Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward.

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

Digital workflow to rehabilitate worn dentition on a non-hinge simulated patient.

This report describes the complete mouth rehabilitation of worn dentition by using a digital workflow on a non-hinge simulated patient. A dentiform was used to simulate a patient with loss of occlusal vertical dimension. Physical diagnostic waxing along with a digital workflow was then used to re-establish the occlusal vertical dimension at the interim and definitive restoration stages.

Actions on sustainable food production and consumption for the post-2020 global biodiversity framework.

Current food production and consumption trends are inconsistent with the Convention on Biological Diversity's 2050 vision of living in harmony with nature. Here, we examine how, and under what conditions, the post-2020 biodiversity framework can support transformative change in food systems. Our analysis of actions proposed in four science-policy fora reveals that subsidy reform, valuation, food waste reduction, sustainability standards, life cycle assessments, sustainable diets, mainstreaming biodiversity, and strengthening governance can support more sustainable food production and consumption. By considering barriers and opportunities of implementing these actions in Peru and the United Kingdom, we derive potential targets and indicators for the post-2020 biodiversity framework. For targets to support transformation, genuine political commitment, accountability and compliance, and wider enabling conditions and actions by diverse agents are needed to shift food systems onto a sustainable path.

Analysing interactions among the sustainable development goals: findings and emerging issues from local and global studies.

The topic of SDG interactions is a relatively new research area with many knowledge gaps. Some of these gaps are addressed in this summary of a Special Feature of Sustainability Science, including new findings and emerging issues on (1) the characteristics of SDG interactions; (2) methods/methodology to analyse these interactions; and (3) the elaboration of drivers that influence SDG synergies. The importance of scale is clear in two emerging issues. First, there is evidence of a disconnect between national planning for SDGs and their implementation at the local scale which is leading to SDG trade-offs between these scales. Second, the concept of a "critical transition zone" is introduced where SDG trade-offs pose a particular challenge to SDG implementation. These are areas (e.g., peri-urban and forest margin areas in the Global South) undergoing rapid biophysical and/or socio-economic changes and inhabited by populations especially vulnerable to these changes. While trade-offs occur among the SDGs, there are also many examples of synergies which provide opportunities for advancing multiple goals. To distinguish between synergies and the actions that exploit them, the term "synergy driver" is introduced to refer to policies and measures that positively advance two or more goals. Several examples of synergy drivers are presented, including sustainable global supply chains, people-centred early warning systems, and joint conservation-public health programmes. To make synergy drivers relevant to the broader policy community, the research community (working with stakeholders) should first consolidate knowledge about these drivers and then evaluate their effectiveness/applicability to different policy settings.

Adverse events associated with ribavirin in sofosbuvir-based therapies for patients with chronic hepatitis C: A community practice experience.

OBJECTIVE: Due to high sustained virological response (SVR) rates, sofosbuvir-based regimens are currently a mainstay for hepatitis C virus (HCV) therapies. The addition of pegylated interferon (PEG-IFN) and ribavirin impacts patients' quality of life during treatment. This study aimed to compare severe adverse events (SAEs) amongst therapeutic combinations for HCV in a community clinic setting. METHODS: From December 2013 to July 2014, 128 chronic HCV-infected patients were treated with sofosbuvir, ribavirin and weekly PEG-IFN for 12 weeks (cohort 1), 12 or 24 weeks of sofosbuvir and ribavirin (cohorts 2 and 3) or sofosbuvir plus simeprevir for 12 weeks (cohort 4). Adverse events were recorded from baseline to 12 or 24 weeks of treatment. RESULTS: SAEs appeared in 15.6-53.8% of ribavirin-inclusive treated patients compared to 4.8% of the ribavirin-free regimen. PEG-IFN, sofosbuvir plus ribavirin had the highest frequencies of fatigue, headache and rash compared to either 12 or 24 weeks of ribavirin and sofosbuvir. However, sofosbuvir and ribavirin regimens led to significant increases in dyspnea, need for ribavirin dose reductions and withdrawal from treatment due to SAEs. Anemia was also more frequent in ribavirin-inclusive combinations (P < 0.001). Conversely, sofosbuvir plus simeprevir reached similar SVR rates at week 12 post-treatment compared to all ribavirin-containing regimens, but with significantly fewer adverse events (P = 0.006). At week 12 post-treatment, cirrhotic patients experienced a higher virological relapse rate than non-cirrhotic patients (P = 0.019). CONCLUSIONS: Ribavirin-inclusive HCV therapies increased the frequencies of SAEs, had higher dropout rates and increased patient morbidity.

Developing a scorecard to assess global progress in scaling up diarrhea control tools: a qualitative study of academic leaders and implementers.

BACKGROUND: In 2010, diarrhea caused 0.75 million child deaths, accounting for nearly 12% of all under-five mortality worldwide. Many evidence-based interventions can reduce diarrhea mortality, including oral rehydration solution (ORS), zinc, and improved sanitation. Yet global coverage levels of such interventions remain low. A new scorecard of diarrhea control, showing how different countries are performing in their control efforts, could draw greater attention to the low coverage levels of proven interventions. METHODS: We conducted in-depth qualitative interviews with 21 experts, purposively sampled for their relevant academic or implementation expertise, to explore their views on (a) the value of a scorecard of global diarrhea control and (b) which indicators should be included in such a scorecard. We then conducted a ranking exercise in which we compiled a list of all 49 indicators suggested by the experts, sent the list to the 21 experts, and asked them to choose 10 indicators that they would include and 10 that they would exclude from such a scorecard. Finally, we created a "prototype" scorecard based on the 9 highest-ranked indicators. RESULTS: Key themes that emerged from coding the interview transcripts were: a scorecard could facilitate country comparisons; it could help to identify best practices, set priorities, and spur donor action; and it could help with goal-setting and accountability in diarrhea control. The nine highest ranking indicators, in descending order, were ORS coverage, rotavirus vaccine coverage, zinc coverage, diarrhea-specific mortality rate, diarrhea prevalence, proportion of population with access to improved sanitation, proportion with access to improved drinking water, exclusive breastfeeding coverage, and measles vaccine coverage. CONCLUSION: A new scorecard of global diarrhea control could help track progress, focus prevention and treatment efforts on the most effective interventions, establish transparency and accountability, and alert donors and ministries of health to inadequacies in diarrhea control efforts.

Standardising analysis of carbon monoxide rebreathing for application in anti-doping.

Determination of total haemoglobin mass (Hbmass) via carbon monoxide (CO) depends critically on repeatable measurement of percent carboxyhaemoglobin (%HbCO) in blood with a hemoximeter. The main aim of this study was to determine, for an OSM3 hemoximeter, the number of replicate measures as well as the theoretical change in percent carboxyhaemoglobin required to yield a random error of analysis (Analyser Error) of ≤1%. Before and after inhalation of CO, nine participants provided a total of 576 blood samples that were each analysed five times for percent carboxyhaemoglobin on one of three OSM3 hemoximeters; with approximately one-third of blood samples analysed on each OSM3. The Analyser Error was calculated for the first two (duplicate), first three (triplicate) and first four (quadruplicate) measures on each OSM3, as well as for all five measures (quintuplicates). Two methods of CO-rebreathing, a 2-min and 10-min procedure, were evaluated for Analyser Error. For duplicate analyses of blood, the Analyser Error for the 2-min method was 3.7, 4.0 and 5.0% for the three OSM3s when the percent carboxyhaemoglobin increased by two above resting values. With quintuplicate analyses of blood, the corresponding errors reduced to .8, .9 and 1.0% for the 2-min method when the percent carboxyhaemoglobin increased by 5.5 above resting values. In summary, to minimise the Analyser Error to ∼≤1% on an OSM3 hemoximeter, researchers should make ≥5 replicates of percent carboxyhaemoglobin and the volume of CO administered should be sufficient increase percent carboxyhaemoglobin by ≥5.5 above baseline levels.

Comprehensive two-dimensional liquid chromatography separations of pharmaceutical samples using dual Fused-Core columns in the 2nd dimension.

This paper focuses on the application of RPLC x RPLC to pharmaceutical analysis and addresses the specific problem of separating co-eluting impurities/degradation products that maybe "hidden" within the peak envelope of the active pharmaceutical ingredient (API) and thus may escape detection by conventional methods. A comprehensive two-dimensional liquid chromatograph (LC x LC) was constructed from commercially available HPLC equipment. This system utilizes two independently configurable 2nd dimension binary pumping systems to deliver independent flow rates, gradient profiles and mobile phase compositions to dual Fused-Core secondary columns. Very fast gradient separations (30s total cycle time) were achieved at ambient temperature without excessive backpressure and without compromising optimal 1st dimension sampling rates. The operation of the interface is demonstrated for the analysis of a 1mg/ml standard mixture containing 0.05% of a minor component. The practicality of using RPLC x RPLC for the analysis of actual co-eluting pharmaceutical degradation products, by exploiting pH-induced changes in selectivity, is also demonstrated using a three component mixture. This mixture (an API, an oxidation product of the API at 1.0%, w/w, and a photo degradant of the API at 0.5%, w/w) was used to assess the stability indicating nature of an established LC method for analysis of the API.

The design of an on-line semi-preparative LC-SPE-NMR system for trace analysis.

This paper reports the design of an on-line semi-preparative LC-SPE-NMR system and its use in the structural analysis of mixture components at the 0.02-1% level. The combination provides at least a five fold mass sensitivity increase over that obtained from typical analytical LC-SPE systems and a >30-fold total NMR sensitivity enhancement over analysis by LC-NMR. This is accomplished by using a novel on-line device to store, dilute (1-100-fold) and deliver (at an optimized flow-rate) the isolated component of interest to an SPE trap unit. The SPE unit consists of two cartridges connected in parallel to increase the overall SPE capacity and also to decrease the flow-rate through each trap for enhanced trapping efficiency. As the coupling of semi-preparative LC with NMR (through SPE) is well matched in terms of optimal mass loading for both techniques, only one LC-SPE cycle is required to enrich a 50 microg ml(-1) component (1% in a 5 mg ml(-1) mixture) for the acquisition of heteronuclear (1)H-(13)C NMR data using a conventional NMR flow probe. Furthermore, analytes at the 0.02% level (approximately 1 microg ml(-1)) can be studied using 2D (1)H NMR techniques if peak cuts from replicate sample injections (> or =3) are accumulated into the storage/dilution unit and the resulting solution processed by just one SPE trap and elute cycle.