[Assessment method of cognitive load and stress inducer factors of surgeons and anesthetists in the operating room]

INTRODUCTION

For many years, surgeons and anesthetists have recognized that stress can be present in their daily professional practice. The goal of this study was to identify tools for assessing stress and cognitive load in the operating room.

MATERIAL AND METHODS

We conducted a literature review in the PubMed database of scientific articles published on the subject without date limit using the keywords anesthesia, surgery, surgeon, cognitive workload, definition, pathophysiology, physiological measurement, objective, subjective, stress.

RESULTS

Nineteen articles were selected, focusing on cardiac surgery, gastrointestinal surgery, vascular surgery and urology. No publications concerning ophthalmology were found through the literature search. The means of measurement found were either subjective, such as questionnaires, or objective, such as the study of heart rate variability (HRV), reaction time, eye movements, electrical conductivity of the skin, biological markers and electroencephalogram. Of all these measurement tools, the NASA-TLX questionnaire, used in four articles, and the HRV study, used in eight articles, appear to be the most widely used and are strongly correlated with stress.

CONCLUSION

The articles reviewed use only some of the available tools for assessment of stress and cognitive load. The main objective is to improve the quality of care and the quality of life of caregivers. It would be interesting to develop other methods to identify and better characterize the risk factors that increase stress and cognitive load.

Tracking heart surface features to determine myocardial contrast agent enrichment

Fluorescent cardiac imaging can be applied for intraoperative quality control after a coronary bypass grafting surgery to ensure the myocardial perfusion by evaluating the increasing contrast agent enrichment in the heart. The motion due to the beating heart impedes the interpretation of the contrast agent enrichment in the vessels and leads to noisy enrichment curves. We propose tracking of the heart surface features to compensate for the motion of the beating heart and thereby improve the analysis of the contrast agent enrichment. Furthermore, we propose a vessel segmentation pipeline for a local evaluation of contrast agent enrichment directly in the vessels.

Robot-Assisted Bone Cement Injection

In this article, assistance to bone cement injection is studied, with a focus on vertebroplasty, a procedure dedicated to the treatment of vertebral compression fractures. A robotic system that can remotely be operated at pressures up to 140 bar is presented. It improves cement polymerization control, combining a cold passive exchanger that slows down the cement curing in the syringe and an active exchanger that controls the injected cement temperature. The cement remote injection uses a rate control teleoperation strategy with force feedback to help monitoring the cement state. In addition to laboratory assessments, cadaver experiments were performed to illustrate the satisfactory operation of the whole system.

Income is associated with hippocampal/amygdala and education with cingulate cortex grey matter volume

Income and education are both elements of a person’s socioeconomic status, which is predictive of a broad range of life outcomes. The brain’s gray matter volume (GMV) is influenced by socioeconomic status and mediators related to an unhealthy life style. We here investigated two independent general population samples comprising 2838 participants (all investigated with the same MRI-scanner) with regard to the association of indicators of the socioeconomic status and gray matter volume. Voxel-based morphometry without prior hypotheses revealed that years of education were positively associated with GMV in the anterior cingulate cortex and net-equivalent income with gray matter volume in the hippocampus/amygdala region. Analyses of possible mediators (alcohol, cigarettes, body mass index (BMI), stress) revealed that the relationship between income and GMV in the hippocampus/amygdala region was partly mediated by self-reported stressors, and the association of years of education with GMV in the anterior cingulate cortex by BMI. These results corrected for whole brain effects (and therefore not restricted to certain brain areas) do now offer possibilities for more detailed hypotheses-driven approaches.

Does statin therapy impact the proximal aortopathy in aortic valve disease?

BACKGROUND

Studies have demonstrated that statin therapy decreases the growth rate of abdominal aneurysms. However, the effect of statin therapy on the proximal aortic disease has not been sufficiently elucidated.

AIM

We aimed to analyse the association between statin treatment and the severity of proximal aortopathy in patients with aortic valve disease.

DESIGN

Cross-sectional study.

METHODS

We prospectively identified 458 patients who were referred for aortic valve surgery from 2008 to 2014. Pre-operative measurement of the proximal aorta was performed by TEE, CT or MRT scan. Data of dyslipidemia treatment was obtained by questionnaire.

RESULTS

The mean ascending aortic diameter in the whole study population was comparable in patients with vs. without statin therapy (i.e. 42.7 mm vs. 43.6 mm, P = 0.46). Logistic regression analysis showed no significant association between statin therapy and proximal aortopathy ≥ 40 mm in the whole study group (OR = 0.69, P = 0.10). For the BAV sub-group, HDL (OR = 0.54, P = 0.038) and cholesterol levels (OR = 2.00, P = 0.038) were found significantly associated with the proximal aortic disease. In the BAV cohort, the statin users with target HDL levels presented a significantly smaller proximal aortic diameter (40.1 mm vs. 46 mm, P = 0.02).

CONCLUSION

Pre-operative statin therapy demonstrated no significant association with the expression of proximal aortopathy. However, more than 40% of the statin users presented uncontrolled lipid levels at the time of the study. In the BAV sub-group, the statins users with target HDL levels showed a significantly smaller ascending aorta diameter. Target HDL and cholesterol levels were strongly associated with proximal aortic dilation in BAV patients.

On-chip THz spectrometer for bunch compression fingerprinting at fourth-generation light sources

The layout of an integrated millimetre-scale on-chip THz spectrometer is presented and its peformance demonstrated. The device is based on eight Schottky-diode detectors which are combined with narrowband THz antennas, thereby enabling the simultaneous detection of eight frequencies in the THz range on one chip. The size of the active detector area matches the focal spot size of superradiant THz radiation utilized in bunch compression monitors of modern linear electron accelerators. The 3 dB bandwidth of the on-chip Schottky-diode detectors is less than 10% of the center frequency and allows pulse-resolved detection at up to 5 GHz repetition rates. The performance of a first prototype device is demonstrated at a repetition rate of 100 kHz at the quasi-cw SRF linear accelerator ELBE operated with electron bunch charges between a few pC and 100 pC.

On the Mathematical Basis of Zelen’s Prerandomized Designs

The mathematical basis of Zelen’s suggestion [4] of pre randomizing patients in a clinical trial and then asking them for their consent is investigated. The first problem is to estimate the therapy and selection effects. In the simple prerandomized design (PRD) this is possible without any problems. Similar observations have been made by Anbar [1] and McHugh [3]. However, for the double PRD additional assumptions are needed in order to render therapy and selection effects estimable. The second problem is to determine the distribution of the statistics. It has to be taken into consideration that the sample sizes are random variables in the PRDs. This is why the distribution of the statistics can only be determined asymptotically, even under the assumption of normal distribution. The behaviour of the statistics for small samples is investigated by means of simulations, where the statistics considered in the present paper are compared with the statistics suggested by Ihm [2]. It turns out that the statistics suggested in [2] may lead to anticonservative decisions, whereas the “canonical statistics” suggested by Zelen [4] and considered in the present paper keep the level quite well or may lead to slightly conservative decisions, if there are considerable selection effects.

Phototoxische und photoallergische Reaktionen

Basierend auf einer Wechselwirkung zwischen elektromagnetischer Strahlung meist aus dem UV-Bereich mit einem Photosensibilisator kann eine photoallergische oder eine phototoxische Dermatitis ausgelöst werden. Unter dem Begriff „Photosensibilisatoren“ werden sowohl synthetisch hergestellte als auch natürlich vorkommende Substanzen verstanden, die nach vorheriger Exposition mit Strahlung meist aus dem UV-A-Bereich auf der Haut phototoxische oder photoallergische Reaktionen hervorrufen können. Im Allgemeinen werden phototoxische Reaktionen sehr viel häufiger beobachtet als photoallergische Dermatitiden. Zum Nachweis derartiger Photosensibilisatoren dient eine belichtete Variante des herkömmlichen Epikutan-Tests, der sog. Photopatch-Test. Bei einem vermutlich falsch negativen Photopatch-Test-Befund können darüber hinaus der Photoprick-, Photoscratch- oder der belichtete Intrakutan-Test herangezogen werden. Ist jedoch erst ein Metabolit einer Testsubstanz der eigentliche Photosensibilisator, dann kommt noch die systemische Photoprovokation als Nachweisverfahren infrage. Da im Einzelfall phototoxische von photoallergischen Testreaktionen klinisch nur schwer abzugrenzen sind, können typische Reaktionsmuster, die im Rahmen von sehr umfangreichen Studien eruiert wurden, bei der Differenzierung zwischen phototoxischen und photoallergischen Dermatitiden hilfreich sein.

Towards a more accurate quantitative assessment of seasonal Cryptosporidium infection risks in surface waters using species and genotype information

Many Cryptosporidium species/genotypes are not considered infectious to humans, and more realistic estimations of seasonal infection risks could be made using human infectious species/genotype information to inform quantitative microbial risk assessments (QMRA). Cryptosporidium oocyst concentration and species/genotype data were collected from three surface water surveillance programs in two river basins [South Nation River, SN (2004-09) and Grand River, GR (2005-13)] in Ontario, Canada to evaluate seasonal infection risks. Main river stems, tributaries, agricultural drainage streams, water treatment plant intakes, and waste water treatment plant effluent impacted sites were sampled. The QMRA employed two sets of exposure data to compute risk: one assuming all observed oocysts were infectious to humans, and the other based on the fraction of oocysts that were C. hominis and/or C. parvum (dominant human infectious forms of the parasite). Viability was not considered and relative infection risk was evaluated using a single hypothetical recreational exposure. Many sample site groupings for both river systems, had significant seasonality in Cryptosporidium occurrence and concentrations (p ≤ 0.05); occurrence and concentrations were generally highest in autumn for SN, and autumn and summer for GR. Mean risk values (probability of infection per exposure) for all sites combined, for each river system, were roughly an order of magnitude lower (avg. of SN and GR 5.3 × 10^-5) when considering just C. parvum and C. hominis oocysts, in relation to mean infection risk (per exposure) assuming all oocysts were infectious to humans (5.5 × 10^-4). Seasonality in mean risk (targeted human infectious oocysts only) was most strongly evident in SN (e.g., 7.9 × 10^-6 in spring and 8.1 × 10^-5 in summer). Such differences are important if QMRA is used to quantify effects of water safety/quality management practices where inputs from a vast array of fecal pollution sources can readily occur. Cryptosporidium seasonality in water appears to match the seasonality of human infections from Cryptosporidium in the study regions. This study highlights the importance of Cryptosporidium species/genotype data to help determine surface water pollution sources and seasonality, as well as to help more accurately quantify human infection risks by the parasite.

High resolution Thomson Parabola Spectrometer for full spectral capture of multi-species ion beams

We report on the experimental characterisation of laser-driven ion beams using a Thomson Parabola Spectrometer (TPS) equipped with trapezoidally shaped electric plates, proposed by Gwynne et al. [Rev. Sci. Instrum. 85, 033304 (2014)]. While a pair of extended (30 cm long) electric plates was able to produce a significant increase in the separation between neighbouring ion species at high energies, deploying a trapezoidal design circumvented the spectral clipping at the low energy end of the ion spectra. The shape of the electric plate was chosen carefully considering, for the given spectrometer configuration, the range of detectable ion energies and species. Analytical tracing of the ion parabolas matches closely with the experimental data, which suggests a minimal effect of fringe fields on the escaping ions close to the wedged edge of the electrode. The analytical formulae were derived considering the relativistic correction required for the high energy ions to be characterised using such spectrometer.

Bacteria, viruses, and parasites in an intermittent stream protected from and exposed to pasturing cattle: prevalence, densities, and quantitative microbial risk assessment

Over 3500 individual water samples, for 131 sampling times, targeting waterborne pathogens/fecal indicator bacteria were collected during a 7-year period from 4 sites along an intermittent stream running through a small livestock pasture system with and without cattle access-to-stream restriction measures. The study assessed the impact of cattle pasturing/riparian zone protection on: pathogen (bacterial, viral, parasite) occurrence, concentrations of fecal indicators, and quantitative microbial risk assessments (QMRA) of the risk of Cryptosporidium, Giardia and Escherichia coli O157:H7 infection in humans. Methodologies were developed to compute QMRA mean risks on the basis of water samples exhibiting potentially human infectious Cryptosporidium and E. coli based on genotyping Crytosporidium, and E. coli O157:H7 presence/absence information paired with enumerated E. coli. All Giardia spp. were considered infectious. No significant pasturing treatment effects were observed among pathogens, with the exception of Campylobacter spp. and E. coli O157:H7. Campylobacter spp. prevalence significantly decreased downstream through pasture treatments and E. coli O157:H7 was observed in a few instances in the middle of the unrestricted pasture. Densities of total coliform, fecal coliform, and E. coli reduced significantly downstream in the restricted pasture system, but not in the unrestricted system. Seasonal and flow conditions were associated with greater indicator bacteria densities, especially in the summer. Norovirus GII was detected at rates of 7-22% of samples for all monitoring sites, and rotavirus in 0-7% of samples for all monitoring sites; pasture treatment trends were not evident, however. Seasonal and stream flow variables (and their interactions) were relatively more important than pasture treatments for initially stratifying pathogen occurrence and higher fecal indicator bacteria densities. Significant positive associations among fecal indicator bacteria and Campylobacter spp. detection were observed. For QMRA, adjusting for the proportion of Cryptosporidium spp. detected that are infectious for humans reduces downstream risk estimates by roughly one order of magnitude. Using QMRA in this manner provides a more refined estimate of beneficial management practice effects on pathogen exposure risks to humans.

Impact of riparian zone protection from cattle on nutrient, bacteria, F-coliphage, and loading of an intermittent stream

This 5-yr study compared, via an upstream-downstream experimental design, nutrient and microbial water quality of an intermittent stream running through a small pasture (∼2.5 animals ha) where cattle are restricted from the riparian zone (restricted cattle access [RCA]) and where cattle have unrestricted access to the stream (unrestricted cattle access [URCA]). Fencing in the RCA excluded pasturing cattle to within ∼3 to 5 m of the stream. Approximately 88% (26/32) of all comparisons of mean contaminant load reduction for lower, higher, and all stream flow conditions during the 5-yr study indicated net contaminant load reductions in the RCA; for the URCA, this percentage was 38% (12/32). For all flow conditions, mean percent load reductions in the RCA for nutrients and bacteria plus F-coliphage were 24 and 23%, respectively. These respective percentages for the URCA were -9 and -57% (positive values are reductions; negative values are increases). However, potentially as a result of protected wildlife habitat in the RCA, the mean percent load reduction for for "all flow" was -321% for the RCA and 60% for the URCA; for , these respective percentages were -209% (RCA) and 73% (URCA). For "all flow" situations, mean load reductions for the RCA were significantly greater ( < 0.1) than those from the URCA for NH-N, dissolved reactive phosphorus (DRP), total coliform, , and . For "high flow" situations, mean load reductions were significantly greater for the RCA for DRP, total coliform, and . For "low flow" conditions, significantly greater mean load reductions were in favor of the RCA for DRP, total P, total coliforms, fecal coliforms, , and . In no case were mean pollutant loads in the URCA significantly higher than RCA pollutant loads. Restricting pasturing livestock to within 3 to 5 m of intermittent streams can improve water quality; however, water quality impairment can occur if livestock have unrestricted access to a stream.

Investigation of an Escherichia coli environmental benchmark for waterborne pathogens in agricultural watersheds in Canada

Canada's National Agri-Environmental Standards Initiative sought to develop an environmental benchmark for low-level waterborne pathogen occurrence in agricultural watersheds. A field study collected 902 water samples from 27 sites in four intensive agricultural watersheds across Canada from 2005 to 2007. Four of the sites were selected as reference sites away from livestock and human fecal pollution sources in each watershed. Water samples were analyzed for Campylobacter spp., Salmonella spp., Escherichia coli O157:H7, Cryptosporidium spp., Giardia spp., and the water quality indicator E. coli. The annual mean number of pathogen species was higher at agricultural sites (1.54 ± 0.07 species per water sample) than at reference sites (0.75 ± 0.14 species per water sample). The annual mean concentration of E. coli was also higher at agricultural sites (491 ± 96 colony-forming units [cfu] 100 mL(-1)) than at reference sites (53 ± 18 cfu 100 mL(-1)). The feasibility of adopting existing E. coli water quality guideline values as an environmental benchmark was assessed, but waterborne pathogens were detected at agricultural sites in 80% of water samples with low E. coli concentrations (<100 cfu 100 mL(-1)). Instead, an approach was developed based on using the natural background occurrence of pathogens at reference sites in agricultural watersheds to derive provisional environmental benchmarks for pathogens at agricultural sites. The environmental benchmarks that were derived were found to represent E. coli values lower than geometric mean values typically found in recreational water quality guidelines. Additional research is needed to investigate environmental benchmarks for waterborne pathogens within the context of the "One World, One Health" perspective for protecting human, domestic animal, and wildlife health.

In vivo treatment with progestogens causes immunosuppression of carp Cyprinus carpio leucocytes by affecting nitric oxide production and arginase activity

In this study, carp Cyprinus carpio were injected with various steroid compounds, including synthetic and natural progestogens and the glucocorticoid cortisol, to investigate effects on leucocytes isolated from their kidneys. Injection of cortisol led to an increased spleeno-somatic index (I(S)) on day 21 post-injection (pi) and immunosuppressive effects measured as decreased nitric oxide (NO) production and increased arginase activity in isolated leucocytes on days 14 and 21 pi, respectively. Moreover, reduced NO production was also observed after injection of the synthetic progestogens, levonorgestrel (LEV) and medroxyprogesterone acetate. In addition, LEV influenced arginase activity in head kidney cells on day 14 and day 21 pi. This study is the first demonstration in fishes that the application of these steroid compounds in vivo affects NO production and arginase activity of isolated leucocytes.

Electron diffraction self-imaging of molecular fragmentation in two-step double ionization of water

We doubly ionize H(2)O by single photon absorption at 43 eV leading to H(+) + OH(+). A direct double ionization and a sequential process in which single ionization is followed by rapid dissociation into a proton and an autoionizing OH(*) are identified. The angular distribution of this delayed autoionization electron shows a preferred emission in the direction of the emitted proton. From this diffraction feature we obtain internuclear distances of 700 to 1100 a.u. at which the autoionization of the OH(*) occurs. The experimental findings are in line with calculations of the excited potential energy surfaces and their lifetimes.

Ionization dynamics of helium dimers in fast collisions with He++

By employing the cold target recoil ion momentum spectroscopy technique, we have investigated the (He+, He+) breakup of a helium dimer (He2) caused by transfer ionization and double capture in collisions with alpha particles (E = 150  keV/u). Surprisingly, the results show a two-step process as well as a one-step process followed by electron exchange. In addition, interatomic Coulombic decay [L. S. Cederbaum, J. Zobeley, and F. Tarantelli, Phys. Rev. Lett. 79, 4778 (1997).] is observed in an ion collision for the first time.

Single photon double ionization of the helium dimer

We show that a single photon can ionize the two helium atoms of the helium dimer in a distance up to 10 A. The energy sharing among the electrons, the angular distributions of the ions and electrons, as well as comparison with electron impact data for helium atoms suggest a knockoff type double ionization process. The Coulomb explosion imaging of He2 provides a direct view of the nuclear wave function of this by far most extended and most diffuse of all naturally existing molecules.

Interatomic Coulombic decay following photoionization of the helium dimer: observation of vibrational structure

Using synchrotron radiation we simultaneously ionize and excite one helium atom of a helium dimer (He2) in a shakeup process. The populated states of the dimer ion [i.e., He(*+)(n = 2, 3) - He] are found to deexcite via interatomic Coulombic decay. This leads to the emission of a second electron from the neutral site and a subsequent Coulomb explosion. In this Letter we present a measurement of the momenta of fragments that are created during this reaction. The electron energy distribution and the kinetic energy release of the two He+ ions show pronounced oscillations which we attribute to the structure of the vibrational wave function of the dimer ion.

Fragmentation dynamics of CO(2)(3+) investigated by multiple electron capture in collisions with slow highly charged ions

Fragmentation of highly charged molecular ions or clusters consisting of more than two atoms can proceed in a one step synchronous manner where all bonds break simultaneously or sequentially by emitting one ion after the other. We separated these decay channels for the fragmentation of CO(2)(3+) ions by measuring the momenta of the ionic fragments. We show that the total energy deposited in the molecular ion is a control parameter which switches between three distinct fragmentation pathways: the sequential fragmentation in which the emission of an O(+) ion leaves a rotating CO(2+) ion behind that fragments after a time delay, the Coulomb explosion and an in-between fragmentation--the asynchronous dissociation. These mechanisms are directly distinguishable in Dalitz plots and Newton diagrams of the fragment momenta. The CO(2)(3+) ions are produced by multiple electron capture in collisions with 3.2 keV/u Ar(8+) ions.

Calendar calculating in savants with autism and healthy calendar calculators

BACKGROUND

Calendar calculation is the ability to quickly name the day that a given date falls on. Previous research has suggested that savant calendar calculation is based on rote memory and the use of rule-based arithmetic skills. The objective of this study was to identify the cognitive processes that distinguish calendar calculation in savant individuals from healthy calendar calculators.

METHOD

Savant calendar calculators with autism (ACC, n=3), healthy calendar calculators (HCC, n=3), non-savant subjects with autism (n=6) and healthy calendar calculator laymen (n=18) were included in the study. All participants calculated dates of the present (current month). In addition, ACC and HCC also calculated dates of the past and future 50 years.

RESULTS

ACC showed shorter reaction times and fewer errors than HCC and non-savant subjects with autism, and significantly fewer errors than healthy calendar calculator laymen when calculating dates of the present. Moreover, ACC performed faster and more accurate than HCC regarding past dates. However, no differences between ACC and HCC were detected for future date calculation.

CONCLUSIONS

The findings may imply distinct calendar calculation strategies in ACC and HCC, with HCC relying on calendar regularities for all types of dates and an involvement of (rote) memory in ACC when processing dates of the past and the present.

Photo- and auger-electron recoil induced dynamics of interatomic Coulombic decay

At photon energies near the Ne K edge it is shown that for 1s ionization the Auger electron, and for 2s ionization the fast photoelectron, launch vibrational wave packets in a Ne dimer. These wave packets then decay by emission of a slow electron via interatomic Coulombic decay (ICD). The measured and computed ICD electron spectra are shown to be significantly modified by the recoil induced nuclear motion.

Conditional associative learning examined in a paralyzed patient with amyotrophic lateral sclerosis using brain-computer interface technology

Background

Brain-computer interface methodology based on self-regulation of slow-cortical potentials (SCPs) of the EEG (electroencephalogram) was used to assess conditional associative learning in one severely paralyzed, late-stage ALS patient. After having been taught arbitrary stimulus relations, he was evaluated for formation of equivalence classes among the trained stimuli.

Methods

A monitor presented visual information in two targets. The method of teaching was matching to sample. Three types of stimuli were presented: signs (A), colored disks (B), and geometrical shapes (C). The sample was one type, and the choice was between two stimuli from another type. The patient used his SCP to steer a cursor to one of the targets. A smiley was presented as a reward when he hit the correct target. The patient was taught A-B and B-C (sample – comparison) matching with three stimuli of each type. Tests for stimulus equivalence involved the untaught B-A, C-B, A-C, and C-A relations. An additional test was discrimination between all three stimuli of one equivalence class presented together versus three unrelated stimuli. The patient also had sessions with identity matching using the same stimuli.

Results

The patient showed high accuracy, close to 100%, on identity matching and could therefore discriminate the stimuli and control the cursor correctly. Acquisition of A-B matching took 11 sessions (of 70 trials each) and had to be broken into simpler units before he could learn it. Acquisition of B-C matching took two sessions. The patient passed all equivalence class tests at 90% or higher.

Conclusion

The patient may have had a deficit in acquisition of the first conditional association of signs and colored disks. In contrast, the patient showed clear evidence that A-B and B-C training had resulted in formation of equivalence classes. The brain-computer interface technology combined with the matching to sample method is a useful way to assess various cognitive abilities of severely paralyzed patients, who are without reliable motor control.

Interference in the collective electron momentum in double photoionization of H2

We investigate single-photon double ionization of H(2) by 130 to 240 eV circularly polarized photons. We find a double slitlike interference pattern in the sum momentum of both electrons in the molecular frame which survives integration over all other degrees of freedom. The difference momentum and the individual electron momentum distributions do not show such a robust interference pattern. We show that this interference results from a non-Heitler-London fraction of the H(2) ground state where both electrons are at the same atomic center.

The simplest double slit: interference and entanglement in double photoionization of H2

The wave nature of particles is rarely observed, in part because of their very short de Broglie wavelengths in most situations. However, even with wavelengths close to the size of their surroundings, the particles couple to their environment (for example, by gravity, Coulomb interaction, or thermal radiation). These couplings shift the wave phases, often in an uncontrolled way, and the resulting decoherence, or loss of phase integrity, is thought to be a main cause of the transition from quantum to classical behavior. How much interaction is needed to induce this transition? Here we show that a photoelectron and two protons form a minimum particle/slit system and that a single additional electron constitutes a minimum environment. Interference fringes observed in the angular distribution of a single electron are lost through its Coulomb interaction with a second electron, though the correlated momenta of the entangled electron pair continue to exhibit quantum interference.

Risk factors for venous thromboembolic events in cancer patients

BACKGROUND

Cancer patients of the Department of Internal Medicine (Cancer Research) of the Essen University Medical School (Tumor Clinics), Germany, were examined and questioned with the aim of identifying those who run a high risk of deep vein thrombosis (DVT).

PATIENTS AND METHODS

Between September 2002 and April 2003, cancer therapy and DVT risk factors of 507 cancer patients (53% males, 47% females, mean age 56+/-12 years) were documented. During a mean follow-up of 8+/-5 months, 60 patients (12%) suffered from new venous thromboembolic events (VTE): 28 at the lower limb, 25 at the upper limb and 13 pulmonary embolisms.

RESULTS

The following factors were considered as predictive for an increased VTE risk: inpatient treatment (P<0.0001), prior DVT in medical history (P=0.0275), DVT in family (P=0.0598), chemotherapy (P=0.0080), fever (P=0.0093) and CRP (P<0.001). After combining factors in one variable (number of factors) the predicted VTE risk increased with the number of factors in both outpatients (OR 1.85, 95% CI 1.18-2.88, P=0.0071) and inpatients (OR 2.34, 95% CI 1.63-3.36, P<or=0.0001). In the absence of all these factors the predicted VTE risk was 2.3%, increasing to 72% if all were present.

CONCLUSIONS

In cancer patients the risk of VTE steadily increases with the number of risk factors, and identification of patients at high risk is possible.

Automatic processing of self-regulation of slow cortical potentials: evidence from brain-computer communication in paralysed patients

OBJECTIVE

Direct brain-computer communication utilizes self-regulation of brain potentials to select letters, words or symbols from a computer menu. Selection of letters or words with brain potentials requires simultaneous processing of several tasks such as production of certain brain potentials at predefined time points simultaneously with processing of presented letter strings. This study addresses the question of whether the self-regulation of slow cortical potentials (SCP) automatizes with practice and can thus be considered as a skill comparable to motor or cognitive skills.

METHODS

Two nearly completely paralysed patients learned over several months to produce electrocortically negative and positive SCP by means of visual feedback. Improved performance and a reduction in performance variability were regarded as behavioural indicators for automaticity, while the topographic focalization of cortical activation was considered as a neurophysiological indicator for automaticity. Different indicators of automaticity were expected to covary along with practice.

RESULTS

In patient 1, performance measured as the percentage of correct SCP shifts increased simultaneously with the topographic focalization of cortical activation. His performance became more stable with practice. For this patient the criteria for automaticity were all met. In patient 2, performance also improved, but his cortical activity became topographically less focal. His performance was less stable than that of patient 1.

CONCLUSIONS

The present findings, albeit on only two subjects, provide preliminary evidence that SCP self-regulation may automatize with long-term practice and can therefore be considered a skill.

Predictors of successful self control during brain-computer communication

OBJECTIVES

Direct brain-computer communication uses self regulation of brain potentials to select letters, words, or symbols from a computer menu to re-establish communication in severely paralysed patients. However, not all healthy subjects, or all paralysed patients acquire the skill to self regulate their brain potentials, and predictors of successful learning have not been found yet. Predictors are particularly important, because only successful self regulation will in the end lead to efficient brain-computer communication. This study investigates the question whether initial performance in the self regulation of slow cortical potentials of the brain (SCPs) may be positively correlated to later performance and could thus be used as a predictor.

METHODS

Five severely paralysed patients diagnosed with amyotrophic lateral sclerosis were trained to produce SCP amplitudes of negative and positive polarity by means of visual feedback and operant conditioning strategies. Performance was measured as percentage of correct SCP amplitude shifts. To determine the relation between initial and later performance in SCP self regulation, Spearman's rank correlations were calculated between maximum and mean performance at the beginning of training (runs 1-30) and mean performance at two later time points (runs 64-93 and 162-191).

RESULTS

Spearman's rank correlations revealed a significant relation between maximum and mean performance in runs 1-30 and mean performance in runs 64-93 (r= 0.9 and 1.0) and maximum and mean performance in runs 1-30 and mean performance in runs 162-191 (r=1.0 and 1.0).

CONCLUSIONS

Initial performance in the self regulation of SCP is positively correlated with later performance in severely paralysed patients, and thus represents a useful predictor for efficient brain-computer communication.

A non-invasive communication device for the paralyzed

An EEG-based communication system has been developed to re-establish communication in severely paralyzed patients who operate the device by generating shifts of their slow cortical potentials. Training to gain control over slow cortical potentials was based on visual feedback and operant conditioning strategies. The vertical movement of a graphic signal on a computer screen informs the patients about the course of their slow cortical potential amplitude. Positive slow cortical potential shifts move the cursor up, negative shifts move it down. These shifts are then translated into binary responses. When a patient has achieved reliable control over his/her slow cortical potential shifts, these responses can be used to select or reject items presented at the bottom of the screen. As learning processes and applications differ considerably between patients, the present paper describes the data from one patient with amyotrophic lateral sclerosis. After about three months of training, this patient gained stable, near-perfect control over his slow cortical potentials. This skill enabled him to operate a specially designed program to communicate messages to his caregivers.

Brain-computer communication: self-regulation of slow cortical potentials for verbal communication

OBJECTIVE

To test a training procedure designed to enable severely paralyzed patients to communicate by means of self-regulation of slow cortical potentials.

DESIGN

Application of the Thought Translation Device to evaluate the procedure in patients with late-stage amyotrophic lateral sclerosis (ALS).

SETTING

Training sessions in the patients' homes.

PARTICIPANTS

Two male patients with late-stage ALS.

INTERVENTIONS

Patients learned voluntary control of their slow cortical potentials by means of an interface between the brain and a computer. Training was based on visual feedback of slow cortical potentials shifts and operant learning principles. The learning process was divided into small steps of increasing difficulty.

MAIN OUTCOME MEASURES

Accuracy of self-control of slow cortical potentials (percentage of correct responses). Learning progress calculated as a function of training session.

RESULTS

Within 3 to 8 weeks, both patients learned to self-regulate their slow cortical potentials and to use this skill to select letters or words in the Language Support Program.

CONCLUSIONS

This training schedule is the first to enable severely paralyzed patients to communicate without any voluntary muscle control by using self-regulation of an electroencephalogram potential only. The protocol could be a model for training patients in other brain-computer interface techniques.

Self-initiation of EEG-based communication in paralyzed patients

OBJECTIVES

Severely paralyzed patients could learn to voluntarily generate slow cortical potential (SCP) shifts in their electroencephalogram and to use these signals to operate a communication device. To enhance the patients' autonomy, the present study describes the development of a permanently available communication system that can be turned on and off by locked-in patients without external assistance. A skill necessary for turning the system on is the ability to regulate one's slow potentials in the absence of continuous feedback.

METHODS

A stepwise learning approach was employed to train two paralyzed patients to regulate their SCPs without continuous feedback. Elements of the original communication system were gradually removed and elements of the new stand-by mode were introduced.

RESULTS

At the end of the learning procedure, both patients achieved correct response rates of above 84% in training sessions without continuous feedback. This skill enabled them to turn the communication device on and off without assistance from others.

CONCLUSIONS

These findings suggest that severely paralyzed individuals can learn to operate an EEG-based communication device autonomously.

The thought translation device (TTD) for completely paralyzed patients

The thought translation device trains locked-in patients to self-regulate slow cortical potentials (SCP's) of their electroencephalogram (EEG). After operant learning of SCP self-control, patients select letters, words or pictograms in a computerized language support program. Results of five respirated, locked-in-patients are described, demonstrating the usefulness of the thought translation device as an alternative communication channel in motivated totally paralyzed patients with amyotrophic lateral sclerosis.