Summary
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, ...based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post‐1984 literature there are no published reports of aspiration‐associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus‐derived algorithm in which each patient is first risk‐stratified during their pre‐sedation assessment, using evidence‐based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
Keywords: procedural sedation; definition; consensus Article Note: Please see Appendix 1 for contributors. CAPTION(S): Appendix S1. An overview of the Delphi methodology, and references for Table 1. ...Byline: S. M. Green, M. G. Irwin, K. P. Mason,, A Absalom, E Alcaino, G Andolfatto, F Babl, E Barbi, D Carlson, L Rezende Costa, P. S. S. Costa, P Leroy, M. G. Roback, J Roelofse, V Yuen
The giant, superfast, interplanetary coronal mass ejection, detected by STEREO A on 2012 July 23, well away from Earth, appears to have reached 1 AU with an unusual set of leading bow waves ...resembling in some ways a subsonic interaction, possibly due to the high pressures present in the very energetic particles produced in this event. Eventually, a front of record high-speed flow reached STEREO. The unusual behavior of this event is illustrated using the magnetic field, plasma, and energetic ion observations obtained by STEREO. Had the Earth been at the location of STEREO, the large southward-oriented magnetic field component in the event, combined with its high speed, would have produced a record storm.
Several fast solar wind streams and stream interaction regions (SIRs) were observed by the Parker Solar Probe (PSP) during its first orbit (2018 September-2019 January). During this time, several ...recurring SIRs were also seen at 1 au at both L1 (Advanced Composition Explorer (ACE) and Wind) and the location of the Solar Terrestrial Relations Observatory-Ahead (STEREO-A). In this paper, we compare four fast streams observed by PSP at different radial distances during its first orbit. For three of these fast stream events, measurements from L1 (ACE and Wind) and STEREO-A indicated that the fast streams were observed by both PSP and at least one of the 1 au monitors. Our associations are supported by simulations made by the ENLIL model driven by GONG-(ADAPT-)WSA, which allows us to contextualize the inner heliospheric conditions during the first orbit of PSP. Additionally, we determine which of these fast streams are associated with an SIR and characterize the SIR properties for these events. From these comparisons, we find that the compression region associated with the fast-speed streams overtaking the preceding solar wind can form at various radial distances from the Sun in the inner heliosphere inside 0.5 au, with the suprathermal ion population (energies between 30 and 586 keV) observed as isolated enhancements suggesting localized acceleration near the SIR stream interface at ∼0.3 au, which is unlike those seen at 1 au, where the suprathermal enhancements extend throughout and behind the SIR. This suprathermal enhancement extends further into the fast stream with increasing distance from the Sun.
Neutron crystallographic analyses at near‐atomic resolution are presented for both reduced and oxidized forms of perdeuterated Pyrococcus furiosus rubredoxin, a small iron–sulfur redox protein with ...remarkable thermostability. Hydronium ions may play a key role in the protonation and charge‐transfer processes associated with the oxidized and reduced forms of the protein. Picture: overall structure showing D3O+ ions (red and gray molecules).
We use combined high-cadence, high-resolution, and multi-point imaging by the Solar-Terrestrial Relations Observatory (STEREO) and the Solar and Heliospheric Observatory to investigate the hour-long ...eruption of a fast and wide coronal mass ejection (CME) on 2011 March 21 when the twin STEREO spacecraft were located beyond the solar limbs. We analyze the relation between the eruption of the CME, the evolution of an Extreme Ultraviolet (EUV) wave, and the onset of a solar energetic particle (SEP) event measured in situ by the STEREO and near-Earth orbiting spacecraft. Combined ultraviolet and white-light images of the lower corona reveal that in an initial CME lateral "expansion phase," the EUV disturbance tracks the laterally expanding flanks of the CME, both moving parallel to the solar surface with speeds of ~450 km s super(-1). When the lateral expansion of the ejecta ceases, the EUV disturbance carries on propagating parallel to the solar surface but devolves rapidly into a less coherent structure. Multi-point tracking of the CME leading edge and the effects of the launched compression waves (e.g., pushed streamers) give anti-sunward speeds that initially exceed 900 km s super(-1) at all measured position angles. We combine our analysis of ultraviolet and white-light images with a comprehensive study of the velocity dispersion of energetic particles measured in situ by particle detectors located at STEREO-A (STA) and first Lagrange point (L1), to demonstrate that the delayed solar particle release times at STA and L1 are consistent with the time required (30-40 minutes) for the CME to perturb the corona over a wide range of longitudes. This study finds an association between the longitudinal extent of the perturbed corona (in EUV and white light) and the longitudinal extent of the SEP event in the heliosphere.
Observations of Solar Energetic Particles (SEPs) using the Suprathermal Ion Spectrograph (SIS), which is part of the Energetic Particle Detector suite on the Solar Orbiter mission, present an ...unprecedented opportunity to investigate the composition and evolution of SEPs in close proximity to the Sun. By analyzing data from the SIS instrument, we have compiled a catalog of extended time periods during the first five orbits of the spacecraft around the Sun, which exhibit a significant abundance of 3He. We have identified 33 periods lasting over one day that show a high abundance of 3He. For each period, we examined the SEP characteristics, the magnetic connectivity of the spacecraft, and the magnetically connected regions. Our findings show that these time periods typically span seven days and consist of multiple injections of 3He, and that the peak in 3He flux is observed two days after the time periods begin. The time periods usually start (end) when the spacecraft’s magnetic connection changes to (from) an active region (AR). In most cases, we observed a stable magnetic connection between the spacecraft and one or more ARs, with an average connection time of 4.1 ± 1.8 days.
Many hospitals, and medical and dental clinics and offices, routinely monitor their procedural-sedation practices—tracking adverse events, outcomes, and efficacy in order to optimize the sedation ...delivery and practice. Currently, there exist substantial differences between settings in the content, collection, definition, and interpretation of such sedation outcomes, with resulting widespread reporting variation. With the objective of reducing such disparities, the International Committee for the Advancement of Procedural Sedation has herein developed a multidisciplinary, consensus-based, standardized tool intended to be applicable for all types of sedation providers in all locations worldwide. This tool is amenable for inclusion in either a paper or an electronic medical record. An additional, parallel research tool is presented to promote consistency and standardized data collection for procedural-sedation investigations.
Notch and Angiopoietin-1 (Ang1)/Tie2 pathways are crucial for vascular maturation and stability. Here we identify the transcription factor ERG as a key regulator of endothelial Notch signalling. We ...show that ERG controls the balance between Notch ligands by driving Delta-like ligand 4 (Dll4) while repressing Jagged1 (Jag1) expression. In vivo, this regulation occurs selectively in the maturing plexus of the mouse developing retina, where Ang1/Tie2 signalling is active. We find that ERG mediates Ang1-dependent regulation of Notch ligands and is required for the stabilizing effects of Ang1 in vivo. We show that Ang1 induces ERG phosphorylation in a phosphoinositide 3-kinase (PI3K)/Akt-dependent manner, resulting in ERG enrichment at Dll4 promoter and multiple enhancers. Finally, we demonstrate that ERG directly interacts with Notch intracellular domain (NICD) and β-catenin and is required for Ang1-dependent β-catenin recruitment at the Dll4 locus. We propose that ERG coordinates Ang1, β-catenin and Notch signalling to promote vascular stability.
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