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Review The biological assessment of rivers i.e., their assessment through use of aquatic assemblages, integrates the effects of multiple-stressors on these systems over time and is essential to evaluate ecosystem condition and establish recovery measures. It has been undertaken in many countries since the 1990s, but not globally. And where national or multi-national monitoring networks have gathered large amounts of data, the poor water body classifications have not necessarily resulted in the rehabilitation of rivers. Thus, here we aimed to identify major gaps in the biological assessment and rehabilitation of rivers worldwide by focusing on the best examples in Asia, Europe, Oceania, and North, Central, and South America. Our study showed that it is not possible so far to draw a world map of the ecological quality of rivers. Biological assessment of rivers and streams is only implemented officially nation-wide and regularly in the European Union, Japan, Republic of Korea, South Africa, and the USA. In Australia, Canada, China, New Zealand, and Singapore it has been implemented officially at the state/province level (in some cases using common protocols) or in major catchments or even only once at the national level to define reference conditions (Australia). In other cases, biological monitoring is driven by a specific problem, impact assessments, water licenses, or the need to rehabilitate a river or a river section (as in Brazil, South Korea, China, Canada, Japan, Australia). In some countries monitoring programs have only been explored by research teams mostly at the catchment or local level (e.g., Brazil, Mexico, Chile, China, India, Malaysia, Thailand, Vietnam) or implemented by citizen science groups (e.g., Southern Africa, Gambia, East Africa, Australia, Brazil, Canada). The existing large-extent assessments show a striking loss of biodiversity in the last 2–3 decades in Japanese and New Zealand rivers (e.g., 42% and 70% of fish species threatened or endangered, respectively). A poor condition (below Good condition) exists in 25% of South Korean rivers, half of the European water bodies, and 44% of USA rivers, while in Australia 30% of the reaches sampled were significantly impaired in 2006. Regarding river rehabilitation, the greatest implementation has occurred in North America, Australia, Northern Europe, Japan, Singapore, and the Republic of Korea. Most rehabilitation measures have been related to improving water quality and river connectivity for fish or the improvement of riparian vegetation. The limited extent of most rehabilitation measures (i.e., not considering the entire catchment) often constrains the improvement of biological condition. Yet, many rehabilitation projects also lack pre-and/or post-monitoring of ecological condition, which prevents assessing the success and shortcomings of the recovery measures. Economic constraints are the most cited limitation for implementing monitoring programs and rehabilitation actions, followed by technical limitations, limited knowledge of the fauna and flora and their life-history traits (especially in Africa, South America and Mexico), and poor awareness by decision-makers. On the other hand, citizen involvement is recognized as key to the success and sustainability of rehabilitation projects. Thus, establishing rehabilitation needs, defining clear goals, tracking progress towards achieving them, and involving local populations and stakeholders are key recommendations for rehabilitation projects (Table 1). Large-extent and long-term monitoring programs are also essential to provide a realistic overview of the condition of rivers worldwide. Soon, the use of DNA biological samples and eDNA to investigate aquatic diversity could contribute to reducing costs and thus increase monitoring efforts and a more complete assessment of biodiversity. Finally, we propose developing transcontinental teams to elaborate and improve technical guidelines for implementing biological monitoring programs and river rehabilitation and establishing common financial and technical frameworks for managing international catchments. We also recommend providing such expert teams through the United Nations Environment Program to aid the extension of biomonitoring, bioassessment, and river rehabilitation knowledge globally info:eu-repo/semantics/publishedVersion

Dear Sir,We write in response to the recently published study by Mitura et al. entitled “Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study”. The authors investigated 161 patients: 104 patch repairs and 57 suture repairs and concluded that for the smallest umbilical hernias, the use of suture repair may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. They found that patch repair was associated with a significantly higher risk of postsurgical pain. The follow-up was performed by a telephone interview.Some initial statements in the manuscript are incorrect. For example, the study by Arroyo et al. is introduced suggesting that small hernias in that study were treated with a flat mesh and that it was not reported that the orifice was widened to place the mesh. Arroyo treated hernia defects up to 3 cm with a mesh plug repair, whereas a mesh sheet was inserted for larger hernias only. Thereafter, suture techniques are mentioned referring to an article on open repair of predominantly incisional hernia and another paper on laparoscopic ventral hernia repair, not comparable to the research presented in this study.In short, from a large randomized controlled trial, there is strong evidence in favour of flat mesh for hernia diameters ≥ 1 cm. In a large database study with similar patient characteristics as in the current study, there is also good evidence for mesh in case of hernia diameters smaller than 1 cm. We, therefore, consider the comparison between patch repair (known for more postoperative complications including postoperative pain from randomized investigation) and suture repair a comparison between two “inferior” techniques and would like to emphasize that flat mesh reinforcement outperforms suture repair (and patches) even in small umbilical hernias in all studies. Ignoring this evidence and the current American and European Hernia Society guidelines is a disservice to patients with an umbilical hernia. Suture repair should be used as “second best” in selected patients with small umbilical hernia defects (

OBJECTIVE The gender balance within medicine, and specifically within otolaryngology, is equalizing. It is important to determine the factors that impact the distribution of female residents among otolaryngology programs in the United States to better understand factors that may affect these changing trends. STUDY DESIGN Retrospective Study. METHODS Cross-sectional analysis was performed using data from 2018 of otolaryngology residents at 90 programs across the United States. Each program's website was searched for a current resident roster. Data of geography, number of female faculty, number of female physicians in leadership positions, program setting, and program size were obtained. Statistical comparison of these factors with number of female residents was performed with P

Background Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery. Methods Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting. Results The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions. Conclusion The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.

Introduction Pulmonary vein isolation (PVI) is an effective but complex treatment option for atrial fibrillation (AF). Therefore preprocedural outcome prediction is of special interest. Left atrial volume (LAVmax) is a commonly used predictor for recurring arrhythmia. Several studies have investigated different parameters for the prediction of sustained rhythm control. We hypothesized that left atrial and left atrial appendage ejection fraction (LAEF & LAAEF) assessed by high-resolution CT-imaging are even more sensitive predictors of the outcome of PVI than LAVmax. Methods All patients who underwent PVI between 2015 and 2018 with available preinterventional cardiac CT were included in this retrospective study and separated into 2 groups: Group A comprises all patients with sinus rhythm (SR) at follow-up and group B all patients in whom recurrence of AF was observed. Volumetric analysis of the left atrium was performed in ventricular systole (30%-Phase of the cardiac cycle) and diastole (0%-Phase). Obtained data were used to calculate left atrial and left appendage ejection fractions (LAEF & LAAEF). Success of pulmonary vein isolation was defined as clinical freedom of symptomatic AF together with sinus rhythm on the available Holter-ECG recordings during follow-up examinations. Uni- and multivariate logistic regression models and NAMS RMLE tests were used to compare LAVmax to these functional parameters. Results In total 152 patients with symptomatic paroxsymal or persistent AF underwent PVI at our hospital from 2015 to 2018. Due to inconsistencies in archiving in our PACS-system, 98 patients had to be excluded from analysis. Four patients were excluded due to motion artifacts. 50 patients were included in the final study (41 patients without and 9 patients with recurring AF on average 254 days after ablation). Significant differences in means were found for all assessed parameters. LAEF (accuracy 94%, sensitivity 67%) and LAAEF (accuracy 90%, sensitivity 67%) had a higher sensitivity than LAVmax (accuracy 86%, sensitivity 33%), though not significant in this study population (p = 0.18). LAVmax and LAEF in combination improved sensitivity significantly from 33% to 78% (p = 0.046). Measurements on cardiac-CT showed an excellent interobserver-reliability. Conclusion Reduced LAEF and LAAEF were found to be significant predictors of the outcome of PVI. Furthermore we found a trend that these functional parameters might be more sensitive than LAVmax. Thus we propose that left atrial function, assessed with preprocedural cardiac CT, offers important prognostic information for successful PVI. Abstract Figure. Surface rendering of LA and LAA

Purpose A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints. Methods Adult patients after elective, open surgical repair of a single, primary umbilical hernia

Purpose Complex abdominal wall hernia repair (CAWHR) is a challenging procedure. Mesh prosthesis is indicated, but the use of synthetic mesh in a contaminated area may add to overall morbidity. Biological meshes may provide a solution, but little is known about long-term results. The aim of our study was to evaluate clinical efficacy and patient satisfaction following Strattice™ (PADM) placement. Methods In this cohort study, all patients operated for CAWHR with PADM in three large community hospitals in Germany were included. Patients underwent abdominal examination, an ultrasound was performed, and patients completed quality-of-life questionnaires. The study was registered in ClinicalTrials.gov under Identifier NCT02168231. Results Twenty-seven patients were assessed (14 male, age 67.5 years, follow-up 42.4 months). The most frequent postoperative complication was wound infection (39.1%). In no case, the PADM had to be removed. Four patients had passed away. During outpatient clinic visit, six out of 23 patients (26.1%) had a recurrence of hernia, one patient had undergone reoperation. Five patients (21.7%) had bulging of the abdominal wall. Quality-of-life questionnaires revealed that patients judged their scar with a median 3.5 out of 10 points (0 = best) and judged their restrictions during daily activities with a median of 0 out of 10.0 (0 = no restriction). Conclusions Despite a high rate of wound infection, no biological mesh had to be removed. In some cases, therefore, the biological meshes provided a safe way out of desperate clinical situations. Both the recurrence rate and the amount of bulging are high (failure rate 47.8%). The reported quality of life is good after repair of these complex hernias.

Deep brain stimulation is an experimental procedure for treatment-resistant depression. Some results show promise, but blinded trials had limited success. Ethical questions center on vulnerability:...

The general trend towards miniaturization of components is leading to an increasing demand for micro cutting tools. Such tools are found in a variety of applications like optics manufacturing, mold machining or medical technology. Indeed, micromachining exhibits a high efficiency, accuracy and low cost in comparison to other micro processing technologies. Micro cutting tools are mostly produced by grinding, a mechanical process, which might damage the tool due to induced forces, vibrations and heat. These detrimental effects cause the high scrap rate in the manufacturing of micro cutting tools and limited geometrical flexibility. A new approach for the manufacturing of micro cutting tools is given by the ultrashort-pulsed laser technology: it enables material removal, which is independent of the hardness of the workpiece material and with only a negligible heat-affected zone. In most cases, laser ablation is disadvantaged in contrast to grinding because of its relatively low material-removal rate. When it comes to the manufacturing of micro cutting tools the small amount of material to be removed makes the ultra-short pulsed laser an interesting alternative to grinding. Furthermore, the laser ablation is a force and wear-free process, which ensures high precision. In this paper, a commercially available micro ball end mill geometry is measured by micro X-ray tomography and 3D microscopy. The movement of the mechanical axes and the path of the laser beam for manufacturing the desired tool are determined based on these measurements. The milling tools with a diameter of 100 µm are produced from cemented carbide blanks, on a 8-axis laser machining center. After machining, the tools are analyzed by SEM and using FIB: By creating a cross section perpendicular to the cutting edge the heat-affected zone is examined. Finally, the cutting tool is successfully applied for the manufacturing of micro electrodes in copper for an EDM process while recording the cutting forces.

Background: Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1–4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. Methods: We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1–4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1–2 cm and >2–4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24–30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. Findings: Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5–33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4–9·4] vs 11·4% (6·8–18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12–0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [

International audience; Agricultural land use is a primary driver of environmental impacts on streams. However, the causal processes that shape these impacts operate through multiple pathways and at several spatial scales. This complexity undermines the development of more effective management approaches, and illustrates the need for more in-depth studies to assess the mechanisms that determine changes in stream biodiversity. Here we present results of the most comprehensive multi-scale assessment of the biological condition of streams in the Amazon to date, examining functional responses of fish assemblages to land use. We sampled fish assemblages from two large human-modified regions, and characterized stream conditions by physical habitat attributes and key landscape-change variables, including density of road crossings (i.e. riverscape fragmentation), deforestation, and agricultural intensification. Fish species were functionally characterized using ecomorphological traits describing feeding, locomotion, and habitat preferences, and these traits were used to derive indices that quantitatively describe the functional structure of the assemblages. Using structural equation modeling, we disentangled multiple drivers operating at different spatial scales, identifying causal pathways that significantly affect stream condition and the structure of the fish assemblages. Deforestation at catchment and riparian network scales altered the channel morphology and the stream bottom structure, changing the functional identity of assemblages. Local deforestation reduced the functional evenness of assemblages (i.e. increased dominance of specific trait combinations) mediated by expansion of aquatic vegetation cover. Riverscape fragmentation reduced functional richness, evenness and divergence, suggesting a trend toward functional homogenization and a reduced range of ecological niches within assemblages following the loss of regional connectivity. These results underscore the often-unrecognized importance of different land use changes, each of which can have marked effects on stream biodiversity. We draw on the relationships observed herein to suggest priorities for the improved management of stream systems in the multiple-use landscapes that predominate in human-modified tropical forests.

Background Yearly approximately 4500 umbilical hernias are repaired in The Netherlands, mostly under general anesthesia. The use of local anesthesia has shown several advantages in groin hernia surgery. Local anesthesia might be useful in the treatment of umbilical hernia as well. However, convincing evidence is lacking. We have conducted a systematic review on safety, feasibility, and advantages of local anesthesia for umbilical hernia repair. Methods A systematic review was conducted according to the PRISMA guidelines. Outcome parameters were duration of surgery, surgical site infection, perioperative and postoperative complications, postoperative pain, hernia recurrence, time before discharge, and patient satisfaction. Results The systematic review resulted in nine included articles. Various anesthetic agents were used, varying from short acting to longer acting agents. There was no consensus regarding the injection technique and no conversions to general anesthesia were described. The most common postoperative complication was surgical site infection, with an overall percentage of 3.4%. There were no postoperative deaths and no allergic reactions described for local anesthesia. The hernia recurrence rate varied from 2 to 7.4%. Almost 90% of umbilical hernia patients treated with local anesthesia were discharged within 24 h, compared with 47% of patients treated with general anesthesia. The overall patient satisfaction rate varied from 89 to 97%. Conclusion Local anesthesia for umbilical hernia seems safe and feasible. However, the advantages of local anesthesia are not sufficiently demonstrated, due to the heterogeneity of included studies. We, therefore, propose a randomized controlled trial comparing general versus local anesthesia for umbilical hernia repair.

Metal-Insulator-Semiconductor Schottky diodes were fabricated on SiC, as a potential use for particle detectors. Nickel was used as Schottky and back ohmic contacts. The dielectrics HfO2 and TiO2 were investigated as insulating layers and deposited by Atomic Layer Deposition, with thicknesses of 1, 2 and 4 nm. Current-Voltage curves were extracted from the diodes, varying the measurement temperature (297 K–373 K). Apparent and real Schottky Barrier Heights (SBHapparent and SBHreal), ideality factor η and insulating layer thicknesses were extracted from the I-V curves. Thicker insulating layers produce higher η and reduce the SBHreal value, for both dielectrics. An interfacial layer of silicon oxycarbide with thickness of 0.2 nm was estimated for all diodes. The SBHreal goes from 1.22 V to 0.66 V and from 1.26 V to 0.59 V, for thicknesses of 1 nm and 4 nm of HfO2 and TiO2, respectively. The reverse currents for all structures at 40 V of bias are of order of tens of pA at room temperature.

Objective In this systematic review, we evaluated all literature reporting on the surgical treatment of primary epigastric hernias, primarily focusing on studies comparing laparoscopic and open repair, and mesh reinforcement and suture repair. Methods A literature search was conducted in Embase.com, PubMed and the Cochrane Library up to 24 April 2019. This review explicitly excluded literature on incisional hernias, ventral hernias not otherwise specified, and isolated (para)umbilical hernias. Primary outcome measures of interest were early and late postoperative complications. Results We obtained a total of 8516 articles and after a strict selection only seven retrospective studies and one randomised controlled trial (RCT) on treatment of primary epigastric hernia were included. In one study (RCT) laparoscopic repair led to less postoperative pain (VAS) compared to open repair (3.6 versus 2.4, p

Background and Aims: The use of mesh repair in a small- or middle-sized umbilical hernia remains controversial, and evidence is based on only few and small heterogeneous randomized trials. The primary aim was to assess differences, if any, in recurrence (clinical and reoperation), and secondary aim was to assess differences in infections, seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. Method: A systematic review (predefined search strategy) and meta-analyses were conducted based on pre-study strict and well-defined methodology. The literature search was completed on 1 January 2018. The study protocol was registered in PROSPERO. Results: Five randomized controlled trials were identified (mesh repair, n = 326 versus non-mesh sutured repair, n = 330) and 602 records were excluded. Randomized controlled trials included patients with defect diameters of ⩾1 to 4 cm. Mesh repair reduced the risk of recurrence compared with sutured repair with a relative risk of 0.28 (95% confidence interval = 0.13–0.58, I2 = 0%, number needed to treat = 13 patients). Additional analyses found no differences between the two surgical techniques regarding infection (relative risk = 0.80, 95% confidence interval = 0.36–1.79), seroma formation (relative risk = 1.38, 95% confidence interval = 0.57–3.32), or hematomas (relative risk = 0.55, 95% confidence interval = 0.23–1.30). Lack of sufficient data precluded meta-analysis evaluating risk of seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. Conclusion: Mesh repair is recommended for umbilical hernia of ⩾1 to 4 cm. More evidence is needed for the optimal placement of the mesh (sublay or onlay) and the role of mesh in patients with an umbilical hernia

Objective: To examine pediatric neuroblastoma survival and management in the head and neck compared to other body sites. Study Design: Retrospective analysis of a large population database. Methods: Patients in the Surveillance, Epidemiology, and End Results (SEER) database with neuroblastoma, NOS; ganglioneuroblastoma; or olfactory neuroblastoma diagnosed from birth to 18 years between 1973 and 2014 were included. These patients were classified into 1 of 3 categories based on primary tumor site: head and neck, adrenal, and “other.” Results: Four thousand five hundred neuroblastoma cases were identified. One hundred seventy-five (3.9%) occurred in the head and neck, 1,934 (43.0%) occurred in the adrenal gland, and 2,391 (53.1%) occurred in “other” sites. The mean age at diagnosis was 4.21 years in the head and neck, 2.23 years in the adrenal gland, and 2.47 years in the “other” cohorts ( P < .001). Two- and 5-year disease-specific survival rates were 89% and 84% in the head and neck versus 77% and 65% in the adrenal and 84% and 77% in the “other” cohorts ( P < .001). The risk of disease-specific death (DSD) was higher in the adrenal cohort (adjusted hazard ratio [aHR] = 2.85; 95% CI, 1.54-5.27) compared to the head and neck cohort. Patients treated with surgery only had the lowest risk of DSD (aHR = 0.22; 95% CI, 0.13-0.35) compared to all other studied treatments. Conclusion: Our results demonstrate that primary neuroblastoma of the head and neck has a better prognosis than primary neuroblastoma of the adrenal gland.

The development team has set itself the task of creating a new type of testing system for faster and more cost-effective reliability and service life evaluation. This system additionally measure in-situ the mechanical deformation and shear forces in the electronic joints during the action of temperature change loads. The system approach begins with a new type of temperature unit, which allows very fast and homogeneous heating of the test specimen and measuring chamber. The selection of suitable sensors for high-resolution, long-term stable measurement under the influence of temperature changes is a further sub-area of system development. The developments are accompanied by virtual system design and numerical calculations. First development results for the evaluation of concrete implementation concepts are presented. The focus will be on concepts for load introduction via a frame construction, through heating, force/displacement sensors and material selection based on thermal-mechanical measurements.

Die histiozytar nekrotisierende Lymphadenitis (Synonym: Kikuchi-Fujimoto-Erkrankung) ist eine seltene Form der Lymphadenitis, die sich charakteristischerweise mit zervikaler Lymphadenopathie und Fieber prasentiert. Atiologie und Pathogenese der Erkrankung sind unbekannt, wobei eine Assoziation mit Autoimmunerkrankungen besteht. Ein Zusammenhang mit Infektionen wird diskutiert. Wir berichten uber eine 23-jahrige pakistanisch-stammige Patientin mit vorbestehendem Diabetes mellitus Typ 1, euthyreoter Autoimmunthyreoiditis und einem (mutmaslichen) Rezidiv ihrer Kikuchi-Fujimoto-Erkrankung im Kontext einer Infektion mit Achromobacter xylosoxidans.

Land use change and forest degradation have myriad effects on tropical ecosystems. Yet their consequences for low-order streams remain very poorly understood, including in the world´s largest freshwater basin, the Amazon. Determine the degree to which physical and chemical characteristics of the instream habitat of low-order Amazonian streams change in response to past local- and catchment-level anthropogenic disturbances. To do so, we collected field instream habitat (i.e., physical habitat and water quality) and landscape data from 99 stream sites in two eastern Brazilian Amazon regions. We used random forest regression trees to assess the relative importance of different predictor variables in determining changes in instream habitat response variables. Multiple drivers, operating at multiple spatial scales, were important in determining changes in the physical habitat and water quality of the sites. Although we found few similarities in modelled relationships between the two regions, we observed non-linear responses of specific instream characteristics to landscape change; for example 20 % of catchment deforestation resulted in consistently warmer streams. Our results highlight the importance of local riparian and catchment-scale forest cover in shaping instream physical environments, but also underscore the importance of other land use changes and activities, such as road crossings and upstream agriculture intensification. In contrast to the property-scale focus of the Brazilian Forest code, which governs environmental regulations on private land, our results reinforce the importance of catchment-wide management strategies to protect stream ecosystem integrity.

Assessing the ecological impacts of anthropogenic pressures is a key task in environmental management. Multimetric indices (MMIs), based on aquatic assemblage responses to anthropogenic pressures, have been used increasingly throughout the world. The MMI approach is a low-cost, rapid field method that produces an aquatic condition index that responds precisely to anthropogenic pressures, making it useful for conservation and environmental management. We developed four candidate MMIs based on benthic macroinvertebrate assemblages sampled at 40 randomly selected sites to assess the environmental condition of streams upstream of a hydroelectric power plant in the Brazilian Neotropical Savanna biome. Those MMIs were built from landscape-adjusted and unadjusted biological metrics as well as two alternative ways of choosing metrics. The alternative MMIs performances were tested by comparing their precision to distinguish least-disturbed areas, responsiveness to discriminate least- and most-disturbed areas, and sensitivity to anthropogenic pressures at catchment and local scales. The best performing MMI had landscape-adjusted metrics and was produced through use of principal component analysis for metric selection. It included 4 metrics: Ephemeroptera richness, average tolerance score per taxon, percentage of predator individuals, and percentage of Odonata individuals adjusted by elevation. This index discriminated well the anthropogenic pressures at local- and catchment-scales, and at both scales simultaneously, as indicated by an integrated disturbance index. Our methodological development included statistical criteria for identifying least- and most-disturbed sites, calibrating for natural landscape variability, and use of non-redundant metrics. Therefore, we expect it will provide a model for environmental assessment of water resources elsewhere in Brazil and in other nations.

In recent decades, the portion of elderly has increased substantially due to demographic changes in developed countries. Dermatological surgery is particularly affected by this development, because a large proportion of the elderly suffer from skin tumors, which are primarily treated surgically. Physiological changes of age and multimorbidity, often associated with polypharmacy, present the treating physician with enormous challenges. What aspects of care are important? What must be considered? What are possible complications and how can they be prevented? These important questions are answered. Finally, selected surgical approaches for the care of very old patients are also described.

Accurate and precise detection of anthropogenic impacts on stream ecosystems using macroinvertebrates as biological indicators depends on the use of appropriate field and laboratory methods. We assessed the responsiveness to anthropogenic disturbances of assemblage metrics and composition by comparing commonly employed alternative combinations of field sampling and individuals counting methods. Four datasets were derived by, in the field 1) conducting multihabitat sampling (MH) or 2) targeting samples in leaf packs (single-habitat sampling – SH) and, in the laboratory A) counting all individuals of the samples, or B) simulating subsampling of 300 individuals per sample. We collected our data from 39 headwater stream sites in a drainage basin located in the Brazilian Cerrado. We used a previously published quantitative integrated disturbance index (IDI), based on both local and catchment disturbance measurements, to characterize the intensity of anthropogenic alterations at each site. Family richness and % Ephemeroptera, Plecoptera and Trichoptera (% EPT) individuals obtained from each dataset were tested against the IDI through simple linear regressions, and the differences in assemblage composition between least- and most-disturbed sites were tested using Permutational Multivariate Analysis of Variance (PERMANOVA). When counting all individuals, differences in taxonomic richness and assemblage composition of macroinvertebrate assemblages between least- and most-disturbed sites were more pronounced in the MH than in the SH sampling method. Leaf packs seemed to concentrate high abundance and diversity of macroinvertebrates in highly disturbed sites, acting as ‘biodiversity hotbeds’ in these situations, which likely reduced the response of the assemblages to the disturbance gradient when this substrate was targeted. However, MH sampling produced weaker results than SH when subsampling was performed. The % EPT individuals responded better to the disturbance gradient when SH was employed, and its efficiency was not affected by the subsampling procedure. We conclude that no single method was the best in all situations, and the efficiency of a sampling protocol depends on the combination of field and laboratory methods being used. Although the total count of individuals with multihabitat sampling obtained the best results for most of the evaluated variables, the decision of which procedures to use depends on the amount of time and resources available, on the variables of interest, on the availability of habitat types in the sites sampled, and on the other methods being employed in the sampling protocol.

Large reservoirs are an increasingly common feature across tropical landscapes because of their importance for water supply, flood control and hydropower, but their ecological conditions are infrequently evaluated. Our objective was to assess the range of disturbances for two large tropical reservoirs and their influences on benthic macroinvertebrates. We tested three hypotheses: i) a wide variation in the level of environmental disturbance can be observed among sites in the reservoirs; ii) the two reservoirs would exhibit a different degree of disturbance level; and iii) the magnitude of disturbance would influence the structure and composition of benthic assemblages. For each reservoir, we assessed land use (macroscale), physical habitat structure (mesoscale), and water quality (microscale). We sampled 40 sites in the littoral zones of both Três Marias and São Simão Reservoirs (Minas Gerais, Brazil). At the macroscale, we measured cover percentages of land use categories in buffer areas at each site, where each buffer was a circular arc of 250 m. At the mesoscale, we assessed the presence of human disturbances in the riparian and drawdown zones at the local (site) scale. At the microscale, we assessed water quality at each macroinvertebrate sampling station using the Micro Disturbance Index (MDI). To evaluate anthropogenic disturbance of each site, we calculated an integrated disturbance index (IDI) from a buffer disturbance index (BDI) and a local disturbance index (LDI). For each site, we calculated richness and abundance of benthic macroinvertebrates, Chironomidae genera richness, abundance and percent Chironomidae individuals, abundance and percent EPT individuals, richness and percent EPT taxa, abundance and percent resistant individuals, and abundance and percent non-native individuals. We also evaluated the influence of disturbance on benthic macroinvertebrate assemblages at the entire-reservoir scale. The BDI, LDI and IDI had significantly greater average scores at São Simão than at Três Marias Reservoir. The significantly greater differences in IDI scores for São Simão Reservoir were reflected in 10 of the 13 Ekman-Birge dredge biotic metrics and in 5 of 13 of the kick-net biotic metrics. We also observed clear ranges of disturbances within both reservoirs at macro (BDI) and mesoscales (LDI) and in water quality, but an insignificant range in MDI results. However, we found no significant relationship between the benthic macroinvertebrate metrics and the BDI, LDI, and IDI among sites within a single reservoir. Hence, we believe that benthic macroinvertebrate distributions in those reservoirs were influenced by other factors or that reservoir macroinvertebrates (dominated by chironomids) were poor indicators of disturbance at the site scale.

Augmented production and transport of fine sediments resulting from increased human activities are major threats to freshwater ecosystems, including reservoirs and their ecosystem services. To support large scale assessment of the likelihood of soil erosion and reservoir sedimentation, we developed and validated an environmental fragility index (EFI) for the Brazilian neotropical savannah. The EFI was derived from measured geoclimatic controls on sediment production (rainfall, variation of elevation and slope, geology) and anthropogenic pressures (natural cover, road density, distance from roads and urban centers) in 111 catchments upstream of four large hydroelectric reservoirs. We evaluated the effectiveness of the EFI by regressing it against a relative bed stability index (LRBS) that assesses the degree to which stream sites draining into the reservoirs are affected by excess fine sediments. We developed the EFI on 111 of these sites and validated our model on the remaining 37 independent sites. We also compared the effectiveness of the EFI in predicting LRBS with that of a multiple linear regression model (via best-subset procedure) using 7 independent variables. The EFI was significantly correlated with the LRBS, with regression R2 values of 0.32 and 0.40, respectively, in development and validation sites. Although the EFI and multiple regression explained similar amounts of variability (R2 = 0.32 vs 0.36), the EFI had a higher F-ratio (51.6 vs 8.5) and better AICc value (333 vs 338). Because the sites were randomly selected and well-distributed across geoclimatic controlling factors, we were able to calculate spatially-explicit EFI values for all hydrologic units within the study area (~38,500 km2). This model-based inference showed that over 65% of those units had high or extreme fragility. This methodology has great potential for application in the management, recovery, and preservation of hydroelectric reservoirs and streams in tropical river basins.

Physical and chemical emergencies are often caused by household or work accidents. Regardless of the medical field and outside specialized clinics, the physician may be confronted with the situation for first or secondary care. The identification of the causing agent and a rapid assessment of the extent and severity of the tissue damage are essential to initiate early transfer to a specialized burn clinic. Grade 2b tissue damage is usually surgically treated. Smaller and superficial injuries can often be conservatively treated. Even supposedly safe and over-the-counter medicines can also lead to serious tissue damage.

Background Exhaled breath analysis is an emerging technology in respiratory disease and infection. Electronic nose devices (e-nose) are small and portable with a potential for point of care application. Ventilator-associated pneumonia (VAP) is a common nosocomial infection occurring in the intensive care unit (ICU). The current best diagnostic approach is based on clinical criteria combined with bronchoalveolar lavage (BAL) and subsequent bacterial culture analysis. BAL is invasive, laborious and time consuming. Exhaled breath analysis by e-nose is non-invasive, easy to perform and could reduce diagnostic time. Aim of this study was to explore whether an e-nose can be used as a non-invasive in vivo diagnostic tool for VAP. Methods Seventy-two patients met the clinical diagnostic criteria of VAP and underwent BAL. In thirty-three patients BAL analysis confirmed the diagnosis of VAP [BAL+(VAP+)], in thirty-nine patients the diagnosis was rejected [BAL−]. Before BAL was performed, exhaled breath was sampled from the expiratory limb of the ventilator into sterile Tedlar bags and subsequently analysed by an e-nose with metal oxide sensors (DiagNose, C-it, Zutphen, The Netherlands). From further fifty-three patients without clinical suspicion of VAP or signs of respiratory disease exhaled breath was collected to serve as a control group [control(VAP−]). The e-nose data from exhaled breath were analysed using logistic regression. Results The ROC curve comparing [BAL+(VAP+)] and [control(VAP−)] patients had an area under the curve (AUC) of 0.82 (95% CI 0.73–0.9). The sensitivity was 88% with a specificity of 66%. The comparison of [BAL+(VAP+)] and [BAL−] patients revealed an AUC of 0.69; 95% CI 0.57–0.81) with a sensitivity of 76% with a specificity of 56%. Conclusion E-nose lacked sensitivity and specificity in the diagnosis of VAP in the present study for current clinical application. Further investigation into this field is warranted to explore the diagnostic possibilities of this promising new technique.

European Heart Journal, 36, ISSN:1522-9645, ISSN:0195-668X

Macroinvertebrates are important for processing leaf detritus in temperate streams, but studies about their role in tropical streams often present conflicting results. Via digestive tract analyses, we assessed the diets of Phylloicus sp. larvae (Trichoptera: Calamoceratidae), collected from streams of two southeastern Brazil river basins (Araguari, Sao Francisco). We classified gut contents as coarse particulate organic matter (CPOM), fine particulate organic matter (FPOM), algae, animal tissue, vascular plant tissue and mineral material. We hypothesized that the diets of Phylloicus larvae would be related to the physical habitat of the streams (e.g., riparian vegetation, organic matter availability and morphological characteristics), larval size and river basin. Although FPOM content predominated in both basins, we found greater CPOM content in Phylloicus larvae of Upper Sao Francisco sites, and this food item was related to greater riparian vegetation canopy density. The FPOM content was greater in larvae of Upper Araguari sites, and this food item was correlated with greater instream brush cover. Algae, animal tissue, vascular plant tissue and mineral material were very rare in the digestive tracts, and therefore could not be explained. These results indicate the importance of riparian vegetation structure in modulating feeding habitats of macroinvertebrates. We conclude that the Phylloicus larvae had more flexibility in what they eat than we might expect based on their traditional classification as shredders. Therefore, trusting in published classifications, ignoring regional or local differences, may be inaccurate. Instead, regional studies of feeding habits are needed for accurate classifications of invertebrate taxa into trophic guilds.

Chronic wounds are of high socio-economic importance. Accurate and efficient treatment includes the use of outcomes measures in clinical care and in research. To date, consented standards for documentation of chronic wounds, agreements on interpretation of wound outcomes and harmonisation about standardised goal setting in wound treatment are lacking. Objective (1) To establish a national German consensus group for the definition of standards in outcomes measurement of chronic wounds, (2) to agree on recommendations for practice and research based on a continuous decision process, including implementation of the standards. Methods The national consensus group includes delegates from the German scientific medical societies involved in health care for chronic wounds, the national boards on nursing, and the chairs of regional wound networks. Moreover, the roof organisations of the German health insurances, the German ministry of health and further single wound experts were invited. The consensus work is based on a structured decision process. Results The consensus group consists of 58 representatives and co-representatives of 26 societies and organisations. Since 2012, in the regular bi-annual meetings a Delphi-based workflow has been followed starting with standards for documentation and outcomes measurement in patients with leg ulcers. Additionally, web-based decision processes are conducted and the results are presented for finalisation in the face-to-face meetings. The following application areas of particular interests were defined: clinical routine, health services research, clinical research, and health economics. In the meantime, 245 single decisions have been approved. Conclusions Based on a national joint process involving medical societies, nursing groups, German sickness funds and health politics, a continuous decision process on standards for outcomes measurement and interpretation could be established. The Delphi based decision processes showed high levels of participations, thus providing a valid and robust set of standards. First results are in process of approval by the societies.

Metal-Insulator-Semiconductor Schottky diodes were fabricated on SiC, as a potential use for particle detectors. Nickel was used as Schottky and back ohmic contacts. The dielectric Al 2 O 3 was investigated as insulating layer and deposited by Atomic Layer Deposition, with thicknesses of 1, 2 and 4 nm. Current-Voltage curves were extracted from the diodes, varying the measurement temperature (297 K–373 K). Apparent and real Schottky Barrier Heights (SBH), ideality factors η and insulating layer thicknesses were extracted from the I-V curves. Thicker insulating layers produce higher η and reduce the real SBH value. An interfacial layer of silicon oxycarbide with thickness of 0.2 nm was estimated for the diodes. The real SBH goes from 1.32 V to 0.87 V for thicknesses of 1 nm and 2 nm of Al 2 O 3 , respectively. The diode with 4 nm of Al 2 O 3 has not presented Schottky characteristics. The reverse currents for the diodes are in the range of hundreds of pA, making them suitable for particle detectors. We also show an application of the MIS structure to be used as He++ particle detector in Rutherford Backscattering Spectroscopy experiment.

Since 2008, German statutory health insurances offer routine skin cancer screening (rSCS) as a standard benefit. Insured persons aged 35 years and older are eligible for screening every 2 years.The aim of the study was to evaluate perception and utilization of rSCS in the general population.A representative random sample of n = 1004 adult members of the German statutory health insurances were surveyed by the Forsa Institute via computer-assisted telephone interviews in a cross-sectional study in April 2015.On 39% of all persons interviewed, skin cancer screening had been executed at least once; the percentage of those entitled for rSCS was 45%. Of the participants, 50% were aware of the rSCS eligibility framework, with multiple sources of information. In 82% of cases, rSCS was performed by a dermatologist. The majority (87%) of those who had already undergone rSCS stated that the advantages of the procedure outweighed inconveniences. While participation in rSCS constantly increased (2011-2013-2015), knowledge of eligibility did not.Seven years after implementation, rSCS has been utilized by almost half of those entitled and was rated positively by the majority. However, lack of knowledge about rSCS eligibility is also present in 50%. Further targeted informative measures are needed to increase awareness of rSCS.

See editorial, p 274. Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems-such as data incompatibility and high costs of collecting, linking, and using data-can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations. [DEEDS Writing Committee: Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A summary report. Ann Emerg Med February 1998;31:264-273.].