Smoking Cessation Through Optimisation of Clinical Care in Pregnancy: the STOP randomised controlled trial

This is a pragmatic randomised controlled trial of a dedicated smoking cessation clinic versus routine antenatal care as an intervention to reduce cigarette smoking behaviour. Smoking mothers randomised to the Smoking cessation Through Optimisation of clinical care in Pregnancy (STOP) clinic will have all antenatal care provided by a team comprising an obstetrician, a midwife, and a smoking cessation practitioner. This intervention includes ultrasound screening for fetal growth restriction. The control arm comprises two groups: one receiving standard care with ultrasound screening for fetal growth restriction, and one receiving standard care with ultrasound screening for growth restriction only if clinically indicated by their healthcare provider. Four hundred and fifty women will be recruited and randomised to either intervention or control arms stratifying for age, parity, and history of fetal growth restriction

First Canadian experience with robotic laparoendoscopic single-site vs. standard laparoscopic living-donor nephrectomy: A prospective comparative study

INTRODUCTION: We aimed to compare the outcomes of robotic laparoendoscopic single-site living donor nephrectomy (R-LESS LDN) vs. standard laparoscopic living donor nephrectomy (LLDN). METHODS: Between October 2013 and November 2015, 39 patients were allocated to either standard LLDN (n=25) or R-LESS LDN (n=14). Patient demographics, perioperative outcomes, analgesic requirement, visual analogue scale of pain at postoperative days 1, 3, 7, and 30, and a health-related quality of life and body image questionnaire were prospectively collected. RESULTS: There were no significant differences in demographics and intraoperative outcomes between the two cohorts. The R-LESS LDN cohort had lower analgesic requirement (p=0.002) and lower visual pain scores on days 1 and 3 (p=0.001). Additionally, body image and satisfaction scores in the R-LESS group were also superior compared to the LLDN cohort (p=0.008). There was no significant difference in the postoperative complications according to the Clavien-Dindo system. Recipient graft functional outcomes were equivalent. CONCLUSIONS: This is the first evidence that R-LESS LDN is safe and associated with comparable surgical and early functional outcomes compared to LLDN, while pain, donor body image, and satisfaction scores were improved compared to LLDN

Transplantation of pediatric renal allografts from donors less than 10 kg

Few transplant programs use kidneys from donors with body weight (BW) BW \u3c 10 kg would provide similar transplant outcomes to larger grafts. All pediatric en bloc renal transplants performed at our center between 2001 and 2017 were reviewed (N = 28). Data were stratified by smaller (donor BW \u3c 10 kg; n = 11) or larger donors (BW \u3e 10 kg; n = 17). Renal volume was assessed during follow-up with ultrasound. Demographic characteristics were similar between the 2 groups of recipients. After mean follow-up of 44 months (smaller donors) and 124 months (larger donors), graft and patient outcomes were similar between groups. Serum creatinine at 1, 3, and 5 years was no different between groups. At 1 day posttransplant, mean total renal volume in the smaller donors was 28 +/- 9 mm(3) vs 45 +/- 12 mm(3) (P \u3c .01). By 3 weeks, it was 53 +/- 19 mm(3) (smaller donors) versus 73 +/- 19 mm(3) (larger donors) (P = NS). Complication rates were similar between both groups with 1 case of venous thrombosis in the smaller group. With experience, outcomes are equivalent to those from larger pediatric donors

Late Triassic to Jurassic Magmatic and Tectonic Evolution of the Intermontane Terranes in Yukon, Northern Canadian Cordillera: Transition From Arc to Syn-Collisional Magmatism and Post-Collisional Lithospheric Delamination

End-on arc collision and onset of the northern Cordilleran orogen is recorded in Late Triassic to Jurassic plutons in the Intermontane terranes of Yukon, and in development of the synorogenic Whitehorse trough (WT). A synthesis of the extensive data set for these plutons supports interpretation of the magmatic and tectonic evolution of the northern Intermontane terranes. Late Triassic juvenile plutons that locally intrude the Yukon-Tanana terrane represent the northern extension of arc magmatism within Stikinia. Early Jurassic plutons that intrude Stikinia and Yukon-Tanana terranes were emplaced during crustal thickening (200–195 Ma) and subsequent exhumation (190–178 Ma). The syn-collisional magmatism migrated to the south and shows increasing crustal contributions with time. This style of magmatism in Yukon contrasts with coeval, juvenile arc magmatism in British Columbia (Hazelton Group), that records southward arc migration in the Early Jurassic. Exhumation and subsidence of the WT in the north were probably linked to the retreating Hazelton arc by a sinistral transform. East of WT, Early Jurassic plutons intruded into Yukon-Tanana record continued arc magmatism in Quesnellia. Middle Jurassic plutons were intruded after final enclosure of the Cache Creek terrane and imbrication of the Intermontane terranes. The post-collisional plutons have juvenile isotopic compositions that, together with stratigraphic evidence of surface uplift, are interpreted to record asthenospheric upwelling and lithospheric delamination. A revised tectonic model proposes that entrapment of the Cache Creek terrane was the result of Hazelton slab rollback and development of a sinistral transform fault system linked to the collision zone to the north

Long-term results of protocol kidney biopsy directing steroid withdrawal in simultaneous pancreas-kidney transplant patients

Introduction: We sought to determine whether protocol biopsies could be used to guide treatment and improve outcomes in simultaneous pancreas-kidney (SPK) patients. Methods: Between 2004 and 2013, protocol biopsies were performed on SPK patients at 3–6 months and one year post-transplant. Maintenance immunosuppression consisted of a calcineurin inhibitor, anti-proliferative agent, and corticosteroid. Corticosteroid was withdrawn in negative early biopsies, maintained in subclinical/ borderline biopsies, and increased if Banff IB or greater rejection was identified. Endpoints included presence of interstitial fibrosis and tubular atrophy on biopsy at one year (IF/TA), rejection episodes, and renal and pancreas function at five years’ followup. Results: Forty-one SPK transplant patients were reviewed and a total of 75 protocol biopsies were identified. On early biopsy, 51% had negative biopsies, 44% had borderline rejection, and 5% had subclinical rejection. Renal and pancreas function were not significantly different at one, two, and five years post-transplant between negative vs. borderline early biopsy patients. No difference in the degree of IF/TA was found between these two groups. Conclusions: To our knowledge, this is the first study to evaluate protocol biopsies as an investigative tool prior to steroid withdrawal in SPK patients. Our study suggests that there are no detrimental functional or histological effects at five years post-transplant, despite weaning steroids in the negative biopsy group

Observation Versus Embolization in Patients with Blunt Splenic Injury after Trauma: A Propensity Score Analysis

Background: Non-operative management (NOM) is the standard of care in hemodynamically stable patients with blunt splenic injury after trauma. Splenic artery embolization (SAE) is reported to increase observation success rate. Studies demonstrating improved splenic salvage rates with SAE primarily compared SAE with historical controls. The aim of this study was to investigate whether SAE improves success rate compared to observation alone in contemporaneous patients with blunt splenic injury. Methods: We included adult patients with blunt splenic injury admitted to five Level 1 Trauma Centers between January 2009 and December 2012 and selected for NOM. Successful treatment was defined as splenic salvage and no splenic re-intervention. We calculated propensity scores, expressing the probability of undergoing SAE, using multivariable logistic regression and created five strata based on the quintiles of the propensity score distribution. A weighted relative risk (RR) was calculated across strata to express the chances of success with SAE. Results: Two hundred and six patients were included in the study. Treatment was successful in 180 patients: 134/146 (92 %) patients treated with observation and 48/57 (84 %) patients treated with SAE. The weighted RR for success with SAE was 1.17 (0.94-1.45); for complications, the weighted RR was 0.71 (0.41-1.22). The mean number of transfused blood products was 4.4 (SD 9.9) in the observation group versus 9.1 (SD 17.2) in the SAE group. Conclusions: After correction for confounders with propensity score stratification technique, there was no significant difference between embolization and observation alone with regard to successful treatment in patients with blunt splenic injury after trauma

The interplay between extrinsic and intrinsic factors in determining migration decisions in brown trout (Salmo trutta): An experimental study

Many species are capable of facultative migration, but the relative roles of extrinsic versus intrinsic factors in generating diverse migratory tactics remain unclear. Here we explore the proximate drivers of facultative migration in brown trout in an experimental laboratory setting. The effects of reduced food, as a putative environmental cue, were examined in two populations: one that exhibits high rates of anadromy (sea-migration) in nature, and one that does not exhibit anadromy in nature. Juveniles derived from wild-caught parents were reared for two years under four environmental treatments: low food in years 1 and 2 (Low-Low); high food in years 1 and 2 (High-High), low food in year 1 and high in year 2 (Low-High), and vice versa (High-Low). Food restriction had a significant effect on migratory tactics, with the frequency of smolts (juveniles choosing migration) highest in the Low-Low treatment in both populations. No individuals became smolts in the High-High treatment, and intermediate smolting rates were observed in the Low-High and High-Low treatments. Higher overall smolting rates in the naturally anadromous population suggested an inherited component to anadromy/migration decisions, but both populations showed variability in migratory tactics. Importantly, some fish from the naturally non-anadromous population became smolts in the experiment, implying the capacity for migration was lying ‘dormant’, but they exhibited lower hypo-osmoregulatory function than smolts from the naturally anadromous population. Tactic frequencies in the naturally anadromous population were more affected by food in the 2nd year, while food in the 1st year appeared more important for the naturally non-anadromous population. Migratory tactics were also related to sex, but underpinned in both sexes by growth in key periods, size and energetic state. Collectively these results reveal how migration decisions are shaped by a complex interplay between extrinsic and intrinsic factors, informing our ability to predict how facultatively migratory populations will respond to environmental change

On Secure Workflow Decentralisation on the Internet

Decentralised workflow management systems are a new research area, where most work to-date has focused on the system's overall architecture. As little attention has been given to the security aspects in such systems, we follow a security driven approach, and consider, from the perspective of available security building blocks, how security can be implemented and what new opportunities are presented when empowering the decentralised environment with modern distributed security protocols. Our research is motivated by a more general question of how to combine the positive enablers that email exchange enjoys, with the general benefits of workflow systems, and more specifically with the benefits that can be introduced in a decentralised environment. This aims to equip email users with a set of tools to manage the semantics of a message exchange, contents, participants and their roles in the exchange in an environment that provides inherent assurances of security and privacy. This work is based on a survey of contemporary distributed security protocols, and considers how these protocols could be used in implementing a distributed workflow management system with decentralised control . We review a set of these protocols, focusing on the required message sequences in reviewing the protocols, and discuss how these security protocols provide the foundations for implementing core control-flow, data, and resource patterns in a distributed workflow environment

Results of pancreas transplantation after steroid withdrawal under tacrolimus immunosuppression

Purpose. The results of steroid withdrawal in pancreas transplant recipients under tacrolimus immunosuppression were analyzed. Methods. From July 4, 1994 until April 30, 1998, 147 pancreas transplantations were performed in 141 patients, including 126 simultaneous pancreas-kidney transplantations, 13 pancreas after kidney transplantation, and 8 pancreas transplantations alone. Baseline immunosuppression consisted of tacrolimus and steroids without antilymphocyte induction. Twenty-three patients were excluded from analysis because of early graft loss in 17 cases, retransplantation in 5 cases, and simultaneous pancreas-kidney transplantation after heart transplantation in 1 patient. Results. With a mean follow-up of 2.8±1.1 years (range 1.0 to 4.8 years), complete steroid withdrawal was achieved in 58 (47%) patients with a mean time to steroid withdrawal of 15.2±8 months (range 4 to 40 months after transplantation). Of the entire cohort of 141 patients, overall 1-, 2-, and 4-year patient survival rates were 98%, 95.5%, and 86%, respectively. Overall 1-, 2-, and 4- year graft survival rates were 83%, 80%, and 71% (pancreas) and 95%, 91%, and 84% (kidney), respectively. Of the 124 patients analyzed for steroid withdrawal, 1-, 2-, and 4-year patient survival rates were 98%, 97%, and 92%, respectively. Overall 1-, 2-, and 4-year graft survival rates were 98%, 91.5%, 83% (pancreas) and 97%, 95%, and 91% (kidney). Patient, pancreas, and kidney survival rates at 1 year were 100%, 100%, and 98% (off steroids) versus 97%, 91%, and 96% (on steroids, all NS) and at 4 years were 100%, 94%, and 95% (off steroids) versus 78%, 68%, and 85% (on steroids, P=0.01, 0.002, and NS, respectively). The cumulative risk of rejection at the time of follow-up was 76% for patients on steroids versus 74% for patients off steroids (P=NS). Seven patients originally tapered off steroids were treated for subsequent rejection episodes, which were all steroid sensitive, and two of these seven patients are currently off steroids. Thirteen patients received antilymphocyte therapy for steroid-resistant rejection, five of whom are now off steroids. Tacrolimus trough levels were 9.3±2.4 ng/ml (off steroids) and 9.7±4.3 (on steroids, P=NS). Mean fasting glucose levels were 98±34 mg/dl (off steroids) and 110±41 mg/dl (on steroids, P=NS). Mean glycosylated hemoglobin levels were 5.2±0.9% (off steroids) and 6.2±2.1% (on steroids, P=0.02), and mean serum creatinine levels were 1.4±0.8 mg/dl (off steroids) and 1.7±1.0 mg/dl (on steroids, P=0.02). Conclusion. These data show for the first time that steroid withdrawal can be safely accomplished in pancreas transplant recipients maintained on tacrolimus-based immunosuppression. Steroid withdrawal is associated with excellent patient and graft survival with no increase in the cumulative risk of rejection

Charm and Bottom Semileptonic Decays

We review the present status of theoretical attempts to calculate the semileptonic charm and bottom decays and then present a calculation of these decays in the light--front frame at the kinematic point $q^2=0$. This allows us to evaluate the form factors at the same value of $q^2$, even though the allowed kinematic ranges for charm and bottom decays are very different. Also, at this kinematic point the decay is given in terms of only one form factor $A_{0}(0)$. For the ratio of the decay rates given by the E653 collaboration we show that the determination of the ratio of the Cabibbo--Kobayashi--Maskawa (CKM) matrix elements is consistent with that obtained from the unitarity constraint. At present, though, the unitarity method still has greater accuracy. Since comparisons of the semileptonic decays into $\rho$ and either electrons or muons will be available soon from the E791 Fermilab experiment, we also look at the massive muon case. We show that for a range of $q^2$ the $SU(3)_F$ symmetry breaking is small even though the contributions of the various helicity amplitudes becomes more complicated. For $B$ decays, the decay $B \rightarrow K^{*} \ell \bar{\ell}$ at $q^2=0$ involves an extra form factor coming from the photon contribution and so is not amenable to the same kind of analysis, leaving only the decay $B \rightarrow K^{*}\nu \bar{\nu}$ as a possibility. As the mass of the decaying particle increases we note that the $SU(3)$ symmetry becomes badly broken at $q^2=0$.Comment: Latex, 19 pages, two figures are attached, a minor change in the manuscript related to thi