Analysis of external flooding and tsunamis for nuclear power plants at tidal rivers

The German regulatory body has issued technical documents on methods and data for probabilistic safety assessment, elaborated for a comprehensive integrated safety review of all nuclear power plants in operation. These documents contain, among others, a graded approach for the probabilistic assessment of external flooding. Main aspects are explained such as the underlying probabilistic considerations and the mathematical procedures for the calculation of exceedance frequencies for nuclear power plants at tidal rivers in Germany. Morever, extreme events such as tsunami waves have been investigated.

[Aesthetic augmentation of the dorsum, mid-term results]

PURPOSE OF THE STUDY

Dorsum aesthetic augmentation can be divided according to their objective, total and partial increase or camouflage. The objective of this original article is to define the valid techniques in each indication through a cohort study, clinical cases, and current data from the literature.

PATIENT AND METHOD

It is a monocentric mono operator retrospective study from 2005 to 2010 included. On 171 rhinoplasties, 57 were augmentation rhinoplasties of which 40 were of interest to the dorsum. Excluded patients were bone grafts, lost and one patient operated on a active Wegener desease. Thus 26 rhinoplasties were analyzed by an independent observer.

RESULTS

All grafts confused there were 11.5% of resorption which corresponds to the data from the literature, 17% of resorption in the camouflage indications and 7% in augmentation, as well as a higher resorption for crushed cartilage (33%) rate. There was more mobility in augmentation (28%) than in the camouflage (8%) and greater visibility of the banks of the graft in augmentation (35%) compared to the camouflage (8%).

CONCLUSION

In the mild to severe saddle nose, the DCF is greater than cartilage monobloc or crushed in terms of stability and visibility, its indications could be expanded to harmonisation. Camouflage crushed cartilage is not sustainable and the temporal aponeurosis could it be preferred. Resorbable fillers can offer an alternative to surgery or improve its results.

Maintaining success, reducing treatment burden, focusing on survivorship: highlights from the third European consensus conference on diagnosis and treatment of germ-cell cancer

In November 2011, the Third European Consensus Conference on Diagnosis and Treatment of Germ-Cell Cancer (GCC) was held in Berlin, Germany. This third conference followed similar meetings in 2003 (Essen, Germany) and 2006 (Amsterdam, The Netherlands) [Schmoll H-J, Souchon R, Krege S et al. European consensus on diagnosis and treatment of germ-cell cancer: a report of the European Germ-Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15: 1377-1399; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53: 478-496; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part II. Eur Urol 2008; 53: 497-513]. A panel of 56 of 60 invited GCC experts from all across Europe discussed all aspects on diagnosis and treatment of GCC, with a particular focus on acute and late toxic effects as well as on survivorship issues. The panel consisted of oncologists, urologic surgeons, radiooncologists, pathologists and basic scientists, who are all actively involved in care of GCC patients. Panelists were chosen based on the publication activity in recent years. Before the meeting, panelists were asked to review the literature published since 2006 in 20 major areas concerning all aspects of diagnosis, treatment and follow-up of GCC patients, and to prepare an updated version of the previous recommendations to be discussed at the conference. In addition, ∼50 E-vote questions were drafted and presented at the conference to address the most controversial areas for a poll of expert opinions. Here, we present the main recommendations and controversies of this meeting. The votes of the panelists are added as online supplements.

Loss of EphA4 impairs short-term spatial recognition memory performance and locomotor habituation

EphA4 receptor (EphA4) tyrosine kinase is an important regulator of central nervous system development and synaptic plasticity in the mature brain, but its relevance to the control of normal behavior remains largely unexplored. This study is the first attempt to obtain a behavioral profile of constitutive homozygous and heterozygous EphA4 knockout mice. A deficit in locomotor habituation in the open field, impairment in spatial recognition in the Y-maze and reduced probability of spatial spontaneous alternation in the T-maze were identified in homozygous EphA4(-/-) mice, while heterozygo us EphA4(+/-) mice appeared normal on these tests in comparison with wild-type (WT) controls. The multiple phenotypes observed in EphA4(-/-) mice might stem from an underlying deficit in habituation learning, reflecting an elementary form of nonassociative learning that is in contrast to Pavlovian associative learning, which appeared unaffected by EphA4 disruption. A deficit in motor coordination on the accelerating rotarod was also demonstrated only in EphA4(-/-) mice--a finding in keeping with the presence of abnormal gait in EphA4(-/-) mice--although they were able to improve performance over training. There was no evidence for substantial changes in major neurochemical markers in various brain regions rich in EphA4 as shown by post-mortem analysis. This excludes the possibility of major neurochemical compensation in the brain of EphA4(-/-) mice. In summary, we have demonstrated for the first time the behavioral significance of EphA4 disruption, supporting further investigation of EphA4 as a possible target for behavioral interventions where habituation deficits are prominent.

Holmium laser ablation of the prostate (HoLAP): intermediate-term results of 144 patients

PURPOSE

To retrospectively analyse the intermediate-term outcome of holmium laser ablation of the prostate (HoLAP) of up to 4 years postoperatively in one of the largest series and to define the selection criteria for patients who benefit from potentially lower complications associated with HoLAP.

METHODS

Between June 2006 and November 2010, 144 patients with benign prostatic obstruction were treated at two centres with standardised HoLAP (2.0 J/50 Hz or 3.2 J/25 Hz with Versapulse(®) 80-100 W laser Lumenis(®)). Median follow-up was 21 months (range, 1-54). International prostate symptom score and quality of life (IPSS-QoL), PSA, prostate volume, maximal flow rate (Qmax), postvoiding residual volume (Vres) were evaluated pre- and postoperatively. All complications were graded according to CTCAE (v4.03).

RESULTS

Mean patient age was 70.1 ± 7.7 years (range, 46-90). With a preoperative median prostate volume of 40 ml (range, 10-130), the median operation time was 50 min (range, 9-138). We observed a median catheterisation time of 1 day (range, 0-12) and hospitalisation time of 2 days (range, 1-16). IPSS-QoL, Qmax and Vres were significantly improved after 3 months, and all parameters remained unchanged after 12, 24 and 36 months. The rate of re-operation was significantly lower in patients with prostate volume <40 ml, compared to patients with prostates ≥ 40 ml (9.1 vs. 25 %, p = 0.04).

CONCLUSIONS

HoLAP is a safe and effective procedure for the treatment of prostates <40 ml. Patients benefit from HoLAP because of a low bleeding rate and short hospital stay. Due to high recurrence rates, HoLAP should be avoided in prostates >40 ml.

Antibody targeting of anaplastic lymphoma kinase induces cytotoxicity of human neuroblastoma

Anaplastic lymphoma kinase (ALK) is a receptor tyrosine kinase aberrantly expressed in neuroblastoma, a devastating pediatric cancer of the sympathetic nervous system. Germline and somatically acquired ALK aberrations induce increased autophosphorylation, constitutive ALK activation and increased downstream signaling. Thus, ALK is a tractable therapeutic target in neuroblastoma, likely to be susceptible to both small-molecule tyrosine kinase inhibitors and therapeutic antibodies-as has been shown for other receptor tyrosine kinases in malignancies such as breast and lung cancer. Small-molecule inhibitors of ALK are currently being studied in the clinic, but common ALK mutations in neuroblastoma appear to show de novo insensitivity, arguing that complementary therapeutic approaches must be developed. We therefore hypothesized that antibody targeting of ALK may be a relevant strategy for the majority of neuroblastoma patients likely to have ALK-positive tumors. We show here that an antagonistic ALK antibody inhibits cell growth and induces in vitro antibody-dependent cellular cytotoxicity of human neuroblastoma-derived cell lines. Cytotoxicity was induced in cell lines harboring either wild type or mutated forms of ALK. Treatment of neuroblastoma cells with the dual Met/ALK inhibitor crizotinib sensitized cells to antibody-induced growth inhibition by promoting cell surface accumulation of ALK and thus increasing the accessibility of antigen for antibody binding. These data support the concept of ALK-targeted immunotherapy as a highly promising therapeutic strategy for neuroblastomas with mutated or wild-type ALK.

[High-dose chemotherapy and residual tumor resection in male germ cell tumors]

As a consequence of the unsatisfactory results of conventional dose salvage regimens, in particular for patients with poor prognostic features at the time of relapse or in patients with refractory disease, high-dose chemotherapy (HDCT) was introduced into clinical practice in the late 1980s. The combination of carboplatin and etoposide (CE) still remains the backbone of most high-dose regimens. Multiple modifications with more dose escalations or addition of further drugs have been explored, most often with increased toxicity. With improved expertise in supportive care and the use of peripheral blood stem cells, hematopoetic recovery has been significantly shortened and the initial high treatment-related mortality reduced from more than 10% to about 3%. Since the incorporation of HDCT, even patients with unfavorable prognostic features or patients with second or subsequent relapses can achieve long-term remission. Following HDCT residual tumor resection plays a major role in achieving these long-term results. The proportion of vital residual tumor after HDCT is much higher than in patients after conventional chemotherapy. The role of HDCT remains controversial particularly as a first-line treatment and less so in the first salvage setting. As these patients are rare HDCT and residual tumor resection should only be be provided by high-volume centers with sufficient expertise in performing these complex procedures.

Pathohistologic findings in patients with nonseminomatous germ cell tumors (NSGCT) who undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for small tumors

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Background: The current guidelines recommend the resection of all visible residual tumors in NSGCT after a cisplatin based chemotherapy. There are controversial data concerning the necessity of PC-RPLND in patients with residual tumours less than one centimetre in diameter. The aim of our study was to evaluate the pathological findings in a modern series with regard of the residual tumour size.

Methods: A retrospective analysis of the patient's charts was performed including patients who underwent PC-RPLND between 1989 and 2010. Of 408 patients 330 had a NSGCT, 78 patients had a pure seminoma or a primary extragonadal germ cell cancer and were excluded from analysis. The tumour size at the time of surgery was available in 261 patients in the remaining 69 pateints no preopretive data with regard to the tumour size were recorded in the radiology reports. Due to the location of the residual tumour a median laparotomy, a thoracoabdominal approach was used. In one center a laparoscopic approach was preferred.

Results: Mean tumour diameter was 4.7 (0 to 32) cm. The patients were stratified in three groups: group 1 n=28 (RT<=1cm), group 2 n=23 (RT>1<=1.5cm) and group 3 n=209 (RT>1.5cm). The histological specimens contained teratoma in 21.4%, 39.1%, 44.5% respectively, viable cancer in 10.7%, 17.4% and 22% respectively, and fibrosis/necrosis in 64.3%, 52.2% and 37.8% respectively in the three grpups respectively.

Conclusions: The finding of both teratoma and viable cancer decreases with decreasing sizes of the residual tumour. Nevertheless lesions <= than 1 cm still harbour a significant pathohistology in one third of the patients. As a consequence PC-RPLND must not be omitted even in small RT.

No significant financial relationships to disclose.

Comparing the perioperative management of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with pure seminomatous and nonseminomatous germ cell tumors (NSGCT)

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Background: PC-RPLND is a potentially complicated intervention. By the time the rate of complications and adjunctive surgery increased. Only few data are available concerning PC-RPLND in patients with advanced seminomas and residual retroperitoneal tumour lesions. We examined the intra and postoperative complications as well as the frequency of adjunctive surgeries in patients with seminoma and compared the data to a cohort of patients with NSGCT who underwent PC-RPLND.

Methods: In our multicenter retrospective analyses 408 patients underwent PC-RPLND between 1989 and 2010. 47 patients with advanced seminomas and 327 patients with NSGCT. The surgical approach was preferred via a midline incision or a thoracoabdominal approach due to the location of the residual tumour. In one center a laparoscopic approach was preferred.

Results: Of the 47 patients with seminoma a total number of 18 adjunctive surgeries were performed in 11 patients (8 nephrectomies, 3 inferior v.cava resections, 3 resections of the abdominal aorta, 2 resections of the colon, one nerv and 2 hepatic resections/biopsies). There was only one major intraoperative complication, injury of the v. cava and two postoperative complications, (prolonged intestinal paralyses). There were no significant differences adjunctive surgeries and postoperative complications (p=0.48 and p=0.133). There were significantly less intraoperative complications in favour of seminomas (p=0.006).

Conclusions: PCRLND in seminomas and NSGCT is a demanding surgical intervention. In contrast to other series we did not find significant differences in the two patient groups concerning adjunctive surgeries and postoperative complications. The indication for PCLND in patients with seminoma is limited, but if necessary it can be performed safely in experienced centers.

No significant financial relationships to disclose.

Prognostic clinical parameters to predict the necessity of reconstructive vascular surgery for patients who undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for advanced nonseminatous germ cell tumors (NSGCT)

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Background: PC-RPLND remains an integral part of the multimodality treatment for advanced NSGCT. The need to resect and to replace the major retroperitoneal vessels must be known preoperatively to enable complete resection of the residual masses.

Methods: PC-RPLND was performed in 411 patients with NSGCT and normalized (81%) or plateauing (19%) tumor markers following 3-4 cycles PEB/PEI. PC-RPLND was performed in 5 institutions with a variable surgical frequency of 14 to 158 PC-RPLNDs. Good, intermediate, and poor prognosis according to the IGCCCG criteria was identified in in 59.8%, 21.2%, and 19% respectively.

Results: Resection of the inferior vena cava was performed in 28 (6.81%), resection of the abdominal aorta was necessary in 13 (3.16%) patients. In 29/41 (70.7%) adjunctive surgical procedures such as nephrectomy, small bowel resection, ureteral resection had to be performed to ensure complete resection of the residual masses. Histologically vital cancer or mature teratoma was identified in 78.1% of the resected vascular specimens. Mean time of surgery was 295 (243-615) Min., mean blood loss was 690 (350 – 3400) ml. Good prognosis was identified in 15.4%, intermediate and poor prognosis was present in 41%and 43.6%, resp. Of all 411 patients involvement of the major retroperitoneal vessels was found in 3.2%, 18.4% and 21.8% with good, intermediate, and poor prognosis, resp. The mean tumor diameter was 5.9 (1.0 – 32) cm for the entire cohort and 9.8 (4-32) cm for the cohort of patients with vascular surgery. Significant prognosticators to predict vascular involvement were identified by multivariate analysis: intermediate/poor prognosis, number of cycles of chemotherapy, tumor diameter > 14cm, circumferential encasement of > 50% of the vessel diameter.

Conclusions: Complete resection of the inferior vena cava or the abdominal aorta during PC-RPLND is necessary in about 10% of patients. The identified predictors enable already preoperatively a risk adapted interdisciplinary approach for complete resection of the residual masses in an experienced centre.

No significant financial relationships to disclose.

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study

OBJECTIVE

To identify specific aspects of teamworking associated with greater clinical efficiency in simulated obstetric emergencies.

DESIGN

Cross-sectional secondary analysis of video recordings from the Simulation & Fire-drill Evaluation (SaFE) randomised controlled trial.

SETTING

Six secondary and tertiary maternity units.

SAMPLE

A total of 114 randomly selected healthcare professionals, in 19 teams of six members.

METHODS

Two independent assessors, a clinician and a language communication specialist identified specific teamwork behaviours using a grid derived from the safety literature.

MAIN OUTCOME MEASURES

Relationship between teamwork behaviours and the time to administration of magnesium sulfate, a validated measure of clinical efficiency, was calculated.

RESULTS

More efficient teams were likely to (1) have stated (recognised and verbally declared) the emergency (eclampsia) earlier (Kendall's rank correlation coefficient τ(b) = -0.53, 95% CI from -0.74 to -0.32, P=0.004); and (2) have managed the critical task using closed-loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged) (τ(b) = 0.46, 95% CI 0.17-0.74, P=0.022). Teams that administered magnesium sulfate within the allocated time (10 minutes) had significantly fewer exits from the labour room compared with teams who did not: a median of three (IQR 2-5) versus six exits (IQR 5-6) (P=0.03, Mann-Whitney U-test).

CONCLUSIONS

Using administration of an essential drug as a valid surrogate of team efficiency and patient outcome after a simulated emergency, we found that more efficient teams were more likely to exhibit certain team behaviours relating to better handover and task allocation.

[3 T MRI of the prostate in patients with symptomatic prostatic utricle cyst]

Cystic lesions of the prostate are rare and often asymptomatic. Medial cysts are conventionally divided into so-called Müllerian duct cysts and prostatic utricle cysts which seems rather questionable in light of recent studies. We report a case of a patient with a 10-year history of dysuria. Diagnostic imaging was performed using 3 T prostate MRI with a body coil. Because of the potential risk of retrograde ejaculation with subsequent infertility and of incontinence by the transurethral resection, the interventional therapy of his utricle cyst was abandoned.

[Deep brain stimulation for neurological and psychiatric diseases: animal experiments on effect and mechanisms]

Deep brain stimulation at high frequencies has emerged as a powerful therapeutic strategy in the treatment of basal ganglia-related movement disorders. Attempts have also been made to establish this for the treatment of therapy-resistant psychiatric disorders. To date the mechanisms underlying the clinical efficacy of high frequency stimulation remain largely unknown. Their detailed description, however, is essential for promoting the extended application of high frequency stimulation as a therapeutic alternative and may simultaneously allow conclusions to be drawn on the pathophysiological mechanisms underlying the diseases benefiting from deep brain stimulation. This review demonstrates how animal models contribute to i) further understand the mechanisms underlying deep brain stimulation at high frequencies and ii) promote the establishment of high frequency stimulation for the treatment of therapy-resistant psychiatric disorders.

Pharmacological inhibition of the lateral habenula improves depressive-like behavior in an animal model of treatment resistant depression

Identifying new treatment approaches for treatment resistant depression (TRD) is an important topic for translational psychiatry. Functional inhibition of the lateral habenula (LHb) has recently been claimed to offer such an option for TRD. Rats which are bred for high susceptibility to develop learned helplessness provide a genetic model for TRD. We used the gamma-aminobutyric acid agonist muscimol to inhibit the LHb in Sprague-Dawley rats with congenital learned helplessness (cLH). Stereotactic pharmacological inhibition of the LHb exerted antidepressive effects in treatment resistant cLH rats.

More to teamwork than knowledge, skill and attitude

OBJECTIVE

To assess whether team performance in simulated eclampsia is related to the knowledge, skills and attitudes of individual team members.

DESIGN

Cross-sectional analysis of data from the Simulation and Fire Drill Evaluation randomised controlled trial.

SETTING

Six secondary and tertiary maternity units in south-west England.

PARTICIPANTS

One hundred and fourteen maternity professionals in 19 teams of six members; one senior and one junior obstetrician; two senior and two junior midwives.

METHODS

We validated a team performance ranking scheme with respect to magnesium administration (Magnesium Administration Rank, MAR) by expert consensus (face validity) and correlation with clinical measures (construct validity). We tested for correlation between MAR and measures of knowledge, skills and attitudes.

MAIN OUTCOME MEASURES

Correlation between team performance (MAR) and scores in validated multiple-choice questionnaires (MCQs) (knowledge), a measure of individual manual skill to manage an obstetric emergency (skill) and scores in a widely used teamwork/safety attitude questionnaire (attitude).

RESULTS

There was no relationship between team performance and cumulative individual MCQs, skill or teamwork/safety attitude scores.

CONCLUSIONS

The knowledge, manual skills and attitudes of the individuals comprising each team, measured by established methods, did not correlate in this study with the team's clinical efficiency in the management of simulated eclampsia. The inference is that unidentified characteristic(s) play a crucial part in the efficiency of teams managing emergencies. Any emphasis of training programmes to promote individual knowledge, skills and attitudes alone may have to be re-examined. This highlights a need to understand what makes a team efficient in dealing with clinical emergencies.

Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial

OBJECTIVE

To compare the effectiveness of carbetocin and oxytocin when they are administered after caesarean section for prevention of postpartum haemorrhage (PPH).

STUDY DESIGN

Double-blind randomised single centre study (1:1 ratio).

SETTING

Teaching hospital in Bristol, UK with 6000 deliveries per annum.

POPULATION

Women at term undergoing elective or emergency caesarean section under regional anaesthesia, excluding women with placenta praevia, multiple gestation and placental abruption.

METHODS

Women were randomised to receive either carbetocin 100 microg or oxytocin 5 IU intravenously after the delivery of the baby. Perioperative care was otherwise normal and use of additional oxytocics was at the discretion of the operating obstetrician. Analysis was by intention to treat.

PRIMARY OUTCOME MEASURE

The proportion of women in each arm of the trial that needed additional pharmacological oxytocic interventions.

RESULTS

Significantly more women needed additional oxytocics in the oxytocin group (45.5% versus 33.5%, Relative risk 0.74, 95% CI 0.57-0.95). The majority of women had oxytocin infusions. There were no significant differences in the secondary outcomes, including major PPH, blood transfusions and fall in haemoglobin.

CONCLUSIONS

Carbetocin is associated with a reduced use of additional oxytocics. It is unclear whether this may reduce rates of PPH and blood transfusions.