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Cayman Islands : beaches, coral reefs, dining, stingray city
Discover the essence of the Cayman Islands. Embrace the local scene as you stroll Seven Mile Beach, hike the Mastic Trail, or visit Pedro St. James Castle. Find choices for every traveler, from swimming with stingrays to diving Cayman's famous wall to dining in fine restaurants with Fodor's in Focus.
Book
Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial
Lung volume reduction surgery improves survival in selected patients with emphysema, and has generated interest in bronchoscopic approaches that might achieve the same effect with less morbidity and mortality. Previous trials with endobronchial valves have yielded modest group benefits because when collateral ventilation is present it prevents lobar atelectasis.
We did a single-centre, double-blind sham-controlled trial in patients with both heterogeneous emphysema and a target lobe with intact interlobar fissures on CT of the thorax. We enrolled stable outpatients with chronic obstructive pulmonary disease who had a forced expiratory volume in 1 s (FEV1) of less than 50% predicted, significant hyperinflation (total lung capacity >100% and residual volume >150%), a restricted exercise capacity (6 min walking distance <450 m), and substantial breathlessness (MRC dyspnoea score ≥3). Participants were randomised (1:1) by computer-generated sequence to receive either valves placed to achieve unilateral lobar occlusion (bronchoscopic lung volume reduction) or a bronchoscopy with sham valve placement (control). Patients and researchers were masked to treatment allocation. The study was powered to detect a 15% improvement in the primary endpoint, the FEV1 3 months after the procedure. Analysis was on an intention-to-treat basis. The trial is registered at controlled-trials.com, ISRCTN04761234.
50 patients (62% male, FEV1 [% predicted] mean 31·7% [SD 10·2]) were enrolled to receive valves (n=25) or sham valve placement (control, n=25) between March 1, 2012, and Sept 30, 2013. In the bronchoscopic lung volume reduction group, FEV1 increased by a median 8·77% (IQR 2·27–35·85) versus 2·88% (0–8·51) in the control group (Mann-Whitney p=0·0326). There were two deaths in the bronchoscopic lung volume reduction group and one control patient was unable to attend for follow-up assessment because of a prolonged pneumothorax.
Unilateral lobar occlusion with endobronchial valves in patients with heterogeneous emphysema and intact interlobar fissures produces significant improvements in lung function. There is a risk of significant complications and further trials are needed that compare valve placement with lung volume reduction surgery.
Efficacy and Mechanism Evaluation Programme, funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
Journal Article
Green Lantern : earth one
\"Hal Jordan yearns for the thrill of discovery, but the days when astronaut and adventure were synonymous are long past. His gig prospecting asteroids for Ferris Galactic is less than fulfilling--but least he's not on Earth, where technology and culture have stagnated. He might be a nobody, but he's in space. When Jordan finds a powerful ring, he also finds a destiny to live up to. There are worlds beyond his own, unlike anything he ever imagined. But revelation comes with a price: the Green Lantern Corps has fallen, long since murdered by ruthless killing machines known as Manhunters. The odds against reinstating the Corps are nearly impossible...but doing the impossible is exactly what an astronaut like Hal Jordan was trained to do\"-- Provided by publisher.
Book
Study protocol for VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer, a UK multicentre randomised controlled trial with an internal pilot (the VIOLET study)
IntroductionLung cancer is a leading cause of cancer deaths worldwide and surgery remains the main treatment for early stage disease. Prior to the introduction of video-assisted thoracoscopic surgery (VATS), lung resection for cancer was undertaken through an open thoracotomy. To date, the evidence base supporting the different surgical approaches is based on non-randomised studies, small randomised trials and is focused mainly on short-term in-hospital outcomes.Methods and analysisThe VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer study is a UK multicentre parallel group randomised controlled trial (RCT) with blinding of outcome assessors and participants (to hospital discharge) comparing the effectiveness, cost-effectiveness and acceptability of VATS lobectomy versus open lobectomy for treatment of lung cancer. We will test the hypothesis that VATS lobectomy is superior to open lobectomy with respect to self-reported physical function 5 weeks after randomisation (approximately 1 month after surgery). Secondary outcomes include assessment of efficacy (hospital stay, pain, proportion and time to uptake of chemotherapy), measures of safety (adverse health events), oncological outcomes (proportion of patients upstaged to pathologic N2 (pN2) disease and disease-free survival), overall survival and health related quality of life to 1 year. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.Ethics and disseminationThis trial has been approved by the UK (Dulwich) National Research Ethics Service Committee London. Findings will be written-up as methodology papers for conference presentation, and publication in peer-reviewed journals. Many aspects of the feasibility work will inform surgical RCTs in general and these will be reported at methodology meetings. We will also link with lung cancer clinical studies groups. The patient and public involvement group that works with the Respiratory Biomedical Research Unit at the Brompton Hospital will help identify how we can best publicise the findings.Trial registration number ISRCTN13472721
Journal Article
Essential Caribbean
Ready to experience the Caribbean? The experts at Fodor's are here to help. Fodor's Essential Caribbean travel guide is packed with top recommendations, detailed maps of the Caribbean, and exclusive tips from locals. Whether you want to stay at an all-inclusive resort, find the best beaches, or snorkel or scuba dive at some of the world's best coral reefs, this user-friendly guidebook will help you plan it all out. Our local writers vet every recommendation to ensure that you not only make the most of your time, but that you also have all the most up-to-date and essential information you need to plan the perfect trip. This new edition has been FULLY-REDESIGNED with a new layout and beautiful images for more intuitive travel planning!
Book
Managing your money all-in-one for dummies
A hands-on, power-packed guide to managing all things money Time and money. Those are the two most important assets you have, and smart people manage both of them wisely. Managing Your Money All-in-One For Dummies is your one-stop resource to turn to when you're ready to manage your money. It offers everything you need to confidently handle your finances. When you're ready to create a budget, pay down debt, and scale back your expenses, you'll find the support you need here. If you're eyeing the future, you'll find advice on improving your credit score, saving for college and retirement, and planning an estate. As if all of that isn't enough, this comprehensive book covers other financial topics such as buying insurance, investing in your 401(k), and so much more. The authors of Managing Your Money All-in-One For Dummies explain how to handle your money in a way that encourages you to think and act positively, no matter what your financial situation looks like. And as you move toward financial freedom, you can come back to this book to get advice on topics that go beyond day-to-day money management, such as taking out a mortgage, investing online, and more. Get your financial life in order, whatever your stage of life Make a budget, manage your credit, and pay down your debt Demystify financial reports, online investing, and retirement plans Save for college and learn how to balance your saving and spending habits in any economy Navigate the new norm of online bankingSpend some time learning how to manage your money today. It'll be a wise investment of both of your most valuable assets.
eBook
Emphysema: time to say farewell to therapeutic nihilism
In 'end-stage' patients, it may be too late to intervene safely.--- Considerations--- Criteria--- [black right triangle] Are they too well to consider intervention?--- [black right triangle] Lung function, exercise capacity, prognosis, Medical Research Council dyspnoea score <3--- [black right triangle] Are they too unwell for intervention to be safe?--- [black right triangle] Lung function, frailty, exercise capacity <100 m, oxygen dependence--- [black right triangle] Is treatment optimal?--- [black right triangle] Smoking cessation, pulmonary rehabilitation, flu vaccination, inhaled and oral medication--- [black right triangle] Is their lung function likely to rule out a procedure on safety grounds?--- [black right triangle] All three of FEV1, TLco and Kco <20% predicted--- [black right triangle] Do they have comorbidities that limit likely benefit or increase risk?--- [black right triangle] For example, pulmonary hypertension, unstable cardiac disease, malignancy, cerebrovascular disease. Ongoing smoking (possibility of intervention may help to promote quit attempts)--- [black right triangle] Have they ever had a CT thorax and if so has it been reported in terms of emphysema pattern?--- [black right triangle] Review existing CT's or obtain a CT if a potential candidate as above--- Review CT and lung function in multi-disciplinary teams including respiratory physician, radiologist, thoracic surgeon Further investigations including echocardiogram, lung perfusion scan and a formal field exercise test (shuttle walk or 6 minute walk test) may be indicated.
Journal Article
Adult congenital heart disease: intensive care management and outcome prediction
Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients.
Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997-2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391+/-130, moderate $13218+/-261, complex $30074+/-689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p=0.0048), creatinine (p=0.0032) and bilirubin (p=0.0021) were highly predictive of mortality.
Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.
Journal Article
Radiomics-based decision support tool assists radiologists in small lung nodule classification and improves lung cancer early diagnosis
BackgroundMethods to improve stratification of small (≤15 mm) lung nodules are needed. We aimed to develop a radiomics model to assist lung cancer diagnosis.MethodsPatients were retrospectively identified using health records from January 2007 to December 2018. The external test set was obtained from the national LIBRA study and a prospective Lung Cancer Screening programme. Radiomics features were extracted from multi-region CT segmentations using TexLab2.0. LASSO regression generated the 5-feature small nodule radiomics-predictive-vector (SN-RPV). K-means clustering was used to split patients into risk groups according to SN-RPV. Model performance was compared to 6 thoracic radiologists. SN-RPV and radiologist risk groups were combined to generate “Safety-Net” and “Early Diagnosis” decision-support tools.ResultsIn total, 810 patients with 990 nodules were included. The AUC for malignancy prediction was 0.85 (95% CI: 0.82–0.87), 0.78 (95% CI: 0.70–0.85) and 0.78 (95% CI: 0.59–0.92) for the training, test and external test datasets, respectively. The test set accuracy was 73% (95% CI: 65–81%) and resulted in 66.67% improvements in potentially missed [8/12] or delayed [6/9] cancers, compared to the radiologist with performance closest to the mean of six readers.ConclusionsSN-RPV may provide net-benefit in terms of earlier cancer diagnosis.
Journal Article
Mixed responses to targeted therapy driven by chromosomal instability through p53 dysfunction and genome doubling
The phenomenon of mixed/heterogenous treatment responses to cancer therapies within an individual patient presents a challenging clinical scenario. Furthermore, the molecular basis of mixed intra-patient tumor responses remains unclear. Here, we show that patients with metastatic lung adenocarcinoma harbouring co-mutations of
EGFR
and
TP53
, are more likely to have mixed intra-patient tumor responses to EGFR tyrosine kinase inhibition (TKI), compared to those with an
EGFR
mutation alone. The combined presence of whole genome doubling (WGD) and
TP53
co-mutations leads to increased genome instability and genomic copy number aberrations in genes implicated in EGFR TKI resistance. Using mouse models and an in vitro isogenic
p53
-mutant model system, we provide evidence that WGD provides diverse routes to drug resistance by increasing the probability of acquiring copy-number gains or losses relative to non-WGD cells. These data provide a molecular basis for mixed tumor responses to targeted therapy, within an individual patient, with implications for therapeutic strategies.
Mixed responses to targeted therapy within a patient are a clinical challenge. Here the authors show that TP53 loss-of-function cooperates with whole genome doubling which increases chromosomal instability. This leads to greater cellular diversity and multiple routes of resistance, which in turn promotes mixed responses to treatment.
Journal Article