These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct ...response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel–bougie–tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
Phytophthora infestans has been a named pathogen for well over 150 years and yet it continues to "emerge", with thousands of articles published each year on it and the late blight disease that it ...causes. This review explores five attributes of this oomycete pathogen that maintain this constant attention. First, the historical tragedy associated with this disease (Irish potato famine) causes many people to be fascinated with the pathogen. Current technology now enables investigators to answer some questions of historical significance. Second, the devastation caused by the pathogen continues to appear in surprising new locations or with surprising new intensity. Third, populations of P. infestans worldwide are in flux, with changes that have major implications to disease management. Fourth, the genomics revolution has enabled investigators to make tremendous progress in terms of understanding the molecular biology (especially the pathogenicity) of P. infestans. Fifth, there remain many compelling unanswered questions.
The prospect of a future soft landing on the surface of Europa is enticing, as it would create science opportunities that could not be achieved through flyby or orbital remote sensing, with direct ...relevance to Europa's potential habitability. Here, we summarize the science of a Europa lander concept, as developed by our NASA-commissioned Science Definition Team. The science concept concentrates on observations that can best be achieved by in situ examination of Europa from its surface. We discuss the suggested science objectives and investigations for a Europa lander mission, along with a model planning payload of instruments that could address these objectives. The highest priority is active sampling of Europa's non-ice material from at least two different depths (0.5-2 cm and 5-10 cm) to understand its detailed composition and chemistry and the specific nature of salts, any organic materials, and other contaminants. A secondary focus is geophysical prospecting of Europa, through seismology and magnetometry, to probe the satellite's ice shell and ocean. Finally, the surface geology can be characterized in situ at a human scale. A Europa lander could take advantage of the complex radiation environment of the satellite, landing where modeling suggests that radiation is about an order of magnitude less intense than in other regions. However, to choose a landing site that is safe and would yield the maximum science return, thorough reconnaissance of Europa would be required prior to selecting a scientifically optimized landing site.
Vascular calcification is associated with increased risk of myocardial infarction and stroke. The objective of this work was to examine the ability of 17β-estradiol (E2) to stimulate calcification of ...vascular smooth muscle cells (VSMC) in vivo, using aged apolipoprotein E-null mice with advanced atherosclerotic lesions, and subsequently to explore underlying mechanisms in vitro.
Silastic E2 capsules were implanted into male and female apolipoprotein E-null mice aged 34 weeks. Plaque and calcified area were measured in the aortic sinus and innominate artery after 8 weeks. Immunohistochemical analysis examined expression of the estrogen receptors (estrogen receptor alpha and estrogen receptor beta ERβ). VSMC expression of osteogenic markers was examined using digital polymerase chain reaction. Advanced atherosclerotic lesions were present in all mice at the end of 8 weeks. In both male and female mice, E2 increased calcified area in a site-specific manner in the aortic sinus independently of plaque growth or lipid levels and occurred in association with a site-specific decrease in the proportion of ERβ-positive intimal cells. Calcified lesions expressed collagen I and bone sialoprotein, with decreased matrix Gla protein. In vitro, E2 suppressed ERβ expression and increased VSMC mineralization, demonstrating increased collagen I and II, osteocalcin and bone sialoprotein, and reduced matrix Gla protein and osteopontin. Antagonism or RNA silencing of estrogen receptor alpha, ERβ, or both further increased VSMC mineralization.
We have demonstrated that E2 can drive calcification in advanced atherosclerotic lesions by promoting the differentiation of VSMC to osteoblast-like cells, a process which is augmented by inhibition of estrogen receptor alpha or ERβ activity.
• We present a 10-year sequence of soil water measurements under eucalypt plantations. • Soil water declines throughout the 1st rotation at many sites. • Soil water is fully replenished at only 1 of ...3 experimental sites in the 2nd rotation. • Modeling shows that many sites will not be fully replenished in the 2nd rotation. • Managers will need to consider fallowing to maintain productivity in the 2nd rotation.
Eucalyptus globulus plantations are thought to use stored soil water when planted on ex-agricultural sites, and we hypothesized that this is likely to affect productivity of 2nd and later rotation plantations because the next rotations have access to less stored soil water. We used a combination of experiments and modeling to understand the impact of E. globulus plantations on soil water stores over the first rotation and early second rotation. The experiments were conducted at 3 contrasting sites in south-western Australia, and modeling was used to extrapolate the results to other climatic zones. Soil water dynamics were assessed to 8m depth under a range of management options, including spacing and nitrogen addition in the first rotation, and coppice or seedling re-establishment in the 2nd rotation. We found that soil water stores declined over the course of the first rotation at all sites, with some (incomplete) annual replenishment evident at the higher rainfall sites, but less replenishment at depth, especially in the lower rainfall sites. Only the wettest of the 3 sites fully replenished with soil water after harvest of the 1st rotation. Plots with higher stocking rates had higher soil water depletion early in the rotation, although by the end of the first rotation, most treatments had similar soil water deficits of around 800mm at all of the sites. Of the sites that were responsive to N fertilizer, there was a strong differential in the degree of soil water deficit between N treatments, with N fertilized trees using more of the soil water store each year, but also producing more wood. A process-based plantation growth model, CABALA, was found to be adequate for predicting soil water dynamics under the range of management options that we explored, and we applied it to understanding the potential replenishment of soil under 2nd rotation plantations in a range of climatic zones within the E. globulus estate in south-western Australia. This modeling showed that most sites with soil depths of more than 4m (i.e., most of the estate) are unlikely to be fully replenished in the 2nd rotation, and that this is likely to have a significant impact on the capacity of sites to achieve similar productivity levels in the second rotation as the first unless the sites are given an opportunity for soil water replenishment between rotations. The results from this study suggest that plantation managers will need to understand soil water dynamics at any given site to be able to predict productivity in 2nd and later rotations, and may need to explore novel management options like fallowing between rotations to allow for soil water replenishment.
Jupiter’s icy moon, Europa, harbors a subsurface liquid water ocean; the prospect of this ocean being habitable motivates further exploration of the moon with the upcoming NASA Europa Clipper ...mission. Key among the mission goals is a comprehensive assessment of the moon’s composition, which is essential for assessing Europa’s habitability. Through powerful remote sensing and
in situ
investigations, the Europa Clipper mission will explore the composition of Europa’s surface and subsurface, its tenuous atmosphere, and the local space environment surrounding the moon. Clues on the interior composition of Europa will be gathered through these assessments, especially in regions that may expose subsurface materials, including compelling geologic landforms or locations indicative of recent or current activity such as potential plumes. The planned reconnaissance of the icy world will constrain models that simulate the ongoing external and internal processes that act to alter its composition. This paper presents the composition-themed goals for the Europa Clipper mission, the synergistic, composition-focused investigations that will be conducted, and how the anticipated scientific return will advance our understanding of the origin, evolution, and current state of Europa.
Background
Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false ...passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency.
Aim
To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD.
Materials & Methods
A multidisciplinary team with expertise in tracheostomy developed a 3‐part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID‐19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post‐implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self‐Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE).
Results
Twenty‐four participants completed pre‐test and post‐test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre‐test to 5.0 (IQR = 1.0) post‐test. The median comfort level score increased from 38.0 (IQR = 7.0) pre‐test to 40.0 (IQR = 5.0) post‐test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU.
Discussion
This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians – definitive management of ATD should adhere to comprehensive multidisciplinary guidelines.
Conclusions
ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events.
Relevance to Clinical Practice
A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.
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