Perioperative Enhanced Recovery Concepts Significantly Improve Postoperative Outcome in Patients with Crohn`s Disease.

BACKGROUND AND AIMS: Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s Disease (CD), postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking. METHODS: In a prospective single-center study, all patients receiving ileocecal resection due to CD between 2020 and 2023 were included. A specific perioperative enhanced recovery concept (ERC) was implemented and patients were divided into two groups (before and after implementation). The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index (CCI), secondary endpoints were severe complications, length of hospital stay, and rates of re-admission. RESULTS: 83 patients were analyzed of which 33 patients participated in the enhanced recovery program (postERC). While patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications (CCI: 21.4 versus 8.4, p=0.0036; Clavien Dindo >2: 38% versus 3.1%, p=0.0002). Additionally, postERC-patients were earlier ready for discharge (6.5 days versus 5 days, p=0.001) and rates of re-admission were significantly lower (20% versus 3.1%, p=0.03). In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications (p=0.019). CONCLUSION: A specific perioperative enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s Disease.

[Personalized treatment of pheochromocytoma]. / Personalisierte Therapie des Phäochromozytoms.

BACKGROUND: Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma. MATERIAL AND METHODS: A narrative review article based on the most recent literature is presented. RESULTS AND DISCUSSION: The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24­h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.

Cladribine treatment specifically affects peripheral blood memory B cell clones and clonal expansion in multiple sclerosis patients.

Introduction: B cells are acknowledged as crucial players in the pathogenesis of multiple sclerosis (MS). Several disease modifying drugs including cladribine have been shown to exert differential effects on peripheral blood B cell subsets. However, little is known regarding functional changes within the peripheral B cell populations. In this study, we obtained a detailed picture of B cell repertoire changes under cladribine treatment on a combined immunoglobulin (Ig) transcriptome and proteome level. Methods: We performed next-generation sequencing of Ig heavy chain (IGH) transcripts and Ig mass spectrometry in cladribine-treated patients with relapsing-remitting multiple sclerosis (n = 8) at baseline and after 6 and 12 months of treatment in order to generate Ig transcriptome and Ig peptide libraries. Ig peptides were overlapped with the corresponding IGH transcriptome in order to analyze B cell clones on a combined transcriptome and proteome level. Results: The analysis of peripheral blood B cell percentages pointed towards a significant decrease of memory B cells and an increase of naive B cells following cladribine therapy. While basic IGH repertoire parameters (e.g. variable heavy chain family usage and Ig subclasses) were only slightly affected by cladribine treatment, a significantly decreased number of clones and significantly lower diversity in the memory subset was noticeable at 6 months following treatment which was sustained at 12 months. When looking at B-cell clones comprising sequences from the different time-points, clones spanning between all three time-points were significantly more frequent than clones including sequences from two time-points. Furthermore, Ig proteome analyses showed that Ig transcriptome specific peptides could mostly be equally aligned to all three time-points pointing towards a proportion of B-cell clones that are maintained during treatment. Discussion: Our findings suggest that peripheral B cell related treatment effects of cladribine tablets might be exerted through a reduction of possibly disease relevant clones in the memory B cell subset without disrupting the overall clonal composition of B cells. Our results -at least partially- might explain the relatively mild side effects regarding infections and the sustained immune response after vaccinations during treatment. However, exact disease driving B cell subsets and their effects remain unknown and should be addressed in future studies.

Cefazolin Might Be Adequate for Perioperative Antibiotic Prophylaxis in Intra-Abdominal Infections without Sepsis: A Quality Improvement Study.

BACKGROUND: The adequate choice of perioperative antibiotic prophylaxis (PAP) could influence the risk of surgical site infections (SSIs) in general surgery. A new local PAP guideline was implemented in May 2017 and set the first-generation cefazolin (CFZ) instead the second-generation cefuroxime (CXM) as the new standard prophylactic antibiotic. The aim of this study was to compare the risk of SSIs after this implementation in intra-abdominal infections (IAIs) without sepsis. METHODS: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Germany analyzing patients after emergency surgery during 2016 to 2019 (n = 985), of which patients receiving CXM or CFZ were selected (n = 587). Propensity score matching was performed to ensure a comparable risk of SSIs in both groups. None-inferiority margin for SSIs was defined as 8% vs. 4%. RESULTS: Two matched cohorts with respectively 196 patients were compared. The rate of SSIs was higher in the CFZ group (7.1% vs. 3.6%, p = 0.117) below the non-inferiority margin. The rate of other postoperative infections was significantly higher in the CFZ group (2.0% vs. 8.7%, p = 0.004). No other differences including postoperative morbidity, mortality or length-of-stay were observed. CONCLUSION: Perioperative antibiotic prophylaxis might be safely maintained by CFZ even in the treatment of intra-abdominal infections.

The Validity of the SEEV Model as a Process Measure of Situation Awareness: The Example of a Simulated Endotracheal Intubation.

OBJECTIVE: In the context of anesthesiology, we investigated whether the salience effort expectancy value (SEEV) model fit is associated with situation awareness and perception scores. BACKGROUND: The distribution of visual attention is important for situation awareness-that is, understanding what is going on-in safety-critical domains. Although the SEEV model has been suggested as a process situation awareness measure, the validity of the model as a predictor of situation awareness has not been tested. METHOD: In a medical simulation, 31 senior and 30 junior anesthesiologists wore a mobile eye tracker and induced general anesthesia into a simulated patient. When inserting a breathing tube into the mannequin's trachea (endotracheal intubation), the scenario included several clinically relevant events for situation awareness and general events in the environment. Both were assessed using direct awareness measures. RESULTS: The overall SEEV model fit was good with no difference between junior and senior anesthesiologists. Overall, the situation awareness scores were low. As expected, the SEEV model fits showed significant positive correlations with situation awareness level 1 scores. CONCLUSION: The SEEV model seems to be suitable as a process situation awareness measure to predict and investigate the perception of changes in the environment (situation awareness level 1). The situation awareness scores indicated that anesthesiologists seem not to perceive the environment well during endotracheal intubation. APPLICATION: The SEEV model fit can be used to capture and assess situation awareness level 1. During endotracheal intubation, anesthesiologists should be supported by technology or staff to notice changes in the environment.

Next Generation Sequencing of Cerebrospinal Fluid B Cell Repertoires in Multiple Sclerosis and Other Neuro-Inflammatory Diseases-A Comprehensive Review.

During the last few decades, the role of B cells has been well established and redefined in neuro-inflammatory diseases, including multiple sclerosis and autoantibody-associated diseases. In particular, B cell maturation and trafficking across the blood-brain barrier (BBB) has recently been deciphered with the development of next-generation sequencing (NGS) approaches, which allow the assessment of representative cerebrospinal fluid (CSF) and peripheral blood B cell repertoires. In this review, we perform literature research focusing on NGS studies that allow further insights into B cell pathophysiology during neuro-inflammation. Besides the analysis of CSF B cells, the paralleled assessment of peripheral blood B cell repertoire provides deep insights into not only the CSF compartment, but also in B cell trafficking patterns across the BBB. In multiple sclerosis, CSF-specific B cell maturation, in combination with a bidirectional exchange of B cells across the BBB, is consistently detectable. These data suggest that B cells most likely encounter antigen(s) within the CSF and migrate across the BBB, with further maturation also taking place in the periphery. Autoantibody-mediated diseases, such as neuromyelitis optica spectrum disorder and LGI1 / NMDAR encephalitis, also show features of a CSF-specific B cell maturation and clonal connectivity with peripheral blood. In conclusion, these data suggest an intense exchange of B cells across the BBB, possibly feeding autoimmune circuits. Further developments in sequencing technologies will help to dissect the exact pathophysiologic mechanisms of B cells during neuro-inflammation.

[Pregnancy and Irreversible Loss of Brain Functions - Case Report]. / Intensivtherapie bei Schwangerer mit irreversiblem Hirnfunktionsausfall.

A 29-year-old woman suffered major traumatic brain injury caused by a car accident. As diagnostic measures had revealed an early pregnancy (9th week), treatment on the intensive care unit was continued for 5 months, after unfavourable cerebral prognosis was followed by an irreversible loss of brain function in the 10th week of pregnancy. After assisted vaginal delivery of a healthy child in the 31th week of pregnancy on the critical care unit, organ procurement took place according to the presumed will of the patient. The article presents the details of the critical care therapy and discusses the supportive medical measures. Those measures served primarily to uphold the pregnancy und support the healthy development and delivery of the fetus and only in second instance the organ preservation aiming on organ donation. Necessary measures included maintenance of vital functions, hemostasis of electrolytes, nutrition, treatment of infection, prevention of adverse effects on the fetus, substitution of hormones and vitamins as well as the preparation of a planned or an unplanned delivery.

[Ethical, Psychosocial and Legal Aspects of the Treatment of Pregnant Patients with Brain Death]. / Ethische, psychosoziale und rechtliche Aspekte der Behandlung hirntoter Schwangerer.

The therapy of brain-dead pregnant women is an extreme example not only of the possibilities in current critical care, but also of resulting ethical, social and legal controversies, an area not familiar to most clinicians. Based on the case of a patient with fatal traumatic brain injury, a previously unknown early pregnancy and stated will to donate organs, we will discuss several aspects using published case reports: therapeutic goals, especially palliative care vs. continuation; implications of brain death diagnosis; considerations on legal care; involvement of relatives, especially the child's father; dynamics within the care team; and finally the issue of putative organ donation. This complex case once more depicts that even facing such highly unfavourable framework and seemingly irreconcilable factors, pregnancy can prevail. The researched facts and considerations in this article are intended to give an overview of potential dilemmas and might serve as a starting point in similar situations.

Treatment of progressive multiple sclerosis with high-dose all-trans retinoic acid - no clear evidence of positive disease modifying effects.

BACKGROUND: All-trans retinoic acid (ATRA) is an acid derivative of vitamin A which is discussed as a promising candidate to ameliorate the disease course of multiple sclerosis (MS) by immunomodulation or even by promoting regeneration in progressive MS. Here we report a patient who significantly improved for MS related disability following administration of chemotherapy including ATRA for mitoxantrone-related acute promyelocytic leukemia and assess the effect of high-dose ATRA in three additional patients with progressive MS. METHODS: Patients with progressive MS who had failed previous therapies were treated with high-dose ATRA. Patients underwent clinical and routine laboratory monitoring. Additionally, PBMCs were analyzed by flow cytometry for lymphocyte subsets. RESULTS: ATRA was well tolerated and no pathological laboratory abnormalities were observed. After initial mild (not statistically significant) improvement of EDSS and mean MSFC z-score, ongoing disease progression was observed. One patient subacutely experienced severe cognitive and motor worsening. Cerebral MRI revealed persistent gadolinium-enhancing lesions. Flow cytometric alterations of peripheral blood naïve, central memory and effector memory CD4 and CD8 T cells, B lymphocytes, plasma cells, memory B cells, plasmablasts and natural killer (NK) cells did not reach statistical significance. CONCLUSIONS: Stand-alone therapy with ATRA did not ameliorate progressive MS in our limited cohort and we did not observe consistent alterations of T and B cell subsets. Intriguingly, application of ATRA may have caused marked disease exacerbation in one patient.

Dual-room twin-CT scanner in multiple trauma care: first results after implementation in a level one trauma centre.

PURPOSE: The trauma centre of the Wuerzburg University Hospital has integrated a pioneering dual-room twin-CT scanner in a multiple trauma pathway. For concurrent treatment of two trauma patients, two carbon CT examination and intervention tables are positioned head to head with one sliding CT-Gantry in the middle. The focus of this study is the process of trauma care with the time to CT (tCT) and the time to operation (tOR) as quality indicator. METHODS: All patients with suspected multiple trauma, who required emergency surgery and who were initially diagnosed by the CT trauma protocol between 05/2018 and 12/2018 were included. Data relating to time spans (tCT and tOR), severity of injury and outcome was obtained. RESULTS: 110 of the 589 screened trauma patients had surgery immediately after finishing primary assessment in the ER. The ISS was 17 (9-34) (median and interquartile range, IQR). tCT was 15 (11-19) minutes (median and IQR) and tOR was 96.5 (75-119) minutes (median and IQR). In the first 30 days, seven patients died (6.4%) including two within the first 24 h (2%). There were two ICU days (1-6) (median and IQR) and one (0-1) (median and IQR) ventilator day. CONCLUSION: The twin-CT technology is a fascinating tool to organize high-quality trauma care for two multiple trauma patients simultaneously.

Giant Nonlinear Circular Dichroism from Intersubband Polaritonic Metasurfaces.

Nonlinear metasurfaces are advancing into a new paradigm of "flat nonlinear optics" owing to the ability to engineer local nonlinear responses in subwavelength-thin films. Recently, attempts have been made to expand the design space of nonlinear metasurfaces through nonlinear chiral responses. However, the development of metasurfaces that display both giant nonlinear circular dichroism and significantly large nonlinear optical response is still an unresolved challenge. Herein, we propose a method that induces giant nonlinear responses with near-unity circular dichroism using polaritonic metasurfaces with optical modes in chiral plasmonic nanocavities coupled with intersubband transitions in semiconductor heterostructures designed to have giant second and third order nonlinear responses. A stark contrast between effective nonlinear susceptibility elements for the two spin states of circularly polarized pump beams was seen in the hybrid structure. Experimentally, near-unity nonlinear circular dichroism and conversion efficiencies beyond 10-4% for second- and third-harmonic generation were achieved simultaneously in a single chip.

Vaginal delivery in the 30+4 weeks of pregnancy and organ donation after brain death in early pregnancy.

A 28-year-old woman suffered a traffic accident resulting in severe head injuries with deleterious prognosis. Diagnostics further revealed a hitherto unknown pregnancy, at suspected week 9. Based on the patient's wish to donate organs, brain death protocol confirmed irreversible loss of brain function. Yet, vital pregnancy rendered organ transplantation impossible. Multiple ethical and legal issues arose, from invalidation of established legal care after brain death to the delivery of a healthy child after trauma and long-term critical care. After medicolegal and ethical counselling, pregnancy was sustained, and the goal of organ donation postponed. Critical care focused on foetal homeostasis. At 30+4 weeks, a viable girl was born via assisted vaginal delivery. Postpartal organ donation resulted in heart, kidney and pancreas transplantation. The case emphasises the medical, legal and ethical challenges to combine two apparently diametrical goals: the successful full-term pregnancy and the fulfilment of a patient's wish to donate organs.

Interdisciplinary complication management of dislodged lumbar interbody spacer in pulmonary artery.

We report the case of an intraoperatively dislodged transforaminal lumbar interbody fusion spacer with creation of a traumatic arteriovenous fistula and device migration to the pulmonary artery. Successful minimally invasive angiographic retrieval of the spacer is discussed with special reference to angiographic and surgical treatment strategies and pitfalls.

III-V-on-Silicon Photonic Integrated Circuits for Spectroscopic Sensing in the 2-4 µm Wavelength Range.

The availability of silicon photonic integrated circuits (ICs) in the 2-4 µm wavelength range enables miniature optical sensors for trace gas and bio-molecule detection. In this paper, we review our recent work on III-V-on-silicon waveguide circuits for spectroscopic sensing in this wavelength range. We first present results on the heterogeneous integration of 2.3 µm wavelength III-V laser sources and photodetectors on silicon photonic ICs for fully integrated optical sensors. Then a compact 2 µm wavelength widely tunable external cavity laser using a silicon photonic IC for the wavelength selective feedback is shown. High-performance silicon arrayed waveguide grating spectrometers are also presented. Further we show an on-chip photothermal transducer using a suspended silicon-on-insulator microring resonator used for mid-infrared photothermal spectroscopy.

2.3 µm range InP-based type-II quantum well Fabry-Perot lasers heterogeneously integrated on a silicon photonic integrated circuit.

Heterogeneously integrated InP-based type-II quantum well Fabry-Perot lasers on a silicon waveguide circuit emitting in the 2.3 µm wavelength range are demonstrated. The devices consist of a "W"-shaped InGaAs/GaAsSb multi-quantum-well gain section, III-V/silicon spot size converters and two silicon Bragg grating reflectors to form the laser cavity. In continuous-wave (CW) operation, we obtain a threshold current density of 2.7 kA/cm2 and output power of 1.3 mW at 5 °C for 2.35 µm lasers. The lasers emit over 3.7 mW of peak power with a threshold current density of 1.6 kA/cm2 in pulsed regime at room temperature. This demonstration of heterogeneously integrated lasers indicates that the material system and heterogeneous integration method are promising to realize fully integrated III-V/silicon photonics spectroscopic sensors in the 2 µm wavelength range.

Attosecond photoelectron streaking with enhanced energy resolution for small-bandgap materials.

Attosecond photoelectron streaking spectroscopy allows time-resolved electron dynamics with a temporal resolution approaching the atomic unit of time. Studies have been performed in numerous systems, including atoms, molecules, and surfaces, and the quest for ever higher temporal resolution called for ever wider spectral extent of the attosecond pulses. For typical experiments relying on attosecond pulses with a duration of 200 as, the time-bandwidth limitation for a Gaussian pulse implies a minimal spectral bandwidth larger than 9 eV translating to a corresponding spread of the detected photoelectron kinetic energies. Here, by utilizing a specially tailored narrowband reflective XUV multilayer mirror, we explore experimentally the minimal spectral width compatible with attosecond time-resolved photoelectron spectroscopy while obtaining the highest possible spectral resolution. The validity of the concept is proven by recording attosecond electron streaking traces from the direct semiconductor gallium arsenide (GaAs), with a nominal bandgap of 1.42 eV at room temperature, proving the potential of the approach for tracking charge dynamics also in these technologically highly relevant materials that previously have been inaccessible to attosecond science.

GaSb-based vertical-cavity surface-emitting lasers with an emission wavelength at 3 µm.

GaSb-based electrically pumped vertical-cavity surface-emitting lasers (VCSELs) with a buried tunnel junction emitting at 3 µm are demonstrated. To achieve this, a low optical loss VCSEL concept with an undoped epitaxial distributed Bragg reflector and intracavity contact is presented. The devices operate up to 5°C continuous wave and up to 50°C in pulsed mode. Single-mode operation with a side-mode suppression ratio of 30 dB and electro-thermal tuning range of 19.7 nm is achieved.

III-V-on-silicon 2-µm-wavelength-range wavelength demultiplexers with heterogeneously integrated InP-based type-II photodetectors.

2-µm-wavelength-range silicon-on-insulator (SOI) arrayed waveguide gratings (AWGs) with heterogeneously integrated InP-based type-II quantum well photodetectors are presented. Low insertion loss (2.5-3 dB) and low crosstalk (-30 to -25 dB) AWGs are realized. The InP-based type-II photodetectors are integrated with the AWGs using two different coupling approaches. Adiabatic-taper-based photodetectors show a responsivity of 1.6 A/W at 2.35 µm wavelength and dark current of 10 nA at -0.5 V, while photodetectors using grating-assisted coupling have a responsivity of 0.1 A/W and dark current of 5 nA at -0.5 V. The integration of the photodetector array does not degrade the insertion loss and crosstalk of the device. The photodetector epitaxial stack can also be used to realize the integration of a broadband light source, thereby enabling fully integrated spectroscopic systems.

A Luciferase-Based Assay to Test Whether Gene Expression Responses to Environmental Inputs Are Temporally Restricted by the Circadian Clock.

Gating is the mechanism by which the influence of an environmental signal on a particular output is temporally restricted by the circadian clock, so that the maximum response of the output to the signal occurs at a specific time. Gated regulation mechanisms have been described for several genes whose expression is strongly induced by light or temperature at certain times but repressed by the circadian clock at others. To reveal a gated pattern of expression in response to light, light pulses are applied in the dark at different times of the 24 h cycle and the transcriptional response of the gene of interest is then monitored with an appropriate technique. Luciferase (LUC) reporters have been the method of choice to study circadian rhythms in the past decades, but this methodology also provides an ideal platform for performing a gating assay. In this chapter, we describe a LUC imaging based protocol designed to test whether the influence of light on the expression of a gene of interest is gated by the circadian clock.