One-year Follow-up of Neuropsychology, MRI, rCBF and Glucose Metabolism (rMRGlu) in Cerebral Microangiopathy

Background: MRI shows lacunar infarctions (LI), deep white matter lesions (DWML) and atrophy in cerebral microangiopathy, which is said to lead to vascular dementia. In a first trial series on 57 patients with confirmed pure cerebral microangiopathy (without concomitant macroangiopathy), neuropsychological impairment and (where present) brain atrophy correlated with decreased rCBF and rMRGlu. LI and DWML did not correlate with either neuropsychological impairment or decreased rCBF/rMRGIu. This study was done one year later to detect changes in any of the study parameters. Methods: 26 patients were re-examined for rCBF, rMRGlu, LI, DWML, atrophy and neuropsychological performance (7 cognitive, 3 mnestic, 4 attentiveness tests). Using a special head holder for exact repositioning, rCBF (SPECT) and rMRGlu (PET) were measured and imaged slice by slice. White matter/cortex were quantified using MRI-defined ROIs. Results: After one year the patients did not show significant decreases in rCBF or rMRGlu either in cortex or in white matter (p >0.05), nor did any patient show LI, DWML or atrophy changes on MRI. There were no significant neuropsychological decreases (p >0.05). Conclusions: Cerebral microangiopathy ought to show progressive neuropsychological, functional (rCBF, rMRGlu) and morphological deterioration over periods >1 year. It is unlikely that direct cortical damage (e.g., incomplete infarction) is responsible for neuropsychological impairment since one-year follow-up of our patients revealed no progression of brain atrophy or any other cortical damage.

Mitochondrial transfer between cells: Methodological constraints in cell culture and animal models

Interest in the recently discovered phenomenon of mitochondrial transfer between mammalian cells has gained momentum since it was first described in cell culture systems more than a decade ago. Mitochondria-targeting fluorescent dyes have been repurposed and are now widely used in these studies and in acute disease models, sometimes without due consideration of their limitations, while vectors containing mitochondrially-imported fluorescent proteins have complemented the use of mitochondria-targeting dyes. Genetic approaches that use mitochondrial DNA polymorphisms have also been used in some in vitro studies and in tumor models and are particularly useful where mtDNA is damaged or deleted. These approaches can also be used to study the long-term consequences of mitochondrial transfer such as in bone marrow and organ transplantation and in tumour biology where inherent mitochondrial damage is often a key feature. As research on intercellular mitochondrial transfer moves from cell culture into animal models and human diseases it will be important to understand the limitations of the various techniques in order to apply appropriate methodologies to address physiological and pathophysiological conditions.

Extracting Aggregation Free Energies of Mixed Clusters from Simulations of Small Systems: Application to Ionic Surfactant Micelles

Micelle cluster distributions from molecular dynamics simulations of a solvent-free coarse-grained model of sodium octyl sulfate (SOS) were analyzed using an improved method to extract equilibrium association constants from small-system simulations containing one or two micelle clusters at equilibrium with free surfactants and counterions. The statistical-thermodynamic and mathematical foundations of this partition-enabled analysis of cluster histograms (PEACH) approach are presented. A dramatic reduction in computational time for analysis was achieved through a strategy similar to the selector variable method to circumvent the need for exhaustive enumeration of the possible partitions of surfactants and counterions into clusters. Using statistics from a set of small-system (up to 60 SOS molecules) simulations as input, equilibrium association constants for micelle clusters were obtained as a function of both number of surfactants and number of associated counterions through a global fitting procedure. The resulting free energies were able to accurately predict micelle size and charge distributions in a large (560 molecule) system. The evolution of micelle size and charge with SOS concentration as predicted by the PEACH-derived free energies and by a phenomenological four-parameter model fit, along with the sensitivity of these predictions to variations in cluster definitions, are analyzed and discussed.

The Anti-helminthic Compound Mebendazole Has Multiple Antifungal Effects against Cryptococcus neoformans

Cryptococcus neoformans is the most lethal pathogen of the central nervous system. The gold standard treatment of cryptococcosis, a combination of amphotericin B with 5-fluorocytosine, involves broad toxicity, high costs, low efficacy, and limited worldwide availability. Although the need for new antifungals is clear, drug research and development (R&D) is costly and time-consuming. Thus, drug repurposing is an alternative to R&D and to the currently available tools for treating fungal diseases. Here we screened a collection of compounds approved for use in humans seeking for those with anti-cryptococcal activity. We found that benzimidazoles consist of a broad class of chemicals inhibiting C. neoformans growth. Mebendazole and fenbendazole were the most efficient antifungals showing in vitro fungicidal activity. Since previous studies showed that mebendazole reaches the brain in biologically active concentrations, this compound was selected for further studies. Mebendazole showed antifungal activity against phagocytized C. neoformans, affected cryptococcal biofilms profoundly and caused marked morphological alterations in C. neoformans, including reduction of capsular dimensions. Amphotericin B and mebendazole had additive anti-cryptococcal effects. Mebendazole was also active against the C. neoformans sibling species, C. gattii. To further characterize the effects of the drug a random C. gattii mutant library was screened and indicated that the antifungal activity of mebendazole requires previously unknown cryptococcal targets. Our results indicate that mebendazole is as a promising prototype for the future development of anti-cryptococcal drugs.

Cervical cord and ventricle affection in neuromyelitis optica

OBJECTIVES

Cervical cord involvement is common in neuromyelitis optica (NMO) and multiple sclerosis (MS), but its impact on disability in NMO has rarely been studied. Recent publications on NMO examined the periventricular system, areas of high aquaporin-4 expression, but not yet by using ventricle volumetry.

PURPOSE

To compare cervical cord atrophy, ventricular widening, and supra- and infratentorial brain measures between NMO and MS, and study their impact on clinical disability.

METHODS

Magnet resonance imaging-based volumetry of upper cervical cord, third and fourth lateral ventricles, grey matter, white matter, brainstem, cerebellum and clinical status of 18 NMO and 20 MS patients, was compared between the groups and with 26 healthy controls. Patterns of ventricular widening relative to healthy controls were inspected by voxel-based morphometry of the cerebrospinal fluid.

RESULTS

Cervical cord atrophy was similar in NMO and MS (75.2 ± 10.0 mm² , respectively, 76.5 ± 9.5 mm² vs 84.1 ± 8.6 mm² in controls).Third ventricle increase in both groups, and specific fourth ventricle widening in MS were detected. Patient groups differed in third to fourth ventricle ratio (P = 0.002). In NMO, white matter correlated inversely with the affected cord segments (P = 0.001) and with cervical cord area (P = 0.043). The disability status was explained by cervical cord area and third ventricle volume (R² =0.524) in NMO, and by grey matter and fourth ventricle volume (R² =0.565) in MS.

CONCLUSION

Cervical cord atrophy and third ventricular enlargement are both clinically relevant in NMO. Third and fourth ventricle volumetry shows differences between NMO and MS regarding the involvement of periventricular structures.

Abstract P3-13-01: Determining the breast tumor margin through genomics of the cancer-stromal interaction

This abstract was withdrawn by the authors.

Nontuberculous Mycobacterial Disease In Rhesus Monkeys

In a colony of rhesus monkeys (Macaca mulatta), 42 cases of nontuberculous mycobacterial-related disease were identified from 1970 to 1978. The disease affected young and old colony-born and wild-caught monkeys of both sexes. Serotypes 1, 2, 4, 8, and 18 of the Mycobacterium avium-intracellulare group were isolated from different monkeys. The lesions were primarily intestinal in 36 monkeys. Lesions of the large intestine, small intestine, and mesenteric lymph nodes were characterized by diffuse accumulations of large macrophages containing many acid-fast bacteria. Acid-fast bacteria could not be identified histologically in four monkeys with typical histories of diarrhea and weight loss, positive skin reactions to the tuberculin test with M. avium tuberculin, and isolation of the organism from tissues on one or more occasions. Two monkeys had histologically positive lesions limited to the lungs, although chronic colitis of undetermined cause was present.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Best practice for perioperative management of patients with cytoreductive surgery and HIPEC

Due to the significantly improved outcome and quality of life of patients with different tumor entities after cytoreductive surgery (CRS) and HIPEC, there is an increasing number of centers performing CRS and HIPEC procedures. As this procedure is technically challenging with potential high morbidity and mortality, respectively, institutional experience also in the anesthetic and intensive care departments is essential for optimal treatment and prevention of adverse events. Clinical pathways have to be developed to achieve also good results in more comorbid patients with border line indications and extensive surgical procedures. The anesthesiologist has deal with relevant fluid, blood and protein losses, increased intraabdominal pressure, systemic hypo-/hyperthermia, and increased metabolic rate in patients undergoing cytoreductive surgery with HIPEC. It is of utmost importance to maintain or restore an adequate volume by aggressive substitution of intravenous fluids, which counteracts the increased fluid loss and venous capacitance during this procedure. Supplementary thoracic epidural analgesia, non-invasive ventilation, and physiotherapy are recommended to guarantee adequate pain therapy and postoperative extubation as well as fast-track concepts. Advanced hemodynamic monitoring is essential to help the anesthesiologist picking up information about the real-time fluid status of the patient. Preoperative preconditioning is mandatory in patients scheduled for HIPEC surgery and will result in improved outcome. Postoperatively, volume status optimization, early nutritional support, sufficient anticoagulation, and point of care coagulation management are essential. This is an extensive update on all relevant topics for anesthetists and intensivists dealing with CRS and HIPEC.

Using the Grade Approach to Support the Development of Recommendations for Public Health Interventions in Radiation Emergencies

The World Health Organization (WHO) guideline development policy requires that WHO guidelines be developed in a manner that is transparent and based on all available evidences, which must be synthesised and formally assessed for quality. To fulfil this requirement, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach of rating quality of evidence and grading strength of recommendations was applied when developing the WHO recommendations on public health interventions in radiation emergencies. The guideline development group (GDG) formulated 10 PICO (P: population; I: intervention; C: comparator; O: outcomes) questions to guide the development of recommendations on response interventions during the early/intermediate and late emergency phases and on risk communications for mitigating psycho-social impact of radiation emergencies. For each PICO question, an extensive evidence search and systematic review was conducted. The GDG then formulated the recommendations using the evidence to recommendation (E-2-R) decision-making matrix and evaluated the strength of each recommendation.

Tree Tensor Network State with Variable Tensor Order: An Efficient Multireference Method for Strongly Correlated Systems

We study the tree-tensor-network-state (TTNS) method with variable tensor orders for quantum chemistry. TTNS is a variational method to efficiently approximate complete active space (CAS) configuration interaction (CI) wave functions in a tensor product form. TTNS can be considered as a higher order generalization of the matrix product state (MPS) method. The MPS wave function is formulated as products of matrices in a multiparticle basis spanning a truncated Hilbert space of the original CAS-CI problem. These matrices belong to active orbitals organized in a one-dimensional array, while tensors in TTNS are defined upon a tree-like arrangement of the same orbitals. The tree-structure is advantageous since the distance between two arbitrary orbitals in the tree scales only logarithmically with the number of orbitals N, whereas the scaling is linear in the MPS array. It is found to be beneficial from the computational costs point of view to keep strongly correlated orbitals in close vicinity in both arrangements; therefore, the TTNS ansatz is better suited for multireference problems with numerous highly correlated orbitals. To exploit the advantages of TTNS a novel algorithm is designed to optimize the tree tensor network topology based on quantum information theory and entanglement. The superior performance of the TTNS method is illustrated on the ionic-neutral avoided crossing of LiF. It is also shown that the avoided crossing of LiF can be localized using only ground state properties, namely one-orbital entanglement.

[Key Points of Intraoperative Diagnostic Measures Performed by Anaesthesiologists]

The main focus of surgeons and anaesthesiologists during a surgical procedure is on safety and optimal treatment of the patient. Within the scope of interdisciplinary collaboration, the intraoperative communication between surgeons and anaesthesiologists is the basis of case-, findings- and surgery-phases-adapted patient management. The perioperative monitoring of patients and the implementation of diagnostic measures by anaesthesiologists are essential for optimal patient management. The results of the examinations may significantly determine the course of surgery. Therefore, it is important for surgeons to be familiar with the relevant intraoperative diagnostic measures.

Allometric exponents as a tool to study the influence of climate on the trade-off between primary and secondary growth in major north-eastern American tree species

BACKGROUND AND AIMS

Trees invest in both primary (e.g. height) and secondary (e.g. diameter) growth. The trade-off between these investments varies between species and changes with the tree growing environment. To better establish this trade-off, readily available allometric exponents relating height to diameter at breast height (γ(h,dbh)) and stem volume to diameter at breast height (α(v,dbh)) were simultaneously studied.

METHODS

Allometric exponents α(v,dbh) and γ(h,dbh) were obtained from 8893 individual tree stem analyses from two broadleaved species (Betula papyrifera, Populus tremuloides) and four conifers (Picea glauca, Picea mariana, Pinus banksiana, Abies balsamea) in the temperate and boreal forests of the province of Quebec, Canada. α(v,dbh) and γ(h,dbh) were related to tree age, stand density index (SDI), and mean temperature (TGS) and total precipitation (PGS) of the growing season.

KEY RESULTS

α(v,dbh) and γ(h,dbh) were found to be invariant with PGS and positively related to SDI and TGS for all species except Pinus banksiana. The parameter values associated with SDI and TGS were of higher value for conifers than for broadleaved species.

CONCLUSIONS

This suggests that conifers and broadleaved species have different growth patterns. This could be explained by their different mode of development, the conifer species having a stronger apical dominance than broadleaved species. Such results could be further considered in allocation studies to quantify future carbon stocks in managed forests.

pH and concentration dependence of the optical properties of thiol-capped CdTe nanocrystals in water and D2O

The optical properties of semiconductor nanocrystals (SC NCs) are largely controlled by their size and surface chemistry, i.e., the chemical nature and number of surface ligands as well as the strength of the particle-ligand bond.

[Surgical strategy during intended total thyroidectomy after loss of EMG signal on the first side of resection]

BACKGROUND

Unambiguous identification of the recurrent laryngeal nerve with detection of nerve dysfunction giving rise to postoperative vocal cord palsy (VCP) is the principal objective of intraoperative neuromonitoring (IONM) in thyroid surgery. Because intraoperative loss of the electromyographic (EMG) signal (LOS) does not result in VCP in one third of patients, controversy surrounds the issue of whether a change in strategy is needed in planned total thyroidectomy after LOS on the first side of resection.

PATIENTS AND METHODS

This was a retrospective institutional study of 1,049 consecutive patients (2,086 nerves at risk) with intended bilateral thyroid surgery who were operated on between April 2010 and July 2012 with the use of IONM. The rates of temporary and permanent VCP were analyzed on the basis of the IONM results of the first side of resection and the extent of contralateral resection for completion: resection without LOS (group 1); resection with LOS and contralateral thyroidectomy (group 2); resection with LOS and contralateral subtotal resection (group 3); resection with LOS without any contralateral resection (group 4).

RESULTS

LOS on the first side of resection was noted in 27 patients (2.6 %). All VCPs were unilateral. The rates of temporary and permanent VCP were 2.5 and 0.4 %, respectively, overall; specifically: group 1: 0.5 and 0 %; group 2: 64 and 9.1 %; group 3: 100 and 50 %; group 4: 83 and 8.3 %, respectively.

CONCLUSION

Because an abnormal intraoperative electromyogram carries an 80 % risk for early postoperative VCP, the initial plan of bilateral surgery needs to be critically reviewed after LOS has occurred on the first side of resection, taking into account the underlying thyroid disease of the patient and surgeon expertise. Since more than 80 % of affected nerves will fully recover after the operation, staged completion thyroidectomy is recommended.

Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring

Background

Continuous monitoring of electromyographic (EMG) amplitudes of the vocal muscles detects impending injury of the recurrent laryngeal nerve (RLN) during thyroid operations earlier than intermittent EMG monitoring. This may alert the surgeon to stop a manoeuvre causing stretching or pressure on the RLN, with better recovery of nerve function.

Methods

Patients with intact preoperative RLN function who underwent thyroid surgery for benign disease between January 2011 and September 2014 under continuous intraoperative nerve monitoring (CIONM) or intermittent intraoperative nerve monitoring (IIONM) were included in this observational study conducted at a tertiary surgical centre. For CIONM, combined EMG events indicative of imminent nerve injury were defined as an EMG amplitude decrease of 50 per cent or more and a latency increase of 10 per cent relative to baseline values. The rates of early and permanent palsy for the two groups of patients were compared.

Results

There were 1526 patients, 788 of whom (1314 nerves at risk) underwent thyroid surgery using CIONM and 738 (965 nerves at risk) had IIONM. With the use of CIONM, 63 (82 per cent) of 77 combined events were reversible during the operation. No permanent vocal fold palsy occurred with CIONM, whereas four unilateral permanent vocal fold palsies (0·4 per cent) were diagnosed after IIONM (P = 0·019).

Conclusion

Operation with CIONM resulted in fewer permanent vocal fold palsies compared with IIONM after thyroid surgery in patients with benign disease.

Supplemented vs. unsupplemented human milk on bone mineralization in very low birth weight preterm infants: a randomized clinical trial

Very low birth weight preterm newborns weighing less than 1500 g were randomized to receive human milk supplemented with FM 85® or not. They have similar bone mineral content (BMC) at baseline, but, at the end of study, BMC was increasingly higher in the FM 85® group.

INTRODUCTION

The purpose of this study is to evaluate the effectiveness of a human milk supplement (FM 85®; Nestlé, Vevey, Switzerland) developed for the purpose of improving nutrition, including bone mineralization, in very low birth weight preterm newborns.

METHODS

Preterm infants weighing less than 1500 g at birth admitted to the neonatal intensive care unit of a university hospital were studied. During hospitalization, they were fed at least 50 % of human milk. Newborns with ≥20 days of age were randomly assigned to the intervention group (n = 19) to receive human milk supplemented with FM 85® or to a control group (n = 19) to receive human milk only. Anthropometric measurements, whole-body bone densitometry (DXA), and biochemical tests were performed at study entry and at the end of the study (shortly before discharge when the infant had reached 2000 g).

RESULTS

There were no start- or end-of-study differences between the two groups, except for daily increase in length (p = 0.010). At baseline, both groups had similar BMC: 5.49 ± 3.65 vs. 4.34 ± 2.98 g (p = 0.39) for the intervention and control group, respectively. However, at the end of the study, BMC was higher in the intervention group: 10.3 ± 4.71 vs. 6.19 ± 3.23 g (p = 0.003). The mean increase in BMC during the observation period was 4.90 ± 4.46 g for the intervention group and 1.86 ± 3.17 g for the control group (p = 0.020). Serum alkaline phosphatase levels were higher in the control group (720 ± 465 vs. 391 ± 177 IU/L; p = 0.007).

CONCLUSIONS

Our data suggest that supplementation of human milk with FM 85® leads to improved bone mineralization in very low birth weight preterm newborns.

[Gender-specific aspects of Lynch syndrome--an update]

Approximately 3-5% of all colorectal cancers are based on a hereditary predisposition, of which Lynch syndrome is by far the most frequent hereditary cancer syndrome. Beside colorectal cancer Lynch-Syndrome is the most frequent predisposing hereditary cause of endometrial cancer and is also associated with gastric cancer, ovarian cancer, cancer of the urinary tract as well as several other cancers. Genetically Lynch syndrome is caused by a germline mutation in one of the so-called mismatch-repair-genes. Based on several epidemiological studies, increasingly differences in the penetrance of the different cancers occurring are associated with the affected gene and also gender of the patient have been reported. The lifetime risk of colorectal cancer for males with Lynch syndrome generally is significantly higher and the age of first manifestation significantly earlier compared to females. The difference is especially notable in men with a MSH6-mutation. Moreover, the lifetime risk for gastric, bladder, and urothelial cancer is much higher in males. Women with an MSH6 mutation have a much higher risk for endometrial (and ovarian) cancer than for colorectal cancer. In patients with Muir Torre syndrome again males are predominantly affected and almost all affected have a mutation in MSH2 rather than in any other MMR gene. This review is an update of the literature analyzing gen and gender specific aspects of Lynch syndrome. To date these associations are based on retrospective studies, that require confirmation in a prospective setting with large patient numbers in order to identify validated, individualized gene and gender screening recommendations in the future. Especially in a syndrome with multiple potential cancer targets, an intense yearly program comprising several invasive procedures has a negative effect on patient compliance.

Adjunctive surgical atrial fibrillation ablation during cardiac surgery: real life experiences

AIM

Several tools have been invented for surgical atrial fibrillation (AF) ablation. In this study, we investigated the real world efficacy of intraoperative AF ablation (AFA) with radiofrequency-energy or cryo-ablation and performed an electro-anatomical remap in some patients with recurrences.

METHODS

Seventy-three consecutive patients (53 male, median age of 69 ± 7 years) with history of AF underwent cardiac surgery for valve repair (74 % mitral defects, 60 % aortic defects) and/or coronary artery bypass graft procedures (56 %). During a follow-up of 23 ± 11 months after AFA we performed intensified holter-monitoring (4-7 days). Patients with symptomatic relapse of atrial arrhythmias (AA) were offered the opportunity for additional electrophysiological examination (EPE).

RESULTS

During 23 ± 11 months after AFA, 45 patients (62 %) had recurrent AA. In eight patients we performed EPE. In all 8 cases, septal circumferential lesions could be demonstrated during mapping with discrete gaps. All lateral veins were isolated however, posteriorly deep inside the vein leaving the antral region completely untreated. Neither roof lines nor mitral isthmus lines were complete. Performing catheter ablation, all veins could be isolated and seven patients were free of any arrhythmias during follow up (9 ± 5 months) without taking antiarrhythmic drugs.

CONCLUSION

Surgical AF ablation may often be incomplete rendering sobering results in unselected patients. Completion of the ablation is feasible with catheter ablation with good clinical outcome.