Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND & AIMS: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. METHODS: An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated "high", "moderate", "low" or "very low". Recommendations were graded as "strong" or "weak". RESULTS: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSIONS: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.

Tous égaux devant Dieu ? Réflexions sur les logiques d'éligibilité des miraculés

Le pentecôtisme a fait du miracle le coeur de sa théologie et l'élément central de ses activités d'évangélisation. Le catholicisme, par contre, a toujours voulu contrôler l'ensemble des déclarations de manifestations divines. Apparitions et guérisons miraculeuses ont donc systématiquement, et de plus en plus, été soumises à de lentes et rigoureuses procédures d'authentification. Les pentecôtistes voient Dieu comme un être extérieur qui surgit sur la terre pour chasser le mal qui l'envahit. Tous les convertis ont donc droit à la libération et personne ne doit accepter sagement la souffrance. Or, les pèlerins catholiques que nous avons étudiés ne partagent pas ces convictions pentecôtistes. Dieu agit de l'intérieur, non pas en les délivrant, mais en les soutenant dans leurs épreuves quotidiennes. Rare et peu recherchée, la guérison physique cède la place à la guérison spirituelle, accessible à tous. Il nous semble que ces deux types de représentations placent les fidèles dans des dispositions d'esprit très divergentes suscitant, dans un cas ou dans l'autre, des espoirs adaptés à la capacité du groupe à produire des miracles. Pentecostalism placed miracles at the centre of its theology as a key element of its evangelization activities. Catholicism, on the other hand, has always tried to control all declarations of divine demonstrations. Miraculous appearances and recoveries have been more and more systematically subjected to slow and rigorous procedures of verification. The Pentecostals see God as an external force which manifests itself on earth to drive out the evil which invades it. All believers have the right to be free from evil, and nobody should have to accept pain meekly. But the Catholic pilgrims we studied do not share these Pentecostal convictions. God acts from inside, not by delivering them but by supporting them in their daily tests. Physical recovery is rare and not very sought after so it takes second place to spiritual recovery which is accessible to everyone. It seems to us that these two types of representation place believers in very divergent frames of mind giving rise, in one group or the other, to hopes that correspond to the group's capacity to produce miracles.

Electronic and magnetic structure of LaMnO3 from hybrid periodic density-functional theory

The electronic and magnetic structures of the LaMnO3 compound have been studied by means of periodic calculations within the framework of spin polarized hybrid density-functional theory. In order to quantify the role of approximations to electronic exchange and correlation three different hybrid functionals have been used which mix nonlocal Fock and local Dirac-Slater exchange. Periodic Hartree-Fock results are also reported for comparative purposes. The A-antiferromagnetic ground state is properly predicted by all methods including Hartree-Fock exchange. In general, the different hybrid methods provide a rather accurate description of the band gap and of the two magnetic coupling constants, strongly suggesting that the corresponding description of the electronic structure is also accurate. An important conclusion emerging from this study is that the nature of the occupied states near the Fermi level is intermediate between the Hartree-Fock and local density approximation descriptions with a comparable participation of both Mn and O states.

Performance of a new gadolinium-based intravascular contrast agent in free-breathing inversion-recovery 3D coronary MRA.

In three-dimensional (3D) coronary magnetic resonance angiography (MRA), the in-flow contrast between the coronary blood and the surrounding myocardium is attenuated as compared to thin-slab two-dimensional (2D) techniques. The application of a gadolinium (Gd)-based intravascular contrast agent may provide an additional source of signal and contrast by reducing T(1blood) and supporting the visualization of more distal or branching segments of the coronary arterial tree. In six healthy adults, the left coronary artery (LCA) system was imaged pre- and postcontrast with a 0.075-mmol/kg bodyweight dose of the intravascular contrast agent B-22956. For imaging, an optimized free-breathing, navigator-gated and -corrected 3D inversion recovery (IR) sequence was used. For comparison, state-of-the-art baseline 3D coronary MRA with T(2) preparation for non-exogenous contrast enhancement was acquired. The combination of IR 3D coronary MRA, sophisticated navigator technology, and B-22956 allowed for an extensive visualization of the LCA system. Postcontrast, a significant increase in both the signal-to-noise ratio (SNR; 46%, P < 0.05) and contrast-to-noise ratio (CNR; 160%, P < 0.01) was observed, while vessel sharpness of the left anterior descending (LAD) artery and the left coronary circumflex (LCX) were improved by 20% (P < 0.05) and 18% (P < 0.05), respectively.

Antiferromagnetic exchange interactions from hybrid density functional theory

A hybrid theory which combines the full nonlocal ¿exact¿ exchange interaction with the local spin-density approximation of density-functional theory is shown to lead to marked improvement in the description of antiferromagnetically coupled systems. Semiquantitative agreement with experiment is found for the magnitude of the coupling constant in La2CuO4, KNiF3, and K2NiF4. The magnitude of the unpaired spin population on the metal site is in excellent agreement with experiment for La2CuO4.

Clinal variation in a brown lemur (Eulemur spp.) hybrid zone: Combining morphological, genetic and climatic data to examine stability.

Studies of hybrid zones can inform our understanding of reproductive isolation and speciation. Two species of brown lemur (Eulemur rufifrons and E. cinereiceps) form an apparently stable hybrid zone in the Andringitra region of south-eastern Madagascar. The aim of this study was to identify factors that contribute to this stability. We sampled animals at 11 sites along a 90-km transect through the hybrid zone and examined variation in 26 microsatellites, the D-loop region of mitochondrial DNA, six pelage and nine morphological traits; we also included samples collected in more distant allopatric sites. Clines in these traits were noncoincident, and there was no increase in either inbreeding coefficients or linkage disequilibrium at the centre of the zone. These results could suggest that the hybrid zone is maintained by weak selection against hybrids, conforming to either the tension zone or geographical selection-gradient model. However, a closer examination of clines in pelage and microsatellites indicates that these clines are not sigmoid or stepped in shape but instead plateau at their centre. Sites within the hybrid zone also occur in a distinct habitat, characterized by greater seasonality in precipitation and lower seasonality in temperature. Together, these findings suggest that the hybrid zone may follow the bounded superiority model, with exogenous selection favouring hybrids within the transitional zone. These findings are noteworthy, as examples supporting the bounded superiority model are rare and may indicate a process of ecologically driven speciation without geographical isolation.

Muscarinic receptor M1 and phosphodiesterase 1 are key determinants in pulmonary vascular dysfunction following perinatal hypoxia in mice.

Perinatal adverse events such as limitation of nutrients or oxygen supply are associated with the occurrence of diseases in adulthood, like cardiovascular diseases and diabetes. We investigated the long-term effects of perinatal hypoxia on the lung circulation, with particular attention to the nitric oxide (NO)/cGMP pathway. Mice were placed under hypoxia in utero 5 days before delivery and for 5 days after birth. Pups were then bred in normoxia until adulthood. Adults born in hypoxia displayed an altered regulation of pulmonary vascular tone with higher right ventricular pressure in normoxia and increased sensitivity to acute hypoxia compared with controls. Perinatal hypoxia dramatically decreased endothelium-dependent relaxation induced by ACh in adult pulmonary arteries (PAs) but did not influence NO-mediated endothelium-independent relaxation. The M(3) muscarinic receptor was implicated in the relaxing action of ACh and M(1) muscarinic receptor (M(1)AChR) in its vasoconstrictive effects. Pirenzepine or telenzepine, two preferential inhibitors of M(1)AChR, abolished the adverse effects of perinatal hypoxia on ACh-induced relaxation. M(1)AChR mRNA expression was increased in lungs and PAs of mice born in hypoxia. The phosphodiesterase 1 (PDE1) inhibitor vinpocetine also reversed the decrease in ACh-induced relaxation following perinatal hypoxia, suggesting that M(1)AChR-mediated alteration of ACh-induced relaxation is due to the activation of calcium-dependent PDE1. Therefore, perinatal hypoxia leads to an altered pulmonary circulation in adulthood with vascular dysfunction characterized by impaired endothelium-dependent relaxation and M(1)AChR plays a predominant role. This raises the possibility that muscarinic receptors could be key determinants in pulmonary vascular diseases in relation to "perinatal imprinting."

Le stigmate de la "folie": de la fatalité au rétablissement [Stigma of "madness" from fate to recovery].

Stigma is a "natural" social reaction, partly unconscious and automatic towards "different" and "vulnerable" populations. Suspicion of danger, unemployment, excluded from society, locked in hospital, assaulted or killed are the possible consequences of mental disorders' stigma. Despite advances in psychiatric treatments, the stigma of the "madness" remains a barrier to access to recovery. The stigmatization process is more complex than simple labeling, and leads to discrimination and loss of social power. Understanding the mechanisms of stigmatization can determine targets for effective interventions to fight stigma at the individual, institutional and political levels. The roles of patient and family associations, as well as the recovery model for the professionals, are essential. The aim of this article is to review the various aspects of mental disorders' stigma and to examine ways to cope with them.

Faster oxygen uptake kinetics during recovery is related to better repeated sprinting ability.

This study was designed to test the hypothesis that subjects having faster oxygen uptake (VO(2)) kinetics during off-transients to exercises of severe intensity would obtain the smallest decrement score during a repeated sprint test. Twelve male soccer players completed a graded test, two severe-intensity exercises, followed by 6 min of passive recovery, and a repeated sprint test, consisting of seven 30-m sprints alternating with 20 s of active recovery. The relative decrease in score during the repeated sprint test was positively correlated with time constants of the primary phase for the VO(2) off-kinetics (r = 0.85; p &lt; 0.001) and negatively correlated with the VO(2) peak (r = -0.83; p &lt; 0.001). These results strengthen the link found between VO(2) kinetics and the ability to maintain sprint performance during repeated sprints.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND: This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS: Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS: Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Assessing the Costs for Hybrid versus Regular Transit Buses, October 2012

This technical brief summarizes information about the costs and benefits that have been attributed to use of hybrid transit buses as found in the literature. Results from a demonstration project that compared fuel economy and emissions for 12 hybrid buses and 7 control buses for the transit agency for Ames, Iowa and Iowa State University, CyRide, were also included.

Evaluation of In-Use Fuel Economy and On-Board Emissions for Hybrid and Regular CyRide Transit Buses, October 2012

The objective of this project was to evaluate the in-use fuel economy and emission differences between hybrid-electric and conventional transit buses for the Ames, Iowa transit authority, CyRide. These CyRide buses were deployed in the fall of 2010. Fuel economy was compared for the hybrid and control buses. Several older bus types were also available and were included in the analysis. Hybrid buses had the highest fuel economy for all time periods for all bus types. Hybrid buses had a fuel economy that was 11.8 percent higher than control buses overall, 12.2 percent higher than buses with model years 2007 and newer, 23.4 percent higher than model years 2004 through 2006, 10.2 percent higher than model years 1998 through 2003, 38.1 percent higher than model years 1994 through 1997, 36.8 percent higher than model years 1991 through 1993, and 36.8 percent higher for model years pre-1991. On-road emissions were also compared for three of the hybrid buses and two control buses using a portable emissions monitor. On-average, carbon dioxide, carbon monoxide, and hybrid carbon emissions were much higher for the control buses than for the hybrid buses. However, on average nitrogen oxide emissions were higher for the hybrid buses.

Postanoxic functional recovery of the developing heart is slightly altered by endogenous or exogenous nitric oxide.

Nitric oxide synthase (NOS) is strongly and transiently expressed in the developing heart but its function is not well documented. This work examined the role, either protective or detrimental, that endogenous and exogenous NO could play in the functioning of the embryonic heart submitted to hypoxia and reoxygenation. Spontaneously beating hearts isolated from 4-day-old chick embryos were either homogenized to determine basal inducible NOS (iNOS) expression and activity or submitted to 30 min anoxia followed by 100 min reoxygenation. The chrono-, dromo- and inotropic responses to anoxia/reoxygenation were determined in the presence of NOS substrate (L-arginine 10 mM), NOS inhibitor L-NIO (1-5 mM), or NO donor (DETA NONOate 10-100 microM). Myocardial iNOS was detectable by immunoblotting and its activity was specifically decreased by 53% in the presence of 5 mM L-NIO. L-Arginine, L-NIO and DETA NONOate at 10 microM had no significant effect on the investigated functional parameters during anoxia/reoxygenation. However, irrespective of anoxia/reoxygenation, DETA NONOate at 100 microM decreased ventricular shortening velocity by about 70%, and reduced atrio-ventricular propagation by 23%. None of the used drugs affected atrial activity and hearts of all experimental groups fully recovered at the end of reoxygenation. These findings indicate that (1) by contrast with adult heart, endogenously released NO plays a minor role in the early response of the embryonic heart to reoxygenation, (2) exogenous NO has to be provided at high concentration to delay postanoxic functional recovery, and (3) sinoatrial pacemaker cells are the less responsive to NO.