Analysis of endonasal sinus surgery in a private outpatient setting in a tropical environment: A STROBE analysis

OBJECTIVES

To evaluate results and failure factors in endonasal surgery in a private outpatient setting in a tropical environment.

MATERIAL AND METHOD

A single-center observational study included 337 patients consecutively undergoing endonasal surgery in a private hospital on Réunion Island, a French overseas administrative Département in the Indian Ocean between 2019 and 2021. The main objective was to assess the success rate of the outpatient pathway. Secondary objectives comprised analysis of complications and identification and management of factors for failure of outpatient management. The study was conducted according to the STROBE editorial guideline.

RESULTS

The 337 surgeries notably comprised 112 septoplasties (37.5%), 104 meatotomies (30.3%), 15 unilateral total ethmoidectomies (4.6%), 48 bilateral total ethmoidectomies with sphenoidotomy (14.3%), and 18 Draf procedures (5.5%). Seventy-five percent of patients (252/337) were operated on as outpatients, with a success rate of 90% (227/252 patients). The rate of severe intraoperative complications was 1.5% (5/337). On multivariate analysis, 3 variables were identified as influencing risk of failure of the outpatient pathway: emergency analgesia in the operating room [odds ratio (OR): 91.61; 95% confidence interval (CI): 22.8-540.3], operating time (OR: 1.05; 95% CI: 1.01-1.09), and recovery room time (OR: 1.02; 95% CI: 1.01-1.03).

CONCLUSION

Our study in a tropical environment found eligibility and success rates for outpatient endonasal surgery similar to those in metropolitan France. This makes surgical and anesthesiological training a key factor in the success of outpatient care, while the location of the care structure and the climate seem to have little impact.

Tattoo Pigment Biokinetics in vivo in a 28-Day Porcine Model: Elements Undergo Fast Distribution to Lymph Nodes and Reach Steady State after 7 Days

INTRODUCTION

Pigments of tattoo inks may over time migrate to other parts of the body. Inks kinetics are still poorly understood and little studied. The aim of this first study was to investigate the kinetics of tattoo inks pigment in tattooed porcine skin, which is closer to human skin than mouse skin studied in the past.

METHODS

Three animals were tattooed on the inner thigh and one animal served as untreated control. Skin biopsies were taken on days 7, 14, and 28 after tattooing. Animals were sacrificed on day 28 and homogenate samples of the liver, spleen, kidney, and brain, as well the local lymph nodes were prepared. All samples were analyzed for ink components using inductively coupled plasma-mass spectrometry. The ink itself was characterized by dynamic light scattering and matrix-assisted laser desorption-ionization mass analysis.

RESULTS

Titanium (212 g/kg), copper (6 mg/kg), aluminum (1 mg/kg), zirconium (1 mg/kg), and chromium (3 mg/kg) were found in the ink. Significant deposits of ink elements were detected in the tattooed skin when compared to non-tattooed skin from the same animal (mean ± standard deviation: titanium 240 ± 81 mg/kg, copper 95 ± 39 mg/kg, aluminum 115 ± 63 mg/kg, zirconium 23 ± 12 mg/kg, and chromium 1.0 ± 0.2 mg/kg; p < 0.05). Lymph node concentrations of titanium, copper, aluminum, zirconium, and chromium were 42 ± 2 mg/kg, 69 ± 25 mg/kg, 49 ± 18 mg/kg, 0.3 ± 0.2 mg/kg, 0.5 ± 0.2 mg/kg, respectively.

CONCLUSION

Deposits in skin were unchanged from days 7-28 indicating no redistribution or elimination. No significant deposits of ink elements were found in the liver, spleen, kidney, and brain. In conclusion, our findings confirmed distribution of elements from tattoos to regional lymph nodes, but neither to excretory organs, e.g., liver and kidney, nor to spleen and brain. Thus systemic internal organ exposure was not found.

4-Axis 3D-Printed Tubular Biomaterials Imitating the Anisotropic Nanofiber Orientation of Porcine Aortae

Many of the peculiar properties of the vasculature are related to the arrangement of anisotropic proteinaceous fibers in vessel walls. Understanding and imitating these arrangements can potentially lead to new therapies for cardiovascular diseases. These can be pre-surgical planning, for which patient-specific ex vivo anatomical models for endograft testing are of interest. Alternatively, therapies can be based on tissue engineering, for which degradable in vitro cell growth substrates are used to culture replacement parts. In both cases, materials are desirable that imitate the biophysical properties of vessels, including their tubular shapes and compliance. This work contributes to these demands by offering methods for the manufacturing of anisotropic 3D-printed nanofibrous tubular structures that have similar biophysical properties as porcine aortae, that are biocompatible, and that allow for controlled nutrient diffusion. Tubes of various sizes with axial, radial, or alternating nanofiber orientation along the blood flow direction are manufactured by a customized method. Blood pressure-resistant, compliant, stable, and cell culture-compatible structures are obtained, that can be degraded in vitro on demand. It is suggested that these healthcare materials can contribute to the next generation of cardiovascular therapies of ex vivo pre-surgical planning or in vitro cell culture.

Biologically derived epicardial patch induces macrophage mediated pathophysiologic repair in chronically infarcted swine hearts

There are nearly 65 million people with chronic heart failure (CHF) globally, with no treatment directed at the pathologic cause of the disease, the loss of functioning cardiomyocytes. We have an allogeneic cardiac patch comprised of cardiomyocytes and human fibroblasts on a bioresorbable matrix. This patch increases blood flow to the damaged heart and improves left ventricular (LV) function in an immune competent rat model of ischemic CHF. After 6 months of treatment in an immune competent Yucatan mini swine ischemic CHF model, this patch restores LV contractility without constrictive physiology, partially reversing maladaptive LV and right ventricular remodeling, increases exercise tolerance, without inducing any cardiac arrhythmias or a change in myocardial oxygen consumption. Digital spatial profiling in mice with patch placement 3 weeks after a myocardial infarction shows that the patch induces a CD45pos immune cell response that results in an infiltration of dendritic cells and macrophages with high expression of macrophages polarization to the anti-inflammatory reparative M2 phenotype. Leveraging the host native immune system allows for the potential use of immunomodulatory therapies for treatment of chronic inflammatory diseases not limited to ischemic CHF.

Human In Vitro Skin Models for Wound Healing and Wound Healing Disorders

Skin wound healing is essential to health and survival. Consequently, high amounts of research effort have been put into investigating the cellular and molecular components involved in the wound healing process. The use of animal experiments has contributed greatly to the knowledge of wound healing, skin diseases, and the exploration of treatment options. However, in addition to ethical concerns, anatomical and physiological inter-species differences often influence the translatability of animal-based studies. Human in vitro skin models, which include essential cellular and structural components for wound healing analyses, would improve the translatability of results and reduce animal experiments during the preclinical evaluation of novel therapy approaches. In this review, we summarize in vitro approaches, which are used to study wound healing as well as wound healing-pathologies such as chronic wounds, keloids, and hypertrophic scars in a human setting.

Modelling the Complexity of Human Skin In Vitro

The skin serves as an important barrier protecting the body from physical, chemical and pathogenic hazards as well as regulating the bi-directional transport of water, ions and nutrients. In order to improve the knowledge on skin structure and function as well as on skin diseases, animal experiments are often employed, but anatomical as well as physiological interspecies differences may result in poor translatability of animal-based data to the clinical situation. In vitro models, such as human reconstructed epidermis or full skin equivalents, are valuable alternatives to animal experiments. Enormous advances have been achieved in establishing skin models of increasing complexity in the past. In this review, human skin structures are described as well as the fast evolving technologies developed to reconstruct the complexity of human skin structures in vitro.

Interleukin-11 drives human and mouse alcohol-related liver disease

OBJECTIVE

Alcoholic hepatitis (AH) reflects acute exacerbation of alcoholic liver disease (ALD) and is a growing healthcare burden worldwide. Interleukin-11 (IL-11) is a profibrotic, proinflammatory cytokine with increasingly recognised toxicities in parenchymal and epithelial cells. We explored IL-11 serum levels and their prognostic value in patients suffering from AH and cirrhosis of various aetiology and experimental ALD.

DESIGN

IL-11 serum concentration and tissue expression was determined in a cohort comprising 50 patients with AH, 110 patients with cirrhosis and 19 healthy volunteers. Findings were replicated in an independent patient cohort (n=186). Primary human hepatocytes exposed to ethanol were studied in vitro. Ethanol-fed wildtype mice were treated with a neutralising murine IL-11 receptor-antibody (anti-IL11RA) and examined for severity signs and markers of ALD.

RESULTS

IL-11 serum concentration and hepatic expression increased with severity of liver disease, mostly pronounced in AH. In a multivariate Cox-regression, a serum level above 6.4 pg/mL was a model of end-stage liver disease independent risk factor for transplant-free survival in patients with compensated and decompensated cirrhosis. In mice, severity of alcohol-induced liver inflammation correlated with enhanced hepatic IL-11 and IL11RA expression. In vitro and in vivo, anti-IL11RA reduced pathogenic signalling pathways (extracellular signal-regulated kinases, c-Jun N-terminal kinase, NADPH oxidase 4) and protected hepatocytes and murine livers from ethanol-induced inflammation and injury.

CONCLUSION

Pathogenic IL-11 signalling in hepatocytes plays a crucial role in the pathogenesis of ALD and could serve as an independent prognostic factor for transplant-free survival. Blocking IL-11 signalling might be a therapeutic option in human ALD, particularly AH.

The Role of Local Inflammation and Hypoxia in the Formation of Hypertrophic Scars-A New Model in the Duroc Pig

Hypertrophic scars continue to be a major burden, especially after burns. Persistent inflammation during wound healing appears to be the precipitating aspect in pathologic scarring. The lack of a standardized model hinders research from fully elucidating pathophysiology and therapy, as most therapeutic approaches have sparse evidence. The goal of this project was to investigate the mechanisms of scar formation after prolonged wound inflammation and to introduce a method for generating standardized hypertrophic scars by inducing prolonged inflammation. Four wound types were created in Duroc pigs: full-thickness wounds, burn wounds, and both of them with induced hyperinflammation by resiquimod. Clinical assessment (Vancouver Scar Scale), tissue oxygenation by hyperspectral imaging, histologic assessment, and gene expression analysis were performed at various time points during the following five months. Native burn wounds as well as resiquimod-induced full-thickness and burn wounds resulted in more hypertrophic scars than full-thickness wounds. The scar scale showed significantly higher scores in burn- and resiquimod-induced wounds compared with full-thickness wounds as of day 77. These three wound types also showed relative hypoxia compared with uninduced full-thickness wounds in hyperspectral imaging and increased expression of HIF1a levels. The highest number of inflammatory cells was detected in resiquimod-induced full-thickness wounds with histologic features of hypertrophic scars in burn and resiquimod-induced wounds. Gene expression analysis revealed increased inflammation with only moderately altered fibrosis markers. We successfully created hypertrophic scars in the Duroc pig by using different wound etiologies. Inflammation caused by burns or resiquimod induction led to scars similar to human hypertrophic scars. This model may allow for the further investigation of the exact mechanisms of pathological scars, the role of hypoxia and inflammation, and the testing of therapeutic approaches.

Sarcoid-like lesions obfuscating the diagnosis of disseminated Mycobacterium genavense infection in a patient with IL-12Rβ1-associated immunodeficiency

Background

Sarcoidosis is a systemic inflammatory disease that is characterized by non-caseating epithelioid-cell granulomas upon histology. However, similar histological findings may also be seen with certain infections. Thus, differentiation from infection is pivotal to ensure appropriate treatment. Here, we present a case of a disseminated infection with Mycobacterium genavense owing to an interleukin 12 receptor subunit beta 1 (IL-12Rβ1) associated immunodeficiency in a previously healthy female who was initially misdiagnosed with sarcoidosis. M. genavense is a nontuberculous mycobacterium which can cause lymphadenopathy, gastrointestinal and bone marrow infiltration in immunocompromised patients. With this case report we aim to highlight that an infection with M. genavense on the ground of a genetic defect of mycobacterial immune control may represent a rare differential diagnosis of sarcoidosis.

Case presentation

A 31-year-old female was referred to our hospital with progressive lymphadenopathy, hepatosplenomegaly, pancytopenia and systemic inflammation. She had previously been evaluated for generalized lymphadenopathy in another hospital. At that time, lymph node biopsies had revealed sarcoid-like lesions and a systemic corticosteroid treatment was initiated based on a putative diagnosis of sarcoidosis. When her condition worsened, she was transferred to our university clinic, where the diagnosis of disseminated M. genavense infection owing to an inborn interferonopathy was made. Her family history revealed that her brother had also suffered from IL-12Rβ1 deficiency and had died from a systemic infection with M. genavense at the age of 21. The patient received antimycobacterial treatment combined with subcutaneous type I interferon, which eventually led to a gradual improvement over the next months.

Conclusions

Differentiating between sarcoidosis and sarcoid-like lesions secondary to infections may be challenging, especially when pathogens are difficult to detect or not expected in an apparently immunocompetent patient. Patients with IL-12Rβ1-associated immunodeficiency may be asymptomatic until adulthood, and disseminated M. genavense infection on the grounds of an IL-12Rβ1-associated immunodeficiency may represent a rare differential diagnosis of sarcoidosis.

The Impact of Thermal Stress on Cognition and the Use of Cooling Wear for Alleviation - an Explorative Study

Increased ambient temperatures during the care of severely burned patients are essential for mitigating hypothermia and minimizing the impact of the consecutive hypermetabolism. For involved medical staff, those conditions may lead to impaired concentration, possibly negatively affecting an optimal patient care. Yet, alleviation strategies are lacking. As a novel coping strategy, cooling wear may be an effective means. This explorative study aimed to investigate the effect of high ambient temperatures on the concentration capacity and cooling wear to alleviate thermal stress. The effects of high ambient temperatures and the additional use of cooling wear on the concentration capacity of medical staff were investigated in six subjects during two simulated burn surgeries. Each individual served as his/her own control undergoing one simulation with and one without cooling wear. Concentration capacity was measured before and after each simulation with a standardized test. The results suggested that high ambient temperatures, as used in burn medicine, negatively affect human concentration capacity. The initial assessment of concentration capacity yielded homogenous values. After heat exposure, subjects wearing cooling wear showed a higher concentration capacity and a lower error rate compared to subjects without cooling wear. Summing up, temperature-related decrements in vigilance and performance among medical personnel may impair the patients' outcome. As an opportunity to withstand thermal stress and improve medical care and safety, cooling wear showed promising results and may be used as heat alleviator. Burn medicine may particularly benefit from further development and rigorous investigation of cooling strategies.

A novel human ex vivo skin model to study early local responses to burn injuries

Burn injuries initiate numerous processes such as heat shock response, inflammation and tissue regeneration. Reliable burn models are needed to elucidate the exact sequence of local events to be able to better predict when local inflammation triggers systemic inflammatory processes. In contrast to other ex vivo skin culture approaches, we used fresh abdominal skin explants to introduce contact burn injuries. Histological and ultrastructural analyses confirmed a partial-thickness burn pathology. Gene expression patterns and cytokine production profiles of key mediators of the local inflammation, heat shock response, and tissue regeneration were analyzed for 24 h after burn injury. We found significantly increased expression of factors involved in tissue regeneration and inflammation soon after burn injury. To investigate purely inflammation-mediated reactions we injected lipopolysaccharide into the dermis. In comparison to burn injury, lipopolysaccharide injection initiated an inflammatory response while expression patterns of heat shock and tissue regeneration genes were unaffected for the duration of the experiment. This novel ex vivo human skin model is suitable to study the local, early responses to skin injuries such as burns while maintaining an intact overall tissue structure and it gives valuable insights into local mechanisms at the very beginning of the wound healing process after burn injuries.

Personal protective equipment in the COVID-19 pandemic and the use of cooling-wear as alleviator of thermal stress : A pilot study in plastic surgery staff members

Background

High temperatures at workplaces lead to health-related risks and premature exhaustion. The coronavirus disease 2019 (COVID-19) pandemic requires many health professionals to perform under unfavorable conditions. Personal protective equipment (PPE) causes thermal stress and negatively affects performance.

Patients, materials and methods

This pilot project investigated the effects of PPE and additional cooling wear on physiological parameters and concentration of six healthy staff members of the Plastic Surgery Department of the Medical University of Graz, Austria during simulated patient care. In this study two 1‑hour cycles with patient care-related tasks with PPE and PPE + cooling-wear, respectively, were conducted. A third cycle with scrubs exclusively served as baseline/negative control. The assessment occurred immediately pre-cycles and post-cycles.

Results

Pre-cycle assessments showed no significant differences between the cycles. After PPE cycle, increased physical stress levels and decrements in concentration capacity were observed. Physiological parameters were significantly less affected in the cooling cycle, while concentration capacity slightly increased.

Conclusion

COVID-19 PPE causes considerable thermal stress, ultimately affecting human performance. As opportunity to withstand thermal stress, and improve patients’ and professionals’ safety, cooling-wear can be considered relevant. Medical personnel performing in exceptional situations may particularly benefit from further development and investigation of cooling strategies.

Remote allergen exposure elicits eosinophil infiltration into allergen nonexposed mucosal organs and primes for allergic inflammation

The natural history of allergic diseases suggests bidirectional and progressive relationships between allergic disorders of the skin, lung, and gut indicative of mucosal organ crosstalk. However, impacts of local allergic inflammation on the cellular landscape of remote mucosal organs along the skin:lung:gut axis are not yet known. Eosinophils are tissue-dwelling innate immune leukocytes associated with allergic diseases. Emerging data suggest heterogeneous phenotypes of tissue-dwelling eosinophils contribute to multifaceted roles that favor homeostasis or disease. This study investigated the impact of acute local allergen exposure on the frequency and phenotype of tissue eosinophils within remote mucosal organs. Our findings demonstrate allergen challenge to skin, lung, or gut elicited not only local eosinophilic inflammation, but also increased the number and frequency of eosinophils within remote, allergen nonexposed lung, and intestine. Remote allergen-elicited lung eosinophils exhibited an inflammatory phenotype and their presence associated with enhanced susceptibility to airway inflammation induced upon subsequent inhalation of a different allergen. These data demonstrate, for the first time, a direct effect of acute allergic inflammation on the phenotype and frequency of tissue eosinophils within antigen nonexposed remote mucosal tissues associated with remote organ priming for allergic inflammation.

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Neuropsychological Considerations of the Cultural and Linguistic Challenges of Working with a Bilingual/Bicultural Patient with Multiple System Atrophy (MSA): A Case Report

Objective

This case highlights the importance of understanding bilingualism, English as a second language (ESL), immigration as an older adult, and acculturation, in light of neuropsychological test results of an individual with MSA.

Case Description

Mrs. X is a right-handed, 73-year-old, South African woman. Her first language is Afrikaans while her second language is English. She has a history of MSA (2015). She reported a significant decline in her previously mastered English fluency. Challenges with language (i.e., reading comprehension, conversation), focus, balance, and activities of daily living, bilateral arm jerks, and difficulties with ambulation, Pisa Syndrome (left), loss of appetite, incontinence, fluctuating temperature, depression, personality changes, and suspected auditory hallucinations were also expressed.

Diagnostic Impressions and Outcomes

The neurocognitive findings indicated global impairment. Aside from an average score in her reading recognition, and low-average in a test of mental flexibility, Mrs. X had impairment in attention, learning, immediate and delayed memory, executive functioning, receptive and expressive language, confrontation naming, and visuospatial abilities. Mrs. X’s motoric difficulties and parkinsonism made it difficult for her to participate in testing comfortably. Language barriers were prominent: Mrs. X occasionally required English-Afrikaans translation and multiple repetitions of prompts. Summary and impressions of test results acknowledged the cultural and linguistic limitations of the evaluation. She was diagnosed with Major Neurocognitive Disorder secondary to MSA.

Discussion

In patients with diffuse impairment, it is essential to understand the role of dual language processes, ESL, and cultural limitations of assessments in order to accurately differentiate between neurodegenerative processes (i.e., Alzheimer’s Disease vs. other disorders), as well as to determine the impact of MSA on the linguistic abilities of bilingual individuals.

B-30 Sturge-Weber Syndrome in Adulthood: A Case Study of Superior Cognitive Reserve

Objective

Sturge-Weber Syndrome (SWS) is a neurological disorder usually diagnosed in childhood and characterized by facial port-wine stains, seizures, and intracranial vascular malformations. SWS is associated with a variety of neuropsychological presentations in children, but the adult cognitive profile of this disease is not well established. Specifically, little is known about how cerebral abnormalities found using Magnetic Resonance Imaging (MRI) correlate with cognitive difficulties in adulthood or if certain prognostic factors can predict cognitive outcome.

Methods

The present case involved a 53-year-old, left-handed, Caucasian female with 20 years of education with SWS, possible seizures, multiple concussions, posttraumatic stress disorder (PTSD; multiple reported traumas) and bipolar disorder, referred for a neuropsychological evaluation for progressive problems with memory, word-finding, and coordination over the last 14 years. A neuropsychological evaluation was administered and structural neuroimaging was reviewed.

Results

MRI studies revealed left hemispheric atrophy with enlargement of the left ventricle, cortical calcification in the left temporo-occipital region, cerebrovascular disease particularly in the frontal lobes, and vascular malformations. Despite severe neuroanatomical abnormalities associated with SWS, as well as comorbid psychiatric disorders, a neuropsychological evaluation revealed a relatively intact cognitive profile, with only scattered minor inefficiencies in attention/processing speed, executive functioning, and motor functioning.

Conclusions

This case provided an example of good prognosis of SWS in adulthood, despite significant brain abnormalities, potential seizure activity, multiple concussions, and psychiatric comorbidity. Further research is needed to conceptualize the neuropsychological impact of SWS in adulthood, specifically whether aspects of superior cognitive reserve (e.g., higher education) are associated with better prognosis.

Novel methods for the assessment of safety pharmacology and toxicology parameters in anesthetized and ventilated dogs receiving inhaled drugs

INTRODUCTION

For nonclinical drug development, it is optimal if safety pharmacology and toxicology studies are performed in a model that reasonably represents the patient the drug is intended to treat. To simulate prolonged inhalation therapy in ventilated patients, GLP inhalation toxicology methods, including safety pharmacology endpoints, in anesthetized, intubated and mechanically ventilated dogs were developed. This model required establishment of a canine intensive care unit (ICU) capable of providing prolonged anesthesia (propofol infusion and morphine titration) and partial parenteral nutrition (dextrose, amino acids and lipids) while safety parameters were monitored.

METHOD

Telemetry was used to continuously monitor heart rate, ECG and blood pressure. Blood gas parameters were periodically measured while oxygen saturation and core temperature were reported continuously. Glucose was measured hourly while other standard clinical pathology (hematology, coagulation, clinical chemistry) samples were evaluated approximately every 12 h. Aerosols were administered continuously over 48 h by inhalation using a mesh nebulizer (Aerogen Solo) fed by a syringe pump into a humidified circuit of a critical care ventilator (LTV® 1000) ending in an endotracheal tube placed in the trachea. Animals were ventilated with pressure control ventilation targeting a respiratory minute volume of 2.0-3.5 l per minute (LPM). Peak inspiratory pressure (PIP) was maintained between 10 and 17 cm H₂O and inspiratory time was set to 1 s with an inspiratory:expiratory (I:E) ratio of 1:2. Ventilator parameters and anesthesia were adjusted to maintain normal PaCO₂ levels and adequate sedation, respectively. Novel methods were developed to determine dose and particle size in vitro as on-line measurements were not feasible during in vivo aerosol delivery.

RESULTS AND DISCUSSION

Acceptable baseline measurements were established for all parameters over the 48-h evaluation period, qualifying the method as appropriate for assessment of GLP safety pharmacology and toxicology studies.

Strong Spin Dependence of Correlation Effects in Ni Due to Stoner Excitations

Using high-resolution angle-resolved photoemission, we observe a strong spin-dependent renormalization and lifetime broadening of the quasiparticle excitations in the electronic band structure of Ni(111) in an energy window of ∼0.3  eV below the Fermi level. We derive a quantitative result for the spin-dependent lifetime broadening by comparing the scattering rates of majority and minority d states, and further show that spin-dependent electron correlations are instead negligible for sp states. From our analysis we experimentally determine the effective on-site Coulomb interaction U caused by Stoner-like interband transitions between majority and minority d states. The present results demonstrate the remarkable impact of spin-dependent electron correlation effects originating from single-particle excitations in a prototypical 3d transition metal, paving the way for further refinement of current many-body theoretical approaches.

Unusual Dirac Fermions on the Surface of a Noncentrosymmetric α-BiPd Superconductor

Combining multiple emergent correlated properties such as superconductivity and magnetism within the topological matrix can have exceptional consequences in garnering new and exotic physics. Here, we study the topological surface states from a noncentrosymmetric α-BiPd superconductor by employing angle-resolved photoemission spectroscopy and first-principles calculations. We observe that the Dirac surface states of this system have several interesting and unusual properties, compared to other topological surface states. The surface state is strongly anisotropic and the in-plane Fermi velocity varies rigorously on rotating the crystal about the y axis. Moreover, it acquires an unusual band gap as a function of k_{y}, possibly due to hybridization with bulk bands, detected upon varying the excitation energy. The coexistence of all the functional properties in addition to the unusual surface state characteristics make this an interesting material.

[Internal Hernia Following Laparoscopic Roux-Y Gastric Bypass - a Challenge not only for the General Surgeon]

The frequency of bariatric operations has increased in Germany. Primary operations are usually performed at specialised centres. However, late complications may develop months or even years after the operation, and every general and visceral surgeon may be confronted with them, regardless of the size and specialisation of their clinics. The laparoscopic Roux-Y gastric bypass is the most frequently performed bariatric operation worldwide. During this procedure, the alimentary loop is lifted up in front of the colon to form a pouch, which creates a mesenteric space, also called the Petersen space, dorsal to the alimentary loop and below the transverse colon. Both here and around the mesenteric space of the Roux anastomosis, an internal hernia may develop, i.e. the small intestine can twist on its own axis. Abdominal discomfort due to intestinal obstruction is unspecific, but very pronounced. Clinically, patients either present with an acute abdomen or with intermittent unspecific abdominal pain with nausea, and rarely also with vomiting. Clinical examinations and lab chemistry tests usually do not reveal any indicative findings. In cases of doubt, therefore, contrast-enhanced computed tomography of the abdomen is the diagnostic imaging procedure of choice. A diagnostic laparoscopy should be performed in every patient with a clinical suspicion of an internal hernia, even if the CT scan is unremarkable. This should be done by a surgeon who is well-versed in laparoscopy and experienced in bariatric surgery, since classification of the intestinal loops is very difficult without knowledge of the hernial orifices. First, an inframesocolic view is obtained with the transverse colon being lifted. From here, the open Petersen space offers a direct view of the ligament of Treitz from the right side. If small intestine is found to the right of the ligament, there is a Petersen hernia. After the inframesocolic view, the gastroenterostomy should be located and the alimentary loop should be followed in distal direction towards the jejunojejunostomy, where the second possible space may be found. Once both spaces have been located and a hernia has been reduced as appropriate, the spaces should be closed with non-absorbable suture.

Value and determinants of the mean systemic filling pressure in critically ill patients

Mean systemic filling pressure (Pmsf) is a major determinant of venous return. Its value is unknown in critically ill patients (ICU). Our objectives were to report Pmsf in critically ill patients and to look for its clinical determinants, if any. We performed a prospective study in 202 patients who died in the ICU with a central venous and/or arterial catheter. One minute after the heart stopped beating, intravascular pressures were recorded in the supine position after ventilator disconnection. Parameters at admission, during the ICU stay, and at the time of death were prospectively collected. One-minute Pmsf was 12.8 ± 5.6 mmHg. It did not differ according to gender, severity score, diagnosis at admission, fluid balance, need for and duration of mechanical ventilation, or length of stay. Nor was there any difference according to suspected cause of death, classified as shock (cardiogenic, septic, and hemorrhagic) and nonshock, although a large variability of values was observed. The presence of norepinephrine at the time of death (102 patients) was associated with a higher 1-min Pmsf (14 ± 6 vs. 11.4 ± 4.5 mmHg), whereas the decision to forgo life-sustaining therapy (34 patients) was associated with a lower 1-min Pmsf (10.9 ± 3.8 vs. 13.1 ± 5.3 mmHg). In a multiple-regression analysis, norepinephrine (β = 2.67, P = 0.0004) and age (β = -0.061, P = 0.022) were associated with 1-min Pmsf. One-minute Pmsf appeared highly variable without any difference according to the kind of shock and fluid balance, but was higher with norepinephrine.

Observation of a universal donor-dependent vibrational mode in graphene

Electron-phonon coupling and the emergence of superconductivity in intercalated graphite have been studied extensively. Yet, phonon-mediated superconductivity has never been observed in the 2D equivalent of these materials, doped monolayer graphene. Here we perform angle-resolved photoemission spectroscopy to try to find an electron donor for graphene that is capable of inducing strong electron-phonon coupling and superconductivity. We examine the electron donor species Cs, Rb, K, Na, Li, Ca and for each we determine the full electronic band structure, the Eliashberg function and the superconducting critical temperature Tc from the spectral function. An unexpected low-energy peak appears for all dopants with an energy and intensity that depend on the dopant atom. We show that this peak is the result of a dopant-related vibration. The low energy and high intensity of this peak are crucially important for achieving superconductivity, with Ca being the most promising candidate for realizing superconductivity in graphene.

High-energy anomaly in the angle-resolved photoemission spectra of Nd(2-x)Ce(x)CuO₄: evidence for a matrix element effect

We use polarization-dependent angle-resolved photoemission spectroscopy (ARPES) to study the high-energy anomaly (HEA) in the dispersion of Nd(2-x)Ce(x)CuO₄, x=0.123. We find that at particular photon energies the anomalous, waterfall-like dispersion gives way to a broad, continuous band. This suggests that the HEA is a matrix element effect: it arises due to a suppression of the intensity of the broadened quasiparticle band in a narrow momentum range. We confirm this interpretation experimentally, by showing that the HEA appears when the matrix element is suppressed deliberately by changing the light polarization. Calculations of the matrix element using atomic wave functions and simulation of the ARPES intensity with one-step model calculations provide further evidence for this scenario. The possibility to detect the full quasiparticle dispersion further allows us to extract the high-energy self-energy function near the center and at the edge of the Brillouin zone.

[Off-label use of recombinant factor VII (rFVIIa) in teaching hospitals in Paris in 2010]

INTRODUCTION

Recombinant activated factor VII (rFVIIa) (Novoseven(®)) was initially developed as a substitutive treatment in haemophiliacs but has then been used in situations of major haemorrhage in non-haemophiliacs (off-label use). The goal of the present study was to assess the practice patterns when rFVIIa is used in off-label indications in major teaching hospitals of Paris in 2010.

METHODS

We retrospectively identified files of patients in whom rFVIIa had been used. Physicians in charge of these patients (or the most proxy physician available) were contacted and files analysed with one of the authors. Quality of rFVIIa used in these off-label situations was determined based on either French or European guidelines or the available literature when no guidelines could be found. Three categories were defined for indication, dosage, timing, associated biological factors and overall use: adequate, acceptable (mainly adequate but lacking some characteristics of an "ideal" prescription) and inadequate (lacking most of the necessary characteristics of an "ideal" prescription).

RESULTS

Among 59 patients who had an off-label prescription of rFVIIa, 49 prescriptions could be analysed. Indication for use and timing of administration were adequate in 100% of multiple trauma cases and 83% of obstetrical cases. Biological criteria associated with an improved efficacy were found in two thirds of prescriptions analysed. Overall, prescriptions were adequate or acceptable in 82% of cases.

CONCLUSION

In the vast majority of patients who received rFVIIa for off-label indications in teaching hospitals of the Paris area in 2010, prescriptions were in line with recommendations.

Resonant elastic soft x-ray scattering

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Coherent excitations and electron-phonon coupling in Ba/EuFe2As2 compounds investigated by femtosecond time- and angle-resolved photoemission spectroscopy

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Medically refractory neurosarcoidosis treated with infliximab

Neurosarcoidosis can worsen despite standard immunosuppressive therapy, a situation for which there is no established medical management. We present three cases of medically refractory neurosarcoidosis treated with infliximab. All three patients showed a clinical response to this treatment and side effects were limited. A summary of reported cases of neurosarcoidosis treated with infliximab is included. This case series supports a role for infliximab in the treatment of patients with medically refractory neurosarcoidosis.

Ultrafast momentum-dependent response of electrons in antiferromagnetic EuFe2As2 driven by optical excitation

Employing the momentum sensitivity of time- and angle-resolved photoemission spectroscopy we demonstrate the analysis of ultrafast single- and many-particle dynamics in antiferromagnetic EuFe(2)As(2). Their separation is based on a temperature-dependent difference of photoexcited hole and electron relaxation times probing the single-particle band and the spin density wave gap, respectively. Reformation of the magnetic order occurs at 800 fs, which is 4 times slower compared to electron-phonon equilibration due to a smaller spin-dependent relaxation phase space.

Large tunable Rashba spin splitting of a two-dimensional electron gas in Bi2Se3

We report a Rashba spin splitting of a two-dimensional electron gas in the topological insulator Bi(2)Se(3) from angle-resolved photoemission spectroscopy. We further demonstrate its electrostatic control, and show that spin splittings can be achieved which are at least an order-of-magnitude larger than in other semiconductors. Together these results show promise for the miniaturization of spintronic devices to the nanoscale and their operation at room temperature.

Experimental state tomography of itinerant single microwave photons

A wide range of experiments studying microwave photons localized in superconducting cavities have made important contributions to our understanding of the quantum properties of radiation. Propagating microwave photons, however, have so far been studied much less intensely. Here we present measurements in which we reconstruct the quantum state of itinerant single photon Fock states and their superposition with the vacuum by analyzing moments of the measured amplitude distribution up to fourth order. Using linear amplifiers and quadrature amplitude detectors, we have developed efficient methods to separate the detected single photon signal from the noise added by the amplifier. From our measurement data we have also reconstructed the corresponding Wigner function.

Tunable band gap in hydrogenated quasi-free-standing graphene

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Strength of correlation effects in the electronic structure of iron

The strength of electronic correlation effects in the spin-dependent electronic structure of ferromagnetic bcc Fe(110) has been investigated by means of spin and angle-resolved photoemission spectroscopy. The experimental results are compared to theoretical calculations within the three-body scattering approximation and within the dynamical mean-field theory, together with one-step model calculations of the photoemission process. This comparison indicates that the present state of the art many-body calculations, although improving the description of correlation effects in Fe, give too small mass renormalizations and scattering rates thus demanding more refined many-body theories including nonlocal fluctuations.

Linear plasmon dispersion in single-wall carbon nanotubes and the collective excitation spectrum of graphene

We have measured a strictly linear pi plasmon dispersion along the axis of individualized single-wall carbon nanotubes, which is completely different from plasmon dispersions of graphite or bundled single-wall carbon nanotubes. Comparative ab initio studies on graphene-based systems allow us to reproduce the different dispersions. This suggests that individualized nanotubes provide viable experimental access to collective electronic excitations of graphene, and it validates the use of graphene to understand electronic excitations of carbon nanotubes. In particular, the calculations reveal that local field effects cause a mixing of electronic transitions, including the "Dirac cone," resulting in the observed linear dispersion.