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Acute respiratory distress syndrome (ARDS) is a life-threatening condition affecting >10% of intensive care unit (ICU) patients worldwide with a mortality of up to 59% depending on severity. Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving procedure in severe ARDS but is technically and financially challenging. In recent years, various scoring systems have been proposed to select patients most likely to benefit from ECMO, with the PREdiction of Survival on ECMO Therapy (PRESET) score being one of the most used. We collected data from 283 patients with ARDS of various etiology who underwent veno-venous (V-V) ECMO therapy at a German tertiary care ICU from January 2012 to December 2022. Median age in the cohort was 56 years, and 64.31% were males. The in-hospital mortality rate was 50.88% (n = 144). The median (25%; 75% quartile) severity scores were 38 (31; 49) for Simplified Acute Physiology Score (SAPS) II, 12 (10; 13) for Sequential Organ Failure Assessment (SOFA) and 7 (5; 8) for PRESET. Simplified Acute Physiology Score-II displayed the best prognostic value (area under the receiver operating characteristic [AUROC]: 0.665 [confidence interval (CI): 0.574–0.756; p= 0.046]). Prediction performance was weak in all analyzed scores despite good calibration. Simplified Acute Physiology Score-II had the best discrimination after adjustment of our original cohort. The use of scores explored in this study for patient selection for eligibility for V-V ECMO is not recommendable.

With a new government in place, the sector is hoping for action to tackle workforce and recruitment issues. Joe Lepperidentifies developments in initial training and ongoing professional development

Abstract:This article highlights feminist thought on hospitality in order to stress the implicit cultural connection between the salon and the hostess in Armance. Furthermore, it argues that theories of hospitality can reopen the debate about impotence in the novel by raising questions of self-mastery and the power to act. Drawing on Derrida's contention that hospitality is a necessary condition for recognisable selfhood, the article suggests that Octave's dilemma of impotence is encapsulated by his fantasy, early in the novel, of owning a salon which no-one else would enter. Considering the potential unruliness of both phallus and hostess, it asks to what extent Armance shows us Stendhal reflecting on the illusory nature of masculine self-sufficiency. By suggesting that potency in the novel can be understood in terms of mastery over detail, moreover, the article connects Octave's preoccupation with his private salon to Stendhal's own concerns with achieving a succinct literary style.

Ridge surfaces represent important features for the analysis of 3-dimensional (3D) datasets in diverse applications and are often derived from varying underlying data including flow fields, geological fault data, and point data, but they can also be present in the original scalar images acquired using a plethora of imaging techniques. Our work is motivated by the analysis of image data acquired using micro-computed tomography ($\mu\text{CT}$) of ancient, rolled and folded thin-layer structures such as papyrus, parchment, and paper as well as silver and lead sheets. From these documents we know that they are 2-dimensional (2D) in nature. Hence, we are particularly interested in reconstructing 2D manifolds that approximate the document's structure. The image data from which we want to reconstruct the 2D manifolds are often very noisy and represent folded, densely-layered structures with many artifacts, such as ruptures or layer splitting and merging. Previous ridge-surface extraction methods fail to extract the desired 2D manifold for such challenging data. We have therefore developed a novel method to extract 2D manifolds. The proposed method uses a local fast marching scheme in combination with a separation of the region covered by fast marching into two sub-regions. The 2D manifold of interest is then extracted as the surface separating the two sub-regions. The local scheme can be applied for both automatic propagation as well as interactive analysis. We demonstrate the applicability and robustness of our method on both artificial data as well as real-world data including folded silver and papyrus sheets.

In Deutschland qualifiziert sich der Akut- und Notfallmediziner durch eine Facharztweiterbildung in Verbindung mit den Zusatz-Weiterbildungen „Klinische Akut- und Notfallmedizin“ und „Notfallmedizin“ gemäß den Vorgaben der Landesärztekammern, die sich auf die Empfehlungen der Bundesärztekammer beziehen. Eine zentrale Säule in der gebietsübergreifenden notfallmedizinischen Versorgung stellt das Gebiet der Inneren Medizin mit seinen Schwerpunkten dar. Das vorliegende Curriculum gibt einen umfassenden Überblick über internistische Weiterbildungsinhalte der Akut- und Notfallmedizin, die nach Ansicht der internistischen Gesellschaften (Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin [DGIIN], Deutsche Gesellschaft für Innere Medizin [DGIM] samt Schwerpunktgesellschaften, Berufsverband Deutscher Internistinnen und Internisten [BDI]) für den Erwerb der erforderlichen Kenntnisse und praktischen Fähigkeiten für eine bestmögliche Versorgung der akut- und notfallmedizinischen Patienten aus internistischer Sicht erforderlich scheinen. Das Curriculum stellt zum einen die allgemeinen Aspekte der klinischen Akut- und Notfallmedizin mit den Inhalten Struktur- und Prozessqualität, Erstdiagnostik, Initialtherapie und Indikationsstellung zur weiterführenden Behandlung, Schockraumversorgung, Diagnostik und Monitoring, generelle Therapieverfahren, Hygienemaßnahmen und Pharmakotherapie dar. Anschließend folgen spezifische Aspekte der Akut- und Notfallmedizin (angiologische, endokrinologische, diabetologische und metabolische, gastroenterologische, geriatrische, hämatoonkologische, infektiologische, kardiologische, nephrologische, palliativmedizinische, pneumologische, rheumatologische und toxikologische). Unterlegt sind die Themen jeweils mit auf das Weiterbildungskonzept zugeschnittenen Publikationen. Das Curriculum stellt für Internistinnen und Internisten alle internistischen Weiterbildungsinhalte der o. g. Zusatz-Weiterbildungen dar, zeigt aber auch allen Notfallmedizinern, mit welchen internistischen Krankheitsbildern sie bei ihrer Tätigkeit rechnen müssen.

With many parts of the sector facing recruitment challenges, Joe Lepperidentifies developments in entry-level requirements and ongoing professional development for children's services practitioners

Interhospital transport of acute respiratory distress syndrome (ARDS) patients bears transport-associated risks. It is unknown how interhospital extracorporeal membrane oxygenation (ECMO) transfer of COVID-19 patients by mobile ECMO units affects ARDS mortality. We compared the outcome of 94 COVID-19 patients cannulated in primary care hospitals and retrieved by mobile ECMO-teams to that of 84 patients cannulated at five German ECMO centers. Patients were recruited from March 2020 to November 2021. Twenty-six transports were airborne, 68 were land-based. Age, sex, body-mass-index, Simplified Acute Physiology Score (SAPS) II, days invasively ventilated, and P/F-Ratio before ECMO initiation were similar in both groups. Counting only regional transports (≤250 km), mean transport distance was 139.5 km ± 17.7 km for helicopter (duration 52.5 ± 10.6 minutes) and 69.8 km ± 44.1 km for ambulance or mobile intensive care unit (duration 57.6 ± 29.4 minutes). Overall time of vvECMO support (20.4 ± 15.2 ECMO days for transported patients vs.21.0 ± 20.5 for control, p= 0.83) and days invasively ventilated (27.9 ± 18.1 days vs.32.6 ± 25.1 days, p= 0.16) were similar. Overall mortality did not differ between transported patients and controls (57/94 [61%] vs.51/83 [61%], p= 0.43). COVID-19 patients cannulated and retrieved by mobile ECMO-teams have no excess risk compared with patients receiving vvECMO at experienced ECMO centers. Patients with COVID-19-associated ARDS, limited comorbidities, and no contraindication for ECMO should be referred early to local ECMO centers.

Amid ongoing shortages of social workers, children's services are increasingly turning to international recruitment to fill staffing gaps. Joe Lepperexplores challenges and best practice

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

Kritisch kranke Patienten, die spezialisierte diagnostische oder therapeutische Verfahren benötigen, jedoch in einem Krankenhaus ohne diesbezügliche Ausstattung versorgt werden, müssen unter Fortführung intensivmedizinischer Maßnahmen zu geeigneten Zentren transportiert werden. Solche Transporte sind herausfordernde Einsätze mit hohem Ressourcenbedarf und logistischem Aufwand, die durch ein spezialisiertes Team bewältigt werden müssen. Hierzu ist neben einem effizienten Crew Resource Management eine gute Planung des Einsatzes notwendig. Bei adäquater Vorbereitung sind solche Einsätze für den Patienten sicher und komplikationsarm durchführbar. Neben Routineintensivtransporten gibt es Sondereinsätze (z. B. isolationspflichtiger Patienten oder Patienten mit extrakorporaler Organunterstützung), die eine Anpassung des Teams oder des vorgehaltenen Materials erfordern. Dieser Beitrag beschreibt die Grundlagen des interhospitalen Intensivtransportes, seine Phasen und Sonderfälle.

Low flow extracorporeal carbon dioxide removal (ECCO2R) is a promising approach to correct hypercapnic lung failure, facilitate lung protective ventilation in acute respiratory distress syndrome and to possibly prevent the application of invasive ventilation. However, the predominant availability of adult membrane lungs (MLs) at most intensive care units are burdens for low flow ECCO2R that intends to reduce cannula size and promote the mobility of the patients. Herein, in a mock setup, we combine the idea of a low flow ECCO2R and the use of adult MLs by installing a recirculation channel into the circuit and comparing the new setup to an already clinically established setup, “the Homburg lung.” Furthermore, to make stronger reference to hypercapnic respiratory failure, we investigate the influence of CO2partial pressure in blood on CO2removal of both setups. A linear association between CO2partial pressure in blood and CO2removal of the ML in the physiologically relevant range was observed. To understand this linear dependence, a simplified mathematical model was proposed. Our new ECCO2R mock setup combines the idea of a low flow ECCO2R and an adult size ML. It shows a reasonable alternative to the current available low flow setups based on pediatric MLs.

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Coronavirus disease 2019 (COVID-19) has drastically increased the number of patients requiring extracorporeal life support. We investigate the efficacy and safety of low-dose recombinant tissue-type plasminogen activator (rtPA) injection into exhausted oxygenators to delay exchange in critically ill COVID-19 patients on veno-venous extracorporeal membrane oxygenation (V-V ECMO). Small doses of rtPA were injected directly into the draining section of a V-V ECMO circuit. We compared transmembrane pressure gradient, pump head efficiency, membrane arterial partial oxygen pressure, and membrane arterial partial carbon dioxide pressure before and after the procedure. Bleeding was compared with a matched control group of 20 COVID-19 patients on V-V ECMO receiving standard anticoagulation. Four patients received 16 oxygenator instillations with rtPA at 5, 10, or 20 mg per dose. Administration of rtPA significantly reduced transmembrane pressure gradient (Δpm= 54.8 ± 18.1 mmHg before vs. 38.3 ± 13.3 mmHg after, p< 0.001) in a dose-dependent manner (Pearson’s R −0.63, p= 0.023), allowing to delay oxygenator exchange, thus reducing the overall number of consumed oxygenators. rtPA increased blood flow efficiency η (1.20 ± 0.28 ml/revolution before vs. 1.24 ± 0.27 ml/r, p= 0.002). Lysis did not affect membrane blood gases or systemic coagulation. Minor bleeding occurred in 2 of 4 patients (50%) receiving oxygenator lysis as well as 19 of 20 control patients (95%). Lysis of ECMO oxygenators effectively delays oxygenator exchange, if exchange is indicated by an increase in transmembrane pressure gradient. Application of lysis did not result in higher bleeding incidences compared with anticoagulated patients on V-V ECMO for COVID-19.

In late 2020, during the second wave of COVID-19 in Germany, we started using the MobyBox, which is a novel fully pneumatically driven ECMO device, on a regular basis to meet the increasing demand for ECMO therapy. In this case series, we performed a retrospective chart review of seven patients with severe COVID-19-related acute respiratory distress syndrome (ARDS) requiring veno-venous (vv)-ECMO support with the MobyBox. During ECMO treatments we have observed no disadvantages in comparison to conventional ECMO systems. There were no system failures or adverse events directly attributable to the MobyBox system. Our data support that providing vv-ECMO with the MobyBox device is safe and feasible. Furthermore, our findings suggest that the MobyBox device might represent an advantage in terms of biocompatibility. Therefore, more data on this issue is needed to better understand how the pneumatically driven pump affects cellular blood components.

It is more than 10 years since the first police and crime commissioners were elected in England and Wales. Joe Lepperexplores what they have achieved for children, young people and families

Reading motivation is a fundamental basis for reading behavior and performance. For learners, interest is an exceedingly important component of reading motivation. Prior research has shown that students’ text‐based interest varies significantly between texts. However, it is still unclear why one text elicits greater interest over another. Therefore, in this study, we investigated whether different text characteristics, such as text genre, topic, and protagonists’ gender, are systematically related to students’ text‐based interest. Furthermore, we examined differences between girls and boys. We used data from a sample of 504 fourth‐grade elementary school students to answer these questions. Eight texts were manipulated experimentally with respect to text genre, topic, and protagonists’ gender. Students were assigned randomly to read one of the eight texts. Structural equation models showed that students’ text‐based interest was related to text genre, topic, and students’ gender. Moreover, students’ gender interacted significantly with text topic and protagonists’ gender, with boys less interested in texts with a more female‐typed text topic and in texts with female protagonists. The findings imply that text characteristics might help educators select reading material to encourage students’ text‐based interest. The results are discussed in terms of research and educational practice.

Ein qualitätsvoller Unterricht ist von zentraler Bedeutung sowohl für leistungsbezogene als auch für motivationale Lernergebnisse von Schülerinnen und Schülern. Die Motivierungsqualität des Unterrichts als eine bedeutsame Facette der Basisdimension konstruktive Unterstützung wurde bisher eher selten untersucht. Um die Bedeutung der wahrgenommenen Motivierungsqualität für motivationale Merkmale von Grundschulkindern zu erforschen, wurde basierend auf Angaben von Viertklässlerinnen und -klässlern (N= 187) analysiert, inwiefern die Motivierungsqualität des Mathematikunterrichts neben der Mathematiknote prädiktiv für die intrinsische Motivation und das Fähigkeitsselbstkonzept der Lernenden ist. Auch wurde geprüft, ob dem Kompetenzerleben der Lernenden eine vermittelnde Funktion zukommt. Die Ergebnisse zeigten, dass die wahrgenommene Motivierungsqualität neben der Mathematiknote ein bedeutsamer Prädiktor für beide motivationalen Merkmale war. Während das Kompetenzerleben die Zusammenhänge zwischen der Motivierungsqualität bzw. der Mathematiknote und dem Fähigkeitsselbstkonzept bedeutsam vermittelte, wurden die Zusammenhänge für die intrinsische Motivation der Schülerinnen und Schüler wiederum nicht mediiert. Resümierend werden die Befunde hinsichtlich möglicher Implikationen für zukünftige Forschung und Praxis diskutiert.

ABSTRACT:The Center for the Future of Museums, in its TrendsWatch 2019 report, identified “Truth, Trust, and Fake News” as key issues for museums to address. Fraudulent artifacts bearing Hebrew inscriptions were planted in Ohio mounds in the 1800s as fake news to promote a combined political, scientific, and religious agenda. Two of these so-called Newark “Holy Stones” are among the most celebrated objects in the collections of the Johnson-Humrickhouse Museum in Coshocton, Ohio. They have been interpreted in various ways over the years, but a recent opportunity to renovate exhibits allowed the staff to develop interpretation in alignment with the recommendations of the Center for the Future of Museums. This is therefore a case study for how contentious objects can be used as “touchstones for the truth.”

The Center for the Future of Museums, in its TrendsWatch 2019 report, identified “Truth, Trust, and Fake News” as key issues for museums to address. Fraudulent artifacts bearing Hebrew inscriptions were planted in Ohio mounds in the 1800s as fake news to promote a combined political, scientific, and religious agenda. Two of these so-called Newark “Holy Stones” are among the most celebrated objects in the collections of the Johnson-Humrickhouse Museum in Coshocton, Ohio. They have been interpreted in various ways over the years, but a recent opportunity to renovate exhibits allowed the staff to develop interpretation in alignment with the recommendations of the Center for the Future of Museums. This is therefore a case study for how contentious objects can be used as “touchstones for the truth.”

The effigy mounds of the Upper Midwest and the Ohio Valley long have been regarded as distinct and independent cultural developments. A review of effigy mound iconography in both regions reveals similarities suggesting that they are elements of a shared cultural tradition. Comparisons with rock art imagery from the Upper Midwest and Missouri, the inferred centers of this artistic and ceremonial florescence, reveal co-occurrences of specific motifs and provide additional evidence of cultural connections among the Late Woodland to early Late Precontact societies inhabiting the lower Missouri, Mississippi, and Ohio river valleys. Oral traditions of Native American groups with documented connections to these regions allow this rich corpus of imagery to be understood as key episodes in their genesis stories.

Hintergrund: Zu Beginn der Coronaviruspandemie wurde eine Überlastung der verfügbaren intensivmedizinischen Ressourcen befürchtet. Vielerorts wurden Routineeingriffe eingeschränkt und Kriterien für die Zuteilung knapper Ressourcen formuliert. In Deutschland kam es regional im Verlauf der Pandemie zeitweise zu Überlastungssituationen in den Kliniken. Speziell auf Intensivstationen zeigte sich eine Ressourcenknappheit, die zur Einschränkung von Leistungen und zu einer strengeren Indikationsstellung für ressourcenintensive Maßnahmen wie der extrakorporalen Membranoxygenierung (ECMO) geführt haben kann. Ziel dieser Arbeit ist es, einen Überblick über den Umgang mit diesen Belastungen an großen ECMO-Zentren in Deutschland zu gewinnen. Methodik: Über persönliche Ansprache wurde im Frühjahr 2021 je ein Vertreter an großen ECMO-Zentren in Deutschland zur Teilnahme an einer Onlineumfrage eingeladen. Ergebnisse: Insgesamt wurden 34 Einladungen verschickt, die Umfrage wurde von 23 Teilnehmern beantwortet. In allen Zentren wurden im Verlauf der Pandemie Routineeingriffe verschoben. Die Hälfte der Zentren erhöhte die Anzahl von Betten, auf denen ECMO-Verfahren durchgeführt werden konnten, in einem Drittel der Zentren wurde dennoch der Beginn mindestens einer ECMO-Unterstützung wegen einer befürchteten Ressourcenknappheit verzögert. In 17 % der Zentren wurde mindestens einem Patienten eine ECMO verweigert, die der Patient unter den Bedingungen vor der Pandemie aller Voraussicht nach erhalten hätte. Diskussion: Die Ergebnisse dieser Onlineumfrage zeigen, dass die erlebten Belastungen und Ressourcenengpässe in einigen Zentren zu einer zurückhaltenden ECMO-Indikationsstellung führten.

There is a paucity of data that describe how program characteristics relate to program outcome goals. This gap limits the use of data to guide and support decisions concerning the selection of applied behavior analysis (ABA) program characteristics. Therefore, the purpose of the present study was to describe a methodology for the evaluation of the relationships between program characteristics and program outcome goals in the context of identifying the ideal program characteristics to propose for a new master of science in ABA program at Franciscan Missionaries of Our Lady University (FranU). For FranU, 11 program characteristics, enrollment, and the 2019 board certified behavior analyst (BCBA) pass rates were selected as variables. We provide a description of the procedures, data analysis and a general overview of our findings. The utility of the methodology for future research is also discussed.

It is unknown if solid organ transplant recipients are at higher risk for severe COVID‐19. The management of a lung transplantation (LTx) program and the therapeutic strategies to adapt the immunosuppressive regimen and antiviral measures is a major issue in the COVID‐19 era, but little is known about worldwide practice. We sent out to 180 LTx centers worldwide in June 2020 a survey with 63 questions, both regarding the management of a LTx program in the COVID‐19 era and the therapeutic strategies to treat COVID‐19 LTx recipients. We received a total of 78 responses from 15 countries. Among participants, 81% declared a reduction of the activity and 47% restricted LTx for urgent cases only. Sixteen centers observed deaths on waiting listed patients and eight centers performed LTx for COVID‐19 disease. In 62% of the centers, COVID‐19 was diagnosed in LTx recipients, most of them not severe cases. The most common immunosuppressive management included a decreased dose or pausing of the cell cycle inhibitors. Remdesivir, hydroxychloroquine, and azithromycin were the most proposed antiviral strategies. Most of the centers have been affected by the COVID‐19 pandemic and proposed an active therapeutic strategy to treat LTx recipients with COVID‐19. This international survey reports on the worldwide impact of COVID‐19 on lung transplant programs at the early stage of the pandemic, showing a dramatic decrease of transplant activity and delineating strategies used to prevent, and treat COVID‐19 in lung transplant recipients.

Before coronavirus, the government promised a renewed focus on devolution of power to the English regions. Joe Lepperexplores its impact on children's services to date and looks at what the future holds

Metal adatoms play a key role in surface diffusion, adsorption conformation, and self-assembly of porphyrin molecules on metal surfaces. Herein, we study the specific influence of coadsorption of Fe, Co, and Pd atoms on the behavior of 2H-tetrakis(p-cyano)phenylporphyrin (2H-TCNPP) on Cu(111) using scanning tunneling microscopy. Upon co-deposition of Fe and Co, the molecules form one-dimensional (1D) linear chains after mild annealing on Cu(111) driven by the interaction of its cyano groups with metal adatoms. A similar behavior has been observed previously on Cu(111), mediated by Cu adatoms, where the functional CN groups were also found to lower the reaction rate of the so-called porphyrin self-metalation reaction with Cu atoms significantly, in comparison to the non-cyano-functionalized porphyrin. Upon co-deposition of Pd and mild annealing, we find a remarkably different behavior, that is, a massive reorganization from 1D molecular chains to a peculiar rectangular 2D (two-dimensional) network. The molecular appearance changes to a clover shape, which is attributed to a Pd-induced dehydrogenation and subsequent ring closure reaction of the phenyl and pyrrole groups.

The use of extracorporeal membrane oxygenation (ECMO) as bridge-to-lung transplantation has been discussed controversially because of discouraging results. We report our experience with this challenging strategy. This retrospective investigation includes all consecutive lung transplantations in our center between January 2012 and July 2017 (n = 88, median Lung Allocation Score 66). Data of patients on ECMO bridge-to-transplant (n = 34) were compared with patients without such support (n = 54). Patients requiring ECMO support underwent lung transplantation after median bridging time of 29 days (range, 0–129 days). Survival was superior if transplantation was performed within 29 days of ECMO (p= 0.04). Donor age and oxygenation (pO2/FiO2) were similar in recipients with ECMO (42.3 ± 15.2 years, 444.5 ± 68.9 mm·Hg) or without ECMO (43.1 ± 13.9 years, 454.5 ± 73.4 mm·Hg). Four patients required postoperative ECMO support >1 day. Survival at 1 year and 3 years was similar in recipients with ECMO support (79%, 63%) or without ECMO support (86%, 71%). Successful lung transplantation after ECMO as bridge-to-transplant can be achieved, even in patients with prolonged support times. Bridging time of less than 30 days, however, is crucial for success. Extracorporeal membrane oxygenation expertise and donor organ quality may be important factors for favorable outcome.

Die akute hyperkapnische respiratorische Insuffizienz (AHRI) gehört zu den häufigen Problemen in der Intensivmedizin und tritt insbesondere bei Patienten mit akut exazerbierter COPD (AECOPD) und acute respiratory distress syndrome (ARDS) auf. In den letzten Jahren wird als erweiterte Therapieoption vermehrt das Verfahren der extrakorporalen CO2-Elimination (ECCO2R) angewendet. Darstellung der aktuellen Datenlage in der Therapie der AHRI unter besonderer Berücksichtigung der ECCO2R. Review auf Basis einer selektiven Literaturrecherche und den klinisch-wissenschaftlichen Erfahrungen der Autoren. Therapie der Wahl der AHRI bei AECOPD ist die nichtinvasive Beatmung (NIV), mit der sich in der Mehrzahl der Fälle eine Stabilisierung und insgesamt eine Verbesserung der Prognose erzielen lassen. Patienten mit Versagen der NIV-Therapie weisen eine erhöhte Mortalität auf. Bei diesen Patienten können mithilfe der ECCO2R möglicherweise Intubationen vermieden und die Beatmungszeit verkürzt werden; die Evidenz hierzu ist jedoch eingeschränkt bzw. im Hinblick auf harte klinische Endpunkte fehlend. Standardtherapie des ARDS ist die lungenprotektive Beatmung nach Empfehlungen des ARDS-Netzwerks. Bei schwerem ARDS kann es unter niedrigen Atemminutenvolumina zur kritischen CO2-Retention kommen. Mithilfe der ECCO2R ist es möglich, eine respiratorische Acidose auch bei „ultraprotektiven“ Ventilatoreinstellungen effektiv auszugleichen. Ein positiver Effekt auf die Prognose konnte bisher nicht nachgewiesen werden. Eine optimierte Anwendung der Standardverfahren NIV bzw. lungenprotektive Beatmung bleibt Goldstandard in der Therapie. Die ECCO2R ist derzeit als experimentelle Therapie einzustufen und sollte nur in erfahrenen Zentren oder im Rahmen von Studien erfolgen. Hypercapnic respiratory failure is a frequent problem in critical care and mainly affects patients with acute exacerbation of COPD (AECOPD) and acute respiratory distress syndrome (ARDS). In recent years, the usage of extracorporeal CO2removal (ECCO2R) has been increasing. Summarizing the state of the art in the management of hypercapnic respiratory failure with special regard to the role of ECCO2R. Review based on a selective literature search and the clinical and scientific experience of the authors. Noninvasive ventilation (NIV) is the therapy of choice in hypercapnic respiratory failure due to AECOPD, enabling stabilization in the majority of cases and generally improving prognosis. Patients in whom NIV fails have an increased mortality. In these patients, ECCO2R may be sufficient to avoid intubation or to shorten time on invasive ventilation; however, corresponding evidence is sparse or even missing when it comes to hard endpoints. Lung-protective ventilation according to the ARDS network is the standard therapy of ARDS. In severe ARDS, low tidal volume ventilation may result in critical hypercapnia. ECCO2R facilitates compensation of respiratory acidosis even under “ultra-protective” ventilator settings. Yet, no positive prognostic effects could be demonstrated so far. Optimized use of NIV and lung-protective ventilation remains standard of care in the management of hypercapnic respiratory failure. Currently, ECCO2R has to be considered an experimental approach, which should only be provided by experienced centers or in the context of clinical trials.

Funding cuts and austerity mean charities can face an uphill struggle to survive. Joe Lepperspeaks to three winners of the CYP Now Awards Children and Young People's Charity Award to see how they are faring

Capnocytophaga canimorsusis a rare cause of serious infections with a high mortality of 10% to 30%. It is usually found in the oral cavity of cats and dogs and can cause severe sepsis in immunocompromised patients. An 81-year-old female Caucasian patient presented with C. canimorsussepsis after a dog bite in her finger three days before presentation to our emergency department. She initially was presented to us with sepsis, thrombopenia, and schistocytes in her laboratory findings, suggesting the differential diagnoses of the multiple subtypes of thrombotic microangiopathy. She was admitted to the medical intensive care unit of the University Hospital of Saarland because of septic shock with circulatory insufficiency. The patient received plasmapheresis, antibiotics, and dialysis, under which she improved significantly. The fingertip of the affected finger developed necrosis and had to be amputated. Furthermore, the patient was diagnosed with a mitral valve endocarditis, a very rare complication of C. canimorsusinfection. It was treated conservatively with antibiotics and was no longer detectable 8?weeks after the diagnosis. Surgical intervention was not needed. The case describes well that it is still difficult to distinguish between thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC), and sepsis-induced coagulopathy (SIC), especially in the early phases of acute disease, especially in C. canimorsus-induced sepsis.

ABSTRACTTreatment with immune checkpoint inhibitors (ICIs) has improved the prognosis of melanoma patients. However, ICIs can cause an overactivation of the immune system followed by diverse immunological side effects known as immune-related adverse events (irAE). Currently, the toxicity of irAE is limiting the usage of ICIs. Here, we studied circulating monocytic myeloid-derived suppressor cells (M-MDSCs) and T cells in course of irAE after the ICI therapy. Our longitudinal study involved 31 melanoma patients with and without adverse events during anti-PD-1 monotherapy or anti-CTLA-4/PD-1 combination therapy. Peripheral blood samples were analyzed before ICI start, during ICI treatment, at the time point of irAE and during immunosuppressive treatment to cure irAE. We observed an enhanced progression-free survival among patients with irAE. In patients with irAE, we found an upregulation of CD69 on CD8+T cells and a decreased frequency of regulatory T cells (Tregs). Moreover, lower frequencies of Tregs correlated with more severe side effects. Patients treated with immunomodulatory drugs after irAE manifestation tend to show an elevated number of M-MDSCs during an immunosuppressive therapy. We suggest that an activation of CD8+T cells and the reduction of Treg frequencies could be responsible for the development of irAE.

ABSTRACTThe debate over the age of Serpent Mound (33AD01) is important because without a cultural context it is impossible to make meaningful statements about what this monumental effigy mound might have meant to its builders. In this response to Romain and Herrmann’s rejoinder, we clarify the provenience of the samples, which yielded the radiocarbon dates that contribute to our argument for a post–Late Woodland age for the effigy. In addition, we extend our critique of Romain and colleagues’ arguments to include the results of an independent study of soil cores extracted from the Serpent and surrounding landscape, which fails to corroborate Romain and colleagues’ assertion that a buried A horizon underlies the mound. Finally, we suggest that the construction of Serpent Mound may be historically linked to droughts in the Mississippi Valley that began at around AD 1100, which resulted in an influx of Mississippian refugees into the region.

ABSTRACTThe price of college is increasingly out of reach for many Americans. Although community colleges are affordable compared to other institutional sectors, many community college students have unmet need. Free college and promise programs are emerging around the country as a solution to make college more affordable. This article examines the Salt Lake Community College (SLCC) Promise program that launched in fall 2016. The article describes the purpose of the program and the critical role of student affairs in the design and implementation of SLCC Promise. The article ends with a descriptive analysis of the outcomes of the first year of implementation of SLCC Promise, and it identifies ways that student affairs and student services can support fair and equitable free college programs.

Kurzfassung:In der Stratigraphischen Tabelle von Deutschland 2016 (STD 2016) umfasst der Buntsandstein als unterer Teil der Germanischen Trias einen Zeitraum von nur noch 6,3 Ma (STD 2002: 8,0 Ma). Der Buntsandstein hat den Rang einer Gruppe, die in die Untergruppen Unterer, Mittlerer und Oberer Buntsandstein gegliedert wird. Er wird in die Folgen s1 bis s7 unterteilt, denen im Norddeutschen Becken – dem Subsidenzzentrum des Mitteleuropäischen Beckens – die lithostratigraphischen Einheiten Calvörde-, Bernburg-, Volpriehausen-, Detfurth-, Hardegsen-, Solling- und Röt-Formation entsprechen. In den gröberklastischen Randbereichen des Beckens, vor allem Süddeutschlands, sind die Folgengrenzen bislang nur teilweise festzustellen. Da auch die in Norddeutschland definierten Formationen nicht überall klar erkennbar sind, werden insbesondere in der Randfazies gebietsweise eigenständige kartierbare Formationen ausgewiesen.Abstract:In the Stratigraphic Table of Germany 2016 (STD 2016), the Buntsandstein Group, as the lower part of the Germanic Triassic, covers a period of only 6.3 Ma (STD 2002: 8.0 Ma). It is subdivided into the subgroups Lower, Middle and Upper Buntsandstein. Alternatively, it is subdivided into allostratigraphic units, called "Folge" s1 to s7, which correspond to the lithostratigraphic units Calvörde, Bernburg, Volpriehausen, Detfurth, Hardegsen, Solling and Röt Formation within the North German Basin – the subsidence centre of the Central European Basin. However, in the coarser clastic marginal facies of the basin, especially in southern Germany, the stratigraphic positions of the "Folgen" boundaries can only partially be identified yet. Since the formations of the central part of the basin cannot be distinguished in all parts of the basin, separate mappable lithostratigraphic units were defined regionally, especially for the marginal facies.

Right heart failure (RHF) because of pulmonary hypertension (PH) is a frequently encountered clinical problem with high mortality. The last resort, if pharmacological therapy fails, is mechanical circulatory support. There is a lack of percutaneous systems to support the right ventricle (RV). Venoarterial extracorporeal membrane oxygenation is widely used as a bailout in acute RHF in non-left ventricular assist device patients. Venoarterial extracorporeal membrane oxygenation does not unload the left ventricle and may cause failure of the left ventricle if used for a longer period of time. We report the long-term use of an ECMO-based percutaneous right ventricular assist system (oxyRVAD) capable to deliver up to 6 L/min of blood flow with a returning cannula placed in the main pulmonary artery used in RHF originating from PH with poor oxygenation. We present a series of four patients on oxyRVAD (mean treatment duration 15 ± 7.6 days). Patients benefited from the system clinically; however, two patients eventually died while on oxyRVAD. Nevertheless, we provide a proof-of-concept of this system in PH patients, which is feasible and might provide a useful “bridge-to-recovery” or “bridge-to-transplant” option in the management of patients with severe RHF because of PH.

Children's professionals across social care, health and education are increasingly leaving their jobs due to “burnout”. Joe Lepperexplores successful strategies to beat burnout and boost staff wellbeing

The Niles-Wolford Mound (33Pi3) was a conical Adena burial mound located along the Scioto River in Jackson Township, Pickaway County, Ohio. Excavations conducted in 1955 by the Ohio History Connection resulted in the discovery of a subfloor tomb with three burials. A tubular pipe found in association with one of the burials contained charred organic residue. Macrobotonical analysis of the material identified root or bark within the sample. Liquid chromatography-mass spectrometry (LC-MS) analyses detected the presence of various compounds, including an alkaloid. Radiocarbon dating places the mound to circa 2120 ± 30 BP. This research furthers our understanding of the timing, geographical extent, and ceremonial contexts of prehistoric plant tobacco use by the Adena culture and demonstrates the importance of museum collections for addressing such questions.

In the Eastern part of the Brunswick area a range of outcropping Mesozoic (5) and Quaternary (1) sedimentary rocks are used since historical times as building, dimension and ornamental stones. They will be studied on representative cultural monuments during this field trip.

Wir berichten über den Fall einer 48-jährigen Frau, bei der vermutlich durch eine intramuskuläre Glukokortikoidinjektion eine Phäochromozytomkrise ausgelöst wurde. Im Rahmen dieser Krise kam es zur Entwicklung eines kardiogenen Schocks mit Reanimationspflichtigkeit, woraufhin die Implantation einer venoarteriellen extrakorporalen Membranoxygenierung (VA-ECMO, Cardiohelp®, Maquet, Rastatt) notwendig wurde. Zur Behandlung eines durch die VA-ECMO entstandenes Lungenödem wurde eine Impella-CP® (Abiomed, Aachen) implantiert. Im weiteren Verlauf führten wir eine Koronarangiographie, die Entnahme von linksventrikulären Endomyokardbiopsien sowie eine Computertomographie (CT) des Thorax und des Abdomens durch. Letztendlich zeigte sich eine 7 cm mal 5 cm große Tumorformation im Bereich der linken Nebenniere. Im Serum konnten wir deutlich erhöhte Katecholaminwerte nachweisen, sodass wir bei der Patientin die Diagnose eines Phäochromozytoms stellen konnten. Als endgültige Therapie wurde im Verlauf eine operative Tumorexzision durchgeführt. We report the case of a 48-year old woman where probably the intramuscular administration of glucocorticoids by an orthopedist induced a pheochromocytoma crisis. The development of a cardiogenic shock with a cardiac arrest made the use of a venoarterial extra corporeal membrane oxygenation (VA-ECMO, Cardiohelp®, Maquet, Rastatt) necessary. To treat a pulmonary edema under VA-ECMO an Impella-CP® (Abiomed, Aachen) was implanted. A coronary angiography, endomyocardial biopsies and a computer tomography were performed. Finally a 7 cm × 5 cm tumor mass in the left adrenal medulla was detected. The blood values presented high levels of catecholamines. The total results of the examinations led us to the final diagnosis of a pheochromocytoma which was finally surgical removed.

Supplemental Digital Content is available in the text.Mortality in patients treated with extracorporeal membrane oxygenation (ECMO) is high. Therefore, it is crucial to better understand conditions that are associated with mortality in ECMO patients. In this retrospective analysis, we observed 51 patients treated with high-flow ECMO in 2013 and 2014 at our center. We recorded laboratory values and intensive care procedures. The hypothesis of bilirubin being a predictor of mortality during ECMO treatment was initially addressed. Therefore, laboratory values were obtained before initiation and at the time of highest bilirubin throughout the procedure. Receiver operating characteristic (ROC) curves and survival analysis were conducted. Our cohort consisted of patients with advanced age (median: 55 years; range: 22–76) and high mortality (26/51; 51%). Lactate, bilirubin, and NT-pro-BNP were significantly (p< 0.05) associated with mortality in univariable analyses. The cut-off values with highest Youden’s index were bilirubin ≥10 mg/dl, lactate ≥2.25 mmol/L, and NT-pro-BNP ≥11,500 pg/ml. A multivariable analysis, revealed an area under the curve (AUC) of 0.85 (95% confidence interval [CI]: 0.74–0.97), sensitivity of 0.79, and specificity of 0.91. Bilirubin, lactate, and NT-pro-BNP were associated with mortality during ECMO treatment. However, laboratory values were only evaluated at the time of peak bilirubin.

National Citizen Service boss sets out rationale for moving programme to a year-round offer while slimming down core residential element to reduce costs, but experts fear it may dilute the experience for young people

ABSTRACTRadiocarbon dates reported by Romain and colleagues (2017) suggesting that Serpent Mound (33AD1) is an Adena effigy mound are problematic because they cannot be linked reliably to cultural activities associated with the original construction of the effigy mound. Additional arguments offered by Romain and colleagues (2017) in support of an Early Woodland age for Serpent Mound also are unconvincing. A Late Prehistoric age for Serpent Mound is supported by the radiocarbon dates reported previously, new radiocarbon dates, the relative abundance of serpent imagery in the Fort Ancient culture and the contemporaneous Mississippian Tradition, the virtual absence of serpent imagery in the Adena culture, and the fact that, whereas effigy-mound building is otherwise unknown in the Early Woodland period, it is well documented, if rare, for the Fort Ancient culture and in the not-so-terribly-far-away upper Midwest it is so common that it defines the broadly contemporaneous Effigy Mound culture.

We investigate the impact of peripheral cyano functionalization of the previously well-studied 2H-tetraphenylporphyrin (2HTPP) by scanning tunneling microscopy (STM) and density functional theory (DFT). The adsorption behavior of 2H-tetrakis(p-cyano)-phenylporphyrin (2HTCNPP) is studied at room temperature and at 80 K on Cu(111) and Ag(111). Interestingly, the cyano-functionalized porphyrins tend to form isolated 1D chains on Cu(111), in particular after mild annealing at 350 K. The individual 2HTCNPPs as well as the formed chains are oriented along the main crystallographic directions of the Cu(111) substrate due to a strongly attractive and site-specific interaction between the iminic nitrogens of the 2HTCNPP and Cu substrate atoms. The linking within the 1D molecular chains is realized by Cu adatoms as evidenced by comparison of STM and DFT. In contrast, on Ag(111) the molecules assemble into 2D supramolecular layers with long-range order and a square unit cell, stabilized by molecule–molecule interactions. The orientation of the molecules with respect to the unit cell lattice vectors leads to organizational chirality. By codeposition of cobalt, the porphyrin molecules are metalated at room temperature. We did not observe any evidence for metal–organic network formation on Ag(111), even after varying the deposition parameters or the order of metal and porphyrin deposition. Our study shows that cyano functionalization of porphyrins can give rise to novel and unique self-assembled structures like 1D molecular chains without any cross-connections via adatom linking.

Recruitment and retention challenges in children's services mean councils are searching for new ways to attract and retain social workers. Joe Lepperlooks at different approaches and investigates what actually works

The pathophysiology underlying the autoimmune disease type 1 diabetes (T1D) is poorly understood. Obtaining an accurate proteomic profile of the T helper cell population is essential for understanding the pathogenesis of T1D. Here, we performed in-depth proteomic profiling of peripheral CD4+ T cells in a pediatric cohort to identify cellular signatures associated with the onset of T1D. Using only 250 000 CD4+ T cells per patient, isolated from biobanked PBMC samples, we identified nearly 6000 proteins using deep-proteome profiling with LC–MS/MS data-independent acquisition. Our analysis revealed an inflammatory signature in patients with T1D; this signature is characterized by circulating mediators of neutrophils, platelets, and the complement system. This signature likely reflects the inflammatory extracellular milieu, which suggests that activation of the innate immune system plays an important role in disease onset. Our results emphasize the potential value of using high-resolution LC–MS/MS to investigate limited quantities of biobanked samples to identify disease-relevant proteomic patterns. Proteomic profiles of 114 individuals have been deposited in a comprehensive portable repository serving as a unique resource for CD4+ T cell expression in the context of both health and T1D disease.

Published ahead of print March 15, 2017.Six patients suffering from acute respiratory distress syndrome with the need for extracorporeal membrane oxygenation (ECMO) therapy in deep sedation were included. Isoflurane sedation with the AnaConDa system was initiated within 24 hours after initiation of ECMO therapy and resulted in a satisfactory sedation (Richmond Agitation-Sedation Scale −4 to −5). Despite deep sedation, spontaneous breathing was possible in 6 of 6 patients. We observed a reduced need for vasopressor therapy and improved lung function (Pao2, Paco2, delta P, and tidal volume) during isoflurane sedation. Opioid consumption could be reduced, and only very low doses of isoflurane were needed (1–3 mL/h). This small case series supports the feasibility of sedation using inhaled anesthetics concurrently with venovenous ECMO.

Research on stimulus–stimulus pairing to induce novel vocalizations in nonverbal children has typically employed response‐independent pairing (RIP) procedures to condition speech sounds as reinforcers. The purpose of the present study was to evaluate the effects of a response‐contingent pairing (RCP) procedure on the vocalizations of three nonverbal boys diagnosed with autism spectrum disorder. During RCP, adult‐delivered sounds that were either paired with a preferred item (target sounds) or not (nontarget sounds) were presented contingent on a button‐press response. In Experiment 1, RCP was compared with an RIP procedure, in which the timing of sound presentations was yoked to the preceding RCP session. RCP produced a greater effect on all participants' target vocalizations than RIP. Experiment 2 demonstrated the effects of differential reinforcement of the vocalizations induced in Experiment 1. The results suggest that RCP may develop vocalizations more reliably than RIP procedures.