Obstruktives Schlafapnoesyndrom als Risikofaktor für postoperative infektiöse Komplikationen nach elektiver koronarer Bypass-Operation: eine prospektive kontrollierte Beobachtungsstudie

Das obstruktive Schlafapnoesyndrom (OSA), als Folge einer teilweisen oder kompletten Verlegung der oberen Atemwege im Schlaf, ist hochprävalent (30%) in der älteren Bevölkerung. Während ein Zusammenhang zwischen OSA-assoziierten Konsequenzen wie repetitiven Sauerstoffdesaturationen, oxidativem Stress, sympathisch-autonomer Aktivierung, endothelialer Dysfunktion, proinflammatorischem Status und damit einer erhöhten Vulnerabilität für vaskuläre, renale und endokrine Erkrankungen wissenschaftlich belegt ist, ist der Einfluss von OSA auf die postoperative Genesung nach großen chirurgischen Eingriffen nur im Ansatz untersucht. Daher stellt sich die Frage, ob eine OSA aufgrund der oben gennannten Veränderungen wichtiger physiologischer Systeme ebenso einen Einfluss auf das postoperative Outcome hat. Hierzu untersuchten wir speziell die infektiösen Komplikationen nach elektiven koronaren Bypassoperationen. Dabei sollte geklärt werden, ob eine OSA schweregradabhängig und unabhängig von anderen Risikofaktoren das postoperative Outcome beeinflusst. Deshalb führten wir eine bizentrische, kontrollierte Studie mit dem Namen Obstructive Sleep Apnea postoperative Risk Stratification Trial (OSARST) durch. Diese untersuchte erstmals prospektiv den Einfluss von OSA auf das postoperative Outcome von 219 Patienten mit koronarer Herzerkrankung und elektiver koronarer Bypassoperation untersucht. Der primäre Endpunkt der Studie war ein binärer Kompositendpunkt schwerwiegender postoperativer kardialer, respiratorischer, neurologischer, chirurgischer, renaler und infektiöser Komplikationen (Major-Eregnisse). Die sekundären Kompositendpunkte fokussierten sich auf inflammatorisch-infektiöse Komplikationen. Weiterhin wurden als sekundäre Kompositendpunkte kardiale, respiratorische, neurologische, chirurgische und renale Minorereignisse und logistische Patientendaten erfasst. Die Diagnose eines OSA erfolgte mittels nächtlicher Polygraphie ein bis zwei Tage vor der Operation. Anschließend wurden die Patienten über 7 Tage engmaschig auf postoperative Komplikationen überwacht. Zur Erfassung der 30-Tage-Mortalität erfolgte ein telefonischer Follow-Up einen Monat nach der OP. Die statistische Analyse erfolgte mittels uni- und multivarianter logistischer Regressionsmodelle. In unserem Studienkollektiv zeigte sich eine OSA-Prävalenz (AHI10/h) von 68,9%. Eine moderate und schwere OSA (AHI20/h) trat mit einer Prävalenz von 42,9% auf. Weiterhin wurde für Patienten mit moderater und schwerer OSA eine erhöhte Mortalität und Morbidität nachgewiesen. So waren bei einem AHI20/h die Krankenhaus- (OR=8,45; 95%-CI=1,00-71,5) und die 30-Tage-Mortalität (OR=10,1; 95%-CI=1,22-83,5) erhöht. Häufige schwerwiegende OSA-assoziierte postoperative Komplikationen waren die Sepsis (OR=3,29; 95%-CI=1,32-8,18) und der septische Schock (OR=3,02; 95%-CI=1,08-8,43). Damit zeigte sich in der OSARST-Studie eine hohe Prävalenz von OSA bei Patienten mit koronarer Herzerkrankung vor elektiven koronaren Bypassoperationen. Eine moderate bis schwere OSA verschlechterte maßgeblich das postoperative Outcome im Sinne von septisch-infektiösen Komplikationen. Der Einfluss auf das Outcome ist damit mit anderen Risikofaktoren vergleichbar. So zeigten zum Beispiel Thourani et al. 1999 einen ähnlichen Effekt von Diabetes mellitus und arterieller Hypertension nach koronarer Bypassoperation auf die Krankenhausmortalität (Diabetes mellitus OR=1,768; 95%-CI=1,315-2,378 und arterielle Hypertension OR=1,575; 95%-CI=1,177-2,108). Eine OSA ist mittels CPAP-Therapie (continuous positive airway pressure) gut behandelbar. So könnte ein präoperatives Screening vor elektiven kardiochirurgischen Eingriffen und wenn nötig eine entsprechende Behandlung das Potenzial besitzen, das operative Risiko zu vermindern und das postoperative Outcome zu verbessern. Hierzu sollten weiterführende Studien zur Validierung unserer Ergebnisse und Interventionsstudien zur Prüfung eines Effektes einer präoperativen CPAP-Therapie durchgeführt werden

Multiple drivers of local (non-) compliance in community-based marine resource management: Case studies from the South Pacific

The outcomes of marine conservation and related management interventions depend to a large extent on people's compliance with these rule systems. In the South Pacific, community-based marine resource management (CBMRM) has gained wide recognition as a strategy for the sustainable management of marine resources. In current practice, CBMRM initiatives often build upon customary forms of marine governance, integrating scientific advice and management principles in collaboration with external partners. However, diverse socio-economic developments as well as limited legal mandates can challenge these approaches. Compliance with and effective (legally-backed) enforcement of local management strategies constitute a growing challenge for communities—often resulting in considerable impact on the success or failure of CBMRM. Marine management arrangements are highly dynamic over time, and similarly compliance with rule systems tends to change depending on context. Understanding the factors contributing to (non-) compliance in a given setting is key to the design and function of adaptive management approaches. Yet, few empirical studies have looked in depth into the dynamics around local (non-) compliance with local marine tenure rules under the transforming management arrangements. Using two case studies from Solomon Islands and Fiji, we investigate what drives local (non-) compliance with CBMRM and what hinders or supports its effective enforcement. The case studies reveal that non-compliance is mainly driven by: (1) diminishing perceived legitimacy of local rules and rule-makers; (2) increased incentives to break rules due to market access and/ or lack of alternative income; and (3) relatively weak enforcement of local rules (i.e., low perceptions of risk from sanctions for rule-breaking). These drivers do not stand alone but can act together and add up to impair effective management. We further analyze how enforcement of CBMRM is challenged through a range of institutional; socio-cultural and technical/financial constraints, which are in parts a result of the dynamism and ongoing transformations of management arrangements. Our study underlines the importance of better understanding and contextualizing marine resource management processes under dynamic conditions for an improved understanding of compliance in a particular setting

Forever niche: Why do organically bred vegetable varieties not diffuse?

While organic food increased its market share in conventional food retail, virtually all organic vegetables are still conventionally bred. For decades, organically bred vegetable varieties remained a market niche, despite their socio-ecological benefits. This paper conceptualizes actors and activities around organic breeding as a Technological Innovation System (TIS) and analyzes what prevents these varieties from widely diffusing into conventional supermarkets. Investigated systemic barriers relate to knowledge, market formation, investments, and legitimacy. The study is based on interviews with food retailers and (commons-based) breeding initiatives across Germany. Theoretically, the paper adds an innovation system perspective on the diffusion of organically bred varieties, a blind spot in the emerging seed commons debate. Furthermore, it contributes to sustainability transitions literature by introducing a novel empirical topic and reframing the TIS framework to analyze agri-food innovations. Identifying barriers and vicious cycles might support practitioners and policymakers seeking to diffuse this agri-food niche

Differential cross section measurements for the production of a W boson in association with jets in proton–proton collisions at √s = 7 TeV

Measurements are reported of differential cross sections for the production of a W boson, which decays into a muon and a neutrino, in association with jets, as a function of several variables, including the transverse momenta (pT) and pseudorapidities of the four leading jets, the scalar sum of jet transverse momenta (HT), and the difference in azimuthal angle between the directions of each jet and the muon. The data sample of pp collisions at a centre-of-mass energy of 7 TeV was collected with the CMS detector at the LHC and corresponds to an integrated luminosity of 5.0 fb[superscript −1]. The measured cross sections are compared to predictions from Monte Carlo generators, MadGraph + pythia and sherpa, and to next-to-leading-order calculations from BlackHat + sherpa. The differential cross sections are found to be in agreement with the predictions, apart from the pT distributions of the leading jets at high pT values, the distributions of the HT at high-HT and low jet multiplicity, and the distribution of the difference in azimuthal angle between the leading jet and the muon at low values.United States. Dept. of EnergyNational Science Foundation (U.S.)Alfred P. Sloan Foundatio

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI

Penilaian Kinerja Keuangan Koperasi di Kabupaten Pelalawan

This paper describe development and financial performance of cooperative in District Pelalawan among 2007 - 2008. Studies on primary and secondary cooperative in 12 sub-districts. Method in this stady use performance measuring of productivity, efficiency, growth, liquidity, and solvability of cooperative. Productivity of cooperative in Pelalawan was highly but efficiency still low. Profit and income were highly, even liquidity of cooperative very high, and solvability was good

Search for stop and higgsino production using diphoton Higgs boson decays

Results are presented of a search for a "natural" supersymmetry scenario with gauge mediated symmetry breaking. It is assumed that only the supersymmetric partners of the top-quark (stop) and the Higgs boson (higgsino) are accessible. Events are examined in which there are two photons forming a Higgs boson candidate, and at least two b-quark jets. In 19.7 inverse femtobarns of proton-proton collision data at sqrt(s) = 8 TeV, recorded in the CMS experiment, no evidence of a signal is found and lower limits at the 95% confidence level are set, excluding the stop mass below 360 to 410 GeV, depending on the higgsino mass

Search for new particles in events with energetic jets and large missing transverse momentum in proton-proton collisions at root s=13 TeV

A search is presented for new particles produced at the LHC in proton-proton collisions at root s = 13 TeV, using events with energetic jets and large missing transverse momentum. The analysis is based on a data sample corresponding to an integrated luminosity of 101 fb(-1), collected in 2017-2018 with the CMS detector. Machine learning techniques are used to define separate categories for events with narrow jets from initial-state radiation and events with large-radius jets consistent with a hadronic decay of a W or Z boson. A statistical combination is made with an earlier search based on a data sample of 36 fb(-1), collected in 2016. No significant excess of events is observed with respect to the standard model background expectation determined from control samples in data. The results are interpreted in terms of limits on the branching fraction of an invisible decay of the Higgs boson, as well as constraints on simplified models of dark matter, on first-generation scalar leptoquarks decaying to quarks and neutrinos, and on models with large extra dimensions. Several of the new limits, specifically for spin-1 dark matter mediators, pseudoscalar mediators, colored mediators, and leptoquarks, are the most restrictive to date.Peer reviewe

Impacts of the Tropical Pacific/Indian Oceans on the Seasonal Cycle of the West African Monsoon

The current consensus is that drought has developed in the Sahel during the second half of the twentieth century as a result of remote effects of oceanic anomalies amplified by local land–atmosphere interactions. This paper focuses on the impacts of oceanic anomalies upon West African climate and specifically aims to identify those from SST anomalies in the Pacific/Indian Oceans during spring and summer seasons, when they were significant. Idealized sensitivity experiments are performed with four atmospheric general circulation models (AGCMs). The prescribed SST patterns used in the AGCMs are based on the leading mode of covariability between SST anomalies over the Pacific/Indian Oceans and summer rainfall over West Africa. The results show that such oceanic anomalies in the Pacific/Indian Ocean lead to a northward shift of an anomalous dry belt from the Gulf of Guinea to the Sahel as the season advances. In the Sahel, the magnitude of rainfall anomalies is comparable to that obtained by other authors using SST anomalies confined to the proximity of the Atlantic Ocean. The mechanism connecting the Pacific/Indian SST anomalies with West African rainfall has a strong seasonal cycle. In spring (May and June), anomalous subsidence develops over both the Maritime Continent and the equatorial Atlantic in response to the enhanced equatorial heating. Precipitation increases over continental West Africa in association with stronger zonal convergence of moisture. In addition, precipitation decreases over the Gulf of Guinea. During the monsoon peak (July and August), the SST anomalies move westward over the equatorial Pacific and the two regions where subsidence occurred earlier in the seasons merge over West Africa. The monsoon weakens and rainfall decreases over the Sahel, especially in August.Peer reviewe

Severe early onset preeclampsia: short and long term clinical, psychosocial and biochemical aspects

Preeclampsia is a pregnancy specific disorder commonly defined as de novo hypertension and proteinuria after 20 weeks gestational age. It occurs in approximately 3-5% of pregnancies and it is still a major cause of both foetal and maternal morbidity and mortality worldwide1. As extensive research has not yet elucidated the aetiology of preeclampsia, there are no rational preventive or therapeutic interventions available. The only rational treatment is delivery, which benefits the mother but is not in the interest of the foetus, if remote from term. Early onset preeclampsia (<32 weeks’ gestational age) occurs in less than 1% of pregnancies. It is, however often associated with maternal morbidity as the risk of progression to severe maternal disease is inversely related with gestational age at onset2. Resulting prematurity is therefore the main cause of neonatal mortality and morbidity in patients with severe preeclampsia3. Although the discussion is ongoing, perinatal survival is suggested to be increased in patients with preterm preeclampsia by expectant, non-interventional management. This temporising treatment option to lengthen pregnancy includes the use of antihypertensive medication to control hypertension, magnesium sulphate to prevent eclampsia and corticosteroids to enhance foetal lung maturity4. With optimal maternal haemodynamic status and reassuring foetal condition this results on average in an extension of 2 weeks. Prolongation of these pregnancies is a great challenge for clinicians to balance between potential maternal risks on one the eve hand and possible foetal benefits on the other. Clinical controversies regarding prolongation of preterm preeclamptic pregnancies still exist – also taking into account that preeclampsia is the leading cause of maternal mortality in the Netherlands5 - a debate which is even more pronounced in very preterm pregnancies with questionable foetal viability6-9. Do maternal risks of prolongation of these very early pregnancies outweigh the chances of neonatal survival? Counselling of women with very early onset preeclampsia not only comprises of knowledge of the outcome of those particular pregnancies, but also knowledge of outcomes of future pregnancies of these women is of major clinical importance. This thesis opens with a review of the literature on identifiable risk factors of preeclampsia