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001). CONCLUSIONS Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection. PURPOSE To assess the ability of pressure measurements to discriminate clinically significant celiac artery (CA) or superior mesenteric artery (SMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). MATERIALS AND METHODS Single-center, retrospective cohort study of 41 intra-arterial pressure measurements during mesenteric angiography with intended revascularization, performed in 37 patients (mean age 67.7 ± 10.8 years, 62% female) between April 2015 and May 2017. Simultaneous prestenotic and poststenotic pressure measurements had been obtained before and after intra-arterial administration of nitroglycerin. Revascularization was performed in 38 of 41 procedures. Definitive diagnosis of CMI was defined as patient-reported symptom relief or improvement after successful revascularization. RESULTS Pressure gradients obtained after vasodilator administration were significantly higher in CAs and SMAs with ≥50% stenosis. Pressure ratios (pressure distal [Pd]/pressure aorta [Pa]) obtained after vasodilator administration were significantly higher in CAs with ≥50% stenosis. Subgroup analysis of 22 patients with a ≥50% stenosis of either CA or SMA showed significantly higher pressure gradients and Pd/Pa ratios after vasodilator administration in CMI patients (median pressure gradient CMI [interquartile ratio] 36 [21-40] mm Hg versus no-CMI 20 [9-21] mm Hg, P = 0.041; Pd/Pa CMI 0.703 [0.598-0.769] versus no-CMI 0.827 [0.818-0.906], P = .009). A ≤0.8 Pd/Pa cutoff value after administration of a vasodilator best identified a clinically relevant stenosis, with 86% sensitivity and 83% specificity. Complications related to the pressure measurements were not observed. CONCLUSIONS Intra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis. PURPOSE To evaluate accuracy of iodine quantification using spectral CT and the potential of quantitative iodized oil analysis as an imaging biomarker of chemoembolization. MATERIALS AND METHODS A phantom of an artificial liver with 6 artificial tumors containing different amounts of iodized oil (0-8 vol%) was scanned by spectral CT, and iodized oil density (mg/mL) and Hounsfield unit (HU) values were measured. In addition, VX2 hepatoma was induced in 23 rabbits. After chemoembolization using iodized oil chemoemulsion, the rabbits were scanned by spectral CT. The accumulation of iodized oil in the tumor was quantified in terms of iodized oil density and HUs, and the performances in predicting a pathologic complete response (CR) were evaluated by receiver operating characteristic curve analyses. RESULTS The mean difference between true iodine densities and spectral image-based measurements was 0.5 mg/mL. Mean HU values were highly correlated with mean iodine density (r2 = 1.000, P less then .001). In the animal study, a pathologic CR was observed in 17 of 23 rabbits (73.9%). The range of area under the curve values of iodine and HU measurements was 0.863-0.882. A tumoral iodine density of 3.57 mg/mL, which corresponds to 0.7 vol% iodized oil in the tumor, predicted a pathologic CR with a sensitivity of 70.6% and a specificity of 100.0%. CONCLUSIONS Spectral CT imaging has a potential to predict tumor responses after chemoembolization by quantitatively assessing iodized oil in targets. INTRODUCTION An adequate amount of sleep is fundamental to health and well-being, especially for individuals recovering from an illness or injury. Trauma patients sustain musculoskeletal and tissue injuries and require a sufficient amount of sleep to promote recovery. However, it is known that patients can face difficulties sleeping in hospitals which impacts on their recovery. AIM To determine the quality of sleep, influence of sleep quality and the impact of sleep quality on recovery in trauma and orthopaedic patients. METHODOLOGY An exploratory descriptive design was applied using a clinical audit. As no standardised sleep assessment tool was identified, a sleep audit tool was developed. FINDINGS A total of 40 patients were recruited from two trauma and orthopaedic wards from a London Hospital in the United Kingdom. Of these 17 patients (43%) rated the quality of sleep as 'poor' and nearly half (n = 19, 46%) reported that the quality of their night-time sleep had affected their recovery. Methotrexate Two-thirds of patients reported noise was the main factor that disrupted their sleep, making it the highest contributing sleep disruptor (n = 26, 65%). CONCLUSION A significant association between poor quality of sleep and patient recovery was identified in this small sample of trauma and orthopaedic patients. The findings suggest that nurses should try to create a suitable sleeping environment to enhance patient recovery. There is a need for a standardised sleep assessment tool and sleep audit tool so that the quality of patients' sleep can be accurately assessed and documented. BACKGROUND Clinical guidance on recommended treatment for older patients with breast cancer is often ambiguous, particularly in the context of comorbidities and poor functional status. Older patients, aged 70 years and over, account for a substantial proportion of women with breast cancer yet are underrepresented in randomized controlled trials. This paper investigates the initiation of adjuvant chemotherapy and trastuzumab in older patients in routine care. MATERIALS AND METHODS Women, aged 50 years and over, newly diagnosed with human epidermal growth receptor 2 (HER2)-positive early invasive breast cancer from January 2014 to December 2017 were identified from the England Cancer Registry. Chemotherapy and trastuzumab use was obtained from the Systemic Anti-Cancer Therapy (SACT) dataset. Patient and tumor characteristics influential in treatment decision-making were included in multilevel mixed-effects logistic regression models. RESULTS 10% of women had HER2-positive tumors. Initiation of adjuvant chemotherapy and trastuzumab decreased with age from ≥70% among women aged 50-64 years to less then 15% among women aged 80+ years. Initiation varied additionally by tumor characteristics and number of comorbidities. Age remained a factor in treatment decisions despite favorable other factors, with lower use among women aged 70+ years. There was also marked variation across geographical regions. CONCLUSIONS In women with operable HER2-positive early invasive breast cancer, adjuvant chemotherapy plus trastuzumab was started less frequently as age increased, regardless of tumor characteristics or comorbidity burden. There was substantial variation in the proportion of women who started these treatments across the country. During the last few years, there has been a shift of focus in rheumatoid arthritis (RA) research towards earlier disease states. The terms early and established RA are inseparable, and having a clear definition of these two terms is crucial in conducting research and trying to understand the immunopathological mechanisms behind these different disease states. Established RA has been connected to chronic inflammation and a high burden of long-standing disease, with joint damage and comorbidities as a consequence of chronic inflammation. A chronological definition does not ensure us clear differentiation between early and established disease, because diagnosis can be delayed significantly. Similarly, a radiological definition does not ensure a clear differentiation either, as there is significant heterogeneity in the RA patient population, with some patients never developing structural damage, even after many years of disease. As the focus is now more on the early stages of disease, we propose to use the term established RA from the time of a definite clinical diagnosis of RA, irrespective of the symptoms' duration or the presence of irreversible damage, to distinguish established disease to a stage of undifferentiated arthritis (UA) or risk for developing RA, which might never progress to RA. Raynaud's phenomenon (RP) is common, affecting approximately 5% of the population, and is important to the rheumatologist because it is often the presenting symptom of connective tissue disease, especially of systemic sclerosis (SSc)-spectrum disorders. RP therefore provides a window of opportunity for early diagnosis. When RP is associated with SSc it is particularly challenging to treat. This review begins with a discussion of some of the recent advances in our understanding of the pathogenesis of RP it is through increased understanding of the complex pathophysiology of RP that we are most likely to develop new therapies. The following questions are then addressed (with three clinical scenarios demonstrating key principles of assessment and management) 1. How can we predict underlying connective tissue disease in the patient presenting with Raynaud's? 2. How can we measure severity of Raynaud's? 3. What are the latest advances in treatment of connective tissue disease-related digital vasculopathy? BACKGROUND The emergency department (ED) is the natural venue for the provision of acute unscheduled care. However, little is known about the nature and proportion of this care that goes to addressing adverse events (AEs)-physical injury to a patient due to health care that requires some intervention-that are present on arrival (POA) to the ED. Described here are AEs that are POA, and population prevalence estimates for these events. METHODS This retrospective observational study tested the ED Trigger Tool, using data from an urban academic medical center. Patients aged ≥18 completing an ED visit were eligible (N = 92,859). A total of 5,582 visits with triggers (findings that increase the likelihood of an AE) were reviewed using the two-tier trigger approach. AEs were categorized by severity, type, and whether they were POA. POA AEs, and sociodemographic and trigger associations with AEs are described. RESULTS Of 1,181 AEs identified, 718 (60.8%) were POA to the ED. Patients with POA AEs were more often white (51.1% vs. 39.7%, p less then 0.001) and older (median age 62 vs. 50, p less then 0.001). The majority of POA AEs were medication-related and patient care-related events. In the population at this center, POA AEs account for an estimated 7.6% of ED visits (95% confidence interval = 6.9%-8.2%). CONCLUSION In this single-center study, the majority of AEs detected using the ED Trigger Tool were POA. These findings highlight the importance of the ED as a safety net for harm occurring across the health system. As an imidazoline I1 receptor agonist with very weak binding affinity for α2-adrenoceptors, moxonidine is commonly used in the treatment of hypertension. Moxonidine also has been implicated to act centrally to reduce airway vagal outflow. However, it is unknown at which central sites moxonidine acts to affect airway vagal activity, and how moxonidine takes effect at synaptic and receptor levels. In this study, airway vagal preganglionic neurons (AVPNs) were retrogradely labeled in neonatal rats from the intrathoracic trachea; retrogradely labeled AVPNs in the external formation of the nucleus ambiguus (NA) were identified in rhythmically active medullary slices using whole-cell patch-clamp techniques; and the effects of moxonidine on the spontaneous excitatory postsynaptic currents (EPSCs) of AVPNs were observed at synaptic level. The results show that moxonidine (10 μmol·L-1) significantly inhibited the frequency of spontaneous EPSCs in both inspiratory-activated and inspiratory-inhibited AVPNs. This effect was partially blocked by SKF-86466 (10 μmol·L-1), a highly selective antagonist of α2-adrenoceptors, or AGN-192403, a selective antagonist of imidazoline I1 receptors, and was completely blocked by efaroxan (10 μmol·L-1), an antagonist of both α2-adrenoceptors and imidazoline I1 receptors.
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