Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study

BACKGROUND

Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing".

MATERIALS AND METHODS

Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: "instrument use", "tissue handling", "near misses and errors", and "end-product quality".

RESULTS

The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for "end-product quality", and "tissue handling" respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the "use of instruments" (M_beg. = 2.33, M_exp. = 3.94, p < 0.001), "tissue handling" (M_beg. = 2.11, M_exp. = 3.72, p < 0.001), "near misses and errors" (M_beg. = 2.67, M_exp. = 3.67, p < 0.001), and "end-product quality" (M_beg. = 2.78, M_exp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle.

CONCLUSIONS

The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.

Influence of on-farm measurements for heat stress indicators on dairy cow productivity, female fertility, and health

The aim of the present study was to quantify the effect of heat stress (HS) from different points in time on production, female fertility, and health traits. In this regard, on-farm measurements for temperature and relative humidity were combined into temperature-humidity indexes (THI), and merged with longitudinal cow traits from electronic recording systems. The study included traits from 22,212 Holstein cows kept in 15 large-scale dairy co-operator herds. Trait and meteorological data recording spanned a period between May 2013 and November 2015. Longitudinal production traits considered 191,911 test-day records for protein yield, protein percentage, and milk urea nitrogen (MUN). Female fertility traits were the pregnancies per AI (P/AI) and the number of daily inseminations per herd cow (INS/HCOW). Health traits considered clinical mastitis (MAST), retained placenta, puerperal disorders (PD) from d 0 to 10 postpartum, and the claw disorders digital phlegmona, digital dermatitis (DD), and interdigital hyperplasia from d 0 to 360 postpartum. For all traits, we analyzed the THI influence from the trait-recording day. In addition, we studied the time-lagged THI effect from the previous week. Linear mixed models were applied to estimate THI effects on Gaussian distributed production traits. For binary health and fertility traits, generalized linear mixed models with a logit link function were used. The continuous THI effect was either modeled linear, or via Legendre polynomials of order 4. Regression models for THI were validated via THI class effects (i.e., 5% percentiles for THI). Protein percentage decreased with increasing test-day THI, and with increasing THI from the previous week. Protein yield obviously decreased beyond THI 68 for both THI measurements (test-day THI and THI from previous week). For MUN, the visually identified test-day HS threshold was THI 70. Time-lagged THI effects on MUN were less obvious. For both THI measuring dates, INS/HCOW was highest at THI 57. Beyond THI 57, INS/HCOW substantially decreased. For P/AI, the visually identified HS threshold at the insemination date was THI 65. Temperature-humidity indexes from the previous week had a moderate detrimental effect on P/AI. Incidences for MAST, retained placenta, and PD during d 0 to 10 postpartum increased with increasing average THI from this period. Studying the whole lactation period, incidences for interdigital hyperplasia also increased with increasing THI from the previous week. An opposite THI response was identified for DD: DD decreased with increasing THI. For all health traits, associations between disease incidences and THI were almost linear. Hence, for health traits, no obvious HS thresholds were detected. Especially in early lactation, HS had a detrimental effect on cow productivity and female fertility. The influence of HS on cow health differed, depending on the disease pathogenesis.

Phenotypic relationships, genetic parameters, genome-wide associations, and identification of potential candidate genes for ketosis and fat-to-protein ratio in German Holstein cows

Energy demand for milk production in early lactation exceeds energy intake, especially in high-yielding Holstein cows. Energy deficiency causes increasing susceptibility to metabolic disorders. In addition to several blood parameters, the fat-to-protein ratio (FPR) is suggested as an indicator for ketosis, because a FPR >1.5 refers to high lipolysis. The aim of this study was to analyze phenotypic, quantitative genetic, and genomic associations between FPR and ketosis. In this regard, 8,912 first-lactation Holstein cows were phenotyped for ketosis according to a veterinarian diagnosis key. Ketosis was diagnosed if the cow showed an abnormal carbohydrate metabolism with increased content of ketone bodies in the blood or urine. At least one entry for ketosis in the first 6 wk after calving implied a score = 1 (diseased); otherwise, a score = 0 (healthy) was assigned. The FPR from the first test-day was defined as a Gaussian distributed trait (FPRgauss), and also as a binary response trait (FPRbin), considering a threshold of FPR = 1.5. After imputation and quality controls, 45,613 SNP markers from the 8,912 genotyped cows were used for genomic studies. Phenotypically, an increasing ketosis incidence was associated with significantly higher FPR, and vice versa. Hence, from a practical trait recording perspective, first test-day FPR is suggested as an indicator for ketosis. The ketosis heritability was slightly larger when modeling the pedigree-based relationship matrix (pedigree-based: 0.17; SNP-based: 0.11). For FPRbin, heritabilities were larger when modeling the genomic relationship matrix (pedigree-based: 0.09; SNP-based: 0.15). For FPRgauss, heritabilities were almost identical for both pedigree and genomic relationship matrices (pedigree-based: 0.14; SNP-based: 0.15). Genetic correlations between ketosis with FPRbin and FPRgauss using either pedigree- or genomic-based relationship matrices were in a moderate range from 0.39 to 0.71. Applying genome-wide association studies, we identified the specific SNP rs109896020 (BTA 5, position: 115,456,438 bp) significantly contributing to ketosis. The identified potential candidate gene PARVB in close chromosomal distance is associated with nonalcoholic fatty liver disease in humans. The most important SNP contributing to FPRbin was located within the DGAT1 gene. Different SNP significantly contributed to ketosis and FPRbin, indicating different mechanisms for both traits genomically.

Four-Body Scale in Universal Few-Boson Systems

The role of an intrinsic four-body scale in universal few-boson systems is the subject of active debate. We study these systems within the framework of effective field theory. For systems of up to six bosons we establish that no four-body scale appears at leading order (LO). However, we find that at next-to-leading order (NLO) a four-body force is needed to obtain renormalized results for binding energies. With the associated parameter fixed to the binding energy of the four-boson system, this force is shown to renormalize the five- and six-body systems as well. We present an original ansatz for the short-distance limit of the bosonic A-body wave function from which we conjecture that new A-body scales appear at N^{A-3} LO. As a specific example, calculations are presented for clusters of helium atoms. Our results apply more generally to other few-body systems governed by a large scattering length, such as light nuclei and halo states, the low-energy properties of which are independent of the detailed internal structure of the constituents.

Fission of Polyanionic Metal Clusters

Size-selected dianionic lead clusters Pb_{n}^{2-}, n=34-56, are stored in a Penning trap and studied with respect to their decay products upon photoexcitation. Contrary to the decay of other dianionic metal clusters, these lead clusters show a variety of decay channels. The mass spectra of the fragments are compared to the corresponding spectra of the monoanionic precursors. This comparison leads to the conclusion that, in the cluster size region below about n=48, the fission reaction Pb_{n}^{2-}→Pb_{n-10}^{-}+Pb_{10}^{-} is the major decay process. Its disappearance at larger cluster sizes may be an indication of a nonmetal to metal transition. Recently, the pair of Pb_{10}^{-} and Pb_{n-10}^{-} were observed as pronounced fragments in electron-attachment studies [S. König et al., Int. J. Mass Spectrom. 421, 129 (2017)IMSPF81387-380610.1016/j.ijms.2017.06.009]. The present findings suggest that this combination is the fingerprint of the decay of doubly charged lead clusters. With this assumption, the dianion clusters have been traced down to Pb_{21}^{2-}, whereas the smallest size for the direct observation was as high as n=28.

Genomic breeding values, SNP effects and gene identification for disease traits in cow training sets

Holstein Friesian cow training sets were created according to disease incidences. The different datasets were used to investigate the impact of random forest (RF) and genomic BLUP (GBLUP) methodology on genomic prediction accuracies. In addition, for further verifications of some specific scenarios, single-step genomic BLUP was applied. Disease traits included the overall trait categories of (i) claw disorders, (ii) clinical mastitis and (iii) infertility from 80 741 first lactation Holstein cows kept in 58 large-scale herds. A subset of 6744 cows was genotyped (50K SNP panel). Response variables for all scenarios were de-regressed proofs (DRPs) and pre-corrected phenotypes (PCPs). Initially, all sick cows were allocated to the testing set, and healthy cows represented the training set. For the ongoing cow allocation schemes, the number of sick cows in the training set increased stepwise by moving 10% of the sick cows from the testing to the training set in each step. The size of training and testing sets was kept constant by replacing the same number of cows in the testing set with (randomly selected) healthy cows from the training set. For both the RF and GBLUP methods, prediction accuracies were larger for DRPs compared to PCPs. For PCPs as a response variable, the largest prediction accuracies were observed when the disease incidences in training sets reflected the disease incidence in the whole population. A further increase in prediction accuracies for some selected cow allocation schemes (i.e. larger prediction accuracies compared to corresponding scenarios with RF or GBLUB) was achieved via single-step GBLUP applications. Correlations between genome-wide association study SNP effects and RF importance criteria for single SNPs were in a moderate range, from 0.42 to 0.57, when considering SNPs from all chromosomes or from specific chromosome segments. RF identified significant SNPs close to potential positional candidate genes: GAS1, GPAT3 and CYP2R1 for clinical mastitis; SPINK5 and SLC26A2 for laminitis; and FGF12 for endometritis.

Genome-wide pleiotropy and shared biological pathways for resistance to bovine pathogens

Host genetic architecture is a major factor in resistance to pathogens and parasites. The collection and analysis of sufficient data on both disease resistance and host genetics has, however, been a major obstacle to dissection the genetics of resistance to single or multiple pathogens. A severe challenge in the estimation of heritabilities and genetic correlations from pedigree-based studies has been the confounding effects of the common environment shared among relatives which are difficult to model in pedigree analyses, especially for health traits with low incidence rates. To circumvent this problem we used genome-wide single-nucleotide polymorphism data and implemented the Genomic-Restricted Maximum Likelihood (G-REML) method to estimate the heritabilities and genetic correlations for resistance to 23 different infectious pathogens in calves and cows in populations undergoing natural pathogen challenge. Furthermore, we conducted gene-based analysis and generalized gene-set analysis to understand the biological background of resistance to infectious diseases. The results showed relatively higher heritabilities of resistance in calves than in cows and significant pleiotropy (both positive and negative) among some calf and cow resistance traits. We also found significant pleiotropy between resistance and performance in both calves and cows. Finally, we confirmed the role of the B-lymphocyte pathway as one of the most important biological pathways associated with resistance to all pathogens. These results both illustrate the potential power of these approaches to illuminate the genetics of pathogen resistance in cattle and provide foundational information for future genomic selection aimed at improving the overall production fitness of cattle.

Live-Wires Using Path-Graphs

Objectives: This article discusses our new Path-Graph approach for the interactive Live-Wire segmentation method in 2D applied to pre-segmented data. Furthermore, we examine whether or not the Live-Lane extension provides advantages in combination with pre-segmentation.

Methods: We automatically over-segment the image data in a preprocessing step, using region growing with an automatic seed point generation. The Live-Wire algorithm is applied on this mosaic data by using the outlines of the homogeneous regions as the basis for graph building. We present a new definition of this underlying graph where the edges of the standard graphs are turning into vertices and the vertices of the new graph are defined by the edge connectivity in the standard graph. For better differentiation we name our new graph Path-Graph and the original defined graph Node-Graph.

Results: The quality evaluation is done by comparing our segmentation results with existing model data. We show that using the Path-Graph as basis for the Live-Wire algorithm instead of the Node-Graph allows for a finer segmentation. We achieve a reduction of incorrectly classified pixels by 20.66 per cent and a decrease of the mean boundary deviation by 11.61 per cent. Since savings on cost tree calculations are compensated by additional computation time required to compute the Live-Lanes, a performance loss of 2.41 per cent is measured.

Conclusions: Our redefinition of the underlying graph increases the quality of the Live-Wire segmentation. The Live-Lane extension in combination with pre-segmentation is not justified for our data.

Sub-arcsecond imaging of the water emission in Arp 220

AIMS

Extragalactic observations of water emission can provide valuable insights into the excitation of the interstellar medium. In particular they allow us to investigate the excitation mechanisms in obscured nuclei, i.e. whether an active galactic nucleus or a starburst dominate.

METHODS

We use sub-arcsecond resolution observations to tackle the nature of the water emission in Arp 220. ALMA Band 5 science verification observations of the 183 GHz H₂O 3₁₃-2₂₀ line, in conjunction with new ALMA Band 7 H₂O 5₁₅-4₂₂ data at 325 GHz, and supplementary 22 GHz H₂O 6₁₆ - 5₂₃ VLA observations, are used to better constrain the parameter space in the excitation modelling of the water lines.

RESULTS

We detect 183 GHz H₂O and 325 GHz water emission towards the two compact nuclei at the center of Arp 220, being brighter in Arp 220 West. The emission at these two frequencies is compared to previous single-dish data and does not show evidence of variability. The 183 and 325 GHz lines show similar spectra and kinematics, but the 22 GHz profile is significantly different in both nuclei due to a blend with an NH₃ absorption line.

CONCLUSIONS

Our findings suggest that the most likely scenario to cause the observed water emission in Arp 220 is a large number of independent masers originating from numerous star-forming regions.

A comprehensive and efficient daily quality assurance for PBS proton therapy

There are several general recommendations for quality assurance (QA) measures, which have to be performed at proton therapy centres. However, almost each centre uses a different therapy system. In particular, there is no standard procedure for centres employing pencil beam scanning and each centre applies a specific QA program. Gantry 2 is an operating therapy system which was developed at PSI and relies on the most advanced technological innovations. We developed a comprehensive daily QA program in order to verify the main beam characteristics to assure the functionality of the therapy delivery system and the patient safety system. The daily QA program entails new hardware and software solutions for a highly efficient clinical operation. In this paper, we describe a dosimetric phantom used for verifying the most critical beam parameters and the software architecture developed for a fully automated QA procedure. The connection between our QA software and the database allows us to store the data collected on a daily basis and use it for trend analysis over longer periods of time. All the data presented here have been collected during a time span of over two years, since the beginning of the Gantry 2 clinical operation in 2013. Our procedure operates in a stable way and delivers the expected beam quality. The daily QA program takes only 20 min. At the same time, the comprehensive approach allows us to avoid most of the weekly and monthly QA checks and increases the clinical beam availability.