Nonlinear Sideband Cooling to a Cat State of Motion.

The ability to prepare a macroscopic mechanical resonator into a quantum superposition state is an outstanding goal of cavity optomechanics. Here, we propose a technique to generate cat states of motion using the intrinsic nonlinearity of a dispersive optomechanical interaction. By applying a bichromatic drive to an optomechanical cavity, our protocol enhances the inherent second-order processes of the system, inducing the requisite two-phonon dissipation. We show that this nonlinear sideband cooling technique can dissipatively engineer a mechanical resonator into a cat state, which we verify using the full Hamiltonian and an adiabatically reduced model. While the fidelity of the cat state is maximized in the single-photon, strong-coupling regime, we demonstrate that Wigner negativity persists even for weak coupling. Finally, we show that our cat state generation protocol is robust to significant thermal decoherence of the mechanical mode, indicating that such a procedure may be feasible for near-term experimental systems.

Developing a craniomaxillofacial and cervical equipment module for surgeons in the austere environment: a systematic review.

The treatment of craniomaxillofacial and cervical wounds in a disaster relief setting is done by clinicians from local medical treatment facilities, non-governmental organisations (NGO), or the military. Although each group and individual surgeon will need specific equipment, this will be restricted by weight, portability and interoperability. We systematically reviewed scientific and commercial publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The papers we identified described the portable equipment that is required to treat patients who need damage-control surgery (decompressive craniectomy, temporary stabilisation, and internal and external fixation of the facial bones) for craniomaxillofacial and cervical injuries in austere or military settings. Austere settings are those in which there is an inherent lack of infrastructure, such as facilities, roads, and power. A total of 35 papers or scientific articles recommended the equipment that is needed to manage these injuries, but we could find no module that was specifically designed for use in these environments. Multiple modules are currently required to provide comprehensive surgical care and many of the items in the existing maxillofacial and neurosurgical kits are rarely used, which increases the cost of initial procurement and resupply. Duplications in equipment between modules also increase the size, weight, and financial cost. We suggest the equipment that is required to make up a rationalised, lightweight, and compact module that can be used for all craniomaxillofacial and cervical operations in austere settings.

Quantum Hypercube States.

We introduce quantum hypercube states, a class of continuous-variable quantum states that are generated as orthographic projections of hypercubes onto the quadrature phase space of a bosonic mode. In addition to their interesting geometry, hypercube states display phase-space features much smaller than Planck's constant, and a large volume of Wigner negativity. We theoretically show that these features make hypercube states sensitive to displacements at extremely small scales in a way that is surprisingly robust to initial thermal occupation and to small separation of the superposed state components. In a high-temperature proof-of-principle optomechanics experiment we observe, and match to theory, the signature outer-edge vertex structure of hypercube states.

Dental care provision to UK military personnel serving on Operation Herrick in Afghanistan. Part 2: aetiology and management.

Aims: To evaluate the nature of tooth-related morbidity in military personnel deployed on Operation Herrick and to compare the management of dental emergencies to that in non-deployed personnel. Method: Data were collected prospectively for UK Service personnel on Operation Herrick (OpH) during an 18-month period and measured against prospectively collected 'home base' (HB) control data. Results: Molar teeth were responsible for 64.1% (2,089/3,259) of presentations on OpH and 69.5% (323/467) at HB, causing 81.4% (622/764) of cases of pain lasting for >60 minutes and/or waking the patient on OpH and 86.0% (129/150) at HB. Third molars were responsible for 48.3% and 43.3% of such cases, respectively, and first molars 20.7% and 26.7%. The ratio of temporary to definitive restorations was 0.42 at HB compared with 0.18 on OpH (P <0.001). Antibiotics were prescribed in 5.7% of all cases of pulpitis /periapical infection on OpH and 7.9% at HB. A third molar causing pericoronitis was 2.4 times more likely to be extracted on OpH than at HB (27.4% cf 11.6%). Conclusions: A more definitive approach to management is evident on deployment, reflecting the effort to conclusively treat immediately. To maintain this standard of care it is vital that military dental surgeons continue to be skilled in minor oral surgery.

Dental care provision to UK military personnel serving on Operation Herrick in Afghanistan. Part 1: access to dental care.

Aims: To assess factors influencing access to dental care and to determine the true level of dental morbidity experienced by UK military personnel serving on Operation Herrick. Methods: Data on dental emergencies were collected prospectively over an 18-month period. Deployed personnel were divided into those co-located with a dental centre and those not co-located. Personnel were separately surveyed on return from Operation Herrick; individuals who had suffered an oral/dental problem whilst deployed were asked to complete a questionnaire. Results: There were 4,017 dental emergency attendances by 3,355 UK military personnel (282/1,000 man years at risk). A total of 278 non-co-located patients were transported with the sole purpose of seeing a dental officer, 79% by helicopter; a median of 24 hours was lost from their operational role (vs one hour for those co-located). In the cohort surveyed after their return from Afghanistan, 37/118 (31.4%) patients who had wanted to see a dentist whilst deployed did not manage to. Conclusions: Dental morbidity is common and can affect operational effectiveness, but this risk is reduced by co-location with a dental centre. There is a substantial component of 'hidden' dental morbidity in deployed personnel. Evaluating dental morbidity using dental centre attendees likely underestimates the true levels by approximately a third.

How are we currently training and maintaining clinical readiness of US and UK military surgeons responsible for managing head, face and neck wounds on deployment?

INTRODUCTION: The conflicts in Iraq and Afghanistan provided military surgeons from the USA and the UK with extensive experience into the management of injuries to the head, face and neck (HFN) from high energy bullets and explosive weaponry. The challenge is now to maintain the expertise in managing such injuries for future military deployments. METHODS: The manner in which each country approaches four parameters required for a surgeon to competently treat HFN wounds in deployed military environments was compared. These comprised initial surgical training (residency/registrar training), surgical fellowships, hospital type and appointment as an attending (USA) or consultant (UK) and predeployment training. RESULTS: Neither country has residents/registrars undertaking surgical training that is military specific. The Major Trauma and Reconstructive Fellowship based in Birmingham UK and the Craniomaxillofacial Trauma fellowship at Duke University USA provide additional training directly applicable to managing HFN trauma on deployment. Placement in level 1 trauma/major trauma centres is encouraged by both countries but is not mandatory. US surgeons attend one of three single-service predeployment courses, of which HFN skills are taught on both cadavers and in a 1-week clinical placement in a level 1 trauma centre. UK surgeons attend the Military Operational Surgical Training programme, a 1-week course that includes 1 day dedicated to teaching HFN injury management on cadavers. CONCLUSIONS: Multiple specialties of surgeon seen in the civilian environment are unlikely to be present, necessitating development of extended competencies. Military-tailored fellowships are capable of generating most of these skills early in a career. Regular training courses including simulation are required to maintain such skills and should not be given only immediately prior to deployment. Strong evidence exists that military consultants and attendings should only work at level 1/major trauma centres.

Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement.

INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

Optimising ballistic facial coverage from military fragmenting munitions: a consensus statement.

VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.

Retrospective analysis of the prevalence and incidence of caries in the distal surface of mandibular second molars in British military personnel.

Mandibular third molars are commonly removed because of distal caries in the adjacent tooth. To find out the prevalence of distal caries in mandibular second molars we retrospectively studied the primary care dental records of 720 British military personnel (653 men and 67 women) from various centres. These records are standardised and personnel are required to attend for inspection regularly. Those who had been under 20 years of age at enlistment, who had served for at least five years, and had five recorded dental inspections, were included. The median (IQR) period from the first to last inspection was 15 (9.7 - 19.2) years, and inspections were a median (IQR) of 14.1 (12.8 - 15.8) months apart. A total of 59/1414 (4.2%) mandibular second molars developed caries in their distal surfaces. This was 4% higher when they were associated with a partially-erupted mandibular third molar than when associated with one that was fully erupted or absent (29/414 (7%) compared with 30/1000 (3%); p=0.001). Carious lesions developed in the distal aspect of 22/133 mandibular second molars (16.5%) that were adjacent to a mesioangularly impacted third molar. Of these, 19/22 were successfully restored. Four mesioangularly impacted mandibular third molars would have to be extracted to prevent one case of distal caries in a second molar (number needed to treat=3.25). Second molars that are associated with a partially-erupted mesioangular mandibular third molar have a higher risk of caries, and this can be reduced by removal of the third molar. However, distal caries in second molars seems to be a treatable and slowly-developing phenomenon and we recommend that the merits and risks of the prophylactic removal of third molars should be discussed with the patient, who should have long-term clinical and radiographic checks if the tooth is retained.

Incidence and survival of childhood central nervous system tumors: A report of the regional registry of childhood cancers in Auvergne-Limousin.

INTRODUCTION: Central nervous system tumors (CNST) are the most lethal of solid tumors in childhood cancer. PATIENTS AND METHODS: We report incidence and survival data for all CNST (International Classification of Diseases for Oncology third edition, category III or Xa) recorded in children under 15 years of age by the Auvergne-Limousin cancer registry for the period 1986-2009. RESULTS: Annual incidence of all CNST was 3.27 per 100,000 and the male to female ratio was 0.95. Over 45.0% of CNST were glial. Astrocytomas (36.2%) showed the highest incidence for each age group except between 1 and 4 years where embryonal tumors were more common. For all CNST, no significant variation in incidence over time was observed for the evaluated period of 23 years (annual percent change: -0.4%, 95% CI, [-2.8-2.1]). Globally, 5 years overall survival was 67% [59-73] and had increased by more than 16% between 1986-1999 and 2000-2009, mainly due to better survival for astrocytomas, other gliomas, ependymomas and choroid plexus tumors (P=0.01). CONCLUSION: We report that the incidence of CNST in Auvergne-Limousin is similar to that in the literature and did not increase between 1986 and 2009. In addition, 5 years overall survival increased after 1999, especially for surgically treatable tumors.

Intrinsic magnetic properties of bimetallic nanoparticles elaborated by cluster beam deposition.

In this paper, we present some specific chemical and magnetic order obtained very recently on characteristic bimetallic nanoalloys prepared by mass-selected Low Energy Cluster Beam Deposition (LECBD). We study how the competition between d-atom hybridization, complex structure, morphology and chemical affinity affects their intrinsic magnetic properties at the nanoscale. The structural and magnetic properties of these nanoalloys were investigated using various experimental techniques that include High Resolution Transmission Electron Microscopy (HRTEM), Superconducting Quantum Interference Device (SQUID) magnetometry, as well as synchrotron techniques such as Extended X-ray Absorption Fine Structure (EXAFS) and X-ray Magnetic Circular Dichroism (XMCD). Depending on the chemical nature of the nanoalloys we observe different magnetic responses compared to their bulk counterparts. In particular, we show how specific relaxation in nanoalloys impacts their magnetic anisotropy; and how finite size effects (size reduction) inversely enhance their magnetic moment.

Quality of care of patients with type 1 diabetes: population-based results in a French region.

AIM: Although the incidence of type 1 diabetes (T1D) has been increasing, little is known of its quality of care. Thus, our survey was designed to retrospectively evaluate this issue in French patients. METHODS: Patients with T1D living in northeastern France were identified thanks to the healthcare system (CPAM) database, and the resulting list reviewed by local diabetes specialists. All of the listed patients and their primary physicians were asked to fill in a questionnaire including clinical data, laboratory results and follow-up habits. The 'optimized results' included CPAM-based results plus any specialized care provided during hospitalizations in diabetes and non-diabetes units, according to questionnaire data. RESULTS: A total of 227 individuals, for whom CPAM data were available, were identified as having T1D. From these patients, 174 questionnaires were answered, and optimized results (having both CPAM data and a completely filled-in questionnaire) were available for 149 patients. Of the 169 patients who responded, 71.3% reported at least a yearly visit with a diabetologist. This number reached 77.9% when optimized results were considered. Patients who received specialized care were younger, underwent HbA(1c) tests more often and were more frequently on optimal treatment; however, there was no difference in HbA(1c) values or in the prevalence of complications. Eye examinations and kidney tests had been performed at least once over the 2-year period in more than 87% of the patients, whereas around 30%, 21% and 23% had an eye exam, creatinine test and urinary albumin excretion measurement, respectively, only once over the same time period. CONCLUSION: This is the first large-scale study of the quality of care in patients with T1DM in France, and it could serve as a preliminary survey for a national study. Although the follow-up was better than previously reported, there is still considerable room for improvement.

Outcome after endoscopically assisted surgical retrieval of symptomatic parotid stones.

10% of symptomatic parotid stones cannot be removed by minimally invasive radiological or endoscopic techniques alone. In these cases endoscopically assisted surgical parotid sialolithectomy can be performed via an extraoral approach, reconstituting the duct and preserving functioning glandular tissue. Between 2003 and 2010, 55 consecutive patients underwent endoscopically assisted surgical removal of parotid stones from 57 glands, two having bilateral procedures. Outcome was assessed using a structured questionnaire. 39/55 patients (71%) patients were successfully contacted (40 procedures; one bilateral case). At median follow-up of 3.1 years 28 glands (70%) were symptomless, whilst 11 (28%) were much improved but causing mild or occasional residual symptoms. One patient required postoperative lithotripsy and basket retrieval of a retained stone, but was subsequently symptom free. A further patient was initially symptom free then relapsed, did not respond to lithotripsy and is awaiting further assessment. In 10% of cases a short-lived sialocoele developed postoperatively. No individual reported facial weakness and one had a scar of concern. 37/39 (95%) patients were pleased to have had the operation and would have the procedure contralaterally in similar circumstances. Endoscopically assisted surgical removal of parotid stones is a successful technique with low morbidity that is well received by patients.

The potential role of glucagon-like peptide-1 or its analogues in enhancing glycaemic control in critically ill adult patients.

Intravenous insulin therapy is the gold standard therapy for glycaemic control in hyperglycaemic critically ill adult patients. However, hypoglycaemia remains a major concern in critically ill patients, even in some populations who are not receiving infused insulin. Furthermore, the influence of factors such as glycaemic variability and nutritional support may conceal any benefit of strict glycaemic control on morbidity and mortality in these patients. The recently revised guidelines of the American Diabetic Association/American College of Clinical Endocrinologists no longer advocate very tight glycaemic control or normalization of glucose levels in all critically ill patients. In the light of various concerns over the optimal glucose level and means to achieve such control, the use of glucagon-like peptide-1 or its analogues administered intravenously may represent an interesting therapeutic option.

Oral and maxillofacial surgical contribution to 21 months of operating theatre activity in Kandahar Field Hospital: 1 February 2007-31 October 2008.

Our aim was to assess oral and maxillofacial operating theatre activity at the NATO Multinational Medical Unit at Kandahar Airfield (MMU KAF). We made a retrospective analysis of the theatre logbook of the MMU KAF between 1 February 2007 and 31 October 2008. During that period, 1778 operations were done for 1639 patients. A total of 563 local civilians (34% of all patients) were operated on. Oral and maxillofacial surgeons were involved in 322/1778 (18%), general surgeons in 943/1778 (53%), and orthopaedic surgeons in 716/1778 (40%) of operations. Neurosurgeons were present only between March and October 2008, resulting in them being involved in 73/789 procedures (9%). Debridement and closure of wounds were the most common procedures in all specialties. A total of 247 operations on the face, neck, and scalp made up 16% of the total operations for trauma (n=1556), but most for coalition service personnel (n=69, 24%). Only 28 operations (10%) on coalition service personnel were done on the torso. This could be accounted for by the increased numbers of blast injuries and the effectiveness of modern body armour among coalition forces. Brain injuries were also more common among this group of patients than among the other groups, showing that helmets have only a limited effect in protecting against the effects of blast injury. Of all procedures, 163 operations (9%) were done for children. Training of general surgeons is becoming more specialised, which may result in greater dependence on larger teams of subspecialists (including oral and maxillofacial surgeons) in future conflicts.

Third molar-related morbidity in deployed Service personnel.

INTRODUCTION: The minimisation of disease and non-battle injury (DNBI) is essential for maintaining efficiency in a fighting force. Third molar-related morbidity is a common cause of DNBI. With extended lines of communication in current military deployments, travelling for dental care is often subject to significant danger. MATERIAL AND METHODS: Military dental officers in Afghanistan and Iraq recorded data on patients presenting with third molar pathology. Related previous history was obtained from the individual and from the military dental records. RESULTS: Three hundred and three individuals presented during the 23 month study period; 27.7% were unable to access care immediately, most commonly citing work pressure or lack of safe transport. Of those needing to travel, 70% were moved by helicopter. Pericoronitis was diagnosed in 84.4% of cases, 20.6% of these teeth being extracted; 53.5% of patients reported no prior symptoms, 22.7% with two or more episodes. There was documented evidence in military dental records of previous problems in 29.2% of cases. 11.3% had previously been listed for extraction of the presenting tooth. DISCUSSION: Dental treatment for troops in combat situations is fraught with difficulty. Special consideration must be given to the management of third molars in military personnel.

Intraoral removal of proximal submandibular stones--an alternative to sialadenectomy?

Submandibular salivary stones account for most symptomatic sialoliths and most are treated by adenectomy. Transoral removal of proximal or hilar stones is an alternative approach that preserves the functioning gland. Between 1999 and 2006, 186 consecutive patients had transoral removal of 186 stones in the proximal third or hilum of the submandibular gland. Both patient and treatment details were recorded prospectively and outcome assessed by a structured questionnaire. Stone removal was achieved in 99% (185/186) of cases treated. Morbidity was low and there were no intra-operative complications. At median follow up of 28 months (range 4-62 months) 4% (7/186) had subsequently undergone sialadenectomy for persisting symptoms. 105/186 responded to a questionnaire, 76% (80/105) were symptom-free and in a further 17% (18/105) symptoms were mild. No patient had lingual nerve anaesthesia but 6% (6/105) reported a mild tingling. 93% (97/105) were pleased to have had the operation. Submandibular stones can be reliably retrieved from the proximal portion of the duct or hilum with minimal morbidity. Evolving review data suggests that the incidence of recurrent disease is low at 2 years, suggesting that this technique may be a viable alternative to adenectomy.

[Aprepitant for the prevention of cisplatine induced nausea and vomiting: an observational study]. / Aprépitant pour la prévention des nausées et vomissements induits par une chimiothérapie à base de cisplatine: étude observationnelle.

Aprepitant is actually recommended in the prevention of nausea and vomiting induced by high emetic risk chemotherapy using cisplatin. We performed an observational prospective study on 101 patients evaluating the efficacy of aprepitant in the clinical conditions of use of cisplatin, out of context of clinical trial. We did not perform any intervention on the choice of anti-emetic treatment by the clinicians. Data on anti-emetic treatments were collected from prescriptions by a pharmacist after prior consultation with a medical doctor. Inclusions were closed when we lay 50 patients who received aprepitant associated to standard anti-emetic treatment (ondansetron and prednisolone) and 51 patients who received standard anti-emetic treatment. We observed a significant positive effect of aprepitant in the prevention of acute (84 vs 74.4 %, P = 0.24) and delayed vomiting (84 vs 60.8%, P = 0.009). But there was not a significant difference between the two groups regarding the prevention of nausea and the rate of complete response (absence of nausea and vomiting during five days).