Journal articles on the topic 'Modified Instrumental Practice'

The study was carried out in 103 patients with psoriasis, who had the consultation of dermatologist and rheumatologist. Answers for 6 questions mPEST (Psoriasis Epydemiology Screening Tool) modified questionnaire were estimated, each positive answer corresponded to 1, PEST ≥ 3 was suggested the presence of psoriatic arthritis (PsA), PEST < 3 was considered the absence of PsA. All the patients were examined by rheumatologist, the gold standard was CASPAR (ClASsification criteria for Psoriatic Arthritis) criteria. If necessary the instrumental tests were performed: roentgenography, ultrasound examination, magnetic resonance imaging (MRI) and laboratory tests. At PEST ≥ 3 diagnosis of PsA was suspected in 60 (58.2%) of 103 patients. Diagnosis of PsA was confirmed by CASPAR criteria in 47 (45.6%) patients. mPEST less than 3 was in 43 (41.7%) of 103 patients. Diagnosis of PsA was absent by CASPAR criteria in 29 (67.4%) patients. Newly diagnosed PsA was in 32 (52.4%) of 61 patients. Any rheumatic disease, mainly PsA, can develop with psoriasis. mPEST questionnaire in most cases reveals PsA in early stage, however, its isolated use is insufficient to establish an accurate diagnosis, it requires a clear diagnostic algorithm of the disease, including consultation of rheumatologist, clinical and instrumental examination.

Tardive dyskinesia is a potentially irreversible, debilitating, hyperkinetic movement disorder that can result from dopamine receptor antagonists. Prompt recognition and resolution of symptoms are instrumental in preventing disease irreversibility, though current treatment options have fallen short of robust, effective, and long-term symptom control. In April 2017, the Food and Drug Administration (FDA) approved 2 new vesicular monoamine transporter 2 (VMAT2) inhibitors, deutetrabenazine and valbenazine, for chorea related to Huntington’s disease and tardive dyskinesia, respectively. These agents were pharmacologically modified from tetrabenazine, a VMAT2 inhibitor used off-label in the treatment of tardive dyskinesia. Despite FDA-labeled indications of deutetrabenazine and valbenazine, each agent was explored as a treatment option for those with tardive dyskinesia. In this study, the pharmacologic modifications of the 2 new VMAT2 inhibitors are described, with detailed explanation as to how these may impact clinical practice. The associated case series, observational studies, and clinical trials exploring their use in the treatment of tardive dyskinesia are reported with expert opinion on practice implication.

Objective To investigate the correlations between clinical, functional, and radiological outcomes in inpatients with coronavirus disease 2019 (COVID-19). Methods In this observational study, we recruited inpatients affected by moderate COVID-19 disease. The clinical evaluation comprised the Cumulative Illness Rating Scale (CIRS), numerical rating scale (NRS), modified Rankin scale (mRS), and the modified Borg dyspnea scale (mBDS). Respiratory involvement was assessed with computed tomography (CT) and graded with a CT-severity score (CT-SS). We retrospectively assessed functioning using the International Classification of Functioning, Disability and Health (ICF) codes of the Clinical Functioning Information Tool (ClinFIT) COVID-19 in the acute phase. Correlation analysis was performed 1) between clinical, instrumental, and functional parameters and 2) between ICF categories. Results The data showed statistically significant moderate correlations between CT-SS and the following categories: b152 “emotional functions” and b440 “respiratory functions”. Conclusion This is the first study to use the ICF framework in people with a moderate form of COVID-19 in the acute phase. Considering the correlations between some ICF categories and radiological findings, our results support the use of the ClinFIT COVID-19 for a comprehensive assessment of COVID-19 patients.

One of the important characteristics of the surface properties of metal parts subjected to friction is hardness. Hardness measurements are important for determining the operational characteristics of parts and monitoring the technological regimes of surface modification. However, hardness measurements of thin modified layers made by different methods can lead to differences in measurement results. The aim of the article was to study the hardness of a metal surface modified with ultrafine particles of minerals by two different methods (instrumental indentation and Vickers hardness measurement) and a comparative analysis of the measurement results obtained by these methods.Standard Vickers hardness measurements at loads of 0.025, 0.1 and 0.5 kgf showed a qualitative difference between the hardness values of the two samples modified with different mixtures of ultrafine particles of minerals and a large heterogeneity of the hardness values over the area. By the method of instrumental hardness, standard measurements were performed without preliminary selection of the indentation site (at a load of 1.05 N) and measurements during indentation into even sections (at low loads of 10 mN).It is noted that the high precision of measurements implemented by instrumental indentation, due to the large roughness of the samples, leads to large values of the error in calculating the measurement results. An additional difference in the results of measurements performed by two methods at shallow indentation depths may be due to the fact that the object under study has a complex structure consisting of a metal matrix and particles distributed over the depth of the sample. A possible way out of the situation lies in the transition from the use of hardness measures when calibrating instruments to standard samples of properties for which the constancy of mechanical properties in the measured range of indentation depths will be ensured, but which are not yet available in research practice. Therefore, at present, when carrying out work related to the search for optimal conditions for obtaining thin wear-resistant layers on the surface of metals modified with ultrafine particles of minerals, comparative measurements performed by one measurement method are recommended.

Objective: to evaluate clinical and instrumental characteristics of axial lesion in psoriatic arthritis (PsA) in real-life clinical practice.Subjects and methods. Examination were made in 52 patients (32 men and 20 women) with back pain recorded either at the time of their admission or in their medical histories. The inflammatory back pain (IBP) was diagnosed according to the Assessment of SpondyloArthritis international Society (ASAS) criteria. Back pain lasting over three months without meeting the ASAS criteria was taken to be chronic back (chrBP). Hands, feet, pelvis, cervical spine (CSP) and lumbar spine (LSP) were X-rayed. Erosions, osteolysis, and periarticular osteo-proliferative lesions were evaluated applying PsA-modified Sharp/van der Heijde score (SHS). Sacroiliitis (SI) was considered radiologically significant (r-sSI) when it was bilateral grade II or higher, or unilateral grade III or higher by Kellgren. 15 patients without r-sSI had their sacroiliac joints (SIJs) scanned using magnetic resonance imaging (MRI). Syndesmophytes, paravertebral ossifications, constriction and ankylosis of the CSP zygapophysial joints were considered to be radiological signs of psoriatic spondylitis. HLA-B27 typing was performed in 45 patients.Results and discussion. IBP was identified in 34 (66.7%), chrBP in 17 (33.3%) patients; 15 patients (28.8%) were of advanced age (over 40) at the onset of IBP/chrBP; 30 cases (57.7%) had r-sSI; in 18 cases SI was not detected. 13 out of 30 r-sSI patients (43.3%) didn’t suffer IBP. Erosions were detected in 38 (76%) patients, osteolysis in 13 (26%) and osteo-proliferative lesions in 18 (36%) patients. Average SHS was 82.79±64.77 correlating with the presence of r-sSI (r=0,46; p<0,05). Correlation of r=0.35 was found between r-sSI and the spine limited mobility according to Bath Ankylosing Spondylitis Metrology Index (BASMI); r-sSI was detected with much higher statistical significance in the presence of periarticular osteo-proliferative lesions than in the absence of such (р=0.02). In PsA patients having periarticular osteolysis, axial lesion in the form of asymmetric syndesmophytes was detected ten times more frequently than in those not having it (OR=10; 95% CI: 1.63–61.327). In CSP, syndesmophytes developed two times more frequently than in LSP (p=0.01). Discrete CSP lesions in the absence of any LSP changes was observed in 30% of cases. SI was MRI detected in 2 (13.3%) patients. In 9 (18.0%) patients axial lesions were observed without SI. 15 patients (33.3%) were HLA-B27 positive. A set of specific PsA axial skeletal involvement features were revealed: possibility of oligosymptomatic clinical presentation; patient’s advanced age at the back pain onset; association with severe destructive peripheral arthritis; and more pronounced CSP lesions as compared to LSP. An alternative phenotype patient group (18%) without X-ray or MRI SI but with spine involvement was identified. Key words: psoriatic arthritis; axial lesion>˂ 0,05). Correlation of r=0.35 was found between r-sSI and the spine limited mobility according to Bath Ankylosing Spondylitis Metrology Index (BASMI); r-sSI was detected with much higher statistical significance in the presence of periarticular osteo-proliferative lesions than in the absence of such (р=0.02). In PsA patients having periarticular osteolysis, axial lesion in the form of asymmetric syndesmophytes was detected ten times more frequently than in those not having it (OR=10; 95% CI: 1.63–61.327). In CSP, syndesmophytes developed two times more frequently than in LSP (p=0.01). Discrete CSP lesions in the absence of any LSP changes was observed in 30% of cases. SI was MRI detected in 2 (13.3%) patients. In 9 (18.0%) patients axial lesions were observed without SI. 15 patients (33.3%) were HLA-B27 positive. A set of specific PsA axial skeletal involvement features were revealed: possibility of oligosymptomatic clinical presentation; patient’s advanced age at the back pain onset; association with severe destructive peripheral arthritis; and more pronounced CSP lesions as compared to LSP. An alternative phenotype patient group (18%) without X-ray or MRI SI but with spine involvement was identified.

Aceclofenac (ACL) is an anti-inflammatory drug, which is taken by patients who mainly suffer from rheumatoid conditions. In this work, we propose a new voltammetric method that allows the determination of ACL in pharmaceutics, urine, and plasma. As a working electrode, a glassy carbon electrode (GCE) modified with carbon nanofibers, carbon nanotubes, and NiCo nanoparticles (eCNF/CNT/NiCo-GCE) was used. The mentioned sensors are characterized by good repeatability and sensitivity, and their process of preparation is simple, fast, and cost-effective. Instrumental and method parameters were optimized, and the influence of interferences was investigated. To validate the analytical performance of the method, calibration was conducted. Good linearity was obtained (0.05–1.4 µM, r = 0.998), as well as excellent limit of detection (LOD) and limit of quantification (LOQ) values (0.7 nM and 2.1 nM, respectively). Calculated recoveries that were in the range of 98%–105% indicate that this method is accurate and might be used in routine laboratory practice.

Fibromyalgia is a disease that remains unrecognized due to ignorance and misinterpretation of symptoms. This article presents a clinical case from the medical practice of Fibromyalgia, while characterizing the pain syndrome and the necessary tests to prove the diagnosis. The clinical case concerned a patient with lumbar pain syndrome who did not respond to non-steroidal anti-inflammatory drugs. No connection has been established with the diseases provided for in the differential diagnosis, such as disc herniation, acute arterial insufficiency, rheumatoid arthritis. The laboratory tests performed are normal, except for a slight increase in AST of about 200 U / l, as well as high CRP values. No instrumental studies such as endophotonic emission computed tomography (SPECT), positron emission tomography (PET), magnetic resonance imaging (MRT) and electroencephalogram (EEG) were performed. The case describes a modified symptom in the elderly. Modified symptoms are experienced differently by patients. In this case, our own (from the doctor’s experience) paradigm was used for diagnosis. The paradigm consists of four main steps, which are: description of the specifics of each symptom; two aspects of the diagnosis: what is and what is not; the symptoms form a whole which represents the diagnosis with a logical connection and sequence and analysis of small deviations and nuances - a way of accurate diagnosis. The burning nature of the pain, the presence of painful nodules in the lumbar and scapular areas bilaterally, point to myositis. Various non-steroidal anti-inflammatory drugs have been administered in various forms (oral, topical and injectable), with no effect. As a last resort, a tricyclic antidepressant, amitriptyline, was included, which showed that the pain disappeared within a month. The presence of a mental component in the field of rheumatic disease, the effect of amitriptyline pain and the presence of sore spots at the predilection sites, led to the disease “Fibromyalgia”. Diagnosis of fibromyalgia is necessary to comply with two conditions clinical analysis of pain with the detection of painful points and instrumental nuclear magnetic resonance imaging to demonstrate dysfunction of the central nervous system and electroencephalogram for sleep disorders. To improve the diagnostic process, it is necessary in practice to apply tests of hormones and neurotransmitters.

18565 Background: In order to describe the elderly population in Institut Curie and to determine if a brief multidimensional assessment may influence our decision to treat elderly patients with cancers we decided to realize a short assessment for each patient, 70 years and older. In a prospective study we evaluated such diverse areas as functional status, comorbidity, nutrition, polypharmacy and the presence or absence of geriatric syndromes. Methods: We studied 105 elderly cancer patients, median age 80 years with solid tumors. In addition to PS, their physical function was assessed by the activity of daily living (ADL) and instrumental activity of daily living (IADL) scales. During consultation comorbidities, Geriatric depression scale (GDS), the number of falls in the past year, concomitant medications, weight measurements and social environment were collected in a questionnaire. Cognitive functions were assesed if troubles were suspected. Blood tests were performed secondary. Results: To date 105 patients were evaluated : 10 % live in institution, 16% have no social environment, 35 % have a loss of autonomy in ADL and 7% were dependant. In the IADL: 30% presented a loss of autonomy and 24% were dependant. The median Body Mass Index (BMI) was 23.8 kg/m2, but the BMI was in 14% < 19kg/m2; 20% of the patients fall more than 2 times in the year and 53% have a suspicion of depression in the GDS in 4 items. 74% take more than 3 drugs per day. The median of comorbidities was 1.3. According to the results the decision of treatment was modified in 28% of patients. Conclusion: This questionnaire is not a replacement for the entire Comprehensive Geriatric assessment but is a reasonable prescreening instrument that may be performed in less than 15 minutes and be helpful to the clinician in his decision. No significant financial relationships to disclose.

Objective. To optimize a pelvic and lower abdominal cavity MRI protocol in the diagnosis of chronic pelvic pain (CPP) in women.Material and methods. A total of 57 reproductive-aged women with complaints of CPP were examined. The first stage of all patients after clinical and laboratory examination for clinical indications was performed ultrasound of the pelvis and abdominal cavity with dopplerometry. In the second stage, all the patients underwent an MRI using the standard Protocol, and then a modified Protocol. The final diagnosis was based on the results of a comprehensive examination, which included a clinical and neurological examination, gynecological examination, pelvic and abdominal ultrasound, radiography of the ileosacral joints and lumbosacral spine, fibrocolonoscopy and laparoscopy with morphological examination of the operating material (according to indications).Results. Forty-six (81%) patients were found to have gynecological factors for the development of CPP; 16 (28%) had extragenital factors. The examination results were verified by the data of surgical intervention (n = 16 (28%)), hysteroscopy (n = 21 (37%)), and laparoscopy (n = 9 (16%)) with morphological examination of biopsy specimens or surgical material.Comparing with the standard pelvic MR protocol provided evidence for the high diagnostic value of the modified protocol statistically significantly (p < 0.05): 99.2% sensitivity and 99.6% specificity.Conclusion. The developed non-contrast 1.5T MRI protocol for the pelvis permits MR images of the pelvis and adjacent anatomical areas to be obtained during one study without increasing time expenditures and upgrading equipment and software. The use of the protocol makes it possible to improve the quality of radiation diagnosis of gynecological and extragenital diseases in CPP and to recommend that the protocol in combination with other clinical and instrumental studies be introduced in clinical practice.

Purpose The purpose of this study is to present a systematic assessment of the distinctive challenges and opportunities associated with creating leadership within the realm of social enterprise. A modified and expanded form of Grint’s leadership lenses heuristic framework (i.e. person, position, process, performance, purpose and place) is used to examine and highlight what is particular about creating leadership in social enterprises by virtue of their distinctive missions, strategic contexts, legal forms and organisational structures and cultures. Based on this initial exploration, five research priorities are identified to better understand and then develop leadership practice in the social enterprise realm. Design/methodology/approach An enhanced heuristic framework for systematically examining leadership within the social enterprise research literature has been applied, drawing on the leadership practice literature. The application is illustrated through six instrumental case studies. Findings While there are a number of similarities between leading in the social enterprise realm and leading within the private, public and not-for-profit sectors, the levels of complexity, ambiguity and the lack of an established theoretical and practical knowledge base makes creating leadership in the social enterprise sector that much more challenging. On the positive side of the ledger, the fact that the purpose is at the core of social enterprise means that it is relatively easier to use the purpose to create a basis for common meaningful action, compared to leadership within the private and public sectors. Related to this, given the strongly local or “glocal” nature of social enterprise, a ready opportunity exists for leaders to draw upon a place as a strategic resource in mobilising followers and other stakeholders. The novel, uncertain and pioneering nature of a social enterprise is also arguably more tolerant and accommodating of a leadership mindset that focuses on posing questions regarding “wicked” problems compared to public, private for-profit and, indeed, traditional not-for-profit sector organisations. Originality/value As far as we can ascertain, this is the first systematic attempt to examine the distinctive challenges and opportunities associated with creating leadership within the social enterprise realm. The application of the heuristic framework leads to the identification of five key inter-related lines of empirical research into leadership practices within social enterprises.

Abstract In 2010, modified RECIST (mRECIST) criteria were proposed as a way of adapting the RECIST criteria to the particularities of hepatocellular carcinoma (HCC). mRECIST was intended to overcome some limitations of RECIST in measuring tumour shrinkage with local and systemic therapies, and also to refine the assessment of progression that could be misinterpreted with conventional RECIST 1.1, due to clinical events related to the natural progression of chronic liver disease. mRECIST has served its purpose since being adopted or included in clinical practice guidelines (European, American and Asian) for the management of HCC; it has also been instrumental for assessing response and time-to-event endpoints in several phase II and III investigations. Nowadays, mRECIST has become the standard tool for measurement of radiological endpoints at early/intermediate stages of HCC. At advanced stages, guidelines recommend both methods. mRECIST has been proven to capture higher objective response rates in tumours treated with molecular therapies and those responses have shown to be independently associated with better survival. With the advent of novel treatment approaches including immunotherapy combination therapies, there is a need to further refine and clarify some concepts around the performance of mRECIST. Citation Format: Riccardo Lencioni. Assessing response and time-to-event end-points: RECIST and mRECIST [abstract]. In: Proceedings of the AACR Special Conference: Advances in the Pathogenesis and Molecular Therapies of Liver Cancer; 2022 May 5-8; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2022;28(17_Suppl):Abstract nr IA17.

This article provides an extended commentary on three books by R. Laymon and A. Franklin about the methodology and epistemology of the scientific experi­ment, as well as their article on the issue of reproducibility of experiments. The reproducibility of scientific results has historically been considered one of the methodological standards of science, and it is associated with ideas about the truth and intersubjective nature of scientific knowledge. The problem of re­producibility has received particular attention in recent decades because special­ized studies have revealed that more than half of the results from the social sci­entific studies cannot be reproduced; many cases of fraud in biomedical sciences have been uncovered; and the collective nature of subjectivity in elementary par­ticle physics has accentuated the instability of the knowledge obtained by large collaborations. In reconstructing discussions about reproducibility in the philo­sophical literature, we distinguish between replicating an experiment by repeat­ing it in a way that is as close as possible to the original and actually reproducing it by re-obtaining a previously observed phenomenon in a significantly modified instrumental-theoretical setting. We also introduce the concept of replication-2 as an intermediate form between replication and reproducing. These kinds of re­search repetitions perform different functions in experimental practice. We show that a variety of kinds of replication and reproduction are at the heart of a set of epistemic strategies: experimental methodological standards identified by Franklin based on decades of research in scientific practice. We analyze a num­ber of experiments in which a single measurement, in the absence of epistemic strategies, was sufficient for the community to accept a new theory. In these cases, we argue, a theory based on high-value symmetry principles turned out to be the dominant lens of the community, while the experiment played a role only as a demonstration. Such examples, in our opinion, indicate that the experiment’s role in a situation of shifting scientific paradigms is different from its role in nor­mal science: the requirements for reproducibility and epistemic strategies are significantly alleviated in the former in comparison to the latter.

Presently, the improvement in the quality of life of patients who underwent a laparoscopic surgical repair of hiatus hernia and the absence of the gastroesophageal reflux disease (GERD) recurrence are the basic characteristics of the surgical treatment. In this connection, further perfection of the tactics and techniques of the surgical GERD treatment becomes an important problem of modern surgery. Here, we present a comparative analysis of the remote results of the surgical treatment of 159 patients with GERD-complicated hiatus hernia. The patients were divided into two groups, depending on the technique of the performed endosurgical treatment. The first group consisted of patients operated via the standard laparoscopic Nissen fundoplication. In the second group, we included those patients who underwent surgical treatment using a modified procedure of Nissen fundoplication with the formation of a non-tension cuff (RF patent No. 2529415 of 27.09.2014). Evaluation of the results, based on the survey questionnaires Gerd-Q, GSRS, SF-36 and the data of instrumental research methods, was performed 1 to 5 years post-treatment. The treatment of the GERD-complicated hiatus hernia patients with application of the technique of forming a non-hanging fundoplication cuff shows the best long-term results: the incidence of the reflux syndrome and signs of hyperfunction of the fundoplication cuff is lower. The revealed differences coincide with the data of the Gerd-Q and GSRS questionnaires, as well as the life quality estimation by the SF-36 questionnaire. The developed techniques do not require application of sophisticated technical skills and re-equipment and may be recommended for the practical use in the everyday practice in surgical hospitals of all levels.

Background: Early detection of abnormal progress and prevention of prolonged labour can significantly improve the outcome of labour. Partograph is an inexpensive tool which can provide a continuous pictorial overview of labour and is essential to monitor and manage labour. The objectives were to study the course of normal and abnormal labour and to evaluate the maternal and perinatal outcome using simple and composite WHO partogram.Methods: This was a randomized study conducted at Department of Obstetrics and Gynaecology, Government Medical College, Amritsar, a tertiary care centre in North India. 200 women with term, singleton, vertex gestation, in spontaneous labor were included in the study. In 100 cases composite partograph was plotted and in rest 100 cases simple partograph was plotted. The following outcomes were compared: labor crossing the alert and action line, augmentation of labor, rate of cesarean section, perinatal and maternal outcome.Results: The partogram crossed the alert line (p 0.008) and action lines (p 0.017), causing increased need for augmentation (p 0.034) in the composite partogram which was statistically significant. The numbers of vaginal deliveries were high (p<0.001) and decrease number of cesarean sections (p 0.007) and instrumental deliveries (p 0.009) in the simplified group. NICU admissions were also higher in the composite group (p<0.05), though most of the NICU admissions were due to hyperbilirubinemia and low birth weight and was not directly related to monitoring of labour.Conclusions: It was observed in the present study that labour can be managed without the latent phase being plotted on the partograph. The interventions were higher when the latent phase was included, with increased number of labours crossing the alert and action lines, increased no. of augmentations and larger number of caesarean sections. Our study favours the use of the WHO modified partograph, which should become routine practice in monitoring labour for better maternal and perinatal outcome.

Since the bifurcation analysis remains the basic tool to inquire into nonlinear system dynamics, then, theoretically, the bifurcation analysis should be widely used to estimate the evolution of the climate dynamics at a certain geographic point over the last centenary. But it does not occur in practice. A viewpoint how to estimate such evolution is proposed and discussed in the paper. The viewpoint can be briefly formulated as the following: the extra-short timescale, plus the novel conceptual model, plus the modified bifurcation diagrams. So, first, only the data of instrumental measurements (hereafter observations) are used to build the bifurcation diagram, correspondingly, the timescale is restricted by the maximal duration of the reliable observations. In particular, 130-years time series of the land surface air temperature in Russia are analyzed in the paper. Second, the conceptual model (HDS-model) to describe the annual warming–cooling cycle dynamics similar to the dynamics of the hysteresis regulator with double synchronization (HDS-regulator) is introduced. Correspondingly, the local climate dynamics is considered as the dynamics of the system with a variable structure. The main advantage of HDS-model is the possibility to describe quite simply the rich variety of the observable temperature evolution based on the known nonlinear phenomena by the combinations of C-bifurcations (or, in other words, border-collision bifurcations) between three conjugate periodical processes with the same period but different orders of structural changes. Then HDS-hypothesis on the climate dynamics is proposed, where the local temperature evolution is considered under the competition between both amplitude and time quantizations within the Sun–Earth–Moon system. Processing the observations follows the SUC-logic conceptions on the experimental bifurcation analysis that allows to untangle the intricate nonlinear nonstationary behavior of a local climate system by using both special sections (S) and units (U) in a certain consequence (C). As a result, the modified bifurcation diagrams to show the temperature evolution in local climate systems are built under the variation of several bifurcation parameters. The diagrams exhibit intermittency phenomena of high activity in the European part of Russia at least. Generally speaking, HDS-hypothesis gives the good approximation to answer the question whether the observable changes in the local climate dynamics are qualitative and, if yes, in what meaning?

e24030 Background: AML is a disease of older adults, with median age of 68 years at presentation. NCCN guidelines suggest comprehensive geriatric assessments (GA) be included in clinical practice to guide treatment decisions. Utility of GA in older AML patients in a real-world environment is not yet established. We tested the feasibility of using a modified GA (mGA), administered by patient self-report on a touchscreen computer, real-time use and utility by clinicians and the correlation of mGA results on treatment decision-making. Methods: Sixty-two patients were recruited from three sites to complete a tablet-based mGA screening at a treatment decision-making time point. The mGA consists of the Frailty Index (FI) that includes four domains: age, activities of daily living, instrumental ADLs, and comorbidities. Falls within the past 6 months and patient reported health interference with function are also assessed. Results are displayed for the clinician to inform the treatment discussion. Results: Participants were mean age 73 years (range 61-88), 63% male, and 90% white. Frailty Index result was 32% fit, 40% intermediate, and 28% frail. Providers were asked the fit/frailty status prior to seeing the results of the mGA. Of 53 provider responses, there was 57% (n=30) provider concordance with the mGA result; 9% (n=5) said fit when mGA said intermediate and 17% (n=9) said intermediate when mGA said frail. When asked their goals of care, nearly all (n=60, 97%) patients agreed with the statement “my cancer is curable”, yet 30% (n=19) disagreed the treatment goal was to get rid of all the cancer. Nearly half (n=30) indicated they want to make treatment decisions together with the provider rather than provider or patient making decision alone. 73% (45/62) of patients were satisfied with the ease of using the survey and took an average 16.3 minutes to complete. Patient self-reported presence/severity of eight symptoms at baseline (see Table). Conclusions: A simple electronic tool may provide valuable insight into patient understanding of disease to better tailor patient-provider discussion and treatment decision-making. Providers overestimated fitness 26% of the time. Final results will be presented to include the outcome at 3 months by Frailty Index. [Table: see text]

e21703 Background: Multiple myeloma (MM) is a disease of older adults (OAs) with > 60% of diagnoses and nearly 75% of deaths occurring in patients > 65 years old (YO). Geriatric Assessment (GA) is associated with toxicity and survival in OAs with MM, but not routinely used in practice. This project pilot tests a tablet-based modified Geriatric Assessment (mGA) that presents compiled GA results, including (the Palumbo) frailty score, to clinicians at a treatment decision-making visit in a single screen dashboard. Methods: In this multisite ongoing study, 210 patients with MM ≥65 YO facing a decision point for care will complete a mGA that includes the Charlson Comorbidity Index (CCI), Katz Activity of Daily Living (ADL) Score, and Lawton Instrumental Activity of Daily Living (IADL) Score prior to meeting with a physician. mGA results, including composite frailty score, are provided to physicians at the start of a visit. Results: Thirty-six patients have been enrolled to date; enrollment continues. Participants are 69% (n = 25) white, 64% (n = 23) male, and mean age of 72 YO (range 65-87). Most (74%, n = 20) currently receive ≥1 therapy and have few co-morbidities (CCI median 1, SD 1.95, range 0-8); 57% require assistance with IADLs and 37% require assistance with ADLs. Based on Palumbo score, 36% of participants were frail (n = 13), 33% intermediate (n = 12), and 31% fit (n = 11). Providers report mGA results influenced treatment decision (54%, n = 28) and frailty score was the most frequently cited result to impact treatment decision-making (61%, n = 39). The most common way the mCGA influenced decision-making was to reduce dose/dose intensity (25%, N = 8). Clinicians on average spent 5 minutesreviewing the mGA results. Patients reported an average of 7 minutes to complete the survey, most independently (83%, n = 30), and were satisfied with the electronic program overall (80%, n = 29), including how easy it was to use (88%, n = 32). Conclusions: Preliminary data support feasibility, usability, and acceptability of the tablet-based mGA and that frailty score influences provider decision-making ≥50% of the time. Future analyses will explore the relationship of the mGA with toxicity, dose modification and/or treatment discontinuation in OAs with MM.

By the end of the 18th and the beginning of the 19th century a new era began in medicine, pharmaceutics and chemistry that was strongly connected with alkaloids and alkaloid drugs. Even before that it was known that certain drugs administered in limited doses were medicines, and toxic if taken in larger doses (opium, coke leaves, belladonna roots, monkshood tubers crocus or hemlock seeds). However, the identification, isolation and structural characterization of the active ingredients of the alkaloid drugs was only possible in the mid 20th century by the use of modern extraction equipment and instrumental methods (NMR, X-ray diffraction and others).In spite of continuing use over a long time, there is still great interest in investigating new drugs, potential raw materials for the pharmaceutical industry, as well as the more detailed investigation and definition of bio-active components and the indication of their activity range, and the partial synthesis of new alkaloid molecules based on natural alkaloids. The scope of these investigations, especially in the field of semi-synthesis is to make better use of the bio-active ingredients of alkaloid drugs, i.e. to improve the pharmacological effect (stronger and prolonged effect of the medicine, decreased toxicity and side effects), or to extend or change the applications. A combined classification of alkaloids was used, based on the chemical structure and origin, i.e. the source of their isolation to study alkaloid structure. For practical reasons, the following classification of alkaloids was used: ergot alkaloids, poppy alkaloids, tropanic alkaloids purine derivative alkaloids, carbon-cyclic alkaloids, and other alkaloids. The second part of this report presents a table of general procedures for alkaloid isolation from plant drugs (extraction by water non-miscible solvents, extraction by water-miscible solvents and extraction by diluted acid solutions). Also, methods for obtaining chelidonine and glaucine as hydrochloride bases and salts were presented in more details. Data from leading world pharmacopoeias (Ph. Eur. Ill/s 2000, DAB 1996, USP 23, JP XIII, BP 1993, Ph. Jug. IV) were used in the study of application of the pure alkaloids in pharmaceutical forms with predetermined doses. A comparative study of these data shows that a great number of preparations are produced worldwide based on alkaloids and alkaloids with modified structure. These medicines have found use in modern therapeutic practice in many countries. Most products are produced on the basis of caffeine, theophylline, ephedrine, atropine, scopolamine, reserpine and pilocarpine.

Abstract Background: Over two thirds of patients with Multiple Myeloma (MM) are ≥ 65 years old at the time of diagnosis. Older adults are at greater risk for treatment related toxicity and inferior survival; such risks are inadequately explained by chronologic age and performance status. In 2015, the International Myeloma Working Group (IMWG) proposed a geriatric assessment (GA) based frailty index to identify older adults with MM at greatest risk of toxicities. Yet, routine implementation of GA in busy oncology practice remains challenging. We have previously shown the feasibility of a tablet-based modified Geriatric Assessment (mGA), capturing the Charlson Comorbidity Index (CCI), Katz Activity of Daily Living (ADL) Score, and Lawton Instrumental Activity of Daily Living (IADL) score, and its impact on clinical decision-making and treatment outcomes (Nathwani, et al. JOP. 2020). In the prior study, physicians recommended integration of the mGA into the electronic medical record (EMR) to improve usefulness at the clinic. Methods: We conducted a single institution pilot study to test the feasibility of integrating an electronic care planning system within the EMR such that with a single sign on, the dashboard showing results of the mGA was visualized within the EMR. Eligible patients had symptomatic MM, &gt; 60 years old, and seeing their oncology providers to make a decision about treatment. After completing informed consent, patients completed a tablet-based mGA in clinic just prior to seeing the physician. Survey results were compiled and were immediately available for evaluation on a dashboard within the EMR. Providers reviewed the mGA results before meeting with the patient and completed a short survey after the visit regarding their own subjective impression of frailty and how the mGA influenced their treatment decision making. Agreement between provider's subjective vs mGA based frailty categorization was measured using Cohen's Kappa statistic. We measured relevant toxicity outcomes at 3 months post treatment initiation. Results: 25 patients were enrolled, with a median age of 68 (range=61-82), 52% (n=13) female, and 68% (n= 17) white. One patient did not complete the mGA survey and was not included in the analysis. The remaining patients completed the mGA successfully without interrupting clinic flow and mGA was immediately available for providers to review during the clinic visit. The average time providers spent reviewing results was of 5 (range 1-10) minutes. Providers subjectively categorized patients as 42% (n=10) fit, 58% (n=14) intermediate fit, and 0% (n=0) frail. According to the mGA, patients were 50% (n=12) fit, 29% (n=7) intermediate fit, and 21% (n=5) frail. There was an overall 46% (n=11) concordance between physician and mGA result. The most agreement was in fit status (58%, n=7) and least was frail (0%, n=0). There was 33% (n=4) agreement on intermediate fit status. The unweighted Cohen's kappa statistic was 0.09 indicating only slight agreement between the two methods. Providers reported mGA influenced their treatment decision in 33% (n=8), with the decision being either chemotherapy modification (n=6) or reduced dose transplant (n=2). One patient, who was frail and received induction treatment, died during the 3-month study period. The remaining patients (n=23) received treatment as planned. Discussion: In this study, we report the feasibility of an EMR integrated mGA tool completed by the patient prior to meeting with the physician. Patients completed the survey with assistance and without disrupting the clinic workflow. The mGA results were reviewed by providers in real time and influenced treatment decisions one third of the time. Nearly all patients (96%, n=24) completed therapy as planned. Providers tended to view the patients as more fit than the mGA result, suggesting that the mGA uncovers additional information related to the patient's ability to tolerate therapy. Toxicity follow up is ongoing and will be updated at the time of presentation. Disclosures Giri: CareVive: Honoraria, Research Funding; PackHealth: Research Funding. Costa: BMS: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Karyopharm: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria, Speakers Bureau.

Background an Aims: For 2003 year until today we treated hundreds of patients with Central Nervous System Injuries (CNSI), using Non-Surgical Laser Therapy (NSLT) obtaining good results in terms of sensibility and movement. In order to increase muscle strength and to further explore new emerging synergies, we have also started using a physical therapy practice based on the most current knowledge about the motor control, called Grimaldi’s Muscle Shortening Maneuver (GMSM). Spasticity is often the most disabling symptom and the current therapies are still not able to heal it at all. The goal of our study is to suggest a new way of treatment of spasticity, supporting it with objective measurements of muscle thresholds. Materials and Methods: In 2016-2017, 36 patients with traumatic or degenerative CNSI were enrolled. Lasers used were 808 nm, 10600 nm, and 1064 nm, applied with a first cycle of 20 sessions, four a day. Patients were subjected to Grimaldi’s Muscle Shortening Maneuver (MSM) twice a day, ten sessions at all, working selectively on hypertonic muscles and their antagonists. Before treatment, tonic stretch reflex thresholds (TSRTs) in Gastrocnemius Lateralis (GL) were assessed through a surface electromyography (sEMG) device paired with an electrogoniometer. Antagonist muscle force (Tibialis Anterioris) was assessed by some electronic hand-held dynamometers. For the clinical measure, we used the Modified Ashworth Scale (MAS). All tests have been performed at the baseline (before starting treatments), after one week (at the end of the last treatment) and after a month. Results: Results were considered positive if the instrumental assessment procedure showed modifications in TSRT values and subjects improved their antagonist muscle strength. Results showed modifications in TSRT values at every follow up. The average comparison between the follow-ups was always statistically significant (p .000). The increase in Tibialis Anterioris muscle strength was statistically significant as well (p .000). MAS showed some differences between followups but not all of them are statistically significant (T0-T1 p .063, T1-T2 p .001, T0-T2 p .000). Encouraging results suggest a possible correlation between laser and MSM therapies and modifications of TSRT in spastic muscles. Conclusion: Associating laser treatment and Grimaldi’s Muscle Shortening Maneuver (MSM) seems to be effective on spasticity in patients affected by traumatic or degenerative CNSI. Obviously, this kind of study design showed a lot of limits however this clinical series could be an important hint for every researcher working in the complex field of spasticity, a symptom that is poorly defined and hardly treated.

Введение. Системная тромболитическая терапия (сТЛТ) является «золотым стандартом» реперфузионной терапии и получила самый высокий уровень доказательности (класс I, уровень А) в европейских и североамериканских руководствах по ведению пациентов в остром периоде ишемического инсульта (ИИ).Залогом успеха и безопасности реперфузионной терапии является тщательное соблюдение протокола ее проведения. Вместе с тем, как и в отношении любого метода лечения, возможно выделение прогностически благоприятных факторов и, наоборот, предикторов неэффективности и повышенного риска осложнений.Цель. Повысить чувствительность и специфичность персонифицированной модели прогнозирования у пациентов с инфарктом мозга с помощью нейросетевого анализа.Материалы и методы. За период с 2008 по 2018 г. в исследование были включены 213 пациентов с ишемическим инсультом, которым проводилась сТЛТ стандартной дозой алтеплазы на базе УЗ «Городская клиническая больница скорой медицинской помощи» и ГУ «МНПЦ хирургии, трансплантологии и гематологии». Функциональный исход проводимой терапии оценивался по критериям модифицированной шкалы Рэнкина (mRS). Благоприятным исходом считали достижение функциональной независимости (mRS 0–2), а неблагоприятным – наступление инвалидности либо летального исхода (mRS 3–6). Для выявления предикторов функционального исхода сТЛТ у пациентов с ИИ ретроспективно были проанализированы 42 клинико-инструментальных параметра.Результаты. С помощью корреляционного анализа Спирмена было выявлено 19 статистически значимых предикторов функционального исхода системной тромболитической терапии у пациентов с ишемическим инсультом, которые включали 4 клинико-анамнестических параметра, 1 лабораторный показатель и 14 нейровизуализационных критериев. Последующий нейросетевой анализ полученных данных позволил создать прогностическую модель,основанную на 24 клинико-инструментальных признаках. Точность данной модели составила 94%, чувствительность 88,5%, специфичность 98,2%, AUC 0,93.Заключение. Применение в повседневной практике результатов нейросетевой прогностической модели функционального исхода сТЛТ, основанной на клинико-патогенетических особенностях заболевания, локализации очага поражения и степени выраженности ранних нейровизуализационных признаков будет способствовать более безопасному и эффективному применению данного метода лечения у пациентов с ИИ. Introduction. Systemic thrombolytic therapy (sTLT) is the “gold standard” of reperfusion therapy; it received the highest level of evidence (class I, level A) in European and North American guidelines for the management of patients with acute ischemic stroke (IS).The key to success and safety of reperfusion therapy is careful adherence to the protocol of its implementation. At the same time, as with any treatment method, it is possible to identify prognostically favorable factors and, conversely, the predictors of ineffectiveness and increased risk of complications.Purpose. To increase the sensitivity and specificity of the personalized predictive model in patients with cerebral infarction using neural network analysis.Materials and methods. During the period from 2008 to 2018, the study included 213 patients with ischemic stroke, who underwent sTLT with the standard dose of alteplase at the City Clinical Emergency Hospital and Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology. The functional outcome of the therapy was assessed, according to the criteria of the modified Rankin scale (mRS). The achievement of functional independence (mRS 0–2) was considered a favorable outcome, and the onset of disability or death (mRS 3–6) was considered unfavorable. To identify the predictors of the functional outcome of sTLT in patients with IS, 42 clinical and instrumental parameters were retrospectively analyzed.Results. Using Spearman’s correlation analysis, 19 statistically significant predictors of the functional outcome of systemic thrombolytic therapy in patients with ischemic stroke were identified, which included 4 clinical and anamnestic parameters, 1 laboratory parameter, and 14 neuroimaging criteria. Subsequent neural network analysis of the obtained data let to create the predictive model based on 24 clinical and instrumental predictors. The accuracy of this model was 94%, sensitivity – 88.5%, specificity – 98.2%, AUC 0.93.Conclusion. The use in everyday practice of the results of the neural network prognostic model of the functional outcome of sTLT, based on the clinical and pathogenetic features of the disease, the localization of the lesion, and the severity of early neuroimaging signs, will contribute to safer and more effective use of this treatment method in patients with IS.

Abstract Older patients are at increased risk for complications and death following allogeneic hematopoietic cell transplantation (allo-HCT). Traditional transplant-specific prognostic indices such as hematopoietic cell transplant comorbidity index (HCT-CI) may not capture all underlying geriatric vulnerabilities, and in-depth evaluation by a geriatrician prior to transplant may not always be available. We hypothesize that routine pre-transplant assessments by interdisciplinary clinical providers including advanced practice providers, nursing staff, physical therapists, occupational therapists, and dietitians, as well as common laboratory tests, may uncover additional geriatric deficits. Using an institutional database and the electronic medical records of 406 adults age 60 years and older (range 60-78.7) who underwent first allo-HCT for hematological malignancies from 2010 to 2016, we examined the prevalence and the prognostic impact of pre-transplant geriatric deficits identified by interdisciplinary clinical providers including geriatric domains of functional activity, cognition, medication, nutrition, and mobility (Table 1), and by routine laboratory tests. With a median follow-up of 39 months for survivors, the 3-year probability of overall survival (OS) and progression-free survival was 47% (95% CI 42-53) and 40% (95% CI 35-45), respectively. The 2-year cumulative incidence of non-relapse mortality (NRM) was 26% (95% CI 22-29). Among pre-transplant geriatric and laboratory variables, we found that impairment in instrumental activities of daily living (IADL) and pre-transplant ferritin level ≥1200 was independently associated with increased NRM and inferior OS. In the multivariate analysis, HCT-CI ≥3, IADL impairment, ferritin level ≥1200, and Karnofsky Performance Scale (KPS) <90 are predictive of NRM (Table 2). Similarly, IADL impairment, ferritin level ≥1200, and high/very high modified disease risk index predict OS (Table 2). Most importantly, the combination of either IADL impairment or ferritin ≥1200 with HCT-CI further stratifies NRM and OS into distinct risk categories, including a group of highly vulnerable, high risk patients with high HCT-CI (≥3) plus IADL impairment and/or ferritin level ≥1200 (Figure 1). Detailed examination of non-relapse death among all vulnerable patients (≥2 risk factors) reveals a higher proportion of death from organ toxicities than patients with zero or 1 risk factor. Our findings establish a rapid and simple assessment tool to risk stratify older patients prior to allo-HCT. While requiring validation, the geriatric vulnerability index can be easily completed and integrated into outpatient clinics and the electronic medical record. It may also provide an entry point for prospective, interventional trials aimed at reducing non-relapse mortality and toxicities, and at improving survival and quality of life of older allo-HCT patients. Disclosures Perales: Takeda: Other: Personal fees; Merck: Other: Personal fees; Incyte: Membership on an entity's Board of Directors or advisory committees, Other: Personal fees and Clinical trial support; Abbvie: Other: Personal fees; Novartis: Other: Personal fees. Sauter:Juno Therapeutics: Consultancy, Research Funding; Sanofi-Genzyme: Consultancy, Research Funding; Spectrum Pharmaceuticals: Consultancy; Novartis: Consultancy; Precision Biosciences: Consultancy; Kite: Consultancy.

In this review, we present the safest and most effective diagnosis and treatment approaches to dysphagia during the novel coronavirus-2019 (COVID-19) pandemic in the light of available data, relevant literature, and personal experiences. Evaluations for dysphagia patients should be based on clinical assessment during the COVID-19 pandemic and instrumental assessment should be planned for very few number of patients. The main approach to rehabilitation must depend on compensatory methods, texture-modified foods, and postural strategies. Direct treatment methods should be avoided and home-based exercise programs should be encouraged. It is also obvious that there is a need for the development of new strategies for telemedicine/telerehabilitation practices in the new world order.

The paper presents a statistical study of nanoindentation results obtained in seven European laboratories that have joined a round robin exercise to assess methods for the evaluation of indentation size effects. The study focuses on the characterization of ferritic/martensitic steels T91 and Eurofer97, envisaged as structural materials for nuclear fission and fusion applications, respectively. Depth-controlled single cycle measurements at various final indentation depths, force-controlled single cycle and force-controlled progressive multi-cycle measurements using Berkovich indenters at room temperature have been combined to calculate the indentation hardness and the elastic modulus as a function of depth applying the Oliver and Pharr method. Intra- and inter-laboratory variabilities have been evaluated. Elastic modulus corrections have been applied to the hardness data to compensate for materials related systematic errors, like pile-up behaviour, which is not accounted for by the Oliver and Pharr theory, and other sources of instrumental or methodological bias. The correction modifies the statistical hardness profiles and allows determining more reliable indentation size effects.

Abstract Background: Acute Myeloid Leukemia (AML) is a disease of older adults, with a median age of 68 years at diagnosis. The NCCN guidelines recommend comprehensive geriatric assessments (GA) be included in clinical practice to guide treatment decisions. Utility of GA in older AML patients in a real-world environment is not yet established. We tested the feasibility of using a modified GA (mGA), administered by patient self-report on a touchscreen computer, real-time use and utility by clinicians and the correlation of mGA results on treatment decision-making. Methods: 77 newly diagnosed patients were recruited from three sites to complete a tablet-based mGA screening at a treatment decision visit. The mGA includes four domains: age, activities of daily living (ADLs), instrumental ADLs, and comorbidities. Survey results along with history of falls was used to create the Frailty Index (FI). Providers were asked what they thought the fit/frailty status of the patient was before viewing the results on a dashboard. After viewing the survey results, the clinician discussed the treatment plan with the patient. Patients received intensive or non-intensive therapy. Additional information was captured on clinical trial enrollment. Baseline and 3 month surveys recorded presence and severity of 8 symptoms using the Edmonton Symptom Assessment Scale (ESAS) with 0=no symptom and 10=worst possible symptom and quality of life using the Functional Assessment of Cancer Treatment: Leukemia (FACT-LEU). Results: Participants had a median age of 71 years ( range:61-88y); 50% were female, and 87% white. Frailty Index results for 76 patients were 28 (36.4%) fit, 25 (32.5%) intermediate, and 23 (29.9%) frail. (One patient did not complete the mGA). 52 of 77 (69%) enrolled patients were alive at 3 months; 21(27%) died and 4 (5%) were lost to follow-up. Providers were asked the fit/frailty status prior to seeing the results of the mGA. Of 75 provider responses, results were 27 (36.0%) fit, 29 (38.7%) intermediate, and 19 (25.3%) frail. There was 63% (n=47) provider concordance with the mGA result. There was more agreement with fit (n=22, 81.5%) and frail status (n=11, 57.9%) and less with intermediate (n=14, 48.3%). Of the 25 of 75 (33.%) provider reports that indicated that the mGA result influenced the treatment decision, 6 patients (5 fit, 1 intermediate) received intensive treatment, 15 received non intensive treatment (1 fit, 6 intermediate, 8 frail) and 4 enrolled in a clinical trial (1 fit, 2 intermediate, and 1 frail). Significant symptom improvement at 3 months was seen for drowsiness, lack of appetite, shortness of breath, and anxiety. FACT Leu results did not change over 3 months. Providers reported an average of 4.45 minutes to review the dashboard. Patients were able to complete the surveys unassisted in an average time of 16.24 minutes. Discussion: There was nearly 40% discordance between the provider and mGA, with the most discordance on the intermediate fit status. However, results of the mGA influenced treatment decision making in one third of provider/patient interactions. Further analysis of the mGA domains is warranted to see if additional insights can be gained. With time, some symptoms improve and others don't. This points to the opportunity to direct resources towards symptom assessment during treatment. Feasibility was demonstrated in this study as providers received the aggregated results in real time and reviewed them in less than 5 minutes. In addition, patients were able to complete the survey unassisted without disturbing clinic operations. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

The balance of people with multiple sclerosis (PwMS) is commonly assessed during neurological examinations through clinical Romberg and tandem gait tests that are often not sensitive enough to unravel subtle deficits in early-stage PwMS. Inertial sensors (IMUs) could overcome this drawback. Nevertheless, IMUs are not yet fully integrated into clinical practice due to issues including the difficulty to understand/interpret the big number of parameters provided and the lack of cut-off values to identify possible abnormalities. In an attempt to overcome these limitations, an instrumented modified Romberg test (ImRomberg: standing on foam with eyes closed while wearing an IMU on the trunk) was administered to 81 early-stage PwMS and 38 healthy subjects (HS). To facilitate clinical interpretation, 21 IMU-based parameters were computed and reduced through principal component analysis into two components, sway complexity and sway intensity, descriptive of independent aspects of balance, presenting a clear clinical meaning and significant correlations with at least one clinical scale. Compared to HS, early-stage PwMS showed a 228% reduction in sway complexity and a 63% increase in sway intensity, indicating, respectively, a less automatic (more conscious) balance control and larger and faster trunk movements during upright posture. Cut-off values were derived to identify the presence of balance abnormalities and if these abnormalities are clinically meaningful. By applying these thresholds and integrating the ImRomberg test with the clinical tandem gait test, balance impairments were identified in 58% of PwMS versus the 17% detected by traditional Romberg and tandem gait tests. The higher sensitivity of the proposed approach would allow for the direct identification of early-stage PwMS who could benefit from preventive rehabilitation interventions aimed at slowing MS-related functional decline during neurological examinations and with minimal modifications to the tests commonly performed.

If the post-war industrial model entails a mix of technological and chemical interventions that increase farm productivity, then post-industrial agriculture (emerging in the 1970s) constitutes agricultural surpluses, as well as an array of trade, aid and biotechnology practices that introduce novel foodstuffs (processed and genetically modified) on an unprecedented scale. While industrial agriculture reduces the farming population, the latter gives rise to new sets of actors who question the nature and validity of the industrial model. This essay explores the rise of one set of such actors. Paysans (peasants) from France's second largest union, the Confederation Paysanne, challenge the industrial model's instrumental rationality of agriculture. Reframing food questions in terms of food sovereignty, paysans propose a solidarity-based production rationality which gives hope to those who believe that another post-industrial food system is possible.

Abstract DLBCL is the most common type of non-Hodgkin lymphoma and it usually affects elderly patients, with a median age at diagnosis of 70 years and an incidence that rises with increasing age. Nevertheless patients > 70 years are rarely included in clinical trials and the management is often different according to local practice. A pre-treatment evaluation based on Performance Status (PS) or comorbidity index is not sufficient to identify patients suitable for treatment with curative intent. We retrospectively reviewed 93 patients with newly diagnosed DLBCL, ≥65 years old , treated from January 2009 to December 2015 at Veneto Institute of Oncology-IRCCS (median age 76 years, range 65-96). Twenty-eight patients (28) were older than 80 years. All but one received at least first line treatment. All patients were evaluated with CGA at diagnosis, based on Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and Cumulative Illness Rating Scale (CIRS). According to these variables they were classified into three categories named 'fit', 'vulnerable' and 'frail'. In addition, a cancer-specific modified multidimensional prognostic index (MPI), called Onco-MPI, was calculated for all patients. Onco-MPI score identify three risk score categories (low, moderate and high risk) that predict one-year mortality in older cancer patients. Onco-MPI was calculated according to a validate algorithm as a weighted linear combination of the following CGA domains: age, sex, ADL, IADL, PS, mini-mental state examination, body mass index, CIRS, number of drugs and the presence of caregiver. Cancer sites were also included in the model. Other features analyzed included clinical characteristics, treatment management and outcomes. In our cohort 48% of patients were at advanced Ann Arbor stage (III-IV) with intermediate-high or high risk IPI score in 31%. In 61% of patients we observed extranodal disease, mainly Waldeyer's ring and gastrointestinal tract. First line treatments received included R-CHOP (38%), R-COMP (R-CHOP with non-pegylated liposomial doxorubicin - 23%), R-CVP (14%), R-CEOP (3%), high dose methotrexate (4 patients with primary central nervous system lymphoma), R-VACOP-B (3%), R-Bendamustine in 2 patients and radiotherapy alone was used in 5 patients. Sixty-eight patients (84%) completed the planned cycles of immunochemotherapy. In this group 48,5% required dose reduction for subsequent cycles of treatment because of side effects, in particular hematological toxicities of grade 3-4 or neurological toxicities. In 23 chemotherapy-treated patients initial doses were reduced according to CGA . We observed, after first line therapy, complete response in 63% and partial response in 21%, 8% of patients experienced a disease progression at the end of treatment and 8% died during first line therapy because of lymphoma progression. At time of diagnosis 49% of patients were considered fit at CGA, 16% vulnerable and 35% frail. According to onco-MPI 24 patients (26%) were at low risk of one year mortality, 31 (33%) at medium risk and 38 (41%) at high risk. With a median follow up of 41,1 months the overall survival (OS) of our cohort is 55,9% (95% CI 25,3-56,9). OS correlates with CGA ( 84,4% in fit patients, 31,2 % in vulnerable and 28,1% in unfit, p< 0,001) and Onco-MPI score seems to discriminate our cohort for one-year mortality (95% in low risk, 77% in moderate and 63% in high, p<0,01). OS also correlates with anthracycline administration (67,8% vs 33,3%, p<0,001) as well as the use of consolidation radiotherapy after chemotherapy induction ( 75% vs 49,3%, p <0,01). Our retrospective, single Center experience demonstrates that elderly DLBCL need a multidimensional evaluation at diagnosis in order to identify patients candidate to treatment with curative intent. CGA confirm its role for choosing correct management. Also Onco-MPI can be a useful tool even if more data are needed in lymphoma patients. Disclosures No relevant conflicts of interest to declare.

The major challenge facing society in the 21st century is to feed and provide shelter for increasing numbers of people while protecting human health, our natural resource base, and the environment. To accomplish this, we must combine traditional technologies that stress conservation with modern technologies that rely heavily on biologically based solutions. Biotechnology, by its historical definition, has play an important role in environmental clean-up, but the contemporary practices of biotechnology will lead to more-sophisticated approaches. These technologies will allow clean-up of existing contamination and even prevention of contamination through more-sensitive and accurate monitoring systems. One of the most important advances is in bioremediation, in which microorganisms and plants remove contaminants from the soil or water and concentrate of volatilize them. In addition, plants are being modified through the changing of single genes so that they are less susceptible to pathogenic microorganisms, viruses, or insects, and more efficient in nitrogen utilization. The use of such modified plants, in concert with good agricultural practices, should lead to reductions in chemical inputs of pesticides and fertilizers. Strategies have also been developed that permit the “manufacture” in plant “pharms” of industrial products that are now produced through the use of nonrenewable resources. These biological approaches are part of the cadre of tools that we need to solve the problems of the next century. In addition, these tools will be instrumental in understanding the basic biological systems upon which the solutions to many of these challenges will come. Biotechnology is not a technological fix, but it should form part of the mind-set from which we design our strategies.

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings. DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999. DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings. DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use. CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.

Abstract Any deviation from the bright-red color of beef leads to discounted price or consumer rejection. Atypical dark-cutting beef represents darker color of lean around a pH 5.6 – 5.8. However, limited studies have determined the postharvest practices to improve the lean color of atypical dark-cutting beef. Therefore, the objective was to evaluate the effects of rosemary-enhancement and modified atmospheric packaging on atypical dark-cutting beef. Atypical dark-cutting beef strip loins (n = 13, pH=5.70 ± 0.09; ADC) and USDA Choice beef strip loins (n = 6, pH=5.57 ± 0.1; CH) were selected within 72 h of harvest. Atypical dark-cutting strip loins were divided into 2 sections, and randomly assigned to one of the following enhancement treatments: control non-enhanced (ADC), or a 1.1% rosemary-enhanced treatment (ADCE). After enhancement, 2.54 cm steaks were cut from CH, ADC, and ADCE strip loins and assigned to 1 of 3 packaging treatments: polyvinyl chloride overwrap (PVC), carbon monoxide modified atmosphere packaging (CO-MAP; 0.4% CO, 69.6% N, and 30% CO2), and high-oxygen modified atmospheric packaging (HiOx-MAP; 80% O2 and 20% CO2). A HunterLab MiniScan was used to determine color during the 6 d simulated retail display. Visual color measurement for muscle darkening (MD), muscle color (MC), and surface discoloration (SD) were recorded on d 2, 4, and 6 of retail display. There was a significant enhancement x packaging interaction for instrumental and visual color measurements. For all packaging types, ADCE steaks possessed greater L* values than DC steaks. In addition, ADCE steaks packaged in HiOx-MAP or CO-MAP had brighter-red color than ADC steaks. Furthermore, ADCE and C steaks had less muscle darkening compared with ADC steaks for MD and MC attributes. The results suggest that enhancement and modified atmospheric packaging have the potential to improve the surface color of atypical dark-cutting beef.

The article discusses the features of moral leadership and its potential for overcoming social tensions. The type of leader is largely determined by the approach to managing intra- and intergroup conflicts. Therefore, the focus is put on the contiguity of conflict as a multifaceted social phenomenon and the phenomenon of leadership. In the 21st century, authoritarian, instrumental methods of coping with social conflicts become ineffective. Traditional forms of governance are much exhausted. The purpose of the article is to outline the contours of some type of leadership, which is based on moral and ethical regulation. The roots of the phenomenon of moral leadership are traced both in the peculiarities of modern society and in the history of moral practices. The establishment of the institution of moral leadership involves the emergence of new communities, forms of activity, and social roles. The moral factor modifies the social conflict, translates it mainly into the moral dimension, makes it constructive. Using elements of logical analysis, as well as historical-genetic and biographical methods, the authors show that in the history of civilization it was the ancient philosophers who influenced others by example and became the first moral leaders in the full sense of the word. And the very philosophy — given the cohesion of philosophical discourse and the philosophical lifestyle — has become a space in which the traditional type of leadership has transformed into an innovative one. The authors conclude that modern society urgently needs a revival of the spirit of practical philosophy. On the one hand, for its growth and improvement, the institution of moral leadership needs a deep ethical and philosophical reflection. On the other hand, philosophy, which has now found itself in the shadow of instrumental scientific knowledge, thanks to its relevance for moral practices, gets a chance to once again take its rightful place in the life of civilization.

People live amidst objects, things, articles, items, artefacts, materials, substances, and stuff – described in social sciences and humanities as material culture, which denotes both natural and human-made entities, which form our physical environment. We, humans, relate to this environment by using, depicting, interacting with or thinking about various material objects or their representations. In other words, material culture is never just about things in themselves, it is also about various ideas, representations, experiences, practices and relations. In contemporary theorising about material culture, the watershed between the tangible and intangible has started to disappear as all the objects have multiple meanings. This paper theorises objects mostly in terms of contemporary socio-cultural anthropology and ethnology by first giving an overview of the development of the material culture studies and then focusing upon consumption studies, material agency, practice theory and the methods for studying material culture. Both anthropology and ethnology in the beginning of the 20th century were dealing mostly with ‘saving’; that is, collecting the ethnographical objects from various cultures for future preservation as societies modernised. The collecting of the everyday items of rural Estonians, which had begun in the 19th century during the period of national awakening, gained its full momentum after the establishment of the Estonian National Museum in 1909. During the museum’s first ten years, 20,000 objects were collected (Õunapuu 2007). First, the focus was on the identification of the historical-geographical typologies of the collected artefacts. In 1919, the first Estonian with a degree in ethnology, Helmi Reiman-Neggo (2013) stressed the need for ethnographical descriptions of the collected items and the theoretical planning of the museum collections. The resulting vast ethnographical collection of the Estonian National Museum (currently about 140,000 items) has also largely influenced ethnology and anthropology as academic disciplines in Estonia (Pärdi 1993). Even though in the first half of the 20th century the focus lay in the systematic collection and comparative analysis of everyday items and folk art, there were studies that centred on meaning already at the end of 19th century. Austrianethnologist Rudolf Meringer suggested in 1891 that a house should be studied as a cultural individual and analysed within the context of its functions and in relation to its inhabitants. Similarly, the 1920s and 1930s saw studies on the roles of artefacts that were not influenced by Anglo-American functionalism: Mathilde Hain (1936) studied how folk costumes contribute to the harmonious functioning of a ‘small community’, and Petr Bogatyrev (1971) published his study on Moravian costumes in 1937. This study, determining the three main functions – instrumental, aesthetic and symbolic – of the folk costume, and translated into English 30 years after first publication, had a substantial influence on the development of material culture studies. The 1970s saw the focus of material culture studies in Western and Northern Europe shifting mainly from the examination of (historical) rural artefacts to the topics surrounding contemporary culture, such as consumption. In Soviet Estonian ethnology, however, the focus on the 19th century ethnographic items was prevalent until the 1980s as the topic was also partially perceived as a protest against the direction of Soviet academia (see Annist and Kaaristo 2013 for a thorough overview). There were, of course, exceptions, as for instance Arved Luts’s (1962) studies on everyday life on collective farms. Meanwhile, however, the communicative and semiotic turn of the 1970s turned European ethnology’s focus to the idea of representation and objects as markers of identity as well as means of materialising the otherwise intangible and immaterial relationships and relations. The theory of cultural communication was established in Scandinavian ethnology and numerous studies on clothing, housing and everyday items as material expressions of social structures, hierarchies, values and ideologies emerged (Lönnqvist 1979, Gustavsson 1991). The Scandinavian influences on Estonia are also reflected in Ants Viires’s (1990) suggestion that ethnologists should study clothing (including contemporary clothing) in general and not just folk costumes, by using a semiotic approach. Löfgren’s (1997) clarion call to bring more ‘flesh and blood’ to the study of material culture was a certain reaction to the above focus. Researchers had for too long focused exclusively upon the meaning and, as Löfgren brought forth, they still did not have enough understanding of what exactly it was that people were actually and practically doing with their things. Ingold’s (2013) criticism on the studies focusing on symbolism, and the lack of studies on the tangible materiality of the materials and their properties, takes a similar position. In the 1990s, there was a turn toward the examination of material-cultural and those studies that were written within the framework of ‘new materialism’ (Hicks 2010, Coole and Frost 2010) started to pay attention to objects as embodied and agentive (Latour 1999, Tilley et al 2006). Nevertheless, as Olsen (2017) notes, all materialities are not created equal in contemporary academic research: while items like prostheses, Boyle’s air pumps or virtual realities enjoy increased attention, objects such as wooden houses, fireplaces, rakes and simple wooden chairs are still largely unexamined. The traditional material culture therefore needs new studying in the light of these post-humanist theories. Where does this leave Estonian ethnology? In the light of the theoretical developments discussed above, we could ask, whether and how has the material Making sense of the material culture turn affected research in Estonia? Here we must first note that for a significant part of the 20th century, Estonian ethnology (or ethnography as the discipline was called before 1990s) has mostly been centred on the material culture (see the overview of the main topics from vehicles to folk costumes in Viires and Vunder 2008). Partly because of this aspect of the discipline’s history, many researchers actually felt the need to somewhat distance themselves from these topics in the 1990s (Pärdi 1998). Compared to topics like religion, identity, memory, oral history and intangible heritage, study of material culture has largely stayed in the background. There are of course notable exceptions such as Vunder’s (1992) study on the history of style, which includes analysis of theirsymbolic aspects. It is also interesting to note that in the 1990s Estonian ethnology, the term ‘material culture’ (‘materiaalne kultuur’) – then seen as incorporating the dualism between material and immaterial – was actually replaced with the Estonian translation of German ‘Sachkultur’ (‘esemekultuur’, literally ‘artefact culture’). Nevertheless, it was soon realised that this was actually a too narrow term (with its exclusion of natural objects and phenomena as well as the intangible and social aspects of culture), slowly fell out of general usage, and was replaced with ‘material culture’ once again. Within the past three decades, studies dealing with material culture have discussed a wide variety of topics from the vernacular interior design (Kannike 2000, 2002, 2012), everyday commodities (Kõresaar 1999b) and spiritual objects (Teidearu 2019), traditional rural architecture (Pärdi 2012, Kask 2012, 2015), museum artefacts (Leete 1996), clothing, textiles and jewellery (Kõresaar 1999a; Järs 2004; Summatavet 2005; Jõeste 2012; Araste and Ventsel 2015), food culture (Piiri 2006; Bardone 2016; Kannike and Bardone 2017), to soviet consumer culture (Ruusmann 2006, Rattus 2013) and its implications in life histories (Kõresaar 1998, Jõesalu and Nugin 2017). All of these these studies deal with how people interpret, remember and use objects. The main keywords of the studies of European material culture have been home, identity and consumption (but also museology and tangible heritage, which have not been covered in this article). Material culture studies are an important part of the studies of everyday life and here social and cultural histories are still important (even though they have been criticised for focusing too much on symbols and representation). Therefore, those studies focusing on physical materials and materialites, sensory experiences, embodiment, and material agency have recently become more and more important. This article has given an overview of the three most prevalent thematic and theoretical strands of the study of material culture: objects as symbols especially in the consumer culture, material agency and practice theory as well as discussing some methodological suggestions for the material culture studies. To conclude, even though on the one hand we could argue that when it comes to the study of material culture there indeed exists a certain hierarchy of „old“ topics that relate to museums or traditional crafts and „new“ and modern materialities, such as smart phones or genetically modified organisms. However, dichotomies like this are often artificial and do not show the whole picture: contemporary children are often as proficient in playing cat’s cradle as they are with video games (Jackson 2016). Thus, studying various (everyday) material objects and entities is still topical and the various theories discussed in this article can help to build both theoretical and empirical bridge between different approaches. Therefore, there is still a lot to do in this regard and we invite researchers to study objects form all branches of material culture, be they 19th century beer mugs in the collections of the Estonian National Museum that can help us to better give meaning to our past, or the digital and virtual design solutions that can give our academic research an applied direction. Keywords: material culture, artefacts, consumption, practice, agency, research methods

Nurses and midwives can be instrumental to global efforts to address child abuse and neglect through a public health approach of prevention and early intervention. However, there is limited understanding of nurses’ and midwives’ roles, and no international or local guidelines to inform and evaluate their safeguarding practices. The aim of this modified Delphi study was to build consensus on the nature and scope of nursing and midwifery practice in safeguarding children in Australia. Sixty-four statements located within seven clusters were developed from a literature review and nursing and midwifery practice standards. Participants ( N = 102) were nurses and midwives working with children in diverse contexts. They were asked to indicate the importance of each statement to their practice setting. Consensus (80%) was achieved on all statements in Round Two. Findings highlight that participating nurses and midwives agreed safeguarding children is a core component of their practice in diverse child-focussed settings. Findings can inform ongoing discussions about development of nursing and midwifery practice standards and guide effective workforce preparation, education, support and resourcing. Further research about ongoing development of nursing and midwifery roles in safeguarding children is essential to explore how to most effectively mobilise these professions to prevent child abuse and neglect.

Abstract Introduction Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data. Patients and methods We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions – i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT – on good functional outcome (modified Rankin Scale ≤2) were estimated. We used three statistical regression-based approaches that vary in assumptions regarding the source of unmeasured confounding: individual-level (two subtypes), ecological, and instrumental variable analyses. In the latter, the preference for using the interventions in each hospital was used as an instrument. Results Use of IVT (range 66–87%) and GA (range 0–93%) varied substantially between hospitals. For IVT, the individual-level (OR ~ 1.33) resulted in significant positive effect estimates whereas in instrumental variable analysis no significant treatment effect was found (OR 1.11; 95% CI 0.58–1.56). The ecological analysis indicated no statistically significant different likelihood (β = − 0.002%; P = 0.99) of good functional outcome at hospitals using IVT 1% more frequently. For GA, we found non-significant opposite directions of points estimates the treatment effect in the individual-level (ORs ~ 0.60) versus the instrumental variable approach (OR = 1.04). The ecological analysis also resulted in a non-significant negative association (0.03% lower probability). Discussion and conclusion Both magnitude and direction of the estimated treatment effects for both interventions depend strongly on the statistical approach and thus on the source of (unmeasured) confounding. These issues should be understood concerning the specific characteristics of data, before applying an approach and interpreting the results. Instrumental variable analysis might be considered when unobserved confounding and practice variation is expected in observational multicenter studies.

Considering the novelty of the area of a 2-year study on impact of family loss and separation on refugee youth in Toronto, the research team decided to conduct a scoping review of the existing literature as a foundation document that included the extent, range, geography, and nature of research on the topic of interest. A collaborative co-design approach for this review bought in wisdom from relevant stakeholders. Arksey and O’Malley’s framework was modified for this scoping review that substantively identified the extent and magnitude of past research, research gaps, and best practice models for conducting such exploratory research on novel ideas. This framework yielded desired output, such as selection and characteristics of sources of evidence, critical appraisal within sources of evidence, and synthesis of results for the next steps of the research. Prudent researchers and professionals in this area of research, service provider agencies, and a university librarian were consulted. The PRISMA-ScR model saved time and ensured the appropriate yield of the search items. The quality of the review process was evaluated by the Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist tool. This article displays a practical example of how the scoping review process was instrumental in a community-based research project with separated refugee youth to generate the foundational evidence for broader research. This quality-embedded process of collecting and charting data for a scoping review is transferable to similar research initiatives. The flexibility and reproducibility of this review method are commendable.

Abstract Current health care practices do not adequately meet the health needs of older adult war veterans. Increasingly, animal assisted interventions (AAIs) are being identified as potentially beneficial for this population. To explore this, this study, informed by a One Health framework, measured the outcomes of the St. John Ambulance ( SJA ) Therapy Dog Program on the wellbeing of older adults at a Veterans Affairs Canada residence in Saskatchewan, Canada. Over a 13 week period, two groups of veterans, of 8 and 10 in number respectively, who were living at the residence were purposively selected to participate in weekly individual and group therapy dog visits. The type of visit varied according to the level of cognition of the veteran, with lower level individuals visiting in a group format. A modified instrumental case study design was applied incorporating both quantitative and qualitative approaches, including questionnaires, focus groups, case history, and observation. Quantitative measures were analyzed descriptively, and qualitative measures were analyzed thematically. The findings revealed a positive influence of therapy dogs on memory recollection and reminiscence among veterans; positive health impacts on veteran wellbeing as understood through the significance of the therapy dog team encounter; and, perceived meaningful support from the therapy dog handlers and love and support from the therapy dogs. The analysis is contextualized within the growing literature on AAIs and contributes important insights to adequately meeting the needs of older adult war veterans, and potentially for the increasing population of recent war veterans. Additionally, key policy, practice, and research recommendations are proposed, including further investigation of therapy dog visits.

Introduction The aim of this study is to understand the patterns of occupations among community-dwelling older adults in Singapore. The objectives are to describe their occupational engagement using the Activity Card Sort Singapore, understand their occupational preferences and perceived barriers and facilitators to engagement. Methods A convergent parallel mixed-method study was conducted over a 5-month period in 2018. Purposive and snowball sampling were used to recruit the participants. Individual 1-h interviews were conducted at participants’ homes. Quantitative data collected include demographic information, Modified Barthel Index scores and activity engagement based on the Activity Card Sort Singapore. Qualitative data was collected using semi-structured interviews. Results 105 participants were enrolled in the study. Overall, older adults engaged mostly in instrumental and social activities. However, leisure and social activities were most preferred. Gender, educational level and age were found to influence occupational engagement. Overall, six main themes relating to perceived barriers and facilitators to occupational engagement were identified: cognition and physical status, self-efficacy, resources, affect and meaningfulness, social influence and environmental factors. Conclusion The findings from this study provided insights into the occupational patterns of community-dwelling older adults in Singapore and their perceived barriers and facilitators to engagement. Recommendations for practice were identified.

Existing methods of anesthesia, drugs used in the field of breast plastic surgery have a number of features compared to anesthesia in the practice of general surgery. In particular, techniques of regional blockades, such as interfascial blocks PECS 1 and PECS 2 are taken into account. Their effectiveness in comparison with standard methods of anesthesia for different types of interventions on the breast is subject to further discussion. Thus, the article presents the results of efficiency in the implementation of the author's development - a modified PECS-block during reconstructive and aesthetic surgery on the mammary glands. Material and methods. During 2018-2020, 58 women (average age 36,8 ± 10,8 years) were included in the prospective study, who underwent low-flow inhalation anesthesia with sevoflurane during surgery, and in the postoperative period were divided into two subgroups: 1) subgroup 1, in whom regional anesthesia according to the author's method used; 2) subgroup 2 with nalbuphine analgesia. At the first visit, clinical and laboratory, instrumental ultrasound examination, completed informed consent cards of patients, as well as long-term observation cards were filled in. The method of postoperative analgesia developed by the author's method is, in essence, a combination of PECS 1 and PECS 2 blockades. The anesthetic solution was administered so as to effectively block the intercostal nerves that run along the posterior surface of the chest and extend outward into the parasternal region. For statistical analysis of the obtained results we used a package of general statistic data “Statistica for Windows” version 6.0 (Stat Soft inc., USA). At p<0, 05, the difference was considered statistically significant. Results. It was found that the use of modified PECS-block was characterized by a shortening of the verticalization time by 58,8%, compared with the introduction of nalbuphine and 2,16 times in the absence of postoperative anesthesia. The absolute efficiency (AE,%) of the modified PECS-block relative to the verticalization time was 68,0% higher compared to the use of nalbuphine, with a probable relative efficiency (RR, p<0,05) and the odds ratio (OR, p<0,05). 3 hours after the intervention of AE modified PECS-block relative to the intensity of pain less than 1 point was 89,0%, with a clinical efficiency of 60,0% relative to the use of nalbuphine, probable RR (p<0,05) and OR (p<0,05). The majority of patients who underwent modified PECS-block rated their physical and motor activity by more than 2 points (86,0%), while using nalbuphine the part was only 43.0% (p<0,05). The reversal, moderate regression relationship between pain self-esteem and physical activity (r=-0.46, p<0.05) persisted for 3 hours after the intervention. Against the background of the modified PECS block, there was no cases of postoperative nausea, in contrast to nalbuphine (AE – 18,0%, RR – 0,02 [0,003-0,97], p<0,05; HS – 0,02 [0,004-0,87], p<0,05). Regarding the parameters of cardio hemodynamics, it was found that against the background of nalbuphine there was an increase in heart rate to 29,3% after 1 hour, by 48,6 and 39,7% after 3 and 8 hours, compared with the modified PECS-block. The tendency to high (greater than 140 mm Hg) and high normal (greater than 130 mm Hg) blood pressure on the background of nalbuphine, in contrast to the modified PECS-block, where the CAT values during the 1st day stayed in the range of optimal pressure (110-130 mm Hg).

Abstract Objectives To evaluate the force delivered by removable thermoplastic appliances (RTAs, aligners), altered with Hilliard precision thermopliers, on an upper central incisor to tip it in the palatal and vestibular directions. Materials and methods A total of 10 aligners made from Ideal Clear® (polyethylene terephthalate glycol copolyester, PET-G) with a thickness of 1 mm were used in force analysis. Different-sized spot-thermoformed protuberances (bumps) were generated by activating the thermoplier (thin and thick) up to 30°, 60° and 90° in the centre of the palatal and vestibular surfaces of the aligner in 15° steps. The tipping (Fx) and intrusive (Fz) force components were measured on the isolated upper central incisor as part of a standardized resin model, with or without vertical loading by a weight equivalent. Results Thermoplier activation at 30°, 60° and 90° resulted in different bump heights. The analysis revealed significantly higher Fx and Fz values with increasing bump heights for every activation step in all cases (p < 0.0001, respectively). Overall, the values of the Fx force component were higher than those observed for Fz. Significant differences between the palatal and vestibular tipping procedures were found depending on the resulting force components when the thin thermoplier was used; in contrast, the thick thermoplier resulted in a larger dispersion of the force magnitudes. Conclusions Aligners modified with Hilliard precision thermopliers showed altered biomechanical parameters. This approach could be an option for treatment modification. Clinical relevance The instrumental examination provided informative results for daily practice, as activation, force dosage and different force values under chewing pressure can be estimated more precisely based on the determined force levels.

Pulse wave velocity (PWV) could be used as a predictor of the course of CVD. A carotid–femoral PWV above 10 m/s was determined in 2018 ESC/ESH Guidelines for the Management of Arterial Hypertension as factors influencing cardiovascular risk in patients with hypertension. Exactly the carotid–femoral PWV is considered the gold standard for arterial stiffness assessment in clinical practice. Usually PWV predict the long-term outcomes (in a few month or years) of the development of cardiovascular events. There are a lack of information about using PWV as prognostic marker in acute coronary syndrome. The aim: to study the features of the clinical course of the non-ST-segment elevation acute coronary syndrome (NSTE-ACS) depending on the carotid–femoral pulse wave velocity (PWV) and find out possibilities of using PWV as marker of intrahospital clinical outcomes. Materials and methods. 80 patients were recruited. All patients were hospitalized into myocardial infarction departments with a diagnosis of NSTE-ACS. Patients over 18 years of age who were hospitalized for the first 3 days after the onset of pain and signed the agreement to participate in the study were included. Exclusion criteria were the moderate or severe anemia, severe chronic renal failure, and chronic diseases in the acute or decompensated stage. The average age of patients was 64.5 [55; 72] years. Male patients are 45 persons (56.3%). Were performed standard general laboratory and instrumental examinations. Measuring of free DNA levels, and ischemic albumin were performed on 1st and 6th days of hospitalization. Also noninvasive measured of PWV. Noninvasive PWV measurements were performed after stabilization of the hemodynamic for excluding incorrect results due to its strong connection with current blood pressure. 2 groups were formed depend on the PWV above or less than 10 m/s. The analysis was performed by using non-parametric statistical methods (Mann-Whitney test, Wilcoxon T-test, Pearson's χ2 test). The results were considered statistically significant at p <0.05. Results. Patients did not have a statistically significant difference in such parameters as gender, anamnestic data (hypertension, myocardial infarction, chronic heart failure, atrial fibrillation, and diabetes mellitus), hemodynamic parameters, ECG changes at the moment of hospitalization and laboratory parameters. There was a tendency that patients with elevated PWV were older (69 [55.3; 77.8] years vs. 63.5 [55.3; 70.8] years) (p = 0.077). Such parameters as left ventricular ejection fraction and discharge diagnosis were similar. Patients with elevated PWV had significantly more active cytolysis. This is proved by significantly higher levels of free DNA both on the first day and on the 6th day of hospitalization. In patients with normal PWV levels, free DNA decreased in dynamics, while in patients with PWV above 10 m / s this marker remained at the same level. It was also founded that patients with elevated PWV had delayed ischemia (on the 6th day of hospital stay), which was confirmed by a higher level of ischemia-modified albumin than in the group with PWV less 10 m / s. Conclusions. Patients with increased and normal PWV have quite similar group characteristic according typical clinical signs, results of laboratory and instrumental investigations. Due to the studying of free DNA and ischemia-modified albumin were clarified that PWV above 10 m/s is associated with delayed ischemia and longer tissue damage and could be used to predict it.

The article discusses topical issues and analyzes the problems related to the problem of packing blocks of different sizes in the metric of binary space to solve the problem of optimal placement of two-dimensional objects on the cutting map in order to minimize the cost of cutting them. To solve this kind of problems, it is necessary to resort to the practice of using bioinspired logic based on the behavior of a pack of gray wolves in nature. On this basis, a modified algorithm was developed that allows one to effectively solve the problem of two-dimensional packing, after which the corresponding experiments were carried out to prove its effectiveness. Based on the effectiveness of this method, a software product was developed and implemented using the developed architecture for finding a solution and promising technologies of augmented virtual reality, which allows the result of the algorithm to be displayed on actual smartphones. The main advantages of applying the principles of integration of virtual and augmented reality technologies are presented and described in detail, a detailed overview and analysis of the problems and prospects for solving packaging problems, their types are given. The relevance of research in this work is explained. After that, the main task of this work is explained, which can be formulated as: finding the optimal principle of filling a two-dimensional container with specified objects. Arguments are made that packing problems are not abstract, but many where applicable. Namely, specific examples of in which areas of industry these problems are applied and to whom the algorithms for their solution help. Each type of packaging problem is explained with examples, followed by an explanation of promising augmented and virtual reality technologies. The most important practically significant result of the research of the indicated problem is the developed software and instrumental design platform in the modern programming language Swift. Despite its recent popularity, this language has almost completely supplanted its main competitor Objective-C, and the ability to support plugins such as Vuforia makes it ideal for application development. The developed software product has a simple and intuitive interface, optimized as much as possible for the weakest devices, which allows you to effectively set the variables in the problem and quickly obtain a solution to the problem. The results of the experimental studies performed allow us to state with confidence about the effectiveness of the program, the obtained theoretical estimates of the time complexity and effectiveness of the proposed approaches and algorithms, including the genetic algorithm, which uses the new solution coding mechanism proposed in the work.

Abstract: Introduction: Most instruments to assess physicians’ delivery of bad news have been developed for patients with cancer and then adapted to other contexts. In clinical practice, some news may not be considered bad by the physicians but may have an important negative impact on the patients’ life. Yet, instruments to assess this communication across diverse clinical settings are needed. Objective: To develop, from the patients’ perspective, an instrument to assess how physicians deliver bad news in clinical practice. Method: This study was conducted using an exploratory qualitative approach by means of semi-structured, in-depth interviews with 109 patients from two referral hospitals in Brazil. Content analysis was used to generate categories, from which the initial instrument items were developed. The clarity and relevance of the items were evaluated by a committee of 11 medical professionals and 10 patients. Results: The instrument included items about the physicians’ attitudes, such as attention, respect, and sincerity, as well as items about sharing information using language that patients could understand. The initial instrument had 19 items, answered in a 5-point Likert scale with labeled endpoints. After evaluation by the committee of judges, 2 items were modified, and 3 were excluded. The final instrument thus had 16 items. Conclusion: A new 16-item instrument was developed from the patients’ perspective to assess physicians’ delivery of bad news. After additional validation, this instrument may be useful in real and diverse bad news settings in clinical practice.

Debate has occurred over many years regarding the ideal procedural skill set for a graduate of a General Internal Medicine (GIM) training program. A mixed methods study was used to establish a list of mandatory and selective procedural skills for all graduates of a 2-year PGY4/5 GIM subspecialty training program. This list was informed by previous literature, a survey of Canadian Society of Internal Medicine (CSIM) members, and a roundtable discussion at the October 2015 CSIM meeting in Prince Edward Island. The study illustrates the remarkable diversity of practice profiles and procedural skills performed by general internists in Canada.RésuméDepuis nombre d’années, l’ensemble idéal d’habiletés qu’un diplômé d’un programme de médecine interne générale (MIG) doit maîtriser fait l’objet de débats. Une étude à méthodologie mixte a été utilisée pour dresser une liste d’habiletés particulières et obligatoires que doivent maîtriser tous les diplômés de 4e et de 5e année d’un programme comportant deux ans de surspécialité en médecine interne générale. Cette liste a été établie à partir de documentation existante, d’un sondage auprès des membres de la Société canadienne de médecine interne (SCMI) et d’une table ronde tenue lors du Congrès de la Société en octobre 2015 à l’Île-du-Prince-Édouard. L’étude montre la remarquable diversité des profils de pratique et des habiletés déployées par les internistes généraux au Canada.Canadian General Internists have had longstanding passionate debates regarding which procedures should be performed competently by graduates of General Internal Medicine (GIM) programs.1–4 Previous studies have shown a diversity of procedures performed in practice, with insufficient consensus as to which procedures should be routinely learned by GIM graduates.3,4 Concurrently literature suggests that Canadian GIM Graduates are not sufficiently prepared to perform procedural skills in practice.3GIM training is now defined as a 2-year PGY 4/5 program which builds on the “core” internal medicine training programs.5 Current (2016) objectives of training for Internal Medicine (IM)5 indicate that all IM residents must be competent in the procedures in Table 1. Additionally, the GIM (PGY 4/5)5 programs mandate competence in further procedures. (Table 1). As of 2016, these would be considered mandatory procedural skills for ALL GIM graduates and therefore each GIM program must be able to provide training for proficiency in the skills in Table 1.Table 1. Procedural Skills in Internal Medicine and General Internal Medicine Objectives of Training as of January 2016The GIM documents were deliberately written to allow flexibility in training, ensuring that GIM trainees have the opportunity to train in additional procedures tailored to their future practice setting. Operationally this has been difficult to implement for 2 major reasons: (1) many residents do not know their future practice location in sufficient time to plan procedural training and (2) programs have had difficulty developing multiple elective training opportunities which may or may not be used.The Royal College of Physicians and Surgeons of Canada (RCPSC) has launched the Competence by Design project with competency based medical education being anticipated to be initiated in GIM programs as of 2018.6 Competence by Design will focus training on outcomes ensuring that graduates are prepared to meet the needs of their future patients and communities.6 As part of this process, the GIM Specialty Committee is obtaining as much data as possible to inform desired educational outcomes for GIM graduates. A mixed method study was developed to provide the RCPSC GIM Specialty Committee with data on which to base decisions regarding which procedural skills should be taught in GIM PGY 4/5 residencies as of 2018. The primary objective was to develop a list of procedural skills for GIM training programs that is separated into the following categories:Mandatory skills – all graduates of all GIM programs must be competent in these procedures.Selective skills – community need requires a sufficient number of GIM graduates to be proficient in these skills, such that all GIM programs must offer the training.Elective skills – a few graduates require these skills to fill community need, but not all GIM programs must offer the training. These procedural skills would not be written into RCPSC documents, but program directors and residents would need to be aware they may be required.The study results were triangulated with previous literature on procedural training for Canadian General Internists3,4 to allow the GIM Specialty Committee (national standard-setting body) to come to a final determination of procedural training standards for Canadian General Internists.MethodsThis was a mixed methods study triangulating data from multiple sources. The study was considered exempt by the University of Saskatchewan research ethics board. The overall intent of the project was to seek the opinions of practicing general internists, GIM program directors and the GIM RCPSC Specialty Committee (the national body which develops standards) regarding which procedures should be learned.Previous Canadian studies3,4 were reviewed in terms of scope of practice and prevalence of procedural skills performed by Canadian General Internists. The initial cohort of Practice Eligibility route applicants for GIM certification was reviewed as to which procedural skills were self- reported to be performed by Canadian General Internists. An electronic survey of Canadian Society of Internal Medicine (CSIM) Members was performed in fall 2015. The data from the preliminary survey was collated and presented at a plenary session at the October 2015 CSIM meeting to validate and gain further information from an additional cohort. Data were compared across previous studies, electronic survey, consensus conference and written comments collated after the conference (Table 2).Table 2. Summary Table of Sources Reviewed to Come to Final ConsensusProcedures were then divided into those for which a clear consensus indicated they should be mandatory, selective or elective; and those for which there was divergence of opinion. The final lists and the data behind the areas with lack of consensus were presented to the RCPSC GIM Specialty Committee (national standards setting committee) in February 2016. A modified Delphi technique was employed to determine the final category for each procedure.For those areas without consensus after that meeting there was further online voting. Table 2 summarizes the data obtained from each component.ResultsThe CSIM online survey (fall 2015) had 150 respondents (presumed 127 full members), an 11% response rate for full members. 48% of respondents had all subspecialists available in their context; 16% had none. Respondents came from a diversity of settings: rural, remote, urban, and ambulatory and hospital based. Approximately 28% were remote or rural, with 72% urban.Information was triangulated from multiple data sources to assign procedures as mandatory (Table 3) or selective (Table 4). All of the current procedures listed in the internal medicine and GIM objectives (Table 1) were confirmed to be mandatory.Table 3. Mandatory GIM Graduate Procedural Skills Procedures for which there is a consensus across multiple data areas that the skill should be mandatory.*Table 4. Selective GIM Graduates Procedural Skills Procedures for which there is a consensus across multiple data areas they should be selective skills. That is available through each GIM program for someone with a defined need for the skill but not needed by each graduate. Those skills for which further clarification as to scope of practice is needed are listed in Table 6.Table 5 illustrates the great diversity of procedures done by general internists in Canada with every procedure surveyed being done by at least one General Internist throughout Canada.Table 5. Diversity of GIM Procedural Skills Skills representing the diversity of skills that may be required by General Internists in different Canadian settings. Procedural skills that are used by at least one General Internist throughout Canada in their practice.Comments from the CSIM online survey illustrated several main themes applicable to GIM training. There is a need to ensure that graduates who need procedural training for their future practice setting receive adequate training to be competent on graduation. At the same time there is a need to avoid dilution of learning opportunities by ensuring that graduates who will actually perform the procedures that they learn through specialized training opportunities have the ability to learn the procedure.Ultrasound-guided bedside procedures (in particular central venous access, paracentesis, and thoracentesis) were repeatedly noted to merit increased prominence in GIM training. Another theme emerging from the survey was that procedures should not take precedence over ensuring good generalist skills – seeing the “whole” patient, diagnostic skills, outpatient skills. Some respondents commented that general internists should be engaged more heavily in training future graduates in procedures as opposed to leaving this to other subspecialists who may be unwilling/unable to train GIM graduates. Individuals also commented that practice-long maintenance of competence was important; such as learning skills “just in case” was not a good strategy.Ultrasound-guided bedside procedures figured prominently in the online CSIM responses. At least 75 respondents took the time to write in various ultrasound-guided bedside procedures as important. The perception was that ultrasound-guided thoracentesis, paracentesis, central line insertion should be learned by GIM graduates.The validation process by the expert stakeholder group was able to elucidate several areas where further clarification was needed prior to final assignment of a procedure to a category (Table 6). For example, participants did not have a shared mental model as to the definition or level of competency that would need to be obtained for several of the procedures (Table 6) including echocardiography, bronchoscopy, and pacemaker interrogation/reprogramming. This is leading to ongoing discussion and information gathering to define not only which procedures should be learned by GIM graduates, but also the appropriate scope of practice.Table 6. Procedures for which Clarification of Level of Expertise is Needed Prior to Assigning to a Final CategoryMany individuals self- identified with both a rural/remote practice and an urban practice; due to small numbers, it was difficult to correlate practice type with procedural practice. However; of note for those currently performing transvenous pacemaker insertion, over 50% reported practicing at least part time in an urban centre.Discussion and ConclusionsGeneral Internists practice in a wide variety of contexts and practice settings. The final list of procedural skills needed by GIM graduates will vary for each graduate; however, this study managed to solidify a list of mandatory skills for all graduates. A wide array of procedural skills are practiced by general internists across Canada. GIM program directors and GIM graduates need to be aware of this diversity and plan the flexible portion of training accordingly.Several of the areas had a divergence of opinion because of an identified lack of common understanding regarding the level of competence to which the procedure should be performed by all or some graduates for example echocardiography. (Table 6) The GIM RCPSC Specialty Committee will be exploring these further to develop explicit recommendations for the level of competence for a GIM graduate in any one of these procedures if they become a Selective. As well some of the “procedural skills” on the CSIM survey such as insulin pump downloads have been reintegrated with other medical expert content due to their integral function in the care of patients with diabetes.As Competence by Design becomes a reality for GIM, there is an ideal opportunity to utilize the transition to practice portion of training to solidify the individualized procedural training skills for each Canadian GIM graduate.As far as we are aware this is the first effort to triangulate data on Canadian General Internists from the literature, a national specialty society, and the Royal College standard-setting committee. The information gained from both the online survey of members and the large group discussion at CSIM was instrumental in improving training standards for GIM. The linkage between practicing physicians and the educational community brought key insights into training GIM graduates for the future. We are grateful for the participation of the members of the practicing GIM community for participating so readily in this endeavour!AcknowledgementsWe are grateful to the Canadian Society of Internal Medicine (CSIM) for support in conducting the survey of members and the production of the Round Table in October 2015.Canadian Society of Medicine (CSIM) is gratefully acknowledged for support of this project. Thanks to Ms. Zoë Stevens-Lavigne, administrative coordinator (CSIM) for survey assistance. All survey participants and the participants of the CSIM Roundtable (2015) are gratefully acknowledged their participation.

An adjunct faculty member and graduate instructional assistant (GIA) introduced inquiry-based activities into a 20-student undergraduate analytical instrumental analysis (AIA) lecture course, and reflect on their teaching assumptions, practices and experiences. The increased need for interdisciplinary scientific programs now has an AIA course serving multiple Bachelor of Science degrees in environmental sciences, forensic sciences, molecular biology, and secondary science education. However, we learned degree specialization also introduces into a course, student populations possessing heterogeneous prior knowledge, making an instructor’s rendering of student prerequisite skills a greater challenge. Guided by a pretest assessment, instructional activities were modified or developed by the authors and aimed at enhancing student engagement and motivation to mitigate prior knowledge gaps, improve analytical problem-solving skills, and facilitate a deeper understanding of modern instrumentation design and function. Detailed activity rationale and descriptions are presented. Activities included using readily available Internet bioinformatics and database tools for analytical problem-solving; demonstrating principles of electronic hardware and software design and integration; and creating interdisciplinary scientific narratives using biological, environmental, and industrial molecular exemplars. Our teaching reflections reference weekly post-lecture instructor/GIA discussions, strategic student questioning, collaborative classroom activity observations, and formative assessments. We propose continual instructional reflection is essential for a course serving multiple specialized degrees programs in a scientific field and facilitates preparation for students entering the workforce or graduate school. Further, our observations suggest inquiry-based, real-world activities relevant to modern instrumentation and its applications, assisted students in resolving heterogeneous prior knowledge gaps.

Abstract Background Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness. Previously, we co-designed a new behaviour change health promotion intervention (“HomeHealth”) to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes. Aim To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU). Methods Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65 + , with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted. Discussion This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective. Trial registration ISRCTN, ISRCTN54268283. Registered 06/04/2020.

Introduction The counterculture that arose during the 1960s and 1970s left lasting social and political reverberations in developed nations. This was a time of increasing affluence and liberalisation which opened up remarkable political opportunities for social change. Within this context, an array of new social movements were a vital ingredient of the ferment that saw existing norms challenged and the establishment of new rights for many oppressed groups. An expanding arena of concerns included the environmental damage caused by 200 years of industrial capitalism. This article examines one aspect of a current environment movement in Australia, the anti-Coal Seam Gas (CSG) movement, and the part played by participants. In particular, the focus is upon one action that emerged during the recent Bentley Blockade, which was a regional mobilisation against proposed unconventional gas mining (UGM) near Lismore, NSW. Over the course of the blockade, the conventional ritual of waving at passers-by was transformed into a mechanism for garnering broad community support. Arguably, this was a crucial factor in the eventual outcome. In this case, we contend that the wave, rather than a countercultural artefact being appropriated by the mainstream, represents an everyday behaviour that builds social solidarity, which is subverted to become an effective part of the repertoire of the movement. At a more general level, this article examines how counterculture and mainstream interact via the subversion of “ordinary” citizens and the role of certain cultural understandings for that purpose. We will begin by examining the nature of the counterculture and its relationship to social movements before discussing the character of the anti-CSG movement in general and the Bentley Blockade in particular, using the personal experience of one of the writers. We will then be able to explore our thesis in detail and make some concluding remarks. The Counterculture and Social Movements In this article, we follow Cox’s understanding of the counterculture as a kind of meta-movement within which specific social movements are situated. For Cox (105), the counterculture that flourished during the 1960s and 1970s was an overarching movement in which existing social relations—in particular the family—were rejected by a younger generation, who succeeded in effectively fusing previously separate political and cultural spheres of dissent into one. Cox (103-04) points out that the precondition for such a phenomenon is “free space”—conditions under which counter-hegemonic activity can occur—for example, being liberated from the constraints of working to subsist, something which the unprecedented prosperity of the post WWII years allowed. Hence, in the 1960s and 1970s, as the counterculture emerged, a wave of activism arose in the western world which later came to be referred to as new social movements. These included the civil rights movement, women’s liberation, pacifism and the anti-nuclear and environment movements. The new movements rejected established power and organisational structures and tended, some scholars argued, to cross class lines, basing their claims on non-material issues. Della Porta and Diani claim this wave of movements is characterised by: a critical ideology in relation to modernism and progress; decentralized and participatory organizational structures; defense of interpersonal solidarity against the great bureaucracies; and the reclamation of autonomous spaces, rather than material advantages. (9) This depiction clearly announces the countercultural nature of the new social movements. As Carter (91) avers, these movements attempted to bypass the state and instead mobilise civil society, employing a range of innovative tactics and strategies—the repertoire of action—which may involve breaking laws. It should be noted that over time, some of these movements did shift towards accommodation of existing power structures and became more reformist in nature, to the point of forming political parties in the case of the Greens. However, inasmuch as the counterculture represented a merging of distinctively non-mainstream ways of life with the practice of actively challenging social arrangements at a political level (Cox 18–19; Grossberg 15–18;), the tactic of mobilising civil society to join social movements demonstrates in fact a reverse direction: large numbers of people are transfigured in radical ways by their involvement in social movements. One important principle underlying much of the repertoire of action of these new movements was non-violence. Again, this signals countercultural norms of the period. As Sharp (583–86) wrote at the time, non-violence is crucial in that it denies the aggressor their rationale for violent repression. This principle is founded on the liberal notion, whose legacy goes back to Locke, that the legitimacy of the government rests upon the consent of the governed—that is, the people can withdraw their consent (Locke in Ball & Dagger 92). Ghandi also relied upon this idea when formulating his non-violent approach to conflict, satyagraha (Sharp 83–84). Thus an idea that upholds the modern state is adopted by the counterculture in order to undermine it (the state), again demonstrating an instance of counterflow from the mainstream. Non-violence does not mean non-resistance. In fact, it usually involves non-compliance with a government or other authority and when practised in large numbers, can be very effective, as Ghandi and those in the civil rights movement showed. The result will be either that the government enters into negotiation with the protestors, or they can engage in violence to suppress them, which generally alienates the wider population, leading to a loss of support (Finley & Soifer 104–105). Tarrow (88) makes the important point that the less threatening an action, the harder it is to repress. As a result, democratic states have generally modified their response towards the “strategic weapon of nonviolent protest and even moved towards accommodation and recognition of this tactic as legitimate” (Tarrow 172). Nevertheless, the potential for state violence remains, and the freedom to protest is proscribed by various laws. One of the key figures to emerge from the new social movements that formed an integral part of the counterculture was Bill Moyer, who, in conjunction with colleagues produced a seminal text for theorising and organising social movements (Moyer et al.). Many contemporary social movements have been significantly influenced by Moyer’s Movement Action Plan (MAP), which describes not only key theoretical concepts but is also a practical guide to movement building and achieving aims. Moyer’s model was utilised in training the Northern Rivers community in the anti-CSG movement in conjunction with the non-violent direct action (NVDA) model developed by the North-East Forest Alliance (NEFA) that resisted logging in the forests of north-eastern NSW during the late 1980s and 1990s (Ricketts 138–40). Indeed, the Northern Rivers region of NSW—dubbed the Rainbow Region—is celebrated, as a “‘meeting place’ of countercultures and for the articulation of social and environmental ideals that challenge mainstream practice” (Ward and van Vuuren 63). As Bible (6–7) outlines, the Northern Rivers’ place in countercultural history is cemented by the holding of the Aquarius Festival in Nimbin in 1973 and the consequent decision of many attendees to stay on and settle in the region. They formed new kinds of communities based on an alternative ethics that eschewed a consumerist, individualist agenda in favour of modes of existence that emphasised living in harmony with the environment. The Terania Creek campaign of the late 1970s made the region famous for its environmental activism, when the new settlers resisted the logging of Nightcap National Park using nonviolent methods (Bible 5). It was also instrumental in developing an array of ingenious actions that were used in subsequent campaigns such as the Franklin Dam blockade in Tasmania in the early 1980s (Kelly 116). Indeed, many of these earlier activists were key figures in the anti-CSG movement that has developed in the Rainbow Region over the last few years. The Anti-CSG Movement Despite opposition to other forms of UGM, such as tight sands and shale oil extraction techniques, the term anti-CSG is used here, as it still seems to attract wide recognition. Unconventional gas extraction usually involves a process called fracking, which is the injection at high pressure of water, sand and a number of highly toxic chemicals underground to release the gas that is trapped in rock formations. Among the risks attributed to fracking are contamination of aquifers, air pollution from fugitive emissions and exposure to radioactive particles with resultant threats to human and animal health, as well as an increased risk of earthquakes (Ellsworth; Hand 13; Sovacool 254–260). Additionally, the vast amount of water that is extracted in the fracking process is saline and may contain residues of the fracking chemicals, heavy metals and radioactive matter. This produced water must either be stored or treated (Howarth 273–73; Sovacool 255). Further, there is potential for accidents and incidents and there are many reports—particularly in the United States where the practice is well established—of adverse events such as compressors exploding, leaks and spills, and water from taps catching fire (Sovacool 255–257). Despite an abundance of anecdotal evidence, until recently authorities and academics believed there was not enough “rigorous evidence” to make a definitive judgment of harm to animal and human health as a result of fracking (Mitka 2135). For example, in Australia, the Queensland Government was unable to find a clear link between fracking and health complaints in the Tara gasfield (Thompson 56), even though it is known that there are fugitive emissions from these gasfields (Tait et al. 3099-103). It is within this context that grassroots opposition to UGM began in Australia. The largest and most sustained challenge has come from the Northern Rivers of New South Wales, where a company called Metgasco has been attempting to engage in UGM for a number of years. Stiff community opposition has developed over this time, with activists training, co-ordinating and organising using the principles of Moyer’s MAP and NEFA’s NVDA. Numerous community and affinity groups opposing UGM sprang up including the Lock the Gate Alliance (LTG), a grassroots organisation opposing coal and gas mining, which formed in 2010 (Lock the Gate Alliance online). The movement put up sustained resistance to Metgasco’s attempts to establish wells at Glenugie, near Grafton and Doubtful Creek, near Kyogle in 2012 and 2013, despite the use of a substantial police presence at both locations. In the event, neither site was used for production despite exploratory wells being sunk (ABC News; Dobney). Metgasco announced it would be withdrawing its operations following new Federal and State government regulations at the time of the Doubtful Creek blockade. However it returned to the fray with a formal announcement in February 2014 (Metgasco), that it would drill at Bentley, 12 kilometres west of Lismore. It was widely believed this would occur with a view to production on an industrial scale should initial exploration prove fruitful. The Bentley Blockade It was known well before the formal announcement that Metgasco planned to drill at Bentley and community actions such as flash mobs, media releases and planning meetings were part of the build-up to direct action at the site. One of the authors of this article was actively involved in the movement and participated in a variety of these actions. By the end of January 2014 it was decided to hold an ongoing vigil at the site, which was still entirely undeveloped. Participants, including one author, volunteered for four-hour shifts which began at 5 a.m. each day and before long, were lasting into the night. The purpose of a vigil is to bear witness, maintain a presence and express a point of view. It thus accords well with the principle of non-violence. Eventually the site mushroomed into a tent village with three gates being blockaded. The main gate, Gate A, sprouted a variety of poles, tripods and other installations together with colourful tents and shelters, peopled by protesters on a 24-hour basis. The vigils persisted on all three gates for the duration of the blockade. As the number of blockaders swelled, popular support grew, lending weight to the notion that countercultural ideas and practices were spreading throughout the community. In response, Metgasco called on the State Government to provide police to coincide with the arrival of equipment. It was rumoured that 200 police would be drafted to defend the site in late April. When alerts were sent out to the community warning of imminent police action, an estimated crowd of 2000 people attended in the early hours of the morning and the police called off their operation (Feliu). As the weeks wore on, training was stepped up, attendees were educated in non-violent resistance and protestors willing to act as police liaison persons were placed on a rotating roster. In May, the State Government was preparing to send up to 800 police and the Riot Squad to break the blockade (NSW Hansard in Buckingham). Local farmers (now a part of the movement) and activist leaders had gone to Sydney in an effort to find a political solution in order to avoid what threatened to be a clash that would involve police violence. A confluence of events, such as: the sudden resignation of the Premier; revelations via the Independent Commission against Corruption about nefarious dealings and undue influence of the coal industry upon the government; a radio interview with locals by a popular broadcaster in Sydney; and the reputed hesitation of the police themselves in engaging with a group of possibly 7,000 to 10,000 protestors, resulted in the Office for Coal Seam Gas suspending Metgasco’s drilling licence on 15 May (NSW Department of Resources & Energy). The grounds were that the company had not adequately fulfilled its obligations to consult with the community. At the date of writing, the suspension still holds. The Wave The repertoire of contention at the Bentley Blockade was expansive, comprising most of the standard actions and strategies developed in earlier environmental struggles. These included direct blocking tactics in addition to the use of more carnivalesque actions like music and theatre, as well as the use of various media to reach a broader public. Non-violence was at the core of all actions, but we would tentatively suggest that Bentley may have provided a novel addition to the repertoire, stemming originally from the vigil, which brought the first protestors to the site. At the beginning of the vigil, which was initially held near the entrance to the proposed drilling site atop a cutting, occupants of passing vehicles below would demonstrate their support by sounding their horns and/or waving to the vigil-keepers, who at first were few in number. There was a precedent for this behaviour in the campaign leading up to the blockade. Activist groups such as the Knitting Nannas against Gas had encouraged vehicles to show support by sounding their horns. So when the motorists tooted spontaneously at Bentley, we waved back. Occupants of other vehicles would show disapproval by means of rude gestures and/or yelling and we would wave to them as well. After some weeks, as a presence began to be established at the site, it became routine for vigil keepers to smile and wave at all passing vehicles. This often elicited a positive response. After the first mass call-out discussed above, a number of us migrated to another gate, where numbers were much sparser and there was a perceived need for a greater presence. At this point, the participating writer had begun to act as a police liaison person, but the practice of waving routinely was continued. Those protecting this gate usually included protestors ready to block access, the police liaison person, a legal observer, vigil-keepers and a passing parade of visitors. Because this location was directly on the road, it was possible to see the drivers of vehicles and make eye contact more easily. Certain vehicles became familiar, passing at regular times, on the way to work or school, for example. As time passed, most of those protecting the gate also joined the waving ritual to the point where it became like a game to try to prise a signal of acknowledgement from the passing motorists, or even to win over a disapprover. Police vehicles, some of which passed at set intervals, were included in this game. Mostly they waved cheerfully. There were some we never managed to win over, but waving and making direct eye contact with regular motorists over time created a sense of community and an acknowledgement of the work we were doing, as they increasingly responded in kind. Motorists could hardly feel threatened when they encountered smiling, waving protestors. By including the disapprovers, we acted inclusively and our determined good humour seemed to de-escalate demonstrated hostility. Locals who did not want drilling to go ahead but who were nevertheless unwilling to join a direct action were thus able to participate in the resistance in a way that may have felt safe for them. Some of them even stopped and visited the site, voicing their support. Standing on the side of the road and waving to passers-by may seem peripheral to the “real” action, even trivial. But we would argue it is a valuable adjunct to a blockade (which is situated near a road) when one of the strategies of the overall campaign is to win popular backing. Hence waving, whilst not a completely new part of the repertoire, constitutes what Tilly (41–45) would call innovation at the margins, something he asserts is necessary to maintain the effectiveness and vitality of contentious action. In this case, it is arguable that the sheer size of community support probably helped to concentrate the minds of the state government politicians in Sydney, particularly as they contemplated initiating a massive, taxpayer-funded police action against the people for the benefit of a commercial operation. Waving is a symbolic gesture indicating acknowledgement and goodwill. It fits well within a repertoire based on the principle of non-violence. Moreover, it is a conventional social norm and everyday behaviour that is so innocuous that it is difficult to see how it could be suppressed by police or other authorities. Therein lies its subversiveness. For in communicating our common humanity in a spirit of friendliness, we drew attention to the fact that we were without rancour and tacitly invited others to join us and to explore our concerns. In this way, the counterculture drew upon a mainstream custom to develop and extend upon a new form of dissent. This constitutes a reversal of the more usual phenomenon of countercultural artefacts—such as “hippie clothing”—being appropriated or co-opted by the prevailing culture (see Reading). But it also fits with the more general phenomenon that we have argued was occurring; that of enticing ordinary residents into joining together in countercultural activity, via the pathway of a social movement. Conclusion The anti-CSG movement in the Northern Rivers was developed and organised by countercultural participants of previous contentious challenges. It was highly effective in building popular support whilst at the same time forging a loose coalition of various activist groups. We have surveyed one practice—the wave—that evolved out of mainstream culture over the course of the Bentley Blockade and suggested it may come to be seen as part of the repertoire of actions that can be beneficially employed under suitable conditions. Waving to passers-by invites them to become part of the movement in a non-threatening and inclusive way. It thus envelops supporters and non-supporters alike, and its very innocuousness makes it difficult to suppress. We have argued that this instance can be referenced to a similar reverse movement at a broader level—that of co-opting liberal notions and involving the general populace in new practices and activities that undermine the status quo. The ability of the counterculture in general and environment movements in particular to innovate in the quest to challenge and change what it perceives as damaging or unethical practices demonstrates its ingenuity and spirit. This movement is testament to its dynamic nature. References ABC News. Metgasco Has No CSG Extraction Plans for Glenugie. 2013. 30 July 2014 ‹http://www.abc.net.au/news/2013-01-22/metgasco-says-no-csg-extraction-planned-for-glenugie/4477652›. Bible, Vanessa. Aquarius Rising: Terania Creek and the Australian Forest Protest Movement. Bachelor of Arts (Honours) Thesis, University of New England, 2010. 4 Nov. 2014 ‹http://www.rainforestinfo.org.au/terania/Vanessa%27s%20Terania%20Thesis2.pdf›. Buckingham, Jeremy. Hansard of Bentley Blockade Motion 15/05/2014. 16 May 2014. 30 July 2014 ‹http://jeremybuckingham.org/2014/05/16/hansard-of-bentley-blockade-motion-moved-by-david-shoebridge-15052014/›. Carter, Neil. The Politics of the Environment: Ideas, Activism, Policy. 2nd ed. New York: Cambridge UP, 2007. Cox, Laurence. Building Counter Culture: The Radical Praxis of Social Movement Milieu. Helsinki: Into-ebooks 2011. 23 July 2014 ‹http://www.into-ebooks.com/book/building_counter_culture/›. Della Porta, Donatella, and Mario Diani. Social Movements: An Introduction. 2nd ed. Oxford: Blackwell Publishing, 2006. Dobney, Chris. “Drill Rig Heads to Doubtful Creek.” Echo Netdaily Feb. 2013. 30 July 2014 ‹http://www.echo.net.au/2013/02/drill-rig-heads-to-doubtful-creek/›. Ellsworth, William. “Injection-Induced Earthquakes”. Science 341.6142 (2013). DOI: 10.1126/science.1225942. 10 July 2014 ‹http://www.sciencemag.org.ezproxy.scu.edu.au/content/341/6142/1225942.full?sid=b4679ca5-0992-4ad3-aa3e-1ac6356f10da›. Feliu, Luis. “Battle for Bentley: 2,000 Protectors on Site.” Echo Netdaily Mar. 2013. 4 Aug. 2014 ‹http://www.echo.net.au/2014/03/battle-bentley-2000-protectors-site/›. Finley, Mary Lou, and Steven Soifer. “Social Movement Theories and Map.” Doing Democracy: The MAP Model for Organizing Social Movements. Eds. Bill Moyer, Johann McAllister, Mary Lou Finley, and Steven Soifer. Gabriola Island, Canada: New Society Publishers, 2001. Grossberg, Lawrence. “Some Preliminary Conjunctural Thoughts on Countercultures”. Journal of Gender and Power 1.1 (2014). Hand, Eric. “Injection Wells Blamed in Oklahoma Earthquakes.” Science 345.6192 (2014): 13–14. Howarth, Terry. “Should Fracking Stop?” Nature 477 (2011): 271–73. Kelly, Russell. “The Mediated Forest: Who Speaks for the Trees?” Belonging in the Rainbow Region: Cultural Perspectives on the NSW North Coast. Ed. Helen Wilson. Lismore: Southern Cross UP, 2003. 101–20. Lock the Gate Alliance. 2014. 15 July 2014 ‹http://www.lockthegate.org.au/history›. Locke, John. “Toleration and Government.” Ideals and Ideologies: A Reader. Eds. Terence Ball & Richard Dagger. New York: Pearson Longman, 2004 (1823). 79–93. Metgasco. Rosella E01 Environment Approval Received 2104. 4 Aug. 2014 ‹http://www.metgasco.com.au/asx-announcements/rosella-e01-environment-approval-received›. Mitka, Mike. “Rigorous Evidence Slim for Determining Health Risks from Natural Gas Fracking.” The Journal of the American Medical Association 307.20 (2012): 2135–36. Moyer, Bill. “The Movement Action Plan.” Doing Democracy: The MAP Model for Organizing Social Movements. Eds. Bill Moyer, Johann McAllister, Mary Lou Finley, and Steven Soifer. Gabriola Island, Canada: New Society Publishers, 2001. NSW Department of Resources & Energy. “Metgasco Drilling Approval Suspended.” Media Release, 15 May 2014. 30 July 2014 ‹http://www.resourcesandenergy.nsw.gov.au/__data/assets/pdf_file/0005/516749/Metgasco-Drilling-Approval-Suspended.pdf›. Reading, Tracey. “Hip versus Square: 1960s Advertising and Clothing Industries and the Counterculture”. Research Papers 2013. 15 July 2014 ‹http://opensuic.lib.siu.edu/gs_rp/396›. Ricketts, Aiden. “The North East Forest Alliance’s Old-Growth Forest Campaign.” Belonging in the Rainbow Region: Cultural Perspectives on the NSW North Coast. Ed. Helen Wilson. Lismore: Southern Cross UP. 2003. 121–148. Sharp, Gene. The Politics of Nonviolent Action: Power and Struggle. Boston, Mass.: Porter Sargent, 1973. Sovacool, Benjamin K. “Cornucopia or Curse? Reviewing the Costs and Benefits of Shale Gas Hydraulic Fracturing (Fracking).” Renewable and Sustainable Energy Reviews (2014): 249–64. Tait, Douglas, Isaac Santos, Damien Maher, Tyler Cyronak, and Rachael Davis. “Enrichment of Radon and Carbon Dioxide in the Open Atmosphere of an Australian Coal Seam Gas Field.” Environmental Science & Technology 47 (2013): 3099–3104. Tarrow, Sidney. Power in Movement: Social Movements and Contentious Politics. 3rd ed. New York: Cambridge UP, 2011. Thompson, Chuck. “The Fracking Feud.” Medicus 53.8 (2013): 56–57. Tilly, Charles. Regimes and Repertoires. Chicago: UCP, 2006. Ward, Susan, and Kitty van Vuuren. “Belonging to the Rainbow Region: Place, Local Media, and the Construction of Civil and Moral Identities Strategic to Climate Change Adaptability.” Environmental Communication 7.1 (2013): 63–79.

Resumen La resección transanal miniinvasiva ha mejorado los resultados de las resecciones transanales clásicas. Estas técnicas se han difundido en los últimos años debido al desarrollo del TAMIS (trans anal minimally invasive surgery), que consiste en un puerto multicanal transanal por el que se introduce instrumental laparoscópico clásico. Debido a esto, no sólo ha aumentado el número de procedimientos transanales realizados, sino también sus indicaciones, incluyendo un amplio abanico de patologías. En esta publicación destacamos su rol como procedimiento miniinvasivo de exéresis de un adenocarcinoma rectal insuficientemente resecado luego de un procedimiento endoscópico, permitiendo un estudio adecuado de la lesión. Se describirán los principales detalles de la técnica y sus resultados Introducción El equilibrio para lograr un tratamiento adecuado y mantener la calidad de vida ha derivado en el desarrollo de nuevas técnicas y tecnologías. Las técnicas transanales combinadas con el abordaje endoscópico surgen como alternativa a la resección local convencional.(1) En 1988, Buess et al.,(2) describen la microcirugía endoscópica transanal (TEM: transanal endoscopic microsurgery) como ejemplo de cirugía por orificios naturales y posteriormente surge la cirugía endoscópica transanal (TEO: transanal endoscopic operation). Estas técnicas permitieron mejorar la visibilidad y calidad de la resección, así como tratar lesiones rectales más proximales.(3) El TAMIS (trans anal minimally invasive surgery) surge a partir del desarrollo de la cirugía mininvasiva de puerto único (single port). Descrita en 2010 por Atallah y cols.(4) como una alternativa al TEM/TEO, consiste en la utilización de un puerto único multicanal transanal combinado con el uso de instrumental laparoscópico.(5) Esto ha facilitado su desarrollo y permitido ampliar las indicaciones de lesiones pasibles de resección transanal incluyendo: lesiones benignas, tumores neuroendócrinos, tumores del estroma gastrointestinal (GIST), resección con criterio curativo en adenocarcinomas rectales T1, reseccion de tumores T2 (casos individualizados), resecciones no oncológicas en pacientes con elevado riesgo quirúrgico o por elección propia, exéresis biópsica de la “cicatriz” de una lesión rectal luego del tratamiento neoadyuvante.(1) En este caso, destacamos su rol como coadyuvante de la resección endoscópica frente a resecciones insuficientes (superficiales, márgenes insuficientes, fragmentación). Método Se presenta el caso de una paciente de 68 años a la que durante una videocolonoscopia se le reseca un polipo rectal sésil localizado a 7 cm del margen anal (foto 1). El informe histológico refleja la resección endoscópica incompleta de un adenocarcinoma de recto bajo, con infiltración submucosa de 4 mm de profundidad y márgenes de resección comprometidos. Se decide realizar una resonancia nuclear magnética de recto (foto 2) y la resección de espesor parietal total por TAMIS para estudio completo de la lesión. Procedimiento bajo anestesia general. Previamente, ayuno y preparación retrógrada del recto para la correcta visualización de la lesión. Profilaxis antibiótica con Ampicilina-Sulbactam. Paciente en posición ginecológica y Trendelemburg optimizando la visión de la luz rectal. El monitor se coloca hacia la cabeza del paciente, el cirujano entre las piernas a derecha y el asistente a izquierda. El tacto rectal no evidencia lesiones. Esfínter normotónico. Dilatación anal suave para facilitar la colocación del dispositivo y disminuir el riesgo de trauma esfintérico. Introducción del GelPOINT PathÒ plegado, lubricado. Fijación a la piel para evitar su rotación o explusión, minimizando el trauma del canal anal (foto 3). Colocación de la tapa hermética de gel y los tres puertos de acceso. En el puerto central se coloca la óptica y en los otros dos, los instrumentos laparoscópicos. El insuflador se conecta en el trócar más superior para evitar que el flujo de CO2 “salpique” la óptica con el líquido acumulado en el sector declive del recto. Conexión del GelPOINT PathÒ a una bolsa de estabilización para mantener una cavidad estable. Neumorrecto a 12 mmHg. Identificación de cicatriz de polipectomía en cara posterolateral derecha, a 7cm del margen anal. Realce de la lesión con azul de Metileno (foto 4). Marcado circunferencial de la misma con electrobisturí (margen de 1 cm). La resección comienza a la hora 6 avanzando por ambos lados hasta el sector proximal. Esta maniobra facilita la disección del margen en profundidad. Se toma la pieza por mucosa sana para evitar su fragmentación, asegurando una pieza única y con margen adecuado (foto 5). Extracción de la lesión retirando la tapa del dispositivo y se repera para su estudio anatomopatológico (foto 6). Cierre de la brecha rectal con sutura barbada 3-0 (V-Loc TM, Covidien, Mansfield, MA). Postoperatorio sin incidentes. Alta el mismo día. Resultado anatomopatológico: cicatriz inflamatoria sin malignidad. Fotos 1. Se observa la cicatriz de aspecto nacarado, con fibrosis convergente. Foto 2. Obsérvese el engrosamiento mucoso en cara posterolateral izquierda. Foto 3. Colocación de la plataforma y comienzo de la cirugía. Foto 4. Realce de la lesión con azul de Metileno. Foto 5. Comienzo de la disección. Foto 6. Resección completa. Marcado de la pieza para anatomía patológica. Discusión El desarrollo del TEM/TEO, trajo un cambio en la indicación y resultados de la cirugía transanal.(3) Asimismo, permitió el tratamiento de lesiones en todos los sectores del recto y colon sigmoides distal, con mejores resultados que la cirugía transanal convencional. El TAMIS surge como alternativa al TEM/TEO presentando ciertas ventajas: menor costo; plataforma más facil de colocar; uso de instrumental laparoscópico; campo visual de 360º (vs 220º del TEM); no requiere cambios de posición del paciente (con posibilidad de abordaje intraperitoneal combinado) y curva de aprendizaje corta para cirujanos expertos en laparoscopía.(1,3,4,5,6) Además de la resección de tumores rectales, se ha descrito su uso para la reparación de fístulas rectoureterales, hemostasis de lesión de Dielafoy rectal, reparación de fallas de suturas colo o ileorrectales, extracción de cuerpos extraños y abordajes transcolostomía.(7) Actualmente, existe un renovado interés en TAMIS debido al desarrollo de la escisión mesorrectal total transanal (ta-TME) combinado con resección laparoscópica intraabdominal, facilitando la escisión completa del mesorrecto, cuya disección es dificultosa por vía abdominal exclusiva,(6,8) En esta publicación, comunicamos también su valor en la resección de cicatrices rectales de procedimientos endoscópicas insuficientes. En TAMIS, las dos plataformas más utilizadas son: SILS portÒ (Covidien, Mansfield, Massachusetts, EEUU) y GelPoint PathÒ (Applied Medical, Rancho Santa Margarita, California, EEUU).(6) Su material flexible basado en un elastómero termoplástico permite ajustar instrumentos laparoscópicos de diferente tamaño. Se adapta al canal anal disminuyendo la distensión del esfínter y, gracias al material de confección, genera un sistema de sellado que minimiza la pérdida de CO2. La menor longitud en comparación al TEM, permite mayor angulación y movimiento de las pinzas durante el procedimiento. 4,7) Una de las dificultades técnicas relacionadas al TAMIS es la inestablidad del neumorrecto por el flujo pulsátil del insuflador. En los últimos años se han desarrollado dispositivos como el insuflador Airseal TM y las bolsas estabilizadoras de gas, como la que hemos utilizado. Esto crea un neumorrecto estable, evitando el flujo rítmico y el colapso de la luz rectal, facilitando el procedimiento.(9) El neumorrecto suele realizarse a 15 mmHg con flujo alto, para lograr una adecuada distensión.(6) Para la resección con márgenes adecuados, destacamos la utilidad del realce de la lesión con tinción vital como el azul de Metileno.(10) Esto permite diferenciar mejor el área patológica de la mucosa normal, facilitando el marcado de la lesión con un margen seguro de 5-10 mm.(3) La resección en profundidad dependerá del tipo de lesión. En las resecciones anteriores de espesor parietal completo debe tenerse cuidado de no lesionar la vagina, la uretra/próstata. Es preferible la utilización del electrobisturí para visualizar los planos de disección, si bien pueden utilizarse otros métodos de hemostasis. La pieza obtenida debe ser única y marcarse adecuadamente para su estudio anatomopatológico.(6) Un punto controversial es el cierre de la brecha rectal a nivel subperitoneal. Las últimas publicaciones recomiendan que debe intentarse siempre que sea posible. En cirujanos experimentados y centros de alto volumen se observa una tendencia a realizar el cierre parietal. Puede utilizarse una sutura barbada 2-0 o 3-0 que facilita la maniobra.(3) Como ventajas, habría menos complicaciones fundamentalmente hemorrágicas y aumentaría la velocidad de cicatrización. Sin embargo, esto no esta completamente demostrado y el cierre puede ser dificultoso.(6) En cuanto a los resultados, el TAMIS tiene resultados similares a otras técnicas endoscópicas de cirugía transanal. (18) Los porcentajes de resección incompleta o de fragmentación varían según las series, pero son mejores en comparación a la resección local clásica. Se reportan mayores márgenes de resección R0 (88-90% para la resección endoscópica vs 55% local clásica), menor fragmentación (1.4% vs 24%) y menor recurrencia local acumulada (4-6% a 20% vs 29%).(1,3,4) La morbilidad global con las resecciones endoscópicas transanales varía entre el 7 y 31% en distintos reportes. Esta variabilidad depende de los criterios utilizados para su evaluación. Afortunadamente, más de la mitad son leves y no requieren tratamiento.(3) Dentro de las complicaciones más relevantes destacamos: la hemorragia y la incontinencia. La hemorragia es la complicación más frecuente (1-13%) y se asocia a dejar abierta la brecha rectal. Generalmente es leve y se detiene espontáneamente. En cuanto a la incontinencia, se ha reportado una incidencia de 10%, de grado variable. Está dada fundamentalmente por la dilatación anal y colocación de la plataforma.(7) Sin embargo, los últimos estudios han mostrado alteraciones prinicpalmente manométricas sin traducción clínica. Se ha reportado tanto para TEM como para para TAMIS.(5) La dehiscencia de la línea de sutura y el desarrollo de abscesos perirrectales se observa en 5% de los casos. Este porcentaje aumenta en pacientes sometidos a neoadyuvancia. Las lesiones uretrales/vaginales se ven en 5,8%. La perforación intraperitoneal en resecciones altas puede repararse por abordaje transanal o laparoscópico abdominal simultáneo.(3) Otras complicaciones poco frecuentes son: estenosis anal, fístulas rectovaginales, lesiones vasculares y nerviosas, embolia gaseosa, neumoretroperitoneo, retención aguda de orina, dolor, fiebre.(7) Conclusión Gracias a la accesibilidad y familiaridad de los materiales laparoscópicos para el cirujano, el TAMIS ha permitido extender la aplicación de los procedimientos endoscópicos por vía transanal, con una mejor calidad de resección que la técnica transanal convencional. Esto permite ampliar sus indicaciones, como en este caso, que se utilizó para la resección de un tumor rectal luego de una resección endoscópica insuficiente, permitiendo su estudio anatomopatológico completo, definiendo la conducta terapéutica. Bibliografía Moreira A, Zapata G, Bollo C, Morales R, Sarotto L. TAMIS: ¿Un nuevo estándar para el tratamiento de los pólipos de recto? Revisión de la bibliografía y reporte de nuestra experiencia. Rev Argent Coloproct (2019) 30(1): 1-11. Buess G, Kipfmüller K, Hack D, Grüssner R, Heintz A, Junginger T. Technique of transanal endoscopic microsurgery. Surg Endosc (1988) 2(2): 71-75. Rossi G. Relato oficial. Resecciones transanales: pasado, presente y futuro. Rev Argent Coloproct (2019) 30(3): 1-77. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: A giant leap forward. Surg Endosc (2010) 24: 2200-2205. Villanueva JA, Alarcón L, Jiménez B. Cirugía endoscópica transanal: nuevas alternativas con instrumentos de cirugía laparoscópica convencional. In: http://www.medigraphic.com/cirugiaendoscopica. (2011) 14(4): 174-179. Quinteros F, Thiruppathy K, Albert M. Transanal Minimally Invasive Surgery (TAMIS): operative technique, pitfalls and tips. In: Minimally invasive approaches to colon and rectal diseases: technique and best practices. Ross HM et al. (eds), Springer Science + Buisness Media New York (2015) 25: 283-91. Heras MA, Cantero R. Cirugía transanal a través de puerto único (TAMIS). Revisión frente otras técnicas de excisión endoscópica de lesiones rectales. Rev Argent coloproct (2013) 2: 55-60. Arroyave MC, De Lacy B, Lacy AM. Transanal total mesorectal excision (TaTME) for rectal cancer: step by step description of the surgical technique for a two-teams approach. Eur J Surg Oncol (2017) 43(2): 502-505. doi: 10.1016/j.ejso.2016.10.024.Epub 2016 Nov 20. Waheed A, Miles A, Kelly J, Monson JRT, Motl JS, Albert M. Insufflation stabilization bag (ISB): a cost-effective approach for stable pneumorectum using a modified CO2 insufflation reservoir for TAMIS and taTME. Tech Coloproctol (2017) 21: 897-900. Moreira Grecco A, Dip F, Sarotto L. Methylene blue TAMIS guided procedure facilitates adenomatous polyps resection. In: https://www.sages.org/meetings/annual-meeting/abstracts-archive/methylen-blue-tamis-guided-procedure-facilitates-adenomatous-polyps-resection/.