Manual Research Articles

Deep learning-based cell segmentation for rapid optical cytopathology of thyroid cancer

Fluorescence polarization (Fpol) imaging of methylene blue (MB) is a promising quantitative approach to thyroid cancer detection. Clinical translation of MB Fpol technology requires reduction of the data analysis time that can be achieved via deep learning-based automated cell segmentation with a 2D U-Net convolutional neural network. The model was trained and tested using images of pathologically diverse human thyroid cells and evaluated by comparing the number of cells selected, segmented areas, and Fpol values obtained using automated (AU) and manual (MA) data processing methods. Overall, the model segmented 15.8% more cells than the human operator. Differences in AU and MA segmented cell areas varied between − 55.2 and + 31.0%, whereas differences in Fpol values varied from − 20.7 and + 10.7%. No statistically significant differences between AU and MA derived Fpol data were observed. The largest differences in Fpol values correlated with greatest discrepancies in AU versus MA segmented cell areas. Time required for auto-processing was reduced to 10 s versus one hour required for MA data processing. Implementation of the automated cell analysis makes quantitative fluorescence polarization-based diagnosis clinically feasible.

Preclinical evaluation of semi-automated laser ablation for pulmonary vein isolation: A comparative study.

Visually-guided laser balloon ablation (VGLA) currently requires careful manual rotation of the laser to create overlapping lesions. A novel semi-automated VGLA may reduce ablation times and lesion gaps. We aimed to compare semi-automated (SA) VGLA to that of manual (MN) VGLA. Acute: Nine swine underwent right superior pulmonary vein isolation (PVI) using either SA (n = 3, 13-18 W), MN (n = 3, 8.5-12 W), or radiofrequency (RF, n = 3, 25-40 W) and were killed acutely. Chronic: 16 swine, underwent PVI using either SA (n = 8, 15 W) or MN (n = 8, 10 W), and were survived for 1 month before being killed. All hearts were then submitted for pathological evaluation. Acute: PVI was successful in all 9/9 swine with lesion counts significantly lower in the SA arm(5.3 ± 5.9, 33.7 ± 10.0, and 28.0 ± 4.4 in SA, MN, and RF arms; p = .007 for SA and MN). At necropsy, circumferentiality and transmurality were 98% and 94% in SA, 98% and 80% in MN, and 100% and 100% in RF arms. A single steam pop was noted on sectioning in the SA arm swine and occurred in the high dose (18 W) strategy. Chronic: PVI was acutely successful in 16/16 swine with no difference in PVI durability rates (62.5% vs. 75.0%), lesion transmurality (95.8 ± 17.4% vs.91.9 ± 25.9%), and circumferentiality (95.8 ± 6.6% vs. 94.8 ± 6.3%) between SA and MN arms. Catheter use time and lesion counts were lower in the SA arm compared to the MN arm (11.5 ± 12.7 vs. 21.8 ± 3.8 min, p = .046 and 4.8 ± 3.83 vs. 35.4 ± 4.4, p < .001). Motor-assisted semi-automated laser balloon ablation can improve upon procedural efficiency by reducing ablation time.

Definition of the Region of Interest for the Assessment of Alveolar Bone Repair Using Micro-computed Tomography.

The objective of this study was to evaluate the influence of the extraction socket (distal or lingual root) and the type of region of interest (ROI) definition (manual or predefined) on the assessment of alveolar repair following tooth extraction using micro-computed tomography (micro-CT). The software package used for scanning, reconstruction, reorientation, and analysis of images (NRecon®, DataViewer®, CT-Analyzer®) was acquired through Bruker < https://www.bruker.com > . The sample comprised the micro-CT volumes of seven Wistar rat mandibles, in which the right first molar was extracted. The reconstructed images were analyzed using the extraction sockets, i.e., the distal and intermediate lingual root and the method of ROI definition: manual (MA), central round (CR), and peripheral round (PR). The bone volume fraction (BV/TV) values obtained were analyzed by two-way ANOVA with Tukey's post hoc test (α = 5%). The distal extraction socket resulted in significantly lower BV/TV values than the intermediate lingual socket for MA (P = 0.001), CR (P < 0.001), and PR (P < 0.001). Regarding the ROI, when evaluating the distal extraction socket, the BV/TV was significantly higher (P < 0.001) for MA than for CR and PR, with a lower BV/TV for CR. However, no significant difference was observed for MA (P = 0.855), CR (P = 0.769), or PR (P = 0.453) in the intermediate lingual extraction socket. The bone neoformation outcome (BV/TV) for alveolar bone repair after tooth extraction is significantly influenced by the ROI and the extraction socket. Using the predefined method with a standardized ROI in the central region of the distal extraction socket resulted in the assessment of bone volume, demonstrating the most critical region of the bone neoformation process.

Atlas-based lung segmentation combined with automatic densitometry characterization in COVID-19 patients: Training, validation and first application in a longitudinal study

PurposeTo develop and validate an automated segmentation tool for COVID-19 lung CTs. To combine it with densitometry information in identifying Aerated, Intermediate and Consolidated Volumes in admission (CT1) and follow up CT (CT3). Materials and MethodsAn Atlas was trained on manually segmented CT1 of 250 patients and validated on 10 CT1 of the training group, 10 new CT1 and 10 CT3, by comparing DICE index between automatic (AUTO), automatic-corrected (AUTOMAN) and manual (MAN) contours. A previously developed automatic method was applied on HU lung density histograms to quantify Aerated, Intermediate and Consolidated Volumes. Volumes of subregions in validation CT1 and CT3 were quantified for each method. ResultsIn validation CT1/CT3, manual correction of automatic contours was not necessary in 40% of cases. Mean DICE values for both lungs were 0.94 for AUTOVsMAN and 0.96 for AUTOMANVsMAN. Differences between Aerated and Intermediate Volumes quantified with AUTOVsMAN contours were always < 6%. Consolidated Volumes showed larger differences (mean: −95 ± 72 cc). If considering AUTOMANVsMAN volumes, differences got further smaller for Aerated and Intermediate, and were drastically reduced for consolidated Volumes (mean: −36 ± 25 cc). The average time for manual correction of automatic lungs contours on CT1 was 5 ± 2 min. ConclusionsAn Atlas for automatic segmentation of lungs in COVID-19 patients was developed and validated. Combined with a previously developed method for lung densitometry characterization, it provides a fast, operator-independent way to extract relevant quantitative parameters with minimal manual intervention.

The First Evaluation of Remote Magnetic Navigation-Guided Pediatric Ventricular Arrhythmia Ablation

Catheter ablation (CA) is an important treatment option for ventricular arrhythmias (VA) in pediatric cardiology. Currently, various CA techniques are available, including remote magnetic navigation (RMN)-guided radiofrequency (RF) ablation. However, no studies evaluate RMN-guided ablative therapy outcomes in children with VA yet. This study aimed to compare procedural and long-term outcomes between RMN-guided and manual (MAN)-guided VA ablation in children. This single-center, retrospective study included all CA procedures for VA performed in children with or without structural heart disease from 2008 until 2020. Two study groups were defined by CA technique: RMN or MAN. Primary outcome was recurrence of VA. Baseline clinical, procedural and safety data were also evaluated. This study included 22 patients, who underwent 30 procedures, with a median age of 15 (IQR 14–17; range 1–17) years and a mean weight of 57 ± 20 kg. In total, 14 procedures were performed using RMN and 16 using MAN (22 first and 8 redo procedures). Regarding first procedures, recurrence rates were significantly lower in RMN compared to MAN (20% versus 67%, P = 0.029), at a mean follow-up of 5.2 ± 3.0 years. Moreover, fluoroscopy dosages were significantly lower in RMN compared to MAN [20 (IQR 14–54) versus 48 (IQR 38–62) mGy, P = 0.043]. In total, 20 patients (91%) were free of VA following their final ablation procedure. This is the first study to investigate the use of RMN in pediatric VA ablation. RMN showed improved outcomes compared to MAN, resulting in lower VA recurrence and reduced fluoroscopy exposure.

The first German grammar, intended for Russian students (1713): Language material peculiarities

The article explores the first grammar of the German language, intended for use of Russian students: “Die Deutsche Grammatica, Aus Unterschiedenen Autoribus zusammen gebracht Und Der in Deutschland Studierenden Rußischen Nation zum besten In einem Compendio herausgegeben von Charmyntes”. Peculiarities of the language material presented in the man ual are investigated. Deviations from the traditional German language description scheme are fixed: assignment of three article types; viewing a person as a nominal category, complicat ing system of verb tenses etc. We append the results of the research conducted by K.Koch (2002) and. conclude, that in addition to J.Bödiker’s work directly referred to in the manual, its author was influenced by the works of linguists from “Fruitbearing Society”: K. von Stieler, J.Clajus, and Ch. Gueintz. The author also relied on French grammar by J.R.Pepliers. The article analyzes the textbook illustrative material. Quotations from the Gospel, Psalms, evan gelic hymns, and catechistic literature were often used as examples. However, it also contained a heretical example — mentioning of Lucifer among angels. The latter, possibly, explains the mysterious circumstances of the manual publication. It was issued in Berlin in 1713 without indicating its printing house. The author also hid his real name. We describe its surviving copies in Saint Petersburg and Rostock libraries and conclude, that the work, brought to Rus sia in the first third of the 18th century, was significant for the national tradition of language description.

Read The Feminist Manual

Read The Feminist Manual is a re-appropriation of RTFM (Read The Fucking Man- ual) and addresses gender discrimination in the Free and Open Source Software (FOSS) communities and the lack of support in accommodating marginalized voic- es. The output of the research is an experimental Firefox addon which replaces gendered pronouns he and she with the neutral pronoun they, intended for use with online technical documentation pages, where the programmer is assumed to be a male (he). The project is accompanied by a zine, in which the readers can find information about the inspiration of the project, about the Firefox addon and screenshots of the addon’s implementation in the browser. Along with the proj- ect’s documentation, the zine introduces the significant role of feminist servers in shaping a queer community of sysadmins to nurture gender diversity. Read The Feminist Manual research was realized during the author’s fellowship at the Media Enterprise Design Lab of Boulder University of Colorado.

Advanced partial occlusion controller allows for increased precision during targeted regional optimization in a porcine model of hemorrhagic shock.

Targeted regional optimization (TRO), a partial resuscitative endovascular balloon occlusion of the aorta strategy, may mitigate distal ischemia and extend the window of effectiveness for this adjunct. An automated device may allow greater control and precise regulation of flow past the balloon, while being less resource-intensive. The objective of this study was to assess the technical feasibility of the novel advanced partial occlusion controller (APOC) in achieving TRO at multiple distal pressures. Female swine (n = 48, 68.1 ± 0.7 kg) were randomized to a target distal mean arterial pressure (MAP) of 25 mm Hg, 35 mm Hg, or 45 mm Hg by either manual (MAN) or APOC regulation (n = 8 per group). Uncontrolled hemorrhage was generated by liver laceration. Targeted regional optimization was performed for 85 minutes, followed by surgical control and a 6-hour critical care phase. Proximal and distal MAP and flow rates were measured continuously. At a target distal MAP of 25 mm Hg, there was no difference in the MAP attained (APOC: 26.2 ± 1.05 vs. MAN: 26.1 ± 1.78 mm Hg) but the APOC had significantly less deviance (10.9%) than manual titration (14.9%, p < 0.0001). Similarly, at a target distal MAP of 45 mm Hg, there was no difference in mean pressure (44.0 ± 0.900 mm Hg vs. 45.2 ± 1.31 mm Hg) but APOC had less deviance (9.34% vs. 11.9%, p < 0.0001). There was no difference between APOC and MAN in mean (34.6 mm Hg vs. 33.7 mm Hg) or deviance (9.95% vs. 10.4%) at a target distal MAP of 35 mm Hg, respectively. The APOC made on average 77 balloon volume adjustments per experiment compared with 29 by manual titrations. The novel APOC consistently achieved and sustained precisely regulated TRO across all groups and demonstrated reduced deviance at the 25 mm Hg and 45 mm Hg groups compared with manual titration.

Live Not by Lies: A Man ual for Christian Dissidents. Rod Dreher

Live Not by Lies: A Man ual for Christian Dissidents. Rod Dreher.New York, U.S: Sentinel, 2020, 256 PP.; ISBN 9780593087398;27.00 USD

Arduino system and ultrasonic sensor for automation of the determination of water infiltration rate in soil

The velocity of water infiltration in soil is important for the design of irrigation systems, drainage, septic tanks, sanitary landfills, dams, channels for water distribution, soil and water management to control erosion and estimate surface runoff. Infiltration tests are generally done with rulers and visual reading, which can lead to errors. The present study therefore aimed to determine the Infiltration Velocity (IV) curves of water in the soil by the concentric ring infiltrometer method, using an Arduino microcontroller and an ultrasonic sensor to measure the lowering of the water depth. For that, in the same infiltration test, four readings in Automatic mode (AT) and four readings in Manual mode (MN) were performed simultaneously, in a red-yellow Argisol type soil, in the Areal Basin, located in the southeastern region of Brazil. municipality of Taubaté, Vale do Paraíba, in the state of São Paulo. Adjustments of kostiakov curves and their equations were made from the data obtained in the field, and the values of R² were determined, as well as the values of Basic Infiltration Velocities (BIV), Accumulated Infiltration (AI) and the Average Percentage Error (APE) of the calculated IS values and those estimated by the equations. The results show that the number of readings in the same test time in Automatic mode (AT) was 2.3 times higher than in the manual (MN). All tests showed that the Red-Yellow Argisol showed a high infiltration speed, and in the pasture area the BIV values were 1.9 times higher than those obtained in the forest area. The R² determination coefficients for all curves are 0.99 in all tests and demonstrate the strong correlation between the data. The APE of the calculated and estimated IS values were low, and the biggest discrepancies that occurred were (APE = 0.30%) in the MN - 4 test and (APE = -0.01%) in the AT - 4. APE of MN mode BIVs for AT was 2.7%. These differences in IS values are reflected in the accumulated infiltration (AI) in the soil over time, and in this study the AI of the ATs tests was on average 4.1mm higher than in the MN tests, which corresponds to a difference of 41m³ ha-1. It was concluded that the use of the Arduino microcontroller with the ultrasonic sensor installed in the ring infiltrometer proved to be efficient in the field measurements and made the determination of the accumulated infiltration and the infiltration speed practical, proving to be an economical and technically viable alternative mainly due to the quantity of possible points to collect for each test and the greater reliability added to the low error values when compared to the manual.

Clinical Evaluation of Deep Learning and Atlas-Based Auto-Contouring of Bladder and Rectum for Prostate Radiation Therapy

PurposeAuto-contouring may reduce workload, interobserver variation, and time associated with manual contouring of organs at risk. Manual contouring remains the standard due in part to uncertainty around the time and workload savings after accounting for the review and editing of auto-contours. This preliminary study compares a standard manual contouring workflow with 2 auto-contouring workflows (atlas and deep learning) for contouring the bladder and rectum in patients with prostate cancer. Methods and MaterialsThree contouring workflows were defined based on the initial contour-generation method including manual (MAN), atlas-based auto-contour (ATLAS), and deep-learning auto-contour (DEEP). For each workflow, initial contour generation was retrospectively performed on 15 patients with prostate cancer. Then, radiation oncologists (ROs) edited each contour while blinded to the manner in which the initial contour was generated. Workflows were compared by time (both in initial contour generation and in RO editing), contour similarity, and dosimetric evaluation. ResultsMean durations for initial contour generation were 10.9 min, 1.4 min, and 1.2 min for MAN, DEEP, and ATLAS, respectively. Initial DEEP contours were more geometrically similar to initial MAN contours. Mean durations of the RO editing steps for MAN, DEEP, and ATLAS contours were 4.1 min, 4.7 min, and 10.2 min, respectively. The geometric extent of RO edits was consistently larger for ATLAS contours compared with MAN and DEEP. No differences in clinically relevant dose-volume metrics were observed between workflows. ConclusionAuto-contouring software affords time savings for initial contour generation; however, it is important to also quantify workload changes at the RO editing step. Using deep-learning auto-contouring for bladder and rectum contour generation reduced contouring time without negatively affecting RO editing times, contour geometry, or clinically relevant dose–volume metrics. This work contributes to growing evidence that deep-learning methods are a clinically viable solution for organ-at-risk contouring in radiation therapy.

Early Leaf Removal as a Strategy to Improve Ripening and Lower Cluster Rot in Cool Climate (Vitis vinifera L.) Pinot Grigio

Removal of basal leaves early in the vegetative and reproductive development of grapevines is a tool used to decrease fruit set, lower cluster rot severity, and improve fruit quality. However, the considerable time required for implementation limits its use by grapegrowers. Efficient mechanization can potentially mitigate these issues, albeit this practice has not yet been compared to manual application at prebloom and after-bloom stages in a cool and humid growing region where cluster rot is the major limitation for yield and fruit quality. The goal of this study was to compare mechanical leaf removal (ME) with the manual (MA) removal of six leaves at the prebloom (PB) and after-bloom (AB) phenological stages over two seasons in Pinot Grigio (a tight-clustered cultivar). Fruit set was only decreased in 2017 by MA of six basal leaves at PB (PB-MA); however, PB reduced cluster compactness in each season. The loss of fruit to gray mold was lowered by all leaf removal treatments in the drier 2017 season, but only MA treatments mitigated loss from sour rot in that year. This indicates that a clear fruit zone and reduced cluster compactness are both needed to lower the effect of cluster rot disease. Only PB treatments enhanced fruit quality, likely driven by a similar reduction in cluster compactness. The results suggest that ME at PB may be used to decrease fruit loss to gray mold in dry seasons and enhance fruit Brix. Nevertheless, PB-MA can be an effective means to reduce fruit loss to sour rot in drier seasons and enhance ripening in years with high precipitation during veraison. This information provides a single approach to alleviate two prominent issues facing seasonal management strategies in cool climate viticulture.

Validity of Digital and Manual Refractometers for Measuring Urine Specific Gravity During Field Operations: A Brief Report.

Dehydration can have an immediate negative impact on the performance of Soldiers in training or combat environments. Field expedient methods for assessing hydration status may be valuable for service members. Measurement of urine-specific gravity (USG) via refractometer is inexpensive, simple, fast, and a validated indicator of hydration status. Manual (MAN) and digital (DIG) refractometers are commonly used in laboratory settings however, digital (DIG) devices have not been validated in the field against MAN devices. The purpose of this study was to determine the validity and feasibility of using a DIG refractometer to assess USG compared to a MAN refractometer during a military field training exercise. Fifty-six military service members provided 672 urine samples during two 10-day field training exercises in central Texas. USG was assessed using a MAN and a DIG refractometer with cutoff value of ≥1.020 indicating hypohydration. The study received a non-human research determination. The MAN measurements were strongly correlated with the DIG (r = 0.91, p < 0.0001) measurements. Bland-Altman analysis demonstrated agreement between the refractometers. The DIG displayed good sensitivity (93.9%) and specificity (85.8%) compared to the MAN. The DIG refractometer used in this study was reliable and valid compared with a MAN device and was feasible for use in a field environment; however, the DIG refractometer tended to over overestimate hypohydration.

Remote magnetic catheter navigation versus conventional ablation in atrial fibrillation ablation: Fluoroscopy reduction

BackgroundPercutaneous transcatheter radiofrequency ablation of atrial fibrillation with remote controlled magnetic navigation (RMN) has been shown to reduce radiation exposure to patients and physicians compared with conventional manual (MAN) ablation techniques. MethodsCatheter ablation for atrial fibrillation was performed utilizing RMN in 214 consecutive patients and MAN ablation techniques in 229 patients. We compared the fluoroscopy and procedural times between RMN and MAN catheter ablation of atrial fibrillation. Secondary objectives included comparing acute procedural success and short-term complication rates between both ablation strategies. ResultsFluoroscopy time was significantly shorter in the RMN group than the MAN group (53.5±30.1 vs 68.1±27.6min, respectively; p<0.01); however, the total procedural time was longer in the RMN group (280.2±74.4min vs 213.1±64.75, respectively; p>0.001). Further subgroup analysis of the most recent 50 ablations each from the RMN and MAN groups, to attenuate the RMN learning curve effect, showed an even greater difference in fluoroscopy time (RMN vs MAN: 53.5±30.1 vs 68.1±27.6min), though a consistently longer procedure time with RMN (249.5±65.5 vs 186.3±65.6min, respectively). The acute procedural success rate was comparable between the groups (98.6% vs 95.6%, respectively; p=0.07). The rates of acute complications were similar in both groups (2.3% vs 4.8%, respectively; p=0.16). ConclusionsIn radiofrequency ablation of atrial fibrillation, RMN appears to significantly reduce fluoroscopy time compared with conventional MAN ablation, though at a cost of increased total procedural time, with comparable acute success rates and safety profile. A reduction in procedure and fluoroscopy times is possible with gaining experience.

Evaluation of Travel Time Data Collection Techniques: A Statistical Analysis

Measuring traffic congestion is a key element of Congestion Management Systems (CMS) and is utilized to document traffic information and make decisions regarding existing traffic congestion problems. With the improvement of Global Positioning Systems (GPS) technologies, amongst other Intelligent Transportation Systems (ITS) components, various data collection procedures can be performed more efficiently. This paper examines travel time data collection methods. Data collection approach is introduced and a non-parametric statistical analysis of three different data collection methods, namely GPS, DMI (Distance Measuring Instrument), and MAN (manual), is conducted. The statistical analysis shows that the GPS approach is more consistent in terms of accuracy than the other two methods. The results also indicate that for short travel distances and trips without any delay, the three methods are accepted as being equal with a 95% confidence level. However, segment with different characteristics need to be investigated further through more data collection and analysis.

Improved Electrogram Attenuation during Ablation of Paroxysmal Atrial Fibrillation with the Hansen Robotic System

Robotic catheter ablation aims to improve outcomes after ablation of atrial fibrillation (AF) through improved lesion quality. This study examined electrogram attenuation as a measure of efficacy in response to robotic (ROB) and manual (MAN) ablation. Patients with paroxysmal AF undergoing ablation as part of an ongoing randomized controlled trial were studied (Clinical Trials Registration NCT01037296). Patients underwent pulmonary vein isolation using NavX (St. Jude Medical, St. Paul, MN, USA). Patients were randomized to MAN or ROB catheter ablation using a 3.5-mm irrigated-tip catheter with standardized ablation settings. Bipolar electrogram voltage was measured at 0, 5, 10, 20, and 30 seconds after ablation onset. Distance from ablation lesion to the left atrial surface on NavX were calculated. Similar ablation energy was delivered in ROB and MAN groups, achieving comparable rates of PV isolation (100% vs 98%). The bipolar voltages of 4,434 electrograms from 303 ablation lesions (146 ROB, 157 MAN) were measured. At 30 seconds, signal attenuation was greater in the ROB group than MAN (mean 65 ± 4% vs 55 ± 4% of baseline voltage, P < 0.01). A total of 2,064 NavX ablation lesions were assessed (906 ROB and 1,158 MAN). ROB lesions were on average 0.52 mm further inside the geometry than MAN (P < 0.0001). Robotic ablation results in greater signal attenuation in man. This is achieved despite manual lesions being closer to the left atrial surface. Catheter stability and constant energy delivery may be key to achieving signal attenuation, rather than increased contact force.

Comparison Between Manual and Semiautomated Volumetric Measurements of Pituitary Adenomas

Linear measurements have many limitations. The aim of this study is to compare manual and semiautomated volumetric measurements of pituitary adenomas. Magnetic resonance imaging (MRI) scans of 38 patients with pituitary adenomas were analyzed. Preoperative MRI was acquired on a 1.5 T. MRI volumes of the pituitary adenomas were obtained by two methods: manual (MA) and semiautomated (SA). The concurrent validity for SA and MA methods on 38 patients in the form of correlation coefficient was 0.97 (p < 0.0001). The intraobserver and the interobserver correlation coefficients for SA volumes were both 0.98, as for the intraobserver MA volumes were 0.98. Although the results of both methods are comparable, analysis of volumetric measurements by SA method is more time-efficient than MA segmentation. Precision in volumetric measurement techniques is likely to increase reliability of posttherapeutic monitoring of pituitary adenomas.

A randomized comparison of manual, mechanical and high-impulse chest compression in a porcine model of prolonged ventricular fibrillation

Elevated coronary perfusion pressure (CPP) during CPR is associated with return of spontaneous circulation (ROSC). We compared CPP achieved with three methods of chest compression: manual (MAN), mechanical (MECH) and high-impulse mechanical (HI) in a porcine model of prolonged ventricular fibrillation (VF). We hypothesized that HI (very rapid acceleration of the down-stroke) would produce greater CPPs than MAN or MECH, and that HI would also produce a higher rate of ROSC. Twenty-eight domestic swine (mean 27.8 kg) were randomly assigned to three methods of chest compression. Animals were instrumented under anesthesia, and VF was induced and untreated for 8 min. After 2 min of CPR, epinephrine (adrenaline) (0. 1 mg/kg), vasopressin (40 U) and propranolol (1.0 mg) were administered. CPR continued for three more minutes, after which up to three rescue shocks were delivered. CPP was determined in an automated fashion by measuring the difference between aortic and right atrial pressures 0.1s prior to the down-stroke of each compression (i.e. end-relaxation). ROSC was defined as a systolic pressure greater than 80 mmHg sustained for at least 1 min. We analyzed CPP and ROSC using repeated measures ANOVA and Fisher's exact test. Over the 5 min of CPR, CPP increased more with HI compression than with MAN compression (p=0.017). ROSC was attained in 4/9 MAN, 6/9 MECH and 10/10 HI (HI versus MAN p=0.01). Over the course of CPR, HI compression increased CPP more than MAN compression. HI compression produced a significantly higher rate of ROSC than MAN, but not MECH compression.

Frameworks to Represent Uncertainty when Level of Service is Determined

The introduction of the concept of level of service (LOS) and the process to measure it are important contributions of the Highway Capacity Man ual(HCM). Recently, the usefulness and validity of the LOS categories have been reexamined. One underlying issue is how to handle uncertainty embedded in the definition of LOS, measurement of the flow condition, and matching the measured condition with the LOS categories. HCM suggests the “use of judgment” to handle uncertainty. The aspects of uncertainty involved in LOS analysis are examined, and different approaches to quantify the uncertainty, depending on its nature, are suggested. The truth of the statement “flow condition Xis LOS = Z” is determined by a deterministic, probabilistic, or possibilistic framework, depending on the character of Xand Z For varying combinations of Xand Z, different frames of analysis must be used. Six combinations of types of Xand Zare identified. One extreme is when both X and Zare assumed to be precise; such is the current HCM practice. The other extreme is when the boundaries of Z and X are assumed to be vague. Between these two extremes, four cases are identified, and an appropriate analytical framework is suggested for each. Results indicate that the aspects of uncertainty should be understood and that the mathematical framework selected for analysis should be consistent with the types of uncertainty involved.

Discussion: medical illness and depression

Division of Behavioral Medicine and Consultation Psychiatry, Mount Sinai/New York University Medical Center Recebido 28-02-06 Aprovado 01-03-06 The comorbidity of medical and psychiatric illness presents many dilemmas for psychiatric diagnosis that have not been sufficiently taken into account in either the Diagnostic and Statistical Manu al of Mental Disorders IV – Text Revision (DSM-IV-TR) or the Tenth Revision of International Classification of Diseases (ICD-10) psychiatric section. These lexicons have not considered the confounds that arise with medical and psychiatric comorbidity. For example, vegetative signs of fatigue, change in appetite (increased or decreased), diminished libido, and sleep disturbances (either hypo or hypersomnia) can accompany medical illness, e.g., cardiac disease, or major affective disorders (MAD). DSM states that if a symptom can be attributable to a medical disease it cannot be enlisted to support a psychiatric diagnosis. Because it is so difficult to ascertain symptom attribution, the diagnosis of depression in the medically ill is significantly compromised with comorbidity. Symptom origin can be psychological, medical – somatic, pharmacological, mixed – or indeterminate. Comorbidity then means that there are two systems of diagnoses, two genres of medications to be considered, two disciplines of medical doctors, and two systems of patient care. Since depression is associated with making many medical illnesses worse it is essential that an attempt be made to diagnose this protean disease in the medical setting. For example, it has been shown that depressed patients with a Discussion: medical illness and depression