Perioperative Inflammation and Microcirculation in Surgery: Clinical Strategies for Improved Surgical Outcomes

Impaired microcirculation secondary to underlying vascular endothelial dysfunction is increasingly recognized to play a central role in the pathophysiology associated with numerous postoperative complications. Noxious stimuli, including direct injury from surgical trauma and hypoxia (e.g., ischemia‐reperfusion injury), trigger adrenergic‐inflammatory‐thrombotic‐immune cascades to impair the microcirculation, with consequent perfusion‐related postoperative complications. The endothelium, characterized by exquisite sensitivity to inflammation and low proliferative potential, has limited self‐repair capacity that is dependent on circulating bone marrow‐derived endothelial progenitor cells for regeneration. As such, the extent to which the endothelial physical and functional integrity is preserved mirrors not only underlying cardiovascular health but is also an important factor in susceptibility to postoperative morbidity. This review explores the effect of perioperative inflammation on the microcirculation and some of the current protective strategies available to clinicians. “Prehabilitation,” with preoperative exercise to improve the underlying endothelial function and bone marrow responsiveness for endogenous endothelial repair mechanisms, and anti‐inflammatory strategies to limit activation of the endothelial‐thrombotic‐inflammatory cascades may provide clinical strategies to preserve the microcirculation to engender optimal surgical outcomes

Die anteriore Diskusdislokation des Kiefergelenks - Eine systematische Analyse und Bewertung verschiedener chirurgischer Therapiekonzepte zum Internal Derangement anhand internationaler Publikationen im Vergleich mit Ergebnissen der Universitätsklinik Marburg

Problemstellung und Zielsetzung: Die anteriore Diskusdislokation zählt zu den funktionellen Erkrankungen des Kiefergelenks und wird international auch unter dem Begriff des Internal Derangement (ID) subsumiert. Die Stellungnahmen zum Krankheitsbild des ID, speziell zur anterioren Diskusdislokation ohne Reposition (ADDoR), sind in großen Teilen nicht einheitlich und oft sogar widersprüchlich. So bieten bereits die multi-kausale Ätiologie und die noch nicht eindeutig geklärte Pathogenese Grundlagen für kontroverse Diskussionen. Die zwei wesentlichen Hauptziele der vorliegenden Arbeit sind: (1) Die Erhebung von Langzeitergebnissen bei Patienten mit einer WILKES-Klassifikation IV und V nach Diskektomie mit direkter Interposition eines gedoppelten Temporalisfaszienlappens unter Berücksichtigung funktioneller Parameter wie dem HELKIMO- und dem MFIQ-Index. Des Weiteren wird geprüft, ob es prognostische Faktoren wie den Schädigungs-grad des Gelenks oder das Vorhandensein eines myofaszialen Schmerz- und Dysfunktionssyndroms (MPDS) gibt, die Einfluss auf das funktionelle Outcome haben. (2) Die systematische Analyse, der Vergleich und die Bewertung der internationalen Literatur zur (chirurgischen) Therapie der anterioren Diskusdislokation ohne Reposition. Material und Methoden: Die vorliegende retrospektive Nachuntersuchung umfasst 28 Patienten, die im Zeitraum von Oktober 1996 bis September 2006 an der Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie der Philipps-Universität Marburg operativ versorgt worden sind. Der durchschnittliche Follow-up-Zeitraum betrug zehn Jahre und drei Monate. Die klinische Befunderhebung umfasste folgende Parameter: VAS, maximale MÖ, MFIQ-Index, HELKIMO-Index, Gelenkgeräusche und subjektive Parameter wie z. B. die Beurteilung des Kauvermögens oder die Zufriedenheit mit der Operation. Bei der statistischen Datenauswertung kamen ausschließlich nicht parametrische Testverfahren zur Anwendung. Bei allen metrischen Variablen wurden die Vergleiche mittels Mann-Whitney-U-Test (Wilcoxon-Vorzeichenrangtest) und bei allen nominalen Variablen mittels Fishers exaktem Test (Chi-Quadrat-Test) durchgeführt. Als Signifikanzniveau wurde eine Irrtumswahrscheinlichkeit von α < 0,05 postuliert. Ergänzend wurden auch die 95 %-Konfidenzintervalle für die Funktionsparameter bestimmt. Zur Bewertung der internationalen Literatur wurde eine systematische Online-Recherche in der Datenbank PUBMED und ergänzend in der Datenbank der COCHRANE COLLABORATION durchgeführt. Die gefundenen Publikationen wurden anhand der Evidenzklassifizierung der „Agency for Health Care Policy and Research“ und eines internen Bewertungsschemas zur Validität der Literatur beurteilt. Ergebnisse: Die Werte zu den Angaben der Schmerzintensität (VAS) verbesserten sich bezogen auf den Mittelwert von präoperativ 7,5 ± 2,4 um 5,6 ± 2,6 auf postoperativ 1,9 ± 2,4. Die maximale MÖ betrug vor der Operation im Mittel 24,8 ± 6,3 mm und verbesserte sich mit einer Zunahme von 12,8 ± 9,0 mm auf 37,6 ± 8,4 mm zum Nachuntersuchungszeitpunkt. Der MFIQ-Punktwert betrug präoperativ im Mittel 50,6 ± 11,5 und zeigte sich postoperativ mit 18,2 ± 16,3 im Mittel. Die Verbesserung betrug 32,4 ± 13,9 Punkte. Alle Veränderungen waren statistisch signifikant (Mann-Whitney-U-Test: p < 0,001). Die vergleichende Analyse der Teilkollektive bezüglich prognostischer Faktoren für ein erfolgreiches Outcome ergab bei den Parametern WILKES-Stadien, dem Vorhandensein eines MPDS sowie dem Einfluss der präoperativen Beschwerdedauer jeweils keine statistische Signifikanz. Diskussion und Schlussfolgerung: Die Ergebnisse der Versorgung von Patienten mit einem gedoppelten Temporalisfaszienlappen nach Diskektomie hinsichtlich des funktionellen Outcomes sind im Vergleich mit den in der internationalen Literatur publizierten Resultaten als positiv zu bewerten. Das Verfahren liefert insbesondere gute Langzeitergebnisse. Die „ideale“ oder „einzig richtige“ Therapieempfehlung zur ADDoR kann basierend auf den Ergebnissen der vorliegenden Arbeit sowie der aktuellen Literaturrecherche jedoch nicht gegeben werden. Ebenso sind auf Grundlage der aktuellen Erhebungen keine Aussagen auf höherem Evidenzniveau möglich, die eindeutige prognostische Faktoren für ein erfolgreiches OP-Outcome erkennen lassen. Eindrucksvoll belegen jedoch die in der vorliegenden Arbeit vorgestellten Literaturdaten, dass die minimalinvasive Arthrozentese den konservativen Maßnahmen bezüglich der Schmerzreduktion sowie einer schnelleren funktionellen Verbesserung auf einem höheren Evidenzniveau (1b) überlegen ist. Es gilt hier, das Dogma, des primären konservativen Behandlungsansatzes aufzubrechen. Lysis und Lavage sollten früher Anwendung finden

Between Differentiation and (Dis)Integration - Theoretical Explanations of a Post-Brexit European Union

The authors of this paper provide a critical analysis of the most prominent theoretical vehicles employed in studying differentiated integration in contemporary, post-Brexit Europe. They discuss the descriptive, explanatory, and interpretative potential of the selected theoretical approaches that are applied at the intersection of disintegration and European differentiation discourse. “The holy grail” of the theorising of the dynamic (and accelerating) processes of (dis)integration and differentiation remains undiscovered. Nevertheless, a constant search for theoretical explanation is needed in the in-depth analyses of the current state of the European Union

Imaging of microwave fields using ultracold atoms

We report a technique that uses clouds of ultracold atoms as sensitive, tunable, and non-invasive probes for microwave field imaging with micrometer spatial resolution. The microwave magnetic field components drive Rabi oscillations on atomic hyperfine transitions whose frequency can be tuned with a static magnetic field. Readout is accomplished using state-selective absorption imaging. Quantitative data extraction is simple and it is possible to reconstruct the distribution of microwave magnetic field amplitudes and phases. While we demonstrate 2d imaging, an extension to 3d imaging is straightforward. We use the method to determine the microwave near-field distribution around a coplanar waveguide integrated on an atom chip.Comment: 11 pages, 4 figure

Regional and overall ventilation inhomogeneities in preterm and term-born infants

Objectives: We compared ventilation inhomogeneity assessed by electrical impedance tomography (EIT) and multiple breath washout (MBW) in preterm and term-born infants. We hypothesised that EIT measurements in spontaneously breathing infants are repeatable and that differences in regional ventilation distribution measured by EIT can distinguish between preterm and term-born infants. Design: Cross-sectional group comparison study. Setting: Lung function laboratory at a University Children's Hospital. Participants: Seventeen healthy term-born and 15 preterm infants at a matched postmenstrual age of 44weeks. Measurements and results: We concurrently measured ventilation inhomogeneity by EIT, ventilation inhomogeneity (LCI) and functional residual capacity (FRC) by MBW and tidal breathing variables during unsedated quiet sleep. EIT measurements were highly repeatable (coefficient of variation 3.6%). Preterm infants showed significantly more ventilation of the independent parts of the lungs compared to healthy term-born infants assessed by EIT (mean difference 5.0, 95 CI 1.3-8%). Whereas the two groups showed no differences in lung volumes or ventilation inhomogeneities assessed by MBW, EIT discriminated better between term and preterm infants. (FRC/kg: mean difference 1.1mL, 95% CI −1.4-3.8mL; LCI: mean difference 0.03, 95% CI −0.32-0.25). Conclusions: EIT shows distinct differences in ventilation distribution between preterm and term-born infants, which cannot be detected by MBW. Although preterm infants are capable of dynamically maintaining overall functional residual volume and ventilation distribution, they show some spatial differences from fullterm infant

Coherent manipulation of Bose-Einstein condensates with state-dependent microwave potentials on an atom chip

Entanglement-based technologies, such as quantum information processing, quantum simulations, and quantum-enhanced metrology, have the potential to revolutionise our way of computing and measuring and help clarifying the puzzling concept of entanglement itself. Ultracold atoms on atom chips are attractive for their implementation, as they provide control over quantum systems in compact, robust, and scalable setups. An important tool in this system is a potential depending on the internal atomic state. Coherent dynamics in this potential combined with collisional interactions allows entanglement generation both for individual atoms and ensembles. Here, we demonstrate coherent manipulation of Bose-condensed atoms in such a potential, generated in a novel way with microwave near-fields on an atom chip. We reversibly entangle atomic internal and motional states, realizing a trapped-atom interferometer with internal-state labelling. Our system provides control over collisions in mesoscopic condensates, paving the way for on-chip generation of many-particle entanglement and quantum-enhanced metrology with spin-squeezed states.Comment: 9 pages, 6 figure

Amygdala fMRI Signal as a Predictor of Reaction Time

Reaction times (RTs) are a valuable measure for assessing cognitive processes. However, RTs are susceptible to confounds and therefore variable. Exposure to threat, for example, speeds up or slows down responses. Distinct task types to some extent account for differential effects of threat on RTs. But also do inter-individual differences like trait anxiety. In this functional magnetic resonance imaging (fMRI) study, we investigated whether activation within the amygdala, a brain region closely linked to the processing of threat, may also function as a predictor of RTs, similar to trait anxiety scores. After threat conditioning by means of aversive electric shocks, 45 participants performed a choice RT task during alternating 30 s blocks in the presence of the threat conditioned stimulus [CS+] or of the safe control stimulus [CS-]. Trait anxiety was assessed with the State-Trait Anxiety Inventory and participants were median split into a high- and a low-anxiety subgroup. We tested three hypotheses: (1) RTs will be faster during the exposure to threat compared to the safe condition in individuals with high trait anxiety. (2) The amygdala fMRI signal will be higher in the threat condition compared to the safe condition. (3) Amygdala fMRI signal prior to a RT trial will be correlated with the corresponding RT. We found that, the high-anxious subgroup showed faster responses in the threat condition compared to the safe condition, while the low-anxious subgroup showed no significant difference in RTs in the threat condition compared to the safe condition. Though the fMRI analysis did not reveal an effect of condition on amygdala activity, we found a trial-by-trial correlation between blood-oxygen-level-dependent signal within the right amygdala prior to the CRT task and the subsequent RT. Taken together, the results of this study showed that exposure to threat modulates task performance. This modulation is influenced by personality trait. Additionally and most importantly, activation in the amygdala predicts behavior in a simple task that is performed during the exposure to threat. This finding is in line with “attentional capture by threat”—a model that includes the amygdala as a key brain region for the process that causes the response slowing

Late Pleistocene hydrological settings at world heritage Tsodilo Hills (NW Kalahari, Botswana), a site of ancient human occupation

Based on genetic studies, a Pleistocene Kalahari “palaeo-wetland”, which spanned the region of the Okavango Delta and the Makgadikgadi Basin, was recently considered the geographic origin of evolutionary modern humans. It was proposed that subsequent out-of-homeland migration was induced by climate shifts. The Tsodilo Hills, which are in relative proximity to the Okavango Delta, represent a site of ancient human occupation since at least 100 ka. Local hydrological dynamics were predominately controlled by climate variability and are archived in the sediments of Palaeolake Tsodilo. This study seeks to better understand the Late Pleistocene environments of the ancient Tsodilo people with a focus on palaeo-hydrological settings, which played a major role for their livelihoods. Our multidisciplinary approach included different remote sensing and geophysical methods, comprehensive application of differential GPS, and sedimentological analyses concentrating on the lake beds. Four palaeo-shorelines could be identified, three of which indicate highstands during which the Tamacha palaeo-river drained Palaeolake Tsodilo towards the Okavango Panhandle. Two highstands during MIS 3b and LGM are related to periods of largely increased fish consumption by humans as has been documented by archaeologists. The palaeolake was likely most extended about 100 ka ago or earlier, when it covered ca. 70 km2 and was 16 m deep. A single (neo-)tectonic fault could be detected. We assume that the Tamacha palaeo-river was a gateway for ancient humans to reach the Tsodilo Hills from these palaeo-wetlands. The people took advantage of the Tsodilo Hills as shelter from weather hazards and as a natural fortress against predators and elephants. Geologically, the Tsodilo Hills were comparatively calm. They represented a relatively safe haven where the social behaviour of early modern humans could evolve to a higher complexity, which relates to the fundamental question when and where modern human behaviour began