Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases

PURPOSE

In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group.

METHODS

Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence.

RESULTS

One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection).

CONCLUSION

Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

The primary stability of two dental implant systems in low-density bone

Primary stability in low-density bone is crucial for the long-term success of implants. Tapered implants have shown particularly favourable properties under such conditions. The aim of this study was to compare the primary stability of tapered titanium and novel cylindrical zirconia dental implant systems in low-density bone. Fifty implants (25 tapered, 25 cylindrical) were placed in the anterior maxillary bone of cadavers meeting the criteria of low-density bone. The maximum insertion (ITV) and removal (RTV) torque values were recorded, and the implant stability quotients (ISQ) determined. To establish the isolated influence of cancellous bone on primary stability, the implantation procedure was performed in standardized low-density polyurethane foam bone blocks (cancellous bone model) using the same procedure. The primary stability parameters of both implant types showed significant positive correlations with bone density (Hounsfield units) and cortical thickness. In the cadaver, the cylindrical zirconia implants showed a significantly higher mean ISQ when compared to the tapered titanium implants (50.58 vs 37.26; P < 0.001). Pearson analysis showed significant positive correlations between ITV and ISQ (P = 0.016) and between RTV and ISQ (P = 0.035) for the cylindrical zirconia implants; no such correlations were observed for the tapered titanium implants. Within the limitations of this study, the results indicate that cylindrical zirconia implants represent a comparable viable treatment option to tapered titanium implants in terms of primary implant stability in low-density human bone.

COVID-19 lockdown moderately increased oligotrophy at a marine coastal site

COVID-19 has led to global population lockdowns that have had indirect effects on terrestrial and marine fauna, yet little is known on their effects on marine planktonic communities. We analysed the effect of the spring 2020 lockdown in a marine coastal area in Blanes Bay, NW Mediterranean. We compared a set of 23 oceanographic, microbial and biogeochemical variables sampled right after the strict lockdown in Spain, with data from the previous 15 years after correcting for long-term trends. Our analysis shows a series of changes in the microbial communities which may have been induced by the combination of the decreased nitrogen atmospheric load, the lower wastewater flux and the reduced fishing activity in the area, among other factors. In particular, we detected a slight decrease beyond the long-term trend in chlorophyll a, in the abundance of several microbial groups (phototrophic nanoflagellates and total prokaryotes) and in prokaryotic activity (heterotrophic prokaryotic production and β-glucosidase activity) which, as a whole, resulted in a moderate increase of oligotrophy in Blanes Bay after the lockdown.

Global COVID-19 lockdown highlights humans as both threats and custodians of the environment

The global lockdown to mitigate COVID-19 pandemic health risks has altered human interactions with nature. Here, we report immediate impacts of changes in human activities on wildlife and environmental threats during the early lockdown months of 2020, based on 877 qualitative reports and 332 quantitative assessments from 89 different studies. Hundreds of reports of unusual species observations from around the world suggest that animals quickly responded to the reductions in human presence. However, negative effects of lockdown on conservation also emerged, as confinement resulted in some park officials being unable to perform conservation, restoration and enforcement tasks, resulting in local increases in illegal activities such as hunting. Overall, there is a complex mixture of positive and negative effects of the pandemic lockdown on nature, all of which have the potential to lead to cascading responses which in turn impact wildlife and nature conservation. While the net effect of the lockdown will need to be assessed over years as data becomes available and persistent effects emerge, immediate responses were detected across the world. Thus, initial qualitative and quantitative data arising from this serendipitous global quasi-experimental perturbation highlights the dual role that humans play in threatening and protecting species and ecosystems. Pathways to favorably tilt this delicate balance include reducing impacts and increasing conservation effectiveness.

Mismatched dynamics of dissolved organic carbon and chromophoric dissolved organic matter in the coastal NW Mediterranean Sea

Coastal marine ecosystems are strongly influenced by different occasional events, such as intense winds, mixing, rain and river discharges. These events can directly or indirectly cause changes in dissolved organic matter (DOM) quality through a cascade of different biotic and abiotic processes. Changes in DOM quality are often associated with changes in DOM optical properties. Thus, examining the dynamics of chromophoric DOM (CDOM) can provide valuable information about biological and physical processes that have occurred in the ecosystem. Episodic meteorological events, particularly in temperate areas, appear very abruptly and induce very rapid responses; therefore, high time-resolved measurements are needed to capture them. We used a weekly sampling scheme to characterize DOM and nutrient dynamics in the NW Mediterranean coastal station 'SOLA'. From February 2013 to April 2014, we measured several physical and chemical variables including temperature, salinity, inorganic nutrients, chlorophyll a dissolved organic carbon (DOC), CDOM and fluorescent DOM (FDOM). During this period, two extremely high fresh water intrusions greatly influenced the dynamics of some DOM fractions, in particular the FDOM. Inorganic nutrients and chlorophyll a showed seasonal patterns: A winter period characterized by a high nutrient concentration in surface waters favored the phytoplankton spring bloom; then, summer stratification extended until autumn. This stratification led to nutrient depletion and, consequently, lower chlorophyll a values in the photic zone. The CDOM and FDOM optical active fractions did not follow temporal trends similar to total DOC. This was likely because the potential sources and sinks of these DOM pools are microbial activity and light exposure, and these were acting simultaneously but in opposite directions. Interestingly, DOC exhibited the highest concentrations in summer, coinciding with nutrient and chlorophyll a minima. To explain this mismatch, we propose a sequence of abiotic and biotic phenomena that drive DOC temporal dynamics.

Immediate dental and skeletal influence of distractor position on surgically assisted rapid palatal expansion with or without pterygomaxillary disjunction

The outcome of surgically assisted rapid palatal expansion (SARPE) can be affected by pterygomaxillary disjunction (PMD) and the distractor position. In this study, SARPE was performed, with or without PMD, in 20 fresh cadaver heads. Transverse expansion was conducted twice using a bone-borne distractor in the anterior and posterior positions, resulting in four groups (n=10). Cone beam computed tomography scans were completed before and after SARPE to evaluate maxillary changes. A comparative anterior decrease and posterior increase in midpalatal opening resulted from SARPE with PMD combined with a posteriorly placed distractor. Significant differences in the internal transverse changes were found between the two SARPE techniques combined with an anterior distractor at the level of the premolars and molars for alveolar ridge width (P=0.040, P=0.024), and at the level of the molars for the dental crown width (P=0.017) and corresponding tooth cusp width (P=0.018). In contrast, using a posteriorly placed distractor led to a significant difference for tooth cusp width only (P=0.050). No statistically significant differences were found between external transverse changes or between distractor positions. PMD is more important in achieving a more uniform and parallel transverse expansion pattern than the distractor position. However, a posterior distractor seems to intensify the effects of PMD.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

The Roses Ocean and Human Health Chair: A New Way to Engage the Public in Oceans and Human Health Challenges

Involving and engaging stakeholders is crucial for studying and managing the complex interactions between marine ecosystems and human health and wellbeing. The Oceans and Human Health Chair was founded in the town of Roses (Catalonia, Spain, NW Mediterranean) in 2018, the fruit of a regional partnership between various stakeholders, and for the purpose of leading the way to better health and wellbeing through ocean research and conservation. The Chair is located in an area of the Mediterranean with a notable fishing, tourist, and seafaring tradition and is close to a marine reserve, providing the opportunity to observe diverse environmental conditions and coastal and maritime activities. The Chair is a case study demonstrating that local, collaborative, transdisciplinary, trans-sector, and bottom-up approaches offer tremendous opportunities for engaging coastal communities to help support long-lasting solutions that benefit everyone, and especially those living by the sea or making their living from the goods and services provided by the sea. Furthermore, the Chair has successfully integrated most of its experts in oceans and human health from the most prestigious institutions in Catalonia. The Chair focuses on three main topics identified by local stakeholders: Fish and Health; Leisure, Health, and Wellbeing; and Medicines from the Sea. Led by stakeholder engagement, the Chair can serve as a novel approach within the oceans and human health field of study to tackle a variety of environmental and public health challenges related to both communicable and non-communicable diseases, within the context of sociocultural issues. Drawing on the example provided by the Chair, four principles are established to encourage improved participatory processes in the oceans and human health field: bottom-up, “think local”, transdisciplinary and trans-sectorial, and “balance the many voices”.

Stepped Coastal Water Warming Revealed by Multiparametric Monitoring at NW Mediterranean Fixed Stations

Since 2014, the global land and sea surface temperature has scaled 0.23 °C above the decadal average (2009-2018). Reports indicate that Mediterranean Sea temperatures have been rising at faster rates than in the global ocean. Oceanographic time series of physical and biogeochemical data collected from an onboard and a multisensor mooring array in the northwestern Mediterranean Sea (Blanes submarine canyon, Balearic Sea) during 2009-2018 revealed an abrupt temperature rising since 2014, in line with regional and global warming. Since 2014, the oligotrophic conditions of the water column have intensified, with temperature increasing 0.61 °C on the surface and 0.47 °C in the whole water column in continental shelf waters. Water transparency has increased due to a decrease in turbidity anomaly of -0.1 FTU. Since 2013, inshore chlorophyll a concentration remained below the average (-0.15 mg·l-1) and silicates showed a declining trend. The mixed layer depth showed deepening in winter and remained steady in summer. The net surface heat fluxes did not show any trend linked to the local warming, probably due to the influence of incoming offshore waters produced by the interaction between the Northern Current and the submarine canyon. Present regional and global water heating pattern is increasing the stress of highly diverse coastal ecosystems at unprecedented levels, as reported by the literature. The strengthening of the oligotrophic conditions in the study area may also apply as a cautionary warning to similar coastal ecosystems around the world following the global warming trend.

Aesthetic aspects of adjacent maxillary single-crown implants-influence of zirconia and titanium as implant materials

The purpose of this retrospective survey was to assess the esthetic aspects of adjacent zirconia and titanium implants in the anterior maxillary area. A total of 40 patients and 109 adjacent implants (17 patients with 47 titanium implants and 23 patients with 62 zirconia implants) was included. The primary aim of this survey was to assess the papillary fill (Jemt score). Additionally, further esthetic aspects were assessed. Papillae were fully present (Jemt score 3) around 39.1% of adjacent zirconia implants and 17.4% of adjacent titanium implants (p<0.01). The papilla deficit was significantly higher 1.64 mm (SD 1.35) around titanium compared to zirconia implants 0.92 mm (SD 0.94, p<0.01). The evaluation of the soft tissue recessions revealed no differences between implant materials, whereas titanium implants presented more visible implant shadows (p<0.01). Zirconia implants had more implants with papillae that filled the entire proximal space compared to titanium implants. Furthermore, titanium implants had a greater frequency of visible implant shadowing than the zirconia implants. Esthetic rules such as the interdental contact area and golden percentage rules did not differ significantly between the titanium and zirconia implants.

Detection of Rickettsia spp. and Bartonella spp. in Ctenocephalides felis fleas from free-ranging crab-eating foxes (Cerdocyon thous)

Fleas are insects with a worldwide distribution that have been implicated in the transmission of several pathogens. The present study aimed to investigate the presence of Rickettsia spp. (Rickettsiales: Rickettsiaceae) and Bartonella spp. (Rhizobiales: Bartonellaceae) in fleas from free-ranging crab-eating foxes Cerdocyon thous (Linnaeus, 1766) (Carnivora: Canidae) from Rio Grande do Sul, southern Brazil. Fleas were collected manually from animals and used for the molecular detection of Rickettsia spp. and Bartonella spp. Twenty-nine C. thous were sampled in six municipalities. Four foxes were parasitized by 10 fleas, all of which were identified as Ctenocephalides felis (Bouché, 1935) (Siphonaptera: Pulicidae). DNA from Rickettsia felis Bouyer et al., 2001 and Rickettsia asembonensis Maina et al., 2016 were found in three and eight fleas, respectively. In four fleas, DNA of Bartonella sp. was identified. Phylogenetic analysis grouped Bartonella sp. together with other genotypes previously reported in C. felis worldwide. The scenario described in the present study highlights a Neotropical canid parasitized by the invasive cosmopolitan cat flea, which in turn, is carrying potentially invasive vector-borne microorganisms. These findings suggest that C. felis is adapted to wild hosts in wilderness areas in southern Brazil, hypothetically exposing the Neotropical fauna to unknown ecological and health disturbances.

Atmospheric Deposition Impact on Bacterial Community Composition in the NW Mediterranean

Atmospheric deposition is a source of inorganic nutrients and organic matter to the ocean, and can favor the growth of some planktonic species over others according to their nutrient requirements. Atmospheric inputs from natural and anthropogenic sources are nowadays increasing due to desertification and industrialization, respectively. While the impact of mineral dust (mainly from the Saharan desert) on phytoplankton and bacterial community composition has been previously assessed, the effect of anthropogenic aerosols on marine bacterial assemblages remains poorly studied. Since marine bacteria play a range of roles in the biogeochemical cycles of inorganic nutrients and organic carbon, it is important to determine which taxa of marine bacteria may benefit from aerosol fertilization and which not. Here, we experimentally assessed the effect of Saharan dust and anthropogenic aerosols on marine bacterioplankton community composition across a spatial and temporal range of trophic conditions in the northwestern Mediterranean Sea. Results from 16S rDNA sequencing showed that bacterial diversity varied significantly with seasonality and geographical location. While atmospheric deposition did not yield significant changes in community composition when all the experiments where considered together, it did produce changes at certain places and during certain times of the year. These effects accounted for shifts in the bacterial community's relative abundance of up to 28%. The effect of aerosols was overall greatest in summer, both types of atmospheric particles stimulating the groups Alphaproteobacteria, Betaproteobacteria, and Cyanobacteria in the location with the highest anthropogenic footprint. Other bacterial groups benefited from one or the other aerosol depending on the season and location. Anthropogenic aerosols increased the relative abundance of groups belonging to the phylum Bacteriodetes (Cytophagia, Flavobacteriia, and Sphingobacteriia), while Saharan dust stimulated most the phytoplanktonic group of Cyanobacteria and, more specifically, Synechococcus.

The new agreement of the international RIGA consensus conference on nasal airway function tests

The report reflects an agreement based on the consensus conference of the International Standardization Committee on the Objective Assessment of the Nasal Airway in Riga, 2nd Nov. 2016. The aim of the conference was to address the existing nasal airway function tests and to take into account physical, mathematical and technical correctness as a base of international standardization as well as the requirements of the Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow, Odiosoft-Rhino, optical rhinometry, 24-h measurements, computational fluid dynamics, nasometry and the mirrow test were evaluated for important diagnostic criteria, which are the precision of the equipment including calibration and the software applied; validity with sensitivity, specificity, positive and negative predictive values, reliability with intra-individual and inter-individual reproducibility and responsiveness in clinical studies. For rhinomanometry, the logarithmic effective resistance was set as the parameter of high diagnostic relevance. In acoustic rhinometry, the area of interest for the minimal cross-sectional area will need further standardization. Peak nasal inspiratory flow is a reproducible and fast test, which showed a high range of mean values in different studies. The state of the art with computational fluid dynamics for the simulation of the airway still depends on high performance computing hardware and will, after standardization of the software and both the software and hardware for imaging protocols, certainly deliver a better understanding of the nasal airway flux.

Release behavior of VAN from four types of CaP-ceramic granules using various loading methods at two different degrees of acidity

The release behavior of vancomycin (VAN) from beta-tricalciumphosphate (βTCP), hydroxyapatite (HA), glass ceramic (GC) and sponge-like collagen βTCP granule composite (sponge) was studied. Vacuum and drip loading methods were compared. The influence of VAN concentration and pH on release behavior was analyzed with respect to a stable release level of VAN above the minimum inhibitory concentration over 14 days. Initially the morphology of the granule carrier systems was examined with ESEM, stereomicroscopy, µCT-imaging and Camsizer® regarding porosity, interconnecting pores and granule size. Drug release patterns following a vacuum and a drip loading method with VAN at concentrations of 5 and 50 mg/ml were compared. The influence of pH 7.4 compared to pH 5.0 on release behavior was studied. The drug was released in bidistilled water at 37 °C, the concentration determined by photometry at 220 nm. For statistical purposes, the mean and standard deviation were calculated and analyzed by Origin 9.1 Professional SR1 (OriginLab). Due to low interconnectivity and low porosity, the vacuum loading method was unable to attain complete drug loading of the ceramic granules. The sponge showed an inhomogeneous distribution of βTCP granules. Drug release was high at pH 7.4, at pH 5.0 it practically did not occur. All samples except for the collagen-complex show an initial VAN burst release with a following steady release. Loading with 5 mg/ml concentrated VAN resulted in a higher percentage of available drug being released. However, when loaded with 50 mg/ml, the absolute amount of drug released was higher.

Coastal Bacterioplankton Metabolism Is Stimulated Stronger by Anthropogenic Aerosols than Saharan Dust

In oligotrophic regions, such as the Mediterranean Sea, atmospheric deposition has the potential to stimulate heterotrophic prokaryote growth and production in surface waters, especially during the summer stratification period. Previous studies focused on the role of leaching nutrients from mineral particles of Saharan (S) origin, and were restricted to single locations at given times of the year. In this study, we evaluate the effect of atmospheric particles from diverse sources and with a markedly different chemical composition [S dust and anthropogenic (A) aerosols] on marine planktonic communities from three locations of the northwestern Mediterranean with contrasted anthropogenic footprint. Experiments were also carried out at different times of the year, considering diverse initial conditions. We followed the dynamics of the heterotrophic community and a range of biogeochemical and physiological parameters in six experiments. While the effect of aerosols on bacterial abundance was overall low, bacterial heterotrophic production was up to 3.3 and 2.1 times higher in the samples amended with A and S aerosols, respectively, than in the controls. Extracellular enzymatic activities [leu-aminopeptidase (AMA) and β-glucosidase (β-Gl)] were also enhanced with aerosols, especially from A origin. AMA and β-Gl increased up to 7.1 in the samples amended with A aerosols, and up to 1.7 and 2.1 times, respectively, with S dust. The larger stimulation observed with A aerosols might be attributed to their higher content in nitrate. However, the response was variable depending the initial status of the seawater. In addition, we found that both A and S aerosols stimulated bacterial abundance and metabolism significantly more in the absence of competitors and predators.

Horizontal and Vertical Distributions of Transparent Exopolymer Particles (TEP) in the NW Mediterranean Sea Are Linked to Chlorophyll a and O2 Variability

Transparent Exopolymer Particles (TEP) are relevant in particle and carbon fluxes in the ocean, and have economic impact in the desalination industry affecting reverse osmosis membrane fouling. However, general models of their occurrence and dynamics are not yet possible because of the poorly known co-variations with other physical and biological variables. Here, we describe TEP distributions in the NW Mediterranean Sea during late spring 2012, along perpendicular and parallel transects to the Catalan coast. The stations in the parallel transect were sampled at the surface, while the stations in the perpendicular transect were sampled from the surface to the bathypelagic, including the bottom nepheloid layers. We also followed the short-term TEP dynamics along a 2-day cycle in offshore waters. TEP concentrations in the area ranged from 4.9 to 122.8 and averaged 31.4 ± 12.0 μg XG eq L⁻¹. The distribution of TEP measured in transects parallel to the Catalan Coast correlated those of chlorophyll a (Chla) in May but not in June, when higher TEP-values with respect to Chla were observed. TEP horizontal variability in epipelagic waters from the coast to the open sea also correlated to that of Chla, O₂ (that we interpret as a proxy of primary production) and bacterial production (BP). In contrast, the TEP vertical distributions in epipelagic waters were uncoupled from those of Chla, as TEP maxima were located above the deep chlorophyll maxima. The vertical distribution of TEP in the epipelagic zone was correlated with O₂ and BP, suggesting combined phytoplankton (through primary production) and bacterial (through carbon reprocessing) TEP sources. However, no clear temporal patterns arose during the 2-day cycle. In meso- and bathypelagic waters, where phytoplanktonic sources are minor, TEP concentrations (10.1 ± 4.3 μg XG eq l⁻¹) were half those in the epipelagic, but we observed relative TEP increments coinciding with the presence of nepheloid layers. These TEP increases were not paralleled by increases in particulate organic carbon, indicating that TEP are likely to act as aggregating agents of the mostly inorganic particles present in these bottom nepheloid layers.

Anthropogenic versus mineral aerosols in the stimulation of microbial planktonic communities in coastal waters of the northwestern Mediterranean Sea

The atmosphere of the northwestern (NW) Mediterranean Sea is affected by continuous inputs of anthropogenic aerosols and episodic Saharan dust events. These atmospheric inputs deliver to the surface waters high amounts of macronutrients and trace metals that can constitute their main source at certain times of the year. The effect of both anthropogenic and crustal particles over the autotrophic and heterotrophic planktonic community assembles was evaluated through three microcosm experiments carried out in the summer of 2013 and in the winter and spring of 2014 at an urban coastal location of the NW Mediterranean (Barcelona, Spain). Particles were added to seawater at a concentration of 0.8mgl^-1. The results showed that (i) a greater stimulation of the whole community was observed in summer and spring than in winter; (ii) both kinds of aerosols produced an increase in the growth of phytoplankton, although the stimulation of nanoeukaryotes was significantly larger with anthropogenic aerosols; and (iii) bacterial abundance increased more with mineral dust, whereas bacterial production was more stimulated with anthropogenic inputs. Overall, the effect of atmospheric particles was dependent on their composition and solubility in seawater, as well as on the initial biogeochemical conditions present in the seawater and had the potential to change the net metabolic balance of the microbial planktonic community.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004

BACKGROUND

Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries.

METHODS

We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method.

RESULTS

In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women.

CONCLUSIONS

In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

TURBOGEN: Computer-controlled vertically oscillating grid system for small-scale turbulence studies on plankton

In recent years, there has been a renewed interest in the impact of turbulence on aquatic organisms. In response to this interest, a novel instrument has been constructed, TURBOGEN, that generates turbulence in water volumes up to 13 l. TURBOGEN is fully computer controlled, thus, allowing for a high level of reproducibility and for variations of the intensity and characteristics of turbulence during the experiment. The calibration tests, carried out by particle image velocimetry, showed TURBOGEN to be successful in generating isotropic turbulence at the typical relatively low levels of the marine environment. TURBOGEN and its sizing have been devised with the long-term scope of analyzing in detail the molecular responses of plankton to different mixing regimes, which is of great importance in both environmental and biotechnological processes.

Dense WDM transmission at 2 μm enabled by an arrayed waveguide grating

We show, for the first time, dense WDM (8×20  Gbit/s) transmission at 2 μm enabled by advanced modulation formats (4-ASK Fast-OFDM) and the development of key components, including a new arrayed waveguide grating (AWGr) at 2 μm. The AWGr shows -12.8±1.78  dB of excess loss with an 18-dB extinction ratio and a thermal tunability of 0.108 nm/°C.

A closer look at the role of healthcare in the recent mortality decline in the Netherlands: results of a record linkage study

BACKGROUND

Since 2002, Dutch mortality rates decreased rapidly after decades of stagnation. On the basis of indirect evidence, previous research has suggested that this decline was due to a sudden expansion of healthcare. We tested two corollaries of this hypothesis--first, that the decline was concentrated among those with ill-health and second, that the decline can be statistically accounted for by increases in healthcare utilisation.

METHODS

We linked the Dutch health interview survey to the mortality register and constructed two cohorts, consisting of 7691 persons interviewed in 2001/2002 and 8362 persons interviewed in 2007/2008, each with a 5-year mortality follow-up (659 deaths in total). The change in mortality between both cohorts was computed using Cox proportional hazard models. We estimated the change in mortality by severity of chronic conditions and with respect to the inclusion of indicators of healthcare utilisation.

RESULTS

Between the two study cohorts, mortality declined by 15% (95% CI 2% to 29%), and mortality reduction was greatest for those suffering from fatal and non-fatal conditions with a decline of 58% (95% CI 35% to 78%). Even after adjustment for health status and risk factors, most indicators of healthcare utilisation were associated with higher instead of lower mortality and changes in healthcare utilisation did not explain the decline in mortality.

CONCLUSIONS

Our results only partly confirm the hypothesis that an expansion of healthcare explains the recent mortality decline in the Netherlands. Owing to confounding by health status, it is difficult to reproduce the mortality-lowering effects of healthcare utilisation of individual level studies in the open population.

Saharan dust deposition may affect phytoplankton growth in the Mediterranean sea at ecological time scales

The surface waters of the Mediterranean Sea are extremely poor in the nutrients necessary for plankton growth. At the same time, the Mediterranean Sea borders with the largest and most active desert areas in the world and the atmosphere over the basin is subject to frequent injections of mineral dust particles. We describe statistical correlations between dust deposition over the Mediterranean Sea and surface chlorophyll concentrations at ecological time scales. Aerosol deposition of Saharan origin may explain 1 to 10% (average 5%) of seasonally detrended chlorophyll variability in the low nutrient-low chlorophyll Mediterranean. Most of the statistically significant correlations are positive with main effects in spring over the Eastern and Central Mediterranean, conforming to a view of dust events fueling needed nutrients to the planktonic community. Some areas show negative effects of dust deposition on chlorophyll, coinciding with regions under a large influence of aerosols from European origin. The influence of dust deposition on chlorophyll dynamics may become larger in future scenarios of increased aridity and shallowing of the mixed layer.

Experimental Investigation of the Cooling Flow in the Film Blowing Process

The film blowing process relies on external air cooling of the extruded polymer hose. The air is supplied by a ring nozzle surrounding the die. We investigate the flow as it emanates from a commercial nozzle by a laser light sheet method which reveals the instantaneous rather than the mean flow structure. Flow separation in the nozzle is diagnosed as well as a high degree of disturbances affecting the thermal boundary layer. To improve the flow a modified nozzle is investigated in the same way, which shows how separation is avoided and how the regular structure of a wall jet is attained. The limits of this approach are highlighted. The optical measurements are amended by pressure measurements inside and outside the nozzle. They show what the flow disturbances mean in terms of normal forces on the film.

Ganglions of the hand and wrist: determinants of treatment choice

The aim of this study was to determine whether psychological factors (depression, catastrophic thinking, and pain anxiety) and pain intensity are associated with choice of operative treatment. Ninety new patients with a ganglion cyst on their hand or wrist completed psychological questionnaires (Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale, and Center for the Epidemiological Study of Depression instrument) and an ordinal measure of pain intensity. After a minimum of 4 months, patients were contacted to determine if they chose operative treatment, to rate their pain intensity, and to complete the Disabilities of the Arm, Shoulder, and Hand questionnaire. Younger patients were more likely to choose operative treatment. Psychological factors were associated with pain intensity at enrolment, but not with treatment choice. Operative treatment did not result in less pain intensity or disability, or higher satisfaction compared with non-operative treatment.

An injectable bone substitute composed of beta-tricalcium phosphate granules, methylcellulose and hyaluronic acid inhibits connective tissue influx into its implantation bed in vivo

In this study, the in vivo tissue reaction to a new triphasic and injectable paste-like bone-substitute material composed of beta-tricalcium phosphate (β-TCP), methylcellulose and hyaluronic acid was analyzed. Using a subcutaneous implantation model, the interaction of these materials and the peri-implant tissue reaction were tested in Wistar rats for up to 60 days by means of established histological methods, including histomorphometrical analysis. The study focused on tissue integration, classification of the cellular inflammatory response and the degradation of the material. Groups composed of animals injected only with β-TCP granules, sham-operated animals and animals injected with saline were used as controls. After implantation, the triphasic bone-substitute material was present as a bulk-like structure with an inner and outer core. Over a period of 60 days, the material underwent continuous degradation from the periphery towards the core. The implantation bed of the β-TCP granule control group was invaded by phagocytes and formed a poorly vascularized connective tissue soon after implantation. This inflammatory response continued throughout the study period and filled the implantation bed. Significantly, the combination of the three biocompatible materials into one injectable paste-like bone-substitute material enabled modification of the tissue reaction to the implant and resulted in a longer in vivo lifetime than that of β-TCP granules alone. In addition, this combination increased the vascularization of the implantation bed, which is essential for successful tissue regeneration.

A fluid mechanical interpretation of hysteresis in rhinomanometry

A hysteresis effect in the pressure/flow rate relationship of nasal breathing has frequently been observed in clinical tests and in lab investigations. Explanations that have been given in the literature are missing a fluid mechanic storage effect coming into play in reciprocating flows. This effect depends primarily on the way the rhinomanometric measurements are set up and not so much on the nose flow itself. This is to be shown by calculations and experiments. The experiments are carried out with orifices because they can represent nose flow and are often implemented in rhinomanometric equipment as flow gauges. To mimic reality also a 1 : 1 nose model is used. It is shown where the hysteresis comes from and what the key parameters for its prediction are. With these results hysteresis in nasal breathing appears in a new light.