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Microcephaly, characterized by crania with an abnormally small occipitofrontal circumference (OFC), is only sporadically described in paleopathological literature. Accurate identification of individuals suffering from microcephaly is challenging when performed in an archeological context, especially in mild cases, as appropriate reference data are often not available. This study aimed to describe the craniometric characteristics of the Meerenberg (MeB) skeletal collection and to identify microcephalic individuals while focusing on the diagnostic criteria and the influence of reference data on the prevalence of the condition. The value of virtual endocasts as a diagnostic tool was also assessed. Forty‐eight adults (1891–1936) excavated from the cemetery of the MeB psychiatric hospital (Bloemendaal, The Netherlands) were investigated. Microcephalic individuals were identified by using the craniometric characteristics of a contemporary Dutch archeological population as reference. In order to investigate the usefulness of modern clinical head circumference reference data on the diagnostic process, cranial OFCs of the MeB individuals were converted to head OFCs. Virtual endocasts were created from the identified microcephalics and three normocephalics. Three MeB females (all <−3 SD) were identified as microcephalic when compared with a sex‐matched contemporary archeological reference sample. The same three MeB females were classified as microcephalic when using sex‐matched modern clinical reference data and when applying −3 SD of the pooled sex archeological craniometric reference data as cut‐off point. No individuals were classified as microcephalic based on the metric characteristics of the virtual endocasts. Microcephaly can only be accurately identified when using sex‐matched contemporary population reference data, or in its absence, modern clinical data after soft tissue correction. Should sex estimation be unreliable, a –3 SD cut‐off point generated using pooled sex reference data seems suitable as diagnostic tool. Virtual endocast did not support the identification of microcephaly in this study. [ABSTRACT FROM AUTHOR]

Since the first ERAS consensus statement was published fifteen years ago, an increasing number of ERAS® Society guidelines and recommendations have been published and proven to be successful in many elective surgical specialties [[1]]. Enhanced recovery after surgery (ERAS®) society consensus guidelines emergency laparotomy part 3: organizational aspects and general considerations for management of the emergency laparotomy patient. [Extracted from the article]

One of the goals of the Forensic Anthropology Society of Europe (FASE) is to map the existing education and practice opportunities in the field of forensic anthropology in order to support the development of the discipline and to optimize the training courses provided by the Society. To address this goal, an online questionnaire was sent to European and South African practitioners of forensic anthropology and related disciplines in 2016. The results of the questionnaire showed that the status and roles of forensic anthropologists vary depending on the national legal systems, education, and employment status of the practitioners. Despite the fact that the expertise of forensic anthropologists has been increasingly requested in a variety of investigations and the spectrum of tasks has become broader, including identification of living persons, specialized education in forensic anthropology is still restricted to a few graduate and postgraduate programs in European countries and to annual FASE courses. [ABSTRACT FROM AUTHOR]

Key clinical message: Bilateral enlarged adrenal glands are rare, and as diagnostic delay may have serious consequences for the patient, we recommend a multidisciplinary approach of specialists in the field of endocrinology, oncology, radiology, and clinical chemistry prior to the start of the diagnostic work‐up. [ABSTRACT FROM AUTHOR]

Summary: Background: After reversal of a rocuronium‐induced neuromuscular blockade with sugammadex, the recovery of train‐of‐four ratio to 0.9 is faster than recovery of first twitch of the train‐of‐four to 90% in adults. These findings after reversal of neuromuscular blockade with sugammadex have not yet been investigated in pediatric patients. Aims: The aim of this retrospective analysis was to investigate the relationship of the recovery of first twitch of the train‐of‐four height and train‐of‐four ratio after reversal of rocuronium‐induced neuromuscular blockade with sugammadex in pediatric patients. Methods: Patients ASA I‐III, aged 2‐11 years, and who underwent abdominal and/or perineal surgery were included in the analysis. After extracting the necessary data from the hospital database, the patients were divided into 2 groups based on the dose of sugammadex received: group A: 2 mg.kg−1 for reversal of moderate neuromuscular blockade and group B: 4 mg.kg−1 for reversal of deep neuromuscular blockade. The relationship of the recovery of first twitch of the train‐of‐four height and train‐of‐four ratio in these 2 groups were analyzed. Results: Data from 43 pediatric patients aged 2‐11 years could be analyzed. The first twitch of the train‐of‐four height at the recovery of train‐of‐four ratio to 0.9 in group B was statistically significantly lower compared with group A. This height 3 and 5 minutes after the train‐of‐four ratio reached 0.9 showed no statistically significant differences between groups. Conclusion: The results were in line with the results found in adults and showed that the train‐of‐four ratio recovered to 0.9 was faster than first twitch of the train‐of‐four height recovered to the same level. [ABSTRACT FROM AUTHOR]

Purpose: A new system for software-controlled, highly automated correction of intrafraction prostate motion,' intrafraction stereographic targeting' (iSGT), is described and evaluated. Methods: At our institute, daily prostate positioning is routinely performed at the start of treatment beam using stereographic targeting (SGT). iSGT was implemented by extension of the SGT software to facilitate fast and accurate intrafraction motion corrections with minimal user interaction. iSGT entails megavoltage (MV) image acquisitions with the first segment of selected IMRT beams, automatic registration of implanted markers, followed by remote couch repositioning to correct for intrafraction motion above a predefined threshold, prior to delivery of the remaining segments. For a group of 120 patients, iSGT with corrections for two nearly lateral beams was evaluated in terms of workload and impact on effective intrafraction displacements in the sagittal plane. Results: SDs of systematic (Σ) and random (σ) displacements relative to the planning CT measured directly after initial SGT setup correction were <0.5 and <0.8 mm, respectively. Without iSGT corrections, effective Σ and σ for the 11-min treatments would increase to Σeff < 1.1 mm and σeff < 1.2 mm. With the iSGT procedure with an action level of 4 mm, effective positioning errors were reduced to Σeff < 0.8 mm and σeff < 1.0 mm, with 23.1% of all fractions requiring a correction. Computer simulations demonstrated that with an action level of 2 mm, the errors would have been reduced to Σeff < 0.6 mm and σeff < 0.7 mm, requiring corrections in 82.4% of the fractions. Because iSGT is highly automated, the extra time added by iSGT is <30 s if a correction is required. Conclusions: Without increasing imaging dose, iSGT successfully reduces intrafraction prostate motion with minimal workload and increase in fraction time. An action level of 2 mm is recommended. [ABSTRACT FROM AUTHOR]

A high dosimetric accuracy is required for radiotherapy treatments where IMRT in combination with narrow treatment margins is applied to achieve optimally conformal dose distributions. In order to routinely verify the in vivo fluence delivery (i.e., during the actual patient treatment), our method for predicting portal dose images with a patient in the beam was validated. A unique feature of this method is that it is fully based on calibration measurements with an EPID. The portal dose image (PDI) behind a patient is dependent on the transmission of primary radiation through the patient and a contribution of scattered radiation from the patient. To derive both components, the patient geometry as observed in the planning CT scan is converted into an equivalent homogeneous phantom. A limited set of EPID measurements is required to derive the input parameters of this model. The accuracy of the in vivo PDI prediction was verified using measurements behind phantoms and four prostate cancer patients treated with IMRT. Behind homogeneous slab phantoms, the local differences between measured and predicted PDIs were within 2% inside the field, while behind a lung and a pelvic phantom, the agreement was within 3% or within 3 mm in regions with steep gradients. Outside the fields, the PDIs agreed within 2% of the global dose maximum. Evaluation of the in vivo PDI measurements behind patients showed that, on average, 87% of the pixels inside the field fulfilled the 3% local dose and 3 mm distance-to-agreement criteria. For half of the failing pixels the differences occurred due to changes in patient geometry with respect to the planning CT or due to beam attenuation by the treatment couch that was not accounted for. A fully EPID-based method for predicting portal dose images using the planning CT scan has been implemented and validated for phantoms and clinical patients. [ABSTRACT FROM AUTHOR]

A 54- year-old man presented with total atrioventricular (AV) block 3 months after dynamic cardiomyoplasty was performed because of heart failure due to idiopathic dilated cardiomyopathy. Though the cardiomyostimulator acted as a back-up pacemaker, a DDDR pacemaker was implanted to optimize hemodynamics. During testing no cross-sensing or cross-stimulation between the pacemaker and the cardiomyostimulator was demonstrable. The synchronization delay, however, had to be adjusted. [ABSTRACT FROM AUTHOR]

A promising new pacemaker that provides on-line measurements of right ventricular (RV) impedance was evaluated in ten patients with symptomatic second- or third-degree atrioventricular (AV) block. We tested the assumption that if changes in RV impedance represented changes in RV stroke volume (SV), conditions known significantly to affect RV SV should be accompanied by significant changes in RV impedance. One week after pacemaker implantation, RV impedance was measured noninvasively during normal respiration in the supine (baseline), left lateral, right lateral, sitting, and standing positions. In addition, all patients performed a Valsalva maneuver test. The amplitude of the impedance signal was different during in- and expiration in every body position studied. At baseline, the amplitude of the signal was 18.80 ± 2.24 mm; in the right lateral position 16.75 ± 3.24 mm (P = 0.04) and 17.80 ± 2.35 mm in the left lateral position (P = 0.04). The amplitude of the signal in the sitting position was 16.65 ± 2.89 mm (P = 0.07) and in the standing position 16.95 ± 3.44 mm (P = 0.11). The most impressive change in amplitude was noted during performance of the Valsalva maneuver. During this test the amplitude decreased to 13 ± 2.81 mm and rose to 20 ± 2.66 mm (P = 0.002) afterwards, These results strongly support the assumption that changes of RV impedance as measured by this catheter represent changes in RV SV. This new pacing system is the first pacemaker that reports on the hemodynamic response of every heartbeat by measuring RV impedance. [ABSTRACT FROM AUTHOR]

We investigated the possibility to use the interval from an atrial stimulus to the ventricular B wave (A-R interval) as an indicator of physical stress, in 16 patients with pacemakers implanted for severe atrial bradycardia but with intact AV conduction. The A-R interval was studied during incremental atrial pacing at rest and during exercise with a constant workload. In addition, the atrial pacing rate was kept constant just above spontaneous sinus rate and the dynamics of the A-R interval were studied during exercise with a low constant workload and during a maximal exercise test with increasing workload. Incremental atrial pacing prolonged the A-R interval and this response was blunted during exercise (P < 0.003). Atrial pacing at a constant rifle and during a constant workload resulted in an almost direct shortening of the A-R interval, When the workload was increased but the atrial rate kept constant. a pronounced shortening of the A-R interval was noted (P < 0.0001). It is concluded that changes of the A-R interval during different kinds of exercise were prompt and predictable in patients with sinus node dysfunction but intact AV conduction. In these patients the shortening of the A-R interval during exercise may be a suitable indicator for rate adaptive atrial pacing. [ABSTRACT FROM AUTHOR]

Differential bipolar sensing was evaluated in 10 consecutive patients with symptomatic heart block managed with dual chamber pacing. During pacemaker implantation atrial and ventricular electrograms were recorded using unipolar (UP) and differential bipolar (DBP) sensing amplifiers. The mean peak-to-peak amplitudes of the UP and DBP atrial electrograms were 3.3 ± 1.2 mV and 4.2 ± 1.2 mV, respectively. The difference was statistically significant (p < 0.05). The mean peak-to-peak amplitudes of the ventricular electrograms were, respectively, 6.8 ± 1.5 mV and 7.5 ± 1.4 mV (p < 0.01). Within 6 weeks after pacemaker implantation, patients visited the outpatient clinic. Isometric exercise tests were performed during UP and DBP sensing of the pacing system. Myopotential sensing in the ventricle occurred in nine patients during UP sensing and in none of the patients during DBP sensing (p < 0.01) at a sensitivity setting of 0.5 mV. In addition, chest wall stimulation was performed to assess the effects of far-field signals on the ventricular sensing circuit of the pulse generator. Chest wail stimuli inhibited ventricular output during UP sensing in all 10 patients, whereas during DBP sensing inhibition of the ventricular channel occurred in three patients and then only at high output (>8 V) settings. The susceptibility of the pacing system to crosstalk was also determined. However, neither during UP sensing nor during DBP sensing could cross-stimulation or cross-inhibition be demonstrated. In conclusion, DBP sensing is superior to UP sensing in terms of myopotential and far-field sensing. In addition, statistically significant differences were observed in amplitudes of UP and DBP atrial or UP and DBP ventricular signals. The clinical relevance of the latter finding remains to be assessed. [ABSTRACT FROM AUTHOR]

In this report we present the case of a patient with recurrent syncopal episodes. During one of the attacks the patient was monitored by telemetry and the ECG lead showed asystole for more than 7 seconds. As in cases of the cardioinhibitory type of hypersensitive carotid sinus syndrome (HCSS), asystole may represent suppression of the sinus node or suppression of both sinus and atrioventricular (AV) node. Unfortunately, in contrast to HCSS, there is no maneuver that can reproducibly induce of sinus arrest. In the patient described in this report, we were able to demonstrate that suppression of sinus and AV nodes occurred simultaneously. It is interesting to note that in this type of syncope data from noninvasive and invasive techniques in assessing sinus nodal and AV nodal conduction may not be conclusive. In the group of patients with this type of syncope, permanent atrial demand pacing is contraindicated. [ABSTRACT FROM AUTHOR]

ECG tracings of three patients in whom AV universal (DDD) pacemakers were implanted intermittently demonstrated dropped P waves. In one patient, true atrial undersensing was present; in the others, sensing of the atrial electrode was appropriate, but sensing of sinus P waves was intermittently blocked by normal pacemaker operation. In this report we discuss the electrocardiographic diagnosis of atrial undersensing in order to avoid unnecessary reinterventions. [ABSTRACT FROM AUTHOR]

A rate smoothing option is available in a new bipolar AV universal (DDD) pacemaker. In three patients, two with intact retrograde conduction and one with retrograde block, rate smoothing values of 3% and 6% were programmed. Irregular pacemaker-mediated tachycardia occurred in one patient and AV synchrony was temporarily lost in the other two patients. In this report, we describe the pacemaker electrocardiography of rate smoothing during DDD pacing. [ABSTRACT FROM AUTHOR]

To evaluate factors playing a role in initiation and perpetuation of pacemaker-mediated tachycardias [PMTs], 22 consecutive patients with symptomatic conduction disorders were studied after implantation of an AV universal [DDD] pulse generator [Cordis 233D]. Patients were divided into two groups, depending upon the presence or absence of ventriculo-atrial (VA) conduction during electrophysiological study (EPS) performed before pacemaker implantation. PMTs could be initiated in six of eight patients of Group I and in none of 14 patients of Group II. Initiation and perpetuation of PMTs during DDD pacing were dependent upon the capacity of the patient to conduct ventricular premature beats (VPJBS) and subsequent paced ventricular beats retrogradely to the atria, and upon three programmable parameters of the pulse generator (AV delay period, upper rate limit, tachycardia response). Programmed single ventricular extrastimulation demonstrated that: (1) merely the presence of VA conduction during EPS, although necessary, was not sufficient to induce PMTs after DDD pacemaker implantation; (2) VPBs introduced late rather than early in the cardiac cycle initiated PMTs in a different way; [3) the initiation of PMTs could be prevented during study by adjusting the programmable parameters (AV delay period, upper rate limit, tachycardia response); (4) one of the two available tachycardia responses of the pulse generator (gradual fall-back response) was able to terminate and initiate PMTs consistently. These observations helped in understanding the responses of the Gordis 233D pulse generator to ventricular premature beats. They indicate that additional refinement of the pulse generator is necessary to solve the problem of PMT. [ABSTRACT FROM AUTHOR]

In 14 patients with symptomatic sinus node dysfunction--sinus bradycardia, sino-atrial exit block, or sinus arrest--electrophysiological studies were performed before implantation of a pacemaker. In 8 patients incremental high right atrial pacing showed AV-nodal Wenckebach at pacing rates equal to or above 130/min (group I); in 6 patients AV-nodal Wenckebach was reached at pacing rates less than 130/min (group II). During ventricular pacing at a rate 10-35% faster than the existing sinus rate, ventriculo-atrial (VA) conduction was present in all patients of group I. while VA conduction was present in only 2 patients of group II (p < 0.05). Patients with symptomatic sinus node dysfunction but with intact AV conduction frequently show VA conduction during ventricular pacing and thus are particularly at risk for developing a pacemaker syndrome when a ventricular demand (VVI) pacemaker is implanted. This complication can be avoided by atrial demand (AAI) pacing or A V sequential (DVI) pacing. When adequate experience has been gathered with A V universal (DDD) pacemakers, the indications for selection of a pacemaker in patients with symptomatic sinus node dysfunction will probably change. [ABSTRACT FROM AUTHOR]

A case is reported in which a child with Duchenne muscular dystrophy received a dose of sugammadex to reverse a rocuronium-induced profound neuromuscular block. Sugammadex is the first selective relaxant binding agent and reverses rocuronium- and vecuronium-induced neuromuscular block. A fast and efficient recovery from profound neuromuscular block was achieved, and no adverse events or other safety concerns were observed. [ABSTRACT FROM AUTHOR]

Background: Although the Absorb bioresorbable vascular scaffold is increasingly used in daily clinical practice for the treatment of coronary artery disease, the exact vascular healing pattern and the resorption process in humans is unknown because histological data are derived only from animal studies., Methods and Results: We have obtained 4 autopsies (5 scaffolds) since August 2013. Duration of bioresorbable vascular scaffold implantation ranged from 3 to 501 days. All autopsies and histological assessments were performed by dedicated cardiovascular pathologists. At 1 week after bioresorbable vascular scaffold implantation, struts were covered with a fine layer of fibrin and platelets. At 113 days, the scaffold struts were fully covered with smooth muscle cells. Hyaline eosinophilic and proteoglycan material infiltrating the scaffold struts was observed at 501 days after implantation. At all time points, we observed the presence of multinuclear foreign body giant cells adjacent to the scaffold struts., Conclusions: Resorption and healing processes after bioresorbable vascular scaffold implantation in human patients mirror those observed in porcine models. The presence of multinucleated foreign body giant cells at both short- and long-term follow-up needs further investigation and may be related to a low-grade absorptive inflammatory response to the polymer., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)