Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. The aim is that they will be used as a basis for instilling good practice.

A vanguard randomised feasibility trial comparing three regimens of peri-operative oxygen therapy on recovery after major surgery.

International recommendations encourage liberal administration of oxygen to patients having surgery under general anaesthesia, ostensibly to reduce surgical site infection. However, the optimal oxygen regimen to minimise postoperative complications and enhance recovery from surgery remains uncertain. The hospital operating theatre randomised oxygen (HOT-ROX) trial is a multicentre, patient- and assessor-blinded, parallel-group, randomised clinical trial designed to assess the effect of a restricted, standard care, or liberal peri-operative oxygen therapy regimen on days alive and at home after surgery in adults undergoing prolonged non-cardiac surgery under general anaesthesia. Here, we report the findings of the internal vanguard feasibility phase of the trial undertaken in four large metropolitan hospitals in Australia and New Zealand that included the first 210 patients of a planned overall 2640 trial sample, with eight pre-specified endpoints evaluating protocol implementation and safety. We screened a total of 956 participants between 1 September 2019 and 26 January 2021, with data from 210 participants included in the analysis. Median (IQR [range]) time-weighted average intra-operative Fi O2 was 0.30 (0.26-0.35 [0.20-0.59]) and 0.47 (0.44-0.51 [0.37-0.68]) for restricted and standard care, respectively (mean difference (95%CI) 0.17 (0.14-0.20), p < 0.001). Median time-weighted average intra-operative Fi O2 was 0.83 (0.80-0.85 [0.70-0.91]) for liberal oxygen therapy (mean difference (95%CI) compared with standard care 0.36 (0.33-0.39), p < 0.001). All feasibility endpoints were met. There were no significant patient adverse events. These data support the feasibility of proceeding with the HOT-ROX trial without major protocol modifications.

Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline.

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.

Clinical presentation of verruca vulgaris in HIV.

BACKGROUND: Immunocompromised patients, including those with human immunodeficiency virus (HIV), have been observed to have verrucae that are more extensive and treatment-resistant compared to those in immunocompetent patients. However, there is a critical lack of data in the current literature on the characteristics of verruca vulgaris in individuals with HIV. METHODS: This retrospective chart review included a cohort of HIV-positive individuals and a control group of immunocompetent individuals presenting to an outpatient, county hospital-based dermatology clinic for evaluation of verruca vulgaris between the years of 2016 and 2018. Clinical characteristics, including gender, age, last CD4 count, viral load, antiretroviral therapy adherence, and total number and location of lesions were recorded. RESULTS: A total of 66 patients (33 HIV-positive, 33 immunocompetent) were included in the study. HIV-positive status was significantly associated with a higher total number of lesions (42% of immunocompromised patients versus 21% of immunocompetent patients presented with four or more lesions, P=0.04) as well as location of lesions on the face, scalp, and neck (51.5% versus 9.1%, P<0.001). CONCLUSIONS: HIV-positive status may be associated not only with a higher burden of verruca vulgaris lesions but also a higher number of lesions in locations at or above the neck.

Environmental effects of stratospheric ozone depletion, UV radiation, and interactions with climate change: UNEP Environmental Effects Assessment Panel, Update 2020.

This assessment by the Environmental Effects Assessment Panel (EEAP) of the United Nations Environment Programme (UNEP) provides the latest scientific update since our most recent comprehensive assessment (Photochemical and Photobiological Sciences, 2019, 18, 595-828). The interactive effects between the stratospheric ozone layer, solar ultraviolet (UV) radiation, and climate change are presented within the framework of the Montreal Protocol and the United Nations Sustainable Development Goals. We address how these global environmental changes affect the atmosphere and air quality; human health; terrestrial and aquatic ecosystems; biogeochemical cycles; and materials used in outdoor construction, solar energy technologies, and fabrics. In many cases, there is a growing influence from changes in seasonality and extreme events due to climate change. Additionally, we assess the transmission and environmental effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the COVID-19 pandemic, in the context of linkages with solar UV radiation and the Montreal Protocol.

Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists.

This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the UK and Ireland, but it is recognised that these guidelines may also be of use in other areas of the world. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and during transfer. There are new sections specifically discussing capnography, sedation and regional anaesthesia. In addition, the indications for processed electroencephalogram and neuromuscular monitoring have been updated.

Examining Psychological Self-Sufficiency Among Low-Income Jobseekers with Mental Health Barriers.

The study is to investigate psychological self-sufficiency-the force within someone that activates cognitive and non-cognitive process of shifting perceived barriers into hope actions-as it relates to economic self-sufficiency among jobseekers with mental health barriers. Among a sample of 2455 low-income jobseekers in job readiness programs at six community-based agencies in Chicago, a subsample of 424 who self-identified as having mental illness barriers are selected to analyze the relationships between employment hope, employment barriers, and economic self-sufficiency using structural equation modeling. Results indicate that employment hope mediates the path between perceived employment barriers and economic self-sufficiency. The study further highlights the positive effects of employment barriers on employment hope among jobseekers with perceived mental illnesses. The findings support growing evidence that psychological self-sufficiency is positively associated with gaining economic self-sufficiency in workforce development programs.

An integrative correlation of myopathology, phenotype and genotype in late onset Pompe disease.

AIMS: Pompe disease is caused by pathogenic mutations in the alpha 1,4-glucosidase (GAA) gene and in patients with late onset Pome disease (LOPD), genotype-phenotype correlations are unpredictable. Skeletal muscle pathology includes glycogen accumulation and altered autophagy of various degrees. A correlation of the muscle morphology with clinical features and the genetic background in GAA may contribute to the understanding of the phenotypic variability. METHODS: Muscle biopsies taken before enzyme replacement therapy were analysed from 53 patients with LOPD. On resin sections, glycogen accumulation, fibrosis, autophagic vacuoles and the degree of muscle damage (morphology-score) were analysed and the results were compared with clinical findings. Additional autophagy markers microtubule-associated protein 1A/1B-light chain 3, p62 and Bcl2-associated athanogene 3 were analysed on cryosections from 22 LOPD biopsies. RESULTS: The myopathology showed a high variability with, in most patients, a moderate glycogen accumulation and a low morphology-score. High morphology-scores were associated with increased fibrosis and autophagy highlighting the role of autophagy in severe stages of skeletal muscle damage. The morphology-score did not correlate with the patient's age at biopsy, disease duration, nor with the residual GAA enzyme activity or creatine-kinase levels. In 37 patients with LOPD, genetic analysis identified the most frequent mutation, c.-32-13T>G, in 95%, most commonly in combination with c.525delT (19%). No significant correlation was found between the different GAA genotypes and muscle morphology type. CONCLUSIONS: Muscle morphology in LOPD patients shows a high variability with, in most cases, moderate pathology. Increased pathology is associated with more fibrosis and autophagy.

Environmental effects of stratospheric ozone depletion, UV radiation and interactions with climate change: UNEP Environmental Effects Assessment Panel, update 2019.

This assessment, by the United Nations Environment Programme (UNEP) Environmental Effects Assessment Panel (EEAP), one of three Panels informing the Parties to the Montreal Protocol, provides an update, since our previous extensive assessment (Photochem. Photobiol. Sci., 2019, 18, 595-828), of recent findings of current and projected interactive environmental effects of ultraviolet (UV) radiation, stratospheric ozone, and climate change. These effects include those on human health, air quality, terrestrial and aquatic ecosystems, biogeochemical cycles, and materials used in construction and other services. The present update evaluates further evidence of the consequences of human activity on climate change that are altering the exposure of organisms and ecosystems to UV radiation. This in turn reveals the interactive effects of many climate change factors with UV radiation that have implications for the atmosphere, feedbacks, contaminant fate and transport, organismal responses, and many outdoor materials including plastics, wood, and fabrics. The universal ratification of the Montreal Protocol, signed by 197 countries, has led to the regulation and phase-out of chemicals that deplete the stratospheric ozone layer. Although this treaty has had unprecedented success in protecting the ozone layer, and hence all life on Earth from damaging UV radiation, it is also making a substantial contribution to reducing climate warming because many of the chemicals under this treaty are greenhouse gases.

Tofacitinib in psoriatic arthritis patients: skin signs and symptoms and health-related quality of life from two randomized phase 3 studies.

BACKGROUND: Psoriatic arthritis (PsA) is a chronic, systemic immune-mediated inflammatory musculoskeletal disease. The onset of dermatologic symptoms often precedes rheumatic manifestations. Tofacitinib is an oral Janus kinase inhibitor for the treatment of PsA that has been shown to improve dermatologic symptoms in patients with PsA. OBJECTIVES: To investigate the efficacy of tofacitinib in improving dermatologic endpoints in adult patients with active PsA. METHODS: This analysis included data from two placebo-controlled, double-blind, phase 3 studies in patients with active PsA and an inadequate response (IR) to ≥1 conventional synthetic disease-modifying antirheumatic drug (csDMARD) who were tumor necrosis factor inhibitor (TNFi)-naïve (OPAL Broaden; NCT01877668) or an IR to ≥1 TNFi (OPAL Beyond; NCT01882439). Patients had active plaque psoriasis at screening and received a stable dose of one csDMARD during the study. Patients were randomized to tofacitinib 5 mg twice daily (BID), 10 mg BID, adalimumab 40 mg subcutaneous injection once every 2 weeks (OPAL Broaden only) or placebo (to Month 3). Dermatologic endpoints: Psoriasis Area and Severity Index (PASI) total score; PASI90 overall; PASI75 and PASI90 by baseline PASI severity; Physician's Global Assessment of Psoriasis; Nail Psoriasis Severity Index; Dermatology Life Quality Index total and sub-dimension scores; Itch Severity Item; and Patient's Global Joint and Skin Assessment-Visual Analog Scale-Psoriasis question. RESULTS: In patients with active PsA, including those stratified by mild or moderate/severe dermatologic symptoms, greater improvements from baseline and percentage of responders were observed in tofacitinib-treated patients vs. placebo for the majority of analyzed dermatologic endpoints at Months 1 and 3, and improvements were maintained to Month 12 in OPAL Broaden and Month 6 in OPAL Beyond. Similar effects were observed in adalimumab-treated patients vs. placebo in OPAL Broaden across dermatologic endpoints. CONCLUSIONS: Tofacitinib provides a treatment option for patients with active PsA, including the burdensome dermatologic symptoms of PsA.

Examining Psychological Self-Sufficiency among African American Low-Income Jobseekers in a Health Profession Career Pathways Program.

The aim of this study was to explore the experiences and perceptions of low-income African American jobseekers participating in the Health Profession Opportunity Grants (HPOG) program by employing a mixed method (Qual-Quant) approach. For qualitative data, two in-depth focus groups were conducted with a total of 12 participants who either completed one program or graduated from the HPOG program. With quantitative data, amediation path analysis was conducted using Model 4 of the PROCESS macro (3.1) with a total of 386 participants. The qualitative content analysis of the focus groups generated an overarching theme of the relationship influence on generating hope that included four phenomenological categories: (a) staff and instructors' approach to engagement and support with on-going accessibility and close follow-up; (b) experience-based career motivation; (c) hope as the core driver to overcoming perceived barriers; and (d) supportive relationships as key to instilling hope. In addition, the quantitative analysis confirmed a full mediation model with the path from perceived employment barriers to economic self-sufficiency being mediated by employment hope. The model suggested that the psychological self-sufficiency (PSS) process is key to increasing the economic self-sufficiency (ESS) outcome. Findings supported the importance ofa relationship-based, culturally competent practice to strengthen the PSS process in health profession workforce development among low-income African American jobseekers.

Effectiveness of an mHealth application to improve hypertension health literacy in India.

AIM: The purpose of this research was to determine the effectiveness of a mobile health or mHealth application to improve hypertension health literacy among vulnerable populations in India. Additionally, we sought to estimate relationships between participant knowledge on hypertension and sociodemographic variables. BACKGROUND: The World Health Organization advocates for the use of mobile technology to improve public health outcomes. INTRODUCTION: The incidence of hypertension is on the rise in India, and effective and sustainable interventions are needed. METHODS: A quantitative single arm pre-test post-test interventional and correlational design was used to test the hypertension mHealth application among participants in a limited resource setting. A paired t-test was performed to compare pre- and post-test results after participant use of the mHealth application. A regression model was used to estimate relationships between participant hypertension health literacy and sociodemographic variables. RESULTS: A statistically significant improvement in test scores among participants after use of the mHealth app was found. Sociodemographic characteristics such as living in an urban environment, married, increased number of people living in household and alcohol use were determined to have a statistically significant effect on improvement of test score. DISCUSSION: Results indicated the application was effective among participants with varied literacy and health literacy levels. These findings contribute to the potential widespread scalability of the app among populations with varied demographics. CONCLUSION: This application provides an effective and valuable culturally tailored educational resource for nurses and other health providers to use to improve hypertension health literacy among vulnerable populations in India. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY: This study contributes to nursing and health policy by answering a call from the World Health Organization to implement and research mHealth interventions to improve health outcomes, particularly in a low and middle income country where preventive health access is limited.

Ozone-climate interactions and effects on solar ultraviolet radiation.

This report assesses the effects of stratospheric ozone depletion and anticipated ozone recovery on the intensity of ultraviolet (UV) radiation at the Earth's surface. Interactions between changes in ozone and changes in climate, as well as their effects on UV radiation, are also considered. These evaluations focus mainly on new knowledge gained from research conducted during the last four years. Furthermore, drivers of changes in UV radiation other than ozone are discussed and their relative importance is assessed. The most important of these factors, namely clouds, aerosols and surface reflectivity, are related to changes in climate, and some of their effects on short- and long-term variations of UV radiation have already been identified from measurements. Finally, projected future developments in stratospheric ozone, climate, and other factors affecting UV radiation have been used to estimate changes in solar UV radiation from the present to the end of the 21st century. New instruments and methods have been assessed with respect to their ability to provide useful and accurate information for monitoring solar UV radiation at the Earth's surface and for determining relevant exposures of humans. Evidence since the last assessment reconfirms that systematic and accurate long-term measurements of UV radiation and stratospheric ozone are essential for assessing the effectiveness of the Montreal Protocol and its Amendments and adjustments. Finally, we have assessed aspects of UV radiation related to biological effects and human health, as well as implications for UV radiation from possible solar radiation management (geoengineering) methods to mitigate climate change.

Kinase activity in the olfactory bulb is required for odor memory consolidation.

Long-term fear memory formation in the hippocampus and neocortex depends upon brain-derived neurotrophic factor (BDNF) signaling after acquisition. Incremental, appetitive odor discrimination learning is thought to depend substantially on the differentiation of adult-born neurons within the olfactory bulb (OB)-a process that is closely associated with BDNF signaling. We sought to elucidate the role of neurotrophin signaling within the OB on odor memory consolidation. Male mice were trained on odor-reward associative discriminations after bilateral infusion of the kinase inhibitor K252a, or vehicle control, into the OB. K252a is a partially selective inhibitor of tyrosine kinase (Trk) receptors, including the TrkB receptor for BDNF, though it also inhibits other plasticity-related kinases such as PKC and CaMKII/IV. K252a infusion into the OB did not impair odor acquisition or short-term (2 h) memory for the learned discriminations, but significantly impaired long-term (48 h) odor memory (LTM). This LTM deficit also was associated with reduced selectivity for the conditioned odorant in a reward-seeking digging task. Infusions of K252a immediately prior to testing did not impair LTM recall. These results indicate that kinase activation in the OB is required for the consolidation of odor memory of incrementally acquired information.

Maternal obesity heritably perturbs offspring metabolism for three generations without serial programming.

Maternal obesity can program offspring metabolism across multiple generations. It is not known whether multigenerational effects reflect true inheritance of the induced phenotype, or are due to serial propagation of the phenotype through repeated exposure to a compromised gestational milieu. Here we sought to distinguish these possibilities, using the Avy mouse model of maternal obesity. In this model, F1 sons of obese dams display a predisposition to hepatic insulin resistance, which remains latent unless the offspring are challenged with a Western diet. We find that F2 grandsons and F3 great grandsons of obese dams also carry the latent predisposition to metabolic dysfunction, but remain metabolically normal on a healthy diet. Given that the breeding animals giving rise to F2 and F3 were maintained on a healthy diet, the latency of the phenotype permits exclusion of serial programming; we also confirmed that F1 females remained metabolically healthy during pregnancy. Molecular analyses of male descendants identified upregulation of hepatic Apoa4 as a consistent signature of the latent phenotype across all generations. Our results exclude serial programming as a factor in transmission of the metabolic phenotype induced by ancestral maternal obesity, and indicate inheritance through the germline, probably via some form of epigenetic inheritance.

Phylogenetic Diversity of Koala Retrovirus within a Wild Koala Population.

Koala populations are in serious decline across many areas of mainland Australia, with infectious disease a contributing factor. Koala retrovirus (KoRV) is a gammaretrovirus present in most wild koala populations and captive colonies. Five subtypes of KoRV (A to E) have been identified based on amino acid sequence divergence in a hypervariable region of the receptor binding domain of the envelope protein. However, analysis of viral genetic diversity has been conducted primarily on KoRV in captive koalas housed in zoos in Japan, the United States, and Germany. Wild koalas within Australia have not been comparably assessed. Here we report a detailed analysis of KoRV genetic diversity in samples collected from 18 wild koalas from southeast Queensland. By employing deep sequencing we identified 108 novel KoRV envelope sequences and determined their phylogenetic diversity. Genetic diversity in KoRV was abundant and fell into three major groups; two comprised the previously identified subtypes A and B, while the third contained the remaining hypervariable region subtypes (C, D, and E) as well as four hypervariable region subtypes that we newly define here (F, G, H, and I). In addition to the ubiquitous presence of KoRV-A, which may represent an exclusively endogenous variant, subtypes B, D, and F were found to be at high prevalence, while subtypes G, H, and I were present in a smaller number of animals. IMPORTANCE: Koala retrovirus (KoRV) is thought to be a significant contributor to koala disease and population decline across mainland Australia. This study is the first to determine KoRV subtype prevalence among a wild koala population, and it significantly expands the total number of KoRV sequences available, providing a more precise picture of genetic diversity. This understanding of KoRV subtype prevalence and genetic diversity will be important for conservation efforts attempting to limit the spread of KoRV. Furthermore, KoRV is one of the only retroviruses shown to exist in both endogenous (transmitted vertically to offspring in the germ line DNA) and exogenous (horizontally transmitted between infected individuals) forms, a division of fundamental evolutionary importance.