Increased sea ice melt as a driver of enhanced Arctic phytoplankton blooming.

Phytoplankton primary production in the Arctic Ocean has been increasing over the last two decades. In 2019, a record spring bloom occurred in Fram Strait, characterized by a peak in chlorophyll that was reached weeks earlier than in other years and was larger than any previously recorded May bloom. Here, we consider the conditions that led to this event and examine drivers of spring phytoplankton blooms in Fram Strait using in situ, remote sensing, and data assimilation methods. From samples collected during the May 2019 bloom, we observe a direct relationship between sea ice meltwater in the upper water column and chlorophyll a pigment concentrations. We place the 2019 spring dynamics in context of the past 20 years, a period marked by rapid change in climatic conditions. Our findings suggest that increased advection of sea ice into the region and warmer surface temperatures led to a rise in meltwater input and stronger near-surface stratification. Over this time period, we identify large-scale spatial correlations in Fram Strait between increased chlorophyll a concentrations and increased freshwater flux from sea ice melt.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany.

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Past, present and future in plastic flap surgery: From surgeon to bioengineer driven progress. A personal view.

By tracking the evolution of flaps in plastic surgery most progress in the beginning has to be credited first by medical professionals during the last centuries by introducing new personal ideas or procedural techniques and second by technical innovations based on bioscientific engineering coupled with public needs and changes in social life as part of the human society. From simply primary wound closure in the very early stages to procedures with donor site morbidity without complete function restoring to most probably sophisticated complete onsite reconstruction without almost any surgeon's help by functional 3D-tissue bioprinting in a large scale bioreactor in the future. By following these major developments from the past to present we will try to get a glimpse of what's maybe next in plastic flap surgery over the following decenniums.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION: There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions. OBJECTIVE: The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications. METHOD: A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis. RESULTS: The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362. CONCLUSIONS: There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial.

BACKGROUND: Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. METHODS/DESIGN: We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods. DISCUSSION: The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives. TRIAL REGISTRATION: German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.

Anatomy, evolution, and clinical aspects of the superextended-intercompartmental-supraretinacular artery perforator flap (SISAP-flap): A proof of concept.

BACKGROUND: Extended soft tissue defects of the fingers-irrespective of their origin-are challenging to treat. In cases of missing amputates or crush injuries, the options are often limited to further amputation, ray resection, or free tissue transplantation. The SISAP-flap was developed to add an extra option to treat finger avulsion injuries or otherwise extended soft tissue finger defects. METHODS: Cadaveric SISAP-flaps were individually dissected, tested for arterial perfusion using red ink and radiopaque dye, and transposed into artificially created same-size defects. After introducing this flap in the clinic, which was partially successful in the first patient, we modified the flap to its definite design. RESULTS: Average cadaver flap size ranges between 11 cm and 22 cm in length, allowing dorsal wrapping of the flap over the fingertip and way back to the palmar metacarpophalangeal-joint. The flap is based on the distal web space perforator, which is commonly used by a dorsal metacarpal artery flap and supercharged using an intercompartmental, supraretinacular artery. Donor sites were closed primarily with little tension. Application of the flap in the clinic resulted in satisfactory functional and esthetic outcomes. CONCLUSION: The SISAP-flap is a new option for the reconstruction of extended finger defects and should be added to the reconstructive surgeon's armamentarium of pedicled flaps, providing relatively short operating times and promising clinical outcomes.

Switch on, switch off: stiction in nanoelectromechanical switches.

We present a theoretical investigation of stiction in nanoscale electromechanical contact switches. We develop a mathematical model to describe the deflection of a cantilever beam in response to both electrostatic and van der Waals forces. Particular focus is given to the question of whether adhesive van der Waals forces cause the cantilever to remain in the 'ON' state even when the electrostatic forces are removed. In contrast to previous studies, our theory accounts for deflections with large slopes (i.e. geometrically nonlinear). We solve the resulting equations numerically to study how a cantilever beam adheres to a rigid electrode: transitions between 'free', 'pinned' and 'clamped' states are shown to be discontinuous and to exhibit significant hysteresis. Our findings are compared to previous results from linearized models and the implications for nanoelectromechanical cantilever switch design are discussed.

The capsaicin 8% patch for neuropathic pain in clinical practice: a retrospective analysis.

OBJECTIVE: To investigate the response of patients with peripheral neuropathic pain (PNP) to capsaicin 8% patch treatment in a clinical setting. DESIGN: Retrospective analysis. SETTING: The Clinic for Pain Therapy and Palliative Medicine at the Medical Centre for the region of Aachen, Germany. SUBJECTS: Patients diagnosed with PNP who attended the clinic for capsaicin 8% patch treatment between January 13, 2010 and February 7, 2011. OUTCOME MEASURES: Pain intensity was assessed using the Numeric Pain Rating Scale (NPRS) at baseline and following each capsaicin 8% patch treatment. Changes in prescribed concomitant neuropathic pain (NP) medications and response duration were recorded. RESULTS: Overall, 68 patients with PNP conditions, including facial neuropathy (severe trigeminal neuralgia in V2), polyneuropathy, post-herpetic neuralgia, and mononeuropathies, received 96 treatments with the capsaicin 8% patch. The 53 patients with a follow-up of ≥8 weeks demonstrated a 48.4% mean reduction in NPRS score from baseline to Weeks 1-8. Among the 37 responders (those exhibiting ≥30% reduction in NPRS score from baseline to Weeks 1-8), the median time to re-treatment was 125 days. Following treatment, there was a significant (P < 0.001) 54% reduction in the mean number of prescribed concomitant NP medications taken by patients. CONCLUSIONS: This analysis demonstrates that in clinical practice, the capsaicin 8% patch provides rapid and sustained pain reductions in patients with a variety of PNP conditions and a significant reduction in prescribed concomitant NP medications. The capsaicin 8% patch can be a valuable addition to the NP treatment armory for certain patients.

The anatomic relationship of dorsal arterial perforators of the distal forearm, wrist, and dorsum of the hand with conclusions for the clinic.

BACKGROUND: Extended soft tissue defects of the fingers are often challenging to treat, and therefore, we performed cadaver dissections to elucidate the anatomic relationship between dorsal arterial perforators of the distal upper extremities to support the development of new local flaps. METHODS: Ten fixated cadaveric distal dorsal lower forearms were dissected to their arterial perforators down to 0.1 mm diameter in size with identification of their relationship. RESULTS: Dorsal distal fascia piercing perforators of the lower forearm come in two distinct rows, radial and ulnar, of the fourth extensor compartment. These were interconnected by subfascial axial arteries in line. The most proximal perforator is usually located 8-10 cm from the dorsal wrist, the most distal about 1-2 cm, and on average, only three subcutaneous bridging vessels connect both axial systems. The number of less reliable subcutaneous arterial connecting vessels between the dorsal wrist and forearm is also fairly limited to only one or two. More constant bridging arteries interconnect at the level of the dorsal retinaculum between the axial systems of the hand and lower forearm. At the level of the dorsum of the hand perforators reaching the skin, they interconnect in an arcuate fashion. This unique distribution pattern could be used for freestyle perforator propellor flaps of the hand, as we demonstrated in a case directly derived from our recent research. CONCLUSION: In our opinion, a super-extended perforator flap should be possible with the inclusion of the bridging arteries in flap design at the level of the dorsal retinaculum.

Floating carpets and the delamination of elastic sheets.

We investigate the deformation of a thin elastic sheet floating on a liquid surface and subject to a uniaxial compression. We show that at a critical compression the sheet delaminates from the liquid over a finite region forming a delamination "blister." This blistering regime adds to the wrinkling and localized folding regimes that have been studied previously. The transition from wrinkled to blistered states occurs when delamination becomes energetically favorable compared with wrinkling. We determine the initial blister size and the evolution of blister size with continuing compression before verifying our theoretical results with experiments at a macroscopic scale.

The capsaicin 8% patch for peripheral neuropathic pain.

Neuropathic pain is thought to affect up to 8% of the adult population in the UK. The condition can severely impact on patients' quality of life and can be difficult to treat. The capsaicin 8% patch has been developed to directly target the source of peripheral neuropathic pain and has been shown to provide pain relief for up to 3 months from a single 30- or 60-minute application. Adherence to the capsaicin 8% patch application procedure is important to achieve effective treatment. The authors are a group of health professionals experienced in using the capsaicin 8% patch. In this article the authors describe the optimal patch application procedure from their real-world clinical experience and provide recommendations on how to optimize the therapeutic benefit of the patch. Other key aspects of the application procedure are also addressed, including the importance of patient management, the ideal treatment setting, the best way to manage application-associated discomfort and post-treatment care. The observations and learning that the authors have gained from their clinical experience with the capsaicin 8% patch will help others to maximize the benefit gained with this novel treatment option.

A Rather Universal Vibrational Resonance in 1:1 Hydrates of Carbonyl Compounds.

When the lower frequency OH stretching fundamental of a water molecule is shifted to the 3500 cm-1 spectral range by the solvation of a carbonyl compound, in this case a ketone, its infrared intensity is shared with a dark state. It is shown by chemical and isotope substitution for more than a dozen systems that the location of this resonance is remarkably substitution-independent. Harmonic and anharmonic model calculations support its assignment to a combination of the water bending overtone and in-plane water libration. This previously unrecognized intramolecular-intermolecular coupling in single solvent water has a strength of 7-10 cm-1. It may have been sporadically observed before in a few other carbonyl compounds such as amides, without any previous exploration of its potential universality. The resulting generic picosecond energy redistribution channel for aqueous solutions may represent a slow counterpart and doorway model of what happens on a subpicosecond time scale when the hydrogen bonds become stronger, such as in carboxylic acid dimers or protonated water clusters.

Development and psychometric characteristics of the Dissociation Tension Scale.

The newly developed Dissoziations-Spannungs-Skala (Dissociation Tension Scale; DSS) is a self-rating instrument for the assessment of psychological and somatoform dissociative features (ranging from normal up to pathological) as well as aversive inner tension occurring within the past 7 days. The DSS contains 21 items assessing dissociative symptoms and 1 additional item assessing aversive inner tension. Ratings are made on a time-oriented scale ranging from 0% (never) to 100% (constantly). We measured the psychometric qualities of the DSS in a total of 294 patients and healthy controls. Internal consistency of the DSS was high (Cronbach's alpha = .92; Gutmann's split-half r = .92). We found good support for convergent, discriminant, and differential validity. There was clear evidence for the DSS being a sensitive instrument for the assessment of changing symptomatology. Assessment of dissociation and other psychopathological features over the same period of time are now possible.

Modeling the breakup of tabular icebergs.

Nearly half of the freshwater flux from the Antarctic Ice Sheet into the Southern Ocean occurs in the form of large tabular icebergs that calve off the continent's ice shelves. However, because of difficulties in adequately simulating their breakup, large Antarctic icebergs to date have either not been represented in models or represented but with no breakup scheme such that they consistently survive too long and travel too far compared with observations. Here, we introduce a representation of iceberg fracturing using a breakup scheme based on the "footloose mechanism." We optimize the parameters of this breakup scheme by forcing the iceberg model with an ocean state estimate and comparing the modeled iceberg trajectories and areas with the Antarctic Iceberg Tracking Database. We show that including large icebergs and a representation of their breakup substantially affects the iceberg meltwater distribution, with implications for the circulation and stratification of the Southern Ocean.

The double-pedicled dorsal-metacarpal-artery (dpDMCA) flap of the hand: a novel DMCA-derived flap.

The dorsal-metacarpal-artery (DMCA) flap in its standard or extended version is considered as the working horse to cover dorsal soft tissue finger defects with exposed extensor tendon or bone. We hereby present a clinical case of an 80-year-old male patient who is right-handed and sustained a soft tissue defect of the proximal dorsal aspect of his left 5th finger and the postoperative outcome employing a modified transposition flap. The double-pedicled DMCA flap (dpDMCA flap) of the hand poses in adequate clinical scenarios a comparably fast and safe solution to cover dorsal finger defects extending just distal to the PIP joint. To the best of our knowledge, this is the first report of a DMCA-based flap with a double pedicle to cover soft tissue defects at the dorsum of the hand. LEVEL OF EVIDENCE: Level V, therapeutic study.

Virtual Incision Pattern Planning using Three-Dimensional Images for Optimization of Syndactyly Surgery.

Syndactyly is a congenital condition characterized by fusion of the fingers. If not treated correctly during infancy, syndactyly may hinder the normal development of hand function. Many surgical techniques have been developed, with the main goal to create a functional hand with the smallest number of operative corrections. Therefore, exact preoperative planning of the reconstructive procedure is essential. An imaging method commonly used for preoperative planning is 3-dimensional (3D) surface imaging. The goal of this study was to implement the use of this technique in hand surgery, by designing a virtual planning tool for a desyndactylization procedure based on 3D hand images. A 3D image of a silicon syndactyly model was made on which the incision pattern was virtually designed. A surgical template of this pattern was printed, placed onto the silicon model and delineated. The accuracy of the transfer from the virtual delineation toward the real delineation was calculated, resulting in a mean difference of 0.82 mm. This first step indicates that by using 3D images, a virtual incision pattern can be created and transferred back onto the patient successfully in an easy and accurate way by using a template. Thereafter, 3D hand images of 3 syndactyly patients were made, and individual virtual incision patterns were created. Each pattern was transferred onto the patient by using a 3D printed template. The resulting incision pattern needed minor modifications by the surgeon before the surgery was performed. Further research and validation are necessary to develop the virtual planning of desyndactylization procedures.

Extended distally based DMCA flap in combination with autologous amputate skin transplantation as a salvage procedure for ring avulsion injury.

A 23-year-old male student presented to our clinic with a traumatic complex ring avulsion of his right dominant index finger. Clinical evaluation revealed a complete distal amputation of the DIP joint with a laceration of the soft tissue at the middle phalanx and a rupture of the FDP-2-tendon far proximally. We hereby present the patient's clinical outcome after reconstruction with a distally based extended DMCA-II flap. To our own knowledge, this is the first report of an extended distally based DMCA flap for coverage of a class IVd ring avulsion injury in combination with autologous amputate skin transplantation. LEVEL OF EVIDENCE: Level V, therapeutic study.

The proximally based long peroneal muscle turnover flap: A novel salvage flap for small to medium-sized defects of the knee.

BACKGROUND AND AIM: Coverage of soft-tissue defects of the knee due to multiple operations, trauma, and infection remains a surgical challenge. Often, these defects are repaired using free tissue transfer. The aim of this study was to find an easy and reliable local method of repair for small to medium-sized defects. The authors describe a new surgical option for tissue coverage using a proximally based long peroneal muscle turnover flap (LPTF) with split-thickness skin graft. METHODS: Proximally based LPTFs were harvested and transposed into same-size created defects in five cadavers. After optimizing this technique, it was clinically used in two patients with defects secondary to total knee replacement revisions. RESULTS: Average cadaver flap size was 4.7 × 15.8 cm allowing reach of all knee joint areas and was based consistently on a sufficient (2-mm-diameter average) proximal arterial branch of the anterior tibial artery. Donor sites were closed without tension. Subsequent application of the flap on two patients resulted in good functional outcome. CONCLUSION: The proximally based LPTF is a new option available in the reconstruction of knee defects and should be added to the reconstructive surgeon's armamentarium of pedicled flaps, providing short operating time and promising clinical outcome.

[Marjolin ulcer; malignant degeneration in a chronic wound]. / Marjolin-ulcus; maligne ontaarding in een chronische wond.

BACKGROUND: A chronic ulcerating wound may turn malignant. The term 'Marjolin ulcer' is used to describe any skin malignancy which develops in an area of chronic ulceration, irritation or inflammation. It is generally a squamous cell carcinoma. CASE DESCRIPTION: A 66-year-old woman was admitted urgently due to pain and signs of infection in wounds on her back which she had had for six to seven years. The patient had sustained wounds to her back as a result of a hot water scalding at the age of two. These wounds had healed and scarred. Pathological examination of three punch biopsies taken from the margins of the largest ulcer indicated a squamous cell carcinoma; a Marjolin ulcer was diagnosed. CONCLUSION: If a patient has chronic skin lesions associated with non-healing ulcers, especially after sustaining burn injuries as a child, pathological examination is indicated. This can allow a potential skin malignancy to be identified and treated at as early a stage as possible.