Light energy management in peach: utilization, photoprotection , photodamage and recovery. Maximizing light absorption in orchard is not always the best solution

The relation between the intercepted light and orchard productivity was considered linear, although this dependence seems to be more subordinate to planting system rather than light intensity. At whole plant level not always the increase of irradiance determines productivity improvement. One of the reasons can be the plant intrinsic un-efficiency in using energy. Generally in full light only the 5 – 10% of the total incoming energy is allocated to net photosynthesis. Therefore preserving or improving this efficiency becomes pivotal for scientist and fruit growers. Even tough a conspicuous energy amount is reflected or transmitted, plants can not avoid to absorb photons in excess. The chlorophyll over-excitation promotes the reactive species production increasing the photoinhibition risks. The dangerous consequences of photoinhibition forced plants to evolve a complex and multilevel machine able to dissipate the energy excess quenching heat (Non Photochemical Quenching), moving electrons (water-water cycle , cyclic transport around PSI, glutathione-ascorbate cycle and photorespiration) and scavenging the generated reactive species. The price plants must pay for this equipment is the use of CO2 and reducing power with a consequent decrease of the photosynthetic efficiency, both because some photons are not used for carboxylation and an effective CO2 and reducing power loss occurs. Net photosynthesis increases with light until the saturation point, additional PPFD doesn’t improve carboxylation but it rises the efficiency of the alternative pathways in energy dissipation but also ROS production and photoinhibition risks. The wide photo-protective apparatus, although is not able to cope with the excessive incoming energy, therefore photodamage occurs. Each event increasing the photon pressure and/or decreasing the efficiency of the described photo-protective mechanisms (i.e. thermal stress, water and nutritional deficiency) can emphasize the photoinhibition. Likely in nature a small amount of not damaged photosystems is found because of the effective, efficient and energy consuming recovery system. Since the damaged PSII is quickly repaired with energy expense, it would be interesting to investigate how much PSII recovery costs to plant productivity. This PhD. dissertation purposes to improve the knowledge about the several strategies accomplished for managing the incoming energy and the light excess implication on photo-damage in peach. The thesis is organized in three scientific units. In the first section a new rapid, non-intrusive, whole tissue and universal technique for functional PSII determination was implemented and validated on different kinds of plants as C3 and C4 species, woody and herbaceous plants, wild type and Chlorophyll b-less mutant and monocot and dicot plants. In the second unit, using a “singular” experimental orchard named “Asymmetric orchard”, the relation between light environment and photosynthetic performance, water use and photoinhibition was investigated in peach at whole plant level, furthermore the effect of photon pressure variation on energy management was considered on single leaf. In the third section the quenching analysis method suggested by Kornyeyev and Hendrickson (2007) was validate on peach. Afterwards it was applied in the field where the influence of moderate light and water reduction on peach photosynthetic performances, water requirements, energy management and photoinhibition was studied. Using solar energy as fuel for life plant is intrinsically suicidal since the high constant photodamage risk. This dissertation would try to highlight the complex relation existing between plant, in particular peach, and light analysing the principal strategies plants developed to manage the incoming light for deriving the maximal benefits as possible minimizing the risks. In the first instance the new method proposed for functional PSII determination based on P700 redox kinetics seems to be a valid, non intrusive, universal and field-applicable technique, even because it is able to measure in deep the whole leaf tissue rather than the first leaf layers as fluorescence. Fluorescence Fv/Fm parameter gives a good estimate of functional PSII but only when data obtained by ad-axial and ab-axial leaf surface are averaged. In addition to this method the energy quenching analysis proposed by Kornyeyev and Hendrickson (2007), combined with the photosynthesis model proposed by von Caemmerer (2000) is a forceful tool to analyse and study, even in the field, the relation between plant and environmental factors such as water, temperature but first of all light. “Asymmetric” training system is a good way to study light energy, photosynthetic performance and water use relations in the field. At whole plant level net carboxylation increases with PPFD reaching a saturating point. Light excess rather than improve photosynthesis may emphasize water and thermal stress leading to stomatal limitation. Furthermore too much light does not promote net carboxylation improvement but PSII damage, in fact in the most light exposed plants about 50-60% of the total PSII is inactivated. At single leaf level, net carboxylation increases till saturation point (1000 – 1200 μmolm-2s-1) and light excess is dissipated by non photochemical quenching and non net carboxylative transports. The latter follows a quite similar pattern of Pn/PPFD curve reaching the saturation point at almost the same photon flux density. At middle-low irradiance NPQ seems to be lumen pH limited because the incoming photon pressure is not enough to generate the optimum lumen pH for violaxanthin de-epoxidase (VDE) full activation. Peach leaves try to cope with the light excess increasing the non net carboxylative transports. While PPFD rises the xanthophyll cycle is more and more activated and the rate of non net carboxylative transports is reduced. Some of these alternative transports, such as the water-water cycle, the cyclic transport around the PSI and the glutathione-ascorbate cycle are able to generate additional H+ in lumen in order to support the VDE activation when light can be limiting. Moreover the alternative transports seems to be involved as an important dissipative way when high temperature and sub-optimal conductance emphasize the photoinhibition risks. In peach, a moderate water and light reduction does not determine net carboxylation decrease but, diminishing the incoming light and the environmental evapo-transpiration request, stomatal conductance decreases, improving water use efficiency. Therefore lowering light intensity till not limiting levels, water could be saved not compromising net photosynthesis. The quenching analysis is able to partition absorbed energy in the several utilization, photoprotection and photo-oxidation pathways. When recovery is permitted only few PSII remained un-repaired, although more net PSII damage is recorded in plants placed in full light. Even in this experiment, in over saturating light the main dissipation pathway is the non photochemical quenching; at middle-low irradiance it seems to be pH limited and other transports, such as photorespiration and alternative transports, are used to support photoprotection and to contribute for creating the optimal trans-thylakoidal ΔpH for violaxanthin de-epoxidase. These alternative pathways become the main quenching mechanisms at very low light environment. Another aspect pointed out by this study is the role of NPQ as dissipative pathway when conductance becomes severely limiting. The evidence that in nature a small amount of damaged PSII is seen indicates the presence of an effective and efficient recovery mechanism that masks the real photodamage occurring during the day. At single leaf level, when repair is not allowed leaves in full light are two fold more photoinhibited than the shaded ones. Therefore light in excess of the photosynthetic optima does not promote net carboxylation but increases water loss and PSII damage. The more is photoinhibition the more must be the photosystems to be repaired and consequently the energy and dry matter to allocate in this essential activity. Since above the saturation point net photosynthesis is constant while photoinhibition increases it would be interesting to investigate how photodamage costs in terms of tree productivity. An other aspect of pivotal importance to be further widened is the combined influence of light and other environmental parameters, like water status, temperature and nutrition on peach light, water and phtosyntate management.

The effects of mechanical ventilation on hepato-splanchnic perfusion

PURPOSE OF REVIEW: Mechanical ventilation is a cornerstone of ICU treatment. Because of its interaction with blood flow and intra-abdominal pressure, mechanical ventilation has the potential to alter hepato-splanchnic perfusion, abdominal organ function and thereby outcome of the most critically ill patients. RECENT FINDINGS: Mechanical ventilation can alter hepato-splanchnic perfusion, but the effects are minimal (with moderate inspiratory pressures, tidal volumes, and positive end-expiratory pressure levels) or variable (with high ones). Routine nursing procedures may cause repeated episodes of inadequate hepato-splanchnic perfusion in critically ill patients, but an association between perfusion and multiple organ dysfunction cannot yet be determined. Clinical research continues to be challenging as a result of difficulties in measuring hepato-splanchnic blood flow at the bedside. SUMMARY: Mechanical ventilation and attempts to improve oxygenation such as intratracheal suctioning and recruitment maneuvers, may have harmful consequences in patients with already limited cardiovascular reserves or deteriorated intestinal perfusion. Due to difficulties in assessing hepato-splanchnic perfusion, such effects are often not detected.

Unexplained syncope--is screening for carotid sinus hypersensitivity indicated in all patients aged >40 years?

OBJECTIVE: To determine the frequency, age distribution and clinical presentation of carotid sinus hypersensitivity (CSH) among 373 patients (age range 15-92 years) referred to two autonomic referral centres during a 10-year period. METHODS: Carotid sinus massage (CSM) was performed both supine and during 60 degree head-up tilt. Beat-to-beat blood pressure, heart rate and a three-lead electrocardiography were recorded continuously. CSH was classified as cardioinhibitory (asystole > or = 3 s), vasodepressor (systolic blood pressure fall > or = 50 mm Hg) or mixed. All patients additionally underwent autonomic screening tests for orthostatic hypotension and autonomic failure. RESULTS: CSH was observed in 13.7% of all patients. The diagnostic yield of CSM was nil in patients aged < 50 years (n = 65), 2.4% in those aged 50-59 years (n = 82), 9.1% in those aged 60-69 years (n = 77), 20.7% in those aged 70-79 years (n = 92) and reached 40.4% in those > 80 years (n = 57). Syncope was the leading clinical symptom in 62.8%. In 27.4% of patients falls without definite loss of consciousness was the main clinical symptom. Mild and mainly systolic orthostatic hypotension was recorded in 17.6%; evidence of sympathetic or parasympathetic dysfunction was found in none. CONCLUSIONS: CSH was confirmed in patients > 50 years, the incidence steeply increasing with age. The current European Society of Cardiology guidelines that recommend testing for CSH in all patients > 40 years with syncope of unknown aetiology may need reconsideration. Orthostatic hypotension was noted in some patients with CSH, but evidence of sympathetic or parasympathetic failure was not found in any of them.

Small is beautiful: why profundaplasty should not be forgotten

BACKGROUND: Surgical profundaplasty (SP)is used mainly as an adjunct to endovascular management of peripheral vascular disease (PAD) today. Results from earlier series of profundaplasty alone have been controversial, especially regarding its hemodynamic effect. The question is: Can profundaplasty alone still be useful? Our aim was to evaluate its role in the modern management of vascular patients. METHODS: This was a retrospective outcome study. A consecutive series of 97 patients (106 legs) from January 2000 through December 2003 were included. In 55 (52%) legs, the superficial femoral artery was occluded. These patients were included in the current analysis. Of these patients 14 (25%) were female. Mean age was 71 ((11) years. Nineteen (35%) were diabetic. The indication for operation was claudication in 29 (53%), critical leg ischemia (CLI) in 26 (47%), either with rest pain in 17 (31%), or ulcer/gangrene in 9 (16%). Endarterectomy with patch angioplasty with bovine pericardium was performed in all cases. Mean follow-up was 33 ( 14 months. Mean preoperative ankle brachial index (ABI) was 0.6. Sustained clinical efficacy was defined as upward shift of 1 or greater on the Rutherford scale without repeat target limb revascularization (TLR) or amputation. Mortality, morbidity, need for TLR, or amputation were separate endpoints. RESULTS: Postoperatively, ABI was significantly improved (mean = 0.7), in 24 (44%) by more than 0.15. At three years, cumulative clinical success rate was 80%. Overall, patients with claudication had a better outcome than those with CLI (p = 0.04). Two (4%) major amputations and 2 (4%) minor ones were performed, all in patients with CLI. None of the 9 (16%) ulcers healed. CONCLUSION: Profundaplasty is still a valuable option for patients with femoral PAD and claudication without tissue loss. It is a straightforward procedure that combines good efficacy with low complication rates. Further endovascular treatment may be facilitated. It is not useful for patients with the combination of critical ischemia and tissue loss.

Effect of risk factors on complicated and uncomplicated ulcers in the TARGET lumiracoxib outcomes study

BACKGROUND ; AIMS: Selective cyclooxygenase-2 inhibitors were developed to reduce the gastrointestinal risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs). The Therapeutic Arthritis Research and Gastrointestinal Event Trial was the largest study to evaluate primarily the gastrointestinal safety outcomes of selective cyclooxygenase-2 inhibitors. Data from the Therapeutic Arthritis Research and Gastrointestinal Event Trial were used to identify risk factors and investigate the safety of lumiracoxib in subgroups. METHODS: Patients with osteoarthritis (age, >or=50 y) were randomized to receive lumiracoxib 400 mg once daily, naproxen 500 mg twice daily, or ibuprofen 800 mg 3 times daily for 12 months. Events were categorized by a blinded adjudication committee. The primary end point was all definite or probable ulcer complications. RESULTS: For patients taking NSAIDs, factors associated with an increased risk of ulcer complications were age 65 years or older (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.48-3.59), previous history of gastrointestinal bleed or ulcer (HR, 3.61; 95% CI, 1.86-7.00), non-Caucasian racial origin (HR, 2.10; 95% CI, 1.35-3.27), and male sex (HR, 1.70; 95% CI, 1.08-2.68). With lumiracoxib, significant risk factors were age 65 years or older (HR, 3.18; 95% CI, 1.40-7.20), male sex (HR, 2.60; 95% CI, 1.25-5.40), non-Caucasian racial origin (HR, 2.16; 95% CI, 1.02-4.59), and concomitant aspirin use (HR, 2.89; 95% CI, 1.40-5.97). Increased risks in patients age 65 years and older were increased further if other risk factors were present. Lumiracoxib maintained an advantage over NSAIDs across all subgroups except aspirin use. CONCLUSIONS: Lumiracoxib was associated with a reduced risk of ulcer complications compared with NSAIDs in all significant subgroups except aspirin users.

Omega-3 fatty acids and the neurovascular responses to mental stress in humans

Hypertension is the most prevalent form of cardiovascular disease (CVD) in the world, and is known to increase the risk for developing other diseases. Recently, the American Heart Association introduced a new classification of blood pressure, prehypertension (PHT). The criteria for PHT include a systolic of 120-139 mmHg and/or a diastolic blood pressure of 80-89 mmHg. It has been observed that individuals with PHT have a higher risk of developing hypertension later in life. Therefore, it is important to understand the mechanisms contributing to PHT in order to possibly prevent hypertension. Omega-3 fatty acids found in fish oils have been suggested as a means of lowering blood pressure. However, little is known on the effects of fish oil in PHT humans. Therefore we conducted two studies. In Study 1 we investigated PHT and normotensive (NT) individuals during a mental stress task. Mental stress is known to contribute to the development of hypertension. In Study 2 PHT and NT subjects were placed in an eight week double-blind placebo controlled study in which subjects consumed 9g/day of either fish oil or placebo (olive oil) in addition to their regular diets. Subjects were tested during a resting baseline (seated and supine), 5 minutes of a mental stress task, and 5 minutes of recovery both pre and post supplementation. We measured arterial pressure (AP), heart rate (HR), muscle sympathetic nerve activity (MSNA), and forearm and calf vascular responses. In Study 1 PHT demonstrated augmented AP and blunted vasodilation during mental stress, but MSNA did not change. In Study 2, fish oil did not directly influence blood pressure, MSNA or vascular responses to mental stress. However, it became clear that fish oil had an effect on some but not all subjects (both PHT and NT). Specifically, subjects who experienced a reduced blood pressure response to fish oil also demonstrated a decrease in MSNA and HR during mental stress. Collectively, the investigations in this dissertation had several novel findings. First, PHT individuals demonstrate an augmented pressor and blunted vascular response to mental stress, a response that may be contributing to the development of hypertension. Second, fish oil does not consistently lower resting blood pressure, but the interindividual responses may be related to MSNA. Third, fish oil attenuated the heart rate and MSNA responses and to mental stress in both PHT and NT. In conclusion, we found that there are both similarities and differences in the way PHT and NT individuals respond to mental stress and fish oil.

Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients

OBJECTIVE: Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy. METHODS: Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years). RESULTS: All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less. CONCLUSION: Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.

Anticoagulation in primary care - a cross sectional study in 14 heterogeneous countries

Background: New oral anticoagulants (NOACs) are predicted to become the new standard treatment for stroke prevention in patients with atrial fibrillation, and may replace vitamin K antagonists (VKAs). NOACs are prescribed less than expected, even though they do not require international normalised ratio (INR) monitoring. In this study we assessed methods for INR monitoring after the introduction of NOACs a in heterogeneous sample of countries. Methods: We asked representatives of the Vasco da Gama Movement, a network of junior and future gen- eral practitioners (GPs) in Europe, and WONCA, the World Organization of Family Doctors, to describe the way INR is monitored in their respective countries. Results: Representatives of 14 countries responded. In most countries, the INR is monitored by GPs; in some countries, these patients are treated by other specialists or in specialised anticoagulation centres. In only a few countries, anticoagulated patients monitor the INR themselves. Conclusion: Our study showed several strategies for managing anticoagulation in different countries. In most countries, the INR is monitored by GPs. These consultations offer opportunities to address other is- sues, such as blood pressure control or medication adherence. These factors may be considered when de- ciding to switch patients from VKAs to NOACs.

Epidemiology of masked and white-coat hypertension: the family-based SKIPOGH study

Objective We investigated factors associated with masked and white-coat hypertension in a Swiss population-based sample. Methods The Swiss Kidney Project on Genes in Hypertension is a family-based cross-sectional study. Office and 24-hour ambulatory blood pressure were measured using validated devices. Masked hypertension was defined as office blood pressure<140/90 mmHg and daytime ambulatory blood pressure≥135/85 mmHg. White-coat hypertension was defined as office blood pressure≥140/90 mmHg and daytime ambulatory blood pressure<135/85 mmHg. Mixed-effect logistic regression was used to examine the relationship of masked and white-coat hypertension with associated factors, while taking familial correlations into account. High-normal office blood pressure was defined as systolic/diastolic blood pressure within the 130–139/85–89 mmHg range. Results Among the 652 participants included in this analysis, 51% were female. Mean age (±SD) was 48 (±18) years. The proportion of participants with masked and white coat hypertension was respectively 15.8% and 2.6%. Masked hypertension was associated with age (odds ratio (OR) = 1.02, p = 0.012), high-normal office blood pressure (OR = 6.68, p<0.001), and obesity (OR = 3.63, p = 0.001). White-coat hypertension was significantly associated with age (OR = 1.07, p<0.001) but not with education, family history of hypertension, or physical activity. Conclusions Our findings suggest that physicians should consider ambulatory blood pressure monitoring for older individuals with high-normal office blood pressure and/or who are obese.

Detection of haemorrhagic shock: Are vital signs obsolete? A commentary by Dr M. Luginbühl

The ATLS program by the American college of surgeons is probably the most important globally active training organization dedicated to improve trauma management. Detection of acute haemorrhagic shock belongs to the key issues in clinical practice and thus also in medical teaching. (In this issue of the journal William Schulz and Ian McConachrie critically review the ATLS shock classification Table 1), which has been criticized after several attempts of validation have failed [1]. The main problem is that distinct ranges of heart rate are related to ranges of uncompensated blood loss and that the heart rate decrease observed in severe haemorrhagic shock is ignored [2]. Table 1. Estimated blood loos based on patient's initial presentation (ATLS Students Course Manual, 9th Edition, American College of Surgeons 2012). Class I Class II Class III Class IV Blood loss ml Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15% 15–30% 30–40% >40% Pulse rate (BPM) <100 100–120 120–140 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased Respiratory rate 14–20 20–30 30–40 >35 Urine output (ml/h) >30 20–30 5–15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Table options In a retrospective evaluation of the Trauma Audit and Research Network (TARN) database blood loss was estimated according to the injuries in nearly 165,000 adult trauma patients and each patient was allocated to one of the four ATLS shock classes [3]. Although heart rate increased and systolic blood pressure decreased from class I to class IV, respiratory rate and GCS were similar. The median heart rate in class IV patients was substantially lower than the value of 140 min−1 postulated by ATLS. Moreover deterioration of the different parameters does not necessarily go parallel as suggested in the ATLS shock classification [4] and [5]. In all these studies injury severity score (ISS) and mortality increased with in increasing shock class [3] and with increasing heart rate and decreasing blood pressure [4] and [5]. This supports the general concept that the higher heart rate and the lower blood pressure, the sicker is the patient. A prospective study attempted to validate a shock classification derived from the ATLS shock classes [6]. The authors used a combination of heart rate, blood pressure, clinically estimated blood loss and response to fluid resuscitation to classify trauma patients (Table 2) [6]. In their initial assessment of 715 predominantly blunt trauma patients 78% were classified as normal (Class 0), 14% as Class I, 6% as Class II and only 1% as Class III and Class IV respectively. This corresponds to the results from the previous retrospective studies [4] and [5]. The main endpoint used in the prospective study was therefore presence or absence of significant haemorrhage, defined as chest tube drainage >500 ml, evidence of >500 ml of blood loss in peritoneum, retroperitoneum or pelvic cavity on CT scan or requirement of any blood transfusion >2000 ml of crystalloid. Because of the low prevalence of class II or higher grades statistical evaluation was limited to a comparison between Class 0 and Class I–IV combined. As in the retrospective studies, Lawton did not find a statistical difference of heart rate and blood pressure among the five groups either, although there was a tendency to a higher heart rate in Class II patients. Apparently classification during primary survey did not rely on vital signs but considered the rather soft criterion of “clinical estimation of blood loss” and requirement of fluid substitution. This suggests that allocation of an individual patient to a shock classification was probably more an intuitive decision than an objective calculation the shock classification. Nevertheless it was a significant predictor of ISS [6]. Table 2. Shock grade categories in prospective validation study (Lawton, 2014) [6]. Normal No haemorrhage Class I Mild Class II Moderate Class III Severe Class IV Moribund Vitals Normal Normal HR > 100 with SBP >90 mmHg SBP < 90 mmHg SBP < 90 mmHg or imminent arrest Response to fluid bolus (1000 ml) NA Yes, no further fluid required Yes, no further fluid required Requires repeated fluid boluses Declining SBP despite fluid boluses Estimated blood loss (ml) None Up to 750 750–1500 1500–2000 >2000 Table options What does this mean for clinical practice and medical teaching? All these studies illustrate the difficulty to validate a useful and accepted physiologic general concept of the response of the organism to fluid loss: Decrease of cardiac output, increase of heart rate, decrease of pulse pressure occurring first and hypotension and bradycardia occurring only later. Increasing heart rate, increasing diastolic blood pressure or decreasing systolic blood pressure should make any clinician consider hypovolaemia first, because it is treatable and deterioration of the patient is preventable. This is true for the patient on the ward, the sedated patient in the intensive care unit or the anesthetized patients in the OR. We will therefore continue to teach this typical pattern but will continue to mention the exceptions and pitfalls on a second stage. The shock classification of ATLS is primarily used to illustrate the typical pattern of acute haemorrhagic shock (tachycardia and hypotension) as opposed to the Cushing reflex (bradycardia and hypertension) in severe head injury and intracranial hypertension or to the neurogenic shock in acute tetraplegia or high paraplegia (relative bradycardia and hypotension). Schulz and McConachrie nicely summarize the various confounders and exceptions from the general pattern and explain why in clinical reality patients often do not present with the “typical” pictures of our textbooks [1]. ATLS refers to the pitfalls in the signs of acute haemorrhage as well: Advanced age, athletes, pregnancy, medications and pace makers and explicitly state that individual subjects may not follow the general pattern. Obviously the ATLS shock classification which is the basis for a number of questions in the written test of the ATLS students course and which has been used for decades probably needs modification and cannot be literally applied in clinical practice. The European Trauma Course, another important Trauma training program uses the same parameters to estimate blood loss together with clinical exam and laboratory findings (e.g. base deficit and lactate) but does not use a shock classification related to absolute values. In conclusion the typical physiologic response to haemorrhage as illustrated by the ATLS shock classes remains an important issue in clinical practice and in teaching. The estimation of the severity haemorrhage in the initial assessment trauma patients is (and was never) solely based on vital signs only but includes the pattern of injuries, the requirement of fluid substitution and potential confounders. Vital signs are not obsolete especially in the course of treatment but must be interpreted in view of the clinical context. Conflict of interest None declared. Member of Swiss national ATLS core faculty.

Familial aggregation, candidate genes and genome scans: Analyzing the role of genetics in stroke

The genetic etiology of stroke likely reflects the influence of multiple loci with small effects, each modulating different pathophysiological processes. This research project utilized three analytical strategies to address the paucity of information related to the identification and characterization of genetic variation associated with stroke in the general population. ^ First, the general contribution of familial factors to stroke susceptibility was evaluated in a population-based sample of unrelated individuals. Increased risk of subclinical cerebral infarction was observed among individuals with a positive parental history of stroke. This association did not appear to be mediated by established stroke risk factors, specifically blood pressure levels or hypertension status. ^ The need to identify specific gene variation associated with stroke in the general population was addressed by evaluating seven candidate gene polymorphisms in a population-based sample of unrelated individuals. Three polymorphisms were significantly associated with increased subclinical cerebral infarction or incident clinical ischemic stroke risk. These relationships include the G-protein β3 subunit 825C/T polymorphism and clinical stroke in Whites, the lipoprotein lipase S/X447 polymorphism and subclinical and clinical stroke in men, and the angiotensin I-converting enzyme Ins/Del polymorphism and subclinical stroke in White men. These associations did not appear to be obfuscated by the stroke risk factors adjusted for in the analysis models specifically blood pressure levels or anti-hypertensive medication use. ^ The final research strategy considered, on a genome-wide scale, the idea that genetic variation may contribute to the occurrence of hypertension or stroke through a common etiologic pathway. Genomic regions were identified for which significant evidence of heterogeneity was observed among hypertensive sibpairs stratified by family history of stroke information. Regions identified on chromosome 15 in African Americans, and chromosome 13 in Whites and African Americans, suggest the presence of genes influencing hypertension and stroke susceptibility. ^ Insight into the role of genetics in stroke is useful for the potential early identification of individuals at increased risk for stroke and improved understanding of the etiology of the disease. The ultimate goal of these endeavors is to guide the development of therapeutic intervention and informed prevention to provide a lasting and positive impact on public health. ^

Metodología de análisis estadístico de roturas en redes de distribución de agua

La presente Tesis plantea una metodología de análisis estadístico de roturas de tubería en redes de distribución de agua, que analiza la relación entre las roturas y la presión de agua y que propone la implantación de una gestión de presiones que reduzca el número de roturas que se producen en dichas redes. Las redes de distribución de agua se deterioran y una de sus graves consecuencias es la aparición de roturas frecuentes en sus tuberías. Las roturas llevan asociados elevados costes sociales, económicos y medioambientales y es por ello por lo que las compañías gestoras del agua tratan de reducirlas en la medida de lo posible. Las redes de distribución de agua se pueden dividir en zonas o sectores que facilitan su control y que pueden ser independientes o aislarse mediante válvulas, como ocurre en las redes de países más desarrollados, o pueden estar intercomunicados hidráulicamente. La implantación de una gestión de presiones suele llevarse a cabo a través de las válvulas reductoras de presión (VPR), que se instalan en las cabeceras de estos sectores y que controlan la presión aguas abajo de la misma, aunque varíe su caudal de entrada. Los métodos más conocidos de la gestión de presiones son la reducción de presiones, que es el control más habitual, el mantenimiento de la presión, la prevención y/o alivio de los aumentos repentinos de presión y el establecimiento de un control por alturas. A partir del año 2005 se empezó a reconocer el efecto de la gestión de presiones sobre la disminución de las roturas. En esta Tesis, se sugiere una gestión de presiones que controle los rangos de los indicadores de la presión de cabecera que más influyan en la probabilidad de roturas de tubería. Así, la presión del agua se caracteriza a través de indicadores obtenidos de la presión registrada en la cabecera de los sectores, debido a que se asume que esta presión es representativa de la presión de operación de todas las tuberías porque las pérdidas de carga son relativamente bajas y las diferencias topográficas se tienen en cuenta en el diseño de los sectores. Y los indicadores de presión, que se pueden definir como el estadístico calculado a partir de las series de la presión de cabecera sobre una ventana de tiempo, pueden proveer la información necesaria para ayudar a la toma de decisiones a los gestores del agua con el fin de reducir las roturas de tubería en las redes de distribución de agua. La primera parte de la metodología que se propone en esta Tesis trata de encontrar los indicadores de presión que influyen más en la probabilidad de roturas de tuberías. Para conocer si un indicador es influyente en la probabilidad de las roturas se comparan las estimaciones de las funciones de distribución acumulada (FDAs) de los indicadores de presiones, considerando dos situaciones: cuando se condicionan a la ocurrencia de una rotura (suceso raro) y cuando se calculan en la situación normal de operación (normal operación). Por lo general, las compañías gestoras cuentan con registros de roturas de los años más recientes y al encontrarse las tuberías enterradas se complica el acceso a la información. Por ello, se propone el uso de funciones de probabilidad que permiten reducir la incertidumbre asociada a los datos registrados. De esta forma, se determinan las funciones de distribución acumuladas (FDAs) de los valores del indicador de la serie de presión (situación normal de operación) y las FDAs de los valores del indicador en el momento de ocurrencia de las roturas (condicionado a las roturas). Si las funciones de distribución provienen de la misma población, no se puede deducir que el indicador claramente influya en la probabilidad de roturas. Sin embargo, si se prueba estadísticamente que las funciones proceden de la misma población, se puede concluir que existe una relación entre el indicador analizado y la ocurrencia de las roturas. Debido a que el número de valores del indicador de la FDA condicionada a las roturas es mucho menor que el número de valores del indicador de la FDA incondicional a las roturas, se generan series aleatorias a partir de los valores de los indicadores con el mismo número de valores que roturas registradas hay. De esta forma, se comparan las FDAs de series aleatorias del indicador con la FDA condicionada a las roturas del mismo indicador y se deduce si el indicador es influyente en la probabilidad de las roturas. Los indicadores de presión pueden depender de unos parámetros. A través de un análisis de sensibilidad y aplicando un test estadístico robusto se determina la situación en la que estos parámetros dan lugar a que el indicador sea más influyente en la probabilidad de las roturas. Al mismo tiempo, los indicadores se pueden calcular en función de dos parámetros de cálculo que se denominan el tiempo de anticipación y el ancho de ventana. El tiempo de anticipación es el tiempo (en horas) entre el final del periodo de computación del indicador de presión y la rotura, y el ancho de ventana es el número de valores de presión que se requieren para calcular el indicador de presión y que es múltiplo de 24 horas debido al comportamiento cíclico diario de la presión. Un análisis de sensibilidad de los parámetros de cálculo explica cuándo los indicadores de presión influyen más en la probabilidad de roturas. En la segunda parte de la metodología se presenta un modelo de diagnóstico bayesiano. Este tipo de modelo forma parte de los modelos estadísticos de prevención de roturas, parten de los datos registrados para establecer patrones de fallo y utilizan el teorema de Bayes para determinar la probabilidad de fallo cuando se condiciona la red a unas determinadas características. Así, a través del teorema de Bayes se comparan la FDA genérica del indicador con la FDA condicionada a las roturas y se determina cuándo la probabilidad de roturas aumenta para ciertos rangos del indicador que se ha inferido como influyente en las roturas. Se determina un ratio de probabilidad (RP) que cuando es superior a la unidad permite distinguir cuándo la probabilidad de roturas incrementa para determinados intervalos del indicador. La primera parte de la metodología se aplica a la red de distribución de la Comunidad de Madrid (España) y a la red de distribución de Ciudad de Panamá (Panamá). Tras el filtrado de datos se deduce que se puede aplicar la metodología en 15 sectores en la Comunidad de Madrid y en dos sectores, llamados corregimientos, en Ciudad de Panamá. Los resultados demuestran que en las dos redes los indicadores más influyentes en la probabilidad de las roturas son el rango de la presión, que supone la diferencia entre la presión máxima y la presión mínima, y la variabilidad de la presión, que considera la propiedad estadística de la desviación típica. Se trata, por tanto, de indicadores que hacen referencia a la dispersión de los datos, a la persistencia de la variación de la presión y que se puede asimilar en resistencia de materiales a la fatiga. La segunda parte de la metodología se ha aplicado a los indicadores influyentes en la probabilidad de las roturas de la Comunidad de Madrid y se ha deducido que la probabilidad de roturas aumenta para valores extremos del indicador del rango de la presión y del indicador de la variabilidad de la presión. Finalmente, se recomienda una gestión de presiones que limite los intervalos de los indicadores influyentes en la probabilidad de roturas que incrementen dicha probabilidad. La metodología propuesta puede aplicarse a otras redes de distribución y puede ayudar a las compañías gestoras a reducir el número de fallos en el sistema a través de la gestión de presiones. This Thesis presents a methodology for the statistical analysis of pipe breaks in water distribution networks. The methodology studies the relationship between pipe breaks and water pressure, and proposes a pressure management procedure to reduce the number of breaks that occur in such networks. One of the manifestations of the deterioration of water supply systems is frequent pipe breaks. System failures are one of the major challenges faced by water utilities, due to their associated social, economic and environmental costs. For all these reasons, water utilities aim at reducing the problem of break occurrence to as great an extent as possible. Water distribution networks can be divided into areas or sectors, which facilitates the control of the network. These areas may be independent or isolated by valves, as it usually happens in developing countries. Alternatively, they can be hydraulically interconnected. The implementation of pressure management strategies is usually carried out through pressure-reducing valves (PRV). These valves are installed at the head of the sectors and, although the inflow may vary significantly, they control the downstream pressure. The most popular methods of pressure management consist of pressure reduction, which is the common form of control, pressure sustaining, prevention and/or alleviation of pressure surges or large variations in pressure, and level/altitude control. From 2005 onwards, the effects of pressure management on burst frequencies have become more widely recognized in the technical literature. This thesis suggests a pressure management that controls the pressure indicator ranges most influential on the probability of pipe breaks. Operating pressure in a sector is characterized by means of a pressure indicator at the head of the DMA, as head losses are relatively small and topographical differences were accounted for at the design stage. The pressure indicator, which may be defined as the calculated statistic from the time series of pressure head over a specific time window, may provide necessary information to help water utilities to make decisions to reduce pipe breaks in water distribution networks. The first part of the methodology presented in this Thesis provides the pressure indicators which have the greatest impact on the probability of pipe breaks to be determined. In order to know whether a pressure indicator influences the probability of pipe breaks, the proposed methodology compares estimates of cumulative distribution functions (CDFs) of a pressure indicator through consideration of two situations: when they are conditioned to the occurrence of a pipe break (a rare event), and when they are not (a normal operation). Water utilities usually have a history of failures limited to recent periods of time, and it is difficult to have access to precise information in an underground network. Therefore, the use of distribution functions to address such imprecision of recorded data is proposed. Cumulative distribution functions (CDFs) derived from the time series of pressure indicators (normal operation) and CDFs of indicator values at times coincident with a reported pipe break (conditioned to breaks) are compared. If all estimated CDFs are drawn from the same population, there is no reason to infer that the studied indicator clearly influences the probability of the rare event. However, when it is statistically proven that the estimated CDFs do not come from the same population, the analysed indicator may have an influence on the occurrence of pipe breaks. Due to the fact that the number of indicator values used to estimate the CDF conditioned to breaks is much lower in comparison with the number of indicator values to estimate the CDF of the unconditional pressure series, and that the obtained results depend on the size of the compared samples, CDFs from random sets of the same size sampled from the unconditional indicator values are estimated. Therefore, the comparison between the estimated CDFs of random sets of the indicator and the estimated CDF conditioned to breaks allows knowledge of if the indicator is influential on the probability of pipe breaks. Pressure indicators depend on various parameters. Sensitivity analysis and a robust statistical test allow determining the indicator for which these parameters result most influential on the probability of pipe breaks. At the same time, indicators can be calculated according to two model parameters, named as the anticipation time and the window width. The anticipation time refers to the time (hours) between the end of the period for the computation of the pressure indicator and the break. The window width is the number of instantaneous pressure values required to calculate the pressure indicator and is multiple of 24 hours, as water pressure has a cyclical behaviour which lasts one day. A sensitivity analysis of the model parameters explains when the pressure indicator is more influential on the probability of pipe breaks. The second part of the methodology presents a Bayesian diagnostic model. This kind of model belongs to the class of statistical predictive models, which are based on historical data, represent break behavior and patterns in water mains, and use the Bayes’ theorem to condition the probability of failure to specific system characteristics. The Bayes’ theorem allows comparing the break-conditioned FDA and the unconditional FDA of the indicators and determining when the probability of pipe breaks increases for certain pressure indicator ranges. A defined probability ratio provides a measure to establish whether the probability of breaks increases for certain ranges of the pressure indicator. The first part of the methodology is applied to the water distribution network of Madrid (Spain) and to the water distribution network of Panama City (Panama). The data filtering method suggests that the methodology can be applied to 15 sectors in Madrid and to two areas in Panama City. The results show that, in both systems, the most influential indicators on the probability of pipe breaks are the pressure range, which is the difference between the maximum pressure and the minimum pressure, and pressure variability, referred to the statistical property of the standard deviation. Therefore, they represent the dispersion of the data, the persistence of the variation in pressure and may be related to the fatigue in material resistance. The second part of the methodology has been applied to the influential indicators on the probability of pipe breaks in the water distribution network of Madrid. The main conclusion is that the probability of pipe breaks increases for the extreme values of the pressure range indicator and of the pressure variability indicator. Finally, a pressure management which limits the ranges of the pressure indicators influential on the probability of pipe breaks that increase such probability is recommended. The methodology presented here is general, may be applied to other water distribution networks, and could help water utilities reduce the number of system failures through pressure management.

Fluid-solid interaction in arteries incorporating the autoregulation concept in boundary conditions

In pre-surgery decisions in hospital emergency cases, fast and reliable results of the solid and fluid mechanics problems are of great interest to clinicians. In the current investigation, an iterative process based on a pressure-type boundary condition is proposed in order to reduce the computational costs of blood flow simulations in arteries, without losing control of the important clinical parameters. The incorporation of cardiovascular autoregulation, together with the well-known impedance boundary condition, forms the basis of the proposed methodology. With autoregulation, the instabilities associated with conventional pressure-type or impedance boundary conditions are avoided without an excessive increase in computational costs. The general behaviour of pulsatile blood flow in arteries, which is important from the clinical point of view, is well reproduced through this new methodology. In addition, the interaction between the blood and the arterial walls occurs via a modified weak coupling, which makes the simulation more stable and computationally efficient. Based on in vitro experiments, the hyperelastic behaviour of the wall is characterised and modelled. The applications and benefits of the proposed pressure-type boundary condition are shown in a model of an idealised aortic arch with and without an ascending aorta dissection, which is a common cardiovascular disorder.

A survey of possible associations between preharvest environment conditions and postharvest rejections of cut freesia flowers

Botrytis cinerea is the major pathogen infecting cut freesia flowers. Flecking symptoms on petals caused by this fungus result in postharvest rejections and substantial economic loss to both growers and sellers. In a limited survey for industry, numbers of freesia stems sent from a specialist grower in The Netherlands and rejected at a cut flower wholesaler in the United Kingdom were documented. Relationships between preharvest environment conditions in Holland that may predispose flowers to infection and postharvest freesia rejection levels in the United Kingdom due to B. cinerea flecking symptom expression are reported. Freesia rejections peaked during spring and, to a lesser degree, autumn periods. However, no clear correlations between preharvest growing environment conditions (e.g. 3-day means for temperature preceding harvest) and postharvest rejection frequency (%) could be discerned. Thus, sporadic freesia rejections in the United Kingdom were probably attributable either to other unresolved variables during the pre- (e.g. infection pressure) and/or postharvest (e.g. condensation events) phases or to interactions among predisposing variables.

On the possibility of elastic strain localisation in a fault

The phenomenon of strain localisation is often observed in shear deformation of particulate materials, e.g., fault gouge. This phenomenon is usually attributed to special types of plastic behaviour of the material (e.g., strain softening or mismatch between dilatancy and pressure sensitivity or both). Observations of strain localisation in situ or in experiments are usually based on displacement measurements and subsequent computation of the displacement gradient. While in conventional continua the symmetric part of the displacement gradient is equal to the strain, it is no longer the case in the more realistic descriptions within the framework of generalised continua. In such models the rotations of the gouge particles are considered as independent degrees of freedom the values of which usually differ from the rotation of an infinitesimal volume element of the continuum, the latter being described for infinitesimal deformations by the non-symmetric part of the displacement gradient. As a model for gouge material we propose a continuum description for an assembly of spherical particles of equal radius in which the particle rotation is treated as an independent degree of freedom. Based on this model we consider simple shear deformations of the fault gouge. We show that there exist values of the model parameters for which the displacement gradient exhibits a pronounced localisation at the mid-layers of the fault, even in the absence of inelasticity. Inelastic effects are neglected in order to highlight the role of the independent rotations and the associated additional parameters. The localisation-like behaviour occurs if (a) the particle rotations on the boundary of the shear layer are constrained (this type of boundary condition does not exist in a standard continuum) and (b) the contact moment-or bending stiffness is much smaller than the product of the effective shear modulus of the granulate and the square of the width of the gouge layer. It should be noted however that the virtual work functional is positive definite over the range of physically meaningful parameters (here: contact stiffnesses, solid volume fraction and coordination number) so that strictly speaking we are not dealing with a material instability.