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Objectives Opioid prescription rates worldwide suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive science show that risk perceptions can differ systematically depending on whether people learn about risks by description or experience. We investigated the effects of descriptive and simulated experience risk formats on patients’ risk perceptions and behavior regarding long-term strong opioid use. Methods 300 German patients with chronic noncancer pain were randomly assigned in an exploratory randomized controlled trial to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary endpoints were subjective and objective risk perceptions and intended intake behavior. Results Both formats significantly improved patients’ objective risk perception; patients who saw the fact box estimated some outcomes more accurately (p = .031). Formats were equally effective in improving patients’ subjective risk perception in terms of opioids’ harms; however, patients receiving the simulation showed a greater reduction and termination of their opioid intake (p = .030) and a higher uptake of alternative therapies. Conclusions Descriptive and simulated experience risk formats improve risk perceptions and behavior regarding potent but highly risky drugs. Practice implications To eliminate risky behavior, simulated experience formats may be superior to descriptive formats.

BACKGROUND: Lesions of articular cartilage represent a crucial risk factor for the early development of osteoarthritis. Autologous chondrocyte implantation (ACI) is a well-established procedure in therapy of those lesions in the knee. The aim of the presented study is to detect differences in short-term radiological outcome depending on defect localization (femoral condyle vs. retropatellar) after spheroid-based ACI. OBJECTIVE: This study aimed to demonstrate that radiological outcome after spheroid-based ACI in the knee is independent of defect localization. METHODS: MRI-scans after retropatellar ACI and ACI of the medial/lateral femoral condyle, with a preoperative Outerbridge grade of III or IV were evaluated regarding MOCART 2.0. RESULTS: The mean defect-size was 5.0 ± 1.8 cm2, with a minimum size of 2 cm2 and a maximum size of 9 cm2. Scans were performed 7.7 months (± 3.1 months) postoperatively. The mean MOCART 2.0 score was 78.5 ± 15.6. No statistically significant influence neither of the localization (p= 0.159), the gender (p= 0.124) nor defect size (< 5 cm2 vs. ⩾ 5 cm2; p= 0.201) could be observed. CONCLUSIONS: The presented data demonstrate good to excellent radiological short-term results after spheroid-based ACI. Data indicates, that at least radiological results are independent of gender, defect-size and defect-localization.

Introduction: In sub-Saharan Africa, a paucity of data exists in respect of the knowledge, attitudes and practices (KAP) of patientson maintenance haemodialysis (MHD) regarding the dietary adaptations they should make.Methods: In a descriptive, cross-sectional study, conducted in 2017, questionnaires were administered during structured interviews with 75 participants in five MHD-units in Bloemfontein to assess socio-demographics and KAP regarding the ‘renal’ diet.Results: The median age was 50.5 years; 70.7% of participants were male. Overall, 49.4% scored low (< 50%) on knowledge regarding restricted foods, food content of restricted minerals, and phosphate binders; 60.0% reported negative attitudes towards the diet, and 61.4% reported poor adherence practices. Participants with tertiary education (28.0%) had significantly higher knowledge scores than participants with only primary school education (6.7%) (95% CI 3.9%; 73.5%), or those who had only partially completed secondary school (17.3%) (95% CI 6.3%; 64.0%). Only 21.0% reported having received written, and 30.7% verbal, nutrition education in their home language, while 24.0% reported never receiving nutrition education in either their home or second language. Having received nutrition education in a home language and/or second language was associated with significantly higher knowledge scores (95% CI 3.7%; 49.5%). Most (77.3%) reported zero to one consultation with a dietitian per MHD year (NKF-K/DOQI recommends at least three/MHD year).Conclusion: This population on MHD presented with poor KAP regarding the ‘renal’ diet, and inadequate involvement of dietitians in their treatment. Receiving nutritional education in a first or second language significantly increased knowledge of, and insight into, the required dietary adaptations.

The electroencephalographic derived indices have been developed for adult patients, however these monitors have not been validated for infants.Frontal EEGs were recorded in 115 infants aged 1 year [0-3-months (N = 27), 4-6-months (N = 30), 7-9-months (N = 29) and 10-12-months (N = 29)] who received general anaesthesia with sevoflurane. Total power (µVNewborns show a mean relative δ-power at 80% in intraoperative EEG compared to infants (10-12 months) showing 47.5%. Relative β-power and α-power are low in newborns (mean 3.2% and 4.6%; respectively), with a marked increase in the older infants (4-6 months) (mean 10.9% and 14.4%; respectively). EEG dynamic in newborns from baseline (relative δ-power of 88%) to the intraoperative situation (80.5%) are discrete. In contrast infants 6-months have a strong reduction of relative δ-power from baseline to the intraoperative situation, which corresponds to an increase of faster frequencies.Age dependent perioperative EEG signatures can be demonstrated in infants younger than one year.We demonstrate significant differences in EEG readouts between newborns and infants which questions our monitoring systems in paediatric anaesthesia.

BACKGROUND: . High-quality comprehensive data on short-/long-term physical/mental health effects of the COVID-19 pandemic are needed. METHODS: . The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT) is an international, multi-language (n=30) project involving >230 investigators from 49 countries/territories/regions, endorsed by national/international professional associations. COH-FIT is a multi-wave, on-line anonymous, cross-sectional survey [wave 1: 04/2020 until the end of the pandemic, 12 months waves 2/3 starting 6/24 months threreafter] for adults, adolescents (14-17), and children (6-13), utilizing non-probability/snowball and representative sampling. COH-FIT aims to identify non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to improve social/health outcomes in the general population/vulnerable subgrous during/after COVID-19. In adults, co-primary outcomes are change from pre-COVID-19 to intra-COVID-19 in well-being (WHO-5) and a composite psychopathology P-Score. Key secondary outcomes are a P-extended score, global mental and physical health. Secondary outcomes include health-service utilization/functioning, treatment adherence, functioning, symptoms/behaviors/emotions, substance use, violence, among others. RESULTS: . Starting 04/26/2020, up to 14/07/2021 >151,000 people from 155 countries/territories/regions and six continents have participated. Representative samples of ≥1,000 adults have been collected in 15 countries. Overall, 43.0% had prior physical disorders, 16.3% had prior mental disorders, 26.5% were health care workers, 8.2% were aged ≥65 years, 19.3% were exposed to someone infected with COVID-19, 76.1% had been in quarantine, and 2.1% had been COVID 19-positive. LIMITATIONS: . Cross-sectional survey, preponderance of non-representative participants. CONCLUSIONS: . Results from COH-FIT will comprehensively quantify the impact of COVID-19, seeking to identify high-risk groups in need for acute and long-term intervention, and inform evidence-based health policies/strategies during this/future pandemics. ispartof: JOURNAL OF AFFECTIVE DISORDERS vol:299 pages:393-407 ispartof: location:Netherlands status: published

BACKGROUND: The COVID-19 pandemic has altered daily routines and family functioning, led to closing schools, and dramatically limited social interactions worldwide. Measuring its impact on mental health of vulnerable children and adolescents is crucial. METHODS: The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT - www.coh-fit.com) is an on-line anonymous survey, available in 30 languages, involving >230 investigators from 49 countries supported by national/international professional associations. COH-FIT has thee waves (until the pandemic is declared over by the WHO, and 6-18 months plus 24-36 months after its end). In addition to adults, COH-FIT also includes adolescents (age 14-17 years), and children (age 6-13 years), recruited via non-probability/snowball and representative sampling and assessed via self-rating and parental rating. Non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to promote health and prevent mental and physical illness in children and adolescents will be generated by COH-FIT. Co-primary outcomes are changes in well-being (WHO-5) and a composite psychopathology P-Score. Multiple behavioral, family, coping strategy and service utilization factors are also assessed, including functioning and quality of life. RESULTS: Up to June 2021, over 13,000 children and adolescents from 59 countries have participated in the COH-FIT project, with representative samples from eleven countries. LIMITATIONS: Cross-sectional and anonymous design. CONCLUSIONS: Evidence generated by COH-FIT will provide an international estimate of the COVID-19 effect on children's, adolescents' and families', mental and physical health, well-being, functioning and quality of life, informing the formulation of present and future evidence-based interventions and policies to minimize adverse effects of the present and future pandemics on youth. ispartof: JOURNAL OF AFFECTIVE DISORDERS vol:299 pages:367-376 ispartof: location:Netherlands status: published

Background: Strong opioids can have unintended effects. Clinical studies of strong opioids mainly report physical side effects, psychiatric or opioid use disorders. To date, too little attention has been paid to the psychological effects of opioids to treat patients with chronic noncancer pain (CNCP). This study aims to identify and measure (i) the nature and frequency of physical and psychological effects and (ii) the degree of physician counseling of patients with CNCP taking strong opioids. Methods: Within a cross-sectional survey-conducted as part of a randomised controlled online intervention trial (ERONA [Experiencing the risk of overusing opioids among patients with chronic non-cancer pain in ambulatory care])-300 German CNCP patients were surveyed via patient-reported outcome measures regarding on both the side effects from their use of strong opioids as well as their counselling experience. Results: Among the patients' reported effects, the psychological outcomes of the opioids in CNCP were: feeling relaxed (84%), fatigue (76%), dizziness (57%), listlessness (37%), difficulty with mental activities (23%), dulled emotions (17%) and poor memory (17%). Ninety-two per cent of the patients reported having received information about opioid effects, and 46% had discussed cessation of the opioid medication with their physicians before commencing the prescription. Conclusions: In addition to the well-known physical side effects, patients with CNCP taking strong opioids experience significant psychological effects. In view of these effects, discontinuation of opioid therapy should be discussed early to ensure their benefits do not outweigh their harm. Significance: In this study, patients with non-cancer pain notice that opioids they have taken do not only cause physical side effects but also may have an impact on their psyche and their emotions and, thus, may also affect quality of life substantially. Clinical trial number: DRKS00020358.

Supplemental Digital Content is available in the text., OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28–29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants’ reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

Traumatische Nervenverletzungen gehen mit einer hohen Morbiditat und langen Rehabilitationszeiten einher. Das Ausmas der Nervenschadigung mit dem damit verbundenen Regenerationspotenzial kann oft erst im Verlauf eingeschatzt werden, wobei das Zeitfenster fur erfolgreiche chirurgische Interventionen begrenzt ist. Inzidenz und Verteilung traumatischer Nervenlasionen, Darstellung von Algorithmen zur Therapieentscheidung. Auswertung von Statistiken aus dem TraumaRegister DGU® sowie internationalen Registern. Diskussion von Grundlagenarbeiten und Expertenempfehlungen zu Diagnostik und Therapie. Ein strategisches Vorgehen bei der konservativen und operativen Behandlung von Nervenlasionen in Abhangigkeit vom Ausmas der Schadigung und dem resultierenden Regenerationspotenzial ist empfohlen. In Zusammenschau mit dem klinischen Verlauf konnen elektrophysiologische und bildgebende Diagnostik wie die Nervensonographie helfen, zwischen Neurapraxie, Axonotmesis und Neurotmesis zu unterscheiden.

Understanding ownership effects on large wildfires is a precursor to the development of risk governance strategies that better protect people and property and restore fire-adapted ecosystems. We analyzed wildfire events in the Pacific Northwest from 1984 to 2018 to explore how area burned responded to ownership, asking whether particular ownerships burned disproportionately more or less, and whether these patterns varied by forest and grass/shrub vegetation types. While many individual fires showed indifference to property lines, taken as a whole, we found patterns of disproportionate burning for both forest and grass/shrub fires. We found that forest fires avoided ownerships with a concentration of highly valued resources—burning less than expected in managed US Forest Service forested lands, private non-industrial, private industrial, and state lands—suggesting the enforcement of strong fire protection policies. US Forest Service wilderness was the only ownership classification that burned more than expected which may result from the management of natural ignitions for resource objectives, its remoteness or both. Results from this study are relevant to inform perspectives on land management among public and private entities, which may share boundaries but not fire management goals, and support effective cross-boundary collaboration and shared stewardship across all-lands.

AIM: A range of residential supports is available for young people experiencing mental health challenges. One Australian example is the Youth Residential Rehabilitation Service, which provides up to 12 months of intensive psychosocial support in a residential setting to young people aged 16-25 experiencing serious mental health challenges. This paper aimed to add to the scant literature on these services, describing the experiences of young people and staff members across the duration of a stay. METHODS: This study drew on collaborative autoethnography to engage and centre the direct lived experience of young people who had lived, and staff who had worked, in a Youth Residential Rehabilitation Service. RESULTS: We identified three phases that young people typically journey through during their stay at the service. The Arriving phase was marked by appropriate referrals, a warm welcome, a period of settling in and the development of trusting relationships. The Discovering phase saw young people identifying and enacting their strengths, hopes and values. Community connections were a focus of the Continuing phase as lives after service exit were envisioned and created. CONCLUSIONS: Drawing on collaborative autoethnography methods represents one approach to amplify the voice of young people in service design and evaluation. This paper richly described some of the possibilities and complexities of the Youth Residential Rehabilitation Service experience, which can be used to inform the service's pacing and structure of support.

Aims Left bundle branch block (LBBB) is the most common conduction disorder after transcatheter aortic valve replacement (TAVR) with an increased risk of atrioventricular (AV) block. The aim of the current study was to identify non-invasive predictors for infranodal conduction delay in patients with LBBB. Methods We analyzed consecutive patients undergoing TAVR with pre-existing or new-onset LBBB between August 2014 and August 2020. His ventricular (HV) interval measurement was performed on day 1 after TAVR. Baseline, procedural, as well as surface and intracardiac electrocardiographic parameters were included. Infranodal conduction delay was defined as HV interval > 55 ms. Results Of 825 patients screened after TAVR, 151 patients (82 ± 6 years, 39% male) with LBBB were included. Among these, infranodal conduction delay was observed in 25%. ΔPR (difference in PR interval after and before TAVR), PR and QRS duration after TAVR were significantly longer in the group with HV prolongation. In a multivariate analysis in patients with sinus rhythm (n = 123), ΔPR (OR per 10 ms increase: 1.52; 95%CI: 1.19–2.01; p = 0.002) was the only independent factor associated with infranodal conduction delay. A change in PR interval by 20 ms yielded a specificity of 83% and a sensitivity of 46%, with a negative predictive value of 84% and a positive predictive value of 45% to predict HV prolongation. Conclusions Simple analysis of surface ECG and a calculated ΔPR Graphical abstract

HIV-associated neurocognitive disorders (HAND) present a challenge in South Africa where the burden of HIV infection is highest. Identification of biological correlates of HAND is required to improve diagnosis and inform interventions. Telomeres maintain genomic integrity and their shortening is a marker of biological aging sensitive to environmental influences. This study examined relative telomere length (rTL) as a predictor of cognitive function in the context of HIV and childhood trauma (CT), a risk factor for HAND. Two hundred and eighty-six women completed a neurocognitive assessment battery and the Childhood Trauma Questionnaire – Short Form (CTQ). Quantitative polymerase chain reaction for amplification of telomeric repeats and the reference gene human beta-globin was used to calculate rTL. Neurocognitive and rTL assessments were repeated at one year in 110 participants. Cross-sectional and longitudinal data were assessed using linear and mixed models, respectively. Participants with HIV (n = 135 in cross-sectional and n = 62 in longitudinal study groups) reported more severe CT and had shorter baseline rTL compared to seronegative controls. Participants without HIV had a greater one-year decline in rTL. Global cognitive and attention/working memory scores declined in participants with HIV. Our data indicate that baseline rTL in the context of CT and HIV did not predict decline in cognitive scores. HIV-associated pathophysiological processes driving cognitive decline may also engage mechanisms that protect against telomere shortening. The results highlight the importance of examining biological correlates in longitudinal studies.

OBJECTIVE The aim of the study was to investigate the effect of different arm positions (hand pronation/supination and elbow flexion/extension) on fragment rotation in extra-articular distal radius fractures in a cadaveric model. METHODS In this study, ten fresh-frozen cadaveric upper extremities from five donors with a mean age of 69 ± 12 years were used. Two cortical pins were inserted in the radius and the ulna. In a custom-made device, different forearm (30°, 60°, and 90° of pronation and supination) and elbow positions (full extension) were tested, using a fluoroscopic analysis. The degree of malrotation between the two pins was measured in these positions. At the last test sequence, the tendon of the brachioradialis muscle was released. RESULTS A significant difference was found in concerns of the rotational angle between the distal fragment and the radial shaft at different degrees of pronation and supination if the elbow joint was in an extended and flexed position. The release of the brachioradialis tendon did not show any effect. CONCLUSION The results of this study supported that rotational malpositions in distal radius fractures can be decreased if the forearm is in a neutral position. Accordingly, the forearm should be in a neutral position while initially immobilization in a plaster splint is performed.

Microglia are involved in many dynamic processes in the central nervous system (CNS) including the development of inflammatory processes and neuromodulation. Several sedative, analgesic or anaesthetic drugs, such as opioids, ∝2-adrenergic agonists, ketamine, benzodiazepines and propofol can cause both neuroprotective and harmful effects on the brain. The purpose of this review is to present the main findings on the use of these drugs and the mechanisms involved in microglial activation. Alpha 2-adrenergic agonists, propofol and benzodiazepines have several pro- or anti-inflammatory effects on microglia. Long-term use of benzodiazepines and propofol causes neuroapoptotic effects and α2-adrenergic agonists may attenuate these effects. Conversely, morphine and fentanyl may have proinflammatory effects, causing behavioural changes in patients and changes in cell viability in vitro. Conversely, chronic administration of morphine induces CCL5 chemokine expression in microglial cells that promotes their survival.

Background: Many patients with COVID-19 did not require hospitalisation, nor underwent COVID-19 testing. There is anecdotal evidence that patients with "mild" COVID-19 may complain about persistent symptoms, even weeks after the infection. This suggests that symptoms during the infection may not resolve spontaneously. The objective of this study was to assess whether multiple relevant symptoms recover following the onset of symptoms in hospitalised and nonhospitalised patients with COVID-19. Methods: A total of 2113 members of two Facebook groups for coronavirus patients with persistent complaints in the Netherlands and Belgium, and from a panel of people who registered on a website of the Lung Foundation Netherlands, were assessed for demographics, pre-existing comorbidities, health status, date of symptoms onset, COVID-19 diagnosis, healthcare utilisation, and the presence of 29 symptoms at the time of the onset of symptoms (retrospectively) and at follow-up (mean±SD 79±17 days after symptoms onset). Results: Overall, 112 hospitalised patients and 2001 nonhospitalised patients (confirmed COVID-19, n=345; symptom-based COVID-19, n=882; and suspected COVID-19, n=774) were analysed. The median number of symptoms during the infection reduced significantly over time (median (interquartile range) 14 (11-17) versus 6 (4-9); p

Goal of this study was the assessment of long-term outcome of arthroscopically assisted repair of Palmer 1B/Atzei 1 triangular fibrocartilage complex tears and the comparison with short- and mid-term results. The study included nineteen patients (mean 49.2 years of age) with a mean follow-up time of 13.6 years (13.1–14.3 years). Examination parameters included disabilities of arm, shoulder, and hand (DASH) questionnaire, modified Mayo Wrist Score (MMWS), Krimmer Score, determination of range of motion in comparison to the contralateral extremity. Grip and pinch grip strength measurement and pain level assessment was performed, as well. The mean MMWS after at least 13.1 years was 95.8 (85–100, SD 5.6). Mean DASH Score was 10.2 (0–55.8, SD 13.6). Mean Krimmer Score was 97.2 (85–100, SD 4.8). Grip strength reached 101% of the contralateral unaffected hand. Range of motion did not differ significantly in comparison to the healthy contralateral extremity. None of the patients suffered from major complications. Fourteen of nineteen patients regarded pain level reduction as excellent. Five patients reported a relevant pain level reduction. Sixteen of nineteen patients regarded functional outcome as excellent, the other three patients reported on a pleasing improvement of the functional outcome. Arthroscopically assisted repair of Palmer 1B/Atzei 1 triangular fibrocartilage complex tears may be an efficacious and safe surgical technique for ulnar-sided TFCC tears in the long term.

Purpose The aim was to report procedural and technical differences of a novel cryoballoon (NCB) ablation catheter for pulmonary vein isolation (PVI) compared to the standard cryoballoon (SCB) catheter. Methods Consecutive patients with atrial fibrillation (AF) undergoing PVI using the NCB and the SCB were included. Procedural parameters, technical differences, acute efficacy, and safety are reported. Results Eighty patients (age 66 ± 10 years, ejection fraction 57 ± 10%, left atrial volume index 40 ± 6 ml/m2) were studied. With the NCB, 156 of 158 PVs (99%) were isolated compared to isolation of 159 of 159 PVs (100%) with the SCB. The median number of freezes in the NCB and the SCB group was 6 (IQR 5–8) and 5 (IQR 4–7), respectively (p = 0.051), with 73% and 71% of the PVs isolated with a single freeze, respectively. Nadir temperature and temperature at isolation were − 59 ± 6 °C and − 45 ± 17 °C in the NCB group and − 46 ± 7 °C and − 32 ± 23 °C in the SCB group, respectively (both p p = 0.003). There was a peri-procedural stroke in one patient in the NCB group. Differences in catheter design were observed that may account for the differences in temperature recordings and ice cap formation. Conclusions Acute efficacy and TTI were similar with the NCB compared to the SCB. Measured temperatures were lower with the NCB, most likely due to differences in catheter design.

Objective Systemic inflammation and monocyte counts have previously been associated with changes in resting state functional connectivity (rsFC) in cross-sectional neuroimaging studies. We therefore investigated this association in a longitudinal study of older patients. Methods We performed a secondary analysis of longitudinal data from older patients who underwent functional magnet resonance imaging (fMRI) scans before and 3 months after elective surgery. Additionally, serum levels of C-reactive protein and Interleukin-6 as markers of inflammation and leukocyte, lymphocyte and monocyte counts were determined. Correlations between these markers and pre- or postoperative rsFC between regions previously associated with inflammatory markers were investigated using general linear regression models. Results We found no significant correlations between inflammatory markers or blood cell counts and mean connectivity within four resting state networks (RSNs), neither preoperatively nor postoperatively. Significant inter-region rsFC was found within these RSNs between a few regions either pre- or postoperatively, but no inter-region connections were consistently observed in both pre- and postoperative fMRI scans. Conclusions Inflammatory markers and monocyte counts were not associated with rsFC in our study, contrasting previous results. Significance Multiple measurements in the same individuals, as performed here, provide a way to reduce the high risk of false positive results in fMRI studies. Trial Registration Clinicaltrials.gov (registration number NCT02265263).

ZusammenfassungInfektionen der Endglieder sind unter allen Handinfektionen am häufigsten. Unterschieden werden die dorsalen Infektionen, die sich im Bereich des Nagelwalls entwickeln und Paronychien genannt werden, und die palmaren Infektionen, die die Fingerbeere oder Fingerkuppe betreffen. Die akuten Paronychien müssen je nach Infektionsort gezielt eröffnet werden. Dazu sind genaue anatomische Kenntnisse des Nagelaufbaus erforderlich. Chronische Paronychien haben meist andere Ursachen, und die Therapie ist deutlich schwieriger. Fingerbeereninfektionen sind häufig stark schmerzhaft, da die Infektion im kompliziert aufgebauten Druckkammersystem stattfindet und eine Schwellung durch die fibrösen Septen begrenzt ist. Eine spätere Ausbreitung, wenn die Septen zerstört sind, in den Knochen oder die Beugesehnenscheide ist aber möglich.

There is a paucity of data regarding racial disparities in the survival of patients with indolent non-Hodgkin lymphomas (iNHL) in the contemporary time-period. Hence, we sought to determine whether racial disparities exist in the survival of patients with iNHLs in the US. We included 68,059 adult patients with follicular lymphoma (FL, n=41,943), marginal zone lymphoma (MZL, n=22,485), and lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia (LPL/WM, n=3,631) who were diagnosed in the US between 2000-2017. Race was categorized as White, Black, Asian/Pacific Islander, or American Indian/Alaska Native (API/AI). The primary outcome was relative survival (RS), which was estimated using flexible parametric survival models. RS estimates varied according to race and disease histology but were consistently lower for racial minorities, including those diagnosed during the most recent 5-year time-period of 2012-2017. On multivariable analysis for RS, Black patients with FL had a 32% higher excess mortality rate compared to White patients [adjusted excess hazard ratio (aEHR), 1.32; 95% CI, 1.15-1.51; P

Objectives This study sought to determine the safety of the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) procedure. Background Transcatheter aortic valve replacement causes coronary artery obstruction in 0.7% of cases, with 40% to 50% mortality. BASILICA is a procedure to prevent coronary obstruction. Safety and feasibility in a large patient cohort is lacking. Methods The international BASILICA registry was a retrospective, multicenter, real-world registry of patients at risk of coronary artery obstruction undergoing BASILICA and transcatheter aortic valve replacement. Valve Academic Research Consortium-2 definitions were used to adjudicate events. Results Between June 2017 and December 2020, 214 patients were included from 25 centers in North America and Europe; 72.8% had bioprosthetic aortic valves and 78.5% underwent solo BASILICA. Leaflet traversal was successful in 94.9% and leaflet laceration in 94.4%. Partial or complete coronary artery obstruction was seen in 4.7%. Procedure success, defined as successful BASILICA traversal and laceration without mortality, coronary obstruction, or emergency intervention, was achieved in 86.9%. Thirty-day mortality was 2.8% and stroke was 2.8%, with 0.5% disabling stroke. Thirty-day death and disabling stroke were seen in 3.4%. Valve Academic Research Consortium-2 composite safety was achieved in 82.8%. One-year survival was 83.9%. Outcomes were similar between solo and doppio BASILICA, between native and bioprosthetic valves, and with the use of cerebral embolic protection. Conclusions BASILICA is safe, with low reported rates of stroke and death. BASILICA is feasible in the real-world setting, with a high procedure success rate and low rates of coronary artery obstruction.

The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions. A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done. Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred. Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance. Therapeutic IV.

Coronavirus disease 2019 (COVID-19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Type I interferons are important in the defense of viral infections. Recently, neutralizing IgG auto-antibodies against type I interferons were found in patients with severe COVID-19 infection. Here, we analyzed expression of CD169/SIGLEC1, a well described downstream molecule in interferon signaling, and found increased monocytic CD169/SIGLEC1 expression levels in patients with mild, acute COVID-19, compared to patients with severe disease. We recommend further clinical studies to evaluate the value of CD169/SIGLEC1 expression in patients with COVID-19 with or without auto-antibodies against type I interferons.

Objective To measure human sperm intracellular pH (pHi) and develop a machine-learning algorithm to predict successful conventional in vitro fertilization (IVF) in normospermic patients. Design Spermatozoa from 76 IVF patients were capacitated in vitro. Flow cytometry was used to measure sperm pHi, and computer-assisted semen analysis was used to measure hyperactivated motility. A gradient-boosted machine-learning algorithm was trained on clinical data and sperm pHi and membrane potential from 58 patients to predict successful conventional IVF, defined as a fertilization ratio (number of fertilized oocytes [2 pronuclei]/number of mature oocytes) greater than 0.66. The algorithm was validated on an independent set of data from 18 patients. Setting Academic medical center. Patient(s) Normospermic men undergoing IVF. Patients were excluded if they used frozen sperm, had known male factor infertility, or used intracytoplasmic sperm injection only. Intervention(s) None. Main Outcome Measure(s) Successful conventional IVF. Result(s) Sperm pHi positively correlated with hyperactivated motility and with conventional IVF ratio (n = 76) but not with intracytoplasmic sperm injection fertilization ratio (n = 38). In receiver operating curve analysis of data from the test set (n = 58), the machine-learning algorithm predicted successful conventional IVF with a mean accuracy of 0.72 (n = 18), a mean area under the curve of 0.81, a mean sensitivity of 0.65, and a mean specificity of 0.80. Conclusion(s) Sperm pHi correlates with conventional fertilization outcomes in normospermic patients undergoing IVF. A machine-learning algorithm can use clinical parameters and markers of capacitation to accurately predict successful fertilization in normospermic men undergoing conventional IVF.

Objectives We aimed to investigate the predictive potential of early pregnancy factors such as lifestyle, gestational weight gain (GWG) and mental well-being on gestational diabetes mellitus (GDM) beyond established risk factors. Methods GDM risk was investigated in the cohort of the German ‘Gesund leben in der Schwangerschaft’/healthy living in pregnancy study. Women were recruited up to the 12th week of gestation. GDM was diagnosed with a 75 g oral glucose tolerance test between the 24th and 28th weeks of gestation. Pre-pregnancy age and weight, mental health and lifestyle were assessed via questionnaires. Maternal weight was measured throughout pregnancy. Early excessive GWG was defined based on the guidelines of the Institute of Medicine. The association between several factors and the odds of developing GDM was assessed using multiple logistic regression analyses. Results Of 1694 included women, 10.8% developed GDM. The odds increased with pre-pregnancy BMI and age (women with obesity: 4.91, CI 3.35–7.19, p p = 0.002). Early excessive GWG, mental health and general lifestyle ratings were no significant risk factors. A 31% reduction in the odds of GDM was observed when p = 0.026). Vigorous physical activity tended to lower the odds without evidence of statistical significance (OR 0.59 per 10 MET-h/week, p = 0.076). Conclusions Maternal age and BMI stand out as the most important drivers of GDM. Early pregnancy factors like dietary fat content seem to be associated with GDM risk. Further evaluation is warranted before providing reliable recommendations.

Background Postoperative delirium (POD) is a frequent and serious complication after surgery. Evidence of a relationship between anticholinergic medication and the development of delirium is inconclusive, but studies on POD are rare. Objectives The objective of this study was to evaluate the anticholinergic load of preoperative medication in older adult patients and its association with the development of POD. Methods This investigation was part of the European BioCog project (http://www.biocog.eu), a prospective multicenter observational study in older adult surgical patients (ClinicalTrials.gov identifier: NCT02265263, 15 October 2014). Patients with a Mini–Mental State Examination score ≤ 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. The preoperative anticholinergic load was calculated using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Cognitive Burden Scale (ACBS), and associations with POD were analyzed using logistic regression analysis adjusting for age, comorbidities, duration of anesthesia and number of drugs used. Results In total, 837 participants were included for analysis, and 165 patients (19.7%) fulfilled the criteria of POD. After adjusting for confounders, we found no association between preoperative anticholinergic load and the development of POD (ADS [points] odds ratio [OR] 0.928; 95% confidence interval [CI] 0.749–1.150; ARS [points] OR 0.832; 95% CI 0.564–1.227; ACBS [points] OR 1.045; 95% CI 0.842–1.296). Conclusion This study found no association between the anticholinergic load of drugs used preoperatively and the development of POD in older adult patients without severe preexisting cognitive impairment. Future analyses should examine the influence of intra- and postoperative administration of anticholinergic drugs as well as dosages of and interactions between medications. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00839-5.

Zusammenfassung Ziel der Studie Für die erfolgreiche Implementierung von Leitlinien sind kontextspezifische Umsetzungsstrategien, welche die spezifische Versorgungssituation sowie mögliche Umsetzungsbarrieren berücksichtigen, vielversprechend. Ziel dieser Untersuchung war es, mögliche Barrieren und präferierte Umsetzungsstrategien für die Implementierung der S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“ aus der Perspektive von Behandlern und Betroffenen zu erfassen. Methodik Als Teil des vom Bundesministerium für Gesundheit geförderten Projekts Implementierung und Evaluation der S3-Leitlinie zu Screening, Diagnose und Behandlung alkoholbezogener Störungen (IMPELA) wurden Barrieren und mögliche Strategien für die Umsetzung der Leitlinienempfehlungen mithilfe eines selbst entwickelten Fragebogens querschnittlich erhoben. Sowohl Gesundheitsfachpersonal aus Primärversorgung und Suchthilfe (Behandler) als auch Betroffene von alkoholbezogenen Störungen und deren Angehörige in der Modellregion Bundesland Bremen wurden mithilfe unterschiedlicher Rekrutierungsstrategien (postalisch, persönlich, über ausgelegte Flyer) zur Teilnahme eingeladen. Der Fragebogen konnte in Papierversion oder online bearbeitet werden. Zusätzlich wurde der Fragebogen online über relevante Fachgesellschaften und Patientenorganisationen mithilfe von E-Mailverteilern bundesweit verbreitet. Ergebnisse Datensätze von 263 Behandlern wurden in die Auswertung eingeschlossen, davon 163 (62%) Behandler aus Bremen und 100 (38%) aus anderen Bundesländern. Die Behandler waren im Mittel zwischen 51,7 (Bremen) und 50,9 (Bundesweit) Jahre alt und hatten 22,8 (Bremen) bzw. 23,7 (Bundesweit) Jahre Berufserfahrung. Die Mehrheit der Befragten waren Ärzte (62,6% Bremen; 50% Bundesweit). Als Hauptbarrieren empfanden die Behandler das mangelnde Wissen über die Existenz der Leitlinie (65,6% Bremen; 44% Bundesweit) und die geringen zeitlichen Ressourcen im Behandlungsalltag (68,7% Bremen; 50% Bundesweit). Als mögliche Umsetzungsstrategien wurden u. a. die stärkere Information der Fachöffentlichkeit (33,7% Bremen; 39% Bundesweit) sowie Fact-Sheets (34,9% Bremen; 38% Bundesweit) genannt. Zusätzlich konnten Daten von 94 Betroffenen/Angehörigen ausgewertet werden (57,7% männlich; Alter M=44,7 Jahre). Von diesen gaben 51 Personen (54,3%) an, bereits selbst eine Suchtbehandlung in Anspruch genommen zu haben. Als Schwierigkeiten für die Versorgung benannten die Betroffenen/Angehörigen am häufigsten, dass Betroffene aus Angst vor Konsequenzen keine Hilfe suchen (n=51; 54%) oder ihre Probleme nicht wahrhaben wollen (n=49, 52,1%), sowie zu lange Wartezeiten auf Behandlungsplätze (n=45; 47,8%). Verbesserungspotential sahen die Betroffenen v. a. in den Bereichen Screening („Ansprechen des Alkoholkonsums“; n=44; 46,8%) und einem nahtlosen Übergang zwischen verschiedenen Behandlungssettings (n=42; 44,6%). Schlussfolgerungen Zusätzlich zu den bisherigen Bemühungen zur Disseminierung der S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Störungen legen die Ergebnisse dieser Studie die Notwendigkeit einer kontextspezifischen Förderung der Leitlinienumsetzung nahe.

Objectives The purpose of this study was to evaluate tip-to-base intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (LAMPOON) in patients undergoing transcatheter mitral valve replacement (TMVR) in annuloplasty rings or surgical mitral valves. Background LAMPOON is an effective adjunct to TMVR that prevents left ventricular outflow tract obstruction (LVOTO). Laceration is typically performed from the base to the tip of the anterior mitral leaflet. A modified laceration technique from leaflet tip to base may be effective in patients with a prosthesis that protects the aortomitral curtain. Methods This is a multicenter, 21-patient, consecutive retrospective observational cohort. Patients underwent tip-to-base LAMPOON to prevent LVOTO and leaflet overhang, or therapeutically to lacerate a long anterior mitral leaflet risking or causing LVOTO. Outcomes were compared with findings from patients in the LAMPOON investigational device exemption trial with a prior mitral annuloplasty. Results Twenty-one patients with a annuloplasty or valve prosthesis–protected mitral annulus underwent tip-to-base LAMPOON (19 preventive, 2 rescue). Leaflet laceration was successful in all and successfully prevented or treated LVOTO in all patients. No patients had significant LVOTO upon discharge. There were 2 cases of unintentional aortic valve injury (1 patient underwent emergency transcatheter aortic valve replacement and 1 patient underwent urgent surgical aortic valve replacement). In both cases, the patients had a supra-annular ring annuloplasty, and the retrograde aortic guiding catheter failed to insulate the guidewire lacerating surface from the aortic root. All patients survived to 30 days. Compared with classic retrograde LAMPOON, there was a trend toward shorter procedure time. Conclusions Tip-to-base laceration is a simple, effective, and safe LAMPOON variant applicable to patients with an appropriately positioned mitral annular ring or bioprosthetic valve. Operators should take care to insulate the lacerating surface from adjacent structures.

Background: To evaluate differences in the proportion of uterine fibroid (UF) treatments that are uterine-sparing between Black women and White women and identify factors that could explain dispari...

Background Predicting and monitoring recruitment in large, complex trials is essential to ensure appropriate resource management and budgeting. In a novel partnership between clinical trial investigators of the South African Medical Research Council and industrial engineers from the Stellenbosch University Health Systems Engineering and Innovation Hub, we developed a trial recruitment tool (TRT). The objective of the tool is to serve as a computerised decisions-support system to aid the planning and management phases of the trial recruitment process. Method The specific requirements of the TRT were determined in several workshops between the partners. A Poisson process simulation model was formulated and incorporated in the TRT to predict the recruitment duration. The assumptions underlying the model were made in consultation with the trial team at the start of the project and were deemed reasonable. Real-world data extracted from a current cluster trial, Project MIND, based in 24 sites in South Africa was used to verify the simulation model and to develop the monitoring component of the TRT. Results The TRT comprises a planning and monitoring component. The planning component generates different trial scenarios for predicted trial recruitment duration based on user inputs, e.g. number of sites, initiation delays. The monitoring component uses and analyses the data retrieved from the trial management information system to generate different levels of information, displayed visually on an interactive, user-friendly dashboard. Users can analyse the results at trial or site level, changing input parameters to see the resultant effect on the duration of trial recruitment. Conclusion This TRT is an easy-to-use tool that assists in the management of the trial recruitment process. The TRT has potential to expedite improved management of clinical trials by providing the appropriate information needed for the planning and monitoring of the trial recruitment phase. This TRT extends prior tools describing historic recruitment only to using historic data to predict future recruitment. The broader project demonstrates the value of collaboration between clinicians and engineers to optimise their respective skillsets.

The COVID-19 pandemic has disrupted the radiology reading room with a potentially lasting impact. This disruption could introduce the risk of obviating the need for the reading room, which would be detrimental to many of the roles of radiology that occur in and around the reading room. This disruption could also create the opportunity for accelerated evolution of the reading room to meet the strategic needs of radiology and health care through thoughtful re-design of the virtual reading room. In this article, we overview the impact of the COVID-19 pandemic on radiology in our institution and across the country, specifically on the dynamics of the radiology reading room. We introduce the concept of the virtual reading room, which is a redesigned alternative to the physical reading room that can serve the diverse needs of radiology and healthcare during and beyond the pandemic.

Biomechanical evaluation of the viscoelastic properties tissue deformation, stiffness, and maximum breaking load of the human A2 pulley. We hypothesized that the A2 pulleys of index, middle, and ring fingers exhibit no difference regarding the aforementioned biomechanical parameters. Forty-one A2 pulleys of 14 upper extremities (8 body donors) were assessed. Cyclic and load-to-failure testing were performed. The biomechanical parameters tissue deformation during cyclic and load-to-failure testing, stiffness, and maximum breaking load were determined. No significant differences between the fingers could be detected regarding the biomechanical parameters. A significant negative correlation could be detected between stiffness and deformation of the pulley. Significant positive correlations could be identified between stiffness and maximum breaking load and between maximum breaking load and deformation of the pulleys. Assessment of the viscoelastic properties of the A2 finger pulley promotes precise diagnosis of pulley lesions and will help to optimize treatment.

After initial investigation of patients presenting with symptoms suggestive of neuropathy, a clinical decision is made for a minority of patients to undergo further assessment with nerve biopsy. Many nerve biopsies do not demonstrate a definitive pathological diagnosis and there is considerable cost and morbidity associated with the procedure. This highlights the need for appropriate selection of patients, nerves and neuropathology techniques. Additionally, concomitant muscle and skin biopsies may improve the diagnostic yield in some cases. Several advances have been made in diagnostics in recent years, particularly in genomics. The indications for nerve biopsy have consequently changed over time. This review explores the current indications for nerve biopsies and some of the issues surrounding its use. Also included are comments on alternative diagnostic modalities that may help to supplant or reduce the use of nerve biopsy as a diagnostic test. These primarily include extraneural biopsy and neuroimaging techniques such as magnetic resonance neurography and nerve ultrasound. Finally, we propose an algorithm to assist in deciding when to perform nerve biopsies.

The high demand for intensive care, which is predicted to further increase in the future, is contrasted by a shortage of trained intensivists and specialized nurses. Telemedicine has been heralded as a promising solution. Yet, there is considerable heterogeneity in tele-critical care when it comes to measurable effects. However, the focus has been on telemedical solutions substituting on-site intensivist functions, and outcome measures have primarily been mortality and length of stay. In a new model of telemedicine for the ICU, telemedicine could be used to increase adherence to best practice guidelines and indicators of process quality. Further, indicators of process quality, functional outcomes and quality of life measures should be incorporated in the evaluation of outcomes, as patients frequently value those higher than mere survival.

Background Fatigue is the most commonly reported symptom in patients with persistent complaints following COVID-19 (ie, long COVID). Longitudinal studies examining the intensity of fatigue and differentiating between physical and mental fatigue are lacking. Objective The objectives of this study were to (1) assess the severity of fatigue over time in members of online long COVID peer support groups, and (2) assess whether members of these groups experienced mental fatigue, physical fatigue, or both. Methods A 2-wave web-based follow-up study was conducted in members of online long COVID peer support groups with a confirmed diagnosis approximately 3 and 6 months after the onset of infectious symptoms. Demographics, COVID-19 diagnosis, received health care (from medical professionals or allied health care professionals), fatigue (Checklist Individual Strength–subscale subjective fatigue [CIS-Fatigue]; 8-56 points), and physical and mental fatigue (self-constructed questions; 3-21 points) were assessed. Higher scores indicated more severe fatigue. A CIS-Fatigue score ≥36 points was used to qualify patients as having severe fatigue. Results A total of 239 patients with polymerase chain reaction/computed tomography–confirmed COVID-19 completed the survey 10 weeks (SD 2) and 23 weeks (SD 2) after onset of infectious symptoms, respectively (T1 and T2). Of these 239 patients, 198 (82.8%) were women; 142 (59.4%) had no self-reported pre-existing comorbidities; 208 (87%) self-reported being in good health before contracting COVID-19; and 62 (25.9%) were hospitalized during acute infection. The median age was 50 years (IQR 39-56). The vast majority of patients had severe fatigue at T1 and T2 (n=204, 85.4%, and n=188, 78.7%, respectively). No significant differences were found in the prevalence of normal, mild, and severe fatigue between T1 and T2 (P=.12). The median CIS-Fatigue score was 48 points (IQR 42-53) at T1, and it decreased from T1 to T2 (median change: –2 points, IQR –7 to 3; P Conclusions Fatigue in members of online long COVID support groups with a confirmed COVID-19 diagnosis decreases from 10 to 23 weeks after onset of symptoms. Despite this, severe fatigue remains highly prevalent. Both physical and mental fatigue are present. It remains unclear whether and to what extent fatigue will resolve spontaneously in the longer term. Trial Registration Netherlands Trial Register NTR8705; https://www.trialregister.nl/trial/8705.

Wir berichten uber einen 30-jahrigen Patienten, der mit Herzrasen bei einer Schmalkomplextachykardie mit einer Herzfrequenz von 215/min in unserer zentralen Notaufnahme vorgestellt wurde. Unter der Arbeitsdiagnose eines Wolf-Parkinson-White-Syndroms mit paroxysmalen orthodromen Tachykardien fuhrten wir eine elektrophysiologische Untersuchung durch. In dieser fand sich eine parahisar gelegene akzessorische Leitungsbahn mit sehr schnellen, prognostisch relevanten Leitungseigenschaften. Um das tiefer im Gewebe liegende His-Bundel zu schonen und eine tiefergehende Lasion zu vermeiden, entschieden wir uns fur eine Ablation mittels „high-power short-duration“. Diese Methode wird neuerdings bei der 3D-gesteuerten Radiofrequenzablation von Pulmonalvenen eingesetzt und verursacht Lasionen mit geringerer Tiefe, um umliegendes Gewebe zu schonen. In unserem Fall konnten wir mit Verwendung der High-power-short-duration-Methode eine parahisar liegende akzessorische Leitungsbahn erfolgreich unter Schonung des tiefer im Gewebe liegenden His-Bundels abladieren.

ZusammenfassungTelemedizinische Versorgungsprogramme sind in der Intensivmedizin weltweit verbreitet und haben einen positiven Effekt auf Mortalität und Behandlungsdauer. Dieser Beitrag zeigt anhand der neuen Versorgungsform „Enhanced Recovery after Intensive Care (ERIC)“, wie Telemedizin in der Intensivmedizin eingesetzt werden kann, um die Qualität der akuten intensivmedizinischen Behandlung zu steigern.

Sieht man von den relativ haufigen Kahnbeinfrakturen ab, sind isolierte Frakturen einzelner Handwurzelknochen selten. Gerade die Seltenheit dieser Verletzungen zusammen mit der komplexen Anatomie und Funktion des Karpus stellen eine Herausforderung fur den Behandler dar. Zudem betreffen Handwurzelfrakturen haufig junge, sportlich aktive und berufstatige Patienten, konnen leicht im konventionellen Rontgenbild ubersehen werden und sind oft von ligamentaren Instabilitaten, neurovaskularen Verletzungen und Sehnenlasionen begleitet. Kleine posttraumatische Veranderungen des fein abgestimmten karpalen Gefuges konnen bereits chronische Beschwerden und Funktionseinbusen bewirken. Daher ist bei Verdacht auf eine Handwurzelfraktur stets eine grundliche klinische und ggf. differenzierte bildgebende Untersuchung notwendig, an deren Ende entweder ein Frakturausschluss oder eine entsprechende konservative oder operative Therapie steht, mit dem Ziel der Wiederherstellung der karpalen Anatomie und Funktion.

Objectives Intracranial hemorrhage is a serious complication in patients receiving venovenous extracorporeal membrane oxygenation during treatment of the acute respiratory distress syndrome. We analyzed timing, outcome, and risk factors of intracranial hemorrhage in patients on venovenous extracorporeal membrane oxygenation. Design Retrospective cohort study. Setting Single acute respiratory distress syndrome referral center. Patients Patients receiving venovenous extracorporeal membrane oxygenation were identified from a cohort of 1,044 patients with acute respiratory distress syndrome. Patients developing an intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy were compared with patients without evidence for intracranial hemorrhage. The primary objective was to assess the association of intracranial hemorrhage with 60-day mortality. Further objectives included the identification of risk factors for intracranial hemorrhage and the evaluation of clinical cutoff values. Interventions None. Measurements and main results Among 444 patients treated with venovenous extracorporeal membrane oxygenation, 49 patients (11.0% [95% CI, 8.3-14.4%]) developed an intracranial hemorrhage. The median time to intracranial hemorrhage occurrence was 4 days (95% CI, 2-7 d). Patients who developed an intracranial hemorrhage had a higher 60-day mortality compared with patients without intracranial hemorrhage (69.4% [54.4-81.3%] vs 44.6% [39.6-49.6%]; odds ratio 3.05 [95% CI, 1.54-6.32%]; p = 0.001). A low platelet count, a high positive end expiratory pressure, and a major initial decrease of Paco2 were identified as independent risk factors for the occurrence of intracranial hemorrhage. A platelet count greater than 100/nL and a positive end expiratory pressure less than or equal to 14 cm H2O during the first 7 days of venovenous extracorporeal membrane oxygenation therapy as well as a decrease of Paco2 less than 24 mm Hg during venovenous extracorporeal membrane oxygenation initiation were identified as clinical cutoff values to prevent intracranial hemorrhage (sensitivity 91% [95% CI, 82-99%], 94% [85-99%], and 67% [48-81%], respectively). Conclusions Intracranial hemorrhage occurs early during venovenous extracorporeal membrane oxygenation and is a determinant for 60-day mortality. Appropriate adjustment of identified modifiable risk factors might lower the prevalence of intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy.

Aim of the study For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA. Methods We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery. Results We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5–30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31−60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61–120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121–240 s after shock. Conclusions Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

ZusammenfassungEin 6-jähriger Galgo-Español-Rüde wurde aufgrund hochgradiger Dyspnoe vorgestellt. Nach röntgenologischer und sonografischer Diagnose eines Thoraxergusses erfolgte eine Thorakozentese, bei der 4 l milchig-rötliche Flüssigkeit abgesogen wurden. Die klinisch-chemische Analyse ergab ein modifiziertes Transsudat mit erhöhtem Triglyzeridgehalt, bei der zytologischen Untersuchung zeigten sich degenerierte neutrophile Granulozyten, einige Lymphozyten und Makrophagen sowie Chylomikronen. Es wurde eine Thoraxdrainage gelegt. Aufgrund des computertomografischen Befunds vergrößerter Sternallymphknoten und verdickter parietaler und viszeraler Pleuralblätter bei unauffälligem Lungengewebe fiel die Entscheidung zur Thorakoskopie, bei der disseminierte herdförmige Proliferationen an der Pleura auffielen. Die histopathologische Untersuchung von Bioptaten ergab eine granulomatöse Pleuritis mit Hinweis auf intraläsionales, polarisationsoptisch anisotropes Fremdmaterial. Durch die energiedispersive Röntgenmikroanalyse wurden rasterelektronenmikroskopisch stark kalziumhaltige Fremdmaterialien in den granulomatösen Herden nachgewiesen. Die erweiterte Anamnese ergab, dass der Hund 15 Monate zuvor einige Zeit in unmittelbarer Nähe einer Baustelle gelebt hatte und kalkzementhaltige Stäube eingeatmet haben könnte. Eine Behandlung mit Prednisolon wurde nach 10 Wochen wegen gastrointestinaler Nebenwirkungen abgesetzt. Nach weiteren 4 Monaten kam es zu einem Rezidiv des Chylothorax. Der erneute Versuch einer immunsuppressiven Therapie mit Prednisolon und Ciclosporin musste wieder wegen Nebenwirkungen abgesetzt werden. Im weiteren Verlauf entwickelte der Hund eine Pneumonie und wurde auf Wunsch der Besitzerin euthanasiert.

Terahertz (THz) spectroscopy provides a noncontact method to measure the ultrafast dynamics and photoconductivity of mobile carriers in semiconducting materials. This has proven useful in studying artificial photosynthesis devices which use semiconductor photoelectrodes. We present a brief introduction to optical-pump THz-probe (OPTP) spectroscopy, a technique that provides unique and useful insight into interfacial electron transfer (from the surface-attached dye to the conduction band of the semiconductor) in dye-sensitized photoelectrochemical cells. Compared with more familiar methods like visible transient absorption spectroscopy, OPTP spectroscopy stands out in offering both sub-picosecond time resolution as well as sensitivity to mobile carriers (electrons and holes) in the semiconductor portion of artificial photosynthesis devices. The mobile carriers are crucial to device performance as only they pass to the other half cell to complete the reaction. In order to highlight these advantages and illustrate the types of questions OPTP spectroscopy can address, we discuss three case studies. In the first, OPTP spectroscopy is used to measure the injection rates from a set of six different dyes, revealing the effect of the energetics and lifetimes of the dye excited states on interfacial electron transfer. The subsequent case studies investigate the influence of varying the moieties which bind to the surface (anchors), as well as the moieties that connect the chromophore with these anchors (linkers). OPTP spectroscopy was used to measure the interfacial electron transfer rate as these moieties were varied.

In the last decade, traditional dictionary learning methods have been successfully applied to various pattern classification tasks. Although these methods produce sparse representations of signals which are robust against distortions and missing data, such representations quite often turn out to be unsuitable if the final objective is signal classification. In order to overcome, or at least to attenuate, such a weakness, several new methods which incorporate discriminant information into sparse-inducing models have emerged in recent years. In particular, methods for discriminant dictionary learning have shown to be more accurate than the traditional ones, which are only focused on minimizing the total representation error. In this work, we present both a novel multi-class discriminant measure and an innovative dictionary learning method. For a given dictionary, this new measure, which takes into account not only when a particular atom is used for representing signals coming from a certain class and the magnitude of its corresponding representation coefficient, but also the effect that such an atom has in the total representation error, is capable of efficiently quantifying the degree of discriminability of each one of the atoms. On the other hand, the new dictionary construction method yields dictionaries which are highly suitable for multi-class classification tasks. Our method was tested with two widely used databases for handwritten digit recognition and for object recognition, and compared with three state-of-the-art classification methods. The results show that our method significantly outperforms the other three achieving good recognition rates and additionally, reducing the computational cost of the classifier.

Belastbare und sensible Defektdeckung an der Fingerkuppe mit ggf. der palmaren Facette des Mittelglieds, um eine fruhzeitige Gebrauchsfahigkeit wiederherzustellen. Palmare, schrage Pulpadefekte am Endglied bzw. Amputationen mit Exposition von Knochen, Sehnen und/oder neurovaskularen Strukturen. Periphere Durchblutungsstorungen jeder Atiologie, Defektausdehnungen, die die Kapazitat der Mobilisation ubersteigen, Obliteration der zufuhrenden Lappenarterie bzw. der kontralateralen Fingerarterie. Vollschichtige Hebung des adipokutanen Lappens mit Mobilisieren des Gefas‑/Nervenstiels nach proximal. Distalisierung des Lappens unter Erhalt der Sensibilitat und primarer Verschluss des Hebedefekts, Lappengrose 4–5 mm groser als Defekt wahlen. Fingergipsschiene fur 2 Wochen, danach Belastungsaufbau mit Konditionierung des Lappens und Narbenpflege. Auserst zuverlassige Defektdeckung mit lediglich 9 % vorubergehenden Komplikationen, die alle folgenlos abheilten.

Skull fractures are common in children both due to abuse and accidental incidences. The accurate detection of these fractures may therefore be critical. The aim of this study was to investigate the reliability of CT, X-ray, and Lodox® scans, the latter which has not previously been evaluated and is commonly employed in South Africa, in detecting the number, location and type of pediatric skull fractures. Blunt force trauma was inflicted with a mallet on ten piglet skulls, which were CT, X-ray, and Lodox® scanned and then macerated. The number, location, and type of skull fractures visible using each imaging modality, and on the cleaned skulls, were recorded. Sensitivities and specificities of each method were calculated. For fracture number and location, CTs had a sensitivity of 47.3%, X-rays 22.4% and Lodox® 23.3%. For fracture type, sensitivities were 46.1%, 16.6%, and 17.8% for CT, X-ray, and Lodox® , respectively. Specificities were high (92.5%-100%) which reduces the risk of incorrectly diagnosing fractures. However, low sensitivities increase the risk of failing to identify fractures and possible victims of abuse. Osteological analysis should preferably be the method of choice when evaluating pediatric skull trauma, and CTs should be used when osteological analysis is not feasible. If CT scanners are not available, X-rays and Lodox® may have to be used. In these cases, additional radiographic views of the skull are imperative and may increase the sensitivity of these methods, although they are not recommended to detect exact pediatric skull fracture number, location, and type.

Even mild paravalvular leak (PVL) is associated with worse quality of life and increased mortality. The Ultra transcatheter heart valve (THV) is intentionally designed to reduce PVL. However, there...