Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

P-124 The impact of Fragile x premutation carrier state on embryo morphokinetic development, A comparison between genetically normal and abnormal embryos

Study question

Does inheritance of FMR1 pre mutant allele affect embryos morphokinetic development?

Summary answer

Embryos that inherit the FMR1 pre-mutant allele are of a lower morphokinetic quality at the blastocyte stage compared to those with the normal allele.

What is known already

Previous studies suggest lower oocyte yield and blastulation rate in FMR1 premutation carriers undergoing preimplantation genetic testing for monogenic diseases (PGT-M). Yet, data is lacking concerning embryo morphokinetic development in this group.

Study design, size, duration

Retrospective analysis, on 529 embryos from 126 in vitro fertilization (IVF)- PGT-M cycles of 39 FMR-1 premutation women carriers.

Participants/materials, setting, methods

Morphological and morphokinetic parameters acquired by the time-lapse monitoring system were compared between embryos carrying the FMR-1 permutated allele (FMR1 group n = 271) to those who inherited the normal allele (Normal group n = 258). Outcomes measures were embryos morphokinetic parameters up to day 3, the start of blasulation time (tSB) for day 5 embryos, and the rate of top-quality embryos at days 3 and 5.

Main results and the role of chance

No differences were found between the groups in all morphokinetic parameters from the time of ICSI until biopsy on day 3. Blastulation rate was comparable between the groups. However, FMR1 embryos exhibited delayed start of blastulation compared to the genetically normal embryos (median tSB 104.2 hrs (99.3-110.3) vs 101.6 hrs (94.5-106.7), P = 0.01) and had lower top quality embryo rate (25.6% vs 38.8%, P = 0.04).

Limitations, reasons for caution

This study is limited by its retrospective design and inability to assess CGG expansion in the embryo.

Wider implications of the findings

This study offers new insight into the impact of permutated FMR1 gene in the early stages of embryo development. Further studies are needed in order to apply these results in clinical decision-making.

Trial registration number

not applicable

Associations between breast implants and postpartum lactational mastitis in breastfeeding women: retrospective study

OBJECTIVE

To examine the putative associations between breast implants and postpartum lactational mastitis.

DESIGN

Observational retrospective study.

SETTING

Digital database of Maccabi Healthcare Services, integrated health maintenance organisation in Israel.

POPULATION

Breastfeeding mothers from 2003 to 2016 based on an initial health maintenance organisation data set of 28 383 singleton live births in Israel.

METHODS

Multivariate analysis and propensity score matching were used to test the extent to which breast implants were associated with lactational mastitis during the 6-month postpartum period in breastfeeding mothers. Analyses for potential confounders were adjusted for socio-economic status, smoking and parity.

MAIN OUTCOME MEASURE

Lactational mastitis among breastfeeding women with breast implants compared with women without breast implants.

RESULTS

Mothers with breast implants (n = 6099) were significantly (P < 0.001) more likely to be diagnosed with postpartum mastitis (8.3%) than mothers with no breast implants(n = 22 284) (6.6%) at an odds ratio of 1.22 (95% CI 1.09-1.35) after adjusting for confounders.

CONCLUSION

Breast augmentation is associated with an increased risk of postpartum lactational mastitis in the 6-month postpartum period. In light of these findings, it is important for health professionals to instruct women who have undergone breast augmentation on correct breastfeeding techniques, ways to avoid risk factors, and to be alert to signs permitting the early detection of lactational mastitis.

TWEETABLE ABSTRACT

A study of over 28,000 breastfeeding women has shown that breast augmentation is associated with an increased risk of postpartum lactational mastitis in the six-month postpartum period.

A multifunctional matching algorithm for sample design in agricultural plots

Collection of accurate and representative data from agricultural fields is required for efficient crop management. Since growers have limited available resources, there is a need for advanced methods to select representative points within a field in order to best satisfy sampling or sensing objectives. The main purpose of this work was to develop a data-driven method for selecting locations across an agricultural field given observations of some covariates at every point in the field. These chosen locations should be representative of the distribution of the covariates in the entire population and represent the spatial variability in the field. They can then be used to sample an unknown target feature whose sampling is expensive and cannot be realistically done at the population scale. An algorithm for determining these optimal sampling locations, namely the multifunctional matching (MFM) criterion, was based on matching of moments (functionals) between sample and population. The selected functionals in this study were standard deviation, mean, and Kendall's tau. An additional algorithm defined the minimal number of observations that could represent the population according to a desired level of accuracy. The MFM was applied to datasets from two agricultural plots: a vineyard and a peach orchard. The data from the plots included measured values of slope, topographic wetness index, normalized difference vegetation index, and apparent soil electrical conductivity. The MFM algorithm selected the number of sampling points according to a representation accuracy of 90% and determined the optimal location of these points. The algorithm was validated against values of vine or tree water status measured as crop water stress index (CWSI). Algorithm performance was then compared to two other sampling methods: the conditioned Latin hypercube sampling (cLHS) model and a uniform random sample with spatial constraints. Comparison among sampling methods was based on measures of similarity between the target variable population distribution and the distribution of the selected sample. MFM represented CWSI distribution better than the cLHS and the uniform random sampling, and the selected locations showed smaller deviations from the mean and standard deviation of the entire population. The MFM functioned better in the vineyard, where spatial variability was larger than in the orchard. In both plots, the spatial pattern of the selected samples captured the spatial variability of CWSI. MFM can be adjusted and applied using other moments/functionals and may be adopted by other disciplines, particularly in cases where small sample sizes are desired.

Two-year follow-up of 196 interstitial lung disease patients after ICU stay

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9-15.5 and OR 12.6, 95% CI 4.9-32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

FMRpolyG accumulates in FMR1 premutation granulosa cells

Background

Fragile X premutation (Amplification of CGG number 55–200) is associated with increased risk for fragile X-Associated Premature Ovarian Insufficiency (FXPOI) in females and fragile X-associated tremor/ataxia syndrome (FXTAS) predominantly in males. Recently, it has been shown that CGG repeats trigger repeat associated non-AUG initiated translation (RAN) of a cryptic polyglycine-containing protein, FMRpolyG. This protein accumulates in ubiquitin-positive inclusions in neuronal brain cells of FXTAS patients and may lead to protein-mediated neurodegeneration. FMRpolyG inclusions were also found in ovary stromal cells of a FXPOI patient. The role of FMRpolyG expression has not been thoroughly examined in folliculogenesis related cells. The main goal of this study is to evaluate whether FMRpolyG accumulates in mural granulosa cells of FMR1 premutation carriers. Following FMRpolyG detection, we aim to examine premutation transfected COV434 as a suitable model used to identify RAN translation functions in FXPOI pathogenesis.

Results

FMRpolyG and ubiquitin immunostained mural granulosa cells from six FMR1 premutation carriers demonstrated FMRpolyG aggregates. However, co-localization of FMRpolyG and ubiquitin appeared to vary within the FMR1 premutation carriers’ group as three exhibited partial ubiquitin and FMRpolyG double staining and three premutation carriers demonstrated FMRpolyG single staining. None of the granulosa cells from the five control women expressed FMRpolyG. Additionally, human ovarian granulosa tumor, COV434, were transfected with two plasmids; both expressing 99CGG repeats but only one enables FMRpolyG expression. Like in granulosa cells from FMR1 premutation carriers, FMRpolyG aggregates were found only in COV434 transfected with expended CGG repeats and the ability to express FMRpolyG.

Conclusions

Corresponding with previous studies in FXTAS, we demonstrated accumulation of FMRpolyG in mural granulosa cells of FMR1 premutation carriers. We also suggest that following further investigation, the premutation transfected COV434 might be an appropriate model for RAN translation studies. Detecting FMRpolyG accumulation in folliculogenesis related cells supports previous observations and imply a possible common protein-mediated toxic mechanism for both FXPOI and FXTAS.

Does the presence of AGG interruptions within the CGG repeat tract have a protective effect on the fertility phenotype of female FMR1 premutation carriers?

PURPOSE

While FMR1 premutation carriers (CGG 55-200) were shown to have reduced success with IVF treatment (lower oocyte yield), studies reporting on the association between the number of CGG repeats and patients' response to controlled ovarian hyperstimulation (COH) are inconsistent. In the present study, we aim to explore whether the number of CGG repeats in women with premutation in FMR1 gene, undergoing COH for IVF, correlates with COH variables and whether the number of AGG interruptions may function as a "protective factor" by improving the ovarian response to COH.

METHODS

Retrospective study, in an academic IVF-PGD unit. Fifty-seven consecutive FMR1 premutation carriers who underwent 285 IVF treatment cycles were included. The numbers of CGG repeats and AGG interruptions were retrieved and correlated to the demographics and COH variables.

RESULTS

There were no significant association between the numbers of CGG or the AGG interruptions and the number of oocyte retrieved or the peak estradiol levels. The lack of association was also observed when including all the IVF treatment cycles or only the first or last IVF treatment cycle. Moreover, no associations were found between the number of CGG repeats or AGG interruptions and other COH variables, i.e., duration of stimulation, the total dose of gonadotropin used, or the number of top-quality embryos.

CONCLUSIONS

No associations were observed between the number of CGG repeats or AGG interruptions and any of the COH variables. Further studies are required to identify early biomarkers of POI to empower FMR1 premutation carriers with risk assessment tools to consider procedures such as fertility preservation.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P4509The cardiopulmonary vicious cycle in patients with heart failure, a mechanism for accelerated decompensation

Background

Hemodynamic congestion appears days prior to the development of clinical congestion. Lung congestion is associated with increased respiratory effort and dyspnoea. The effects of increased respiratory effort on pulmonary circulation were not well-defined.

Purpose

The study investigates the cardiopulmonary interactions and the role of the respiratory effort in the development of decompensation. It is well-accepted that lung congestion affects the lung mechanics and increases the respiratory effort. On the other hand, changes in the intrathoracic and alveolar pressures, due to the increase in the respiratory effort, may have detrimental effects on the pulmonary circulation and the workloads of the heart.

Methods

We have simultaneously measured the hemodynamic indices and the respiratory mechanics in patients undergoing right heart catheterization (n=56) for the diagnosis of dyspnoea. The patients were classified either as heart failure (HF) or lung disease, according to their clinical history, symptoms and signs. The pulmonary capillary wedge pressure (PCWP) was decomposed into cardiac and respiratory waves. The respiratory effort (Presp) was defined as the respiratory wave amplitude that modulates the PCWP. Lung compliance was calculated as the ratio of the tidal volume to Presp.

Results and discussion

The HF patients (n=35) exhibited huge Presp of 9.6±3.7 mmHg [2.6–16.7], ∼4 fold the normal Presp, of about 2–3 mmHg (figure below). Their lung compliance decreased with increasing PCWP (2.0±0.4%/mmHg of PCWP). Both PCWP and pulmonary artery pressure (PAP) rose with Presp, by 0.92±0.36 mmHg and 1.68±0.47 mmHg, for 1 mmHg of Presp, respectively (Figure below). Interestingly, PCWP always exceeded Presp, leading to the stipulation of a novel fundamental constraint/law: the continuous pulmonary flow throughout the respiratory cycle requires that PCWP > Presp (above the identity line in figure A), otherwise the capillary pressure will decrease below the surrounding alveolar pressure and the pulmonary circulation will collapse, especially during inspiration. This constraint imposes a positive feedback of Presp on the pulmonary circulatory pressures. It is also supported by the increase in PWCP with Presp in the patients with lung diseases (Figure A). The bigger rise in PAP than in PWCP is attributed to the increase in the pulmonary vascular resistance (PVR) with Presp (0.3±0.06 wood units for 1mmHg Presp). The latter constructs additional positive feedback of Presp on the cardiac workload. A decrease in the intrathoracic pressure that surrounds the heart increases the LV apparent afterload. The increase in PAP and PVR elevates the right ventricle afterload.

PCWP (A) and PAP (B) vs. Presp

Conclusions

The respiratory effort is not just a hallmark of HF but plays a pivotal role in the cardiopulmonary vicious cycle. An increase in the respiratory effort increases the PWCP, PAP, PVR, and the afterloads of both ventricles, and thereby may accelerate cardiac decompensation.

A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO2 removal in a large metropolis area

Background

Extracorporeal carbon dioxide removal (ECCO₂R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis.

Methods

To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO₂R devices in 10 intensive care units (ICU) during a 2-year period.

Results

Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO₂R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median V_T was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO₂ values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO₂R was 5 days (IQR 3–8). Reasons for ECCO₂R discontinuation were improvement (n = 33), ECCO₂R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO₂R-related.

Conclusions

Based on a registry, we report a low rate of ECCO₂R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO₂R, and to guide the choice between different devices.

Trial registration

ClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079

[Rhabdomyolysis in patients treated by corticosteroids for acute asthma in intensive care unit]

INTRODUCTION

Acute muscle involvement is an infrequent complication of corticosteroids, characterized by muscle weakness and a rhabdomyolysis, rapidly regressive after withdrawal of corticosteroids.

CASE REPORT

We report the case of a woman admitted in intensive care unit for acute severe asthma, treated with high doses of methylprednisolone. Serum CPK level raised with a peak at 28,160 UI/L (n<250 UI/L) at day 15, suggesting acute rhabdomyolysis with renal failure. CPK rapidly normalized when corticosteroids were discontinued. Other causes of rhabdomyolysis were ruled out.

CONCLUSION

This necrosing myopathy under high doses of corticosteroids has been described in patients with severe acute asthma. The mechanism of the muscle damage results from a combination of corticosteroids toxicity, respiratory acidosis and mechanic ventilation.

Probing the internal micromechanical properties of Pseudomonas aeruginosa biofilms by Brillouin imaging

Biofilms are organised aggregates of bacteria that adhere to each other or surfaces. The matrix of extracellular polymeric substances that holds the cells together provides the mechanical stability of the biofilm. In this study, we have applied Brillouin microscopy, a technique that is capable of measuring mechanical properties of specimens on a micrometre scale based on the shift in frequency of light incident upon a sample due to thermal fluctuations, to investigate the micromechanical properties of an active, live Pseudomonas aeruginosa biofilm. Using this non-contact and label-free technique, we have extracted information about the internal stiffness of biofilms under continuous flow. No correlation with colony size was found when comparing the averages of Brillouin shifts of two-dimensional cross-sections of randomly selected colonies. However, when focusing on single colonies, we observed two distinct spatial patterns: in smaller colonies, stiffness increased towards their interior, indicating a more compact structure of the centre of the colony, whereas, larger (over 45 μm) colonies were found to have less stiff interiors.

A specialized microscopy technique can monitor biofilm stiffness in a non-destructive manner, yielding insights into biofilm structure and development. The technique, called Brillouin imaging, uses changes in the frequency of light interacting with a substance to reveal fine detail about the material’s mechanical properties. Peter Török and colleagues at Imperial College London, with co-workers in Singapore, used Brillouin imaging to study biofilms of Pseudomonas aeruginosa bacteria at different stages in their life cycle. In young colonies, stiffness increased towards the interior of the biofilm, while mature colonies had less stiff interiors. The older biofilms may therefore have hollow interiors or may have been moving towards a phase of bacterial dispersal from the biofilm state. This non-disruptive method to study mechanical variations within and between living biofilms may help efforts to combat biofilms in clinical, environmental and industrial situations.

Eustachian tube dysfunction leading to middle-ear pathology in patients on chronic mechanical ventilation

OBJECTIVE

This study aimed to investigate the prevalence of and risk factors for Eustachian tube dysfunction leading to middle-ear pathology in patients on chronic mechanical ventilation via tracheostomy tube.

METHODS

A total of 40 patients on chronic ventilation were included in a prospective cohort study. Middle-ear status was determined by tympanometry. Tympanograms were categorised as types A, B or C; types B and C were defined as middle-ear pathology.

RESULTS

In all, 57 ears of 40 patients were examined. Disease was found in at least 1 ear in 26 out of 40 patients. Middle-ear pathology was found in 25 out of 34 patients who were tube fed (via nasogastric tube or percutaneous endoscopic gastrostomy) vs 1 patient out of the 6 fed orally (p = 0.014), and in 23 out of 31 with conscious or cognitive impairment vs 3 out of 9 cognitively intact patients (p = 0.044).

CONCLUSION

Middle-ear pathology is common in patients on chronic mechanical ventilation via tracheostomy tube. The highest prevalence was in those with impaired consciousness or cognition, and oral feeding appeared protective.

High-frequency measurement of depressive severity in a patient treated for severe treatment-resistant depression with deep-brain stimulation

Although there have been previous studies of deep-brain stimulation (DBS), we present, to our knowledge, the first example of high-frequency depressive severity measurement-based DBS treatment in particular and psychiatric treatment in general. Daily post-surgical e-mail prompts for a period of 6 months resulted in 93 administrations of a computerized adaptive test (CAT) of depression severity (CAT-Depression Inventory or CAT-DI) via the internet. There was an average of 3.37 weekly measurements with an average separation of 2.12 days. No additional incentive was provided to the patient for completing the adaptive tests. The patient is a 55-year-old female with six psychiatric hospitalizations for depression, two suicide attempts, marginal response to eight electroconvulsive therapy (ECT) treatments and 35 psychotropic medications. We report results after high-frequency stimulation of the superolateral branch of the medial forebrain bundle. The CAT-DI was used for daily assessments before, during and after (remotely in response to an e-mail prompt) the DBS procedure. Two follow-up Hamilton Depression Scales (HAM-Ds) were also collected. Response to treatment varied markedly, with a decrease from severe (>75) to mild (60), which is three times the size of the uncertainty level. Although the HAM-D scores decreased, they missed the more complete temporal pattern identified by CAT-DI daily monitoring. We demonstrated feasibility of daily depressive severity measurement at high levels of precision and compliance. Clinician ratings confirm the general pattern of treatment benefit, but mask the marked variability in mood and more marked periods of benefit and decline.

Laplacian networks: Growth, local symmetry, and shape optimization

Inspired by river networks and other structures formed by Laplacian growth, we use the Loewner equation to investigate the growth of a network of thin fingers in a diffusion field. We first review previous contributions to illustrate how this formalism reduces the network's expansion to three rules, which respectively govern the velocity, the direction, and the nucleation of its growing branches. This framework allows us to establish the mathematical equivalence between three formulations of the direction rule, namely geodesic growth, growth that maintains local symmetry, and growth that maximizes flux into tips for a given amount of growth. Surprisingly, we find that this growth rule may result in a network different from the static configuration that optimizes flux into tips.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Simulated Low Earth Orbit Environment Interaction with Different Types of Polyethylene

The present study investigated the interactions of four different types of polyethylene (PE) surfaces with RF oxygen plasma components, simulating the low Earth orbit (LEO) environment. The samples were exposed in the plasma afterglow, with and without the plasma-generated vacuum UV (VUV) radiation. The polymers studied were low-density polyethylene (LDPE), ultra high molecular weight polyethylene (UHMWPE), high-density polyethylene (HDPE), and a composite of highly-oriented fibres of ultra-high molecular weight polyethylene (PolyEitan) having crystalline-to-amorphous phases ratio of 65, 74, 87 and 92%, respectively. Erosion of the LDPE, UHMWPE, and HDPE samples under atomic oxygen (AO) irradiation showed an etching rate dependence on the degree of crystallinity - the higher the crystallinity level the lower the erosion rate. The addition of VUV radiation to the AO flux resulted in a significant increase of the etching rate. An increase of the crystallinity level resulted in a decrease of the total oxygen uptake and an increase of the surface roughness. The composite polyethylene, although highly crystalline, revealed similar erosion rate and chemical composition changes as highly amorphous LDPE. The erosion mechanism of the different PE samples under AO or AO+VUV is discussed in terms of the initial internal structure.

A Novel Treatment of Contact Dermatitis by Topical Application of Phospholipase A2 Inhibitor: A Double-Blind Placebo-Controlled Pilot Study

Phospholipase A2 hydrolyzes membrane phospholipids releasing arachidonic acid and lysophospholipids. These are key precursors of inflammatory mediators, such as prostaglandins, leukotrienes, thromboxanes and PAF, in numerous inflammatory/allergic diseases, including skin inflammation. Accordingly, inhibition of PLA2 has long been postulated as a potentially potent antiinflammatory therapy. In the present study we tested the effect of a novel PLA2 inhibitor on contact dermatitis in human subjects. A double-blind, placebo-controlled pilot study was conducted on contact dermatitis patients (n = 11) treated with the inhibitor-containing topical preparation (1% cream). Disease severity was assessed by physician's assessment before treatment (day 0) as well as after 14-days and 30-days. Patients treated with 1% PLA2 inhibitor-containing cream showed a 69.9% reduction in disease score while placebo-treated patients showed a reduction of 36.5% with p = 0.0024. The clear improvement in the disease score of inhibitor-treated patients supports the involvement of PLA2 activity in skin inflammation and the therapeutic prospective of its inhibition.

Variables Associated with Severity of Bacterial Canker and Wilt Caused by Clavibacter michiganensis subsp. michiganensis in Tomato Greenhouses

Clavibacter michiganensis subsp. michiganensis, the causal agent of bacterial canker and wilt of tomato, is considered to be one of the most important bacterial pathogens worldwide. In the year 2000 there was an increase in the number of infected greenhouses and in the severity of the disease in Israel. As part of the effort to cope with the disease, a comprehensive survey was conducted. Scouts recorded disease severity monthly in 681 production units. At the end of the season the scouts met with the growers and together recorded relevant details about the crop and cultural practices employed. The results suggested an absence of anisotropy pattern in the study region. Global Moran's I analysis showed that disease severity had significant spatial autocorrelation. The strongest spatial autocorrelation occurred within a 1,500 m neighborhood, which is comparable to the distance between production units maintained by one grower (Farm). Next, we tested three groups of variables including or excluding the Farm as a variable. When the Farm was included the explained variation increased in all the studied models. Overall, results of this study demonstrate that the most influential factor on bacterial canker severity was the Farm. This variable probably encompasses variation in experience, differences in agricultural practices between growers, and the quality of implementation of management practices.

Seven years after ratification of the UNCRPD: Are there any advances for patients with mental health conditions?

The Convention on the Rights of Persons with Disabilities (CRPD) is the first highest international legally-binding standard which aims to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, including those with mental health conditions, and to promote respect for their inherent dignity. The CRPD embodies a ‘paradigm shift’, from the charitable and the medical approaches to disability to one, which is firmly rooted in human rights. It provides a clear path towards non-discrimination, full and effective participation and inclusion in society, respect for difference and acceptance of persons with disabilities as part of human diversity and humanity, equality of opportunity and accessibility just to name a few.

States which have signed the CRPD have an obligation to respect, protect and fulfil the internationally agreed upon set of standards guaranteed to all people included in the Convention. However, even in signatory states, violations often occur behind “closed or open doors” and go unreported and consequently unprevented. The growing number of people with mental health conditions in the world has further contributed to a level of attention paid to quality and human rights conditions in both outpatient and inpatient facilities, which has never been greater. Persons with mental health conditions need both de jure human rights protection and de facto human rights practices.

Seven years after the CRPD came into force the care available in many mental health facilities around Europe is still not only of poor quality but in many instances hinders recovery. The level of knowledge and understanding by staff of the rights of people with mental disabilities is very poor. It is still common for people to be locked away or to be chained to their beds, unable to move. Inhuman and degrading treatment is common, and people in facilities are often stripped of their dignity and treated with contempt. Violations are not restricted to inpatient and residential facilities; many people seeking care from outpatient and community care services are disempowered and also experience extensive restrictions to their basic human rights.

In the wider community, many people with mental disabilities are still denied many basic rights that most people take for granted. For example, they are denied opportunities to live where they choose, marry, have families, attend school and seek employment. There is a commonly held, yet false, assumption that people with mental health conditions lack the capacity to assume responsibility, manage their affairs and make decisions about their lives. These misconceptions contribute to the ongoing marginalization, disenfranchisement and invisibility of this group of people in their communities.

One of the underlying reasons it is difficult to move through the obstacles to fully embrace the CRPD, is that discrimination continues to affect people with mental health conditions on many levels. Changing laws is only a partial solution. We have to change the ways that we relate to each other at every level, and to offer people information and tools to make the transition to a more equitable social reality.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Value in mental healthcare: The patient aspect

From the patients’ point of view, valued-based mental healthcare is mental healthcare based on a holistic vision of care, according to which patients are actively involved in their treatment to achieve the best possible outcomes. They are invited to collaborate with both mental health care providers such as psychiatrists and primary caregivers to determine what types of treatment are the most effective.

GAMIAN-Europe believes that the best package of care includes the following four elements:

– medication – antipsychotic medication is consensually regarded as first-line treatment for people with mental health problems;

– psychotherapy/counselling – although antipsychotic medications are the mainstay of treatment for mental health problems, pharmacotherapy alone produces only limited improvement in negative symptoms, cognitive function, social functioning and quality of life. Additionally, many patients continue to suffer from persistent positive symptoms and relapses, particularly when they fail to adhere to prescribed medications. These situations emphasize the need for multimodal care, which includes psychosocial therapies as adjuncts to antipsychotic medications in order to alleviate symptoms and to improve social functioning and quality of life;

– psycho-education – the more a patient learns about his/her condition the better placed he/she will be to take control of it. Psycho-education embodies this principle by using a clearly-defined therapeutic programme, in which a trained therapist delivers targeted information designed to reduce both the frequency and the severity of symptoms. Psycho-education increases patients’ knowledge and understanding of their illness and treatment options and helps them cope more effectively. Many people find that they benefit not only from the information they receive during psycho-education, but also from the learning process itself. There are several different ways in which psycho-education can be delivered, including one-to-one sessions with a therapist, sessions aimed specifically at carers and family members, group sessions attended by several people coping with mental illness and mixed group sessions attended by people with mental illnesses and family members;

– self-help – self-help groups offer patients a voice and an audience with the time and inclination to listen to patients’ concerns and reassure them and ease their anxiety. For example, a self-help group may be able to quell anxiety regarding side effects, to reassure the patient, from first-hand experience, that these side effects are transient, normal and non-threatening and will diminish over time. The real experts on living with a mental disorder are those who are already doing so. Therefore, most support groups are full of people who can share information about how they have managed to cope with their illnesses.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Cryogenic-temperature electron microscopy direct imaging of carbon nanotubes and graphene solutions in superacids

Cryogenic electron microscopy (cryo-EM) is a powerful tool for imaging liquid and semiliquid systems. While cryogenic transmission electron microscopy (cryo-TEM) is a standard technique in many fields, cryogenic scanning electron microscopy (cryo-SEM) is still not that widely used and is far less developed. The vast majority of systems under investigation by cryo-EM involve either water or organic components. In this paper, we introduce the use of novel cryo-TEM and cryo-SEM specimen preparation and imaging methodologies, suitable for highly acidic and very reactive systems. Both preserve the native nanostructure in the system, while not harming the expensive equipment or the user. We present examples of direct imaging of single-walled, multiwalled carbon nanotubes and graphene, dissolved in chlorosulfonic acid and oleum. Moreover, we demonstrate the ability of these new cryo-TEM and cryo-SEM methodologies to follow phase transitions in carbon nanotube (CNT)/superacid systems, starting from dilute solutions up to the concentrated nematic liquid-crystalline CNT phases, used as the 'dope' for all-carbon-fibre spinning. Originally developed for direct imaging of CNTs and graphene dissolution and self-assembly in superacids, these methodologies can be implemented for a variety of highly acidic systems, paving a way for a new field of nonaqueous cryogenic electron microscopy.

Conservative management of preterm premature rupture of membranes beyond 32 weeks' gestation: is it worthwhile?

We aimed to investigate whether conservative management of preterm premature rupture of membranes (PPROM) at 32-34 weeks' gestation improves outcome. In this retrospective analysis of singleton pregnancies, the study group included patients with PPROM at 28-34 weeks' gestation and the control group included patients presented with spontaneous preterm delivery at 28-34 weeks' gestation. Both groups were subdivided according to gestational age - early (28-31 weeks' gestation) versus late (32-34 weeks' gestation). Adverse neonatal outcome included neonatal death, intraventricular haemorrhage grade 3/4, respiratory distress syndrome, periventricular leucomalacia and neonatal sepsis. The study and control groups included 94 and 86 women, respectively. The study group had a lower incidence of adverse neonatal outcome at the earlier weeks (28-31), compared with the control group at the same gestational age. In contrast, at 32-34 weeks' gestation no difference in the risk for adverse neonatal outcome was noticed. Additionally, within the study group, chorioamnionitis rate was significantly higher among those who delivered at 32-34 weeks' gestation (p < 0.01). No advantage for conservative management of PPROM was demonstrated beyond 31 weeks' gestation. Moreover, conservative management of PPROM at 32-34 weeks' gestation may expose both mother and neonate to infectious morbidity.

Direct experimental observation of a new mechanism for sputtering of solids by a large polyatomic projectile: velocity-correlated cluster emission

We have measured kinetic energy distributions of Ta(n)C(n)(+) (n=1-10) and Ag(n)(+) (n=1-9) cluster ions sputtered off Ta and Ag targets, following impact of C(60)(-) at 14 keV kinetic energy. A gradual increase of the most probable kinetic energies with increased size of the emitted cluster was observed (nearly the same velocity for all n values). This behavior is in sharp contrast to that reported for cluster emission induced by the impact of a monoatomic projectile. Our observation is in good agreement with a mechanism based on the new concept of a superhot moving precursor as the source of the emitted clusters.

Exposure of fallopian tube epithelium to follicular fluid mimics carcinogenic changes in precursor lesions of serous papillary carcinoma

OBJECTIVES

Ovulation-related inflammation is suspected to have a causal role in ovarian carcinogenesis, but there are no human models to study the molecular pathways. Our aim is to develop such an ex-vivo model based on human fallopian tube (FT) epithelium exposed to human follicular fluid (FF).

METHODS

FT epithelium was dissociated from normal surgical specimens. FF was obtained from donors undergoing in-vitro fertilization. The cells were cultured on collagen-coated Transwells and incubated with FF for various periods of time. The transcriptomic changes resulting from FF treatment were profiled using Affymetrix expression arrays. Specific characteristics of the FT pre-cancerous lesions were studied using immunohistochemistry, immunofluorescence, RT-PCR and XTT assay.

RESULTS

We show that FF exposure causes up-regulation of inflammatory and DNA repair pathways. Double stranded DNA breaks are induced. There is a minor increase in cell proliferation. TP53, which is the hallmark of the precursor lesion in-vivo, is accumulated. Levels of expression and secretion of Interleukin-8 are significantly increased.

CONCLUSIONS

Our model addresses the main non-genetic risk factor for ovarian cancer, namely the impact of ovulation. This study demonstrates the biological implications of in-vitro exposure of human FT epithelial cells to FF. The model replicates elements characterizing the precursor lesions of ovarian cancer, and warrants further investigation of the linkage between repeated exposure to ovulation-related damage and accumulation of neoplastic changes.

First Report of the Occurrence and Resistance to Mefenoxam of Peronospora belbahrii, Causal Agent of Downy Mildew of Basil (Ocimum basilicum) in Israel

Downy mildew in basil was first reported from Uganda in 1933 (4). In 2004, it was reported from Italy (3) and, thereafter, from other countries around the world. In Israel, the disease was first observed in November 2011 in two greenhouses located in the northern part of the Jordan Valley. Within a month, second and third outbreaks of the disease occurred simultaneously near the southwest and southeast borders of Israel, 250 km from the initial disease outbreak. By the summer of 2012, the disease had appeared throughout the country, causing major economic damage. The causal agent, identified as Peronospora belbahrii (see below), produced chlorotic lesions on leaf blades with sporangia developing on the lower leaf surfaces. Lesions gradually turn necrotic, and infected leaves abscised. Sporangia were dark purple, oval, 30.4 ± 2.9 μm long × 21.4 ± 1.7 μm wide. Sporangiophores emerged from stomatal openings in a saturated atmosphere, were hyaline, 400 to 600 μm long, dichotomously branched, with three to five branches per sporangiophore, and bore a single sporangium on each branchlet tip. Oospores, seldom seen, were brown, round, and 46.2 ± 2.8 μm in diameter. Sporangia germinated directly, each producing a single germ tube that penetrated the periclinal wall of epidermal cells. PCR assays using sporangia and infected leaves as the template, and specific BAZ primers (1), produced a 134-bp band typical of P. belbahrii (1,2). Twenty isolates, collected from 12 locations in Israel from December 2011 to September 2012, were all sensitive to mefenoxam as the isolates did not cause symptoms on 15-leaf, potted basil plants (cv. Peri, Volcani Center, Israel) that were sprayed with 10 μg mefenoxam/ml (Ridomil Gold 48%, Syngenta, Basel, Switzerland) prior to inoculation. However, one isolate collected in early October 2012 from a severely infected plant in a greenhouse at Rehov in Bet-Shaan Valley, in which the plants had been treated with mefenoxam, was resistant to mefenoxan, showing abundant sporulation on leaves of potted basil plants that had been sprayed with 1,000 μg of mefenoxam/ml prior to inoculation. To our knowledge, this is the first report of the occurrence of downy mildew in basil in Israel. This is also the first global report of resistance to mefenoxam in P. belbahrii. References: (1) L. Belbahri et al. Mycol. Res. 109:1276, 2005. (2) R. Djalali et al. Mycol. Progress 11:961, 2012. (3) A. Garibaldi et al., Plant Dis. 89:683, 2004. (4) C. G. Hansford. Rev. Appl. Mycol. 12:421, 1933.

First Report on the Occurrence of A2 Mating Type of the Cucurbit Downy Mildew Agent Pseudoperonospora cubensis in China

Pseudoperonospora cubensis is a foliar pathogen of cucurbits. In cucumber, it produces chlorotic, angular lesions with dark sporangia on their under-surface. The distribution of pathotypes and mating types of P. cubensis were investigated in seven provinces in China. Twenty-nine isolates were obtained from Guangdong, Anhui, Hubei, Sichuan, Shandong, Beijing, and Harbin, one to six isolates from each province. They were collected from cucumber during summer 2011, except those from Harbin, which were collected from cucumber in summer 2012. Isolates were tested for pathogenicity and mating type. Pathogenicity was tested by inoculation of detached leaves of: cucumber (Cucumis sativum cvs. Bet-Alpha, SMR18), melon (Cucumis melo reticulatus cv. Ananas-Yokneam), pumpkin (Cucurbita maxima cv. Tripoli), squash (Cucurbita pepo, cv. Beruti), butternut gourd (Cucurbita moschata cv. Waltham), watermelon (Citrullus lanatus, cv. Malali), and sponge gourd (Luffa cylindrica, cultivar unknown). Mating type was determined by oospore production in melon leaf discs inoculated with mixed sporangia of a test isolate and A1 or A2 tester isolates, as recently described (2). The results showed that 22 isolates belonged to pathotype 3, sporulating on cucumber and melon; five isolates belonged to pathotype 6, sporulating on cucumber, melon, pumpkin, squash, and butternut gourd; one isolate belonged to pathotype 5, sporulating on the above five species and watermelon (1), and one isolate was capable of sporulating on the mentioned five species and sponge gourd, herein called pathotype 7. Of the 29 isolates tested, 22 belonged to the A1 mating type, six to the A2 mating type, and one did not produce oospores with either testers. Of the six A2 isolates, two originated from Sichuan, one from Beijing, and three from Harbin. All 22 isolates belonging to pathotype 3 were A1, whereas the other six isolates (four pathotype 6, one pathotype 5, and one pathotype 7) were A2. Crosses made between Chinese isolates belonging to opposite mating types resulted in the formation of abundant oospores in detached melon or cucumber leaves. The results prove that the A2 mating type of P. cubensis occurs in China. This explains the abundant occurrence of oospores of P. cubensis in nature in China (4). The data corroborate with Runge et al. (3), who suggested that the recent changes in the population structure of P. cubensis around the world resulted from the migration of a new genotype of P. cubensis from the Far East to Europe and the U.S.A. In Israel, a new pathotype attacking both Cucumis and Cucurbita appeared in 2002 (1), and A2 mating type first appeared in 2010 (2). References: (1) Y. Cohen et al. Phytoparasitica 31:458, 2003. (2) Y. Cohen and A. E. Rubin. Eur. J. Plant Pathol. 132:577, 2012. (3) F. Runge et al. Eur. J. Plant Pathol. 129:135, 2011. (4) Y. J. Zhang et al. J. Phytopathol. 160:469, 2012.

Host Preference of Mating Type in Pseudoperonospora cubensis, the Downy Mildew Causal Agent of Cucurbits

The A2 mating type of Pseudoperonospora cubensis was first discovered in Israel in May 2010 on butternut gourd (Cucurbita moschata) (1). We monitored the occurrence of the A2 mating type of P. cubensis in isolates collected during May 2010 through September 2012 from downy mildew-infected cucurbit crops growing along the coastal plain of Israel. Mating type was determined by oospore production in melon leaf discs co-inoculated with sporangia of a test isolate mixed with sporangia of A1 or A2 tester isolates (2). The A1 and A2 tester isolates were maintained at 14°C (14 h light/day) by repeated inoculation of detached leaves of cucumber and pumpkin, respectively. The 29 isolates that were collected from cucumber (Cucumis sativum) were all A1. Of the 33 isolates collected from pumpkin (Cucurbita maxima), squash (C. pepo), or butternut gourd (C. moschata), 88% were A2 and 12% were A1. The host preference of mating type in P. cubensis was monitored at Bar-Ilan University farm during April to July 2012, among about 800 plants of eight cucurbit species (~100 plants per species) that were grown side-by-side in three adjacent net-houses (two 6 × 50 m and one 6 × 100 m) and exposed to natural infection. Downy mildew developed on cucumber, melon, pumpkin, squash, and butternut gourd, but not on watermelon, sponge gourd (Luffa cylindrica), or Momordica balsamina. Three-hundred and three isolates of P. cubensis were collected and tested for mating type: 123 from cucumber, 53 from melon, 30 from pumpkin, 48 from butternut gourd, and 41 from squash. The cucumber isolates expressed A1, A2, and A1A2 at a ratio of 94.3%, 3.3%, and 2.4%, respectively; the melon isolates 58.5%, 26.4%, and 15.1%; the pumpkin isolates 0%, 96.7%, and 3.3%; the butternut isolate 7.3%, 87.3%, and 5.5%; and the squash isolates 2.4%, 97.6%, and 0%, respectively. A1A2 isolates produce oospores when crossed with either A1 or A2 tester isolates. This is the first evidence suggesting a preference of A1 isolates to Cucumis spp. and of A2 isolates to Cucurbita spp. similar preference was recently observed among Chinese isolates of this pathogen (unpublished data). The mechanism(s) controlling this preference is not known. Classical genetics is currently employed to P. cubensis in order to understand if it derives from true linkage. The practical implication for downy mildew management is that growing cucumber/melon in close proximity to pumpkin/squash/butternut gourd should be avoided as it may enhance oospore production in nature. Oospores in soil were recently shown to serve as a primary source of downy mildew infection in cucumber (3). References: (1) Y. Cohen, A. E. Rubin, and M.Galperin. Plant Dis. 95:874, 2011; (2) Y. Cohen and A. E. Rubin. Eur. J. Plant Pathol. 132:577, 2012; (3) Y. J. Zhang et al. J. Phytopathol. 160:469, 2012.