Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations.

BACKGROUND: Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures. METHODS: We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. RESULTS: We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations. CONCLUSIONS: Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis.

AIM: Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery. METHODS: Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO. RESULTS: Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar. CONCLUSIONS: Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.

A Systematic Review of Behavioral Interventions to Decrease Opioid Prescribing After Surgery.

OBJECTIVE: The aim of this study was to summarize strategies to reduce postsurgical opioid prescribing at discharge. SUMMARY BACKGROUND DATA: Current practices for the prescription of opioids at discharge after surgery are highly variable and often excessive. We conducted a systematic review to identify behavioral interventions designed to improve these practices. METHODS: We searched MEDLINE, EMBASE, CINAHL, and PsycINFO until December 14, 2018 to identify studies of behavioral interventions designed to decrease opioid prescribing at discharge among adults undergoing surgery. Behavioral interventions were defined according to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We assessed the risk of bias of included studies using criteria suggested by Cochrane EPOC and the Newcastle-Ottawa scale. RESULTS: Of 8048 citations that were screened, 24 studies were included in our review. Six types of behavioral interventions were identified: local consensus-based processes (18 studies), patient-mediated interventions (2 studies), clinical practice guidelines (1 study), educational meetings (1 study), interprofessional education (1 study), and clinician reminder (1 study). All but one study reported a statistically significant decrease in the amount of opioid prescribed at discharge after surgery, and only 2 studies reported evidence of increased pain intensity. Reductions in prescribed opioids ranged from 34.4 to 212.3 mg morphine equivalents. All studies were found to have medium-to-high risks of bias. CONCLUSIONS: We identified 6 types of behavioral strategies to decrease opioid prescription at discharge after surgery. Despite the risk of bias, almost all types of intervention seemed effective in reducing opioid prescriptions at discharge after surgery without negatively impacting pain control.

The causality analysis of climate change and large-scale human crisis.

Recent studies have shown strong temporal correlations between past climate changes and societal crises. However, the specific causal mechanisms underlying this relation have not been addressed. We explored quantitative responses of 14 fine-grained agro-ecological, socioeconomic, and demographic variables to climate fluctuations from A.D. 1500-1800 in Europe. Results show that cooling from A.D. 1560-1660 caused successive agro-ecological, socioeconomic, and demographic catastrophes, leading to the General Crisis of the Seventeenth Century. We identified a set of causal linkages between climate change and human crisis. Using temperature data and climate-driven economic variables, we simulated the alternation of defined "golden" and "dark" ages in Europe and the Northern Hemisphere during the past millennium. Our findings indicate that climate change was the ultimate cause, and climate-driven economic downturn was the direct cause, of large-scale human crises in preindustrial Europe and the Northern Hemisphere.

Earliest parietal art: hominin hand and foot traces from the middle Pleistocene of Tibet.

At Quesang on the Tibetan Plateau we report a series of hand and foot impressions that appear to have been intentionally placed on the surface of a unit of soft travertine. The travertine was deposited by water from a hot spring which is now inactive and as the travertine lithified it preserved the traces. On the basis of the sizes of the hand and foot traces, we suggest that two track-makers were involved and were likely children. We interpret this event as a deliberate artistic act that created a work of parietal art. The travertine unit on which the traces were imprinted dates to between ∼169 and 226 ka BP. This would make the site the earliest currently known example of parietal art in the world and would also provide the earliest evidence discovered to date for hominins on the High Tibetan Plateau (above 4000 m a.s.l.). This remarkable discovery adds to the body of research that identifies children as some of the earliest artists within the genus Homo.

Global climate change, war, and population decline in recent human history.

Although scientists have warned of possible social perils resulting from climate change, the impacts of long-term climate change on social unrest and population collapse have not been quantitatively investigated. In this study, high-resolution paleo-climatic data have been used to explore at a macroscale the effects of climate change on the outbreak of war and population decline in the preindustrial era. We show that long-term fluctuations of war frequency and population changes followed the cycles of temperature change. Further analyses show that cooling impeded agricultural production, which brought about a series of serious social problems, including price inflation, then successively war outbreak, famine, and population decline successively. The findings suggest that worldwide and synchronistic war-peace, population, and price cycles in recent centuries have been driven mainly by long-term climate change. The findings also imply that social mechanisms that might mitigate the impact of climate change were not significantly effective during the study period. Climate change may thus have played a more important role and imposed a wider ranging effect on human civilization than has so far been suggested. Findings of this research may lend an additional dimension to the classic concepts of Malthusianism and Darwinism.

Climate change fostered cultural dynamics of human resilience in Europe in the past 2500 years.

Humans possess limited knowledge on what generated cultural dynamics to strengthen human resilience to overcome climate-induced stresses. Although the highly developed mental ability of humans could have enabled significant human resilience in history, no study has empirically explained or has even scientifically confirmed how and when such dynamics arose. To fill the current research gap, this study therefore explores the associations among climatic conditions, the evolutional dynamics of human thinkers and their thoughts, and human ecological-socioeconomic conditions in the past 2500 years in Europe. Results from quantitative modellings and causal analyses confirm that climatic-ecological stresses led to human ecological-socioeconomic crises, and thereby dramatically increased twice of the thinkers' number and their thoughts' impact across different philosophies in truth, knowledge, and ethics for adaptation at multi-decadal to centennial temporal scales, especially in spirituality oriented mentality. The process of the stress-generated cultural dynamics displays some similarities with the stress-induced mutagenesis in organism evolution. Ultimately, climatic-ecological stresses prompt the escalation in the number of thinkers and impacts of their thoughts and flourishing of philosophy. Such stress-regenerated cultural dynamics imply that the current climate change threat may stimulate another thriving phase of cultural selection and lift humans to the next homeostatic plateau of civilization. Findings also extend the cognate scope of psychological, sociological, and civilization studies.

Recommendations for the Prescription of Opioids at Discharge After Abdominopelvic Surgery: A Systematic Review.

Importance: The prescription of opioids at discharge after abdominopelvic surgery is variable and often excessive. A lack of guidance for abdominopelvic surgeons may explain the suboptimal nature of current prescribing practices. Objective: To systematically review existing recommendations on the prescription of opioids at discharge, the appropriate disposal of opioids, and the prevention of chronic postsurgical opioid use after abdominopelvic surgery. Evidence Review: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From January 2010 to December 2018, a search of MEDLINE, PsycINFO, HealthSTAR, Embase, and the difficult to locate and unpublished (ie, gray) literature was performed using a peer-reviewed strategy with variations of the terms opioid, surgery, and guideline to identify English-language documents that contained recommendations published by professional societies or health care institutions. The quality of clinical practice guidelines was assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. A descriptive synthesis of results was performed. Findings: Of 5530 citations screened, 41 full-text documents were included in the systematic review. Fifteen clinical practice guidelines were identified. AGREE II domain scores varied substantially. Identified among the 41 included documents were 98 recommended interventions for the prescription of opioids at discharge, 8 interventions for the disposal of opioids, and 8 interventions for the prevention of chronic postsurgical opioid use. Only 13 of 114 interventions (11.4%) were supported by an assessment of strength or level of evidence, and the amount of opioid recommended after specific abdominopelvic surgical procedures varied widely between guidance documents, even for the same procedure. Conclusions and Relevance: Current guidance for the prescription of opioids at discharge after abdominopelvic surgery is heterogeneous and rarely supported by evidence. More research is needed on this topic to guide the development of future recommendations.

Comment on "Permanent human occupation of the central Tibetan Plateau in the early Holocene".

Meyer et al (Reports, 6 January 2017, p. 64) suggest a new chronology for permanent human occupation of Tibet based on their dating of the travertine and colluvium deposits that contain or are deposited near fossil human handprints and footprints. However, misinterpretations in both stratigraphic reconstruction and dating data may have caused the newly proposed age of these human imprints to have been seriously underestimated.

Two centuries of April-July temperature change in southeastern China and its influence on grain productivity.

China is a traditional agriculture based country and one main region for crop production is southeastern China where temperature is a dominant climate variable affecting agriculture. Temperature and social disturbances both influence crop production, yet distinguishing their relative impacts is difficult due to a lack of reliable, high-resolution historical climatic records before the very recent period. Here we present the first tree-ring based warm-season temperature reconstruction for southeastern China, a core region of the East Asian monsoon, for the past 227years. The reconstruction target was April-July mean temperature, and our model explained 60.6% of the observed temperature variance during 1953-2012. Spatial correlation analysis showed that the reconstruction is representative of April-July temperature change over most of eastern China. The reconstructed temperature series agrees well with China-scale (heavily weighted in eastern China) agricultural production index values quite well at decadal timescales. The impacts of social upheavals on food production, such as those in the period 1920-1949, were confirmed after climatic influences were excluded. Our study should help distinguish the influence of social disturbance and warm-season temperature on grain productivity in the core agricultural region of China during the past two centuries.

Climate change and the macroeconomic structure in pre-industrial europe: new evidence from wavelet analysis.

The relationship between climate change and the macroeconomy in pre-industrial Europe has attracted considerable attention in recent years. This study follows the combined paradigms of evolutionary economics and ecological economics, in which wavelet analysis (spectrum analysis and coherence analysis) is applied as the first attempt to examine the relationship between climate change and the macroeconomic structure in pre-industrial Europe in the frequency domain. Aside from confirming previous results, this study aims to further substantiate the association between climate change and macroeconomy by presenting new evidence obtained from the wavelet analysis. Our spectrum analysis shows a consistent and continuous frequency band of 60-80 years in the temperature, grain yield ratio, grain price, consumer price index, and real wage throughout the study period. Besides, coherence analysis shows that the macroeconomic structure is shaped more by climate change than population change. In addition, temperature is proven as a key climatic factor that influences the macroeconomic structure. The analysis reveals a unique frequency band of about 20 years (15-35 years) in the temperature in AD1600-1700, which could have contributed to the widespread economic crisis in pre-industrial Europe. Our findings may have indications in re-examining the Malthusian theory.

Epidemics in Ming and Qing China: Impacts of changes of climate and economic well-being.

We investigated the mechanism of epidemics with the impacts of climate change and socio-economic fluctuations in the Ming and Qing Dynasties in China (AD 1368-1901). Using long-term and high-quality datasets, this study is the first quantitative research that verifies the 'climate change â†’ economy â†’ epidemics' mechanism in historical China by statistical methods that include correlation analysis, Granger causality analysis, ARX, and Poisson-ARX modeling. The analysis provides the evidences that climate change could only fundamentally lead to the epidemics spread and occurrence, but the depressed economic well-being is the direct trigger of epidemics spread and occurrence at the national and long term scale in historical China. Moreover, statistical modeling shows that economic well-being is more important than population pressure in the mechanism of epidemics. However, population pressure remains a key element in determining the social vulnerability of the epidemics occurrence under climate change. Notably, the findings not only support adaptation theories but also enhance our confidence to address climatic shocks if economic buffering capacity can be promoted steadily. The findings can be a basis for scientists and policymakers in addressing global and regional environmental changes.

Quantifying the Intra-Regional Precipitation Variability in Northwestern China over the Past 1,400 Years.

There has been a surge of paleo-climatic/environmental studies of Northwestern China (NW China), a region characterized by a diverse assortment of hydro-climatic systems. Their common approach, however, focuses on "deducing regional resemblance" rather than "exploring regional variance." To date, efforts to produce a quantitative assessment of long-term intra-regional precipitation variability (IRPV) in NW China has been inadequate. In the present study, we base on historical flood/drought records to compile a decadal IRPV index for NW China spanned AD580-1979 and to find its major determinants via wavelet analysis. Results show that our IRPV index captures the footprints of internal hydro-climatic disparity in NW China. In addition, we find distinct ~120-200 year periodicities in the IRPV index over the Little Ice Age, which are attributable to the change of hydro-climatic influence of ocean-atmospheric modes during the period. Also, we offer statistical evidence of El Niño Southern Oscillation (Indo-Pacific warm pool sea surface temperature and China-wide land surface temperature) as the prominent multi-decadal to centennial (centennial to multi-centennial) determinant of the IRPV in NW China. The present study contributes to the quantitative validation of the long-term IRPV in NW China and its driving forces, covering the periods with and without instrumental records. It may help to comprehend the complex hydro-climatic regimes in the region.

Rapid changes of precipitation pH in Qinghai Province, the northeastern Tibetan Plateau.

Rainfall monitoring programs were conducted in two industrial cities of China's Qinghai Province, Xining and Germu, in some periods of the 1980s and 1990s. The results show that the natural precipitation in this area is originally alkaline. Compared with the late 1980s records, pH values declined significantly from approximately 8 in the 1980s to below 7 in mid-1990s. Such rapid and drastic changes were attributed to fast industrial development that released a large amount of pollutants. Subsequent tough control on pollutant emission partly restored pH values back to above 7 in the late 1990s. The pH and rainfall chemical analyses indicate that alkaline rain in this continental arid region is caused by airborne dusts which originate from local alkaline soils. With decrease of pH value, the total ionic concentration of rainwater is increased because acids were added to the rainwater.

Climate change and macro-economic cycles in pre-industrial europe.

Climate change has been proven to be the ultimate cause of social crisis in pre-industrial Europe at a large scale. However, detailed analyses on climate change and macro-economic cycles in the pre-industrial era remain lacking, especially within different temporal scales. Therefore, fine-grained, paleo-climate, and economic data were employed with statistical methods to quantitatively assess the relations between climate change and agrarian economy in Europe during AD 1500 to 1800. In the study, the Butterworth filter was adopted to filter the data series into a long-term trend (low-frequency) and short-term fluctuations (high-frequency). Granger Causality Analysis was conducted to scrutinize the associations between climate change and macro-economic cycle at different frequency bands. Based on quantitative results, climate change can only show significant effects on the macro-economic cycle within the long-term. In terms of the short-term effects, society can relieve the influences from climate variations by social adaptation methods and self-adjustment mechanism. On a large spatial scale, temperature holds higher importance for the European agrarian economy than precipitation. By examining the supply-demand mechanism in the grain market, population during the study period acted as the producer in the long term, whereas as the consumer in the short term. These findings merely reflect the general interactions between climate change and macro-economic cycles at the large spatial region with a long-term study period. The findings neither illustrate individual incidents that can temporarily distort the agrarian economy nor explain some specific cases. In the study, the scale thinking in the analysis is raised as an essential methodological issue for the first time to interpret the associations between climatic impact and macro-economy in the past agrarian society within different temporal scales.

Perceiving the environment from the lay perspective in desertified areas, northern China.

Investigating local people's environmental perceptions can produce useful information that could be incorporated into decision making processes that help resolve environmental problems. Although China is undergoing severe desertification, the perceptions of the local people toward their degraded environment and the related issues have so far not been actively solicited. This article, which is a supplement to Lee and Zhang's (2004, 2005) studies, seeks to further investigate the lay public's general environmental attitudes, perceptions of desertification, interpretations of land-degrading activities, and particularly their interrelations in severely desertified areas. Minqin County in Gansu Province, northern China, was chosen to be the study area. Data was collected via a questionnaire survey (n=1138) administered in December 2002. Major findings were: (1) Most respondents had only weak altruistic environmental attitudes, with educational level to be a significant determinant. (2) Respondents' perceptions of desertification and interpretations of land-degrading activities were contingent on personal attributes, general environmental attitudes, and other conceptions related to desertification. It is recommended that the interrelations between the various aspects of the public's environmental perceptions should be thoroughly examined to facilitate their participation in environmental management.

Perceiving land-degrading activities from the lay perspective in northern China.

Investigation into local peoples' perceptions can produce useful information that could be incorporated into the decision-making process to help resolve environmental problems. Within the arena of land degradation, a number of studies have also been conducted to explore local peoples' views of the problem. However, the perceptions of land-degrading practices of the general public have so far not been actively solicited. This study aimed to contribute to this area of research by adopting the psychometric scaling technique to empirically explore the lay public's ecological risk perceptions of land-degrading activities in Minqin County in Gansu Province, northern China. The primary data were collected via a questionnaire survey (n=1,138) administered between 14 and 31 December 2002. The major findings of the survey were: (1) Respondents perceived the ecological risks posed by different land-degrading activities to be different. (2) There was a considerable incongruence in the way in which mining of groundwater was conceived by experts and laymen, respectively. (3) Respondents were pretty unsure of expert knowledge. (4) Respondents' ecological risk perceptions were significantly affected by their personal attributes. As far as the policy implications of these findings are concerned, this study accentuates that we must be aware of, and involved in, the environmental perceptions of the lay public in order to succeed in guiding any human-environment tensions along more sustainable trajectories and navigating the transition to sustainability.