Variation in time to notification of enrollment and rates of withdrawal in resuscitation trials conducted under exception from informed consent

IMPORTANCE

Emergency research is challenging to do well as it involves time sensitive interventions in unstable patients. There is limited time to obtain informed consent from the patient or their legally authorized representative (LAR). Such research is permitted under exception from informed consent (EFIC) if specific criteria are met, including notification after enrollment. Some question whether the risks of EFIC outweighs its benefits. To date, there is limited empiric information about time to notification (TTN) and rates of withdrawal in such trials.

OBJECTIVE

To describe variation in TTN and rates of withdrawal among that patients enrolled in EFIC trials over a twelve-year period.

DESIGN

We performed post hoc descriptive analyses of data from five trials conducted under EFIC.

SETTING

Emergency medical services and receiving hospitals participating in the Resuscitation Outcomes Consortium in the United States and Canada.

PARTICIPANTS

Patients with out-of-hospital cardiac arrest or life-threatening traumatic injury.

EXPOSURES

Notification strategies were specified at each site before initiation of enrollment by a local institutional review board. We monitored TTN within each site centrally throughout each study's enrollment period.

OUTCOMES

TTN was defined as time from randomization to first-reported notification of patient or LAR of enrollment. Withdrawal was defined as patient or LAR opt out of ongoing participation at the time of notification.

RESULTS

Of 35,442 patients enrolled in five trials, 33,805 had cardiac arrest; and 1636 had traumatic injury. TTN varied overall and by patient outcome. Among those with cardiac arrest, TTN ranged from median (5%ile, 95%ile) of 6 (1,27) days to 28 (2, 53) days across sites. 0.3% of notified patients with cardiac arrest withdrew. Among those with traumatic injury, TTN ranged from 0 (0, 5) days to 36 (5, 68) days across sites. 7.7% of notified patients with traumatic injury withdrew.

CONCLUSIONS AND RELEVANCE

There is large variation in TTN in trials conducted under EFIC for emergency research. This may be due to several factors. It may or may not be modifiable. Overall rates of withdrawal are low, which suggests current practices related to EFIC are acceptable to those who have participated in emergency research.

Ancient genomes provide insights into family structure and the heredity of social status in the early Bronze Age of southeastern Europe

Twenty-four palaeogenomes from Mokrin, a major Early Bronze Age necropolis in southeastern Europe, were sequenced to analyse kinship between individuals and to better understand prehistoric social organization. 15 investigated individuals were involved in genetic relationships of varying degrees. The Mokrin sample resembles a genetically unstructured population, suggesting that the community’s social hierarchies were not accompanied by strict marriage barriers. We find evidence for female exogamy but no indications for strict patrilocality. Individual status differences at Mokrin, as indicated by grave goods, support the inference that females could inherit status, but could not transmit status to all their sons. We further show that sons had the possibility to acquire status during their lifetimes, but not necessarily to inherit it. Taken together, these findings suggest that Southeastern Europe in the Early Bronze Age had a significantly different family and social structure than Late Neolithic and Early Bronze Age societies of Central Europe.

Modular multipin electrodes for comfortable dry EEG

Electrode and cap concepts for continuous and ubiquitous monitoring of brain activity will open up new fields of application and contribute to increased use of electroencephalography (EEG) in clinical routine, neurosciences, brain-computer-interfacing and out-of-the-lab monitoring. However, mobile and unobtrusive applications are currently hindered by the lack of applicable convenient and reliable electrode and cap systems. We propose a novel modular electrode concept based on a flexible polymer substrate, coated with electrically conductive metallic films. The overall concept enables design adaptation to different head regions and cap designs. We describe the single modules of the system and investigate the influence of electrode pin number, coating material and adduction force on electrode-skin impedance and perceived wearing comfort. Our results contribute to rapid and comfortable multichannel dry EEG.

Dynamical Quasicondensation of Hard-Core Bosons at Finite Momenta

Long-range order in quantum many-body systems is usually associated with equilibrium situations. Here, we experimentally investigate the quasicondensation of strongly interacting bosons at finite momenta in a far-from-equilibrium case. We prepare an inhomogeneous initial state consisting of one-dimensional Mott insulators in the center of otherwise empty one-dimensional chains in an optical lattice with a lattice constant d. After suddenly quenching the trapping potential to zero, we observe the onset of coherence in spontaneously forming quasicondensates in the lattice. Remarkably, the emerging phase order differs from the ground-state order and is characterized by peaks at finite momenta ±(π/2)(ℏ/d) in the momentum distribution function.

Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate

Background

We aimed to create a theoretical tool to model the effect of three haemostatic agents containing fibrinogen (therapeutic plasma, cryoprecipitate, and fibrinogen concentrate) on the patient's plasma fibrinogen level.

Methods

A mathematical model was developed step-wise. The relationship between the amount of haemostatic agent and plasma fibrinogen level was plotted for each agent. A fibrinogen concentration simulator (FCS_amount) was developed, where the amount of haemostatic agent was calculated from patient characteristics, agent characteristics, and target plasma fibrinogen level. Refinements were introduced so that (i) FCS_amount would account for in vivo fibrinogen recovery, (ii) circulatory volume would not increase ad infinitum with increasing amounts, and (iii) red blood cells would be included in the simulation if haematocrit decreased below a certain level. A second FCS (FCS_level) was created to calculate fibrinogen levels resulting from specified amounts of haemostatic agents.

Results

Fibrinogen concentration in haemostatic agents has a critical impact on their ability to increase patients' fibrinogen levels. If the target plasma fibrinogen level approaches the concentration of the fibrinogen source, the required amounts increase exponentially; it is impossible to achieve a target above the concentration of the fibrinogen source.

Conclusions

We successfully developed two theoretical tools answering the questions: ‘How much therapeutic plasma, cryoprecipitate, or fibrinogen concentrate would be needed to achieve a specified target fibrinogen level?’ and ‘What would be the resultant fibrinogen level for a specified amount of haemostatic agent?’ The current tools are not intended for clinical application, but they are potentially useful for educational purposes.

Higher plasma CXCL12 levels predict incident myocardial infarction and death in chronic kidney disease: findings from the Chronic Renal Insufficiency Cohort study

AIMS

Genome-wide association studies revealed an association between a locus at 10q11, downstream from CXCL12, and myocardial infarction (MI). However, the relationship among plasma CXCL12, cardiovascular disease (CVD) risk factors, incident MI, and death is unknown.

METHODS AND RESULTS

We analysed study-entry plasma CXCL12 levels in 3687 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study, a prospective study of cardiovascular and kidney outcomes in chronic kidney disease (CKD) patients. Mean follow-up was 6 years for incident MI or death. Plasma CXCL12 levels were positively associated with several cardiovascular risk factors (age, hypertension, diabetes, hypercholesterolaemia), lower estimated glomerular filtration rate (eGFR), and higher inflammatory cytokine levels (P < 0.05). In fully adjusted models, higher study-entry CXCL12 was associated with increased odds of prevalent CVD (OR 1.23; 95% confidence interval 1.14, 1.33, P < 0.001) for one standard deviation (SD) increase in CXCL12. Similarly, one SD higher CXCL12 increased the hazard of incident MI (1.26; 1.09,1.45, P < 0.001), death (1.20; 1.09,1.33, P < 0.001), and combined MI/death (1.23; 1.13-1.34, P < 0.001) adjusting for demographic factors, known CVD risk factors, and inflammatory markers and remained significant for MI (1.19; 1.03,1.39, P = 0.01) and the combined MI/death (1.13; 1.03,1.24, P = 0.01) after further controlling for eGFR and urinary albumin:creatinine ratio.

CONCLUSIONS

In CKD, higher plasma CXCL12 was associated with CVD risk factors and prevalent CVD as well as the hazard of incident MI and death. Further studies are required to establish if plasma CXCL12 reflect causal actions at the vessel wall and is a tool for genomic and therapeutic trials.

Expansion dynamics of interacting bosons in homogeneous lattices in one and two dimensions

We experimentally and numerically investigate the expansion of initially localized ultracold bosons in homogeneous one- and two-dimensional optical lattices. We find that both dimensionality and interaction strength crucially influence these nonequilibrium dynamics. While the atoms expand ballistically in all integrable limits, deviations from these limits dramatically suppress the expansion and lead to the appearance of almost bimodal cloud shapes, indicating diffusive dynamics in the center surrounded by ballistic wings. For strongly interacting bosons, we observe a dimensional crossover of the dynamics from ballistic in the one-dimensional hard-core case to diffusive in two dimensions, as well as a similar crossover when higher occupancies are introduced into the system.

DFT study of vibronic properties of d8 (Ni-, Pd-, and Pt-) phthalocyanines

By means of density functional theory, we have studied the electronic structure and vibronic properties of single neutral NiPc, PdPc, and PtPc molecules and their singly and doubly ionized cations and anions. In particular, the vibronic couplings and reorganization energies of all systems are compared. Partitioning of the reorganization energy, corresponding to the photoelectron spectra of the first and second ionizations of studied molecules, into normal mode contributions shows that the major contributions are due to several vibrational modes with a(1g) symmetry and energies lower than 1600 cm(-1). The results reveal that the reorganization energy due to the singly positive ionization in the studied molecules is up to about one order of magnitude less than other reorganization energies. This makes these metal phthalocyanines, from the perspective of intramolecular reorganization energies, attractive as electron donor for intramolecular electron transfer in electron acceptor-donor systems.

Swollen joint count in psoriatic arthritis is associated with progressive radiological damage in hands and feet

OBJECTIVES

Psoriatic arthritis (PsA) may progress to joint damage. Determining clinical predictors of joint damage assessed by radiography is important. The aim of this study was to determine clinical factors as possible predictors for radiological damage in hands and feet of PsA patients with a 12-month follow-up.

METHODS

We conducted a retrospective study on 53 PsA patients who were taking disease-modifying anti-rheumatic drugs (DMARDs) and/or tumour necrosis factor (TNF)-alpha-blockers at a fixed dosage. The patients were observed in 118 follow-up visits (intervals of 12 months ± 3 months), according to a clinical and radiological protocol which included the documentation of the number of swollen and tender joints in hands and feet, the applied therapy, psoriasis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and global health assessment. Outcome was defined as radiographic damage of hands and feet (Ratingen score). For the statistical analysis the Chi-Square test for 2x2 crosstables (with Fisher's correction, as required) was used.

RESULTS

Progressive radiological damage was more frequent among patients with an increasing swollen joint count (8 of 26 visits; 30.8%) than among those with a stable or decreased number of swollen joints (5 of 89 visits; 5.6%; p=0.001). The analysis of the patients stratified into the different treatment modalities resulted in a significant higher rate of radiological progress (20.8%) in patients on DMARD therapy compared with TNF-alpha blocking agents (0%) (p=0.009).

CONCLUSIONS

During a 12-month follow-up of PsA patients, an increasing number of swollen joints heralds progression of radiological damage. TNF-alpha-blocker therapy appears to be superior to DMARDs in the protection from radiological progress.

Prognostic relevance of hypoxia inducible factor-1alpha expression in patients with melanoma

Overexpression of hypoxia inducible factor (HIF)-1alpha has been found in several human cancers and is thought to correlate with aggressive disease and poor response. A retrospective analysis was carried out on 89 patients with primary cutaneous melanoma. HIF-1alpha expression was assessed by immunohistochemistry in formalin-fixed, paraffin wax-embedded tumour sections. Overall survival (OS) and disease-free survival (DFS) were determined using univariate and multivariate analyses. Of the 89 patients, 78 (87.6%) expressed HIF-1alpha, and the remaining 11 patients (12.4%) did not. HIF-1alpha expression correlated with age (P = 0.002), but not with the main predictive factors in melanoma. Survival analysis disclosed no difference between the groups for OS and DFS. In multivariate analysis, only Breslow Index and ulceration were significantly associated with poor OS. Our results indicate that HIF-1alpha overexpression is present in most primary melanomas, but is not associated with clinicopathological variables, patient prognosis or survival.

[Legal aspects of ritual circumcision]

Female circumcision (genital mutilation) is a criminal violation of human rights under German law. Even with consent of the person to be circumcised and/or her legal representative this procedure must not be carried out since a consent to female circumcision is unethical and therefore void. As much consent as there is on female circumcision the legal situation with ritual male circumcision is very unclear. In practice and unnoticed by the public male circumcision is carried out - be it for medical or ritual reasons - without deeper-going reflexions on the clearness of the medical indication or the legal situation with ritual circumcision. From the medical aspect there are big differences between female and male circumcision but also certain parallels. Various reasons, partly founded in prejudice and misinformation, make people refrain from regarding circumcision of boys also as illegal. Contrary to the prevailing opinion male circumcision also represents a bodily harm which a doctor can only carry out after a preoperative interview and with the consent of the affected person. Since ritual male circumcision does not serve the wellbeing of a child it is not possible for the parents to give their consent to the circumcision in lieu of the child. Male circumcision is only permitted if the child has given his consent and is thus only legally permitted if the child has reached an age at which he is mature enough to understand the meaning and extent of such an action which is hardly the case before he has completed his 16 (th) year.

[Prehospital assessment and treatment decisions of a suspected acute coronary syndrome: what are the problems? Results of the "Emergency Doctor and Acute Myocardial Infarction" study (NAAMI)]

BACKGROUND

Interpretation of prehospital 12-lead electrocardiograms (ECG) in acute ST-elevation myocardial infarction (STEMI) remains a diagnostic challenge in many cases. The aim of this study was to determine whether board-certified emergency physicians (BCEP) are able to distinguish STEMI from non-STEMI in a large proportion of cases, thus assuring more precise prehospital triage and treatment.

METHODS

Electrocardiograms of eight patients with acute non-traumatic chest pain (with 6 ECGs demonstrating STEMI, one with pericarditis, and one with pulmonary embolism) were assessed in a blinded fashion by 73 BCEP (19 female, mean age 37 +/- 5.3 years). Decisions had to be made by them regarding the diagnosis (STEMI or not) and treatment (immediate reperfusion or transfer to the nearest hospital without facilities for percutaneous coronary intervention).

RESULTS

In the ECGs with STEMI 83% of BCEPs made the correct diagnosis without significant differences between the subgroups. But in cases of non-STEMI-ECG only 30% of BECP made the correct diagnosis. The results in interpreting non-STEMI were better in older (> 50 years) BCEPs and in those with a background in internal medicine (p = 0.045, and p = 0.01, respectively). In case of STEMI 75% of BCEPs initiated the correct therapy, without significant differences between the subgroups. In case of non-STEMI ECG only 33% of BECPs made the correct diagnosis. Also, the therapeutic decisions in case of non-STEMI were better in older (> 50 years) BCEPs and in those with a background in internal medicine (p = 0.04, and p = 0.02 respectively).

CONCLUSION

In cases of acute non-traumatic chest pain the interpretation of the electrocardiogram by prehospital emergency doctors give to unsatisfactory results. The present study suggests, that additional training in ECG interpretation may be a critical component of the education of physicians who care for patients presenting with acute coronary syndrome.

[Spontaneous perirenal hematomas in patients taking anticoagulation medication or having a bleeding diathesis]

Spontaneous perirenal hematoma is a rare condition. The clinical features are acute flank or abdominal pain, haematuria, hypotension and shock. Bleeding is most commonly caused by renal tumours, especially angiomyolipomas. Other known causes are long-term haemodialysis, arteriosclerosis or arteritis. A total of 6 patients with spontaneous perirenal haemorrhage have been treated in our hospital since 2003. Nearly all patients had been taking anticoagulation medication. One had a bleeding diathesis. One of the patients died immediately after admission at the hospital. All other patients had an exploratory laparotomy. In three cases total nephrectomy had to be performed, two other patients could be treated with partial nephrectomy. In patients with non-traumatic acute flank or abdominal pain it is important to determine whether the patient has been taking anticoagulation medication or suffers from bleeding diathesis because there is a high incidence of bleeding complications in these cases. If an emergent laparotomy is not necessary we recommend that these cases should be treated surgically after clinical stabilisation because tumours are the main reason for the haematomas and the patients have an urgent need for further anticoagulation therapy.

[Penoscrotal elephantiasis: diagnostics and treatment options]

Penoscrotal elephantiasis is a symptom that can be caused by local but also by systemic disorders. When the changes are reversible, conservative measures such as physical and antiphlogistic approaches lead to success. In cases of irreversible penoscrotal elephantiasis, excision and amputation of the affected penoscrotal areas are recommended to eliminate the functional disturbances. In all manifestations it is important to prevent and treat those diseases known to cause elephantiasis.

Monitoring with EEG entropy decreases propofol requirement and maintains cardiovascular stability during induction of anaesthesia in elderly patients

BACKGROUND AND OBJECTIVES

Electroencephalographic entropy is used to measure the degree of brain hypnosis and anaesthesia depth. Two parameters are displayed in the monitor, state entropy (SE) and response entropy (RE). Ageing leads to reduction in liver mass as well as hepatic blood flow, which decreases clearance of propofol and increases the risk of cardiovascular adverse effects. The aim of this study is to demonstrate the effect of electroencephalographic entropy on propofol requirement and haemodynamic parameters during induction of anaesthesia in elderly patients.

METHODS

We studied 72 elderly patients. Standard monitoring was performed for all patients together with entropy monitor. Patients were allocated randomly either to the control group, which were given the recommended induction dose of propofol, or to the entropy group which was induced with propofol based on entropy reading where the end-point was SE 50 and SE-RE difference less than 10. Propofol induction doses and haemodynamic changes were recorded. Anaesthesia was maintained using sevoflurane and O2 air mixture.

RESULTS

After induction of anaesthesia, the systolic, diastolic, mean arterial pressure, RE and SE were significantly lower in the control group (P value < 0.05). Total dose of propofol and the dose kg-1 were significantly reduced by 37.1% and 31.8%, respectively, in the entropy group (P value < 0.01).

CONCLUSION

The use of electroencephalographic entropy during induction of anaesthesia in elderly patients reduces propofol requirements and maintains cardiovascular stability.

The transcription factor ZEB1 (deltaEF1) promotes tumour cell dedifferentiation by repressing master regulators of epithelial polarity

Epithelial to mesenchymal transition (EMT) is implicated in the progression of primary tumours towards metastasis and is likely caused by a pathological activation of transcription factors regulating EMT in embryonic development. To analyse EMT-causing pathways in tumourigenesis, we identified transcriptional targets of the E-cadherin repressor ZEB1 in invasive human cancer cells. We show that ZEB1 repressed multiple key determinants of epithelial differentiation and cell-cell adhesion, including the cell polarity genes Crumbs3, HUGL2 and Pals1-associated tight junction protein. ZEB1 associated with their endogenous promoters in vivo, and strongly repressed promotor activities in reporter assays. ZEB1 downregulation in undifferentiated cancer cells by RNA interference was sufficient to upregulate expression of these cell polarity genes on the RNA and protein level, to re-establish epithelial features and to impair cell motility in vitro. In human colorectal cancer, ZEB1 expression was limited to the tumour-host interface and was accompanied by loss of intercellular adhesion and tumour cell invasion. In invasive ductal and lobular breast cancer, upregulation of ZEB1 was stringently coupled to cancer cell dedifferentiation. Our data show that ZEB1 represents a key player in pathologic EMTs associated with tumour progression.

[Urinary bladder augmentation using the stomach in patients with compensated renal insufficiency]

This case report describes a female patient with bladder exstrophy and chronic compensated renal insufficiency as it relates to the topic of urinary bladder augmentation using the stomach and cutaneous vesicostomy with a Mitrofanoff continent stoma. Due to complete congenital bladder exstrophy the patient underwent functional reconstructive surgery for cystoschisis and several revision procedures. Because of a low-capacity, low-compliance bladder with bilateral urinary stasis in the kidneys, temporary percutaneous renal fistulas were created on both sides. After the patient had declined any follow-up during her pubertal years, advanced bilateral renal damage ensued. In a state of compensated renal insufficiency with creatinine levels >2 mg/dl, the patient was offered surgery for placement of an incontinent bladder substitute as an ileal or colon conduit because of the progressive kidney damage with obstructive uropathy. Since the patient rejected any form of wet stoma despite several consultations, after adequate preparations were met, a gastrocystoplasty and Mitrofanoff cutaneous vesicostomy with an umbilical stoma and artificial umbilicoplasty were performed. The patient catheterizes herself six times daily and is under close urological/nephrological supervision.In exceptional cases, gastrocystoplasty is an alternative to construction of a neobladder from bowel segments. It is particularly indicated for patients with compensated or already poor kidney function. The interventions are associated with several specific complications. There have as yet been no reports of malignant degeneration inside the gastric portion used for augmentation or the urothelium exposed to stomach acid. However, pathological and precancerous alterations of mucous membranes have been observed, which should be regularly monitored by endoscopy/biopsy and warrant further long-term studies.

Cognitive plasticity in people at risk for dementia: optimising the testing-the-limits-approach

A topic of great interest in gerontology research is the prediction of cognitive deterioration which marks the transition from mild cognitive impairment (MCI) to dementia. In this area, the term cognitive plasticity can be of great interest. We examined the utility of the Adaptive Figure Series Learning Test (ADAFI) to evoke cognitive plasticity and to show whether reduced plasticity can be found in people with MCI. In a pre-test-intervention-post-test design, intervention with the ADAFI was compared to an unspecific brain jogging task in MCI participants and healthy controls. A total of 42 subjects were included. Independent of mental health status only using the ADAFI led to pronounced improvements in post-test performances, but MCI participants profited less from the intervention with the ADAFI than healthy controls, that is, showed lower cognitive plasticity. Thus, the overlap in performance distributions between healthy participants and MCI individuals at pre-test was reduced at the time of post-test once the ADAFI had been given as intervention. The findings of the present article indicate that plasticity oriented information can be gained when the ADAFI is given as an intervention in a pre-test-training-post-test-design. The cognitive plasticity approach seems potentially useful for purposes of early identification of dementia.

Theoretical investigation of excited states of C(3)

In this work, we present ab initio calculations for the potential energy surfaces of C(3) in different electronic configurations, including the singlet ground state [X (1)Sigma(g) (+),((1)A(1))], the triplet ground state [a (3)Pi(u),((3)B(1), (3)A(1))], and some higher excited states. The geometries studied include triangular shapes with two identical bond lengths, but different bond angles between them. For the singlet and triplet ground states in the linear geometry, the total energies resulting from the mixed density functional--Hartree-Fock and quadratic configuration interaction methods reproduce the experimental values, i.e., the triplet occurs 2.1 eV above the singlet. In the geometry of an equilateral triangle, we find a low-lying triplet state with an energy of only 0.8 eV above the energy of the singlet in the linear configuration, so that the triangular geometry yields the lowest excited state of C(3). For the higher excited states up to about 8 eV above the ground state, we apply time-dependent density functional theory. Even though the systematic error produced by this approach is of the order of 0.4 eV, the results give different prospective to insight into the potential energy landscape for higher excitation energies.

Adsorption of PTCDA on a partially KBr covered Ag(111) substrate

Ordered growth of 3,4,9,10-perylene-tetracarboxylic-dianhydride (PTCDA) on Ag(111) partially covered by one or two monolayers of KBr was investigated by non-contact AFM with molecular resolution. Different adsorption patterns are found on the pure substrate, the one covered by a single monolayer, and the one covered by two monolayers KBr. Simulations with an extended Ising-type model reproduce these experimental patterns very well. The adsorbate-adsorbate and the adsorbate-substrate interaction parameters obtained from the simulation are discussed with respect to the interactions at the Ag(111)|KBr interface. As a result, alkali halide covered metals can be used for tuning the interactions and designing adsorption systems, which opens up new possibilities in the control of self-assembled nanostructures.