Abstract This study analyzed the surgical outcome and complications of 1000 microvascular free flaps performed at the authors’ institution in Germany, between 1987 and 2010. 972 patients underwent ...reconstruction with 1000 flaps: 28% latissimus dorsi flaps, 27% radial forearm flaps, 20% iliac crest flaps, 12% fibula flaps, 6% jejunal flaps, 2% anterolateral thigh flaps, and 5% other flaps. 130 failures (7.6%) were encountered, including 58 complete flap failures (44.6%) and 72 partial free-flap failures (55.4%). This study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck, but it is essential that complications be recognized and addressed early in their course to prevent or minimize devastating consequences. Owing to the large number of possible errors in flap transplantation, microsurgeons should always check everything for themselves. The on-duty doctors and nursing staff should not be trusted blindly. Venous thrombosis and cervical haematoma are the most common complications at the recipient site and are mainly responsible for flap failure, while complications occurring at the donor site may result from dehiscence and graft necrosis. When a compromised flap is identified, surgical re-exploration should not be deferred.
Core Ideas
Pre‐alpine areas face more intense warming and extreme hydrological events than the global average.
Climate and land management change have far‐reaching impacts on ecosystem functions and ...services.
We have improved knowledge of water, energy, and matter exchange by long‐term observations and modeling.
Global change has triggered several transformations, such as alterations in climate, land productivity, water resources, and atmospheric chemistry, with far reaching impacts on ecosystem functions and services. Finding solutions to climate and land cover change‐driven impacts on our terrestrial environment is one of the most important scientific challenges of the 21st century, with far‐reaching interlinkages to the socio‐economy. The setup of the German Terrestrial Environmental Observatories (TERENO) Pre‐Alpine Observatory was motivated by the fact that mountain areas, such as the pre‐alpine region in southern Germany, have been exposed to more intense warming compared with the global average trend and to higher frequencies of extreme hydrological events, such as droughts and intense rainfall. Scientific research questions in the TERENO Pre‐Alpine Observatory focus on improved process understanding and closing of combined energy, water, C, and N cycles at site to regional scales. The main long‐term objectives of the TERENO Pre‐Alpine Observatory include the characterization and quantification of climate change and land cover–management effects on terrestrial hydrology and biogeochemical processes at site and regional scales by joint measuring and modeling approaches. Here we present a detailed climatic and biogeophysical characterization of the TERENO Pre‐Alpine Observatory and a summary of novel scientific findings from observations and projects. Finally, we reflect on future directions of climate impact research in this particularly vulnerable region of Germany.
Peatlands are poorly represented in global Earth system modeling frameworks. Here we add a peatland‐specific land surface hydrology module (PEAT‐CLSM) to the Catchment Land Surface Model (CLSM) of ...the NASA Goddard Earth Observing System (GEOS) framework. The amended TOPMODEL approach of the original CLSM that uses topography characteristics to model catchment processes is discarded, and a peatland‐specific model concept is realized in its place. To facilitate its utilization in operational GEOS efforts, PEAT‐CLSM uses the basic structure of CLSM and the same global input data. Parameters used in PEAT‐CLSM are based on literature data. A suite of CLSM and PEAT‐CLSM simulations for peatland areas between 40°N and 75°N is presented and evaluated against a newly compiled data set of groundwater table depth and eddy covariance observations of latent and sensible heat fluxes in natural and seminatural peatlands. CLSM's simulated groundwater tables are too deep and variable, whereas PEAT‐CLSM simulates a mean groundwater table depth of −0.20 m (snow‐free unfrozen period) with moderate temporal fluctuations (standard deviation of 0.10 m), in significantly better agreement with in situ observations. Relative to an operational CLSM version that simply includes peat as a soil class, the temporal correlation coefficient is increased on average by 0.16 and reaches 0.64 for bogs and 0.66 for fens when driven with global atmospheric forcing data. In PEAT‐CLSM, runoff is increased on average by 38% and evapotranspiration is reduced by 19%. The evapotranspiration reduction constitutes a significant improvement relative to eddy covariance measurements.
Plain Language Summary
Peatlands are wetlands in which plant matter has accumulated over thousands of years under almost permanently water‐logged conditions. Alterations in these conditions as a result of global climate change can lead to the release of the huge peatland carbon pool as carbon dioxide over much shorter timescales than were required for accumulation. The additional emissions would amplify global warming. A better representation of the peatland hydrology in global Earth system models can help quantify how peatlands respond to a changing climate. In this paper, we add a peatland‐specific land surface hydrology module to the land surface model used in NASA's GEOS Earth system modeling framework. Comparisons of numerical simulations encompassing northern peatlands against field observations show that the new model version significantly improves our ability to capture the hydrological dynamics of peatlands. The new peatland representation in GEOS offers new opportunities, including the potential for merging model information and remote sensing observations in a way that improves our understanding of the overall role played by peatlands in the global water and carbon cycles.
Key Points
A peatland‐specific land surface hydrology was added to an Earth system model and constrained by literature data, without parameter tuning
Simulations were evaluated with a data set of groundwater table depth and evapotranspiration with unprecedented coverage in high latitudes
The peatland model version performs significantly better in terms of hydrological variables over peatlands than the operational model
Abstract Cluster headache (CH) is a debilitating, severe form of headache. A novel non-systemic therapy has been developed that produces therapeutic electrical stimulation to the sphenopalatine ...ganglion (SPG). A transoral surgical technique for inserting the Pulsante SPG Microstimulator into the pterygopalatine fossa (PPF) is presented herein. Technical aspects include detailed descriptions of the preoperative planning using computed tomography or cone beam computed tomography scans for presurgical digital microstimulator insertion into the patient-specific anatomy and intraoperative verification of microstimulator placement. Surgical aspects include techniques to insert the microstimulator into the proper midface location atraumatically. During the Pathway CH-1 and Pathway R-1 studies, 99 CH patients received an SPG microstimulator. Ninety-six had a microstimulator placed within the PPF during their initial procedure. Perioperative surgical sequelae included sensory disturbances, pain, and swelling. Follow-up procedures included placement of a second microstimulator on the opposite side ( n = 2), adjustment of the microstimulator lead location ( n = 13), re-placement after initial unsuccessful placement ( n = 1), and removal ( n = 5). This SPG microstimulator insertion procedure has sequelae comparable to other oral cavity procedures including tooth extractions, sinus surgery, and dental implant placement. Twenty-five of 29 subjects (86%) completing a self-assessment questionnaire indicated that the surgical effects were tolerable and 90% would make the same decision again.
Excessively high soil P can increase P loss with surface runoff. This study used indoor rainfall simulations to characterize soil and runoff P relationships for five Midwest soils (Argiudoll, ...Calciaquaoll, Hapludalf, and two Hapludolls). Topsoil (15-cm depth, 241-289 g clay kg(-1) and pH 6.0-8.0) was incubated with five NH4H2PO4 rates (0-600 mg P kg(-1)) for 30 d. Total soil P (TPS) and soil-test P (STP) measured with Bray-P1 (BP), Mehlich-3 (M3P), Olsen (OP), Fe-oxide-impregnated paper (FeP), and water (WP) tests were 370 to 1360, 3 to 530, 10 to 675, 4 to 640, 7 to 507, and 2 to 568 mg P kg(-1), respectively. Degree of soil P saturation (DPS) was estimated by indices based on P sorption index (PSI) and STP (DPS(STP)) and P, Fe, and Al extracted by ammonium oxalate (DPS(ox)) or Mehlich-3 (DPS(M3)). Soil was packed to 1.1 g cm(-3) bulk density in triplicate boxes set at 4% slope. Surface runoff was collected during 75 min of 6.5 cm h(-1) rain. Runoff bioavailable P (BAP) and dissolved reactive P (DRP) increased linearly with increased P rate, STP, DPS(ox), and DPS(M3) but curvilinearly with DPS(STP). Correlations between DRP or BAP and soil tests or saturation indices across soils were greatest (r greater than or equal to 0.95) for FeP, OP, and WP and poorest for BP and TPS (r = 0.83-0.88). Excluding the calcareous soil (Calciaquoll) significantly improved correlations only for BP. Differences in relationships between runoff P and the soil tests were small or nonexistent among the noncalcareous soils. Routine soil P tests can estimate relationships between runoff P concentration and P application or soil P, although estimates would be improved by separate calibrations for calcareous and noncalcareous soils.
Lind, N. S., & Rabe-Hemp, C. E. (Eds). (2017). Corruption, accountability, and discretion. United Kingdom: Emerald Publishing Limited. $95.00 (hardback), ISBN: 978-1787435568.
Abstract Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the ...causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified ( n = 42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death ( n = 26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9 h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.
Abstract Purpose This study aimed to evaluate the use of intraoperative cone-beam computed tomography (CBCT) in monitoring the results of repositioning and osteosynthesis of condylar process and head ...(capitulum) fractures of the mandible to see if CBCT is beneficial for these patients. Patients and methods Sixty patients (22 females and 38 males, age range 16–17 years, average 36.5 years) with condylar process and head fractures according to the classification of Spiessl and Schroll were treated during the study period. Thirty-four of the 60 patients received a CBCT scan immediately after surgical treatment under aseptic conditions. Results In all 34 cases, intraoperative CBCT provided high-quality imaging of the condylar process in all three planes. In four patients (11.8%), unsatisfactory reposition or unexpected complications were detected which could immediately be corrected with a surgical revision. Conclusion Intraoperative use of CBCT enables optimization of the surgical outcome for fractures of the condylar process and head of the mandible, reduces postoperative complications, and spares patients from repeated intervention. In addition, intraoperative CBCT enables safer treatment with minimally invasive approaches.
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