[An optimised assessment of "severely injured patients" for the documentation of road traffic accident black spots]

INTRODUCTION

The success of traffic safety improvement strategies is based on documentation. Analysis and remedy of accident black spots in addition to improvements in automobile production involve the work of traffic engineers, politicians, traffic regulations, police, and medical care. To create priorities, the traffic statistics differentiate accidents in a 3-class system in relation to severe accidents: slightly injured, severely injured and fatally injured (death). This study assesses the validity of the existing classification of "severely injured" compared with the actual injury severity.

MATERIAL AND METHOD

We analysed accidents resulting in 182 "severely injured" people in one year in a city model. A synchronisation of anonymous police documentation with the medical notes of admitted casualties which were validated by established trauma scores and medical classification was undertaken. A correlation analysis of length of stay should give indications of the actual injury severity.

RESULTS

The study group showed a ubiquitous range of age, sex and injuries despite a relatively low case number. The range of MAIS, ISS and NACA index scores shows the inhomogeneity of the people classified as "severely injured". 70 % of the study group revealed ISS < 16 which means that they are not polytraumatised patients. The correlation analysis according to Spearman certifies the validity of these scores (r MAIS/NACA = 0.645 and r ISS/NACA = 0.592). The further differentiation on the basis of MAIS, ISS and NACA showed that 51 % of the study group should be classified as slightly injured and 83 % of these were discharged in less than 5 days.

CONCLUSION

This study shows that the traffic safety classification of "severely injured" people is not sufficient and most severely injured people are not even approximately recorded. We propose that a new continuous link system between police and medical data will be inevitable for future improvements in traffic safety. The use of established trauma scores and a differentiated look at lengths of stay could be an option.

Boys do it the right way: sex-dependent amygdala lateralization during face processing in adolescents

Previous studies have observed a sex-dependent lateralization of amygdala activation related to emotional memory. Specifically, it was shown that the activity of the right amygdala correlates significantly stronger with memory for images judged as arousing in men than in women, and that there is a significantly stronger relationship in women than in men between activity of the left amygdala and memory for arousing images. Using a large sample of 235 male adolescents and 235 females matched for age and handedness, we investigated the sex-specific lateralization of amygdala activation during an emotional face perception fMRI task. Performing a formal sex by hemisphere analysis, we observed in males a significantly stronger right amygdala activation as compared to females. Our results indicate that adolescents display a sex-dependent lateralization of amygdala activation that is also present in basic processes of emotional perception. This finding suggests a sex-dependent development of human emotion processing and may further implicate possible etiological pathways for mental disorders most frequent in adolescent males (i.e., conduct disorder).

Venous air embolism during semi-sitting craniotomy evokes thrombocytopenia

Venous air embolism activates platelets in vitro and can evoke platelet dysfunction in swine. We tested the hypothesis that venous air embolism during semi-sitting craniotomy induces thrombocytopenia in humans. We analysed the charts of 799 patients who had an elective craniotomy in the semi-sitting position between 1990 and June 2009. Venous air embolism occurred in 52 patients (6.5%) and was associated with a decrease in mean (SD) in platelet count from 270 (75) × 10⁹ l⁻¹ to 194 (62) × 10⁹ l⁻¹ (p < 0.001). In age-matched controls without venous air embolism mean (SD) platelet count did not change (254 (82) × 10⁹ l⁻¹ vs. 250 (97) × 10⁹ l⁻¹ (NS). While mean (SD) haematocrit fell slightly in both groups (venous air embolism: 0.40 (0.05) to 0.32 (0.04), p <0.001; no venous air embolism: 0.41 (0.04) to 0.35 (0.05), p < 0.001), normalising platelet count to haematocrit did not alter the results.

Equine penile squamous cell carcinomas are associated with the presence of equine papillomavirus type 2 DNA sequences

Forty cases of equine penile disease were screened with polymerase chain reaction for the presence of papillomaviral DNA. Cases consisted of 20 squamous cell carcinomas (average age of horse, 23.9 years) and 20 non-squamous cell carcinoma diseases (average age of horse, 13.3 years). All horses but one originated from the Northeastern United States. Breeds were not recorded. As based on MY09/MY11 consensus primers, DNA sequences from equine papillomavirus type 2 were amplified from 9 of 20 horses (45%) with penile squamous cell carcinoma and only 1 of 20 horses (5%) with non-squamous cell carcinoma penile disease. Equine papillomavirus type 2 DNA was the only papillomaviral DNA amplified from any of the 40 horses. Tissues from the 10 horses in which papillomaviral DNA was detected by polymerase chain reaction were also screened with in situ hybridization and immunohistochemistry. The presence of papillomavirus was demonstrated in a subset of these by in situ hybridization (6 of 10) and immunohistochemistry (1 of 10). This report describes a possible association between equine penile squamous cell carcinomas and equine papillomavirus type 2. This study is also the first report of equine papillomavirus type 2 infection in North American horses.

The safety and efficacy of sunitinib before planned nephrectomy in metastatic clear cell renal cancer

Background: The safety and efficacy of upfront sunitinib, before nephrectomy in metastatic clear cell renal cancer (mCRC), has not been prospectively evaluated.

Methods: Two prospective single-arm phase II studies investigated either two cycles (study A: n = 19) or three cycles (study B: n = 33) of sunitinib before nephrectomy in mCRC.

Results: Overall, 38 of 52 (73%) of patients obtained clinical benefit (by RECIST) before surgery. The partial response rate of the primary tumour was 6% [median reduction in longest diameter of 12% (range 8%−35%)]. No patients became ineligible due to local progression of disease. A nephrectomy was carried out in 37 (71%) of patients. Necrosis (>50%) was a prominent feature at nephrectomy in 49%. Surgical complications (Clavien–Dindo classification) occurred in 10 (27%) patients, including one death (3%). The median blood loss and surgical time were 725 (90–4200) ml and 189 (70–420) min, respectively. The median progression-free survival was 8 months (95% confidence interval 6–15 months). A comparison of two versus three pre-surgery cycles showed no significant difference in terms of surgical complications or efficacy.

Conclusions: Nephrectomy after upfront sunitinib can be carried out safely. It obtains control of disease. Randomised studies are required to address if this approach is beneficial.

Phylogeography, genetic structure and population divergence time of cheetahs in Africa and Asia: evidence for long-term geographic isolates

The cheetah (Acinonyx jubatus) has been described as a species with low levels of genetic variation. This has been suggested to be the consequence of a demographic bottleneck 10 000–12 000 years ago (ya) and also led to the assumption that only small genetic differences exist between the described subspecies. However, analysing mitochondrial DNA and microsatellites in cheetah samples from most of the historic range of the species we found relatively deep phylogeographic breaks between some of the investigated populations, and most of the methods assessed divergence time estimates predating the postulated bottleneck. Mitochondrial DNA monophyly and overall levels of genetic differentiation support the distinctiveness of Northern-East African cheetahs (Acinonyx jubatus soemmeringii). Moreover, combining archaeozoological and contemporary samples, we show that Asiatic cheetahs (Acinonyx jubatus venaticus) are unambiguously separated from African subspecies. Divergence time estimates from mitochondrial and nuclear data place the split between Asiatic and Southern African cheetahs (Acinonyx jubatus jubatus) at 32 000–67 000 ya using an average mammalian microsatellite mutation rate and at 4700–44 000 ya employing human microsatellite mutation rates. Cheetahs are vulnerable to extinction globally and critically endangered in their Asiatic range, where the last 70–110 individuals survive only in Iran. We demonstrate that these extant Iranian cheetahs are an autochthonous monophyletic population and the last representatives of the Asiatic subspecies A. j. venaticus. We advocate that conservation strategies should consider the uncovered independent evolutionary histories of Asiatic and African cheetahs, as well as among some African subspecies. This would facilitate the dual conservation priorities of maintaining locally adapted ecotypes and genetic diversity.

Towards brain-robot interfaces in stroke rehabilitation

A neurorehabilitation approach that combines robot-assisted active physical therapy and Brain-Computer Interfaces (BCIs) may provide an additional mileage with respect to traditional rehabilitation methods for patients with severe motor impairment due to cerebrovascular brain damage (e.g., stroke) and other neurological conditions. In this paper, we describe the design and modes of operation of a robot-based rehabilitation framework that enables artificial support of the sensorimotor feedback loop. The aim is to increase cortical plasticity by means of Hebbian-type learning rules. A BCI-based shared-control strategy is used to drive a Barret WAM 7-degree-of-freedom arm that guides a subject's arm. Experimental validation of our setup is carried out both with healthy subjects and stroke patients. We review the empirical results which we have obtained to date, and argue that they support the feasibility of future rehabilitative treatments employing this novel approach.

Venous air embolism and intracardiac thrombus after pressurized fibrin glue during liver surgery

After segmental liver resection, a fibrin glue aerosol was used to stop diffuse bleeding from the liver resection site. Immediately after pressurized administration, severe hypotension and bradycardia occurred, requiring cardiopulmonary resuscitation and inotropic support. Transoesophageal echocardiography demonstrated air in both ventricles deriving from the inferior vena cava; contractility of both ventricles was markedly reduced. In addition, a 3 cm floating thrombus was detected in the right ventricle. This case demonstrates that sprayed fibrin glue can cause life-threatening air embolism and intracardiac thrombus formation in liver surgery.

Increased haematopoietic progenitor cells are associated with poor outcome in patients with metastatic renal cancer treated with sunitinib

BACKGROUND

Haematopoietic progenitor cells (HPCs) are present in blood in metastatic renal cell cancer (mRCC). We investigate their expression in mRCC patients treated with sunitinib and correlate their expression with plasma growth factor levels [insulin-like growth factor (IGF)-1].

METHODS

Circulating HPCs (CD34(+)/CD45(+)) and plasma IGF-1 levels were measured at specific sequential time points (0, 6, 18 and 28 weeks) in 43 untreated mRCC patients receiving sunitinib (50 mg for 28 days followed by 14-day off treatment). Univariate and multivariate analysis assessed the prognostic significance of HPCs and IGF-1.

RESULTS

HPCs levels were raised in 40 of 43 (93%) of patients. IGF-1 levels were raised in 9 of 43 patients (21%). Univariate and multivariate analysis revealed that high HPCs before treatment were associated with a significantly shorter overall survival (hazard ratio 3.3, 95% confidence interval 1.23-8.8, P=0.01), which was not the case for IGF-1 levels. Both HPC and IGF-1 levels fell with sunitinib (61% and 14% fall, respectively, P <0.05 for both). A positive correlation between the falls in HPC and IGF-1 occurred (P<0.001).

CONCLUSIONS

HPCs are over expressed in the peripheral blood in the majority of patients with mRCC. Higher levels are associated with poor prognosis. A concurrent fall in HPCs and growth factor expression (IGF-1) with sunitinib occurs.

[Current aspects of anesthetic management in urological patients]

Patients with coronary stents should take clopidogrel and acetylsalicylic acid for 4 weeks or 12 months after stenting. Stopping this medication early, e.g., for surgery, results in a 90-fold increase in the patient's risk for myocardial infarction from stent thrombosis. The mortality due to perioperative acute coronary syndrome clearly exceeds that due to perioperative bleeding complications. If oral medication resulting in platelet inhibition has to be paused "bridging" with short-acting, intravenous GPIIb/IIIa antagonists is possible. In recent years perioperative beta-blockade has been recommended for patients with high coronary vascular risk, and recently also for those with medium or low risk. Current studies, however, indicate that patients on beta-blockers have increased perioperative mortality because of bradycardia, hypotension, and anemia. Therefore, anemia and hypotension should be rigorously avoided.Anesthetic management may have an influence on the postoperative course of cancer. Combined epidural-general anesthesia provides a benefit by minimizing the use of systemic opioids and volatile anesthetics. Presumably, this and a decreased response to surgical stress increase the ability of the patient's immune system to deal with cancer dissemination and micrometastasis.

Cardiogenic shock following cesarean delivery due to undiagnosed tuberculous constrictive pericarditis

We describe an uncommon cause of cardiogenic shock following cesarean delivery in a 24-year-old multiparous woman at 26 weeks of gestation. Hemodynamic instability was erroneously attributed to amniotic infection syndrome and sepsis, which resulted in delayed diagnosis and treatment of tuberculous constrictive pericarditis. Inotropic support, pericardectomy, and implantation of a left ventricular assist device were required for maternal survival.

Reference intervals for aldosterone, renin, and the aldosterone-to-renin ratio in the population-based Study of Health in Pomerania (SHIP-1)

The renin-angiotensin-aldosterone system plays a key role in the regulation of human blood pressure. The aldosterone-to-renin ratio (ARR) is widely accepted for screening the primary hyperaldosteronism (PAL). Various cutoffs for positive PAL screening have been defined in patient cohorts from endocrinological referral centers and primary care. However, the distribution of the ARR in the general population is largely unknown. We aim to provide reference ranges for plasma aldosterone concentration (PAC), plasma renin concentration (PRC), and the ARR for the general population of north-east Germany. A cohort of 3 300 subjects participated in the first follow-up of the longitudinal, population-based Study of Health in Pomerania (SHIP). PAC and PRC were measured by radioimmunometric procedures. The reference interval was defined as the central 95% range between the 2.5(th) and 97.5(th) percentiles. A reference population comprising 1,347 healthy subjects was selected. Sex and age-specific (25-54 and 55-74 years) reference ranges are presented. The upper reference limit for the ARR was 14.2 and 20.3 in younger, and 22.4 and 25.5 in older men and women, respectively. Time of blood sampling had no influence on the ARR, while beta blockers, and agents acting on the renin-angiotensin system were associated with higher and lower ARR, respectively. Our upper reference limit for the ARR is clearly lower than previously reported values from studies of hypertensive patients in primary care or hypertension referral centers. We confirm that PAC and PRC are associated with various factors, including sex, age, intake of estrogen, and various antihypertensive medications.

Strategies of leaf expansion in Ficus carica under semiarid conditions

Leaf area expansion, thickness and inclination, gas exchange parameters and relative chlorophyll content were analysed in field-grown fig (Ficus carica L.) leaves over time, from emergence until after full leaf expansion (FLE). Ficus carica leaves showed a subtle change in shape during the early stages of development, and FLE was reached within ca. 30 days after emergence. Changes in leaf thickness and inclination after FLE demonstrated good adaptation to environmental conditions during summer in areas with a Mediterranean climate. Changes in gas exchange parameters and relative chlorophyll content showed that F. carica is a delayed-greening species, reaching maximum values 20 days after FLE. Correlation analysis of datasets collected during leaf expansion, confirmed dependence among structural and functional traits in F. carica. Pn was directly correlated with stomatal conductance (Gs), transpiration (E), leaf area (LA) and relative chlorophyll content up to FLE. The effect of pruning on leaf expansion, a cultural technique commonly applied in this fruit tree, was also evaluated. Although leaf development in pruned branches gave a significantly higher relative leaf area growth rate (RGR(l)) and higher LA than non-pruned branches, no significant differences were found in other morphological and physiological traits, indicating no pruning effect on leaf development. All studied morphological and physiological characteristics indicate that F. carica is well adapted to semiarid conditions. The delayed greening strategy of this species is discussed.

Neural representations of subjective reward value

Decision neuroscience suggests that there exists a core network for the subjective valuation of rewards from a range of different domains, encompassing the ventral striatum and regions of the orbitofrontal cortex (OFC), in particular the ventromedial aspect of the OFC. Here we first review ways to measure subjective value experimentally in a cognitive neuroscience context, and provide a brief overview over different types of value (outcome, goal and decision value). We then compare results of functional neuroimaging studies of subjective value representations across these different types of value. Our analysis suggests that the same region of the mOFC represents the outcome values of primary reinforcers, but also more complex decision values in which multiple dimensions of the reward need to be integrated. The subjective (hedonic) experience of processing highly valued decision options (regardless of whether they refer to actually experienced rewards or merely potential future rewards) appears to be what is reflected in value-related mOFC activity.