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Difficult Cases (difficult + case)
Selected AbstractsRotation speed and stellar axis inclination from p modes: how CoRoT would see other sunsMONTHLY NOTICES OF THE ROYAL ASTRONOMICAL SOCIETY, Issue 3 2006J. Ballot ABSTRACT In the context of future space-based asteroseismic missions, we have studied the problem of extracting the rotation speed and the rotation-axis inclination of solar-like stars from the expected data. We have focused on slow rotators (at most twice solar rotation speed), first, because they constitute the most difficult case and, secondly, because some of the Convection Rotation and planetary Transits (CoRoT) main targets are expected to have slow rotation rates. Our study of the likelihood function has shown a correlation between the estimates of inclination of the rotation axis i and the rotational splitting ,, of the star. By using the parameters, i and ,,,=,, sin i, we propose and discuss new fitting strategies. Monte Carlo simulations have shown that we can extract a mean splitting and the rotation-axis inclination down to solar rotation rates. However, at the solar rotation rate we are not able to correctly recover the angle i, although we are still able to measure a correct ,,, with a dispersion less than 40 nHz. [source] Optimal parameters in the HSS-like methods for saddle-point problemsNUMERICAL LINEAR ALGEBRA WITH APPLICATIONS, Issue 6 2009Zhong-Zhi BaiArticle first published online: 17 NOV 200 Abstract For the Hermitian and skew-Hermitian splitting iteration method and its accelerated variant for solving the large sparse saddle-point problems, we compute their quasi-optimal iteration parameters and the corresponding quasi-optimal convergence factors for the more practical but more difficult case that the (1, 1)-block of the saddle-point matrix is not algebraically equivalent to the identity matrix. In addition, the algebraic behaviors and the clustering properties of the eigenvalues of the preconditioned matrices with respect to these two iterations are investigated in detail, and the formulas for computing good iteration parameters are given under certain principle for optimizing the distribution of the eigenvalues. Copyright © 2008 John Wiley & Sons, Ltd. [source] The nurse's odyssey: the professional folktale in New Zealand backblocks nurses' stories, 1910,1915NURSING INQUIRY, Issue 2 2009Pamela J WoodArticle first published online: 12 MAY 200 Nurses have a long tradition of storytelling. Nurses in the New Zealand government's Backblocks Nursing Service, established in 1909 for settlers in remote rural areas, related narratives of personal experience in articles, conference papers and letters to their chief nurse that were published in the country's nursing journal. Analysis of the 16 stories published between 1910 and 1915 revealed 14 had a common storyline and structure. Structural elements included a call, arduous journey, arrival and reconnaissance, trial (difficult case or circumstance), resolution and homily. Using a literary folkloristics approach, this article argues that repetition of the story by nurses in different regions traditionalised it as a professional folktale, ,The nurse's odyssey'. It enabled nurses to debrief from difficult cases and write-into-being this new role and practice. Striking differences in the practice setting ensured the story's reportability, while clinical details connected writer and readers through a common professional aesthetic context and strengthened the story's credibility. For the chief nurse who was also a journal editor, publishing the stories allowed her to potentially attract nurses to the service while alerting them to its harsh realities, and show policy-makers the profession's value in meeting new health service needs. [source] An audit of ,equivocal' (C3) and ,suspicious' (C4) categories in fine needle aspiration cytology of the breastCYTOPATHOLOGY, Issue 4 2001R. A. Deb An audit of ,equivocal' (C3) and ,suspicious' (C4) categories in fine needle aspiration cytology of the breast We have audited the frequency of use and outcome of the ,equivocal/atypia probably benign' (C3) and ,suspicious of malignancy' (C4) category for breast cytology in our Unit. A total of 14 935 cytological specimens were reported by at least one of the three pathologists with a special interest in breast pathology, according to five categories of the NHSBSP guidelines for cytology reporting, 1992; 3.7% (555 cases) and 3.9% (587 cases) of cases were classified as equivocal (C3) and suspicious (C4), respectively, giving a total rate (C3 + C4) of 7.6%. Of the C3 cases, 68% were subsequently benign and 32% were malignant. Of the C4 cases, 19% were subsequently benign and 81% malignant. The commonest benign lesions in both categories were fibroadenomas (7.6% of C3 and 19.8% of C4), fibrocystic change (14.3% of C3 and 12.5% of C4), radial scars (6.2% of C3 and 10.4% of C4) and papillomas (6.2% of C3 and 6.3% of C4). Of the malignant lesions (particularly those classified as C3), a high proportion were low grade or special type cancers. The categories of atypia probably benign (C3) and suspicious of malignancy (C4) in breast cytology provide a strategy for classification of problematic or uncertain cases; this maintains the predictive value of the benign (C2) and malignant (C5) categories, and allows separation of these difficult cases into clinically useful groups with differing probabilities of malignancy. [source] Has the education of professional caregivers and lay people in dental trauma care failed?DENTAL TRAUMATOLOGY, Issue 1 2009Ulf Glendor This situation could seriously affect the outcome of TDIs, especially a complicated TDI. The overall aim of this study was to present a review of dental trauma care with focus on treatment and dentists and lay persons' lack of knowledge on how to manage a TDI. A further aim is to introduce the actors involved and the outcome of their education. Material and method:, The databases Medline, Cochrane, SSCI, SCI and CINAHL from the year 1995 to the present were used. Focus was on treatment need, inadequate care, lack of knowledge and poor organization of emergency care. Result:, Studies from different countries demonstrated that treatment needs were not properly met despite the fact that not all untreated teeth needed treatment. Treatment in emergency dental care was often inadequate or inappropriate. With the exception of lay people, teachers, medical personnel and even dentists performed inadequate care. Furthermore, information to the public was insufficient. Despite a low level of knowledge, lay people expressed a strong interest in helping someone with a TDI. Conclusion:, The conclusion from this review is that consideration must be given the problematic results from different studies on education or information about dental trauma care. Despite that the studies reviewed were from different countries and groups of people, the results seem to be consistent, i.e. that a large part of the educational process of professional caregivers and lay people has failed. Too much hope seems to be put on lay people to handle difficult cases such as tooth avulsion. Education of caregivers and lay people is a field where much remains to be explored. [source] Viral meningoencephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 8 2010I. Steiner Background:, Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. Methods:, We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points. Recommendations:, Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Viral encephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 5 2005I. Steiner Viral encephalitis is a medical emergency. The spectrum of brain involvement and the prognosis are dependent mainly on the specific pathogen and the immunological state of the host. Although specific therapy is limited to only several viral agents, correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury in survivors. We searched MEDLINE (National Library of Medicine) for relevant literature from 1966 to May 2004. Review articles and book chapters were also included. Recommendations are based on this literature based on our judgment of the relevance of the references to the subject. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. Diagnosis should be based on medical history, examination followed by analysis of cerebrospinal fluid for protein and glucose contents, cellular analysis and identification of the pathogen by polymerase chain reaction (PCR) amplification (recommendation level A) and serology (recommendation level B). Neuroimaging, preferably by magnetic resonance imaging, is an essential aspect of evaluation (recommendation level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be obtained at the shortest span of time it should be delayed only in the presence of strict contraindications. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. All encephalitis cases must be hospitalized with an access to intensive care units. Supportive therapy is an important basis of management. Specific, evidence-based, anti-viral therapy, acyclovir, is available for herpes encephalitis (recommendation level A). Acyclovir might also be effective for varicella-zoster virus encephalitis, gancyclovir and foscarnet for cytomegalovirus encephalitis and pleconaril for enterovirus encephalitis (IV class of evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective and their use is controversial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Resolution of persistent periapical infection by endodontic surgeryINTERNATIONAL ENDODONTIC JOURNAL, Issue 1 2004F. B. A. Ferreira Abstract Aim, To examine the surfaces of a root tip removed during surgical endodontic treatment for the presence of microorganisms. Summary, The present clinical case illustrates an endodontic retreatment of a maxillary premolar tooth with a fistula and periapical reaction. The case was under treatment for 1 year, during which an intracanal medicament was replaced several times. As the lesion did not decrease and exudate was persistent through the fistula and root canal, root end resection with root end filling was performed. Microbiological samples were collected from the fistula, where Propionibacterium acnes, a species associated with endodontic failures, was detected by appropriate anaerobic technique. The resected root apex was observed by scanning electron microscopy (SEM), which revealed cocci and fungal forms surrounding one of the foramina. After 12 months, the periapical lesion had reduced. Key learning points ,,Persistent extraradicular infections are not affected by the action of antimicrobial agents such as irrigants and medicaments used during root canal treatment. ,,Apical surgery is a suitable alternative for definitive removal of an established refractory infection, promoting repair of difficult cases. [source] Evaluation of SnB for the location of anomalous scattering atoms in SAD/MAD phasingJOURNAL OF APPLIED CRYSTALLOGRAPHY, Issue 6 2003Jun Wang Sixteen existing single-wavelength/multi-wavelength anomalous diffraction (SAD/MAD) data sets with a broad range of crystallographic properties have been used to investigate the various parameters in SnB with the goal of finding the optimum values for locating the positions of anomalous scatterers. The results of the analysis indicate some changes in default parameters that may be useful for non-routine and difficult cases. [source] X-Cell: a novel indexing algorithm for routine tasks and difficult casesJOURNAL OF APPLIED CRYSTALLOGRAPHY, Issue 2 2003Marcus A. Neumann X-Cell is a novel indexing algorithm that makes explicit use of systematic absences to search for possible indexing solutions from cells with low numbers of calculated reflections to cells with high numbers of reflections. Space groups with the same pattern of systematic absences are grouped together in powder extinction classes, and for a given peak number range an independent search is carried out in each powder extinction class. The method has the advantage that the correct cell is likely to be found before the rapid increase of possible solutions slows down the search significantly. A successive dichotomy approach is used to establish a complete list of all possible indexing solutions. The dichotomy procedure is combined with a search for the zero-point shift of the diffraction pattern, and impurity peaks can be dealt with by allowing for a user-defined portion of unindexed reflections. To rank indexing solutions with varying numbers of unindexed reflections, a new figure of merit is introduced that takes into account the highest level of agreement typically obtained for completely incorrect unit cells. The indexing of long and flat unit cells is facilitated by the possibility to search for rows or zones in reciprocal space first and then to use the lattice parameters of the dominant row or zone in the unit-cell search. The main advantages of X-Cell are robustness and completeness, as demonstrated by a validation study on a variety of compounds. The dominant phase of phase mixtures can be indexed in the presence of up to 50% of impurity peaks if high-quality synchrotron data are available. [source] Use of a Long Preshaped Sheath to Facilitate Cannulation of the Coronary Sinus at Electrophysiologic StudyJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 12 2001CHRIS B. PEPPER B.Sc. CS Cannulation Using a Long Sheath. Introduction: Catheterization of the coronary sinus (CS) from the femoral vein can be challenging. We tested whether use of a long preshaped sheath facilitates CS cannulation. Methods and Results: One hundred four patients were randomized into two phases. In phase 1, consecutive patients were allocated to CS catheterization using the long sheath (n = 26) or standard 7-French 15-cm sheath (n = 25). If unsuccessful within 10 minutes, the alternative technique was used. Phase 2 assessed the utility of the long sheath in difficult cases. All patients initially were approached using the standard sheath. If cannulation failed after 10 minutes, patients were randomly allocated to the standard or long sheath approach. In phase 1, the standard approach failed in 4 (16%) of 25 cases. In each case, a long sheath proved successful (mean 3.2 min). The long sheath approach was successful within 10 minutes in all 26 cases. Catheter deployment was significantly quicker with the long sheath, but this was offset by the time required for sheath insertion. In phase 2, the standard approach was successful in 46 (87%) of 53 cases. Of 7 "failures," 3 were randomized to continue the standard approach, which was successful in 1; 4 were randomized to the long sheath approach, and success was achieved in all (mean 4.4 ± 1.5 min). Overall, the CS could not be promptly catheterized in 15% of cases within 10 minutes using the standard sheath, and no failures were seen using the long sheath. No complications arose from the use of either technique. Conclusion: The long sheath was uniformly successful in permitting catheterization of the CS from the femoral approach in both unselected and difficult cases. [source] Human Herpesvirus-8: A Useful Marker for Distinguishing Kaposi Sarcoma and Kaposi Sarcoma-like Pyogenic GranulomaJOURNAL OF CUTANEOUS PATHOLOGY, Issue 1 2005A. Uzieblo Kaposi's sarcoma (KS) is a vascular neoplasm associated with human herpesvirus-8 (HHV-8) infection. On occasion, KS may histologically mimic pyogenic granulomas (PG), a common benign vascular tumor of the skin. Using immunoperoxidase stains, we examined 28 PG and 4 PG-like KS for HHV-8 to determine the specificity of positive staining in this setting. All PG-like KS demonstrated nuclear staining for HHV-8. No staining was identified in any of the PG. Furthermore, histologic criteria often used to differentiate between these two entities were not helpful in difficult cases. The only distinguishing features were the presence/absence of HHV-8 staining and, in some cases, clinical history. The presence of HHV-8 nuclear staining appears to be a specific marker for KS when comparing PG and PG-like KS. Given the lack of distinguishing morphologic criteria, we suggest performing immunoperoxidase stains for HHV-8 on any PG occurring in a clinically atypical setting. [source] Failure to confirm HIV infection in two end-stage HIV/AIDS patients using a popular commercial line immunoassayJOURNAL OF MEDICAL VIROLOGY, Issue 9 2008Julian W. Tang Abstract Immunoassays using either viral lysate (Western blot) or recombinant/synthetic antigen (immunoblot) for anti-HIV capture are still the preferred method to confirm HIV infection. Two cases of HIV-1-infected patients presented with acquired immunodeficiency syndrome (AIDS)-defining illnesses. Laboratory tests were performed using multiple commercial HIV test kits on multiple sera from both patients over several weeks. Both patients were strongly positive on the anti-HIV/p24 antigen combined screening assay. Yet, HIV-1 infection could not be confirmed using a popular commercial immunoassay. Eventually, HIV infection was confirmed using an alternative commercial Western blot assay as well as an HIV quantitative PCR test. In laboratories without nucleic acid testing (NAT) for HIV, indeterminate results may delay confirmation of HIV infection, if commercial line immunoassays alone are available. Some end-stage HIV/AIDS patients may not produce antibodies to specific HIV antigens and may therefore give indeterminant or negative results on some immunoassays, depending on the type of antigen used. This report highlights the utility of having NAT available when diagnosing difficult cases of HIV infection, especially in light of the recent Centers for Disease Control and Prevention move towards more universal, routine, HIV testing. J. Med. Virol. 80:1515,1522, 2008. © 2008 Wiley-Liss, Inc. [source] The King County (Washington) Systems Integration Initiative: A First Look at the Kent District Dual System Youth Pilot ProgramJUVENILE AND FAMILY COURT JOURNAL, Issue 4 2009Gene Siegel ABSTRACT King County is one of five counties in Washington State participating in the John D. and Catherine T. MacArthur Foundation's Models for Change juvenile justice reform initiative. One key aspect of King County's Models for Change participation involves ongoing "systems integration" work intended to improve how youth who have cross-over involvement in multiple systems,e.g., juvenile justice, child welfare, education, mental health, and/or others,are handled. These cross-over cases often present a range of challenges to juvenile courts including substantial risk factors that increase their likelihood of continuing system involvement. This article provides a first look at an emerging pilot project in King County that is intended to improve how cross-over cases are handled by child welfare and juvenile probation with the longer term goal of improving outcomes for these difficult cases. [source] Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforatorsMICROSURGERY, Issue 5 2008BMedSc, PGDipSurgAnat, W. M. Rozen MBBS Preoperative imaging of the donor site vasculature for deep inferior epigastric artery (DIEA) perforator flaps and other abdominal wall reconstructive flaps has become more commonplace. Abdominal wall computed tomography angiography (CTA) has been described as the most accurate and reproducible modality available for demonstrating the location, size, and course of individual perforators. We drew on our experience of 75 consecutive patients planned for DIEA-based flap surgery undertaking CTA at a single institution. Seven of these cases have been reported to highlight the utility of CTA for preoperative planning, emphasizing the unique information supplied by CTA that may influence operative outcome. Among all cases that underwent preoperative imaging with CTA, there was 100% flap survival, with no partial or complete flap necrosis. We found that in three of the cases described, the choice of operation was necessarily selected based on CTA findings (DIEA perforator flap, transverse rectus abdominis myocutaneous flap, and superficial superior epigastric artery flap). In addition, three cases demonstrate that CTA findings may dictate the decision to operate at all, and one case demonstrates the utility of CTA for evaluating the entire abdominal contents for comorbid conditions. Our experience with CTA for abdominal wall perforator mapping has been highly beneficial. CTA may guide operative technique and improve perforator selection in uncomplicated cases, and in difficult cases it can guide the most appropriate operation or indeed if an operation is appropriate at all. This is particularly the case in the setting of comorbidities or previous abdominal surgery. © 2008 Wiley-Liss, Inc. Microsurgery, 2008. [source] Late free-flap salvage with catheter-directed thrombolysisMICROSURGERY, Issue 4 2008Andrew P. Trussler M.D. Introduction: Despite high success rates with free-tissue transfer, flap loss continues to be a devastating event. Flap salvage is often successful if vascular complications are recognized and treated early. However, delayed presentation of flap compromise is an ominous predictor of flap loss. Late free-flap salvage has been described with poor long-term results. Catheter-directed thrombolysis (CDT) has only been described in context with free-tissue transfer in a case of distal bypass salvage. Objectives: The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise. Methods: Two patients underwent highly selective CDT after delayed presentation (>5 days) of flap compromise. Patient 1 is a 59-year-old woman who underwent delayed breast reconstruction with a free TRAM flap and presented with arterial thrombosis 12 days postoperatively. Patient 2 is a 53-year-old man who underwent fibular osteocutaneous free-flap reconstruction of a floor of mouth defect who developed venous thrombosis 6 days postoperatively. Patient 2 underwent two attempted operative anastamotic revisions with thrombectomies and local thrombolysis prior to CDT. Results: The average time of presentation was 9 days, with the average time to CDT being 9.5 days. Patient 1 had an arterial thrombosis, whereas Patient 2 had a venous thrombosis. Both patients underwent successful thrombolysis after super-selective angiograms. Continuous infusions of thrombolytic agents were used in both patients for ,24 h. Average length of stay postCDT was 7 days with no perioperative complications. Long-term follow-up demonstrated complete flap salvage with no soft tissue loss. Conclusion: Despite extremely delayed presentation, aggressive CDT was successful in both breast, and head and neck reconstructions with excellent long-term flap results. CDT appears to be a useful modality in managing difficult cases of free-flap salvage. © 2008 Wiley-Liss, Inc. Microsurgery, 2008. [source] Management of difficult cases in female urology and neurourology at the Reed M. Nesbit society meeting festschrift in honor of Edward J. McGuire, MD,,§NEUROUROLOGY AND URODYNAMICS, Issue S1 2010Jerry Blaivas Abstract This is a panel discussion of seven complex urologic cases in female urology and neurourology. Differences in diagnosis and management are discussed by this international panel of experts. Neurourol. Urodynam. 29:S2,S12, 2010. © 2010 Wiley-Liss, Inc. [source] The nurse's odyssey: the professional folktale in New Zealand backblocks nurses' stories, 1910,1915NURSING INQUIRY, Issue 2 2009Pamela J WoodArticle first published online: 12 MAY 200 Nurses have a long tradition of storytelling. Nurses in the New Zealand government's Backblocks Nursing Service, established in 1909 for settlers in remote rural areas, related narratives of personal experience in articles, conference papers and letters to their chief nurse that were published in the country's nursing journal. Analysis of the 16 stories published between 1910 and 1915 revealed 14 had a common storyline and structure. Structural elements included a call, arduous journey, arrival and reconnaissance, trial (difficult case or circumstance), resolution and homily. Using a literary folkloristics approach, this article argues that repetition of the story by nurses in different regions traditionalised it as a professional folktale, ,The nurse's odyssey'. It enabled nurses to debrief from difficult cases and write-into-being this new role and practice. Striking differences in the practice setting ensured the story's reportability, while clinical details connected writer and readers through a common professional aesthetic context and strengthened the story's credibility. For the chief nurse who was also a journal editor, publishing the stories allowed her to potentially attract nurses to the service while alerting them to its harsh realities, and show policy-makers the profession's value in meeting new health service needs. [source] Three cases of PICU sedation with isoflurane delivered by the ,AnaConDa®'PEDIATRIC ANESTHESIA, Issue 10 2005PETER V. SACKEY MD Summary Prolonged sedation in the pediatric intensive care unit may be difficult because of tolerance, drug dependence and withdrawal, drug interactions and unwanted drug effects. We present three patients sedated with isoflurane via the Anesthetic Conserving Device, AnaConDa®. AnaConDa® is a modified heat and moisture exchanger that allows evaporation and delivery of inhalational anesthetics without an anesthesia machine, vaporizer or adapted ventilator. Two patients with abdominal complications and prolonged sedation for mechanical ventilation were converted to isoflurane sedation for several days. The third patient with refractory status epilepticus received isoflurane to treat epileptiform electroencephalogram activity. Patients weighing 40 and 30 kg were treated with AnaConDa® placed at the Y-piece, while the patient weighing 20 kg was treated with AnaConDa® in the inspiratory limb of the respiratory circuit. Adequate sedation was achieved with endtidal isoflurane concentration of 0.3,0.4%, while antiepileptic effect was achieved at a higher dose, 0.9%. Intravenous sedatives could be reduced or discontinued during isoflurane sedation. Inhaled sedation of isoflurane with AnaConDa® was effective in these patients. It may provide an alternative in difficult cases needing prolonged sedation and should be evaluated further. [source] Coping with Time-Varying Demand When Setting Staffing Requirements for a Service SystemPRODUCTION AND OPERATIONS MANAGEMENT, Issue 1 2007Linda V. Green We review queueing-theory methods for setting staffing requirements in service systems where customer demand varies in a predictable pattern over the day. Analyzing these systems is not straightforward, because standard queueing theory focuses on the long-run steady-state behavior of stationary models. We show how to adapt stationary queueing models for use in nonstationary environments so that time-dependent performance is captured and staffing requirements can be set. Relatively little modification of straightforward stationary analysis applies in systems where service times are short and the targeted quality of service is high. When service times are moderate and the targeted quality of service is still high, time-lag refinements can improve traditional stationary independent period-by-period and peak-hour approximations. Time-varying infinite-server models help develop refinements, because closed-form expressions exist for their time-dependent behavior. More difficult cases with very long service times and other complicated features, such as end-of-day effects, can often be treated by a modified-offered-load approximation, which is based on an associated infinite-server model. Numerical algorithms and deterministic fluid models are useful when the system is overloaded for an extensive period of time. Our discussion focuses on telephone call centers, but applications to police patrol, banking, and hospital emergency rooms are also mentioned. [source] Pleomorphic lobular carcinoma of the breast: role of comprehensive molecular pathology in characterization of an entityTHE JOURNAL OF PATHOLOGY, Issue 1 2005Jorge S Reis-Filho Abstract Immunohistochemical analysis of E-cadherin has changed the way lobular neoplasia is perceived. It has helped to classify difficult cases of carcinoma in situ with indeterminate features and led to the identification of new variants of lobular carcinoma. Pleomorphic lobular carcinoma (PLC) and pleomorphic lobular carcinoma in situ (PLCIS), recently described variants of invasive and in situ classic lobular carcinoma, are reported to be associated with more aggressive clinical behaviour. Although PLC/PLCIS show morphological features of classic lobular neoplasia and lack E-cadherin expression, it is still unclear whether these lesions evolve through the same genetic pathway as lobular carcinomas or are high-grade ductal neoplasms that have lost E-cadherin. Here we have analysed a case of extensive PLCIS and invasive PLC associated with areas of E-cadherin-negative carcinoma in situ with indeterminate features, using immunohistochemistry, chromogenic in situ hybridization, high-resolution comparative genomic hybridization (CGH) and array-based CGH. We observed that all lesions lacked E-cadherin and ,-catenin and showed gain of 1q and loss of 16q, features that are typical of lobular carcinomas but are not seen in high-grade ductal lesions. In addition, amplifications of c-myc and HER2 were detected in the pleomorphic components, which may account for the high-grade features in this case and the reported aggressive clinical behaviour of these lesions. Taken together, these data suggest that at least some PLCs may evolve from the same precursor or through the same genetic pathway as classic lobular carcinomas. Copyright © 2005 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd. [source] Future Uncertainty as a Challenge to Law's Programmes: The Dilemma of Parental DisputesTHE MODERN LAW REVIEW, Issue 4 2000Michael King The article poses the problem of the need for judges to make ,right' decisions. It then describes how judges have attempted to meet this requirement in difficult cases concerning parental disputes over contact with children where there have been allegations of domestic violence. Applying Luhmann's concepts of the legal system, law's function, law's coding and law's programmes (Das Recht der Gesellschaft (Society's Law) 1997), offers a very different perspective on the issue to that of the judiciary or legal commentators who tend to see the issue of the law, determining, with expert help, what is best for the child. Law's function of stabilizing expectations over time obliges it to deal with all matters that come before the courts through the application of ,conditional programmes' and prevents it from applying the ,purpose oriented programmes' of politics and those who see the issue in terms of ideological conflict. [source] Outcomes of the overlay graft technique in tympanoplastyANZ JOURNAL OF SURGERY, Issue 9 2010Jennifer E. Ryan Abstract Background:, This audit was undertaken to review the outcomes achieved with the overlay graft technique of tympanic membrane repair in tympanoplasty surgery. Methods:, The charts of all patients who underwent tympanoplasty, in whom an overlay graft technique of temporalis fascia tympanic membrane repair was used, between 1994 and 2007 were reviewed. Information with respect to patient demographics, presence of cholesteatoma or active infection and perforation size was documented. Details of the surgical procedure and clinical outcomes and pre- and post-operative hearing thresholds were recorded in a computer database. Results:, A total of 147 overlay graft procedures were performed in 130 patients. Graft failure with reperforation occurred following five procedures, for an overall success rate of 96.6%. Eighty Type 1 tympanoplasty procedures were performed in which one failure occurred for a 98.75% success rate. Overlay grafting was combined with intact canal wall mastoidectomy (ICW) in 38 cases and with modified radical mastoidectomy (MRM) in 17 cases for a success rate of 93.8 and 95%, respectively. Delayed graft healing as a result of infection, problems such as epithelial pearl, blunting and myringitis occurred in 39 cases (26.5%). Thirty-one cases underwent procedures for ossicular chain reconstruction, 21 of which were 2nd stage procedures. Hearing outcomes were significantly better with Type 1 tympanoplasty compared with ICW or MRM procedures. Conclusion:, This review demonstrates the overlay graft technique of tympanoplasty to be highly successful for tympanic membrane repair, particularly for the more difficult cases such as revision surgery, subtotal perforations and mesotympanic cholesteatoma. [source] MrBUMP: an automated pipeline for molecular replacementACTA CRYSTALLOGRAPHICA SECTION D, Issue 1 2008Ronan M. Keegan A novel automation pipeline for macromolecular structure solution by molecular replacement is described. There is a special emphasis on the discovery and preparation of a large number of search models, all of which can be passed to the core molecular-replacement programs. For routine molecular-replacement problems, the pipeline automates what a crystallographer might do and its value is simply one of convenience. For more difficult cases, the pipeline aims to discover the particular template structure and model edits required to produce a viable search model and may succeed in finding an efficacious combination that would be missed otherwise. An overview of MrBUMP is given and some recent additions to its functionality are highlighted. [source] Automated search-model discovery and preparation for structure solution by molecular replacementACTA CRYSTALLOGRAPHICA SECTION D, Issue 4 2007Ronan M. Keegan A novel automation pipeline for macromolecular structure solution by molecular replacement is described. There is a special emphasis on the discovery and preparation of a large number of search models, all of which can be passed to the core molecular-replacement programs. For routine molecular-replacement problems, the pipeline automates what a crystallographer might do and its value is simply one of convenience. For more difficult cases, the pipeline aims to discover the particular template structure and model edits required to produce a viable search model and may succeed in finding an efficacious combination that would be missed otherwise. The pipeline is described in detail and a number of examples are given. The examples are chosen to illustrate successes in real crystallography problems and also particular features of the pipeline. It is concluded that exploring a range of search models automatically can be valuable in many cases. [source] 1226: Techniques and complications of anaesthesia for vitreoretinal surgery and a new technique of local anaesthesiaACTA OPHTHALMOLOGICA, Issue 2010K GOMBOSArticle first published online: 23 SEP 2010 Purpose Since the 1970s, the methods of vitrectomy procedures in ophthalmology have changed due to technical developments. Consequently certain procedures are less painful and less time consuming. On the other hand, due the modern technology more difficult cases can be operated, which may result in increase the time and strain of the operation. Methods General anaesthesia (GA) is one possibility, but it may have lots of side effects, can cause serious life threatening complications, is time consuming, expensive and sometimes to organise general anaesthesia leads to delay of the operation, consequently possibly hindering the proper timing of it. Despite these, the GA seemed to be necessary when a longer procedure planned. Results Using our method we could avoid some of the well-known complications of RBA and PBA. Painless operations were provided and the surgeons were satisfied with the anaesthesia. The serum Lidocain level was lower in cRBA compared with the single dose technique. Moreover the presence of postoperative pain could be reduced by using anaesthesia via cannula. Conclusion The benefits and disadvantages of cRBA will be apparent only by the spread of the new technique, which could also contribute to its improvement. This method means a perspective for postoperative pain relief. Hopefully more widespread use of this method helps continuous regional techniques to find their well deserved place in ophthalmic anaesthesia. [source] 1333: OCT: from single use to combined use in macular degenerationACTA OPHTHALMOLOGICA, Issue 2010C CREUZOT Purpose Optical Coherence Tomography (OCT) plays a key role in the diagnosis and the treatment of Age Macular Degeneration (AMD). Authors will present the different signs observed in OCT in exudative AMD. Methods Authors will present clinical cases to illustrate the place of the OCT in AMD diagnosis. OCT has progressively replaced the first-line tool played by angiography especially for the following of the patient once the treatment initiated. The different schemas currently proposed emphasize the role of the OCT combined with visual acuity measurement and fundus examination. Results However, the role of fluorescein and indocyanin green angiography remained essential especially to precise the clinical form before treatment. The combination of OCT and angiography remained a "key association" especially when there is some discrepancy between results or in case of treatment failure to consider another option. It is also the only opportunity for us to understand better the prognosis of these cases under treatment. Conclusion OCT has dramatically changed the supervision of exudative AMD especially during treatment. However, the combination with fluorescein and indocyanin angiograms is highly recommended not only for initial diagnosis but also in difficult cases during follow-up. [source] Clinical application of the multifocal visual evoked potentialCLINICAL AND EXPERIMENTAL OPTOMETRY, Issue 3 2004David P. Crewther PhD Background: Measures of visual function thresholds such as visual acuity and visual fields are generally dependent on subjective responses and assume maintenance of fixation, attention and motivation. In the young, elderly, cognitively impaired or malingering populations, such measures may be inaccurate or difficult to obtain. The Visual Evoked Response Imaging System (VERIS) has been claimed to give more objective topographic recordings of retinal and cortical function. This paper aims to explore the adequacy of this technique in four unusual, unrelated, clinically difficult cases. Methods: Multifocal visual evoked potentials (mfVEPs) recorded on the VERIS System 3.01 are used to assess visual function in four cases with contradictory clinical findings or unreliable subjective responses. Results: Patient 1 had sustained a head injury and had normal ocular and pupil examination but light perception in the right eye and 6/5 acuity in the left. Multifocal VEPs showed a marked depression of the right visual field with little macular response. Patient 2 had sustained a head injury, had a left field hemianopia, possible macular sparing and loss of much of the right field, reduced but variable visual acuities, good near vision and normal ocular fundi. Multifocal VEPs showed a severe depression in both visual fields (L more than R) with little macular response. Patient 3 had a left optic nerve meningioma and experienced great difficulty with visual field assessment. mfVEPs showed a bilateral depression in the superior field particularly the left field, with a larger deficit in the left eye. Patient 4 had unexplained visual acuity and peripheral field deficits. mfVEP results were inconclusive in this case. Discussion: Where there is difficulty performing traditional techniques or conflicting clinical findings, mfVEPs may provide additional objective information to aid in the assessment of patients. [source] | |||||||||||||||||||