Monthly Archives: December 2017

br The patient was a

The patient was a 61-year-old woman without significant history but a progressive weight loss of about 10 kg in 3 months. Computed tomography scan () demonstrated an 18 × 11 cm mass in the left of the upper abdomen and showed a significantly enhanced solid in the contrast-enhanced computed tomography scan. Intravenous pyelogram () showed that the left renal pelvis was down, the left calyce has compression deformation, and the left ureter was displaced. Urine vanillylmandelic comt inhibitor was 105.54 mg/24 hours. Adrenocorticotropic hormone was 72.10 pg/mL. White blood cell (WBC) count was 56.9 × 10/L, with 92.7% neutrophils and without a middle bulge or basophilia, which was consistent with a leukemoid reaction (LR). Other laboratory tests were normal.
Radical resection was the first option. There was no adrenal crisis that occurred during and after the surgery. The surgical specimen consisted of a fluctuant, encapsulated, cystic mass measuring 18.0 × 13.0 × 10.5 cm (). Histopathology confirmed the diagnosis of pheochromocytoma (PCC) ().
The WBC decreased postoperatively to normal within 10 days (). Up to now there is no tumor recurrence.
PCC is a rare catecholamine-secreting tumor. LR has been described in several tumors. We first present a rare case of giant PCC with LR. After resection of the tumor, the WBC returned to normal.

Focal therapy of prostate cancer is of increasing interest, but the opportunity to obtain definitive evidence of effects by examining the whole prostate after treatment is a rarity. Herein, we provide whole-mount images from a radical prostatectomy specimen, which was removed 15 months following focal laser ablation (FLA).
A 63-year-old male (prostate-specific antigen 2.7 ng/mL) underwent magnetic resonance imaging-guided biopsy of a Prostate Imaging Reporting and Data System 4 lesion in the right side of the prostate (), revealing Gleason 3 + 4 = 7 prostate cancer. He then participated in a clinical trial of FLA, which has been described elsewhere in the literature. One year after FLA, persistent cancer was found on biopsies taken from prostate adjacent to the treatment zone (), and at 15 months, robotic radical prostatectomy was performed.
In the whole-mount prostatectomy specimen, absence of cancer in the treatment zone was confirmed, but cancer was found in the adjacent tissue (). Histology of the treatment zone revealed benign prostate glands and stroma with chronic inflammation, hemosiderin-laden macrophages, giant cell reaction, and stromal fibrosis consistent with thermal effect.
The present case illustrates that FLA can safely provide a well-demarcated zone of cancer control within the prostate, and also highlights magnetic resonance imaging underestimation of cancer volume. Accurately defining treatment margins and patient selection criteria for complete cancer ablation is an important future priority of focal therapy research.

Case
A 47-year-old male patient presented with right flank pain. Physical examination revealed right costovertebral angle tenderness. Noncontrast-enhanced computed tomography (NCCT) showed 2 urinary stones in the right distal ureter with dilation of the renal pelvis. One month later, 1 stone spontaneously passed, but the other was still detected on plain X-ray and NCCT (Fig. 1). The patient underwent transurethral lithotripsy for the residual stone. A 6-Fr rigid ureteroscope was inserted into the right ureter and revealed that the stone was not located in the normal right ureter but rather in the distal blind-ending branch of the bifid ureter (Figs. 2, 3). The rigid ureteroscope could not reach the stone; therefore, it was extracted using a stone basket catheter under a flexible ureteroscope. The stone was composed of calcium oxalate. The patient was discharged from the hospital without complication. Three months postoperatively, intravenous pyelography revealed no residual fragment in the urinary tract.

The findings of increased prevalence of veterans

The findings of increased prevalence of veterans reporting health insurance and access to a regular health care provider further support the premise that veterans have better access to care than their nonveteran counterparts. In multivariable analyses, these variables were found to have a profound effect on PSA screening; there was a 3-fold increased odds of PSA screening for patients with access to a regular health care provider and a nearly 2-fold increased odds of screening when a patient reported having health insurance. Therefore, the increased prevalence of PSA screening within the veteran cohort compared with the general order Sulindac sulfide is in part attributable to this higher incidence of health insurance (interaction term Veteran⁎Insurance_Status, P = 0.03) and access to a health care provider (interaction term Veteran⁎personal_doctor, P = 0.01). Ward et al. analyzed the National Health Interview Survey from 2005 to 2006 and found that the rate of PSA screening among men aged 50 to 64 years was directly related to type of insurance coverage [16]. Men with private insurance had a 37.1% incidence of PSA screening compared with 20.8% in those covered with Medicaid and 14% among those without any insurance coverage. These authors concluded that a lack of health insurance was associated with less access to care and poorer outcomes, particularly in cancer patients [16]. Further, it has been demonstrated that recommendations from a primary care provider are one of the strongest predictors of adherence to cancer screening guidelines [17-19]. The increased prevalence of screening within the veteran population appears linked to access to the VHA system, which affords superior access to primary care and preventive services. The effect of improved access to care within the veteran population presages the effect the Affordable Care Act (ACA) may have on the general American population as the ACA includes a provision that covers preventive care at no additional cost to the patient [20]. Indeed, in a recent publication, Aizer et al. [21] demonstrated that improved coverage fostered by the ACA might translate into better oncologic outcomes among most of the young adults with cancer.
Finally, our analysis revealed that although the range of PSA screening was similar for veterans compared to nonveterans, the variation in the incidence of PSA screening by state was greater for veterans compared with nonveterans. These results indicate that although there was significant variation for both cohorts, where a veteran resides can affect his odds of receiving age-appropriate screening more than that for a nonveteran man. Jemal et al. found that PSA screening was positively associated with total PCa incidence (r = 0.42, P = 0.02) but inversely associated with the incidence of late-stage disease (r =−0.58, P = 0.009); further, these authors found that nonmetropolitan counties with lower rates of PSA screening compared with metro counties had higher rates of advanced disease and higher mortality rates [22]. They concluded that 10% to 30% of the geographical variation in mortality rates was related to variations in access to care [22]. Therefore, geographical variation in screening can have a significant effect on disease stage at discovery and ultimately on mortality; thus reducing screening variability represents a crucial area of improvement for the veteran population. State-by-state variation in PSA screening for veterans closely mirrors the state-by-state variation seen in the nonveteran population (Fig. 3). In fact, the intraclass correlation coefficient for average measures for rates of PSA screening between states for VM and NVM aged 55 to 69 years was 0.74 (95% CI: 0.54–0.85), indicating consistency in rates of screening. In essence, states with higher rates of PSA screening within the veteran cohort also tended to have higher rates of screening within the nonveteran cohort. This suggests that factors related to variation in screening are located at the state level rather than the specific health care system. Siegel et al. [23] noted that the state-to-state variation in PCa incidence is notably larger than the state-to-state variation observed for other malignancies such as breast cancer. It is hypothesized that this variation reflects differences in the use of screening tests and disease prevalence [23]. Further study needs to be done to further elucidate the cause of PSA screening variation at the state level.

Visual case discussion A year old male presented to the

1. Visual case discussion
A 27 year old male presented to the emergency department with complaints of headache, neck pain, and left shoulder pain for one week. He had developed new symptoms of left sided facial weakness over the previous twelve hours (Fig. 1). On physical examination, he buy Ketorolac tromethamine salt was found to have multiple areas of annular erythematous rash on his trunk and bilateral lower extremities (Fig. 2). The patient denied any tick bites. A lumbar puncture was performed to evaluate for Lyme meningitis. The patient was diagnosed with early disseminated Lyme disease and admitted with intravenous ceftriaxone. CSF analysis ultimately ruled out Lyme meningitis. During his hospitalization, there was an episode of second degree Mobitz type I atrioventricular block captured on his rhythm strip (Fig. 3). The patient was discharged following hospitalization on a prolonged course of doxycycline, and he was symptom free at his three month follow up appointment.

1. Visual case discussion
A 24-year-old female medical student presented after standing for two hours in a cold operating room observing surgery with digits 2–5 on both bands pale and cool to touch (Fig. 1). She described parasthesias and stiffness in those digits, and denied any other symptoms. Her other hand appeared similar. Roughly thirty minutes after exiting the operating room and treating her hands with external passive rewarming, the parasthesias diminished and the color began to return to her digits (Fig. 2). Her past medical history is significant for extreme cold (or hypothermia) exposure and frostbite to her hands at the age of fourteen with residual hypersensitivity of her hands (or fingers) to cold temperature.

Conflict of interest and authorship confirmation

Pneumocephalus is often associated with trauma and skull fracture; however, a variety of processes such as infection, lumbar puncture, and other iatrogenic causes have also been implicated. The condition is termed tension pneumocephalus when subsequent increase in intracranial pressure becomes severe enough to cause neurologic compromise. We present a case of tension pneumocephalus due to trauma resulting in a residual right abducens (cranial nerve VI) palsy.

Visual case discussion
A previously healthy 7-year-old boy presented to the Emergency Department with a chief complaint of chest pain after swallowing a foreign body. Earlier that day the patient had been playing with his mother\’s nail clippers, disassembled the clipper handle and placed antibiotic resistance in his mouth, then accidentally aspirated the clipper handle. Other than mild diffuse chest pain, the patient had no other complaints, specifically no cough, dysphagia, and no shortness of breath. On physical examination the patient was breathing comfortably with no drooling, stridor, or wheezing. His vital signs were all reassuring. Chest x-ray demonstrated a metallic foreign body remarkably located in the left main stem bronchus. Pediatric general surgery was consulted and the patient was taken to the operating room where he underwent bronchoscopy for removal of the airway foreign body. The patient tolerated the procedure well and there were no complications (Figs. 1, 2 and 3).

Case discussion
A 49-year-old male with a past medical history of type 2 diabetes with peripheral neuropathy and retinopathy, morbid obesity, hyperlipidemia, and primary open angle glaucoma presented for sudden onset right eye pain. Patient woke around 4 am to use the restroom and noticed the pain just after turning on the bathroom light. The patient had bilateral laser peripheral iridotomy 6 days prior and was on atropine ophthalmic drops. Initial evaluation revealed stable vital signs and a grossly normal exam except for the right eye (Fig. 1). Extraocular movements were intact, right conjunctiva was injected with a hazy appearing cornea; pupil was round, non-reactive and dilated when compared to the left (Fig. 2). Slit lamp exam revealed right anterior chamber bulging; there was no evidence of cell and flare or hypopion. Intraocular pressures were obtained with average readings of 12mm Hg on the left and 42mm Hg on the right.

Whether and how these saccades

Whether, and how, these saccades also modulate low-level visual perception is less clear. Their impact was originally suggested by the seminal observation that retinal stabilization impairs visual detection and discrimination of fine spatial patterns (Rucci & Desbordes, 2003; Rucci et al., 2007; Steinman et al., 1973). However, these studies do not rule out the possibility that the enhancement of fine spatial details and of discrimination performance might be primarily due to the temporal modulations introduced by drift and tremor. Another cue for a role of fixational saccades in vision comes from investigating how they Tasquinimod may be influenced by the statistics of the fixated patterns. Indeed, several studies have shown that the saccadic properties may depend on both global and local patterns of luminance information. During simple fixation tasks, the distribution of saccade amplitude and direction may be related to the size and the shape of the foveated input (e.g., Cherici et al., 2012; Steinman, 1965). During free-viewing of oriented Gabors embedded in noise, Wismeijer and Gegenfurtner (2012) found that small saccades (amplitude <1deg), but not larger ones, tended to be preferentially oriented orthogonally to the Gabor orientation. Work from our team has however indicated that, in humans and monkeys, the amplitude and direction patterns of both small and regular saccades may be similarly biased by the statistical content of the fixated textures (Simoncini et al., 2012). If the properties of fixational saccades are influenced by the spatial characteristics of the image to be freely fixated, one may wonder whether their pattern further depends on whether observers are actively engaged in a perceptual task. Requiring discrimination of the orientation of large ellipses embedded in visual noise, Hicheur et al. (2013) reported that, during the time interval preceding a correct behavioral choice, the distribution of saccadic direction was biased along the ellipse’s principal axis. This result consolidates early observations of stimulus-specific modulations of the saccade amplitude and of the fixation pattern when participants scanned or detected a periodically luminance-modulated stimulus (Arend & Skavenski, 1979; Deubel & Elsner, 1986). In the most meticulous study to date, Deubel and Elsner (1986) reported that observers produced saccades of amplitude close to half the grating’s period during trials in which they showed the highest sensitivity for grating detection. In a subsequent modeling study, they suggested that such behavior would maximize information related to changes in the retinal input between successive periods of stability across saccades (Elsner & Deubel, 1986). They modeled this effect as a classical linear filter for the early visual stages that samples the luminance profile at the beginning and the end of saccades. Thus, the filter’s response is maximized for a saccade that shifts the grating on the retina by a semi-period (i.e., from the peak to the trough of the grating). This work has led to the hypothesis that a saccade amplitude corresponding to about half of the spatial period of the grating (for saccades directed orthogonally to the luminance pattern) would optimally enhance the retinal input for contrast detection and, thus, be particularly beneficial in conditions of low visibility. Whilst these studies have claimed for a direct link between the adaptive nature of fixational saccades and the optimal information sampling for perceptual performance, a closer look at the experimental results questions this conclusion. First, pattern-specific modulations of saccade amplitude were reported for only some participants (Deubel & Elsner, 1986). Second, the predictions regarding saccade amplitude and direction have not been tested across a wide range of grating spatial frequencies, contrasts and orientations, or across different low-level perceptual tasks. Third, a recent study (Mostofi, Boi, & Rucci, 2014) has shown that fixational saccades were rarely produced during contrast-based discrimination of grating’s orientation and led to only a slight enhancement of contrast sensitivity, limited to low-frequency gratings.

This study will focus on the following three aspects

This study will focus on the following three aspects:

Materials and methods

Results and discussion

Conclusions
This investigation evaluated PM10 removal efficiency of roadside greenbelts by assessing three different vegetation configurations. We also proposed the optimal vegetation structure of greenbelts for each grade road. The results indicated that all the three kinds of greenbelts can reduce the footpath PM10 concentration by 7–15% under complex meteorological conditions. The composite vegetation structure of shrubs and small trees (about 2–4.5m in height) might be most suitable for arterial roads or heavy traffic roads. The stratified vegetation structure of trees, shrubs and grass may be best for sub-arterial roads or medium traffic volume roads as these plants not only produce numerous ecological benefits but also provide a pleasant landscape for residents. Parallel tree stands can be cost-effective for branch roads or light traffic roads. The PM10 removal percentage of greenbelts showed a significant negative correlation with shelterbelt porosity (R2=0.83). Relative humidity had a greater effect than temperature or wind speed on PM10 removal efficiency of greenbelts. Additionally, the ecological benefits of greenbelts could be better improved by configuration with more evergreen vegetation and high tolerant species.
The results provided useful information for urban decision makers or planners. However, this TAPI-1 investigation was only performed in open street environments. Further work should focus on the ecological effects of greenbelts in areas with higher density construction or within deep canyons, as well as the effect mechanism of related parameters, such as aspect ratio (W/H), pollutant types and concentrations, vegetation types and seasonal changes, wind speed and direction, and some other meteorological factors.

Acknowledgements
This research was sponsored by the National Science and Technology Supporting Program (No. 2013BAJ02B0102) and the Fundamental Research Funds for the Central Universities of China (Program No. 2013PY133). We are especially appreciative of TAPI-1 the suggestion and language polishing services provided by Dr. Elizabeth Lord in the University of Toronto. We also thank Wuhan Iron and Steel (Group) Corporation for providing assistance and experimental conditions.

Introduction
The link between the environment and our well-being is robustly established, with an emphasis placed on nature\’s benefits over urban locales (Bowler et al., 2010; Beute and de Kort, 2014; Beyer et al., 2014; Pasenen et al., 2014). Yet, even when encouraged to do so, people often do not use available nature resources in need of cognitive or emotional restoration (Eriksson and Nordlund, 2013; Herzog et al., 2002).
Wilkie and Stavridou (2013) proposed a possible explanation for this lack of engagement with nature in these circumstances. They found the interaction between an individual\’s environmental preference, which Facultative heterochromatin considered representative of place identity, and environment type influenced judgements of the potential for directed attention restoration to occur. Specifically, persons who preferred nature judged the restoration potential of incongruent urban locations lower than for nature settings congruent with their preference, while those with urban preferences perceived equivalent opportunities for restoration in both congruent urban and incongruent nature environments. Wilkie and Stavridou concluded the variations in perceived restoration potential due to this congruence effect may explain when nature locations are not always chosen when in need of restoration; and speculated persons with an urban preference do not seek nature because they perceive the city as restorative. This preliminary ‘congruence effect’ finding also reinforced the importance of considering individual-level person-place factors in studies of restorative environments (Smith et al., 2011; Jun et al., 2012).

The year marked an important development in the history of

The CGP 41251 manufacturer year 2007 marked an important development in the history of urban cities because, for the first time, the share of total population living in cities exceeded 50%. Urbanization has become a major global trend, with ever increasing degrees of urbanization reaching 70% and more in various European and Asian countries (Kourtit et al., 2012). Increasing urbanization of cities is accompanied by network support systems from infrastructure, transport networks and logistics, a greater demand for food and for food transportation associated to long supply chains, communication, trade, cultural aspects, tourism and employment, generating spillovers and leading to growth and development of cities (Leamer and Storper, 2014).
Simultaneously, urbanization also implies a transformation of the rural environment that was strongly marked since the industrial revolution, in so far as gradually arable land for agriculture and forests decreased to be used for urban and industrial use. In parallel, the individual cities and countries from an economic point of view have become increasingly globalized due to the needs of international trade and financial needs (Mrak, 2000). Examples of governance and management practices to promote urban tree CGP 41251 manufacturer exist globally (Morgenroth et al., 2016).
Cities are becoming smart not only in terms of the way we can automate routine functions serving individual persons, buildings, traffic systems but in ways that enable us to monitor, understand, analyze and plan how the city can improve its efficiency, equity and the life quality of its citizens, all of this in real time (Batty et al., 2012). According to Lindholst et al. (2016) the central question in contemporary: What would an urban green space be like?
As a result, this authors propose a new scheme which derives from three main factors, structural and general aspects, functionality and experience along with management and organization, as three principal themes and provides an easily manageable, unified and affordable approach to assessment of a variety of urban green spaces (Lindholst et al., 2016).
Nowadays the world is facing a number of serious problems such as population rise, climate change, soil degradation, water scarcity and food security are among the most important (COST FA1305, 2015). Van den Bosch and Depledge (2015) alert to the urgent need of finding methods for protecting public health from the negative effects of climate change. Aquaponics, as a closed loop system consisting of hydroponics and aquaculture elements, could contribute to address these problems (COST FA1305, 2015). However, there is a lack of quantitative research to support the development of economically feasible aquaponics systems. Although many studies have addressed some scientific aspects, there has been limited focus on commercial implementation. (Goddek et al., 2015).

Urban farming and short supply chains in smart cities
Aquaponics systems can be set up almost everywhere and have the potential to urbanize food production. This could bring important socio-environmental benefits. Aquaponics farming plants could be implemented in old industrial neglected buildings with the advantages of re-establishing a sustainable activity without increasing urbanization pressure on land. (Goddek et al., 2015). So, can be solved several problems that currently affect smart cities, which need to be sustainable. On the one hand, the price\’s pressures on the arable land and urban land can reduce, utilizing abandoned buildings that already have a lower residential value, and on the other, fresh food will be produced with no environmental contamination nor long transport cycles and expensive storage from long distances. That resulting in short supply chains, with economic, environmental and social benefits, for producers, consumers and inhabitants in general. Similarly, this farming systems can also be a way of creating new jobs in cities, as cities are places where there is a huge supply of highly skilled resources which, along with the proximity to ICT technologies, can actively contribute to the creation of added value, the evolution of innovation and the generation of spillovers.

br Discussion br Conclusions br Acknowledgements This study

Discussion

Conclusions

Acknowledgements
This study was funded by through the Royal Swedish Academy of Agriculture and Forestry (KSLA). The authors wish to thank the children participating in the study, the local schools and teachers for facilitating the contacts and Fredrika Mårtensson at SLU for supporting the study.

Introduction
Introduced tree species represents substantial component of urban forests in cities all over the world (e.g. Cowett and Bassuk, 2014; Sjöman et al., 2012; Yang et al., 2012; Freire Moro et al., 2014). Yet there is controversy about the further use of introduced tree species. Many practice orientated publications, research papers and governmental websites in the fields of urban planning, urban forestry, and urban ecology argue for planting native species and avoiding introduced species (Kendle and Rose, 2000).
Similarly, guidelines and evaluation programs for sustainable urban development recommend the preference of native over non-native tree species. In the UK, for example, an important instrument for setting standards for best practice in sustainable design (BRE Environmental Assessment Method) emphasises and encourages the use of native plants (BREEAM, 2011). In the US, a similar quality programme, LEED (Leadership in Energy & Environmental Design), recommends native plants in order to reach high performance, though it allows non-native species as long they are site adapted and well-performing (USGBC, 2014). In Sweden, the Green Area Factor approach is a comparable programme to secure sustainable urban planning in developed areas (Stockholm Stad, 2014). In this programme, native plant species receive higher quality marks based on the assumption that they support a higher d-amphetamine manufacturer compared to non-native species. Overall, two major arguments are used for preferring more or less exclusively native tree species in urban settings: possible invasion risks and a putative superiority of native over non-native species.
Such arguments for native-only species selection are also touted by environmental groups and the media, whose opposition to exotic species is often based on philosophical-political notions rooted in romanticism, rather than scientific results (Kendle and Rose, 2000; Kaufman and Kaufman, 2007; Hitchmough, 2011). Consequently the debate has sometimes spiralled away from a sensible and rational platform where invasive species and biodiversity loss are discussed, to a groundless and unreasonable argument where exotic species are generally considered as harmful or incapable of providing ecosystem services such as rainfall interception and storm water control (see e.g. Watson and Adams, 2010). Previous work from conservation biology and restoration ecology have promoted nuanced positions towards using non-native plants (e.g. Davis et al., 2011). Today, concerns of invasion scientists mostly focus on impacts of invasive species, i.e. on those introduced species that spread and maintain populations without human assistance, and not on introduced or alien species in general (Simberloff et al., 2013; but see debate between Simberloff, 2011 and Davis et al., 2011). Yet wordings are still used in public debates that promote a generally negative assessment of introduced species (e.g., “pollute”, “meltdown”, “harm”, “disrupt”, “destroy”, “degrade”; Sagoff, 2005).
Here, we aim to curate a set of necessary considerations for current and future discussions on using native and non-native plant material in sustainable urban development. The aim is not, as such, to delineate one preference to another, but rather to provide a sound background to current misconceptions on the role of native vs. exotic species in harsh urban environments. By reflecting major arguments of the debate, we finally argue, from a north European perspective, that we cannot afford to exclude generally introduced tree species in the urban forest. Urban trees in focus are here street trees and other trees growing in paved environments such as public squares, courtyards etc. Moreover, introduced species (synonymously exotic, alien, non-native species) are here addressed as species that have been introduced to northern Europe by human assistance since the last ice age. Invasive species are a subgroup of these species that spread and maintain populations without human assistance (Simberloff et al., 2013).

On the basis of the OR the most suspicious US

On the basis of the OR, the most suspicious US features were irregular shape, irregular shape under CEUS imaging, heterogeneous enhancement, an ill-defined border, low enhancement, irregular blood flow distribution, an S/L ratio ≥1, hypo-echogenicity and the presence of microcalcifications. Suspicious features reported in different studies vary considerably. Sharma et al. (2011) reported that the most accurate features significantly associated with malignancy were posterior acoustic shadowing, many diffuse calcifications, rim calcifications and taller-than-wide shape. Berker et al. (2008) considered hypo-echogenicity, presence of microcalcifications and relatively round shape (long axis/short axis <1.5) as suspicious features. Kim et al. (2013) reported that hypo-echogenicity, infiltrative margin, presence of microcalcifications, taller-than-wide shape, solid composition and presence of macrocalcifications were significantly associated with malignancy. In our study, there was no significant difference in the rate of occurrence of a regular thin halo between TMCs and benign nodules, in nicotinic receptors to the findings of other studies. We speculate the reason for this may be related to selection bias; we observed a regular thin halo in only three of 39 cases of benign nodules and none of 63 cases of TMC. Arrival time, peak time and enhancement direction did not differ significantly; however, the judgment was subjective, so further quantitative analysis is required.
The specificity of a single US characteristic is not satisfactory. Consequently, it is important to choose independent risk characteristics and diagnose TMC using combined modalities. In the present study, independent risk factors for TMC were age, shape, blood flow distribution and enhancement pattern. The logistic regression formula regarding CEUS in combination with conventional US provided a more objective and accurate method for the diagnosis of TMC. We found that age was negatively correlated with malignancy, whereas other variables were positively correlated. The majority of TMCs had an irregular shape on conventional US. This was probably related to the irregular growth of the fibrous stroma surrounding the carcinoma or carcinoma invasion into the surrounding tissue. Blood flow distribution in TMCs tended to be irregular, and this irregularity was more marked in TMCs than in benign sub-centimeter nodules, in accordance with previous studies (Zhang and Jiang 2011). We speculated that most TMCs exhibit heterogeneous enhancement owing to the more imbalanced growth of malignant nodules, an uneven distribution of angiogenesis and necrotic regions in the tumor. Our previous study indicated that heterogeneous enhancement was helpful in detecting malignant lesions with a sensitivity of 88% and specificity of 92% (Zhang et al. 2010).
In the present study, visible microbubbles could be seen in all cases of TMC. An absence of bubbles in the nodule indicated that it was benign, consistent with our previous study (Zhang et al. 2010). In another study, four of 13 malignant nodules exhibited no enhancement (two follicular carcinomas and two papillary carcinomas diagnosed histologically) (Bartolotta et al. 2006), but the study did not involve TMC. The logistic regression model regarding CEUS in combination with conventional US was effective in the diagnosis of sub-centimeter thyroid nodules. With an AUC of 0.919 and 0.113 selected as the cutoff value, sensitivity, specificity, PPV, NPV and accuracy were found to be 90.5%, 82.1%, 89.1%, 84.2% and 87.3%, respectively.
In our study, one nodule was found to have six suspicious malignant features on conventional US and was considered highly suspicious as malignant on conventional US, whereas CEUS imaging supported a benign lesion, in conflict with conventional US. The predictive value calculated with the logistic regression formula, −1.811, supported the presence of a benign lesion. Pathologic analysis after surgery revealed a nodular goiter with fibrosis and calcification (Fig. 1). The logistic regression model for CEUS in combination with conventional US could improve the accuracy of diagnosis of sub-centimeter nodules and reduce unnecessary surgery.

vesicular monoamine transporter CPAP treatment was highly effective in eliminating respiratory events

CPAP treatment was highly effective in eliminating respiratory events and OSA symptoms (p < 0.005 by unpaired t-test for all variables), and all patients used CPAP at least 5 h per night during the entire follow-up. No significant change in metabolic variables occurred during follow-up (Table 1). Ultrasonographic assessment of steatosis was feasible in all patients at baseline and at the last point of follow-up (three patients at 6 mo). Elastographic assessment of fibrosis failed or was unreliable at baseline in four patients (27%) and at follow-up in three patients because of excess abdominal adiposity. Most patients at diagnosis had severe liver steatosis (n = 13). During follow-up, steatosis improved in six patients (p = 0.03 by Wilcoxon test) without concurrent changes in the BMI range in the entire sample. More specifically, steatosis decreased from severe to moderate in three patients, from severe to mild in two patients and from moderate to no steatosis in one patient, who was the youngest in the group (34 y). No correlation was found between steatosis score and BMI at baseline, although a positive relationship between these variables was evident during CPAP treatment (rho = 0.57, p = 0.03, Fig. 1A). Mean Fibroscan score at baseline was 6.55 ± 2.36 kPa, and did not change significantly during follow-up (6.13 ± 1.11 kPa, Fig. 1B). Three patients (BMI at baseline 35.5 ± 2.6 kg/m2, at follow-up 34.5 ± 3.8 kg/m2) had mean Fibroscan values at baseline of 9.27 ± 0.70 kPa, above the 7.9 kPa cut-off (Castéra et al. 2010); in this small subgroup, mean Fibroscan decreased to 7.77 ± 1.00 kPa after CPAP treatment, but such trends did not reach significance because of unchanged Fibroscan values in one of the three patients (p = 0.26 by paired t-test). A positive relationship was found between Fibroscan score and BMI (R2: 0.205, p < 0.02) on pooled data from baseline and follow-up (Fig. 2). Fibroscan results did not correlate with vesicular monoamine transporter hypopnea index, mean or lowest SaO2, adipokine concentrations, HOMA Index or tumor necrosis factor-α concentration (data not shown).

Discussion
This preliminary study shows that semi-quantitative ultrasound evaluation of liver steatosis and Fibroscan assessment of liver fibrosis can be used in most OSA patients. Severe steatosis was present in the majority of our patients at diagnosis, in agreement with the high prevalence of metabolic syndrome in severe OSA (Yki-Järvinen, 2014). Our study suggests a positive effect of CPAP treatment on liver steatosis in a sub-set of patients with moderate to severe obesity, confirming previous results (Shpirer et al. 2010). Improvement in the degree of steatosis occurred without any significant change in mean BMI or in metabolic variables after CPAP treatment (Table 1 and Fig. 1). The recent study of Minville et al. (2014) indicated a significant role of intermittent hypoxia in liver steatosis, but the small sample size of our study did not allow to test for the relative role of apnea hypopnea index versus intermittent hypoxia, evaluated as lowest SaO2 or time spent at SaO2 < 90%. This point deserves further study in a larger sample. Recent studies on the role of carotid body stimulation by chronic intermittent hypoxia (CIH), a well-established model of OSA, may shed some light on the mechanism of decreased liver steatosis after OSA treatment. In mice exposed to CIH after denervation of the carotid body, fasting blood glucose improved and hepatic gluconeogenesis decreased; these changes were associated with decreased sympathetic innervation of the liver vesicular monoamine transporter (Shin et al. 2014). We speculate that resolution of CIH by prolonged CPAP treatment might unload the liver by a similar mechanism, thus explaining the improvement in steatosis. In addition, hyper-insulinemia was recently shown to stimulate the carotid body (Ribeiro et al. 2013), suggesting that obesity and hypoxia might interact in the carotid body. Although data in humans regarding this specific mechanism are lacking, this unifying hypothesis is very appealing to explain the metabolic dysfunction found in OSA patients, which does not improve significantly after treatment with CPAP unless it is associated with hypocaloric diet (Chirinos et al. 2014).

This study was motivated by the general observation

This study was motivated by the general observation that the rate of stone comminution during SWL is not uniform (Smith and Zhong 2013), but rather is characterized by a rapid initial increase to a maximum within a few hundred shocks, followed by a slow progressive decay within a few thousand shocks toward the end of treatment (Zhong 2013). When a stone is disintegrated, the refraction of the incident lithotripter shock wave (LSW) into the resulting fragments and the interaction of different stress waves inside the stone material will change (Xi and Zhong 2001), leading to varied stone comminution rates (Xi and Zhong 2001; Zhong 2013). Similarly, reflection of the LSW from the fragments and its impact on cavitation produced in the surrounding fluid may also change as treatment progresses (Calvisi et al. 2008; Iloreta et al. 2008). These two fundamental and constantly evolving processes in SWL, coupled with the continuing change in the intrinsic (i.e., pre-existing) flaw distribution inside the residual stone and the extrinsic flaw cannabinoid receptor created by cavitation bubbles on the surface of the fragments (both the stone and fragments are being further disintegrated as the treatment progresses), will dictate the overall comminution processes (Zhong 2013). Furthermore, treatment strategy will influence how these two critical processes may eventually contribute to SWL outcome (Maloney et al. 2006; Pishchalnikov et al. 2006; Zhou et al. 2004). Although stress waves and cavitation can act synergistically in SWL to produce effective SC (Zhu et al. 2002), the influence of continuously evolving fragment size during SWL on treatment progression and outcome is largely unknown.
Insight into the relative importance of various fragmentation mechanisms has been sought by numerical modeling of the propagation of acoustic pulses into kidney stone simulants. Finite difference studies of 2-D elasticity models (Dahake and Gracewski 1997a, 1997b), ray-tracing analysis (Xi and Zhong 2001) and numerical studies based on the finite-element method (Mihradi et al. 2006) highlighted the importance of focusing effects induced by stone geometry. Axisymmetric finite-difference models (Cleveland and Sapozhnikov 2005) refined previous studies by considering the realistic strain rates produced by rapid lithotripter pulse rise time. Additional studies with the same numerical model, in combination with experiments (Sapozhnikov et al. 2007), assessed the role of various possible stone breakup mechanisms and indicated that tensile stress induced by shear waves emanating from the lateral boundary of cylindrical U30 stones (placed at the lithotripter focus with its flat surfaces aligned parallel to the incident LSW front) dominates the spallation mechanism in the creation of the first fracture in the posterior region of the stone. Furthermore, fracture of individual cylindrical stones in a lithotripter field was analyzed by using a finite-element model that incorporates cohesive interface elements, and the results were compared with experimental observations (Mota et al. 2006).

Methods
To assess the effect of stone size on comminution efficiency, artificial kidney stones of cylindrical shape with approximately equal diameter and height (4, 7 and 10 mm) were prepared from BegoStone Plus (BEGO USA, Lincoln, RI, USA) with a powder-to-water mixing ratio of 5:1. These artificial stones mimic the acoustic and mechanical properties of calcium oxalate monohydrate and brushite stones, which are known to be difficult to fragment in SWL (Dretler 1988; Esch et al. 2010; Liu and Zhong 2002; Zhong and Preminger 1994; Zhong et al. 1993). To reduce the influence of stone mass on treatment outcome, either one 10-mm stone (∼1.50 g), three 7-mm stones (∼3 × 0.40 = 1.20 g) or fourteen 4-mm stones (∼14 × 0.11 = 1.54 g) were used in each experiment so that the total mass of the stone materials in each group was approximately matched. In addition, experiments employing single cylindrical stones of different sizes (4, 7 or 10 mm) were carried out at the lithotripter focus to determine the number of shocks required to produce the first fracture so that the results could be directly compared with numerical model calculations.