Discovery of ultrafast spontaneous spin switching in an antiferromagnet by femtosecond noise correlation spectroscopy.

Owing to their high magnon frequencies, antiferromagnets are key materials for future high-speed spintronics. Picosecond switching of antiferromagnetic spin systems has been viewed a milestone for decades and pursued only by using ultrafast external perturbations. Here, we show that picosecond spin switching occurs spontaneously due to thermal fluctuations in the antiferromagnetic orthoferrite Sm0.7Er0.3FeO3. By analysing the correlation between the pulse-to-pulse polarisation fluctuations of two femtosecond optical probes, we extract the autocorrelation of incoherent magnon fluctuations. We observe a strong enhancement of the magnon fluctuation amplitude and the coherence time around the critical temperature of the spin reorientation transition. The spectrum shows two distinct features, one corresponding to the quasi-ferromagnetic mode and another one which has not been previously reported in pump-probe experiments. Comparison to a stochastic spin dynamics simulation reveals this new mode as smoking gun of ultrafast spontaneous spin switching within the double-well anisotropy potential.

Study protocol of a cluster-randomised controlled trial assessing a multimodal machine-based exercise training programme in senior care facilities over 6 months - the bestform study (best function of range of motion).

BACKGROUND: Physical functioning is a crucial factor for independence and quality of life in old age. The aim of the "bestform-Best function of range of motion" trial is to investigate the effects of a 6 months multimodal machine-based strength, coordination and endurance training on physical function, risk of falls and health parameters in older adults. METHODS: Bestform is a cluster-randomised trial including older adults ≥ 65 years living in senior care facilities in Southern Germany. Senior care facilities are randomly allocated to the control group with usual care (n ≥ 10 care facilities) and to the intervention group (n ≥ 10 care facilities), overall including ≥ 400 seniors. Residents belonging to the intervention group are offered a supervised machine-based exercise training programme twice weekly over 45-60 min over six months in small groups, while those in the usual care facilities will not receive active intervention. The primary outcome is the change in Short Physical Performance Battery over six months between groups. Secondary outcomes are change in risk of falling, fear of falling, number of falls and fall-related injuries, physical exercise capacity, handgrip strength, body composition, cardiac function, blood parameters, quality of life, risk of sarcopenia, activities of daily living, and cognition over three and six months. DISCUSSION: The bestform study investigates the change in physical function between seniors performing exercise intervention versus usual care over six months. The results of the study will contribute to the development of effective physical activity concepts in senior care facilities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04207307. Registered December 2019.

Healthcare utilization and unmet needs of patients with antisynthetase syndrome: An international patient survey.

Antisynthease syndrome (ASSD) is a rare, complex and understudied autoimmune disease. Internet-based studies can overcome barriers of traditional on-site research and are therefore very appealing for rare diseases. The aim of this study was to investigate patient-reported symptoms, diagnostic delay, symptoms, medical care, health status, working status, disease knowledge and willingness to participate in research of ASSD patients by conducting an international web-based survey. The multilingual questionnaire was created by an international group of rheumatologists and patients and distributed online. 236 participants from 22 countries completed the survey. 184/236 (78.0%) were female, mean age (SD) was 49.6 years (11.3) and most common antisynthetase antibody was Jo-1 (169/236, 71.6%). 79/236 (33.5%) reported to work full-time. Median diagnostic delay was one year. The most common symptom at disease onset was fatigue 159/236 (67.4%), followed by myalgia 130/236 (55.1%). The complete triad of myositis, arthritis and lung involvement verified by a clinician was present in 42/236 (17.8%) at disease onset and in 88/236 (37.3%) during the disease course. 36/236 (15.3%) reported to have been diagnosed with fibromyalgia and 40/236 (16.3%) with depression. The most reported immunosuppressive treatments were oral corticosteroids 179/236 (75.9%), followed by rituximab 85/236 (36.0%). 73/236 (30.9%) had received physiotherapy treatment. 71/236 (30.1%) reported to know useful online information sources related to ASSD. 223/236 (94.5%) were willing to share health data for research purposes once a year. Our results reiterate that internet-based research is invaluable for cooperating with patients to foster knowledge in rare diseases.

The JAK1/2 inhibitor ruxolitinib in patients with COVID-19 triggered hyperinflammation: the RuxCoFlam trial.

Dysregulated hyperinflammatory response is key in the pathogenesis in patients with severe COVID-19 leading to acute respiratory distress syndrome and multiorgan failure. Whilst immunosuppression has been proven to be effective, potential biological targets and optimal timing of treatment are still conflicting. We sought to evaluate efficacy and safety of the Janus Kinase 1/2 inhibitor ruxolitinib, employing the previously developed COVID-19 Inflammation Score (CIS) in a prospective multicenter open label phase II trial (NCT04338958). Primary objective was reversal of hyperinflammation (CIS reduction of ≥25% at day 7 in ≥20% of patients). In 184 patients with a CIS of ≥10 (median 12) ruxolitinib was commenced at an initial dose of 10 mg twice daily and applied over a median of 14 days (range, 2-31). On day 7, median CIS declined to 6 (range, 1-13); 71% of patients (CI 64-77%) achieved a ≥25% CIS reduction accompanied by a reduction of markers of inflammation. Median cumulative dose was 272.5 mg/d. Treatment was well tolerated without any grade 3-5 adverse events related to ruxolitinib. Forty-four patients (23.9%) died, all without reported association to study drug. In conclusion, ruxolitinib proved to be safe and effective in a cohort of COVID-19 patients with defined hyperinflammation.

Ramsey Spectroscopy of the 2S_{1/2} Hyperfine Interval in Atomic Hydrogen.

The 2S_{1/2} hyperfine interval in atomic hydrogen was measured using Ramsey spectroscopy with a thermal beam cooled to cryogenic temperatures. The measured value is 177 556 838.87(85) Hz, which represents the most precise determination of this interval to date. The 1S_{1/2} hyperfine interval f(1S_{1/2}) and the 2S_{1/2} hyperfine interval f(2S_{1/2}) can be combined to give the quantity D_{21}=8f(2S_{1/2})-f(1S_{1/2}), which mostly eliminates uncertainty due to nuclear structure effects and is well described by bound-state quantum electrodynamics. Using the value of f(2S_{1/2}) from this work gives a value of D_{21}^{expt}=48 959.2(6.8) Hz, which is in agreement with the theoretical value of D_{21}^{Theory}=48 954.1(2.3) Hz.

Non-surgical external jugular vein catheterization using an ear vein access in piglets.

The objective of this study was to investigate the feasibility of external jugular vein catheterization through an ear vein in piglets. Forty-six sevoflurane-midazolam anaesthetized piglets were included. External jugular vein catheterization was conducted through the ear vein using the Seldinger technique. Part 1 (n = 27): optimal puncture site was based on the deltoid tuberosity as a landmark to reach the external jugular vein. The final position of the catheter was verified in 25 piglets using computer tomography. Catheterization time was recorded and patency of the catheter assessed by repeated blood sampling for up to 4 h. Part 2 (n = 19): ear vein catheterization was without taking into account any landmarks. Functionality for blood sampling was evaluated as described in part 1. Catheter advancement was possible in 25/27 and 18/19 piglets in parts 1 and 2, respectively. Median (range) time required for successful catheterization was 1.95 (1-10) min (n = 38). The deltoid tuberosity was a good landmark to reach the external jugular vein. But blood sampling was also possible through catheters ending slightly cranial to the external jugular vein. Despite successful catheter advancement, blood sampling was not possible from one catheter in each part of the study (total: two piglets). One of these catheters presented luminal damage, while the other one presented as normal after being removed from the animal. Summarizing, central vein catheterization through the ear vein was feasible in 93.5% and repeated blood sampling was possible in 89.1% of the piglets (n = 46).

End-of-life practices in 11 German intensive care units : Results from the ETHICUS-2 study.

BACKGROUND: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. OBJECTIVES: To study the practice of end-of-life care. METHODS: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus­2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. RESULTS: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). CONCLUSIONS: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

A meta-analysis on the effects of incarceration-based opioid substitution treatment.

Objective: Opioid substitution treatment (OST) is a common treatment for individuals who use opioids; however, empirical evidence on the effects of OST during incarceration is scarce. Our aim was to conduct a meta-analysis on the effects of incarceration-based OST on substance use, treatment engagement post-release and re-incarceration. Method: We searched for studies on individuals who were incarcerated and treated with OST, compared to a comparison group. Studies were only included if they reported data post-release. Results: N = 15 studies met the inclusion criteria. We found less opioid use, less other drug use, higher treatment engagement post-release and less re-incarceration among treated individuals compared to the comparison group. Moderator analyses showed some influence of length of follow-up period and study quality. Conclusions: Incarceration-based OST reduces drug use, re-incarceration and leads to higher treatment engagement after release. More research is needed on the effects of incarceration-based OST on secondary outcomes (e.g. health and social integration) and on factors that moderate these effects.

Estimated Impact of Deemed Consent Legislation for Organ Donation on Individuals With Kidney Failure: A Dynamic Decision Analytic Model.

Background: There is little data modeling the impact of deemed consent legislation (eligible individuals who do not register their decision to decline to be a donor are presumed to consent after death) on outcomes for individuals with kidney failure. Objective: To estimate the change in life-years (LYs) and quality-adjusted life-years (QALYs) resulting from different changes in the rate of deceased donor kidney transplantation associated with deemed consent legislation and health system transformation. Design: Dynamic Decision Analytic Model. Setting: This modeling study included kidney failure patients in Atlantic Canada (all of whom receive their kidney transplants in Halifax, Nova Scotia). The adoption of deemed consent legislation was the intervention, and opt-in (the status quo) was the reference comparator. Patients: Prevalent kidney failure patients at the end of 2019 in all of Atlantic Canada (N = 3615) served as the starting population. Methods: We compared expected outcomes between the intervention and comparator. Changes in QALYs and total LYs were modeled under different changes to the proportion of patients receiving a deceased donor kidney transplant (from -10% to 20%) resulting from deemed consent relative to the status quo. Changes in QALYs and LYs were reported for 3 different time horizons (5, 10, and 30 years). Uncertainty around QALYs and total LYs was reported using 95% confidence intervals (CIs) constructed from a probabilistic sensitivity analysis using 1000 Monte Carlo Simulations. Results: The increase in QALYs ranged from 7 QALYs (95% CI: 5-10) with a 5% increase using a 5-year time frame to 882 QALYs (95% CI: 619-1144) with a 20% increase over a 30-year time frame. Parallel changes in total LYs were also observed. In contrast, decreases in deceased donor kidney transplantation resulted in a loss of QALYs (for example, -463 QALYs; 95% CI: -633 to -306 for a 10% decrease over a 30-year time frame). Using the most optimistic scenario (a 20% increase), there was an 18% increase in the cumulative number of deceased donor kidney transplant recipients over a 30-year observation period. Limitations: The results are subject to uncertainty depending on changes to the dialysis or transplant population that were not modeled and that may not be fully captured with probabilistic sensitivity analysis. Conclusions: Deemed consent legislation will lead to variable changes in QALYs and total LYs for the kidney failure population, depending on the degree to which deceased donor transplantation rates change and the time horizon of observation. This modeling study may serve as a baseline to monitor the future impact of deemed consent legislation.

Contexte: Il existe peu de données modélisant l'impact d'une loi sur le consentement présumé (les personnes admissibles qui n'enregistrent pas leur décision de refuser d'être un donneur sont présumées consentir après leur décès) sur les résultats des personnes atteintes d'insuffisance rénale. Objectif: Estimer les variations dans les années de vie (AV) et les années de vie corrigées en fonction de leur qualité (AVCQ) résultant de changements dans les taux de transplantation rénale provenant d'un donneur décédé; changements qui seraient associés à la loi sur le consentement présumé et à la transformation du système de santé. Conception: Modèle dynamique d'analyse décisionnelle. Cadre: L'étude a été modélisée avec des patients du Canada atlantique atteints d'insuffisance rénale terminale (tous avaient reçu leur greffe de rein à Halifax, en Nouvelle-Écosse). L'intervention consistait en l'adoption d'une loi sur le consentement présumé, alors que le statu quo représentait le comparateur de référence. Sujets: La population de départ était constituée des patients atteints d'insuffisance rénale terminale à la fin de 2019 dans l'ensemble du Canada atlantique (N=3615). Méthodologie: Nous avons comparé les résultats attendus pour l'intervention et le comparateur. Les variations dans les AVCQ et les AV totales ont été modélisées en fonction de divers changements résultant du consentement présumé par rapport au statu quo dans la proportion de patients recevant une transplantation rénale d'un donneur décédé (de -10 à 20 %). Les variations dans les AVCQ et les AV ont été rapportées pour trois horizons temporels (5, 10 et 30 ans). L'incertitude entourant les AVCQ et les années de vie totales a été rapportée avec des intervalles de confiance à 95 % établis à partir d'une analyse de sensibilité probabiliste réalisée par la méthode de Monte Carlo. Résultats: En ce qui concerne les AVCQ, la variation passait de 7 AVCQ (IC 95 % : 5, 10), avec une augmentation de 5 % sur une période de 5 ans, à 882 AVCQ (IC 95 % : 619, 1 144) avec une augmentation de 20 % sur une période de 30 ans. Des variations parallèles ont été observées pour les AV totales. En revanche, la diminution du taux de transplantations rénales provenant d'un donneur décédé a entraîné une perte d'AVCQ (par ex. - 463 AVQ; IC à 95 % : -633, -306 pour une diminution de 10 % sur une période de 30 ans). Dans le scénario le plus optimiste (augmentation de 20 %), on a observé une augmentation de 18 % du nombre cumulatif de transplantations rénales provenant de donneurs décédés au cours d'une période d'observation de 30 ans. Limites: Les résultats sont sujets à des incertitudes en fonction de variations dans la population de patients sous dialyse ou greffés qui n'auraient pas été modélisées et qui pourraient ne pas être entièrement prises en compte par une analyse de sensibilité probabiliste. Conclusion: La loi sur le consentement présumé entraînera des changements variables dans les AV totales et les AVCQ des patients atteints d'insuffisance rénale terminale, selon le degré d'évolution des taux de transplantation provenant de donneurs décédés et de l'horizon d'observation. Cette étude de modélisation peut servir de référence pour surveiller les impacts futurs d'une loi sur le consentement présumé.

High throughput screen of small molecules as potential countermeasures to galactic cosmic radiation induced cellular dysfunction.

Space travel increases galactic cosmic ray exposure to flight crews and this is significantly elevated once travel moves beyond low Earth orbit. This includes combinations of high energy protons and heavy ions such as 56Fe or 16O. There are distinct differences in the biological response to low-energy transfer (x-rays) or high-energy transfer (High-LET). However, given the relatively low fluence rate of exposure during flight operations, it might be possible to manage these deleterious effects using small molecules currently available. Virtually all reports to date examining small molecule management of radiation exposure are based on low-LET challenges. To that end an FDA approved drug library (725 drugs) was used to perform a high throughput screen of cultured cells following exposure to galactic cosmic radiation. The H9c2 myoblasts, ES-D3 pluripotent cells, and Hy926 endothelial cell lines were exposed to a single exposure (75 cGy) using the 5-ion GCRsim protocol developed at the NASA Space Radiation Laboratory (NSRL). Following GCR exposure cells were maintained for up to two weeks. For each drug (@10µM), a hierarchical cumulative score was developed incorporating measures of mitochondrial and cellular function, oxidant stress and cell senescence. The top 160 scores were retested following a similar protocol using 1µM of each drug. Within the 160 drugs, 33 are considered to have an anti-inflammatory capacity, while others also indirectly suppressed pro-inflammatory pathways or had noted antioxidant capacity. Lead candidates came from different drug classes that included angiotensin converting enzyme inhibitors or AT1 antagonists, COX2 inhibitors, as well as drugs mediated by histamine receptors. Surprisingly, different classes of anti-diabetic medications were observed to be useful including sulfonylureas and metformin. Using a hierarchical decision structure, we have identified several lead candidates. That no one drug or even drug class was completely successful across all parameters tested suggests the complexity of managing the consequences of galactic cosmic radiation exposure.

The Impact of Tax Refund Delays on the Experience of Hardship Among Lower-Income Households.

The Earned Income Tax Credit (EITC) provides substantial financial support to low-income workers in the USA, yet around a quarter of EITC payments are estimated to be erroneous or fraudulent. Beginning in 2017, the Protecting Americans from Tax Hikes Act of 2015 requires the Internal Revenue Service to spend additional time processing early EITC claims, delaying the issuance of tax refunds. Leveraging unique data, this paper investigates how delayed tax refunds affected the experience of hardship and unsecured debt among EITC recipients. Results indicate that early filers experienced increased food insecurity relative to later filers after the implementation of the refund delay.

Progressive machine-based resistance training for prevention and treatment of sarcopenia in the oldest old: A systematic review and meta-analysis.

The muscle disease sarcopenia, which is characterised by a loss of muscle strength, muscle quantity, and physical performance, restricts mobility and independence in an ageing society. The aim of this systematic review and meta-analysis is to analyse the effects that long-term progressive resistance training interventions performed on weight machines have on sarcopenia (European Working Group on Sarcopenia in Older People) and how the interventions are composed. In total, 779 articles published between 2000 and 2020 were scanned (PubMed, Web of Science, CINAHL) and 14 randomised controlled trials were included within the review. Populations, interventions, control groups and outcomes were analysed. Subsequent meta-analysis (10 studies, 902 participants) revealed that the time needed in a chair-stand-test, as an indicator for leg strength, was predominantly reduced, whereas grip strength remained unchanged after the interventions. Data concerning the effects of machine-based progressive resistance training on muscle quantity were insufficient for meta-analysis. Physical performance measured by undergoing the Timed-Up-and-Go-test, gait speed test, Short Physical Performance Battery and 6 min-walk-test improved significantly as well. The quality of evidence (GRADE) in the analysed studies was low or moderate. In summary, machine-based progressive resistance training has the potential to reverse sarcopenia in the oldest old, as reflected by enhanced muscle strength and physical performance. The systematic review revealed promising initial results for muscle quantity.

Adaptive response of a metal-organic framework through reversible disorder-disorder transitions.

The ultrahigh porosity and varied functionalities of porous metal-organic frameworks make them excellent candidates for applications that range widely from gas storage and separation to catalysis and sensing. An interesting feature of some frameworks is the ability to open their pores to a specific guest, enabling highly selective separation. A prerequisite for this is bistability of the host structure, which enables the framework to breathe, that is, to switch between two stability minima in response to its environment. Here we describe a porous framework DUT-8(Ni)-which consists of nickel paddle wheel clusters and carboxylate linkers-that adopts a configurationally degenerate family of disordered states in the presence of specific guests. This disorder originates from the nonlinear linkers arranging the clusters in closed loops of different local symmetries that in turn propagate as complex tilings. Solvent exchange stimulates the formation of distinct disordered frameworks, as demonstrated by high-resolution transmission electron microscopy and diffraction techniques. Guest exchange was shown to stimulate repeatable switching transitions between distinct disorder states.

Amygdala and Insula Connectivity Changes Following Psychotherapy for Posttraumatic Stress Disorder: A Randomized Clinical Trial.

BACKGROUND: Exposure-based psychotherapy is a first-line treatment for posttraumatic stress disorder (PTSD), but its mechanisms are poorly understood. Functional brain connectivity is a promising metric for identifying treatment mechanisms and biosignatures of therapeutic response. To this end, we assessed amygdala and insula treatment-related connectivity changes and their relationship to PTSD symptom improvements. METHODS: Individuals with a primary PTSD diagnosis (N = 66) participated in a randomized clinical trial of prolonged exposure therapy (n = 36) versus treatment waiting list (n = 30). Task-free functional magnetic resonance imaging was completed prior to randomization and 1 month following cessation of treatment/waiting list. Whole-brain blood oxygenation level-dependent responses were acquired. Intrinsic connectivity was assessed by subregion in the amygdala and insula, limbic structures key to the disorder pathophysiology. Dynamic causal modeling assessed evidence for effective connectivity changes in select nodes informed by intrinsic connectivity findings. RESULTS: The amygdala and insula displayed widespread patterns of primarily subregion-uniform intrinsic connectivity change, including increased connectivity between the amygdala and insula; increased connectivity of both regions with the ventral prefrontal cortex and frontopolar and sensory cortices; and decreased connectivity of both regions with the left frontoparietal nodes of the executive control network. Larger decreases in amygdala-frontal connectivity and insula-parietal connectivity were associated with larger PTSD symptom reductions. Dynamic causal modeling evidence suggested that treatment decreased left frontal inhibition of the left amygdala, and larger decreases were associated with larger symptom reductions. CONCLUSIONS: PTSD psychotherapy adaptively attenuates functional interactions between frontoparietal and limbic brain circuitry at rest, which may reflect a potential mechanism or biosignature of recovery.

Scoring Cercospora Leaf Spot on Sugar Beet: Comparison of UGV and UAV Phenotyping Systems.

Selection of sugar beet (Beta vulgaris L.) cultivars that are resistant to Cercospora Leaf Spot (CLS) disease is critical to increase yield. Such selection requires an automatic, fast, and objective method to assess CLS severity on thousands of cultivars in the field. For this purpose, we compare the use of submillimeter scale RGB imagery acquired from an Unmanned Ground Vehicle (UGV) under active illumination and centimeter scale multispectral imagery acquired from an Unmanned Aerial Vehicle (UAV) under passive illumination. Several variables are extracted from the images (spot density and spot size for UGV, green fraction for UGV and UAV) and related to visual scores assessed by an expert. Results show that spot density and green fraction are critical variables to assess low and high CLS severities, respectively, which emphasizes the importance of having submillimeter images to early detect CLS in field conditions. Genotype sensitivity to CLS can then be accurately retrieved based on time integrals of UGV- and UAV-derived scores. While UGV shows the best estimation performance, UAV can show accurate estimates of cultivar sensitivity if the data are properly acquired. Advantages and limitations of UGV, UAV, and visual scoring methods are finally discussed in the perspective of high-throughput phenotyping.

Metachronous hepatic resection for liver only pancreatic metastases.

BACKGROUND: The value of liver resection (LR) for metachronous pancreatic ductal adenocarcinoma (PDAC) metastases remains controversial. However, in light of increasing safety of liver resections, surgery might be a valuable option for metastasized PDAC in selected patients. METHODS: We performed a retrospective, multicenter study including patients undergoing hepatectomy for metachronous PDAC liver metastases between 2004 and 2015 to analyze postoperative outcome and overall survival. All patients were operated with curative intent. Patients with oligometastatic metachronous liver metastasis with definitive chemotherapy (n = 8) served as controls. RESULTS: Overall 25 patients in seven centers were included in this study. The median age at the time of LR was 63.8 years (56.9-69.9) and the median number of metastases in the liver was 1 (IQR 1-2). There were eight non-anatomical resections (32%), 15 anatomical minor (60%) and 2 major LR (8%). Postoperative complications occurred in eleven patients (eight Clavien-Dindo grade I complications (32%) and three grade IIIa complications (12%), respectively). The 30-day mortality was 0%. The median length of stay was 8.6 days (IQR 5-11). Median overall survival following LR was 36.8 months compared to 9.2 months in patients with metachronous liver metastasis with chemotherapy (p = 0007). DISCUSSION: Liver resection for metachronous PDAC metastasis is safe and feasible in selected patients. To address general applicability and to find factors for patient selection, larger trials are urgently warranted.

Microsurgical lymphatic vascular grafting and secondary liposuction: Results of combination treatment in secondary lymphedema.

Surgical treatment of lymphedema with liposuction typically requires subsequent compression therapy. Here we describe an approach where secondary arm lymphedemas are initially treated by autologous lymphatic grafting to bypass the axilla and restore lymphatic flow. In the presence of excess adipose tissue, liposuction is then performed in a second procedure. To assess outcomes, the authors evaluated 28 consecutive adult patients who had undergone secondary liposuction following lymphatic grafting. Arm volumes were measured prior to lymphatic grafting and after the secondary liposuction. The necessity for additional treatment by compression garment and manual lymphatic drainage was assessed prior to lymphatic grafting and after the secondary liposuction following the direct postoperative regimen. The mean arm volumes were reduced significantly (p<0.001) from a mean of 3417± 171 (SEM) cm3 prior to lymphatic grafting to 3020±125 cm3 after reconstruction of the lymphatic vascular system and finally to 2516±104 cm3 after the secondary liposuction (SLS). All 28 adult patients underwent continuous compression and manual lymph-drainage (MLD) prior to the reconstructive surgery. All 28 patients were evaluated regarding necessity of any additional therapy more than 6 months after SLS with a median follow up period of 37 months (range, 7-160 months). 18 of 28 patients did not require any supportive therapy beyond 6 months after SLS to maintain the results. Three patients continued to utilize manual lymphatic drainage, 4 used a combination of MLD and compression therapy and 3 used elastic compression therapy (one patient only while at work). These results indicate that microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two thirds of patients.

Frequency, Extent, and Correlates of Superficial Siderosis and Ependymal Siderosis in Premature Infants with Germinal Matrix Hemorrhage: An SWI Study.

BACKGROUND AND PURPOSE: Germinal matrix intraventricular hemorrhage is a common complication of prematurity. An underrecognized complication of germinal matrix intraventricular hemorrhage is superficial siderosis, and the clinical consequences of superficial siderosis are not well-known. We aimed to investigate the prevalence, anatomic distribution, and severity of superficial siderosis and ependymal siderosis in premature infants with germinal matrix intraventricular hemorrhage using SWI. MATERIALS AND METHODS: In this retrospective study, we included 88 patients across all grades of germinal matrix intraventricular hemorrhage who underwent MR imaging at term-equivalent age. Images were evaluated for the presence, distribution, and severity of superficial siderosis and ependymal siderosis. Univariate and multivariate logistic regression analyses were performed to determine factors associated with superficial siderosis and ependymal siderosis. The agreement among T1, T2, and SWI sequences was examined. RESULTS: Seventy-two patients had brain stem superficial siderosis, and 79 patients had ependymal siderosis. The presence, extent, and severity of superficial siderosis and ependymal siderosis were closely related to the grade of germinal matrix intraventricular hemorrhage and intraventricular hematoma volume. Brain stem superficial siderosis had a stronger correlation with intraventricular hemorrhage than with cerebellar hemorrhage. Compared with SWI, T1 and T2 sequences detected only small proportions of patients with superficial siderosis (12.5% and 6.9%, respectively). CONCLUSIONS: The incidence of superficial siderosis and ependymal siderosis is very high in preterm infants with germinal matrix intraventricular hemorrhage when assessed by SWI at term-equivalent age. The presence and extent of superficial siderosis and ependymal siderosis are closely related to germinal matrix intraventricular hemorrhage grade and intraventricular hematoma volume. Additional prospective studies using SWI are needed to clearly determine the clinical consequences of germinal matrix intraventricular hemorrhage with superficial siderosis and ependymal siderosis.