Respiratory insufficiency in patients with progressive neuromuscular disease can sometimes be treated effectively with ventilatory support

Three patients with myotonic dystrophy (MD) developed respiratory failure. The first was a 55-year-old man with MD who had been admitted elsewhere with pneumonia and respiratory failure. After discharge he was re-admitted with respiratory failure due to respiratory pump failure. Ultimately, he was given a tracheostomy and was ventilated during the night. The second patient was a 38-year-old man who was admitted to the intensive care unit when he could not be weaned off the ventilator following cholecystectomy for symptomatic gall stones. It appeared that he had partial respiratory failure due to MD and overweight. Ultimately he was able to be weaned during the day with nightly non-invasive ventilation. The third patient was a 55-year-old woman who was admitted with recurrent pneumonia and respiratory failure. She appeared to have chronic respiratory failure due to MD. She was ventilated at night via a tracheostomy. All three patients reported a gradual decline in physical and mental performance in the years preceding this acute episode. All three experienced a remarkable recovery of performance after the institution of mechanical ventilatory support. Respiratory failure that develops over a number of years can be easily missed in aging patients with slowly progressing neuromuscular disease. Timely recognition may lead to improved survival and quality of life by the application of non-invasive ventilatory support.     

Declining vulnerability to river floods and the global benefits of adaptation

The global impacts of river floods are substantial and rising. Effective adaptation to the increasing risks requires an in-depth understanding of the physical and socioeconomic drivers of risk. Whereas the modeling of flood hazard and exposure has improved greatly, compelling evidence on spatiotemporal patterns in vulnerability of societies around the world is still lacking. Due to this knowledge gap, the effects of vulnerability on global flood risk are not fully understood, and future projections of fatalities and losses available today are based on simplistic assumptions or do not include vulnerability. We show for the first time (to our knowledge) that trends and fluctuations in vulnerability to river floods around the world can be estimated by dynamic high-resolution modeling of flood hazard and exposure. We find that rising per-capita income coincided with a global decline in vulnerability between 1980 and 2010, which is reflected in decreasing mortality and losses as a share of the people and gross domestic product exposed to inundation. The results also demonstrate that vulnerability levels in low- and high-income countries have been converging, due to a relatively strong trend of vulnerability reduction in developing countries. Finally, we present projections of flood losses and fatalities under 100 individual scenario and model combinations, and three possible global vulnerability scenarios. The projections emphasize that materialized flood risk largely results from human behavior and that future risk increases can be largely contained using effective disaster risk reduction strategies.Flooding is one of the most frequent and damaging natural hazards affecting societies across the globe, with average annual reported losses and fatalities between 1980 and 2012 exceeding $23 billion (bn) (in 2010 prices) and 5,900 people, respectively (1). These risks have been shown to negatively affect economic growth on a country level (2). Global trends and regional differences in flood risk result from the dynamics of hazard (i.e., the natural frequency and intensity of floods, without human interference), exposure (i.e., the population and economic assets located in flood hazard-prone areas), and vulnerability (i.e., the susceptibility of the exposed elements to the hazard) (3, 4). Each of these contributing factors can be expected to change over time.Trends in global flood losses have been increasing over the past decades and have been attributed mainly to increasing exposure due to high population growth and economic development in flood-prone areas (4–9). At the same time, rainfall patterns and intensities may shift under climate change (10, 11), which could influence the flood hazard (12–15). In addition, interannual variations in peak discharge, caused by climatic oscillations such as El Niño Southern Oscillation, may lead to strong spatiotemporal fluctuations in the occurrence of floods (16, 17). These hazard and exposure elements can only partly explain spatiotemporal patterns in flood risk, because of the importance of vulnerability (8, 18). There are many different and competing definitions of vulnerability in literature (see ref. 4, chap. 2, for a discussion on these). Vulnerability is considered in this study to include all man-made efforts to reduce the impact of the natural flood hazard on the exposed elements, including structural flood defenses, building quality early-warning systems, and available health care and communication facilities (19–21). Vulnerability is dynamic and varying across temporal and spatial scales, and may depend on economic, social, geographic, demographic, cultural, institutional, governance, and environmental factors (ref. 4, chap. 2). The level of vulnerability is therefore affected by socioeconomic development (ref. 4, chap. 2; see also ref. 22) and can specifically be influenced by deliberate disaster risk reduction efforts (19, 23). The reduction of vulnerability over time makes countries less prone to the adverse effects of the current and future flood hazard and is therefore considered as a display of adaptation.For example, two similar tropical cyclones made landfall in eastern India, one in 2013 (Phailin) and one in 1999 (Cyclone 05B). Exposed population was greater in 2013 due to population growth and development in cyclone-prone areas. However, the vulnerability in the region had drastically decreased with the implementation of a disaster management authority; cyclone shelters and early-warning systems ensured that only a small fraction of the population was vulnerable to this event. Because of this, the total reported impacts for the similar event in 2013 were much lower; fewer than 50 lives were lost in 2013, whereas the cyclone in 1999 was responsible for more than 10,000 lives lost (24). A similar study examined the effect of mangrove forests in the 1999 event; controlling for distance from the coast and storm surge (exposure and hazard, respectively), they found a differential vulnerability in the number of deaths as a percentage of the potentially exposed population (25).The level of vulnerability of a community is therefore reflected in the actual losses and fatalities as a share of the people and assets exposed to the flood hazard (26). In vulnerable communities, these mortality and loss rates can be expected to be higher than in less vulnerable communities for the same hazard event.Understanding the complexity of the risk chain and the resulting past and future trends in flood risk is increasingly important for international decisions on risk financing (13, 27), for the allocation of disaster risk reduction (DRR)-related development aid (28, 29), and for designing effective climate change adaptation policies (4, 30, 31). Recently, disentangling the contribution of hazard, exposure, and vulnerability has once again been emphasized explicitly in the climate change debate, as the acceptance of the Warsaw International Mechanism for Loss and Damage Associated with Climate Change Impacts in December 2013 (32) raises questions of causality, responsibility, and equity (33).The understanding of climatic and socioeconomic drivers of risk has improved considerably over the past years, and a range of studies have demonstrated that feasible estimates can be made of current and future flood hazard (34, 35) and exposure (19, 36) at a global scale. These scientific advances have recently been combined in first global-scale risk assessments under current and future climate conditions (37–39). However, the understanding of vulnerability remains one of the biggest hurdles in existing continental to global-scale flood risk assessments (33, 37). To disentangle the risk chain and identify the contribution of vulnerability on historical flood losses, it is critical to have consistent information on global flood hazard, exposure, and reported impacts. Previous recent studies (6–9) have tried to unravel reported flood loss patterns from various disaster databases by normalizing the trends using data on gross domestic product (GDP) and population growth (exposure) and, at best, simplistic climate proxies (hazard). Whereas increases in the proxies for hazard and exposure have been statistically linked to rising long-term global trends in losses, they do not represent interannual variability in flood occurrence and offer limited explanatory power for year-to-year global loss patterns. Finding evidence for changes in vulnerability in these long-term trends has therefore been very difficult (8). No previous study has yet been able to quantify the contribution of the individual risk drivers and convincingly disentangle the dynamics of hazard, exposure, and vulnerability on a global scale.Consequently, little quantitative evidence is yet available about regional differences in human and economic vulnerability to flooding; changes in this vulnerability over time under socioeconomic growth, adaptation, and DRR efforts; and how this relates to observed trends in global disaster risk (8). As a result, past trends in losses and fatalities are not fully understood; the potential effect of climate change-induced increases in flood hazard remains unclear; the global effects of adaptation measures are unquantified; and future projections of fatalities and losses available today are based on simplistic assumptions or do not include vulnerability (8, 13, 40).Here, we focus on analyzing this missing link in the risk chain. We show that variation and trends in vulnerability can be derived by modeling flood hazard and exposure at a high level of detail and paralleling these to reported impacts over the past decades. We investigate the relationship between GDP per capita and vulnerability, whereby we consider vulnerability to be represented by mortality rates (reported fatalities as a percentage of modeled exposed population) and loss rates (reported losses as a percentage of modeled exposed GDP). We also show how the vulnerability of different world regions has changed over time. Finally, we demonstrate how reducing vulnerability by improved adaptation efforts may strongly lower the magnitude of human and economic flood losses in the future.     

A comparison between two NIRS oximeters (INVOS,OxyPrem) using measurement on the arm of adults and head of infants after caesarean section

Previously the NIRS oximeter OxyPrem was calibrated by comparison to the INVOS in a blood-lipid phantom. The aim of the present study was to test this calibration clinically. During vasculur occlusions in 10 adults and after birth in 25 term infants the relationship was OxyPrem = 1.24 x INVOS - 23.6% and OxyPrem = 1.15 x INVOS - 16.2% on the adult arm and infant head, respectively. The precsion during steady state was 4.0% (CI 3.4% to 4.6%) and 3.4% (CI 2.9% to 3.9%) on the arm, and 6.7% (CI 5.9% to 7.6%) and 4.7% (CI 3.5% to 5.9%) on the infant head for OxyPrem and INVOS, respectively. We conclude that the calibration on the blood-lipid phantom was unsuccessful in achieving agreement in clinical measurements.OCIS codes: (170.1470) Blood or tissue constituent monitoring, (170.6510) Spectroscopy, tissue diagnostics     

Home mechanical ventilation in the Netherlands

Over the last 20 years the number of Dutch patients on home mechanical ventilation has increased from 200 to 2000. Home mechanical ventilation is a cost-effective treatment which significantly improves the quality of life of patients. In 2011 83% of patients on home mechanical ventilation in the Netherlands is living at home. In the future further growth can be expected in the number of patients with obesity hypoventilation syndrome and a potential new group of patients with COPD. Strict conditions are necessary to ensure safety in the complex care that home mechanical ventilation entails.     

Use of the thermal laser effect of laser irradiation for cardiovascular applications exemplified by the Nd:YAG laser

Techniques of percutaneous transluminal application of laser energy for vessel recanalization have been used clinically since 1983. The commonly used Nd:YAG and argon lasers achieve ablation of atherosclerotic plaques by thermal action (vaporization). In order to reduce undesirable thermal damage in the neighborhood of the target tissue and to avoid vessel perforation, optimal irradiation parameters, modified (atraumatic) fiber tips (hot tips, sapphires), and steerable catheter systems needed to be implemented. Favorable results from peripheral application have encouraged use in the coronary circulation. More recently, coagulative tissue effects of circumferential irradiation of the vessel wall during balloon dilatation have been used for stabilization of acute and late results after mechanical balloon angioplasty. Enhancement of the differential light absorption of atherosclerotic plaque by use of biological dyes may further improve selective intravascular laser application. Intraoperative ECG-guided laser coagulation of arrhythmogenic areas of myocardium is a method for treatment of malignant arrhythmias. Transluminal non-operative application of myocardial laser photocoagulation has now been tested experimentally and shown to be safe and effective. There was no arrhythmogenicity or thermal damage of coronary arteries associated with this method. Innovative techniques such as nanosecond pulsed excimer lasers (athermal action) and development of "intelligent" lasers--which are equipped with spectroscopy-guided feedback systems for plaque recognition--have opened new perspectives and will further improve safety and efficacy of clinical laser application. However, according to current experience, the thermally acting Nd:YAG laser is an effective and versatile mode of laser therapy for selected cardiovascular indications.     

„Über das Renin”. Ein experimenteller Beitrag zur Pathogenese des renalen Hochdrucks

Ohne Zusammenfassung     

Überlegungen zur bilateralen CI-Versorgung

Patienten mit einer beidseitigen, an Taubheit grenzenden innenohrbedingten H?rst?rung werden seit nunmehr 20 Jahren erfolgreich mit Kochleaimplantat (CI)-Systemen therapiert. Dabei erschien es aus rehabilitativen und finanziellen Gründen bisher ausreichend, die Prothese einseitig zu implantieren. Nun tritt auch die bilaterale CI-Versorgung in den Blickpunkt des Interesses. Als m?gliche Vorteile einer bilateralen CI-Versorgung sind Verbesserungen der Schalllokalisation und des Sprachverst?ndnisses im St?rl?rm zu erwarten. Obwohl bisher nur sehr wenige wissenschaftlich fundierte human- und tierexperimentelle Ergebnisse über den Nutzen der beidseitigen CI-Versorgung vorliegen [10], wurden Patienten beidseitig implantiert. Vor- und Nachteile der bilateralen CI-Versorgung werden seitdem sehr kontrovers diskutiert. Im Mittelpunkt der Diskussion stehen vorwiegend gesundheitspolitische überlegungen und technische Aspekte, wohingegen dem Problem der zentralnerv?sen Verarbeitung wenig Aufmerksamkeit gewidmet wird. Ziel dieses Artikels ist es, die m?glichen neurobiologischen und technischen Vor- und Nachteile einer bilateralen CI-Versorgung gleicherma?en zu beleuchten.     

The N-DSK gamma-chain binds to immunoprecipitated GP IIb-IIIa

The CNBr-split N-terminal disulphide knot of the fibrinogen molecule (N-DSK) binds to ADP-stimulated gel-filtered platelets and immunoprecipitated fibrinogen receptor. To investigate which part of the N-DSK molecule that is involved in this binding, the glycoprotein IIb-IIIa complex (the fibrinogen receptor) was immunoprecipitated in crossed immunoelectrophoresis of Triton X-100 extracts of platelets against rabbit antibodies to whole platelet proteins. The immunoelectrophoresis plates were incubated with solubilized, carboxymethylated 125I-labelled A alpha -, B beta - or gamma-chains of N-DSK, and investigated for binding by autoradiography. The N-DSK gamma-chain, but not the A alpha - or B beta -chains demonstrated binding to the GP IIb-IIIa complex. These results show that the fibrinogen molecule contains a third sequence of amino acids, in addition to the two previously reported ones that can be involved in binding of fibrinogen to the fibrinogen receptor on the platelets.