Enhanced intrapulse difference frequency generation in the mid-infrared by a spectrally dependent polarization state.

We present a technique to optimize the intrapulse difference frequency generation efficiency for mid-infrared generation. The approach employs a multi-order wave plate that is designed to selectively rotate the polarization state of the incoming spectral components on the relevant orthogonal axes for subsequent nonlinear interaction. We demonstrate a significant increase of the mid-infrared average power generated, of a factor ≥2.5 compared with the conventional scheme, owing to an optimally distributed number of photons enrolled in the difference frequency generation process.

Watt-scale 50-MHz source of single-cycle waveform-stable pulses in the molecular fingerprint region.

We report a coherent mid-infrared (MIR) source with a combination of broad spectral coverage (6-18 µm), high repetition rate (50 MHz), and high average power (0.5 W). The waveform-stable pulses emerge via intrapulse difference-frequency generation (IPDFG) in a GaSe crystal, driven by a 30-W-average-power train of 32-fs pulses spectrally centered at 2 µm, delivered by a fiber-laser system. Electro-optic sampling (EOS) of the waveform-stable MIR waveforms reveals their single-cycle nature, confirming the excellent phase matching both of IPDFG and of EOS with 2-µm pulses in GaSe.

Enhancement cavities for few-cycle pulses.

We address the challenge of increasing the bandwidth of high-finesse femtosecond enhancement cavities and demonstrate a broad spectrum spanning 1800 cm-1 (195 nm) at -10 dB around a central wavelength of 1050 nm in an EC with an average finesse exceeding 300. This will benefit a host of spectroscopic applications, including transient absorption spectroscopy, direct frequency comb spectroscopy, and Raman spectroscopy. The pulse circulating in the EC is composed of only 5.4 optical cycles, at a kilowatt-level average power. Together with a suitable gating technique, this paves the way to the efficient generation of multi-megahertz-repetition-rate isolated extreme ultraviolet attosecond pulses via intracavity high-order harmonic generation.

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery.

BACKGROUND: The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. METHODS: We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). RESULTS: A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. CONCLUSIONS: Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.

On central focusing for contrast optimization in direct electron ptychography of thick samples.

Ptychography provides high dose efficiency images that can reveal light elements next to heavy atoms. However, despite ptychography having an otherwise single signed contrast transfer function, contrast reversals can occur when the projected potential becomes strong for both direct and iterative inversion ptychography methods. It has recently been shown that these reversals can often be counteracted in direct ptychography methods by adapting the focus. Here we provide an explanation of why the best contrast is often found with the probe focused to the middle of the sample. The phase contribution due to defocus at each sample slice above and below the central plane in this configuration effectively cancels out, which can prevent contrast reversals when dynamical scattering effects are not overly strong. In addition we show that the convergence angle can be an important consideration for removal of contrast reversals in relatively thin samples.

Comparison of pregnancy characteristics and outcomes between HIV-infected and HIV-non-infected women in Brazil.

The aim of this study is to evaluate the characteristics of pregnant women whether they are HIV infected or not and their prenatal care. It is a cross-sectional study. HIV-infected women were derived from a cohort study of all HIV-infected pregnant women followed from 1995 to 2005, at the Instituto de Puericultura e Pediatria Martagão Gesteira - Rio de Janeiro. HIV-non-infected women were derived from a random sample of all pregnant women who gave birth at Rio de Janeiro municipality between 1999 and 2001. All relevant sociodemographic, clinical, and pregnancy outcomes data were retrieved from both studies. To evaluate the prenatal care, we calculated the Kotelchuck Modified Index (KMI). The index is based on the months of initiation of prenatal care and the proportion of visits observed in each trimester, according to gestational age at birth. Comparisons were performed using Student t- and chi-square tests. Variables with p-value < 0.25 were included in an unconditional logistic regression model. There were 713 HIV-infected women and 2145 HIV-non-infected women. Variables independently associated with HIV status were: inadequate KMI (OR=4.08, 95% CI=3.17-5.24); lower educational level (OR=1.32, 95% CI=1.04-1.68); does not live with a partner (OR=3.54, 95% CI=2.66-4.64); lower family income (OR=4.71, 95% CI=3.62-6.14); tobacco use (OR=2.17, 95% CI=1.63-2.88); and hypertension (OR=1.47, 95% CI=1.01-2.17). Prematurity was not independently associated with HIV status. Although in Brazil, the HIV care is free of charge, pregnant women are still having difficulty to reach the specialized care. Better access to care must be offered to this population and studies of prematurity in the HIV-infected women must evaluate their prenatal care.

Performance of a new pulse contour method for continuous cardiac output monitoring: validation in critically ill patients.

BACKGROUND: A new calibrated pulse wave analysis method (VolumeView™/EV1000™, Edwards Lifesciences, Irvine, CA, USA) has been developed to continuously monitor cardiac output (CO). The aim of this study was to compare the performance of the VolumeView method, and of the PiCCO2™ pulse contour method (Pulsion Medical Systems, Munich, Germany), with reference transpulmonary thermodilution (TPTD) CO measurements. METHODS: This was a prospective, multicentre observational study performed in the surgical and interdisciplinary intensive care units of four tertiary hospitals. Seventy-two critically ill patients were monitored with a central venous catheter, and a thermistor-tipped femoral arterial VolumeView™ catheter connected to the EV1000™ monitor. After initial calibration by TPTD CO was continuously assessed using the VolumeView-CCO software (CCO(VolumeView)) during a 72 h period. TPTD was performed in order to obtain reference CO values (COREF). TPTD and arterial wave signals were transmitted to a PiCCO2™ monitor in order to obtain CCO(PiCCO) values. CCO(VolumeView) and CCO(PiCCO) were recorded over a 5 min interval before assessment of CO(TPTD). Bland-Altman analysis, %(errors), and concordance (trend analysis) were calculated. RESULTS: A total of 338 matched sets of data were available for comparison. Bias for CCO(VolumeView)-CO(REF) was -0.07 litre min(-1) and for CCO(PiCCO)-CO(REF) +0.03 litre min(-1). Corresponding limits of agreement were 2.00 and 2.48 litre min(-1) (P<0.01), %(errors) 29 and 37%, respectively. Trending capabilities were comparable for both techniques. CONCLUSIONS: The performance of the new VolumeView™-CCO method is as reliable as the PiCCO2™-CCO pulse wave analysis in critically ill patients. However, an improved precision was observed with the VolumeView™ technique. CLINICALTRIALS.GOV IDENTIFIER: NCT01405040.

[Principles of perioperative coagulation management]. / Prinzipien des perioperativen Gerinnungsmanagements.

The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.

Event driven 4D STEM acquisition with a Timepix3 detector: Microsecond dwell time and faster scans for high precision and low dose applications.

Four dimensional scanning transmission electron microscopy (4D STEM) records the scattering of electrons in a material in great detail. The benefits offered by 4D STEM are substantial, with the wealth of data it provides facilitating for instance high precision, high electron dose efficiency phase imaging via centre of mass or ptychography based analysis. However the requirement for a 2D image of the scattering to be recorded at each probe position has long placed a severe bottleneck on the speed at which 4D STEM can be performed. Recent advances in camera technology have greatly reduced this bottleneck, with the detection efficiency of direct electron detectors being especially well suited to the technique. However even the fastest frame driven pixelated detectors still significantly limit the scan speed which can be used in 4D STEM, making the resulting data susceptible to drift and hampering its use for low dose beam sensitive applications. Here we report the development of the use of an event driven Timepix3 direct electron camera that allows us to overcome this bottleneck and achieve 4D STEM dwell times down to 100 ns; orders of magnitude faster than what has been possible with frame based readout. We characterize the detector for different acceleration voltages and show that the method is especially well suited for low dose imaging and promises rich datasets without compromising dwell time when compared to conventional STEM imaging.

Pregnancy outcome in women infected with HIV-1 receiving combination antiretroviral therapy before versus after conception.

OBJECTIVE: The potential adverse effects of antiretroviral drugs during pregnancy are discrepant and few studies, mostly from Europe, have provided information about pregnancy outcomes of those already on treatment at conception. The aim of this study was to investigate the impact of antiretrovirals (ARVs) on pregnancy outcome according to the timing of treatment initiation in a cohort of pregnant women from Brazil infected with HIV. METHODS: A prospective cohort of 696 pregnant women followed up in one single centre between 1996 and 2006 was studied. Patients who had ARV treatment before pregnancy were compared with those treated after the first trimester. The outcomes evaluated were preterm delivery (PTD) (<37 weeks), severe PTD (<34 weeks), low birth weight (LBW) (<2500 g) and very LBW (<1500 g). RESULTS: Patients who were using ARVs pre-conception had higher rates of LBW (33.3% vs 16.5%; p<0.001) and a similar trend for PTD (26.3% vs 17.7%; p = 0.09). Stratification by type of therapy (dual vs highly active antiretroviral therapy (HAART)) according to timing of initiation of ARVs showed that patients who use HAART pre-conception have a higher rate of PTD (20.2% vs 10.2%; p = 0.03) and LBW (24.2% vs 10.2%; p = 0.002). After adjusting for several factors, HAART used pre-conception was associated with an increased risk for PTD (AOR 5.0; 95% CI 1.5 to 17.0; p = 0.009) and LBW (OR 3.6; 95% CI 1.7 to 7.7; p = 0.001). CONCLUSIONS: We identified an increased risk for LBW and PTD in patients who had HAART prior to pregnancy.

Structural determinants of the interaction between influenza A virus matrix protein M1 and lipid membranes.

Influenza A virus is a pathogen responsible for severe seasonal epidemics threatening human and animal populations every year. One of the ten major proteins encoded by the viral genome, the matrix protein M1, is abundantly produced in infected cells and plays a structural role in determining the morphology of the virus. During assembly of new viral particles, M1 is recruited to the host cell membrane where it associates with lipids and other viral proteins. The structure of M1 is only partially known. In particular, structural details of M1 interactions with the cellular plasma membrane as well as M1-protein interactions and multimerization have not been clarified, yet. In this work, we employed a set of complementary experimental and theoretical tools to tackle these issues. Using raster image correlation, surface plasmon resonance and circular dichroism spectroscopies, we quantified membrane association and oligomerization of full-length M1 and of different genetically engineered M1 constructs (i.e., N- and C-terminally truncated constructs and a mutant of the polybasic region, residues 95-105). Furthermore, we report novel information on structural changes in M1 occurring upon binding to membranes. Our experimental results are corroborated by an all-atom model of the full-length M1 protein bound to a negatively charged lipid bilayer.

Long-term implant of intramuscular sensors and nerve transfers for wireless control of robotic arms in above-elbow amputees.

Targeted muscle reinnervation (TMR) amplifies the electrical activity of nerves at the stump of amputees by redirecting them in remnant muscles above the amputation. The electrical activity of the reinnervated muscles can be used to extract natural control signals. Nonetheless, current control systems, mainly based on noninvasive muscle recordings, fail to provide accurate and reliable control over time. This is one of the major reasons for prosthetic abandonment. This prospective interventional study includes three unilateral above-elbow amputees and reports the long-term (2.5 years) implant of wireless myoelectric sensors in the reinnervation sites after TMR and their use for control of robotic arms in daily life. It therefore demonstrates the clinical viability of chronically implanted myoelectric interfaces that amplify nerve activity through TMR. The patients showed substantial functional improvements using the implanted system compared with control based on surface electrodes. The combination of TMR and chronically implanted sensors may drastically improve robotic limb replacement in above-elbow amputees.

Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil.

The objective of this study was to describe the adherence to antiretroviral therapy (ART) among adolescents followed-up in Rio de Janeiro. This cross-sectional study included all adolescents (aged 10-19 years) followed at Instituto de Puericultura e Pediatria Martagão Gesteira and Hospital Universitário Clementino Fraga Filho. Adherence was determined by self-report (number of missed ART doses in three days prior to the interview). Adherence was categorized as taking > or = 95% of the ARTs (adherent), or < 95% (non-adherent). Variables related to demographics and treatment were evaluated and if P value < or = 0.15, they were selected for a logistic regression analysis. One hundred and one adolescents were interviewed. The mean time on ART was 91 months and the mean adherence was 94% of this, 21 were non-adherent, and 80 adherent. The risk factors associated with non-adherence were: if the patient was not concerned about ART, odds ratio (OR) = 3.47 (95% confidence interval [CI] = 1.13-10.68); if they do not carry an extra dose of ART, OR = 6.63 (95% CI = 1.73-25.47); if a health-care worker taught them how to take ART, OR = 0.27 (95% CI = 0.08-0.93). Adherence among adolescents was higher than expected. Factors associated with lack of adherence were: interviewees being unaware of ARTs and lack of commitment to the treatment. Interventions involving these factors must be evaluated.

A novel mechanotronic orthosis enables symmetrical gait kinematics in a patient with a femoral nerve palsy - a case study.

The usage of stance- and swing-phase control orthoses (SSCOs) is a good option in patients with neuromuscular insufficiency of the quadriceps muscle in a broad range of musculo-skeletal disorders. The subjective sensation of improved mobility in daily life and walking comfort could be objectively confirmed by the ability to walk without crutches and by harmonization of the gait patterns in hip and knee. They could also be a considered mobility device after limb salvage surgery, which may even have an impact on preoperative decision making. IMPLICATIONS FOR REHABILITATION Symmetric gate in spite of femoral nerve palsy. Early gate improvements even after hours. High patient?s motivation to use the device.

Quality of hand hygiene in a pediatric hospital in Rio de Janeiro, Brazil.

We assessed the quality of hand hygiene among healthcare workers at a pediatrics hospital in Rio de Janeiro, Brazil. Hand hygiene was performed in 491 (34%) of 1,455 opportunities. Of these hand hygiene events, correct performance was observed in only 173 (35%). Multivariate analysis revealed that correct performance of hand hygiene was associated with the use of an alcohol-based product and a lack of jewelry (for all events) and employment in an infirmary with a comparatively higher ratio of nurses to patients (for events involving nurses).

Risk factors for udder edema and its association with lactation performance on primiparous Holstein cows in a large Florida herd, U.S.A.

The objective of this study was to determine risk factors for udder edema (case-control study) and to evaluate the association of udder edema in primiparous Holstein cows with their lactation performance (cohort study). Values for the first 10 test day for milk yield, fat, protein, and somatic cell counts (SCC) linear score as well as mature equivalent (ME) 305 days milk yield, fat, protein, SCC linear score, and incidences of periparturient diseases from a computerized farm recording system were compared between primiparous cows with and without udder edema. Data consisted of 118 dairy heifers with udder edema, induced for parturition, and treated with diuretics and 889 control heifers that received no treatment. Primiparous cows giving birth to male calves, were 1.72 (1.01, 3.24; 95% CI) times more likely to develop udder edema than cows giving birth to female calves. Primiparous cows calving in winter season were 3.68 (1.09, 12.5; 95% CI) times more likely to develop udder edema than cows calving in summer. For each extra 10cm in height the odds of udder edemas was 1.23 (1.03, 1.47; 95% CI). The first test day DHIA milk yield was lower in cows that developed udder edema (3.6kg/day) than in normal cows. However, the subsequent test days and ME measurements were not statistically different between groups. Cows with udder edema were 1.62 (1.18, 2.14; 95% CI) times more likely to develop udder edema in the second lactation than control animals. It is concluded that the gender of the offspring, calving season and height at parturition were significant risk factors for udder edema. Only milk yield on the first DHIA test day was lower in cows with udder edema than in cows without udder edema.

Impairment of cellular redox status and membrane protein activities in kidneys from rats with ischemic acute renal failure.

Cellular redox status and membrane protein activities were analyzed in kidneys from rats with ischemic acute renal failure (ARF). ARF was induced by clamping the left renal artery for 50 min. A parallel group of control animals was processed. In the ischemic group urea plasma levels were statistically increased as compared with the control group. Studies employing whole kidney homogenates revealed that ischemia produces an increment in lipid peroxidation levels and a reduction in glutathione concentration and in superoxide dismutase and glutathione peroxidase activities. Since lipid peroxidation may alter the function of membrane proteins we determined succinate cytochrome c reductase (SuccR), sodium-potassium ATPase (Na-K-ATPase), glucose-6-phosphatase (G-6-Pase) and alkaline phosphatase (ALP) activities in whole renal homogenates. Only G-6-Pase and ALP activities were modified by ischemia. Since ALP is a brush border membrane (BBM) enzyme and BBM is one of the main target structures in ARF, we assessed some parameters of BBM functionality. ALP, gamma-glutamyl transferase (gamma-GT) and 5'-nucleotidase (5'-NT) showed diminished activities in BBM from ischemic kidneys. Ischemia also modified the Vmax of paraaminohippuric acid (PAH) uptake without altering Km. An increment of lipid peroxidation and membrane fluidity in BBM was observed after the treatment. Total membrane proteins and protein recoveries in BBM were similar in both experimental groups. Sialic acid and sulfhydryl levels were similar in BBM from ischemic kidney and control ones. In summary, ARF induced by renal artery clamping for 50 min takes place with a significant increase in urea plasma levels. A decrease in the antioxidant defense system is detected. This induces lipid peroxidation in whole renal tissue, which may justify the diminished activities of some membrane enzymes such as G-6-Pase and ALP. A specific analysis of BBM function reveals a significant increment of lipid peroxidation which may be the cause of an increased membrane fluidity. This latter parameter might be, at least in part, responsible for the damaged function of apical ALP, 5'-NT, gamma-GT and PAH carrier.

Influence of body core temperature on blood loss and transfusion requirements during off-pump coronary artery bypass grafting: a comparison of 3 warming systems.

BACKGROUND: The aim of this prospective randomized trial was to evaluate the efficacy of 3 intraoperative warming systems (Warm-Touch, Thermamed SmartCare OP system, and Allon 2001) on maintenance of normothermia and to investigate their effects on perioperative bleeding and transfusion requirements in patients undergoing off-pump coronary artery bypass grafting. METHODS: With institutional approval/patient informed consent, 90 patients presenting for elective multiple off-pump coronary artery bypass grafting were randomly assigned to 1 of the 3 warming systems. Active warming was started after the induction of anesthesia. Perioperative transfusion was based on international guidelines. Body core temperature was recorded every 30 minutes during operation. Perioperative blood loss, autotransfusion, and allogenic transfusions were recorded. Analysis of variance was performed with post hoc Scheffé tests and chi 2 tests. RESULTS: Normothermia could be sufficiently maintained during operation by the Allon 2001 only. Final body core temperature was 34.7 degrees C +/- 0.9 degrees C (Warm-Touch), 35.6 degrees C +/- 0.8 degrees C (Thermamed SmartCare OP), and 36.5 degrees C +/- 0.4 degrees C (Allon 2001; P < .001, Warm-Touch vs Thermamed SmartCare OP, Warm-Touch vs Allon 2001, and Thermamed SmartCare OP vs Allon 2001). Perioperative blood loss was 2683 +/- 1049 mL (Warm-Touch), 2300 +/- 788 mL (Thermamed SmartCare OP), and 1497 +/- 497 mL (Allon 2001; P = .195, Warm-Touch vs Thermamed SmartCare OP; P < .001, Warm-Touch vs Allon 2001; P = .001, Thermamed SmartCare OP vs Allon 2001). Transfusion requirements were 1097 +/- 874 mL (Warm-Touch), 986 +/- 744 mL (Thermamed SmartCare OP), and 431 +/- 387 mL (Allon 2001; P = .838, Warm-Touch vs Thermamed SmartCare OP; P = .003, Warm-Touch vs Allon 2001; P = .013, Thermamed SmartCare OP vs Allon 2001). Free of allogenic transfusion were 15 (51.7%; Warm-Touch), 18 (60%; Thermamed SmartCare OP), and 24 (82.8%; Allon 2001) patients ( P = .037). CONCLUSIONS: The goal of normothermia during off-pump coronary artery bypass grafting was best achieved by the Allon system. With this concept, overall blood loss and transfusion requirements were reduced, hence indicating improved quality of perioperative care.

Off-pump coronary artery bypass grafting: the Zurich experience.

Coronary artery bypass grafting (CABG) is the surgical procedure of choice for treatment of multi-vessel coronary artery disease. The rising risk profile of the patients requiring isolated CABG and the economic pressure have prompted us to devise new operative strategies to treat these patients. Elimination of the cardiopulmonary bypass is one possible answer to the dilemma of maintaining the quality of care and reducing the exploding costs of our health system. Therefore, we developed the off-pump coronary artery bypass grafting (OPCAB) for patients requiring isolated CABG. In our experience the key to successful OPCAB relies on the order of revascularization of the myocardial walls (anterior, inferior, lateral), use of intracoronary shunt, no-touch technique for the proximal aortic anastomosis with heart string â (Guidant, IN, USA), close collaboration with the anesthesiologists, early and aggressive administration of anti-platelet therapy, endoscopic vein harvest by perfusionists, and improved body temperature control. Following these concepts, we have been able to offer the OPCAB procedure to over 90% of our patients and to reduce perioperative morbidity and global costs.

Stable dispersions of azide functionalized ferromagnetic metal nanoparticles.

Ferromagnetic nanoparticles are covalently modified in order to enhance the dispersion stability as well as the antifouling properties. Insertion of an azide moiety allows "click"-reaction of a relevant tag molecule. This and the high saturation magnetization of the presented nanocomposite offer a promising platform for magnetic biosensors.