Synergistic use of Lagrangian dispersion and radiative transfer modelling with satellite and surface remote sensing measurements for the investigation of volcanic plumes: the Mount Etna eruption of 25–27 October 2013

Abstract. In this paper we combine SO2 and ash plume dispersion modelling with satellite and surface remote sensing observations to study the regional influence of a relatively weak volcanic eruption from Mount Etna on the optical and micro-physical properties of Mediterranean aerosols. We analyse the Mount Etna eruption episode of 25–27 October 2013. The evolution of the plume along the trajectory is investigated by means of the FLEXible PARTicle Lagrangian dispersion (FLEXPART) model. The satellite data set includes true colour images, retrieved values of volcanic SO2 and ash, estimates of SO2 and ash emission rates derived from MODIS (MODerate resolution Imaging Spectroradiometer) observations and estimates of cloud top pressure from SEVIRI (Spinning Enhanced Visible and InfraRed Imager). Surface remote sensing measurements of aerosol and SO2 made at the ENEA Station for Climate Observations (35.52° N, 12.63° E; 50 m a.s.l.) on the island of Lampedusa are used in the analysis. The combination of these different data sets suggests that SO2 and ash, despite the initial injection at about 7.0 km altitude, reached altitudes around 10–12 km and influenced the column average aerosol particle size distribution at a distance of more than 350 km downwind. This study indicates that even a relatively weak volcanic eruption may produce an observable effect on the aerosol properties at the regional scale. The impact of secondary sulfate particles on the aerosol size distribution at Lampedusa is discussed and estimates of the clear-sky direct aerosol radiative forcing are derived. Daily shortwave radiative forcing efficiencies, i.e. radiative forcing per unit AOD (aerosol optical depth), are calculated with the LibRadtran model. They are estimated between −39 and −48 W m−2 AOD−1 at the top of the atmosphere and between −66 and −49 W m−2 AOD−1 at the surface, with the variability in the estimates mainly depending on the aerosol single scattering albedo. These results suggest that sulfate particles played a large role in the transported plume composition and radiative forcing, while the contribution by ash particles was small in the volcanic plume arriving at Lampedusa during this event

Surgical predictors of acute postoperative pain after hip arthroscopy

BACKGROUND: Pain following hip arthroscopy is highly variable and can be severe. Little published data exists demonstrating reliable predictors of significant pain after hip arthroscopy. The aim of this study was to identify influence of intraoperative factors (arthroscopic fluid infusion pressure, operative type) on the severity of postoperative pain. METHODS: A retrospective review of 131 patients who had received a variety of arthroscopic hip interventions was performed. A standardized anaesthetic technique was used on all patients and postoperative pain was analysed using recovery pain severity outcomes and analgesic use. A multivariate logistic regression analysis was performed on intraoperative factors including patient age, sex and BMI, arthroscopic infusion pressures (40 vs 80 mm Hg), amount of fluid used, length of surgery and types of arthroscopic interventions performed. Thirty six patients were also prospectively examined to determine arthroscopic fluid infusion rates for 40 and 80 mm Hg infusion pressures. RESULTS: Use of a higher infusion pressure of 80 mm Hg was strongly associated with all pain severity endpoints (OR 2.8 – 8.2). Other significant factors included hip arthroscopy that involved femoral chondro-ostectomy (OR 5.8) and labral repair (OR 7.5). Length of surgery and total amount of infusion fluid used were not associated with increased pain. CONCLUSIONS: 80 mm Hg arthroscopic infusion pressures, femoral chondro-osteoectomy and labral repair are strongly associated with significant postoperative pain, whereas intraoperative infusion volumes or surgical duration are not. Identification of these predictors in individual patients may guide clinical practice regarding the choice of more invasive regional analgesia options. The use of 40 mm Hg arthroscopic infusion pressures will assist in reducing postoperative pain

Overactive bladder – 18 years – part I

ABSTRACT Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics – pillars of the overactive bladder pharmacotherapy – started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning – as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder – 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder

International delphi consensus on the management of AQP4-IgG+ NMOSD: recommendations for eculizumab, inebilizumab, and satralizumab

BACKGROUND AND OBJECTIVES: Neuromyelitis optica spectrum disorder (NMOSD) is a rare debilitating autoimmune disease of the CNS. Three monoclonal antibodies were recently approved as maintenance therapies for aquaporin-4 immunoglobulin G (AQP4-IgG)-seropositive NMOSD (eculizumab, inebilizumab, and satralizumab), prompting the need to consider best practice therapeutic decision-making for this indication. Our objective was to develop validated statements for the management of AQP4-IgG-seropositive NMOSD, through an evidence-based Delphi consensus process, with a focus on recommendations for eculizumab, inebilizumab, and satralizumab. METHODS: We recruited an international panel of clinical experts in NMOSD and asked them to complete a questionnaire on NMOSD management. Panel members received a summary of evidence identified through a targeted literature review and provided free-text responses to the questionnaire based on both the data provided and their clinical experience. Responses were used to generate draft statements on NMOSD-related themes. Statements were voted on over a maximum of 3 rounds; participation in at least 1 of the first 2 rounds was mandatory. Panel members anonymously provided their level of agreement (6-point Likert scale) on each statement. Statements that failed to reach a predefined consensus threshold (≥67%) were revised based on feedback and then voted on in the next round. Final statements were those that met the consensus threshold (≥67%). RESULTS: The Delphi panel comprised 24 experts, who completed the Delphi process in November 2021 after 2 voting rounds. In round 1, 23/25 statements reached consensus and were accepted as final. The 2 statements that failed to reach consensus were revised. In round 2, both revised statements reached consensus. Twenty-five statements were agreed in total: 11 on initiation of or switching between eculizumab, inebilizumab, and satralizumab; 3 on monotherapy/combination therapy; 7 on safety and patient population considerations; 3 on biomarkers/patient-reported outcomes; and 1 on research gaps. DISCUSSION: An established consensus method was used to develop statements relevant to the management of AQP4-IgG-seropositive NMOSD. These international statements will be valuable for informing individualized therapeutic decision-making and could form the basis for standardized practice guidelines

Hérnias intra-raquidianas dos discos intervertebrais lombares: resultados da excisão em 128 casos

O tratamento cirúrgico das hérnias de discos intervertebrals lombares tem indicações precisas e os resultados dependem de condições que devem ser convenientemente satisfeitas. Nos casos em que só existe sintomatologia dolorosa subjetiva que não regride com o tratamento conservador, a intervenção cirúrgica deve ser condicionada à comprovação diagnóstica mediante um dado objetivo, qual seja a radiologia contrastada, que não só informa quanto à existência e situação de prolapso discal, como permite o diagnóstico diferencial com outras afecções. Nos casos em que, além da sintomatologia dolorosa subjetiva, existem sintomas objetivos sensitivos e/ou motores, indicando sofrimento das raízes raquidianas, o tratamento cirúrgico tem indicação absoluta, devendo o ato operatório ser precedido de exame radiológico contrastado. Não deve haver qualquer contemporização no ato cirúrgico quando a sintomatologia plurirradicular e de caráter agudo fizer suspeitar da ocorrência de retropulsão maciça de discos intervertebrals. Quanto à tática cirúrgica, deve ser feita laminectomia parcial unilateral quando o prolapso discai ocupar situação póstero-lateral, na altura dos espaços Lv4-Lv5 e LV5-Sv1 quando o prolapso estiver situado em níveis mais altos ou quando estiver em situação mediana ou, mesmo, quando se tratar de herniações bilaterais de um mesmo disco intervertebral, deve ser feita a laminectomia total, para evitar trações exageradas sôbre as raízes raquidianas, trações que podem ocasionar seqüelas sensitivo-motoras irreversíveis. O cirurgião deve considerar que seu alvo principal é suprimir as causas de compressão de raízes raquidianas; para isso, deve excisar o disco intervertebral herniado e, eventualmente, fazer a exérese de bordas escleróticas das vértebras; a excisão do disco lesado deve ser tão completa quanto possível, mediante curetagem, para evitar recidivas. Quando a herniação discai estiver situada no buraco de conjugação, deve ser feita a facetectomia, sendo a intervenção completada com artródese para imobilização. Para a exposição de hérnia discai, a bainha durai da raiz raquidiana deve sempre ser deslocada para a linha mediana, qualquer que seja a situação do prolapso, pois, dêsse modo, são diminuídas as possibilidades de lesões traumáticas da raiz que está sendo manipulada. Fragmentos livres de disco intervertebral no espaço epidural devem ser extirpados; o cirurgião deve ter presente a possibilidade da existência de tais fragmentos em níveis situados imediatamente acima ou abaixo do disco herniado. A rizotomia posterior deve ser praticada quando existir fibrose intensa da bainha durai de raízes raquidianas e, eventualmente, quando a excisão da hérnia discai não fôr julgada satisfatória; a rizotomia posterior deve ser feita, também, tôdas as vêzes em que a reparação de uma lesão acidental da bainha de uma raiz raquidiana não tenha sido satisfatória. A electrocoagulação do ligamento longitudinal posterior, visando à destruição da maior parte do nervo sinuvertebral de Luschka, deve complementar a operação para diminuir a persistência ou a incidência de lombalgias. A hemostasia deve ser perfeita para diminuir a formação de tecido cicatricial, causa de sintomatologia dolorosa no pós-operatório. Com êsse mesmo intuito deve ser interposta lâmina de esponja de gelatina isolando a bainha durai da raiz raquidiana das formações circunvizinhas. Neste trabalho são apresentados os resultados obtidos em 128 casos, escolhidos entre 571 pacientes operados de hérnias intra-raquidianas de discos intervertebrals lombares; êstes 128 casos foram selecionados por terem seguimento de um ano, no mínimo, para permitir boa avaliação dos resultados. Foram considerados como bons tão sòmente os resultados obtidos nos pacientes que, um ano após a intervenção cirúrgica, não apresentavam qualquer sintoma objetivo ou subjetivo decorrente da afecção (100/128 casos, ou sejam 78,1%); como regulares, aquêles em que houve apenas melhoras (14/128 casos, ou sejam 10,9%); como maus aquêles em que os pacientes não foram beneficiados com a intervenção (14/128 casos, ou sejam 10,9%). Dentro de criteriosas indicações, as hérnias intra-raquidianas de discos intravertebrais lombares devem ser tratadas com métodos cirúrgicos; salvo casos excepcionais, tais operações devem ser feitas por neurocirurgiões