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Kurzfassung: Die Formen der politischen Auseinandersetzungen sind laufend Veränderungen unterworfen. Carl von Clausewitz hat dies in seinem berühmten Bild des Chamäleons für den Wandel des Krieges charakterisiert. Konflikte zwischen Staaten werden heute hybrid und unterhalb der völkerrechtlich relevanten Schwelle für internationale bewaffnete Auseinandersetzungen ausgetragen. In der Folge muss sich auch die Sicherheitspolitik darauf ausrichten und das Verteidigungsdispositiv neu definieren. Abschreckung in Zeiten hybrider Konflikte heißt auch, über die militärische Komponente hinaus Maßnahmen zu entwickeln. Wenn Soldaten in Marsch gesetzt werden, um Territorien zu besetzen, ist der Konflikt in der letzten Phase. Dann ist es bereits zu spät für eine Reaktion, da zuvor die notwendigen politischen Fakten geschaffen wurden. Sicherheitspolitik muss daher hybriden Konflikten bereits im nicht-militärischen Raum wirksam begegnen.

Rationale: Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by cutaneous port wine capillary malformations, varicose veins with hemihypertrophy of soft tissue and bone. Pelvic and retroperitoneal vascular malformations have been described up to the 30% of patients with KTS while hemangiomas of the urinary tract have been reported in 6% Patient concerns: A 30-year-old man with KTS was referred to our center for primary erectile dysfunction (ED) associated with varicosities of unusual distribution and asymmetry of the lower limbs. Furthermore, he suffered from hypertension and autosomal dominant polycystic kidney disease. During penile prosthesis implantation, a significant intraoperative bleeding (1 liter) due to large scrotal venous malformations and profuse bleeding from both corpora was recorded. One month later, the day after the first prosthesis training session, the patient returned with swelling in the penoscrotal region. A large inguino-scrotal hematoma was drained. There was a complete bilateral dehiscence of corpora cavernosa with a spread venous bleeding in the scrotum. Diagnoses: CT scan showed hypertrophy of the right hypogastric artery with severe vascular malformations: the right pudendal artery was massively dilated with early visualization of venous drainage without evidence of arteriovenous fistulae; regular bulbocavernous capillary blush; right upper gluteus artery hypertrophic and dilated. Multiple twisting and aneurysms of the right internal pudenda artery were bleeding from multiple points. Cystoscopy showed a fistula between the proximal urethra and the penoscrotal dartos. Coagulation tests revealed the presence of factor XIII deficiency Interventions: The patient underwent several procedures including percutaneous scleroembolization of the internal pudendal arteries, removal of the penile implant, recombinant factor XIII (FXIII) administration, and cord blood platelet gel application. Outcomes: The patient was discharged after almost 3 months in hospital, hemodynamically stable. Lessons: Experience regarding management of ED in KTS patient is limited and in case of concomitant factor XIII deficiency, the clinical scenario can be life-threatening. A multidisciplinary approach including a urologist, an interventional radiologist and a hematologist in our experience represented the key approach in case of severe bleeding following surgery for ED.

Virtual reality (VR) simulates real world scenarios by creating a presence in users. Such immersive scenarios lead to more similar behaviour to that displayed in real world settings, which may facilitate the transfer of knowledge and skills acquired in VR to real world situations. VR has already been used in education, psychotherapy, rehabilitation and it is an appealing choice for training intervention. The aim was to investigate to what extend VR technology can be used in a magnetic resonance imaging scanner(MRI), addressing the question of whether brain connectivity differs between VR and screen via mirror projection presentations. Moreover, we investigate whether stereoscopic goggle stimulation, where eyes receive different input, would elicit more brain connectivity than stimulation where both eyes receive the same input (monoscopic). To our knowledge, there is no previous research addressing this question. Multiple analyses were performed to cover different aspects of brain connectivity: fractional low frequency fluctuation, independent component analysis, seed-based functional connectivity and graph analysis. In goggles (mono and stereoscopic) vs. screen, we found connectivity differences in cerebellum and postcentral gyrus and in visual and frontal inferior cortex in visual/default-mode networks. Considering specific areas, we found higher connectivity between superior frontal cortex and temporal lobe, as well as inferior parietal cortex with calcarine and lingual. Furthermore, superior frontal cortex and insula/putamen were more strongly connected in stereoscopic, in line with our hypothesis. We assume that conditions eliciting most connectivity should be suited for long-term interventions as extended training under these conditions could permanently improve functional/structural connectivity.

ObjectiveThis study evaluated the efficacy of FlowVR, a virtual reality (VR) game designed to improve mood and reduce feelings of depression. The aim is to contribute to the question of whether and how VR could be used for depression therapy, as research in this area is quite rare.Method18 healthy participants (9 female; Mage = 25.9) underwent three conditions, playing FlowVR in VR with a head-mounted display, playing FlowVR on a tablet or reading a text on a tablet. For each condition, they were tested on a separate day at the same time of day within a two-week period. Before and after every condition participants completed the Becks Depression Inventory II (BDI-II), the state part of the State-Trait-Anxiety-Depression-Inventory (STADI(S)) and the Positive Affect Negative Affect Schedule-Expanded Form (PANAS-X).ResultsWhile the participants showed only a reduction in acute anxiety in the control and the tablet conditions, they showed improved affectivity in all variables measured in the VR condition. In addition, VR had significantly better results than the control condition in improving positive affectivity, negative affectivity and acute feelings of depression. Using a less conservative statistical approach, these significant differences could also be found between the tablet and the VR condition. There were no significant differences between the tablet and the control condition.ConclusionThe results indicate that due to its immersive nature, VR can be used effectively to improve mood and temporarily reduce feelings of depression. Long-term effects of FlowVR on participants with depression must be investigated in consecutive research.

Objective: To assess risks and predictors of ischemic/bleeding complications in consecutive patients with at least one cardiovascular disease undergoing elective major non-cardiac surgery. Methods: Subgroup analysis of the PRAGUE-14 study was performed. This prospective study analyzed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease. Logistic regression models were applied to assess the association between potential predictors and selected binary coded end-points (perioperative ischemia, bleeding and hospital mortality). Results: Study population consisted of 1200 patients, 742 of them underwent elective surgery; age (median) 72.0, 66.2% males, CAD in 396, stroke in 70, atrial fibrillation in 209, venous thromboembolism (VTE) in 55, valvular heart disease in 108, artificial valve in 18, cardiomyopathy in 13. Preoperatively, 62.0% patients were receiving betablockers, 55.1% ACE inhibitors, 32.9% statins. 84.6% of patients were treated with antithrombotic therapy i.e. 439 aspirin, 31 DAPT, 192 oral anticoagulants. Prophylaxis of VTE in perioperative period was applied in 93.5%. In-hospital ischemic complications occurred in 3% (vs 9.8% in acutely operated patients, p Multivariate linear regression identified that pre-procedural anemia and history of (coronary or non-coronary) stent implantation were significantly related to ischemic complications. Periprocedural antithrombotic management has no impact on ischemic complications. Termination of warfarin less than 4 days before surgery was significantly related to the risk of bleeding. Conclusions: Risk of perioperative ischemic complications is significantly lower in cardiac patients who are undergoing non-cardiac surgery electively (in comparison to acutely), and this risk is significantly related to a history of preprocedural anemia and history of stent implantation. For prevention from periprocedural bleeding, warfarin should be discontinued more than 4 days before surgery

Virtual reality (VR) simulates real-world scenarios by creating a sense of presence in its users. Such immersive scenarios lead to behavior that is more similar to that displayed in real world settings, which may facilitate the transfer of knowledge and skills acquired in VR to similar real world situations. VR has already been used in education, psychotherapy, rehabilitation and it comes as an appealing choice for training intervention purposes. The aim of the present study was to investigate to what extent VR technology for games presented via goggles can be used in a magnetic resonance imaging scanner (MRI), addressing the question of whether brain connectivity differs between VR stimulation via goggles and a presentation from a screen via mirror projection. Moreover, we wanted to investigate whether stereoscopic goggle stimulation, where both eyes receive different visual input, would elicit stronger brain connectivity than a stimulation in which both eyes receive the same visual input (monoscopic). To our knowledge, there is no previous research using games and functional connectivity (FC) in MRI to address this question. Multiple analyses approaches were taken so that different aspects of brain connectivity could be covered: fractional low-frequency fluctuation, independent component analysis (ICA), seed-based FC (SeedFC) and graph analysis. In goggle presentation (mono and stereoscopic) as contrasted to screen, we found differences in brain activation in left cerebellum and postcentral gyrus as well as differences in connectivity in the visual cortex and frontal inferior cortex [when focusing on the visual and default mode network (DMN)]. When considering connectivity in specific areas of interest, we found higher connectivity between bilateral superior frontal cortex and the temporal lobe, as well as bilateral inferior parietal cortex with right calcarine and right lingual cortex. Furthermore, we found superior frontal cortex and insula/putamen to be more strongly connected in goggle stereoscopic vs. goggle monoscopic, in line with our hypothesis. We assume that the condition that elicits higher brain connectivity values should be most suited for long-term brain training interventions given that, extended training under these conditions could permanently improve brain connectivity on a functional as well as on a structural level.