A Randomised Controlled Trial

Liver surgery is still associated with a high rate of morbidity and mortality. We aimed to compare different haemodynamic treatments in liver surgery. In a prospective, blinded, randomised, controlled pilot trial patients undergoing liver resection were randomised to receive haemodynamic management guided by conventional haemodynamic parameters or by oesophageal Doppler monitor (ODM, CardioQ-ODM) or by pulse power wave analysis (PPA, LiDCOrapid) within a goal- directed algorithm adapted for liver surgery. The primary endpoint was stroke volume index before intra-operative start of liver resection. Secondary endpoints were the haemodynamic course during surgery and postoperative pain levels. Due to an unbalance in the extension of the surgical procedures with a high rate of only minor procedures the conventional group was dropped from the analysis. Eleven patients in the ODM group and 10 patients in the PPA group were eligible for statistical analysis. Stroke volume index before start of liver resection was 49 (37; 53) ml/m2 and 48 (41; 56) ml/m2 in the ODM and PPA group, respectively (p=0.397). The ODM guided group was haemodynamically stable as shown by ODM and PPA measurements. However, the PPA guided group showed a significant increase of pulse-pressure-variability (p=0.002) that was not accompanied by a decline of stroke volume index displayed by the PPA (p=0.556) but indicated by a decline of stroke volume index by the ODM (p<0.001). The PPA group had significantly higher postoperative pain levels than the ODM group (p=0.036). In conclusion, goal-directed optimization by ODM and PPA showed differences in intraoperative cardiovascular parameters indicating that haemodynamic optimization is not consistent between the two monitors

Multi-messenger observations of a binary neutron star merger

On 2017 August 17 a binary neutron star coalescence candidate (later designated GW170817) with merger time 12:41:04 UTC was observed through gravitational waves by the Advanced LIGO and Advanced Virgo detectors. The Fermi Gamma-ray Burst Monitor independently detected a gamma-ray burst (GRB 170817A) with a time delay of ~1.7 s with respect to the merger time. From the gravitational-wave signal, the source was initially localized to a sky region of 31 deg2 at a luminosity distance of 40+8-8 Mpc and with component masses consistent with neutron stars. The component masses were later measured to be in the range 0.86 to 2.26 Mo. An extensive observing campaign was launched across the electromagnetic spectrum leading to the discovery of a bright optical transient (SSS17a, now with the IAU identification of AT 2017gfo) in NGC 4993 (at ~40 Mpc) less than 11 hours after the merger by the One- Meter, Two Hemisphere (1M2H) team using the 1 m Swope Telescope. The optical transient was independently detected by multiple teams within an hour. Subsequent observations targeted the object and its environment. Early ultraviolet observations revealed a blue transient that faded within 48 hours. Optical and infrared observations showed a redward evolution over ~10 days. Following early non-detections, X-ray and radio emission were discovered at the transient’s position ~9 and ~16 days, respectively, after the merger. Both the X-ray and radio emission likely arise from a physical process that is distinct from the one that generates the UV/optical/near-infrared emission. No ultra-high-energy gamma-rays and no neutrino candidates consistent with the source were found in follow-up searches. These observations support the hypothesis that GW170817 was produced by the merger of two neutron stars in NGC4993 followed by a short gamma-ray burst (GRB 170817A) and a kilonova/macronova powered by the radioactive decay of r-process nuclei synthesized in the ejecta

Vertebral fracture due to Actinobacillus pleuropneumoniae osteomyelitis in a weaner

Abstract Background: Osteomyelitis is relatively frequent in young pigs and a few bacterial species have been postulated to be potential causative agents. Although Actinobacillus (A.) pleuropneumoniae has been sporadically described to cause osteomyelitis, typically, actinobacillosis is characterized by respiratory symptoms. Nevertheless, subclinical infections are a challenging problem in pig herds. To the authors’ knowledge, this is the first case description that reports clinical, diagnostic imaging, pathological and histopathological findings of vertebral osteomyelitis in a pig and first describes A. pleuropneumoniae as the causative agent identified by advanced molecular methods. Case presentation: An eight-week-old female weaner was presented with a non-ambulatory tetraparesis. The neurological signs were consistent with a lesion in the C6-T2 spinal cord segments. Imaging studies revealed a collapse of the seventh cervical vertebral body (C7) with a well demarcated extradural space-occupying mass ventrally within the vertebral canal severely compressing the spinal cord. Post-mortem examination identified an abscess and osteomyelitis of C7 and associated meningitis and neuritis with subsequent pathological fracture of C7 and compression of the spinal cord. In the microbiological analysis, A. pleuropneumoniae was identified using PCR and DNA sequence analysis. Conclusions: A. pleuropneumoniae can be responsible for chronic vertebral abscess formation with subsequent pathological fracture and spinal cord compression in pigs. Keywords: Diskospondylitis, Abscess, Porcine, DNA sequence analysis Background Vertebral osteomyelitis is a well-known condition in food animals and has been documented in various species [1–4]. Nevertheless, to the authors’ knowledge no case repor

Transdisciplinary knowledge management : A key but underdeveloped skill in EBM decision-making

The ecosystem-based management (EBM) philosophy draws upon the principle that holistic understanding of the system to be governed needs to guide the decision-making process. However, empirical evidence is growing that knowledge integration is still a main bottleneck for EBM decision-makers. This paper argues that transdisciplinary knowledge management (TKM) is a key competence in achieving knowledge integration, while simultaneously it represents an underdeveloped research area in EBM if understood as a process of human interaction. Based on a literature review, this article summarizes and reflects upon the most recent development in the field of TKM. The paper presents a detailed definition and in-depth description of TKM as a process of human interaction and a diversity of organizational structures that effectuate TKM. Theoretically discussed premises are furthermore illuminated and evaluated by a case study that exemplifies pro-active development and implementation of TKM. Deviating case observations are presented as novel contributions to the field. They suggest new ideas and inspiration for future EBM research and policy agendas.</p

Haemodynamic Optimization by Oesophageal Doppler and Pulse Power Wave Analysis in Liver Surgery: A Randomised Controlled Trial

<div><p>Liver surgery is still associated with a high rate of morbidity and mortality. We aimed to compare different haemodynamic treatments in liver surgery. In a prospective, blinded, randomised, controlled pilot trial patients undergoing liver resection were randomised to receive haemodynamic management guided by conventional haemodynamic parameters or by oesophageal Doppler monitor (ODM, CardioQ-ODM) or by pulse power wave analysis (PPA, LiDCOrapid) within a goal-directed algorithm adapted for liver surgery. The primary endpoint was stroke volume index before intra-operative start of liver resection. Secondary endpoints were the haemodynamic course during surgery and postoperative pain levels. Due to an unbalance in the extension of the surgical procedures with a high rate of only minor procedures the conventional group was dropped from the analysis. Eleven patients in the ODM group and 10 patients in the PPA group were eligible for statistical analysis. Stroke volume index before start of liver resection was 49 (37; 53) ml/m² and 48 (41; 56) ml/m² in the ODM and PPA group, respectively (p=0.397). The ODM guided group was haemodynamically stable as shown by ODM and PPA measurements. However, the PPA guided group showed a significant increase of pulse-pressure-variability (p=0.002) that was not accompanied by a decline of stroke volume index displayed by the PPA (p=0.556) but indicated by a decline of stroke volume index by the ODM (p<0.001). The PPA group had significantly higher postoperative pain levels than the ODM group (p=0.036). In conclusion, goal-directed optimization by ODM and PPA showed differences in intraoperative cardiovascular parameters indicating that haemodynamic optimization is not consistent between the two monitors.</p><p>Trial Registration</p><p>ISRCTN.com <a href="http://www.isrctn.com/ISRCTN64578872?q=ISRCTN64578872&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search" target="_blank">ISRCTN64578872</a></p></div

Time course of intraoperative haemodynamic parameters.

<p>Time course of stroke volume index (SVI) of the two intervention groups displayed by ODM (A1) and PPA (A2); time course of pulse pressure variation (PPV) of the two intervention groups displayed by PPA (B) and systemic vascular resistance index (SVRI) of the two intervention groups displayed by ODM (C). Data are shown as median (25%; 75%) quartiles over the time course of surgery and the nonparametric analysis for the parameters that are outlined with corresponding p values. Statistical significances: # for comparisons with respect to time points within the group (exact Wilcoxon tests); #1: p<0.05 vs. T1, #2: p<0.05 vs. T2, #3: p<0.05 vs. T3 and * for comparisons between the ODM and PPA group (Mann-Whitney tests) with p<0.05 at the time point ODM group vs. PPA group.</p

Goal-directed haemodynamic algorithm for liver surgery.

<p><b>Haemodynamic algorithm-abbreviations:</b> SVI: stroke volume index [ml/m²], MAP: mean arterial pressure [mmHg], SBP: systolic blood pressure [mmHg], CVP: central venous pressure [mmHg]. <b>Guidelines on the use of the algorithm:</b> After induction of anaesthesia and implementation of advanced haemodynamic monitoring a fluid challenge with 200ml of a colloid solution is performed. If stroke SVI increases by more than 10% a further fluid challenge is performed up to the point SVI is not increasing anymore. The value of SVI after the last fluid challenge is defined as Starting-SVI. After determining the Starting-SVI the second time period of the haemodynamic algorithm starts up to the point the liver resection area is surgically sealed. During that period arterial blood pressure is maintained by titration of continuous administration of norepinephrine to reach a systolic blood pressure (SBP) of more than 100mmHg and a mean arterial blood pressure (MAP) of more than 65mmHg. If SVI falls by more than 25% in relation to the Starting-SVI (#) or SVI drops below 40ml/m² a fluid challenge with 200ml of a colloid solution is performed. The performance of a fluid challenge is not followed up to SVI is not increasing anymore as in published algorithm for preload optimization. Instead the volume administration is stopped if the SVI is higher than 40ml/m² and not lower than 25% of the Starting-SVI (#). If there is still central venous congestion measured by an increased central venous pressure (CVP) and the clinical judgment of venous bleeding during incision of the liver by the surgeon administration of either enoximone or nitroglycerine could be performed (^X). After sealing the liver resection area volume administration can once again be guided to optimize SVI according to the previously published algorithms up to the end of surgery[<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0132715#pone.0132715.ref020" target="_blank">20</a>].</p

CONSORT Flow Diagram of the study.

<p>CONSORT Flow Diagram of the study.</p

General patient characteristics.

<p>Data are shown as median (25%; 75%) quartiles or as number n of patients (%). p-values calculated for the ODM versus the PPA group using the exact Wilcoxon-Mann-Whitney test #, the exact Mantel-Haenszel test (ordered categories)</p><p>§ or the exact Chi-square test</p><p>$ as appropriate.</p><p>Abreviations: ACEI: angiotensin converting enzyme inhibitor, LOS: length of stay, PACU: postanaesthesia care unit, HDU: high dependency care unit.</p><p>General patient characteristics.</p