Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.

Background: National guidelines and standards recommend that stroke survivors be assessed for, and receive rehabilitation. However available data suggests variable practice. Aims: To describe current practice and determinants of rehabilitation assessment and referral following acute stroke in Queensland. Methods: Prospective multi-centre observational cohort study of consecutive patients surviving acute stroke in six Queensland hospitals with acute stroke units. We collected demographics, clinical history, initial stroke impairments, modified Rankin Scale (mRS) (premorbid and 72- hours post stroke), and rehabilitation assessment and referral details. Descriptive statistics were used to quantify assessment and referral patterns. Multivariable logistic regression models were derived to determine predictors of rehabilitation assessment and referral, including age, gender, premorbid conditions, premorbid mRS, 72-hour mRS, early post stroke impairments, and clustering by hospital. Results: Data from the first 205 patients (mean age 72 þ/ 14 years, 42% female) were available. 90% were assessed (inter-site range 68% 100%, p 2) (OR 5.8, CI 1.3, 25.8 p ¼ 0.02). Predictors of referral for rehabilitation were: assessment (OR 104.7, CI 15.4, 711.3 p < 0.001), functional dependence at 72-hours (OR 20.6, CI 6.1, 70.3 p < 0.001) and presence of a cognitive or perceptual deficit (OR 4.0, CI 1.4, 10.9 p < 0.005). Conclusions: Rehabilitation assessment practices vary significantly. Assessment for rehabilitation is the primary determinant of subsequent referral and should be the target for efforts to improve access.

The Mid-Atlantic Regional Association Coastal Ocean Observing System (MARACOOS) is one of the eleven Regional Associations (RAs) comprising the coastal network of the U.S. Integrated Ocean Observing System (US IOOS). MARACOOS involves participants from academia, government, the private sector, and non-profit entities, and covers the ocean and estuaries from Cape Cod, MA to Cape Hatteras, NC.The high quality of MARACOOS-served data is predicated on the quality assurance and quality control (QA/QC) and data flow of the internal and external data streams that MARACOOS makes available through an interactive map/data display (oceansmap.maracoos.org) as well as through THREDDS servers. These data are from (1) High Frequency Radar (HF-Radar), (2) Ocean Gliders, (3) the Advanced Very High Resolution Radiometer (AVHRR) satellite imagery, (4) the Hudson River Environmental Conditions Observing System (HRECOS), and (5) the Maryland Department of Natural Resources (Maryland DNR). This documented and sustained QA/QC elevates MARACOOS-served data to be federally-equivalent a pre-requisite to becoming a certified Regional Information Coordination Entity (RICE), which MARACOOS achieved in December 2016.

Implementation of the recommendations from the Organ Donation Taskforce has introduced for the first time into the UK a nationwide framework for deceased donation. This framework is based, in principle, upon a conviction that donation should be viewed as part of end-of-life care and that the actions often necessary to facilitate it become justified when donation is recognized to be consistent with the wishes and interests of a dying patient. The implementation of the Taskforce recommendations across the complex landscape of acute hospital care in the UK represents a challenging programme of change management that has three more or less distinct phases. This programme has involved first creating and communicating the Taskforce’s vision for donation in the UK, secondly introducing the structural elements of this new framework into hospital practice, and finally creating the environment in which these new elements can deliver the overall programme goals. Implementation has focused heavily upon areas of practice where significant opportunities to increase donor numbers exist. It is recognized that the greatest challenge is to overcome the societal and clinical behaviours and beliefs that currently create barriers to donation. Although national audit data may point to some of these areas of practice, international comparisons suggest that differences in approach to the care of patients with catastrophic brain injury may have a profound influence on the size of the potential donor pool.

Some individuals have rather specific digestive issues. For example, some populations have difficulty digesting dairy products. In the United States, nearly 10% of the population is considered lactose intolerant. Some populations have even higher incidence of intolerance, such as Native Americans, with rates as high as 80% in adults.

The primary aim of the intensive care management of traumatic brain injury (TBI) is to prevent and treat secondary brain injury using a multi-faceted neuroprotective strategy to maintain cerebral perfusion in order to meet the brain’s metabolic demands. Raised intracranial pressure (ICP) is an important cause of secondary brain injury and associated with adverse outcome after TBI. It can be related to intracranial mass lesions, contusional injuries, vascular engorgement, and brain edema. The prevention and control of raised ICP, and maintenance of cerebral perfusion pressure (CPP), are fundamental therapeutic goals after TBI. Despite the absence of class-1 studies, ICP monitoring has developed a prominent role in the management of severe TBI and is recommended by international consensus guidance. It is generally accepted as a relatively low-risk, high-yield, and value for money intervention, although there are wide variations in its application.

Background: Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME. Methods: We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method. Results: Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6–96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39–7.07). Conclusion: Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages.

The yeast Saccharomyces cerevisiae has three cell types distinguished by the proteins encoded in their mating-type (MAT) loci: the a and alpha haploids, which express the DNA-binding proteins a1, and alpha1 and alpha2, respectively, and the a/alpha diploid which expresses both a1 and alpha2 proteins. In a/alpha cells, a1-alpha2 heterodimers repress haploid-specific genes and MATalpha1, whereas alpha2 homodimers repress a-specific genes, indicating dual regulatory functions for alpha2 in mating-type control. We previously demonstrated that the two leucine zipper-like coiled-coil motifs, called alpha2A and alpha2B, in the alpha2 N-terminal domain are important to a1-alpha2 heterodimerization. A unique feature of alpha2B is the occurrence of three atypical amino acid residues at a positions within the hydrophobic core. We have conducted mutational analyses of alpha2B peptides and the full-length protein. Our data suggest that these residues may play a critical role in partitioning of the alpha2 protein between heterodimerization with a1 and homodimerization with itself.

OBJECTIVE Biological products that neutralize tumour necrosis factor alpha (TNF-alpha) are beneficial in rheumatoid arthritis (RA). We studied the effects of CDP870, a novel anti-TNF-alpha antibody fragment modified to obtain a prolonged plasma half-life ( approximately 14 days). METHODS Thirty-six patients were randomized in a double-blind, ascending-dose group study to a single intravenous infusion of placebo (n = 12) or 1, 5 or 20 mg/kg CDP870 (each n = 8). The patients were predominantly female (30/36), had a mean age of 56 yr and a mean duration of RA of 13 years. They had received a mean of five DMARDs or experimental therapies (with 1 month washout before the study started) and had active disease. Continuation of NSAIDs and up to 7.5 mg prednisolone daily was allowed. Following the blinded dosing period, 32 patients received a single open-label infusion of either 5 or 20 mg/kg CDP870. RESULTS In the blinded dosing period, 6/12 placebo patients withdrew from the study (for deteriorating RA < or =4 weeks after dosing). Two of 24 CDP870-treated patients withdrew, both in the 1 mg/kg group (for deteriorating RA or lost to follow up >4 weeks after dosing). The proportion of patients with ACR20 improvement for the per-protocol population with the last observation carried forward was 16.7, 50, 87.5 and 62.5% after 0, 1, 5 and 20 mg/kg CDP870 respectively (combined treatment effect, P = 0.012, primary analysis) at 4 weeks and 16.7, 25, 75 and 75% (P = 0.032) at 8 weeks. The proportion of patients with ACR50 improvement for the per-protocol population with the last observation carried forward was 0, 12.5, 12.5 and 50% after 0, 1, 5 and 20 mg/kg CDP870 respectively (combined treatment effect, P = 0.079) at 4 weeks and 0, 12.5, 12.5 and 50% (P = 0.079) at 8 weeks. Following the open-label dose of CDP870, similar beneficial effects were achieved. CONCLUSION CDP870 is effective, was very well tolerated in this small study, and has an extended duration of action following one or more intravenous doses.