Omental Vascularized Lymph Node Flap: A Radiographic Analysis

Background Vascularized lymph node transfer is an increasingly popular option for the treatment of lymphedema. The omental donor site is advantageous for its copious soft tissue, well-defined collateral circulation, and large number of available nodes, without the risk of iatrogenic lymphedema. The purpose of this study is to define the anatomy of the omental flap in the context of vascularized lymph node harvest. Methods Consecutive abdominal computed tomography angiography (CTA) images performed at a single institution over a 1-year period were reviewed. Right gastroepiploic artery (RGEA) length, artery caliber, lymph node size, and lymph node location in relation to the artery were recorded. A two-tailed Z-test was used to compare means. A Gaussian Mixture Model confirmed by normalized entropy criterion was used to calculate three-dimensional lymph node cluster locations along the RGEA. Results In total, 156 CTA images met inclusion criteria. The RGEA caliber at its origin was significantly larger in males compared with females (p < 0.001). An average of 3.1 (1.7) lymph nodes were present per patient. There was no significant gender difference in the number of lymph nodes identified. Average lymph node size was significantly larger in males (4.9 [1.9] × 3.3 [0.6] mm in males vs. 4.5 [1.5] × 3.1 [0.5] mm in females; p < 0.001). Three distinct anatomical variations of the RGEA course were noted, each with a distinct lymph node clustering pattern. Total lymph node number and size did not differ among anatomical subgroups. Conclusion The omentum is a reliable lymph node donor site with consistent anatomy. This study serves as an aid in preoperative planning for vascularized lymph node transfer using the omental flap

AGROINDUSTRIALIZATION IN EMERGING MARKETS: OVERVIEW AND STRATEGIC CONTEXT

This article offers an overview for a special issue on agroindustrialization. It reviews eleven articles analyzing the agroindustrialization process in Latin America and Asia. It sets out a conceptual framework from the organizational economics and strategic management literature to enhance the understanding of the process of agroindustrialization from a competitive strategy point of view.Agribusiness, Industrial Organization,

The Grand Jury: A Shield of a Different Sort

According to the Washington Post, 991 people were shot to death by police officers in the United States during calendar year 2015, and 957 people were fatally shot in 2016. A disproportionate percentage of the citizens killed in these police-civilian encounters were black. Events in Ferguson, Missouri; Chicago, Illinois; Charlotte, North Carolina; Baton Rouge, Louisiana; and Staten Island, New York - to name but a few affected cities - have now exposed deep distrust between communities of color and law enforcement. Greater transparency is necessary to begin to heal this culture of distrust and to inform the debate going forward about police practices in America. The recent spate of deadly police-civilian encounters has generated enormous media coverage, national discourse, and a proliferation of recommended solutions. In this Essay, we will suggest three modest but important reforms to the grand jury process that we think will help increase transparency, reduce the legitimacy deficit, and restore public confidence in what are admittedly very difficult charging decisions involving the police use of deadly force. Part I examines grand jury secrecy rules in the context of externally created evidence (e.g., dash-cam and body-cam videos) and argues for a uniform, interpretive approach consistent with that followed by a majority of states. Part II discusses evidence presentation before the- grand jury and urges the adoption of a rule that mandates the recording of grand jury instructions. Finally, Part III argues that state criminal procedure rules should be amended to empower states\u27 attorneys to move the court for the public release of redacted grand jury minutes in instances when a no-bill is returned and it is in the public interest

Measurement of Plasmodium falciparum transmission intensity using serological cohort data from Indonesian schoolchildren.

BACKGROUND: As malaria transmission intensity approaches zero, measuring it becomes progressively more difficult and inefficient because parasite-positive individuals are hard to detect. This situation may arise shortly before achieving local elimination, or during surveillance post-elimination to prevent reintroduction. Antibody responses against the parasite last longer than the infections themselves. This "footprint" of infection may thus be used for assessing transmission intensity. A statistical approach is presented for measuring the seroconversion rate (SCR), a correlate of the force of infection, from individual-level longitudinal data on antibody titres in an area of low Plasmodium falciparum transmission. METHODS: Blood samples were collected from 160 Indonesian schoolchildren every month for six months. Titres of antibodies against AMA-1 and MSP-1(19) antigens of P. falciparum were measured using ELISA. The distribution of antibody titres among seronegative and -positive individuals, respectively, was estimated by comparing the titres from the study data (a mixture of both seropositive and -negative individuals) with titres from a (unexposed) negative control group of Indonesian individuals. Two Markov-Chain models for the transition of individuals between serological states were fitted to individual anti-PfAMA-1 or anti-PfMSP-1 titre time series using Bayesian Markov-Chain-Monte-Carlo (MCMC). This yielded estimates of SCR as well as of the duration of seropositivity. RESULTS: A posterior median SCR of 0.02 (Pf AMA-1) and 0.09 (PfMSP-1) person(-1) year(-1) was estimated, with credible intervals ranging from 1E-4 to 0.2 person(-1) year(-1). This level of transmission intensity is at the lower range of what can reliably be measured with the present study size. A Bayesian test for seroconversion of an individual between two observations is presented and used to identify the subjects who have most likely experienced an infection. Furthermore, the theoretical limits of measuring transmission intensity, and how these depend on duration and size of a study as well as on transmission intensity itself, is illustrated. CONCLUSIONS: This analysis shows that it is possible to measure SCR's from individual-level longitudinal data on antibody titres. In addition, individual seroconversion events can be identified, which can be useful in assessing interruption of transmission. Analyses of further serological datasets using the present method are required to improve and validate it. This includes measurement of the duration of antibody responses, how it depends on host age or cumulative exposure, or on the particular antigen used

Predictors and outcomes of sustained, intermittent or never achieving remission in patients with recent onset inflammatory polyarthritis:Results from the Norfolk Arthritis Register

Objectives: Early remission is the current treatment strategy for patients with inflammatory polyarthritis (IP) and RA. Our objective was to identify baseline factors associated with achieving remission: sustained (SR), intermittent (IR) or never (NR) over a 5-year period in patients with early IP.  Methods: Clinical and demographic data of patients with IP recruited to the Norfolk Arthritis Register (NOAR) were obtained at baseline and years 1, 2, 3 and 5. Remission was defined as no tender or swollen joints (out of 51). Patients were classified as NR or PR, respectively, if they were in remission at: no assessment or ⩾3 consecutive assessments after baseline, and IR otherwise. Ordinal regression and a random effects model, respectively, were used to examine the association between baseline factors, remission group and HAQ scores over time.  Results: A total of 868 patients (66% female) were included. Of these, 54%, 34% and 12% achieved NR, IR and SR, respectively. In multivariate analysis, female sex (odds ratio, OR 0.47, 95% CI: 0.35, 0.63), higher tender joint count (OR = 0.94, 95% CI: 0.93, 0.96), higher HAQ (OR = 0.59, 95% CI: 0.48, 0.74), being obese (OR = 0.70, 95% CI: 0.50, 0.99), hypertensive (OR = 0.67, 95% CI: 0.50, 0.90) or depressed (OR = 0.74, 95% CI: 0.55, 1.00) at baseline were independent predictors of being in a lower remission group. IR and SR were associated with lower HAQ scores over time and lower DAS28 at year 5.  Conclusion: Women with higher tender joint count and disability at baseline, depression, obesity and hypertension were less likely to achieve remission. This information could help when stratifying patients for more aggressive therapy

Concomitant medication use and clinical outcome of repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Major Depressive Disorder.

BackgroundRepetitive Transcranial Magnetic Stimulation (rTMS) is commonly administered to Major Depressive Disorder (MDD) patients taking psychotropic medications, yet the effects on treatment outcomes remain unknown. We explored how concomitant medication use relates to clinical response to a standard course of rTMS.MethodsMedications were tabulated for 181 MDD patients who underwent a six-week rTMS treatment course. All patients received 10&nbsp;Hz rTMS administered to left dorsolateral prefrontal cortex (DLPFC), with 1&nbsp;Hz administered to right DLPFC in patients with inadequate response to and/or intolerance of left-sided stimulation. Primary outcomes were change in Inventory of Depressive Symptomatology Self Report (IDS-SR30) total score after 2, 4, and 6&nbsp;weeks.ResultsUse of benzodiazepines was associated with less improvement at week 2, whereas use of psychostimulants was associated with greater improvement at week 2 and across 6&nbsp;weeks. These effects were significant controlling for baseline variables including age, overall symptom severity, and severity of anxiety symptoms. Response rates at week 6 were lower in benzodiazepine users versus non-users (16.4% vs. 35.5%, p&nbsp;=&nbsp;0.008), and higher in psychostimulant users versus non-users (39.2% vs. 22.0%, p&nbsp;=&nbsp;0.02).ConclusionsConcomitant medication use may impact rTMS treatment outcome. While the differences reported here could be considered clinically significant, results were not corrected for multiple comparisons and findings should be replicated before clinicians incorporate the evidence into clinical practice. Prospective, hypothesis-based treatment studies will aid in determining causal relationships between medication treatments and outcome

High-accuracy comparison of numerical relativity simulations with post-Newtonian expansions

Numerical simulations of 15 orbits of an equal-mass binary black hole system are presented. Gravitational waveforms from these simulations, covering more than 30 cycles and ending about 1.5 cycles before merger, are compared with those from quasi-circular zero-spin post-Newtonian (PN) formulae. The cumulative phase uncertainty of these comparisons is about 0.05 radians, dominated by effects arising from the small residual spins of the black holes and the small residual orbital eccentricity in the simulations. Matching numerical results to PN waveforms early in the run yields excellent agreement (within 0.05 radians) over the first $\sim 15$ cycles, thus validating the numerical simulation and establishing a regime where PN theory is accurate. In the last 15 cycles to merger, however, {\em generic} time-domain Taylor approximants build up phase differences of several radians. But, apparently by coincidence, one specific post-Newtonian approximant, TaylorT4 at 3.5PN order, agrees much better with the numerical simulations, with accumulated phase differences of less than 0.05 radians over the 30-cycle waveform. Gravitational-wave amplitude comparisons are also done between numerical simulations and post-Newtonian, and the agreement depends on the post-Newtonian order of the amplitude expansion: the amplitude difference is about 6--7% for zeroth order and becomes smaller for increasing order. A newly derived 3.0PN amplitude correction improves agreement significantly ($<1$ amplitude difference throughout most of the run, increasing to 4% near merger) over the previously known 2.5PN amplitude terms.Comment: Updated to agree with published version (various minor clarifications; added description of AH finder in Sec IIB; added discussion of tidal heating in Sec VC