bluuebunny/crossref_metadata_2025 huggingface dataset:
4. Divorce, Dissolution, and (Judicial) Separation
Authors: Gaffney-Rhys Ruth
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam and assignment questions. Each book includes key debates, typical questions, diagram answer plans, suggested answers, author commentary, and tips to gain extra marks. This chapter deals with divorce, dissolution, separation orders, and judicial separation, and contains a mixture of essay and problem questions. The first question is a problem question that considers the ground and facts for divorce contained in the Matrimonial Causes Act 1973 and the equivalent provisions of the Civil Partnership Act 2004. The second is a problem question that also requires students to apply the law of divorce, but further necessitates consideration of judicial separation. The third and fourth questions are essay questions that focus on reform of divorce law and the use of mediation in divorce proceedings.
5. Domestic Violence
Authors: Gaffney-Rhys Ruth
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam and assignment questions. Each book includes key debates, typical questions, diagram answer plans, suggested answers, author commentary, and tips to gain extra marks. This chapter focuses on domestic violence and considers the civil and criminal law. The first question is a problem question concerning non-molestation orders under the Family Law Act 1996 and injunctions under the Protection from Harassment Act 1997. The second question is an essay focusing on occupation orders, whilst the third is a problem question on the criminal law.
1. Exam Skills for Success in Criminal Law
Authors: Allen Mischa
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, suggested answers, author commentary and advice on study skills. This introductory chapter provides an overview of the nature and complexities of the criminal law and the common features of all crimes such as actus reus, mens rea, and the defences. It outlines some techniques for achieving success in criminal law examinations. The chapter notes that to achieve success it is important to exercise good study skills from the outset and learn how to manage your time well. Relevance and structure are vital. Planning answers carefully, and providing critical analysis of the issues raised are essential.
6. Property Offences
Authors: Allen Mischa
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, suggested answers, author commentary and advice on study skills. This chapter presents sample exam questions on theft, fraud, and other property offences such as robbery, burglary, along with suggested answers. The law of property is vast, and contained in a number of different pieces of legislation. As this chapter explains, the Fraud Act 2006 was designed to replace many of the discrepancies and inconsistencies in the diverse provisions of the Theft Acts of 1968 and 1978. It pays to be methodical in approaching property problems. Dishonesty is an important concept throughout the property offences. The recent decision in Ivey v Genting Casinos, which has an important effect on the definition of dishonesty in criminal law, is dealt with in detail in this chapter.
10. Skills for Success in Coursework Assessments
Authors: Allen Mischa
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, suggested answers, author commentary and advice on study skills This chapter deals with how to achieve success in coursework assessments in criminal law. It offers advice on how to get started, and the different approaches needed to write the longer, more detailed answers required of coursework. An example of a coursework answer is provided. Research and planning are essential. It is crucial to employ critical analysis, to stay relevant, and to stick to the word limit. Assessments must be approached logically and be tightly structured. Finally, students need to become familiar with correct referencing of legal authorities.
3. The Sources, Forms, and Individual Remedies of EU Law
Authors: Foster Nigel
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter includes questions on a wide variety of often overlapping points concerned with the sources of European Union (EU) law. The EU sources of law are the Treaties, Protocols, and the EU Charter of Fundamental Rights, which are regarded as primary sources and secondary legislation which can be enacted by the institutions of the Union by virtue of the powers given by the Member States and contained in the Treaties. Additional sources of law in the EU legal order are agreements with third countries, fundamental rights, general principles, and the case law of the European Court of Justice (ECJ) establishing, amongst other case law developments, the doctrine of direct effects, supremacy of EU law, and state liability.
4. The Supremacy of EU Law and its Reception in the Member States
Authors: Foster Nigel
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter presents sample exam questions along with examiner’s tips, answer plans, and suggested answers about the supremacy of EU law and its reception in Member States. Both the legal arguments for supremacy and the political logic are often considered in establishing the reasoning for EU law supremacy. The first question concentrates on the reasons for EU law supremacy from the point of view of the Union and in the view of the Court of Justice of the European Union (CJEU (or also abbreviated CoJ)).
3. Adverse Possession
Authors: Malcolm Rosalind
Published: September 2018

The Q&A series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter presents issues related to adverse possession.
8. Proprietary Estoppel
Authors: Malcolm Rosalind
Published: September 2018

The Q&A series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter examines proprietary estoppels.
12. Mortgages
Authors: Malcolm Rosalind
Published: September 2018

The Q&A series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter presents sample exam questions about the law of mortgages. The questions deal with issues such as their creation; clogs on the equity of redemption; the remedies of a mortgagee and protection of the mortgagor; and undue influence.
13. Skills for Success in Coursework Assessments
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans, suggested answers and author commentary. This chapter gives advice on skills for success in coursework assessments.
1. Exam Skills for Success in Equity and Trusts Law
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. This chapter gives students advice on skills for success in equity and trusts exams. It includes tips on what to do during the module, the revision period and in the exam room, as well as advice on the structure and approach to problem questions.
10. Trusts of the Family Home
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans, suggested answers and author commentary. This book offers advice on what to expect in exams and how best to prepare. This chapter covers questions on trusts of the family home.
16. Skills for Success in Coursework Assessments
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans, suggested answers and author commentary. This book offers advice on what to expect in exams and how best to prepare. This chapter gives advice on skills for success in coursework assessments.
3. The Corporate Constitution
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. This chapter discusses the company’s constitution, which can be a popular area for examination questions. The chapter focuses on the company’s articles of association, considering in particular alteration of the articles and the legal effect of the articles (the ‘statutory contract’). The chapter also considers shareholder agreements, which are often used as a supplement to the company’s constitution.
4. Shares and Shareholders
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. Shareholders in a company own shares, but the nature of a share and the rights of a shareholder are not easily defined. This chapter discusses the definition and characteristics of a share; the differences between different types of share, particularly ordinary and preference shares; transfer of shares; pre-emption rights; share certificates and estoppel; and variation of class rights.
5. Directors’ Duties
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. This chapter examines the very important topic of directors’ duties. The chapter considers the main duties, as codified in the Companies Act 2006, including: the duty to act within powers; the duty to promote the success of the company; the duty to exercise independent judgment; the duty to exercise reasonable care, skill, and diligence; the duty to avoid conflicts of interest; and the duty to disclose an interest in a proposed transaction with the company. Related areas such as substantial property transactions are considered. This chapter considers who is a ‘director’, examining the concepts of de facto and shadow directors and how far they owe duties to the company.
8. Corporate Liability: Contracts, Torts, and Crimes
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. This chapter examines company contracts including: pre-incorporation contracts; the company’s capacity; directors’ authority; and restrictions on the powers of directors to bind the company. The chapter also considers liability of the company for tortious and criminal acts, including corporate manslaughter and the effect of the Corporate Manslaughter and Corporate Homicide Act 2007 on attribution of liability.
2. Nature and Enforcement of Human Rights and Civil Liberties
Authors: Foster Steve
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, caution advice, suggested answers, illustrative diagrams and flowcharts, and advice on gaining extra marks. Concentrate Q&A Human Rights & Civil Liberties offers expert advice on what to expect from your human rights and civil liberties exam, how best to prepare, and guidance on what examiners are really looking for. Written by experienced examiners, it provides: clear commentary with each question and answer; bullet point and diagram answer plans; tips to make your answer really stand out from the crowd; and further reading suggestions at the end of every chapter. The book should help you to: identify typical law exam questions; structure a first-class answer; avoid common mistakes; show the examiner what you know; make your answer stand out from the crowd.

This chapter covers the nature and enforcement of human rights, including their values and inherent restrictions and their protection at both domestic and international levels.
7. Due Process, Liberty and Security of the Person, and the Right to a Fair Trial
Authors: Foster Steve
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, caution advice, suggested answers, illustrative diagrams and flowcharts, and advice on gaining extra marks. Concentrate Q&A Human Rights & Civil Liberties offers expert advice on what to expect from your human rights and civil liberties exam, how best to prepare, and guidance on what examiners are really looking for. Written by experienced examiners, it provides: clear commentary with each question and answer; bullet point and diagram answer plans; tips to make your answer really stand out from the crowd; and further reading suggestions at the end of every chapter. The book should help you to: identify typical law exam questions; structure a first-class answer; avoid common mistakes; show the examiner what you know; make your answer stand out from the crowd.

This chapter covers due process, liberty, and security of the person, and the right to a fair trial, including articles 5, 6, and 7 of the ECHR and their application to matters such as prison discipline, police powers, and the fight against terrorism.
11. Freedom of Religion, Association, and Peaceful Assembly
Authors: Foster Steve
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, caution advice, suggested answers, illustrative diagrams and flowcharts, and advice on gaining extra marks. Concentrate Q&A Human Rights & Civil Liberties; offers expert advice on what to expect from your human rights and civil liberties exam, how best to prepare, and guidance on what examiners are really looking for. Written by experienced examiners, it provides: clear commentary with each question and answer; bullet point and diagram answer plans; tips to make your answer really stand out from the crowd; and further reading suggestions at the end of every chapter. The book should help you to: identify typical law exam questions; structure a first-class answer; avoid common mistakes; show the examiner what you know; make your answer stand out from the crowd. This chapter covers freedom of religion, freedom of association, and the right to peaceful assembly, including the scope of those rights, their protection in domestic law and under the ECHR and their application to matters such as religious practices, trade unions, and political organisations, and the right to demonstrate.
12. Skills for Success in Coursework Assessments
Authors: Foster Steve
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, caution advice, suggested answers, illustrative diagrams and flowcharts, and advice on gaining extra marks. Concentrate Q&A Human Rights & Civil Liberties offers expert advice on what to expect from your human rights and civil liberties exam, how best to prepare, and guidance on what examiners are really looking for. Written by experienced examiners, it provides: clear commentary with each question and answer; bullet point and diagram answer plans; tips to make your answer really stand out from the crowd; and further reading suggestions at the end of every chapter. The book should help you to: identify typical law exam questions; structure a first-class answer; avoid common mistakes; show the examiner what you know; and make your answer stand out from the crowd.

This chapter covers the skills required from students when completing assessments, including how to achieve success and high marks. It highlights the approach that needs to be taken when writing coursework in this legal area. The need for logical structured answers is also stressed. A coursework example question, with accompanying answer guidance, is also available.
2. Burden and standard of proof: Presumptions
Authors: Spencer Maureen , Spencer John
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter discusses the allocation of the burden of proof in civil and criminal trials, depending on who should bear the risk. In criminal trials the ‘presumption of innocence’ means that the burden is on the prosecution, unless reversed by express or implied statutory provision. The law of evidence safeguards what in some jurisdictions is a civil right backed by the constitution. It is important to understand the difference between the legal and evidential burden and the occasions where they are separately allocated. Tricky areas are where there is a divorce of the legal and evidential burden, primarily in situations where the prosecution cannot expect to put up evidence to anticipate every specific defence the accused may present.
11. Mixed topic questions
Authors: Spencer Maureen , Spencer John
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and diagrams and flow charts. This chapter describes how examination questions frequently cover several issues. It is impossible to cover each area in the same depth as single-issue questions so it is important to take time listing matters that raise points of law, then specifying the appropriate statute or case law, and finally applying the law to the given facts. A well-crafted question will not contain redundant information, so be prepared to comment on all parts of it. These questions do not ask for an evaluation or criticism of the law as it is, but for identification of legal issues in the narrative given and application of the law to each. It may be appropriate to refer to academic commentary, particularly in new areas of law.
6. Parliamentary sovereignty
Authors: Clements Richard
Published: September 2018

The Q&A series offers the best preparation for tackling exam questions. Each chapter includes typical questions; diagram problem and essay answer plans, suggested answers, notes of caution, tips on obtaining extra marks, the key debates on each topic and suggestions on further reading. This chapter considers questions relating to parliamentary sovereignty. There is a traditional doctrine of parliamentary supremacy, but it has had to be adapted to accommodate membership of the European Union. The questions deal with issues such as the meaning and implications of ‘parliamentary supremacy’; the impact of the UK’s EU membership on the doctrine of parliamentary sovereignty; the effect of EU legislation, such as directives, in English Law; how the European Union works; and how Brexit will affect Parliamentary Supremacy.
Remodeling Ancestral Phenotypic Plasticity in Local Adaptation: A New Framework to Explore the Role of Genetic Compensation in the Evolution of Homeostasis
Authors: Velotta Jonathan P , Cheviron Zachary A
Published: September 2018

Phenotypic plasticity is not universally adaptive. In certain cases, plasticity can result in phenotypic shifts that reduce fitness relative to the un-induced state. A common cause of such maladaptive plasticity is the co-option of ancestral developmental and physiological response systems to meet novel challenges. Because these systems evolved to meet specific challenges in an ancestral environment (e.g., localized and transient hypoxia), their co-option to meet a similar, but novel, stressor (e.g., reductions in ambient pO2 at high elevation) can lead to misdirected responses that reduce fitness. In such cases, natural selection should act to remodel phenotypic plasticity to suppress the expression of these maladaptive responses. Because these maladaptive responses reduce the fitness of colonizers in new environments, this remodeling of ancestral plasticity may be among the earliest steps in adaptive walks toward new local optima. Genetic compensation has been proposed as a general form of adaptive evolution that leads to the suppression of maladaptive plasticity to restore the ancestral trait value in the face of novel stimuli. Given their central role in the regulation of basic physiological functions, we argue that genetic compensation may often be achieved by modifications of homeostatic regulatory systems. We further suggest that genetic compensation to modify homeostatic systems can be achieved by two alternative strategies that differ in their mechanistic underpinnings; to our knowledge, these strategies have not been formally recognized by previous workers. We then consider how the mechanistic details of these alternative strategies may constrain their evolution. These considerations lead us to argue that genetic compensation is most likely to evolve by compensatory physiological changes that safeguard internal homeostatic conditions to prevent the expression of maladaptive portions of conserved reaction norms, rather than direct evolution of plasticity itself. Finally, we outline a simple experimental framework to test this hypothesis. Our goal is to stimulate research aimed at providing a deeper mechanistic understanding of whether and how phenotypic plasticity can be remodeled following environmental shifts that render ancestral responses maladaptive, an issue with increasing importance in our current era of rapid environmental change.
The evolving response of mesopelagic fishes to declining midwater oxygen concentrations in the southern and central California Current
Authors: Koslow J Anthony , Davison Pete , Ferrer Erica , Jiménez Rosenberg S Patricia A , Aceves-Medina Gerardo , Watson William
Published: September 2018

Declining oxygen concentrations in the deep ocean, particularly in areas with pronounced oxygen minimum zones (OMZs), are a growing global concern related to global climate change. Its potential impacts on marine life remain poorly understood. A previous study suggested that the abundance of a diverse suite of mesopelagic fishes off southern California was closely linked to trends in midwater oxygen concentration. This study expands the spatial and temporal scale of that analysis to examine how mesopelagic fishes are responding to declining oxygen levels in the California Current (CC) off central, southern, and Baja California. Several warm-water mesopelagic species, apparently adapted to the shallower, more intense OMZ off Baja California, are shown to be increasing despite declining midwater oxygen concentrations and becoming increasingly dominant, initially off Baja California and subsequently in the CC region to the north. Their increased abundance is associated with warming near-surface ocean temperature, the warm phase of the Pacific Decadal oscillation and Multivariate El Niño-Southern Oscillation Index, and the increased flux of Pacific Equatorial Water into the southern CC.
Mapping of HIE CT terms to LOINC®: analysis of content-dependent coverage and coverage improvement through new term creation
Authors: Peng Paul , Beitia Anton Oscar , Vreeman Daniel J , Loo George T , Delman Bradley N , Thum Frederick , Lowry Tina , Shapiro Jason S
Published: September 2018

Objective

We describe and evaluate the mapping of computerized tomography (CT) terms from 40 hospitals participating in a health information exchange (HIE) to a standard terminology.

Methods

Proprietary CT exam terms and corresponding exam frequency data were obtained from 40 participant HIE sites that transmitted radiology data to the HIE from January 2013 through October 2015. These terms were mapped to the Logical Observations Identifiers Names and Codes (LOINC®) terminology using the Regenstrief LOINC mapping assistant (RELMA) beginning in January 2016. Terms without initial LOINC match were submitted to LOINC as new term requests on an ongoing basis. After new LOINC terms were created, proprietary terms without an initial match were reviewed and mapped to these new LOINC terms where appropriate. Content type and token coverage were calculated for the LOINC version at the time of initial mapping (v2.54) and for the most recently released version at the time of our analysis (v2.63). Descriptive analysis was performed to assess for significant differences in content-dependent coverage between the 2 versions.

Results

LOINC’s content type and token coverages of HIE CT exam terms for version 2.54 were 83% and 95%, respectively. Two-hundred-fifteen new LOINC CT terms were created in the interval between the releases of version 2.54 and 2.63, and content type and token coverages, respectively, increased to 93% and 99% (P < .001).

Conclusion

LOINC’s content type coverage of proprietary CT terms across 40 HIE sites was 83% but improved significantly to 93% following new term creation.
Stereoscopic Surgical Video of Combined Petrosectomy With Virtual Reality Headset: 3-Dimensional Operative Video
Authors: Bernard Florian , Troude Lucas , Laccourreye Laurent , Roche Pierre-Hugues , Fournier Henri-Dominique
Published: September 2018

The use of 3-dimensional (3D) videos allows students to visualize surgical procedures from the perspective of the surgeon without missing the essential parts.
1
This 3D commented video demonstrates the operative technique and surgical nuances of the combined petrosectomy, visualize using virtual reality headsets.

Historically, traditional intradural cisternal routes using suboccipital and pterional approaches have been proposed to remove petroclival tumors.
2-5
It allows rapid identification of neurovascular structures and a short exposure time. However, access to the petroclival region is far, not direct, and requires intradural cerebral retraction.
6

In order to improve the access for tumoral dissection, lateral transpetrosal approaches have been proposed.
7-12
The extradural route shortened the distance to the petroclival region, allows to better preserve the veins, to decrease the cerebral retraction, to interrupt early the tumor vascular supply, and a larger extent of resection.
6
Transpetrosal approaches includes middle fossa approach
8,10
(removing the petrous apex), posterior petrosal approach
9,13,14
(removing of presigmoid retrolabyrinthine bone), and translabyrinthine petrosectomy.
12

A combined petrosectomy may be used to approach larger tumor extending across the clival midline, upward to the tentorium or downward to the lower cranial nerves.
6,10,15,16
Alternatively, according to Nanda, a retro-sigmoid approach may need to be performed to avoid critical draining veins injury.
10,17
Good resection and outcomes are obtained when experienced surgeons use familiar approaches and microsurgical techniques.
10
Recurrent Rathke's Cleft Cysts: Incidence and Surgical Management in a Tertiary Pituitary Center over 2 Decades
Authors: Wedemeyer Michelle A , Lin Michelle , Fredrickson Vance L , Arakelyan Anush , Bradley Daniel , Donoho Daniel A , Hurth Kyle M , Weiss Martin H , Carmichael John D , Zada Gabriel
Published: September 2018

Background

Limited data exist pertaining to outcomes following surgery for recurrent Rathke's cleft cysts (RCC).

Objective

To determine treatment outcomes in patients undergoing reoperation for recurrent or residual RCCs.

Methods

A retrospective analysis of 112 consecutive RCC operations in 109 patients between 1995 and 2017 was conducted.

Results

Eighteen patients underwent 21 RCC reoperations with a mean follow-up of 58 mo. Patient symptoms prior to reoperation included headaches (14, 66.7%) and vision loss (12, 57.1%). Thirteen of 18 patients (72.2%) required hormone supplementation prior to reoperation including 5 with diabetes insipidus (DI). Mean RCC diameter was 16 mm and 76% had suprasellar extension. Compared to index RCC cases, intraoperative cerebrospinal fluid leak repair was more common in reoperation cases (15/21, 71% vs 43/91, 47%, P = .05). There was 1 carotid artery injury without neurological sequelae, and 2 postoperative cerebrospinal fluid (CSF) leaks (9.5%). Rates of transient hyponatremia (3/10, 30% vs 4/91, 4.4%, P = .04) and transient DI (5/10, 50% vs 17/91, 18.7%, P = .04) were higher in the reoperation vs index group. Improved headaches and vision were reported in 4/12 (33%) and 8/12 (61.5%) of RCC reoperation patients, respectively. Two patients developed new permanent DI. A higher proportion of reoperation patients had RCC squamous metaplasia (24% vs 5.4%, P = .02) or wall inflammation (42.9% vs 2.2%, P < .001) on pathological examination.

CONCLUSION

Reoperation for RCCs is generally safe at tertiary pituitary centers and often results in improved vision. Hypopituitarism is less likely to improve following reoperation for recurrent RCCs. Several histopathological features may help characterize “atypical RCCs” with a higher likelihood of recurrence/progression.
Next-Generation Robotic Spine Surgery: First Report on Feasibility, Safety, and Learning Curve
Authors: Khan Asham , Meyers Joshua E , Siasios Ioannis , Pollina John
Published: September 2018

Background

Pedicle screw placement is a commonly performed procedure. Robot-guided screw placement is a recent technological advance that has shown accuracy and reliability with first-generation platforms.

Objective

To report our initial experience with the safety, feasibility, and learning curve associated with pedicle screw placement utilizing next-generation robotic guidance.

Methods

A retrospective chart review was conducted to obtain data for 20 patients who underwent lumbar pedicle screw placement under robotic guidance after undergoing interbody fusion for lumbar spinal stabilization for degenerative disc disease with or without spondylolisthesis. The newest generation Mazor X (Mazor Robotics Ltd, Caesarea, Israel) was used. Accuracy of screw placement was determined to be grade I to IV. Grade I was in the pedicle (no breach/deviation), grade II was breach < 2 mm, grade III was breach 2 to 4 mm, and grade IV was breach >4 mm; breach direction (superior, lateral, inferior, or medial) was also recorded.

Results

Twenty patients underwent robotically assisted pedicle screw placement of 75 screws at 24 levels. Seventy-four screw placements (98.7%) were grade I; 1 (1.3%) was grade II (medial). No complications occurred. Mean time for screw insertion was 3.6 min. Mean fluoroscopy time was 13.1 s and mean radiation dose was 29.9 mGy.

CONCLUSION

We found that next-generation robotic spine surgery was safe and feasible with reliable and precise accuracy and a minimal learning curve. As this technology improves, further novel applications are expected to develop. Further research is needed to determine long-term efficacy.
Increased Osteoblastic Activity Suppressed Proliferation of Multiple Myeloma Plasma Cells
Authors: Cho Yoo-Kyung , Kim Sang-Il , Ha Kee-Yong , Kim Young-Hoon , Park Hyung-Youl , Min Chang-Ki
Published: September 2018

Study Design.

In vitro experimental study.

Objective.

To investigate the impact of increased osteoblastic activity on the proliferation and survival of multiple myeloma (MM) plasma cells in vitro

Summary of Background Data.

MM is one of representative hematologic malignancies that cause skeletal-related events (SREs) and dysregulation of bone remodeling is known as a key pathomechanism of disease progression and skeletal-related events. However, decreased proliferation of MM at fracture sites is frequently noted in clinical situations regardless of systemic disease activity.

Methods.

Co-culture under various conditions was used to investigate effects of increased osteoblastic activity on survival and proliferation of MM plasma cells. MM plasma cells were cultured in culture media (control) and co-cultured with human mesenchymal stem cells (hMSCs, group I), osteoblasts (OBs) induced from hMSCs (group II) or bone morphogenic protein-2 (BMP-2, group III). Proliferation measured as extracellular signal-regulated kinase (ERK) and immunoglobulin G (Ig G) expression and apoptosis measured as fluorescence-activated cell sorting (FACS) with annexin V method, caspase-3, and stat-3 expression were assessed for cultured MM plasma cells, along with expression of sclerostin.

Results.

After 72 hours of co-culture, group II and III showed decreased ERK expression compared with controls. Lower Ig G expression was also noted for groups II and III compared with controls. Group I did not show significantly decreased Ig G and ERK expression compared with controls. Expressions of caspase-3 in groups II and III were higher than controls. Co-culture with hMSCs showed decreased caspase-3 expression compared with control. FACS with annexin V showed higher apoptosis in groups II and III. Sclerostin expression was also decreased in osteoblastic conditions compared with the control and hMSCs co-culture condition.

Conclusion.

Collectively, our data suggest that increased osteoblastic conditions may provide not only prevention of SREs but also anti-tumor effects on MM cells in the bone marrow environment.

Level of Evidence: N/A
Does Extension Dysfunction Affect Postoperative Loss of Cervical Lordosis in Patients Who Undergo Laminoplasty?
Authors: Lee Su Hun , Son Dong Wuk , Lee Jun Seok , Sung Soon Ki , Lee Sang Weon , Song Geun Sung
Published: September 2018

Study Design.

Retrospective study.

Objective.

To investigate whether loss of cervical lordosis (LCL) after laminoplasty can be predicted from specific preoperative dynamic radiograph measurements.

Summary of Background Data.

Recent studies have focused on the correlation between LCL after laminoplasty and T1 slope. These studies explain this correlation through the injury of the posterior neck muscular-ligament complex (PMLC); however, this muscle injury model could not explain the less kyphotic change in high T1s patients, as reported in some studies as controversy. We have focused on the PMLC constriction reservoir which was represented by extension function (EF).

Methods.

We retrospectively analyzed 50 consecutive patients who underwent open-door laminoplasty (>1-year follow-up). EF is defined as extension C2–7 Cobb angle (CA) minus neutral C2–7 CA (Ext CA – CA). LCL is defined as follow-up CA minus preoperative CA (CA [FU] – CA [PRE]), and significant kyphotic change was defined as LCL smaller than –10°.

Results.

The distribution of LCL was –3.70 ± 7.98 and the significant kyphotic change occurred in 20% of the patients (10/50). EF, C2–7 sagittal vertical axis (PRE), and C2 slope (PRE) were found to be risk factors for LCL by multiple linear regression analysis. The receiver operating characteristic curve analysis revealed that EF could predict the significant kyphotic change well than previously known risk factors. The cutoff value of EF was 14°. No significant kyphotic change occurred at EF greater than or equal to 14°. Upon limiting the number of patients with preoperative straight curvature (n = 28), there is also no significant kyphotic change occurred in any patient whose EF was greater than or equal to 14°.

Conclusion.

In our study sample, we found that there is no relation between T1 slope and LCL. We have identified a new factor, EF, that could predict LCL after laminoplasty. No significant kyphotic changes after laminoplasty occurred particularly when the EF was greater than or equal to 14°.

Level of Evidence: 3
What are the Demographics and Epidemiology of Legg-Calvé-Perthes Disease in a Large Southern California Integrated Health System?
Authors: Kessler Jeffrey I. , Cannamela Peter C.
Published: September 2018

Background

Although many authors have reported the incidence of Legg-Calvé-Perthes disease (LCPD), there have been few incidence studies in the United States on large, self-contained populations such as those within an integrated health system. Understanding the epidemiology and demographics of LCPD in this setting may help clinicians identify patients at the greatest risk and aid in diagnosis and subsequent treatment.

Questions/purposes

In this study we sought (1) to determine the incidence and demographics of LCPD in a large cohort of children and adolescents in a Southern California integrated healthcare system, and (2) to identify any demographic or clinical factors (such as age, sex, race/ethnicity, or BMI) that are independently associated with LCPD.

Methods

A retrospective chart analysis was done on patients diagnosed with LCPD within our integrated healthcare system in patients aged 2 to 12 years over a 3-year period between 2010-2012. There were nearly 800,000 children in this cohort. Patient demographics were recorded; the incidence of LCPD was determined for the entire group and by sex, age, and race/ethnicity. Odds ratios for an association with LCPD based on age, sex, BMI and race/ethnicity were determined using logistic regression models.

Results

The LCPD incidence per 100,000 for all children was 2.84, with the highest incidence in 2- to 5-year-old children (3.05; 95% CI, 1.51-4.59) and the lowest in 9- to 12-year-old children (1.06; 95% CI, 0.21-1.91). Incidence varied markedly among ethnicities, with the highest incidence in whites (5.69; 95% CI, 3.13-8.24) and the lowest in Asians (0.78; 95% CI, 0.00-2.32). Data analysis revealed a 3.13-times increased odds ratio (OR) of LCPD in 2- to 5-year-old patients versus 9- to 12-year-olds (p = 0.011), and boys had a 12.44 times greater OR of LCPD than girls (p < 0.001). Data analysis showed an increased OR for LCPD (3.41; 95% CI, 1.28-9.09) in patients with extreme obesity (BMI-for-age ≥ 1.2 × 95th percentile or a BMI ≥ 35 kg/m2) compared with patients with a normal BMI.

Conclusions

Our study of a large integrated healthcare system in Southern California revealed an increased association of male sex and young age (2 to 5 years old) with LCPD. The overall incidence was lower overall than previously reported, although the incidence seen in white patients was similar to that in prior studies. The finding that patients with extreme obesity may have an increased association with LCPD merits further study. These findings may increase providers’ awareness of the risk of the disease in younger patients and in extremely obese patients, and it also merits further future investigation as to whether there is a cause or effect relationship between extreme obesity and LCPD.

Level of Evidence

Level IV, prognostic study.
Spatial learning and flexibility in 129S2/SvHsd and C57BL/6J mouse strains using different variants of the Barnes maze
Authors: Riedel Gernot , Robinson Lianne , Crouch Barry
Published: September 2018

Behavioural flexibility is the ability to switch between tasks and strategies following a change in rules, and involves intact functioning of the medial prefrontal cortex. Impairments of behavioural flexibility have frequently been reported in patients with schizophrenia and rodents with disruption/dysfunction of the prefrontal cortex. The discovery of a mutation in the disrupted in schizophrenia 1 (DISC1) gene in the 129 mouse strain suggests that these mice may be exploited as a ‘naturally occurring’ model of schizophrenia. The aim of this present study was to assess cognition and behavioural flexibility of 129S2/SvHsd mice in comparison with C57BL/6J mice in the Barnes maze, using three different maze variations that consisted of either 8, 16 or 32 holes. Whereas C57BL/6J mice were able to perform both acquisition and reversal learning in all three mazes, 129S2/SvHsd mice displayed impairments dependent on the complexity of the test. Intact acquisition and reversal occurred in the 8-hole maze; intact acquisition, but impaired reversal, was evident in the 16-hole maze and impaired acquisition was evident in the most difficult 32-hole test. Furthermore, analysis of search strategies confirmed strain differences in the adoption of spatial searches across both acquisition and reversal trials. 129S2/SvHsd mice displayed fewer spatial-type trials than C57BL/6J mice and instead employed more random or serial/chaining search behaviours. The deficits observed in both cognition and behavioural flexibility support the notion of the 129 mouse strain as a potential model of schizophrenia.
Relevance of Swept-Source Anterior Segment Optical Coherence Tomography for Corneal Imaging in Patients With Flap-Related Complications After LASIK
Authors: Abdelazeem Khaled , Sharaf Mohamed , Saleh Mohamed G. A. , Fathalla Ahmed M. , Soliman Wael
Published: September 2018

Purpose:

To evaluate the role of swept-source anterior segment optical coherence tomography (AS-OCT) in the diagnosis and management of laser in situ keratomileusis (LASIK) flap-related complications.

Methods:

This prospective study included 25 eyes with LASIK flap-related complications imaged using swept-source AS-OCT between February and August 2016 at Alforsan Eye Centre, Assiut, Egypt. The images were acquired using a 6-mm line scan.

Results:

Imaging of flap-related LASIK complications using AS-OCT revealed specific and nonspecific findings. Of note, epithelial ingrowth appeared as highly reflective lesions below the LASIK flap in the form of islands, nests, or a continuous sheet with or without changes in the overlying flap. Macrostriae manifested as dome-shaped irregularities on the stromal surface with regular overlying epithelium, whereas microstriae appeared as corrugations on the stromal surface with regular overlying epithelium. Less common complications included multiple flap macrostriae accompanied by a traumatic folded flap with a flap edge at the interface. Interface debris appeared as a highly reflective interface lesion with or without a surrounding reaction. One eye with a flap that was torn and lost intraoperatively showed epithelialization over a thin residual stroma underlying a contact lens with no stromal infiltration on the second postoperative day. AS-OCT was useful for the assessment of flap thickness and planning of the new flap thickness in the event of an incomplete cut.

Conclusions:

Swept-source AS-OCT is useful not only for diagnosis but also for management of eyes with LASIK flap-related complications by allowing noninvasive, noncontact, real-time acquisition of cross-sectional AS images.
Gynecologic Screening for Men in an OBGYN Resident Community Outreach Clinic: The Transgender Care Experience
Authors: Woodland Mark B. , Callanan Laura , Schnatz Peter F. , Jiang Xuezhi
Published: September 2018

Objective

The aim of the study was to promote the importance of providing gynecologic screening for transgender men (TGM) who desire to keep their female organs.

Materials and Methods

In June 2015, the Women's Health Center (WHC) at Reading Hospital was approached to become a resource for transgender (TG) patients in our community. This also presented the opportunity to develop an educational program for OBGYN residents/providers in TG healthcare. From June 2015 to August 2016, we educated ourselves, established standards of care, collaborated with other services, and reached out to the community we represent. We present our experience in creating this specialty clinic as well as our first 16 months of experiential data to help other facilities meet the needs of this community.

Results

The primary outcome was the establishment of a comprehensive service for TG patients in our community. From August 2016 to December 2017, a total of 27,516 patient visits were conducted in WHC, 67 (0.2%) were TG patient visits with an average age of 33 years. Of 67, 16 (23.9%) were TGM and 51 (76.1%) were transgender women (TGW) visits, representing a total of 20 new TG patients including 9 (45%) TGM and 11 (55%) TG women. A total of 5 (55.6%) of 9 TGM received vaginal/cervical cytology screening. Sexually transmitted infection screenings were performed in 14 (70%) TG patients versus 6,689 (40.7%) in a non-TG WHC population.

Conclusions

Servicing the transgender community is an important aspect of care for OBGYN providers. Our data suggest that TGM have similar gynecologic needs to the rest of our clinic population.
Urinary Tract Infection
Authors: Liska DeAnn , Derrig Linda , Mah Eunice
Published: September 2018

Urinary tract infection (UTI) is one of the most common afflictions worldwide, with most occurring as uncomplicated UTI in the lower urinary tract (ie, cystitis) in otherwise healthy women. In fact, a woman has 50% risk of a experiencing an episode of cystitis over her lifetime. Most concerning is that a third to half these women have a UTI recurrence within a year. Antibiotics have been the main approach for treating UTIs and are also used as a prophylaxis in women prone to UTI recurrence. However, the rapid rise of multidrug resistant uropathogens has become an issue, and nonantibiotic approaches to prevention of UTI are of clinical interest. In addition, the recent discovery of a urinary tract microbiome has furthered the interest in these nonantibiotic approaches to UTI, and both cranberry and probiotics have putative mechanisms for decreasing uropathogens in the microbiome. Cranberries have historically been associated with urinary tract health, but the literature has been mixed. Although data are limited for cranberry as a treatment for UTI, the evidence for cranberry products (eg, fruit powder capsules, cranberry juices) in preventing recurrence of uncomplicated UTI in women is positive. Therefore, cranberry may be a promising nonantibiotic option for decreasing the risk of recurrent UTI in otherwise healthy women. Although less extensively studied, certain beneficial live microorganisms, also known as probiotics, have been suggested as alternatives to antibiotics in the prevention of uncomplicated UTIs; however, data on oral intake of probiotics, particularly via food, are limited.