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Background: Traditionally, surgical removal of glioblastoma is performed with general anaesthesia but a recent meta-analysis revealed that awake surgery in glioblastoma resulted in better surgical outcomes than non-awake surgery. Preoperative severe aphasia is one of the exclusion criteria for awake surgery because of difficulties in intraoperative interpretation of language deterioration and the distinction between preoperative vs. intraoperative induced paraphasias. As severe aphasia is common in glioblastoma patients, many potential patients who may benefit from awake surgery are excluded. Aims: We aim to investigate the feasibility of awake surgery in glioblastoma patients with severe aphasia using a patient-tailored approach with adapted intraoperative language tasks. We also examined the effect of awake surgery on language outcomes. Methods & Procedures: We discuss five case studies of patients elected for awake surgery with presumed glioblastoma in eloquent language areas and severe aphasia. Pre- and postoperatively, an extensive test-protocol was administered at different linguistic levels and modalities. A patient-tailored intraoperative language test-protocol was applied. Outcomes & Results: Preoperatively, all patients had severe impairments on all language and cognitive tests. Intraoperative language tasks for direct electrical stimulation and resection were selected and adapted to patients’ preoperative level. Despite preoperative severe aphasia, functional boundaries for critical language areas could be identified in each patient. Postoperatively, all patients had stable or improved language outcome. One of the patients recovered to maximum scores on nearly all language tests. Conclusions: Our cases demonstrate that awake surgery in severely aphasic glioblastoma patients is feasible and did not cause further deterioration of aphasia. An extensive preoperative neurolinguistic examination is necessary for adequate patient-tailored intraoperative monitoring with maximal tumour resection and to consequently increase the chance of language preservation and quality of life.

A 600 MW offshore wind farm is under construction in the Netherlands Exclusive Economic Zone at a site called Gemini situated 55 km north of the Wadden Sea island of Schiermonnikoog and 85 km from the nearest Dutch port of Eemshaven. This chapter investigates the option of introducing a multi-use design for the Gemini site by adding mussel cultivation (48 kt wet weight per year) and seaweed cultivation (480 kt wet weight per year) to the wind farm. An institutional analysis indicates a political will in the Netherlands to support the development of adding uses to offshore wind farms, but a number of implementation obstacles are also identified. Those obstacles include an absence of licences for multi-use production and legal restrictions against third-party access to wind farms. There is therefore a need for a regulatory framework for multi-use and trust-building among actors involved in multi-use installations. A financial and economic assessment, and a cost-benefit analysis also taking into account monetized changes in CO2 emissions, indicate that adding mussel cultivation to the wind farm is likely to be both financially and socio-economically viable. Including a seaweed cultivation function is probably not financially and socio-economically viable under current technical and economic conditions. Knowledge gaps and uncertainties in these assessments with respect to, for example, missing site-specific data and non-monetized externalities suggest further research, also including pilot cultivations of mussels and seaweed in planned single-use or multi-use installations.

European seas are encountering an upsurge in competing marine activities and infrastructures. Traditional exploitation such as fisheries, tourism, transportation, and oil production are accompanied by new sustainable economic activities such as offshore windfarms, aquaculture, and tidal and wave energy. One proposed solution to overcome possible competing claims at sea lies in combining these economic activities as part of Multi-Use Platforms at Sea (MUPS). MUPS can be understood as areas at sea, designated for a combination of activities, either completely integrated in a platform or in shared marine space. MUPS can potentially benefit from each other in terms of infrastructure, maintenance, etc. Developing MUPS in the marine environment demands adequate governance. In this article, we investigate four European sites to find out how governance arrangements may facilitate or complicate MUPs. In particular, we apply a framework specifying policy, economic, social, technical, environmental, and legal (PESTEL) factors to explore governance arrangements in four case study sites in different sea basins around Europe ( the Mediterranean Sea, the Atlantic Ocean, the North Sea, and the Baltic Sea). The article concludes with policy recommendations on a governance regime for facilitating the development of MUPS in the future.

European oceans are subject to rapid development. New activities such as aquaculture and ocean energy have gained importance. This triggers interest in ?multi-use platforms at sea? (MUPS), i.e., areas at sea in which different activities are combined. MUPS are complex features with regards to technology, governance, and financial, socioeconomic, and environmental aspects. To identify realistic and sustainable solutions and designs for MUPS, the MERMAID project applied a participatory design process (PDP) involving a range of stakeholders representing companies, authorities, researchers, and NGOs. This paper evaluates if and how the participatory design process contributed to the design of multi-use platforms. It is based on interviews with the managers of the case study sites and a questionnaire administered to all stakeholders participating in the PDP workshops. Analyzing the four case studies, we conclude that the participatory design process has had a valuable contribution to the development of the four different designs of MUPS, even though the preconditions for carrying out a participatory design process differed between sites. In all four cases, the process has been beneficial in generating new and shared knowledge. It brought new design issues to the table and increased knowledge and understanding among the different stakeholders. This research was funded under the Seventh Framework Program, Theme [OCEAN.2011-1]. “Innovative Multi-purpose off-shore platforms: planning, design and operation” Grant Agreement no.: 288710.

Approximately 50% of severely head-injured patients suffer additional potentially life-threatening extracranial injuries such as multiple fractures, lung contusion, traumatic pneumothorax, and injury to intra-abdominal organs. Despite the high prevalence of multiple trauma in brain-injured patients, only a few studies have investigated the effect of extracranial injuries on the clinical course and outcome of patients with traumatic brain injury (TBI) (1, 2). Nevertheless, the prognosis and outcome have been shown to be worsened when multiple extracranial injuries are involved (1, 3). This exacerbation of injury is believed to be a consequence of secondary insults to the brain resulting from hypoxemia, hypotension, elevated intracranial pressure, insufficient cerebral perfusion pressure, hypercapnia, hyperthermia, hypo/hyperglycemia, hyponatremia, and sepsis (4-6) that can be caused by extracranial traumatic injuries. Although the uninjured brain can normally withstand these secondary insults by activating compensatory mechanisms, the brain is rendered vulnerable to secondary insults due to TBI-induced structural and metabolic deficits. Blood loss and subsequent systemic hypotension are major causes of secondary insult to the brain following TBI and occur more frequently in multiply injured patients (4, 7). Moreover, hypotension in the traumatically injured patient has been shown to be predictive for higher mortality and morbidity rates (8). Under laboratory conditions, experimentally induced hemorrhagic hypotension (HH) when superimposed on a traumatically injured brain has been shown to impair cerebral perfusion (9, 10) and reduce the amount of oxygen carriers contributing to the already reduced brain tissue oxygenation (11, 12). Additionally, secondary hypotension, with and without concomitant hypoxia, following TBI has been reported to impair systemic pressure autoregulation (13-15), impair cerebral autoregulation (15, 16), and aggravate TBI-induced structural damage as reflected by a significant increase in contusion volume (9, 17-19). Secondary hypoxia has also been reported to exacerbate acute sensorimotor and cognitive deficits following moderate fluid percussion (FP) brain injury in rats (20). To date, most preclinical pathophysiologic and pharmacologic studies have been conducted primarily in animals subjected to isolated TBI without HH, and a strong need exists to develop combined injury models to elucidate optimal treatment and management strategies for multiply-injured patients (see the excellent review in Ref. 21). Although several rodent models of combined injury (TBI with hypoxia, with and without HH) have been established (9, 15, 17, 20, 22, 23), experimental studies investigating the impact of superimposed HH have focused primarily on the pharmacologic restitution of mean arterial blood pressure (MABP) and/or cerebral perfusion pressure by infusing catecholamines (15, 24) and the evaluation of various resuscitation fluids (13, 25, 26). To date, the impact of hemorrhagic hypotension on neurologic and cognitive outcome following TBI has not been investigated. The present study was designed to reproduce the clinical scenario in which a TBI patient experiences an acute, transient (≤30 mins) arterial hemorrhage immediately following TBI. In one subgroup of brain-injured animals, lactated Ringer’s solution was infused to reverse the arterial hypotension whereas another subgroup was not fluid resuscitated. The impact of superimposed compensated or uncompensated HH on the acute pathologic response to TBI (brain edema formation at 24 hrs postinjury), long-term (5 month) neurobehavioral outcome variables, and hemispheric tissue loss after TBI was also evaluated in the current study.