Vitamin D to prevent lung injury following esophagectomy: A randomized, placebo-controlled trial

Objectives: Observational studies suggest an association between vitamin D deficiency and adverse outcomes of critical illness and identify it as a potential risk factor for the development of lung injury. To determine whether pre-operative administration of oral high-dose cholecalciferol ameliorates early acute lung injury post-operatively in adults undergoing elective esophagectomy. Design: A double-blind, randomized, placebo-controlled trial. Setting: Three large UK university hospitals. Patients: Seventy-nine adult patients undergoing elective esophagectomy were randomized. Intervention: A single oral preoperative (3-14 days) dose of 7.5mg (300,000IU; 15mls) cholecalciferol or matched placebo. Measurements and Main Results: Primary outcome was change in extravascular lung water index (EVLWI) at the end of esophagectomy. Secondary outcomes included PaO2:FiO2 ratio, development of lung injury, ventilator and organ-failure free days, 28 and 90 day survival, safety of cholecalciferol supplementation, plasma vitamin D status (25(OH)D, 1,25(OH)2D and vitamin D binding protein), pulmonary vascular permeability index (PVPI) and EVLWI day 1 postoperatively. An exploratory study measured biomarkers of alveolar-capillary inflammation and injury. Forty patients were randomized to cholecalciferol and 39 to placebo. There was no significant change in EVLWI at the end of the operation between treatment groups (placebo median 1.0[IQR 0.4 – 1.8] vs cholecalciferol median 0.4[IQR 0.4 – 1.2] ml/kg, p=0.059). Median PVPI values were significantly lower in the cholecalciferol treatment group (placebo 0.4[IQR 0 – 0.7] vs cholecalciferol 0.1[IQR -0.15 -0.35], p=0.027). Cholecalciferol treatment effectively increased 25(OH)D concentrations but surgery resulted in a decrease in 25(OH)D concentrations at day 3 in both arms. There was no difference in clinical outcomes. Conclusions: High-dose preoperative treatment with oral cholecalciferol was effective at increasing 25(OH)D concentrations, and reduced changes in postoperative PVPI but not EVLWI

Extension of a Multiscale Particle Scheme to Near-Equilibrium Viscous Flows

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/76880/1/AIAA-40262-641.pd

Evaluation of a new model of care for people with complications of diabetic retinopathy : The EMERALD Study

Objectives The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent and life-long follow-up, have markedly increased hospital demands. Resulting delays in the evaluation/treatment of patients are leading to sight loss. Strategies to increase capacity of medical retina clinics are urgently needed. EMERALD tested diagnostic accuracy, acceptability and costs of a new health care pathway for people with previously treated DME/PDR. Design Prospective, multicentric, case-referent, cross-sectional, diagnostic accuracy study, undertaken in 13 hospitals in the United Kingdom. Participants Adults with type 1 or 2 diabetes and previously successfully treated DME/PDR who, at the time of enrolment, had active or inactive disease. Methods A new health care pathway entailing multimodal imaging (spectral domain optical coherence tomography [SD-OCT] for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-wide-field fundus images [UWF] for PDR) interpreted by trained non-medical staff (ophthalmic graders) to detect re-activation of disease was compared with the current standard care (ophthalmologists face-to-face examination). Main outcome measures Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, with inadequate images/indeterminate findings. Results The new pathway had sensitivity of 97% (95% confidence interval [CI] 92-99%) and specificity of 31% (95% CI 23-40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS (85%, 95% CI 77-91%; 48%; 95% CI 41-56%, respectively) or UWF (83%, 95% CI 75-89%; 54%; 95% CI 46-61%, respectively) were comparable. For detection of high risk PDR sensitivity and specificity were higher when using UWF images (87%, 95% CI 78-93%; 49% 95% CI 42-56%, respectively for UWF, versus 80%, 95% CI 69-88%; 40% CI 34-47%, respectively, for 7-field ETDRS). Participants preferred ophthalmologist’s assessments; in their absence, wished immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard care, the new pathway could save £1,390/100 DME visits and between £461-£1,189/100 PDR visits. Conclusion The new ophthalmic grader pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementatio

Systematic KMTNet planetary anomaly search. VIII. Complete sample of 2019 subprime field planets

We complete the publication of all microlensing planets (and “possible planets”) identified by the uniform approach of the KMT AnomalyFinder system in the 21 KMT subprime fields during the 2019 observing season, namely, KMT-2019-BLG-0298, KMT-2019-BLG-1216, KMT-2019-BLG-2783, OGLE-2019-BLG-0249, and OGLE-2019-BLG-0679 (planets), as well as OGLE-2019-BLG-0344 and KMT-2019-BLG-0304 (possible planets). The five planets have mean log mass ratio measurements of (−2.6, −3.6, −2.5, −2.2, −2.3), median mass estimates of (1.81, 0.094, 1.16, 7.12, 3.34) M Jup, and median distance estimates of (6.7, 2.7, 5.9, 6.4, 5.6) kpc, respectively. The main scientific interest of these planets is that they complete the AnomalyFinder sample for 2019, which has a total of 25 planets that are likely to enter the statistical sample. We find statistical consistency with the previously published 33 planets from the 2018 AnomalyFinder analysis according to an ensemble of five tests. Of the 58 planets from 2018–2019, 23 were newly discovered by AnomalyFinder. Within statistical precision, half of the planets have caustic crossings, while half do not; an equal number of detected planets result from major- and minor-image light-curve perturbations; and an equal number come from KMT prime fields versus subprime fields

Reducing the run-time of MCMC programs by multithreading on SMP architectures

The increasing availability of multi-core and multiprocessor architectures provides new opportunities for improving the performance of many computer simulations. Markov Chain Monte Carlo (MCMC) simulations are widely used for approximate counting problems, Bayesian inference and as a means for estimating very high-dimensional integrals. As such MCMC has found a wide variety of applications in fields including computational biology and physics, financial econometrics, machine learning and image processing. This paper presents a new method for reducing the run-time of Markov Chain Monte Carlo simulations by using SMP machines to speculatively perform iterations in parallel, reducing the runtime of MCMC programs whilst producing statistically identical results to conventional sequential implementations. We calculate the theoretical reduction in runtime that may be achieved using our technique under perfect conditions, and test and compare the method on a selection of multi-core and multi-processor architectures. Experiments are presented that show reductions in runtime of 35% using two cores and 55% using four cores

Creation of a Continent Urinary Bladder Reservoir Vascularized by Omentum as a Possible Surgical Option for Canine Trigonal/Urethral Urothelial Carcinoma

Surgical procedures that maintain continence with minimal complication following resection of trigono-urethral urothelial carcinoma (UC) are limited in canines; therefore, palliative options are often pursued. A feasible tumor resection option may improve disease control and survival. The study’s objective was to evaluate a continent urine reservoir created from the urinary bladder body and vascularized solely by omentum. We hypothesized that a viable urine reservoir could be created, and staged omentalization would provide improved vascularity. Nine normal female Beagles were randomized to one of three groups. Group A urinary bladders were transected cranial to the ureteral papillae to create a closed bladder vesicle which was concomitantly omentalized. Group B underwent omentalization two weeks prior to vesicle creation. Based on Group A and B results, Group C underwent neoureterocystostomy and omentalization followed by neoreservoir formation and tube cystostomy 2 weeks later. Serial ultrasounds and histopathology confirmed adequate omental neovascularization in Groups B and C with continent Group C neoreservoirs maintained for 2 months. Some pylectasia and ureteral dilation was documented in all Group C dogs at variable timepoints. Progressive hydroureteronephrosis developed in 2/6 kidneys. Transient azotemia was noted in only 1 Group C dog, although all developed treatable urinary tract infections. The sample size is limited, and the efficacy of this technique in providing disease control for UC is unknown. However, this novel option could allow for primary UC resection while providing continence and limiting complications. Postoperative local or systemic adjuvant therapy, ultrasonographic neoreservoir monitoring, and BRAF analysis would be indicated

Reporting achievement of medical student milestones to residency program directors: An educational handover

Copyright © by the Association of American Medical Colleges. Problem Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear - as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. Approach A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. Outcomes In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. Next Steps An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions

Model for Developing Educational Research Productivity: The Medical Education Research Group

Introduction: Education research and scholarship are essential for promotion of faculty as well as dissemination of new educational practices. Educational faculty frequently spend the majority of their time on administrative and educational commitments and as a result educators often fall behind on scholarship and research. The objective of this educational advance is to promote scholarly productivity as a template for others to follow. Methods: We formed the Medical Education Research Group (MERG) of education leaders from our emergency medicine residency, fellowship, and clerkship programs, as well as residents with a focus on education. First, we incorporated scholarship into the required activities of our education missions by evaluating the impact of programmatic changes and then submitting the curricula or process as peer-reviewed work. Second, we worked as a team, sharing projects that led to improved motivation, accountability, and work completion. Third, our monthly meetings served as brainstorming sessions for new projects, research skill building, and tracking work completion. Lastly, we incorporated a work-study graduate student to assist with basic but time-consuming tasks of completing manuscripts.Results: The MERG group has been highly productive, achieving the following scholarship over a three-year period: 102 abstract presentations, 46 journal article publications, 13 MedEd Portal publications, 35 national didactic presentations and five faculty promotions to the next academic level.Conclusion: An intentional focus on scholarship has led to a collaborative group of educators successfully improving their scholarship through team productivity, which ultimately leads to faculty promotions and dissemination of innovations in education

Lower urinary tract transitional cell carcinoma in cats: Clinical findings, treatments, and outcomes in 118 cases.

BackgroundLower urinary tract transitional cell carcinoma (TCC) is an important but rarely described disease of cats.ObjectivesTo report the clinical characteristics, treatments, and outcomes in a cohort of cats with lower urinary tract TCC and to test identified variables for prognostic relevance.AnimalsOne-hundred eighteen client-owned cats with lower urinary tract carcinoma.MethodsMedical records were retrospectively reviewed to obtain information regarding clinical characteristics, treatments, and outcomes. Recorded variables were analyzed statistically.ResultsMedian age of affected cats was 15 years (range, 5.0-20.8 years) and median duration of clinical signs was 30 days (range, 0-730 days). The trigone was the most common tumor location (32/118; 27.1%) as assessed by ultrasound examination, cystoscopy, or both. Treatment was carried out in 73 of 118 (61.9%) cats. Metastatic disease was documented in 25 of 118 (21.2%) cats. Median progression-free survival and survival time for all cats were 113 days (95% confidence interval [CI], 69-153) and 155 days (95% CI, 110-222), respectively. Survival increased significantly (P < .001) when comparing cats across the ordered treatment groups: no treatment, treatment without partial cystectomy, and treatment with partial cystectomy. Partial cystectomy (hazard ratio [HR], 0.31; 95% CI, 0.17-0.87) and treatment with nonsteroidal anti-inflammatory drugs (HR, 0.55; 95% CI, 0.33-0.93) were significantly associated with longer survival times.Conclusions and clinical importanceThe results support treatment using partial cystectomy and NSAIDs in cats with TCC