Neurosurgical treatment of pediatric brain tumors - results from a single center multidisciplinary setup

OBJECTIVE

The challenge of pediatric brain tumor surgery is given due to a relative low prevalence but high heterogeneity in age, localization, and pathology. Improvements of long-term overall survival rates were achieved during the past decades stressing the importance of a multidisciplinary decision process guided by a national treatment protocol. We reviewed the entire spectrum of pediatric brain tumor surgeries from the perspective of an interdisciplinary pediatric neuro-oncology center in Germany.

METHODS

Every patient who underwent brain tumor surgery from January 2010 to June 2017 in our Pediatric Neurosurgery department was retrospectively included and evaluated regarding the course of treatment. Perioperative data such as tumor localization, timing of surgery, extent of resection, neuropathological diagnosis, transfusion rates, oncologic and radiation therapy, and neurological follow-up including morbidity and mortality were evaluated.

RESULTS

Two hundred ninety-three pediatric brain tumor patients were applicable (age: 8.28 ± 5.62 years, 1.22:1.0 m:f). A total of 531 tumor surgical interventions was performed within these patients (457 tumor resections, 74 tumor biopsies; mean interventions per patient 1.8 ± 1.2). Due to a critical neurologic status, 32 operations (6%) were performed on the day of admission. In 65.2% of all cases, tumor were approached supratentorially. Most frequent diagnoses of the cases were glial tumors (47.8%) and embryonal tumors (17.6%). Preoperative planned extent of resection was achieved in 92.7%. Pre- and postoperative neurologic deficits resolved completely in 30.7%, whereas symptom regressed in 28.6% of surgical interventions. New postoperative neurologic deficit was observed in 10.7%, which resolved or improved in 80% of these cases during 30 days. The mortality rate was 1%.

CONCLUSION

We outlined the center perspective of a specialized pediatric neuro-oncological center describing the heterogeneous distribution of cases regarding age-related prevalence, tumor localization, and biology, which requires a high multidisciplinary expertise. The study contributes to define challenges in treating pediatric brain tumors and to develop quality indicators for pediatric neuro-oncological surgery. We assume that an adequate volume load of patients within a interdisciplinary infrastructure is warranted to aim for effective treatment and decent quality of life for the majority of long-term surviving pediatric tumor patients.

Drug monitoring during ciprofloxacin prophylaxis of allogeneic stem cell transplant patients: associations with bacterial infections through a monocentric observational prospective study

BACKGROUND

Bacterial infection ranks amongst the most common causes of morbidity and mortality in patients undergoing allogeneic haematopoietic stem cell transplantation (alloHSCT). Although ciprofloxacin (CIP) prophylaxis is recommended, information on serum levels and clinical course is lacking.

AIM

To investigate relationships between CIP level and failure of prophylaxis, particularly in terms of whether different pharmacokinetic (PK) indices [area under the concentration-time curve (AUC0-24h) vs single time samples] correlate differently with the outcome.

METHODS

This prospective observational monocentric study was conducted at a 1500-bed teaching hospital (March 2018-March 2019), including 63 adult patients with alloHSCT receiving CIP prophylaxis. Blood samples were drawn at three sampling times (1, 6 and 12 h post-administration), twice per week, and measured via high performance liquid chromatography. The onset of febrile episodes (FEBs) indicated suspected failure of CIP prophylaxis. Positive blood cultures [bloodstream infection (BSI)] indicated confirmed failure of prophylaxis.

FINDINGS

Seven of 63 patients died without significant differences in their average CIP levels compared with survivors, with patients experiencing FEBs (54/63) displaying a 13% [95% confidence interval (CI) 4-22%] lower probability of survival. In total, 225 sets of three values (triplets) were obtained from 58 primary CIP episodes. Triplets preceding BSI with Gram-negative bacteria (GNB-BSI) showed lower AUC0-24h on average, but similar single time sample indices. An AUC0-24h of ≤21.61 mgh/L resulted in four-fold higher odds of GNB-BSI (adjusted odds ratio 3.96, 95% CI 1.21-13.00). These results were independent of the administration route, patient demographics or sampling protocol deviations, indicating reduced CIP exposure upon GNB-BSI events.

CONCLUSION

Monitoring CIP levels, using multiple sampling times, may be useful to reduce alloHSCT-associated bacterial infections. Further analysis is needed to investigate causality.

Retrospective evaluation of the orthodontic treatment needs in primary school children with Robin sequence following Tübingen palatal plate therapy in infancy

INTRODUCTION

The aim of this study was to investigate the orthodontic treatment needs (OTN) of children with RS treated with the TPP in infancy compared to age- and sex-matched controls.

METHODS

The aim of this study was to investigate the orthodontic treatment needs (OTN) of children with RS treated with the TPP in infancy compared to age- and sex-matched controls.

RESULTS

In 21 children with RS (n = 23; 19 non-syndromic, 4 syndromic; average age 9.9 years) showed high OTN, which was significantly higher than in controls (n = 21). The latter of 9 controls had minor OTN, followed by 8 participants with borderline OTN. Regarding the intraoral picture, patients with RS had an increased open bite tendency. Without considering the presence of a cleft palate, 16 children with RS had high or very high OTN, compared to 4 of controls.

CONCLUSIONS

Patients with RS have significantly higher OTN than healthy controls, independent of cleft occurrence. RS is associated with dental anomalies and special skeletal growth patterns, both increasing malocclusion and negatively affecting dentoalveolar growth. This should raise awareness for identifying these needs and provide a comprehensive orthodontic treatment, where functional rehabilitation should be favored over aesthetic results.

Biopsies of caudal brainstem tumors in pediatric patients - a single center retrospective case series

OBJECTIVE

The indication for performing biopsies in patients with diffuse lesions in the brain stem is controversial. Possible risks associated with the technical challenging interventions need to be balanced against clarifying the diagnosis and possible therapeutic options. We reviewed the feasibility, risk profile and diagnostic yield of different biopsy techniques in a pediatric cohort.

METHODS

We retrospectively included all patients under 18 years of age that received a biopsy of the caudal brainstem region (pons, medulla oblongata) at our pediatric neurosurgical center from 2009-2022.

RESULTS

We identified 27 children. Biopsies were performed using frameless stereotactic (Varioguide) (n=12), robotic assisted (Autoguide) (n=4), endoscopic (n=3) and open biopsy (n=8) technique. Intervention related mortality was not observed. Three patients experienced transient post-surgical neurological deficit. No patient showed intervention related permanent morbidity. Biopsy yielded histopathological diagnosis in all cases. Molecular analysis was feasible in 97% of cases. Most common diagnosis was H3K27M mutated diffuse midline glioma (60%). Low-grade gliomas were identified in 14%. Overall survival was 62.5% after 24 months of follow up.

CONCLUSION

Biopsies of the caudal brainstem in children were feasible and safe in the presented setup. The amount of acquired tumor material allowing integrated diagnosis and was obtained at reasonable risk. The selection of the surgical technique depends on tumor location and growth pattern. We recommend brainstem tumor biopsies in children being performed at specialized centers to better understand the biology and enable possible novel therapeutic options.

Increased Demand for Pharmaceutical Drugs Containing Potassium Iodide In Connection with the Russia-Ukraine Conflict

The current conflict between Russia and Ukraine increased concerns in the German population of a release of radioactive substances, e.g.radioactive iodine. A high dose of potassium iodide (PI) may prevent accumulation of radioactive iodine in the thyroid gland. Therefore, the German government keeps a sufficient quantity of PI in stock for public supply in case of an emergency. We investigated ambulatory drug dispensing rates of PI and found that the total dispensing of PI (statutory health insurance (SHI), private health insurance (PHI), and overthe-counter (OTC)) increased by 106% from February to March 2022. Changes in PI dispensing were mainly due to an increase in OTC sales, where PI as an antidote showed a sevenfold increase from around 930 packages (February 2022) to 6,500 packages (March 2022), while SHI and PHI dispensing remained relatively low. Furthermore, we investigated whether these changes in dispensing raised the number of suspected adverse drug reactions (ADR). We found no increase of ADR reports related to the use of PI-containing medicinal products between February and September 2022, neither in our national pharmacovigilance nor in the European EudraVigilance database. The data suggest that the mere possibility of a nuclear disaster in Ukraine raised the demand of PI in Germany. Thus, timely and proactive information and reassurance of the public of supply reliability by the Government in a case of a nuclear emergency could be helpful in preventing potential drug shortages and unfounded concern.

Hyperglycemia Alters the CD27:CD70 Axis of Human Immune Cells

Introduction/Objective

The exact mechanism that inflammation plays in the pathogenesis from obesity to Type 2 diabetes is unclear, however, activated immune cells and pro-inflammatory cytokines have been found in the adipose tissue of Type 2 diabetics, implicating their role in the disease process. While the CD27-CD70 axis is being explored in other models of chronic inflammation, such as rheumatoid arthritis and colitis, the role played in Type 2 diabetes remains unknown.

Objective

Evaluate whether hyperglycemia alters immune cells phenotype and effector function, specifically of the CD27:CD70 axis on human immune cells.

Methods/Case Report

Human peripheral blood from donors was divided into three groups. n=40 total those that have a healthy blood glucose value and are without any co-morbidities (normoglycemic), patients identified as having pre-diabetes per their hemoglobin A1c (HgbA1c) value (5.6-6.5%), and patients with diabetes, having an elevated blood glucose and HgbA1c value (> 6.5%). The blood was then stained with monoclonal antibodies towards cell surface markers associated with inflammation, including CD27/CD70 and analyzed via flow cytometry. Previous data using cell cultures of human PBMC-derived T cells and autologous dendritic cells exposed to varing concentrations of glucose to simulate hyperglycemia and pre-diabetes was compared to this data.

Results (if a Case Study enter NA)

1) T cells directly analyzed from pre-diabetic and hyperglycemia individuals down-regulate their CD27 expression. CD70 is up-regulated on immune cells directly analyzed from pre-diabetic individual when compared to immune cells from normoglycemic individuals. In accordance with the above resutls, CD4 T cells have an activated effector phenotype after co-culture with glucose stimulated dendritic cells. This includes down-regulation of CD27 on T cells and up-regulation of CD70 on dendritic cells.

Conclusion

Our data shows that certain markers of inflammation are up-regulated on the surface of immune cells from pre-diabetic and/or diabetic patients. Specifically, we demonstrate novel evidence that the CD27-CD70 axis is activated in diabetes or hyperglycemic conditions. These molecules may offer a potential target for therapeutics. Alternatively, our findings would allow a further way to characterize where a patient with an elevated blood glucose value is on the spectrum between pre-diabetes and full-blown diabetes.

Income-based differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. Guideline-recommended therapy and specialized outpatient care are essential for optimal treatment. Income-based inequalities in diagnosis and treatment of cardiovascular diseases are present, while differences for PAD are scarse. Knowledge of the treatment structures in the outpatient setting are essential to identify and solve income-based inequalities in this high-risk population.

Purpose

Aim of the study was to identify income-based inequalities in outpatient treatment care and pharmacotherapy in PAD patients.

Methods

We analyzed income-based differences in PAD prevalence, pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, cardiology) in all statutorily insured patients with PAD presenting to outpatient care facilities in Germany between 2009 and 2018. The study is based on ambulatory claims data of the panel doctors' services according to §295 SGB V and drug prescription data according to §300 SGB V. Diagnosis of PAD was defined upon medical diagnoses of PAD ICD I70.2-9. Statistical analysis was performed with chi-squared test for trend and two-way Anova.

Results

Overall, 17,633,970 patients were included in the study. Prevalence of PAD was higher in low-income states. This income-driven gap widened between 2009 (2.3% vs 1.7%) and 2018 (4.4% vs 2.8%). Angiology outpatient care density was higher in low-income states, whereas vascular surgery and cardiology outpatient care density was higher in high-income states (p<0.05). While overall specialised outpatient care was underutilized, patients in low-income states were more likely to present to angiologists, while patients in high-income states more frequently presented to vascular surgeons. Patients with more progressed PAD stages were less likely to present to a specialist and to receive guideline recommended medical therapy, irrespective of the income-structure.

Pharmacotherapy also showed income-based differences. While overall prescription rates of statins and antiplatelet drugs were low, patients in low-income states had higher prescription rates than patients in high-income states. The income-driven gap decreased between 2009 and 2016 (statins: 2009 60% vs 48%; 2016 68% vs 65%; antiplatelets: 2009 50% vs 39%; 2016 53% vs 51%).

Conclusion

Our results demonstrate that income-based differences in pharmacotherapy and specialized outpatient care of PAD patients are evident in Germany. While overall outpatient treatment by vascular specialists and guideline recommended medical therapy with antiplatelets and statins are low, German low-income states have higher PAD prevalence, a higher angiology than vascular surgery density and higher prescription rates of guideline recommended pharmacotherapy.

Funding Acknowledgement

Type of funding sources: None.

Interaction of inherited genetic variants in the NLRP3 inflammasome/IL-6 pathway with acquired clonal hematopoiesis to modulate mortality risk in patients with HFrEF

Aims

Clonal hematopoiesis (CH), defined as the presence of an expanded somatic blood cell clone due to acquired mutations in leukemia driver genes, was shown to be associated with increased mortality in patients with chronic ischemic heart failure with reduced ejection fraction (HFrEF). Mechanistically, circulating monocytes of mutation carriers display increased expression of proinflammatory genes involved in inflammasome and IL-6 signaling. Inherited single nucleotide variants (SNPs) in the IL-6 pathway are well known to affect inflammatory activation. Therefore, we investigated whether known SNPs in genes encoding for components of the inflammasome/IL-6 signaling pathway modulate fatal outcomes in HFrEF patients with CH.

Methods and results

In a total of 446 patients with chronic HFrEF, peripheral blood or bone marrow mononuclear cells were analyzed for the CH driver mutations DNMT3A and TET2 as well as 40 preselected SNPs affecting genes in the NLRP3 inflammasome/IL-6 signaling pathway. The 103 patients carrying a CH driver mutation demonstrated significantly increased mortality compared to the 343 patients without CH mutations (25,24% vs 13.99% at five years; p=0.0064). We identified three commonly occurring variants known to disrupt IL-6 signaling (rs2228145, rs4129267 and rs4537545) which are in strong linkage disequilibrium and present in more than 50% of CH carriers. As illustrated in Figure 1A, harboring one of those SNPs abrogated the increased mortality risk in patients with HFrEF and CH (p≤0.05 for each SNP). On the contrary, three different SNPs namely rs2250417, which is associated with increased IL-18 levels as well as rs4722172 and rs4845625, which are known to activate IL-6 signaling, were identified to mediate fatal outcomes in patients with HFrEF and CH (p<0.05 for each; Figure 1B). None of the assessed SNPs influenced outcomes in patients without CH. Single cell RNA-sequencing of circulating monocytes of patients with HFrEF revealed increased inflammatory signaling in DNMT3A mutation carriers without protective SNPs with genes upregulated in pathways such as “Cellular response to stress” (FDR −log 24.3), “Regulation of cell activation” (FDR −log 22.7) or “Cytokine signaling in the immune system” (FDR −log18.2).

Conclusion

Among CHIP carriers with HFrEF, inherited variants in loci encoding for genes involved in inflammatory signaling associate with mortality. These data not only provide mechanistic insights into inflammatory mechanisms contributing to fatal outcome of HFrEF in CH carriers but may also inform trials evaluating precision-targeted anti-inflammatory therapy in patients with DNMT3A and TET2 mutations and chronic HFrEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Center of Cardiovascular Research;Cardiopulmonary Institute, Frankfurt, Germany

P04.03.B Rapid DNA methylation-based classification of pediatric brain tumors from ultrasonic aspirate specimens

Background

Cavitating ultrasonic aspirator (CUSA) devices are commonly used in neurosurgical procedures to carefully debulk tumor from adjacent healthy brain tissue. Here, we explore the feasibility of using ultrasonic minced tumor tissue to classify otherwise discarded sample material by DNA methylation according to the respective World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS) using low pass nanopore whole genome sequencing.

Material and Methods

21 ultrasonic aspirated specimens from patients undergoing surgery in the department of pediatric neurosurgery at the Charité-Universitätsmedizin Berlin with either newly diagnosed cerebral lesions or pre-treated lesions were processed by nanopore sequencing to generate copy number profiles and ad-hoc random forest classification. Results were compared to microarray-based routine profiling. Tumor purity was assessed.

Results

In 19/21 (90.5 %) samples the minimum amount of 1,000 CpG sites were sequenced. In 20/21 (95.2 %) cases copy number variation profiles could be generated and matched microarray derived copy number profiles, allowing for identification of diagnostically or therapeutically relevant pathognomonic alterations. 12/17 (70.6 %) samples were concordantly classified to the corresponding microarray-based diagnosis by routine neuropathological workup. Applying recently defined thresholds for nanopore-based classification resulted in sensitivity of 64.7 % and specificity of 100 %.

Conclusion

CUSA referred sample material of pediatric brain tumors allows for methylation-based classification according to the respective WHO classification of CNS tumors with acceptable sensitivity and high specificity. Hereby, a promising opportunity for accurate classification of pediatric brain tumors by a time- and cost-efficient advanced molecular technique is offered using otherwise discarded tumor tissue.

Tooth agenesis in German orthodontic patients with non-syndromic craniofacial disorder: a retrospective evaluation of panoramic radiographs

Objectives

The study objective was to evaluate the tooth agenesis in German orthodontic patients with non-syndromic cleft lip and/or palate and Robin sequence compared to a control group without craniofacial disorder.

Materials/methods

A total of 108 panoramic radiographs were examined using the binary system of Tooth Agenesis Code (TAC) (excluding the third molar). Patients were divided into the craniofacial disorder group 1 (n = 43) and the healthy control group 2 (n = 65). Parameters such as skeletal class malformation, sex, localization of the cleft, craniofacial disorder, and interobserver reliability were assessed.

Results

Permanent tooth agenesis was observed in 44% of group 1 and 14% in group 2 with a statistically significant higher prevalence (p = 0.00162 (χ²)). Fourteen different TAC patterns were observed in group 1, ten of these occurring only once in separate patients. The distribution of the TAC codes in group 2 showed nine different possibilities of TAC code patterns; seven TACs were unique. In group 1, the most frequently absent teeth were the maxillary lateral incisor of the left side (30%); in group 2, the second premolar of the lower jaw on the right side (9%). Male patients with craniofacial disorder showed a higher percentage of tooth agenesis than female.

Conclusion

The data presented here shows a statistically significant higher prevalence of tooth agenesis in German patients with non-syndromic craniofacial disorder.

Clinical relevance

Radiographic evaluation enables the diagnosis of tooth agenesis. Recognizing early on the higher prevalence of tooth agenesis in patients exhibiting a craniofacial disorder is an important issue when developing long-term and comprehensive interdisciplinary treatment.

A new cynodont from the Upper Triassic Los Colorados Formation (Argentina, South America) reveals a novel paleobiogeographic context for mammalian ancestors

Probainognathia is a derived lineage of cynodonts which encompass Mammalia as their crown-group. The rich record of probainognathians from the Carnian of Argentina contrasts with their Norian representation, with only one named species. Here we describe a new probainognathian, Tessellatia bonapartei gen. et sp. nov., from the Norian Los Colorados Formation of the Ischigualasto-Villa Unión Basin of Argentina. The new taxon, represented by a partial cranium with associated lower jaws, was analyzed through neutron and X-rays micro-tomography (μCT). The high-resolution neutron μCT data allowed the identification of a unique character combination, including features inaccessible through traditional techniques. We constructed the largest phylogenetic data matrix of non-mammalian cynodonts. The new species and its sister taxon, the Brazilian Therioherpeton cargnini, are recovered as probainognathians, closely related to Mammaliamorpha. We conducted the first quantitative paleobiogeographic analysis of non-mammalian cynodonts, focusing in probainognathians. The results indicate that Probainognathia and Mammaliamorpha originated in southwestern Gondwana (in the Brazilian Paraná Basin), which was an important center of diversification during the Triassic. Finally, the Chinese Lufeng Basin is identified as the ancestral area of Mammaliaformes. These new findings, besides adding to the knowledge of the poorly represented Norian cynodonts from the Los Colorados Formation, are significant to improve our understanding of probainognathian diversity, evolution, and paleobiogeographic history.

Suppression of self-stratification in colloidal mixtures with high Péclet numbers

The non-equilibrium assembly of bimodal colloids during evaporative processes is an attractive means to achieve gradient or stratified layers in thick films. Here, we show that the stratification of small colloids on top of large is prevented when the viscosity of the continuous aqueous phase is too high. We propose a model where a too narrow width of the gradient in concentration of small colloids suppresses the stratification.

Feasibility and outcomes of a general practice and specialist alcohol and other drug collaborative care program in Sydney, Australia

Alcohol and other drug (AoD) use is an important health and community issue and may be positively affected by collaborative care programs between specialist AoD services and general practice. This paper describes the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure. There were 367 referrals to the collaborative care program. GPs referred 210 patients, whereas the AoD service referred 157 patients. Most GP referrals (91.9%) were for AoD problems, whereas nearly half the AoD service referrals were for other issues. The primary drugs of concern in the GP group were either opioids or non-opioids (mostly alcohol). The AoD service-referred patients were primarily using opioids. An ATOP was completed for 152 patients. At the time of referral, those in the GP-referred non-opioid group were significantly less likely to be abstinent, used their primary drug of concern more days and were more likely to be employed (all P < 0.001). A second ATOP was completed for 93 patients. These data showed a significant improvement in the number of days the primary drug of concern was used (P = 0.026) and trends towards abstinence, improved quality of life and physical and psychological well-being for patients in the program. There are few studies of GP-AoD collaborative care programs and nothing in the Australian context. This study suggests that GP-AoD collaborative care programs in Australia are feasible and improve drug use.

Retrospective single-center historical comparative study between proGAV and proGAV2.0 for surgical revision and implant duration

OBJECTIVE

Cerebrospinal fluid (CSF) diversion shunt systems remain to be the most common treatment for pediatric hydrocephalus. Different valve systems are used to regulate CSF diversion. Preventing complications such as occlusions, ruptures, malpositioning, and over- or underdrainage are the focus for further developments. The proGAV and proGAV2.0 valve system are compared in this retrospective study for revision-free survival and isolated valve revision paradigms.

METHODS

In the first part of the study, the shunt and valve revision-free survival rates were investigated in a retrospective historical comparison design for a period of 2 years in which each valve was used as standard valve (proGAV: July 2012-June 2014; proGAV2.0: January 2015-December 2016) with subsequent 30-month follow-up period, respectively. In the second part of the study, the implant duration was calculated by detecting isolated valve (valve-only) revisions together with another valve explantation during the entire period of the first study and its follow-up period.

RESULTS

Two hundred sixty-two patients (145 male and 117 female, mean age 6.2 ± 6.1 years) were included in the cohort of revision-free survival. During the 30-month follow-up period, 41 shunt revisions, including 27 valve revisions (shunt survival rate: 72.1%, valve survival rate: 81.6%) were performed in the proGAV cohort and 37 shunt revisions, including 21 valve revisions (shunt survival rate: 74.8% and valve survival rate: 85.0%) were performed in the proGAV2.0 cohort without showing statistically significant differences. In the second part of the study, 38 cases (mean age 4.0 ± 3.9 years) met the inclusion criteria of receiving a valve-only-revision. In those patients, a total of 44 proGAV and 42 proGAV2.0 were implanted and explanted during the entire study time. In those, a significantly longer implant duration was observed for proGAV (mean valve duration 961.9 ± 650.8 days) compared to proGAV2.0 (mean length of implantation period 601.4 ± 487.8 days; p = 0.004).

CONCLUSION

The shunt and valve revision-free survival rates were found to be similar among the groups during 30 month follow-up. In patients who received "valve only" revisions and a subsequent explanation, the implant duration was significantly longer in the proGAV. Although the amount of patients with valve-only-revisions are small compared to the entire cohort certain patients seem to be at higher risk for repeated valve revisions.

New perspectives for neutron imaging through advanced event-mode data acquisition

Imaging using scintillators is a widespread and cost-effective approach in radiography. While different types of scintillator and sensor configurations exist, it can be stated that the detection efficiency and resolution of a scintillator-based system strongly depend on the scintillator material and its thickness. Recently developed event-driven detectors are capable of registering spots of light emitted by the scintillator after a particle interaction, allowing to reconstruct the Center-of-Mass of the interaction within the scintillator. This results in a more precise location of the event and therefore provides a pathway to overcome the scintillator thickness limitation and increase the effective spatial resolution of the system. Utilizing this principle, we present a detector capable of Time-of-Flight imaging with an adjustable field-of-view, ad-hoc binning and re-binning of data based on the requirements of the experiment including the possibility of particle discrimination via the analysis of the event shape in space and time. It is considered that this novel concept might replace regular cameras in neutron imaging detectors as it provides superior detection capabilities with the most recent results providing an increase by a factor 3 in image resolution and an increase by up to a factor of 7.5 in signal-to-noise for thermal neutron imaging.

Regional differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral arterial disease (PAD) is one of the most common diseases worldwide and affected patients have an increased risk for cardiovascular events. The main goals of PAD treatment include modification of risk factors and prevention of cardiovascular events by means of guideline-recommended and specialized ambulatory care. Knowledge on treatment regimens and outpatient care structures in different German states is essential to improve the overall quality of medical care as well as patient outcome.

Aim

The aim of this study was to analyze the care of PAD patients with emphasis on pharmacotherapy and outpatient treatment patterns with special focus on regional differences in Germany.

Methods

This study included data of 17.633.970 patients collected in Germany between 2009 and 2018. This data was provided by analyzing all statutory health insured patients with PAD in Germany. Ambulatory care structure included treatments by vascular surgeons, angiologists, cardiologist, internal medicine physician and primary care physicians. Furthermore, prescription of guideline-recommended pharmacotherapy (statins and antiplatelets) was analyzed for the period of 2012–2016. For our analysis we used chi-squared test and two-way Anova.

Results

Nationwide, prescription frequency of statins increased from 40% in 2009 to 50% (p&lt;0,0001) in 2016. Similar results were seen in the prescription frequency of antiplatelet agents, which increased from 26% in 2009 to 30% (p&lt;0,0001) in 2016. In fact, prescription frequency of both statins and antiplatelet drugs remained insufficient in every federal state (p&gt;0,05), despite wide access to general practitioners. Nevertheless, there is a significant difference between rural and urban regions (Bavaria 46% vs. North Rhine-Westphalia 44%, p&lt;0,05). However, in every federal state, treatment by the vascular specialist is low. In 2018 only 10% of patients were treated by vascular surgeons and 9% by angiologists.

Conclusion

Our study shows that, for PAD patients, outpatient care as well as prescription frequency of guideline-based therapy is insufficient in every federal German state. According to our data, there is a need to establish regional structures for PAD patients that can improve current care and ultimately reduce mortality in this high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Gender-based differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. Guideline-recommended therapy and specialized outpatient care are essential for optimal treatment. Gender-based inequalities in diagnosis and treatment of cardiovascular diseases are still present, despite clear guideline recommendations. Knowledge of the treatment structures in the outpatient setting are essential to identify and solve gender-based inequalities in this high-risk population.

Purpose

Aim of the study was to identify gender-based inequalities in an outpatient clinic setting in terms of treatment structures and pharmacotherapy in patients with PAD.

Methods

We analyzed gender-based differences in pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, internal medicine, cardiology) in 17.633.970 patients with PAD and statutorily insurance presenting to outpatient care facilities in Germany between 2009 and 2018. The study is based on the ambulatory claims data of the panel doctors' services according to § 295 SGB V and drug prescription data according to § 300 SGB V. Diagnosis of PAD was defined upon medical diagnoses of PAD ICD I70.2–9. Statistical analysis was performed with chi-squared test for trend and two-way Anova.

Results

Overall, 17.633.970 patients were included in the study and 53% were female. Only a minority of 37,1% presented to a vascular specialist (8,5% angiology, 10,2% vascular surgery, 24,6% cardiology) with no significant change over the course between 2009 and 2018. Interestingly, female patients were less likely to present to a vascular specialist and less likely to receive guideline recommended medical therapy.

The gender gap between male and female patients presenting to a vascular specialist, however, narrowed in the observed time frame (angiology in 2009 1,8% vs 2018 1,0%, p&lt;0,0001; vascular surgery 2009 3,2% vs 2018 1,5%, p&lt;0,0001).

Pharmacotherapy also significantly differed between female and male patients over the course of time. While prescription rates of statins and antiplatelet drugs increased in the observed time period (statins 42,8% vs 55,7% (male), 35,1% vs 45% (female); antiplatelets 29,2% vs 34,4% (male), 20,2 vs 24,3% (female)), the gender gap also increased between 2009 and 2018 (7,7% vs 10,7%, p&lt;0,0001 (statins); 8,9% vs 10%, p&lt;0,0001 (antiplatelets)).

Conclusion

Our results demonstrate that gender-based differences in pharmacotherapy and specialized outpatient care of patients with PAD are still evident in Germany. While overall outpatient treatment by a vascular specialist and guideline recommended medical therapy of PAD with antiplatelets and statins are overall remarkably low, female patients are even less likely to receive both, compared to male patients. While adherence to guideline recommended therapy is increasing, the gender-gap still continues to widen over the course of time.

Funding Acknowledgement

Type of funding sources: None.

Descriptive analysis of adverse drug reaction reports in children and adolescents from Germany: frequently reported reactions and suspected drugs

BACKGROUND

Adverse drug reactions (ADRs) in the pediatric population may differ in types and frequencies compared to other populations. Respective studies analyzing ADR reports referring to children have already been performed for certain countries. However, differences in drug prescriptions, among others, complicate the transferability of the results from other countries to Germany or were rarely considered. Hence, the first aim of our study was to analyze the drugs and ADRs reported most frequently in ADR reports from Germany referring to children contained in the European ADR database (EudraVigilance). The second aim was to set the number of ADR reports in relation to the number of drug prescriptions. These were provided by the Research Institute for Ambulatory Health Care in Germany.

METHODS

For patients aged 0-17 years 20,854 spontaneous ADR reports were received between 01/01/2000-28/2/2019. The drugs and ADRs reported most frequently were identified. Stratified analyses with regard to age, sex and drugs used "off-label" were performed. Reporting rates (number of ADR reports/number of drug prescriptions) were calculated.

RESULTS

Methylphenidate (5.5%), ibuprofen (2.3%), and palivizumab (2.0%) were most frequently reported as suspected. If related to the number of drug prescriptions, the ranking changed (palivizumab, methylphenidate, ibuprofen). Irrespective of the applied drugs, vomiting (5.4%), urticaria (4.6%) and dyspnea (4.2%) were the ADRs reported most frequently. For children aged 0-1 year, drugs for the treatment of nervous system disorders and foetal exposure during pregnancy were most commonly reported. In contrast, methylphenidate ranked first in children older than 6 years and referred 3.5 times more often to males compared to females. If age- and sex-specific exposure was considered, more ADR reports for methylphenidate referred to children 4-6 years and females 13-17 years. Drugs for the treatment of nervous system disorders ranked first among "off-label" ADR reports.

CONCLUSIONS

Our analysis underlines the importance of putting the number of ADR reports of a drug in context with its prescriptions. Additionally, differences in age- and sex-stratified analysis were observed which may be associated with age- and sex-specific diseases and, thus, drug exposure. The drugs most frequently included in "off-label" ADR reports differed from those most often used according to literature.

Validation of the hen's egg test for micronucleus induction (HETMN): Detailed protocol including scoring atlas, historical control data and statistical analysis

A validation exercise of the hen's egg test for micronucleus induction (HET-MN) was finalised with a very good predictivity based on the analysis of micronuclei in peripheral erythrocytes of fertilised chicken eggs [1]. For transparency reasons this complementary publication provides further details on the assay especially as this was the first validation study in the field of genotoxicity testing involving the use of chicken eggs. Thus, the experimental protocol is described in detail and is complemented by a scoring atlas for microscopic analysis of blood cells. In addition, general characteristics of the test system, which is able to mirror the systemic availability of test compounds, are delineated: the test compound passes the egg membrane and is taken up by the blood vessels of the underlying chorioallantoic membrane. Subsequently, it is distributed by the circulating blood, metabolised by the developing liver and the yolk sac membrane, and finally excreted into the allantois, a bladder equivalent. In specific, the suitability of the test system for genotoxicity testing is shown by, inter alia, a low background DNA damage in a comprehensive historical control database. In addition, the state-of-the-art statistical method used to evaluate obtained data is delineated. It combines laboratory-specific effect threshold with the Umbrella-Williams test a statistical model also of interest for other genotoxicity test methods.

Biparietal meander expansion technique for sagittal suture synostosis in patients older than 1 year of age-technical note

OBJECTIVE

Sagittal suture synostosis (SSS) is the most common form of craniosynostosis. For older patients, the strategy for surgical correction needs to consider diminished growth dynamics of the skull and an active reconstruction cranioplasty aims to sustain stability for the active child. We describe our technique of biparietal meander expansion (BME) technique for SSS for patients older than 1 year and retrospectively reviewed the perioperative course as well as the subjective experience of patients and caregivers during follow-up.

METHODS

The BME technique incorporates bilateral serpentine craniotomies and fixation of the consecutively expanded bone tongues with crossing sutures for patients with SSS older than 12 months of age at surgery. We reviewed patients undergoing this surgical technique for correction of SSS and collected data about the clinical course and performed a patients reported outcome measure (PROM) for patients or caregivers to evaluate subjective experience and outcome after surgical treatment.

RESULTS

BME was performed in 31 patients (8 females; median age: 43 months; range 13-388). The mean length of operation was 172.7±43 minutes (range 115-294). Patients experienced no immediate complications or neurological morbidity after surgery. Considering a total of 21 completed PROM questionnaires, the head shape after surgery was evaluated as either "better" (57%) or "much better" (43%) compared to preoperatively. Eighty-one percent of patients or caregivers answered that the patient experiences no limitation in daily activities. Although 42.8% perceived the hospital as strenuous, 90.5% would choose to undergo this treatment again.

CONCLUSION

BME is a feasible technique for older SSS patients resulting in immediate stability of the remodelled calvarium with a more normal head shape. The survey among caregivers or patients revealed a favourable subjectively experienced outcome after this type of surgical treatment of SSS in the more complex context of an older patient cohort.

Impact of a global leader on pharmaceutical practice and policy around the world

This commentary describes the contributions of a Dutch pharmacist who contributed in a unique manner to the development of community pharmacy practice in Europe, to the evolution of practice-based research and to its publication. With an interest in pharmaceutical care and in clinical pharmacy, Dr. van Mil changed practice and policy in Europe over the last decades in a very visible way, here documented through a summary of some of his main written contributions. We write this to honour his memory and contribute to the preservation of his legacy.

[Regional distribution of the cochlear implant (CI) centers in Germany]

The treatment of patients with severe hearing loss or deafness with a cochlear implant (CI) represents a standard in Germany today. However, there is hardly any data on the current number of clinical CI centers (CI clinics) and their geographical distribution. The patient self-help organization, German Cochlear Implant Society (DCIG), and the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) have therefore initiated a survey to determine the regional distribution, the range of services, the consideration of existing quality standards and cooperation with patient self-help organizations of the individual clinical CI centers.For this purpose, a total number of 170 ENT departments or their directors (37 professors and 133 chief physicians), respectively, were contacted by e-mail and provided with a questionnaire. The survey took place from October 2019 to February 2020.Of the 170 departments contacted, 71 (41.8 %) took part in the survey. Of these, 70 departments (98.6 %) confirmed to perform CI surgeries. Thus, 41.8 % of all clinics contacted reported to perform CI surgeries (70 of 170 clinics), while this information was not available from 99 clinics. All 70 clinical CI centers (100 %) reported to conduct CI surgeries on adults, 60 centers (85.7 %) also on children (< 18 years). 36 departments (51.4 %) reported that the total number of CI surgeries at their facility in 2018 was more than 50. In 64 departments (91.4 %), the recommendations of the DGHNO-KHC on CI care (according to the White Paper CI care 2018) were followed. A collaboration between the department and patient self-help organization was confirmed by 67 institutions (95.7 %). The geographical distribution of the clinical CI centers showed a heterogeneous distribution pattern between the individual federal states and also within the respective federal state.The work presented here is a first assessment of the situation with regard to the regional distribution of clinical CI centers in Germany. A clustering of CI centers was noticeable in metropolitan areas, sometimes with several facilities in one city. The predominant attention to quality-related aspects, such as the consideration of the DGHNO-KHC white paper and the cooperation with patient self-help, is gratifying. The limitations of the study result from limited participation in the survey (41.8 % of the contacted clinics).

Prevalence, specialized ambulatory care and guideline-recommended therapy of peripheral vascular diseases in Germany

Background

Cardiovascular diseases are the leading causes of death in the industrialized world. In addition to coronary heart disease, PAD defines morbidity and is associated with increased mortality. Guideline-recommended therapy and specialized ambulatory care is essential for optimal treatment. Knowledge of the treatment structures, contact with dedicated specialists and pharmacotherapy in the outpatient area are essential for improving treatment, reducing symptoms and finally improve mortality in this high-risk population.

Methods

The study is based on the ambulatory claims data of the panel doctors services according to § 295 SGB V and drug prescription data according to § 300 SGB V. The prevalence of PAD in Germany (medical diagnoses of PAD ICD I70.2–9) was analyzed by age and gender-specific characteristics with a timeframe of 10 years (2009–2018). In addition, the current ambulatory care structure was examined subdivided by vascular specialist (vascular surgeons or angiologists) and primary care physicians (internal medicine or general practitioners). Additionally, the prescription of guideline-recommended pharmacotherapy like statins and antiplatelet inhibitors was analyzed for the years 2009–2016.

Results

An increase of PAD diagnosis was observed with a maximum in 2018 with 2.280.000 patients in Germany. The rise of PAD patients strongly correlates with increased age (age group 50–59: 243.000, age group 60–69: 533.000, age group 70–79: 735.000, age group 75–79: 438.000, age group 80–89: 710.000) and more commonly affects males (55%) than females (45%). Access to vascular specialist was low for all age groups with only 11% of patients receiving care from vascular surgeons and only 9% from angiologists. However, 99% received care by a primary care physician.

The prescription of lipid-lowering drugs and platelet aggregation inhibitors in the current analysis period from 2009–2016 is insufficient, with only 46% receiving statins and 29% receiving antiplatelets and 15% oral anticoagulation,

Conclusion

There are relevant differences in age and gender-specific prevalence of PAD in Germany. In addition to the regular care provided by primary care physicians, PAD patients are in need for specialized vascular care. Guideline recommended prescriptions are alarmingly low in PAD patients. There is a clear need to improve the treatment algorithms in the high-risk PAD population.

Funding Acknowledgement

Type of funding source: None

Bounding Global Aerosol Radiative Forcing of Climate Change

Aerosols interact with radiation and clouds. Substantial progress made over the past 40 years in observing, understanding, and modeling these processes helped quantify the imbalance in the Earth's radiation budget caused by anthropogenic aerosols, called aerosol radiative forcing, but uncertainties remain large. This review provides a new range of aerosol radiative forcing over the industrial era based on multiple, traceable, and arguable lines of evidence, including modeling approaches, theoretical considerations, and observations. Improved understanding of aerosol absorption and the causes of trends in surface radiative fluxes constrain the forcing from aerosol-radiation interactions. A robust theoretical foundation and convincing evidence constrain the forcing caused by aerosol-driven increases in liquid cloud droplet number concentration. However, the influence of anthropogenic aerosols on cloud liquid water content and cloud fraction is less clear, and the influence on mixed-phase and ice clouds remains poorly constrained. Observed changes in surface temperature and radiative fluxes provide additional constraints. These multiple lines of evidence lead to a 68% confidence interval for the total aerosol effective radiative forcing of -1.6 to -0.6 W m-2, or -2.0 to -0.4 W m-2 with a 90% likelihood. Those intervals are of similar width to the last Intergovernmental Panel on Climate Change assessment but shifted toward more negative values. The uncertainty will narrow in the future by continuing to critically combine multiple lines of evidence, especially those addressing industrial-era changes in aerosol sources and aerosol effects on liquid cloud amount and on ice clouds.

The Quest to solve the HL-LHC data access puzzle

HL-LHC will confront the WLCG community with enormous data storage, management and access challenges. These are as much technical as economical. In the WLCG-DOMA Access working group, members of the experiments and site managers have explored different models for data access and storage strategies to reduce cost and complexity, taking into account the boundary conditions given by our community.Several of these scenarios have been evaluated quantitatively, such as the Data Lake model and incremental improvements of the current computing model with respect to resource needs, costs and operational complexity.To better understand these models in depth, analysis of traces of current data accesses and simulations of the impact of new concepts have been carried out. In parallel, evaluations of the required technologies took place. These were done in testbed and production environments at small and large scale.We will give an overview of the activities and results of the working group, describe the models and summarise the results of the technology evaluation focusing on the impact of storage consolidation in the form of Data Lakes, where the use of streaming caches has emerged as a successful approach to reduce the impact of latency and bandwidth limitation.We will describe the experience and evaluation of these approaches in different environments and usage scenarios. In addition we will present the results of the analysis and modelling efforts based on data access traces of the experiments.

Endoscopic third ventriculostomy in children with third ventricular pressure gradient and open ventricular outlets on MRI

OBJECTIVE

Patients with non-communicating hydrocephalus due to aqueductal stenosis are often successfully treated with endoscopic third ventriculocisternostomy (ETV). In hydrocephalus, due to other locations of obstruction of the major CSF pathways, endoscopic treatment may also be a good option. We investigated our cohort of patients treated by ETV with patent ventricular outflow but pressure gradient signs at the third ventricle in a single-center retrospective study.

METHODS

We retrospectively reviewed records and imaging studies of 137 patients who underwent an ETV in our department in the time period of June 2010 to March 2018. We included patients who showed the following findings in MRI: 1st: open Sylvian aqueduct, 2nd: open outlets of the 4th ventricle, 3rd: open spinal canal, 4th: intra-/extraventricular pressure gradient seen at the 3rd ventricle and excluded patients with history of CSF infection or hemorrhage. Perioperative clinical state and possible complications or reoperations were recorded. Shunt dependency and changes in ventricular dilatation were measured as frontal and occipital horn ratio (FOHR) before surgery and during follow-up.

RESULTS

A total of 21 patients met the defined criteria. During the mean follow-up time of 40.7 ± 30 months (range; 5-102 months), two children had to undergo a re-ETV, and six children (all < 1 year of age) received a VP shunt. ETV shunt-free survival was 100% for children > 1 year of age. The ventricular width measured as FOHR was significantly reduced after ETV 0.5 ± 0.08 (range 0.42-0.69; p < 0.05). FOHR was significantly reduced at last follow-up shunt independent patients (0.47 ± 0.05; range 0.41-0.55; p < 0.001) CONCLUSION: We conclude that ETV seems to be a successful treatment option for patients with MRI signs of intra-/extraventricular pressure gradient at the 3rd ventricle and patent aqueduct and fourth ventricular outlets in children older than 1 year of age. This condition is observed only rarely and warrants further research on a multicenter basis in order to get more solid data of its pathophysiology.

Determination of Sucralose in Soft Drinks by High-Performance Thin-Layer Chromatography: Interlaboratory Study

An interlaboratory comparison was carried out to evaluate the effectiveness of a method based on HPTLC in which reagent-free derivatization is followed by UV/fluorescence detection. The method was tested for the determination of sucralose (C12H19Cl3O8; (2R,3R,4R,5S,6R)-2- [(2R,3S,4S,5S)-2,5-bis(chloromethyl)-3,4-dihydroxyoxolan- 2-yl]oxy-5-chloro-6-hydroxymethyl)oxane-3, 4-diol; CAS Registry No. 56038-13-2) in carbonated and still beverages at the proposed European regulatory limits. For still beverages, a portion of the sample was diluted with methanolwater. For carbonated beverages, a portion of the sample was degassed in an ultrasonic bath before dilution. Turbid beverages were filtered after dilution through an HPLC syringe filter. The separation of sucralose was performed by direct application on amino-bonded (NH2) silica gel HPTLC plates (no cleanup needed) with the mobile phase acetonitrilewater. Sucralose was determined after reagent-free derivatization at 190C; it was quantified by measurements of both UV absorption and fluorescence. The samples, both spiked and containing sucralose, were sent to 14 laboratories in five different countries. Test portions of a sample found to contain no sucralose were spiked at levels of 30.5, 100.7, and 299 mg/L. Recoveries ranged from 104.3 to 124.6 and averaged 112 for determination by UV detection; recoveries ranged from 98.4 to 101.3 and averaged 99.9 for determination by fluorescence detection. On the basis of the results for spiked samples (blind duplicates at three levels), as well as sucralosecontaining samples (blind duplicates at three levels and one split level), the values for the RSDr ranged from 10.3 to 31.4 for determinations by UV detection and from 8.9 to 15.9 for determinations by fluorescence detection. The values for the RSDR values ranged from 13.5 to 31.4 for determinations by UV detection and from 8.9 to 20.7 for determinations by fluorescence detection.

The frequency of photosensitizing drug dispensings in Austria and Germany: a correlation with their photosensitizing potential based on published literature

Background

Drug‐induced photosensitivity refers to the development of cutaneous adverse events due to interaction between a pharmaceutical compound and sunlight. Although photosensitivity is a very commonly listed side‐effect of systemic drugs, reliable data on its actual incidence are lacking so far.

Objectives

A possible approach to evaluate the real‐life extent of drug‐induced photosensitivity would be an analysis of the frequency of exposure to a given photosensitizing drug combined with an indicator of its photosensitizing potential. This could serve as a basis for developing a pharmaceutical ‘heatmap’ of photosensitivity.

Methods

The present study investigated the number of reimbursed dispensed packages of potentially photosensitizing drugs in Germany (DE) and Austria (AT) between 2010 and 2017 based on nationwide health insurance‐based databases. In addition, an indicator for the photosensitizing potential was established for each drug based on the number of reports on photosensitivity in the literature.

Results

This analysis includes means of 632 826 944 (+/−14 894 918) drug dispensings per year in DE and 113 270 754 (+/−1 964 690) in AT. Out of these, the mean percentage of drugs that enlist photosensitivity as a potential side‐effect was 49.5% (±0.7) in DE and 48.2% (±1.2) in AT. When plotting the number of reimbursed dispensed packages vs. the number of reports on photosensitivity, two categories of drugs show high numbers for both parameters, that is diuretics and non‐steroidal anti‐inflammatory drugs (NSAIDs).

Conclusions

Diuretics and NSAIDs appear to be responsible for the greatest part of exposure to photosensitizing drugs with potential implication on public health.

Frequency of extreme precipitation increases extensively with event rareness under global warming

The intensity of the heaviest extreme precipitation events is known to increase with global warming. How often such events occur in a warmer world is however less well established, and the combined effect of changes in frequency and intensity on the total amount of rain falling as extreme precipitation is much less explored, in spite of potentially large societal impacts. Here, we employ observations and climate model simulations to document strong increases in the frequencies of extreme precipitation events occurring on decadal timescales. Based on observations we find that the total precipitation from these intense events almost doubles per degree of warming, mainly due to changes in frequency, while the intensity changes are relatively weak, in accordance to previous studies. This shift towards stronger total precipitation from extreme events is seen in observations and climate models, and increases with the strength - and hence the rareness - of the event. Based on these results, we project that if historical trends continue, the most intense precipitation events observed today are likely to almost double in occurrence for each degree of further global warming. Changes to extreme precipitation of this magnitude are dramatically stronger than the more widely communicated changes to global mean precipitation.

Elucidation of removal processes in sequential biofiltration (SBF) and soil aquifer treatment (SAT) by analysis of a broad range of trace organic chemicals (TOrCs) and their transformation products (TPs)

Many chemicals with different physico-chemical properties are present in municipal wastewater. In this study, the removal of a broad range of trace organic chemicals (TOrCs) was determined in two biological treatment processes differing in hydraulic retention time: sequential biofiltration (SBF) and soil-aquifer treatment (SAT), operated in Germany and Spain. Occurrence and the degree of removal of more than 150 TOrCs with different physico-chemical properties were analysed, including precursors as well as human metabolites and environmental transformation products (TPs). Ninety TOrCs were detected in the feed water of the SBF system, 40% of these showed removal efficiencies of higher than 30% during biological treatment. In SAT, 70 TOrCs were detected in the feed water, 60% of these could be reduced by more than 30% after approximately 3 days of subsurface treatment. For uncharged and negatively charged TOrCs biological degradation was mainly responsible for the removal, while positively charged TOrCs were most likely also removed by ionic interactions. The detections of TPs confirmed that biodegradation was a major removal process in both systems. The analysis of positively and negatively charged, neutral and zwitterionic TOrCs and the simultaneous analysis of precursors and their biologically formed TPs enabled a detailed understanding of underlying mechanisms of their removal in the two systems. On this basis, criteria for site-specific indicator selection were proposed.

Simulation and visualization of material flows in sanitation systems for streamlined sustainability assessment

New and alternative sanitation systems are increasingly discussed and find their way into implementation. However, discussions on sanitation concepts often are held in a rather emotional way. Furthermore, not all the available sanitation concepts might be known to the decision maker. The work presented here attempts to contribute to a good discussion and decision making process by compiling available technologies, by defining easy-to-implement criteria for a sustainability assessment method and by integrating these results into a simulation tool which allows to visualize the related resource fluxes (e.g. those on nutrients, such as N, P and K) and to analyse different sanitation options with regard to their capital and operational costs and with regard to environmental impact criteria such as greenhouse gas emissions. Whilst the calculations are to be considered as being approximate in their nature (due to uncertainties or lack of suitable input data), this tool allows the planners, with sometimes little modelling experience, to consider the characteristics of sanitation systems. Whilst starting from earlier work, such as Eawag's Sanitation Compendium and work on material flow analysis, work described in this contribution merges resource flux modelling, easy-to-use simulation and visualization and methods of life cycle assessment and life cycle costing. The simulation tool is freely available on https://www.ifak.eu/en/products/sampsons.

Acceptance of a medication refill reminder service in German community pharmacy practice

Medication refill reminder services (MRRS), having the potential to support the detection of non-adherence and to promote periodic medication refilling by addressing forgetfulness, are not generally available in community pharmacy practice. Based on a new software module, a MRRS was developed. The acceptance of this service was tested in community pharmacies in Germany. Patients were recruited by trained pharmacy staff. Supported by the software, the pharmacies reminded patients to refill their prescription. After 7 months, the service was evaluated by patients and pharmacy staff. The pharmacy owners/managers were interviewed. Ten pharmacies applied the service to 148 patients, with 806 refill reminders for 391 drugs. Seventy-five patients (50.7%) chose to be reminded by a phone call, followed by text message (n=25), and email (n=18). Of all patients, 75 (50.7%) completed the paper-based questionnaire. Sixty-eight (90.7%) rated the service as good or very good and 54 (72.0%) felt more satisfied with their pharmacy. Sixty-four patients (85.3%) considered the service as supportive and wanted to continue. Thirty-nine pharmacy staff members (61.9%) answered the online questionnaire. Twenty-four (61.5%) stated that they found it difficult to use and apply the MRRS; twenty-six (66.6%) experienced technical problems. The service was rated good by 16 (41.0%) pharmacy staff members. They regarded the service helpful for some patients and wanted to continue after the end of the study. The majority of the ten interviewed pharmacy owners/managers expressed the opinion that the service was not very suitable for increasing customer loyalty and not cost-effective. Nevertheless, six (60.0%) of them wanted to continue using the service. The MRRS seems to be feasible, apart from technical difficulties. Patients rated the service as supportive, and the personal contact seems to be of high importance; most patients would like to continue the service. However, offering the service to patients turned out to be challenging in daily German community pharmacy practice.

Stark Many-Body Localization

We consider spinless fermions on a finite one-dimensional lattice, interacting via nearest-neighbor repulsion and subject to a strong electric field. In the noninteracting case, due to Wannier-Stark localization, the single-particle wave functions are exponentially localized even though the model has no quenched disorder. We show that this system remains localized in the presence of interactions and exhibits physics analogous to models of conventional many-body localization (MBL). In particular, the entanglement entropy grows logarithmically with time after a quench, albeit with a slightly different functional form from the MBL case, and the level statistics of the many-body energy spectrum are Poissonian. We moreover predict that a quench experiment starting from a charge-density wave state would show results similar to those of Schreiber et al. [Science 349, 842 (2015)SCIEAS0036-807510.1126/science.aaa7432].

Clinical ethics consultations in psychiatric compared to non-psychiatric medical settings: characteristics and outcomes

BACKGROUND

In the recent years clinical ethics consultations (CEC) received an increasing attention not only in patients with medical conditions but also in those with mental disorders. However, the systematic and empirical knowledge is still small. The aim of this observational study was to investigate whether CECs differ between psychiatric and medical hospital inpatients regarding ethical issues, goals, characteristics, processes, and outcomes.

METHODS

This is a retrospective and in parts prospective analysis of a semi-structured CEC approach provided by the CEC service at a large German general hospital between January 2006 and June 2015.

RESULTS

A total of 259 CECs in three inpatient settings were investigated, i.e. intensive care units (ICU, 43.6%), low care units (LCU, 33.6%), and psychiatric care units (PCU, 22.8%). In all groups, most ethical issues addressed treatment intensity (80.6%) and resulted in over 93% in participants' agreement on final ethical recommendations as well as in high implementation rates (>89%). However, we found significant group differences: In PCUs patients participated more often in the CEC (p < .001), the number of all participants was higher (p < .001), CECs were more time expensive (p < .001), and more recommendations focused on interventions against the patients' declared intention (37.7% versus 0%) than in the other groups.

DISCUSSION

In spite of different clinical characteristics and ethical issues between patients and settings, consensus and implementation of the CEC recommendation could be achieved at a high rate in all groups. There are substantial differences regarding goals, participation of patients, and processes. It is worth considering adapting the CEC to the special needs in psychiatric settings, especially under the aspect of the patients' perspective and involvement.

Trends and regional variations in the administrative prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Germany

There is a controversy regarding temporal trends in prevalence of attention-deficit/hyperactivity disorder (ADHD). Using nationwide claims data containing data for approximately six million statutory health insured children we aimed to examine a) trends of ADHD administrative prevalence during 2009-2016; b) regional variations in prevalence, and c) factors associated with an increased chance of ADHD diagnosis. The ICD-10 code 'F90-hyperkinetic disorder' was used to define an ADHD case. Global and Local Moran's I tests were used to examine the spatial autocorrelation and k-means-cluster analysis to examine the course of ADHD prevalence in administrative districts over years. Two-level logistic regression was applied to examine individual- and district-level factors associated with ADHD diagnosis. The administrative prevalence of ADHD was 4.33% (95% CI: 4.31-4.34%). We observed pronounced small-area differences on the district level with prevalences ranging between 1.6% and 9.7%. There was evidence of strong spatial autocorrelation (Global Moran's I: 0.46, p < 0.0001). The k-means-method identified six clusters of different size; all with a stagnating trend in the prevalence over the observation period of eight years. On the district level, a lower proportion of foreign citizens, and a higher density of paediatric psychiatrists and paediatricians were positively associated with ADHD with a more pronounced effect in urban districts.

Fabrication of gadolinium particle-based absorption gratings for neutron grating interferometry

The imaging performance of a neutron-based Talbot-Lau interferometer depends to a great extent on the absorption characteristics of the source and analyzer gratings. Due to its high neutron attenuation, gadolinium (Gd) is the preferred material for grating fabrication, but suffers from difficulties with deposition time, stability, uniformity, and selectivity into high aspect ratio structures. Here we present a simple alternative method of Gd deposition into grating structures based on metallic particle suspension casting and subsequent doctor-blading. Surface analysis by confocal and electron scanning microscopy shows that a nearly clear, particle free silicon interface of the grating structure over a large area could be reached. Additionally, characterization by neutron radiography confirms a high effective Gd height and homogeneity over the whole grating area. In particular, grating trenches well below 10 μm width could be successfully filled with Gd and deliver excellent absorbing performance down to the sub-2 Å wavelength range. The findings confirm that we obtained an effective binary absorption profile for the fabricated gratings which is of great benefit for grating-based neutron imaging.

Neuroendoscopic lavage for the treatment of CSF infection with hydrocephalus in children

OBJECTIVE

The treatment of infectious CSF condition with ventriculitis and hydrocephalus in children is an interdisciplinary challenge. Conventional surgical treatment includes external ventricular drain (EVD) and systemic antibiotic therapy. However, infectious contamination of large ventricles combined with CSF protein overload often requires long treatment regimens. We retrospectively investigated neuroendoscopic lavage as a new option for clearance of CSF in children with hydrocephalus and active CSF infection.

PATIENTS AND METHODS

A database review identified 50 consecutive patients treated for CSF infection with hydrocephalus at our institution. Twenty-seven patients (control group, CG) were treated conventionally between 2004 and 2010, while 23 patients (neuroendoscopic group, NEG) underwent neuroendoscopic lavage for removal of intraventricular debris between 2010 and 2015. Clinical data, microbiology, laboratory measures, shunt dependency, and shunt revision rate were evaluated retrospectively.

RESULTS

The patient groups did not differ regarding basic clinical characteristics. Patients in NEG received neuroendoscopic lavage at mean of 1.6 ± 1times (1-4). No immediate postoperative complications were observed in NEG patients. Shunt rate in NEG patients was 91% as compared 100% in CG patients (p = 0.109). Within 24 months after shunt implantation, incidence of shunt revision was higher in CG (23/27) compared to NEG (5/23; p < 0.001). Reinfection was observed more often in CG (n = 17) compared to one patient in NEG (p < 0.001).

CONCLUSIONS

We experienced that neuroendoscopic lavage is a safe and effective treatment for hydrocephalus in children with infectious conditions. Neuroendoscopic lavage resulted in a decreased number of overall shunt revisions in shunt-depended patients as well as a lower number of recurrent infections.

MRI and sonography in Legg-Calvé-Perthes disease: clinical relevance of containment and influence on treatment

PURPOSE

The containment orientated treatment of Legg-Calvé-Perthes disease (LCPD) affected hip joints is broadly accepted in the literature. The prerequisite is early recognition of loss of containment. An often-used quantitative MRI containment parameter is the cartilaginous acetabulum-head-index (CAHI). Based on ultrasound (US), we analyzed the newly created 'femoral head extrusion angle' (HA) as a containment parameter in comparison with the CAHI in severe LCPD.

METHODS

In a prospective study with 40 children (mean age 5.8 years sd 2.3) with unilateral LCPD classified as Catterall group III/IV, we measured the CAHI versus HA to assess the containment of the femoral head. HA in US was determined by the tangent from the bony acetabular rim to the cartilaginous cranio-lateral femoral head.

RESULTS

The HA was significantly higher in LCPD-affected hip joints (25° sd 7°) than in healthy ones (13° sd 5°; p < 0.001). Correlation analysis of all hip joints revealed a significant correlation between HA and CAHI (r = -0.69; p < 0.001). Hip joints with a low CAHI indicating loss of containment showed a higher HA in sonography.

CONCLUSION

The results of our study suggest that the HA in US is a reliable containment parameter in severe LCPD with a HA > 22° defining a pathologic value. In comparison with the CAHI, HA measurement in ultrasound is easier than the assessment of various parameters to calculate an index. Frequent sonographical follow-up assessment in critical joints is an alternative if MRI is not available, helping to detect an impending loss of containment early enough.

LEVEL OF EVIDENCE

Level II.

A critical and quantitative review of the stratification of particles during the drying of colloidal films

For a wide range of applications, films are deposited from colloidal particles suspended in a volatile liquid. There is burgeoning interest in stratifying colloidal particles into separate layers within the final dry film to impart properties at the surface different to the interior. Here, we outline the mechanisms by which colloidal mixtures can stratify during the drying process. The problem is considered here as a three-way competition between evaporation of the continuous liquid, sedimentation of particles, and their Brownian diffusion. In particle mixtures, the sedimentation of larger or denser particles offers one means of stratification. When the rate of evaporation is fast relative to diffusion, binary mixtures of large and small particles can stratify with small particles on the top, according to physical models and computer simulations. We compare experimental results found in the scientific literature to the predictions of several recent models in a quantitative way. Although there is not perfect agreement between them, some general trends emerge in the experiments, simulations and models. The stratification of small particles on the top of a film is favoured when the colloidal suspension is dilute but when both the concentration of the small particles and the solvent evaporation rate are sufficiently high. A higher particle size ratio also favours stratification by size. This review points to ways that microstructures can be designed and controlled in colloidal materials to achieve desired properties.

The use of a smartphone-assisted ventricle catheter guide for Ommaya reservoir placement-experience of a retrospective bi-center study

BACKGROUND

For intraventricular chemotherapy (IVC) as part of many oncological treatment protocols, Ommaya reservoir is enabling repeated access to the cerebro-spinal fluid (CSF). The correct placement of the catheter in the ventricle is essential for correct application of drugs, which is enabled by sophisticated techniques such as neuronavigation.

OBJECTIVE

In a bi-center retrospective study, we reviewed our experience using a smartphone-assisted ventricle catheter guide as simple solution for correct Ommaya reservoir placement.

METHODS

Sixty Ommaya reservoirs have been placed in 60 patients between 2011 and 2017 with the smartphone-assisted ventricular catheter guidance technique. Patient characteristics, preoperative frontal and occipital horn ratio (FOHR), postoperative catheter position, and complications were assessed.

RESULTS

The majority of our patients (71.6%) have got narrow or slit-like ventricles (FOHR ≤ 0.4). All Ommaya reservoirs were placed successfully. Fifty-eight ventricular catheters (97%) were inserted at the first and 2 (3%) at the second attempt using the same technique. No immediate perioperative complications were observed. All catheters (100%) could be used for IVC. Postoperative imaging was available in 52 patients. Thirty-two (61.5%) of ventricular catheters were rated as grade I, 20 (38.5%) as grade II, and none (0%) as grade III. Four patients (6.7%) showed postoperative complications during a median follow-up of 8.5 months (hydrocephalus, n = 1; infection, n = 1; parenchymal cyst around catheter, n = 1; shunt revision, n = 1).

CONCLUSIONS

The smartphone-assisted guide offers decent accuracy of ventricle catheter placement with ease and simplicity for a small surgical intervention. We propose this technique as routine tool for Ommaya reservoir placement independent of lateral ventricular size to decrease the rate of ventricle catheter malposition as reasonable alternative to a neuronavigation system.

[Prehospital assessment of injury type and severity in severely injured patients by emergency physicians : An analysis of the TraumaRegister DGU®]

BACKGROUND

Prehospital assessment of injury type and severity by emergency medical services physicians impacts treatment including appropriate destination hospital selection, especially in (potentially) life-threatening cases. Injuries which are underestimated or overlooked by the emergency physician can delay adequate therapy and thus significantly influence the overall outcome. The current study used data from the TraumaRegister DGU® to evaluate the reliability of prehospital injury assessments made by emergency physicians.

MATERIAL AND METHODS

Data of 30,777 patients from the TraumaRegister DGU® between 1993 and 2009 were retrospectively evaluated. Using the abbreviated injury scale (AIS), subjective prehospital assessments of injury severity by emergency physicians were correlated with objectively identified injuries diagnosed after admission to hospital. For this evaluation, prehospital injury assessments rated moderate or severe by the emergency physician as well as injuries diagnosed in hospital with an AIS score ≥3 points were deemed relevant.

RESULTS

The 30,777 patients with an injury severity score (ISS) ≥ 9 suffered a total of 202,496 injuries and of these 26 % (51,839 out of 202,496) were considered relevant with an AIS ≥3 points. The most frequent relevant injuries were to the head (47 %) and chest (46 %). Of the 51,839 relevant injuries, the prehospital assessment by the emergency physician was accurate for 71 % and in 29 % of the cases relevant injuries were underestimated. Relevant injuries were unrecognized or underestimated in prehospital assessments for almost 1 out of every 7 cases of head trauma, almost 1 out of every 3 thoracic trauma and almost 1 out of every 2 abdominal and pelvic trauma.

CONCLUSION

The assessment of injury severity by emergency medical services physicians based on physical examination at the scene of the trauma is not very reliable. Thus, mechanisms of injury and overall presentation as well as identifiable injuries and vital parameters should be recognized by the emergency physician when considering treatment strategies and choice of appropriate destination hospital. The patient should be re-evaluated in a priority-oriented manner at the latest on arrival in the trauma room to avoid the consequences of unrecognized or underestimated injuries.