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This qualitative study focuses on how knowings and learning take place in full-scale simulation training of medical and nursing students, by drawing upon actor-network theory (ANT). ANT situates materiality as a part of the social practic-es. Knowing and learning, according to ANT, are not simply cognitive or social phenomena, but are seen as emerging as effects of the relation between material assemblages and human actors being performed into being in particular locations. Data consists of observations of simulations performed by ten groups of students. The analysis focuses on the emerging knowings in the socio-material—arrangements of three locations involved in the simulation—the simulation room, the observation room and the reflection room. The findings indicate that medical knowing, affective knowing and communicative knowing are produced in different ways in the different locations and material arrangements of the simulation cycle.
New deep brain stimulation (DBS) electrode designs offer operation in voltage and current mode and capability to steer the electric field (EF). The aim of the study was to compare the EF distributions of four DBS leads at equivalent amplitudes (3 V and 3.4 mA). Finite element method (FEM) simulations (n = 38) around cylindrical contacts (leads 3389, 6148) or equivalent contact configurations (leads 6180, SureStim1) were performed using homogeneous and patient-specific (heterogeneous) brain tissue models. Steering effects of 6180 and SureStim1 were compared with symmetric stimulation fields. To make relative comparisons between simulations, an EF isolevel of 0.2 V/mm was chosen based on neuron model simulations (n = 832) applied before EF visualization and comparisons. The simulations show that the EF distribution is largely influenced by the heterogeneity of the tissue, and the operating mode. Equivalent contact configurations result in similar EF distributions. In steering configurations, larger EF volumes were achieved in current mode using equivalent amplitudes. The methodology was demonstrated in a patient-specific simulation around the zona incerta and a "virtual" ventral intermediate nucleus target. In conclusion, lead design differences are enhanced when using patient-specific tissue models and current stimulation mode.
Objectives: Previous investigations have shown the appearance of cysts i.e. Virchow-Robin spaces (VR) in the basal ganglia and their relationship with parkinsonian symptoms [1-3]. Simulations [4]using the finite element method (FEM) suggests that VR affects the electric field around deep brain stimulation (DBS) electrodes. The aim of the study was to evaluate how the electric field is modified by the presence of cysts in the STN. Methods: The effect of cysts on the electric field around the DBS lead placed in the STN was evaluated using FEM. 3D patient-specific brain models were built with COMSOL 5.2 (COMSOL AB, Sweden) and an in-house developed software [5] to convert a T2 weighted MRI of Parkinsonian patients (ethics approval no: 2012/434-3) into electrical conductivity matrix readable by FEM software. VR was classified as CSF [6]assigning a high electrical conductivity (2.0 S/m). The stimulation amplitudes were set to the clinically programmed values. Depending on the lead used, the stimulation was set to voltage control (3389) or current control (6180, ring mode). The coordinates corresponding to the lowest (first) electrode and the third higher up in the lead, taken from the postoperative CT electrode artefact, were used to localize the leads in the brain model [7]. The electric field was visualized with a 0.2V/mm isosurface. Results: Simulations showed that the electric field distribution is affected by the cysts. The higher conductivity at these regions in the vicinity of the electrode redistributes the electric field pushing it away from the cyst. The same effect occurs regardless of the operating mode or the lead design as long as the directional lead is configured in ring mode. Conclusions: The use of patient-specific models has shown the importance of considering nuances of the patients' anatomy in the STN. This information can be used to determine the stimulation parameter and to support the analysis of side effects induced by the stimulation. The potential advantage of directional leads can also be assessed by including in the model patient-specific data.
BACKGROUND Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved. OBJECTIVE To evaluate postoperative (30-d) mortality in younger vs elderly (70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables. METHODS This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190. EXPECTED OUTCOMES We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified. DISCUSSION An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.
ObjectivesThe median survival in glioblastoma (GBM) patients used to be less than 1year. Surgical removal of the tumor with subsequent concomitant radiation/temozolomide (the Stupp regimen) has been shown to prolong survival. The Stupp protocol was implemented in the county of Jonkoping in 2006. The purpose of this study was to examine if the Stupp treatment has prolonged overall survival, in an unselected patient cohort with histologically verified GBM. Material and MethodThis study includes all patients from the county of Jonkoping, with a diagnosis of GBM from January 2001 to December 2012. Patients were divided into 2 cohorts, 2001-2005 and 2006-2012, that is before and after implementation of the Stupp regimen. By reviewing the medical case notes, the dates of the histological diagnosis and of death were identified. The median and mean overall survival and Kaplan-Meier survival analysis were calculated and compared between the 2 cohorts. ResultsThe mean survival was 110days longer in the cohort treated according to the Stupp regimen. Four patients in the 2006-2012 cohort and 1 patient in the 2001-2005 cohort are still alive. When comparing survival in patients with radical surgery vs biopsy, those that underwent radical surgery survived longer. The significance was slightly greater in the 2001-2005 cohort (mean 163 vs 344days, Pamp;lt;.001) than in the 2006-2012 cohort (mean 220 vs 397days, P=.02). ConclusionSurvival significantly improved after the implementation of the Stupp regimen in the study region of Sweden.
Background. In the last decade, increasing evidence has evolved for early and maximal safe resection of diffuse low-grade gliomas (LGGs) regarding survival. However, changes in clinical practice are known to occur slowly and we do not know if the scientific evidence has yet resulted in changes in neurosurgical patterns of care. Methods. The Swedish Brain Tumor Registry was used to identify all patients with a first-time histopathological diagnosis of LGG between 2005 and 2015. For analysis of surgical treatment patterns, we subdivided assessed time periods into 2005-2008, 2009-2012, and 2013-2015. Population-based data on patient and disease characteristics, surgical management, and outcomes were extracted. Results. A total of 548 patients with diffuse World Health Organization grade II gliomas were identified: 142 diagnosed during 2005-2008, 244 during 2009-2012, and 162 during 2013-2015. Resection as opposed to biopsy was performed in 64.3% during 2005-2008, 74.2% during 2009-2012, and 74.1% during 2013-2015 (P =.08). There was no difference among the 3 periods regarding overall survival (P =.11). However, post hoc analysis of data from the 4 (out of 6) centers that covered all 3 time periods demonstrated a resection rate of 64.3% during 2005-2008, 77.4% during 2009-2012, and 75.4% during 2013-2015 (P =.02) and longer survival of patients diagnosed 2009 and onward (P =.04). Conclusion. In this nationwide, population-based study we observed a shift over time in favor of LGG resection. Further, a positive correlation between the more active surgical strategy and longer survival is shown, although no causality can be claimed because of possible confounding factors.
5-Aza-deoxycytidine (5-aza-dC) confers neuroprotection in ischemic mice by inhibiting DNA methylation. Zebularine is another DNA methylation inhibitor, less toxic and more stable in aqueous solutions and, therefore more biologically suitable. We investigated Zebularines effects on brain ischemia in a rat middle cerebral artery occlusion (MCAo) model in order to elucidate its therapeutic potential. Male Wistar wild-type (WT) rats were randomly allocated to three treatment groups, vehicle, Zebularine 100 mu g, and Zebularine 500 mu g. Saline (10 mu L) or Zebularine (10 mu L) was administered intracerebroventricularly 20 min before 45-min occlusion of the middle cerebral artery. Reperfusion was allowed after 45-min occlusion, and the rats were sacrificed at 24-h reperfusion. The brains were removed, sliced, and stained with 2 % 2,3,5-triphenyltetrazolium chloride (TTC) before measuring infarct size. Zebularine (500 mu g) reduced infarct volumes significantly (p less than 0.05) by 61 % from 20.7 +/- 4.2 % in the vehicle treated to 8.1 +/- 1.6 % in the Zebularine treated. Zebularine (100 mu g) also reduced infarct volumes dramatically by 55 to 9.4 +/- 1.2 %. The mechanisms behind this neuroprotection is not yet known, but the results agree with previous studies and support the notion that Zebularine-induced inhibition of DNA methyltransferase ameliorates ischemic brain injury in rats.
There are only few studies with specific focus on predictors of survival in nursing home residents (NHRs). The aim was to study whether 1-year changes in complete blood count (including hemoglobin, red blood cells, erythrocyte volume fraction, mean corpuscular volume, mean corpuscular hemoglobin concentration, white blood cells count and platelet count), C-reactive protein and interleukin-1 beta (IL-1 beta), IL-1Ra, IL-6, IL-8 and IL-10, are associated with 8-year survival in elderly NHRs, aged amp;gt;= 80 years. Complete blood count, C-reactive protein and interleukins were measured at baseline, after 6 and 12 months from 167 NHRs aged 80-101 years, mean age 88 +/- 4.5 years, 75% of whom were women. Dates of death were collected from the National Death Register 8 years after baseline. Levels of hemoglobin, red blood cells and mean corpuscular hemoglobin concentration were lower after 1-year, but higher for mean corpuscular volume and IL-1 beta, compared to baseline or 6 month follow-up. In the Cox regression model with a time-dependent covariate, raised levels of C-reactive protein and IL-8 were associated with reduced survival time. Elevated levels of C-reactive protein and IL-8 during 1-year follow-up were related to reduce lengths of survival in elderly NHRs.
Vascular injuries in transsphenoidal surgery for pituitary adenomas are uncommon but can result in serious disability or death.
A 46-year-old man, who underwent resection of a pituitary adenoma with suprasellar extension via a transsphenoidal approach, presented with massive epistaxis five days postoperatively. Angiography revealed an arteriovenous fistula (AVF) between the right sphenopalatine artery and a deep vein draining to the right internal jugular vein, as well as contrast agent extravasation at the fistula point. The AVF was catheterized and successfully occluded with N-butyl-2-cyanoacrylate.
Transsphenoidal pituitary surgery can be complicated by massive epistaxis from a lesion of a small branch of the external carotid artery. Airway protection through intubation and investigation with conventional digital subtraction angiography is recommended. The treatment of choice is endovascular embolization because it can be done immediately at the angiography suite.
The authors aimed to develop the first clinical grading scale for patients with surgically treated spontaneous supratentorial intracerebral hemorrhage (ICH).
A nationwide multicenter study including 401 ICH patients surgically treated by craniotomy and evacuation of a spontaneous supratentorial ICH was conducted between January 1, 2011, and December 31, 2015. All neurosurgical centers in Sweden were included. All medical records and neuroimaging studies were retrospectively reviewed. Independent predictors of 30-day mortality were identified by logistic regression. A risk stratification scale (the Surgical Swedish ICH [SwICH] Score) was developed using weighting of independent predictors based on strength of association.
Factors independently associated with 30-day mortality were Glasgow Coma Scale (GCS) score (p = 0.00015), ICH volume ≥ 50 mL (p = 0.031), patient age ≥ 75 years (p = 0.0056), prior myocardial infarction (MI) (p = 0.00081), and type 2 diabetes (p = 0.0093). The Surgical SwICH Score was the sum of individual points assigned as follows: GCS score 15–13 (0 points), 12–5 (1 point), 4–3 (2 points); age ≥ 75 years (1 point); ICH volume ≥ 50 mL (1 point); type 2 diabetes (1 point); prior MI (1 point). Each increase in the Surgical SwICH Score was associated with a progressively increased 30-day mortality (p = 0.0002). No patient with a Surgical SwICH Score of 0 died, whereas the 30-day mortality rates for patients with Surgical SwICH Scores of 1, 2, 3, and 4 were 5%, 12%, 31%, and 58%, respectively.
The Surgical SwICH Score is a predictor of 30-day mortality in patients treated surgically for spontaneous supratentorial ICH. External validation is needed to assess the predictive value as well as the generalizability of the Surgical SwICH Score.
Supratentorial intracerebral haemorrhage (ICH) carries an excessive mortality and morbidity. Although surgical ICH treatment can be life-saving, the indications for surgery in larger cohorts of ICH patients are controversial and not well defined. We hypothesised that surgical indications vary substantially among neurosurgical centres in Sweden.
In this nation-wide retrospective observational study, differences in treatment strategies among all neurosurgical departments in Sweden were evaluated.
Patient records, neuroimaging and clinical outcome focused on 30-day mortality were collected on each operated ICH patient treated at any of the six neurosurgical centres in Sweden from 1 January 2011 to 31 December 2015.
In total, 578 consecutive surgically treated ICH patients were evaluated. There was a similar incidence of surgical treatment among different neurosurgical catchment areas. Patient selection for surgery was similar among the centres in terms of patient age, pre-operative level of consciousness and co-morbidities, but differed in ICH volume, proportion of deep-seated vs. lobar ICH and pre-operative signs of herniation (p < .05). Post-operative patient management strategies, including the use of ICP-monitoring, CSF-drainage and mechanical ventilation, varied among centres (p < .05). The 30-day mortality ranged between 10 and 28%.
Although indications for surgical treatment of ICH in the six Swedish neurosurgical centres were homogenous with regard to age and pre-operative level of consciousness, important differences in ICH volume, proportion of deep-seated haemorrhages and pre-operative signs of herniation were observed, and there was a substantial variability in post-operative management. The present results reflect the need for refined evidence-based guidelines for surgical management of ICH.
Background: Deep brain stimulation (DBS) is a growing treatment modality, and most DBS systems require replacement of the implantable pulse generator (IPG) every few years. The literature regarding the potential impact of adverse events of IPG replacement on the longevity of DBS treatments is rather scarce. Objective: To investigate the incidence of adverse events, including postoperative infections, associated with IPG replacements in a multicenter cohort. Methods: The medical records of 808 patients from one Australian and five Swedish DBS centers with a total of 1,293 IPG replacements were audited. A logistic regression model was used to ascertain the influence of possible predictors on the incidence of adverse events. Results: The overall incidence of major infections was 2.3% per procedure, 3.7% per patient and 1.7% per replaced IPG. For 28 of 30 patients this resulted in partial or complete DBS system removal. There was an increased risk of infection for males (OR 3.6, p = 0.026), and the risk of infection increased with the number of prior IPG replacements (OR 1.6, p amp;lt; 0.005). Conclusions: The risk of postoperative infection with DBS IPG replacement increases with the number of previous procedures. There is a need to reduce the frequency of IPG replacements. (C) 2016 S. Karger AG, Basel
Objective: To determine whether transient hypoxia during breath-hold diving causes neuronal damage or dysfunction or alters amyloid metabolism as measured by certain blood biomarkers.
Design: Sixteen divers competing in the national Swedish championship in breath-hold diving and five age-matched healthy control subjects were included. Blood samples were collected at baseline and over a course of 3 days where the divers competed in static apnea (STA), dynamic apnea without fins (DYN1) and dynamic apnea with fins (DYN2).
Main outcomes: Biomarkers reflecting brain injury and amyloid metabolism were analysed in serum (S-100β, NFL) and plasma (T-tau, Aβ42) using immunochemical methods.
Results: Compared to divers' baseline, Aβ42 increased after the first event of static apnea (p = 0.0006). T-tau increased (p = 0.001) in STA vs baseline and decreased after one of the dynamic events, DYN2 (p = 0.03). Further, T-tau correlated with the length of the apneic time during STA (ρ = 0.7226, p = 0.004) and during DYN1 (ρ = 0.66, p = 0.01).
Conclusion: The findings suggest that transient hypoxia may acutely increase the levels of Aβ42 and T-tau in plasma of healthy adults, further supporting that general hypoxia may cause mild neuronal dysfunction or damage and stimulate Aβ production.
Lead movement after deep brain stimulation (DBS) may occur and influence the area of stimulation. The cause of the displacement is not fully understood. The aim of the study was to investigate differences in lead position between the day after surgery and approximately one month postoperatively and also simulate the electric field (EF) around the active contacts.
23 patients with movement disorders underwent DBS surgery (37 leads). CT at the two time points were co-fused respectively with the stereotactic images in Surgiplan. The coordinates (x, y, z) of the lead tips were compared between the two dates (paired t-test). 8 of these patients were selected for the EF simulation in Comsol Multiphysics.
There was a significant discrepancy (mean ± s.d.) on the left lead: x (0.44 ± 0.72, p < 0.01), y (0.64 ± 0.54, p < 0.001), z (0.62 ± 0.71, p < 0.001). On the right lead, corresponding values were: x (-0.11 ± 0.61, n.s.), y (0.71 ± 0.54, p < 0.001), z (0.49 ± 0.81, p < 0.05). No correlation was found between bilateral (n =14) vs. unilateral DBS, gender (n = 17 male) and age < 60 years (n = 8). The lead movement affected the EF spread (Fig. 1).
The left lead tip displayed a tendency to move lateral, anterior and inferior and the right a tendency to move anterior and inferior. Lead movement after DBS can be a factor to consider before starting the stimulation. The differences in the area of stimulation might affect clinical outcome.
Resection of brain tumor is a challenging task as the tumor does not have clear borders and the malignant types specifically have often a diffuse and infiltrative pattern of growth. Recently, neurosurgical microscopes have been modified to incorporate fluorescence modules for detection of tumor when 5-aminolevulinic acid (5-ALA) is used as a contrast. We have in combination with the fluorescence microscopes implemented and evaluated a fluorescence spectroscopy based handheld probe for detecting the 5-aminolevulinic acid (ALA) induced protoporphyrin IX (PpIX) in the gliomas in 50 patients intraoperatively. The results show a significantly high sensitivity for differentiating tumor from the healthy tissue and distinguished fluorescence intensity levels in the tumor cell infiltration zone around the tumor. However, knowledge on association of the quantified fluorescence signals specifically in the intermediate inflammatory zone with the infiltrative tumor cells can be complemented with volumetric tissue imaging and a higher precision histopathological analysis. In this work, a spectral domain optical coherence tomography (OCT) system with central wavelength of 1325nm has been used to image the tissue volume that the fluorescence is collected from and is evaluated against histopathological analysis for a higher precision slicing. The results show that although healthy brain has a homogenous microstructure in the OCT images, the brain tumor shows a distinguished texture in the images correlated with the PpIX fluorescence intensity and histopathology.
Resection of brain tumor is a challenging task as the tumor does not have clear borders and the malignant types specifically have often a diffuse and infiltrative pattern of growth. We have previously implemented and evaluated a fluorescence spectroscopy based handheld probe for detecting the 5-aminolevulinic acid induced protoporphyrin IX (PpIX) in the gliomas. To add another dimension to the brain tumor detection and volumetric analysis of the tissue that exhibits fluorescence, optical coherence tomography was investigated on tumor specimens.
Material and Methods:
A fluorescence microscopy and a spectroscopy system as reported previously were used for detecting the fluorescence signals [1, 2]. A total of 50 patients have been included for intraoperative assessment of the tumor borders using the fluorescence techniques. A spectral domain OCT imaging system (TELESTO II, Thorlabs, Inc., NJ, USA) with central wavelength of 1325 nm was used to study the tissue microstructure post operatively. The system has a resolution of 13 and 5.5 μm in the lateral and axial directions, respectively. Tissue specimens from three patients undergoing brain tumor surgery were studied using the OCT system.
Results and Conclusion:
Using fluorescence spectroscopy the tumor could be detected with a sensitivity of 0.84 which was significantly higher than that of the surgical microscope (0.30). Brain tissue appeared rather homogeneous in the OCT images however the highly malignant tissue showed a clear structural difference from the non-malignant or low malignant brain tumor tissue which could be related to the fluorescence signal intensities.
To provide guidance for targeting diagnostic tumor tissue and to avoid vessel rupture during the biopsy procedure an application specific fiber optic probe was devel-oped. The setup incorporated an in-house developed fluorescence spectroscopy system for 5-aminolevulinic acid (5-ALA) induced protopophyrin IX (PpIX) for detection in the tumor, and laser Doppler flowmeter (LDF) system for measurement of blood perfusion. Fluorescence and blood flow were recorded millimeter-wise towards the pre-calculated target. In conclusion, the optical probe made real-time detection of tumor possible and has a potential for vessel detection during the biopsy procedures. Moreover, the PpIX fluorescence, autofluorescence and blood flow in the tumor could be studied at precise positions in the brain and the tumor. In the next step, further anal-ysis will be added.
Using 5-aminolevulinic acid (ALA) as an intraoperative fluorescence contrast has been proven to improve the resection of glioblastoma and contribute to prolonged patient survival. ALA accumulates as protoporphyrin IX (PpIX) in the tumor cells and is administered in an advised dose of 20 mg/kg body weight (b.w.) for brain tumor resection using fluorescence surgical microscopes. PpIX fluorescence availability and intensities of a four folds lower ALA dose (5 mg/kg b.w.) has been investigated in glioblastomas and skin using a spectroscopy system adapted for surgical guidance.
A total of 30 adult patients diagnosed with high grade gliomas were included in the analysis. ALA was orally administered in doses of 5 mg/kg b.w. (n = 15) dissolved in orange juice or 20 mg/kg b.w. (n = 15) dissolved in water. A fluorescence spectroscopy system with a handheld fiber-optical probe was used for performing the quantitative fluorescence measurements.
The binominal comparison of the diagnostic performance parameters showed no significant statistical difference (p > 0.05). The median fluorescence values in tumor were 2-3 times higher for the high ALA dose group. No PpIX was detected in the skin of the patients in the low dose group (0/4) while PpIX was detected in the skin of the majority of the patients in the high ALA dose group (13/14).
Application of 5 mg/kg ALA was evaluated as equally reliable as the higher dose regarding the diagnostic performance when guidance was performed using a spectroscopic system. Moreover, no PpIX was detected in the skin of the patients.
To provide guidance during stereotactic biopsy in brain tumors, fluorescence spectroscopy was used in ten patients. It was shown that the fiber optical probe could provide real-time guidance with clear fluorescence in all patients.
A fiber optic probe was developed for guidance during stereotactic brain biopsy procedures to target tumor tissue and reduce the risk of hemorrhage. The probe was connected to a setup for the measurement of 5-aminolevulinic acid (5-ALA) induced fluorescence and microvascular blood flow. Along three stereotactic trajectories, fluorescence (n = 109) and laser Doppler flowmetry (LDF) (n = 144) measurements were done in millimeter increments. The recorded signals were compared to histopathology and radiology images. The median ratio of protoporphyrin IX (PpIX) fluorescence and autofluorescence (AF) in the tumor was considerably higher than the marginal zone (17.3 vs 0.9). The blood flow showed two high spots (3%) in total. The proposed setup allows simultaneous and real-time detection of tumor tissue and microvascular blood flow for tracking the vessels.
During stereotactic biopsy on suspected tumors in the brain, tissue samples are harvested to determine the malignancy. To provide guidance for finding the diagnostic tumor sites and to avoid vessel rupture, an application specific probe was developed. The setup incorporated spectroscopy for detection of 5-aminolevulinic acid induced protoporphyrin (PpIX) fluorescence and blood flow using laser Doppler flowmetry. The PpIX fluorescence was significantly different in the tumor compared to the gliotic marginal zone (p < 0.05). In conclusion, the systems made real-time tumor detection and vessel tracking possible. Moreover, the autofluorescence and blood perfusion could be studied in the tumor.
Introduction: Venous thromboembolism (VTE) is a common problem among patients with glioblastoma multi-forme (GBM) and with some other cancers. Here, we evaluated genetic and non-genetic potential risk factors for VTE among GBM patients. Materials and methods: A cohort of 139 patients treated with concomitant radiotherapy and temozolomide were included in the study. Next generation sequencing and genotyping approaches were applied to assess genetic risk factors in the haemostatic system. Clinical data including surgery, reoperation as well as blood group and patient information such as age and gender were available from patient records. Logistic regression analysis was performed to asses VTE risk. Results: In the study 47 patients (34%) were diagnosed for VTE during the course of their disease. When genetic and non-genetic potential risk factors were evaluated, only B blood group was found to be significantly associated with VTE incidence (odds ratio [OR] = 6.91; confidence interval [CI] = 2.19-24.14; P = 0.001). In contrast, A and O blood groups did not correlate with VTE risk. Frontal lobe tumor location also seemed to slightly increase VTE risk compared to other brain sites (OR = 3.14; CI = 1.1-10.7) although the significance level was at borderline (P = 0.05). Current study identified B blood group as the component in non-O blood groups that is responsible for increased VTE risk. Conclusion: In conclusion, these results suggest for the first time that B blood group is predictive for VTE incidence among patients with glioblastoma, information that may be potentially valuable when selecting GBM patients who are at risk for VTE for anticoagulant prophylaxis.
Background: Stroke is among the leading causes of death and disability. Although intense research efforts have provided promising treatment options in animals, most clinical trials in humans have failed and the therapeutic options are few. Several factors have been suggested to explain this translational difficulty, particularly concerning methodology and study design. Consistent infarcts and low mortality might be desirable in some, but not all, studies. Here, we aimed to investigate whether the use of laser Doppler flowmetry (LDF) and the occlusion time (60 vs. 45 min) affected outcome variability and mortality in a rat stroke model. Eighty ovariectomized female Wistar rats were subjected to ischemic stroke using intraluminal filament middle cerebral artery occlusion with or without LDF and with occlusion times of 45 or 60 min. Outcome was evaluated by triphenyl tetrazolium chloride staining of brain slices to measure infarct size and a modified sticky tape test. Results: Neither LDF nor occlusion times of 45 versus 60 min significantly affected mortality, outcome variability or outcome severity. Conclusions: Due to the unexpectedly high mortality and variability the statistical power was very low and thus the results were inconclusive.
Although hundreds of promising substances have been tested in clinical trials, thrombolysis currently remains the only specifi c pharmacological treatment for ischemic stroke. Poor quality, e.g. low statistical power, in the preclinical studies has been suggested to play an important role in these failures. Therefore, it would be attractive to use animal models optimized to minimize unnecessary mortality and outcome variability, or at least to be able to power studies more exactly by predicting variability and mortality given a certain experimental setup. The possible combinations of methodological parameters are innumerous, and an experimental comparison of them all is therefore not feasible. As an alternative approach, we extracted data from 334 experimental mouse stroke articles and, using a hypothesis-driven meta-analysis, investigated the method parameters' impact on infarct size variability and mortality. The use of Swiss and C57BL6 mice as well as permanent occlusion of the middle cerebral artery rendered the lowest variability of the infarct size while the emboli methods increased variability. The use of Swiss mice increased mortality. Our study offers guidance for researchers striving to optimize mouse stroke models.
Background: The elevated body swing test (EBST) is a behavioral test used to evaluate experimental stroke in rodents. The basic idea is that when the animal is suspended vertically by the tail, it will swing its head laterally to the left or right depending on lesion side. In a previous study from our lab using the EBST after middle cerebral artery occlusion (MCAo), rats swung contralateral to the infarct day 1 post-MCAo, but ipsilateral day 3 post-MCAo. This shift was unexpected and prompted us to perform the present study. First, the literature was systematically reviewed to elucidate whether a similar shift had been noticed before, and if consensus existed regarding swing direction. Secondly, an experiment was conducted to systematically investigate the suggested behavior. Eighty-three adult male and female Sprague-Dawley rats were subjected to MCAo or sham surgery and the EBST was performed up to 7 days after the lesion. Results: Both experimentally and through systematic literature review, the present study shows that the direction of biased swing activity in the EBST for rodents after cerebral ischemia can differ and even shift over time in some situations. The EBST curve for females was significantly different from that of males after the same occlusion time (p = 0.023). Conclusions: This study highlights the importance of adequate reporting of behavioral tests for lateralization and it is concluded that the EBST cannot be recommended as a test for motor asymmetry after MCAo in rats.
The majority of the numerous animal studies of the effects of estrogens on cerebral ischemia have reported neuroprotective results, but a few have shown increased damage. Differences in hormone administration methods, resulting in highly different 17 beta-estradiol levels, may explain the discrepancies in previously reported effects. The objective of the present study was to test the hypothesis that it is the delivered dose per se, and not the route and method of administration, that determines the effect, and that high doses are damaging while lower doses are protective. One hundred and twenty ovariectomized female Wistar rats (n = 40 per group) were randomized into three groups, subcutaneously administered different doses of 17 beta-estradiol and subjected to transient middle cerebral artery occlusion. The modified sticky tape test was performed after 24 h and the rats were subsequently sacrificed for infarct size measurements. In contrast to our hypothesis, a significant negative correlation between 17 beta-estradiol dose and infarct size was found (p = 0.018). Thus, no support was found for the hypothesis that 17 beta-estradiol can be both neuroprotective and neurotoxic merely depending on dose. In fact, on the contrary, the findings indicate that the higher the dose of 17 beta-estradiol, the smaller the infarct.
The majority of the numerous animal studies of the effects of estrogens on cerebral ischemia have reported neuroprotective results, but a few have shown increased damage. Differences in hormone administration methods, resulting in highly different 17β-estradiol levels, may explain the discrepancies in previously reported effects. The objective of the present study was to test the hypothesis that it is the delivered dose per se, and not the route and method of administration, that determines the effect, and that high doses are damaging while lower doses are protective. One hundred and twenty ovariectomized female Wistar rats (n=40 per group) were randomized into three groups, subcutaneously administered different doses of 17β-estradiol and subjected to transient middle cerebral artery occlusion. The modifi ed sticky tape test was performed after 24 h and the rats were subsequently sacrifi ced for infarct size measurements. In contrast to our hypothesis, a signifi cant negative correlation between 17β-estradiol dose and infarct size was found (p=0.018). Thus, no support was found for the hypothesis that 17β-estradiol can be both neuroprotective and neurotoxic merely depending on dose. In fact, on the contrary, the fi ndings indicate that the higher the dose of 17β-estradiol, the smaller the infarct.
Cortisol concentrations in plasma display a circadian rhythm in adults and children older than one year. Earlier studies report divergent results regarding when cortisol circadian rhythm is established. The present study aims to investigate at what age infants develop a circadian rhythm, as well as the possible influences of behavioral regularity and daily life trauma on when the rhythm is established. Furthermore, we determine age-related reference intervals for cortisol concentrations in saliva during the first year of life.
130 healthy full-term infants were included in a prospective, longitudinal study with saliva sampling on two consecutive days, in the morning (07:30-09:30), noon (10:00-12:00) and evening (19:30-21:30), each month from birth until the infant was twelve months old. Information about development of behavioral regularity and potential exposure to trauma was obtained from the parents through the Baby Behavior Questionnaire and the Life Incidence of Traumatic Events checklist.
A significant group-level circadian rhythm of salivary cortisol secretion was established at one month, and remained throughout the first year of life, although there was considerable individual variability. No correlation was found between development of cortisol circadian rhythm and the results from either the Baby Behavior Questionnaire or the Life Incidence of Traumatic Events checklist. The study presents salivary cortisol reference intervals for infants during the first twelve months of life.
Cortisol circadian rhythm in infants is already established by one month of age, earlier than previous studies have shown. The current study also provides first year age-related reference intervals for salivary cortisol levels in healthy, full-term infants.
Background Cortisol concentrations in plasma display a circadian rhythm in adults and children older than one year. Earlier studies report divergent results regarding when cortisol circadian rhythm is established. The present study aims to investigate at what age infants develop a circadian rhythm, as well as the possible influences of behavioral regularity and daily life trauma on when the rhythm is established. Furthermore, we determine age-related reference intervals for cortisol concentrations in saliva during the first year of life. Methods 130 healthy full-term infants were included in a prospective, longitudinal study with saliva sampling on two consecutive days, in the morning (07:30-09:30), noon (10:00-12:00) and evening (19:30-21:30), each month from birth until the infant was twelve months old. Information about development of behavioral regularity and potential exposure to trauma was obtained from the parents through the Baby Behavior Questionnaire and the Life Incidence of Traumatic Events checklist. Results A significant group-level circadian rhythm of salivary cortisol secretion was established at one month, and remained throughout the first year of life, although there was considerable individual variability. No correlation was found between development of cortisol circadian rhythm and the results from either the Baby Behavior Questionnaire or the Life Incidence of Traumatic Events checklist. The study presents salivary cortisol reference intervals for infants during the first twelve months of life. Conclusions Cortisol circadian rhythm in infants is already established by one month of age, earlier than previous studies have shown. The current study also provides first year age-related reference intervals for salivary cortisol levels in healthy, full-term infants.
OBJECTIVES: To investigate at what age preterm infants develop a salivary cortisol circadian rhythm and identify whether it is dependent on gestational age and/or postnatal age. To evaluate whether salivary cortisol circadian rhythm development is related to behavioral regularity. To elucidate salivary cortisol levels in preterm infants during the first year of life.
METHODS: This prospective, longitudinal study included 51 preterm infants. 130 healthy full-term infants served as controls. Monthly salivary cortisol levels were obtained in the morning (07:30-09:30), at noon (10:00-12:00), and in the evening (19:30-21:30), beginning at gestational age week 28-32 and continuing until twelve months corrected age. Behavioral regularity was studied using the Baby Behavior Questionnaire.
RESULTS: A salivary cortisol circadian rhythm was established by one month corrected age and persisted throughout the first year. The preterm infants showed a cortisol pattern increasingly more alike the full-term infants as the first year progressed. The preterm infants increase in behavioral regularity with age but no correlation was found between the development of salivary cortisol circadian rhythm and the development of behavior regularity. The time to establish salivary cortisol circadian rhythm differed between preterm and full-term infants according to postnatal age (p = 0.001) and was dependent on gestational age. Monthly salivary cortisol levels for preterm infants from birth until twelve months are presented. Additional findings were that topical corticosteroid medication was associated with higher concentrations of salivary cortisol (p = 0.02) and establishment of salivary cortisol circadian rhythm occurred later in infants treated with topical corticosteroid medication (p = 0.02).
CONCLUSIONS: Salivary cortisol circadian rhythm is established by one month corrected age in preterm infants. Establishment of salivary cortisol circadian rhythm is related to gestational age rather than to postnatal age. Salivary cortisol circadian rhythm development is not related to behavioral regularity.
STUDY DESIGN: Cross-sectional study. BACKGROUND: Findings of fat infiltration in cervical spine multifidus, as a sign of degenerative morphometric changes due to whiplash injury, need to be verified. OBJECTIVES: To develop a method using water/fat magnetic resonance imaging (MRI) to investigate fat infiltration and cross-sectional area of multifidus muscle in individuals with whiplash associated disorders (WADS) compared to healthy controls. METHODS: Fat infiltration and cross-sectional area in the multifidus muscles spanning the C4 to C7 segmental levels were investigated by manual segmentation using water/fat-separated MRI in 31 participants with WAD and 31 controls, matched for age and sex. RESULTS: Based on average values for data spanning C4 to C7, participants with severe disability related to WAD had 38% greater muscular fat infiltration compared to healthy controls (P = .03) and 45% greater fat infiltration compared to those with mild to moderate disability related to WAD (P = .02). There were no significant differences between those with mild to moderate disability and healthy controls. No significant differences between groups were found for multifidus cross-sectional area. Significant differences were observed for both cross-sectional area and fat infiltration between segmental levels. CONCLUSION: Participants with severe disability after a whiplash injury had higher fat infiltration in the multifidus compared to controls and to those with mild/moderate disability secondary to WAD. Earlier reported findings using T1-weighted MRI were reproduced using refined imaging technology. The results of the study also indicate a risk when segmenting single cross-sectional slices, as both cross-sectional area and fat infiltration differ between cervical levels.
BackgroundWith life expectancy continuing to rise in the United Kingdom there is an increasing public health focus on the maintenance of physical independence among all older adults. Identifying interventions that improve physical outcomes in pre-frail and frail older adults is imperative.MethodsA systematic review of the literature 2000 to 2017 following PRISMA guidelines and registered with PROSPERO (no. CRD42016045325).ResultsTen RCT trials fulfilled selection criteria and quality appraisal. The study quality was moderate to good. Interventions included physical activity; nutrition, physical activity combined with nutrition. Interventions that incorporated one or more physical activity components significantly improved physical outcomes in pre-frail and/or frail older adults.ConclusionsPhysical activity interventions are key to maintaining independence in pre-frail and frail older adults. A lack of consensus regarding the definition of frailty, and an absence of core measures to assess this means any attempt to create an optimal intervention will be impeded. This absence may ultimately impact on the ability of older and frail adults to live well and for longer in the community.
BACKGROUND: Rehabilitation approaches should be based on an understanding of the mechanisms underpinning functional recovery. Yet, the mediators that drive an improvement in post-surgical pain-related disability in individuals with cervical radiculopathy (CR) are unknown. The aim of the present study is to use Bayesian networks (BN) to learn the probabilistic relationships between physical and psychological factors, and pain-related disability in CR.
METHODS: We analysed a prospective cohort dataset of 201 post-surgical individuals with CR. In all, 15 variables were used to build a BN model: age, sex, neck muscle endurance, neck range of motion, neck proprioception, hand grip strength, self-efficacy, catastrophizing, depression, somatic perception, arm pain intensity, neck pain intensity and disability.
RESULTS: A one point increase in a change of self-efficacy at 6 months was associated with a 0.09 point decrease in a change in disability at 12 months (t = -64.09, p < .001). Two pathways led to a change in disability: a direct path leading from a change in self-efficacy at 6 months to disability, and an indirect path which was mediated by neck and arm pain intensity changes at 6 and 12 months.
CONCLUSIONS: This is the first study to apply BN modelling to understand the mechanisms of recovery in post-surgical individuals with CR. Improvements in pain-related disability was directly and indirectly driven by changes in self-efficacy levels. The present study provides potentially modifiable mediators that could be the target of future intervention trials. BN models could increase the precision of treatment and outcome assessment of individuals with CR.
SIGNIFICANCE: Using Bayesian Network modelling, we found that changes in self-efficacy levels at 6-month post-surgery directly and indirectly influenced the change in disability in individuals with CR. A mechanistic understanding of recovery provides potentially modifiable mediators that could be the target of future intervention trials.
Telomerase reverse transcriptase (TERT) activity is up-regulated in several types of tumors including glioblastoma (GBM). In the present study, 128 primary glioblastoma patients were examined for single nucleotide polymorphisms of TERT in blood and in 92 cases for TERT promoter mutations in tumors. TERT promoter mutations were observed in 86% of the tumors and of these, C228T (-124 bp upstream start codon) was detected in 75% and C250T (-146 bp) in 25% of cases. TERT promoter mutations were associated with shorter overall survival (11 vs. 20 months p = 0.002 and 12 vs. 20, p = 0.04 for C228T and C250T, respectively). The minor alleles of rs2736100 and rs10069690 SNPs, located in intron 2 and the promotor regions, respectively, were associated with an increased risk of developing GBM (p = 0.004 and 0.001). GBM patients having both TERT promoter mutations and being homozygous carriers of the rs2853669 C-allele displayed significantly shorter overall survival than those with the wild type allele. The rs2853669 SNP is located in a putative Ets2 binding site in the promoter (-246 bp upstream start codon) close to the C228T and C250T mutation hot spots. Interleukin-6 (IL-6) expression regulated by TERT promoter status and polymorphism, what leads us to think that TERT and IL-6 plays a significant role in GBM, where specific SNPs increase the risk of developing GBM while the rs2853669 SNP and specific mutations in the TERT promoter of the tumor lead to shorter survival.
Aim: The aim of this study was to explore the lived experiences of conscious patients in neurosurgical intensive care. Method: Data collection was performed by qualitative interviews using an interview guide. Eleven former patients, seven women and four men, were interviewed two to 14 months after discharge. The interviews were recorded and transcribed verbatim and analysed using an interpretive phenomenological approach. Findings: The analysis revealed three themes: To feel safe in an unfamiliar situation, to experience strains and limitations, and to be confirmed as a human being. These three themes culminated in the essence: To feel strong in an unfamiliar situation. Patients experienced a soothing environment where, despite strains, they felt safe being cared for in a ward with specialised medical treatment. When mental and physical strains decreased during the period of care, they experienced the ability to cope with the simplest tasks as a sign of regained identity. Conclusion: Patients main experience during intensive care was security. Security along with human contact and interaction with staff and next of kin made the patients feel strengthened as human beings in an unfamiliar situation. The fact that the patients were conscious enabled them to understand their situation and to experience security. (C) 2015 Elsevier Ltd. All rights reserved.
Study Design. Cross-sectional study. Objective. To investigate the factors associated with work ability in patients undergoing surgery for cervical radiculopathy. Summary of Background Data. Surgery is a common treatment of cervical radiculopathy in people of working age. However, few studies have investigated the impact on the work ability of these patients. Methods. Patients undergoing surgery for cervical radiculopathy (n = 201) were recruited from spine centers in Sweden to complete a battery of questionnaires and physical measures the day before surgery. The associations between various individual, psychological, and work-related factors and self-reported work ability were investigated by Spearman rank correlation coefficient, multivariate linear regression, and forward stepwise regression analyses. Factors that were significant (P < 0.05) in each statistical analysis were entered into the successive analysis to reveal the factors most related to work ability. Work ability was assessed using the Work Ability Index. Results. The mean Work Ability Index score was 28 (SD, 9.0). The forward stepwise regression analysis revealed 6 factors significantly associated with work ability, which explained 62% of the variance in the Work Ability Index. Factors highly correlated with greater work ability included greater self-efficacy in performing self-cares, lower physical load on the neck at work, greater self-reported chance of being able to work in 6 months time, greater use of active coping strategies, lower frequency of hand weakness, and higher health-related quality of life. Conclusion. Psychological, work-related and individual factors were significantly associated with work ability in patients undergoing surgery for cervical radiculopathy. High self-efficacy was most associated with greater work ability. Consideration of these factors by surgeons preoperatively may provide optimal return to work outcomes after surgery.
Objective: One patient received oral levodopa during a study aiming for better understanding of the basal ganglia and of the mechanisms of deep brain stimulation of the subthalamic nucleus (STN DBS) with and without intravenous (IV) levodopa infusion in patients with Parkinson's disease (PD). The results from oral and IV levodopa treatment are presented.
Methods: Five patients with advanced PD were included in the original study. During planned STN DBS surgery microdialysis probes were implanted in the right putamen and in the right and left globus pallidus interna (Gpi). During the study, microdialysis was performed continuously and STN DBS, with and without IV levodopa infusion, was performed according to a specific protocol. After DBS surgery, but before STN DBS was started, one patient received oral levodopa/ benserazide and entacapone tablets out of protocol due to distressing parkinsonism.
Results: The levodopa levels increased prompt in the central nervous system after the first PD medication intakes but declined after the last. Immediately the levodopa seemed to be metabolized to dopamine (DA) since the levels of DA correlated well with levodopa concentrations. Left STN DBS seemed to further increase DA levels in left Gpi while right STN DBS seemed to increase DA levels in the right putamen and right Gpi. There was no obvious effect on levodopa levels.
Conclusions: The results indicate that PD patients still have capacity to metabolize levodopa to DA despite advanced disease with on-off symptoms and probably pronounced nigral degeneration. STN DBS seems to increase DA levels with a more pronounced effect on ipsilateral structures in striatum.
To describe the impact of episodes of supraventricular tachycardia (SVT) on a persons daily life from a holistic perspective.
Deep brain stimulation (DBS) in zona incerta (Zi) is used for symptom alleviation in essential tremor (ET). Zi is positioned along the dentato-rubro-thalamic tract (DRT). Electric field simulations with the finite element method (FEM) can be used for estimation of a volume where the stimulation affects the tissue by applying a fixed isolevel (VDBS). This work aims to develop a workflow for combined patient-specific electric field simulation and white matter tracing of the DRT, and to investigate the influence on the VDBS from different brain tissue models, lead design and stimulation modes. The novelty of this work lies in the combination of all these components.
Patients with ET were implanted in Zi (lead 3389, n = 3, voltage mode; directional lead 6172, n = 1, current mode). Probabilistic reconstruction from diffusion MRI (dMRI) of the DRT (n = 8) was computed with FSL Toolbox. Brain tissue models were created for each patient (two homogenous, one heterogenous isotropic, one heterogenous anisotropic) and the respective VDBS (n = 48) calculated from the Comsol Multiphysics FEM simulations. The DRT and VDBS were visualized with 3DSlicer and superimposed on the preoperative T2 MRI, and the common volumes calculated. Dice Coefficient (DC) and level of anisotropy were used to evaluate and compare the brain models.
Combined patient-specific tractography and electric field simulation was designed and evaluated, and all patients showed benefit from DBS. All VDBS overlapped the reconstructed DRT. Current stimulation showed prominent difference between the tissue models, where the homogenous grey matter deviated most (67 < DC < 69). Result from heterogenous isotropic and anisotropic models were similar (DC > 0.95), however the anisotropic model consistently generated larger volumes related to a greater extension of the electric field along the DBS lead. Independent of tissue model, the steering effect of the directional lead was evident and consistent.
A workflow for patient-specific electric field simulations in combination with reconstruction of DRT was successfully implemented. Accurate tissue classification is essential for electric field simulations, especially when using the current control stimulation. With an accurate targeting and tractography reconstruction, directional leads have the potential to tailor the electric field into the desired region.
BackgroundThere is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls.MethodsParticipants are a sub-group (n=30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the butterfly test and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n=30).DiscussionThe study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD.Trial registrationClinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.
OBJECTIVE Information about postoperative rehabilitation for cervical radiculopathy (CR) is scarce. The aim of this study was to investigate the additional benefits of structured postoperative rehabilitation (SPT), which was performed in all patients, compared with a pragmatic standard postoperative approach (SA), in which rehabilitation was used as needed and patients sought physiotherapy on their own without a referral, in patients with MRI evidence of disc herniation and concomitant clinical signs who underwent surgery for CR. METHODS Patients (n = 202) were randomized to receive SPT or SA. Included key variables in the present study were primary and selected secondary outcomes of a prospective randomized controlled multicenter study. The main outcome was the Neck Disability Index (NDI) score. The NDI score, pain variables, self-efficacy, and health-related quality of life were investigated at baseline and 3, 6, 12, and 24 months postoperatively. RESULTS SPT provided no additional benefits over SA (p = 0.08 to p = 0.99) at the postoperative 2-year follow-up. Both groups improved over time (p amp;lt; 0.0001), with no reported adverse effects. CONCLUSIONS One can conclude that SPT offered no additional benefits over SA; however, patients tolerated postoperative neck exercises without any negative side effects. These findings are important for the development of future active and neck-specific post-operative rehabilitation interventions for patients with CR.
Cough and fever are the initial symptoms of lower respiratory infection. Severe cases might be fatal. Therefore, particularly in the non-equipped centers, the lack of diagnostic methods to identify the severe cases has resulted in overconsumption of antibiotics. On the basis of the knowledge about non-specific immune response at the site of injury, we developed a colorimetric dip-test that shows abrupt, sensitive and quite specific color change upon contact with sputum in the cases of lower respiratory infection. We further explored the mechanism of the test.
Background Pneumonia is a serious and widespread cause of morbidity and mortality. At an early stage, the symptoms are similar to other respiratory disorders, and there is no single criterion standard for diagnosis. Antibiotics are used too often as a precaution.
Objectives The objective of this study was to perform an assessment and clinical evaluation of a rapid sputum screening test (index test) to rule out pneumonia.
Methods Leftover sputum samples (467) collected at the Department of Microbiology from November 2016 to March 2017 were blindly analyzed within 72 hours with the index test. The clinical accuracy of the test was estimated for pneumonia by comparison with the established diagnosis by independent physicians (International Classification of Diseases, 10th Revision). Hepatocyte growth factor and calprotectin were measured on random samples (80), and layman volunteers (40) were asked to perform the test on artificial samples.
Results Two of 73 cases of pneumonia (community-acquired and nosocomial) showed negative results by the sputum strip test (97% sensitivity and 94% negative predictive value). The test results were highly correlated to hepatocyte growth factor and calprotectin concentrations in samples (R 2 = 67% respective 39%). Importantly, all of the volunteers were able to estimate the correct positive and negative results.
Conclusions The novel rapid sputum test represents a feasible tool for screening and ruling out the overwhelming majority of nonsevere respiratory infections at primary care settings, at home or when properly equipped laboratories are not available.
BACKGROUND: Due to anatomical restrictions, the inflammatory response to intracerebral bacterial infections exposes swollen brain tissues to pressure and ischemia, resulting in life-threatening damage. Rapid diagnosis and immediate empirical antibiotic therapy is highly important. However, diagnosing meningitis in patients after neurosurgery is complicated, due to brain tissue damage and changes in cerebrospinal fluid (CSF) caused by surgery. Hepatocyte growth factor (HGF) is a local, acute-phase protein with healing properties. Previous studies on community-acquired septic meningitis reported high levels of intrathecally produced HGF. The present study focused on nosocomial meningitis in assessing the levels of HGF in the CSF.
METHODS: HGF concentrations (ELISA) and HGF binding to receptors; c-Met receptor and heparan sulfate proteoglycan were determined in CSF samples (surface plasmon resonance). CSF samples from patients with community-acquired or nosocomial meningitis (217 samples from 135 patients) were compared to those from controls without signs of cerebral nervous system involvement (N = 36) and patients with Alzheimer's disease (N = 20).
RESULTS: Compared to samples from patients that had undergone neurosurgery and had other infectious diseases, CSF samples from patients with nosocomial meningitis had significantly higher HGF concentrations (p < 0.001) and binding affinity to c-Met (p < 0.001) and HSPG (p = 0.043) receptors. The sensitivity and specificity to identify nosocomial septic meningitis were 69.7 and 93.4 %, respectively. The HGF concentration and binding affinity to HGF receptors were significantly higher in CSF from patients with community-acquired septic meningitis compared to patients with aseptic (viral and subacute) meningitis as well as controls (p < 0.001). The sensitivity and specificity to identify community-acquired septic meningitis were 95.4 and 95.7 %, respectively.
DISCUSSION: In febrile nosocomial infections that occurred post neurosurgery, HGF assessment could substantially improve the differentiation of meningitis from other infections and therefore might be a tool for rapid diagnosis, limiting injuries and guiding antibiotic therapy.
Continuous optical monitoring of local cerebral microcirculation could benefit neurointensive care patients treated for subarachnoid hemorrhage (SAH). The aim of the study was to evaluate laser Doppler flowmetry (LDF) and diffuse reflectance spectroscopy (DRS) for long-term monitoring of brain microcirculation and oxygen saturation (SO2) in the neurointensive care unit (NICU). A fiber optic probe was designed for intraparenchymal use and connected to LDF and DRS for assessment of the local blood flow (perfusion and tissue reflectance (TLI)) and SO2in the brain. The optically monitored parameters were compared with conventional NICU monitors and Xe-CT. The LDF signals were low with median and 25 to 75% interquartiles of perfusion = 70 (59 to 83) a.u. and TLI = 2.0 (1.0 to 2.4) a.u. and showed correlation with the NICU monitors in terms of heart rate. Median and interquartiles of SO2 were 17.4 (15.7 to 19.8) %. The lack of correlation between local perfusion and cerebral perfusion pressure indicated intact cerebral autoregulation. The systems were capable of monitoring both local perfusion and SO2 with stable signals in the NICU over 4 days. Further clinical studies are required to evaluate the optical systems' potential for assessing the onset of secondary brain injury.
Diffuse reflectance spectroscopy (DRS) can be used to estimate oxygen saturation (SO2) of hemoglobin and blood fraction (fB) in brain tissue. The aim of the study was to investigate the SO2 and fB in different positions along deep brain stimulation (DBS) trajectories and in specific target regions using DRS and a novel algorithm. DRS measurements were done at 166 well-defined anatomical positions in relation to stereotactic DBS-implantation along 20 trajectories toward 4 DBS targets (STN, Vim, GPi and Zi). The measurements were dived into groups (gray, white and light gray matter) related to anatomical position, and DBS targets, before comparison and statistical analysis. The median SO2 in gray, white and light gray matter were 52%, 24% and 20%, respectively. Median fB in gray matter (3.9%) was different from values in white (1.0%, p < 0.05) and light gray (0.9%, p < 0.001) matter. No significant difference in median SO2 and fB was found between DBS target regions. The novel algorithm allows for quick and reliable estimation of SO2 and fB in human brain tissue.


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TORNILLO – Federal officials at the tent city temporarily sheltering hundreds of unaccompanied immigrant children in West Texas pushed back Friday against reports that children there did not have adequate access to education, legal representation and mental-health care.
But Mark Weber, a spokesman for the U.S. Department of Health and Human Services, acknowledged that logistical challenges were slowing down the process of placing the children with sponsors – usually parents or closer relatives – who already live in the country.
HHS requires background checks for everyone in a potential sponsor's home. But those background checks are taking more than three months to process. Last week, 900 kids in Tornillo were waiting for the return of those checks before they could be released.
"We're working through the process and wanting to speed it up," Weber said. "But that's balanced with safety."
About 1,500 children between the ages of 13 and 17 are currently living in the facility. The majority of them are boys, but about 300 girls also live in the temporary shelter. Boys and girls never mix, the shelter's administrators said.
Weber said children in these shelters are "treated with dignity and respect."
"They're provided a bed, clothing as needed, medical care, education, mental-health services, access to lawyers and any other things the kids would actually enjoy in a domestic setting like this," he told a group of more than a dozen reporters who toured the Tornillo facility Friday.
The temporary shelter was activated in June when President Donald Trump's "zero tolerance" policy separated thousands of children from their parents and overwhelmed the federal government's more than 100 existing shelters dedicated to housing unaccompanied children. The facility, however, does not house children separated from their parents by the policy, officials said.
The Tornillo facility, located 35 miles southeast of El Paso in an arid area, has been described as a "tent city" and has been criticized as inhumane by activists who say the children there have little access to services.
The facility's operators say a staff of 1,500 people works around the clock to monitor the children and provide them educational and medical services.
The facility is in large part for children who are on the cusp of being released. The average number of days a child stays in the facility, officials said, is 29.
"Our goal is to release kids as quickly as possible," Weber said.
Weber said the background checks for parents were implemented after a surge of immigrant children crossing the border in 2014, when the government released children to people who were not their parents.
Jennifer Podkul, the policy director for the legal advocacy group Kids in Need of Defense, or KIND, had a different view of the delay. Podkul said a new agreement between immigration authorities and Health and Human Services means that fingerprint information from the sponsors and any adult in the sponsor's household will be turned over to federal immigration authorities.
"That news spread like wildfire. People knew it was not safe anymore to come forward," Podkul said last week.
News reports had said that arrests by immigration authorities of dozens of persons who had applied to be sponsors could deter other potential sponsors who are also unauthorized immigrant from coming forward. But Weber said that was not the case.
"Sponsors are continuing to come forward," he said. "The numbers are not bearing that out. People are showing up."
Inside the facility
At the Tornillo facility, the boys sleep in tents that hold 20 bunk beds each about two feet away from the next. The beds are numbered and the boys' names are taped to them to identify their temporary owner: Gaspar, Cristopher, Yojan, Espino.
There's a stuffy scent - which comes when you cram many teen boys into one tent - and Halloween decorations hang from the beds. At the end of the tent, which is supervised by three adult staffers, the boys have hung up posters. "Bienvenidos a Alpha 11" reads one poster of an eagle, which refers to their tent name. Next to it hangs a portrait of Jesus with an inscription: "Jesus, I trust in you."
Despite the tight quarters, officials say the children are treated well. They get a "Know Your Rights" legal orientation – required by a federal court settlement and provided by legal aid organizations – and access to medical and education services, as well as recreation.
The girls sleep in a much bigger tent that has a capacity for 300 bunk beds for 600 girls. Rows of these bunk beds - decorated by "happy birthday" balloons and Little Mermaid posters - are divided by sheets that act as makeshift walls.
Last week in a news conference, Podkul said unaccompanied migrant minors shouldn't be put in an emergency shelter like Tornillo when there is no "true emergency."
Border Patrol statistics show about 46,000 children were apprehended at the southern border in the first 11 months of this year. While those numbers are higher than last year, it's less than in 2014 when about 68,000 were apprehended and the Obama administration called it a crisis. The numbers were high again in 2016 when nearly 60,000 unaccompanied minors came in.
There are now what's believed to be a record number of children, 13,000, in the network of shelters overseen by HHS and its Office of Refugee Resettlement, or ORR, a government spokesman said last week. That consistently high number of children flowing into their custody has also impacted the long wait times to connect children with a sponsor, Weber said.
Podkul is also concerned that Tornillo isn't licensed by the state to care for children, and it has more limited education and legal services than the traditional shelters, which are better equipped for unaccompanied children.
"We don't want them relying on emergency facilities just to run substandard programs to house children needlessly," Podkul said.
Dr. Alan Shapiro of the American Academy of Pediatrics has called for independent monitoring of immigrant children in all types of government custody. "This immigration detention system is continuously retraumatizing children," said Shapiro, who was on the same press call last week with the KIND attorney.
But officials at the facility pushed back on these criticisms, saying children receive round-the-clock care from qualified professionals and are medically screened and vaccinated within 48 hours of arriving at Tornillo. The facility has 40 mental-health staffers, including 32 certified counselors who work directly with the children and do welfare checks twice a day.
The children, who have between a 2nd- and 4th-grade reading level, also receive educational services from experienced teachers, officials said. Most of the children are focused on learning English for when they are released.
But they admit the education is not as formalized as a normal school, with test-taking and grades.
This summer, federal officials expanded the facility's capacity to 3,800 beds, leading to fears that more children would be housed in the controversial shelter. But officials said that escalation was to create room for 1,400 reserve beds in case a permanent shelter in Homestead, Florida was hit by a hurricane.
The Tornillo facility's contract was extended until Dec. 31. But officials are not sure if it will be extended again after that.
"It depends on how many kids come," Weber said.

subset: commoncrawl


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I can't wait until it's complete…I have to give you a sneak peek at something I'm working on: a digital-oil portrait of my youngest daughter, Pippi. I am almost finished her face–I always paint the face first when I paint a portrait, because if it doesn't look like my muse, what is the point?
Pippi's lips are ruby red as she will be holding a cherry popsicle. The painting will be fairly large: 3 feet in length. Now that the face is nearly complete (just a little more work), the rest of the painting should flow more quickly.
I have painted each daughter's portrait when she was an infant or toddler. After a decade, I have finally made the time to paint my youngest daughter's toddlerhood portrait.
Painting and writing are very different creative activities for me. I can write when I'm tired or feeling unwell because one can write anywhere: at Starbucks or even propped up in bed with a fever. With writing, I know I can clean it up later when I'm feeling better. However, with painting, it's surgery: I stand and hold my brush precisely and make precise marks on the canvas. There is no cleaning it up later–sloppy brushstrokes ruin the painting. I have to be on top of my game for each brush stroke–no more Starbucks for me!
I'll post the finished canvas as soon as it is completed.


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Emeldi Becomes a Certified Supplier in GOV.UK Digital Marketplace
London, UK – EMELDI LTD. UK is pleased to announce becoming a certified supplier in GOV.UK Digital Marketplace.
The Digital Marketplace is used by public sector organisations, including agencies and arm's length bodies, to find people and technology for digital projects. For becoming a certified supplier, Emeldi proved having an experienced team with various skill sets in digital projects development. This also confirms that Emeldi works according to the UK Civil Service values, government's digital-by-default service standard, and government technology code of practice.
This step will enable Emeldi to expand its services and partner with more UK public sector organisations. Emeldi has already developed multiple projects for public sector customers in different countries including Stevenage Borough Council, Czech Post, and The London Borough of Camden.


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Document and Mail Folders
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ATLAS-AS Air-Feed Document Folder
The ATLAS-AS Air-Feed Document Folder combines high-volume output with user-friendly features in a rugged, small footprint. With variable speed control, it can process up to 27,500 sheets per hour. Its 7" full-color touchscreen control panel allows operators to set up jobs easily and to program an unlimited number of jobs into memory. Fully-enclosed fold plates feature dials to select fold…
FD 3200 Air Suction Folder
The FD 3200 Air-Suction Document Folder offers high performance folding in a compact tabletop unit, ideal for digitally printed documents on heavy and coated stock. The air-suction feed technology reduces static electricity and minimizes feed marks common in traditional friction feed systems. The FD 3200 utilizes internal fans to produce air and suction for quiet operation in a smaller footprint…
Formax FD 300
The FD 300 Office Desktop Folder provides an economical solution for low-volume folding projects. This compact folder processes 11″ and 14″ paper at speeds up to 7,400 sheets per hour, and is pre-marked for four popular folds: C, Z, Half and Double Parallel. User-friendly features include an LCD control panel with 3-digit resettable counter, AutoBatch for processing sets of documents,…
Formax FD 314
The FD 314 Office Desktop Folder provides an economical solution for low-volume folding projects. It combines a compact footprint with push-button controls, so it's simple to use, right out of the box! Fold plates are clearly marked for four common folds – letter, zig-zag, half and double parallel – and can be easily adjusted for custom folds. With a three-tire drop-in feed system, it…
Formax FD 322
The FD 322 Document Folder offers an unmatched level of performance and affordability. Designed with ease of operation in mind, it utilizes a drop-in feed system, eliminating the need to fan paper. Simply square the paper stack and load it into the feed tray. The FD 322 can handle 11", 14" and 17" paper sizes, and is pre-marked for three standard folds: Letter, Zig-Zag, Half….
Formax FD 346 Touchscreen Desktop Office Folder
The FD 346 Document Folder is a fast, dependable and easy-to-use solution for virtually all folding applications. Its color touchscreen control panel features internationally-recognized symbols in place of text, making it easy for anyone to use. Six popular folds are clearly marked on the fold plates for quick set-up and operation, simply slide the fold stop to the desired fold and go….
The Automatic FD 382 Document Folder offers any business, church, school or print for pay center quick, easy set-up, and the versatility to complete a variety of fold jobs in minutes. Jobs are completed exceptionally fast with the FD 382, folding up to 20,100 pieces per hour! Fully automated fold plates provide one touch setup of the 18 pre-programmed fold settings or for choosing one of the 25…
The Fully Automatic FD 38X Document Folder is the ideal folding solution for any business, church, school or print-for-pay center that demands quick and easy set-up. Jobs are completed exceptionally fast with the FD 38X folding up to 20,100 pieces per hour! The new 2.8" (71mm) backlit LCD display and control panel makes the FD 38X extremely easy to use and provides a user interface that is…
The ATLAS Air-Feed Document Folder
The ATLAS Air-Feed Document Folder combines high-volume output with user-friendly features in a rugged, small footprint. With variable speed control, it can process up to 27,000 sheets per hour. Six standard folds are pre-set in letter, legal and ledger paper sizes, making it easy for operators to setup and run jobs. Fully-enclosed fold plates feature dials to select fold plate position and LED…


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» Decorative Carpets » Unusual Spanish Carpet
Unusual Spanish Carpet
This rare carpet was produced in Spain, and has a design taken from early Spanish Cuenca carpets. The colours are interesting, and the pile has a chunky handle. Woven horizontally, it would look stunning in an appropriate setting.
Cat No: Chy3
Dimensions: 4.15m x 3.70m
Date: early 20th century
Price: £POR


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Classical Gas
Classical Gas is an independent web site and is not affiliated to any of the clubs or organisers of the events featured. Words and Pictures by Michael unless attributed otherwise. Michael is a proud member of the MCC, ACTC, Dellow Register and Falcon amongst others, but does not represent their views nor the views of any other organisers or clubs.
Exe Valley
The organisers have decided that as they are mainly an old car club, not primarily into organising competitive events, that they cannot run the event in 2008


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Children may be getting higher than recommended levels of calcium, nickel and manganese, a survey of metal concentrations in food and beverages said.
By the time they reach middle age, many women put on weight and it seems impossible to get rid of it. However, Brazilian researchers claim that just by making sure you walk 6,000 steps a day, you can not only lose weight, but also reduce your risk of encountering conditions associated with menopause - like diabetes and metabolic syndrome.


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The NBS PhD programme is a full-time doctoral programme. The time needed to complete a PhD typically ranges from 4 to 5 years.
The first 18 months consist of coursework concentrated in the student's area of specialisation. Students are required to complete at least 24 academic units as graduation requirement. They will need to have completed at least 12 academic units before undergoing the Qualifying Exams.
Typically, the course requirement ranges from 8 to 11 courses (click here for the course outlines). The lists below show courses generally required for each specialisation, which may be subject to changes. They do not include electives (if any).


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Rooney: England must improve, but we are ready for Euro 2016
Wayne Rooney admitted there is plenty of room for improvement for England after they concluded their Euro 2016 preparations with a 1-0 win over 10-man Portugal at Wembley on Thursday.
Chris Smalling headed home Raheem Sterling's cross four minutes from time for a maiden international goal against a side reduced to 10 men for 55 minutes after Bruno Alves was punished for kicking Harry Kane in the head with a flying challenge.
England found it difficult to break Portugal down thereafter, however, struggling for fluency and creativity, and Rooney did not allow Smalling's late intervention to paper over the cracks.
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"We won the game but it was always difficult. They went to 10 men and that [struggling against depleted opponents] can happen in football," he told ITV.
"We kept going and we got the win. That was obviously important to us. I thought we were the better team, I thought even at 11 v 11 we were the better team.
"We need to play better, we know that. But it's a good sign when you don't play as well as you can do and you win the game."
Rooney lined up in the same England starting XI as strikers Harry Kane and Jamie Vardy for the first time and the attacking trio largely failed to fire, with the Tottenham and Leicester City stars too often confined to duties out wide.
Hodgson's skipper confirmed that forward line-up is under consideration for next weekend's opening Euro 2016 Group B match with Russia but insisted England's destiny will be decided by more than three players.
"We didn't have many chances, any of us. It's something the manager is working on and Portugal made it difficult," Rooney explained.
"There are 23 men in the squad, it's not three players. It's 23 and it's about all of us."
Despite not always convincing in previous outings against Turkey and Australia, England head to France on the back of three consecutive friendly wins and Rooney added: "We are ready.
"We've made a lot of changes to the team and we haven't been at our best but we have won the three games, which is important - especially for a young team."


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ASU Electronic Theses and Dissertations
This collection includes most of the ASU Theses and Dissertations from 2011 to present. ASU Theses and Dissertations are available in downloadable PDF format; however, a small percentage of items are under embargo. Information about the dissertations/theses includes degree information, committee members, an abstract, supporting data or media.
In addition to the electronic theses found in the ASU Digital Repository, ASU Theses and Dissertations can be found in the ASU Library Catalog.
Dissertations and Theses granted by Arizona State University are archived and made available through a joint effort of the ASU Graduate College and the ASU Libraries. For more information or questions about this collection contact or visit the Digital Repository ETD Library Guide or contact the ASU Graduate College at firstname.lastname@example.com.
- McCartney, Martha
- Chowdhury, Srabanti
- 1 Arizona State University
- 1 Eller, Brianna
- 1 Nemanich, Robert J
- 1 Ponce, Fernando
- 1 Smith, David
- 1 Public
- Mobile Crowd Sensing in Edge Computing Environment
- The Effect of Disability on Subjective Well-Being across the Adult Lifespan: The Moderating Roles of Age at Disability Onset and Disability Type
- Mechanically Active Heterogeneous Polymer Matrix Composites
- Attribute-Based Encryption for Fine-Grained Access Control over Sensitive Data
- 并购背景下教育行业品牌价值研究
GaN and AlGaN have shown great potential in next-generation power and RF electronics. However, these devices are limited by reliability issues such as leakage current and current collapse that result from surface and interface states on GaN and AlGaN. This dissertation, therefore, examined these electronic states, focusing on the following two points: First, the surface electronic state configuration was examined with regards to the polarization bound 1013 charges/cm2 that increases with aluminum content. This large bound charge requires compensation either externally by surface states or internally by the space charge regions as relates to band bending. In this work, band …
- Contributors
- Eller, Brianna, Nemanich, Robert J, Chowdhury, Srabanti, et al.
- Created Date
- 2015


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Italian Rounds
Olive Oil Rounds
Originally uploaded by monkeycat238.
1 pkg. active dry yeast
1 1/4 cup water
1-1.5 tbs salt
2 tbs olive oil
3+ cups all-purpose flour
Preheat oven to 375ºF
Add warm water (warm that you can keep you hand in it, but warmer than lukewarm) to a Kitchenaid mixer (or your mixter). Whisk in the yeast and let it sit for 10 minutes.
Once the yeast has bloomed, add 2 cups of the flour and turn on the mixer with the dough hook. Add in the salt and olive oil, then start adding the rest of the flour, a little bit at a time. I stop when the yeast pulls off the bottom of the bowl at medium speed.
Let the dough knead in the mixer by running it for 10-15 minutes on medium-high speed. This replaces hand-kneading for 30 minutes (unless you want a workout - my forearms are sore after kneading!).
Grease a bowl with olive oil and turn the dough out into the bowl. Coat the dough in the olive oil in the bowl and cover with a cloth and put on the stove-top of the preheated oven. The heat from the oven helps the dough to rise.
Let rise for 1.5hrs at which time it will be BIG. Punch it down and let rise again for 1 hr.
Turn out dough onto a floured surface. Cut into two balls and put onto a cornmealed or floured baking sheet. Let the balls rise again for 1 hr.
Score the top of each loaf - I use a serated steak knife, but I'm sure almost any knife will work.
Put in the oven for 20-25 minutes.
Antonia and I really like this bread because, like all of our home-made breads, there are no preservatives - this lets all of the flavors of the ingredients come through. The olive oil gives the bread a great flavor, and the salt sets of the yeasty flavor perfectly.


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By Sambit Dash
What happens in the high seas in its backyard, concerning India's national aspirations, is India's business.
With 70 percent of the world's petroleum shipment, 50 percent of world's container traffic, dependence of world's two most populous nations for their huge satiety for growth and with an Asian world order establishing, Indian Ocean Region has emerged to be the centre of geopolitical fluxes. This important Sea Lane of Communication (SLOC) however is being used by China to make strategic manoeuvres to encircle India and to assert its hegemony in the region. India, with a geographical advantage, needs to be proactive in order to establish its position as a responsible global power, right signals of which has been shown by the Narendra Modi government.
Indian Ocean Region extends from Australia in the east to South Africa in the west and leading economies of the world China, India, Japan and Australia depend on it. Of late, the docking of Chinese submarines in Sri Lanka and Pakistan, forcing an Indian submarine to surface, building of islands in the South China Sea, forging friendships with smaller Indian Ocean countries, an ambitious Maritime Silk Road (MSR) touted as 'String of Pearls' and the massive expansion of PLA-Navy of late has created a buzz of discomfort in India. Strengthening military capabilities should be a prominent feature of the "reverse string of pearl" strategy.
(Image: thetimes.co.uk)
Military Capabilities
India has been fundamentally against militarisation of Indian Ocean. However of late, the massive spurt in growing its military presence in the region, pretty much exponentially, by the Chinese only mean that India needs to build an effective deterrence. Chinese economy and PLA-Navy's massive fleet are far from India's reach but backing on better security relationships it has and a regime that has set its priorities in the region, an effort is underway to catch up.
Andaman & Nicobar Command (ANC): This facility overseeing the crucial Malacca Strait through which about 60,000 ships pass each year, is India's easternmost bastion and has not seen much capacity building since its establishment in 2001. However Indian Navy chief Admiral Robin Dhowan has reiterated that the defence ministry has set ANC as a priority and probably will have a division-level force with 15,000 troops, fighter squadron, more airstrips and major warships. There is a need to equip it with Anti Submarine Warfare (ASW), keeping in view the increase in Chinese submarine excursions. A bold 'geo-economic vision', as analyst C Raja Mohan calls it, needs to be realised in this 572 group of island. Additionally for India, ANC can prove to be an example for functioning of an otherwise mired in squabble unified command. India needs to take advantage of China's 'Malacca dilemma' through this strategic point.
Shipbuilding: India has 28 shipyards, which thanks to public sector work culture and being stuck in pre-modern era have failed the aspirations of a Navy in need. China has over 800 shipyards and even countries like Vietnam and Phillipines produce quality ships at competitive price. Privatisation of shipbuilding industry needs to be undertaken if India is to make great strides in sea. There are about 2600 ships capable of ocean transport in China which surpasses all others by more than a mile. The new ship acquisition policy announced by Arun jaitley in July 2014, in order to raise India's home fleet by four times its current capacity, has been a welcome move. Perhaps a policy like China to build new ships fitting specifications by Navy so as to ne ready for ocean transport could be explored.
Dredge: Incessant dredging activity by China and its 'creation' of 'Spratly Island Chain' and 'Fiery Cross Reef', which is against the UNCLOS, and has all machinations for military use, has concerned the international community. India's dredging industry has been plagued by slow pace of project award and implementation. The Maritime Agenda 2010-2020 pegs an investment of Rs 200 billion by 2020 for dredging and with opportunities which cannot be met by Dredging Coporation of India, forming a policy on dredging and opening that sector to private players could help explore posibilities of extending it to meet military needs.
Aircraft carriers: India currently possesses an ageing and limited capacity INS Viraat which is set to be decommissioned in 2016. INS Vikramaditya is India's primary aircraft carrier and serves as a statement in the Indian Ocean backyard. India home-grown aircraft carrier INS Vikraant, made by Cochin Shipyard could be inducted in 2017 and the other nuclear powered carrier INS Vishal is in the design phase. While China has two aircraft carriers, one which it built on its own, the building of world's longest dock at Sanya captured the world's attention. With the aid of its partner US, which has its 6th fleet in the Indian Ocean, with whom it is set to carry out its 19th war exercise in October, and who sees India as a 'lynchpin' in the 'pivot' strategy of strenghening its position in the Asia-Pacific, India should speed up the process of technology transfer in building indigenous aircraft carriers.
Submarines: China has 68 submarines and India has 14 and that speaks volumes, if not all, about China's under sea capabilities. They might be a generation behind the West but suffices to counters India's posse. India has however attempted to catch up by adding 15 submarines to its fleet, including three nuclear ballistic-missile (SSBN) ones but the key feature is that most of them are built in India itself. This should boost India's abilities to build more and at home. But an effective strategy to counter China's huge submarine fleet is to develop anti-submarine warfare (ASW). The current fleet of about 6 ASW aircrafts might pale in front of the Chinese.
Mission Sea-Base: China is keen on sea-basing, a concept where overseas missions can be undertaken without land based command, control and support. It acquired a Mobile Landing Platform in July this year, rolled out its fifth replenishment ship and has made laws for commercial ships to meet naval standards. India's sea-basing capabilities are negligent however its long-standing naval partner US could help India develop capacity in that regard and that is what India should look for from its strategic partner.
Indian Ocean – the hotbed of activities
A conventional full-scale war may be a thing of past and thus India's long standing policy of not having overseas military bases may hold good but in a scenario where isolated conflicts and posturing might demand show of power, 'Places not bases' strategy would help. In that regard India's healthy relation with Indian Ocean countries is very important.
India's maritime focus should be to go beyond A2/AD (Anti Access/ Area Denial). New Delhi has mandated a three pronged strategy for the high seas which involves bolstering submarine capacity, augmenting carrier battle groups and stregthening air power and thorugh its humanitarian and peace-keeping objectives. By the way of anti-piracy operations in Gulf of Aden (incidentally with China) and Operation Rahat in Yemen it has demostrated its intent of a responsible sea power.
India's naval policy plagued by structural and institutional issues riding on a deep disconnect between Navy and bureaucracy has not espoused great faith in building its capabilities. It will take much more, than the state of affairs presently to put forth a sea-based deterrent vis-à-vis China. A beginning step could be to have a single government agency with the expertise and mandate which would replace the current 14 odd agencies that work in an uncoordinated manner in ocean related matters.
It might be true what the Chinese say, Indian Ocean may not be India's ocean, but what happens in the high seas in its backyard, concerning India's national aspirations, is definitely India's business.
Sambit Dash is a faculty member in Melaka Manipal Medical College at Manipal University, is an alumnus of Takshashila's public policy course, the Graduate Certificate in Public Policy and writes on public policy, social issues and geopolitics. The views are personal.


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Supplementary essay for an exhibition of plaquettes at the Villa Cagnola library: Il fascino dell'antico nelle placchette in bronzo della Collezione Cagnola (October 2017)
Tag: Master IO.F.F.
Three Plaquettes by Francesco Francia or his Circle: proposing an identity for Pseudo-Fra Antonio da Brescia
Proposed is an identity for the elusive plaquette maker dubbed Pseudo-Fra Antonio da Brescia. Also suggested is the possibility a plaquette may have been inspired by Albrecht Durer's visit to Bologna in 1506-07.


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May 21 (UPI) -- Ravens in a lab setting can experience negative emotional contagion, according to a new study by researchers in Austria.
Emotional contagion is said to occur when the emotional state of one individual effects the emotional state of another. The emotional state -- sadness or anger, for example -- can travel from one individual to the next. If one bird becomes depressed, the whole flock can soon be mopping around.
New experiments proved ravens in a laboratory setting can experience the social phenomenon.
"Scientific research on animal emotions is often received with skepticism," Jessie Adriaense, a cognitive biologist at the University of Vienna in Austria, said in a news release. "Research has advanced and we no longer follow the idea that emotions are less important than for example cognitive skills."
"Just like humans, animals are driven and motivated by their emotional states, which is reflected in their cognitive performance and behavioral expressions," Adriaense said. "Although it remains a challenging research endeavor, this study demonstrates we're heading in the right direction."
For the tests, researchers divided eight birds into four pairs and presented each twosome with a choice between two boxes, one empty and one hiding a hunk of cheese. Ravens like cheese.
After only a few repetitions, the ravens were able to figure out which box had the cheese in it. Once the ravens had figured out the test, researchers added a third box to the mix and observed the reactions of the two birds -- a so-called cognitive bias test. Scientists noted whether the ravens responded with optimism or pessimism.
Next, the pairs were separated and presented with a new choice: between carrots and dried dog food. Ravens don't like carrots. While one raven selected between two boxes, the other raven watched. The observer was only able to see the reaction of their former test partner, not the contents of the chosen box.
Finally, the ravens were presented the cognitive bias test again. Observers that watched a disappointed response were more likely to take their time and investigate the third box with apprehension. Ravens who witnessed normal behavior reacted normally to the third box.
The findings, published this week in the journal PNAS, suggest ravens can experience negative emotional contagion. Researchers suggest their unique study methods, which involved the integration of behavioral and psychological testing strategies, could be used to study other animals.
"Now that we know how it works, we can apply it to various animals," Adriaense said. "Getting to that stage was difficult, though, and we strongly profited from the interdisciplinary collaboration across faculties and research fields."