Uninterrupted Use Research Articles

Abstract 15797: Peri-procedural Use of Novel Anticoagulation Agents During Cardiac Device Implantation

Introduction: The timing of discontinuation and re-initiation of novel anticoagulant agents (NOACs) such as dabigatran, apixaban and rivaroxaban in the peri-procedural setting is important to minimize the risk of stroke and procedure-related bleeding. Methods: Consecutive patients who were on treatment with either dabigatran, rivaroxaban or apixaban and underwent a cardiac device generator change, upgrade or new implantation procedure at two high volume centers were noted (Group A). Age and gender matched patients on warfarin who underwent similar procedures were collected for controls (Group B). Patients were followed for three months for hematoma and other complications. Results: A total of 185 patients in group A underwent above procedures with new device implant in 50%, device upgrade in 23% and generator change in 25% of patients. There were 61 patients on dabigatran, 90 on rivaroxaban, 34 on apixaban in group A and 185 patients on coumadin in group B. Mean age of the total population was 68±12 years with 71% males and 84% Whites with no differences between groups. There were more patients on dual antiplatelet therapy in group A (10%) compared to group B (1%). Mean INR in Group B was 2.1 pre and post procedure. In 3 patients, NOACs were held for 24 to 48 hours prior to the procedure, while they were continued un-interrupted in the rest of the patients. NOACs were resumed after the procedure within 24 hours in all patients except in one patient. There was no difference noted in the incidence of minor or major hematoma in each of these groups (see table). None of the patients in Group A required evacuation. Two patients in Group B developed infection of the hematoma that prompted extraction of the device. No stroke or bleeding related complications were noted in both groups Conclusion: Uninterrupted use of the NOACs is safe in the peri-procedural setting during implantation of cardiac devices. Our study is the first to compare the three NOACs with warfarin.

Commentary on “The Impact of Uninterrupted Warfarin on Hand and Wrist Surgery”

Discontinuation of warfarin-based anticoagulation has been a routine perioperative step for many surgical interventions. The risk of bleeding complications is weighed against the transient increase in the risk of thromboembolism. In surgeries in which laceration or transection of large vessels is a possibility or in invasive procedures in which control of bleeding would be difficult or impossible, the balance between an increased risk of thromboembolism versus uncontrolled or fatal bleeding seems intuitive. In addition, in cases in which hematoma formation is associated with substantial morbidity (eg, compartment syndrome), the tradeoff is not difficult to understand. The Impact of Uninterrupted Warfarin on Hand and Wrist SurgeryJournal of Hand SurgeryVol. 40Issue 11PreviewTo determine the impact of uninterrupted use of warfarin on hand and wrist surgery. Full-Text PDF Letter Regarding “Commentary on ‘The Impact of Uninterrupted Warfarin on Hand and Wrist Surgery’”Journal of Hand SurgeryVol. 41Issue 3PreviewWe appreciate the commentary by Dr. Bryan Chung regarding our paper, “The impact of uninterrupted warfarin on hand and wrist surgery.”1 It is important to note that our study was not designed to quantify the risk of thromboembolic complications attributable to perioperative discontinuation of warfarin. We stress, however, that although the exact incidence of perioperative cerebral vascular accident, myocardial infarction, and venous thrombosis in surgical patients prescribed warfarin is debatable, there is consensus that the risk of these events is heightened when an anticoagulant is discontinued. Full-Text PDF

The Impact of Uninterrupted Warfarin on Hand and Wrist Surgery

To determine the impact of uninterrupted use of warfarin on hand and wrist surgery. This single-center, prospective cohort trial enrolled adult patients undergoing hand and wrist surgery. Between May 2009 and August 2014, 47 surgical patients receiving uninterrupted warfarin (50 procedures) were enrolled and matched as a group by age and procedure type to 48 surgical patients (50 procedures) who were not prescribed warfarin. Complications, defined as bleeding, infection, or wound dehiscence requiring reoperation, were recorded for each group. Surgical outcome measures were composed of objective findings affected by surgical site bleeding (ie, ecchymosis extent, hematoma presence, 2-point discrimination) and standardized patient-rated assessments (Quick-Disabilities of the Arm, Shoulder, and Hand, and visual analog scales: pain and swelling). We collected data preoperatively and at 2 and 4 weeks postoperatively. Statistical analyses contrasted complications and outcomes data between patient groups. One procedure (2%; 95% confidence interval, 0% to 11%) in a patient taking warfarin was complicated by hematoma requiring reoperation resulting from an elevated postoperative international normalized ratio of 5.4. There were no complications among controls (0%; 95% confidence interval, 0% to 7%). At 2 weeks postoperatively, patients receiving warfarin more frequently had hematomas (28% vs 10%) and demonstrated a greater extent of ecchymosis from the surgical incision (50 vs 19 mm). At 4 weeks, no differences existed in hematoma presence or extent of ecchymosis between groups. The incidence of transiently elevated 2-point discrimination was not different between groups (10% warfarin; 6% controls). Visual analog scores for pain and swelling were not significantly different between groups at any time. Differences in Quick-Disabilities of the Arm, Shoulder, and Hand scores between groups did not exceed a minimal clinically important difference. Uninterrupted use of warfarin in patients undergoing surgery of the hand and wrist was associated with an infrequent risk of bleeding complication requiring reoperation. Increased rates of hematoma and ecchymosis in patients taking warfarin normalized by 4weeks postoperatively. Therapeutic II.

TCT-215 Uninterrupted Novel Oral Anticoagulants and Warfarin Use for Peri-procedural Anticoagulation during Atrial Fibrillation Ablation

Uninterrupted warfarin with intra-procedural heparin is a commonly used anticoagulation strategy during atrial fibrillation (AF) ablation to decrease thromboembolic risk. We intended to study if novel oral anticoagulants (NOAC) had comparable efficacy and safety to that of warfarin for AF ablation

Convento di San Francesco a Folloni: the function of a Medieval Franciscan Friary seen through the burials

The Franciscan Friary in Montella near Avellino in Southern Italy is of special interest because according to historical sources it was founded by St. Francis himself in AD 1221–1222. Human remains of several hundred individuals interred in the cloister walk have been unearthed during two excavation campaigns conducted in 2007–2008 and 2010. The environs of the friary have remained rural since the foundation preventing much modern contamination. The state of preservation of the skeletons is fair to good making a suite of analyses worthwhile. The skeletons have been examined anthropologically and tissue samples have been subjected to radiocarbon dating, stable isotope measurements and trace element analyses by Inductively Coupled Plasma Mass Spectrometry and Cold Vapour Atomic Absorption Spectrometry. The radiocarbon dates are consistent with the historical sources and show that the cemetery in the cloister walk has been in uninterrupted use from the foundation of the friary in AD 1221–1222 and until the cemetery went out of use in AD 1524. The anthropological investigations show that the individuals interred at the friary would have been shorter than other Italians from the same time, and it seems that tuberculosis was more prevalent than leprosy. Isotopic measurements show a mixed agricultural and pastoral diet and none of the individuals were consuming marine protein. Based on the trace element analysis it seems that the people resided mainly at two distinct geographical areas, one of which was Montella. One individual stands out from the rest, because he was born and raised at some third geographical location distinct from Montella and because he sports the second oldest radiocarbon date of AD 1050–1249 (two sigma calibrated range). This date is consistent with the first generation of the founders of the friary—perhaps one of St. Francis’ fellow travellers from Assisi.

Suppression of red rot disease by Bacillus sp. based biopesticide formulated in non-sterilized sugarcane filter cake

Red rot disease affects sugarcane production adversely throughout the world. Intensive cropping and uninterrupted use of chemicals results in evolution of new pathotypes which can infect the resistant cultivars. Bacillus sp. inhabiting plant rhizosphere can protect the plants from multiple pathogens. In the present study, two antagonistic strains Bacillus subtilis NH-100 and Bacillus sp. NH-217 were able to maintain their population at 9.0 log CFU g−1 in sugarcane filter cake until nine months. These strains were compatibile to the indigenous bacteria of sugarcane filter cake which maintained their population at 7.8–8.0 log CFU g−1. The developed bioformulation induced the activity of various defense-related enzymes (0.6–6.9 change in absorbance min−1 g−1 of tissue), suppressed the red rot disease and enhanced crop yield under field conditions. This formulation could be used as potential biopesticide to control red rot disease of sugarcane.

Rapid structural condition assessment using radio frequency identification (RFID) based wireless strain sensor

Abstract This paper presents a wireless structural condition scanning system that utilizes the building information modeling (BIM) and radio frequency identification (RFID) based wireless strain sensor technologies to enable non-contact scanning of structural deformation. In buildings, structural members are often hidden behind drywalls, and thus buckling or yielding in steel members are difficult to detect, often requiring removal of coverings and thus time consuming and costly. Fast and accurate assessment of structural conditions is important to the occupant safety and uninterrupted use after extreme load events such as strong earthquakes. BIM can integrate all types of structural and condition assessment information collected in the life cycle of civil structures and also provides the visual data displaying mechanism that makes the structural health monitoring information easily understandable and actionable. Breakage-triggered (BT) strain sensor that uses RFID tag for non-contact scanning of structural deformation condition has been developed to detect the surpass of pre-set strain threshold corresponding to structural damage conditions such as yielding or buckling. This system can rapidly identify the spot where the pre-set strain threshold has been surpassed and the corresponding structural element in the BIM model would be highlighted to provide alert signal to engineers and decision makers.

Diel pattern of fish presence at the Changzhou fishway (Pearl River, China) during the flood season

Summary Restoration of fish populations is required in China with the use of fishways at dammed rivers, but scant biological data is available for their design and operation. The Changzhou fishway (CFW) on the Pearl River is the largest in China, providing a channel for multispecies upstream migrations. This preliminary study used a combination of fish traps and hydroacoustic detection to document the diurnal presence of fish in the CFW, with the purpose of providing essential data for a future, solid performance of this fishway. Eighteen species from a total of 1362 fish individuals were collected in the traps. Three species were dominant, namely, Squaliobarbus curriculus, Pseudobagrus vachellii and Cirrhinus molitorella, altogether sharing proportions of 74.70 and 76.26% in the daytime and nighttime, respectively. Balanced by the up-/downward movements of each fish, they entered the fishway with net numbers of 339.9 ± 113.4 ind.h−1, and exited with net numbers of 234.54 ± 26.66 ind.h−1. In diel fishway use, no significant differences were observed in either species composition or individual size during a diurnal period. Fish presence at the monitored sites within the fishway was recorded primarily during the daytime, showing a particular trend towards crepuscular use at the entrance and an uninterrupted use at the exit. This initial study showed a significant fish presence in the CFW during the flood season; the outcome of the study will be the basis of future research aimed at evaluating the passage efficiency of the CFW and the use thereof in other seasons.

Meta-analysis of continuous oral anticoagulants versus heparin bridging in patients undergoing CIED surgery: reappraisal after the BRUISE study.

Management of patients treated with oral anticoagulation (OAC) requiring a cardiovascular implantable electronic device (CIED) surgery is a challenge that requires balancing the risk of bleeding complications with the risk of thromboembolic events. Recently the approach of performing these procedures while the patient remains with a therapeutic international normalized ratio has gained interest due to several publications showing its relative safety. To evaluate the safety and effectiveness of continuous use of OAC compared with heparin bridging in the perioperative setting of CIED surgery using a meta-analysis. A systematic review of PubMed/MEDLINE, Ovid, and Elsevier databases was performed. Eligible randomized controlled trials and cohort studies were included. The outcomes studied were risk of clinically significant bleeding and of thromboembolic events. Our analysis was restricted to OAC with vitamin K antagonists. Of 560 manuscripts initially considered relevant, seven were included in the meta-analysis, totaling 2,191 patients. Data are reported as odds ratios (ORs) with confidence interval (CI) of 95%. Maintenance of OAC was associated with a significantly lower risk of postoperative bleeding compared with heparin bridge (OR = 0.25, 95% CI 0.17-0.36, P < 0.00001). There was no difference noted in the risk of thromboembolic events between the two strategies (OR = 1.86, 95% CI 0.29-12.17, P = 0.57). Uninterrupted use of OAC in the perioperative of CIED surgery was associated with a reduced risk of bleeding. This strategy should be considered the preferred one in patients at moderate-to-high risk of thromboembolic events.

A glacial cryptic refuge in south‐east Australia: human occupation and mobility from 36 000 years ago in the Sydney Basin, New South Wales

ABSTRACTExcavations across a source‐bordering dune overlooking the Hawkesbury River in north‐west Sydney, Australia, suggest initial occupation of the region by at least 36 ka, with variable but uninterrupted use until the early Holocene; following abandonment, the site was then re‐occupied by ∼3 ka. Along with a handful of other sites, the results provide the earliest reliable evidence of permanent regional populations within south‐eastern Australia, and support a model in which early colonizers followed the coastal fringe with forays along the main river systems. The evidence is consistent with the demographic model of Williams, 2013 (Proceedings of the Royal Society Series B 280: 20130486), which suggested low, but established regional populations before the Last Glacial Maximum (LGM), a population nadir following the LGM and increasing use of the region from ∼12 to 8 ka. The site exhibits increased use at the onset and peak of the LGM, and provides an example of a cryptic refuge as defined by Smith, 2013 (The Archaeology of Australia's Deserts. Cambridge University Press: New York). Specifically, changing artefact densities and attributes show the site was used repeatedly, but for shorter periods through this time, and suggest it formed one of a series of key localities in a point‐to‐point (rather than home‐base) subsistence strategy. This strategy was maintained until the site's abandonment in the early Holocene, despite changing population and climatic conditions through the Terminal Pleistocene.

Levels and determinants of switching following intrauterine device discontinuation in 14 developing countries

ObjectiveTo examine the levels and determinants of switching to any reversible modern contraceptive method following intrauterine device (IUD) discontinuation due to method-related reasons among women in developing countries. Study DesignWe analysed 5-year contraceptive calendar data from 14 Demographic and Health Surveys, conducted in 1993–2008 (n=218,092 women; 17,151 women contributed a total of 18,485 IUD episodes). Life-table methods were used to determine overall and cause-specific probabilities of IUD discontinuation at 12 months of use. For IUD episodes discontinued due to method-related reasons, the probability of switching to another reversible modern method within 3 months was estimated, overall and by place of residence, education level, motivation for use, age category and wealth tertiles. Country-specific rate ratios (RR) were estimated using generalized linear models, and pooled RRs using meta-analyses. ResultsThe median duration of uninterrupted IUD use was 37 months. At 12 months, median probability of discontinuation was 13.2% and median probability of discontinuation due to method-related reasons was 8.9%. Within 3 months of discontinuation due to method-related reasons, half of the women had switched to another reversible modern method, 12% switched to traditional methods, 12% became pregnant, and 25% remained at risk for pregnancy. More educated women were more likely to switch to another reversible modern method than women with primary education or less (pooled RR 1.47; 95% CI 1.10–1.96), as were women in the highest wealth tertile (pooled RR 1.38; 95% CI 1.04–1.83) and women who were limiting births (pooled RR 1.35; 95% CI 1.08–1.68). ConclusionDelays to switching and switching to less reliable methods following IUD discontinuation remain a problem, exposing women to the risk of unwanted pregnancy. Family planning programmes should aim to improve quality of services through strengthening of counselling and follow-up services to support women's continuation of effective methods. ImplicationsThe risk of unintended pregnancy following IUD discontinuation remains high in developing countries. The quality of family planning services may be an important factor in switching to alternative modern contraceptive methods. Service providers should focus on counselling services and follow-up of women to support the continued use of effective methods.

Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate

ObjectivesTo evaluate feasibility, acceptability, continuation, and trough serum levels following self-administration of subcutaneous (sc) depot medroxyprogesterone acetate (DMPA). Study designWomen presenting to a family planning clinic to initiate, restart or continue DMPA were offered study entry. Participants were randomized in a 2:1 ratio to self- or clinician administered sc DMPA 104 mg. Those randomized to self-administration were taught to self-inject and were supervised in performing the initial injection; they received printed instructions and a supply of contraceptive injections for home use. Participants randomized to clinician administration received usual care. Continued DMPA use was assessed by self-report and trough medroxyprogesterone acetate levels at 6 and 12 months. ResultsTwo hundred fifty women were invited to participate, and 137 (55%) enrolled. Of these, 91 were allocated to self-administration, and 90/91 were able to correctly self-administer sc DMPA. Eighty-seven percent completed follow-up. DMPA use at 1 year was 71% for the self-administration group and 63% for the clinic group (p=0.47). Uninterrupted DMPA use was 47% and 48% for the self and clinic administration groups at 1 year (p=0.70), respectively. Serum analyses confirmed similar mean DMPA levels in both groups and therapeutic trough levels in all participants. ConclusionsSixty-three percent of women approached were interested in trying self-administration of DMPA, even in the context of a randomized trial, and nearly all eligible for enrollment were successful at doing so. Self-administration and clinic administration resulted in similar continuation rates and similar DMPA serum levels. Self-administration of sc DMPA is feasible and may be an attractive alternative for many women. ImplicationsSelf-administration of sc DMPA is a feasible and attractive option for many women. Benefits include increased control over contraceptive measures and less time spent on contracepting behaviors. Globally, self-administration has the potential to revolutionize contraceptive uptake by increasing the number of women with access to DMPA.

Rethinking Virtue, Reforming Society: New Directions in Renaissance Ethics, c.1350–c.1650 ed. by David A. Lines and Sabrina Ebbersmeyer (review)

Reviewed by: Rethinking Virtue, Reforming Society: New Directions in Renaissance Ethics, c.1350–c.1650 ed. by David A. Lines and Sabrina Ebbersmeyer Anne-Marie Sorrenti Rethinking Virtue, Reforming Society: New Directions in Renaissance Ethics, c.1350–c.1650, ed. David A. Lines and Sabrina Ebbersmeyer, Cursor Mundi 3 (Turnhout: Brepols 2013) 351 pp. In this volume, the editors and contributors affirm the importance of moral philosophy as a serious discipline in the Renaissance, inherently rejecting Cartesian claims that, because of the rhetorical methodologies employed by humanists, Renaissance philosophy is a misnomer. David Lines’s informative introduction and his articles in the collection focus on the uninterrupted use, from the medieval period to the Renaissance, of Aristotle’s Ethics as the foundational text for the study of moral philosophy in Europe. The contributions in the volume support his view that the commentary tradition existed well into the sixteenth century alongside innovations in methodology, sources, and genre in the teaching of ethics from the age of Petrarch to the mid-seventeenth century. The field of Renaissance ethics is so rich and complex, he claims, because the influx of Platonic, Ciceronian, Stoic, Epicurean, and newly discovered Aristotelian sources was met with attempts to reconcile these various strands of thought with existing Aristotelian commentary, Christian doctrine, and the Bible. In her epilogue, co-editor Sabrina Ebbersmeyer focuses on the displacement of Renaissance ethics in the seventeenth century by the new grounding of moral philosophy on reason, and by the preoccupation with human self-preservation as opposed to the cultivation of personal virtue. The collection is divided into three parts, namely, Contexts, Approaches and Genres, and Themes. In the first part, David Lines and Jill Kraye summarize the sources available from 1350 to 1650 for the study of ethics. In addition to a study of Marsilio Ficino and Lorenzo de’ Medici, they also include analyses of English Aristotelian John Case, Justus Lipsius’s interpretation of Stoic ethics, and Francisco de Quevedo’s reading of Stoic and Epicurean moral thought. These are refreshing and novel contributions in a field that has tended to concentrate on Aristotelianism and Neoplatonism in the Italian context. The second paper, also by David Lines, provides a survey of how and where moral philosophy was taught and discussed throughout Europe, including schools, universities, religious studia (especially of the Dominican order), humanist circles, academies, and courts. He makes the important point that the teaching of ethics became accessible to a much broader audience because of the new appearance of vernacular texts on the topic of ethics and the emergence of new and popular [End Page 317] genres for ethical instruction, including dialogues, poems, and essays. Risto Saarinen’s article concentrates on ethics in the sixteenth century European Reformations, and provides clear analyses of both the Lutheran and Calvinist contexts. He makes the point that while the former concentrates on doctrine and theory, the latter focuses on the practice of ethical living. The second part of the collection includes an important paper by Eckhard Kessler in which he identifies two distinguishing features of Renaissance moral philosophy that set it apart from medieval approaches to the discipline. The first is the new awareness of the contingency involved in making moral judgments. The second is the self-conscious reliance on rhetorical methods that the humanists used to deliberate on these issues. Luca Bianchi, in contrast, argues that the commentary tradition survived well into the sixteenth century. He also acknowledges the co-mingling of different strands of thought and the gradual mutation of the traditional forms of commentary into a much looser and more accessible formats that could be composed in vernacular instead of Latin, and that often include references to literature, poetry, the visual arts, history, contemporary affairs, the New World, and autobiographical details. This is a fitting segue to Ann Moss’ article about the proliferation of the printed commonplace book in the sixteenth century, and its status as a new and widely accessible genre for moral instruction. These handbooks blended short, easily referenced quotes from philosophy, poetry, and the Bible. She also discusses the genesis of the emblem book and its blending of text with image as an enhanced means of communicating on ethical...

Paintball-related ocular trauma: Paintball or Painball?

BackgroundThe aim of this study is to describe the type and severity of paintball-related ocular trauma and to determine the necessary precautions to minimize the risk of ocular injury regardless of whether adequate eye protection was used.Material/MethodsA retrospective chart review identified patients treated for paintball-related ocular trauma at the Ataturk University Medical Hospital from June 2010 through March 2013. A descriptive analysis of data was performed.ResultsTen patients with paintball-related ocular trauma were identified. At the time of their first examination, 7 of these patients had visual acuity (VA) of 20/200 or worse. One patient had a final VA of no light perception and 4 patients had a final VA of 20/200 or worse. Hyphema was noted in 7 patients, traumatic cataract in 2, iridodialysis in 2, retinal detachment in 3, and secondary glaucoma in 1. Six patients required surgery. Although all victims have used eye protection during the game, all patients were injured after they thought the game was over and had taken off their helmets or eye-protective devices.ConclusionsPaintball-related accidents result in serious ocular trauma and most of the patients require surgery. These injuries result in severe loss of VA in some patients. Uninterrupted use of proper eye protection whenever a player is in the game field, even after they believe the game has ended, may reduce the incidence of severe ocular trauma in paintball players.

Multiresource Leveling in Line-of-Balance Scheduling

AbstractLine-of-balance (LOB) methodology produces a work schedule in which resource allocation is automatically performed to provide a continuous and uninterrupted use of resources, but the distribution of resources could be further improved by resource leveling even if multiple resources are involved. The objective of this study is to develop a genetic algorithm (GA)-based multiresource leveling model for schedules that are established by LOB. The proposed model postulates that the production rate and duration of an activity are governed by the resource that requires the longest duration in completing a unit. Once the LOB schedule is established, resource leveling is performed according to the principle of optimum crew size that makes use of a utility data curve, which shows that productivity will suffer if the crew size is different than the optimum crew size, and the principle of natural rhythm that allows shifting the start times of an activity forward or backward at different units of production by ...

Impact of Uninterrupted Use of Clopidogrel on Postoperative Complications After Extracavitary Vascular Surgical Procedures

Impact of Uninterrupted Use of Clopidogrel on Postoperative Complications After Extracavitary Vascular Surgical Procedures

A high-performance neural prosthesis enabled by control algorithm design

Neural prostheses translate neural activity from the brain into control signals for guiding prosthetic devices, such as computer cursors and robotic limbs, and thus offer disabled patients greater interaction with the world. However, relatively low performance remains a critical barrier to successful clinical translation; current neural prostheses are considerably slower with less accurate control than the native arm. Here we present a new control algorithm, the recalibrated feedback intention-trained Kalman filter (ReFIT-KF), that incorporates assumptions about the nature of closed loop neural prosthetic control. When tested with rhesus monkeys implanted with motor cortical electrode arrays, the ReFIT-KF algorithm outperforms existing neural prostheses in all measured domains and halves acquisition time. This control algorithm permits sustained uninterrupted use for hours and generalizes to more challenging tasks without retraining. Using this algorithm, we demonstrate repeatable high performance for years after implantation across two monkeys, thereby increasing the clinical viability of neural prostheses.

Timing of the Initiation of Hydroxyurea and Hematologic Outcomes in Patients with Sickle Cell Disease (SCD)

AbstractAbstract 1004▪▪This icon denotes a clinically relevant abstractHydroxyurea (HU) is approved for use in adults with Sickle Cell Disease (SCD) and increases the production of fetal hemoglobin (HbF). Increased HbF is associated with decreased clinical severity in adults and children with SCD, such as decreased numbers of vaso-occlusive events, transfusions, and hospitalizations. Higher HbF at initiation of HU is predictive of HbF response, but association between age of hydroxyurea initiation and HbF response has not been investigated. We hypothesize that starting hydroxyurea at an early age may improve hematological and clinical response. In order to determine if younger age at hydroxyurea initiation affects the percentage of HbF achieved with hydroxyurea, we conducted a retrospective cohort study. We identified subjects enrolled in the Duke University Medical Center Comprehensive Sickle Cell program who initiated hydroxyurea when they were less than 17.99 years of age and were prescribed hydroxyurea for at least six months. The following data were abstracted from the medical record between December 1996 and April 2011: age, hemoglobin, percentage HbF, and mean corpuscular volume (MCV) at start of HU and at maximum tolerated dose (MTD) of HU therapy. The correlation coefficient and p-values for various parameters were calculated. Seventy-three patients (41 males and 32 females) were included in the analysis. The mean age at hydroxyurea initiation was 5.5 years (1.2–14.1). The mean hydroxyurea dose at MTD was 28.6 ± 3.2 mg/kg/day. At initiation, the mean hemoglobin was 8.2 ± 1.2 g/dL, the mean MCV was 83±7.4 fl and mean HbF was 10 ± 5.7%. At MTD, the mean hemoglobin was 9.4 ± 1.1 g/dL, the mean MCV was 99 ± 11.1 fl, and the mean HbF was 21.7 ± 9.4%. As expected, at MTD, an elevated MCV was correlated with elevated fetal hemoglobin (r2= 0.19, p= 0.0001) [Table 1]. There was a statistically significant relationship between the age at HU initiation and the HbF at MTD (r2= 0.08, p= 0.015) [Figure 1] as well as the age at HU initiation and the hemoglobin at MTD (r2= 0.19, p= 0.016). The relationship between the age at starting HU and the overall change in HbF (DHbF) was not statistically significant (r2= 0.01, p= 0.41). There was not a statistically significant relationship between age at HU initiation and the MTD of HU (r2= 0.003, p= 0.61). The 6 patients started on HU at age less than 2 years (mean 1.5 ± 0.3 years) maintained a mean elevated HbF of 19.1 ± 5% at last documented follow-up with follow-up ranging from 1.4–13 year of uninterrupted hydroxyurea use. Starting hydroxyurea therapy at a younger age appears to improve HbF response as measured at MTD, although there is variability in the level of fetal hemoglobin attained. There is not an association seen with the DHbF or dose at MTD and age at hydroxyurea initiation. In summary, starting hydroxyurea at a younger age, when HbF is >20%, leads to persistence of HbF production and overall improvement in hematological efficacy. This was not simply the result of achieving MTD at a younger age before physiologic decline of HbF. [Display omitted] [Display omitted] Disclosures:Off Label Use: Hydroxyurea for complications of sickle cell disease in pediatrics. Shah:Eisai: Research Funding; Adventrx: Consultancy.

Prescriptive Water Rights in California: An Addendum

other western states, including Utah before and since its interesting 1939 legislation,2 emphasizes the soundness of Mr. Kletzing's conclusions. The issue discussed in most of the western appellate courts is whether the so-called codes, now adopted in some form in every western state, provide an exclusive or only an alternative method for acquiring new water rights by physical diversions of water. On United States lands new water rights are acquired only by appropriation, since according to well-known principles prescriptive rights can never be acquired against the government.3 However, where watercourses traverse private lands, rights may be acquired by prescription in most of the western states. The codes usually provide for filing formal applications, accompanied by maps and engineering data, with some state officer who then holds hearings and grants permits, often on conditions protecting the rights of other water users, present or future. The officer, of course, has the power to deny permits for good cause shown. The majority of the western courts have held that these codes are in the nature of recording acts, giving priority to applicants as of their filing dates regardless of the length of time of use, and are not the exclusive method for acquiring new rights. The continued, open, notorious, exclusive, uninterrupted, and adverse use and enjoyment of the water under a claim of right for the statutory period (in California five years)5 in most western jurisdictions constitutes the perfection of new water rights as of the end of the statutory period. These rights often are not matters of public record and when in question require proof of all the necessary facts to the satisfaction of a court.

Oral candidiasis mimicking an oral squamous cell carcinoma: report of a case

Oral candidiasis is a significant problem in immune-compromised patients. The most common forms of mucosal candidiasis are oropharyngeal, oesophageal and vaginal, and more than 90% of HIV positive persons will manifest at least one episode of oropharyngeal candidiasis. Local and systemic factors such as uninterrupted daily use of a prosthesis by patients, smoking habit, as well as high glucose intake may contribute to the development of the lesion. The aim of this article is to report an uncommon case of oral candidiasis presenting an aggressive clinical behaviour in a 64-year-old male patient, with a significant smoking habit and a medical history of non-controlled diabetes. The lesion affected the hard and soft palate of the right side, revealing erythematous and ulcerated areas, elevated borders and central portions resembling necrosis, mimicking the clinical features of oral squamous cell carcinoma. However, the correct diagnosis of oral candidiasis was obtained after histopathological and cytological examinations and the patient was easily treated with traditional antifungal drugs and correction of his glucose levels.