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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jet.2008.10.004 Byline: Enrico Diecidue (a), Ulrich Schmidt (b)(c), Horst Zank (d) Keywords: Comonotonic independence; Probability weighting function; Preference foundation; Rank-dependent utility Abstract: This paper provides preference foundations for parametric weighting functions under rank-dependent utility. This is achieved by decomposing the independence axiom of expected utility into separate meaningful properties. These conditions allow us to characterize rank-dependent utility with power and exponential weighting functions. Moreover, by allowing probabilistic risk attitudes to vary within the probability interval, a preference foundation for rank-dependent utility with parametric inverse-S shaped weighting function is obtained. Author Affiliation: (a) Decision Sciences Area, INSEAD, Fontainebleau, France (b) Christian-Albrechts-Universitat zu Kiel, Germany (c) Kiel Institute for the World Economy, Germany (d) Economics, School of Social Sciences, The University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom Article History: Received 28 January 2007; Accepted 21 October 2008 Article Note: (footnote) [star] We thank two anonymous referees and the associate editor for their constructive reports. Duncan R. Luce has provided us with detailed and helpful comments. Also, we acknowledge financial support from the Manchester School Visiting Fellowship Scheme.

The effect of increasing household consumption economies of scale as the number of household members increase is described by analyzing household data obtained from Germany and France. The correlation between household consumption economies of scale and living standards is examined.

An axiomatic theory for addressing the loop holes of risk-value models of production management is presented.

Research describing rank dependent expected utility with a weakened variant tradeoff consistency is presented. In particular tradeoff consistency for equally likely outcomes is investigated with reference to lotteries.

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services - including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic. [ABSTRACT FROM AUTHOR]

This performance improvement project was undertaken to reduce costly delays in first-case, operating room (OR) start times. Two Plan, Do, Study, Act (PDSA) cycles. In PDSA 1, student nurses observed 30 patients' paths of travel from hospital entrance to OR and documented time spent at key stopping points. Directional signs were placed after PDSA 1. PDSA 2 consisted of an electronic medical record (EMR) review of pre- and postsignage cases (n = 492 and n = 538 respectively). In the initial PDSA cycle (n = 30), one reason for delay was the time patients spent finding the preoperative area (POA). Signage was placed at strategic points noted to confuse patients. PDSA cycle 2 found median presignage POA arrival times (34 minutes) were significantly higher than postsignage POA arrival times (20 minutes) (U = 51,618.0, z = −16.934, P <.001). Delayed wayfinding contributed to delayed OR starts but improved with appropriate signage. [ABSTRACT FROM AUTHOR]

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future. [ABSTRACT FROM AUTHOR]

To examine risk factors associated with 30-day unplanned reintubation after pleurodesis. A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program surgical outcomes registry. United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. The study comprised 2,358 patients who underwent video-assisted thorascopic surgery for pleurodesis from 2007 to 2016. None. The final sample included 2,358 cases, of which 93 (3.9%) required 30-day unplanned reintubation. Cases with 30-day unplanned reintubation, compared to those without, had higher unadjusted rates of American Society of Anesthesiologists physical status (ASA PS) score ≥4 (54.8% v 27.2%), preoperative dyspnea (71% v 57%), congestive heart failure (14% v 5.4%), functional dependence (28% v 10.3%), and diabetes mellitus (29% v 17.8%) (all p < 0.05). Patients with 30-day reintubation experienced higher unadjusted rates of 30-day outcomes including mortality (50.5% v 10.1%), pneumonia (28% v 4.9%), ventilator dependence (50.5% v 10.1%), sepsis (7.5% v 1.9%), myocardial infarction (5.4% v 0.1%), cardiac arrest (18.3% v 0.6%), transfusion (14% v 4.5%), and reoperation (15.1% v 3.2%) (all p < 0.05). The odds of 30-day unplanned reintubation were increased significantly on multivariable analysis for patients with ASA PS score ≥4, functional dependence, disseminated cancer, renal dialysis, and weight loss (all p < 0.05). Given the dearth of population-based studies addressing risk factors of reintubation after pleurodesis, this study suggests further review of preoperative optimization, which is required to improve patient outcomes and safety. [ABSTRACT FROM AUTHOR]

Objective To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. Design A prospective, randomized trial. Setting Single university hospital. Participants Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. Interventions PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. Measurements and Main Results Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. Conclusion TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study. [ABSTRACT FROM AUTHOR]

Objective Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. Design This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. Setting Multi-institutional, prospective, surgical outcome-oriented database study. Participants Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. Intervention None. Measurement and Main Results The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). Conclusions Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay. [ABSTRACT FROM AUTHOR]

Study Objective: There is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality.Design: Retrospective analysis.Setting: U.S. healthcare facilities.Patients: Adult patients undergoing emergency surgery and general anesthesia.Interventions: No intervention.Measurements: Utilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period.Main Results: There were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90-1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality.Conclusions: Although, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery. [ABSTRACT FROM AUTHOR]

Background: There is sparse evidence on the benefit of neuraxial (NA) vs general anesthesia (GA) as the primary anesthetic in postoperative outcomes following bilateral total knee arthroplasty. We sought to elucidate differences in outcomes in this surgical population using a national database.Methods: We used data from the National Surgical Quality Improvement Program from 2007 to 2013 and compared rates of various postoperative outcomes in propensity-matched cohorts (NA vs GA).Results: After exclusion, there were 1957 patients included in the final analysis, of which 26% received NA as the primary anesthetic. Propensity-matched cohorts were generated to ensure no differences in various comorbidities (including bleeding disorders or inadequate cessation of anticoagulation therapy), case duration, and patient demographics between both cohorts. Among the matched cohorts, there were no differences in preoperative platelet count, hematocrit, or international normalized ratio. NA was associated with decreased blood transfusion requirement and decreased total number of units of blood products transfused (P < .0001 for both outcomes). However, there were no differences in other outcomes, including hospital length of stay, pulmonary embolism, deep vein thrombosis, or urinary tract infections.Conclusion: Our study demonstrates that in matched cohorts, NA is associated with decreased blood transfusion requirements in patients undergoing bilateral total knee arthroplasty when compared to GA as the primary anesthetic. [ABSTRACT FROM AUTHOR]

Objective Perioperative risk factors and the clinical impact of acute kidney injury (AKI) and failure after lung transplantation are not well described. The incidences of AKI and acute renal failure (ARF), potential perioperative contributors to their development, and postdischarge healthcare needs were evaluated. Design Retrospective. Setting University hospital. Participants Patients undergoing lung transplantation between January 1, 2011 and December 31, 2015. Measured Data The incidences of AKI and ARF, as defined using the Risk, Injury, Failure, Loss, End-Stage Renal Disease criteria, were measured. Perioperative events were analyzed to identify risk factors for renal compromise. A comparison of ventilator days, intensive care unit (ICU) and hospital lengths of stay (LOS), 1-year readmissions, and emergency department visits was performed among AKI, ARF, and uninjured patients. Measurements and Main Results Ninety-seven patients underwent lung transplantation; 22 patients developed AKI and 35 patients developed ARF. Patients with ARF had significantly longer ICU LOS (12 days v 4 days, p < 0.001); ventilator days (4.5 days v 1 day, p < 0.001); and hospital LOS (22.5 days v 14 days, p < 0.001) compared with uninjured patients. Patients with AKI also had significantly longer ICU and hospital LOS. Patients with ARF had significantly more emergency department visits and hospital readmissions (2 v 1 readmissions, p = 0.002) compared with uninjured patients. A univariable analysis suggested that prolonged surgical time, intraoperative vasopressor use, and cardiopulmonary bypass use were associated with the highest increased risk for AKI. Intraoperative vasopressor use and cardiopulmonary bypass mean arterial pressure <60 mmHg were identified as independent risk factors by multivariable analysis for AKI. Conclusion The severity of AKI was associated with an increase in the use of healthcare resources after surgery and discharge. Certain risk factors appeared modifiable and may reduce the incidence of AKI and ARF. [ABSTRACT FROM AUTHOR]

Objectives The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO 2 during transport and hemodynamic parameters in patients post-cardiac surgery. Design A prospective, randomized trial. Setting A university-affiliated tertiary care hospital. Participants Cardiac surgery patients. Interventions Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO 2 ) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. Measurements and Main Results Outcomes were changes from baseline in end-tidal CO 2 , hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO 2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO 2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PA mean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. Conclusions Hand ventilation during transport was associated with greater change from baseline of ETCO 2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated. [ABSTRACT FROM AUTHOR]

Purpose: Plasma coenzyme Q10 (CoQ10) levels are lower in patients with septic shock (SS) than in healthy controls (HCs). However, CoQ10 status in critically ill patients without SS is unknown. Here, we investigated CoQ10 concentrations in patients with SS and without SS as compared with HCs. Materials and Methods: We enrolled 36 critically ill patients and 18 HCs. Plasma CoQ10 concentrations were measured, and patients' clinical and demographical data were collected. Results: Plasma CoQ10 concentrations were lower in critically ill patients (0.50 ± 0.36 μg/mL, P b .001), both in patients with SS (0.37 ± 0.25 μg/mL, P = .002) and patients without SS (0.56 ± 0.39, P = .04), as compared with HCs (0.79 ± 0.19). Coenzyme Q10 levels did not differ between patients with SS and patients without SS (P = .13). In critically ill patients, CoQ10 levels inversely correlated with age (r = -0.40, P = .015) and did not correlate with partial pressure of oxygen in the arterial blood/fraction of inspired oxygen, Simplified Acute Physiology Score II, Systemic Organ Failure Assessment score, or mortality. Lower CoQ10 levels were associated with lower activities of daily living score after discharge (P = .005), independent of age. Conclusions: Decreased plasma CoQ10 levels are not specific to patients with SS, but rather observed in a broad range of critically ill patients. In critically ill patients, CoQ10 insufficiency may be associated with various conditions; age may be a risk factor. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the evolution of lung-protective ventilation strategies during anesthesia and identified factors associated with the selection of a nonprotective ventilation strategy. Methods: This retrospective observational study covered a 5-year period from March 2006 to March 2011. It included 45 575 adult patients who underwent intubation de novo in the operating room. We considered a tidal volume (VT) greater than 10 mL/kg of ideal body weight (IBW) and/or positive endexpiratory pressure (PEEP) less than 5 cm H2O as not lung protective. We evaluated the use of nonprotective ventilation strategies over time in men and women, by American Society of Anesthesiologists classification, and for elective vs emergent surgery. Results: Over the duration of the study, there was a significant reduction in the percentage of patients receiving a VT greater than 10 mL/kg IBW (28.5%-16.3%, P b .001), zero PEEP (27.5%-18.2%, P b .001), and VT greater than 10 mL/kg IBW with PEEP less than 5 cm H2O (13.4%-8.0%, P b .001). The odds of receiving nonprotective ventilation were greater for women than for men, in the first year compared with the last year, and for elective compared with emergent surgery. Conclusion: Although use of nonprotective ventilation decreased over time, an important percentage of patients continue to receive nonprotective ventilation. [ABSTRACT FROM AUTHOR]

Abstract: The case of an 18 year-old double-lung transplant recipient recovering from acute respiratory distress syndrome who developed repeated episodes of bradycardia and asystole (maximum duration: 10 sec) during dexmedetomidine administration is presented. Increased baseline vagal tone, paroxysmal coughing spells, and opioid administration were likely contributors to the episodes. Discontinuation of the drug restored regular sinus rhythm. Double-lung transplant recipients may be at especially increased risk for this phenomenon as a result of changes in the autonomic innervation of the heart. [Copyright &y& Elsevier]

Abstract: To investigate the cellular mechanisms for altered cardiac function in senescence, we measured Ca2+ transients and Ca2+ sparks in ventricular cardiomyocytes from 6- to 24-month-old Fisher 344 (F344) rat hearts. The single channel properties of ryanodine receptors from adult and senescent hearts were also studied. In senescent myocytes, we observed a decreased peak [Ca2+]i amplitude and an increased time constant for decay (τ), both of which correlated with a reduced Ca2+ content of the sarcoplasmic reticulum (SR). Our studies also revealed that senescent cardiomyocytes had an increased frequency of Ca2+ sparks and a slight but statistically significant decrease in average amplitude, full-width-at-half-maximum (FWHM) and full-duration-at-half-maximum (FDHM). Single channel recordings of ryanodine receptors (RyR2) demonstrated that in aging hearts, the open probability (P o) of RyR2 was increased but the mean open time was shorter, providing a molecular correlate for the increased frequency of Ca2+ sparks and decreased size of sparks, respectively. Thus, modifications of normal RyR2 gating properties may play a role in the altered Ca2+ homeostasis observed in senescent myocytes. [Copyright &y& Elsevier]

Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV. To create a memorable, single-step, sex-independent equation to estimate LTVV based on height. We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6–8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6–8-mL/kg IBW Vt. A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht -60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6–8 mL/kg IBW in 3720 (100%) of ICU patients. A novel equation successfully predicted a 6–8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Critically ill patients are frequently managed with invasive technologies as part of their medical care. Little is known about use patterns. We examined use trends for invasive technologies used in critically ill patients. Materials and Methods: Using time series analysis and data on 26 989 patients from 3 medical-surgical intensive care units (ICUs) (n = 18 224) and 1 surgical ICU (n = 8765) between January 1, 1999, and January 1, 2007, we measured changes in the proportion of patients receiving the 4 most frequently used invasive technologies used in critically ill patients. Results: The 4 most common invasive technologies used in critically ill patients during the study period were arterial lines (71%), endotracheal intubations (61%), central venous catheters (51%), and pulmonary artery catheters (18%). The proportion of ICU patients who received pulmonary artery catheters decreased from 25% in 1999 to 8% in 2006 (P < .001). Use of central venous catheters increased from 39% to 46% (P < .001). After adjusting for baseline characteristics, patients admitted in 2006 were 4 times less likely to receive a pulmonary artery catheter (odds ratio, 0.28; 95% confidence interval, 0.24-0.33), but 42% (odds ratio, 1.42; 95% confidence interval, 1.27-1.58) more likely to receive a central venous catheter than patients admitted in 1999. No significant changes were observed for intubations and arterial lines. Conclusions: The use of invasive technologies in critically ill patients is changing and may have important implications for resource use, clinician education, and patient care. Initiatives should be considered for ensuring clinician competency during technology transitions. [Copyright &y& Elsevier]

Abstract: Most studies investigating the influence of H2O2 on cells in culture apply nonphysiological concentrations over nonphysiological time periods (i.e., a one-time bolus that is metabolized in minutes). As an alternative, the glucose oxidase/catalase (GOX/CAT) system allows application of physiologically relevant H2O2 concentrations (300nM–10µM) over physiologically relevant time periods (up to 24h). Recent findings suggest that bolus and GOX/CAT treatments can lead to opposing cellular responses, thus warranting a quantitative comparison between the two approaches. First, we established a reaction–diffusion model that can predict the behavior of the GOX/CAT system with spatiotemporal resolution, thus aiding selection of optimal experimental conditions for its application. Measurements of H2O2 concentration in the cellular supernatant with the luminol/hypochlorite system were consistent with the predictions of the model. Second, we compared the impact of bolus and GOX/CAT treatments on cytosolic H2O2 levels over time. Intracellular H2O2 was monitored by the response of the thiol peroxidase Prx2 and the H2O2 sensor roGFP2-Orp1. We found that Prx2 rapidly and reversibly responds to submicromolar H2O2 levels and accurately reflects kinetic competition with cellular catalase. Our measurements reveal fundamental differences in the dynamic response of cellular H2O2 concentrations following either bolus or GOX/CAT treatments. Thus, different, or even opposing, biological outcomes from differing means of H2O2 delivery may be expected. Cellular responses induced by bolus treatment may not occur under GOX/CAT conditions, and vice versa. [Copyright &y& Elsevier]

Abstract: The Kiel Canal in Germany connects ports on the Baltic Sea with the rest of the world and is the most-used artificial waterway in the world. Despite this fact, it generates a balance sheet loss. Revenues, which are mainly generated by the transit charge, do not cover its operating expenses. This situation raises the question how the current charging system could be redesigned to make the canal generate a balance sheet profit. In this paper, we focus solely on the canal’s revenue. Because the canal is a monopoly that allows, in principle, for perfect price discrimination, we contrast the current charging system with an optimal charging system based on the willingness-to-pay (WTP) approach. We devise a general approach to calculate optimal transit charges and apply it in a case study that includes four ship types on three routes. The findings of the case study indicate that, in principle, much higher revenues could be generated if the transit charges were based not only on ship size but also on fuel prices and a ship’s departure and destination ports, as these affect a ship’s costs in terms of fuel costs and required sailing time. [Copyright &y& Elsevier]

Abstract: Sheehan''s syndrome is a well described entity that refers to hypopituitarism with pituitary infarction secondary to postpartum shock or hemorrhage. Antepartum pituitary infarction is a very rare condition that has been reported only in patients with longstanding type 1 diabetes mellitus or uncontrolled gestational diabetes. A case of severe, acute hypopituitarism in the setting of hemorrhagic shock from a gunshot wound is presented. Our case report highlights the importance of including hypopituitarism in the differential diagnosis of a critically ill parturient. [Copyright &y& Elsevier]

Abstract: Preliminary data suggest that hypericum extract LI160 is effective in atypical depression. Reported is the outcome of an 8-week double-blind, placebo-controlled, randomized trial of 600mg LI160 vs. placebo in patients with vegetative features of atypical depression, i.e. hyperphagia or hypersomnia. One-hundred (100) patients with mild and 100 patients with moderate severity of a major depression according to ICD-10 were randomized. Patients needed to meet a score of 2 in at least one of the items 22–26 of the Hamilton-Depression-Rating-Scale (HAM-D) 28-item version and episode duration of at least 3months. The primary outcome variable was the relative change of the HAM-D17 from Baseline. Secondary outcome variables were the depression sub-score of the Patient Health Questionnaire (PHQ-9), the Clinical Global Impression (CGI), a patient’s satisfaction scale, the Hamilton-Anxiety-Scale (HAM-A) and the sum score of atypical vegetative symptoms of the HAM-D28. The percentage reduction of the HAM-D17 for LI160 compared to placebo approached statistical significance (p =0.051) in the Full Analysis Set (FAS)-population. Using the conventional criterion of the absolute reduction of the HAM-D17 significance was achieved (p <0.05). No significant benefit could be observed for the sum score of the atypical vegetative items of the HAM-D28; however, the sum score of the hypersomnia items (items 22–24) showed a significant superiority for LI160. The HAM-A, PHQ-9, and CGI-I scales demonstrated superiority of LI160 (p <0.01). Confining the analysis to moderately depressed patients, a highly significant benefit for the primary outcome variable was revealed. The study supports the beneficial effect of LI160 in depression with atypical features and the validity of the definition of atypical depression on the basis of reversed vegetative signs. Further, it identifies the PHQ-9 as a useful outcome variable in this population. [Copyright &y& Elsevier]

Abstract: The exchange of carbonyl sulfide (OCS) and between the atmosphere and the pedosphere was investigated in a temperate zone spruce forest in the Solling Mountains (51°N), Germany during three field campaigns in 1999. Dynamic (flow-through) chambers were used to measure the OCS and carbon disulfide () exchange fluxes between the soil and the atmosphere. All measurements showed a net OCS flux from the atmosphere into the soil. On average ( standard error of the mean), the OCS uptake rate of the soil was and the total range was between 0.23 and . fluxes varied between an uptake of and an emission of . Therefore, is emitted by the soil in a nearly balanced mean flux of . Slight dependencies of the OCS flux on soil temperature and soil water content were detected. The fluxes varied by about a factor of 2 over a distance of 10m. A comparison of the OCS fluxes between soil and atmosphere with the fluxes observed simultaneously above the canopies revealed that only 1% of the OCS which was taken up by the whole forest ecosystem is deposited in the soil. The impact of the exchange between soil and atmosphere for the whole ecosystem flux of was even more negligible. [Copyright &y& Elsevier]