Eye-gaze driven surgical workflow segmentation

In today's climate of clinical governance there is growing pressure on surgeons to demonstrate their competence, improve standards and reduce surgical errors. This paper presents a study on developing a novel eye-gaze driven technique for surgical assessment and workflow recovery. The proposed technique investigates the use of a Parallel Layer Perceptor (PLP) to automate the recognition of a key surgical step in a porcine laparoscopic cholecystectomy model. The classifier is eye-gaze contingent but combined with image based visual feature detection for improved system performance. Experimental results show that by fusing image instrument likelihood measures, an overall classification accuracy of 75% is achieved.

Violence and aggression in the emergency department

OBJECTIVE

To investigate the characteristics of incidents of aggression and violence directed towards staff in an urban UK emergency department.

METHODS

A retrospective review of incident report forms submitted over a 1 year period that collected data pertaining to the characteristics of assailants, the outcome of incidents, and the presence of possible contributory factors.

RESULTS

A total of 218 incident reports were reviewed. It was found that the majority of assailants were patients, most were male, and the median age was 32 years. Assailants were more likely to live in deprived areas than other patients and repeat offenders committed 45 of the incidents reported during the study period. The incident report indicated that staff thought the assailant was under the influence of alcohol on 114 occasions. Incidents in which the assailant was documented to have expressed suicidal ideation or had been referred to the psychiatric services were significantly more likely to describe physical violence, as were those incidents in which the assailant was female.

CONCLUSION

Departments should seek to monitor individuals responsible for episodes of violence and aggression in order to detect repeat offenders. A prospective study comprising post-incident reviews may provide a valuable insight into the causes of violence and aggression.

National and international impacts of animal diseases

It is not useful to attempt to estimate the total cost of animal diseases. The impact of animal disease can only be assessed in terms of the costs and benefits of alternative practical disease control policies. The techniques used in animal disease economics are reviewed and their potential value in decision-making discussed. The direct and indirect economic impacts of animal diseases and control programmes are discussed.

Reduced apoptosis of memory T-cells in the inner airway wall of mild and severe asthma

Effector memory T-cells (CD45RO+) may provide pro-inflammatory signals that contribute to the persistent airway inflammation that is characteristic of asthma, and reduced apoptosis of these cells may prolong their effects. The present authors compared apoptosis of CD45RO+ T-cells in the inner airway wall in nonfatal asthma (n = 7), fatal asthma (n = 7) and control (n = 8) cases. Apoptotic cells were identified using both the terminal deoxynucleotidyl transferase dNTP nick end-labelling (TUNEL) technique and cell morphology. The percentage of CD45RO+ T-cells that were apoptotic was significantly greater in control cases compared with nonfatal and fatal cases of asthma, respectively, in small (42+/-19, 16+/-9, 7+/-6%), medium (40+/-12, 15+/-11, 12+/-8%) and large airways (42+/-15, 23+/-18, 18+/-12%). The reduction in the percentage of apoptotic CD45RO+ cells in the cases of asthma was observed in both blood vessels and the interstitium in large airways. In conclusion, these data suggest that reduced apoptosis may prolong the active life of effector memory T-cells in the airways. It is possible that survival signals may be received before cells migrate into the interstitium of the inner airway wall.

Remodelling of airway smooth muscle in asthma: what sort do you have?

BACKGROUND

Shortening of smooth muscle around airways is the basis of symptoms and abnormal lung function in asthma. The airway wall is increased in thickness in small and large airways asthma, in relation to the clinical severity of asthma and the airway smooth muscle layer is the main contributor to this thickening. The relative contributions of more airway smooth muscle cells, bigger cells or more extracellular matrix to the increased thickness of the smooth muscle layer in asthma is not clear and has been examined in only a small number of cases, Studies of the natural history of asthma suggest that the clinical severity of asthma is relatively constant over time, deficits in lung function compared with nonasthmatic subjects occur early in the course of the disease and the decline in lung function with age is increased in asthma.

HYPOTHESIS

The observations from studies of the quantitative pathology and the natural history of asthma might be combined in the hypothesis that the severity of asthma is determined early (in its natural history) and is related mainly to increased volume density of airways smooth muscle cells (hyperplasia) and that later deposition of extracellular matrix from larger, hypertrophic smooth muscle cells results in fixed and increasing deficits in lung function.

SPECULATION

The relative contribution of more smooth muscle cells, bigger cells and extracellular matrix will be determined by unbiased stereological measurements in many cases of asthma of varying severity. The outcomes of such studies will be methods of monitoring and of treatment that will be tailored to the sort of smooth muscle modelling that is present in individual cases.

Observation of turbulent-driven shear flow in a cylindrical laboratory plasma device

An azimuthally symmetric radially sheared plasma fluid flow is observed to spontaneously form in a cylindrical magnetized helicon plasma device with no external sources of momentum input. A turbulent momentum conservation analysis shows that this shear flow is sustained by the Reynolds stress generated by collisional drift turbulence in the device. The results provide direct experimental support for the basic theoretical picture of drift-wave-shear-flow interactions.

Mycophenolic acid 12-h trough level monitoring in renal transplantation: association with acute rejection and toxicity

Studies of renal transplantation utilizing trough plasma level monitoring of mycophenolic acid (MPA) have shown inconsistent associations with toxicity and rejection. In this study, 5600 12-h trough MPA samples from 121 renal transplant recipients immunosuppressed with mycophenolate mofetil (MMF) and tacrolimus in a steroid sparing protocol (steroids for 7 days only) were sequentially analyzed. Higher MPA levels were associated with lower hemoglobin concentrations and anemia (hemoglobin <10 g/dL). Similarly, higher MPA levels were associated with lower total white cell counts and an increased incidence of leucopenia (total white cell count <4.0 x 10(9)/L). Hypoalbuminemia and renal impairment were also associated with hemotoxicity. MMF-associated diarrhea and viral infection were associated with higher MPA levels. Conversely, biopsy-proven acute rejection within the first month post-transplantation was associated with lower MPA levels. Anti-CD25 antibody induction was also associated with reduced rejection rates. No association was seen between MPA levels and platelet count, thrombocytopenia or bacterial infection. An MPA level of 1.60 mg/L early post-transplantation best discriminated patients with and without rejection, and an MPA level of 2.75 mg/L best discriminated patients with and without toxicity later post-transplantation.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Childhood and adolescent anxiety disorders are relatively common, occurring in between 5-18% of all children and adolescents. They are associated with significant morbidity and impairment in social and academic functioning, and when persistent, there is a risk of depression, suicide attempts and substance abuse in adulthood. There is accumulating evidence for the efficacy of cognitive behavioural therapy (CBT), with a number of randomised controlled trials (RCTs) suggesting benefit.

OBJECTIVES

To determine whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention controls.

SEARCH STRATEGY

Search of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register, which includes relevant randomised controlled trials from the bibliographic databases - The Cochrane Library ( to January 2004), EMBASE, (1970-2004) MEDLINE (1970-2004) and PsycINFO (1970-2004). We also searched the references of all included studies and relevant textbooks, and contacted authors in order to identify further trials.

SELECTION CRITERIA

. Each identified study was assessed for possible inclusion by two reviewers independently. Inclusion criteria consisted of randomised controlled trials of CBT versus waiting list/attention controls in children (more than six years of age) and adolescents (under the age of 19 years) with a DSM (Diagnostic Statistical Manual) or ICD (International Classification of Diseases) anxiety diagnosis; and excluding simple phobia, obsessive compulsive disorder and post-traumatic stress disorder. Each study was required to conform to the principles of CBT through use of a protocol and comprising at least eight sessions of CBT.

DATA COLLECTION AND ANALYSIS

The methodological quality of included trials was assessed by two reviewers independently. The dichotomous outcome of remission of anxiety diagnosis was pooled using relative risk (RR) with 95% confidence intervals. Means and standard deviations of anxiety symptom continuous scores were pooled using the standardised mean difference (SMD). Heterogeneity was assessed and intention-to-treat (ITT) analyses undertaken. The presence of publication bias was assessed using funnel plots.

MAIN RESULTS

Thirteen studies with 498 subjects and 311 controls met the inclusion criteria and were included in the analyses. The studies involved community or outpatient subjects only, with anxiety of only mild to moderate severity. ITT analyses showed a response rate for remission of any anxiety diagnosis of 56% for CBT versus 28.2% for controls (RR 0.61,95%CI 0.53 to 0.69), with no evidence of heterogeneity. The number needed to treat (NNT) was 3.0 (95%CI 2.5 to 4.5). For reduction in anxiety symptoms, the SMD was -0.58 (95% CI 0.76 to -0.40) with no significant heterogeneity indicated. Individual, group and family/parental formats of CBT produced fairly similar outcomes.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy appears an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention control. There was no evidence for a difference between an individual, group or parental/family format. CBT can be recommended for the treatment of childhood and anxiety disorders, although with only just over half improving, there is a need for further therapeutic developments.

Tacrolimus Monitoring in Renal Transplantation: A Comparison Between High-Performance Liquid Chromatography and Immunoassay

It is recommended that specific methods of tacrolimus monitoring rather than immunoassays, which overestimate tacrolimus levels, should be used in transplant recipients. Direct comparison of these techniques, however, has not been conducted in renal transplantation. In this study, 40 renal transplant recipients with tacrolimus monitoring by microparticle enzyme immunoassay (MEIA; target trough level 10 to 15 ng/mL) were compared with 40 patients monitored by high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS; target trough level 8 to 13 ng/mL). All patients received anti CD25 antibody induction and mycophenolate mofetil in a steroid-sparing protocol. No differences were seen between MEIA and HPLC-MS groups in patient demographics. All patients were followed for 6 months. Patient survival was 100% in both groups; graft survival was 100% in the MEIA group and 97.5% in the HPLC-MS group. The groups did not differ in the number of dose changes required in the first 6 months or in the number of patients displaying tacrolimus levels within target range at 3 and 6 months. Delayed graft function occurred in 14 patients in the MEIA group and 12 patients in the HPLC-MS group (P = NS). Biopsy-proven acute rejection occurred in four patients in the MEIA group and one patient in the HPLC-MS group (P < .2). No differences were seen for the following parameters at 3 or 6 months: biopsy-proven tacrolimus nephrotoxicity, serum creatinine or estimated creatinine clearance, systolic or diastolic blood pressure, cholesterol, cytomegalovirus disease, posttransplant diabetes, or tremor. This study suggests that renal transplantation with HPLC-MS monitoring of tacrolimus is safe and effective.

Attention deficit hyperactivity disorder and suicide: a review of possible associations

OBJECTIVE

To review the evidence of a possible association between attention deficit hyperactivity disorder (ADHD) and suicide.

DESIGN

We searched the electronic data bases: Medline, Psych LIT, between 1966 and March 2003 looking for articles on ADHD, attention deficit disorder, hyperactivity and suicide.

RESULTS

An association of ADHD and completed suicide was found, especially for younger males. However, the evidence for any direct or independent link was modest with an overall suicide rate from long-term follow-up studies of ADHD of 0.63-0.78%. The estimated relative risk ratio, compared with US national suicide rates (males 5-24 years) is 2.91 (95% confidence interval 1.47-5.7, chi2 = 9.3, d.f. = 1, P = 0.002). ADHD appears to increase the risk of suicide in males via increasing severity of comorbid conditions, particularly conduct disorder (CD) and depression.

CONCLUSION

Identification of those at risk, particularly males with comorbid ADHD, depression and CD, may represent a useful clinical means of reducing completed suicide.

Cochlear implant positioning in children: a survey of patient satisfaction

INTRODUCTION

The past decade has been witness to significant diminution in incision size and placement for pediatric cochlear implantation at our institution. Furthermore, the orientation of the long axis of the implant relative to the skull base plane has generally evolved from a retro-verted to ante-verted direction to accommodate the ear level receiver stimulator and the new minimal access technique.

OBJECTIVE

To characterize the cosmetic, functional and clinical implications of this evolution in cochlear implant positioning by means of a patient satisfaction survey.

METHODS

A survey of patient satisfaction was administered to 100 cochlear implant recipients or their parents. The survey elicits the patient's level of satisfaction with respect to implant position and functional limitations. In addition, the angle formed by the long axis of the implant and the skull base plane (implant angle) was determined from lateral skull radiographs to detect the temporal evolution in implant positioning.

RESULTS

Analysis of the radiographs revealed an implant angle of 65.4-125 degrees in patients implanted prior to 1997, an implant angle of 56.3-87.5 degrees in patients implanted from 1997 to 2001, and an implant angle of 35.1-78.1 degrees after 2002. In spite of this evolution in positioning, the patient satisfaction survey did not reveal any change in incidence of cosmetic, functional or clinical problems.

DISCUSSION

The significant changes in incision and implant positioning represent a technical evolution in pediatric cochlear implant surgery. The fact that patients have been consistently satisfied over time suggests that the cosmetic, functional and clinical implications are minimal.

Two-generation reproductive toxicity study of inhaled tertiary amyl methyl ether (TAME) vapor in CD rats

Under Office of Prevention, Pesticides and Toxic Substances draft guidelines, CD weanling F0 rats (30 of each gender per group) inhaled tertiary amyl methyl ether vapor at 0, 250, 1500 or 3000 ppm 5 days a week and 6 h a day for 10 weeks, with vaginal cytology evaluated for weeks 8-10. The F0 animals then produced F1 offspring, with exposure 7 days a week from mating through to lactation. During the F1 prebreed exposure period, vaginal patency, preputial separation (PPS) and vaginal cytology were evaluated. The F1 animals were mated, with F2 anogenital distance measured on postnatal day zero. At F2 weaning 30 of each gender per group were selected for postwean retention, with no exposures, through vaginal patency and PPS. Body weights, feed consumption and clinical signs were recorded throughout the study. Adult F0 and F1 systemic toxicity was present at 1500 and 3000 ppm. Minor adult male reproductive toxicity was present at 3000 ppm. There were no adult effects on vaginal cyclicity, estrous cycle length, mating, fertility, pregnancy, gestational length or ovarian and uterine weights. There were no treatment-related gross or histopathologic findings in parental male or female systemic or reproductive organs. The F1 and F2 offspring toxicity was present at 1500 and 3000 ppm. The no-observable-adverse-effect level for adult systemic and offspring toxicity was 250 ppm and 1500 ppm for male reproductive toxicity (females at >3000 ppm).

Evaluation of synthetic, M type-specific peptides as antigens in a multivalent group A streptococcal vaccine

The recent development of emm gene sequence-based typing methodology has allowed group A streptococci (GAS) M serotype prevalence data to be determined. This information has been used to identify the components of a multivalent M protein peptide vaccine that could theoretically prevent most of the GAS-mediated diseases in the USA. In this study, we have evaluated in mice the immunogenicity and protective ability of multiple synthetic, M type-specific peptides, derived from the N-termini of three prevalent GAS serotypes (three peptides per serotype, total of nine peptides). At least one peptide, representing each of the three M types tested, was immunogenic. Five of the nine synthetic peptides tested, elicited an immune response in mice, and sera raised against four of the peptides, all possessed functional activity as demonstrated in a bactericidal assay. In vivo nasopharyngeal challenge experiments were carried out with peptides from the M1 (peptide M1-3) and M3 (peptide M3-2) proteins induced in vivo immune protection by reducing intranasal carriage. Reduction in colonization for M1-3 and M3-2 was 90% (P=0.02) and 66% (P<0.17), respectively. A reduction in colonization of 67% (P=0.03) was observed for M3-2 immunized mice when M43, a heterologous serotype, was used as the challenge strain. These results show the utility of synthetic, M type-specific peptides as antigens in a multivalent GAS vaccine.