Optimizing electrode implantation in sacral nerve stimulation—an anatomical cadaver study controlled by a laparoscopic camera

Background and aim: Sacral nerve stimulation is the therapy of choice in patients with neurogenic faecal and urine incontinence, constipation and some pelvic pain syndromes. The aim of this study is to determine the best insertion angles of the electrode under laparoscopic visualization of the sacral nerves. Materials and methods: Five fresh cadaver pelvises were dissected through an anterior approach of the presacral space, exposing the ventral sacral roots. Needles and electrodes were inserted into the S3 foramen. Both right and left sides were used, with the traditional percutaneous procedure. The validation was done by a laparoscopic camera controlling the position of the needle and electrode on the nerve. The angles were assessed with a goniometer and were confirmed in two living patients. Results: The mean angle of insertion in the sagittal plane was 62.9 ± 3° (range, 59-70). In the axial plane, the mean angle for the left side was 91.7 ± 13.5° (range, 80-110) and 83.2 ± 7.7° for the right side (range, 75-95). These angles resulted in the optimal placement of the leads along the S3 sacral root, in all these cases. Conclusions: This study allows direct visualization during the placement of the needle and electrode, thus permitting accurate calculations of the best angle of approach during the surgical procedure in sacral nerve stimulation. These objective findings attempt to standardize this technique, which is often performed with the aid of intra-operative fluoroscopy but still leaving a lot to chance. These insertion angles should help to find more consistent and reproducible results and thus improved outcome in patient

Certification of spin-based quantum simulators

Quantum simulators are engineered devices controllably designed to emulate complex and classically intractable quantum systems. A key challenge is to certify whether the simulator truly mimics the Hamiltonian of interest. This certification step requires the comparison of a simulator's output to a known answer, which is usually limited to small systems due to the exponential scaling of the Hilbert space. Here, in the context of Fermi-Hubbard spin-based analog simulators, we propose a modular many-body spin to charge conversion scheme that scales linearly with both the system size and the number of low-energy eigenstates to discriminate. Our protocol is based on the global charge state measurement of a 1D spin chain performed at different detuning potentials along the chain. In the context of semiconductor-based systems, we identify realistic conditions for detuning the chain adiabatically to avoid state mixing while preserving charge coherence. Large simulators with vanishing energy gaps, including 2D arrays, can be certified block-by-block with a number of measurements scaling only linearly with the system size

Projected long-term outcomes in patients with type 1 diabetes treated with fast-acting insulin aspart versus conventional insulin aspart in the UK setting

Aims: Many patients with type 1 diabetes mellitus (T1DM) fail to achieve optimal glycemic control and mealtime insulins that more closely match physiological insulin secretion can help improve treatment. In the onset 1 trial, fast-acting insulin aspart (faster aspart) was shown to improve glycemic control in patients with T1DM compared with conventional insulin aspart (insulin aspart). In the UK, faster aspart and insulin aspart are associated with the same acquisition cost, and therefore the present analysis assessed the impact of faster aspart versus insulin aspart on long-term clinical outcomes and costs for patients with T1DM in the UK setting. Methods: The QuintilesIMS CORE Diabetes Model was used to project clinical outcomes and costs over patient lifetimes in a cohort with baseline characteristics from the onset 1 trial. Treatment effects were taken from the 26-week main phase of the onset 1 trial, with costs and utilities based on literature review. Future costs and clinical benefits were discounted at 3.5% annually. Results: Projections indicated that faster aspart was associated with improved discounted quality-adjusted life expectancy (by 0.13 quality-adjusted life years) versus insulin aspart). Improved clinical outcomes resulted from fewer diabetes-related complications and a delayed time to their onset with faster aspart. Faster aspart was found to be associated with reduced costs versus insulin aspart (cost savings of GBP 1,715), resulting from diabetes-related complications avoided and reduced treatment costs. Conclusions: Faster aspart was associated with improved clinical outcomes and cost savings versus insulin aspart for patients with T1DM in the UK setting

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery

Background: The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery. Materials and methods: All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database. Results: The median age of patients was 73 (range 17-98)years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500cm3 (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score ≥3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003). Conclusions: The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surger

Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial.

Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults. A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death. The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality. Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults. Clinical Trials.gov Identifier: NCT02084108 . Retrospectively registered on March 10(th) 2014

Phenotypic redshifts with self-organizing maps: A novel method to characterize redshift distributions of source galaxies for weak lensing

Wide-field imaging surveys such as the Dark Energy Survey (DES) rely on coarse measurements of spectral energy distributions in a few filters to estimate the redshift distribution of source galaxies. In this regime, sample variance, shot noise, and selection effects limit the attainable accuracy of redshift calibration and thus of cosmological constraints. We present a new method to combine wide-field, few-filter measurements with catalogs from deep fields with additional filters and sufficiently low photometric noise to break degeneracies in photometric redshifts. The multi-band deep field is used as an intermediary between wide-field observations and accurate redshifts, greatly reducing sample variance, shot noise, and selection effects. Our implementation of the method uses self-organizing maps to group galaxies into phenotypes based on their observed fluxes, and is tested using a mock DES catalog created from N-body simulations. It yields a typical uncertainty on the mean redshift in each of five tomographic bins for an idealized simulation of the DES Year 3 weak-lensing tomographic analysis of $\sigma_{\Delta z} = 0.007$, which is a 60% improvement compared to the Year 1 analysis. Although the implementation of the method is tailored to DES, its formalism can be applied to other large photometric surveys with a similar observing strategy.Comment: 24 pages, 11 figures; matches version accepted to MNRA

Louisville Seamount Trail: implications for geodynamic mantle flow models and the geochemical evolution of primary hotspots

The Louisville Seamount Trail is a 4300 km long volcanic chain that has been built in the past 80 m.y. as the Pacific plate moved over a persistent mantle melting anomaly or hotspot. Because of its linear morphology and its long-lived age-progressive volcanism, Louisville is the South Pacific counterpart of the much better studied Hawaiian-Emperor Seamount Trail. Together, Louisville and Hawaii are textbook examples of two primary hotspots that have been keystones in deciphering the motion of the Pacific plate relative to a set of "fixed" deep-mantle plumes. However, drilling during Ocean Drilling Program (ODP) Leg 197 in the Emperor Seamounts documented a large ~15° southward motion of the Hawaiian hotspot prior to 50 Ma. Is it possible that the Hawaiian and Louisville hotspots moved in concert and thus constitute a moving reference frame for modeling plate motion in the Pacific? Alternatively, could they have moved independently, as predicted by mantle flow models that reproduce the observed latitudinal motion for Hawaii but that predict a largely longitudinal shift for the Louisville hotspot? These two end-member geodynamic models were tested during Integrated Ocean Drilling Program (IODP) Expedition 330 to the Louisville Seamount Trail. In addition, existing data from dredged lavas suggest that the mantle plume source of the Louisville hotspot has been remarkably homogeneous for as long as 80 m.y. These lavas are predominantly alkali basalts and likely represent a mostly alkalic shield-building stage, which is in sharp contrast to the massive tholeiitic shield-building stage of Hawaiian volcanoes. Geochemical and isotopic data for the recovered lavas during Expedition 330 will provide insights into the magmatic evolution and melting processes of individual Louisville volcanoes, their progression from shield-building to postshield and (maybe) posterosional stages, the temperature and depth of partial melting of their mantle plume source, and the enigmatic long-lived and apparent geochemical homogeneity of the Louisville mantle source. Collectively, this will enable us to characterize the Louisville Seamount Trail as a product of one of the few global primary hotspots, to better constrain its plume-lithosphere interactions, and to further test the hypothesis that the Ontong Java Plateau formed from the plume head of the Louisville mantle plume around 120 Ma. During Expedition 330 we replicated the drilling strategy of Leg 197, the first expedition to provide compelling evidence for the motion of the Hawaiian mantle plume between 80 and 50 Ma. For that reason we targeted Louisville seamounts that have ages similar to Detroit, Suiko, Nintoku, and Koko Seamounts in the Emperor Seamount Trail. In total, five seamounts were drilled in the Louisville Seamount Trail: Canopus, Rigil, Burton, Achernar, and Hadar Guyots (old to young). By analyzing a large number of time-independent in situ lava flows (and other volcanic eruptive products) from these seamounts using modern paleomagnetic, 40Ar/39Ar geochronological, and geochemical techniques, we will be able to directly compare the paleolatitude estimates and geochemical signatures between the two longest-lived hotspot systems in the Pacific Ocean. We drilled into the summits of the five Louisville guyots and reached volcanic basement at four of these drilling targets. In two cases we targeted larger seamount structures and drilled near the flanks of these ancient volcanoes, and in the other three cases we selected smaller edifices that we drilled closer to their centers. Drilling and logging plans for each of these sites were similar, with coring reaching 522.0 meters below seafloor (mbsf) for Site U1374 and 232.9, 65.7, 11.5, 182.8, and 53.3 mbsf for Sites U1372, U1373, U1375, U1376, and U1377, respectively. Some Expedition 330 drill sites were capped with only a thin layer of pelagic ooze between 6.6 and 13.5 m thick, and, if present, these were cored by using a low-rotation gravity-push technique with the rotary core barrel to maximize recovery. However, at Sites U1373 and U1376 no pelagic ooze was present, and the holes needed to be started directly into cobble-rich hardgrounds. In all cases, the bulk of the seamount sediment cover comprised sequences of volcanic sandstones and various kinds of basalt breccia or basalt conglomerate, which often were interspersed with basaltic lava flows, the spatter/tephra products of submarine eruptions, or other volcanic products, including auto-brecciated flows or peperites. Also several intervals of carbonate were cored, with the special occurrence of a ~15 m thick algal limestone reef at Site U1376 on Burton Guyot. In addition, some condensed pelagic limestone units were recovered on three of the other seamounts, but these did not exceed 30 cm in thickness. Despite their limited presence in the drilled sediment, these limestones provide valuable insights for the paleoclimate record at high ~50° southern latitudes since Mesozoic times. Several Louisville sites progressed from subaerial conditions in the top of volcanic basement into submarine eruptive environments, or drilling of the igneous basement immediately started in submarine volcanic sequences, as was the case for Sites U1376 and U1377 on Burton and Hadar Guyots. At three sites we cored >100 m into the igneous basement: 187.3 m at Site U1372, 505.3 m at Site U1374, and 140.9 m at Site U1376. At the other sites we did not core into basement (Site U1375) or we cored only 38.2 m (Site U1377) because of unstable hole conditions. Even so, drilling during Expedition 330 resulted in a large number of in situ lava flows, pillow basalts, or other types of volcanic products such as auto-brecciated lava flows, intrusive sheets or dikes, and peperites. In particular, the three holes on Canopus and Rigil Guyots (the two oldest seamounts drilled in the Louisville Seamount Trail), resulted in adequate numbers of in situ lava flows to average out paleosecular variation, with probable eruption ages estimated at ~78 and 73 Ma, respectively. Remarkably, at all drill sites large quantities of hyaloclastites, volcanic sandstones, and basaltic breccias were also recovered, which in many cases show consistent paleomagnetic inclinations compared to the lava flows bracketing these units. For Site U1374 on Rigil Guyot we also observed a magnetic polarity reversal in the cored sequence. Overall, this is very promising for determining a reliable paleolatitude record for the Louisville Seamounts following detailed postcruise examinations. The deeper penetrations of several hundred meters required bit changes and reentries using free-fall funnels. Basement penetration rates were 1.8–2.5 m/h depending on drill depth. In total, 1114 m of sediment and igneous basement at five seamounts was drilled, and 806 m was recovered (average recovery = 72.4%). At Site U1374 on Rigil Guyot, a total of 522 m was drilled, with a record-breaking 87.8% recovery. Most outstandingly, nearly all Expedition 330 core material is characterized by low degrees of alteration, providing us with a large quantity of samples of mostly well-preserved basalt, containing, for example, pristine olivine crystals with melt inclusions, fresh volcanic glass, unaltered plagioclase, carbonate, zeolite and celadonite alteration minerals, various micro- and macrofossils, and, in one case, mantle xenoliths and xenocrysts. The large quantity and excellent quality of the recovered sample material allow us to address all the scientific objectives of this expedition and beyond

The Impact of Insulin Pump Therapy on Glycemic Profiles in Patients with Type 2 Diabetes: Data from the OpT2mise Study

Background: The OpT2mise randomized trial was designed to compare the effects of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) on glucose profiles in patients with type 2 diabetes. Research Design and Methods: Patients with glycated hemoglobin (HbA1c) levels of ≥8% (64 mmol/mol) and ≤12% (108 mmol/mol) despite insulin doses of 0.7-1.8 U/kg/day via MDI were randomized to CSII (n=168) or continued MDI (n=163). Changes in glucose profiles were evaluated using continuous glucose monitoring data collected over 6-day periods before and 6 months after randomization. Results: After 6 months, reductions in HbA1c levels were significantly greater with CSII (-1.1±1.2% [-12.0±13.1 mmol/mol]) than with MDI (-0.4±1.1% [-4.4±12.0 mmol/mol]) (P&lt;0.001). Similarly, compared with patients receiving MDI, those receiving CSII showed significantly greater reductions in 24-h mean sensor glucose (SG) (treatment difference, -17.1 mg/dL; P=0.0023), less exposure to SG &gt;180 mg/dL (-12.4%; P=0.0004) and SG &gt;250 mg/dL (-5.5%; P=0.0153), and more time in the SG range of 70-180 mg/dL (12.3%; P=0.0002), with no differences in exposure to SG&lt;70 mg/dL or in glucose variability. Changes in postprandial (4-h) glucose area under the curve &gt;180 mg/dL were significantly greater with CSII than with MDI after breakfast (-775.9±1,441.2 mg/dL/min vs. -160.7±1,074.1 mg/dL/min; P=0.0015) and after dinner (-731.4±1,580.7 mg/dL/min vs. -71.1±1,083.5 mg/dL/min; P=0.0014). Conclusions: In patients with suboptimally controlled type 2 diabetes, CSII significantly improves selected glucometrics, compared with MDI, without increasing the risk of hypoglycemia