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Cholangiocarcinoma (CCA) are the second most common primary liver tumors and carry a dismal prognosis. Chemosaturation with percutaneous hepatic perfusion (PHP) is a palliative, intra-arterial therapeutic approach that provides a high dose chemotherapy of the liver with reduced systemic exposure. Aim of this retrospective, monocentric study was to analyze PHP as a palliative treatment for unresectable CCA. Toxicity, adverse events and complications were classified using the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Overall response rate (ORR) and disease control rate (DCR) were evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST1.1). Median overall survival (mOS), median progression-free survival (mPFS) and hepatic mPFS (mhPFS) were computed using Kaplan–Meier estimation. In total 17 patients were treated with 42 PHP between 10/2014 and 09/2020. No significant complications occurred during the interventions. mOS was 27.6 (interquartile range (IQR) 16.5–37) months from first diagnosis and 9.9 (IQR 3.8–21) months from first PHP. mPFS was 4 (IQR 2–7) and mhPFS was 4 (IQR 3–10) months. ORR was 25% and DCR 75%. Significant, but transient hematotoxicity was frequent with grade 3/4 thrombopenia after 50%, leukopenia after 26% and anaemia after 21% of the interventions. An increase of transaminases (AST increase after 21% and ALT increase after 14% of the PHP) developed more often than a deterioration of the liver synthesis capacity. Salvage treatment with PHP has the potential to prolong life in selected patients with unresectable, refractory cholangiocarcinoma. The interventional procedure is safe. Post-interventional toxicity is frequent but manageable.

Background: There are various experimental measurement techniques used to measure residual stress and this work describes one such method, the slotting method, and its application to measure near surface residual stresses. Objective: This work examines its application to macro-scale specimens. Methods: A series of numerical experiments were performed to understand the size required to assume that the specimen is infinitely large, namely the thickness, width, and height. To assess measurement repeatability, 12 slotting measurements were performed in a shot peened aluminum plate. Results: The numerical experiments determined the specimen should have a thickness greater than or equal to 21.6mm (0.85in), a total specimen width (normal to the slot length) greater than or equal to 44.5mm (1.75in), and total height (parallel to the slot) greater than or equal to 38.1mm (1.5in) for the specimen to be assumed to be infinite. Slotting measurement repeatability was found to have a maximum repeatability standard deviation of 30MPa at the surface that decays rapidly to 5MPa at a depth of 0.3mm from the surface. Comparison x-ray diffraction measurements were performed. Conclusions: Infinite plate dimensions and slot length were determined as well as measurement repeatability. Slotting was shown to have significantly better repeatability than X-ray diffraction with layer removal for this application.

Although multi-sectoral coordination in disaster risk management has been progressing in South Africa for over two decades, there has been limited commitment to an integrated regime in managing marine oil spill incidents. Poor incident management persists despite the availability of data, protocols, legislation, and resources housed in different government and private sector entities. This study identified practices that enhance a coordination process for the effective management of oil spill pollution. A grounded theory approach is applied to the coordination issue, which is characterized by an interactive process of simultaneously considering theoretical grounding during our empirical research. Empirical evidence includes observations of 47 meetings and three oil spill exercises with 79 delegates from 32 different organizations, which supports the coordination process of instituting a national Incident Management System for marine oil spills in South Africa. An additional 44 individual open-ended questionnaires supplement this earlier body of evidence for data triangulation and validation. Analysis of development of the Incident Management System process revealed that, when designing a novel long-term project that is reliant on a shared vision from multiple organizations, enhanced coordination and collaboration for successful implementation is dependent on the following practices: (1) obtaining political commitment, (2) bridging knowledge gaps, and (3) sharing resources.

Purpose To retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH). Materials and methods Retrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed. Results Pre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms. Conclusion Embolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

Background The personal, environmental, and behavioral risk factors that play an important role in the spread of SARS-CoV-2 are still largely unclear. At the same time, there is limited evidence on the effectiveness of specific countermeasures for SARS-CoV-2. As a first approach to these questions, we use data from the Cologne Corona Surveillance (CoCoS) study, a large cross-sectional study conducted in Cologne, Germany, in June 2021. Methods This study was conducted in Cologne, Germany. Six thousand randomly selected Cologne residents who were 18 years of age or older were invited to participate in this study. Participant information was obtained via an online survey. Previous SARS-CoV-2 infections were recorded using self-reports. Sociodemographic and environmental information such as age, sex, living situation were collected. Potential SARS-CoV-2 risk behaviors were captured (workplace situation, adherence to hygiene regulations, and regular use of public transportation). Adherence to hygiene regulations was surveyed by determining the compliance with the ‘AHA’-rules (German acronym that stands for keeping a distance of 1.5 m from fellow citizens, hand disinfection, and wearing a face mask). Binary logistic regression analysis was used to identify risk factors for SARS-CoV-2 infection. Results A sample of 2,433 study participants provided information. Comparison of the sample with the general population showed representativeness for most sociodemographic characteristics with a preference for higher level of education in the study sample. Younger age, as well as living with minor children (under 18 years) in the same household were associated with a higher number of self-reported SARS-CoV-2 infections. Adherence to hygiene regulations was associated with fewer self-reported SARS-CoV-2 infections in adults. Gender, size of living space per person, workplace situation (work from home versus working with contact to colleagues/customers), and regular use of public transportation showed no significant association with self-reported SARS-CoV-2 infections in multivariable analysis. Conclusion The presented results provide initial indications of which sociodemographic and behavioral factors may be associated with SARS-CoV-2 infection. However, the fact that these factors were recorded without exact dates and could have changed accordingly during the pandemic or after infection limits the strength of the results. Trial registration DRKS.de, German Clinical Trials Register (DRKS), Identifier: DRKS00024046, Registered on 25 February 2021.

Obtaining a burning plasma is a critical step towards self-sustaining fusion energy1. A burning plasma is one in which the fusion reactions themselves are the primary source of heating in the plasma, which is necessary to sustain and propagate the burn, enabling high energy gain. After decades of fusion research, here we achieve a burning-plasma state in the laboratory. These experiments were conducted at the US National Ignition Facility, a laser facility delivering up to 1.9 megajoules of energy in pulses with peak powers up to 500 terawatts. We use the lasers to generate X-rays in a radiation cavity to indirectly drive a fuel-containing capsule via the X-ray ablation pressure, which results in the implosion process compressing and heating the fuel via mechanical work. The burning-plasma state was created using a strategy to increase the spatial scale of the capsule2,3 through two different implosion concepts4–7. These experiments show fusion self-heating in excess of the mechanical work injected into the implosions, satisfying several burning-plasma metrics3,8. Additionally, we describe a subset of experiments that appear to have crossed the static self-heating boundary, where fusion heating surpasses the energy losses from radiation and conduction. These results provide an opportunity to study α-particle-dominated plasmas and burning-plasma physics in the laboratory.

In a burning plasma state1–7, alpha particles from deuterium–tritium fusion reactions redeposit their energy and are the dominant source of heating. This state has recently been achieved at the US National Ignition Facility8 using indirect-drive inertial-confinement fusion. Our experiments use a laser-generated radiation-filled cavity (a hohlraum) to spherically implode capsules containing deuterium and tritium fuel in a central hot spot where the fusion reactions occur. We have developed more efficient hohlraums to implode larger fusion targets compared with previous experiments9,10. This delivered more energy to the hot spot, whereas other parameters were optimized to maintain the high pressures required for inertial-confinement fusion. We also report improvements in implosion symmetry control by moving energy between the laser beams11–16 and designing advanced hohlraum geometry17 that allows for these larger implosions to be driven at the present laser energy and power capability of the National Ignition Facility. These design changes resulted in fusion powers of 1.5 petawatts, greater than the input power of the laser, and 170 kJ of fusion energy18,19. Radiation hydrodynamics simulations20,21 show energy deposition by alpha particles as the dominant term in the hot-spot energy balance, indicative of a burning plasma state.

Purpose To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. Materials and Methods In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated. Results Transsplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. Conclusions Transsplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

ZusammenfassungDesorientierung kann ein frühes Merkmal eines Delirs sein. Für die Überwachung eines Delirs testet die im deutschsprachigen Raum weit verbreitete „Confusion Assessment Method for Intensive Care Unit“ (CAM-ICU) die Orientierung nicht, da intubierte Intensivpatienten sich nicht verbal äußern können. Die Mehrheit der Patienten auf deutschen Intensivstationen ist aber nicht beatmet, sie könnten hinsichtlich ihrer Orientiertheit befragt werden. Die vorliegende Studie untersuchte, ob sich durch das Kriterium „Desorientierung“ bei extubierten Patienten im Vergleich zur CAM-ICU divergierende Befunde ergeben und ob sich die Sensitivität der CAM-ICU durch Kombination mit dem Merkmal „Desorientierung“ („CAM-IMC“) erhöhen lassen. Insgesamt 86 gepaarte Untersuchungen fanden bei 50 extubierten Patienten statt. Ein Delir fand sich bei 19,8 % (n = 17) aller Untersuchungen. Die CAM-ICU hatte eine Sensitivität von 71 % (95%-KI: 44–90 %) und eine Spezifität von 100 % (95–100 %). Für „Desorientierung“ als alleiniges Delir-Merkmal fand sich eine Sensitivität von 77 % (50–93 %) und eine Spezifität von 93 % (89–100 %). Die CAM-IMC erreichte eine Sensitivität von 88 % (64–99 %) bei einer Spezifität von 100 % (95–100 %). Die „Receiver-Operating-Characteristics(ROC)-Analyse“ fand mit einer „area under the curve“ (AUC) von 0,941 (95%-KI: 0,851–1,000) für die CAM-IMC den höchsten Wert im Vergleich zu den anderen Delir-Tests (CAM-ICU, AUC 0,853 [0,720–0,986]; Desorientierung, AUC 0,868 [0,745–0,991]). Diese Arbeit unterstreicht die Wertigkeit des Merkmals „Desorientierung“ für Delir-Tests bei verbal kommunikationsfähigen Patienten und erklärt einige diskrepante Beurteilungen schwierig einzuschätzender Patienten in der täglichen Praxis. Die CAM-IMC scheint als Delir-Test für extubierte Patienten günstigere Eigenschaften als die CAM-ICU zu haben und sollte eingehender überprüft werden.

Purpose of Review In this scoping review, we aimed to (1) provide an overview of chronic sleep reduction by systematically reviewing the existing literature (limited to systematic reviews and meta-analyses), (2) investigate the evidence of the effects of short sleep duration on daytime functioning, and (3) identify research gaps in this field. Recent Findings The results showed that (1) clear definitions of chronicity of sleep reduction are lacking—none of the included reviews/meta-analyses provided a full definition—and (2) short sleep duration appeared to be related to obesity and diabetes, whereas relations with cardiovascular disease (CVD), cognitive functioning, emotional problems, general health, and mortality, showed either small effects and appeared to be complex (e.g., for CVD and cognitive functioning), or studies were scarce or completely lacking (e.g., mortality in children/adolescents and emotional problems in adults). Summary Although short or insufficient sleep is highly prevalent and is associated with impaired mental and physical wellbeing, as well as pervasive negative consequences for daytime functioning, the concepts of “chronicity” and “chronic sleep reduction” have not been clearly defined and its effects on health are therefore still largely unknown. Moreover, there are large research gaps concerning studies on the relations between short sleep and health consequences. Further studies are recommended to define and operationalize chronicity of sleep reduction and develop measurements that adequately represent the complexity of the concept.

Both social exclusion and loneliness are aversive experiences that can lead to hostile behavioral reactions, including aggressive behavior. This study aimed to assess whether a social exclusion scenario in the subject’s imagination elicits aggressive reactions towards an excluding person as measured with the hot sauce paradigm. Furthermore, we studied the effect of loneliness on such reactions. In total, 251 subjects (67.7% female; mean age 27.3 ± 9.3 years) participated in this study which was based on an online survey. After trait loneliness was assessed with the UCLA Loneliness scale at baseline, two imaginary scenarios were presented in randomized order, i.e., an exclusion condition (with one of two working colleagues excluding the participant from a social activity) and an inclusion condition (without exclusion). Following each scenario, participants had the task to allocate the amount of hot sauce to each colleague that they find appropriate. Participants distributed significantly more hot sauce to the excluder than to the includers. The amount of hot sauce was significantly correlated with loneliness for all includer interactions (i.e., after the inclusion as well as the exclusion scenario), but not for the interaction with the excluder. Our results support the hypothesis that social exclusion elicits aggressive behavior. Interestingly, the experience of loneliness seems to be associated with an increase in aggressive behavioral tendencies or a lack of their inhibition. The cognitive and/or emotional processes underlying the interplay between social exclusion, loneliness and aggression should be a focus of future research.

Purpose To evaluate the feasibility and effect of an approach to adrenal venous sampling (AVS) analysis by combining established selective cortisol and aldosterone indices with the acquisition of a collimated C-arm CT(CACTColl). Methods Overall, 107 consecutive patients (45f,62 m; 54 ± 10 years) undergoing 111 AVS procedures without hormonal stimulation from 7/13 to 2/20 in a single institution were retrospectively analysed. Hormone levels were measured in sequential samples of the suspected adrenal veins and right iliac vein, and selectivity indices (SI) computed. Stand-alone SICortisol and/or SIAldosterone ≥ 2.0 as well as SICortisol and/or SIAldosterone ≥ 1.1 combined with positive right-sided CACTColl of the adrenals (n = 80; opacified right adrenal vein) were defined as a successful AVS procedure. Radiation exposure of CACT was measured via dose area product (DAP) and weighed against an age-/weight-matched cohort (n = 66). Results Preliminary success rates (SICortisol and/or SIAldosterone ≥ 2.0) were 99.1% (left) and 72.1% (right). These could be significantly increased to a 90.1% success rate on the right, by combining an adjusted SI of 1.1 with a positive CACTColl proving the correct sampling position. Sensitivity for stand-alone collimated CACT (CACTColl) was 0.93, with 74/80 acquired CACTColl confirming selective cannulation by adrenal vein enhancement. Mean DAPColl_CACT measured 2414 ± 958 μGyxm2, while mean DAPFull-FOV_CACT in the matched cohort measured 8766 ± 1956 μGyxm2 (p Conclusion Collimated CACT in AVS procedures is feasible and leads to a significant increase in success rates of (right-sided) selective cannulation and may in combination with adapted hormone indices, offer a successful alternative to previously published AVS analysis algorithms with lower radiation exposure compared to a full-FOV CACT.

Measurement precision and uncertainty estimation are important factors for all residual stress measurement techniques. The values of these quantities can help to determine whether a particular measurement technique would be viable option. This paper determines the precision of hole-drilling residual stress measurement using repeatability studies and develops an updated uncertainty estimator. Two repeatability studies were performed on test specimens extracted from aluminum and titanium shot peened plates. Each repeatability study included 12 hole-drilling measurements performed using a bespoke automated milling machine. Repeatability standard deviations were determined for each population. The repeatability studies were replicated using a commercially available manual hole-drilling milling machine (RS-200, Micro-Measurements). An updated uncertainty estimator was developed and was assessed using an acceptance criterion. The acceptance criterion compared an expected percentage of points (68%) to the fraction of points in the stress versus depth profile where the measured stresses ± its total uncertainty contained the mean stress of the repeatability studies. Both repeatability studies showed larger repeatability standard deviations at the surface that decay quickly (over about 0.3 mm). The repeatability standard deviation was significantly smaller in the aluminum plate (max ≈ 15 MPa, RMS ≈ 6.4 MPa) than in the titanium plate (max ≈ 60 MPa, RMS ≈ 21.0 MPa). The repeatability standard deviations were significantly larger when using the manual milling machine in the aluminum plate (RMS ≈ 21.7 MPa), and for the titanium plate (RMS ≈ 18.9 MPa). The single measurement uncertainty estimate met a defined acceptance criterion based on the confidence interval of the uncertainty estimate.

The ferrous industry keeps evolving, and the demand for castings with complex geometries is increasing. Due to this, some foundries are facing several challenges when it comes to producing highly complex parts with a specific microstructure. Normally, heat treatment is performed when a ferritic matrix is desired. However, distortion and cracking can become a problem too. Because of this, it is important to explore alternative methods that can potentially help with these problems. In ductile iron, cobalt additions are known to increase the nodule count, which favors higher ferrite fractions. Hence, the addition of cobalt was studied to investigate its effects on the microstructure and tensile properties of ductile iron. Five heats were produced and cast into ½ inch ASTM A536 Y-blocks: 0 wt%, 1 wt%, 2 wt%, 3 wt%, and 4 wt% Co. Metallography was performed to evaluate the percent nodularity, nodule count (N/mm2), and ferrite/pearlite percentages. Tensile testing was executed using sub-size round samples. Brinell hardness and micro-Vickers were conducted on each Y-block to assess the macro and microscopic behavior of the cobalt bearing ductile iron. The addition of 4 wt% Co was found to decrease the nodule size and increase the percent nodularity and nodule count resulting in higher ferrite contents. Cobalt did not have a statistically significant effect in tensile strength and percent elongation. However, cobalt was found to increase the yield strength due to the solid solution strengthening effect in ferrite.

The production of thin-wall ductile iron can be challenging due to the formation of carbides during the solidification process. One way to reduce carbides in thin sections is by the addition of silicon, but this is detrimental for the impact strength and fracture toughness of ductile iron. It is known that cobalt as an alloying element in ductile iron increases the nodule count resulting in a larger fraction of ferrite. Therefore, the ability of cobalt to inhibit carbide formation was studied. The goal was to inhibit carbide formation without increasing silicon content. Five heats were produced: Co-free ductile iron, 1 wt%, 2 wt%, 3 wt%, and 4 wt% Co. These were cast into plates with thicknesses of 2, 2.5, 3, 3.5, 4, and 6 mm. Metallography was performed to evaluate the percent nodularity, nodule count (N/mm2), and ferrite/pearlite/carbide percentages. Tensile testing was performed using flat sub-size dogbone samples. Also, the fracture surfaces of the 2 and 6 mm sections were analyzed using SEM. Finally, Brinell hardness was performed on each section thickness. There was no increase in the percent nodularity with the addition of cobalt, but with 4 wt% Co an increase in nodule count was observed. With the addition of 3 wt% and 4 wt% Co, there was a reduction in carbide percentage due to an increase in ferrite content. With the addition of 4 wt% Co, there is a reduction in yield strength and an increase in elongation due to a higher ferrite percentage. It was discovered that with the addition of 4 wt% Co the production of carbide-free sections is possible without increasing the silicon percentage above 2.41 wt% Si.

Both linear and nonlinear electromyographic (EMG) connectivity has been reported during the expression of stretch reflexes, though it is not clear whether they are generated by the same neural pathways. To answer this question, we aim to distinguish linear and nonlinear connectivity, as well as their delays in muscle responses, resulting from continuous elbow joint perturbations. We recorded EMG from Biceps Brachii muscle when eight able-bodied participants were performing a steady elbow flexion torque while simultaneously receiving a continuous position perturbation. Using a recently developed phase coupling metric, we estimated linear and nonlinear connectivity as well as their associated delays between Biceps EMG responses and perturbations. We found that the time delay for linear connectivity (24.5 ± 5.4 ms) is in the range of short-latency stretch reflex period (< 35 ms), while that for nonlinear connectivity (53.8 ± 3.2 ms) is in the range of long-latency stretch reflex period (40–70 ms). These results suggest that the estimated linear connectivity between EMG and perturbations is very likely generated by the mono-synaptic spinal stretch reflex loop, while the nonlinear connectivity may be associated with multi-synaptic supraspinal stretch reflex loops. As such, this study provides new evidence of the nature of neural connectivity related to the stretch reflex.