Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients

OBJECT The etiology of chronic subdural hematoma (CSDH) in nongeriatric patients (≤ 60 years old) often remains unclear. The primary objective of this study was to identify spinal CSF leaks in young patients, after formulating the hypothesis that spinal CSF leaks are causally related to CSDH. METHODS All consecutive patients 60 years of age or younger who underwent operations for CSDH between September 2009 and April 2011 at Bern University Hospital were included in this prospective cohort study. The patient workup included an extended search for a spinal CSF leak using a systematic algorithm: MRI of the spinal axis with or without intrathecal contrast application, myelography/fluoroscopy, and postmyelography CT. Spinal pathologies were classified according to direct proof of CSF outflow from the intrathecal to the extrathecal space, presence of extrathecal fluid accumulation, presence of spinal meningeal cysts, or no pathological findings. The primary outcome was proof of a CSF leak. RESULTS Twenty-seven patients, with a mean age of 49.6 ± 9.2 years, underwent operations for CSDH. Hematomas were unilateral in 20 patients and bilateral in 7 patients. In 7 (25.9%) of 27 patients, spinal CSF leakage was proven, in 9 patients (33.3%) spinal meningeal cysts in the cervicothoracic region were found, and 3 patients (11.1%) had spinal cysts in the sacral region. The remaining 8 patients (29.6%) showed no pathological findings. CONCLUSIONS The direct proof of spinal CSF leakage in 25.9% of patients suggests that spinal CSF leaks may be a frequent cause of nongeriatric CSDH.

Transapical transcatheter aortic valve implantation using the second-generation self-expanding Symetis ACURATE TA valve

Transapical transcatheter aortic valve implantation (TA-TAVI) is the recognized first choice surgical TAVI access. Expansion of this well-established treatment modality with subsequent broader patient inclusion has accelerated development of second-generation TA-TAVI devices. The Swiss ACURATE TA Symetis valve allows for excellent anatomical positioning, resulting in a very low incidence of paravalvular leaks. The self-expanding stent features an hourglass shape to wedge the native aortic valve annulus. A specially designed delivery system facilitates controlled release aided by tactile operator feedback. The ACURATE TA valve made of three native porcine non-coronary leaflets has received CE approval in September 2011. Since then, this valve is the third most frequently implanted TAVI device with over 1200 implants in Europe and South America. Results from the Symetis ACURATE TA™ Valve Implantation ('SAVI') Registry showed a procedural success rate of 98.0% and a survival rate of 93.2% at 30 days. This presentation provides technical considerations and detailed procedural aspects of device implantation.

Validation of multiple-breath washout equipment for infants and young children.

INTRODUCTION The new ATS/ERS consensus report recommends in vitro validation of multiple-breath inert gas washout (MBW) equipment based on a lung model with simulated physiologic conditions. We aimed to assess accuracy of two MBW setups for infants and young children using this model, and to compare functional residual capacity (FRC) from helium MBW (FRCMBW ) with FRC from plethysmography (FRCpleth ) in vivo. METHODS The MBW setups were based on ultrasonic flow meter technology. Sulfur hexafluoride and helium were used as tracer gases. We measured FRC in vitro for specific model settings with and without carbon dioxide and calculated differences of measured to generated FRC. For in vivo evaluation, difference between FRCMBW and FRCpleth was calculated in 20 healthy children, median age 6.1 years. Coefficient of variation (CV) was calculated per FRC. RESULTS In the infant model (51 runs, FRC 80-300 ml), mean (SD) relative difference between generated and measured FRCs was 0.7 (4.7) %, median CV was 4.4% for measured FRCs. In the young child model, one setting (8 runs, FRC 400 ml) showed a relative difference of up to 13%. For the remaining FRCs (42 runs, FRC 600-1,400 ml), mean (SD) relative difference was -2.0 (3.4) %; median CV was 1.4% for measured FRCs. In vivo FRCpleth exceeded FRCMBW values by 37% on average. CONCLUSIONS Both setups measure lung volumes in the intended age group reliably and reproducibly. Characteristics of different techniques should be considered when measuring lung volumes in vivo. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc.

Continental degassing of 4He by surficial discharge of deep groundwater

Radiogenic He is produced by the decay of uranium and thorium in the Earth’s mantle and crust. From here, it is degassed to the atmosphere and eventually escapes to space. Assuming that all of the 4He produced is degassed, about 70% of the total He degassed from Earth comes from the continental crust. However, the outgoing flux of crustal He has not been directly measured at the Earth’s surface and the migration pathways are poorly understood. Here we present measurements of helium isotopes and the long-lived cosmogenic radio-isotope Kr in the deep, continental-scale Guarani aquifer in Brazil and show that crustal He reaches the atmosphere primarily by the surficial discharge of deep groundwater. We estimate that He in Guarani groundwater discharge accounts for about 20% of the assumed global flux from continental crust, and that other large aquifers may account for about 33%. Old groundwater ages suggest that He in the Guarani aquifer accumulates over half- to one-millionyear timescales. We conclude that He degassing from the continents is regulated by groundwater discharge, rather than episodic tectonic events, and suggest that the assumed steady state between crustal production and degassing of He, and its resulting atmospheric residence time, should be re-examined.

Auswirkungen von anthropogenen Einflüssen auf einen Küstengrundwasserleiter am Beispiel des Ems-Ästuars

Im ostfriesischen Moormerland sind Einflüsse auf einen Küstengrundwasserleiter zu finden. Zum einen wird der Tidefluss Ems durch Ausbaggerungen und den Betrieb des Emssperrwerks bei Gandersum stark bewirtschaftet, zum anderen bewirken das Wasserwerk Tergast in unmittelbarer Umgebung der Ems sowie der durch die Entwässerungsverbände künstlich erniedrigte Grundwasserspiegel ein hydraulisches Gefälle von der Ems hin zum Binnenland. In mehreren Projekten wurden von 1999 bis 2013 die hydrochemische Beschaffenheit und die hydraulischen Bedingungen untersucht, um die zukünftige Entwicklung des Küstengrundwasserleiters abzuschätzen. Mit den Umwelttracern Tritium, Helium-3, Helium-4, Argon-39 und Kohlenstoff-14 konnte nachgewiesen werden, dass die heutige Verteilung von höher und gering mineralisierten Grundwässern das Resultat einer Überprägung des älteren, anthropogen unbeeinflussten Grundwasserströmungsfeldes durch ein jüngeres, anthropogen verändertes Strömungsfeld ist. Modellrechnungen zeigen, dass im Laufe der nächsten Jahrhunderte die Relikte des älteren Strömungsfeldes vollständig durch höher mineralisierte Grundwässer, die der künstlich induzierten Abflussrichtung folgen, überprägt werden.

Aortic valve replacement and concomitant procedures with the Perceval valve: results of European trials.

BACKGROUND The Perceval (Sorin Group, Milan, Italy) is a self-anchoring sutureless aortic valve prosthesis. We report the short- to midterm results of combined aortic valve replacement (AVR) with concomitant procedures in elderly patients undergoing operation as part of 3 consecutive prospective multicenter European studies. METHODS From April 2007 to February 2013, 243 patients (mean age, 79.7 ± 5.1 years; female patients, 61%; median EuroSCORE, 9%) underwent AVR with concomitant procedures. The concomitant procedures were coronary artery bypass grafting (CABG) (182 cases), septal myectomy (21 cases), CABG + other procedures (18 cases), and 22 other procedures. Primary and secondary end points included implant feasibility and safety (for mortality and morbidity) and efficacy (New York Heart Association [NYHA] class improvement and hemodynamic results) of the prosthesis at the different follow-up periods. Data were expressed as mean ± standard deviation. Kaplan-Meier analysis was performed for survival analysis. RESULTS Mean aortic cross-clamp and extracorporeal circulation (ECC) times were 50.7 ± 22.8 minutes and 78.9 ± 32.3 minutes, respectively. Thirty-day mortality was 2.1%. Mean postoperative gradient and effective orifice area were 10.1 ± 4.7 mm Hg and 1.5 ± 0.4 cm(2) and 8.9 ± 5.6 mm Hg and 1.6 ± 0.4 cm(2), respectively, at 1 year. There were early explantations, 4 of which resulted from paravalvular leaks. One additional valve explantation resulted from aortic root bleeding, probably caused by excessively extensive decalcification. In the late period, there was 1 mild paravalvular leak and no intravalvular insufficiency. No migration, dislodgement, or degeneration of the valve occurred during follow-up. Median follow-up was 444 days. CONCLUSIONS These trials confirm the safety and efficacy of the Perceval sutureless aortic valve, especially in elderly patients requiring AVR + concomitant procedures. In this patient group, sutureless valves may be advantageous compared to transcatheter valve implantations as concomitant procedures other than percutaneous coronary artery angioplasty are not always possible in the latter.

Scientific rationale for Saturn׳s in situ exploration

Remote sensing observations meet some limitations when used to study the bulk atmospheric composition of the giant planets of our solar system. A remarkable example of the superiority of in situ probe measurements is illustrated by the exploration of Jupiter, where key measurements such as the determination of the noble gases׳ abundances and the precise measurement of the helium mixing ratio have only been made available through in situ measurements by the Galileo probe. This paper describes the main scientific goals to be addressed by the future in situ exploration of Saturn placing the Galileo probe exploration of Jupiter in a broader context and before the future probe exploration of the more remote ice giants. In situ exploration of Saturn׳s atmosphere addresses two broad themes that are discussed throughout this paper: first, the formation history of our solar system and second, the processes at play in planetary atmospheres. In this context, we detail the reasons why measurements of Saturn׳s bulk elemental and isotopic composition would place important constraints on the volatile reservoirs in the protosolar nebula. We also show that the in situ measurement of CO (or any other disequilibrium species that is depleted by reaction with water) in Saturn׳s upper troposphere may help constraining its bulk O/H ratio. We compare predictions of Jupiter and Saturn׳s bulk compositions from different formation scenarios, and highlight the key measurements required to distinguish competing theories to shed light on giant planet formation as a common process in planetary systems with potential applications to most extrasolar systems. In situ measurements of Saturn׳s stratospheric and tropospheric dynamics, chemistry and cloud-forming processes will provide access to phenomena unreachable to remote sensing studies. Different mission architectures are envisaged, which would benefit from strong international collaborations, all based on an entry probe that would descend through Saturn׳s stratosphere and troposphere under parachute down to a minimum of 10 bar of atmospheric pressure. We finally discuss the science payload required on a Saturn probe to match the measurement requirements.

First direct observation of sputtered lunar oxygen

We present the first direct measurement of neutral oxygen in the lunar exosphere, detected by the Chandrayaan-1 Energetic Neutral Analyzer (CENA). With the lunar surface consisting of about 60% of oxygen in number, the neutral oxygen detected in CENA's energy range (11 eV−3.3 keV) is attributed to have originated from the lunar surface, where it was released through solar wind ion sputtering. Fitting of CENA's mass spectra with calibration spectra from ground and in-flight data resulted in the detection of a robust oxygen signal, with a flux of 0.2 to 0.4 times the flux of backscattered hydrogen, depending on the solar wind helium content and particle velocity. For the two solar wind types observed, we derive subsolar surface oxygen atom densities of N0= (1.1 ± 0.3) · 107m−3 and (1.4 ± 0.4) · 107m−3, respectively, which agree well with earlier model predictions and measured upper limits. From these surface densities, we derive column densities of NC= (1.5 ± 0.5) · 1013 m−2and (1.6 ± 0.5) · 1013 m−2. In addition, we identified for the first time a helium component. This helium is attributed to backscattering of solar wind helium (alpha particles) from the lunar surface as neutral energetic helium atoms, which has also been observed for the first time. This identification is supported by the characteristic energy of the measured helium atoms, which is roughly 4 times the energy of reflected solar wind hydrogen, and the correlation with solar wind helium content.

Efficient and Safe Small-Bowel Adhesiolysis

Small-intestine adhesiolysis can be very time consuming and may be associated with bowel wall damage. The risk for injuries to the small or large bowel resulting in increased morbidity and costs is considerable. Both efficient and gentle dissection of adhesions is important in order to avoid intraoperative perforation or, worse, postoperative intestinal leaks. We present a technique using drops of body-warm isotonic saline solution to create an edematous swelling of the adhesions. This procedure not only protects the bowel from cooling and drying, but also simplifies the dissection and, thus, lowers the risk of intestinal lesions.

On the reduced sensitivity of the Atlantic overturning to Greenland ice sheet melting in projections: a multi-model assessment

Large uncertainties exist concerning the impact of Greenland ice sheet melting on the Atlantic meridional overturning circulation (AMOC) in the future, partly due to different sensitivity of the AMOC to freshwater input in the North Atlantic among climate models. Here we analyse five projections from different coupled ocean–atmosphere models with an additional 0.1 Sv (1 Sv = 10 6 m3/s) of freshwater released around Greenland between 2050 and 2089. We find on average a further weakening of the AMOC at 26°N of 1.1 ± 0.6 Sv representing a 27 ± 14% supplementary weakening in 2080–2089, as compared to the weakening relative to 2006–2015 due to the effect of the external forcing only. This weakening is lower than what has been found with the same ensemble of models in an identical experimen - tal set-up but under recent historical climate conditions. This lower sensitivity in a warmer world is explained by two main factors. First, a tendency of decoupling is detected between the surface and the deep ocean caused by an increased thermal stratification in the North Atlantic under the effect of global warming. This induces a shoaling of ocean deep ventilation through convection hence ventilating only intermediate levels. The second important effect concerns the so-called Canary Current freshwater leakage; a process by which additionally released fresh water in the North Atlantic leaks along the Canary Current and escapes the convection zones towards the subtropical area. This leakage is increasing in a warming climate, which is a consequence of decreasing gyres asymmetry due to changes in Ekman rumping. We suggest that these modifications are related with the northward shift of the jet stream in a warmer world. For these two reasons the AMOC is less susceptible to freshwater perturbations (near the deep water formation sides) in the North Atlantic as compared to the recent historical climate conditions. Finally, we propose a bilinear model that accounts for the two former processes to give a conceptual explanation about the decreasing AMOC sensitivity due to freshwater input. Within the limit of this bilinear model, we find that 62 ± 8% of the reduction in sensitivity is related with the changes in gyre asymmetry and freshwater leakage and 38 ± 8% is due to the reduction in deep ocean ventilation associated with the increased stratification in the North Atlantic.

In situ plasma measurements of fragmented comet 73P Schwassmann–Wachmann 3

The interiors of comets contain some of the most pristine material in the solar system. Comet 73P/Schwassmann–Wachmann 3, discovered in 1930, is a Jupiter-family comet with a 5.34-year period. This comet split into 5 fragments in 1995 and disintegrated into nearly 70 major pieces in 2006. In 2006 May and June, recently ionized cometary particles originating from fragments including and surrounding some of these major objects were collected with the ACE/SWICS and Wind/STICS sensors. Due to a combination of the instrument characteristics and the close proximity of the fragments passing between those spacecraft and the Sun, unique measurements regarding the charge state composition and the elemental abundances of both cometary and heliospheric plasma were made during that time. The cometary material released from some of these fragments can be identified by the concentrations of water-group pickup ions having a mass-per-charge ratio of 16–18 amu e−1, indicating that while these fragments are small, they are still actively sublimating. We present an analysis of cometary composition, spatial distribution, and heliospheric interactions, with a focus on helium, C+/O+, and water-group ions.

Breastfeeding, lung volumes and alveolar size at school-age.

BACKGROUND Previous studies found larger lung volumes at school-age in formerly breastfed children, with some studies suggesting an effect modification by maternal asthma. We wanted to explore this further in children who had undergone extensive lung function testing. The current study aimed to assess whether breastfeeding was associated with larger lung volumes and, if so, whether all compartments were affected. We also assessed association of breastfeeding with apparent diffusion coefficient (ADC), which measures freedom of gas diffusion in alveolar-acinar compartments and is a surrogate of alveolar dimensions. Additionally, we assessed whether these effects were modified by maternal asthma. METHODS We analysed data from 111 children and young adults aged 11-21 years, who had participated in detailed lung function testing, including spirometry, plethysmography and measurement of ADC of (3)Helium ((3)He) by MR. Information on breastfeeding came from questionnaires applied in early childhood (age 1-4 years). We determined the association between breastfeeding and these measurements using linear regression, controlling for potential confounders. RESULTS We did not find significant evidence for an association between duration of breastfeeding and lung volumes or alveolar dimensions in the entire sample. In breastfed children of mothers with asthma, we observed larger lung volumes and larger average alveolar size than in non-breastfed children, but the differences did not reach significance levels. CONCLUSIONS Confirmation of effects of breastfeeding on lung volumes would have important implications for public health. Further investigations with larger sample sizes are warranted.

Sutureless aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND Sutureless aortic valve replacement (SU-AVR) has emerged as an innovative alternative for treatment of aortic stenosis. By avoiding the placement of sutures, this approach aims to reduce cross-clamp and cardiopulmonary bypass (CPB) duration and thereby improve surgical outcomes and facilitate a minimally invasive approach suitable for higher risk patients. The present systematic review and meta-analysis aims to assess the safety and efficacy of SU-AVR approach in the current literature. METHODS Electronic searches were performed using six databases from their inception to January 2014. Relevant studies utilizing sutureless valves for aortic valve implantation were identified. Data were extracted and analyzed according to predefined clinical endpoints. RESULTS Twelve studies were identified for inclusion of qualitative and quantitative analyses, all of which were observational reports. The minimally invasive approach was used in 40.4% of included patients, while 22.8% underwent concomitant coronary bypass surgery. Pooled cross-clamp and CPB duration for isolated AVR was 56.7 and 46.5 minutes, respectively. Pooled 30-day and 1-year mortality rates were 2.1% and 4.9%, respectively, while the incidences of strokes (1.5%), valve degenerations (0.4%) and paravalvular leaks (PVL) (3.0%) were acceptable. CONCLUSIONS The evaluation of current observational evidence suggests that sutureless aortic valve implantation is a safe procedure associated with shorter cross-clamp and CPB duration, and comparable complication rates to the conventional approach in the short-term.

Structural elucidation and antisense properties of a sugar-modified DNA analogue

Antisense oligonucleotides deserve great attention as potential drug candidates for the treatment of genetic disorders. For example, muscle dystrophy can be treated successfully in mice by antisense-induced exon skipping in the pre-mRNA coding for the structural protein dystrophin in muscle cells. For this purpose a sugar- and backbone-modified DNA analogue was designed, in which a tricyclic ring system substitutes the deoxyribose. These chemical modifications stabilize the dimers formed with the targeted RNA relative to native nucleic acid duplexes and increase the biostability of the antisense oligonucleotide. While evading enzymatic degradation constitutes an essential property of antisense oligonucleotides for therapeutic application, it renders the oligonucleotide inaccessible to biochemical sequencing techniques and requires the development of alternative methods based on mass spectrometry. The set of sequences studied includes tcDNA oligonucleotides ranging from 10 to 15 nucleotides in length as well as their hybrid duplexes with DNA and RNA complements. All samples were analyzed on a LTQ Orbitrap XL instrument equipped with a nano-electrospray source. For tandem mass spectrometric experiments collision-induced dissociation was performed, using helium as collision gas. Mass spectrometric sequencing of tcDNA oligomers manifests the applicability of the technique to substrates beyond the scope of enzyme-based methods. Sequencing requires the formation of characteristic backbone fragments, which take the form of a-B- and w-ions in the product ion spectra of tcDNA. These types of product ions are typically associated with unmodified DNA, which suggests a DNA-like fragmentation mechanism in tcDNA. The loss of nucleobases constitutes the second prevalent dissociation pathway observed in tcDNA. Comparison of partially and fully modified oligonucleotides indicates a pronounced impact of the sugar-moiety on the base loss. As this event initiates cleavage of the backbone, the presented results provide new mechanistic insights into the fragmentation of DNA in the gas-phase. The influence of the sugar-moiety on the dissociation extends to tcDNA:DNA and tcDNA:RNA hybrid duplexes, where base loss was found to be much more prominent from sugar-modified oligonucleotides than from their natural complements. Further prominent dissociation channels are strand separation and backbone cleavage of the single strands, as well as the ejection of backbone fragments from the intact duplex. The latter pathway depends noticeably on the base sequence. Moreover, it gives evidence of the high stability of the hybrid dimers, and thus directly reflects the affinity of tcDNA for its target in the cell. As the cellular target of tcDNA is a pre-mRNA, the structure was designed to discriminate RNA from DNA complements, which could be demonstrated by mass spectrometric experiments.

Impact of Planetary Gravitation on High Precision Neutral Atom Measurements

Measurements of energetic neutral atoms (ENAs) have been extremely successful in providing very important information on the physical processes inside and outside of our heliosphere. For instance, recent Interstellar Boundary Explorer (IBEX) observations have provided new insights into the local interstellar environment and improved measurements of the interstellar He temperature, velocity, and direction of the interstellar flow vector. Since particle collisions are rare, and radiation pressure is negligible for these neutrals, gravitational forces mainly determine the trajectories of neutral He atoms. Depending on the distance of an ENA to the source of a gravitational field and its relative speed and direction, this can result in significant deflection and acceleration. In this paper, we investigate the impact of the gravitational effects of Earth, the Moon, and Jupiter on ENA measurements performed in Earth's orbit. The results show that current analysis of the interstellar neutral parameters by IBEX is not significantly affected by planetary gravitational effects. We further studied the possibility of whether or not the Helium focusing cone of the Sun and Jupiter could be measured by IBEX and whether or not these cones could be used as an independent measure of the temperature of interstellar Helium.