Kontrastverstärkte Ultraschall-Ventrikulographie bei kritisch kranken neurochirurgischen Intensivpatienten

Während des Entwöhnens von einer EVD gehören wiederholt durchgeführte cCTs und CT-Ventrikulographien zur Routineprozedur. Damit verbunden sind Risiken für die Patienten, einmal bedingt durch den intrahospitalen Transport (Beckmann et al., 2004; Bercault et al., 2005) sowie durch die Strahlenbelastung der CT-Untersuchung (Moskowitz et al., 2010). Darüber hinaus stellt der Transport eines kritisch kranken Patienten ein zeit- und kostenintensives Geschehen dar (Waydhas, 1999). Von Vorteil erscheint es daher, eine aussagekräftige bettseitige bildgebende Methode zur Hand zu haben. In der Neurochirurgischen Klinik des Universitätsklinikums Marburg wurde die CEUS-Ventrikulographie entwickelt, bei der ein UKV über die einliegende EVD in die Ventrikel appliziert und mittels des Gewebe-Harmonic-Imaging Modus dargestellt wird. Die vorliegende Arbeit beschäftigte sich mit der Fragestellung, ob die Darstellung der Liquorzirkulation durch die CEUS-Ventrikulographie sicher gelingt, jedoch weniger risikobehaftet als die Durchführung einer cCT-Ventrikulographie ist. Ein erfahrener Ultraschall-Untersucher führte bei 13 Patienten in insgesamt 16 Fällen nach einem transkraniellen Ultraschall der Ventrikel die CEUS-Ventrikulographie durch. Die im nativen US gemessenen Ventrikelweiten wurden mit denen aus der cCT-Bildgebung, die nach der CEUS-Ventrikulographie angefertigt wurde, verglichen. In einem Zeitraum von fünf Tagen vor und nach der Applikation des UKV SonoVue® wurde die Zusammensetzung des Liquors und des Serums auf Veränderungen untersucht (Leukozyten, CRP, PCT, LZZ, LPrt, LLak, LGlc/BGlc) und die tägliche maximale Körpertemperatur erfasst. Es konnte gezeigt werden, dass die Weiten der Ventrikel im nativen Ultraschall und der cCT sich nicht signifikant unterscheiden (III.Ventrikel p-Wert: 0,267; IV.Ventrikel p-Wert: 0,075; VH re. p-Wert: 0,256; VH li. p-Wert: 0,716; SV re. p-Wert: 0,481; SV li. p-Wert: 0,603). Es gelang in allen 16 Fällen die Liquorzirkulation nach intraventrikulärer Applikation des UKV darzustellen. In 15 Fällen konnte der Übertritt des UKV gezeigt werden. Es konnte keine klinische Verschlechterung der Patienten in einer 30-minütigen Nachbeobachtungszeit festgestellt werden. Auch in der Labor- und Liquordiagnostik wurden unter Heranziehen der Kasuistiken in einem fünftägigen Nachuntersuchungszeitraum keine Hinweise auf eine Ventrikulitits gefunden. Werden CT-Ventrikulographie und CEUS-Ventrikulographie hinsichtlich des Kosten- und Zeitfaktors miteinander verglichen, so belaufen sich die Kosten für die CT-Ventrikulographie auf 148,39 € bis 156,79 € bei einem Zeitaufwand von ungefähr 40-50 Minuten, während für eine CEUS-Ventrikulographie 93,85 € veranschlagt werden müssen bei ungefähr 6-minütiger Untersuchungsdauer. Die Aussagekraft der Ergebnisse wird durch die geringe Stichprobengröße eingeschränkt. Dennoch liefert die CEUS-Ventrikulographie eindeutige Ergebnisse, die großes Potential im Bereich der Darstellung der Ventrikel bei verschiedenen Krankheitsbildern bergen. Die Labor- und Liquordiagnostik konnte aufgrund von Verlegung oder Entlassung der Patienten und Entfernen der EVD nach Durchführung der CEUS-Ventrikulographie nur bei der Minderheit der Patienten lückenlos durchgeführt werden. Antibiotische Behandlungen, Infekte der Patienten, Wechsel von EVD auf LD und die zur Aufnahme führenden Krankheitsbilder stellen Confounder dar, welche die erfassten Parameter beeinflussen können. Die in der vorliegenden Arbeit dargestellten deskriptiven Verläufe der Labor- und Liquorparameter liefern keine Hinweise dafür, dass die intraventrikuläre Applikation von SonoVue® eine Infektion des Ventrikelsytems hervorruft. Um dies zu beweisen, sind in der Zukunft weitere Untersuchungen mit größeren Patientenkollektiven anzustreben

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

BackgroundPostoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.MethodsA prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.ResultsOn the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8–19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9–11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1–1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5–4.4) and diclofenac (OR 2.0, 95% CI: 1. 3–3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9–4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7–11.6).ConclusionsThe main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome

Paternal inflammatory arthritis is associated with a higher risk of miscarriage:results of a large multicentre study (iFAME-Fertility)

OBJECTIVES: Paternal preconception health is recognized as an important contributor to pregnancy outcomes. Nonetheless, pregnancy outcomes of partners of men with inflammatory arthritis (IA) have never been studied. Our objective was to describe the pregnancy outcomes of partners of men diagnosed with IA.METHODS: We performed a multicentre cross-sectional retrospective study conducted in the Netherlands. Men with IA who were over 40 years old that reported at least one positive pregnancy test were included. To analyse the impact of IA on pregnancy outcomes, pregnancies were classified into two groups: pregnancies conceived after the diagnosis of IA and before the diagnosis of IA.RESULTS: In total, 408 male participants diagnosed with IA reported 897 singleton pregnancies that resulted in 794 live births. Pregnancies conceived after the diagnosis of IA had higher rate of miscarriage (12.27 vs 7.53%, P = &lt;0.05). This increased risk was still present after adjusting for confounders [OR 2.03 (95% CI 1.12, 3.69) P = 0.015].CONCLUSIONS: This is the largest study to describe the pregnancy outcomes of partners of men diagnosed with IA and the first to demonstrate that paternal IA is associated with a higher risk of miscarriage. Notwithstanding, the overall rate of miscarriage reported in our study could be comparable to previously reported population estimates.</p

EULAR recommendations for terminology and research in individuals at risk of rheumatoid arthritis: report from the Study Group for Risk Factors for Rheumatoid Arthritis

The Study Group for Risk Factors for Rheumatoid Arthritis was established by the EULAR Standing Committee on Investigative Rheumatology to facilitate research into the preclinical and earliest clinically apparent phases of rheumatoid arthritis (RA). This report describes the recommendation for terminology to be used to define specific subgroups during different phases of disease, and defines the priorities for research in this area. Terminology was discussed by way of a three-stage structured process: A provisional list of descriptors for each of the possible phases preceding the diagnosis of RA were circulated to members of the study group for review and feedback. Anonymised comments from the members on this list were fed back to participants before a 2-day meeting. 18 participants met to discuss these data, agree terminologies and prioritise important research questions. The study group recommended that, in prospective studies, individuals without RA are described as having: genetic risk factors for RA; environmental risk factors for RA; systemic autoimmunity associated with RA; symptoms without clinical arthritis; unclassified arthritis; which may be used in a combinatorial manner. It was recommended that the prefix ‘pre-RA with:’ could be used before any/any combination of the five points above but only to describe retrospectively a phase that an individual had progressed through once it was known that they have developed RA. An approach to dating disease onset was recommended. In addition, important areas for research were proposed, including research of other tissues in which an adaptive immune response may be initiated, and the identification of additional risk factors and biomarkers for the development of RA, its progression and the development of extra-articular features. These recommendations provide guidance on approaches to describe phases before the development of RA that will facilitate communication between researchers and comparisons between studies. A number of research questions have been defined, requiring new cohorts to be established and new techniques to be developed to image and collect material from different sites

Use of risk stratification to target therapies in patients with recent onset arthritis; design of a prospective randomized multicenter controlled trial

Background. Early and intensive treatment is important to inducing remission and preventing joint damage in patients with rheumatoid arthritis. While intensive combination therapy (Disease Modifying Anti-rheumatic Drugs and/or biologicals) is the most effective, rheumatologists in daily clinical practice prefer to start with monotherapy methotrexate and bridging corticosteroids. Intensive treatment should be started as soon as the first symptoms manifest, but at this early stage, ACR criteria may not be fulfilled, and there is a danger of over-treatment. We will therefore determine which induction therapy is most effective in the very early stage of persistent arthritis. To overcome over-treatment and under-treatment, the intensity of induction therapy will be based on a prediction model that predicts patients' propensity for persistent arthritis. Methods. A multicenter stratified randomized single-blind controlled trial is currently being performed in patients 18 years or older with recent-onset arthritis. Eight hundred ten patients are being stratified according to the likelihood of their developing persistent arthritis. In patients with a high probability of persistent arthritis, we will study combination Disease Modifying Antirheumatic Drug therapy compared to monotherapy methotrexate. In patients with an intermediate probability of persistent arthritis, we will study Disease Modifying Antirheumatic Drug of various intensities. In patients with a low probability, we will study non-steroidal anti-inflammatory drugs, hydroxychloroquine and a single dose of corticosteroids. If disease activity is not sufficiently reduced, treatment will be adjusted according to a step-up protocol. If remission is achieved for at least six months, medication will be tapered off. Patients will be followed up every three months over two years. Discussion. This is the first rheumatological study to base treatment in early arthritis on a prediction rule. Treatment will be stratified according to the probability of persistent arthritis, and different combinations of treatment per stratum will be evaluated. Treatment will be started early, and patients will not need to meet the ACR-criteria for rheumatoid arthritis. Trial registration. This trial has been registered in Current Controlled Trials with the ISRCTN26791028

Molecular understanding of the suppression of new-particle formation by isoprene

Nucleation of atmospheric vapours produces more than half of global cloud condensation nuclei and so has an important influence on climate. Recent studies show that monoterpene (C10H16) oxidation yields highly oxygenated products that can nucleate with or without sulfuric acid. Monoterpenes are emitted mainly by trees, frequently together with isoprene (C5H8), which has the highest global emission of all organic vapours. Previous studies have shown that isoprene suppresses new-particle formation from monoterpenes, but the cause of this suppression is under debate. Here, in experiments performed under atmospheric conditions in the CERN CLOUD chamber, we show that isoprene reduces the yield of highly oxygenated dimers with 19 or 20 carbon atoms - which drive particle nucleation and early growth - while increasing the production of dimers with 14 or 15 carbon atoms. The dimers (termed C-20 and C-15, respectively) are produced by termination reactions between pairs of peroxy radicals (RO2 center dot) arising from monoterpenes or isoprene. Compared with pure monoterpene conditions, isoprene reduces nucleation rates at 1.7 nm (depending on the isoprene = monoterpene ratio) and approximately halves particle growth rates between 1.3 and 3.2 nm. However, above 3.2 nm, C-15 dimers contribute to secondary organic aerosol, and the growth rates are unaffected by isoprene. We further show that increased hydroxyl radical (OH center dot) reduces particle formation in our chemical system rather than enhances it as previously proposed, since it increases isoprene-derived RO2 center dot radicals that reduce C-20 formation. RO2 center dot termination emerges as the critical step that determines the highly oxygenated organic molecule (HOM) distribution and the corresponding nucleation capability. Species that reduce the C-20 yield, such as NO, HO2 and as we show isoprene, can thus effectively reduce biogenic nucleation and early growth. Therefore the formation rate of organic aerosol in a particular region of the atmosphere under study will vary according to the precise ambient conditions.Peer reviewe

The TESS Grand Unified Hot Jupiter Survey. II. Twenty New Giant Planets

NASA's Transiting Exoplanet Survey Satellite (TESS) mission promises to improve our understanding of hot Jupiters by providing an all-sky, magnitude-limited sample of transiting hot Jupiters suitable for population studies. Assembling such a sample requires confirming hundreds of planet candidates with additional follow-up observations. Here, we present twenty hot Jupiters that were detected using TESS data and confirmed to be planets through photometric, spectroscopic, and imaging observations coordinated by the TESS Follow-up Observing Program (TFOP). These twenty planets have orbital periods shorter than 7 days and orbit relatively bright FGK stars ($10.9 < G < 13.0$). Most of the planets are comparable in mass to Jupiter, although there are four planets with masses less than that of Saturn. TOI-3976 b, the longest period planet in our sample ($P = 6.6$ days), may be on a moderately eccentric orbit ($e = 0.18\pm0.06$), while observations of the other targets are consistent with them being on circular orbits. We measured the projected stellar obliquity of TOI-1937A b, a hot Jupiter on a 22.4 hour orbit with the Rossiter-McLaughlin effect, finding the planet's orbit to be well-aligned with the stellar spin axis ($|\lambda| = 4.0\pm3.5^\circ$). We also investigated the possibility that TOI-1937 is a member of the NGC 2516 open cluster, but ultimately found the evidence for cluster membership to be ambiguous. These objects are part of a larger effort to build a complete sample of hot Jupiters to be used for future demographic and detailed characterization work.Comment: 67 pages, 11 tables, 13 figures, 2 figure sets. Resubmitted to ApJS after revision