The neurocognitive effects of a conducted electrical weapon compared to high intensity interval training and alcohol intoxication - implications for Miranda and consent.

While the physiologic effects of conducted electrical weapons (CEW) have been the subjects of numerous studies over nearly two decades, their effects on neurocognitive functioning, both short-term and long-term, have only recently been studied. In a 2014 study involving use-of-force scenarios, including a CEW scenario, we found that there was a decline in neurocognitive performance immediately post-scenario in all groups; however this effect was transient, of questionable clinical/legal significance, not statistically different between the groups, and, returned to baseline by one hour post-scenario. Two subsequent studies by other authors have also found transient neurocognitive effects in the immediate post-exposure period; however, in one study, the effect was greater in one measure (of 5) for the CEW compared to exertion, and the authors suggested that this effect could have implications for the Miranda waiver obtained before custodial interrogation as well as consent. In our current study, we compared the neurocognitive effects of an exposure to a CEW to another exertion regimen, as well as to alcohol intoxication given the latter has significant established case law with regard to the Miranda waiver and consent. Such a comparison may offer more insight into the clinical/legal significance of any measured changes. As with the prior studies, the neurocognitive performance decrements of the CEW and exertion regimens, found only in one measure in this study (of three), were transient, and here, non-significant. Only alcohol intoxication resulted in statistically significant performance declines across all measures and these were persistent over the study period. Given that the neurocognitive changes associated with the CEW were non-significant, but were significant for alcohol intoxication, and given that current case law does not use intoxication as a per se or bright line barrier to Miranda and consent, our results do not suggest that a CEW exposure should preclude waiving of Miranda rights or obtaining consent.

Repulsion-attraction switching of nematic colloids formed by liquid crystal dispersions of polygonal prisms.

Self-assembly of colloidal particles due to elastic interactions in nematic liquid crystals promises tunable composite materials and can be guided by exploiting surface functionalization, geometric shape and topology, though these means of controlling self-assembly remain limited. Here, we realize low-symmetry achiral and chiral elastic colloids in the nematic liquid crystals using colloidal polygonal concave and convex prisms. We show that the controlled pinning of disclinations at the prism edges alters the symmetry of director distortions around the prisms and their orientation with respect to the far-field director. The controlled localization of the disclinations at the prism's edges significantly influences the anisotropy of the diffusion properties of prisms dispersed in liquid crystals and allows one to modify their self-assembly. We show that elastic interactions between polygonal prisms can be switched between repulsive and attractive just by controlled re-pinning the disclinations at different edges using laser tweezers. Our findings demonstrate that elastic interactions between colloidal particles dispersed in nematic liquid crystals are sensitive to the topologically equivalent but geometrically rich controlled configurations of the particle-induced defects.

Analysis of correlations between measures of skeletal development and dental mineralization in Pan troglodytes.

OBJECTIVES: This study seeks to assess the relationship between dental mineralization and skeletal development in chimpanzees (Pan troglodytes) and to evaluate the effect that differing numbers of ordinal and continuous variables have on correlation statistics, particularly in comparison with prior human studies. MATERIALS AND METHODS: This study evaluated epiphyseal fusion, dental mineralization, and growth in length of long bones using 145 juvenile chimpanzee skeletons housed in osteological collections at the Powell-Cotton Museum, the Museum of Central Africa, and the Adolph Schultz Collection. RESULTS: Correlations between multiple epiphyseal fusion sites and dental maturity scores for crown and root mineralization were produced using Pearson's r, Spearman's ρ, and Kendall's τ. Correlation statistics were produced using different subgroups of epiphyseal fusion sites and long bone lengths, and both summary and individual tooth development scores. DISCUSSION: Methodological considerations were discussed as differences in sample, measurement scale, and statistical technique had an effect on the outcome of correlations obtained. These results suggest that sampling and methodological differences between studies may affect the interpretation and comparison of correlation results, and that correlation strength differences between extant species must be considered before applying such results to questions in human biology and palaeoanthropology. Even after consideration of such factors, the correlation coefficient values for chimpanzees obtained in this study were generally stronger than those previously published in human studies, and may reflect differences in skeletal and dental developmental patterns between species. Am J Phys Anthropol 158:279-287, 2015. © 2015 Wiley Periodicals, Inc.

Baseline patterns of adipose tissue fatty acids and long-term risk of breast cancer: a case-cohort study in the Danish cohort Diet, Cancer and Health.

BACKGROUND/OBJECTIVES: The evidence regarding fatty acids and breast cancer risk is inconclusive. Adipose tissue fatty acids can be used as biomarkers of fatty acid intake and of endogenous fatty acid exposure. Fatty acids in adipose tissue are correlated owing to common dietary sources and shared metabolic pathways, which group fatty acids into naturally occurring patterns. We aimed to prospectively investigate associations between adipose tissue fatty acid patterns and long-term risk of total breast cancer and breast cancer subtypes characterised by oestrogen and progesterone receptor status (ER and PR). SUBJECTS/METHODS: This case-cohort study was based on data from the Danish cohort Diet, Cancer and Health. At baseline, a fat biopsy and information on lifestyle and reproductive factors were collected. From the 31 original fatty acids measured, patterns of fatty acids were identified using the treelet transform. During a median follow-up of 5.3 years, 474 breast cancer cases were identified. Hazard ratios and 95% confidence intervals of risk of total breast cancer and of subtypes according to quintiles of factor score were determined by weighted Cox proportional hazards regression. RESULTS: After adjustment for potential confounders, factor scores for the seven patterns identified by the treelet transform were not associated with risk of total breast cancer, nor with risk of ER+, ER-, PR+ or PR- tumours. CONCLUSIONS: No clear associations between the patterns of fatty acids at baseline and long-term risk of total breast cancer or ER+, ER-, PR+ or PR- tumours were observed.

Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients.

AIM: The Biodesign(®) anal fistula plug was introduced as a means of obliterating the fistula tract and promoting healing through biocompatibility. The results demonstrated unexplained variations from good to bad. This report analysed the results of a retrospective multicentre study. METHOD: All plug procedures performed in four Stockholm hospitals between June 2006 and June 2010 were identified and studied using a common protocol. The outcome after the first plug-insertion procedure was assessed by chart review performed a minimum of 8 months after plug insertion. Cox proportional-hazards models were used to assess the associations of various factors with fistula healing. RESULTS: One-hundred and twenty-six patients (mean age 47 years) were deemed suitable for the plug procedure. Eighty-five per cent of fistulae were cryptoglandular, 64% of patients were male and a mean of 2.9 previous fistulae procedures had been performed. All patients, except four, had an indwelling seton at the time of the plug procedure, which was performed in accordance with previously established principles of day surgery. After a median of 13 months, 30 (24%) fistulae had closed with no discomfort or secretion reported. The outcome in the four hospitals varied from 13% to 33% with similar numbers of patients in each hospital. A success rate of 12% was observed for patients with anterior fistula compared with 32% for those with posterior tracks [hazard ratio (HR) for successful healing = 2.98; 95% CI: 1.01-8.78) and 41% for those with a lateral internal opening (HR = 3.76; 95% CI: 1.03-13.75). Age, sex and number of previous procedures were not associated with healing. CONCLUSION: Four independent patient groups showed low success rates after the first plug-insertion procedure. Anterior fistulae were much less likely to heal compared with fistulae in other locations.

Outcome of 132 consecutive reconstructive operations for intestinal fistula--staged operation without primary anastomosis improved outcome in retrospective analysis.

AIM: To study factors that influenced healing and survival after attempted closure of enterocutaneous fistula. MATERIAL AND METHODS: Retrospective analysis of prospective data concerning 101 patients operated on 132 instances for 110 enterocutaneous fistulae at two hospitals. RESULTS: In all, 96 (87%) of the 110 fistulae healed and 92 (91%) patients survived. A total of 9 patients with unhealed fistula died. Multivariate analysis revealed jaundice as an independent factor for both death and failed closure and operation without anastomosis as an independent positive factor for healing. Failure rate was lower after an operation with stoma without anastomosis (6 of 43, 14%) than after an operation with anastomosis (30 of 89, 34%) p = 0.0213. Of the 36 instances with unhealed fistula, 13 (36%) could be ascribed to inadvertent bowel lesions at the reconstructive operation. In addition, univariate analysis revealed that patients with previous multiple laparotomies or with multiple operations for enterocutaneous fistula healed less likely and had higher mortality. A low serum albumin, high white blood cell count, high C-reactive protein concentration, high fistula output, total parenteral nutrition, and operation for recurrent fistula were associated with death together with long operation time and operative bleeding, both indicators of surgical complexity. Over time, staged surgery avoiding anastomosis increased from 27% to 57%. Mortality decreased from 12% to 6%, and healing increased from 73% to 94%. CONCLUSIONS: Chronic inflammation, malnutrition, and liver failure causing an impaired healing capacity are important reasons for failure. Staged operation without primary anastomosis may allow the patient to reverse this condition and improve outcome. The high surgical complexity is a negative factor that requires careful planning of the operation.

Long-term results of stapled haemorrhoidopexy in a prospective single centre study of 153 patients with 1-6 years' follow-up.

AIM: The long-term results of stapled haemorrhoidopexy for prolapsed haemorrhoids were assessed using uniform methods to acquire data and pre-set definitions of failure, recurrence, residual symptoms and impaired continence. METHOD: From October 1999 to May 2005, 153 patients underwent a stapled haemorrhoidopexy and were enrolled prospectively. They were assessed preoperatively, postoperatively and at the end of the study from replies to a questionnaire about symptoms and continence. Preoperatively, manual reduction of prolapse was required in 103 patients, skin tags were found in 115 patients (circumferential in 22) and impaired continence in 63. RESULTS: In all, 145 patients completed preoperative and long-term protocols and were analysed as paired data, at a mean follow-up of 32 months. Failure to control the prolapse or recurrence was seen in 19 (13%) patients including nine reoperations for prolapse. Symptoms improved from 8.1 to 2.5 points on a 15-point scale (P = 0.001). Symptoms were not controlled in 25 (17%) patients. Continence improved from 4.7 to 2.9 points on a 15-point scale (P = 0.001). Twenty-five (17%) patients still had a continence disturbance. Altogether 51 (35%) patients had a deficient outcome with respect to prolapse, symptoms or continence. There were no major adverse events. CONCLUSION: Restoration of the anal anatomy by stapled haemorrhoidopexy resulted in a significant improvement in haemorrhoid-associated symptoms and continence but a third of patients had poor symptom control including 13% with persisting prolapse.

Endoanal ultrasonography may distinguish Crohn's anal fistulae from cryptoglandular fistulae in patients with Crohn's disease: a cross-sectional study.

BACKGROUND: The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography. METHODS: The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions. RESULTS: The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169). CONCLUSIONS: Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

Analysis of outcome of Lichtenstein groin hernia repair by surgeons-in-training versus a specialized surgeon.

PURPOSE: Groin hernia repair is a common procedure in general surgery, and is taught to and performed by surgeons early in their training. The aim of this observational study was to compare hernia repair performance and results of surgical trainees with those of a specialized surgeon, to identify what factors may influence short and long-term outcome, and areas for improvement in surgical training. METHODS: A non-randomized parallel cohort study was designed; 200 Lichtenstein repairs in adult males were included, of which 96 were performed by surgical trainees. Patient characteristics, surgical experience, and operative data, including duration of procedural parts and surgical complexity, were noted at surgery. Postoperative complications, recurrence, chronic pain and residual symptoms were assessed at long-term follow-up after a median of 34.5 months. RESULTS: Surgical trainees required longer overall operative time, with a disproportionally longer time for mobilizing the sac and cord. They perceived exposure and mobilization as more difficult than the specialist, and also a greater demand on their own experience during surgery. The trainee repairs had a higher rate of postoperative complications (14.7% vs 5.0%) but recurrence rate was the same as for specialist repairs. At long-term follow-up, specialist repairs had higher symptom burden and more chronic pain. CONCLUSIONS: It was more efficient, but not necessarily better, to let a specialized surgeon perform the repairs. It seems likely that targeted training in dissection and mobilization could decrease level of perceived complexity and shorten the operative time required by surgical trainees.

Randomized clinical trial of symptom control after stapled anopexy or diathermy excision for haemorrhoid prolapse.

BACKGROUND: : This multicentre randomized clinical trial studied how symptoms improved after either stapled anopexy or diathermy excision of haemorrhoids. METHODS: : The study involved 18 hospitals in Sweden, Denmark and the UK. Some 207 patients were randomized to either anopexy or Milligan-Morgan haemorrhoidectomy, of whom 90 in each group were operated on. Patients reported symptoms before surgery and after 1 year. Daily postoperative pain scores were recorded in a patient diary. Surgeons evaluated the anal anatomy before surgery and after 1 year. RESULTS: : Correction of prolapse in the anopexy and haemorrhoidectomy groups was similar at 1 year (88 and 90 per cent respectively; P = 0.80). Freedom from symptoms was obtained in 44 and 69 per cent respectively (P = 0.002). Stapled anopexy was associated with less postoperative pain, which resolved more quickly (P = 0.004). Significant improvements were noted in anal continence and well-being 1 year after both operations (P < 0.001). Excessive pain was the most common complication after diathermy excision and disturbed bowel function after stapled anopexy. CONCLUSION: : Haemorrhoidal prolapse was corrected equally by either operation. Diathermy haemorrhoidectomy gave better symptom relief but was more painful. Neither operation provided complete cure but well-being was greatly improved. REGISTRATION NUMBER: ISRCTN68315343 (http://www.controlled-trials.com).

Randomized clinical trial of stapled haemorrhoidopexy performed under local perianal block versus general anaesthesia.

BACKGROUND: The aim was to assess the feasibility of performing stapled haemorrhoidopexy under local anaesthesia. METHODS: Fifty-eight patients with haemorrhoid prolapse were randomized to receive local or general anaesthesia. The perianal block was applied immediately peripheral to the external sphincter. Submucosal block was added after applying the purse-string suture. Patients reported average and peak pain daily for 14 days using a visual analogue scale (VAS). They also completed anal symptom questionnaires before the operation and at follow-up. The surgeon assessed the restoration of the anal anatomy 3-6 months after surgery. RESULTS: The anal block was sufficient in all patients. The mean accumulated VAS score for average pain was 23.1 in the general anaesthesia group and 29.4 in the local anaesthesia group (P = 0.376); mean peak pain scores were 42.1 and 47.9 respectively (P = 0.537). Mean change in symptom load was also similar between the groups, with score differences of 7.0 in the general anaesthesia group and 6.1 in the local anaesthesia group. No patient had a recurrence of prolapse. CONCLUSION: Perianal local block is easy to apply with a high degree of acceptability among patients. Postoperative pain, restoration of anatomy and symptom resolution were similar to that of stapled haemorrhoidopexy performed under general anaesthesia. REGISTRATION NUMBER: ISRCTN19930199 (http://www.controlled-trials.com).

Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients.

PURPOSE: Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery. METHOD: A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential. RESULTS: Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively. CONCLUSION: This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.

Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection.

BACKGROUND: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery. METHODS: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days. RESULTS: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not. CONCLUSION: MBP does not lower the complication rate and can be omitted before elective colonic resection. REGISTRATION NUMBER: ISRCTN28535118 (http://www.controlled-trials.com).

Excision of residual skin tags during stapled anopexy does not increase postoperative pain.

OBJECTIVE: We studied whether excision of residual external skin tags causes additional pain in patients undergoing a stapled anopexy for muco-anal prolapse. METHOD: Seventeen patients in whom skin tags had been excised were compared with 24 patients having no excision. The patients were selected from a prospective database of haemorrhoid surgery if they had submitted a diary with self-reported postoperative pain scores as well as a self-reported symptom questionnaire preoperatively and postoperatively. The tags were excised with preservation of the subdermal fascia. RESULTS: There were 41 patients who fulfilled the criteria for inclusion. Seventeen (group 1) had tags excised and 24 (group 2) did not. Fifty-nine per cent in group 1 and 67% in group 2 experienced preoperative prolapse needing manual reposition. The mean height of the staple line was 2 cm above the dentate line in both groups. Daily average postoperative pain recorded as the sum of a self-reported VAS rating over 14 days was 26 points in both groups. The peak pain experienced was 42 and 43 points respectively (not significant). Resolution of postoperative pain over 14 days was identical. The preoperative and postoperative symptom score was comparable in both groups. CONCLUSION: Excision of anal skin tags should be carried out at the time of stapled anopexy.

An evidence-based treatment algorithm for anal fissure.

Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation.

An international working party was convened in Rome, Italy on 16-17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so-called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

[Enterocutaneous fistulas--persisting conditions but the healing capacity can be surgically restored. Current treatment and surgical skills reduce the mortality]. / Enterokutana fistlar--krävande tillstånd som kan opereras till läkning. Modern behandling och kirurgisk erfarenhet minskar mortaliteten.

Persisting enterocutaneous fistulae are difficult to treat. Mortality and morbidity are high. Patients are characterized by chronic infection, systemic inflammation, catabolism and impaired healing. During 1988-2002 69 patients were operated at the University Hospital, Linköping. The mortality was 18% in 1988 to 1996 but decreased to 7% in 1997 to 2002 after establishment of present treatment strategies. It's main feature is staged surgery rising ostomies rather than doing primary anastomoses. The ostomies are closed several months later when infection and systemic inflammation are overcome and nutrition and healing capacity are restored. All patients that survived healed their fistula after surgery. Open abdomen, high output fistulas, impaired liver function and a low serum albumin were associated with a poor prognosis for healing and mortality. Effective techniques for management of abdominal defects, methods to establish enteral nutrition, minimize chronic inflammation and liver impairment as well as operative techniques and strategies are important.

Local perianal block for anal surgery.

BACKGROUND: We refined a technique for local block of all terminal nerve branches to the anus. METHODS: A total of 30 consecutive patients with proctological disorders consented to ambulatory (n=29) or hospitalised (n=1) operation with local perianal block for skin tags, Milligan- Morgan haemorrhoidectomy, stapled haemorrhoidopexy or anocutaneous fistulae. Patients were operated prone. A total of 40 ml of a 4.75 mg/ml solution of ropivacaine (Narop; Astra, Sweden) was injected in 8 directions (5 ml each) into the ischiorectal fat immediately peripheral to the external sphincter as anaesthetic columns reaching from the skin to the levator. This injection scheme targets the terminal nerve branches of the anus rather than blocking the trunk of major nerves. The relaxation of a pain-free anus was obtained in 2-3 minutes with exposure similar to a general anaesthetic. Postoperative pain was evaluated on a 0 to 10 visual analogue scale (VAS). RESULTS: Patients were pain-free at discharge. However, mean postoperative VAS score at 24 hours was 3.2 following Milligan-Morgan haemorrhoidectomy, 4.8 following stapled haemorrhoidopexy and skin tags or polyps excision, and 2.7 after fistula lay-open. At telephone follow-up 1-2 weeks later, the patients were satisfied with the method of anaesthesia and would willingly accept it for any further anal surgery. CONCLUSIONS: The perianal block is easy to apply and effective as sole method of anaesthesia for proctological operations.

Stapled haemorrhoidopexy: a consensus position paper by an international working party - indications, contra-indications and technique.

An international working party with experience in the performance of an alternative haemorrhoid operation through the use of the circular stapler was convened for the purpose of developing a consensus as to the criteria for undertaking this procedure. The agenda consisted of first, naming the operation; second, the indications and contra-indications for its performance; and third, the preferred surgical technique. Among the recommendations for individuals who plan to embark on this surgery are that experience with anorectal surgery and an understanding of anorectal anatomy are requisites; experience with circular stapling devices is essential; and the surgeon must attend a formal course which should include lectures, videos, the application of the instrument in models, and observation of the operation as performed by a surgeon recognized by his or her peers-leading ultimately to undertaking the procedure while being observed by an experienced surgeon. Following satisfactory completion of the above, independent responsibility should be determined by an individual's department of surgery.