A multi-pressure analysis of ecosystem services for conservation planning in the Alps

Increasing anthropogenic pressures such as pollution, climate change or invasive species can have multiple impacts on ecosystems and the services (ES) they provide. To address the potential effects on ES provision, we propose a geospatial framework to identify and analyze the cumulative effects on terrestrial and freshwater ES. The framework includs an impact chain analysis based on ten pressures grouped into six categories (pollution, climate change, land-use change, overexploitation, land fragmentation, invasive species) and their single or multiple effects on five key ES of the Alpine environment (recreation, forest protection, CO2 sequestration, habitat maintenance, grassland biomass). Results show that the areas most affected by cumulative effects were located in major urban centers, in the Po Valley, Germany, Slovenia, and in coastal areas of the Adriatic Sea. The spatial coincidence analysis of pressure P-ES on IUCN protected sites showed that protection categories IV and V mostly had high P/high ES scores. Our approach will help in management and planning for mountain conservation aimed at reducing multi-pressure occurrences in transboundary environments. The framework can be used to identify areas with the highest ES provision, characterize areas with high stress from anthropogenic pressures, and examine the effects of pressures on protected areas

Results from a real-time dosimetry study during left atrial ablations performed with ultra-low dose radiation settings

Background: Three-dimensional mapping systems and the use of ultra-low dose radiation protocols have supported minimization of radiation dose during left atrial ablation procedures. By using optimal shielding, scattered radiation reaching the operator can be further reduced. This prospective study was designed to determine the remaining operator radiation exposure during left atrial catheter ablations using real-time dosimetry. Methods: Radiation dose was recorded using real-time digital dosimetry badges outside the lead apron during 201 consecutive left atrial fibrillation ablation procedures. All procedures were performed using the same X‑ray system (Siemens Healthineers Artis dBc; Siemens Healthcare AG, Erlangen, Germany) programmed with ultra-low dose radiation settings including a low frame rate (two frames per second), maximum copper filtration, and an optimized detector dose. To reduce scattered radiation to the operators, table-suspended lead curtains, ceiling-suspended leaded plastic shields, and radiation-absorbing shields on the patient were positioned in an overlapping configuration. Results: The 201 procedures included 139 (69%) pulmonary vein isolations (PVI) (20 cryoballoon ablations, 119 radiofrequency ablations, with 35 cases receiving additional ablation of the cavotricuspid isthmus) and 62 (31%) PVI plus further left atrial substrate ablation. Mean radiation dose measured as dose area product for all procedures was 128.09 ± 187.87 cGy ∙ cm2 with a mean fluoroscopy duration of 9.4 ± 8.7 min. Real-time dosimetry showed very low average operator doses of 0.52 ± 0.10 µSv. A subanalysis of 51 (25%) procedures showed that the radiation burden for the operator was highest during pulmonary vein angiography. Conclusion: The use of ultra-low dose radiation protocols in combination with optimized shielding results in extremely low scattered radiation reaching the operator.Hintergrund: Der Einsatz von dreidimensionalen Mapping-Systemen und von Niedrigdosiseinstellungen der Röntgenanlage führte zu einer Minimierung der Strahlenbelastung bei linksatrialen Ablationen. Optimierte Abschirmung kann die Streustrahlung als Strahlenbelastung des Untersuchers weiter reduzieren. In dieser prospektiven Studie wurde untersucht, welcher Strahlenbelastung der Untersucher unter Anwendung dieser Maßnahmen während linksatrialer Ablationen noch ausgesetzt ist. Methoden: Die Strahlenbelastung wurde mittels Echtzeitdosimetrie an der Außenseite der Bleischürze während 201 konsekutiven linksatrialen Ablationen gemessen. Alle Prozeduren wurden mit demselben Röntgensystem (Siemens Healthineers Artis dBc; Siemens Healthcare AG, Erlangen, Deutschland) und mit strahlensparenden Einstellungen durchgeführt, unter anderem mit einer niedrigen Bildrate von 2 Bildern/s, maximaler Kupferfilterung und angepasster Detektoreingangsdosis. Um Streustrahlung zu reduzieren, wurden die Seitenlamellen, die mobile Acrylscheibe und die strahlenabsorbierenden Schilde auf dem Patienten überlappend angeordnet. Ergebnisse: Die 201 Prozeduren umfassten 139 (69%) Pulmonalvenenisolationen (PVI; 20 Kryoballonablationen, 119 Radiofrequenzablationen, in 35 Fällen mit zusätzlicher Ablation des kavotrikuspidalen Isthmus) und 62 (31%) PVI mit zusätzlicher linksatrialer Substratmodifikation. Die Strahlendosis als Dosis-Flächen-Produkt (DAP) betrug durchschnittlich 128,09± 187,87 cGy ⋅cm2 bei einer Fluoroskopiedauer von imMittel 9,4± 8,7min. Die per Echtzeitdosimetrie erhobene mittlere Strahlendosis des Untersuchers zeigte sich mit 0,52± 0,10 μSv als sehr gering. Eine Subanalyse bei 51 (25 %) Prozeduren zeigte, dass die Strahlendosis des Untersuchers während der Pulmonalvenenangiographie am höchsten war. Schlussfolgerung: Die Kombination von Niedrigdosiseinstellungen und optimierter Abschirmung führt zu einer extremniedrigen Streustrahlung als Strahlenbelastung des Untersuchers

Hematocrit and the Risk of Recurrent Venous Thrombosis: A Prospective Cohort Study

BACKGROUND: Venous thromboembolism (VTE) is a multicausal disease which recurs. Hematocrit is associated with a thrombotic risk. We aimed to investigate if hematocrit is associated with the recurrence risk. METHODS: Patients with a first VTE were followed after anticoagulation. Patients with VTE provoked by a transient risk factor, natural inhibitor deficiency, lupus anticoagulant, homozygous or double heterozygous defects, cancer, or long-term antithrombotic treatment were excluded. The study endpoint was recurrent VTE. RESULTS: 150 (23%) of 653 patients had recurrence. Only high hematocrit was significantly associated with recurrence risk [hazard ratio (HR) for 1% hematocrit increase with the third tertile 1.08; 95% CI 1.01-1.15]. No or only a weak association for hematocrits within the first and second tertile was seen (HR 1.03; 95% CI 0.97-1.09, and 1.07; 95% CI 1.00-1.13). Hematocrit was associated with recurrence risk only among women. After five years, the probability of recurrence was 9.9% (95% CI 3.7%-15.7%), 15.6% (95% CI 9.7%-21.2%) and 25.5% (95% CI 15.1%-34.6%) in women, and was 29.2% (95% CI 21.1%-36.5%), 30.1% (95% CI 24.1%-35.7%) and 30.8% (95% CI 22.0%-38.7%) in men for hematocrits in the first, second and third tertile, respectively. Men had a higher recurrence risk (1.9; 95% CI 1.1-2.7; p = 0.03), which dropped by 23.5% after adjustment for hematocrit. Hematocrit was not a significant mediator of the sex-difference in recurrence risk (p = 0.223). CONCLUSIONS: High hematocrit is associated with the recurrence only in women. The different recurrence risk between men and women is possibly partly explained by hematocrit

Endurance performance is influenced by perceptions of pain and temperature: Theory, applications and safety considerations.

Models of endurance performance now recognise input from the brain, including an athlete’s ability to cope with various non-pleasurable perceptions during exercise, such as pain and temperature. Exercise training can reduce perceptions of both pain and temperature over time, partly explaining why athletes generally have a higher pain tolerance, despite a similar pain threshold, compared with active controls. Several strategies with varying efficacy may ameliorate the perceptions of pain (e.g. acetaminophen, transcranial direct current stimulation and transcutaneous electrical stimulation) and temperature (e.g. menthol beverages, topical menthol products and other cooling strategies, especially those targeting the head) during exercise to improve athletic performance. This review describes both the theory and practical applications of these interventions in the endurance sport setting, as well as the potentially harmful health consequences of their use

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

BACKGROUND: Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS: During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS: Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .)

Visual-palpatory versus fluoroscopic intraoperative determination of the femoral entry point in medial patellofemoral ligament reconstruction

PURPOSE: Malpositioning of the femoral entry point in reconstruction of the medial patellofemoral ligament (MPFL) can lead to abnormal and painful patellar kinematics and loss of flexion. Determination of this point is usually performed by palpation of anatomic landmarks. Accuracy of this method has not yet been investigated. The hypotheses were: 1. palpatory method is not as accurate as fluoroscopically guided method using established radiological criteria; 2. accuracy correlates with surgical experience. METHODS: Three surgeons of varying experience defined the femoral entry point for the MPFL by palpation in ten cadaveric legs. The blinded procedures were repeated three times, and subjective difficulty of the determination was recorded. Results were documented by fluoroscopy on a true lateral radiograph. The accuracy was assessed using established radiological criteria. Surgical experience was correlated with the results, and confounding or interacting variables were assessed. RESULTS: Mean deviation from the correct zone for the femoral entry point was 3.5 mm (range 0-18 mm). Twenty-nine percent of all palpatory determinations were inside the correct zone, 47 % were within 5 mm distance from the correct zone, and 23 % were further than 5 mm apart from the correct zone ("outliers"). No significant difference was found between surgeons of varying experience. No correlation was observed between subjective difficulty of the procedure and accuracy of determination. CONCLUSIONS: The validity of the isolated palpatory determination of the femoral entry point in MPFL reconstruction seems to be insufficient, regardless of surgical experience. Derived from this study, fluoroscopic guidance is used in our clinic by default

Clinical and radiological results after one hundred fifteen MPFL reconstructions with or without tibial tubercle transfer in patients with recurrent patellar dislocation-a mean follow-up of 5.4 years

PURPOSE Medial patellofemoral ligament reconstruction (MPFLR) shows low recurrent rates and high satisfaction. Reports on outcome at mid-term follow-up in a large cohort with or without tibial tubercle transfer (TTT) are scarce. METHODS One hundred six patients (115 knees; 24.3 ± 8.7 years) with recurrent patellar dislocation underwent MPFLR with ipsilateral gracilis autograft and were included in this retrospective follow-up study. In 43 knees, simultaneous TTT was performed for patellar maltracking due to patella alta or increased tibial tubercle trochlear groove distance (TT-TG). Kujala and subjective knee scores were recorded pre- and post-operatively. RESULTS Eighty-seven percent of the patients were satisfied at a mean follow-up of 5.4 ± 3.1 years. The Kujala score increased in 81.7% of all knees from 50.9 to 76.2 points (p < 0.01). Patients with a decreased Kujala score were not different in terms of follow-up time, age, trochlear dysplasia, or post-operative patellar height. The decline was related to an increase in pain, whereas functional scores remained identical. There were six patients with persisting instability, three with patellar re-dislocation. Re-operation was necessary in 24 patients (21.2%), mainly for implant removal after TTT and loss of flexion. Performing TTT had no significant influence on the subjective outcome. Patients with more than eight years of follow-up (n = 27) did not show any difference in the subjective outcome parameters, or in osteoarthritis progression. CONCLUSION MPFLR with and without TTT is a reliable treatment option for recurrent patellar dislocation without deterioration at mid-term follow-up. Persisting pain is a major post-operative issue that seems to be unrelated to patellofemoral anatomy