Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution

Continuing aortic neck dilatation, most probably an expression of ongoing aneurysmal wall degeneration of the infrarenal aortic segment, has been shown to seriously impair clinical results after endovascular abdominal aortic aneurysm repair. However, conflicting data on the extent and clinical relevance on this observation have recently been published. This article reviews the recent literature, summarizing our current understanding of the role of aortic neck dilatation after open surgical and endovascular abdominal aortic aneurysm repair. In addition, differences in methodology of studies on aortic neck dilatation are highlighted.

The long-term effects of whole-tree harvest at final felling on soil properties in a Norway Spruce (Picea Abies (L) Karst.) Stand

Increased demand for forest-derived biomass has resulted in changes in harvest intensities in Finland. Conventional stem-only harvest (CH) has to some extent been replaced with whole-tree harvest (WTH). The latter involves a greater removal of nutrients from the forest ecosystem, as all the above ground biomass is exported from the site. This has raised concerns that WTH could result in large changes in the nutrient dynamics of a forest stand and could eventually lower its site productivity. Little empirical data exists to support this assumption as only a limited number of studies have been conducted on the topic. A majority of these discuss the short-term effects, thus the long-term consequences remain unknown. The objective of this study was to compare differences in soil properties after CH and WTH in a fertile Norway spruce (Picea abies (L) Karst.) stand in Southern Finland. The site was clear-felled in August 2000 and spruce seedlings were planted in the following summer. Soil sampling in the form of systematic randomized sampling was carried out in May 2011. Changes in base saturation, cation exchange capacity, elemental pools (total and exchangeable) and acidity were studied in both organic and mineral horizons. The results indicate that WTH lowered effective cation exchange capacity and base saturation particularly in the humus layer. The pools of exchangeable Al and Fe were increased in the humus layer, whereas the amount of exchangeable Ca decreased in both layers. WTH also resulted in lower Ca/Al-ratios across the sampled layers. Treatment did not have a significant effect on pH, total pools of elements or on the C/N-ratio of the soil. The results suggest that although the stand possesses significant pools of nutrients at present, WTH, if continued, could have long-term effects on site productivity.

Time-domain modeling of high-frequency electromagnetic wave propagation, overhead wires, and earth

Prediction of radiated fields from transmission lines has not previously been studied from a panoptical power system perspective. The application of BPL technologies to overhead transmission lines would benefit greatly from an ability to simulate real power system environments, not limited to the transmission lines themselves. Presently circuitbased transmission line models used by EMTP-type programs utilize Carson’s formula for a waveguide parallel to an interface. This formula is not valid for calculations at high frequencies, considering effects of earth return currents. This thesis explains the challenges of developing such improved models, explores an approach to combining circuit-based and electromagnetics modeling to predict radiated fields from transmission lines, exposes inadequacies of simulation tools, and suggests methods of extending the validity of transmission line models into very high frequency ranges. Electromagnetics programs are commonly used to study radiated fields from transmission lines. However, an approach is proposed here which is also able to incorporate the components of a power system through the combined use of EMTP-type models. Carson’s formulas address the series impedance of electrical conductors above and parallel to the earth. These equations have been analyzed to show their inherent assumptions and what the implications are. Additionally, the lack of validity into higher frequencies has been demonstrated, showing the need to replace Carson’s formulas for these types of studies. This body of work leads to several conclusions about the relatively new study of BPL. Foremost, there is a gap in modeling capabilities which has been bridged through integration of circuit-based and electromagnetics modeling, allowing more realistic prediction of BPL performance and radiated fields. The proposed approach is limited in its scope of validity due to the formulas used by EMTP-type software. To extend the range of validity, a new set of equations must be identified and implemented in the approach. Several potential methods of implementation have been explored. Though an appropriate set of equations has not yet been identified, further research in this area will benefit from a clear depiction of the next important steps and how they can be accomplished. Prediction of radiated fields from transmission lines has not previously been studied from a panoptical power system perspective. The application of BPL technologies to overhead transmission lines would benefit greatly from an ability to simulate real power system environments, not limited to the transmission lines themselves. Presently circuitbased transmission line models used by EMTP-type programs utilize Carson’s formula for a waveguide parallel to an interface. This formula is not valid for calculations at high frequencies, considering effects of earth return currents. This thesis explains the challenges of developing such improved models, explores an approach to combining circuit-based and electromagnetics modeling to predict radiated fields from transmission lines, exposes inadequacies of simulation tools, and suggests methods of extending the validity of transmission line models into very high frequency ranges. Electromagnetics programs are commonly used to study radiated fields from transmission lines. However, an approach is proposed here which is also able to incorporate the components of a power system through the combined use of EMTP-type models. Carson’s formulas address the series impedance of electrical conductors above and parallel to the earth. These equations have been analyzed to show their inherent assumptions and what the implications are. Additionally, the lack of validity into higher frequencies has been demonstrated, showing the need to replace Carson’s formulas for these types of studies. This body of work leads to several conclusions about the relatively new study of BPL. Foremost, there is a gap in modeling capabilities which has been bridged through integration of circuit-based and electromagnetics modeling, allowing more realistic prediction of BPL performance and radiated fields. The proposed approach is limited in its scope of validity due to the formulas used by EMTP-type software. To extend the range of validity, a new set of equations must be identified and implemented in the approach. Several potential methods of implementation have been explored. Though an appropriate set of equations has not yet been identified, further research in this area will benefit from a clear depiction of the next important steps and how they can be accomplished.

An empirical comparison of methods for meta-analysis of diagnostic accuracy showed hierarchical models are necessary

OBJECTIVE: Meta-analysis of studies of the accuracy of diagnostic tests currently uses a variety of methods. Statistically rigorous hierarchical models require expertise and sophisticated software. We assessed whether any of the simpler methods can in practice give adequately accurate and reliable results. STUDY DESIGN AND SETTING: We reviewed six methods for meta-analysis of diagnostic accuracy: four simple commonly used methods (simple pooling, separate random-effects meta-analyses of sensitivity and specificity, separate meta-analyses of positive and negative likelihood ratios, and the Littenberg-Moses summary receiver operating characteristic [ROC] curve) and two more statistically rigorous approaches using hierarchical models (bivariate random-effects meta-analysis and hierarchical summary ROC curve analysis). We applied the methods to data from a sample of eight systematic reviews chosen to illustrate a variety of patterns of results. RESULTS: In each meta-analysis, there was substantial heterogeneity between the results of different studies. Simple pooling of results gave misleading summary estimates of sensitivity and specificity in some meta-analyses, and the Littenberg-Moses method produced summary ROC curves that diverged from those produced by more rigorous methods in some situations. CONCLUSION: The closely related hierarchical summary ROC curve or bivariate models should be used as the standard method for meta-analysis of diagnostic accuracy.

Systematic review of the empirical evidence of study publication bias and outcome reporting bias

BACKGROUND: The increased use of meta-analysis in systematic reviews of healthcare interventions has highlighted several types of bias that can arise during the completion of a randomised controlled trial. Study publication bias has been recognised as a potential threat to the validity of meta-analysis and can make the readily available evidence unreliable for decision making. Until recently, outcome reporting bias has received less attention. METHODOLOGY/PRINCIPAL FINDINGS: We review and summarise the evidence from a series of cohort studies that have assessed study publication bias and outcome reporting bias in randomised controlled trials. Sixteen studies were eligible of which only two followed the cohort all the way through from protocol approval to information regarding publication of outcomes. Eleven of the studies investigated study publication bias and five investigated outcome reporting bias. Three studies have found that statistically significant outcomes had a higher odds of being fully reported compared to non-significant outcomes (range of odds ratios: 2.2 to 4.7). In comparing trial publications to protocols, we found that 40-62% of studies had at least one primary outcome that was changed, introduced, or omitted. We decided not to undertake meta-analysis due to the differences between studies. CONCLUSIONS: Recent work provides direct empirical evidence for the existence of study publication bias and outcome reporting bias. There is strong evidence of an association between significant results and publication; studies that report positive or significant results are more likely to be published and outcomes that are statistically significant have higher odds of being fully reported. Publications have been found to be inconsistent with their protocols. Researchers need to be aware of the problems of both types of bias and efforts should be concentrated on improving the reporting of trials.

[Opinions of German-Speaking Experts about Strabismus Surgery.]

BACKGROUND: There is a lack of studies about how to proceed surgically in rare strabismus diseases. It was the aim of this study to inteview experienced German-speaking strabismologists about how they perform surgery in rare but also some frequent strabismic conditions. The focus was on the choice of the technique, the timing, and the dosage. METHOD: A validated questionnaire was sent to 11 experienced strabismus surgeons. It contained questions about the following topics: congenital fibrosis syndrome, Jaentsch-Brown syndrome, intermittent exotropia, maximum dosage for rectus muscle surgery, Kestenbaum surgery, sixth nerve palsy, heterophorias, myokymia of the superior oblique muscle, thyroid endocrine orbitopathy, dissociated vertical deviation, adjustable sutures, advancement of previously recessed rectus muscles, retroequatorial myopiexia, and congenital esotropia. RESULTS: Ten experts answered the questionnaire (91 %). There was a large consent for many topics. However, for many procedures there was disagreement about the dosage and the timing. Since some questions addressed rare diseases and many strabismologists use only certain types of surgical procedures, some questions could only be answered by a few surgeons. CONCLUSIONS: German-speaking strabismologist show a large consensus about the type of surgical procedure to use, but often disagree about the dosage and timing of the operation.

Content comparison of health-related quality of life instruments for obstructive sleep apnea

BACKGROUND AND PURPOSE: Due to the increasing importance of quality of life assessments in obstructive sleep apnea (OSA) patients and due to an increased use of the International Classification of Functioning, Disability and Health (ICF), for comparative purposes it is essential to understand the relationship between health-related quality of life (HRQOL) instruments and the ICF. The purpose of this study was to compare the content covered by OSA-specific instruments using the ICF. PATIENTS AND METHODS: OSA-specific instruments were identified, including the Calgary Sleep Apnea Quality of Life Index, the Functional Outcomes of Sleep Questionnaire, the Obstructive Sleep Apnea Patient-Oriented Severity Index, and the Quebec Sleep Questionnaire, and linked to the ICF by six health professionals according to standardized guidelines. The degree of agreement between health professionals was calculated by means of the kappa statistic. RESULTS: A total of 308 concepts were identified and linked to 78 different ICF categories; 35 categories of the component body function, one category of the component body structure, 38 categories of the component activities and participation, and four categories of the component environmental factors. Only contents within the chapters mental functions, mobility and social life were addressed by all instruments. Forty-seven categories were covered by only one instrument. CONCLUSION: The ICF proved highly useful for the comparison of HRQOL instruments. This analysis may help researchers and clinicians to choose the most appropriate HRQOL instrument for a specific purpose as well as help to compare study outcomes of studies using different instruments for HRQOL assessment.

Effects of Chemical Deicers on Amphibian Communites

Roads and highways present a unique challenge to wildlife as they exhibit substantial impacts on the surrounding ecosystem through the interruption of a number of ecological processes. With new roads added to the national highway system every year, an understanding of these impacts is required for effective mitigation of potential environmental impacts. A major contributor to these negative effects is the deposition of chemicals used in winter deicing activities to nearby surface waters. These chemicals often vary in composition and may affect freshwater species differently. The negative impacts of widespread deposition of sodium chloride (NaCl) have prompted a search for an `environmentally friendly' alternative. However, little research has investigated the potential environmental effects of widespread use of these alternatives. Herein, I detail the results of laboratory tests and field surveys designed to determine the impacts of road salt (NaCl) and other chemical deicers on amphibian communities in Michigan's Upper Peninsula. Using larval amphibians I demonstrate the lethal impacts of a suite of chemical deicers on this sensitive, freshwater species. Larval wood frogs (Lithobates sylvatica) were tolerant of short-term (96 hours) exposure to urea (CH4N2O), sodium chloride (NaCl), and magnesium chloride (MgCl2). However, these larvae were very sensitive to acetate products (C8H12CaMgO8, CH3COOK) and calcium chloride (CaCl2). These differences in tolerance suggest that certain deicers may be more harmful to amphibians than others. Secondly, I expanded this analysis to include an experiment designed to determine the sublethal effects of chronic exposure to environmentally realistic concentrations of NaCl on two unique amphibian species, L. sylvatica and green frogs (L. clamitans). L. sylvatica tend to breed in small, ephemeral wetlands and metamorphose within a single season. However, L. clamitans breed primarily in more permanent wetlands and often remain as tadpoles for one year or more. These species employ different life history strategies in this region which may influence their response to chronic NaCl exposure. Both species demonstrated potentially harmful effects on individual fitness. L. sylvatica larvae had a high incidence of edema suggesting the NaCl exposure was a significant physiologic stressor to these larvae. L. clamitans larvae reduced tail length during their exposure which may affect adult fitness of these individuals. In order to determine the risk local amphibians face when using these roadside pools, I conducted a survey of the spatial distribution of chloride in the three northernmost counties of Michigan. This area receives a relatively low amount of NaCl which is confined to state and federal highways. The chloride concentrations in this region were much lower than those in urban systems; however, amphibians breeding in the local area may encounter harmful chloride levels arising from temporal variations in hydroperiods. Spatial variation of chloride levels suggests the road-effect zone for amphibians may be as large as 1000 m from a salt-treated highway. Lastly, I performed an analysis of the use of specific conductance to predict chloride concentrations in natural surface water bodies. A number of studies have used this regression to predict chloride concentrations from measurements of specific conductance. This method is often chosen in the place of ion chromatography due to budget and time constraints. However, using a regression method to characterize this relationship does not result in accurate chloride ion concentration estimates.

Survival and failure rates of orthodontic temporary anchorage devices: a systematic review

AIM: The purpose of this study was to systematically review the literature on the survival rates of palatal implants, Onplants((R)), miniplates and mini screws. MATERIAL AND METHODS: An electronic MEDLINE search supplemented by manual searching was conducted to identify randomized clinical trials, prospective and retrospective cohort studies on palatal implants, Onplants((R)), miniplates and miniscrews with a mean follow-up time of at least 12 weeks and of at least 10 units per modality having been examined clinically at a follow-up visit. Assessment of studies and data abstraction was performed independently by two reviewers. Reported failures of used devices were analyzed using random-effects Poisson regression models to obtain summary estimates and 95% confidence intervals (CI) of failure and survival proportions. RESULTS: The search up to January 2009 provided 390 titles and 71 abstracts with full-text analysis of 34 articles, yielding 27 studies that met the inclusion criteria. In meta-analysis, the failure rate for Onplants((R)) was 17.2% (95% CI: 5.9-35.8%), 10.5% for palatal implants (95% CI: 6.1-18.1%), 16.4% for miniscrews (95% CI: 13.4-20.1%) and 7.3% for miniplates (95% CI: 5.4-9.9%). Miniplates and palatal implants, representing torque-resisting temporary anchorage devices (TADs), when grouped together, showed a 1.92-fold (95% CI: 1.06-2.78) lower clinical failure rate than miniscrews. CONCLUSION: Based on the available evidence in the literature, palatal implants and miniplates showed comparable survival rates of >or=90% over a period of at least 12 weeks, and yielded superior survival than miniscrews. Palatal implants and miniplates for temporary anchorage provide reliable absolute orthodontic anchorage. If the intended orthodontic treatment would require multiple miniscrew placement to provide adequate anchorage, the reliability of such systems is questionable. For patients who are undergoing extensive orthodontic treatment, force vectors may need to be varied or the roots of the teeth to be moved may need to slide past the anchors. In this context, palatal implants or miniplates should be the TADs of choice.

A systematic review of the performance of ceramic and metal implant abutments supporting fixed implant reconstructions

OBJECTIVES: The objective of this systematic review was to assess the 5-year survival rates and incidences of complications associated with ceramic abutments and to compare them with those of metal abutments. METHODS: An electronic Medline search complemented by manual searching was conducted to identify randomized-controlled clinical trials, and prospective and retrospective studies providing information on ceramic and metal abutments with a mean follow-up time of at least 3 years. Patients had to have been examined clinically at the follow-up visit. Assessment of the identified studies and data abstraction was performed independently by three reviewers. Failure rates were analyzed using standard and random-effects Poisson regression models to obtain summary estimates of 5-year survival proportions. RESULTS: Twenty-nine clinical and 22 laboratory studies were selected from an initial yield of 7136 titles and data were extracted. The estimated 5-year survival rate of ceramic abutments was 99.1% [95% confidence interval (CI): 93.8-99.9%] and 97.4% (95% CI: 96-98.3%) for metal abutments. The estimated cumulative incidence of technical complications after 5 years was 6.9% (95% CI: 3.5-13.4%) for ceramic abutments and 15.9% (95% CI: 11.6-21.5%) for metal abutments. Abutment screw loosening was the most frequent technical problem, occurring at an estimated cumulative incidence after 5 years of 5.1% (95% CI: 3.3-7.7%). All-ceramic crowns supported by ceramic abutments exhibited similar annual fracture rates as metal-ceramic crowns supported by metal abutments. The cumulative incidence of biological complications after 5 years was estimated at 5.2% (95% CI: 0.4-52%) for ceramic and 7.7% (95% CI: 4.7-12.5%) for metal abutments. Esthetic complications tended to be more frequent at metal abutments. A meta-analysis of the laboratory data was impossible due to the non-standardized test methods of the studies included. CONCLUSION: The 5-year survival rates estimated from annual failure rates appeared to be similar for ceramic and metal abutments. The information included in this review did not provide evidence for differences of the technical and biological outcomes of ceramic and metal abutments. However, the information for ceramic abutments was limited in the number of studies and abutments analyzed as well as the accrued follow-up time. Standardized methods for the analysis of abutment strength are needed.

Clinical and esthetic outcomes of implants placed in postextraction sites

PURPOSE: The aim of this review was to evaluate the clinical outcomes for the different time points of implant placement following tooth extraction. MATERIALS AND METHODS: A PubMed search and a hand search of selected journals were performed to identify clinical studies published in English that reported on outcomes of implants in postextraction sites. Only studies that included 10 or more patients were accepted. For implant success/survival outcomes, only studies with a mean follow-up period of at least 12 months from the time of implant placement were included. The following outcomes were identified: (1) change in peri-implant defect dimension, (2) implant survival and success, and (3) esthetic outcomes. RESULTS AND CONCLUSIONS: Of 1,107 abstracts and 170 full-text articles considered, 91 studies met the inclusion criteria for this review. Bone augmentation procedures are effective in promoting bone fill and defect resolution at implants in postextraction sites, and are more successful with immediate (type 1) and early placement (type 2 and type 3) than with late placement (type 4). The majority of studies reported survival rates of over 95%. Similar survival rates were observed for immediate (type 1) and early (type 2) placement. Recession of the facial mucosal margin is common with immediate (type 1) placement. Risk indicators included a thin tissue biotype, a facial malposition of the implant, and a thin or damaged facial bone wall. Early implant placement (type 2 and type 3) is associated with a lower frequency of mucosal recession compared to immediate placement (type 1).

Predictors of attempted suicide among Swiss patients with alcohol-use disorders

Objective: Suicide attempts are common in patients being treated for alcohol-use disorders (AUDs). However, clinical assessment of suicide risk is difficult. In this Swiss multisite study, we propose a decision tree to facilitate identification of profiles of AUD patients at high risk for suicidal behavior. Method: In this retrospective study, we used a sample of 700 patients (243 female), attending 1 of 12 treatment programs for AUDs in the German-speaking part of Switzerland. Sixty-nine patients who reported a suicide attempt in the 3 months before the index treatment were compared using risk factors with 631 patients without a suicide attempt. Receiver operating characteristic (ROC) analyses were used to identify patients at risk of having had a suicide attempt in the previous 3 months. Results: Consistent with previous empirical findings in AUD patients, a prior history of attempted suicide and severe symptoms of depression and aggression considerably increased the risk of a suicide attempt and, in combination, raised the likelihood of a prior suicide attempt to 52%. In addition, one third of AUD patients who had a history of suicide attempts and previous inpatient psychiatric treatment, or who were male and had previous inpatient psychiatric treatment, also reported a suicide attempt. Conclusions: The empirically supported decision tree helps to identify profiles of suicidal AUD patients in Switzerland and supplements clinicians' judgments in making triage decisions for suicide management.

Call for a reference model of chronic hind limb ischemia to investigate therapeutic angiogenesis

A large number of studies utilize animal models to investigate therapeutic angiogenesis. However, the lack of a standardized experimental model leaves the comparison of different studies problematic. To establish a reference model of prolonged moderate tissue ischemia, we created unilateral hind limb ischemia in athymic rnu-rats by surgical excision of the femoral vessels. Blood flow of the limb was monitored for 60 days by laser Doppler imaging. Following a short postoperative period of substantially depressed perfusion, the animals showed a status of moderate hind limb ischemia from day 14 onwards. Thereafter, the perfusion remained at a constant level (55.5% of normal value) until the end of the observation period. Histopathological assessment of the ischemic musculature on postoperative days 28 and 60 showed essentially no inflammatory cell infiltrate or fibrosis. However, the mitochondrial activity and capillary-to-fiber ratio of the muscular tissue was reduced to 52.7% of normal, presenting with a significant weakness of the ischemic limb evidenced by a progressive decline in performance. Intramuscular injection of culture-expanded human endothelial progenitor cells (EPC) resulted in a significant increase in blood flow (82.0+/-3.5% of normal), capillary density (1.60+/-0.08/muscle fiber) and smooth muscle covered arterioles (8.0+/-0.6/high power field) in the ischemic hind limb as compared to controls (55.0+/-3.1%; 0.99+/-0.03; 5.0+/-0.2). In conclusion, chronic, moderate hind limb ischemia with consistently reduced perfusion levels persisting over a prolonged period can be established reliably in rnu athymic nude rats and is responsive to pro-angiogenic treatments such as EPC transplantation. This study provides a detailed protocol of a highly reproducible reference model to test novel therapeutic options for limb ischemia.

Better conduct of clinical trials: the control group in critical care trials

OBJECTIVE: To review trial design issues related to control groups. DESIGN: Review of the literature with specific reference to critical care trials. MAIN RESULTS AND CONCLUSIONS: Performing randomized controlled trials in the critical care setting presents specific problems: studies include patients with rapidly lethal conditions, the majority of intensive care patients suffer from syndromes rather than from well-definable diseases, the severity of such syndromes cannot be precisely assessed, and the treatment consists of interacting therapies. Interactions between physiology, pathophysiology, and therapies are at best marginally understood and may have a major impact on study design and interpretation of results. Selection of the right control group is crucial for the interpretation and clinical implementation of results. Studies comparing new interventions with current ones or different levels of current treatments have the problem of the necessity of defining "usual care." Usual care controls without any constraints typically include substantial heterogeneity. Constraints in the usual therapy may help to reduce some variation. Inclusion of unrestricted usual care groups may help to enhance safety. Practice misalignment is a novel problem in which patients receive a treatment that is the direct opposite of usual care, and occurs when fixed-dose interventions are used in situations where care is normally titrated. Practice misalignment should be considered in the design and interpretation of studies on titrated therapies.

Vision and night driving abilities of elderly drivers

OBJECTIVE: In this article, we review the impact of vision on older people's night driving abilities. Driving is the preferred and primary mode of transport for older people. It is a complex activity where intact vision is seminal for road safety. Night driving requires mesopic rather than scotopic vision, because there is always some light available when driving at night. Scotopic refers to night vision, photopic refers to vision under well-lit conditions, and mesopic vision is a combination of photopic and scotopic vision in low but not quite dark lighting situations. With increasing age, mesopic vision decreases and glare sensitivity increases, even in the absence of ocular diseases. Because of the increasing number of elderly drivers, more drivers are affected by night vision difficulties. Vision tests, which accurately predict night driving ability, are therefore of great interest. METHODS: We reviewed existing literature on age-related influences on vision and vision tests that correlate or predict night driving ability. RESULTS: We identified several studies that investigated the relationship between vision tests and night driving. These studies found correlations between impaired mesopic vision or increased glare sensitivity and impaired night driving, but no correlation was found among other tests; for example, useful field of view or visual field. The correlation between photopic visual acuity, the most commonly used test when assessing elderly drivers, and night driving ability has not yet been fully clarified. CONCLUSIONS: Photopic visual acuity alone is not a good predictor of night driving ability. Mesopic visual acuity and glare sensitivity seem relevant for night driving. Due to the small number of studies evaluating predictors for night driving ability, further research is needed.