Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications

BACKGROUND: Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). METHODS AND RESULTS: Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). CONCLUSIONS: The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients.

Diffusion of contrast medium after perineural injection of the palmar nerves: an in vivo and in vitro study

REASONS FOR PERFORMING STUDY: Proximal diffusion of local anaesthetic solution after perineural anaesthesia may lead to the desensitisation of structures other than those intended. However, there is no evidence-based study demonstrating the potential distribution and diffusion of local anaesthetic solution after perineural analgesia in the distal limb. OBJECTIVE: To document the potential diffusion of local anaesthetic solution using a radiopaque contrast model and to evaluate the influence of walking compared with confinement in a stable after injection. METHODS: Radiopaque contrast medium was injected subcutaneously over one palmar nerve at the base of the proximal sesamoid bones in 6 nonlame mature horses. Horses were assigned randomly to stand still or walk after injection. Radiographs were obtained 0, 5, 10, 15, 20 and 30 min after injection and were analysed to determine the distribution and diffusion of the contrast medium. RESULTS: In 89% of injections an elongated pattern of the contrast medium was observed suggesting distribution along the neurovascular bundle. After 49% of injections a fine radiopaque line extended proximally from the contrast 'patch', and in 25% of injections a line extended distally. There was significant proximal and distal diffusion with time when sequential radiographs of each limb were compared. The greatest diffusion occurred in the first 10 min. Walking did not significantly influence the extent of either proximal or distal diffusion. CONCLUSIONS AND POTENTIAL RELEVANCE: Significant proximal diffusion occurs in the first 10 min after perineural injection in the distal aspect of the limb and should be considered when interpreting nerve blocks. Distribution of local anaesthetic solution outside the fascia surrounding the neurovascular bundle or in lymphatic vessels may explain delayed or decreased effects.

«Wir stehen da, gefesselte Betrachter». Theater und Gesellschaft

Das Theater inszeniert eine Spielwirklichkeit, die von der gesellschaftlichen Wirklichkeit nie ganz zu trennen ist - und, je nach Ansatz, auch nicht zu trennen sein soll. Die historischen und aktuellen Formen von Theater und ihre gesellschaftlichen Wechselwirkungen sind vielfältig und reichen von der Inszenierung der Gemeinschaft und Konstruktion nationaler Identität im Festspiel zu Krisenzeiten bis zu den Versuchsanordnungen, mit welchen Lukas Bärfuss gesellschaftliche Phänomene der Gegenwart in einem Kontext des postdramatischen Theaters freilegt. Zeigt sich bei Friedrich Dürrenmatt und Max Frisch ein je grundlegend divergierendes Verhältnis zur Möglichkeit einer Entwicklung zum Besseren, so zählt Rolf Hochhuth auf die aufklärerische Wirkung des Dokumentarischen. In den Theatertexten von Thomas Hürlimann spiegelt sich eine Schweizer Gesellschaft, die sich als Theater-Zuschauerin der sie umgebenden Katastrophen konstituiert. Die Spannung zwischen literarischem Text und Praxis des Regietheaters, wie sie für die Multimedialität des Theaters charakteristisch ist, zeigt sich exemplarisch in den Erfahrungen der Autorin Maja Beutler. Mit Texten von: Ursula Amrein, Lukas Bärfuss, Peter von Matt, Franziska Kolp, Elio Pellin, Rudolf Probst, Ursula Ruch, Peter Utz und Ulrich Weber

Detecting offsets in GPS time series: first results from the Detection of Offsets in GPS Experiment

The accuracy of Global Positioning System (GPS) time series is degraded by the presence of offsets. To assess the effectiveness of methods that detect and remove these offsets, we designed and managed the Detection of Offsets in GPS Experiment. We simulated time series that mimicked realistic GPS data consisting of a velocity component, offsets, white and flicker noises (1/f spectrum noises) composed in an additive model. The data set was made available to the GPS analysis community without revealing the offsets, and several groups conducted blind tests with a range of detection approaches. The results show that, at present, manual methods (where offsets are hand picked) almost always give better results than automated or semi‒automated methods (two automated methods give quite similar velocity bias as the best manual solutions). For instance, the fifth percentile range (5% to 95%) in velocity bias for automated approaches is equal to 4.2 mm/year (most commonly ±0.4 mm/yr from the truth), whereas it is equal to 1.8 mm/yr for the manual solutions (most commonly 0.2 mm/yr from the truth). The magnitude of offsets detectable by manual solutions is smaller than for automated solutions, with the smallest detectable offset for the best manual and automatic solutions equal to 5 mm and 8 mm, respectively. Assuming the simulated time series noise levels are representative of real GPS time series, robust geophysical interpretation of individual site velocities lower than 0.2–0.4 mm/yr is therefore certainly not robust, although a limit of nearer 1 mm/yr would be a more conservative choice. Further work to improve offset detection in GPS coordinates time series is required before we can routinely interpret sub‒mm/yr velocities for single GPS stations.

Three decades of global methane sources and sinks

Methane is an important greenhouse gas, responsible for about 20 of the warming induced by long-lived greenhouse gases since pre-industrial times. By reacting with hydroxyl radicals, methane reduces the oxidizing capacity of the atmosphere and generates ozone in the troposphere. Although most sources and sinks of methane have been identified, their relative contributions to atmospheric methane levels are highly uncertain. As such, the factors responsible for the observed stabilization of atmospheric methane levels in the early 2000s, and the renewed rise after 2006, remain unclear. Here, we construct decadal budgets for methane sources and sinks between 1980 and 2010, using a combination of atmospheric measurements and results from chemical transport models, ecosystem models, climate chemistry models and inventories of anthropogenic emissions. The resultant budgets suggest that data-driven approaches and ecosystem models overestimate total natural emissions. We build three contrasting emission scenarios � which differ in fossil fuel and microbial emissions � to explain the decadal variability in atmospheric methane levels detected, here and in previous studies, since 1985. Although uncertainties in emission trends do not allow definitive conclusions to be drawn, we show that the observed stabilization of methane levels between 1999 and 2006 can potentially be explained by decreasing-to-stable fossil fuel emissions, combined with stable-to-increasing microbial emissions. We show that a rise in natural wetland emissions and fossil fuel emissions probably accounts for the renewed increase in global methane levels after 2006, although the relative contribution of these two sources remains uncertain.

Baylor History of Medicine Society Schedule 2007-2008

"Medicine: Perspectives in History and Art" (Robert E. Greenspan) Eight Practical Lessons from Osler That Will Better Your Life (Bryan Boutwell) History of the American Mental Hospital: From networking to not working & Back (Ed Fann) Ambiguities and Amputations: Methods, mishaps, and the surgical quest to cure breast cancer (Student Essay Contest Winner) (Matt Luedke) An Automated, Algorithmic, Retrospective Analysis of the Growing Influence of Statistics in Medicine (Student Essay Contest Winner) (Ryan Rochat) What’s Special about William Osler? (Charles S. Bryan) The Virtuous Physician: Lessons from Medical Biography (Charles S. Bryan) Legacy: 50 Years of Loving Care – The History of Texas Children’s Hospital, 1954-2004 (Betsy Parish) The Education of a University President: Edgar Odell Lovett of Rice University (John B. Boles) Artists and Illness: The Effect of Illness on an Artist’s Work (David Bybee)

Paleoclimate data-model comparison and the role of climate forcings over the past 1500 years

The past 1500 years provide a valuable opportunity to study the response of the climate system to external forcings. However, the integration of paleoclimate proxies with climate modeling is critical to improving the understanding of climate dynamics. In this paper, a climate system model and proxy records are therefore used to study the role of natural and anthropogenic forcings in driving the global climate. The inverse and forward approaches to paleoclimate data–model comparison are applied, and sources of uncertainty are identified and discussed. In the first of two case studies, the climate model simulations are compared with multiproxy temperature reconstructions. Robust solar and volcanic signals are detected in Southern Hemisphere temperatures, with a possible volcanic signal detected in the Northern Hemisphere. The anthropogenic signal dominates during the industrial period. It is also found that seasonal and geographical biases may cause multiproxy reconstructions to overestimate the magnitude of the long-term preindustrial cooling trend. In the second case study, the model simulations are compared with a coral δ18O record from the central Pacific Ocean. It is found that greenhouse gases, solar irradiance, and volcanic eruptions all influence the mean state of the central Pacific, but there is no evidence that natural or anthropogenic forcings have any systematic impact on El Niño–Southern Oscillation. The proxy climate relationship is found to change over time, challenging the assumption of stationarity that underlies the interpretation of paleoclimate proxies. These case studies demonstrate the value of paleoclimate data–model comparison but also highlight the limitations of current techniques and demonstrate the need to develop alternative approaches.

Reconstructing Disturbances and Their Biogeochemical Consequences over Multiple Timescales

Ongoing changes in disturbance regimes are predicted to cause acute changes in ecosystem structure and function in the coming decades, but many aspects of these predictions are uncertain. A key challenge is to improve the predictability of postdisturbance biogeochemical trajectories at the ecosystem level. Ecosystem ecologists and paleoecologists have generated complementary data sets about disturbance (type, severity, frequency) and ecosystem response (net primary productivity, nutrient cycling) spanning decadal to millennial timescales. Here, we take the first steps toward a full integration of these data sets by reviewing how disturbances are reconstructed using dendrochronological and sedimentary archives and by summarizing the conceptual frameworks for carbon, nitrogen, and hydrologic responses to disturbances. Key research priorities include further development of paleoecological techniques that reconstruct both disturbances and terrestrial ecosystem dynamics. In addition, mechanistic detail from disturbance experiments, long-term observations, and chronosequences can help increase the understanding of ecosystem resilience.

Climate refugia: joint inference from fossil records, species distribution models and phylogeography

Climate refugia, locations where taxa survive periods of regionally adverse climate, are thought to be critical for maintaining biodiversity through the glacial–interglacial climate changes of the Quaternary. A critical research need is to better integrate and reconcile the three major lines of evidence used to infer the existence of past refugia – fossil records, species distribution models and phylogeographic surveys – in order to characterize the complex spatiotemporal trajectories of species and populations in and out of refugia. Here we review the complementary strengths, limitations and new advances for these three approaches. We provide case studies to illustrate their combined application, and point the way towards new opportunities for synthesizing these disparate lines of evidence. Case studies with European beech, Qinghai spruce and Douglas-fir illustrate how the combination of these three approaches successfully resolves complex species histories not attainable from any one approach. Promising new statistical techniques can capitalize on the strengths of each method and provide a robust quantitative reconstruction of species history. Studying past refugia can help identify contemporary refugia and clarify their conservation significance, in particular by elucidating the fine-scale processes and the particular geographic locations that buffer species against rapidly changing climate.

Terrestrial and submarine evidence for the extent and timing of the Last Glacial Maximum and the onset of deglaciation on the maritime-Antarctic and sub-Antarctic islands

This paper is the maritime and sub–Antarctic contribution to the Scientific Committee for Antarctic Research (SCAR) Past Antarctic Ice Sheet Dynamics (PAIS) community Antarctic Ice Sheet reconstruction. The overarching aim for all sectors of Antarctica was to reconstruct the Last Glacial Maximum (LGM) ice sheet extent and thickness, and map the subsequent deglaciation in a series of 5000 year time slices. However, our review of the literature found surprisingly few high quality chronological constraints on changing glacier extents on these timescales in the maritime and sub–Antarctic sector. Therefore, in this paper we focus on an assessment of the terrestrial and offshore evidence for the LGM ice extent, establishing minimum ages for the onset of deglaciation, and separating evidence of deglaciation from LGM limits from those associated with later Holocene glacier fluctuations. Evidence included geomorphological descriptions of glacial landscapes, radiocarbon dated basal peat and lake sediment deposits, cosmogenic isotope ages of glacial features and molecular biological data. We propose a classification of the glacial history of the maritime and sub–Antarctic islands based on this assembled evidence. These include: (Type I) islands which accumulated little or no LGM ice; (Type II) islands with a limited LGM ice extent but evidence of extensive earlier continental shelf glaciations; (Type III) seamounts and volcanoes unlikely to have accumulated significant LGM ice cover; (Type IV) islands on shallow shelves with both terrestrial and submarine evidence of LGM (and/or earlier) ice expansion; (Type V) Islands north of the Antarctic Polar Front with terrestrial evidence of LGM ice expansion; and (Type VI) islands with no data. Finally, we review the climatological and geomorphological settings that separate the glaciological history of the islands within this classification scheme.

Off-pump compared to minimal extracorporeal circulation surgery in coronary artery bypass grafting.

OBJECTIVE Coronary artery bypass grafting (CABG) using extracorporeal circulation (ECC) is still the gold standard. However, alternative techniques have been developed to avoid ECC and its potential adverse effects. These encompass minimal extracorporeal circulation (MECC) or off-pump coronary artery bypass grafting (OPCAB). However, the prevailing potential benefits when comparing MECC and OPCABG are not yet clearly established. METHODS In this retrospective study we investigated the potential benefits of MECC and OPCABG in 697 patients undergoing CABG. Of these, 555 patients had been operated with MECC and 142 off-pump. The primary endpoint was Troponin T level as an indicator for myocardial damage. RESULTS Study groups were not significantly different in general. However, patients undergoing OPCABG were significantly older (65.01 years ± 9.5 vs. 69.39 years ± 9.5; p value <0.001) with a higher Logistic EuroSCORE I (4.92% ± 6.5 vs. 5.88% ± 6.8; p value = 0.017). Operating off pump significantly reduced the need for intra-operative blood products (0.7% vs. 8.6%; p-value <0.001) and the length of stay in the intensive care unit (ICU) (2.04 days ± 2.63 vs. 2.76 days ± 2.79; p value <0.001). Regarding other blood values a significant difference could not be found in the adjusted calculations. The combined secondary endpoint, major cardiac or cerebrovascular events (MACCE), was equal in both groups as well. CONCLUSIONS Coronary artery bypass grafting using MECC or OPCABG are two comparable techniques with advantages for OPCABG regarding the reduced need for intra-operative blood products and shorter length of stay in the ICU. However serological values and combined endpoint MACCE did not differ significantly in both groups.