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Intravenous pharmacologic sedation is often chosen for surgical and nonsurgical procedures and is administered by an anesthesiologist, nurse anesthetist, or other trained professional. Sedation is described as a continuum, encompassing minimal, moderate, and deep sedation that can be categorized according to the patient’s level of consciousness (Figure 12.1). This categorization is subjective and the different levels of sedation can be achieved through changes in medication choice and dosage. There exist overlapping zones between levels of sedation. In clinical practice, deep sedation and general anesthesia share many of the same features in terms of patient awareness, lack of responsiveness, and risk of airway compromise.
Certain patient populations requiring sedation for procedures present the clinician with challenging decisions regarding their care and management. Some underlying medical disease states, airway abnormalities, or extremes of age require cautious pre-procedural assessment and planning when sedation is required to minimize the incidence of morbidity or mortality. It should be noted that some of these higher-risk patients should only be sedated by trained anesthesia providers. The following commonly encountered conditions are considered high risk and are associated with a higher rate of complications: old age, obesity, chronic obstructive pulmonary disease, coronary artery disease, and chronic renal failure. This chapter discusses important features of these higher-risk patients and practice management when sedation is required. In all cases, appropriate monitoring, prudent selection and dosing of sedative agents, and careful assessment are important to ensure the best outcome for these higher-risk patients.
Objectives: Activities that require active thinking, like occupations, may influence cognitive function and its change over time. Associations between retirement and dementia risk have been reported, however the role of retirement age in these associations is unclear. We assessed associations of occupation and retirement age with cognitive decline in the US community-based Atherosclerosis Risk in Communities (ARIC)cohort.
Methods: We included 14,090 ARIC participants, followed for changes in cognition during up to 21 years. Information on current or most recent occupation was collected at ARIC baseline (1987–1989; participants aged 45–64 years) and categorized according to the 1980 US Census protocols and the Nam-Powers-Boyd occupational status score. Follow-up data on retirement was collected during 1999–2007 and classified as retired versus not retired at age 70. Trajectories of global cognitive factor scores from ARIC visit 2 (1990–1992) to visit 5 (2011–2013) were presented, and associations with occupation and age at retirement were studied using generalized estimating equation models, stratified by race and sex, and adjusted for demographics andcomorbidities.
Results: Mean age (SD) at first cognitive assessment was 57.0 (5.72) years. Higher occupational status and white- collar occupations were significantly associated with higher cognitive function at baseline. Occupation was associated with cognitive decline over 21 years only in women, and the direction of the effect on cognitive function differed between black and white women: in white women, the decline in cognitive function was greater in homemakers and low status occupations, whereas in black women, less decline was found in homemakers and low (compared to high) occupational status. Interestingly, retirement on or before age 70 was associated with less 21-year cognitive decline in all race-sex strata, except for blackwomen.
Conclusions: Associations between occupation, retirement age and cognitive function substantially differed by race and sex. Further research should explore reasons for the observed associations and race-sex differences.
Helicopters are used in complex and harsh operational environments, such as search and rescue missions and firefighting, that require operating in ground proximity, tracking targets while avoiding impacting obstacles, namely a combination of point tracking (positive) and boundary avoidance (negative) objectives. A simulation task representing simplified helicopter dynamics is used to investigate point tracking and boundary avoidance tasks. The variance and regression analysis are used to study the effects of task conditions on participants’ tracking errors and input aggression. The overall tracking error shows a negative correlation with input aggression. The participants tend to have higher input aggression and lower tracking error near the boundaries, exposing the switching of manipulation input strategies under different task conditions. It also suggests a potential way of designing simulation tasks for human operators manipulating helicopters and a trigger for investigating pilots’ biodynamic feedthrough.
Schistosoma species have traditionally been arranged in groups based on egg morphology, geographical origins, and the genus or family of snail intermediate host. One of these groups is the ‘S. indicum group’ comprising species from Asia that use pulmonate snails as intermediate hosts. DNA sequences were obtained from the four members of this group (S. indicum, S. spindale, S. nasale and S. incognitum) to provide information concerning their phylogenetic relationships with other Asian and African species and species groups. The sequences came from the second internal transcribed spacer (ITS2) of the ribosomal gene repeat, part of the 28S ribosomal RNA gene (28S), and part of the mitochondrial cytochrome c oxidase subunit 1 (CO1) gene. Tree analyses using both distance and parsimony methods showed the S. indicum group not to be monophyletic. Schistosoma indicum, S. spindale and S. nasale were clustered among African schistosomes, while S. incognitum was placed as sister to the African species (using ITS2 and 28S nucleotide sequences and CO1 amino acid sequences), or as sister to all other species of Schistosoma (CO1 nucleotide sequences). Based on the present molecular data, a scenario for the evolution of the S. indicum group is discussed.
The status of Schistosoma sinensium (samples from Thailand and from Sichuan, China) relative to other species of the genus Schistosoma was investigated using DNA sequences from the mitochondrial cytochrome c oxidase subunit 1 (CO1) gene (partial) and the nuclear ribosomal DNA second internal transcribed spacer 2 (ITS2). Trees inferred from these sequences place S. sinensium as sister to the S. japonicum group and suggest a basal position in the clade utilizing snails of the family Pomatiopsidae. The sequence differences between specimens of S. sinensium from China and Thailand are at least as great as between S. malayensis and S. mekongi. Schistosoma sinensium is probably best regarded as a species complex.
Despite advances in incorporating diversity and structural competency into medical education curriculum, there is limited curriculum for public health research professionals. We developed and implemented a four-part diversity, equity, and inclusion (DEI) training series tailored for academic health research professionals to increase foundational knowledge of core diversity concepts and improve skills.
Methods:
We analyzed close- and open-ended attendee survey data to evaluate within- and between-session changes in DEI knowledge and perceived skills.
Results:
Over the four sessions, workshop attendance ranged from 45 to 82 attendees from our 250-person academic department and represented a mix of staff (64%), faculty (25%), and trainees (11%). Most identified as female (74%), 28% as a member of an underrepresented racial and ethnic minority (URM) group, and 17% as LGBTQI. During all four sessions, attendees increased their level of DEI knowledge, and within sessions two through four, attendees’ perception of DEI skills increased. We observed increased situational DEI awareness as higher proportions of attendees noted disparities in mentoring and opportunities for advancement/promotion. An increase in a perceived lack of DEI in the workplace as a problem was observed; but only statistically significant among URM attendees.
Discussion:
Developing applied curricula yielded measurable improvements in knowledge and skills for a diverse health research department of faculty, staff, and students. Nesting this training within a more extensive program of departmental activities to improve climate and address systematic exclusion likely contributed to the series’ success. Additional research is underway to understand the series’ longer-term impact on applying skills for behavior change.
It has been previously identified that levels of peripheral inflammatory proteins, such as cytokines, are altered in people with schizophrenia spectrum disorders (SSD).
Objectives
As there is considerable inconsistency in the literature with respect to how inflammatory profiles differ between acute and chronic stages of SSD, a systematic review and network meta-analysis was performed.
Methods
Records from CINAHL, the Cochrane Central Register of Controlled Trials, EMBASE, PubMed, and PsycINFO were systematically searched from inception until 31 March 2022 for published studies that had measured levels of inflammatory proteins in cases of SSD and healthy controls. Pairwise and network meta-analyses were performed to determine whether there were significant differences in mean peripheral protein concentrations between acute SSD, chronic SSD, and healthy controls.
Results
After application of the screening process, 215 articles were included for data-analysis. One group of markers were consistently elevated (p<0·05) in both acute and chronic SSD, relative to healthy controls; this group comprised interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), soluble interleukin-2 receptor (sIL-2R), IL-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, and high sensitivity C-reactive protein (hsCRP). A second group of markers were inconsistently altered between illness stages: IL-2 and interferon (IFN)-γ were significantly elevated (p<0·05) in acute SSD, whilst IL-4, IL-12 and IFN-γ were significantly decreased (p<0·05) in chronic SSD.
Conclusions
These results indicate that a baseline level of inflammatory protein alteration occurs in SSD throughout the course of illness. This was evident from the group of markers that were consistently elevated in acute and chronic SSD (e.g., IL-6), representing possible trait markers. Moreover, superimposed immune activity may occur in acute SSD, given the group of possible state markers that were increased only in acute illness (e.g., IFN-γ). Further research is required to elucidate whether these peripheral changes are reflected within the central nervous system.
Background: In meningiomas, CDKN2A/B deletions are associated with poor outcomes but are rare in most cohorts (1-5%). Large molecular datasets are therefore required to explore these deletions and their relationship to other prognostic CDKN2A alterations. Methods: We utilized multidimensional molecular data of 560 meningiomas from 5 independent cohorts to comprehensively interrogate the spectrum of CDKN2A alterations through DNA methylation, copy number variation, transcriptomics, and proteomics using an integrated molecular approach. Results: Meningiomas with either CDKN2A/B deletions (partial or homozygous loss) or an intact CDKN2A gene locus but elevated mRNA expression (CDKN2Ahigh) both had poor clinical outcomes. Increased CDKN2A mRNA expression was a poor prognostic factor independent of CDKN2A deletion. CDKN2A expression and p16 protein increased with tumor grade and more aggressive molecular and methylation groups. CDKN2Ahigh meningiomas and meningiomas with CDKN2A deletions were enriched for similar cell cycling pathways dysregulated at different checkpoints. p16 immunohistochemistry was unreliable in differentiating between meningiomas with and without CDKN2A deletions, but increased positivity was associated with increased mRNA expression. CDKN2Ahigh meningiomas were associated with gene hypermethylation, Rb-deficiency, and lack of response to CDK inhibition. Conclusions: These findings support the role of CDKN2A mRNA expression as a biomarker of clinically aggressive meningiomas with potential therapeutic implications.
Surgical management is the mainstay of treatment for tumours in the parapharyngeal space. This study aimed to evaluate the indications, limits and technical nuances of the endoscopic transoral approach.
Method
Thirteen patients with parapharyngeal space tumours that were treated between May 2017 and November 2020 were included in this retrospective study.
Results
All patients underwent surgery for complete oncological resection except one patient who received treatment for diagnostic purposes. No major complications were reported, with excellent control of the vital structures of the parapharyngeal space.
Conclusion
The endoscopic transoral approach to the parapharyngeal space is a promising alternative approach for selected parapharyngeal space tumours with satisfactory outcomes.
Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS.
Methods
Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale – Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample).
Results
Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms.
Conclusions
These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.
Background: Despite a higher prevalence of traumatic spinal cord injury (TSCI) amongst Canadian Indigenous peoples, there is a paucity of studies focused on Indigenous TSCI. We present the first Canada-wide study comparing TSCI amongst Canadian Indigenous and non-Indigenous peoples. Methods: This study is a retrospective analysis of prospectively-collected TSCI data from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) from 2004-2019. We divided participants into Indigenous and non-Indigenous cohorts and compared them with respect to demographics, injury mechanism, level, severity, and outcomes. Results: Compared with non-Indigenous patients, Indigenous patients were younger, more female, less likely to have higher education, and less likely to be employed. The mechanism of injury was more likely due to assault or transportation-related trauma in the Indigenous group. The length of stay for Indigenous patients was longer. Indigenous patients were more likely to be discharged to a rural setting, less likely to be discharged home, and more likely to be unemployed following injury. Conclusions: Our results suggest that more resources need to be dedicated for transitioning Indigenous patients sustaining a TSCI to community living and for supporting these patients in their home communities. A focus on resources and infrastructure for Indigenous patients by engagement with Indigenous communities is needed.
Background: This is a population-based retrospective study of neurological and cardiac complications of COVID-19 among Ontario visible minorities: Chinese and South Asian Canadians Methods: From January 1, 2020 to September 30, 2020, using the last name algorithm, rates and types of cardiac and neurological complication of these two cohorts along with the general population in Ontario with COVID-19 were analysed by Institue of Clinical Evaluative Sciences. Results: Preliminary results show that Chinese-Canadians (N= 1,186) with COVID-19 are older with a mean age of 50.74 years old compared to general population (N= 42,547) of 47.57 years old (P< .001), while South Asians (N= 3,459) have a younger mean age of 42.08 years old (P< .001). Total cardiac and neurological complication rates, hospitalization rates and ICU admission rates are all higher for Chinese-Canadians while they are lower in South Asians and all achieving statistical significance (P < .001). Overall mortality rate is significantly higher for Chinese-Canadians at 8.1% vs 5.0% general population (P < .001). Conclusions: Chinese-Canadians with COVID-19 in Ontario were much older and have higher cardiac and neurological complication rates and overall mortality rate than the general population. These data have significant implications for proper prevention and appropriate management for these vulnerble elderly Chinese-Canadians.
Mars exploration motivates the search for extraterrestrial life, the development of space technologies, and the design of human missions and habitations. Here, we seek new insights and pose unresolved questions relating to the natural history of Mars, habitability, robotic and human exploration, planetary protection, and the impacts on human society. Key observations and findings include:
– high escape rates of early Mars' atmosphere, including loss of water, impact present-day habitability;
– putative fossils on Mars will likely be ambiguous biomarkers for life;
– microbial contamination resulting from human habitation is unavoidable; and
– based on Mars' current planetary protection category, robotic payload(s) should characterize the local martian environment for any life-forms prior to human habitation.
Some of the outstanding questions are:
– which interpretation of the hemispheric dichotomy of the planet is correct;
– to what degree did deep-penetrating faults transport subsurface liquids to Mars' surface;
– in what abundance are carbonates formed by atmospheric processes;
– what properties of martian meteorites could be used to constrain their source locations;
– the origin(s) of organic macromolecules;
– was/is Mars inhabited;
– how can missions designed to uncover microbial activity in the subsurface eliminate potential false positives caused by microbial contaminants from Earth;
– how can we ensure that humans and microbes form a stable and benign biosphere; and
– should humans relate to putative extraterrestrial life from a biocentric viewpoint (preservation of all biology), or anthropocentric viewpoint of expanding habitation of space?
Studies of Mars' evolution can shed light on the habitability of extrasolar planets. In addition, Mars exploration can drive future policy developments and confirm (or put into question) the feasibility and/or extent of human habitability of space.
High-energy and high-intensity lasers are essential for pushing the boundaries of science. Their development has allowed leaps forward in basic research areas, including laser–plasma interaction, high-energy density science, metrology, biology and medical technology. The Helmholtz International Beamline for Extreme Fields user consortium contributes and operates two high-peak-power optical lasers using the high energy density instrument at the European X-ray free electron laser (EuXFEL) facility. These lasers will be used to generate transient extreme states of density and temperature to be probed by the X-ray beam. This paper introduces the ReLaX laser, a short-pulse high-intensity Ti:Sa laser system, and discusses its characteristics as available for user experiments. It will also present the first experimental commissioning results validating its successful integration into the EuXFEL infrastructure and viability as a relativistic-intensity laser driver.
This study investigated the audiometric and sound localisation results in patients with conductive hearing loss after bilateral Bonebridge implantation.
Method
Eight patients with congenital microtia and atresia supplied with bilateral Bonebridge devices were enrolled in this study. Hearing tests and sound localisation were tested under unaided, unilateral and bilateral aided conditions.
Results
Mean functional gain was higher with a bilateral fitting than with a unilateral fitting, especially at 1.0–4.0 kHz (p < 0.05, both). The improvement in speech reception threshold in noise with a bilateral fitting was a 2.3 dB higher signal-to-noise ratio compared with unilateral fitting (p < 0.05). Bilateral fitting had better sound localisation than unilateral fitting (p <0.001). Four participants who attended follow up showed improved sound localisation ability after one year.
Conclusion
Patients demonstrated better hearing threshold, speech reception thresholds in noise and directional hearing with bilateral Bonebridge devices than with a unilateral Bonebridge device. Sound localisation ability with bilateral Bonebridge devices can be improved through long-term training.
Recent well-powered genome-wide association studies have enhanced prediction of substance use outcomes via polygenic scores (PGSs). Here, we test (1) whether these scores contribute to prediction over-and-above family history, (2) the extent to which PGS prediction reflects inherited genetic variation v. demography (population stratification and assortative mating) and indirect genetic effects of parents (genetic nurture), and (3) whether PGS prediction is mediated by behavioral disinhibition prior to substance use onset.
Methods
PGSs for alcohol, cannabis, and nicotine use/use disorder were calculated for Minnesota Twin Family Study participants (N = 2483, 1565 monozygotic/918 dizygotic). Twins' parents were assessed for histories of substance use disorder. Twins were assessed for behavioral disinhibition at age 11 and substance use from ages 14 to 24. PGS prediction of substance use was examined using linear mixed-effects, within-twin pair, and structural equation models.
Results
Nearly all PGS measures were associated with multiple types of substance use independently of family history. However, most within-pair PGS prediction estimates were substantially smaller than the corresponding between-pair estimates, suggesting that prediction is driven in part by demography and indirect genetic effects of parents. Path analyses indicated the effects of both PGSs and family history on substance use were mediated via disinhibition in preadolescence.
Conclusions
PGSs capturing risk of substance use and use disorder can be combined with family history measures to augment prediction of substance use outcomes. Results highlight indirect sources of genetic associations and preadolescent elevations in behavioral disinhibition as two routes through which these scores may relate to substance use.
There is emerging evidence linking fruit and vegetable consumption and cognitive function. However, studies focusing on the nutrients underlying this relationship are lacking. We aim to examine the association between plasma nutrients and cognition in a population at risk for cognitive decline with a suboptimal diet. The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) trial is a randomized controlled intervention that examines the effects of the MIND diet to prevent cognitive decline. The primary outcome is global cognition. A multivariate linear model was used to investigate the association between blood nutrients and global and/or domain-specific cognition. The model was adjusted for age, sex, education, study site, smoking status, cognitive activities and physical activities. High plasma α-carotene was associated with better global cognition. Participants in the highest tertile of plasma α-carotene had a higher global cognition z score of 0⋅17 when compared with individuals in the lowest tertile (P 0⋅002). Circulating α-carotene levels were also associated with higher semantic memory scores (P for trend 0⋅007). Lutein and zeaxanthin (combined) was positively associated with higher semantic memory scores (P for trend 0⋅009). Our study demonstrated that higher α-carotene levels in blood were associated with higher global cognition scores in a US population at risk for cognitive decline. The higher α-carotene levels in blood reflected greater intakes of fruits, other types of vegetables and lesser intakes of butter and margarine and meat. The higher circulating levels of lutein plus zeaxanthin reflected a dietary pattern with high intakes of fruits, green leafy, other vegetables and cheese, and low consumption of fried foods. Objective nutrient markers in the blood can better characterize dietary intake, which may facilitate the implementation of a tailored dietary intervention for the prevention of cognitive decline.