End-of-life practices in European intensive care units: the Ethicus Study

CONTEXT

While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures.

OBJECTIVES

To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences.

DESIGN AND SETTING

A prospective, observational study of European ICUs.

PARTICIPANTS

Consecutive patients who died or had any limitation of therapy.

INTERVENTION

Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000.

MAIN OUTCOME MEASURES

Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals.

RESULTS

Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001).

CONCLUSION

The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.

OptFlux: an open-source software platform for in silico metabolic engineering

Background

Over the last few years a number of methods have been proposed for the phenotype simulation of microorganisms under different environmental and genetic conditions. These have been used as the basis to support the discovery of successful genetic modifications of the microbial metabolism to address industrial goals. However, the use of these methods has been restricted to bioinformaticians or other expert researchers. The main aim of this work is, therefore, to provide a user-friendly computational tool for Metabolic Engineering applications.

Results

OptFlux is an open-source and modular software aimed at being the reference computational application in the field. It is the first tool to incorporate strain optimization tasks, i.e., the identification of Metabolic Engineering targets, using Evolutionary Algorithms/Simulated Annealing metaheuristics or the previously proposed OptKnock algorithm. It also allows the use of stoichiometric metabolic models for (i) phenotype simulation of both wild-type and mutant organisms, using the methods of Flux Balance Analysis, Minimization of Metabolic Adjustment or Regulatory on/off Minimization of Metabolic flux changes, (ii) Metabolic Flux Analysis, computing the admissible flux space given a set of measured fluxes, and (iii) pathway analysis through the calculation of Elementary Flux Modes.

OptFlux also contemplates several methods for model simplification and other pre-processing operations aimed at reducing the search space for optimization algorithms.

The software supports importing/exporting to several flat file formats and it is compatible with the SBML standard. OptFlux has a visualization module that allows the analysis of the model structure that is compatible with the layout information of Cell Designer, allowing the superimposition of simulation results with the model graph.

Conclusions

The OptFlux software is freely available, together with documentation and other resources, thus bridging the gap from research in strain optimization algorithms and the final users. It is a valuable platform for researchers in the field that have available a number of useful tools. Its open-source nature invites contributions by all those interested in making their methods available for the community.

Given its plug-in based architecture it can be extended with new functionalities. Currently, several plug-ins are being developed, including network topology analysis tools and the integration with Boolean network based regulatory models.

The importance of religious affiliation and culture on end-of-life decisions in European intensive care units

OBJECTIVE

To determine the influence of religious affiliation and culture on end-of-life decisions in European intensive care units (ICUs).

DESIGN AND SETTING

A prospective, observational study of European ICUs was performed on consecutive patients with any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries studied from 1 January 1999 to 30 June 2000 were compared for frequencies, patterns, timing, and communication by religious affiliation of physicians and patients and regions.

RESULTS

Of the 31,417 patients 3,086 had limitations. Withholding occurred more often than withdrawing if the physician was Jewish (81%), Greek Orthodox (78%), or Moslem (63%). Withdrawing occurred more often for physicians who were Catholic (53%), Protestant (49%), or had no religious affiliation (47%). End-of-life decisions differed for physicians between regions and who had any religious affiliation vs. no religious affiliation in all three geographical regions. Median time from ICU admission to first limitation of therapy was 3.2 days but varied by religious affiliation; from 1.6 days for Protestant to 7.6 days for Greek Orthodox physicians. Median times from limitations to death also varied by physician's religious affiliation. Decisions were discussed with the families more often if the physician was Protestant (80%), Catholic (70%), had no religious affiliation (66%) or was Jewish (63%).

CONCLUSIONS

Significant differences associated with religious affiliation and culture were observed for the type of end of life decision, the times to therapy limitation and death, and discussion of decisions with patient families.

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

IMPORTANCE

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

OBJECTIVE

To determine the changes in end-of-life practices in European ICUs after 16 years.

DESIGN, SETTING, AND PARTICIPANTS

Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

EXPOSURES

Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

MAIN OUTCOMES AND MEASURES

End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

RESULTS

Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Communication of end-of-life decisions in European intensive care units

OBJECTIVE

To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, patients and families.

DESIGN

Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.

SETTING

37 European ICUs in 17 countries.

PATIENTS

ICU physicians collected data on 4,248 patients.

RESULTS

95% of patients lacked decision making capacity at the time of EOL decision and patient's wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients' wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians' reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).

CONCLUSIONS

ICU patients typically lack decision-making capacity, and physicians know patients' wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication.

Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study

OBJECTIVE

To evaluate attitudes of Europeans regarding end-of-life decisions.

DESIGN AND SETTING

Responses to a questionnaire by physicians and nurses working in ICUs, patients who survived ICU, and families of ICU patients in six European countries were compared for attitudes regarding quality and value of life, ICU treatments, active euthanasia, and place of treatment.

MEASUREMENTS AND RESULTS

Questionnaires were distributed to 4,389 individuals and completed by 1,899 (43%). Physicians (88%) and nurses (87%) found quality of life more important and value of life less important in their decisions for themselves than patients (51%) and families (63%). If diagnosed with a terminal illness, health professionals wanted fewer ICU admissions, uses of CPR, and ventilators (21%, 8%, 10%, respectively) than patients and families (58%, 49%, 44%, respectively). More physicians (79%) and nurses (61%) than patients (58%) and families (48%) preferred being home or in a hospice if they had a terminal illness with only a short time to live.

CONCLUSIONS

Quality of life was more important for physicians and nurses than patients and families. More medical professionals want fewer ICU treatments and prefer being home or in a hospice for a terminal illness than patients and families.

Nurse involvement in end-of-life decision making: the ETHICUS Study

OBJECTIVE

The purpose was to investigate physicians' perceptions of the role of European intensive care nurses in end-of-life decision making.

DESIGN

This study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.

SETTING

The study took place in 37 intensive care units in 17 European countries.

PATIENTS AND PARTICIPANTS

Physician investigators reported data related to patients from 37 centers in 17 European countries.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Physicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.

CONCLUSIONS

Physicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

Stress and burnout among Portuguese anaesthesiologists

BACKGROUND AND OBJECTIVE

Anaesthesiology is considered a stressful occupation. Our purpose was to assess stress and burnout among Portuguese anaesthesiologists.

METHODS

A cross-sectional survey based on an anonymous questionnaire was sent to all Portuguese anaesthesiologists registered by the Portuguese Medical Association. Data on patient characteristics and professional variables, perceived stress (Perceived Stress Scale), the subscale of work satisfaction of the Pressure Management Indicator scale, burnout (Maslach Burnout Inventory) and main stress factors were collected. The proportion of participation was 31.8%.

RESULTS

The average value of perceived stress scale was 24.0 (range: 0-56). Among the 263 anaesthesiologists, 57.9% experienced emotional exhaustion, 44.8% lack of personal accomplishment and 90.9% depersonalisation. Lack of personal accomplishment increased with number of children among women but not among men; depersonalisation was more frequent among anaesthesiologists working in community hospitals and anaesthesiologists with leadership functions experienced less professional stress.

CONCLUSION

There are stress conditions and burnout amongst Portuguese anaesthesiologists. The prevalence of depersonalisation was extremely high in the studied sample. Emotional exhaustion is partially explained by high perceived-stress and low satisfaction with organisation in the job according to Pressure Management Indicator scale.

Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States

Purpose

Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one’s job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics.

Methods

Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62–0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77–0.98]) were all associated with a lower intent to leave.

Conclusion

This is the first large multicenter study showing an independent association between clinicians’ intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05829-1) contains supplementary material, which is available to authorized users.

A Review of Dynamic Modeling Approaches and Their Application in Computational Strain Optimization for Metabolic Engineering

Mathematical modeling is a key process to describe the behavior of biological networks. One of the most difficult challenges is to build models that allow quantitative predictions of the cells' states along time. Recently, this issue started to be tackled through novel in silico approaches, such as the reconstruction of dynamic models, the use of phenotype prediction methods, and pathway design via efficient strain optimization algorithms. The use of dynamic models, which include detailed kinetic information of the biological systems, potentially increases the scope of the applications and the accuracy of the phenotype predictions. New efforts in metabolic engineering aim at bridging the gap between this approach and other different paradigms of mathematical modeling, as constraint-based approaches. These strategies take advantage of the best features of each method, and deal with the most remarkable limitation—the lack of available experimental information—which affects the accuracy and feasibility of solutions. Parameter estimation helps to solve this problem, but adding more computational cost to the overall process. Moreover, the existing approaches include limitations such as their scalability, flexibility, convergence time of the simulations, among others. The aim is to establish a trade-off between the size of the model and the level of accuracy of the solutions. In this work, we review the state of the art of dynamic modeling and related methods used for metabolic engineering applications, including approaches based on hybrid modeling. We describe approaches developed to undertake issues regarding the mathematical formulation and the underlying optimization algorithms, and that address the phenotype prediction by including available kinetic rate laws of metabolic processes. Then, we discuss how these have been used and combined as the basis to build computational strain optimization methods for metabolic engineering purposes, how they lead to bi-level schemes that can be used in the industry, including a consideration of their limitations.

Fit of complete-arch implant-supported prostheses produced from an intraoral scan by using an auxiliary device and from an elastomeric impression: A pilot clinical trial

STATEMENT OF PROBLEM

The accuracy of impressions for implant-supported prostheses is essential to ensure a passive fit of the definitive prosthesis. Intraoral scanners (IOSs) have been developed as an alternative to complete-arch implant-supported restorations; however, whether they are sufficiently accurate when more than 3 nonaligned implants are involved is unclear.

PURPOSE

The purpose of this pilot clinical study was to determine whether the fit of complete-arch zirconia implant-supported frameworks processed on a cast obtained with an IOS and adjusted with an auxiliary device is equivalent to a prosthesis obtained from an elastomeric impression.

MATERIAL AND METHODS

Twelve consecutive participants who were ready for complete-arch restorations on already osseointegrated implants were enrolled. Two records were made, one open-tray with polyether and splinted impression copings and the second with an IOS. A verification gypsum device was used for the elastomeric impression, and a prefabricated auxiliary device was used to adjust the intraoral scans. Two zirconia frameworks with the same design were processed and evaluated intraorally by 2 independent calibrated observers.

RESULTS

In 11 of the 12 participants, the digitally processed prosthesis was preferred over the conventionally processed prosthesis. The clinical fit of the prostheses obtained with the completely digital workflow was better than that of those obtained with the conventional workflow.

CONCLUSIONS

The use of a prefabricated auxiliary device after intraoral scanning allowed delivery of complete-arch implant-supported monolithic zirconia prostheses with a fit better than those fabricated from conventional impressions.

AIBench: a rapid application development framework for translational research in biomedicine

Applied research in both biomedical discovery and translational medicine today often requires the rapid development of fully featured applications containing both advanced and specific functionalities, for real use in practice. In this context, new tools are demanded that allow for efficient generation, deployment and reutilization of such biomedical applications as well as their associated functionalities. In this context this paper presents AIBench, an open-source Java desktop application framework for scientific software development with the goal of providing support to both fundamental and applied research in the domain of translational biomedicine. AIBench incorporates a powerful plug-in engine, a flexible scripting platform and takes advantage of Java annotations, reflection and various design principles in order to make it easy to use, lightweight and non-intrusive. By following a basic input-processing-output life cycle, it is possible to fully develop multiplatform applications using only three types of concepts: operations, data-types and views. The framework automatically provides functionalities that are present in a typical scientific application including user parameter definition, logging facilities, multi-threading execution, experiment repeatability and user interface workflow management, among others. The proposed framework architecture defines a reusable component model which also allows assembling new applications by the reuse of libraries from past projects or third-party software.

@Note: a workbench for biomedical text mining

Biomedical Text Mining (BioTM) is providing valuable approaches to the automated curation of scientific literature. However, most efforts have addressed the benchmarking of new algorithms rather than user operational needs. Bridging the gap between BioTM researchers and biologists' needs is crucial to solve real-world problems and promote further research. We present @Note, a platform for BioTM that aims at the effective translation of the advances between three distinct classes of users: biologists, text miners and software developers. Its main functional contributions are the ability to process abstracts and full-texts; an information retrieval module enabling PubMed search and journal crawling; a pre-processing module with PDF-to-text conversion, tokenisation and stopword removal; a semantic annotation schema; a lexicon-based annotator; a user-friendly annotation view that allows to correct annotations and a Text Mining Module supporting dataset preparation and algorithm evaluation. @Note improves the interoperability, modularity and flexibility when integrating in-home and open-source third-party components. Its component-based architecture allows the rapid development of new applications, emphasizing the principles of transparency and simplicity of use. Although it is still on-going, it has already allowed the development of applications that are currently being used.

Professional Quality of Life Among Physicians and Nurses Working in Portuguese Hospitals During the Third Wave of the COVID-19 Pandemic

BACKGROUND

In the last 2 weeks of January 2021, Portugal was the worst country in the world in incidence of infections and deaths due to COVID-19. As a result, the pressure on the healthcare system increased exponentially, exceeding its capacities and leaving hospitals in near collapse. This scenario caused multiple constraints, particularly for hospital medical staff. Previous studies conducted at different moments during the pandemic reported that COVID-19 has had significant negative impacts on healthcare workers' psychological health, including stress, anxiety, depression, burnout, post-traumatic stress symptoms, and sleep disturbances. However, there are many uncertainties regarding the professional quality of life of hospital nurses and physicians. To address gaps in previous research on secondary traumatic stress, we focused on healthcare workers working in hospitals affected by a major traumatic event: the third wave of COVID-19.

OBJECTIVES

The aim of the present study was to identify the contribution of personal and work-related contextual variables (gender, age, parental status, occupation, years of experience, working with patients affected by COVID-19) on professional quality of life of healthcare workers.

METHODS

Cross-sectional study with a web-based questionnaire given to physicians and nurses working in a hospital setting. A total of 853 healthcare professionals (276 physicians and 586 nurses; median age 37 years old) participated in the survey assessing professional quality of life compassion satisfaction, secondary traumatic stress, and burnout. Factors of professional quality of life were assessed using regression analysis.

RESULTS

Most of the participants showed moderate (80%; n = 684) or high (18%; n = 155) levels of compassion satisfaction, whereas the majority of them experienced moderate levels of burnout (72%; n = 613) and secondary traumatic stress (69%; n = 592). The analyzed variables demonstrated no differences between professionals who were directly or not involved in the care of COVID-19 patients. Parental status was found to be a significant factor in compassion satisfaction. Female gender was significantly associated with more susceptibility to secondary traumatization. Factors that may potentially contribute to burnout include years of professional experience and the number of work hours per week.

CONCLUSION

The COVID-19 pandemic has created a new challenge for the healthcare system. Burnout and secondary traumatic stress can lead to medical errors and impact standards of patient care, particularly compromising compassionate care. It is therefore recommended that hospitals develop psychoeducational initiatives to support professionals in dealing with barriers to compassion.

In vitro comparison of the accuracy of four intraoral scanners and three conventional impression methods for two neighboring implants

Purpose

To determine whether the accuracy of two-implant model impressions taken with optical scanners was inferior to that of those taken with elastomeric materials.

Materials and Methods

Impressions of a resin reference model with two almost parallel implants were taken using three elastomeric impressions (closed tray technique, open tray nonsplinted technique and open tray splinted technique) and scanned with four optical scanners (CEREC Omnicam, 3M True Definition Scanner, 3Shape TRIOS3 and Carestream CS 3600). STL files of the different methods were superimposed and analyzed with control software (Geomagic Control X, 3D systems) to determine the mean deviation between scans.

Results

Compared to elastomeric impressions, optical impressions showed a significantly improved mean precision. TRIOS3 and CS3600 showed a significantly improved mean trueness compared to that of closed tray, CEREC Omnicam and TrueDefinition. All methods showed a certain degree of implant rotation over their axes, which was significantly higher in the closed tray and the open tray nonsplinted techniques.

Conclusions

Optical impressions, taken under these in vitro conditions, showed improved accuracy compared with that of elastomeric impressions.

Acquired antiprothrombin antibodies: an unusual cause of bleeding

Acquired inhibitors of coagulation causing bleeding manifestations are rare in children. They emerge, normally in the context of autoimmune diseases or drug ingestion, but transient and self-limiting cases can occur after viral infection. We describe, an otherwise healthy, 7-year-old girl who had gingival bleeding after a tooth extraction. The prothrombin time (PT) and the activated partial thromboplastin time (APTT) were both prolonged with evidence of an immediate acting inhibitor (lupic anticoagulant). Further coagulation studies demonstrated prothrombin (FII) deficiency and prothrombin directed (FII) antibodies. The serological tests to detect an underlying autoimmune disease were all negative. The coagulation studies normalised alongside the disappearance of the antibody. This article presents lupus anticoagulant hypoprothrombinaemia syndrome (LAHS) as a rare case of acquired bleeding diathesis in childhood.

Model-guided development of an evolutionarily stable yeast chassis

First-principle metabolic modelling holds potential for designing microbial chassis that are resilient against phenotype reversal due to adaptive mutations. Yet, the theory of model-based chassis design has rarely been put to rigorous experimental test. Here, we report the development of Saccharomyces cerevisiae chassis strains for dicarboxylic acid production using genome-scale metabolic modelling. The chassis strains, albeit geared for higher flux towards succinate, fumarate and malate, do not appreciably secrete these metabolites. As predicted by the model, introducing product-specific TCA cycle disruptions resulted in the secretion of the corresponding acid. Adaptive laboratory evolution further improved production of succinate and fumarate, demonstrating the evolutionary robustness of the engineered cells. In the case of malate, multi-omics analysis revealed a flux bypass at peroxisomal malate dehydrogenase that was missing in the yeast metabolic model. In all three cases, flux balance analysis integrating transcriptomics, proteomics and metabolomics data confirmed the flux re-routing predicted by the model. Taken together, our modelling and experimental results have implications for the computer-aided design of microbial cell factories.

Multiple Complex Odontomas of the Mandible: A Rare Case Report and Literature Review

A 53-year-old female appeared with pain in the right mandible ramus, for the past 9 months, after tooth extraction. Clinical and radiological examination using conventional and advanced computerized tomography diagnostic imaging led to a provisional diagnosis of multiple complex odontomas. Complete conservative excision of the lesion was performed. The clinical diagnosis was confirmed histopathologically. Postoperative period was uneventful with no evidence of recurrence. According to an extensive literature review, this report describes the oldest patient ever diagnosed with multiple odontomas in the literature.

Comparison of peribulbar block and general anaesthesia in mechanical vitrectomy: a prospective observational study

INTRODUCTION

Vitrectomy surgery is a common procedure for the treatment of several types of ophthalmologic conditions. It can be performed under regional anaesthesia with peribulbar block (PB) or general anaesthesia (GA). There are no evidence-based recommendations on the optimal anaesthesia strategy for this procedure. The aim of this study was to compare the advantages of PB and GA for vitrectomy surgery.

MATERIALS AND METHODS

A prospective observational study was conducted on adults submitted for mechanical vitrectomy between January 2017 and December 2017. Demographic and perioperative data were collected, namely ASA physical status, median arterial pressure, heart rate, postoperative opioid consumption, postoperative nausea and vomiting, times of induction, surgery, recovery, and hospital stay and costs considering medication and material needed. Statistical analysis was performed using SPSS v.25, with chi-square, Fisher and Mann-Whitney U tests, according to the type of variables analysed.

RESULTS AND DISCUSSION

We included 179 patients submitted for mechanical vitrectomy: 91 (51%) with PB and 88 (49%) under GA. Patients submitted to PB were older (69.0 vs. 64.5 years, p=.006) and presented with higher ASA physical status (p=.001). For haemodynamic outcomes, patients submitted to PB presented with less variation of median arterial pressure (-3.0 vs. -13.5mmHg, p=.000) and with no significant differences in heart rate (-2.0 vs. -3.0 bpm, p=.825). In the postoperative period, the PB group presented with decreased need of postoperative analgesia (0.0 vs. 5.0, p=.026) and a lower incidence of nausea and vomiting (1.0 vs. 12.0, p=.001). Times related to anaesthesia and surgery were better in PB group, with shorter induction time (10.0 vs. 11.0min, p=.000), surgery time (56.5 vs. 62.0min, p=.001), recovery time (10.0 vs. 75.5min, p=.000), and hospital stay (2.0 vs. 3.0 days, p=.000). When analysing costs, PB was less expensive than GA (4.65 vs. 12.09 euros, p=.021) CONCLUSION: PB is a reliable and safe alternative to GA for patients undergoing mechanical vitrectomy, permitting good anaesthesia and akinesia conditions during surgery, better haemodynamic stability, and less postoperative complications, especially in older patients and those with more comorbidities.

Analyzing and Designing Cell Factories with OptFlux

OptFlux was launched in 2010 as the first open-source and user-friendly platform containing all the major methods for performing metabolic engineering tasks in silico. Main features included the possibility of performing microbial strain simulations with widely used methods such as Flux Balance Analysis and strain design using Evolutionary Algorithms. Since then, OptFlux suffered a major re-factoring to improve its efficiency and reliability, while many features were added in the form of novel plug-ins, such as the BioVisualizer and the over/under expression plug-ins. The current chapter described the main mathematical formulations of the major methods implemented within OptFlux, also providing a detailed guide on the usage of those functionalities.