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The investigation of the predictors of outcome after hepatic resection for solitary colorectal liver metastasis. We recruited 350 patients with solitary colorectal liver metastasis at the University Hospitals of Jena and Magdeburg, who underwent curative liver resection between 1993 and 2014. All patients had follow-up until death or till summer 2016. The follow-up data concern 96.6% of observed patients. The 5- and 10-year overall survival rates were 47 and 28%, respectively. The 5- and 10-year disease-free survival rates were 30 and 20%, respectively. The analysis of the prognostic factors revealed that the pT category of primary tumour, size and grade of the metastasis and extension of the liver resection had no statistically significant impact on survival and recurrence rates. In multivariate analysis, age, status of lymph node metastasis at the primary tumour, location of primary tumour, time of appearance of the metastasis, the use of preoperative chemotherapy and the presence of extrahepatic tumour proved to be independent statistically significant predictors for the prognosis. Moreover, patients with rectal cancer had a lower intrahepatic recurrence rate, but a higher extrahepatic recurrence rate. The long-term follow-up of patients with R0-resected liver metastasis is multifactorially influenced. Age and comorbidity have a role only in the overall survival. More than three lymph node metastasis reduced both the overall and disease-free survival. Extrahepatic tumour had a negative influence on the extrahepatic recurrence and on the overall survival. Neither overall survival nor recurrence rates was improved using neoadjuvant chemotherapy.

Zusammenfassung Einleitung Ziel war es, den Einfluss von Diabetes mellitus (DM) auf das frühpostoperative und langfristige „Outcome“ nach operativer Intervention beim Rektumkarzinom anhand prospektiv-multizentrisch gewonnener Daten einer repräsentativen Patientenzahl zu untersuchen. Methode Es wurden Daten der Qualitätssicherungsstudie „Rektum-Karzinom (Primärtumor) – Elektiv-Operation“ der Jahre 2008 – 2011 herangezogen, die über einen Erfassungsbogen mit 68 Items dokumentiert wurden. Über ein freiwilliges und regelmäßiges „Follow-up“ wurden Langzeitdaten eruiert. Unterteilt wurde in Patienten ohne DM und solche mit nicht- bzw. insulinpflichtigem DM (NIDDM bzw. IDDM). Ergebnisse Insgesamt wurden 10 442 Patienten eingeschlossen, zu 11,0 % NIDDM- und zu 7,2 % IDDM-Patienten. Patienten ohne DM waren mit durchschnittlich 67,3 (95 %-KI: 67,07; 67,55) Jahren jünger als IDDM- mit 71,7 (95 %-KI: 71,01; 72,35) Jahren oder NIDDM-Patienten mit 70,9 (95 %-KI: 70,41; 71,45) Jahren (p Diskussion Die metabolische Störung DM stellt wahrscheinlich neben dem patienteneigenen Risikopotenzial durch die Kombination der vergesellschafteten Komorbiditäten einen relevanten Einflussfaktor auf das „Outcome“ nach Rektumkarzinom-Chirurgie dar. Die postoperative Morbidität und Letalität werden erhöht, das onkochirurgische Überleben verringert.

Background and purpose This study presents the evaluation of acute and late toxicities of the lung in children and adolescents after irradiation in terms of dose–volume effects. Materials and methods Irradiated children and adolescents in Germany have prospectively been documented since 2001 in the “Registry for the Evaluation of Side-Effects after Radiotherapy in Childhood and Adolescence (RiSK)”; in Sweden since 2008 in the RADTOX registry. Results Up to April 2012, 1,392 children were recruited from RiSK, and up to June 2013, 485 from the RADTOX-registry. Of these patients, 295 were irradiated to the lung. Information about acute toxicity was available for 228 patients. 179 patients have been documented concerning late toxicity (≥grade 1: n = 28). The acute toxicity rate was noticeably higher in children irradiated with 5–20 Gy (p < 0.05). In the univariate analysis, a shorter time until late toxicity was noticeably associated with irradiation with 5–15 Gy (p < 0.05). Conclusion Acute and late toxicities appear to be correlated with higher irradiation volumes and low doses. Our data indicate that similar to the situation in adult patients, V5, V10, V15 and V20 should be kept as low as possible (e.g., at least V5 < 50%, V10 and V15 < 35% and V20 < 30%) in children and adolescents to lower the risk of toxicity. (Less)

From the perspective of policymakers, young people are often regarded as the most important group for the future development of rural regions experiencing socioeconomic polarisation. They, in turn,...

Zusammenfassung Einleitung Pathologische Fistelungen des arteriellen Systems zu luminalen Organsystemen stellen eine Herausforderung in ihrem adäquaten Management dar. Ziel Wissenschaftlicher Fallbericht zur kombiniert gefäßchirurgisch und interventionell-radiologischen Versorgung einer seltenen rechtsseitigen uretero-iliakalen Fistel unter Diskussion des Vorgehens und Zusammenfassung gewonnener klinischer Erfahrungen. Fallkonstellation Stationäre Aufnahme eines 79-jährigen Patienten mit Hämaturie und Blasentamponade bei aktinisch bedingten Ureterstrikturen beidseits infolge neoadjuvanter Radiochemotherapie (im Rahmen der Vorbereitung einer abdominoperinealen Rektumexstirpation wegen suprasphinktären Karzinoms [ypT3ypN0M0]). Das Labor erbrachte eine Anämie, die transabdominale Sonografie eine Harnstauung bds. Die CT wies keine manifeste Blutung infolge wechselnder Hämorrhagieepisoden nach. Interventionelle Maßnahmen Zunächst erfolgten Blasenspülung und Katheterwechsel in den Ureteren. Aufgrund der ausgelösten rechtsseitigen endoluminalen Blutung in den rechten Ureter wurde die kombiniert gefäßchirurgische/interventionell-radiologische Versorgung mit i) Amplatzer-Insertion (AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, U.S.A.) in die A. iliaca interna dextra und ii) rechts-iliacalem Stenting durch „cross-over“-Manöver von links-femoral vorgenommen. Verlauf Infolge einer Dissektion am arteriellen Zugang rechts-femoral erfolgte eine Gefäßdesobliteration und Intimarefixation in der A. femoralis superficialis dextra. Der Patient stabilisierte sich zeitgerecht (u. a. periinterventionelle ITS-Betreuung) bei Entlassung am 15. postinterventionellen Tag ohne Anhalt für lokales Rektumkarzinomrezidiv. Eine Re-Blutung war nicht aufgetreten. Weiterhin waren Doppel-J-Katheterwechsel erforderlich. Zusammenfassung Die zügige Hybrid-Operation ist im präsentierten Fall als absolut indizierte und prognostisch aussichtsreiche Vorgehensweise für die rezidivierende arterielle Blutung einer uretero-iliakalen Fistel anzusehen. Schlussfolgerung Das minimal-invasive Herangehen mittels Stenting ist die Methode der Wahl im stufenweisen und zeitgerechten Management der potenziell lebensbedrohlichen uretero-iliakalen Fistel bei arterieller endoluminaler Blutung und drohendem hämorrhagischen Schock.

Zusammenfassung Hintergrund/Zielsetzung In den chirurgischen Fächern ist seit Jahren ein Nachwuchsmangel festzustellen. Wegen des abnehmenden Interesses an Chirurgie bereits im Studium empfehlen die Fachgesellschaften u. a. eine Stärkung der Betreuung während der praktischen Phasen des Medizinstudiums zur Steigerung der Attraktivität des Fachbereichs. Innerhalb der curricularen Praxisphasen des Medizinstudiums nimmt die Famulatur als erste ärztliche Tätigkeit eine besondere Stellung ein. Ziel dieser Studie war es, Bedeutung und Einflüsse von Famulaturerfahrungen für die Fachpräferenz einer Wunschdisziplin bei Famulierenden zu untersuchen. Methoden Es wurden Humanmedizinstudierende der Otto-von-Guericke-Universität Magdeburg zu 4 verschiedenen Zeitpunkten im klinischen Studienabschnitt (n total = 373) über ihre Auswahlkriterien der Famulaturfächer und zu ihren Famulatureindrücken befragt. Hierzu wurden Fragen zu 5 Themenblöcken anhand einer 5-stufigen „Likert-Skala“ von 1 bis 5 (trifft „außerordentlich“ bis „gar nicht“ zu) eingeschätzt. Die Ergebnisse wurden statistisch analysiert. Ergebnisse Die Famulatur hat eine erhebliche Bedeutung für die frühe Laufbahn eines Studierenden. Medizinstudierende nutzen die Famulatur, um gezielt Fächer, die für ihre spätere Weiterbildung infrage kommen, kennenzulernen. Eigene und besonders auch fremde Einschätzungen und Erfahrungen einer Klinik oder von Ausbildern beeinflussen die Entscheidung zu Famulaturfach und -ort. Famulaturvorbereitende Lehrformate können diesen Effekt verstärken. Aus Sicht der befragten Studierenden sollten sich Inhalte der Famulatur an Gelehrtes und Gelerntes des Studiums anschließen. Studierende erwarten Einblick und praktische, bereichsübergreifende, auch interdisziplinär geprägte Mitarbeit in einem Famulaturfach. Aus studentischer Sicht beeinflussen die Famulaturerfahrungen in den chirurgischen Fächern im Gegensatz zu den nicht chirurgischen Erfahrungen eine Weiterbildungspräferenz für operative Fächer und sind somit ein relevanter Prädiktor. Schlussfolgerung Lehre im Spannungsfeld der Famulatur ist als wichtige Komponente für die Orientierung zu einer chirurgischen Laufbahn wirksam. Unterstützende fachspezifische Lehre zur Famulatur kann durch Verbesserung des Praktikumserlebens zu einer zusätzlichen Verstärkung dieses fachpräferenzbildenden Effekts einer Famulatur beitragen. Positive Famulaturerfahrungen werden von Studierenden attraktivitätssteigernd für das Fach wahrgenommen und können so ein Interesse an einer chirurgischen Tätigkeit bereits im Studium stärken.

The dimensional stability of a UV printed polymer microstructure for a novel glazing system for seasonal regulation and daylighting based on a periodic array of parabolic micro-mirrors is investigated. The objectives of the work are: i) to analyze the dimensional changes of UV-printed microstructures related to polymerization and thermal aging; and ii) to identify the impact of these changes on the optical properties of the system. The period was found to be stable, with shrinkage below 1.5% after printing, independent of PI concentration, and remained constant upon thermal exposure. In contrast, dimension W 1/2 decreased by up to 14.5% with time at 80°C, presumably due to physical aging processes. A change of height also occurred, but it was partly compensated by the change of W 1/2 as a result of Poisson's effects and a complex distribution of internal stress. The impacts of these dimensional changes on the redirection of daylight were also investigated.

In many parts of Germany, processes of secularization overlap with ongoing sociodemographic changes such as outmigration and population decline. As a result, Christian churches face significant financial pressure due to plummeting numbers of parish members. In East Germany, these circumstances are aggravated by policies of de-Christianization during the socialist past. Using a case study in the Evangelical Church in Central Germany and its church district Altenburger Land, we argue that forms of post-secular rapprochement – transgression of boundaries of belief – develop following severe budget cuts and the withdrawal of pastoral positions. Contemporary literature on post-secular rapprochement specifically illuminates social issues emerging in urban landscapes due to neoliberal policies. In contrast, we highlight corresponding incidents of cooperation in peripheralized regions. On the one hand, parish members in our case study region aim to cooperate with local clubs to organize common festivities and increase their visibility. On the other hand, they attempt to get in touch with other Christian groups in a more subtle way. Hereby, we illuminate the everyday work of post-secular rapprochement in peripheralized regions using an empirically driven and practice–theory-based approach.

Papillary thyroid carcinoma is the most common neoplasm of the thyroid gland which is usually associated with a very good prognosis. The aim of this case report is to present the disease course of a rare tumor of the thyroid gland, which is worthwhile due to its extraordinary appearance and specific management. A 46-year-old patient presented with a pronounced right-sided, but bilateral, multinodular goiter, with a volume of approximately 80 mL, as assessed on ultrasonography. Surgical removal was indicated as scintigraphy showed a 4-cm cold nodule that almost completely took up the right thyroid lobe. Because of the micronodular texture of the left thyroid lobe, complete thyroidectomy was performed according to well-established guidelines. Histopathological investigation of the specimen revealed a follicular adenoma without any malignancy in the right thyroid lobe and the tall-cell variant of the papillary thyroid microcarcinoma in the left lobe, with a capsular invasion and diameter of 0.6 cm. Because this rare tumor subtype is known for its aggressive behavior, and there was capsular invasion, low-grade differentiation, and an increased risk for lymphatic metastases, completion lymphadenectomy of the central compartments was performed after an interdisciplinary board decision. On histopathology, there were 30 tumor-free lymph nodes; final TNM classification was as follows: pT3 pN0 [0/30] L0 V0 Pn0 R0). The postoperative course was uneventful, and surgery was followed by radioiodine therapy. Six months after the surgery, clinical follow-up did revealed any sign of recurrence. The tall-cell variant is a rare and aggressive subtype of the papillary thyroid carcinoma, and it is characterized by poor 5-year survival and high recurrence rate. According to our understanding and based on current literature, this disease requires an aggressive surgical treatment and a close follow-up, as recommended by the current guidelines.

Zusammenfassung Hintergrund Die akute Leberfunktionsstörung als akutes Leberversagen (ALV) oder akut-auf-chronisches Leberversagen (ACLV) ist ein intensivmedizinisches, interdisziplinär zu behandelndes Krankheitsbild mit einem hohen Letalitätsrisiko. Ziel Nomenklatur, Pathophysiologie, Prognose und mögliche Therapieoptionen des ALV und des ACLV sollen erläutert werden einschließlich der Möglichkeiten der extrakorporalen Leberersatztherapie an der Schwelle zur Lebertransplantation (LTx). Methode Narrative Übersicht mit selektiver Literaturrecherche und eigenen repräsentativen Fallbeispielen. Ergebnisse/Eckpunkte ALV und ACLV haben vielfältige Ursachen und eine hohe Letalität. Beim ALV kommt es auf die genaue Ermittlung der Ursache an, weil teilweise spezielle Therapiemöglichkeiten zur Verfügung stehen. Sowohl bei ALV und ACLV kann zum Überleben eine Lebertransplantation erforderlich sein, für ALV und ACLV existieren unterschiedliche Kriterien für Indikationsstellung und Transplantatallokation. Zur extrakorporalen Leberunterstützung haben sich 2 Verfahren etabliert (MARS [molecuar adsorbent recirculating system] und FPSA [fractionated plasma separation and adsorption] Prometheus®). Beide Verfahren können in der Lage sein, bei einem ALV oder einem ACLV die Überlebenswahrscheinlichkeit zu erhöhen, und sie werden in einzelnen Fällen zum Bridging zur LTx eingesetzt, außerdem in Einzelfällen zur primären Giftelimination, z. B. nach Amatoxiningestion. Beide Verfahren sind nicht als Dauertherapie geeignet. Schlussfolgerung Akutes Leberversagen und akut-auf-chronisches Leberversagen sind schwerwiegende Krankheitsbilder mit hohem Letalitätsrisiko. Betroffene Patienten sollten schnellstmöglich einer interdisziplinären Intensivtherapie in einem (tertiären) Zentrum zugeführt werden mit dem Ziel, die Krankheitsursache und mögliche Therapieoptionen hinsichtlich vorgehaltener extrakorporaler Leberunterstützungsverfahren und Lebertransplantation abzuklären.

The article presents the agreements, institutional structures, and mechanisms that govern cooperation between Switzerland and the EU in justice and home affairs. It starts with illuminating the main interests that guide and constrain the Swiss Government’s efforts to regulate cooperation. They have been moulded into a distinct political strategy which will be introduced and specified with respect to the cooperation model it has brought about. Against this background deficits and limitations of the present approach will be analysed to test its potential for becoming an option for the future UK–EU relationship. In this regard the special economic, political, and geographic position of Switzerland will be looked at and taken into account.

PURPOSE To evaluate prognostic factors and impact of participation in a randomized trial in non-metastatic medulloblastoma. METHODS AND PATIENTS 382 patients with non-metastatic medulloblastoma aged 4–21 years with primary neurosurgical resections between 2001 and 2011 were enrolled into the HIT 2000 trial and centrally reviewed. Between 2001 and 2006, 176 of these patients participated in the randomized trial HIT-SIOP PNET 4. Three different radiotherapy protocols were applied. Molecular subgroup was available for 157 patients. RESULTS Median follow-up was 6.35 [0.09–13.86] years. The 5-year progression-free (PFS) and overall survival (OS) rates were 80.3 % ± 2.1 % and 86.5 % ± 1.8 %, respectively. On univariate analysis, there was no difference in PFS and OS according to radiotherapy protocols or in patients who participated in the HIT-SIOP PNET 4 trial or not, while histology, molecular subgroup and postoperative residual tumor influenced PFS significantly. Time interval between surgery and irradiation (≤48 days vs. ≥49 days) failed the significance level (p=0.052). On multivariate analyses, molecular subgroup (WNT activated vs. Group3 HR 5.49; p=0.014) and time interval between surgery and irradiation (HR 2.2; p=0.018) were confirmed as independent risk factors. CONCLUSION Using a centralized review system, multiprofessional and multiinstitutional collaboration as established for pediatric brain tumor patients in Germany, and risk-stratified therapy, outcome for non-metastatic medulloblastoma treated within HIT-SIOP PNET4 could be maintained outside the randomized trial. Prolonged time to radiotherapy negatively influenced survival.

Aside from haematomas, pseudoaneurysms (PSA) are considered the most frequent complications after catheter-guided interventions.Narrative compact short overview to describe aetiopathogenesis and characteristics of pseudoaneurysms and the options for diagnostic measures, therapy and its complications.Aetiopathogenesis: via the closed access site, the puncture channel, there is continuous bleeding out of the vessel which forms a pseudoaneurysm-associated cavity within the perivascular tissue. This is not surrounded by a regular vascular wall as in true aneurysms but is only formed by the surrounding tissue structures. However, this border is not sufficient and the pseudoaneurysm may extend, with diffuse bleeding episodes into the tissue. Thus, surrounding structures such as nerves and veins can be compressed by the expanding pseudoaneurysm, which can lead to irreversible damage. Diagnostic measures: duplex ultra-sonography absolutely predominant. CT-A, MR-A and DSA for specific problems and clinical case characteristics (e.g., accompanying diseases etc.) - DSA is to be linked with the option of image-guided intervention during the same session.by manual compression and subsequent dressing with compression, ultrasound-guided compression, thrombin injection and surgical intervention, there are several therapeutic measures for appropriate selection according to the specific need. Ultrasound-guided compression should be immediately used since it is highly efficient and widely available. In addition to compression, thrombin can be injected into the pseudoaneurysm-preserving nerval structures and tissue from alterations. This provides much better occlusion rates but is more demanding. Surgical intervention is the most efficient approach to occlude a pseudoaneurysm but is demanding and can be associated with complications such as disturbances of wound healing in altered tissue and the longest hospital stay. Alternative approaches have not been established yet.The diagnostic and therapeutic management of pseudoaneurysms for different findings and patients can be considered a great challenge, and requires an experienced angiologist or vascular surgeon.Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Asset recovery has been considered a key element in the fight against organized crime for almost two decades. Yet, its celebration in policy documents and civil society debates stands in stark contrast to the realities on the ground. The EU wants to change this. After approximating national confiscation instruments with Directive 2014/42/EU the new confiscation regulation intends to boost their cross-border enforcement based on mutual recognition. Unlike Directive 2014/42/EU the new regulation encompasses non-conviction-based confiscations and provides for their mutual recognition without first adopting harmonisation measures and devising a coherent set of admissibility requirements and grounds for refusal. Even more concerning, the new regulation does not seem to address the many problems and obstacles that made transnational asset recovery ineffective in the first place. The article discusses these aspects, critiques the EU’s approach and evaluates what difficulties and challenges courts and prosecutors will encounter when starting to apply the new regulation.

We explore GaP at cryogenic temperatures for optical rectification (OR) at 100 W average excitation power for the first time. Our results indicate this is a promising route for broadband THz radiation using kW-class excitation.

We demonstrate a THz source using the tilted pulse front technique in Lithium Niobate, reaching a record-high average power of 66mW at 13.3MHz repetition rate, driven by a high-power Yb-based modelocked thin-disk laser.

We present latest progress in the demonstration of single-cycle THz sources with high average power, based on excitation with MHz repetition rate, hundred-watt class modelocked thin-disk oscillators

We demonstrate the broadband THz antireflection coating based on bismuth nanofilms. The antireflection effect stems from the complex-valued conductivity of bismuth, providing excellent impedance matching with high-index dielectrics such as silicon, in the range of at least 0–4 THz. The details of THz conductivity of bismuth will also be presented.

We demonstrate a THz source based on optical rectification of a high-power thin-disk laser using the tilted pulse front technique in Lithium Niobate, reaching a record-high average power of 66mW at 13.3MHz repetition rate.

We demonstrate THz generation using the tilted pulse front method in Lithium Niobate, driven at unprecedented high average power of more than 100 W and at 13.3 MHz repetition rate, provided by a compact amplifier-free modelocked thin-disk oscillator. The conversion efficiency was optimized with respect to pump spot size and pump pulse duration, enabling us to generate a maximum THz average power of 66 mW, which is the highest reported to date from a laser-driven, few-cycle THz source. Furthermore, we identify beam walk-off as the main obstacle that currently limits the conversion efficiency in this excitation regime (with moderate pulse energies and small spot sizes). Further upscaling to the watt level and beyond is within reach, paving the way for linear and nonlinear high-average power THz spectroscopy experiments with exceptional signal-to-noise ratio at MHz repetition rates., Comment: Submitted to Optics Letters

Introduction The evaluation of head protection systems needs proper knowledge of the head impact conditions in terms of impact speed and angle, as well as a realistic estimation of brain tolerance limits. In current bicycle helmet test procedures, both of these aspects should be improved. Method: The present paper suggests a bicycle helmet evaluation methodology based on realistic impact conditions and consideration of tissue level brain injury risk, in addition to well known headform kinematic parameters. The method is then applied to a set of 32 existing helmets, leading to a total of 576 experimental impact tests followed by 576 numerical simulations of the brain response. Results: It is shown that the most critical impacts are the linear-lateral ones as well as the oblique impact leading to rotation around the vertical axis (ZRot), leading both to around 50% risks of moderate neurological injuries. Based on this test method, the study enables us to compare the protection capability of a given helmet and eventually to compare helmets via a dedicated rating system.

Polymer dielectrics have been in use for various layers in IC packages starting from substrates up to Epoxy Molding Compounds. There is a variety of various polymer chemistry approaches applied, mainly polyimides, polybenzoxazoles, epoxy resins and benzocyclobutene. Processing from solution in combination with photolithography has been the main technique to make small features e.g. for Re-Distribution Layer (RDL) or Stress Buffer (SB) applications. That method has been perfected over the years and delivers the required patterns and yield on the production. It is considered as standard process by default for enabling the assembly of flip-chip packages. However, spin-coating followed by photolithography is known to be rather wasteful, with only 10-20% of material staying on the substrate after patterning - all because it is subtractive method. In this paper we present InkJet printing as an alternative additive method approach for selected applications, where features' resolution is pushing beyond 20-50um line/spacing.

Trefoil factor family 2 (TFF2) and the mucin MUC6 are co-secreted from human gastric and duodenal glands. TFF2 binds MUC6 as a lectin and is a constituent of the gastric mucus. Herein, we investigated human gastric extracts by FPLC and identified mainly high- but also low-molecular-mass forms of TFF2. From the high-molecular-mass forms, TFF2 can be completely released by boiling in SDS or by harsh denaturing extraction. The low-molecular-mass form representing monomeric TFF2 can be washed out in part from gastric mucosa specimens with buffer. Overlay assays with radioactively labeled TFF2 revealed binding to the mucin MUC6 and not MUC5AC. This binding is modulated by Ca2+ and can be blocked by the lectin GSA-II and the monoclonal antibody HIK1083. TFF2 binding was also inhibited by Me-&beta, Gal, but not the &alpha, anomer. Thus, both the &alpha, 1,4GlcNAc as well as the juxtaperipheral &beta, galactoside residues of the characteristic GlcNAc&alpha, 1&rarr, 4Gal&beta, R moiety of human MUC6 are essential for TFF2 binding. Furthermore, there are major differences in the TFF2 binding characteristics when human is compared with the porcine system. Taken together, TFF2 appears to fulfill an important role in stabilizing the inner insoluble gastric mucus barrier layer, particularly by its binding to the mucin MUC6.

Appropriate medication of intensive care patients is complicated by disturbed organ functions and organ failure, pathophysiological changes in severely ill patients as well as possible sepsis, ongoing haemodialysis for renal and hepatic insufficiency, varying pharmacokinetics/-dynamics (PK/PD) of drugs as well as numerous drug interactions.Illustration of an interdisciplinary approach in daily clinical practice to optimise regular "polymedication" as well as the ongoing medication of patients prior to surgical interventions as indicated and as part of the appropriate peri- and postoperative intensive care management.A so-called "drug interaction stewardship" (DIS) is very similar to the already established "antibiotic stewardship" (ABS) during daily clinical routine of an intensive care unit and has been implemented. In addition, therapeutic drug monitoring (TDM) has been extended to antibiotics/antimycotics (such as meropenem, piperacillin-tazobactam, ceftazidime, linezolide, voriconazole, fluconazole, caspofungin), for which TDM had not yet been established. This was in a consecutive cohort of patients with abdominal surgery over a defined time period and was part of a systematic clinical single centre observational study (tertiary centre).From 01 - 2012 to 08 - 2016, 1,454 single drug patient consultations led to 385 (26.5%) changes in medical treatment, which had been previously initiated by an experienced intensive care physician. Most frequently in 156 cases (10.7%) this was due to newly calculated PK/PD. Analysis of 2,333 TDM samples resulted in a minimum serum level within the adequate range in 1,130 cases (48.4%). In 427 cases (18.3%), the drug serum level was too low and in 776 subjects (33.3%), prompting a change in the type, dose, dose interval and application route.DIS and TDM provide a high rate of detection of unwanted drug interactions and inappropriate drug levels in surgical intensive care patients and help to assure targeted therapy changes.Die Medikation des chirurgischen Intensivpatienten ist schwer kalkulierbar durch gestörte Organfunktionen, Organversagen, pathophysiologische Veränderungen bei schwerer Erkrankung und in der Sepsis, laufende Organersatz-, Nierenersatz- und Leberersatzverfahren sowie die unterschiedliche Pharmakokinetik/Pharmakodynamik (PK/PD) von medikamentösen Substanzen und zahlreichen Medikamenteninteraktionen. ZIEL: Interdisziplinäres Vorgehen im klinischen Alltag zur Optimierung sowohl der Vielfachmedikation als auch der laufenden medikamentösen Therapie von Patienten vor indizierten Operationen oder Interventionen sowie im Rahmen des peri- und postoperativen intensivmedizinischen Managements.Etablierung einer „Drug Interaction Stewardship“ (DIS), analog und zeitgleich zur bereits etablierten Antibiotic Stewardship (ABS) in der Routine einer chirurgischen Intensivstation. Erweiterung des etablierten therapeutischen Drug-Monitorings (TDM) auf Standard-Antiinfektiva (Meropenem, Piperacillin-Tazobactam, Ceftazidim, Linezolid, Voriconazol, Fluconazol, Caspofungin), für die bisher kein TDM etabliert ist, an einer konsekutiven Patientenkohorte über einen definierten Zeitraum im Rahmen einer klinisch-systematischen „Single-Center“-Beobachtungsstudie (tertiäres Zentrum).Im Zeitraum 01/2012 bis 08/2016 führten 1454 klinisch-pharmakologische Patientenvisiten zu 385 (26,5%) Änderungen einer vorher vom erfahrenen Intensivmediziner eingestellten medikamentösen Therapie, am häufigsten in 156 (10,7%) Fällen infolge einer neu kalkulierten PK/PD. 2333 Proben TDM ergaben in 1130 Fällen (48,4%) einen Talspiegel im gewünschten Bereich. In 427 (18,3%) Fällen war wegen eines zu niedrigen und in 776 (33,3%) Fällen wegen eines zu hohen Substanzspiegels eine Änderung der antiinfektiven Therapie nach Art, Dosis, Dosisintervall oder Applikationsart erforderlich.DIS und TDM führen bei chirurgischen Intensivpatienten in einer hohen Rate zur Detektion von unerwünschten Medikamenteninteraktionen sowie inadäquaten Substanzspiegeln mit dem Ansatz für gezielte Therapieänderungen.

Circuits of abdominal arteries to adjoining lumenal organs, especially in triggering circumstances, are rare diseases that are increasingly evident in endovascular therapies and complex viscero-/tumor-surgical procedures with subsequent lengthy adjuvant therapies. Their care is a challenge and involves frequent complications and mortality.Narrative overview on the basis of current scientific references and our clinical and surgical experience.Uretero-arterial fistulas are usually associated with recurrent and intermittent gross haematuria. The diagnostic test of choice continues to be angiography with the potential for endovascular therapy, which has displaced open surgical procedures due to minimal invasiveness, low morbidity and mortality. Aorto-oesophageal fistulas may result from underlying infectious and malignant diseases as well as open and endovascular therapies of the aorta. Multi-line contrast CT of the thorax/abdomen and gastroscopy have priority in diagnostic testing. Endovascular procedures can only be understood as bridging procedures, and only the removal of prostheses with aortic and gastrointestinal reconstruction are curative. Aorto-enteric fistulas are secondary complications of open and endovascular aortic surgery. Contrast enhanced multi-line CT has high sensitivity and specificity. In contrast, open surgical therapy involves in-situ reconstruction of extra-anatomical reconstructions with aortic ligature. Endovascular therapy is reserved for exceptional cases. Inflammatory aneurysms of visceral arteries may be associated with adjacent inflammatory processes, most commonly pseudoaneurysms. The most suitable diagnostic procedure is contrast-enhanced thin-film CT angiography. The treatment of choice is endovascular ablation using covered stents or embolisation.Arterio-visceral/arterio-lumenal fistulas are similar in pathogenesis, predisposing factors and clinical symptoms. An interdisciplinary consultation is employed to identify individualised therapy. Endovascular/interventional procedures are safe and effective, and open surgical rehabilitation is mostly curative.Verbindungen abdomineller Arterien zu umgebenden luminären Organen, insbesondere bei triggernden Begleitumständen, sind seltene Erkrankungen, die jedoch im Rahmen der Verbreitung endovaskulärer Therapien und komplexer viszeral-/tumorchirurgischer Eingriffe mit nachfolgenden langwierigen adjuvanten Therapien zunehmend in Erscheinung treten.Narrative Übersicht auf Basis aktueller wissenschaftlicher Referenzen und eigener klinischer und operativer Erfahrungen im entscheidungstechnischen Herangehen, im taktischen Vorgehen, den operativen Möglichkeiten sowie deren perioperativem Management anhand von 5 repräsentativen Fallkomplexen.Ureteroarterielle Fisteln werden i. d. R. durch eine rezidivierende und intermittierende Makrohämaturie symptomatisch. Das Diagnostikum der Wahl stellt nach wie vor die Angiografie bei gleichzeitiger Möglichkeit der endovaskulären Therapie dar, die aufgrund der minimalen Invasivität, geringen Morbidität und Mortalität die offen chirurgischen Verfahren verdrängt hat. Aortoösophageale Fisteln können Folge von infektiösen und malignen Grunderkrankungen sowie offener und endovaskulärer Therapien an der Aorta sein. Das Mehrzeilen-Kontrast-CT des Thoraxes und Abdomens sowie die Gastroskopie haben in der Diagnostik Vorrang. Endovaskuläre Verfahren können nur als Bridging-Verfahren verstanden werden, allein der Prothesenausbau mit aortaler und gastrointestinaler Rekonstruktion gilt als kurativ. Aortoenterale Fisteln sind in sekundärer Form seltene Komplikationen der offenen und endovaskulären Aortenchirurgie. Das kontrastmittelverstärkte Mehrzeilen-CT weist eine hohe Sensitivität und Spezifität auf. Die offen chirurgische Therapie unterscheidet eine In-situ-Rekonstruktion von der extraanatomischen Rekonstruktion mit Aortenligatur. Die endovaskuläre Therapie ist Ausnahmefällen vorbehalten. Entzündliche Aneurysmen viszeraler Arterien können im Zusammenhang mit nahe gelegenen Entzündungsprozessen auftreten, wobei es sich meist um Pseudoaneurysmen handelt. Das geeignetste diagnostische Mittel besteht in der kontrastmittelverstärkten Dünnschicht-CT-Angiografie. Therapie der Wahl ist die endovaskuläre Ausschaltung mittels gecoverter Stents oder Embolisation.Arterioviszerale/-lumenale Fisteln sind in Pathogenese, prädisponierenden Faktoren und klinischen Symptomen ähnlich. Unterstützt durch ein modernes Mehrzeilen-CT mit Kontrastmittel ist eine schnelle Verifizierung und Therapieplanung möglich. Die Suche nach einem individuellen Therapieansatz im interdisziplinären Konsil sollte berücksichtigen, dass die endovaskulären/interventionellen Verfahren primär sicher und effektiv sind, während die offene chirurgische Sanierung meist einzig kurativ ist.

Trefoil factor family 2 (TFF2) and the mucin MUC6 are co-secreted from human gastric and duodenal glands. TFF2 binds MUC6 as a lectin and is a constituent of the gastric mucus. Herein, we investigated human gastric extracts by FPLC and identified mainly high- but also low-molecular-mass forms of TFF2. From the high-molecular-mass forms, TFF2 can be completely released by boiling in SDS or by harsh denaturing extraction. The low-molecular-mass form representing monomeric TFF2 can be washed out in part from gastric mucosa specimens with buffer. Overlay assays with radioactively labeled TFF2 revealed binding to the mucin MUC6 and not MUC5AC. This binding is modulated by Ca2+ and can be blocked by the lectin GSA-II and the monoclonal antibody HIK1083. TFF2 binding was also inhibited by Me-β-Gal, but not the α anomer. Thus, both the α1,4GlcNAc as well as the juxtaperipheral β-galactoside residues of the characteristic GlcNAcα1→4Galβ1→R moiety of human MUC6 are essential for TFF2 binding. Furthermore, there are major differences in the TFF2 binding characteristics when human is compared with the porcine system. Taken together, TFF2 appears to fulfill an important role in stabilizing the inner insoluble gastric mucus barrier layer, particularly by its binding to the mucin MUC6.

We demonstrate optical rectification in GaP crystals driven by a 100 W-class thin-disk oscillator, nonlinearly compressed to sub-100 fs in a multi-pass cell. In optimized conditions, we obtain a power of 1.35 mW, which is the highest average power achieved in GaP so far. Additionally, we explore the effect of temperature of the crystal down to 77 K, showing that controlling the temperature of the crystal could be a key aspect for further power scaling and for handling thermal effects that become important at such high driving powers.

We demonstrate efficient pulse compression of a 13.4 MHz, 534 fs, 123 W, Yb:YAG thin-disk oscillator down to 27 fs at 98 W average power, resulting in a record-high 166 MW peak power from an amplifier-free oscillator-driven setup. Our compressor is based on two stages: one multipass cell allowing us to reduce the pulse duration to sub-90 fs and, subsequently, a multiple-plate compressor, allowing us to reach 27 fs. The overall average power compression efficiency is 80%, and the beam has excellent beam quality and homogeneity. In addition, we demonstrate further spectral broadening that supports a transform limit of 5 fs in a second multiple-plate stage, demonstrating the potential for reaching a 100 W class, amplifier-free, few-cycle source in the near future. The performance of this unique source is very promising for applications previously restricted to amplified sources, such as efficient generation of extreme ultraviolet light at high repetition rate, and the generation of high-power broadband THz radiation.

Training machine learning models requires the storage of an ever-growing number n of parameters, which leads to memory management issues. In this paper, we propose a novel approach to accurately estimate the largest parameters sufficient for prediction tasks while saving memory. Inspired by the heavy hitter identification problem in data stream analysis, our count-sketch based strategy consists in independently storing t ∼ 10 times all parameter values on different sets of r << n counters by randomly aggregating several values in the same counters. Each parameter is then approximated by the median of the values stored in its t associated counters. We conduct experiments on the popular use case of the linear regression problem for nine multi-label datasets inducing various model sizes (up to 11.7 GB of RAM). It shows that replacing the regular storage of all parameters with the proposed count-sketch storage preserves the quality of predictive performances while significantly reducing the use of memory (from 80% to 99.9%). A theoretical bound on the approximation error completes the experiments. In practice, this work gives a chance to several potentially interesting memory-hungry models to be implemented without having to resort to costly computational environments.

Based on real-world bicycle accident reconstructions and virtual accident simulations, the present study proposes realistic head-impact conditions in terms of oblique impact velocities. Thus, an ex...

Interdisciplinary cooperation between surgeons can help to optimise outcome in the management of complex surgical diseases. The indication for surgical intervention has gradually expanded in advanced multivisceral tumour growth, with iatrogenic vascular injuries in the field of abdominal and oncological surgery and mesenteric ischemia. Appropriate expertise in vascular surgery is then essential, although this is not always available or in all hospitals.Narrative review based on current scientific references in the relevant literature and our own clinical and surgical experiences in decision making, the approach in clinical management and various options of vascular reconstruction in abdominal surgery.Prognosis is still limited in pancreatic cancer. R0 resection is the only curative therapeutic option - thus, the surgeon has to provide specific intraoperative expertise. Arterial reconstruction is still controversial, due to increased postoperative morbidity and limited evidence. But in specific cases, venous reconstruction has been established in clinical practice. In addition, in retroperitoneal sarcoma with advanced/extended tumour growth, reconstruction of the infiltrated inferior V. cava or common iliac artery by means of patch plasty or autologous bypass/segmental vascular prosthesis can become necessary as part of multivisceral resections. During inflammatory processes or with tumour adhesions/infiltrations to surrounding anatomical structures, intraoperative vascular injuries or postoperative vascular alterations can occur, further complicated by anatomical variants. The extremely strict demands on the abdominal surgeons, in particular in mesenteric ischemia, are influenced by i) a competent assessment of the mesenteric vessels based on ii) adequate imaging as well as iii) appropriate time management. Prompt recanalisation can play a decisive role for the prognosis.Vascular reconstructions in abdominal surgery, in particular, in oncological surgery, require great expertise of the surgeon. In this context, competent preoperative diagnostic testing, extensive specific experience in vascular surgery/interventions, appropriate interdisciplinary case management, adequate surgical tactic and technique are all important.Das Ineinandergreifen der chirurgischen Fachdisziplinen bei der Bewältigung komplexer, chirurgisch therapierbarer Erkrankungen ist eine eminente Voraussetzung, um die Erfolgschancen der Behandlung zu steigern. Bei der zunehmenden Erweiterung der Indikationsgrenzen zur operativen Behandlung von ausgedehnten multiviszeralen Tumoren, bei iatrogenen Gefäßverletzungen im viszeral- und onkologisch-chirurgischen Operationsfeld und der mesenterialen Ischämie ist eine gefäßchirurgische Expertise vonnöten.Narrative Übersicht auf Basis aktueller wissenschaftlicher Referenzen und eigener klinischer und operativer Erfahrungen im entscheidungstechnischen Herangehen zum taktischen Vorgehen und zu gefäßrekonstruktiven Möglichkeiten bei viszeralchirurgischen Eingriffen.Beim Pankreaskarzinom mit seiner anhaltend schlechten Prognose ist die R0-Resektion die einzig kurative Therapieoption – damit werden intraoperativ erweiterte Anforderungen an den Chirurgen gestellt. Während die arterielle Gefäßrekonstruktion aufgrund erhöhter Morbidität und limitierter Evidenz weiter in der Diskussion und spezifischen Fallkonstellationen vorbehalten bleibt, ist die venöse Rekonstruktion mittlerweile etabliert. Auch bei ausgedehnten retroperitonealen Sarkomen ist im Rahmen multiviszeraler Resektionen die Rekonstruktion der infiltrierten V. cava inferior oder A. iliaca communis durch eine Patchplastik oder autologen Bypass-/Segmentersatz notwendig. Im Rahmen von inflammatorischen Prozessen sowie Tumoradhäsionen/-infiltrationen zu angrenzenden anatomischen Strukturen können intraoperative Gefäßverletzungen oder postoperative Gefäßalterationen auftreten, deren Rekonstruktion durch anatomische Varianten erschwert wird. Die extrem hohe Anforderung an den Viszeralchirurgen bei mesenterialen Ischämien wird durch eine kompetente Beurteilung der mesenterialen Gefäßstrecke auf Basis einer adäquaten Bildgebung und durch den Zeitfaktor bestimmt. Ein promptes rekanalisierendes Vorgehen entscheidet mit über die Prognose des Krankheitsbildes.Gefäßrekonstruktionen in der Viszeralchirurgie, insbesondere der Tumorchirurgie, stellen hohe Anforderungen an die Expertise des Operateurs. Eminent dabei ist neben einer guten präoperativen Diagnostik eine entwickelte spezifisch gefäßchirurgisch-medizinische wie auch fachübergreifende Erfahrung in Fallmanagement und in der OP-Taktik/-Technik.

The wide application possibilities of terahertz time domain spectroscopy (THz-TDS) has led to a rapid progress in the performance of table-top phase-stable, few-cycle THz sources, which keep setting new records in terms of bandwidth, tunability and pulse energy. One aspect, however, that has so far remained difficult to tackle is their average power, which typically remains in the μW range. This is because using traditional ultrafast driving lasers such as Ti:Sa lasers, an inevitable compromise between pulse energy and repetition rate needs to be met. However, many applications suffering from low signal-to-noise-ratio and long measurement times, both in linear and nonlinear spectroscopy, would largely benefit from having both high-field and high-repetition rate — i.e. high average power. Increasing the average power of THz-TDS sources calls for higher driving powers than provided by commonly used Ti:Sa lasers. Yb-doped, diode-pumped ultrafast solid-state lasers with power levels from hundreds of watts up to several kilowatts with sub-ps pulse duration are now readily available, however THz generation with more than a few tens of watts remains widely unexplored. In a recent proof-of-principle experiment, we demonstrated THz generation by optical rectification (OR) using a one-box Yb:YAG modelocked thin-disk oscillator with an average power of more than 100 W [1]. We obtained a THz power of 78 μW, mainly limited by the long 580 fs pulses of our laser. Here, we increase the conversion efficiency by an order of magnitude by using 88 fs long pulses nonlinearly compressed in a multi-pass cell (MPC) [2]. We measure an average power of 1.35 mW, which is to the best of our knowledge the highest THz power so far achieved at MHz repetition rate, improving the current state-of-the-art by more than a factor of 4 [3].

THz-TDS is a well-established technique for an extremely large variety of applications. However, many areas are stalled by the low average power of ultrafast laser driven THz sources. One example of an area that would immensely benefit from higher average powers is the exploration of molecular dynamics in liquids using both linear and nonlinear spectroscopy, which is hardly possible using currently available lab-based THz sources (with typical average powers

Ultrafast thin-disk lasers (TDLs) have consistently been at the forefront of progress in the performance of ultrafast laser sources in the last decades. Modelocked TDLs are particularly attractive for applications calling for high (MHz) repetition rates and high pulse energy, from a compact one-box oscillator. Average powers of several hundreds of watts and pulse energies approaching 100 μΐ have been demonstrated [1], surpassing any other modelocked oscillator technology. However, their long pulse duration remains a problem for many applications, and pulse durations 20 W. An alternative approach is to use external pulse compression. Previously, high-throughput (>60%) external pulse compressors have been demonstrated based on (1) gas-filled Kagome-type fibers where P peak =105 MW (at Pavg=46 W) have been achieved, but with a pulse-width Δt = 108 fs [2], and (2) multi-pass cells, where P peak =67 MW with Pavg=75 W, Δt=40 fs [3], and 60 MW peak power with Pavg=60 W, At=16 fs have been demonstrated [4]. Here, we compress our 13.4 MHz, 123 W(9μJ), 534 fs (P peak =15.7 MW) thin-disk oscillator down to 27 fs at 98 W average power, reaching 166 MW of peak power at 80% overall efficiency, which is to the best of our knowledge, the highest peak power amplifier-free source so far demonstrated.

The prognosis of patients with colorectal cancer (CRC) is highly dependent on the disease stage at diagnosis. Therefore, it is crucial to study molecules involved in the progression of colorectal cancer tumorigenesis and to shed light on their potential use as targetable proteins in diagnostics and therapy. As syndecan-4 (SDC4) is a transmembrane proteoglycan with important functions in cell adhesion, migration, cytoskeleton organization, and gene expression through the binding of extracellular matrix molecules, it might play a role in local tumor cell invasion. To clarify its impact on the progression of CRC, we analyzed 177 patients for SDC4 expression in colon carcinoma tissue, lymph node and liver metastasis under consideration of specific morphological features and cellular elements of CRC. Highly upregulated SDC4 was particularly expressed at the tumor invasion front. Expression was strongest in tumor cell buds appearing as membranous expression polarized to peritumoral stromal cells. Increased SDC4 expression directed to the tumor-stromal- or tumor-endothelial-interface was also confirmed for metastasis and angioinvasive tumor cell clusters. Furthermore, strong immunoreactivity of SDC4 in fibroblasts and macrophages being in contact with invasive tumor cells suggests a cooperation between the different types of cells in tumor progression at the cell-matrix interface and a role for SDC4 in tumor cells attached to the extracellular matrix. Overexpression of SDC4 in tumor cells at the invasion front was significantly associated with progressive pathological features and inversely related to disease-free and overall survival. Therefore, overexpression of SDC4 may be a predictor for poor prognosis in patients with CRC and might prove useful in clinical practice, thus identifying patients with potential disease progression. Further investigations will have to reveal the functional role of SDC4 in tumor cell buds, fibroblasts and macrophages at the tumor stromal interface to confirm that SDC4 might also be a possible therapeutic target for the treatment of patients with advanced CRC.