Telecom-Wavelength Quantum Repeater Node Based on a Trapped-Ion Processor.

A quantum repeater node is presented based on trapped ions that act as single-photon emitters, quantum memories, and an elementary quantum processor. The node's ability to establish entanglement across two 25-km-long optical fibers independently, then to swap that entanglement efficiently to extend it over both fibers, is demonstrated. The resultant entanglement is established between telecom-wavelength photons at either end of the 50 km channel. Finally, the system improvements to allow for repeater-node chains to establish stored entanglement over 800 km at hertz rates are calculated, revealing a near-term path to distributed networks of entangled sensors, atomic clocks, and quantum processors.

Entanglement of Trapped-Ion Qubits Separated by 230 Meters.

We report on an elementary quantum network of two atomic ions separated by 230 m. The ions are trapped in different buildings and connected with 520(2) m of optical fiber. At each network node, the electronic state of an ion is entangled with the polarization state of a single cavity photon; subsequent to interference of the photons at a beam splitter, photon detection heralds entanglement between the two ions. Fidelities of up to (88.0+2.2-4.7)% are achieved with respect to a maximally entangled Bell state, with a success probability of 4×10^{-5}. We analyze the routes to improve these metrics, paving the way for long-distance networks of entangled quantum processors.

Risk factors for incident delirium among urological patients: a systematic review and meta-analysis with GRADE summary of findings.

BACKGROUND: Post-operative delirium is an important, yet under-researched complication of surgery. Patients undergoing urological surgery may be at especially high risk of POD, as they are often older, and interventions can be associated with conditions that trigger delirium. The main aim of this systematic review was to evaluate the available evidence for risk factors in this patient group. METHODS: Five databases were searched (MEDLINE, Web of Science, EMBASE, CINAHL and PsychInfo) between January 1987 and June 2019. The Newcastle-Ottawa Scale was used to assess for risk of bias. Pooled odds ratio or mean difference (MD) for individual risk factors were estimated using the Mantel-Haenzel and inverse variance methods. RESULTS: Seven articles met the inclusion criteria, giving a total population of 1937. The incidence of POD ranged from 5 to 29%. Three studies were deemed low risk of bias and four at a high risk of bias. Nine risk factors were suitable for meta-analysis, with age (MD 4.314 95% CI 1.597, 7.032 p = 0.002) and the clock drawing test (MD - 2.443 95% CI - 3.029, - 1.857 p < 0.001) having a statistically significant association with POD in pooled analyses. CONCLUSION: Delirium is common in urological patients. This review has identified a lack of studies in this surgical population, with wide heterogeneity and high risk of bias. It also highlights a number of potential risk factors for post-operative delirium, of which some are modifiable. However, the strength of evidence is weak at present and so future research should focus on assessing comparable risk factors in this patient group in order to inform future clinical practice. Review registration The review protocol was prospectively registered with the PROSPERO database (reference CRD42017054613).

Single centre versus multi-centre pooled morbidity data in PCNL and the implications for informed consent.

Background: National and international outcome data following PCNL have been available for many years, but multi-centre data may not reflect the outcome from an individual surgeon or hospital.Methods: A combination of retrospective and prospective single centre data was collated from 2000-2016 and are compared to large single and multi-centre series.Results: Data were available on 801 unique cases performed between 2000 and 2016, mean age = 55.2 (SD = 14.8) (range = 17-93). The mean change in haemoglobin after PCNL was 1.65 g/dL ± 0.05, n = 630. Twenty-seven patients required a blood transfusion (3.37%). In 470 cases, data on pre-operative urine culture was available. One hundred and nineteen (25%) demonstrated evidence of bacteriuria pre-operatively. The most common isolated species were E. Coli and Proteus Mirabilis. Pre-operative urine infection was associated with a greater drop in haemoglobin following surgery, but this difference was not found to be statistically significant. Changes in serum creatinine and eGFR rise following surgery were calculated. The mean rise was found to be 15.21 µmol/L (SE = 2.08, n = 208). The mean drop in eGFR was estimated to be 7.35 ml/min/1.73 m2 (± 0.895, n = 205). Eight cases of 801 (1%) required admission to higher level care. There was one small bowel puncture and one pleural perforation recorded. Sub-selective embolization due to bleeding occurred in six cases (0 .75%) and there were no peri-operative deaths in this series. Published data comparing single centres with > 500 cases are presented.Conclusion: To facilitate transparent consent, single-centre rather than pooled outcome data should be utilized.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone.

INTRODUCTION: The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain. METHODS: A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention. RESULTS: A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8). CONCLUSIONS: This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Laparoscopic versus open surgery for colorectal cancer in the older person: A systematic review.

BACKGROUND: Laparoscopic surgery is being increasingly offered to the older person. OBJECTIVE: To systematically review the literature regarding laparoscopic colorectal cancer surgery in older people and compare to younger adult populations. STUDY SELECTION: We included randomized controlled trials that compared open to laparoscopic colorectal cancer surgery. Older people were defined as being 65 years and above. OUTCOME MEASURES: Overall survival and post-operative morbidity and mortality. Secondary endpoints were length of hospital stay, wound recurrence, disease-free survival and conversion rate. RESULTS: Seven trials included older people, average age of approximately 70 years. Two reported data specific to older patients (over 70 years): The ALCCaS study reported reduced length of stay and short-term complication rates in the laparoscopic group when compared to open surgery (8 versus 10 days, and 36.7% versus 50.6% respectively) and the CLASICC study reported equivalent 5 year survival between arms and a reduction of 2 days length of stay following laparoscopic surgery in older people. In trials which considered data on older and younger participants all five trials reported comparable overall survival and showed comparable or reduced complication rates; two demonstrated significantly shorter length of stay following laparoscopic surgery compared to open surgery. CONCLUSION: Large numbers of older people have been included in well-conducted, multi-centre, randomized controlled trials for laparoscopic and open colorectal cancer surgery. This systematic review suggests that age itself should not be a factor when considering the best surgical option for older patients.

Risk factors for local recurrence in Wilms tumour and the potential influence of biopsy - the United Kingdom experience.

RATIONALE: The UKW3 trial compared biopsy/pre-operative chemotherapy versus immediate nephrectomy and afforded the opportunity to examine the influence of percutaneous retroperitoneal biopsy and other factors on local and distant relapse of Wilms tumour (WT). METHODS: Patients with unilateral WT (stages I-IV) excluding metachronous relapse or early progressive disease were eligible. Metastatic and 'inoperable' tumours were biopsied electively. 'Local' was defined as relapse within the abdomen, except for liver metastases considered as 'distant' relapse, together with other haematogenous routes. Uni- and multivariable analyses estimated the risk factors for relapse. RESULTS: Overall, 285/635 (44.9%) patients had a biopsy. With a median follow-up of 10.1 years, 35 (5.5%) patients experienced a 'local', 15 a combined (2.4%) and 60 (9.4%) a 'distant' relapse. On univariate analysis, biopsy, anaplasia and tumour size were associated with an increased risk of local relapse. On multivariable analysis, anaplasia and tumour size remained significant for local relapse whereas the elevated risk of biopsy (hazards ratio (HR) = 1.80: 95% confidence interval (CI) 0.97-3.32, p = 0.060) was marginal. Age, anaplasia, tumour size, lymph nodes metastases and stage, but not biopsy, were individually associated with increased risk of distant relapse but only age and anaplasia remained significant following multivariable analysis. CONCLUSIONS: The UKW3 trial provides some reassurance that biopsy should not automatically lead to 'upstaging' of WT. Further assessment of this controversial area is required. Comparison of local relapse rates in a multinational trial in which the United Kingdom (UK) continued the practice of routinely biopsying all patients in contrast to the standard European approach will afford this opportunity and is planned.

Outcome of surgically treated octogenarians with breast cancer.

CONTEXT: Breast cancer is the commonest cancer in women worldwide and its incidence increases with increasing age. In an era of evidence-based practice, there is a paucity of evidence relating to the management of breast cancer in an oncogeriatric population. The authors define oncogeriatrics as cancer in patients aged 80 years or more. AIM: The study aimed to evaluate the survival benefit of surgically managed octogenarians with breast cancer. MATERIALS AND METHODS: This was a retrospective study of octogenarians diagnosed with breast cancer over a 5-year period and who were treated surgically. Kaplan-Meier survival analysis was used to determine the overall survival. The differences in survival were tested using the logrank (Mantel-Cox) test. A P-value of <0.05 was considered to be statistically significant. RESULTS: One hundred patients were included (median age- 84 years, median follow up 3.3 years). A validated adult comorbidity evaluation-27 (ACE-27) index score system was used to characterize patient comorbidities. Fourteen percent of patients had severe comorbidities, 55% nonsevere, 11% no comorbidities, and 20% with unknown comorbidities. The estrogen receptor was positive in 67% of tumors. Eighty-four percent had mastectomy and 15% had wide local excision. Sixty-eight percent had axillary lymph node dissection, 10% had sentinel lymph node biopsy, and 5% had no axillary surgery. The majority (72%) of the tumors were pathologically T1 or T2 tumor. The Nottingham Prognostic Index (NPI) mean score was 4.4. The Kaplan-Meier survival analysis showed a median survival of 5 years. Forty-eight percent died during the observation period, with 54.2% of this group dying of causes unrelated to breast cancer. CONCLUSION: The surgically treated octogenarians in our sample had an acceptable survival outcome.

Systematic review of anorectal varices.

AIM: Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise. METHOD: A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices. RESULTS: Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure. CONCLUSION: As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.

Narrow-band imaging in the evaluation of villous morphology: a feasibility study assessing a simplified classification and observer agreement.

BACKGROUND AND STUDY AIMS: To determine the utility of narrow-band imaging with optical magnification (NBI-Z) in the evaluation of villous morphology. PATIENTS AND METHODS: Patients considered at risk of having celiac disease were invited. After standard endoscopy, they underwent further evaluation with NBI-Z which was digitally recorded. Targeted biopsies of each area videoed with NBI-Z were performed and tissue sent for histopathological analysis. Two expert endoscopists then selected the best representative videos (developmental phase). Next, 41 representative images of these videos were classified as follows: villous patterns present (N) or absent (A). Images showing absence of villi were then classified as cerebriform (C) or flat (F), corresponding to partial or total villous atrophy respectively. Three NBI-Z-naïve endoscopists then graded the videos. They underwent an interactive training session (learning phase) with video and images from a digital library before embarking on the actual assessment. To test for reproducibility, all videos were randomly reordered and graded again after a week. RESULTS: Forty-one videos (10 celiac disease, 31 normal) from 21 patients (3 celiac disease, 18 normal) were analyzed. The overall sensitivity and specificity in correctly distinguishing the presence or absence of villi were 93.3% and 97.8% respectively, with interobserver and intraobserver agreement (kappa, κ) at 0.82 and 0.86. The sensitivity and specificity in differentiating partial from total villous atrophy were 83.3% and 100%, κ at 0.73 and 0.68 respectively. CONCLUSIONS: Using a simplified classification, we demonstrated the feasibility of using NBI-Z to detect villous atrophy in patients presenting with suspected celiac disease.

A child with laryngo-onychocutaneous syndrome partially responsive to treatment with thalidomide.

Laryngo-onychocutaneous syndrome (LOCS) is a condition characterized by erosive or ulcerative skin lesions associated with excessive granulation tissue, at sites of trauma such as the digits, elbows and knees. Similar lesions can occur within the conjunctival mucosa, leading to corneal scarring and blindness. The main complications, however, occur in the respiratory tract, where a similar process of erosions and subsequent formation of granulation tissue causes airway obstruction which may lead to premature death. LOCS is now believed to be a nonblistering variant of junctional epidermolysis bullosa and to date there are no efficacious treatments available. We report a 16-year-old girl with LOCS who failed to respond to methylprednisolone and cyclophosphamide, but had a partial response to oral thalidomide with marked decrease in granulation tissue and tracheal secretions. Interruption of treatment resulted in prompt resurgence of the granulation tissue which was again controlled by reintroduction of thalidomide. We propose that in the absence of effective therapies for LOCS, a trial of thalidomide in these patients should be considered.

Glycine induces a novel form of long-term potentiation in the superficial layers of the superior colliculus.

1. The mammalian superior colliculus (SC) is a midbrain nucleus containing space maps of different sensory modalities which show various forms of age- and activity-dependent plasticity in vivo and in vitro. In the present study, we aimed to characterize the role of glycine (Gly) receptors in the SC, and we observed that application of glycine (Gly; 500 microM and 3 mM) for 7 min to SC slices of adult guinea-pigs caused a novel form of long-term potentiation (termed LTPgly) of evoked excitatory postsynaptic potentials recorded in the superficial layers. 2. The strength of potentiation was found to be concentration-dependent and partially independent from synaptic stimulation. 3. LTPgly did not involve NMDA receptor activation as proven by the lack of inhibition by 100 microM D,L-2-amino-5-phosphonovaleric acid (APV) and 10 microM MK-801. 4. LTPgly could only be masked but not prevented by strychnine (100 microM) and remained undisturbed in the presence of picrotoxin (100 microM). 5. Inhibition of carbonic anhydrase by acetazolamide (20 microM) had no effect on LTPgly suggesting that the excitatory action of Gly is not due to a differential breakdown of the Cl-/HCO3 gradients. 6. As indicated by the inhibition of LTPgly of the fEPSP slope by the L-type calcium channel blocker nifedipine (20 microM), voltage-dependent calcium channels are the source for Ca2+ elevation as the intracellular trigger. 7. Our data provide the first evidence for a role of Gly in SC synaptic transmission. They illustrate a so far unknown action of Gly which can lead to long-lasting changes of synaptic efficacy and which is not mediated via NMDA-related or strychnine-sensitive binding sites.

Immunohistochemical analysis of cutaneous malignant melanoma: comparison of S-100 protein, HMB-45 monoclonal antibody and NKI/C3 monoclonal antibody.

Immunohistochemical analysis was carried out on 144 formalin fixed paraffin embedded cutaneous melanomas to ascertain the value of 3 different immune markers. The sensitivity and staining patterns regarding intensity and distribution, as well as correlation to pigment content, cell type, surface ulceration and host response was noted. The stains used were monoclonal HMB-45 (Dako product No M634), NKI/C3 antibodies (Biogenex product No MU077) and polyclonal rabbit anti S-100A protein (Dako product No L1845). Of the lesions tested, 63 were malignant melanoma with an adjacent component of superficial spreading type, 61 were malignant melanoma with no adjacent component, 2 were malignant melanoma with adjacent lentigo maligna, 8 were in situ with 7 superficial spreading melanoma and one lentigo maligna (HMF) and 10 were metastatic melanoma. All 144 lesions stained for S-100 (100% sensitivity). One hundred and thirty-seven stained for NKI/C3 (95%); 132 stained for HMB-45 (92% sensitivity). S-100 was the most sensitive marker and stained tumor cells diffusely. With HMB-45 and NKI/C3, though marginally less sensitive, staining was stronger and patchy. In addition, NKI/C3 showed a tendency for peripheral (membrane) staining. HMB-45 staining was directly proportional to the pigment content, with stronger staining of radial growth phase melanoma and negative staining of those lesions where pigment content was minimal or absent. Also, with HMB-45 a decrease in staining intensity with depth or vertical growth phase was observed. There was no relationship to cell type with HMB-45 but with NKI/C3, 5 out of the 7 that failed to stain showed spindle cell differentiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Audit in general practice by a receptionist: a feasibility study.

OBJECTIVE: To examine whether audit can be done cost effectively by a practice's receptionist. DESIGN: The practice set goals for various aspects of care, and forms were devised for the receptionist to collect, analyse, and present data to assess whether these goals had been achieved in the previous year. SETTING: Six doctor practice in south London looking after 11,500 patients. MAIN OUTCOME MEASURES: Ability of receptionist to present data showing the level of attainment of the practice's goals; time spent on audit by receptionist each week. RESULTS: The practice set goals for immunisation; follow up of patients with abnormal cervical smears; frequency of recording of blood pressure and smoking habit; screening of patients over 75; care of diabetic patients and patients with serious mental illness; antenatal care; variations in workload; and availability of appointments. The receptionist was able to audit all these tasks in four hours a week; this increased her job satisfaction and extended her skills. A small amount of regular supervision was necessary--roughly 30 minutes a week in the first year of the study and 30 minutes a fortnight in the second--to ensure accuracy and deal with any difficulties that arose. CONCLUSION: The method developed enabled a receptionist to audit aspects of the practice cost effectively. There is great scope for enlarging the conventional role of the receptionist.

The effect of smoking on immediate post-extraction socket filling with blood and on the incidence of painful socket.

The effect of habitual smoking on post-extraction socket filling with blood and on the incidence of painful socket, was investigated. Data were collected from 2417 adult dental out-patients in whom 3541 extractions were performed under local anaesthesia. Post-operative socket filling with blood was significantly reduced in smokers, compared with non-smokers (p less than 0.01). There was a higher incidence of painful socket in heavy smokers (20 or more cigarettes per day), compared with nonsmokers (p less than 0.05). There was a significant relationship between immediate post-extraction socket blood level and the incidence of painful socket; sockets which showed poorer filling were more likely to develop painful socket (p less than 0.02). Smoking appeared to have an adverse effect upon the healing of extraction wounds.

Toxicity of interferon.

The effects of partially purified human leucocyte interferon (PIF) and of a preparation purified by passage twice through a monoclonal antibody affinity chromatography column (NK21F) were compared with those of a control solution in healhty volunteers. After intramuscular injections both interferon preparations caused rises in pulse rate and body temperature, changes in circulating white cell counts, and various unpleasant symptoms, the most common of which were headache, malaise, and fever. Slightly lower doses of NK21F were given, and this was reflected in lower peak serum concentrations. Mean symptom scores, however, were not lower after NK21F than after PIF. Local inflammatory reactions eight hours after intradermal inoculations of these interferons were similar. Purification of interferon using a monoclonal antibody does not reduce the facets of its activity considered in this study. They are therefore inherent in the leucocyte interferon type selected by the antibody.