Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations.

BACKGROUND Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed. METHODS Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management. RESULTS A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001. CONCLUSION Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology

Global distribution and bioclimatic characterization of alpine biomes

Although there is a general consensus on the distribution and ecological features of terrestrial biomes, the allocation of alpine ecosystems in the global biogeographic system is still unclear. Here, we delineate a global map of alpine areas above the treeline by modelling regional treeline elevation at 30 m resolution, using global forest cover data and quantile regression. We then used global datasets to 1) assess the climatic characteristics of alpine ecosystems using principal component analysis, 2) define bioclimatic groups by an optimized cluster analysis and 3) evaluate patterns of primary productivity based on the normalized difference vegetation index. As defined here, alpine biomes cover 3.56 Mkm(2) or 2.64% of land outside Antarctica. Despite temperature differences across latitude, these ecosystems converge below a sharp threshold of 5.9 degrees C and towards the colder end of the global climatic space. Below that temperature threshold, alpine ecosystems are influenced by a latitudinal gradient of mean annual temperature and they are climatically differentiated by seasonality and continentality. This gradient delineates a climatic envelope of global alpine biomes around temperate, boreal and tundra biomes as defined in Whittaker's scheme. Although alpine biomes are similarly dominated by poorly vegetated areas, world ecoregions show strong differences in the productivity of their alpine belt irrespectively of major climate zones. These results suggest that vegetation structure and function of alpine ecosystems are driven by regional and local contingencies in addition to macroclimatic factors

Meta-analysis of neural systems underlying placebo analgesia from individual participant fMRI data

The brain systems underlying placebo analgesia are insufficiently understood. Here we performed a systematic, participant-level meta-analysis of experimental functional neuroimaging studies of evoked pain under stimulus-intensity-matched placebo and control conditions, encompassing 603 healthy participants from 20 (out of 28 eligible) studies. We find that placebo vs. control treatments induce small, widespread reductions in pain-related activity, particularly in regions belonging to ventral attention (including mid-insula) and somatomotor networks (including posterior insula). Behavioral placebo analgesia correlates with reduced pain-related activity in these networks and the thalamus, habenula, mid-cingulate, and supplementary motor area. Placebo-associated activity increases occur mainly in frontoparietal regions, with high between-study heterogeneity. We conclude that placebo treatments affect pain-related activity in multiple brain areas, which may reflect changes in nociception and/or other affective and decision-making processes surrounding pain. Between-study heterogeneity suggests that placebo analgesia is a multi-faceted phenomenon involving multiple cerebral mechanisms that differ across studies

A large ungated TPC with GEM amplification

A Time Projection Chamber (TPC) is an ideal device for the detection of charged particle tracks in a large volume covering a solid angle of almost . The high density of hits on a given particle track facilitates the task of pattern recognition in a high-occupancy environment and in addition provides particle identification by measuring the specific energy loss for each track. For these reasons, TPCs with Multiwire Proportional Chamber (MWPC) amplification have been and are widely used in experiments recording heavy-ion collisions. A significant drawback, however, is the large dead time of the order of 1 ms per event generated by the use of a gating grid, which is mandatory to prevent ions created in the amplification region from drifting back into the drift volume, where they would severely distort the drift path of subsequent tracks. For experiments with higher event rates this concept of a conventional TPC operating with a triggered gating grid can therefore not be applied without a significant loss of data. A continuous readout of the signals is the more appropriate way of operation. This, however, constitutes a change of paradigm with considerable challenges to be met concerning the amplification region, the design and bandwidth of the readout electronics, and the data handling. A mandatory prerequisite for such an operation is a sufficiently good suppression of the ion backflow from the avalanche region, which otherwise limits the tracking and particle identification capabilities of such a detector. Gas Electron Multipliers (GEM) are a promising candidate to combine excellent spatial resolution with an intrinsic suppression of ions. In this paper we describe the design, construction and the commissioning of a large TPC with GEM amplification and without gating grid (GEM-TPC). The design requirements have driven innovations in the construction of a light-weight field-cage, a supporting media flange, the GEM amplification and the readout system, which are presented in this paper. We further describe the support infrastructure such as gas, cooling and slow control. Finally, we report on the operation of the GEM-TPC in the FOPI experiment, and describe the calibration procedures which are applied to achieve the design performance of the device.Peer reviewe

Modulated Martensite: Why it forms and why it deforms easily

Diffusionless phase transitions are at the core of the multifunctionality of (magnetic) shape memory alloys, ferroelectrics and multiferroics. Giant strain effects under external fields are obtained in low symmetric modulated martensitic phases. We outline the origin of modulated phases, their connection with tetragonal martensite and consequences for their functional properties by analysing the martensitic microstructure of epitaxial Ni-Mn-Ga films from the atomic to macroscale. Geometrical constraints at an austenite-martensite phase boundary act down to the atomic scale. Hence a martensitic microstructure of nanotwinned tetragonal martensite can form. Coarsening of twin variants can reduce twin boundary energy, a process we could follow from the atomic to the millimetre scale. Coarsening is a fractal process, proceeding in discrete steps by doubling twin periodicity. The collective defect energy results in a substantial hysteresis, which allows retaining modulated martensite as a metastable phase at room temperature. In this metastable state elastic energy is released by the formation of a 'twins within twins' microstructure which can be observed from the nanometre to millimetre scale. This hierarchical twinning results in mesoscopic twin boundaries which are diffuse, in contrast to the common atomically sharp twin boundaries of tetragonal martensite. We suggest that observed extraordinarily high mobility of such mesoscopic twin boundaries originates from their diffuse nature which renders pinning by atomistic point defects ineffective.Comment: 34 pages, 8 figure

Dynamical locality and covariance: What makes a physical theory the same in all spacetimes?

The question of what it means for a theory to describe the same physics on all spacetimes (SPASs) is discussed. As there may be many answers to this question, we isolate a necessary condition, the SPASs property, that should be satisfied by any reasonable notion of SPASs. This requires that if two theories conform to a common notion of SPASs, with one a subtheory of the other, and are isomorphic in some particular spacetime, then they should be isomorphic in all globally hyperbolic spacetimes (of given dimension). The SPASs property is formulated in a functorial setting broad enough to describe general physical theories describing processes in spacetime, subject to very minimal assumptions. By explicit constructions, the full class of locally covariant theories is shown not to satisfy the SPASs property, establishing that there is no notion of SPASs encompassing all such theories. It is also shown that all locally covariant theories obeying the time-slice property possess two local substructures, one kinematical (obtained directly from the functorial structure) and the other dynamical (obtained from a natural form of dynamics, termed relative Cauchy evolution). The covariance properties of relative Cauchy evolution and the kinematic and dynamical substructures are analyzed in detail. Calling local covariant theories dynamically local if their kinematical and dynamical local substructures coincide, it is shown that the class of dynamically local theories fulfills the SPASs property. As an application in quantum field theory, we give a model independent proof of the impossibility of making a covariant choice of preferred state in all spacetimes, for theories obeying dynamical locality together with typical assumptions.Comment: 60 pages, LaTeX. Version to appear in Annales Henri Poincar

Low bone mass in microscopic colitis

<p>Abstract</p> <p>Background</p> <p>Microscopic colitis presents with similar symptoms to classic inflammatory bowel diseases. Osteoporosis is a common complication of Crohn's disease but there are no data concerning bone metabolism in microscopic colitis.</p> <p>Aims</p> <p>The aim of the present study was to evaluate bone density and metabolism in patients with microscopic colitis.</p> <p>Methods</p> <p>Fourteen patients microscopic colitis were included in the study, and 28 healthy persons and 28 age and gender matched Crohn's disease patients were enrolled as controls. Bone mineral density was measured using dual x-ray absorptiometry at the lumbar spine, femoral neck and the radius. Serum bone formation and bone resorption markers (osteocalcin and beta-crosslaps, respectively) were measured using immunoassays.</p> <p>Results</p> <p>Low bone mass was measured in 57.14% patients with microscopic colitis. Bone mineral density at the femoral neck in patients suffering from microscopic colitis and Crohn's disease was lower than in healthy controls (0.852 ± 0.165 and 0.807 ± 0.136 vs. 1.056 ± 0.126 g/cm²; p < 0.01). Bone mineral density at the non-dominant radius was decreased in microscopic colitis patients (0.565 ± 0.093 vs. 0.667 ± 0.072 g/cm²; p < 0.05) but unaffected in Crohn's disease patients (0.672 ± 0.056 g/cm²). Mean beta-crosslaps concentration was higher in microscopic colitis and Crohn's disease patients than controls (417.714 ± 250.37 and 466.071 ± 249.96 vs. 264.75 ± 138.65 pg/ml; p < 0.05). A negative correlation between beta-crosslaps concentration and the femoral and radius t-scores was evident in microscopic colitis patients.</p> <p>Conclusions</p> <p>Low bone mass is frequent in microscopic colitis, and alterations to bone metabolism are similar to those present in Crohn's disease. Therefore, microscopic colitis-associated osteopenia could be a significant problem in such patients.</p

The Plastid Genome of Eutreptiella Provides a Window into the Process of Secondary Endosymbiosis of Plastid in Euglenids

Euglenids are a group of protists that comprises species with diverse feeding modes. One distinct and diversified clade of euglenids is photoautotrophic, and its members bear green secondary plastids. In this paper we present the plastid genome of the euglenid Eutreptiella, which we assembled from 454 sequencing of Eutreptiella gDNA. Comparison of this genome and the only other available plastid genomes of photosynthetic euglenid, Euglena gracilis, revealed that they contain a virtually identical set of 57 protein coding genes, 24 genes fewer than the genome of Pyramimonas parkeae, the closest extant algal relative of the euglenid plastid. Searching within the transcriptomes of Euglena and Eutreptiella showed that 6 of the missing genes were transferred to the nucleus of the euglenid host while 18 have been probably lost completely. Euglena and Eutreptiella represent the deepest bifurcation in the photosynthetic clade, and therefore all these gene transfers and losses must have happened before the last common ancestor of all known photosynthetic euglenids. After the split of Euglena and Eutreptiella only one additional gene loss took place. The conservation of gene content in the two lineages of euglenids is in contrast to the variability of gene order and intron counts, which diversified dramatically. Our results show that the early secondary plastid of euglenids was much more susceptible to gene losses and endosymbiotic gene transfers than the established plastid, which is surprisingly resistant to changes in gene content