On the Construction of Pareto-Compliant Combined Indicators.

The most relevant property that a quality indicator (QI) is expected to have is Pareto compliance, which means that every time an approximation set strictly dominates another in a Pareto sense, the indicator must reflect this. The hypervolume indicator and its variants are the only unary QIs known to be Pareto-compliant but there are many commonly used weakly Pareto-compliant indicators such as R2, IGD+, and ε+. Currently, an open research area is related to finding new Pareto-compliant indicators whose preferences are different from those of the hypervolume indicator. In this article, we propose a theoretical basis to combine existing weakly Pareto-compliant indicators with at least one being Pareto-compliant, such that the resulting combined indicator is Pareto-compliant as well. Most importantly, we show that the combination of Pareto-compliant QIs with weakly Pareto-compliant indicators leads to indicators that inherit properties of the weakly compliant indicators in terms of optimal point distributions. The consequences of these new combined indicators are threefold: (1) to increase the variety of available Pareto-compliant QIs by correcting weakly Pareto-compliant indicators, (2) to introduce a general framework for the combination of QIs, and (3) to generate new selection mechanisms for multiobjective evolutionary algorithms where it is possible to achieve/adjust desired distributions on the Pareto front.

British Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists.

BACKGROUND: We conducted a re-audit of the surgical practice of UK dermatologists for the treatment of nonmelanoma skin cancer and examined changes with reference to our previous audit in 2014. The audit was supplemented by a detailed assessment of completeness of the histopathology reports for each tumour. METHODS: UK dermatologists collected data on 10 consecutive nonmicrographic excisions for basal cell carcinoma (BCC) and 5 for squamous cell carcinoma (SCC). Data were collected on site, preoperative diagnosis, histological diagnosis, proximity to previous scars, and histological deep and peripheral margins. RESULTS: In total, 222 responses were received from 135 centres, reporting on 3290 excisions. Excisions from the head and neck accounted for 56.7% of cases. Tumour diameter (mean ± SD) was 11.4 ± SD 7.1 mm (maximum size 100 mm) and 97% of cases were primary excisions. BCCs and SCCs respectively accounted for 65.7% and 26.8% of total cases. Of the suspected BCCs and SCCs, 95.8% and 80.4%, respectively, were confirmed histologically. All margins for any tumour were clear in 97.0% of cases, and complication rate in the audit was < 1%. Of the 2864 histology reports evaluated, only 706 (24.6%) contained all core data items; 95% of these were structure (synoptic) reports. Commonly omitted items were level of invasion, risk and T stage, which were absent from 35.7%, 64.2% and 44.1% of reports, respectively. CONCLUSIONS: Diagnostic accuracy and complete excision rates remain high. Complication rates may be under-reported owing to lack of follow-up. Histopathology reporting has a greater chance of being complete if reports are generated on a field-based platform (synoptic reporting).

Search Dynamics on Multimodal Multiobjective Problems.

We continue recent work on the definition of multimodality in multiobjective optimization (MO) and the introduction of a test bed for multimodal MO problems. This goes beyond well-known diversity maintenance approaches but instead focuses on the landscape topology induced by the objective functions. More general multimodal MO problems are considered by allowing ellipsoid contours for single-objective subproblems. An experimental analysis compares two MO algorithms, one that explicitly relies on hypervolume gradient approximation, and one that is based on local search, both on a selection of generated example problems. We do not focus on performance but on the interaction induced by the problems and algorithms, which can be described by means of specific characteristics explicitly designed for the multimodal MO setting. Furthermore, we widen the scope of our analysis by additionally applying visualization techniques in the decision space. This strengthens and extends the foundations for Exploratory Landscape Analysis (ELA) in MO.

Cesarean section in a patient with non-compaction cardiomyopathy managed with ECMO.

Isolated ventricular non-compaction is a rare cardiomyopathy associated with left heart failure, severe arrhythmias and thromboembolism. We report about our interdisciplinary strategy in a patient with severe isolated ventricular non-compaction cardiomyopathy scheduled for caesarean section in general anaesthesia. Monitoring included placement of an arterial line, a central venous catheter and a pulmonary artery catheter with pacing option. Small introducer gates were placed in the femoral artery and vein to facilitate quick percutaneous institution of extracorporeal life support via extracorporeal membrane oxygenation in case of acute cardiac failure refractory to medical treatment. Inotropic pharmacological therapy with 3 µg/kg/min dobutamine and 0.25 mg/kg/min milrinone was started before surgery. Induction of general anesthesia and rapid sequence intubation was performed with an analgesic dose of 0.5 mg/kg S ketamine, 0.25 mg/kg etomidate and 5 mg rocoronium followed by 1.5 mg/kg succinylcholine. This regimen provided completely stable hemodynamics in this critical period until delivery of the child and continuation of anaesthesia with continuous infusion of propofol and remifentanyl. The current strategies, particularly the preparation for femoro-femoral extracorporeal membrane oxygenation, may be considered in similar cases with a high risk of acute cardiac decompensation which may be refractory to medical treatment. Anaesthesiologist involved in performing caesarean section in women with complex cardiac disease, should encompass extracorporeal membrane oxygenation standby in management of the perioperative period.

[Postoperative assessment of daily energy expenditure. Comparison of two methods]. / Postoperative bestimmung des täglichen energiebedarfs. Vergleich von zwei methoden.

BACKGROUND: The reference method for determining resting energy expenditure (REE) in clinical nutrition practice is measurement by indirect calorimetry; however, indirect calorimetry has some limitations, is expensive and not widely available. Therefore, the most used methods to estimate the caloric requirements in intensive care patients are predictive equations. The Harris-Benedict equations (HBE) are the most common formulae in the clinical setting. The SenseWear(®) armlet (SWA) is a noninvasive device that monitors skin temperature, heat flux, galvanic skin response and movement. These data as well as anthropometric characteristics are used to calculate REE. The aim of this study was to evaluate the levels of agreement and interchangeability of REE estimated by HBE (EEHBE) and measured by SWA (EESWA) in normometabolic patients after elective bowel resection with laparotomy. Furthermore, postsurgical pain therapy by continuous thoracic epidural anaesthesia (t-PDA) was compared with continuous intravenous pain therapy regarding EESWA in these patients. METHODS: After obtaining approval by the ethics committee and written informed consent 57 patients participated in the study procedures. A total of 50 patients (23 male, 27 female) were finally included in the data analysis because 7 patients did not meet the criterion of > 80% on-body time of the SWA. Additional (a priori) exclusion criteria were metabolic or cardiopulmonary decompensation or postoperative mechanical ventilation. Before induction of general anesthesia 26 patients received a thoracic epidural catheter. Immediately after surgery the SWA was placed on the right upper arm of each patient for 24 h. A continuous pain therapy was started either an epidural application of ropivacain 0.2% and sufentanil or in the other 24 patients an intravenous infusion of metamizol and tramadol. RESULTS AND DISCUSSION: The data showed good agreement between EESWA and EEHBE. The mean on-body time was found to be 22.94±4.77 h. There were no significant differences between EESWA and EEHBE (p>0.05) corresponding to a high Pearson's coefficient of correlation of 0.985. The mean bias (EESWA-EEHBE) was -0.569±0.378 kcal/kgBW/24 h reflecting a minimal systematic underestimation of REE by SWA of -2.9% compared to EEHBE. The Bland-Altman plot shows interchangeability of EESWA and EEHBE. It was noted that 94% of the data points (47 out of 50 patients) were within ±2 SD and the remaining 3 data points were lying close to the 95% interval. The same results (no significant differences between EESWA and EEHBE) were obtained after differentiation of EEHBE into low (<18 kcal/kgBW/24 h, n=9), medium (18-21 kcal/kgBW/24 h, n=30) and high (>21 kcal/kgBW/24 h, n=11) energy ranges. There were no significant differences in EESWA regarding postsurgical pain therapy regimens. CONCLUSIONS: The SWA showed reliable concordance with daily REE estimated by HBE in normometabolic postsurgery patients. This noninvasive, convenient and easy to handle device may be helpful in determining energy requirements as part of metabolic monitoring. Further research is needed to validate the method in patients with severe metabolic disturbances. The energetic requirements of patients with postoperative t-PDA were not different from those with intravenous pain therapy.

[Use of the i-gel laryngeal mask for management of a difficult airway]. / Einsatz der i-gel-Larynxmaske bei schwierigem Atemweg.

The authors report on the airway management during induction of general anaesthesia in a patient with known difficulties with intubation. After failed optimized attempts at direct laryngoscopy ventilation was secured with the new single-use laryngeal mask i-gel. The special construction of the i-gel allowed the fiber optic confirmation of a good view of the glottis and trachea, allowing successful fiber optic-guided intubation of the trachea using a size 6 mm cuffed tracheal tube.

Design of graph-based evolutionary algorithms: a case study for chemical process networks.

This paper describes the adaptation of evolutionary algorithms (EAs) to the structural optimization of chemical engineering plants, using rigorous process simulation combined with realistic costing procedures to calculate target function values. To represent chemical engineering plants, a network representation with typed vertices and variable structure will be introduced. For this representation, we introduce a technique on how to create problem specific search operators and apply them in stochastic optimization procedures. The applicability of the approach is demonstrated by a reference example. The design of the algorithms will be oriented at the systematic framework of metric-based evolutionary algorithms (MBEAs). MBEAs are a special class of evolutionary algorithms, fulfilling certain guidelines for the design of search operators, whose benefits have been proven in theory and practice. MBEAs rely upon a suitable definition of a metric on the search space. The definition of a metric for the graph representation will be one of the main issues discussed in this paper. Although this article deals with the problem domain of chemical plant optimization, the algorithmic design can be easily transferred to similar network optimization problems. A useful distance measure for variable dimensionality search spaces is suggested.

[Semi-invasive cardiac output measurement using a combined transesophageal ultrasound device. Early experiences]. / Semiinvasive Herzzeitvolumenmessung mittels kombiniertem ösophagealen Ultraschallkopf. Erste Erfahrungen.

OBJECTIVE: Measurement of cardiac output (CO) with pulmonary artery catheter (PAC) is currently item of many discussions. We investigated the reliability of results using the noninvasive measurement of aortic blood flow (ABF) (combined Doppler- and M-Mode transesophageal ultrasound, Dynemo 3000, Sometec Inc, Paris, France). METHODS: In 75 patients during cardiac or major abdominal surgery we performed 313 simultaneous measurements of CO and ABF. RESULTS: Placement of ultrasound probe into correct position took less than 2 min. Quality and stability of ultrasound signals were good. The coefficient of correlation between ABF and CO was found to be 0.89 with CO = 0.97 x ABF + 1.1, Bland-Altman-Test positive. CONCLUSION: Results of ABF detected by combined Doppler- and M-Mode-Echography are comparable with results of CO obtained by PAC. Therefore we are convinced that this noninvasive method will find its place in clinical situations of compromised CO.

(AC)23 [Z-2] polymorphism of the aldose reductase gene and fast progression of retinopathy in Chilean type 2 diabetics.

A recent case-control study suggests that the allele (AC)23 of a variable number tandem repeat (VNTR) associated to the aldose reductase (ALR2) gene could be related to early retinopathy in Type 2 diabetics. By means of a longitudinal-retrospective study, we aimed to seek for a relationship between the rate of progression of retinopathy and the (AC)23 allele of the VNTR associated to the ALR2 gene. A random sample was obtained of 27 Type 2 diabetics (aged 68.1 +/- 10.6 years, diabetes duration = 20.7 +/- 4.8 years, mean HbA1 = 10.6 +/- 1.6%). The mean HbA1 was the arithmetic average of 2.2 measurements per patient per year of total glycosilated hemoglobin (Gabbay method, normal range: 4.2-7.5%). Retinopathy was graded by an Ophthalmologist in a scale from zero to four score points. The genotype of the (AC), VNTR was determined by 32P-PCR plus sequenciation in a Perkin-Elmer laser device. The Mann-Whitney test and either chi2 or Fisher's exact test were used. A P < 0.05 was considered as statistically significant. The retinopathy progression rate (RPR, points x year(-1)) was calculated by dividing the increment of retinopathy score (delta Retinopathy Score, [points]), by the duration of the follow up [years]. The 12 diabetics having the (AC)23 allele had a mean RPR 8.9 times higher (0.40 +/- 0.61 points x year(-1)) than the 15 patients who had alleles other than (AC)23 (0.045 +/- 0.099 points x year(-1), P = 0.037). Both groups were similar with respect to: mean HbA1 (10.5 +/- 1.4 and 10.7 +/- 1.7%, P = 0.95), age at diagnosis (48.5 +/- 6.3 and 46.3 +/- 14.0 years, P = 0.81), diabetes' duration (21.3 +/- 4.7 and 20.2 +/- 4.9 years, P = 0.41) and serum creatinine (0.89 +/- 0.2 and 1.13 +/- 0.5 mg dl(-1), P = 0.35). We concluded that, in Type-2 diabetics having similar glycemic control, the (AC)23 allele of the VNTR associated to the ALR2 gene, is associated to a 8.9 times faster progression of retinopathy than in patients who have other alleles.

[Aldose reductase gene polymorphism and rate of appearance of retinopathy in non insulin dependent diabetics]. / Polimorfismo del gen de aldosa reductasa y velocidad de aparición de retinopatía en diabéticos no insulinodependientes.

BACKGROUND: Recent studies suggest that polymorphisms associated to the aldose reductase gene could be related to early retinopathy in noninsulin dependent diabetics (NIDDM). There is also new interest on the genetic modulation of coagulation factors in relation to this complication. AIM: To look for a possible relationship between the rate of appearance of retinopathy and the genotype of (AC)n polymorphic marker associated to aldose reductase gene. PATIENTS AND METHODS: A random sample of 27 NIDDM, aged 68.1 +/- 10.6 years, with a mean diabetes duration of 20.7 +/- 4.8 years and a mean glycosilated hemoglobin of 10.6 +/- 1.6%, was studied. The genotype of the (AC)n, polymorphic marker associated to the 5' end of the aldose reductase (ALR2) gene was determined by 32P-PCR plus sequenciation. Mutations of the factor XIII-A gene were studied by single stranded conformational polymorphism, sequenciation and restriction fragment length polymorphism. RESULTS: Four patients lacked the (AC)24 and had a higher rate of appearance of retinopathy than patients with the (AC)24 allele (0.0167 and 0.0907 score points per year respectively, p = 0.047). Both groups had similar glycosilated hemoglobin (11.7 +/- 0.2 and 10.5 +/- 1.6% respectively). Factor XIII gene mutations were not related to the rate of appearance of retinopathy. CONCLUSIONS: Our data suggest that the absence of the (AC)24 allele of the (AC)n polymorphic marker associated to the 5' end of the aldose reductase gene, is associated to a five fold reduction of retinopathy appearance rate.

Intrapartum fetal atrial bigeminy--diagnostic and therapeutic role of the fetal scalp stimulation test.

Concern for fetal hypoxia often leads to cesarean delivery when persistent fetal bradycardia is identified. A fetus with premature atrial contractions had a prolonged second-stage heart rate of 80 beats/min. Intrapartum echocardiography and electronic fetal heart rate monitoring distinguished bradycardia caused by blocked atrial bigeminy from hypoxic bradycardia. The fetal scalp stimulation test documented normal acid-base balance and normalized the ventricular rate, avoiding cesarean delivery.

[The marginal sealing of composite inlays with different cavity liners]. / Randdichtigkeit von Komposit-Inlays bei verschiedenen Unterfüllungen.

In this in-vitro study we investigated the sealing properties of composite inlays (EOS system) dependent on 8 different base materials. Using a dye-penetration test, the sealing was determined after mechanical and thermal cycling. A partially massive dye-penetration was detected in most cases when one of the following materials was used: a calciumsalicylate cement (Dycal), a combination of calciumsalicylate cement and a resin (Basic), a calcium hydroxide filled resin (Prisma VLC-Dycal), or a zinc phosphate cement (Harvard Cement). In contrast to this, we discovered a complete or almost complete sealing in most cases after application of chemically-cured glass ionomer cements (Ketac-Bond, Ketac-Bond Aplicap, Base-Line) or a light-cured glass ionomer cement (XR-Ionomer) as base materials. From these results it can be concluded that the choice of base materials has an influence on the marginal sealing of composite inlays after thermal and mechanical cycling. However, it is not possible to make a definitive statement on the suitability of these base materials under clinical conditions, because the results of dye-penetration tests have only limited clinical validity.

[Validation of electronic by conventional pain diaries]. / Validierung elektronischer an konventionellen Schmerztagebüchern.

A new type of electronic pain diary was validated in an open, randomized, crossover study. The main target variables were the comparison of the correctly realized pain assessment entries as well as the recording of the number of adverse events. Selected for the study were 20 patients, who were either hospitalized, partially-hospitalized or treated on an out-patient basis, with painful spondylogenic spinal syndrome or osteoarthritis of the trunk-proximal large joints. The patients were randomly-assigned to the two groups. The first group initially received the conventional diary and thereafter the electronic diary; the sequence was reversed for the second group. The drug therapy consisted of the NSAID, Ibuprofen, at an individually-adjusted dosage. Additional therapeutic measures were carried out by all the patients. The electronic pain diary proved to be equivalent to the conventional diary with regard to adherence of the pain assessment entry times. At a defined equivalence range of +/- 20%, the statistical comparison showed that the limits were never exceeded. The equivalence test of Anderson-Hauck showed a significance level of p less than 0.0001. The minimum equivalence range was +/- 2%. It therefore follows, that the conventional method of data recording can indeed be fully replaced by the electronic method. Comparing the individual data of the 16 patients, from whom entries with both the electronic as well as the conventional pain diaries were submitted, a clear tendency for increased entries on adverse events in the electronic diary (C.D. 6.4 +/- 10.5/E.D. 36.4 +/- 44.1) was demonstrated. No significant difference, however, was shown for the number of patients making data entries on adverse events in the electronic pain diary compared to those patients, who made their entries on adverse events in the conventional diary. According to the data from the physicians and patients, the Ibuprofen treatment results in an improvement in 90%/75% of cases, respectively. Likewise, the functional impairment of the affected joints as well as the swelling decreased markedly. The advantages of the electronic data recording system, i.e. closely-meshed controls can be carried out, transcriptional errors are minimized, data can be processed on-line, no possibility to subsequently change an entry, stand in contrast to the feature that there is no possibility to make free-style entries. The employment of the electronic system in the recording of individual data and subjective data represents a substantial improvement with regard to the quantity and quality of the data.

CD20 positive human B lymphocytes separated with the magnetic cell sorter (MACS) can be induced to proliferation and antibody secretion in vitro.

A method is described for the efficient purification of human B lymphocytes from peripheral blood by magnetic separation. Biotinylated, superparamagnetic particles were coupled to target cells by fluorescein isothiocyanate conjugated avidin and biotinylated monoclonal antibodies directed against cell surface antigens. This combination permitted flow cytometric control of the magnetic separation. Ficoll-Paque-separated peripheral blood mononuclear cells were first eliminated from monocytes by leucine-methyl ester treatment. B cells were enriched to 97% after magnetic depletion of CD3-positive T cells and magnetic enrichment of CD20-positive B cells. The separated B cells could be induced to proliferation and antibody production by various in vitro stimuli.

Ventricular volume and cognitive deficit: a computed tomographic study.

A group of 35 patients with presumptive diagnosis of Alzheimer disease and 29 normal volunteer spouse controls, all over the age of 60, underwent medical and neurologic evaluation, an extensive psychometric battery, and CT scanning. CT ventricular volume was derived for each CT section by algorithm summation of the number of pixels within a user-defined cerebrospinal fluid range. Composite ventricular volume for each patient, obtained by summation of the individual section ventricular volumes, was corrected for brain size by dividing by the sum of the five largest brain section volumes. For the normal group, composite ventricular volume thus derived was 5.2% and for the impaired group 7.5%; the 44% difference was significant (p less than .009). Increasing ventricular volume was significantly associated with increasing severity of cognitive impairment (p less than .05).