Ultrasound Guided Placement of Single-Lumen Peripheral Intravenous Catheters in the Internal Jugular Vein

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications. Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections. Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access

AXL modulates extracellular matrix protein expression and is essential for invasion and metastasis in endometrial cancer

The receptor tyrosine kinase AXL promotes migration, invasion, and metastasis. Here, we evaluated the role of AXL in endometrial cancer. High immunohistochemical expression of AXL was found in 76% (63/83) of advanced-stage, and 77% (82/107) of high-grade specimens and correlated with worse survival in uterine serous cancer patients. In vitro, genetic silencing of AXL inhibited migration and invasion but had no effect on proliferation of ARK1 endometrial cancer cells. AXL-deficient cells showed significantly decreased expression of phospho-AKT as well as uPA, MMP-1, MMP-2, MMP-3, and MMP-9. In a xenograft model of human uterine serous carcinoma with AXL-deficient ARK1 cells, there was significantly less tumor burden than xenografts with control ARK1 cells. Together, these findings underscore the therapeutic potentials of AXL as a candidate target for treatment of metastatic endometrial cancer

The Changing U.S. China Watching Community and the Demise of Engagement with the People’s Republic of China

Recent years have seen the rapid descent of relations between the United States and the People's Republic of China (prc). Hopes for cooperation in places of common concern like climate change gave way to strains in almost all areas. In place of "engagement,"the administration of Donald J. Trump adopted a tougher approach of "strategic competition"that its successor so far has continued. This article explores the relationship between the demise of engagement and opinions coming from the American China expert community. Specifically, it questions the impact on engagement of five secular dynamics that these China authorities have experienced - generational turnover; the field's vast expansion and diversification; increased disciplinary specialization; the enhanced prominence of the generalist in national security discussions in place of China specialists; and changes in the media leading to more skeptical journalistic voices on U.S.-prc relations. Without over-emphasizing either the influence of the expert community on U.S. decision-making, or underplaying the more repressive and authoritarian actions of the Chinese Communist Party, this article suggests that the China expert community has been more of a factor in the end of engagement than current accounts of academics and commentators acknowledge

American Power and International Theory at the Council on Foreign Relations, 1953-54

Between December 1953 and June 1954, the elite think-tank the Council on Foreign Relations (CFR) joined prominent figures in International Relations, including Pennsylvania’s Robert Strausz-Hupé, Yale’s Arnold Wolfers, the Rockefeller Foundation’s William Thompson, government adviser Dorothy Fosdick, and nuclear strategist William Kaufmann. They spent seven meetings assessing approaches to world politics—from the “realist” theory of Hans Morgenthau to theories of imperialism of Karl Marx and V.I. Lenin—to discern basic elements of a theory of international relations. The study group’s materials are an indispensable window to the development of IR theory, illuminating the seeds of the theory-practice nexus in Cold War U.S. foreign policy. Historians of International Relations recently revised the standard narrative of the field’s origins, showing that IR witnessed a sharp turn to theoretical consideration of international politics beginning around 1950, and remained preoccupied with theory. Taking place in 1953–54, the CFR study group represents a vital snapshot of this shift This book situates the CFR study group in its historical and historiographical contexts, and offers a biographical analysis of the participants. It includes seven preparatory papers on diverse theoretical approaches, penned by former Berkeley political scientist George A. Lipsky, followed by the digest of discussions from the study group meetings. American Power and International Theory at the Council on Foreign Relations, 1953–54 offers new insights into the early development of IR as well as the thinking of prominent elites in the early years of the Cold War

Cameron is right to let voters shape the UK's future

First paragraph: 'I have not become the King’s First Minister in order to preside over the liquidation of the British Empire'. So Winston Churchill declared in 1942. Seventy years on, David Cameron no doubt feels something similar. Yet three recent developments appear to signal the downsizing of Britain’s role in the world: next year’s referendum on Scottish independence, as laid out in this week’s White Paper; a UK referendum on EU membership, promised for 2017; and the Commons vote against action in Syria. Read article on The Conversation website: https://theconversation.com/cameron-is-right-to-let-voters-shape-the-uks-future-2051

Adult Comorbidity Evaluation 27 score as a predictor of survival in endometrial cancer patients

BACKGROUND The incidence of endometrial cancer increases with age and is associated with medical comorbidities such as obesity and diabetes. While a few cohort studies of less than 500 patients showed an association between comorbidity and survival in endometrial cancer patients, the degree of association needs to be better described. The Adult Comorbidity Evaluation 27 (ACE-27) is a validated comorbidity instrument that provides a score (0–3) based on the number and severity of medical comorbidities. OBJECTIVE This study was performed to explore the association between medical comorbidities and survival of endometrial cancer patients. STUDY DESIGN Patients diagnosed with endometrial cancer from 2000–2012 were identified from the prospectively maintained Siteman Cancer Center tumor registry. Patients undergoing primary surgical treatment for endometrioid, serous and clear cell endometrial carcinoma were included. Patients primarily treated with radiation, chemotherapy or hormone therapy were excluded. Patients with uterine sarcomas or neuroendocrine tumors were excluded. Patients with missing ACE-27 scores were also excluded from analysis. Information including patient demographics, ACE-27 score, tumor characteristics, adjuvant treatment and survival data were extracted from the database. The association of ACE-27 and overall as well as recurrence-free survival was explored in a multivariable Cox regression analysis after controlling for variables found to be significantly associated with survival in univariable analysis. RESULTS A total of 2073 patients with a median age of 61 years (range 20–94) at diagnosis were identified. ACE-27 score was 0, 1, 2 and 3 in 22%, 38%, 28% and 12% of patients, respectively. Stage distribution was I (73%), II (5%), III (15%) and IV (7%) and grade distribution was 1 (52%), 2 (23%) and 3 (25%). Most patients had endometrioid histology (87%) followed by serous (11%) and clear cell (3%). The median OS for the entire cohort was 54 months [95% confidence interval (CI) 3, 154 months] and median PFS was 50 months [95% CI 2, 154 months]., On univariable analysis, age, race, marital status, stage, grade, histology and treatment type were significantly associated with overall survival and recurrence-free survival. After adjusting for these covariates, patients with ACE-27 score of 2 had a 52% higher risk of death [95% CI 1.16, 2.00] and patients with ACE-27 score of 3 had a 2.35-fold increased risk of death [95% CI 1.73, 3.21] compared to patients with an ACE-27 score of 0. Similarly, patients with ACE-27 score of 2 had a 38% higher risk of recurrence [95% CI 1.07, 1.78] and patients with ACE-27 score of 3 had a 2.05-fold increased risk of recurrence [95% CI 1.53, 2.75] compared to patients with an ACE-27 score of 0. We found no interaction between ACE-27 score and age, stage or treatment type. CONCLUSIONS Our findings demonstrate the importance of comorbidities in estimating the prognosis of endometrial cancer patients, even after adjusting for age and known tumor-specific prognostic factors like stage, grade, histology and adjuvant treatment

Multiphase, non-spherical gas accretion onto a black hole

(Abridged) We investigate non-spherical behavior of gas accreting onto a central supermassive black hole performing simulations using the SPH code GADGET-3 including radiative cooling and heating by the central X-ray source. As found in earlier 1D studies, our 3D simulations show that the accretion mode depends on the X-ray luminosity (L_X) for a fixed density at infinity and accretion efficiency. In the low L_X limit, gas accretes in a stable, spherically symmetric fashion. In the high L_X limit, the inner gas is significantly heated up and expands, reducing the central mass inflow rate. The expanding gas can turn into a strong enough outflow capable of expelling most of the gas at larger radii. For some intermediate L_X, the accretion flow becomes unstable developing prominent non-spherical features, the key reason for which is thermal instability (TI) as shown by our analyses. Small perturbations of the initially spherically symmetric accretion flow that is heated by the intermediate L_X quickly grow to form cold and dense clumps surrounded by overheated low density regions. The cold clumps continue their inward motion forming filamentary structures; while the hot infalling gas slows down because of buoyancy and can even start outflowing through the channels in between the filaments. We found that the ratio between the mass inflow rates of the cold and hot gas is a dynamical quantity depending on several factors: time, spatial location, and L_X; and ranges between 0 and 4. We briefly discuss astrophysical implications of such TI-driven fragmentation of accreting gas on the formation of clouds in narrow and broad line regions of AGN, the formation of stars, and the observed variability of the AGN luminiosity.Comment: 25 pages, 13 figures. Version accepted for publication in MNRAS. Uploaded version contains low-resolution color figures. Complete paper with high-resolution figures can be found at: http://adlibitum.oats.inaf.it/barai/AllPages/Images-Movies/BHaccr_MultiPhase.pd

A phase II evaluation of cediranib in the treatment of recurrent or persistent endometrial cancer: An NRG Oncology/Gynecologic Oncology Group study

PURPOSE: Cediranib is a multi-tyrosine kinase inhibitor targeting vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF) receptors. This phase II study was conducted to assess activity and tolerability of single-agent cediranib in recurrent/persistent endometrial cancer. PATIENTS AND METHODS: Eligible patients had recurrent or persistent endometrial cancer after receiving one or two prior cytotoxic regimens, measurable disease, and Gynecologic Oncology Group (GOG) performance status of ≤2 (≤1 if two prior cytotoxic regimens given). Cediranib 30mg orally daily for a 28daycycle was administered until disease progression or prohibitive toxicity. Microvessel density (MVD) was measured in tumor tissue from initial hysterectomy specimens and correlated with clinical outcome. Primary endpoints were tumor response and surviving progression-free for six months without subsequent therapy (6-month event-free survival [EFS]). RESULTS: Of 53 patients enrolled, 48 were evaluable for cediranib efficacy and toxicity. Median age was 65.5 years, 52% of patients had received prior radiation, and 73% of patients received only one prior chemotherapy regimen. A partial response was observed in 12.5%. Fourteen patients (29%) had six-month EFS. Median progression-free survival (PFS) was 3.65 months and median overall survival (OS) 12.5 months. No grade 4 or 5 toxicities were observed. A trend towards improved PFS was found in patients whose tumors expressed high MVD. CONCLUSION: Cediranib as a monotherapy treatment for recurrent or persistent endometrial cancer is well tolerated and met protocol set objectives for sufficient activity to warrant further investigation. MVD may be a useful biomarker for activity