We present here the first climatology of extreme sub-daily rainfall for a large part of western Europe, developed using a newly developed set of sub-daily rainfall indices, derived from a recently ...created global sub-daily rainfall (GSDR) dataset. The indices describe sub-daily (3-hourly) rainfall extremes in terms of their intensity, frequency and timing. Analysis of the frequency index (number of 3hr periods with >20 mm rain (R3hr20mm)) and a suite of intensity indices including the annual maxima (Rx3hr) and values of the 99.9th percentile at each gauge (R99.9p3hr) indicate a peak in the frequency and intensity of short-duration rainfall extremes in summer across most of western Europe, while areas around the north-west Mediterranean experience the highest intensities and frequencies of 3-hr rainfall in autumn. The index of contribution from 3-h annual maxima to the daily total (Rx3hrP) indicates that these events are often produced by very short-duration or very peaked storms, with a tendency towards a late afternoon or evening peak in the time of occurrence. There are also clear differences in the spatiotemporal occurrence of the sub-daily extremes when compared to extreme daily rainfall indices, which could have repercussions for flood management. Additional analysis of the sub-daily rainfall indices within the context of Köppen-Geiger climate zones indicates Mediterranean-type climate zones experience more intense and more frequent sub-daily extremes, while the intensity of rainfall within cooler climate zones is lower and the most intense events are restricted to summer. The climate zones are found to be a relatively good indicator of the extreme rainfall characteristics that can be expected in a region. Being able to compare sub-daily rainfall characteristics across a wide region in this manner greatly enhances our ability to investigate future variability and change in sub-daily extremes and will aid in high-resolution climate model validation.
Objective
Healthcare systems, specifically operating rooms, significantly contribute to greenhouse gas emissions. Addressing operating room environmental sustainability requires understanding current ...practices, opinions, and barriers. This is the first study assessing the attitudes and perceptions of otolaryngologists on environmental sustainability.
Study Design
Cross‐sectional virtual survey.
Setting
Email survey to active members of the Canadian Society of Otolaryngology–Head and Neck Surgery.
Methods
A 23‐question survey was developed in REDCap. The questions focused on four themes: (1) demographics, (2) attitudes and beliefs, (3) institutional practices, and (4) education. A combination of multiple choice, Likert‐scale, and open‐ended questions were employed.
Results
Response rate was 11% (n = 80/699). Most respondents strongly believed in climate change (86%). Only 20% strongly agree that operating rooms contribute to the climate crisis. Most agree environmental sustainability is very important at home (62%) and in their community (64%), only 46% said it was very important in the operating room. Barriers to environmental sustainability were incentives (68%), hospital supports (60%), information/knowledge (59%), cost (58%), and time (50%). Of those involved in residency programs, 89% (n = 49/55) reported there was no education on environmental sustainability or they were unsure if there was.
Conclusion
Canadian otolaryngologists strongly believe in climate change, but there is more ambivalence regarding operating rooms as a significant contributor. There is a need for further education and a systemic reduction of barriers to facilitate eco‐action in otolaryngology operating rooms.
The incidence of falling, due to aging, is related to both personal and environmental factors. There is a clear need to understand the nature of the major risk factors and design features of a safe ...and navigable living environment for potential fallers. The aim of this scoping review was to identify studies that have examined the effectiveness of environments, which promote physical activity and have an impact on falls prevention. Selected studies were identified and categorized into four main topics: built environment, environment modifications, enriched environments, and task constraints. The results of this analysis showed that there are a limited number of studies aiming to enhance dynamic postural stability and fall prevention through designing more functional environments. This scoping review study suggests that the design of interventions and the evaluation of an environment to support fall prevention are topics for future research.
On June 29, 2012, a rapidly moving line of intense thunderstorms with high winds swept across the midwestern and eastern United States, causing widespread damage and power outages. Afterward, the ...area experienced extreme heat, with maximum temperatures exceeding 100°F (37.8°C). This report describes 32 heat-related deaths in Maryland, Ohio, Virginia, and West Virginia that occurred during the 2 weeks following the storms and power outages. Median age of the decedents was 65 years, and most of the excessive heat exposures occurred within homes. During 1999-2009, an annual average of 658 heat-related deaths occurred in the United States. Heat-related deaths are preventable, and heat response plans should be in place before an extreme heat event (EHE). Interventions should focus on identifying and limiting heat exposure among vulnerable populations.
Nicotine and cannabis use during adolescence has the potential to induce long lasting changes on affective and cognitive function. Here, we examined whether adolescent exposure to nicotine, the ...cannabinoid agonist WIN55-212,2 (WIN), or co-exposure to both would alter operant learning, locomotion, and anxiety- and reward-related behaviors in male and female mice during adulthood. Males exposed to a moderate dose of WIN (2 mg/kg) or co-exposed to nicotine and the moderate dose of WIN exhibited decreased anxiety-associated behaviors and increased cognitive flexibility, but did not differ in operant learning or generalized locomotion. In contrast, differences were not found among the females in these measures at the moderate WIN dose or in both sexes with exposure to a low WIN dose (0.2 mg/kg). Furthermore, a sex-dependent dissociative effect was found in natural reward consumption. Males exposed to the moderate dose of WIN or co-exposed to nicotine and the moderate dose of WIN demonstrated increased sucrose consumption. In contrast, females exposed to the moderate dose of WIN exhibited a decrease in sucrose consumption, which was ameliorated with co-administration of nicotine. Together, these novel findings demonstrate that adolescent exposure to cannabinoids in the presence or absence of nicotine results in altered affective and reward-related behaviors during adulthood.
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with mortality of more than 20%. Combining standard therapy with a β-lactam antibiotic has been associated with reduced ...mortality, although adequately powered randomized clinical trials of this intervention have not been conducted.
To determine whether combining an antistaphylococcal β-lactam with standard therapy is more effective than standard therapy alone in patients with MRSA bacteremia.
Open-label, randomized clinical trial conducted at 27 hospital sites in 4 countries from August 2015 to July 2018 among 352 hospitalized adults with MRSA bacteremia. Follow-up was complete on October 23, 2018.
Participants were randomized to standard therapy (intravenous vancomycin or daptomycin) plus an antistaphylococcal β-lactam (intravenous flucloxacillin, cloxacillin, or cefazolin) (n = 174) or standard therapy alone (n = 178). Total duration of therapy was determined by treating clinicians and the β-lactam was administered for 7 days.
The primary end point was a 90-day composite of mortality, persistent bacteremia at day 5, microbiological relapse, and microbiological treatment failure. Secondary outcomes included mortality at days 14, 42, and 90; persistent bacteremia at days 2 and 5; acute kidney injury (AKI); microbiological relapse; microbiological treatment failure; and duration of intravenous antibiotics.
The data and safety monitoring board recommended early termination of the study prior to enrollment of 440 patients because of safety. Among 352 patients randomized (mean age, 62.2 SD, 17.7 years; 121 women 34.4%), 345 (98%) completed the trial. The primary end point was met by 59 (35%) with combination therapy and 68 (39%) with standard therapy (absolute difference, -4.2%; 95% CI, -14.3% to 6.0%). Seven of 9 prespecified secondary end points showed no significant difference. For the combination therapy vs standard therapy groups, all-cause 90-day mortality occurred in 35 (21%) vs 28 (16%) (difference, 4.5%; 95% CI, -3.7% to 12.7%); persistent bacteremia at day 5 was observed in 19 of 166 (11%) vs 35 of 172 (20%) (difference, -8.9%; 95% CI, -16.6% to -1.2%); and, excluding patients receiving dialysis at baseline, AKI occurred in 34 of 145 (23%) vs 9 of 145 (6%) (difference, 17.2%; 95% CI, 9.3%-25.2%).
Among patients with MRSA bacteremia, addition of an antistaphylococcal β-lactam to standard antibiotic therapy with vancomycin or daptomycin did not result in significant improvement in the primary composite end point of mortality, persistent bacteremia, relapse, or treatment failure. Early trial termination for safety concerns and the possibility that the study was underpowered to detect clinically important differences in favor of the intervention should be considered when interpreting the findings.
ClinicalTrials.gov Identifier: NCT02365493.
Background & Aims The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. Methods A ...systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Results Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti–tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn’s disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. Conclusions Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
The ability of drugs of abuse to increase dopamine in nucleus accumbens underlies their reinforcing effects. However, preclinical studies have shown that with repeated drug exposure neutral stimuli ...paired with the drug (conditioned stimuli) start to increase dopamine by themselves, which is an effect that could underlie drug-seeking behavior. Here we test whether dopamine increases occur to conditioned stimuli in human subjects addicted to cocaine and whether this is associated with drug craving. We tested eighteen cocaine-addicted subjects using positron emission tomography and 11Craclopride (dopamine D2 receptor radioligand sensitive to competition with endogenous dopamine). We measured changes in dopamine by comparing the specific binding of 11Craclopride when subjects watched a neutral video (nature scenes) versus when they watched a cocaine-cue video (scenes of subjects smoking cocaine). The specific binding of 11Craclopride in dorsal (caudate and putamen) but not in ventral striatum (in which nucleus accumbens is located) was significantly reduced in the cocaine-cue condition and the magnitude of this reduction correlated with self-reports of craving. Moreover, subjects with the highest scores on measures of withdrawal symptoms and of addiction severity that have been shown to predict treatment outcomes, had the largest dopamine changes in dorsal striatum. This provides evidence that dopamine in the dorsal striatum (region implicated in habit learning and in action initiation) is involved with craving and is a fundamental component of addiction. Because craving is a key contributor to relapse, strategies aimed at inhibiting dopamine increases from conditioned responses are likely to be therapeutically beneficial in cocaine addiction.
Numerous genes for monogenic kidney diseases with classical patterns of inheritance, as well as genes for complex kidney diseases that manifest in combination with environmental factors, have been ...discovered. Genetic findings are increasingly used to inform clinical management of nephropathies, and have led to improved diagnostics, disease surveillance, choice of therapy, and family counseling. All of these steps rely on accurate interpretation of genetic data, which can be outpaced by current rates of data collection. In March of 2021, Kidney Diseases: Improving Global Outcomes (KDIGO) held a Controversies Conference on “Genetics in Chronic Kidney Disease (CKD)” to review the current state of understanding of monogenic and complex (polygenic) kidney diseases, processes for applying genetic findings in clinical medicine, and use of genomics for defining and stratifying CKD. Given the important contribution of genetic variants to CKD, practitioners with CKD patients are advised to “think genetic,” which specifically involves obtaining a family history, collecting detailed information on age of CKD onset, performing clinical examination for extrarenal symptoms, and considering genetic testing. To improve the use of genetics in nephrology, meeting participants advised developing an advanced training or subspecialty track for nephrologists, crafting guidelines for testing and treatment, and educating patients, students, and practitioners. Key areas of future research, including clinical interpretation of genome variation, electronic phenotyping, global representation, kidney-specific molecular data, polygenic scores, translational epidemiology, and open data resources, were also identified.
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