Structure solution and refinement of beam-sensitive nano-crystals

Radiation sensitive materials are among the most difficult materials to study, even more so if they exist only as nanometer-sized particles, where their size is either intentional because of enhanced properties at the nano-scale or it is unintentional because it is impossible to obtain bigger particles of the same structure. In both cases characterization methods need to be optimized to get the most information out of these particles before the radiation damages them to a point where their structure is altered. When the particles are crystallized, both characteristics, the small size and the beam sensitivity, call for electron diffraction as a privileged investigation tool. The strong interaction of electrons (as compared to X-rays) with matter allows single crystal diffraction experiments on nanometer-sized crystals and for the same amount of beam damage, electron diffraction yields more information than X-rays. These inherent advantages of electron diffraction are optimized in the recently developed low-dose electron diffraction tomography (LD-EDT) by minimizing the necessary dose for a complete data collection. In this contribution we show that in some cases even doses as low as 2 e-/Ų can induce damage in crystal structures that inhibit a correct structure refinement. However, by LD-EDT we can obtain data using extremely low doses that don't alter the structure which make it then possible not only to solve crystal structures but also to refine them using dynamical diffraction theory. Here a synthetic oxide containing volatile Na and a metal-organic framework are given as examples. A dynamical refinement of the structures is possible with data sets requiring a dose of less than 0.15 e-/Ų.

Localisation of atmospheric release of radioisotopes using inverse methods and footprints of receptors as sources

Releases of radionuclides to the atmosphere occasionally occur with no warning and with first observation at radioactivity monitoring stations. The Chernobyl accident of 1986 was first detected at Forsmark, Sweden, long before the official announcement by the Soviet Union, and the release of Ruthenium 106 detected across Europe in 2017 still has no official release location. The current study details a method based on footprint analysis of an atmospheric dispersion model to locate the source of an atmospheric release. The method was applied to the European Tracer EXperiment of 1994 to validate the method and to the Ruthenium observations of autumn 2017 to determine likely release locations and time characteristics of this release. The method can readily utilise an ensemble of numerical weather prediction data which improves the localisation results by taking into account meteorological uncertainties compared to only using deterministic weather data. In applying the method to the ETEX scenario, the most likely release location improved from a distance of 113 km from the true release location when using deterministic meteorology, to a distance of 63 km when using ensemble meteorology data, although such improvements may be scenario dependent. The method was constructed to be robust with respect to the choices of model parameters and measurement uncertainties. The localisation method can be useful for decision makers to enact countermeasures to protect the environment against the effects of radioactivity when observations are available from environmental radioactivity monitoring networks.

Comparing model skills for deterministic versus ensemble dispersion modelling: The Fukushima Daiichi NPP accident as a case study

Atmospheric dispersion models are crucial for nuclear risk assessment and emergency response systems since they rapidly predict air concentrations and deposition of released radionuclides, providing a basis for dose estimations and countermeasure strategies. Atmospheric dispersion models are associated with relatively large and often unknown uncertainties that are mostly attributed to meteorology, source terms and parametrisation of the dispersion model. By developing methods that can provide reliable uncertainty ranges for model outputs, decision makers have an improved basis for handling nuclear emergency situations. In the present work, model skill of the Severe Nuclear Accident Programme (SNAP) model was quantified by employing an ensemble method in which 51 meteorological realisations from a numerical weather prediction model were combined with 9 source term descriptions for the accidental ¹³⁷Cs releases from Fukushima Daiichi Nuclear Power Plant during 14th-17th March 2011. The meteorological forecast was compared to observations of wind speed from 30 meteorological stations. The 459 dispersion realisations were compared with hourly observations of activity concentrations from 100 air filter stations. Exclusive use of deterministic meteorology resulted in most members of the dispersion ensemble showing too low concentration values, however this was mitigated by applying ensemble meteorology. Ensemble predictions, including both the meteorological and source term ensemble, show an overall higher prediction skill compared to individual meteorology and source term runs, with true predictive rate accuracy increasing from 30%-50% to 70%-90%, with a decrease in positive predictive rate accuracy from 75%-80% to 65%-75%. Skill scores and other ensemble indicators also showed improvements in using ensembles of source terms and meteorology. From the present study on the Fukushima accident there are strong indications that ensemble predictions improve the basis for decision making in the early phase after a nuclear accident, which emphasises the importance of including ensemble prediction in nuclear preparedness tools of the future.

Subjective Cognitive Decline in a Registry Sample: Relation to Psychiatric History, Loneliness, and Personality

BACKGROUND

With the increasing focus on prevention of Alzheimer's disease, there is need for characterization of preclinical populations. Local participant registries offer an opportunity to facilitate research engagement via remote data collection, inform recruitment, and characterize preclinical samples, including individuals with subjective cognitive decline.

OBJECTIVES

We sought to characterize subjective cognitive decline in a registry sample, as related to psychiatric history and related variables, including personality and loneliness, quality of life, and factors related to dementia risk (e.g., family history of dementia).

DESIGN, SETTING, PARTICIPANTS

Participants were 366 individuals (mean age=67.2 (range 50-88), 65% female, 94% white, 97% non-Hispanic or Latino, 82% with at least a bachelor's degree) with no reported history of mild cognitive impairment or dementia. All participants had expressed interest in research, primarily via community outreach events and prior research involvement. Data was collected via electronic surveys, distributed using REDCap. Electronic questionnaires included questions on demographic variables, subjective cognitive decline, quality of life, loneliness, and personality.

RESULTS

There was a high prevalence of risk factors for dementia in the registry sample (68% with family history of dementia, 31% with subjective cognitive decline). Subjective cognitive decline was more common in women and associated with history of depression, but not with family history of dementia. Subjective cognitive decline was also associated with lower conscientiousness and lower emotional stability, as well as higher loneliness and lower quality of life. Among participants who endorsed a psychiatric history, most reported onset more than 10 years prior, rather than within the last 10 years.

CONCLUSIONS

Subjective cognitive decline in a registry sample may be more strongly associated with longstanding psychiatric and personality variables, rather than family history of dementia, adding to the literature on characterization of subjective cognitive decline across different settings. These findings highlight the acceptability of remote data collection and the potential of registries to inform recruitment by characterizing registrants, which may help to stratify dementia risk and match participants to eligible trials.

Consequences for Norway from a hypothetical accident at the Sellafield reprocessing plant: Atmospheric transport of radionuclides

The potential consequences for Norway should a nuclear accident at the Sellafield nuclear site occur, have been of concern for Norwegian authorities for several decades. Meteorological data from a 33-year period and the dispersion model 'SNAP' were used to evaluate meteorological conditions for which atmospheric transport of radionuclides from Sellafield to Norway would lead to the most severe impacts. The worst-case meteorological scenario for Norway, was found on 25^th June 1989 for a low elevation (0-800 m) release and on 29^th June 2001 for a higher elevation (800-1600 m) release. In both cases the western part of Norway was most affected. In general, the probability for depositions (>10 Bq/m² of ¹³⁷Cs) increased about 40% during the autumn and winter compared to the spring and summer months. An influence of climate change on the depositions was analysed, but not verified. Results from a number of simulations were also compared to identify how factors such as radioactive particle characteristics and initial release conditions could affect the predicted radionuclide deposition. The impact on predicted total depositions as well as hot-spot depositions by varying particle density and size as well as release elevation in worst-case scenario simulations amounted to about 40%-50%.

Uncertainties in short term prediction of atmospheric dispersion of radionuclides. A case study of a hypothetical accident in a nuclear floating power plant off the West coast of Norway

Short-term predictions for dispersion of radionuclides in the atmosphere following releases from nuclear incidents are associated with uncertainties originating from meteorology, source term and parameterization. Characterization of these uncertainties is of key importance for preparedness, decision making during an accident and for the further uncertainty propagation in the subsequent modelling of human and ecosystem exposures. Increased traffic of nuclear-propulsion vessels in Norwegian territorial waters gives rise to growing concern of a potential nuclear accident along the coast of Norway. In the present study, we have quantified and inter-compared the uncertainties associated with the model outputs for a hypothetical loss of coolant accident with an ensuing fire in a nuclear vessel situated along the Norwegian coastline, applying two different atmospheric dispersion models: the SNAP Lagrangian particle model (SNAP-Severe Nuclear Accident Program) and the DIPCOT Lagrangian puff model (DIPCOT - Dispersion over Complex Terrain). The case highlights a situation with atmospheric transport from the offshore area to the coast of Western Norway, combined with large wet deposition in inland mountainous terrain, i.e. a common weather situation in this region. The meteorological data include an Ensemble Prediction System with nine ensemble members in addition to a deterministic base run. Five different 7 h emission scenarios with the same total released activity were considered. Hourly wind data at 10 m above ground for a 24 h period, showed that 36% of the wind direction and 41% of the wind speed data were outside the spread of the meteorological ensemble. About 55% and 13% of the measured values fell outside the ensemble for hourly 2 m above ground temperatures and 3 hourly accumulated precipitation, respectively, indicating that the ensemble did not cover all uncertainties in the meteorological fields. The maps of accumulated concentrations and depositions were qualitatively similar for the two models, but SNAP predicted higher accumulated concentration levels compared to DIPCOT for quite large areas, while DIPCOT yielded larger total depositions in the same areas. Furthermore, the direction, speed of movement and spatial extension of the radioactive plume from the accident varied considerably from one model to the other. The spread in the dispersion of the radionuclides ranged from a factor of about 1-3 in the source area to a factor of about 2-5 further away. The spreads due to meteorology and emission scenarios were of similar magnitude. Considering the ratio of the 50th percentiles of the two models, the spread varied by a factor of about 1-9, indicating that uncertainties arising from the formulation of the dispersion model could be as important or even larger than those associated with meteorology and emissions. Thus, it is recommended to include the uncertainty originating from the choice of the dispersion model into the overall uncertainty of short-term prediction of the dispersion of radionuclides and to exploit this further by generating an ensemble of several dispersion models.

Uncertainties in atmospheric dispersion modelling during nuclear accidents

Predictions of the atmospheric dispersion of radionuclides accidentally released from a nuclear power plant are influenced by two large sources of uncertainty: one associated with the meteorological data employed, and one with the source term, i.e. the temporal evolution of the amount and physical and chemical properties of the release. A methodology is presented for quantitative estimation of the variability of the prediction of atmospheric dispersion resulting from both sources of uncertainty. The methodology, which allows for efficient calculation, and thus is well suited for real-time assessment, is applied to a hypothetical accidental release of radionuclides.

Electrical molecular switch addressed by chemical stimuli

We demonstrate that the conductance switching of benzo-bis(imidazole) molecules upon protonation depends on the lateral functional groups. The protonated H-substituted molecule shows a higher conductance than the neutral one (Gpro > Gneu), while the opposite (Gneu > Gpro) is observed for a molecule laterally functionalized by amino-phenyl groups. These results are demonstrated at various scale lengths: self-assembled monolayers, tiny nanodot-molecule junctions and single molecules. From ab initio theoretical calculations, we conclude that for the H-substituted molecule, the result Gpro > Gneu is correctly explained by a reduction of the LUMO-HOMO gap, while for the amino-phenyl functionnalized molecule, the result Gneu > Gpro is consistent with a shift of the HOMO, which reduces the density of states at the Fermi energy.

Using a chain of models to predict health and environmental impacts in Norway from a hypothetical nuclear accident at the Sellafield site

When a nuclear accident occurs, decision makers in the affected country/countries would need to act promptly to protect people, the environment and societal interests from harmful impacts of radioactive fallout. The decisions are usually based on a combination of model prognoses, measurements, and expert judgements within in an emergency decision support system (DSS). Large scale nuclear accidents would need predictive models for the atmospheric, terrestrial, freshwater, and marine ecosystems, for the connections between these in terms of radionuclide fluxes, and for the various exposure pathways to both humans and biota. Our study showed that eight different models and DSS modules could be linked to assess the total human and environmental consequences in Norway from a hypothetical nuclear accident, here chosen to be the Sellafield nuclear reprocessing plant. Activity concentrations and dose rates from ¹³⁷Cs for both humans and the environment via various exposure routes were successfully modelled. The study showed that a release of 1% of the total inventory of ¹³⁷Cs in the Highly Active Liquor Tanks at Sellafield Ltd is predicted to severely impact humans and the environment in Norway if strong winds are blowing towards the country at the time of an accidental atmospheric release. Furthermore, since the models did not have built-in uncertainty ranges when this Sellafield study was performed, investigations were conducted to identify the key factors contributing to uncertainty in various models and prioritise the ones to focus on in future research.

P3522Vagus nerve stimulation for chronic heart failure: differences in therapy delivery and clinical efficacy in ANTHEM-HF, INOVATE-HF, and NECTAR-HF

Background

Vagus Nerve Stimulation (VNS) is meant to deliver Autonomic Regulation Therapy (ART) to neurological targets with sufficient neuromodulation (NM) to ameliorate chronic heart failure (CHF). VNS delivery consists of its intensity (a combination of pulse amplitude, pulse frequency, and pulse duration), polarity, duty cycle (DC; stimulation “on” time and “off” time), and mode (continuous, or intermittent and periodic). In the ANTHEM-HF Pilot Study patients with CHF and reduced ejection fraction (HFrEF), VNS intensity was up-titrated until a change in heart rate (HR) dynamics was objectively confirmed. This did not require any change in GDMT and was associated with significant improvements in LVEF, 6-minute walk distance (6MWD), Minnesota Living with HF (MLWHF) score, and HR variability.

Methods

Qualitative and quantitative analyses used data from peer-reviewed publications and other sources in the public domain to compare VNS delivery in ANTHEM-HF, INOVATE-HF, and NECTAR-HF.

Results (Table): Up-titration of VNS intensity was attempted in all 3 studies. In contrast to ANTHEM-HF, INOVATE-HF aimed only at peripheral neural targets. VNS intensity was delivered at a lower pulse frequency, and had a variable DC as a consequence of R-wave synchronization and only intermittent, periodic stimulation. In NECTAR-HF VNS intensity was delivered at a higher pulse frequency, and this was associated with intolerable adverse off-target effects which restricted VNS up-titration. Significant improvements in EF, 6MWD, MLWHF, and SDNN occurred in ANTHEM-HF relative to the other studies.

ANTHEM-HF (n=60) INOVATE-HF (n=436) NECTAR-HF (n=63) Neural Target Central/Peripheral Peripheral Central/Peripheral Delivery Site Left or right CVN Right CVN Right CVN Delivery Intensity:   Amplitude (milliamperes) 2.0±0.6 3.9±1.0 1.4±0.8   Frequency (Hertz) 10 1–2 20   Duration (microseconds) 250 500 300 Electrode Polarity (Cathode) Caudal Cephalad Caudal Duty Cycle 23% 25% 17% On Time/Off Time (seconds) 18/62 Variable 10/50 Mode of Delivery Cyclic/Continuous Intermittent/Periodic Cyclic/Continuous Clinical Efficacy at 6 Months:   EF 32.4±7.2 to 37.2±10.4 Not available 30.5±6.0 to 32.7±6.4   6MWD 287±66 to 346±78 317±109 to 347±123 Not available   MLWHFS 40±14 to 21±10 Not available 44.2±22.2 to 35.8±20.8   SDNN 94±26 to 111±50 Not available 146±48 to 130±52 Values reported as mean ± standard deviation; CVN = Cervical vagus nerve. *p<0.05 versus NECTAR-HF; **p<0.05 versus INOVATE-HF; ***p<0.025 versus NECTAR-HF; ****p<0.001 versus NECTAR-HF (Analysis using two-sample t-test of the means).

Conclusion

VNS differed in ANTHEM-HF when compared to INOVATE-HF and NECTAR-HF. The neural targets, pulse frequencies for titration, and the DC for NM were different. VNS in ANTHEM-HF was clinically efficacious. The ongoing ANTHEM-HFrEF Pivotal Study uses a similar paradigm.

Acknowledgement/Funding

LivaNova PLC

Modelling Environmental Impacts of Cesium-137 Under a Hypothetical Release of Radioactive Waste

Waste tanks at the nuclear facility located at Sellafield, UK, represent a nuclear source which could release radionuclides to the atmosphere. A model chain which combines atmospheric transport, deposition as well as riverine transport to sea has been developed to predict the riverine activity concentrations of ¹³⁷Cs. The source term was estimated to be 9 × 10⁴ TBq of ¹³⁷Cs, or 1% of the assumed total ¹³⁷Cs inventory of the HAL (Highly Active Liquid) storage tanks. Air dispersion modelling predicted ¹³⁷Cs deposition reaching 127 kBq m^-2 at the Vikedal catchment in Western Norway. Thus, the riverine transport model predicted that the activity concentration of ¹³⁷Cs in water at the river outlet could reach 9000 Bq m^-3 in the aqueous phase and 1000 Bq kg^-1 in solid phase at peak level. The lake and river reaches showed different transport patterns due to the buffering effects caused by dilution and slowing down of water velocity.

From nano to microcrystals: effects of different synthetic pathways on the defect architecture in heavily Gd-doped ceria

The evolution of the defect structure and microstructure of heavily Gd-doped ceria (Ce_1-μRE_μO_2-y, 0.313 ≤ μ ≤ 0.438) for different synthetic pathways is investigated here to explore the way defects interact with each other in a composition range known to effectively hamper the application of the material as an electrolyte. Synchrotron radiation powder diffraction is exploited by combining conventional Rietveld analysis with the Pair Distribution Function to get a multiscale picture of defect structures, and it is combined with Raman spectroscopy to assess local scale interactions. Samples were prepared via both the sol-gel route and coprecipitation of oxalates by sintering the powders at different temperatures to obtain samples with different defect distributions and crystallite sizes, investigated using electron microscopy and Whole Powder Pattern Modelling from diffraction data. As a general scheme, increasing the doping amount transforms the fluorite structure of ceria into C-type Gd₂O₃. For samples annealed at and above 900 °C, containing crystals at least ∼100 nm in size, this transformation occurs through a mechanism involving first the formation of distorted Gd-rich droplets on the local scale, then the growth of extended C-type nanodomains. Nanoparticles, resulting from thermal treatments at lower temperature, are less distorted on the local scale and transform abruptly upon doping, without forming larger dopant-rich aggregations, from fluorite to the C-type. The annealing temperature not only acts on the sintering of the crystallites, it is also found to promote a radical change in the microstructure as a consequence of the preferential aggregation of oxygen vacancies.

Describing oxymethylene ether synthesis based on the application of non-stoichiomsetric Gibbs minimisation

A naturally inspired non-Stochastic Global Optimiser is used to describe the synthesis of oxymethylene ethers.

An xQTL map integrates the genetic architecture of the human brain's transcriptome and epigenome

We report a multi-omic resource generated by applying quantitative trait locus (xQTL) analyses to RNA sequence, DNA methylation and histone acetylation data from the dorsolateral prefrontal cortex of 411 older adults who have all three data types. We identify SNPs significantly associated with gene expression, DNA methylation and histone modification levels. Many of these SNPs influence multiple molecular features, and we demonstrate that SNP effects on RNA expression are fully mediated by epigenetic features in 9% of these loci. Further, we illustrate the utility of our new resource, xQTL Serve, by using it to prioritize the cell type(s) most affected by an xQTL. We also reanalyze published genome wide association studies using an xQTL-weighted analysis approach and identify 18 new schizophrenia and 2 new bipolar susceptibility variants, which is more than double the number of loci that can be discovered with a larger blood-based expression eQTL resource.

Poly(oxymethylene) dimethyl ether synthesis – a combined chemical equilibrium investigation towards an increasingly efficient and potentially sustainable synthetic route

Poly(oxymethylene) dimethyl ethers (denoted as OME) are potential sustainable energy carriers and platform chemicals.

Impacts on the terrestrial environment in case of a hypothetical accident involving the recovery of the dumped Russian submarine K-27

Objects containing radioactivity have been routinely dumped in Arctic waters near NW Russia up until the 1990s. One of the most radioactive objects in this region, the nuclear submarine K-27, was dumped in Stepogovo Fjord and contained spent nuclear fuel (SNF). Although the two K-27 submarine reactors were mothballed before dumping, concerns about the potential long term risks of contamination remain and plans to retrieve and decommission K-27 exist. In this article, human dose and environmental impact aseessments are presented for two possible future scenarios involving: (1) an ingress of water into a reactor in situ leading to a spontaneous chain reaction (SCR) and (2) an on-board fire when SNF is being removed at the mainland decommissiong site at Gremhika Bay on the Kola Peninsula. Assessments have been completed using conservative assumptions, focusing on possible effects to Norwegian territory. Atmospheric transport and deposition of radioactivity was modelled near field and regionally, using appropriate models, whilst human doses and environmental exposures were modelled using a standard IAEA approach and the ERICA tool, respectively. Results indicate that large areas of Norwegian territory could be affected by fallout from the Gremhika scenario, especially in the north, though at levels two orders of magnitude lower than those observed after the Chernobyl accident. Potential doses, primarily due to ground shine, to a critical group of personnel on-site at Stepogovo resulting from a SCR could require preventative measures based on ICRP recommendations (20-100 mSv). Doses to non-human biota in Norway for the Gremhika scenario would be negligible, typical of background dose rates for terrestrial organisms.

Knowledge about HIV in a Community Sample of Urban African Americans in the South

PURPOSE

Race and HIV are intertwined in complex ways. African Americans, particularly those residing in the southern United States, are at great risk for contracting and subsequently transmitting HIV. Research on the extent to which members of this population understand the risks associated with engaging in specific behaviors is limited. This paper examines HIV knowledge among at-risk adult African American men and women and the factors associated with levels of HIV knowledge.

METHODS

Based on a conceptual model derived from Social Disorganization Theory and Syndemics Theory, interviews were conducted between 2009 and 2011. Questionnaire-based interviews were conducted with 1,864 respondents from 80 strategically-chosen census block groups in Atlanta, Georgia. An innovative approach to assessing amount of HIV knowledge was implemented, to derive better estimates of the extent of knowledge.

RESULTS

Overall, HIV knowledge was low (average=43.5% correct answers). Seven factors were identified as contributing uniquely to having higher levels of knowledge about HIV transmission: (1) younger age, (2) being educated beyond the high school level, (3) being gay, lesbian or bisexual, (4) experiencing sexual abuse during childhood and/or adolescence, (5) drinking alcohol less frequently, (6) knowing a larger number of HIV-infected persons and (7) knowing anyone currently living with "full blown" AIDS.

CONCLUSION

HIV educational and intervention programs targeting at-risk African American adults need to develop effective ways of bolstering a solid understanding of how HIV is/not transmitted. In particular, efforts need to be targeted toward older adults, those with lower levels of educational attainment and persons who are not acquainted with anyone who is HIV-infected.

How the Interaction of Childhood Sexual Abuse and Gender Relates to HIV Risk Practices among Urban-Dwelling African Americans

Purpose

Previous research has demonstrated that HIV risk practices often differ based on gender and on whether or not people experienced sexual abuse during their formative (i.e., childhood and adolescence) years. The interaction of these two factors, which is the focus of this paper, has received limited attention.

Methods

Based on a model derived from Social Disorganization Theory and Syndemics Theory, interviews were conducted between 2009 and 2012 with 1,864 African American adults residing in Atlanta, Georgia in 80 strategically-chosen consensus block groups.

Results

Based on multiple regression and structural equation analyses, the interaction of sexual abuse and gender was found to be a significant predictor of involvement in (un)protected sex. The interaction of sexual abuse and gender also was related to condom use self-efficacy, which was one of the strongest factors underlying (un)protected sex.

Conclusion

The relationship of sexual abuse history and gender is relevant in the understanding of HIV risk practices. The interaction of these factors with one another and with other relevant influences that shape people's HIV risk profiles is complex. The Syndemics Theory approach used to conceptualize the relationships among relevant variables in this study is an effective way of trying to understand and address HIV risk practices.

Atmospheric transport of radioactive debris to Norway in case of a hypothetical accident related to the recovery of the Russian submarine K-27

The Russian nuclear submarine K-27 suffered a loss of coolant accident in 1968 and with nuclear fuel in both reactors it was scuttled in 1981 in the outer part of Stepovogo Bay located on the eastern coast of Novaya Zemlya. The inventory of spent nuclear fuel on board the submarine is of concern because it represents a potential source of radioactive contamination of the Kara Sea and a criticality accident with potential for long-range atmospheric transport of radioactive particles cannot be ruled out. To address these concerns and to provide a better basis for evaluating possible radiological impacts of potential releases in case a salvage operation is initiated, we assessed the atmospheric transport of radionuclides and deposition in Norway from a hypothetical criticality accident on board the K-27. To achieve this, a long term (33 years) meteorological database has been prepared and used for selection of the worst case meteorological scenarios for each of three selected locations of the potential accident. Next, the dispersion model SNAP was run with the source term for the worst-case accident scenario and selected meteorological scenarios. The results showed predictions to be very sensitive to the estimation of the source term for the worst-case accident and especially to the sizes and densities of released radioactive particles. The results indicated that a large area of Norway could be affected, but that the deposition in Northern Norway would be considerably higher than in other areas of the country. The simulations showed that deposition from the worst-case scenario of a hypothetical K-27 accident would be at least two orders of magnitude lower than the deposition observed in Norway following the Chernobyl accident.

Individual patient data network meta-analysis of mortality effects of implantable cardiac devices

OBJECTIVE

Implantable cardioverter defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and the combination therapy (CRT-D) have been shown to reduce all-cause mortality compared with medical therapy alone in patients with heart failure and reduced EF. Our aim was to synthesise data from major randomised controlled trials to estimate the comparative mortality effects of these devices and how these vary according to patients' characteristics.

METHODS

Data from 13 randomised trials (12 638 patients) were provided by medical technology companies. Individual patient data were synthesised using network meta-analysis.

RESULTS

Unadjusted analyses found CRT-D to be the most effective treatment (reduction in rate of death vs medical therapy: 42% (95% credible interval: 32-50%), followed by ICD (29% (20-37%)) and CRT-P (28% (15-40%)). CRT-D reduced mortality compared with CRT-P (19% (1-33%)) and ICD (18% (7-28%)). QRS duration, left bundle branch block (LBBB) morphology, age and gender were included as predictors of benefit in the final adjusted model. In this model, CRT-D reduced mortality in all subgroups (range: 53% (34-66%) to 28% (-1% to 49%)). Patients with QRS duration ≥150 ms, LBBB morphology and female gender benefited more from CRT-P and CRT-D. Men and those <60 years benefited more from ICD.

CONCLUSIONS

These data provide estimates for the mortality benefits of device therapy conditional upon multiple patient characteristics. They can be used to estimate an individual patient's expected relative benefit and thus inform shared decision making. Clinical guidelines should discuss age and gender as predictors of device benefits.

Transfusion of fresh vs. older red blood cells in the context of infection

The red blood cell (RBC) storage interval has been extended from less than a week to the current storage interval of 6-8 weeks. Regulatory criteria for extending storage rely upon a minimal degree of hemolysis and acceptable in vivo 24-h post transfusion recovery. Clinical studies of safety and efficacy have never been required. Concerns have arisen that RBC toward the end of storage develop a 'storage lesion' with previously unrecognized toxicity. Of the several mechanisms proposed, the bolus of iron delivered to macrophages as a result of hemolysis of stored RBC might pose a particular risk to patients with existing infections. We developed a canine model of pneumonia to compare the toxicity of stored RBC transfusion. We described increased mortality after transfusion of old RBC. We found that transfused older RBC increased mortality, in vivo hemolysis, circulating cell-free hemoglobin that scavenges nitric oxide, and elevations of non-transferrin bound and plasma labile iron. Disappearance of circulating iron correlated with increased mortality, worsening pulmonary function, and bacterial proliferation. Washing decreased the mortality associated with transfusing older RBC, but had the opposite effect on fresher blood. With low doses of bacteria, survival was unaffected by the age of blood, whereas high bacteria doses masked any effect of RBC age on mortality. Older RBC may have adverse effects, but the patient's clinical status, the age, volume and method of preparation of the RBC may be critical variables. Several mechanisms may account for this toxicity, but in the presence of bacterial infection, availability of iron likely plays a major role.

Kreuth III: European consensus proposals for treatment of haemophilia with coagulation factor concentrates

This report summarizes recommendations relating to haemophilia therapy arising from discussions among experts from 36 European countries during the Kreuth III meeting in April 2013. To optimize the organization of haemophilia care nationally, it is recommended that a formal body be established in each country to include the relevant clinicians, national haemophilia patient organization, health ministry, paying authority and (if appropriate) regulatory authorities. The minimum factor VIII consumption level in a country should be 3 I.U. per capita. Decisions on whether to adopt a new product should not be based solely on cost. Prophylaxis for children with severe haemophilia is already recognized as the optimum therapy. Ongoing prophylaxis for individual adults should also be provided when required based on clinical decision making by the clinician in consultation with the patient. Children with inhibitors who have failed, or who are not suitable for, immune tolerance therapy should be offered prophylaxis with bypassing agents. Single factor concentrates should be used as therapy wherever possible in patients with rare bleeding disorders. Orphan drug designation for a factor concentrate should not be used to hinder the development, licencing and marketing of other products for the same condition which have demonstrably different protein modification or enhancement.

[Development of a claim form for the initiation of post-treatment rehabilitation for nationwide use by all reimbursement agencies: a report and plea for reducing administrative barriers]

We describe the results of a survey of claim forms that are used when starting rehabilitation following inpatient treatment and of an evaluation of a claim form developed on the basis of the results. The survey of different existing forms shows a high overlapping in content, suggesting the possibility of unification to one claim form that can be accepted by all insurers. In analogy to the Delphi method criteria for evaluation were consented and applied by the author group to assess the relevance of the claim forms content items for the process of initiating rehabilitation. A group of further experts added their evaluations. We prioritised the results and extracted the essential contents to conceive a unified claim form eligible for all types of rehabilitation. The claim form was discussed in 3 focus groups, revised accordingly and tested in the Hannover Medical School. Test results show that all relevant information is asked for and that the form is well manageable. The users' request for an IT-based solution and further ideas for improvement were integrated into the revised and validated version of the claim form. It is now available for all stake holders, in particular for insurers, as a means to improve quality of care and efficiency by standardisation of rehabilitation claim forms.

Spinodal Decomposition in a Polystyren/ Cyclohexane Solution of Critical Composition

Results of experiments are reported demonstrating spinoidal decomposition in a critical mixture of polystyrene and cyclohexane. If time and length are properly scaled using data obtained from static and dynamic light scattering exper­ iments, the time evolution of the “spinodal ring” is repre­sented to a good approximation by an empirical equation proposed by Snyder and Meakin which describes spinodal decomposition for various types of systems.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.