Academic literature on the topic '8-point NISUS'

Notes on the reproduction, breeding biology and ethology of the Eurasian pygmy owl (Glaucidium passerinum) in Slovakia Accessible data on 78 breeding occurrences of the Eurasian pygmy owl (Glaucidium passerinum) in Slovakia are evaluated. Data from the oldest known breeding in 1846 up to 2010 were used. The breeding of this species has been proved in 24 orographic units, at altitudes from 450 (400) to 1450 m. Distribution of the species in Slovakia closely follows the distribution of fir (Abies alba) and spruce (Picea abies) and breeding has also been recorded in forest habitats with an abundance of scots pine (Pinus silvestris) and black pine (Pinus nigra). From the point of view of natural and secondary origin of these forest habitats, the species breeds in both ‘natural’ habitats such as montane spruce forests and Euro-Siberian coniferous forests, forests with beech and fir, oak-hornbeam forests with lime and fir, as well as in secondary forest spruce plantations. From 22 evaluated Slovakian nests as many as 17 (70.8%) were situated no farther than 200 m from water. A high number of nests (72.5%) were situated at altitudes between 600-1100 m, with 13% above this range and 14.5% below. As many as 25 nest holes were located in spruce, both living and dead, and in snags, ten in fir (with a significant number of dead stumps), six in beech, four in oak and four in aspen. Nests were also found on one occasion each in larch, maple and black pine. On one occasion breeding took place in a nest-box. On several occasions the same nest hole was used repeatedly, with the highest number of such occasions being four times in the same tree in an eight year period. On three occasions a shift of nest location of ca. 200-350 m within the same territory occurred and two neighbouring pairs, and nests, were once found at the same time just 400 m from each other. Nest holes excavated by the Dendrocopos major and Picoides tridactylus are often used. On four occasions breeding took place in natural cavities (2x beech, 1x larch, 1x maple). The lowest situated nest was placed lower than one m above ground level and the highest 13 m above the ground. From 44 evaluated nest holes the highest number (26) were situated between 4-7 m. The production of young was evaluated in 57 cases, 34 of which were successful (69.7%). Young were found on 27 occasions, from which 80 fledged: an average of 2.96 per nest. This average is slightly lower than that calculated in Austria and Germany. In the colder than usual years of 2009 and 2010, which were poorer in food availability and characterized by high precipitation, the numbers of fledglings was even lower: on average only 2.3 and 2.0 fledglings per nest respectively. The average number of fledglings per nest from 8 Slovakian nests in three consecutive years (1989 to 1991) was 3.75 fledglings per nest but the same parameter from nine Slovakian nests in six years (2005 to 2010) dropped to 2.88. This indicates a diminishing trend in nest productivity. On one occasion the movements of fledglings in the territory after their fledging were observed for 27 days. On other occasions disturbance due to human activity (tree felling) was recorded as the reason for an abandoned breeding attempt. Such disturbance can be extreme, for example, in the Kysuce Region in the Javorníky Mts and Turzovská vrchovina Mts, two breeding sites with nests in 1999 and 2003 were later destroyed because of complete removal of those forest tracts attacked by bark-beetles. In 2009 in the Strážovské vrchy Mts, a curious case was observed where, during the period of parent care of nestlings, the male disappeared but the female continued to feed her two nestlings alone until they fledged. Just after fledging these fledglings were predated, probably by a Pernis apivorus or an Accipiter nisus, both of which bred nearby. The authors made several remarkable ethological observations in the life of Eurasian pygmy owls. In the Strážovské vrchy Mts the ‘nest-showing’ of more than one cavity in its territory by the male to the female was observed. Copulation was observed a total of eleven times during the months February - May in the years 1989-2010, with the following frequency: February 1x, March 3x, first half of April 5x, second half of April 1x, beginning of May 1x. Interactions of the Eurasian pygmy owls with diurnal raptors, other owl species and other cavity-breeders were also documented. In the Strážovské vrchy Mts the breeding of an Eurasian pygmy owl pair at a relatively close distance to the nests of various diurnal raptors were as follows (species/distance from nest of the raptor from nest of the Eurasian pygmy owl): Pernis apivorus 7 m, Accipiter nisus 230 m, Buteo buteo 250 m, Aquila pomarina 500 m, Accipiter gentilis 700 m. In the Volovské vrchy Mts a pair of Eurasian pygmy owls successfully bred at a distance of 600 m from two nests of Strix uralensis, and another pair bred at a distance of 500 m from a nest of Strix aluco. The breeding of another pair of Strix aluco just 30 m from a cavity used by a pair of Eurasian pygmy owl led to unsuccessful breeding/abandoned nest by this pair. Competitive behaviour was observed between the Eurasian pygmy owl and other cavity-breeders such as Sitta europaea and Dendrocopos major, and an occasion of the predatory killing of an owl fledgling by Strix uralensis was suspected. An attack by Aegolius funereus on a Eurasian pygmy owl was also observed.

PurposeThe purpose of this pilot study was to demonstrate the applicability of time-resolved three-dimensional (3D) reconstructions from 3D digital subtraction angiography (DSA) rotational angiography (RA) datasets (four-dimensional (4D) DSA) to provide a more detailed display of the architecture of intracranial vascular malformations.MethodsThe experimental reconstruction software was applied to the existing 3D DSA datasets obtained with Siemens Artis zee biplane neuroangiography equipment. We included 27 patients with clinical indications for 3DRA for preinterventional or preoperative evaluation of intracranial dural arteriovenous fistulas (dAVFs, n=8) or arteriovenous malformations (AVMs, n=19). A modified DSA acquisition protocol covering an extended rotation angle of the C-arm of 260° during a scan time of 12 s was used. 4D volumes were displayed with up to 30 frames/s in a transparent volume rendering (VRT) mode and time-resolved multiplanar reconstructions (MPRs). Arterial feeders, fistulous points, or the shunt zone within the AVM nidus and venous drainage patterns as well as associated aneurysms were assessed after definition of a standardized evaluation procedure by consensus of two reviewers in comparison with 2D DSA and conventional 3D reconstructions.ResultsIn all cases calculation of 4D reconstructions were technically feasible and evaluable. In two cases image quality was slightly compromised by movement artifacts. Compared with standard DSA projection images and 3D reconstructions, 4D VRTs and MPRs were rated significantly superior to define a proper projection and display of the shunt zone. In 12 out of 27 cases 4D reconstructions showed details of the angioarchitecture at the fistulous point or the nidus better than the other modalities and came close to the quality of superselective angiography. The efficacy of 3D and 4D applications was equal in the detection of pre- and intranidal aneurysms. The course of long arterial feeders and draining veins was difficult to assess on VRTs and MPRs. Especially for dAVFs, 2D DSA was clearly superior in identifying meningeal feeders. For detecting smaller vessels and for distinction between angiographic phases, 2D DSA is still considered to be superior to 4D imaging. Venous drainage was slightly better displayed in 4D reconstructions.ConclusionsTime-resolved 3DRA with 4D VRTs and MPRs is technically feasible and provides a detailed display of the angioarchitecture at the fistulous point or the nidus. Visualization of all angiographic features demands additional post-processing. Further standardization of evaluation tools and studies with blinded independent reviewers are necessary before the new technique can replace conventional neuroangiographic approaches.

Objective This study aimed to determine the prevalence of confirmed novel coronavirus disease 2019 (COVID-19) disease or infants under investigation among a cohort of U.S. neonatal intensive care units (NICUs). Secondarily, to evaluate hospital policies regarding maternal COVID-19 screening and related to those infants born to mothers under investigation or confirmed to have COVID-19. Study Design Serial cross-sectional surveys of MEDNAX-affiliated NICUs from March 26 to April 3, April 8 to April 19, May 4 to May 22, and July 13 to August 2, 2020. The surveys included questions regarding COVID-19 patient burden and policies regarding infant separation, feeding practices, and universal maternal screening. Results Among 386 MEDNAX-affiliated NICUs, responses were received from 153 (42%), 160 (44%), 165 (45%), 148 (38%) across four rounds representing an active patient census of 3,465, 3,486, 3,452, and 3,442 NICU admitted patients on the day of survey completion. Confirmed COVID-19 disease in NICU admitted infants was rare, with the prevalence rising from 0.03 (1 patient) to 0.44% (15 patients) across the four survey rounds, while the prevalence of patients under investigation increased from 0.8 to 2.6%. Hospitals isolating infants from COVID-19-positive mothers fell from 46 to 20% between the second and fourth surveys, while centers permitting direct maternal breastfeeding increased 17 to 47% over the same period. Centers reporting universal severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) screening for all expectant mothers increased from 52 to 69%. Conclusion Among a large cohort of NICU infants, the prevalence of infants under investigation or with confirmed neonatal COVID-19 disease was low. Policies regarding universal maternal screening for SARS-CoV-2, infant isolation from positive mothers, and direct maternal breastfeeding for infants born to positive mothers are rapidly evolving. As universal maternal screening for SARS-CoV-2 becomes more common, the impact of these policies requires further investigation. Key Points

Objectives: The management of the adolescent athlete who presents for initial treatment after shoulder instability remains controversial. Risk factors such as age, gender, athletic status, and patient goals have all been demonstrated to result in a higher risk of recurrence with nonoperative management, but little work has been done to determine a treatment algorithm that would combine these factors into a decision making algorithm. The purpose of this study, therefore, was to evaluate patients managed nonoperatively for shoulder instability, and to identify factors that led to failure, defined as an inability to return to sport with no subsequent missed time due to shoulder issues. We sought to integrate these factors into a scoring system that would predict the success or failure of nonoperative management in the treatment of shoulder instability in the adolescent athlete. Methods: A retrospective study was conducted of 57 patients who were first time presenters for anterior shoulder instability to a single orthopaedic practice. Inclusion criteria were that patients were managed nonoperatively, that they were involved in high school sports with at least one season of eligibility remaining, and that complete information was available on their ultimate return to their previous sport. Success was defined as those patients who returned to their sport at the same level, and who played at least one subsequent season without any time being missed due to the shoulder that had been unstable. Patient specific risk factors were individually evaluated, and those that were predictive of a higher risk of failure were incorporated into a 10-point Nonoperative Injury Severity Index (NISIS). This score was then retrospectively applied with regression analysis as well as a chi-square analysis to determine the overall score that predicted failure of nonoperative management. Results: Six factors were identified as risk factors and included in the NISIS. Age greater than 15, the presence of bone loss, type of instability (subluxation or dislocation), type of sport (collision vs. non-collision), female gender, and arm dominance, were assigned points based on individual risk. Overall, 79% of patients treated nonoperatively were able to achieve full return to sport without subsequent surgical intervention or missing any time as a result of their shoulder. Patients who had a preoperative NISIS score of >7 returned at over 90% to sport, compared to a success rate of 50% for those who scored <8, revealing an odds ratio of 9.3 times higher risk of failure for those in the high risk group (p=0.001). Conclusion: The non-operative instability severity index is simple and effective preoperative method to determine who is likely to be successful at returning to scholastic sports after presenting for anterior shoulder instability. Further study with a larger prospective cohort should be accomplished to independently validate this score, but this information may be useful for the treating physician to help guide decision making when presented with the unstable shoulder. [Figure: see text]

Object The authors describe a method that utilizes an image-guided robotic radiosurgical apparatus (the CyberKnife) for treatment of cerebral arteriovenous malformations (AVMs). This procedure required the development of an original technique that allows a high degree of automation. Methods Angiographic images were imported into the treatment planning software by coregistering CT and 3D rotational angiography. The nidus contour was delineated using the contouring tools of the treatment planning system. Functional MR imaging was employed for contouring critical cortical regions, such as the motor cortex and language areas. Once the radiation dose to be delivered to the target volume and dose constraints to critical structures were prescribed, the inverse treatment planning function determined the optimal treatment plan. Results A series of 279 patients with cerebral AVMs underwent CyberKnife radiosurgery. One transitory adverse effect of the radiation procedure was observed. Eight bleeding occurrences were noted before complete AVM obliteration. Of the 102 patients with follow-up > 36 months, 80 underwent angiographic evaluation. In this group, 65 patients (81.2%) showed complete angiographic obliteration of their AVM. In 8 more patients, complete angiographic obliteration was demonstrated by MR angiography only. Conclusions This is the first report describing a technique developed for CyberKnife radiosurgery of cerebral AVMs. The use of different imaging modalities for automatic delineation of the target and critical structures combined with the employment of the inverse treatment planning capability is the crucial point of the procedure. The procedure proved to be safe and efficient.

Background and Objectives.—Even though Switzerland has a compulsory insurance system, there is a lack of detailed information on the treatment and outcome following trauma. The objective of this evaluation was to examine to what extent cases insured by the largest accident-insurer (Suva) are representative of all significantly injured. Methods.—Trauma center analysis of all ≥16 year old trauma patients with a New Injury Severity Score (NISS) ≥8, comparing the characteristics of Suva- vs non-Suva cases (chi-square; univariate explained variance R2; multivariate logistic regression analysis, Nagelkerke R2). Results.—Over 7 years, 2233 trauma patients were treated at the hospital, of whom 29.4% were Suva-insured. Compared to non-Suva-insured, Suva cases were younger (41.6 vs 64.2, R2 = 0.23) and more often male (88.0% vs 59.4%; R2 = 0.08). In multivariate analysis, these two factors together explained 37.5% of the differences between groups. No other investigated factor explained more than 2%. If only those patients of obligatory working age were analyzed (n = 1264), Suva cases (50.6%) were more often male than non-Suva-insured (n = 562 [87.8%] vs n = 393 [63.0%], resp.; p&lt;0.001, R2 = 0.08). In multivariate analysis, other factors taken together were only 2.6% of the variance. Conclusions.—Significantly injured patients in Switzerland may be considered comparable from a statistical point of view whether insured by the main accident-insurer or not, provided groups are adequately controlled for age and gender. Other differences appear to be only marginal. Respecting these limitations such data can justifiably be given as Swiss reference statistics and the relevant insurer outcome information used for international comparison.

OBJECTIVE Successful stereotactic radiosurgery (SRS) for the treatment of arteriovenous malformations (AVMs) results in nidus obliteration without new neurological deficits related to either intracranial hemorrhage (ICH) or radiation-induced complications (RICs). In this study the authors compared 5 AVM grading scales (Spetzler-Martin grading scale, radiosurgery-based AVM score [RBAS], Heidelberg score, Virginia Radiosurgery AVM Scale [VRAS], and proton radiosurgery AVM scale [PRAS]) at predicting outcomes after SRS. METHODS The study group consisted of 381 patients with sporadic AVMs who underwent Gamma Knife SRS between January 1990 and December 2009; none of the patients underwent prior radiation therapy. The primary end point was AVM obliteration without a decline in modified Rankin Scale (mRS) score (excellent outcome). Comparison of the area under the receiver operating characteristic curve (AUC) and accuracy was performed between the AVM grading scales and the best linear regression model (generalized linear model, elastic net [GLMnet]). RESULTS The median radiological follow-up after initial SRS was 77 months; the median clinical follow-up was 93 months. AVM obliteration was documented in 297 patients (78.0%). Obliteration was 59% at 4 years and 85% at 8 years. Fifty-five patients (14.4%) had a decline in mRS score secondary to RICs (n = 29, 7.6%) or ICH (n = 26, 6.8%). The mRS score declined by 10% at 4 years and 15% at 8 years. Overall, 274 patients (71.9%) had excellent outcomes. There was no difference between the AUC for the GLMnet (0.69 [95% CI 0.64–0.75]), RBAS (0.68 [95% CI 0.62–0.74]), or PRAS (0.69 [95% CI 0.62–0.74]). Pairwise comparison for accuracy showed no difference between the GLMnet and the RBAS (p = 0.08) or PRAS (p = 0.16), but it did show a significant difference between the GLMnet and the Spetzler-Martin grading system (p < 0.001), Heidelberg score (p < 0.001), and the VRAS (p < 0.001). The RBAS and the PRAS were more accurate when compared with the Spetzler-Martin grading scale (p = 0.03 and p = 0.01), Heidelberg score (p = 0.02 and p = 0.02), and VRAS (p = 0.03 and p = 0.02). CONCLUSIONS SRS provides AVM obliteration without functional decline in the majority of treated patients. AVM grading scales having continuous scores (RBAS and PRAS) outperformed integer-based grading systems in the prediction of AVM obliteration without mRS score decline after SRS.

Abstract BACKGROUND Transitions to new healthcare environments can negatively impact patient care and threaten patient safety. Immersive in situ simulation conducted in newly constructed single family room (SFR) Neonatal Intensive Care Units (NICUs) prior to occupancy, has been shown to be effective in testing new environments and identifying latent safety threats (LSTs). These simulations overlay human factors to identify LSTs as new and existing process and systems are implemented in the new environment OBJECTIVES We aimed to demonstrate that large-scale, immersive, in situ simulation prior to the transition to a new SFR NICU improves: 1) systems readiness, 2) staff preparedness, 3) patient safety, 4) staff comfort with simulation, and 5) staff attitude towards culture change. DESIGN/METHODS Multidisciplinary teams of neonatal healthcare providers (HCP) and parents of former NICU patients participated in large-scale, immersive in-situ simulations conducted in the new NICU prior to occupancy. One eighth of the NICU was outfitted with equipment and mannequins and staff performed in their native roles. Multidisciplinary debriefings, which included parents, were conducted immediately after simulations to identify LSTs. Through an iterative process issues were resolved and additional simulations conducted. Debriefings were documented and debriefing transcripts transcribed and LSTs classified using qualitative methods. To assess systems readiness and staff preparedness for transition into the new NICU, HCPs completed surveys prior to transition, post-simulation and post-transition. Systems readiness and staff preparedness were rated on a 5-point Likert scale. Average survey responses were analyzed using dependent samples t-tests and repeated measures ANOVAs. RESULTS One hundred eight HCPs and 24 parents participated in six half-day simulation sessions. A total of 75 LSTs were identified and were categorized into eight themes: 1) work organization, 2) orientation and parent wayfinding, 3) communication devices/systems, 4) nursing and resuscitation equipment, 5) ergonomics, 6) parent comfort; 7) work processes, and 8) interdepartmental interactions. Prior to the transition to the new NICU, 76% of the LSTs were resolved. Survey response rate was 31%, 16%, 7% for baseline, post-simulation and post-move surveys, respectively. System readiness at baseline was 1.3/5,. Post-simulation systems readiness was 3.5/5 (p = 0.0001) and post-transition was 3.9/5 (p = 0.02). Staff preparedness at baseline was 1.4/5. Staff preparedness post-simulation was 3.3/5 (p = 0.006) and post-transition was 3.9/5 (p = 0.03). CONCLUSION Large-scale, immersive in situ simulation is a feasible and effective methodology for identifying LSTs, improving systems readiness and staff preparedness in a new SFR NICU prior to occupancy. However, to optimize patient safety, identified LSTs must be mitigated prior to occupancy. Coordinating large-scale simulations is worth the time and cost investment necessary to optimize systems and ensure patient safety prior to transition to a new SFR NICU.

High flow arteriovenous malformations (AVMs) are infiltrative, invading tissue planes and structures and may be life threatening when they bleed.1 They have a feeding artery and an anomalous capillary bed shunting blood from the arterial system to the venous system.1 The present trend of management of small AVMs is surgical excision with a high success rate. The problematic cases are diffuse AVMs infiltrating structures that render them impossible to totally extirpate surgically without causing much blood loss and tissue damage. The mainstay of management is embolization, surgical resection and reconstruction.2 Ligation or proximal embolization (alone) of feeding vessels should never be done because such maneuvers result in rapid recruitment of new vessels from adjacent arteries to supply the AVM nidus.2 Incomplete surgical excision definitely leads to recurrences, making this type of AVM very difficult to manage. What is the point of this paper? The complete destruction of the “nidus” of the AVM, from the artery to the capillary to the venous component, is the only potential cure.3 Well and good if there could be a way of doing this by sclerosing the entire vascular malformation. But since sclerosis only works well in low flow vascular malformations and tumors like hemangiomas, and poorly or not at all in high flow lesions,4 we have to convert this high flow AVM into a “no-flow” or “low flow” AVM by ligating the feeding and draining vessel and injecting the sclerosant intra-arterially thereafter at a dose sufficient enough to blanch out the AVM even up to its peripheral branches. This paper aims to demonstrate how we do this. Definition of Terms Vascular malformation: They are a result of abnormal development of vascular elements during embryonic or fetal stages of life.2 They originate from mesenchymal cells at an early stage of embryogenesis.3 and most are present at birth but there are several case reports of these lesions presenting after trauma in adults.1 Some AVMs appear as part of a familial genetic disorder called angiomatous syndrome i.e. Rendu-Osler-Weber Syndrome presenting with telangiectasia of the skin and mucous membranes.3 Some propose that a defect in vascular stabilization like TGF-beta signaling could be a cause of AVM development.5,6 Still, progesterone receptors have been isolated in AVMs explaining their expansion during puberty.7 Hemangioma: These are vascular tumors that exhibit endothelial proliferation.2 A hemangioma of infancy usually undergoes 3 stages: a proliferative phase of rapid growth up to 10 to 12 months of age; an involuting phase where growth slows down and signs of regression appear usually at 1 to 7 years; and an involuted phase.2 Sclerosants: Agents used in sclerotherapy that induce a toxic effect on the vascular endothelium and results in fibrosis. There are 3 types: Detergents that disrupt cell membranes by protein theft desaturation ie: ethanolamine oleate, sodium morrhuate, polidocanol, sodium tetradecyl sulfate; Osmotic agents ie: sclerodex; and Chemical irritants that damage cell walls by direct contact ie: chromatin glycerine, polyiodinated iodine.8 Sclerodex: an osmotic sclerosant that is a combination of dextrose monohydrate 250mg/ml and sodium chloride 100mg/ml. It shifts water balance through cellular gradient (osmotic) dehydration that leads to endothelial destruction. Since component materials are naturally occurring bodily, it has no molecular toxicity in calibrated dosages. If extravasated, it could cause tissue necrosis.8 It is manufactured by OMEGA Laboratories, Ltd. Montreal, QC, Canada. REVIEW OF PRESENT PRACTICE AND LITERATURE The first task of the physician is to establish a diagnosis, whether the lesion is a vascular malformation or a vascular tumor. Taking the history of the patient could point to a diagnosis as vascular tumors like hemangiomas usually proliferate and involute from the time of infancy to about the age of 10. Vascular malformations grow as the child grows and do not involute. Vascular malformations have an arterial supply and a venous drainage and are classified into high or low flow. Capillary, venous and lymphatic types are low flow while arteriovenous malformations are usually high flow. A high flow AVM has an arterial blood supply and a venous drainage. In rare instances, a vascular malformation could co-exist with a hemangioma forming a mass effect.2 On physical examination, a bruit and a strong pulsation (thrill) is appreciated. The head and neck is the most common location of AVMs at 70%. When fully developed, they are deeper in color with increasing erythema, local warmth, palpable mass and a bruit.9 These malformations are composed of vascular channels lined by flat mature epithelium and are not hypercellular and not proliferative.10 Schobinger proposed a staging system for Head and Neck AVM. Stage 1 are AVMs that are quiescent and remain stable for long periods of time. Stage 2 is a time for expansion followed by pain and bleeding. Stage 3 is heralded by destruction of adjacent tissues and ulceration. Stage 4 is presented by decompensation where symptoms of cardiac failure are present.11 Ultrasound with color Doppler imaging, Magnetic Resonance Imaging and Phlebography (arteriography/venography) contribute to diagnosis, classification and management.3 In our setting were we do not have the facilities, we use CT- angiography. These imaging modalities should be used to evaluate the characteristics of the lesion, such as size, flow velocity, flow direction, relation to surrounding structures and lesion content.3 Ultrasound demonstrates flow rates, contrast-enhanced magnetic resonance imaging (MRI) shows presence or absence of a mass, and CT angiography reveals the arborization (the blood supply and drainage) of the vascular anomaly. Vascular tumors like hemangioma, if located in non-strategic areas where function is not impaired can be observed over its developmental phases until involution at about 10 years old.2 For hemangiomas that impair function or are possibly life threatening because of potential hemorrhage, these tumors are treated with the following modalities: 1. Intralesional corticosteroids ie: triamcinolone; 2.Systemic corticosteroids in a tapered dose like prednisolone and some second choice pharmacotherapeutics like interferon, vincristine; and 3. Propranolol. Surgery is indicated in ulcerating, bleeding, and life threatening lesions like airway obstruction.2 Over 90% demonstrate dramatic reduction in size of hemangioma in one to two weeks from the above medical therapeutic modalities. Propranolol has been successfully used as hemangioma treatment since 2008 and is believed to have an antiproliferative effect on the vascular endothelium. The mechanism of action may involve the regulation of growth factors.1 Low flow vascular malformations are treated with sclerotherapy or surgical excision for accessible tumors. These malformations do not regress like hemangioma but grow in time. High flow AVMs are treated with surgical excision if they have limited extent and are surgically accessible. Embolization before surgery decreases bleeding and is the standard. Embolization followed by repeated sclerotherapy is recommended for surgically inaccessible areas.4 There is a 64 to 96% response rate , defined as improvement in symptoms or a reduction in the lesion size after ethanol sclerotherapy of venous low flow malformations.3 Partial surgical excision leads to only temporary improvement followed by re-expansion of tumor overtime.9 Sometimes, complete resection is not possible in diffuse or infiltrating AVMs and surgery can result in severe disfigurement and impairment of function of involved structures.9 METHODS After establishing the diagnosis of a high flow AVM with identification of an arterial feeding vessel and a venous draining vessel, surgery is commenced away from the malformation to expose the arterial and venous supplies. The procedure is done under general anesthesia because sclerotherapy of large malformations and vascular tumors is very painful. We do this because we have no interventional radiology services in our hospital. We ligate the feeding artery and if possible, the draining vein to convert the AVM into a “ low or no flow” and to allow ample contact time between the sclerosant (sclerogen) and the vessel endothelium. The sclerosant is then injected intravascularly distal to the ligation until all visible malformation blanches out. Aspirating the blood content of the ligated (arterial supply and venous drainage) malformation before introduction of the sclerosant will further potentiate the action of the sclerosant. While injecting the sclerosant slowly, the patient’s vital signs are monitored. A drop in the pulse rate is a signal to stop or slow down the injection of the sclerosant because it may be a sign that some sclerosant is escaping the venous drainage and reaching the general circulation in a concentration picked up by the sensors of the vascular system. Injections resume in a slower manner as the vital signs revert to normal. Our sclerosing agent sclerogen is an osmotic agent composed of sodium chloride and dextrose which are naturally present in our body so they are not toxic in manageable concentrations. Other sclerosants can be nephrotoxic so we must be very careful in injecting not to overload the vascular system. The objective is to push the sclerosant to all branches of the malformation to eliminate all possible nidus. The end point of injection is when all cutaneous or mucosal components of the malformation blanch out. Injection of the sclerosant intravascularly is done under direct visualization to prevent extravascular introduction. A review of literature has this to say about sclerotherapy. Extravascular injection of the sclerosant causes tissue necrosis.4 Ethanol injection to high flow fistulous lesions is contraindicated because of high risk of” early wash “ into the systemic circulation.4 Sclerosants could cause hemolysis, denaturation of blood proteins, thrombus formation and nephrotoxicity.3,4,12 Ethanolamine oleate, in comparison to ethanol, has less effect in the deep vascular layer and no penetrative effect. It is not associated with neuronal side effects despite of the proximity of the nervous system to the vascular system.3 CASES Our first case was a 62-year-old woman with a pinna and periauricular vascular malformation, noted since 5 years prior to consultation. The inferior concha was bulging and pulsating with a strong bruit. The periauricular area was elevated with microvascular malformations in reddish discoloration. The left posterior auricular artery was identified as the feeding artery and the diagnosis was a high flow AVM. She consulted a hospital in Sacramento, California where she worked and was advised to have a resection of her left ear. She got frightened and decided to come home to the Philippines for a second opinion. I suggested our procedure which she gladly accepted but warned her of possible pinna necrosis. At least, she said, it is just a possibility and not an outright pinna loss. I dissected 1 cm below the malformation avoiding any of its extensions below the pinna and mandibular angle and moved towards the external carotid. I immediately located the pulsating, abnormally dilated posterior auricular artery feeding vessel and ligated it. Further dissection deep towards the styloid process revealed the venous drainage that penetrated the mastoid bone toward the direction of the sigmoid sinus. I too did the venous drainage ligation. I injected sclerogen distal to the posterior artery ligation after aspiration of 8 cc of AVM blood until all the malformation main mass and the peripheral branches blanched out. Total volume of sclerosant was 10 cc. There was no change in the vital signs as I slowly introduced the sclerosant. I closed the surgical defect and observed the patient for three days in the hospital. There was post-operative pain and swelling in the sclerosed malformation, relieved by ice packs and celecoxib 200 mg every 12 hours. After three days, the swelling started to subside and the pain lessened so the patient was sent home. She followed up in a week and the malformation had shrunk. Sutures were removed. Two weeks post-operatively, the malformation was just a trace skin discoloration with no tissue necrosis, no more bulge and pulsations and no pain. She asked permission to go back to work the following week in California. Our second case was a 13-year-old girl with a right tonsillar and hypopharyngeal vascular malformation. She had recurrent bleeding episodes necessitating blood transfusions in their province. I suggested our procedure which the parents and the patient consented to. We did surgery, ligating the right external carotid artery and external jugular vein and introduced the sclerosant (sclerogen) slowly until the tonsillar and hypopharyngeal malformation blanched out. There was no abnormal fluctuation of the patient’s vital signs. After closing the surgical access wound, I did tonsillectomy of the right since the bulging tonsillar malformation was obstructing the airway. There was very minimal bleeding and I was able to cauterize the remaining sclerosed malformation not included in the tonsil with ease. Two weeks post-surgery, she followed up with healed tonsillectomy wound and a disappearing malformation. She however had gastritis because of her co-amoxiclav antibiotic and her inability to eat well because of pain in swallowing. She eventually recovered from her gastric problems. At one-month follow-up, there was no trace of the malformation on visual examination. Looking back, doing tonsillectomy in an AVM would have been very bloody without sclerotherapy. Our third case was a nasopharyngeal AV malformation in a 35-year-old woman. She had episodes of severe bleeding requiring emergency tracheostomy, oral packing and blood transfusions. CT-angiography revealed two feeding vessels, one from the left external carotid artery and a minor one from the internal carotid artery. We decided to sclerose the left external carotid artery and see what happened to the internal carotid artery branch that could not be accessed. Since CT angiography did not identify the venous drainage, we introduced the sclerosant (sclerogen) very slowly, stopping when the pulse rate started to drop below 60 beats per minute and resuming slow injection when the pulse rate was normal. Oxygen saturation was noted to be stable at 98 to 100 %. We stopped when the AVM blanched out, injecting 15 ml of sclerosant. In two weeks time the AVM shrank except for a 1 x 1 cm bulge at the left posterior nasopharynx that was supplied by the internal carotid artery branch that could not be sclerosed at the time of surgery. The patient was decannulated from tracheostomy and was able to resume normal diet and activity. She is on regular follow-up and is being maintained with propranolol 40 mg once a day hoping that it may work as it does in hemangioma. 1 year post operatively, the bulge has not grown nor disappeared. Looking back, had we done surgery as suggested by colleagues, we could have encountered massive bleeding, inability to take the AVM all out, and eventual recurrence. Pondering upon the case of a second arterial blood supply of the AVM, the malformation could have recruited this second blood supply. The forward force of introduction of the sclerosant was not able to overcome the arterial pressure of the internal carotid artery feeding branch so the sclerotherapy effect stopped where the flow forces where at equilibrium. Note that in this case, we did not ligate the specific venous drainage as the CT-angiography did not identify it. DISCUSSION Managing AVMs that are diffuse and infiltrative can be very difficult. Surgical extirpation of all the nidus may not be possible and will surely lead to recurrences. Besides, malformations located in functionally strategic areas may present with structural deformities and functional disturbances when they are damaged by surgery. Small AVMs can be resected with high rates of success and no recurrences. In one series, all 16 patients with surgically accessible, localized, non-infiltrating AVMs who underwent angio-embolization with subsequent surgical excision demonstrated no evidence of recurrence on angiography during follow-up averaging 3 months.9 In low flow venous malformations, sclerotherapy administered by trans-arterial, trans-venous or direct puncture injection without embolization or feeding vessel ligation has a 64 to 96% response rate, defined as improvement in symptoms or reduction of the lesion and not necessarily cure.3 The cure rate for small malformations was 69% with excision only and 62% for extensive lesions with combined embolization and resection. At 6 years average follow-up, cure rate was 75% for stage 1; 67% for stage 2; and 48% for stage 3 malformations. The outcomes were not significantly affected by age at treatment, Schobinger stage, or treatment method.11 Embolo-sclerotherapy is a new therapeutic modality for surgically inaccessible lesions like diffuse and infiltrating AVMs.4 This procedure is done repeatedly since the embolus recanalizes and the sclerosant is injected distal to the embolus. This method is reserved as an adjunct to subsequent surgical resection.4 Our immediate results for ligation of feeding artery or draining vein before sclerotherapy were dramatic without functional or anatomic compromise. With sclerogen, whose components exist in the body naturally, we found no significant complications in our 3 cases. This technique could be ideal for diffuse and infiltrating AVMs. It is more effective if the feeding artery and the draining vein are identified and ligated so that the sclerosant can be pushed to all branches of the AVM. With a “no-flow or a slow-flow” AVM, we are able to prolong the contact of the sclerosant with the vascular endothelium thereby increasing the success rate of totally eliminating the nidus of the vascular malformation. More studies and experience are needed to prove the durability of this technique. Are we able to eliminate all the nidus of the AVM if we are able to ligate all feeding arteries and draining veins before sclerotherapy? Our center is not so equipped so more technically advanced institutions dealing with vascular tumors and malformations can validate the efficacy of this technique. After all, it might not be bane to ligate AVM feeding and draining vessels if we are able to destroy the entire nidus of the AVM by whatever means like sclerotherapy in this case. Acknowledgements I wish to acknowledge my anesthesiologist Dr. Julius Apostol who encouraged me to try new things and promised to research on management of possible egress of sclerosants in the systemic circulation as he puts my patients to sleep. My residents at the Department of Otolaryngology-Head and Neck Surgery, Baguio General Hospital did the pre- and post-operative patient care while I was away, and the photography: Dr. Carlo Pagalilauan, Chief Resident and photographer, Dr. Sherwin Valdez, Dr. Beverly Carbonel, Dr. Jeff Peckley and Dr. Wingleaf Yu who are my assistants. Thank you.

AbstractThe immune response to major trauma has been analysed mainly within post-hospital admission settings where the inflammatory response is already underway and the early drivers of clinical outcome cannot be readily determined. Thus, there is a need to better understand the immediate immune response to injury and how this might influence important patient outcomes such as multi-organ dysfunction syndrome (MODS). In this study, we have assessed the immune response to trauma in 61 patients at three different post-injury time points (ultra-early (<=1 h), 4–12 h, 48–72 h) and analysed relationships with the development of MODS. We developed a pipeline using Absolute Shrinkage and Selection Operator and Elastic Net feature selection methods that were able to identify 3 physiological features (decrease in neutrophil CD62L and CD63 expression and monocyte CD63 expression and frequency) as possible biomarkers for MODS development. After univariate and multivariate analysis for each feature alongside a stability analysis, the addition of these 3 markers to standard clinical trauma injury severity scores yields a Generalized Liner Model (GLM) with an average Area Under the Curve value of 0.92 ± 0.06. This performance provides an 8% improvement over the Probability of Survival (PS14) outcome measure and a 13% improvement over the New Injury Severity Score (NISS) for identifying patients at risk of MODS.

This thesis studies advection modeling for heat transfer and fluid flow problems using a new Non--Inverted Skew Upwind Scheme (called NISUS). Variants of the new scheme are formulated and developed with 8-noded hexahedral elements using the Finite Element Method (FEM)and rectangular elements based on a Finite Volume Method (FVM). A new method of mass weighting to predict convective fluxes of each scalar from the nodal point values is developed. Due to an explicit representation in terms of nodal variables, local inversion of the upwind coefficient matrix is not needed. Also, this thesis evaluates two variants of the new scheme (i.e., 3-node / 3-point and 4-node / 8-point formulations) within a 3--D FEM and a third variant within a 2--D FVM. The 3--D FEM variants are applied to a variety of test problems involving the transport of a scalar variable, while the 2--D FVM variant is applied to fluid flow problems including natural convection in an enclosure and micro--channel flow simulations. The promising performance of NISUS, as compared with exact and previous solutions, is demonstrated both in terms of accuracy and stability. Furthermore, a new data storage format called Compressed Banded Data (CBD) is developed for sparse banded matrices generated by the control volume finite element method (CVFEM). The platform of the new CBD structure permits dynamic switching between various solvers, without any procedural change in the implementation of existing simulation software. The performance of different Krylov techniques with an ILU(0) preconditioner is observed and compared in three test problems with a direct solver.
October 2006