No Routine Postoperative Head CT following Elective Craniotomy - A Paradigm Shift?

INTRODUCTION Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data. METHODS Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings. RESULTS Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11-62.37]). DISCUSSION Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT01987648.

Tropically-driven climate shifts in southwestern Europe during MIS 19, a low eccentricity interglacial

The relative roles of high- versus low-latitude forcing of millennial-scale climate variability are still not well understood. Here we present terrestrial–marine climate profiles from the southwestern Iberian margin, a region particularly affected by precession, that show millennial climate oscillations related to a nonlinear response to the Earth's precession cycle during Marine Isotope Stage (MIS) 19. MIS 19 has been considered the best analogue to our present interglacial from an astronomical point of view due to the reduced eccentricity centred at 785 ka. In our records, seven millennial-scale forest contractions punctuated MIS 19 superimposed to two orbitally-driven Mediterranean forest expansions. In contrast to our present interglacial, we evidence for the first time low latitude-driven 5000-yr cycles of drying and cooling in the western Mediterranean region, along with warmth in the subtropical gyre related to the fourth harmonic of precession. These cycles indicate repeated intensification of North Atlantic meridional moisture transport that along with decrease in boreal summer insolation triggered ice growth and may have contributed to the glacial inception, at ∼774 ka. The freshwater fluxes during MIS 19ab amplified the cooling events in the North Atlantic promoting further cooling and leading to MIS 18 glaciation. The discrepancy between the dominant cyclicity observed during MIS 1, 2500-yr, and that of MIS 19, 5000-yr, challenges the similar duration of the Holocene and MIS 19c interglacials under natural boundary conditions.

Trade Policy, Investment and Migration: The Liberalisation Paradigm

Presentation by Thomas Cottier & Charlotte Sieber-Gasser prepared for the Markets for Migration and Development (M4MD) Conference, Bern, 13-15 September 2011. This presentation is part of Session 1 "Why Trade, Development and Migration?" of the M4MD conference, which was one of the thematic meetings held in the context of the 2011 Global Forum on Migration and Development (GFMD) chaired by Switzerland. Session 1 seeked to understand to what extent international trade and foreign direct investment drives migration and why states find it more difficult to liberalise the trans‐boundary movement of persons than to liberalise cross‐border trade in goods and services. One discussed aspect was why globalisation, trade liberalisation and FDI can lead not only to more, but also to less migration and what the corresponding effects on development would be. This Session provided a timely opportunity to broaden the perspective on international migration and explore the interaction between migration, development and trade policymaking.