Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling

OBJECTIVE: To analyse decompressive hemicraniectomy (DHC) in patients with aneurysmal subarachnoid haemorrhage (SAH) with regard to infarction, haemorrhage or brain swelling. METHODS: DHC was performed in 43 of 787 patients with SAH. Patients were stratified according to (1) primary brain swelling without and (2) with additional intracerebral haematoma, (3) secondary brain swelling without rebleeding or infarcts and (4) with infarcts or (5) with rebleeding. Outcome was assessed according to the modified Rankin scale at 6 months RESULTS: Overall, 36 of 43 patients (83.7%) with DHC and 241 of 744 patients (32.4%) without DHC have been of a poor grade on admission (World Federation of Neurological Societies grading 4-5; p<0.0001). Favourable outcome was achieved in 11 of 43 (25.6%) patients with DHC. There was no difference in favourable outcome after primary (25%) versus secondary (26.1%) DHC (p = 1.0). Subgroup analysis (brain swelling vs bleeding vs infarcts) revealed no difference in the rate of favourable outcome. In a multivariate analysis, acute hydrocephalus (p = 0.02) and clinical herniation (p = 0.03) were significantly associated with unfavourable outcome. CONCLUSIONS: We conclude that primary and secondary hemicraniectomy may be warranted, irrespective of the underlying aetiology-infarction, haemorrhage or brain swelling. The time from onset of intractable ICP to DHC seems to be crucial, rather than the time from SAH to DHC.

Climate-induced interannual variability of marine primary and export production in three global coupled climate carbon cycle models

Fully coupled climate carbon cycle models are sophisticated tools that are used to predict future climate change and its impact on the land and ocean carbon cycles. These models should be able to adequately represent natural variability, requiring model validation by observations. The present study focuses on the ocean carbon cycle component, in particular the spatial and temporal variability in net primary productivity (PP) and export production (EP) of particulate organic carbon (POC). Results from three coupled climate carbon cycle models (IPSL, MPIM, NCAR) are compared with observation-based estimates derived from satellite measurements of ocean colour and results from inverse modelling (data assimilation). Satellite observations of ocean colour have shown that temporal variability of PP on the global scale is largely dominated by the permanently stratified, low-latitude ocean (Behrenfeld et al., 2006) with stronger stratification (higher sea surface temperature; SST) being associated with negative PP anomalies. Results from all three coupled models confirm the role of the low-latitude, permanently stratified ocean for anomalies in globally integrated PP, but only one model (IPSL) also reproduces the inverse relationship between stratification (SST) and PP. An adequate representation of iron and macronutrient co-limitation of phytoplankton growth in the tropical ocean has shown to be the crucial mechanism determining the capability of the models to reproduce observed interactions between climate and PP.

Walter Friedländer (1891-1984) – Between Social Democracy and Social Darwinism

If the profession of social work is to have a future we must know where it came from, and the series of portraits of our pioneers is one of the paths into the origins of that profession. I feel grateful to the publishers for this online-journal and also honoured to be asked to continue the series on pioneers in social work. I gladly comply because, in connection with my research on Alice Salomon and other social workers who were expelled from Germany and other Nazi-occupied territories (Wieler1989 and 1995) I had the pleasure and privilege of meeting and interviewing Walter Friedländer shortly before he passed away. It is years ago that I visited him in his home among stacks of books and piles of papers. My memories are vivid. I still see his sparkling eyes and hear his soft voice with a very heavy German accent. I was most impressed by his memory of historical events and people which, it seemed, only a large hard-drive could retain these days. Now, I wish I had asked more questions but instead, we will have to rely largely on primary and secondary literature and box upon box of archival materials. I draw heavily on the comprehensive German and Jewish Intellectual Emigré Collection (http://library.albany.edu/speccoll/findaids/ger003.htm) which consists of nearly 50 cubic feet and another collection of the German Central Institute („Deutsches Zentralinstitut für Soziale Fragen-DZI“) in Berlin (www.dzi.de). Some of the more current archival materials were lost in a flood, and much of Friedländer’s early memorabilia up to 1933 was lost in Germany. There are also internet resources with widely differing information. I hope that I will not have overlooked too much in order to do justice to this remarkable pioneer and colleague. In order to appreciate and pay tribute to Walter Friedländer and his contributions we will have to reconsider the historical and international context of more than the 93 years of his life span: the German Monarchy, the Weimar Republic, Nazi-Fascism, Swiss, French and American exile and numerous visits to other countries.

Virtual characters designed for forensic assessment and rehabilitation of sex offenders: standardized and made-to-measure

This paper presents two studies pertaining to the use of virtual characters applied in clinical forensic rehabilitation of sex offenders. The first study is about the validation of the perceived age of virtual characters designed to simulate primary and secondary sexual character of typical adult and child individuals. The second study puts to use these virtual characters in comparing a group of sex offenders and a group of non deviant individuals on their sexual arousal responses as recorded in virtual immersion. Finally, two clinical vignettes illustrating the use of made-to-measure virtual characters to more closely fit sexual preferences are presented in Discussion.

Clinically-driven need for secondary interventions after endovascular revascularization of tibial arteries in patients with critical limb ischemia

PURPOSE To assess the need for clinically-driven secondary revascularization in critical limb ischemia (CLI) patients subsequent to tibial angioplasty during a 2-year follow-up. METHODS Between 2008 and 2010, a total of 128 consecutive CLI patients (80 men; mean age 76.5±9.8 years) underwent tibial angioplasty in 139 limbs. Rutherford categories, ankle-brachial index measurements, and lower limb oscillometries were prospectively assessed. All patients were followed at 3, 6, 12 months, and annually thereafter. Rates of death, primary and secondary sustained clinical improvement, target lesion (TLR) and target extremity revascularization (TER), as well as major amputation, were analyzed retrospectively. Primary clinical improvement was defined as improvement in Rutherford category to a level of intermittent claudication without unplanned amputation or TLR. RESULTS All-cause mortality was 8.6%, 14.8%, 22.9%, and 29.1% at 3, 6, 12, and 24 months. At the same intervals, rates of primary sustained clinical improvement were 74.5%, 53.0%, 42.7%, and 37.1%; for secondary improvement, the rates were 89.1%, 76.0%, 68.4%, and 65.0%. Clinically-driven TLR rates were 14.6%, 29.1%, 41.6%, 46.2%; the rates for TER were 3.0%, 13.6%, 17.2%, and 27.6% in corresponding intervals, while the rates of major amputation were 1.5%, 5.5%, 10.1%, and 10.1%. CONCLUSION Clinically-driven TLR is frequently required to maintain favorable functional clinical outcomes in CLI patients following tibial angioplasty. Dedicated technologies addressing tibial arterial restenosis warrant further academic scrutiny.

Responses of lung cells to realistic exposure of primary and aged carbonaceous aerosols

Diesel exhaust and wood burning are important sources of ambient atmospheric particles due to increasing numbers of diesel cars and the importance of wood as a source of renewable energy. Inhalation is the predominant route of entry and uptake for fine and ultrafine particles into the body. Health effects of atmospheric particles are still not completely understood. There is consistent evidence from epidemiology that particle exposure contributes to respiratory and cardiovascular diseases. This study aimed at examining acute responses of airway epithelial cells and luminal macrophages after exposure to freshly emitted and photochemically aged carbonaceous aerosols under realistic atmospheric conditions. In addition to a bronchial epithelial cell line advanced cell cultures namely fully differentiated respiratory epithelia and primary surface macrophages were used. Our results demonstrate that a single exposure of the cells to realistic particle doses of 0.3–3 ng diesel or 3–9 ng wood aerosol per cm2 cell surface induces small, particle-specific responses. The release of interleukin-6 and -8 was found to be decreased in differentiated airway epithelia but not in the other cell models studied. Aerosol exposure decreased macrophage phagocytic activity by 45–90%. Cell and tissue integrity remained unaffected. Overall, primary and aged particles from the same combustion induced similar responses in the cell models tested, whereby particles from diesel exhaust affected the cells more than those from wood combustion.

Migrant Background and Higher Education Participation in Europe. The Effect of the Educational Systems

The main aim of this article is to shed light on the extent to which differences in higher education participation between people with and without a migrant background of low/higher social origin can be explained by two macro-level characteristics of national educational institutions: stratification of the secondary school system and provision of alternative access to higher education. General assumptions are that people with a migrant background of low social origin benefit in low-stratified secondary school systems and in systems that provide alternative access to institutions of higher education more than their native peers in the same social stratum, owing to primary and secondary effects of migrant background. Database is a pooled dataset of the five waves of the European Social Survey. Results of logistic multi-level analyses indicate that a low-stratified secondary school system improves the probability of people with a migrant background/low social origin attaining a higher education degree. On the other hand, a stratified secondary school system reduces their chances regarding this educational stage. The provision of alternative access to an institution of higher education improves their likelihood of becoming higher education graduates.

Gender differences at the transition to higher education between migrants and non-migrants: A comparison between Switzerland and France

Within Western societies women or girls meanwhile outperform men or boys with regard to attainments in primary and secondary education. For example concerning upper secondary degrees the share of females attaining the Matura approaches two thirds in Switzerland, while the share of females attaining the Baccalaureate exceeds fifty per cent in France. However, if transitions to higher education are regarded, the share of entitled females entering such institutions is significantly lower than among men in Switzerland. An opposite pattern is observed in France where females outperform men at this educational stage, too. With regard to migrant background, it has been shown by previous research focussing on secondary effects of ethnic origin that such youths enter the more demanding educational tracks (e.g. higher education) more often than their non-migrant peers if controlled for eligibility, their lower socioeconomic status and performances. However, so far only a few studies refer to the question of a possible gender gap regarding secondary effects of ethnic origin (e.g. Fleischmann et al., mimeo). Thus, with regard to a possible interaction of a migrant background and - for example - a female gender, it is important to note that in both countries many migrant groups have their origins in countries and regions where male advantage remains very strong. This is in particular the case for migrant groups from non-Western countries, e.g. Turkey, Algeria, Marocco or Tunisie, where gender gaps in the literacy rates of up to 18 per cent are still observed. In order to investigate the question of a possible disadvantages of women with a migrant background stemming from such countries when compared to non-migrant females two panel studies - the Tree data in Switzerland and the Panel d’élèves 1995 in France -, are analysed.

IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial

BACKGROUND The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate "patient-centric" outcomes of functional limb preservation, mobility and quality of life (QoL). METHODS/DESIGN IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. DISCUSSION This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. TRIAL REGISTRATION NCT00941733

Effect of ticagrelor on the outcomes of patients with prior coronary artery bypass graft surgery: insights from the PLATelet inhibition and patient outcomes (PLATO) trial

BACKGROUND Patients with prior coronary artery bypass graft surgery (CABG) who present with an acute coronary syndrome have a high risk for recurrent events. Whether intensive antiplatelet therapy with ticagrelor might be beneficial compared with clopidogrel is unknown. In this substudy of the PLATO trial, we studied the effects of randomized treatment dependent on history of CABG. METHODS Patients participating in PLATO were classified according to whether they had undergone prior CABG. The trial's primary and secondary end points were compared using Cox proportional hazards regression. RESULTS Of the 18,613 study patients, 1,133 (6.1%) had prior CABG. Prior-CABG patients had more high-risk characteristics at study entry and a 2-fold increase in clinical events during follow-up, but less major bleeding. The primary end point (composite of cardiovascular death, myocardial infarction, and stroke) was reduced to a similar extent by ticagrelor among patients with (19.6% vs 21.4%; adjusted hazard ratio [HR], 0.91 [0.67, 1.24]) and without (9.2% vs 11.0%; adjusted HR, 0.86 [0.77, 0.96]; P(interaction) = .73) prior CABG. Major bleeding was similar with ticagrelor versus clopidogrel among patients with (8.1% vs 8.7%; adjusted HR, 0.89 [0.55, 1.47]) and without (11.8% vs 11.4%; HR, 1.08 [0.98, 1.20]; P(interaction) = .46) prior CABG. CONCLUSIONS Prior-CABG patients presenting with acute coronary syndrome are a high-risk cohort for death and recurrent cardiovascular events but have a lower risk for major bleeding. Similar to the results in no-prior-CABG patients, ticagrelor was associated with a reduction in ischemic events without an increase in major bleeding.

Salivary Contamination and Decontamination: Bond Strength to Dentin of Primary and Permanent Teeth

Aim: To evaluate the effects of salivary contamination and decontamination on bond strength of two one-step adhesives to primary and permanent dentin. Methods: Dentin specimens were prepared from extracted primary and permanent molars (210 of each) and were distributed to seven groups (n=15/group/molar type) for each adhesive (Xeno V+ and Scotchbond Universal): no saliva contamination (control); saliva contamination before or after light-curing of the adhesives followed either by air-drying, by rinsing with water and air-drying, or by rinsing with water, air-drying and reapplication of the adhesives. Resin composite was applied and the specimens were stored for 24h (37°C, 100% humidity). Then, shear bond strength (SBS) was measured and data analyzed with nonparametric ANOVA and Wilcoxon rank sum tests. Results: Saliva contamination reduced SBS of Xeno V+, the reduction being more pronounced when contamination occurred before light-curing than after. In both situations, decontamination involving reapplication of the adhesive restored SBS. Saliva contamination had no significant effect on Scotchbond Universal. There were no differences in SBS between primary and permanent teeth. Conclusion: Saliva contamination reduced SBS of Xeno V+, but not of Scotchbond Universal. SBS was restored when contaminated dentin was rinsed with water and air-dried followed by reapplication of the adhesive.

Effect of Salivary Contamination and Decontamination on Bond Strength of Two One-Step Self-Etching Adhesives to Dentin of Primary and Permanent Teeth

Purpose: To evaluate the effects of human saliva contamination and two decontamination procedures at different stages of the bonding procedure on the bond strength of two one-step self-etching adhesives to primary and permanent dentin. Materials and Methods: Extracted human primary and permanent molars (210 of each) were ground to mid-coronal dentin. The dentin specimens were randomly divided into 7 groups (n = 15/group/molar type) for each adhesive (Xeno V+ and Scotchbond Universal): no saliva contamination (control); saliva contamination before or after light curing of the adhesives followed by air drying, rinsing with water spray/air drying, or by rinsing with water spray/air drying/reapplication of the adhesives. Resin composite (Filtek Z250) was applied on the treated dentin surfaces. The specimens were stored at 37°C and 100% humidity for 24 h. After storage, shear bond strength (SBS) was measured and data analyzed with nonparametric ANOVA followed by exact Wilcoxon rank sum tests. Results: Xeno V+ generated significantly higher SBS than Scotchbond Universal when no saliva contamination occurred. Saliva contamination reduced SBS of Xeno V+, with the reduction being more pronounced when contamination occurred before light curing than after. In both situations, decontamination involving reapplication of the adhesive restored SBS. Saliva contamination had no significant effect on Scotchbond Universal. There were no differences in SBS between primary and permanent teeth. Conclusion: Rinsing with water and air drying followed by reapplication of the adhesive restored bond strength to saliva-contaminated dentin.