Identification of risk factors for postoperative delirium in patients following intraoral reconstruction with microvascular free flaps: a matched-pair analysis

Postoperative delirium (POD) following microvascular head and neck reconstruction negatively impacts patient outcomes, and only a few risk factors have been identified. The aim of this study was to identify additional risk factors for POD after intraoral reconstruction with microvascular free flaps. Data from 377 patients who underwent intraoral microvascular free flap reconstruction between 2011 and 2019 were analysed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between 40 patients with POD and 40 patients without POD who were matched for previously identified risk factors (i.e., sex, age, American Society of Anesthesiologists class, preoperative arterial hypertension, tracheotomy, operation time, and blood transfusion). A multivariable regression analysis was then performed to identify risk factors associated with POD. POD occurred in 50 (13.3%) of the 377 cases studied; the median time of onset was postoperative day 2. Excessive preoperative alcohol consumption (odds ratio 9.22, 95% confidence interval 1.09-77.97; P = 0.041) and postoperative transplant revision (odds ratio 25.72, 95% confidence interval 1.26-525.43; P = 0.035) were identified as risk factors for POD. The identification of patients at high risk of POD based on these two risk factors may allow early adjustment of diagnostic and therapeutic modalities to improve outcomes and reduce healthcare costs.

Performance of commercial growing-finishing pigs fed supplemental isoquinoline alkaloids: a statistical process control analysis

BACKGROUND

Statistical Process Control (SPC) is a powerful statistical tool that can be used in animal production to evaluate the evolution of production parameters overtime in response to the implementation of a specific strategy. The aim of this study was to evaluate the effect of supplementing growing-finishing pigs with isoquinoline alkaloids (IQ) on growth performance parameters by using the SPC method. IQ are natural secondary plant metabolites which have been extensively investigated in food animals due to their efficacy in supporting growth performance and the overall health status. Performance parameters and medication usage were collected from 1,283,880 growing-finishing pigs fed the same basal diet, 147,727 of which were supplemented with IQ from day 70 of life until slaughter.

RESULTS

Supplementation with IQ improved feed conversion ratio, while feed intake and daily gain were maintained.

CONCLUSION

SPC methods are useful statistical tools to evaluate the effect of using a new feed additive in the feed of pigs on growth performance at a commercial level. Additionally, IQ supplementation improved growth performance and it can be considered as a good strategy to reduce feed conversion in growing-finishing pigs.

A59 GLOBAL PROTEOMIC PROFILING OF HUMAN COLONOID MONOLAYERS UNDERGOING IN VITRO CHRONIC DAMAGE

Background

An in vitro damage model has been established in our lab using human colonoids grown as 2D monolayers. Upon being subjected to repeated rounds of air-liquid interface (ALI) growth and injury by submergence, these colonoid monolayers lost their barrier integrity and regrowth potential. Changes in mRNA expression and DNA methylation in genes from this human model of injury were similar to those that occur in Inflammatory Bowel Disease (IBD) and colon cancer. Significant morphological changes were observed in these monolayers after they were subjected to subsequent rounds of submergence injury, compared to when they were differentiated in ALI.

Purpose

Submergence injury is predicted to be involved in unfolded protein response (UPR) activation which can specifically alter translation. Hence proteomics studies will help undertand these changes.

Method

To determine if these changes are mirrored in the proteomes of damaged colonoids, we employed a Single-Plot, Solid-Phase-enhanced Sample Preparation (SP3) technology for Mass Spectrometry (MS) based proteomics analysis to characterize these monolayers at baseline, once they were differentiated in ALI, after one and five rounds of injury after differentiation in ALI, and after stimulation with the Toll-like receptor 5 (TLR5) agonist FliC. Hierarchical clustering, enrichment analysis, volcano plot analysis after pre-processing and normalization of the proteomics data set revealed differentially expressed proteins across various groups of monolayers.

Result(s)

Preliminary proteomic data analysis revealed changes in the profile of proteins involved in cellular differentiation, mitochondrial proteins, hypoxia upregulated proteins, those responsible for the maintenance and reorganization of the cytoskeletal structure and Golgi structure. These changes in protein profile may account for the significant morphological changes observed in these monolayers when subjected to submergence injury. Some outliers in monolayers subjected to microbial stimulation included proteins involved in regulation of extracellular matrix dependent motility and components of Adaptor Protein Complexes. Further studies are needed to ascertain if these account for the protective effect of FliC on these monolayers.

Conclusion(s)

This study suggests that the submergence injury to these healthy human derived colonoid monolayers leads to changes in their protein profile which mirror those seen in case of acute and chronic inflammation like IBD and colon cancer. It corroborates with the findings of gene expression and epigenetic analyses using the in vitro model established in our lab.

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CCC

Disclosure of Interest

None Declared

A36 INVESTIGATING TYPE 1 REGULATORY T CELLS AS A THERAPY FOR INFLAMMATORY BOWEL DISEASE USING A MOUSE MODEL OF ACUTE INTESTINAL EPITHELIAL DAMAGE

Background

Inflammatory bowel disease (IBD) affects an estimated 270,000 people in Canada and is rapidly increasing in prevalence. All patients have relapsing disease, and a subset of individuals do not respond to current treatments. Further, there are no approved treatment options in Canada that reverse IBD-induced intestinal fibrosis. We have previously shown type 1 regulatory cells (Tr1s) are capable of suppressing inflammatory macrophages, promote barrier function of human intestinal epithelial cells, and induce differentiation of mucin-producing goblet cells. We hypothesize that Tr1 cells can prevent inflammatory damage and fibrosis in an mouse model of acute gut damage.

Purpose

We hypothesize that Tr1 cells can prevent inflammatory damage and fibrosis in an mouse model of gut damage. Here we evalute the therapeutic potential of Tr1 cells in an model of acute intestinal epithelial damage.

Method

Tr1 cells were isolated and expanded from CD4⁺ CD44^high FOXP3^- cells. Their phenotype was characterized by flow cytometry and cytokine secretion was measured via ELISA. WT B6 mice were given 2% DSS in H₂O for 7 days, followed by H₂O alone for 7 days. Prior to DSS treatment, mice were sub-lethally irradiated to facilitate engraftment, and given I.P. injections of PBS or 0.5 – 2 x 10⁶ Tr1 cells. Mice weights and health scores were recorded daily. At the endpoint, blood, spleen, and mesenteric lymph nodes were analyzed for Tr1 cell engraftment (or lack thereof) for each mouse. Complete white blood counts were performed for each mouse. Additionally, proximal, medial, and distal portions of the ileum were processed for histologic scoring.

Result(s)

Tr1 cells isolated from CD4⁺ CD44^high FOXP3^- cells produce high levels of IL-10 following stimulation (>35,000 pg/ml/1 x 10⁵ cells). Additionally, these cells express high levels of Tr1 markers CD49b and Lag-3. Optimization experiments indicated no significant differences between mice irradiated and given DSS and mice only given DSS (no irradiation). Our results suggest no significant differences in inflammatory cell infiltrate scores between control and Tr1 treated mice. However, gut architecture scores appeared to improve with increasing Tr1 doses. Further, weight change improved with Tr1 treatment, as compared to PBS controls. Interestingly, Tr1 treatment appeared to decrease total eosinophil and neutrophil counts from peripheral blood.

Conclusion(s)

Our initial findings indicate Tr1 adoptive transfer prior to acute damage via DSS improves gut damage and weight loss.

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CIHR

Disclosure of Interest

None Declared

Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation

Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.

European Stroke Organisation (ESO) standard operating procedure for the preparation and publishing of guidelines

The first European Stroke Organization (ESO) standard operating procedure (SOP) published in 2015 aimed at the implementation the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to provide evidence-based guidelines for stroke management. This second ESO-SOP is aiming at further increase of the practicability of ESO guidelines and its technical implications. Authors comprised of the members of the ESO guideline Board and ESO Executive Committee. The final document was agreed on by several internal reviews. The second SOP comprises of the following aspects: rational for the SOP, the introduction of expert consensus statements, types of guideline documents, structures involved and detailed description of the guideline preparation process, handling of financial and intellectual conflicts of interest (CoI), involvement of ESO members in the guideline process, review process, authorship and publication policy, updating of guidelines, cooperation with other societies, and dealing with falsified data. This second SOP supersedes the first SOP published in 2015.

COVID-19 in Sub-Saharan Africa: A Multi-Institutional Survey of the Impact of the Global Pandemic on Cancer Care Resources

Purpose/Objective(s)

The COVID-19 pandemic has direct and indirect impact on patients with cancer. Low- and middle-income regions, especially sub-Saharan Africa, are especially vulnerable to a negative impact on cancer resources and outcomes. We report the initial indirect impact of COVID-19 on cancer care in the sub-Saharan Africa region approximately 14 months into the pandemic.

Materials/Methods

At the start of the pandemic, we created a consortium of African and North American cancer centers and NGOs for the distribution of factual and timely information and data on COVID-19 and cancer care. A survey was distributed to consortium members and other colleagues from the sub-Saharan Africa region to understand the impact of COVID-19 in cancer care resources. Survey respondents represent cancer experts from 8 centers in Ghana, Nigeria, Kenya, Ethiopia, South Africa, Rwanda, and Zimbabwe.

Results

All sites report SARS-COv-2 transmission amongst cancer patients and staff. A total of 48 staff developed COVID-19 infection with one site reporting a single death. Additionally, 62.5% of sites report loss of oncology physician or nursing staff due to redeployment for COVID-19 care resulting in minimal (20%), moderate (60%), or other (20%) impact on cancer care. All 8 sites report a government mandated lockdown with a median duration of 2.3 months (IQR .9-4.2 months). Impact of the lockdown on cancer care was reported as none (12.5%), minimal (12.5%), moderate (50%) and severe (25%). Additionally, we surveyed the impact of COVID-19 on resources in radiation, medical and surgical oncology services. A total of 25% of responders reported decreases in radiation resources while 37.5% reported changes in medical and surgical oncology resources. For radiation oncology, the most common impact was access to CT imaging for 3D-conformal planning (25%), access to brachytherapy (12.5%), and medical physics support (12.5%). For medical oncology, the most frequent impact was access to chemotherapy (37.5%) and blood products (12.5%), and loss of oncology ward space (12.5%). The most frequent impact for surgical oncology was access to operating rooms (37.5%), ventilators (12.5%), anesthesia (25%), blood products (25%), and other supply chain issues (25%). Of centers who reported impact on cancer care, severity of impact was none (50%) and moderate (50%) for radiation oncology; mild (25%) and moderate (75%) for medical oncology; and moderate (75%) and severe (25%) for surgical oncology.

Conclusion

Our survey identified diffuse impact of COVID-19 on all facets of cancer care across sub-Saharan Africa. Based on physician assessment of impact, the discipline of surgical oncology may be impacted the greatest. Additional studies measuring the impact of COVID-19 on cancer outcomes are ongoing.

[Follow-up of renal cell carcinoma based on stage and initial treatment]

BACKGROUND

Renal cell carcinoma is the third most common tumor of the genitourinary system. Small tumors are increasingly treated by nephron-sparing surgery, focal therapy via cryoablation or radiofrequency ablation and also active surveillance. These treatment options are associated with increased follow-up care.

OBJECTIVES

What are the current recommendations on follow-up care for different therapeutic approaches in renal cell carcinoma?

MATERIALS AND METHODS

We analyzed different biological aspects regarding renal cell carcinoma, diagnostic procedures as well as recommendations of current guidelines (e.g. German S3, EAU AUA).

RESULTS

Follow-up of renal cell carcinoma is not well standardized due to the limited amount of data. In general, follow-up should be intensified during the first 3 years following initial therapy as well as in patients with increased risk for tumor recurrence. For risk calculation different prognostic models based on clinical parameters have been published.

CONCLUSIONS

Current recommendations on follow-up care in renal cell carcinoma are based on retrospective studies. Future strategies must include markers and be studied in a prospective manner.

A202 DYSREGULATED ENDOPLASMIC RETICULUM STRESS PATHWAYS IN COLON-DERIVED ENTEROIDS FROM INFLAMMATORY BOWEL DISEASE PATIENTS DRIVE DC MATURATION LEADING TO A PRO-INFLAMMATORY PHENOTYPE

Background

Intestinal epithelial cells (IECs) rely on danger signals such as adenosine triphosphate (ATP) and endoplasmic reticulum (ER) stress to form an appropriate, coordinated immune response. Moreover, ER stress in IECs contributes to the pathogenesis of inflammatory bowel disease (IBD), and an increase in extracellular ATP concentrations is a risk factor for Crohn’s disease (CD).

Aims

We hypothesized that cells exposed to ER stress or ATP modulate innate immune responses, creating a pro-inflammatory environment that drives dendritic cell (DC) maturation.

Methods

Caco-2 cells and human colon-derived enteroid monolayers were exposed to ATP or the ER stress inducer thapsigargin, stimulated with E. coli FliC flagellin, and ER stress markers CHOP, GRP78, and XBP1 s/u were measured via qPCR and western blot, and cytokine release was measured by ELISA. Next, monocyte-derived dendritic cells (moDCs) were cultured in Caco-2 or enteroid conditioned supernatants and their activation status measured via flow cytometry, and cytokine analysis was performed using Luminex platform. We also assessed ER stress markers, TLR5 expression, and cytokine expression differences between IBD and healthy controls (HC).

Results

We found that ER stress amplified FliC-induced IL-8 and decreased CCL20 in Caco-2 cells. Moreover, in IBD subjects, we found an increase FliC-induced IL-8 response, and decreased TNFa and CCL20. moDCs cultured with conditioned media from Caco-2 or enteroid monolayers showed a proinflammatroy phenotype, with an increase in CD80, CD86, MHCII, and a decrease in CD103. Moreover, moDCs cultured in stressed Caco-2 supernatants increased release of IL-6, TNFa, and IL-12p70, and decreased IL-10, suggesting potential to induce inflammatory Th1 and/or Th17 cells.. DC activation correlated with the amount of FliC-induced IL-8. Interestingly, there were distinct differences in cytokine expression and basal ER stress between IBD and HC enteroid monolayers, suggesting a dysregulated ER stress pathway in IBD-derived enteroids.

Conclusions

ER stress in Caco-2 cells and colon-derived enteroid monolayers enhances FliC-induced TLR5 responses, leading to a pro-inflammatory environment that drives DC maturation, which may link epithelial ER stress and immune cell activation in IBD. Furthermore, the cytokine and ER stress pathway differences between IBD and HC-derived enteroids suggests that prolonged periods of stress in IBD patients may rewire the IEC stem cell compartment, further perpetuating inflammation and disease.

Funding Agencies

CCC, CIHR

A10 TR1 CELL-BASED THERAPY FOR INFLAMMATORY ILEITIS IN SHIP-/- MICE

Background

Crohn’s disease (CD), a form of inflammatory bowel disease (IBD), is characterized by chronic inflammation that can occur anywhere along the gastrointestinal (GI) tract, but commonly involves the distal portion of the ileum. Src homology 2 (SH2) domain-containing inositol polyphosphate 5-phosphatase 1 (SHIP) is a hematopoietic-specific regulator of secondary signals generated by the PI3K pathway and regulates immune activation. SHIP-/- mice, at 6–8 weeks of age, spontaneously develop inflammatory ileitis due to myeloid proliferation, a lack of T cells, and an increase in IL-1β.

Aims

Here we investigated the efficacy of type 1 regulatory T (Tr1) cells, which are characterized by high IL-10 production, a broadly acting anti-inflammatory cytokine that promotes gut homeostasis, to treat ileitis in SHIP-/- mice.

Methods

Using IL-10GFPFOXP3RFP B6 reporter mice, we sorted FOXP3-CD44High Tr1 cells, FOXP3+ Tregs, and FOXP3-CD44Low naive T cells from total CD4+ T cells, and cultured them with immobilized α-CD3, soluble α-CD28 and recombinant IL-2 for 3 days. Naive T cells were grown in undifferentiated conditions or polarized to Th1 or Th17 cells. Cell phenotypes were characterized by ELISA and flow cytometry.

For the adoptive Tr1 cell transfer, CD44High cells were sorted from FOXP3GFP Thy1.1 reporter mice and cultured as above with an additional 2 days’ rest in the presence of IL-2 alone. SHIP-/- mice and wild type (WT) littermates were sublethally irradiated at 5 weeks of age, followed 24h later by IP injection with 0.7 – 1.0 x 106 Tr1 cells or PBS vehicle. At 7 weeks of age, mice were euthanized and blood, mesenteric lymph nodes (MLNs), and ileal tissue were processed.

Results

After 3 days of stimulation, FOXP3-CD44High Tr1 cells produced more IL-10 than Tregs and less IFN-γ than Th1 cells. Additionally, CD44High cells had higher co-expression of CD49b and Lag3, biomarkers for Tr1 cells, in comparison to nT cells, Tregs, Th1, and Th17 cells, a higher percentages of IL-10 producing cells than FOXP3+ Tregs and produced less IFN-γ, IL-17, and TNF-α in comparison to Th1, Th17 and naive T cells, respectively.

We found that Tr1 cells successfully engrafted irradiated SHIP-/- mice. Furthermore, engrafted Tr1 cells had high co-expression of CD49b and Lag3, with the majority of these cells located in the MLNs and spleen. SHIP KO mice that received Tr1 cells had comparable ileal length and appearance to SHIP WT, and significantly longer ilea versus SHIP PBS controls — indicating decreased inflammation as a result of successful engraftment.

Conclusions

In conclusion, ex-vivo expansion and adoptive transfer of Tr1 cells to SHIP-/- mice led to cellular engraftment and improvement in spontaneous ileitis. Hence, Tr1 cellular therapy shows promise as a therapeutic approach in CD. Future experiments will be needed to determine the therapeutic dose range of Tr1 cells and the mechanisms of protection.

Funding Agencies

CCC

[Parkinson's syndromes in geriatric patients : Epidemiological, clinical and therapeutic characteristics]

Due to their high prevalence, Parkinson's syndromes are exemplary geriatric syndromes. In addition to idiopathic Parkinson's disease, drug-induced and vascular Parkinson's syndromes are especially relevant in older age. A comprehensive anamnesis, thorough clinical neurological examination and rational additional diagnostics ensure the correct differential diagnostic classification. The multidimensional geriatric assessment is used to quantify the syndrome-specific ability impairments. The primary therapeutic objective in old age is the preservation of everyday competences. Drug treatment is centered around L‑dopa because of its favorable effect-side effect ratio. In cases of motor fluctuations, entacapone, opicapone or safinamide can be added, whereas dopamine agonists are generally unsuitable. Rivastigmine is indicated in mild to moderate Parkinson's dementia and furthermore can possibly improve gait stability. Speech therapy, as well as physical and occupational therapy, including the Parkinson's disease-specific Lee Silverman voice treatment are indispensable components of the multiprofessional treatment concept.

Comparison of mucosal and mucoperiosteal wound cover for the treatment of medication-related osteonecrosis of the jaw lesions: a retrospective cohort study

OBJECTIVES

Actually, there is no detailed guidance on how to deal with wound closure after surgical removal of medication-related osteonecrosis of the jaw (MRONJ) lesions. This study attempts to compare the difference in outcome between the mucosal and the mucoperiosteal flap closure after surgery.

PATIENTS AND METHODS

In this retrospective monocentric cohort study, patients (n = 61; 35 female/26 male) suffering from MRONJ and requiring surgical therapy at the University of Aachen between 2013 and 2015 were included. Due to intra-institutional variances, one group was treated with the mucosal, the other group with the mucoperiosteal technique. The success rate, i.e., mucosal closure and no relapse at the point of follow-up, was evaluated and compared. All patients were clinically investigated for the postoperative follow-up during a special consultation appointment.

RESULTS

The success rates between the different techniques after 2 years follow-up were very similar. In the group of mucosal wound closure, 22 of 29 (75.86%) patients revealed mucosal integrity without signs of MRONJ. The rate in the mucoperiosteal wound closure group was almost identical (24 of 32 (75%)).

CONCLUSION

No differences in the success rates between the two different techniques could be evaluated.

CLINICAL RELEVANCE

The results of this study suggest that the complete removal of the necrotic bone might have a higher impact on the success rates than the technique of the wound closure. Due to the fact that the mucoperiosteal wound closure technique offers a better overview of the extent of the MRONJ lesion, the authors advise to use this technique.

An Integrated Approach for a Knowledge-based Clinical Workstation: Architecture and Experience

Today, the demand for medical decision support to improve the quality of patient care and to reduce costs in health services is generally recognized. Nevertheless, decision support is not yet established in daily routine within hospital information systems which often show a heterogeneous architecture but offer possibilities of interoperability. Currently, the integration of decision support functions into clinical workstations is the most promising way. Therefore, we first discuss aspects of integrating decision support into clinical workstations including clinical needs, integration of database and knowledge base, knowledge sharing and reuse and the role of standardized terminology. In addition, we draw up functional requirements to support the physician dealing with patient care, medical research and administrative tasks. As a consequence, we propose a general architecture of an integrated knowledge-based clinical workstation. Based on an example application we discuss our experiences concerning clinical applicability and relevance. We show that, although our approach promotes the integration of decision support into hospital information systems, the success of decision support depends above all on an adequate transformation of clinical needs.

Perioperative serum levels of procalcitonin, C-reactive protein, and leukocytes in head and neck free flaps

Microvascular free flaps are considered to be the gold standard in reconstructive head and neck surgery. However, reduced postoperative transplant perfusion is one of the serious postoperative complications and calls for close and reliable monitoring. Procalcitonin, C-reactive protein, and leukocytes are closely associated with local and systemic inflammatory reactions and might have prognostic capacity concerning tissue necrosis. This study aimed to evaluate perioperative serum levels of these three biomarkers to assess their potential in postoperative flap monitoring. A total of 100 patients with microvascular head and neck reconstructions were included in the study. Perioperative serum levels of parameters were measured and the clinical data were analyzed and correlated. A total of 13% of all flaps developed reduced postoperative perfusion. Analysis of the parameters revealed statistically significant differences in the overall patient collective over time, irrespective of clinically reduced flap perfusion. Co-factors such as sex and history of tobacco and alcohol abuse showed significant differences. The efficacy of the parameters in free flap monitoring has not been verified, although the role of procalcitonin in postoperative monitoring, with special regard to the early detection of infections, is underlined by the present study results.

Molecular effects of fractional ablative erbium:YAG laser treatment with multiple stacked pulses on standardized human three-dimensional organotypic skin models

The molecular changes in gene expression following ablative laser treatment of skin lesions, such as atrophic scars and UV-damaged skin, are not completely understood. A standardized in vitro model of human skin, to study the effects of laser treatment on human skin, has been recently developed. Therefore, the aim of the investigation was to examine morphological and molecular changes caused by fractional ablative erbium:YAG laser treatment on an in vitro full-thickness 3D standardized organotypic model of human skin. A fractional ablative erbium:YAG laser was used to irradiate organotypic human 3D models. Laser treatments were performed at four different settings using a variety of stacked pulses with similar cumulative total energy fluence (60 J/cm²). Specimens were harvested at specified time points and real-time PCR (qRT-PCR) and microarray studies were performed. Frozen sections were examined histologically. Three days after erbium:YAG laser treatment, a significantly increased mRNA expression of matrix metalloproteinases and their inhibitors (MMP1, MMP2, MMP3, TIMP1, and TIMP2), chemokines (CXCL1, CXCL2, CXCL5, and CXCL6), and cytokines such as IL6, IL8, and IL24 could be detected. qRT-PCR studies confirmed the enhanced mRNA expression of IL6, IL8, IL24, CXCLs, and MMPs. In contrast, the mRNA expression of epidermal differentiation markers, such as keratin-associated protein 4, filaggrin, filaggrin 2, and loricrin, and antimicrobial peptides (S100A7A, S100A9, and S100A12) as well as CASP14, DSG2, IL18, and IL36β was reduced. Four different settings with similar cumulative doses have been tested (N10%, C10%, E10%, and W25%). These laser treatments resulted in different morphological changes and effects on gene regulations. Longer pulse durations (1000 μs) especially had the strongest impact on gene expression and resulted in an upregulation of genes, such as collagen-1A2, collagen-5A2, and collagen-6A2, as well as FGF2. Histologically, all treatment settings resulted in a complete regeneration of the epidermis 3 days after irradiation. Fractional ablative erbium:YAG laser treatment with a pulse stacking technique resulted in histological alterations and shifts in the expression of various genes related to epidermal differentiation, inflammation, and dermal remodeling depending on the treatment setting applied. A standardized in vitro 3D model of human skin proved to be a useful tool for exploring the effects of various laser settings both on skin morphology and gene expression during wound healing. It provides novel data on the gene expression and microscopic architecture of the exposed skin. This may enhance our understanding of laser treatment at a molecular level.

Corrigendum to "Heat generation and drill wear during dental implant site preparation: systematic review" [Br. J. Oral Maxillofac. Surg. 53(8) (2015) 679–689]

The authors regret D. A. Mitchell’s affiliation address was listed incorrectly in the original paper. The correct affiliation addressis: Maxillofacial Unit, Bradford Teaching Hospitals NHS Foundation Trust, St Lukes, Hospital, Little Horton Lane, Bradford,West Yorkshire, BD5 0NA, England, UK.The authors would like to apologise for any inconvenience caused.

"Heidelberg standard examination" and "Heidelberg standard procedures" - Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education

The competent physical examination of patients and the safe and professional implementation of clinical procedures constitute essential components of medical practice in nearly all areas of medicine. The central objective of the projects "Heidelberg standard examination" and "Heidelberg standard procedures", which were initiated by students, was to establish uniform interdisciplinary standards for physical examination and clinical procedures, and to distribute them in coordination with all clinical disciplines at the Heidelberg University Hospital. The presented project report illuminates the background of the initiative and its methodological implementation. Moreover, it describes the multimedia documentation in the form of pocketbooks and a multimedia internet-based platform, as well as the integration into the curriculum. The project presentation aims to provide orientation and action guidelines to facilitate similar processes in other faculties.

[Deep vein thrombosis and lung embolisms in patients with stroke: prevention and therapy]

Prevention and therapy of deep vein thrombosis and pulmonary embolisms in patients with acute stroke (ischemia and hemorrhage) represent a special challenge in the clinical routine. This article gives an overview on the epidemiology, risk factors and causes of deep vein thrombosis and pulmonary embolism in patients with acute stroke. The focus lies on the efficacy and safety of prophylactic treatment with compression stockings, compression devices and anticoagulants. Special therapeutic options in the event of symptomatic deep vein thrombosis and pulmonary embolisms in patients with intracerebral hemorrhage and increased risk of recurrent bleeding are presented.

Heat generation and drill wear during dental implant site preparation: systematic review

To identify factors that minimise damage during the drilling of sites for dental implants, we reviewed published papers on the amount of heat that is generated. We systematically searched English language studies published between January 2000 and February 2014 on MEDLINE/PubMed and found 41 articles, of which 27 related to an increase in temperature during preparation of the site. We found only basic research with a low level of evidence. Most of the studies were in vitro, and osteotomies were usually made in non-vital bone from cows or pigs. To measure heat in real time, thermocouples were used in 18 studies and infrared thermographs in 7. Three studies reported the use of immunohistochemical analysis to investigate immediate viability of cells. The highest temperature measured was 64.4°C and the lowest 28.4°C. Drill wear was reported after preparation of 50 sites, and there was a significant increase in temperature and a small change in the physiological balance of the proteins in the bone cells. Differences in the study designs meant that meta-analysis was not appropriate. For future work, we recommend the use of standard variables: an axial load of 2kg, drilling speed of 1500rpm, irrigation, standard artificial bone blocks, and the use of infrared thermography.

Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study

BACKGROUND

The anaesthetic conserving device, AnaConDa(®), allows use of inhaled anaesthetics for sedation in the intensive care unit. We prospectively measured cerebral and cardiopulmonary parameters in patients with acute stroke or subarachnoid haemorrhage during a switch from i.v. to inhalative sedation.

METHODS

25 patients were switched from i.v. to an indefinite period of inhaled sedation with sevoflurane. Mean arterial (MAP), intracranial (ICP), and cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (MFV) and fractional tissue oxygen extraction (FTOE), systemic cardiopulmonary parameters, and administered drugs were assessed before and after the change (-6 to +12 h).

RESULTS

In 8 patients, critically reduced MAP or ICP crisis led to premature termination of sevoflurane sedation. In the other 17 patients, after the first hour, mean ICP increased [2.4 (4.5) mm Hg; P=0.046], MAP decreased [7.8 (14.1) mm Hg; P=0.036] and thus CPP decreased also [-10.2 (15.1) mm Hg; P=0.014]. MFV and FTOE did not change. Over a 12 hour post switch observational period, [Formula: see text] increased slightly [0.3 (0.8) kPa; P=0.104], ICP did not change [0.2 (3.9) mm Hg; P=0.865], but MAP [-6 (6.9) mm Hg; P=0.002] and thus CPP decreased [-6 (8.5) mm Hg; P=0.010].

CONCLUSION

Sevoflurane led to sufficient sedation, but decreased MAP and CPP in a selected cerebrovascular neurocritical care population. In about a third of these patients, severe adverse reactions, including intolerable ICP increases, were observed.

Replicate Measurements of Haemoglobin Mass during a Single Day are Feasible and Precise

Duplicate haemoglobin mass (Hb_mass) measurements are recommended before and after altitude training sojourns to identify individual adaptations in athletes with a high level of certainty. Duplicate measurements reduce typical error (TE) and disclose measurement outliers, but are usually made on separate days, which is not a practical protocol for routine services in elite sport settings. The aim of this study was therefore to investigate whether it is safe (carboxyhaemoglobin<10%) to measure Hb_mass twice on the same day and to compare TE with measurements made on separate days. 18 healthy men completed 3 different procedures to measure Hb_mass twice a day with the carbon monoxide rebreathing method: A (Hb_mass measured twice within 6 h), B (dito A, combined with 1 h of hyperoxic training between the tests), C (dito B, within 2 h). First Hb_mass measurements of the 3 test days served as procedure D. Carboxyhaemoglobin did not exceed 10% in any procedure. TE and confidence limits for procedures A, B, C and D were 1.4% (1.0-2.1%), 1.1% (0.8-1.7%), 1.3% (1.0-2.0%) and 1.5% (1.2-2.1%), respectively. Duplicate measurements of Hb_mass on the same day are feasible and show TE similar to triplicate measurements on separate days.