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This single-center study examines the incidence, etiology, and outcomes associated with prolonged mechanical ventilation (PMV), defined as time to definite spontaneous ventilation >21 days after double lung transplantation (LTx). A total of 690 LTx recipients between January 2005 and December 2012 were analyzed. PMV was necessary in 95 (13.8%) patients with decreasing incidence during the observation period (p < 0.001). Independent predictors of PMV were renal replacement therapy (odds ratio [OR] 11.13 [95% CI, 5.82-21.29], p < 0.001), anastomotic dehiscence (OR 8.74 [95% CI 2.42-31.58], p = 0.001), autoimmune comorbidity (OR 5.52 [95% CI 1.86-16.41], p = 0.002), and postoperative neurologic complications (OR 5.03 [95% CI 1.98-12.81], p = 0.001), among others. Overall 1-year survival was 86.0% (90.4% for LTx between 2010 and 2012); it was 60.7% after PMV and 90.0% in controls (p < 0.001). Conditional long-term outcome among hospital survivors, however, did not differ between the groups (p = 0.78). Multivariate analysis identified renal replacement therapy (hazard ratio [HR] 3.55 [95% CI 2.40-5.25], p < 0.001), post-LTx extracorporeal membrane oxygenation (HR 3.47 [95% CI 2.06-5.83], p < 0.001), and prolonged inotropic support (HR 1.95 [95% CI 1.39-2.75], p < 0.001), among others, as independent predictors of mortality. In conclusion, PMV complicated 14% of LTx procedures and, although associated with increased in-hospital mortality, outcomes among patients surviving to hospital discharge were unaffected., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Aggressive behavior in traffic is a widespread phenomenon. Up to 90% of the population are involved in mild forms such as shouting or gesturing. More dramatic cases with injury to individuals affect at least 1100 people in the US annually. Certain factors such as a male sex, a young age and an urban residency have been identified to contribute to the likelihood of road rage. Central to this analysis is the determination of specific features regarding the conflicting parties, the crime scene and the injury pattern in violent offenses related to traffic. In a retrospective study spanning 10 years, cases of road rage-linked injuries were identified amongst patients at the Medico-Legal Center of the Institute of Legal Medicine in Hamburg, Germany. The data were digitized and then analyzed using descriptive statistics via SPSS. There are disproportionately large numbers of males (85.7%) and motorists (61.2%) amongst road rage perpetrators. Usually the conflicting parties have no prior relationship (89.7%). In 68.1% of the cases, the violence applied was exclusively physical. Objects were utilized in 31.0% of all cases, and in more than half (55.6%) of these cases the vehicle was used as a weapon. The resulting trauma in road rage is mostly blunt and applied to the face and the extremities. There are characteristic features regarding the demographics, time and place of incident, as well as severity and pattern of injury in road rage associated offenses. Identifying these factors may lead to appropriate measures in the reduction of road rage., (Copyright © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Determining the composition of viral populations is becoming increasingly important in the field of medical virology. While recently developed computational tools for viral haplotype analysis allow for correcting sequencing errors, they do not always allow for the removal of errors occurring in the upstream experimental protocol, such as PCR errors. Primer IDs (pIDs) are one method to address this problem by harnessing redundant template resampling for error correction. By using a reference mixture of five HIV-1 strains, we show how pIDs can be useful for estimating key experimental parameters, such as the substitution rate of the PCR process and the reverse transcription (RT) error rate. In addition, we introduce a hidden Markov model for determining the recombination rate of the RT PCR process. We found no strong sequence-specific bias in pID abundances (the same RT efficiencies as compared to commonly used short, specific RT primers) and no effects of pIDs on the estimated distribution of the references viruses., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

A qualitative interview based study on ways of addressing and managing domestic violence (DV) by general practitioners (GPs) is presented. Problem centred semi-structured topic-guided interviews were conducted with 10 male and nine female GPs. Transcribed passages were analysed with the deductive approach of qualitative content analysis. Female doctors gave broader definitions of DV. Addressing of DV by a patient was perceived as a demand to act by all doctors. Documentation of injuries was considered to be important. Time constraints, feelings of being ashamed and helpless were described as barriers in addressing DV. Female doctors reported being anxious about losing their professional distance in cases of female victims. While female participants tend to take an 'acting' role in managing cases of DV by being responsible for treatment and finding a solution in collaboration with the patient, male doctors preferred an 'organising' role, assisting patients finding further help. Definitions of DV and differences in addressing the issue seemed to be strongly affected by personal professional experience. Definitions of DV, personal barriers in addressing the subject and understanding of the own role in management and treatment of DV cases differed between male and female doctors. Pre-existing definitions of DV, personal experience and gender aspects have to be taken into account when planning educational programmes for GPs on the issue of DV., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Tracer experiments during clogging and de-clogging experiments in a 2D sand box were via an image analysis used to establish a data set on the relation between changes in hydraulic conductivity (K) and relative porosity (β). Clogging appears to create a finger-like tracer transport, which could be caused by an initial heterogeneous distribution of biomass in the sand box. De-clogging occurs at a slower rate possibly due to the presence of inert biomass that is not affected by the starvation conditions by sudden removal of the substrate source. The tracer front was observed to get disturbed closer and closer to the substrate source during the experiments suggesting that the zone of clogging moved upstream. Three clogging models, K(β), from the literature were tested for their ability to describe the temporal changes in clogging at the scale of the sand box; the model of Clement et al. (1996) that makes no assumption on biomass distribution, the plug formation model of Thullner et al. (2002a), and the biofilm-plug formation model of Vandevivere (1995). The plug formation and biofilm-plug formation models both match the observed changes between the hydraulic conductivity of the sand box and the relative porosity. Unfortunately our experiments did not reach low relative porosities where the two models predict different behaviors. The model by Clement et al. (1996) underestimates clogging., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Tracer tests were conducted in three laboratory columns to study changes in the hydraulic properties of a porous medium due to bioclogging. About 30 breakthrough curves (BTCs) for each column were obtained. The BTCs were analyzed using analytical equilibrium and dual-porosity models, and estimates of the hydrodynamic dispersion and mass transfer coefficients were obtained by curve fitting. The change in transport properties developed in three stages: an initial phase (I) with no significant changes in transport properties, phase II with growth of biomass near the inlet of the columns causing changes in dispersivity, and phase III with added growth of micro-colonies deeper in the columns causing mass transfer of solutes from the water phase to the biophase. Tracer transport changed from being uniform to more non-uniform with increase in mass transfer of the tracer between the mobile phase and the immobile biomass. An increase in the bulk dispersivity value of up to one order of magnitude was observed. Numerical simulations suggest that local dispersivity values may be as much as 40 times higher in the more severe clogged areas inside the column. The bulk hydraulic conductivities of the columns decreased by up to three orders of magnitude. The hydraulic conductivity and dispersivity parameters were almost recovered after disinfection of the columns. Different models relating the changes of the hydraulic conductivity to the changes in the mobile porosity due to bioclogging were reviewed, and the micro-colony relation of Thullner et al. [Thullner, M., Zeyer, J., Kinzelbach, W., 2002. Influence of microbial growth on hydraulic properties of pore networks, Transport in Porous Media, 49, 99-122.] was found to best describe the relation between the bulk hydraulic parameters.

Background: Borderline personality disorder (BPD) is characterized by a high prevalence of comorbid psychiatric disorders, including major depression (MD). The aim of this study was to examine whether a co-occurrence of MD is associated with structural changes in the amygdala of BPD patients., Methods: Twenty-five right-handed, female patients with BPD and 25 matched healthy control subjects were examined. Diagnoses of BPD and MD were made according to DSM IV. Depressive symptomatology was determined with the Hamilton Depression Scale (HAMD). Magnetic resonance imaging scans were performed with 1.5 T Magnetom Vision (Siemens, Erlangen, Germany). The software program "BRAINS" was applied for brain volumetry and segmentation. The amygdala was delineated as "region of interest.", Results: Comparison of amygdala volumes between the whole group of BPD patients and control subjects revealed no significant difference. Amygdala volumes in both hemispheres were significantly larger in BPD patients with MD compared with those without MD. There was a significant correlation in BPD patients between left amygdala volume and depressive symptoms as measured by HAMD., Conclusions: Correlation of amygdala volume with depression in BPD patients might indicate a causal relationship. Future studies should clarify whether amygdala enlargement is a risk factor for MD in BPD patients or a consequence of the affective disorder.

Background: The assessment of recidivism in sexual offenders is an urgent topic for forensic psychiatry in Germany. The call for useful predictive measures is therefore getting louder., Aims: The present study analyses which criteria are employed by therapists in forensic hospitals to assess the dangerousness of sexual offenders. Of particular interest is whether the criteria listed in presently known prediction scores as decisive are actually used in decision-making in current forensic psychiatric practice., Method: Data are collected in a prospective prediction study funded by the German Research Association., Results: The results reveal that therapists employ mainly clinical and less historical criteria, thus indicating substantial differences from currently known prediction scores and results of other studies., Conclusions: That therapists base their prediction of dangerousness primarily on clinical variables reveals a substantial error that has to be remedied. Further research on the extent of relevance of clinical variables is needed.

Background: International normalized ratio (INR) self-management can significantly reduce INR fluctuations, bleeding, and thromboembolic events compared with INR control managed by general practitioners. However, even patients with INR self-management may have an increased risk of bleeding if their INR value is above 3.5. This study evaluated the compliance, clinical complications, and survival of patients after mechanical heart valve replacement with low-dose INR self-management compared with conventional-dose anticoagulation., Methods: Group 1 (n = 908) received low-dose anticoagulation with a target INR range of 1.8 to 2.8 for aortic valve replacement and 2.5 to 3.5 for mitral or double valve replacement. Group 2 (n = 910) received conventional-dose anticoagulation with a target INR range of 2.5 to 4.5 for all heart valve prostheses., Results: In groups 1 and 2, 76% and 75% of INR values, respectively, were in the target range. Results did not differ according to schooling and age. The rate of thromboembolic events per patient year was 0.18% in group 1 and 0.40% in group 2 (p = 0.210). The rate of bleeding complications was 0.74% for group 1 and 1.20% for group 2 (p = 0.502). In most patients with clinically relevant bleeding, these complications occurred although their measured INR values were below 3.5. The survival rate did not differ between the study groups (p = 0.495)., Conclusions: Low-dose INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. INR self-management is applicable for all patients in whom permanent anticoagulation therapy is indicated. Even INR values below 3.5 can bear the risk of bleeding complications.

Fractures and biopores can act as preferential flow paths in clay aquitards and may rapidly transmit contaminants into underlying aquifers. Reliable numerical models for assessment of groundwater contamination from such aquitards are needed for planning, regulatory and remediation purposes. In this investigation, high resolution preferential water-saturated flow and bromide transport data were used to evaluate the suitability of equivalent porous medium (EPM), dual porosity (DP) and discrete fracture/matrix diffusion (DFMD) numerical modeling approaches for assessment of flow and non-reactive solute transport in clayey till. The experimental data were obtained from four large undisturbed soil columns (taken from 1.5 to 3.5 m depth) in which biopores and channels along fractures controlled 96-99% of water-saturated flow. Simulating the transport data with the EPM effective porosity model (FRACTRAN in EPM mode) was not successful because calibrated effective porosity for the same column had to be varied up to 1 order of magnitude in order to simulate solute breakthrough for the applied flow rates between 11 and 49 mm/day. Attempts to simulate the same data with the DP models CXTFIT and MODFLOW/MT3D were also unsuccessful because fitted values for dispersion, mobile zone porosity, and mass transfer coefficient between mobile and immobile zones varied several orders of magnitude for the different flow rates, and because dispersion values were furthermore not physically realistic. Only the DFMD modeling approach (FRACTRAN in DFMD mode) was capable to simulate the observed changes in solute transport behavior during alternating flow rate without changing values of calibrated fracture spacing and fracture aperture to represent the macropores.

Background: During the past years several systems for mechanical circulatory support have become available. In this study we describe our experience with short-term and mid-term application of the ABIOMED and Thoratec device., Methods: Since 1990 the ABIOMED BVS and since 1992 the Thoratec VAD have been applied to 75 and 103 patients, respectively, with postcardiotomy heart failure, as a bridge-to-transplant procedure, and with different other indications., Results: In the ABIOMED collective 25 of 50 patients (50%) with postcardiotomy heart failure and 1 of 4 patients with miscellaneous other indications could be discharged from hospital, 7 of 14 bridge-to-transplant patients (50%) underwent transplantation with a posttransplant survival of 86%. In the Thoratec collective 6 of 10 patients (60%) with postcardiotomy heart failure and 4 of 8 patients (50%) with miscellaneous indications could be discharged from hospital, 48 bridge-to-transplant patients (74%) underwent transplantation with a posttransplant survival of 90%., Conclusions: The results show the versatility of the Thoratec VAD for short-term and mid-term application in patients with postcardiotomy heart failure and as a bridge-to-transplant procedure. The use of the ABIOMED device is not indicated for bridging patients to transplantation. Although in case of postcardiotomy heart failure, Thoratec is also superior to ABIOMED, the high costs of the Thoratec VAD limits its wide acceptance in this patient cohort.

From September 1987 to February 1994, we treated 147 patients ranging between 11 and 82 years old with different mechanical circulatory support systems. The applied devices were the Bio-Medicus centrifugal pump in 61 patients, the Abiomed BVS System 5000 in 49 patients, the Thoratec ventricular assist device in 42 patients, and the Novacor left ventricular assist device in 7 patients. On the basis of indication for mechanical circulatory support, the patients were divided into three groups: group 1 consisted of 72 patients with postcardiotomy cardiogenic shock; group 2, 50 patients in whom mechanical support was used as a bridge to cardiac transplantation; and group 3 (miscellaneous), 25 patients in cardiogenic shock resulting from acute myocardial infarction (n = 14), acute fulminant myocarditis (n = 3), primary graft failure (n = 2), right heart failure after heart transplantation (n = 3), and acute rejection (n = 3). Time of support ranged from 1 hour to 97 days (mean duration, 10.8 days). Seventy-five patients (51%) were discharged from the hospital. The best survival rate was achieved in group 2 with 72%, followed by group 1 with 44% and then group 3 with 28%. The most frequent complications in group 1 were bleeding (44%), multiple-organ failure (24%), neurologic disorders (18%), and acute renal failure (15%). In group 2, the major complications were bleeding (34%) and cerebrovascular disorders (22%) and in group 3, multiple-organ failure and sepsis (60%) and bleeding (32%).