

Classically, until now, the management of cholecystitis has consisted of immediate and judicious clinical assessment of the affected patient, interpolating into the assessment of the physical findings and results from appropriate laboratory, x-ray, and scanning techniques (sonography and scintigraphy) to formulate a clinical impression. Usually, after the diagnosis has been established, the patient is subjected to a cholecystectomy, although the timing of the surgery may vary depending on the clinical condition of the patient. Alternatives to this management (cholecystectomy, medical management) scheme have been suggested, but these are dependent upon the clinical condition ofthe patient and considerations of risks. Percutaneous drainage of the gallbladder or cholecystostomy is sufficient enough to provide drainage, relieve obstruction, and the consequences of infection, i.e., sepsis, and prevent perforation. A contributory role of endoscopic retrograde cholangiopancreatography (ERCP) in this schema has not been a consideration. An ERCP is rarely employed for therapy (or diagnosis) when cholecystitis is suspected but it might assume a more significant role if it is considered an efficacious alternative in specific conditions. We have had the unusual experience of managing 11 patients with cholecystitis employing ERCP and its therapeutic modalities, i.e., sphincterotomy, selective cannulation of the cystic duct, and relieving obstruction of that structure by catheter displacement of an obstructing stone. Endoscopic techniques providing decompression of the gallbladder are described, and the feasibility of utilizing endoscopic procedures for treatment of cholecystitis will be given consideration

Stent Scraping for Histology: An Alternative Method for Obtaining Tissue to Rule out Neoplasia

Despite improvement in diagnostic modalities, confirmation of a histologic diagnosis of cancer of the biliary tree and pancreas remains elusive. Attempts to collect positive cytology specimens from vigorous brushings or washings obtained at endoscopy or percutaneously are often unsuccessful. In our unit, we have increased the yield by obtaining tissue scraped from prostheses that have been previously placed in either the bile duct or the pancreatic duct. The stents are first flushed with saline to collect cytology specimens, after which, they are bisected and scraped, and these contents are prepared in a manner similar to that used to prepare biopsy samples. Twelve of 16 scraped samples, 9 bile duct and 3 pancreas, were positive for adenocarcinoma. The cytology specimens were positive in only 4 of the 12. We recommend this method of sampling from material contained within prostheses as an adjunct when previous brushings, washings, or biopsies are negative

The Neural Substrates of Infant Sleep in Rats

Sleep is a poorly understood behavior that predominates during infancy but is studied almost exclusively in adults. One perceived impediment to investigations of sleep early in ontogeny is the absence of state-dependent neocortical activity. Nonetheless, in infant rats, sleep is reliably characterized by the presence of tonic (i.e., muscle atonia) and phasic (i.e., myoclonic twitching) components; the neural circuitry underlying these components, however, is unknown. Recently, we described a medullary inhibitory area (MIA) in week-old rats that is necessary but not sufficient for the normal expression of atonia. Here we report that the infant MIA receives projections from areas containing neurons that exhibit state-dependent activity. Specifically, neurons within these areas, including the subcoeruleus (SubLC), pontis oralis (PO), and dorsolateral pontine tegmentum (DLPT), exhibit discharge profiles that suggest causal roles in the modulation of muscle tone and the production of myoclonic twitches. Indeed, lesions in the SubLC and PO decreased the expression of muscle atonia without affecting twitching (resulting in “REM sleep without atonia”), whereas lesions of the DLPT increased the expression of atonia while decreasing the amount of twitching. Thus, the neural substrates of infant sleep are strikingly similar to those of adults, a surprising finding in light of theories that discount the contribution of supraspinal neural elements to sleep before the onset of state-dependent neocortical activity

New Directions in the Development of Population Estimates in the United States?

The advent of a continuously updated Master Area File (MAF) following the 2000 census represents an information resource that can be tapped for purposes of developing timely, cost-effective, and precise population estimates for even the smallest of geographical units (e.g., census blocks). We argue that the MAF can be enhanced (EMAF) for these purposes. In support of our argument we describe a set of activities needed to develop EMAF, each of which is well within the current capabilities of the U.S. Census Bureau and discuss various costs and benefits of each. We also describe how EMAF would provide population estimates containing a wide range of demographic (e.g., age, race, and sex) and socio-economic characteristics (e.g., educational attainment, income, and employment). As such, it could largely negate and eliminate the need for many of the traditional demographic methods of population estimation and possibly reduce the number of sample surveys. We identify important challenges that must be surmounted in order to realize EMAF and make suggestions for doing so. We conclude by noting that the idea of the EMAF could be of interest to other countries with MAF files and strong administrative records systems that, like the United States, are facing the challenge of producing good population information in the face of increasing census costs

Evaluation of individual and ensemble probabilistic forecasts of COVID-19 mortality in the United States

Short-term probabilistic forecasts of the trajectory of the COVID-19 pandemic in the United States have served as a visible and important communication channel between the scientific modeling community and both the general public and decision-makers. Forecasting models provide specific, quantitative, and evaluable predictions that inform short-term decisions such as healthcare staffing needs, school closures, and allocation of medical supplies. Starting in April 2020, the US COVID-19 Forecast Hub (https://covid19forecasthub.org/) collected, disseminated, and synthesized tens of millions of specific predictions from more than 90 different academic, industry, and independent research groups. A multimodel ensemble forecast that combined predictions from dozens of groups every week provided the most consistently accurate probabilistic forecasts of incident deaths due to COVID-19 at the state and national level from April 2020 through October 2021. The performance of 27 individual models that submitted complete forecasts of COVID-19 deaths consistently throughout this year showed high variability in forecast skill across time, geospatial units, and forecast horizons. Two-thirds of the models evaluated showed better accuracy than a naïve baseline model. Forecast accuracy degraded as models made predictions further into the future, with probabilistic error at a 20-wk horizon three to five times larger than when predicting at a 1-wk horizon. This project underscores the role that collaboration and active coordination between governmental public-health agencies, academic modeling teams, and industry partners can play in developing modern modeling capabilities to support local, state, and federal response to outbreaks

The United States COVID-19 Forecast Hub dataset

Academic researchers, government agencies, industry groups, and individuals have produced forecasts at an unprecedented scale during the COVID-19 pandemic. To leverage these forecasts, the United States Centers for Disease Control and Prevention (CDC) partnered with an academic research lab at the University of Massachusetts Amherst to create the US COVID-19 Forecast Hub. Launched in April 2020, the Forecast Hub is a dataset with point and probabilistic forecasts of incident cases, incident hospitalizations, incident deaths, and cumulative deaths due to COVID-19 at county, state, and national, levels in the United States. Included forecasts represent a variety of modeling approaches, data sources, and assumptions regarding the spread of COVID-19. The goal of this dataset is to establish a standardized and comparable set of short-term forecasts from modeling teams. These data can be used to develop ensemble models, communicate forecasts to the public, create visualizations, compare models, and inform policies regarding COVID-19 mitigation. These open-source data are available via download from GitHub, through an online API, and through R packages

Search for eccentric black hole coalescences during the third observing run of LIGO and Virgo

Despite the growing number of confident binary black hole coalescences observed through gravitational waves so far, the astrophysical origin of these binaries remains uncertain. Orbital eccentricity is one of the clearest tracers of binary formation channels. Identifying binary eccentricity, however, remains challenging due to the limited availability of gravitational waveforms that include effects of eccentricity. Here, we present observational results for a waveform-independent search sensitive to eccentric black hole coalescences, covering the third observing run (O3) of the LIGO and Virgo detectors. We identified no new high-significance candidates beyond those that were already identified with searches focusing on quasi-circular binaries. We determine the sensitivity of our search to high-mass (total mass M>70 M⊙) binaries covering eccentricities up to 0.3 at 15 Hz orbital frequency, and use this to compare model predictions to search results. Assuming all detections are indeed quasi-circular, for our fiducial population model, we place an upper limit for the merger rate density of high-mass binaries with eccentricities 0<e≤0.3 at 0.33 Gpc−3 yr−1 at 90\% confidence level