Functionalization of hyperbranched polycarbosilanes - block copolymers and electrochemistry

Polycarbosilanes are a class of polymers at the interface between organic and inorganic chemistry. They are characterized by a high thermal and chemical inertness and high flexibility, especially pronounced for branched structures. Linear polycarbosilanes are well known as precursors for the preparation of SiCx ceramics. Additionally, more sophisticated architectures like dendrimers, hyperbranched polymers or block copolymers have been the subject of research for more than a decade. The scope of this work was to expand the properties and fields of application for polycarbosilane-containing structures. Thus, the work is divided in two major parts. The first part covers the synthesis and characterization of hyperbranched polycarbosilanes containing organometallic moieties. Hyperbranched poly-carbosilanes were synthesized using hydrosilylation of diallylmethylsilane and methyldiundecenylsilane. The degree of branching for polydiallymethylsilane was determined using standard 1H-NMR spectroscopy. The functional building blocks ferrocenyldimethylsilane and diferrocenylmethylsilane were synthesized which contain an isolated ferrocene unit or two ferrocenes bridged by silicon, respectively. Hyperbranched polycarbosilanes functionalized with ferrocenyl moieties were synthesized by modification of preformed polymers or by copolymerization of AB2 carbosilane monomers with AX-type ferrocenylsilanes. Polymers with Mn = 2500-9000g/mol and ferrocene contents of up to 67wt% were obtained. Electrochemical characterization by cyclic voltammetry revealed that polymers functionalized with isolated ferrocene units showed a single reversible oxidation wave, while voltammograms for polymers functionalized with diferrocenyl silane exhibited two well-separated reversible oxidation-reduction waves. This shows that the polymer bound ferrocenes bridged by silicon are electronically communicating and thus oxidation of the first ferrocene shifts the oxidation potential for the adjacent one. The polymers were utilized successfully for the preparation of modified electrodes with persistent and reproducible electrochemical response in organic solvents as well as in aqueous solution. The presented work has proven that ferrocenyl-functionalized hyperbranched polymers exhibit similar electrochemical properties as the analogous dendrimers. In a further approach it was shown that hyperbranched polymers containing organometallic moieties can be synthesized by polymerization of a new ferrocene-containing AB2 monomer - diallylferrocenylsilane. The second part of this work is dedicated to the preparation of core-functional hyperbranched polycarbosilanes. Low molecular weight ambifunctional molecules were synthesized that contain double bonds for the attachment of a polycarbosilane polymer as well as a second functionality available for further reaction and modification. Reactive vinyl groups in the core molecule allow an efficient attachment of hyperbranched polycarbosilane which was proven by MALDI-ToF and GPC. In combination with slow monomer addition techniques molecular weight and polydispersity of the polymers were controlled successfully. Core-functional polymers were characterized by NMR-spectroscopy, MALDI-ToF and GPC. Polymers with polydispersities <2 and molecular weights up to 5300g/mol were obtained. Transformation of the double bonds of the carbosilane was demonstrated with various silanes using hydrosilylation reaction or hydrogenation. Additionally, the core-functionality was varied resulting in polymers with bromo-, phthalimide-, amine- or azide moieties. Thus, a versatile synthetic strategy was developed that allows the synthesis of tailor-made polymers.A promising approach is the application of the polymer building blocks in copolymer synthesis. Bisglycidolization of amine-functional polycarbosilanes produces macro-initiators that are suitable for the multibranching-ring opening polymerization of glycidol. This experiments lead to the first example of hyperbranched-hyperbranched amphiphilic block copolymers, hb-PG-b-hb-PCS. Furthermore, the implementation of copper-catalyzed cycloaddition between azide-functional polycarbosilane and alkyne-functional poly(ethoxyethyl glycidylether) resulted in linear-hyperbranched block copolymers. The facile removal of acetal protecting groups provided convenient access to lin-PG-b-hb-PCS.

Temperatur- und ortsabhängige Zustandsdichte des organischen Supraleiters Kappa-(BEDT-TTF) 2 Cu[N(CN) 2]Br

Im Rahmen dieser Arbeit wurde die temperatur- und ortsabhängige Zustandsdichte des organischen Supraleiters kappa-(BEDT-TTF)2Cu[N(CN)2]Br mit Rastertunnelspektroskopie bei tiefen Temperaturen untersucht.rnZusätzlich zur bereits bekannten supraleitenden Energielücke wird dabei eine logarithmische Unterdrückung der Zustandsdichte an der Fermikante beobachtet, die auch oberhalb der kritischen Temperatur erhalten bleibt. In der vorliegenden Arbeit wird gezeigt, dass sich dieses Verhalten durch ein für ungeordnete elektronische Systeme entwickeltes Modell unter Berücksichtigung von Coulomb-Wechselwirkungen beschreiben lässt. Die daraus resultierenden Fluktuationen der elektronischen Struktur führen zu einer Verbreiterung der gemessenen supraleitenden Energielücke, die sich durch sehr kleine Kohärenzmaxima im entsprechenden Quasiteilchenanregungsspektrum äußert. Dieses Verhalten wurde bereits beobachtet, konnte jedoch bisher nicht erklärt werden. Die theoretische Beschreibung der logarithmischen Unterdrückung trägt somit zusätzlich zum Verständnis des supraleitenden Beitrags bei, sodass die gesamte Zustandsdichte vollständig beschrieben werden kann. Die Analyse der gemessenen supraleitenden Energielücke wurde für verschiedene Symmetrien des Ordnungsparameters durchgeführt, wobei die beste Übereinstimmung für die Annahme einer d-wellenartigen Symmetrie mit zwei unterschiedlich stark ausgeprägten Energielücken gefunden wurde. Der Paarbildungsmechanismus, der zur Bindung zweier Elektronen zu einem Cooper-Paar führt, kann mit einer $d$-wellenartigen Symmetrie nicht durch die in konventionellen Supraleitern gefundene Elektron-Phonon-Kopplung erklärt werden. Stattdessen wird in Analogie zur Hochtemperatur-Supraleitung eine durch antiferromagnetische Spin-Wechselwirkungen induzierte Kopplung der Elektronen vermutet. Dies wird zum einen durch die oberhalb der kritischen Temperatur auftretende, zweite Energielücke und zum anderen durch die zwischen 4,66 und 5,28 liegende Kopplungsstärke 2Delta/(kB Tc) unterstützt, die deutlich größer als für konventionelle Supraleiter mit Elektron-Phonon-Kopplung ist.

Einzelmolekülspektroskopische Untersuchung von Rylenfarbstoffen zur elektronischen Wechselwirkung in multichromophoren Systemen und zur thermischen Besetzung molekularer Schwingungszustände

Im ersten Teil der Arbeit wurde die Abstandsabhängigkeit des elektronischen Kopplungsverhaltens für eine homologe Reihe von Perylendiimid-Dimeren (PDI-(Ph)x-PDI, x=0-3) mithilfe der Einzelmolekülspektroskopie bei tiefen Temperaturen untersucht. Während für große Abstände überwiegend „schwache“ Kopplung dominierte, wurde für den kleinsten Abstand „starke“ Kopplung gefunden. Im Gegensatz dazu zeigte das p-Phenylen-verbrückte Dimer (x=1) in Abhängigkeit vom untersuchten Molekül ein für beide Grenzfälle typisches Verhalten. Hier entscheidet die Größe der Kopplungsstärke im Vergleich zum statischen Energieunterschied, welcher Kopplungsmechanismus vorliegt. Die homologe Reihe ermöglichte zusätzlich die quantitative Untersuchung der Abstandsabhängigkeit der elektronischen Kopplungsstärke im Grenzfall „schwacher“ Kopplung. Sie konnte direkt aus der zugrunde liegenden Energietransferdynamik ermittelt werden. Der Vergleich mit quantenchemisch berechneten Werten lieferte eine gute Übereinstimmung. Die Abweichung betrug lediglich 20%.rnIm zweiten Teil der Arbeit wurde die thermische Besetzung der Schwingungszustände einzelner Terrylen-Moleküle untersucht. Im elektronischen Grundzustand konnte sie mithilfe von anti-Stokes-Fluoreszenz infolge von „Hot Band“ Absorption nachgewiesen werden. Darüber hinaus wurde Fluoreszenz aus höheren Schwingungszuständen des elektronisch angeregten Zustandes gefunden, die auf „Hot Band“ Emission infolge von thermischer Besetzung zurückgeführt werden konnte. Durch die Kombination von Emissions- und Anregungsspektroskopie konnte die Temperaturabhängigkeit beider Prozesse im Temperaturbereich von 209-311 K untersucht werden. Sie folgt der Boltzmann-Statistik, was eine Temperaturmessung mit einzelnen Molekülen ermöglicht. rn

Compliance- und Lebensqualitätsmessung bei Patienten vor einer Nieren- oder Lebertransplantation

Die Arzneimittelcompliance hat eine hohe Vorhersagekraft für den Ausgang einer Organtransplantation. Allerdings wurden soweit keine Studien zur Arzneimittelcompliance mittels eletronischen Compliancemessung bei Dialyse- und Leberzirrhosepatienten durchgeführt. Das primäre Ziel dieser Studie war die Arzneimittelcompliance dieser beiden Patientenkollektive zu evaluieren und als sekundäres Ziel wurden die Einflussfaktoren von Non-Compliance untersucht. rnLeberzirrhosepatinten, die Propranolol und Dialysepatienten, die Phosphatbinder, jeweils 3 x tgl. einnahmen, konnten in der Studie teilnehmen. Die Arzneimittelcompliance wurde mittels MEMSTM über einen Zeitraum von jeweils 6 Monaten bestimmt. Des Weiteren wurde nach Einflussfaktoren wie die demopraphischen Daten, Depression, Lebensqualität und der Gesundheitszustand, bei den Dialysepatienten zusätzlich die Formulierung der Phosphatbinder und die Anzahl evaluiert. Zwischen den organinsuffizienten Patientenkollektiven war ein signifikanter Unterschied in der Dosing Compliancerate auszumachen (p<0,023). Die mittlere DC Rate war bei 61%±6% für Leberzirrhosepatienten im Vergleich zu 43%±5% in Dialysepatienten. Nur 10 Leberzirrhosepatienten (30%) and 6 Dialysepatienten (17%) konnten als compliant eingestuft werden. Je höher die Phosphatbinderdosen waren, umso niedrigere Dosing Complianceraten wurden erzielt. Bei 1,5-3 Tabletten pro Tag betrug die Compliancerate 55%±8% (n=16), bei 4-6 Tabletten pro Tag nur noch 37%±7% (n=15) und bei mehr als 7 Tabletten lediglich 21%±10% (n=5) (p<0,036). Bei den Dialysepatienten war jedoch auffällig, dass die Dosing Compliancerate in Abhängigkeit von der Anzahl der dokumentierten Erkrankungen inkl. Grunderkrankung stieg (Dosing Compliancerate 34%±9% für ≤1 Grunderkrankung, 42%±6% für 1-4 Komorbiditäten, 83%±3% für ≥5 Komorbiditäten; p<0,036).Das geringe Patientenwissen über die Arzneimittel und die Erkrankung und die niedrige Compliancerate bedürfen weitere Untersuchungen um die Aspekte zu verbessern. Diese Studie zeigte das eine pharmazeutische Betreuung schon vor einer Transplantation benötigt wird. Aber eine pharmazeutische Betreuung ist sehr kosten- und zeitintensiv. Vielleicht müssen neue Modelle der pharmazeutische Betreuung untersucht werden oder non-compliante Patienten müssen noch besser identifiziert werden für eine selektive pharmazeutische Betreuung.

Vergleichende, prospektive Untersuchung der Arzneimittelcompliance, Funktionskapazität und Lebensqualität bei Patienten mit Rheuma, die mit Methotrexat peroral oder subkutan behandelt werden

Um einen positiven Einfluss auf den Krankheitsverlauf bei Patienten mit Rheumatoider Arthritis zu nehmen, ist die Compliance mit dem Basistherapeutikum Methotrexat unerlässlich. Therapietreue mit Methotrexat kann die Krankheitsprogression verhindern und irreversiblen Knochenerosionen vorbeugen. Methotrexat wird sowohl in subkutaner als auch in peroraler Applikationsform verordnet. Im Rahmen der vorliegenden Arbeit wurde die Compliance mit der Anwendung von Methotrexat Fertigspritzen und Tabletten mit einer elektronischen Messmethode (MEMS™) bestimmt. Hauptziel der Studie war die Bestimmung der Taking Compliance mit Methotrexat. Untersucht wurde hinsichtlich eines Unterschieds zwischen der Applikationsform und der Erkrankungsdauer. Daneben wurde die Dosing Compliance mit peroralem Methotrexat erfasst, sowie Einschätzungen der Patienten bezüglich der Compliance, Funktionskapazität, Lebensqualität und Zufriedenheit erhoben. Die Compliancestudie erfolgte in Kooperation mit dem Netzwerk ADAPTHERA. 74 Studienpatienten wurden 3 Gruppen zugeteilt: Gruppe 1 Methotrexat p.o.; Gruppe 2 Methotrexat s.c. und Erkrankungsdauer <24 Monate; Gruppe 3 Methotrexat s.c. und Erkrankungsdauer >24 Monate. Die Beobachtungsdauer betrug bei peroraler Applikationsform 9 Monate und bei subkutaner 6 Monate. Im Median wurde eine Taking und Dosing Compliance von 100% gemessen. Anhand der subjektiven Einschätzung der Patienten zur Funktionskapazität konnten geringe Einschränkungen für die Patienten im Alltag verzeichnet werden. 25% des Studienkollektivs litt unter einem reduzierten Wohlbefinden. Die Studie konnte zeigen, dass Patienten von einer frühzeitigen Therapie und einer hohen Compliancerate profitieren.

Validation of the Swiss Monte Carlo Plan for a static and dynamic 6 MV photon beam

Monte Carlo (MC) based dose calculations can compute dose distributions with an accuracy surpassing that of conventional algorithms used in radiotherapy, especially in regions of tissue inhomogeneities and surface discontinuities. The Swiss Monte Carlo Plan (SMCP) is a GUI-based framework for photon MC treatment planning (MCTP) interfaced to the Eclipse treatment planning system (TPS). As for any dose calculation algorithm, also the MCTP needs to be commissioned and validated before using the algorithm for clinical cases. Aim of this study is the investigation of a 6 MV beam for clinical situations within the framework of the SMCP. In this respect, all parts i.e. open fields and all the clinically available beam modifiers have to be configured so that the calculated dose distributions match the corresponding measurements. Dose distributions for the 6 MV beam were simulated in a water phantom using a phase space source above the beam modifiers. The VMC++ code was used for the radiation transport through the beam modifiers (jaws, wedges, block and multileaf collimator (MLC)) as well as for the calculation of the dose distributions within the phantom. The voxel size of the dose distributions was 2mm in all directions. The statistical uncertainty of the calculated dose distributions was below 0.4%. Simulated depth dose curves and dose profiles in terms of [Gy/MU] for static and dynamic fields were compared with the corresponding measurements using dose difference and γ analysis. For the dose difference criterion of ±1% of D(max) and the distance to agreement criterion of ±1 mm, the γ analysis showed an excellent agreement between measurements and simulations for all static open and MLC fields. The tuning of the density and the thickness for all hard wedges lead to an agreement with the corresponding measurements within 1% or 1mm. Similar results have been achieved for the block. For the validation of the tuned hard wedges, a very good agreement between calculated and measured dose distributions was achieved using a 1%/1mm criteria for the γ analysis. The calculated dose distributions of the enhanced dynamic wedges (10°, 15°, 20°, 25°, 30°, 45° and 60°) met the criteria of 1%/1mm when compared with the measurements for all situations considered. For the IMRT fields all compared measured dose values agreed with the calculated dose values within a 2% dose difference or within 1 mm distance. The SMCP has been successfully validated for a static and dynamic 6 MV photon beam, thus resulting in accurate dose calculations suitable for applications in clinical cases.

Reduction of Transient Particulate Matter Spikes with Decision Tree Based Control

Decision trees have been proposed as a basis for modifying table based injection to reduce transient particulate spikes during the turbocharger lag period. It has been shown that decision trees can detect particulate spikes in real time. In well calibrated electronically controlled diesel engines these spikes are narrow and are encompassed by a wider NOx spike. Decision trees have been shown to pinpoint the exact location of measured opacity spikes in real time thus enabling targeted PM reduction with near zero NOx penalty. A calibrated dimensional model has been used to demonstrate the possible reduction of particulate matter with targeted injection pressure pulses. Post injection strategy optimized for near stoichiometric combustion has been shown to provide additional benefits. Empirical models have been used to calculate emission tradeoffs over the entire FTP cycle. An empirical model based transient calibration has been used to demonstrate that such targeted transient modifiers are more beneficial at lower engine-out NOx levels.

A Decision-Tree-Based Approach to Smoke Spike Detection in a Heavy-Duty Diesel Engine

Smoke spikes occurring during transient engine operation have detrimental health effects and increase fuel consumption by requiring more frequent regeneration of the diesel particulate filter. This paper proposes a decision tree approach to real-time detection of smoke spikes for control and on-board diagnostics purposes. A contemporary, electronically controlled heavy-duty diesel engine was used to investigate the deficiencies of smoke control based on the fuel-to-oxygen-ratio limit. With the aid of transient and steady state data analysis and empirical as well as dimensional modeling, it was shown that the fuel-to-oxygen ratio was not estimated correctly during the turbocharger lag period. This inaccuracy was attributed to the large manifold pressure ratios and low exhaust gas recirculation flows recorded during the turbocharger lag period, which meant that engine control module correlations for the exhaust gas recirculation flow and the volumetric efficiency had to be extrapolated. The engine control module correlations were based on steady state data and it was shown that, unless the turbocharger efficiency is artificially reduced, the large manifold pressure ratios observed during the turbocharger lag period cannot be achieved at steady state. Additionally, the cylinder-to-cylinder variation during this period were shown to be sufficiently significant to make the average fuel-to-oxygen ratio a poor predictor of the transient smoke emissions. The steady state data also showed higher smoke emissions with higher exhaust gas recirculation fractions at constant fuel-to-oxygen-ratio levels. This suggests that, even if the fuel-to-oxygen ratios were to be estimated accurately for each cylinder, they would still be ineffective as smoke limiters. A decision tree trained on snap throttle data and pruned with engineering knowledge was able to use the inaccurate engine control module estimates of the fuel-to-oxygen ratio together with information on the engine control module estimate of the exhaust gas recirculation fraction, the engine speed, and the manifold pressure ratio to predict 94% of all spikes occurring over the Federal Test Procedure cycle. The advantages of this non-parametric approach over other commonly used parametric empirical methods such as regression were described. An application of accurate smoke spike detection in which the injection pressure is increased at points with a high opacity to reduce the cumulative particulate matter emissions substantially with a minimum increase in the cumulative nitrogrn oxide emissions was illustrated with dimensional and empirical modeling.

A Model to Predict Percolation Threshold and Effective Conductivity of Infiltrated Electrodes for Solid Oxide Fuel Cells

We present a mechanistic modeling methodology to predict both the percolation threshold and effective conductivity of infiltrated Solid Oxide Fuel Cell (SOFC) electrodes. The model has been developed to mirror each step of the experimental fabrication process. The primary model output is the infiltrated electrode effective conductivity which provides results over a range of infiltrate loadings that are independent of the chosen electronically conducting material. The percolation threshold is utilized as a valuable output data point directly related to the effective conductivity to compare a wide range of input value choices. The predictive capability of the model is demonstrated by favorable comparison to two separate published experimental studies, one using strontium molybdate and one using La0.8Sr0.2FeO3-δ as infiltrate materials. Effective conductivities and percolation thresholds are shown for varied infiltrate particle size, pore size, and porosity with the infiltrate particle size having the largest impact on the results.

A Model to Predict Percolation Threshold and Effective Conductivity of Infiltrated Electrodes for Solid Oxide Fuel Cells

We present a mechanistic modeling methodology to predict both the percolation threshold and effective conductivity of infiltrated Solid Oxide Fuel Cell (SOFC) electrodes. The model has been developed to mirror each step of the experimental fabrication process. The primary model output is the infiltrated electrode effective conductivity which provides results over a range of infiltrate loadings that are independent of the chosen electronically conducting material. The percolation threshold is utilized as a valuable output data point directly related to the effective conductivity to compare a wide range of input value choices. The predictive capability of the model is demonstrated by favorable comparison to two separate published experimental studies, one using strontium molybdate and one using La0.8Sr0.2FeO3-delta as infiltrate materials. Effective conductivities and percolation thresholds are shown for varied infiltrate particle size, pore size, and porosity with the infiltrate particle size having the largest impact on the results. (C) 2013 The Electrochemical Society. All rights reserved.

Targeting p-Conjugated Multiple Donor-Acceptor Motifs Exemplified by Tetrathiafulvalene-Linked Quinoxalines and Tetrabenz bc,ef,hi,uv ovalenes: Synthesis, Spectroscopic, Electrochemical, and Theoretical Characterization

An efficient synthetic approach to a symmetrically functionalized tetrathiafulvalene (TTF) derivative with two diamine moieties, 2-[5,6-diamino-4,7-bis(4-pentylphenoxy)-1,3-benzodithiol-2-ylidene]-4,7- bis(4-pentylphenoxy)-1,3-benzodithiole-5,6-diamine (2), is reported. The subsequent Schiff-base reactions of 2 afford large p-conjugated multiple donoracceptor (DA) arrays, for example, the triad 2-[4,9-bis(4-pentylphenoxy)-1,3-dithiolo[4,5-g]quinoxalin-2-ylidene]-4,9 -bis(4-pentylphenoxy)-1,3-dithiolo[4,5-g]quinoxaline (8) and the corresponding tetrabenz[bc,ef,hi,uv]ovalene-fused pentad 1, in good yields and high purity. The novel redox-active nanographene 1 is so far the largest known TTF-functionalized polycyclic aromatic hydrocarbon (PAH) with a well-resolved 1H NMR spectrum. The electrochemically highly amphoteric pentad 1 and triad 8 exhibit various electronically excited charge-transfer states in different oxidation states, thus leading to intense optical intramolecular charge-transfer (ICT) absorbances over a wide spectral range. The chemical and electrochemical oxidations of 1 result in an unprecedented TTF+ radical cation dimerization, thereby leading to the formation of [1+]2 at room temperature in solution due to the stabilizing effect, which arises from strong pp interactions. Moreover, ICT fluorescence is observed with large solvent-dependent Stokes shifts and quantum efficiencies of 0.05 for 1 and 0.035 for 8 in dichloromethane.

Analysis and Prediction of Transient Opacity Spikes Using Dimensional Modeling

Dimensional modeling, GT-Power in particular, has been used for two related purposes-to quantify and understand the inaccuracies of transient engine flow estimates that cause transient smoke spikes and to improve empirical models of opacity or particulate matter used for engine calibration. It has been proposed by dimensional modeling that exhaust gas recirculation flow rate was significantly underestimated and volumetric efficiency was overestimated by the electronic control module during the turbocharger lag period of an electronically controlled heavy duty diesel engine. Factoring in cylinder-to-cylinder variation, it has been shown that the electronic control module estimated fuel-Oxygen ratio was lower than actual by up to 35% during the turbocharger lag period but within 2% of actual elsewhere, thus hindering fuel-Oxygen ratio limit-based smoke control. The dimensional modeling of transient flow was enabled with a new method of simulating transient data in which the manifold pressures and exhaust gas recirculation system flow resistance, characterized as a function of exhaust gas recirculation valve position at each measured transient data point, were replicated by quasi-static or transient simulation to predict engine flows. Dimensional modeling was also used to transform the engine operating parameter model input space to a more fundamental lower dimensional space so that a nearest neighbor approach could be used to predict smoke emissions. This new approach, intended for engine calibration and control modeling, was termed the "nonparametric reduced dimensionality" approach. It was used to predict federal test procedure cumulative particulate matter within 7% of measured value, based solely on steady-state training data. Very little correlation between the model inputs in the transformed space was observed as compared to the engine operating parameter space. This more uniform, smaller, shrunken model input space might explain how the nonparametric reduced dimensionality approach model could successfully predict federal test procedure emissions when roughly 40% of all transient points were classified as outliers as per the steady-state training data.

Computer-assisted, fluoroscopy-based ventral spondylodesis of thoracolumbar fractures

OBJECTIVE: To design and evaluate a novel computer-assisted, fluoroscopy-based planning and navigation system for minimally invasive ventral spondylodesis of thoracolumbar fractures. MATERIALS AND METHODS: Instruments and an image intensifier are tracked with the SurgiGATE navigation system (Praxim-Medivision). Two fluoroscopic images, one acquired from anterior-posterior (AP) direction and the other from lateral-medial (LM) direction, are used for the complete procedure of planning and navigation. Both of them are calibrated with a custom-made software to recover their projection geometry and to co-register them to a common patient reference coordinate system, which is established by attaching an opto-electronically trackable dynamic reference base (DRB) on the operated vertebra. A bi-planar landmark reconstruction method is used to acquire deep-seated anatomical landmarks such that an intraoperative planning of graft bed can be interactively done. Finally, surgical actions such as the placement of the stabilization devices and the formation of the graft bed using a custom-made chisel are visualized to the surgeon by superimposing virtual instrument representations onto the acquired images. The distance between the instrument tip and each wall of the planned graft bed are calculated on the fly and presented to the surgeon so that the surgeon could formalize the graft bed exactly according to his/her plan. RESULTS: Laboratory studies on phantom and on 27 plastic vertebras demonstrate the high precision of the proposed navigation system. Compared with CT-based measurement, a mean error of 1.0 mm with a standard deviation of 0.1 mm was found. CONCLUSIONS: The proposed computer assisted, fluoroscopy-based planning and navigation system promises to increase the accuracy and reliability of minimally invasive ventral spondylodesis of thoracolumbar fractures.

Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: a meta-analysis

While the benefits of intensified insulin treatment in insulin-dependent (Type 1) diabetes mellitus (IDDM) are well recognized, the risks have not been comprehensively characterized. We examined the risk of severe hypoglycaemia, ketoacidosis, and death in a meta-analysis of randomized controlled trials. The MEDLINE database, reference lists, and specialist journals were searched electronically or by hand to identify relevant studies with at least 6 months of follow-up and the monitoring of glycaemia by glycosylated haemoglobin measurements. Logistic regression was used for calculation of combined odds ratios and 95% confidence intervals (95% CI). The influence of covariates was examined by including covariate-by-treatment interaction terms. Methodological study quality was assessed and sensitivity analyses were performed. Fourteen trials were identified. These contributed 16 comparisons with 1028 patients allocated to intensified and 1039 allocated to conventional treatment. A total of 846 patients suffered at least one episode of severe hypoglycaemia, 175 patients experienced ketoacidosis and 26 patients died. The combined odds ratio (95% CI) for hypoglycaemia was 2.99 (2.45-3.64), for ketoacidosis 1.74 (1.27-2.38) and for death from all causes 1.40 (0.65-3.01). The risk of severe hypoglycaemia was determined by the degree of normalization of glycaemia achieved (p=0.005 for interaction term), with the results from the Diabetes Control and Complications Trial (DCCT) in line with the other trials. Ketoacidosis risk depended on the type of intensified treatment used. Odds ratios (95% CI) were 7.20 (2.95-17.58) for exclusive use of pumps, 1.13 (0.15-8.35) for multiple daily injections and 1.28 (0.90-1.83) for trials offering a choice between the two (p = 0.004 for interaction). Mortality was significantly (p = 0.007) increased for causes potentially associated with acute complications (7 vs 0 deaths, 5 deaths attributed to ketoacidosis, and 2 sudden deaths), and non-significantly (p = 0.16) decreased for macrovascular causes (3 vs 8 deaths). We conclude that there is a substantial risk of severe adverse effects associated with intensified insulin treatment. Mortality from acute metabolic causes is increased; however, this is largely counterbalanced by a reduction in cardiovascular mortality. The excess of severe hypoglycemia in the DCCT is not exceptional. Multiple daily injection schemes may be safer than treatment with insulin pumps.

Feasibility and acceptance of electronic quality of life assessment in general practice: an implementation study

Background Patients' health related quality of life (HRQoL) has rarely been systematically monitored in general practice. Electronic tools and practice training might facilitate the routine application of HRQoL questionnaires. Thorough piloting of innovative procedures is strongly recommended before the conduction of large-scale studies. Therefore, we aimed to assess i) the feasibility and acceptance of HRQoL assessment using tablet computers in general practice, ii) the perceived practical utility of HRQoL results and iii) to identify possible barriers hindering wider application of this approach. Methods Two HRQoL questionnaires (St. George's Respiratory Questionnaire SGRQ and EORTC QLQ-C30) were electronically presented on portable tablet computers. Wireless network (WLAN) integration into practice computer systems of 14 German general practices with varying infrastructure allowed automatic data exchange and the generation of a printout or a PDF file. General practitioners (GPs) and practice assistants were trained in a 1-hour course, after which they could invite patients with chronic diseases to fill in the electronic questionnaire during their waiting time. We surveyed patients, practice assistants and GPs regarding their acceptance of this tool in semi-structured telephone interviews. The number of assessments, HRQoL results and interview responses were analysed using quantitative and qualitative methods. Results Over the course of 1 year, 523 patients filled in the electronic questionnaires (1–5 times; 664 total assessments). On average, results showed specific HRQoL impairments, e.g. with respect to fatigue, pain and sleep disturbances. The number of electronic assessments varied substantially between practices. A total of 280 patients, 27 practice assistants and 17 GPs participated in the telephone interviews. Almost all GPs (16/17 = 94%; 95% CI = 73–99%), most practice assistants (19/27 = 70%; 95% CI = 50–86%) and the majority of patients (240/280 = 86%; 95% CI = 82–91%) indicated that they would welcome the use of electronic HRQoL questionnaires in the future. GPs mentioned availability of local health services (e.g. supportive, physiotherapy) (mean: 9.4 ± 1.0 SD; scale: 1 – 10), sufficient extra time (8.9 ± 1.5) and easy interpretation of HRQoL results (8.6 ± 1.6) as the most important prerequisites for their use. They believed HRQoL assessment facilitated both communication and follow up of patients' conditions. Practice assistants emphasised that this process demonstrated an extra commitment to patient centred care; patients viewed it as a tool, which contributed to the physicians' understanding of their personal condition and circumstances. Conclusion This pilot study indicates that electronic HRQoL assessment is technically feasible in general practices. It can provide clinically significant information, which can either be used in the consultation for routine care, or for research purposes. While GPs, practice assistants and patients were generally positive about the electronic procedure, several barriers (e.g. practices' lack of time and routine in HRQoL assessment) need to be overcome to enable broader application of electronic questionnaires in every day medical practice.