Iron (hydr)oxide formation in Andosols under extreme climate conditions

Redox-driven biogeochemical cycling of iron plays an integral role in the complex process network of ecosystems, such as carbon cycling, the fate of nutrients and greenhouse gas emissions. We investigate Fe-(hydr)oxide (trans)formation pathways from rhyolitic tephra in acidic topsoils of South Patagonian Andosols to evaluate the ecological relevance of terrestrial iron cycling for this sensitive fjord ecosystem. Using bulk geochemical analyses combined with micrometer-scale-measurements on individual soil aggregates and tephra pumice, we document biotic and abiotic pathways of Fe released from the glassy tephra matrix and titanomagnetite phenocrysts. During successive redox cycles that are controlled by frequent hydrological perturbations under hyper-humid climate, (trans)formations of ferrihydrite-organic matter coprecipitates, maghemite and hematite are closely linked to tephra weathering and organic matter turnover. These Fe-(hydr)oxides nucleate after glass dissolution and complexation with organic ligands, through maghemitization or dissolution-(re)crystallization processes from metastable precursors. Ultimately, hematite represents the most thermodynamically stable Fe-(hydr)oxide formed under these conditions and physically accumulates at redox interfaces, whereas the ferrihydrite coprecipitates represent a so far underappreciated terrestrial source of bio-available iron for fjord bioproductivity. The insights into Fe-(hydr)oxide (trans)formation in Andosols have implications for a better understanding of biogeochemical cycling of iron in this unique Patagonian fjord ecosystem.

Redo Transcatheter Aortic Valve Implantation with the ALLEGRA Transcatheter Heart Valve: Insights from Bench Testing

PURPOSE

Failure of transcatheter heart valves (THV) may potentially be treated with repeat transcatheter aortic valve implantation (redo TAVI). We assessed hydrodynamic performance, stability and pinwheeling utilizing the ALLEGRA (New Valve Technology, Hechingen, Germany) THV, a CE approved and marketed THV in Europe, inside different THVs.

METHODS

Redo TAVI was simulated with the 27 mm ALLEGRA THV at three implantation depths (-4 mm, 0 mm and +4 mm) in seven different 'failed' THVs: 26 mm Evolut Pro, 25 mm Lotus, 25 mm JenaValve, 25 mm Portico, 23 mm Sapien 3, 27 mm ALLEGRA and M ACURATE neo. Hydrodynamic evaluation was performed according to International Standards Organization 5840-3:2021.

RESULTS

The ALLEGRA THV was stable with acceptable performance (gradient <20 mmHg, effective orifice area >2 cm², and regurgitant fraction <20%) in all 'failed' THVs except the Evolut Pro at -4 mm implantation depth. In this configuration, the outflow of the ALLEGRA frame was constrained by the Evolut Pro THV and the ALLEGRA leaflets were unable to fully close. Pinwheeling was severe for the ALLEGRA in Evolut Pro. The neo-skirt was higher with taller frame THVs.

CONCLUSION

The ALLEGRA THV had favorable hydrodynamic performance, stability and pinwheeling in all redo TAVI samples except the Evolut Pro at low implantation depth with compromised function. The choice of initial THV may have late implications on new THV choice and function.

Panic Disorder Severity Scale self-report: transcultural validation and sensitivity to change of the French-Canadian adaptation

Introduction

The self-report version of the Panic Disorder Severity Scale (PDSS-SR) is a reliable and valid instrument to assess panic disorder, but is unavailable in French.

Objectives

The aim of this study was to conduct a transcultural validation of the French-Canadian PDSS-SR and examine its psychometric properties.

Methods

This study is part of a pragmatic RCT of group transdiagnostic CBT for anxiety disorders, and includes 272 adults meeting DSM-5 panic disorder diagnostic criteria. At baseline, participants completed the Anxiety and Related Disorders Interview Schedule (ADIS-5), the French-Canadian PDSS-SR and self-report measures. Convergent validity was assessed with Spearman correlations, Cronbach’s α was used to analyse internal consistency, and confirmatory factor analysis (CFA) evaluated its factor structure. Sensitivity to change was assessed with paired sample t-tests in patients (n = 72) meeting DSM-5 criteria for panic disorder at baseline with posttreatment data.

Results

108 patients met DSM-5 criteria for panic disorder, including 58 with agoraphobia. The majority were women (85.3%) and mean age was 37.1 (SD = 12.4). Internal consistency (Cronbach’s α) was 0.91. For convergent validity, the highest correlation was with the Beck Anxiety Inventory (r = 0.64). CFA suggested a two-factor model. Optimal threshold for probable diagnosis was 10. Analyses support sensitivity to change when comparing transdiagnostic group CBT and control conditions.

Conclusions

With its good psychometric properties in primary care patients, the French-Canadian self-report version of the Panic Disorder Severity Scale is an efficient and practical instrument for both clinicians and researchers working in the field of mental health.

Disclosure

No significant relationships.

Neosinus and Sinus Flow After Self-Expanding and Balloon-Expandable Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to evaluate flow dynamics in the aortic sinus and the neosinus (NS) after transcatheter heart valve (THV) implantation in valve-in-valve (ViV).

BACKGROUND

Leaflet thrombosis may occur on THVs and affect performance and durability. Differences in flow dynamics may affect the risk for leaflet thrombosis.

METHODS

Hemodynamic assessment following THV implantation in a surgical aortic valve was performed in a left heart simulator under pulsatile physiological conditions. Assessment was performed using a 23-mm polymeric surgical aortic valve (not diseased) and multiple THV platforms, including self-expanding devices (26-mm Evolut, 23-mm Allegra, small ACURATE neo) and a balloon-expandable device (23-mm SAPIEN 3). Particle image velocimetry was performed to assess flow in the sinus and NS. Sinus and NS washout, shear stress, and velocity were calculated.

RESULTS

Sinus and NS washout was fastest and approximately 1 cardiac cycle for each with the Evolut, ACURATE neo, and Allegra compared with the SAPIEN 3, with washout in 2 and 3 cardiac cycles, respectively. The Allegra showed the largest shear stress distribution in the sinus, followed by the SAPIEN 3. In the NS, all 4 valves showed equal likelihoods of occurrence of shear stress <1 Pa, but the Allegra showed the highest likelihoods of occurrence for shear stress >1 Pa. The velocities in the sinus and NS were 0.05, 0.078, 0.080, and 0.075 m/s for Evolut, SAPIEN 3, ACURATE neo, and Allegra ViV, respectively.

CONCLUSIONS

Sinus and NS flow dynamics differ substantially among THVs after ViV. Self-expanding supra-annular valves seem to have faster washouts compared with an equivalent-size balloon-expandable THV.

Transapical transcatheter mitral valve implantation in patients with degenerated mitral bioprostheses or failed ring annuloplasty

Background

We sought to evaluate the outcomes of transapical transcatheter mitral valve replacement in patients with degenerated mitral bioprostheses or failed mitral ring annuloplasty and high surgical risk for redo mitral valve procedure.

Methods

Between August 2012 and December 2020, 41 consecutive high-risk patients underwent transcatheter mitral 'valve-in-valve' (TM-ViV, n=25) or 'valve-in-ring' (TM-ViR, n=16) implantation at our institution. All procedures were performed in a hybrid operating theater using the SAPIEN XT/3™ or the DIRECT FLOW MEDICAL™ prostheses. Data was collected prospectively according to MVARC criteria.

Results

The logistic EuroSCORE-I was 42.3%±20.5% (mean ± SD), the Society of Thoracic Surgeons (STS) score was 11.9%±10.8%, and the STS/ACC-score was 7.6%±4.2%. Transcatheter mitral valve implantations were successful in all patients (100%). Early echocardiographic examinations showed no obstruction of the left ventricular outflow tract (LVOT), no paravalvular leakage, and only trace transvalvular leakage in eight patients. There was no operative mortality; thirty-day mortality was 9.8%. Survival was 72% at one year and 63% at three years. At two-year follow-up, transvalvular mean pressure gradients were 4.6±1.4 mmHg.

Conclusions

Transapical transcatheter mitral valve-in-valve or valve-in-ring implantation represents a true minimally invasive alternative to surgical redo procedures, especially in high-risk patients with failed bioprosthetic mitral valves or annuloplasty and favorable anatomy.

Mitral surgical redo versus transapical transcatheter mitral valve implantation

Background

Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty.

Methods and material

Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria.

Results

The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups.

Conclusion

Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

Expanding Monomers as Anti-Shrinkage Additives

Commonly, volumetric shrinkage occurs during polymerizations due to the shortening of the equilibrium Van der Waals distance of two molecules to the length of a (significantly shorter) covalent bond. This volumetric shrinkage can have severe influence on the materials’ properties. One strategy to overcome this volumetric shrinkage is the use of expanding monomers that show volumetric expansion during polymerization reactions. Such monomers exhibit cyclic or even oligocyclic structural motifs with a correspondingly dense atomic packing. During the ring-opening reaction of such monomers, linear structures with atomic packing of lower density are formed, which results in volumetric expansion or at least reduced volumetric shrinkage. This review provides a concise overview of expanding monomers with a focus on the elucidation of structure-property relationships. Preceded by a brief introduction of measuring techniques for the quantification of volumetric changes, the most prominent classes of expanding monomers will be presented and discussed, namely cycloalkanes and cycloalkenes, oxacycles, benzoxazines, as well as thiocyclic compounds. Spiroorthoesters, spiroorthocarbonates, cyclic carbonates, and benzoxazines are particularly highlighted.

A wearable EIT system for detection of muscular activity in the extremities

Electrical Impedance Tomography (EIT) is a method for measuring physiological states and processes that can be used as an imaging method for muscular activities. In addition to the medical evaluation of the EIT data of the lung, this technology can be used to make a statement about muscular activity in the extremities. This paper presents a developed, mobile EIT system that can be used with an electrode bracelet on the arm. In a rst study, the EIT data for different hand gestures were evaluated.

Universal School-Based Intervention Does Not Reduce Socioeconomic Inequalities in Weight Status among Adolescents

Background: Differences in weight status by socioeconomic position occur during adolescence and is known as weight social gradient (WSG). The PRALIMAP (Promotion de l'ALIMentation et de l'Activité Physique) trial highlighted that a universal intervention was effective in reducing overweight and obesity prevalence among adolescents. However, its ability to reduce the WSG is unclear. This study aimed to evaluate the impact of the PRALIMAP intervention on the WSG among adolescents. Methods: Data were obtained from 3504 adolescents who participated in the school-based PRALIMAP trial between 2006 and 2009. The PRALIMAP study consisted of three interventional strategies: educational, environmental, screening and care. Weight status was assessed by body mass index (BMI) z-score and overweight and obesity prevalence. The "indice de position sociale des élèves" was used to measure adolescents' socioeconomic status. Linear regression and hierarchical models were used to assess the WSG and its evolution, respectively. Results: Among all adolescents (14-18 years old), significant WSG was identified at baseline: BMI z-score (β = -0.06; p < 0.0001), overweight and obesity prevalence (β = -2.86; p < 0.0001). Overall, the intervention conferred no significant reduction in the WSG: BMI z-score (β = -0.01 [-0.02 to 0.01], p = 0.48), overweight and obesity prevalence (β = -0.01 [-0.07 to 0.05], p = 0.73). Similar results were observed for adolescents whatever the interventional strategy they benefited from in the PRALIMAP trial. Conclusions: This study provided no evidence that the PRALIMAP universal intervention was effective in reducing the socioeconomic inequalities in weight status among adolescents. Different interventions that account for social differences should be considered to tackle these inequalities.

[Guideline "Legal evaluation after closed brain injury in adulthood"]

In 2005 and 2013, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Evaluation) together with other societies developed and consented guidelines fort the legal evaluation of patients with closed head injuries and published them trough the National Working Group of Scientific Medical Societies and in this journal. Five years later, a revision was necessary, this was developed on the higher S2 k level of consent through a Delphi conference.

Heat Dissipation in Epoxy/Amine-Based Gradient Composites with Alumina Particles: A Critical Evaluation of Thermal Conductivity Measurements

For the design of the next generation of microelectronic packages, thermal management is one of the key aspects and must be met by the development of polymers with enhanced thermal conductivity. While all polymer classes show a very low thermal conductivity, this shortcoming can be compensated for by the addition of fillers, yielding polymer-based composite materials with high thermal conductivity. The inorganic fillers, however, are often available only in submicron- and micron-scaled dimensions and, consequently, can sediment during the curing reaction of the polymer matrix. In this study, an epoxy/amine resin was filled with nano- and submicron-scaled alumina particles, yielding a gradient composite. It was found that the thermal conductivity according to laser flash analysis of a sliced specimen ranged from 0.25 to 0.45 W·m-1·K-1 at room temperature. If the thermal conductivity of an uncut specimen was measured with a guarded heat flow meter, the 'averaged' thermal conductivity was measured to be only 0.25 W·m-1·K-1. Finite element analysis revealed that the heat dissipation through a gradient composite was of intermediate speed in comparison with homogeneous composites exhibiting a non-gradient thermal conductivity of 0.25 and 0.45 W·m-1·K-1.

Transit time flow measurement and high frequency ultrasound epicardial imaging to guide coronary artery bypass surgery

BACKGROUND

Transit-time flow measurement (TTFM) should be routinely used in CABG surgery to verify graft function. Most recently, a 2D high-frequency-ultrasound (HF-US) epicardial imaging probe has been released (MiraQ™, Medistim, Oslo, Norway), which allows to evaluate the cannulation/clamping site of the aorta morphologically and to evaluate the completed anastomosis. We aimed to evaluate the use of TTFM and HF-US on surgical strategy during CABG surgery.

METHODS

A total of 65 consecutive patients undergoing CABG surgery were evaluated. The target vessels, the clamping/cannulation site and the anastomosis were evaluated by HF-US. TTFM was performed on all grafts and the mean flow (mL/min) and pulsatility indices (PI) were recorded. Troponin-I levels (ng/L) were obtained within the first 4 postoperative days.

RESULTS

A total of 3.3±0.9 grafts were performed, with 98.5% LIMA use and a sequential graft was performed in 55.4%. The mean PI and flow (mL/min) were 2.3±2.7 and 70.8±50.6 for the right coronary artery system, 2.4±2.2 and 82.0±47.6 for the circumflex system, and 2.1±1.2 and 78.0±35.0 for the LAD system, respectively. Postoperative troponin-I levels showed a maximum on postoperative day 1. A surgical strategy change, based on imaging, was done in 15%. Moreover, we observed a correlation of PI and flow with maximum postoperative troponin-I levels.

CONCLUSIONS

The present study evaluated the combination of TTFM and HF-US in CABG surgery. Epicardial scanning was helpful to evaluate the potential opening site of the vessel, to evaluate the completed anastomosis or to evaluate the clamping or cannulation site. Troponin-I levels were directly correlated to mean graft flow and PI levels.

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

Background

Transcatheter aortic valve implantation (TAVI) is the standard therapy for high-risk patients with aortic stenosis (AS). TAVI-outcomes are widely investigated in comparison to surgical aortic valve replacement (SAVR), but less is known about infectious complications after TAVI. We aimed to compare early and mid-term infectious outcomes of patients undergoing TAVI or SAVR.

Methods

The present study is a prospective single-centre study including 200 consecutive patients between 06/2014-03/2015 undergoing TAVI (either transfemoral or transapical and transaortic, n=47+53=100) or SAVR (either isolated or concomitant with CABG, n=52+48=100). The mean age and log. EuroSCORE were significantly different between both groups (81±6 versus 69±11 years, P<0.001 and 23.1%±13.8% versus 8.7%±9.5%, P<0.001). Primary endpoints included wound healing disorders, respiratory and urinary tract infections and incidence of endocarditis or sepsis within hospital stay. Secondary endpoints included infectious parameters, infectious related rehospitalisation and 2-year mortality.

Results

Primary endpoints showed no difference in overall TAVI- versus SAVR-groups regarding respiratory- (14% versus 19%, P=0.45), urinary-tract (7% versus 4%, P=0.54) infections, sepsis (5% versus 6%, P=1.0), endocarditis (0% versus 1%, P=1.0) or 30-day mortality (10% versus 4%, P=0.09), except for wound disorders, which were significantly lower in the TAVI-group (1% versus 8%, P=0.035), respectively. Secondary endpoints reported no difference regarding infectious related rehospitalisation (4% versus 4%, P=1.0), but significantly higher 2-year mortality (28% versus 16%, P=0.048) in the TAVI-group.

Conclusions

So far, little has been studied about infectious complications after TAVI. This study reports no difference between the overall TAVI and SAVR groups regarding infectious complications. However, SAVR group show more wound healing disorders but less mortality than TAVI group.

Enhancement of the Insulation Properties of Poly(2-oxazoline)-co-Polyester Networks by the Addition of Nanofillers

Copoly(2-nonyl-2-oxazoline)-stat-poly(2-dec-9'enyl-2-oxazoline)s can be crosslinked by the thiol-ene reaction with glycol dimercaptoacetate. The copoly(2-oxazoline)-stat-copolyester is tested as dielectric for high-voltage applications, either as unfilled resin or as composite with nanoscaled fillers of silica, alumina, and hexagonal boron nitride. During AC voltage tests, all materials have an average breakdown strength of 45-50 kV mm^-1 . For DC voltage tests, samples with SiO₂ (hBN) have an average breakdown strength of ≈100 (80) kV mm^-1 , while the unfilled copoly(2-oxazoline) has an average breakdown strength of ≈60 kV mm^-1 . Permittivity measurements at 20 °C and 50 Hz reveal that all nanocomposites are dielectrics (D = 0.06-0.08), while the unfilled copoly(2-oxazoline)s has a high loss factor of D = 8.43. This phenomenon can be retraced to the phase separation in the crosslinked copolymer, the M-OH functionality of silica and alumina particles, and models of polymer-particle interactions such as the Tanaka model, revealing that the nanofillers reduce the interfacial and dipolar polarizability.

Effect of Interfacial Polarization and Water Absorption on the Dielectric Properties of Epoxy-Nanocomposites

Five types of nanofillers, namely, silica, surface-silylated silica, alumina, surface-silylated alumina, and boron nitride, were tested in this study. Nanocomposites composed of an epoxy/amine resin and one of the five types of nanoparticles were tested as dielectrics with a focus on (i) the surface functionalization of the nanoparticles and (ii) the water absorption by the materials. The dispersability of the nanoparticles in the resin correlated with the composition (OH content) of their surfaces. The interfacial polarization of the thoroughly dried samples was found to increase at lowered frequencies and increased temperatures. The β relaxation, unlike the interfacial polarization, was not significantly increased at elevated temperatures (below the glass-transition temperature). Upon the absorption of water under ambient conditions, the interfacial polarization increased significantly, and the insulating properties decreased or even deteriorated. This effect was most pronounced in the nanocomposite containing silica, and occurred as well in the nanocomposites containing silylated silica or non-functionalized alumina. The alternating current (AC) breakdown strength of all specimens was in the range of 30 to 35 kV·mm-1. In direct current (DC) breakdown tests, the epoxy resin exhibited the lowest strength of 110 kV·mm-1; the nanocomposite containing surface-silylated alumina had a strength of 170 kV·mm-1. In summary, water absorption had the most relevant impact on the dielectric properties of nanocomposites containing nanoparticles, the surfaces of which interacted with the water molecules. Nanocomposites containing silylated alumina particles or boron nitride showed the best dielectric properties in this study.

Lessons from the canine Oxtr gene: populations, variants and functional aspects

Oxytocin receptor (OXTR) acts as a key behavioral modulator of the central nervous system, affecting social behavior, stress, affiliation and cognitive functions. Variants of the Oxtr gene are known to influence behavior both in animals and humans; however, canine Oxtr polymorphisms are less characterized in terms of possible relevance to function, selection criteria in breeding and domestication. In this report, we provide a detailed characterization of common variants of the canine Oxtr gene. In particular (1) novel polymorphisms were identified by direct sequencing of wolf and dog samples, (2) allelic distributions and pairwise linkage disequilibrium patterns of several canine populations were compared, (3) neighbor joining (NJ) tree based on common single nucleotide polymorphisms (SNPs) was constructed, (4) mRNA expression features were assessed, (5) a novel splice variant was detected and (6) in vitro functional assays were performed. Results indicate marked differences regarding Oxtr variations between purebred dogs of different breeds, free-ranging dog populations, wolf subspecies and golden jackals. This, together with existence of explicitly dog-specific alleles and data obtained from the NJ tree implies that Oxtr could indeed have been a target gene during domestication and selection for human preferred aspects of temperament and social behavior. This assumption is further supported by the present observations on gene expression patterns within the brain and luciferase reporter experiments, providing a molecular level link between certain canine Oxtr polymorphisms and differences in nervous system function and behavior.

The investigation of systolic and diastolic leaflet kinematics of bioprostheses with a new in-vitro test method

OBJECTIVES

We aimed to investigate leaflet kinematics of bioprostheses with a novel high-speed imaging method.

MATERIAL AND METHODS

High-speed-imaging (1000 Hz) was used to evaluate leaflet kinematics of the Carpentier-Edwards Perimount Magna (PM) and Magna Ease (PME) aortic bioprostheses. Both prostheses (diameter 23 mm) were placed inside a model aorta under pulsatile flow conditions. Frequencies (F) and different stroke volumes (S) were simulated. Maximum aortic valve area (AVA), total ejection time (TET), rapid valve opening time (RVOT) and rapid valve closing time (RVCT) as well as opening (OS) and closing (CS) speeds were evaluated.

RESULTS

Both bioprostheses showed different results dependent on flow conditions. The test setup was capable of identifying small AVA-differences between both valves (235 vs. 202 mm², F60/S60; 272 vs. 207 mm²; F70/S80), as well as differences in OS and CS (2.36 vs. 1.62 mm²/ms; 2.97 vs. 2.44 mm²/ms, F80/S60). TET was comparable (638 vs. 645 ms F60/S60; 341 vs. 343 ms, F90/S60), while results for RVOT and RVCT were equal, and dependent on frequency and stroke volume.

CONCLUSIONS

The novel evaluation method is sensitive to detect differences between valves, although differences were found to be small. PM has a larger visible AVA associated with higher opening and closing speeds in contrast to PME.

[Driving ability with cerebral perfusion disorders]

In Germany expert testimony on driving ability requires knowledge of the corresponding legislation, the guidelines for expertises on driver aptitude and a qualification in traffic medicine. The testimony should clearly identify handicaps with regard to driving, give estimates on the risks of a sudden loss of the driving capability by stroke recurrence or epileptic seizures, and also consider personal attitudes, such as inadequate behaviour and lack of insight. Physical handicaps can often be compensated for by restraints, such as vehicle modifications and restrictions, such as daylight driving only.The testimony must also give estimates on the risks of a sudden loss of the driving capability by stroke recurrence or epileptic seizures. Two models are proposed by which an estimate of harmful traffic accidents due to stroke recurrence can be made.

[The German guideline "legal evaluation after closed head injury"]

In 2005, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Legal Evaluation) together with other Societies published a guideline for the legal evaluation of patients with closed head injuries. Meanwhile, not only scientific progress in imaging techniques but also in other fields such as neuropsychology has necessitated a revision, which is presented here. In the mean time, the handling of guidelines has been systematised in Germany so that a registration with the Cooperation of German Medical Learned Societies is applied for and publication in the German Guideline Registry is expected.

Recombinant varicella vaccines induce neutralizing antibodies and cellular immune responses to SIV and reduce viral loads in immunized rhesus macaques

The development of an effective AIDS vaccine remains one of the highest priorities in HIV research. The live, attenuated varicella-zoster virus (VZV) Oka vaccine, safe and effective for prevention of chickenpox and zoster, also has potential as a recombinant vaccine against other pathogens, including human immunodeficiency virus (HIV). The simian varicella model, utilizing simian varicella virus (SVV), offers an approach to evaluate recombinant varicella vaccine candidates. Recombinant SVV (rSVV) vaccine viruses expressing simian immunodeficiency virus (SIV) env and gag antigens were constructed. The hypothesis tested was that a live, attenuated rSVV-SIV vaccine will induce immune responses against SIV in the rhesus macaques and provide protection against SIV challenge. The results demonstrated that rSVV-SIV vaccination induced low levels of neutralizing antibodies and cellular immune responses to SIV in immunized rhesus macaques and significantly reduced viral loads following intravenous challenge with pathogenic SIVmac251-CX-1.

Control of downy mildew (Pseudoperonospora cubensis) of greenhouse grown cucumbers with alternative biological agents

In organic cucumber production infection with downy mildew (Pseudoperonospora cubensis) is a major problem. Plant extracts from Glycyrrhiza glabra L. (licorice), a plant belonging to the family Fabaceae, and Salvia officinalis (sage) as well as cultures of the bacterium Aneurinibacillus migulanus were investigated for efficacy of disease control under commercial growing conditions. Contrary to bioassays, where sage extract and the microorganism showed highest activity, in the trials of 2008 G. glabra extract was more effective than sage extract or A. migulanus against P. cubensis. Parameters such as concentrations of the preparations or application intervals could have been the reason for this. In the following year's trial (2009) the concentration of these agents was therefore increased somewhat and plants were either treated in seven day application intervals or in ten day application intervals. In the semi-commercial trials of 2009 all alternative biological agents showed good efficacies up to around 80% against infection with downy mildew. The application interval seemed to have a marginal effect only. Again, the licorice extract tended to be the best agent.

[Manipulative treatment of the cervical spine and stroke]

Manipulative therapy of the cervical spine is associated with a considerable risk of stroke. We evaluated all cases with the diagnosis of arterial dissection submitted between 1996 and 2005 to the Schlichtungsstelle für Arzthaftpflichtfragen der Norddeutschen Arztekammern for assessment of the accusations brought against the therapists who conducted the manipulation. Neither in the 7 carotid nor in the 9 vertebral artery cases could a causal link be made between the dissection and the manipulation. However, in 5 of the 7 carotid and 7 of the 9 vertebral artery dissections there was clear evidence or high probability that the dissection was present prior to the manipulation, and had caused neck pain, segmental dysfunction and, in some cases, even neurological symptoms. Stroke after manipulative therapy was due to embolisation of thrombotic material from the dissected artery. As both cervical arterial dissection and cervical spine disorder usually cause similar signs and symptoms physicians must differentiate between these two entities prior to any manipulative therapy. Clinical indicators of pre-existent dissection and the medicolegal implications are discussed in this paper.

Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are used to prevent ischaemic stroke in patients with stenosis of the internal carotid artery. Better knowledge of risk factors could improve assignment of patients to these procedures and reduce overall risk. We aimed to assess the risk of stroke or death associated with CEA and CAS in patients with different risk factors.

METHODS

We analysed data from 1196 patients randomised to CAS or CEA in the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial. The primary outcome event was death or ipsilateral stroke (ischaemic or haemorrhagic) with symptoms that lasted more than 24 h between randomisation and 30 days after therapy. Six predefined variables were assessed as potential risk factors for this outcome: age, sex, type of qualifying event, side of intervention, degree of stenosis, and presence of high-grade contralateral stenosis or occlusion. The SPACE trial is registered at Current Controlled Trials, with the international standard randomised controlled trial number ISRCTN57874028.

FINDINGS

Risk of ipsilateral stroke or death increased significantly with age in the CAS group (p=0.001) but not in the CEA group (p=0.534). Classification and regression tree analysis showed that the age that gave the greatest separation between high-risk and low-risk populations who had CAS was 68 years: the rate of primary outcome events was 2.7% (8/293) in patients who were 68 years old or younger and 10.8% (34/314) in older patients. Other variables did not differ between the CEA and CAS groups.

INTERPRETATION

Of the predefined covariates, only age was significantly associated with the risk of stroke and death. The lower risk after CAS versus CEA in patients up to 68 years of age was not detectable in older patients. This finding should be interpreted with caution because of the drawbacks of post-hoc analyses.

30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial

BACKGROUND

Carotid endarterectomy is effective in stroke prevention for patients with severe symptomatic carotid-artery stenosis, and carotid-artery stenting has been widely used as alternative treatment. Since equivalence or superiority has not been convincingly shown for either treatment, we aimed to compare the two.

METHODS

1200 patients with symptomatic carotid-artery stenosis were randomly assigned within 180 days of transient ischaemic attack or moderate stroke (modified Rankin scale score of < or =3) carotid-artery stenting (n=605) or carotid endarterectomy (n=595). The primary endpoint of this hospital-based study was ipsilateral ischaemic stroke or death from time of randomisation to 30 days after the procedure. The non-inferiority margin was defined as less than 2.5% on the basis of an expected event rate of 5%. Analyses were on an intention-to-treat basis. This trial is registered at Current Controlled Trials with the international standard randomised controlled trial number ISRCTN57874028.

FINDINGS

1183 patients were included in the analysis. The rate of death or ipsilateral ischaemic stroke from randomisation to 30 days after the procedure was 6.84% with carotid-artery stenting and 6.34% with carotid endarterectomy (absolute difference 0.51%, 90% CI -1.89% to 2.91%). The one-sided p value for non-inferiority is 0.09.

INTERPRETATION

SPACE failed to prove non-inferiority of carotid-artery stenting compared with carotid endarterectomy for the periprocedural complication rate. The results of this trial do not justify the widespread use in the short-term of carotid-artery stenting for treatment of carotid-artery stenoses. Results at 6-24 months are awaited.

[Jejunal perforation by a fish bone diagnosed by CT-Scan: report of two cases]

The authors relate two cases of peritonitis secondary to jejunal perforation by a fish bone. Clinically, the first patient presented signs and symptoms of acute diverticulitis and the second had signs of duodenal perforation. In both cases, the diagnosis was made by the CT-scan revealing a linear radio-opaque object suggestive of a fish bone perforating the jejunum. At laparotomy of the first case, we found a perforation located above several loops of small bowel densely adhered to the nonabsorbable intra-abdominal mesh. Removal of the fish bone, suture of the jejunal perforation, washing and drainage of the abdominal cavity were performed. The mesh was removed and replaced by a polyglycolic acid mesh. In the second case, jejunal perforation occurred in an unaltered small bowel loop and a short intestinal resection was performed. The postoperative course was uneventful for both patients. These clinical cases allow us to discuss the several fish bone perforation site and our patients precipitating factors.

Neuroleptic malignant syndrome in a patient with succinic semialdehyde dehydrogenase deficiency

A patient suffering from a rare enzyme deficiency developed a malignant neuroleptic syndrome after having been treated with one single dose of haloperidol. We investigated the patient's serum for all frequent polymorphisms in cytochrome P450 2D6, assuming him to be a poor neuroleptic metabolizer. We will also discuss other potential mechanisms inducing this disturbance and its differential diagnoses.

Peripheral hemodialysis shunt with intracranial venous congestion

BACKGROUND

Intracranial venous congestion is often caused by local venous thrombosis or brain arteriovenous fistulas. Hemodialysis shunts are known to cause venous enlargement in the arm or chest but have not been related to intracranial vascular pathology. Case Description- A 59-year-old woman who presented with increasing headache, gait instability, and memory loss was a renal transplant recipient who still carried a left upper arm shunt. Cranial CT scan showed enlarged veins in the posterior fossa with incipient hydrocephalus. Extracranial duplex sonography revealed reversed flow in the left internal jugular vein, which normalized on cuff inflation around the shunt-carrying arm. The reversed flow, intracranial venous congestion, and neurological status improved after surgical shunt ligation.

CONCLUSIONS

To our knowledge, this is the first case description of an intracranial venous outflow obstruction caused by a peripheral arteriovenous shunt.

Compliance with secondary prevention of ischemic stroke: a prospective evaluation

BACKGROUND AND PURPOSE

Compliance with pharmacological therapy is essential for the efficiency of secondary prevention of ischemic stroke. Few data exist regarding patient compliance with antithrombotic and risk factor treatment outside of controlled clinical trials. The aim of the present study was to assess the rate of and predictors for compliance with secondary stroke prevention 1 year after cerebral ischemia and to identify reasons for noncompliance.

METHODS

Patients with a diagnosis of ischemic stroke or TIA and antithrombotic discharge medication were prospectively recruited. At 1 year, the proportion of patients compliant with antithrombotic treatment and with medication for risk factors (eg, hypertension, diabetes, hyperlipidemia) was evaluated through structured telephone interviews. In addition, the reasons for nontreatment with antithrombotic and risk factor medication were determined. Independent predictors for compliance were analyzed by logistic regression analyses.

RESULTS

Of 588 consecutive patients admitted to our stroke unit, 470 had a discharge diagnosis of cerebral ischemia (TIA 26.2%, cerebral infarct 73.8%) and recommendations for antithrombotic therapy. At 1 year, 63 patients (13.4%) had died and 21 (4.5%) were lost to follow-up, thus, 386 could finally be evaluated. Of the patients, 87.6% were still on antithrombotic medication, and 70.2% were treated with the same agent prescribed on discharge. Of the patients with hypertension, diabetes, and hyperlipidemia, 90.8%, 84.9%, and 70.2% were still treated for their respective risk factors. Logistic regression analyses revealed age (OR 1.03, 95% CI 1.00 to 1.06), stroke severity on admission (OR 1.09, 95% CI 1.00 to 1.20), and cardioembolic cause (OR 4.13, 95% CI 1.23 to 13.83) as independent predictors of compliance.

CONCLUSIONS

Compliance with secondary prevention in patients with ischemic stroke is rather good in the setting of our study. Higher age, a more severe neurological deficit on admission, and cardioembolic stroke cause are associated with better long-term compliance. Knowledge of these determinants may help to further improve the quality of stroke prevention.