Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma.

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

Long-term spring through fall capture data of Eptesicus fuscus in the eastern USA before and after white-nose syndrome.

Emerging infectious diseases threaten wildlife populations. Without well monitored wildlife systems, it is challenging to determine accurate population and ecosystem losses following disease emergence. North American temperate bats present a unique opportunity for studying the broad impacts of wildlife disease emergence, as their federal monitoring programs were prioritized in the USA throughout the 20th century and they are currently threatened by the invasive fungal pathogen, Pseudogymnoascus destructans (Pd), which causes white-nose syndrome. Here we provide a long-term dataset for capture records of Eptesicus fuscus (big brown bat) across the eastern USA, spanning 16 years before and 14 years after Pd invasion into North America. These data represent 30,496 E. fuscus captures across 3,567 unique sites. We encourage the use of this dataset for quantifying impacts of wildlife disease and other threats to wildlife (e.g., climate change) with the incorporation of other available data. We welcome additional data contributions for E. fuscus captures across North and Central America as well as the inclusion of other variables into the dataset that contribute to the quantification of wildlife health.

Estimating impact likelihoods from probabilistic projections of climate and socio-economic change using impact response surfaces.

Estimates of future climate change impacts using numerical impact models are commonly based on a limited selection of projections of climate and other key drivers. However, the availability of large ensembles of such projections offers an opportunity to estimate impact responses probabilistically. This study demonstrates an approach that combines model-based impact response surfaces (IRSs) with probabilistic projections of climate change and population to estimate the likelihood of exceeding pre-specified thresholds of impact. The changing likelihood of exceeding impact thresholds during the 21st century was estimated for selected indicators in three European case study regions (Iberian Peninsula, Scotland and Hungary), comparing simulations that incorporate adaptation to those without adaptation. The results showed high likelihoods of increases in heat-related human mortality and of yield decreases for some crops, whereas a decrease of NPP was estimated to be exceptionally unlikely. For a water reservoir in a Portuguese catchment, increased likelihoods of severe water scarce conditions were estimated for the current rice cultivation. Switching from rice to other crops with lower irrigation demand changes production risks, allowing for expansion of the irrigated areas but introducing a stronger sensitivity to changes in rainfall. The IRS-based risk assessment shown in this paper is of relevance for policy making by addressing the relative sensitivity of impacts to key climate and socio-economic drivers, and the urgency for action expressed as a time series of the likelihood of crossing critical impact thresholds. It also examines options to respond by incorporating alternative adaptation actions in the analysis framework, which may be useful for exploring the types, choice and timing of adaptation responses.

Canada geese (Branta canadensis) nesting on elevated structures in urban Indiana, USA.

The Canada goose (Branta canadensis) population has radically changed over the past 60 years-from once being extirpated in the state of Indiana to the current level of approximately 113,000. High urban densities have resulted in persistent human-wildlife conflicts and novel interactions between geese and their physical environment. Canada geese typically choose nest sites that are on the ground or slightly elevated sites such as muskrat lodge, but we report observations of Canada geese nesting on rooftops 2.6-12.2 m above ground level in central Indiana. These observations suggest that alternative, unpredicted nesting sites are being chosen over more traditional sites, in a likely attempt to reduce risks of disturbance and predation. This atypical nest-site selection may pose new management challenges, but further research is needed.

Lessons from COVID-19 for managing transboundary climate risks and building resilience.

COVID-19 has revealed how challenging it is to manage global, systemic and compounding crises. Like COVID-19, climate change impacts, and maladaptive responses to them, have potential to disrupt societies at multiple scales via networks of trade, finance, mobility and communication, and to impact hardest on the most vulnerable. However, these complex systems can also facilitate resilience if managed effectively. This review aims to distil lessons related to the transboundary management of systemic risks from the COVID-19 experience, to inform climate change policy and resilience building. Evidence from diverse fields is synthesised to illustrate the nature of systemic risks and our evolving understanding of resilience. We describe research methods that aim to capture systemic complexity to inform better management practices and increase resilience to crises. Finally, we recommend specific, practical actions for improving transboundary climate risk management and resilience building. These include mapping the direct, cross-border and cross-sectoral impacts of potential climate extremes, adopting adaptive risk management strategies that embrace heterogenous decision-making and uncertainty, and taking a broader approach to resilience which elevates human wellbeing, including societal and ecological resilience.

National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

OBJECTIVE: Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement. METHODS: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models. RESULTS: A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke (p = 0.91)/cerebrovascular disease (p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002). CONCLUSION: TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.

A qualitative study of service users' experiences of mental health nurses' knowledge and skills in relation to medication.

INTRODUCTION: The role of the mental health nurse in relation to medications remains complex. Despite an increasing focus on pharmacology within pre-registration nurse education, there is limited research exploring how mental health service users experience mental health nurses' knowledge and skills in relation to medication. AIM: To explore the experiences of service users working with mental health nurses, in relation to the nurses' knowledge and skills associated with medicines management. METHOD: The research prioritized the principles of co-production and was undertaken collaboratively with a researcher with lived experience. Data were collected via semi-structured interviews with individuals who have accessed UK mental health services. Interviews were audio-recorded, transcribed verbatim and subjected to thematic analysis. RESULTS: Three themes were generated from the data: inconsistencies in knowledge and practice, holistic therapeutic engagement and dialogical approach to medicines. DISCUSSION: Service users may have a sense of uncertainty around the role of the nurse, potentially resulting in frustration and anxiety. However, mental health nurses also possess unique skills in relation to medicines management. IMPLICATIONS FOR PRACTICE: The findings emphasize that service users value not only pharmacological knowledge but also unique skills in facilitating dialogue, prioritising shared decision-making and practical support in medicines optimization.

Achievements and needs for the climate change scenario framework.

Long-term global scenarios have underpinned research and assessment of global environmental change for four decades. Over the past ten years, the climate change research community has developed a scenario framework combining alternative futures of climate and society to facilitate integrated research and consistent assessment to inform policy. Here we assess how well this framework is working and what challenges it faces. We synthesize insights from scenario-based literature, community discussions and recent experience in assessments, concluding that the framework has been widely adopted across research communities and is largely meeting immediate needs. However, some mixed successes and a changing policy and research landscape present key challenges, and we recommend several new directions for the development and use of this framework.

Improving the representation of adaptation in climate change impact models.

Climate change adaptation is a complex human process, framed by uncertainties and constraints, which is difficult to capture in existing assessment models. Attempts to improve model representations are hampered by a shortage of systematic descriptions of adaptation processes and their relevance to models. This paper reviews the scientific literature to investigate conceptualisations and models of climate change adaptation, and the ways in which representation of adaptation in models can be improved. The review shows that real-world adaptive responses can be differentiated along a number of dimensions including intent or purpose, timescale, spatial scale, beneficiaries and providers, type of action, and sector. However, models of climate change consequences for land use and water management currently provide poor coverage of these dimensions, instead modelling adaptation in an artificial and subjective manner. While different modelling approaches do capture distinct aspects of the adaptive process, they have done so in relative isolation, without producing improved unified representations. Furthermore, adaptation is often assumed to be objective, effective and consistent through time, with only a minority of models taking account of the human decisions underpinning the choice of adaptation measures (14%), the triggers that motivate actions (38%) or the time-lags and constraints that may limit their uptake and effectiveness (14%). No models included adaptation to take advantage of beneficial opportunities of climate change. Based on these insights, transferable recommendations are made on directions for future model development that may enhance realism within models, while also advancing our understanding of the processes and effectiveness of adaptation to a changing climate.

The Ross Operation in the Adult: What, Why, and When?

The normal aortic valve is a sophisticated and dynamic structure whose equal replacement has not yet been actualized by modern technology. The use of the pulmonary autograft as a substitute for a diseased aortic valve (the Ross procedure) has been in practice for several decades in many types of patient. In the adult, it has not been adopted widely due to concerns about its technical challenge, complex perioperative care, the development of pulmonic valve disease, and concerns about long-term dilatation of the neo-aortic root, among others. There has been a substantial body of data showing excellent long-term survival, freedom from reoperation, and quality of life, in contradistinction to these preconceptions. The authors review the available data pertinent to these questions to further define the role of the Ross procedure in the adult cardiac surgery patient.

Pharmacology training in mental health nurse education: Justification for an increase in frequency and depth in the UK.

This article explores the role and importance of Pharmacology within mental health nurse education. The article proposes that a lack of pharmacology content within undergraduate mental health nurse education may not fully prepare nurses for their role once qualified and as a result influence negatively upon service user care.

Co-producing a digital educational programme for registered children's nurses to improve care of children and young people admitted with self-harm.

Despite the increasing prevalence of hospital admissions for self-harm in children and young people (CYP), there is paucity of registered children's nurse (rCN) training or involvement of children to improve care for this often stigmatized patient group. This article describes a participatory approach towards using co-production with CYP and rCN to develop a digital educational programme to improve nurses' knowledge, attitudes and confidence in caring for CYP with self-harm injuries. A priority-setting workshop with rCNs was used to establish consensus of information needs. This was followed by an e-learning content development workshop undertaken with CYP whom had previously experienced hospital admissions for self-harm injuries. Findings from the nurse priority-setting workshop identified three educational priorities: (1) knowledge of self-harm, (2) effective communication and (3) risk management. The CYP subsequently developed these topic areas to ensure the contents and design of the e-learning resource had fidelity by reflecting the experiences of CYP and needs when cared for in hospital. This article illustrates that involving service users to co-develop educational materials is a feasible and important step in designing educational resources and ensures the content is relevant, appropriate and sensitive to both the recipient of care and those responsible for its delivery.

Fetal sex alters maternal anti-Mullerian hormone during pregnancy in cattle.

Anti-Mullerian hormone (AMH) is expressed by both male and female fetuses during mammalian development, with males expressing AMH earlier and at significantly higher concentration. The aim of the current study was to explore the potential impact of pregnancy and fetal sex on maternal AMH and to determine if plasma (Pl) AMH or placenta intercotyledonary membrane and cotyledonary AMH receptor 2 (AMHR2) mRNA expression differ in pregnant cows carrying male vs. female fetuses. AMH levels in blood were measured using a bovine optimized ELISA kit. Cows pregnant with a male fetus were observed to have a significantly greater difference in Pl AMH between day 35 and 135 of gestation. Average fetal AMH level between 54 and 220days of gestation was also observed to be significantly higher in male vs. female fetuses. Intercotyledonary membranes and cotyledons were found to express AMHR2 between days 38 and 80 of gestation at similar levels in both fetal sexes. These findings support the hypothesis that fetal sex alters maternal Pl AMH during pregnancy in cattle.

A randomized controlled pilot study of VO2 max testing: a potential model for measuring relative in vivo efficacy of different red blood cell products.

BACKGROUND: Randomized trials, for example, RECESS, comparing "young" (median, 7-day) versus "middle-aged" (median, 28-day) red blood cells (RBCs), showed no difference in outcome. These data are important; however, they do not inform us about the safety and effectiveness of the oldest RBCs, which some patients receive. It may not be feasible to conduct a clinical trial randomizing patients to receive the oldest blood. Therefore, we propose strenuous exercise (VO2 max testing) as a model to study the relative efficacy to increase oxygen delivery to tissue of different RBC products, for example, extremes of storage duration. STUDY DESIGN AND METHODS: In this pilot study, eight healthy subjects had 2 units of leukoreduced RBCs collected by apheresis in AS-3 using standard methods. Subjects were randomized to receive both (2) units of their autologous RBCs at either 7 or 42 days after blood collection. VO2 max testing on a cycle ergometer was performed 2 days before (Monday) and 2 days after (Friday) the transfusion visit (Wednesday). This design avoids confounding effects on intravascular volume from the 2-unit blood transfusion. The primary outcome was the difference in VO2 max between Friday and Monday (delta VO2 max). RESULTS: VO2 max increased more in the 7-day RBC arm (8.7 ± 6.9% vs. 1.9 ± 6.5%, p = 0.202 for comparison between arms). Exercise duration (seconds) increased in the 7-day RBC arm (8.4 ± 1.7%) but actually decreased in the 42-day arm (-2.6 ± 3.6%, p = 0.002). CONCLUSIONS: This pilot study suggests that VO2 max testing has potential as a rigorous and quantitative in vivo functional assay of RBC function. Our preliminary results suggest that 42-day RBCs are inferior to 7-day RBCs at delivering oxygen to tissues.

Systemic and local anti-Mullerian hormone reflects differences in the reproduction potential of Zebu and European type cattle.

This study was conducted to evaluate plasma anti-Mullerian hormone (Pl AMH), follicular fluid AMH (FF AMH) and granulosa cell AMH transcript (GC AMH) levels and their relationships with reproductive parameters in two cattle subspecies, Bos taurus indicus (Zebu), and Bos taurus taurus (European type cattle). Two-dimensional ultrasound examination and serum collection were performed on Zebu, European type and crossbreed cows to determine antral follicle count (AFC), ovary diameter (OD) and Pl AMH concentration. Slaughterhouse ovaries for Zebu and European type cattle were collected to determine FF AMH concentrations, GC AMH RNA levels, AFC, oocyte number, cleavage and blastocyst rate. Additionally GC AMH receptor 2 (AMHR2) RNA level was measured for European type cattle. Relationship between AMH and reproductive parameters was found to be significantly greater in Zebu compared to European cattle. Average Pl AMH mean ± SE for Zebu and European cattle was 0.77 ± 0.09 and 0.33 ± 0.24 ng/ml respectively (p = 0.01), whereas average antral FF AMH mean ± SE for Zebu and European cattle was 4934.3 ± 568.5 and 2977.9 ± 214.1 ng/ml respectively (p < 0.05). This is the first published report of FF and GC AMH in Zebu cattle. Levels of GC AMHR2 RNA in European cattle were correlated to oocyte number (p = 0.01). Crossbred animals were found more similar to their maternal Zebu counterparts with respect to their Pl AMH to AFC and OD relationships. These results demonstrate that AMH reflects differences between reproduction potential of the two cattle subspecies therefore can potentially be used as a reproductive marker. Furthermore these results reinforce the importance of separately considering the genetic backgrounds of animals when collecting or interpreting bovine AMH data for reproductive performance.

Genetics, Morphology, Advertisement Calls, and Historical Records Distinguish Six New Polyploid Species of African Clawed Frog (Xenopus, Pipidae) from West and Central Africa.

African clawed frogs, genus Xenopus, are extraordinary among vertebrates in the diversity of their polyploid species and the high number of independent polyploidization events that occurred during their diversification. Here we update current understanding of the evolutionary history of this group and describe six new species from west and central sub-Saharan Africa, including four tetraploids and two dodecaploids. We provide information on molecular variation, morphology, karyotypes, vocalizations, and estimated geographic ranges, which support the distinctiveness of these new species. We resurrect Xenopus calcaratus from synonymy of Xenopus tropicalis and refer populations from Bioko Island and coastal Cameroon (near Mt. Cameroon) to this species. To facilitate comparisons to the new species, we also provide comments on the type specimens, morphology, and distributions of X. epitropicalis, X. tropicalis, and X. fraseri. This includes significantly restricted application of the names X. fraseri and X. epitropicalis, the first of which we argue is known definitively only from type specimens and possibly one other specimen. Inferring the evolutionary histories of these new species allows refinement of species groups within Xenopus and leads to our recognition of two subgenera (Xenopus and Silurana) and three species groups within the subgenus Xenopus (amieti, laevis, and muelleri species groups).

Predicting the risk of death following coronary artery bypass graft made simple: a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database.

INTRODUCTION: Risk models to predict 30-day mortality following isolated coronary artery bypass graft is an active area of research. Simple risk predictors are particularly important for cardiothoracic surgeons who are coming under increased scrutiny since these physicians typically care for higher risk patients and thus expect worse outcomes. The objective of this study was to develop a 30-day postoperative mortality risk model for patients undergoing CABG using the American College of Surgeons National Surgical Quality Improvement Program database. MATERIAL AND METHODS: Data was extracted and analyzed from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2010). Patients that had ischemic heart disease (ICD9 410-414) undergoing one to four vessel CABG (CPT 33533-33536) were selected. To select for acquired heart disease, only patients age 40 and older were included. Multivariate logistic regression analysis was used to create a risk model. The C-statistic and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the model. Bootstrap-validated C-statistic was calculated. RESULTS: A total of 2254 cases met selection criteria. Forty-nine patients (2.2%) died within 30 days. Six independent risk factors predictive of short-term mortality were identified including age, preoperative sodium, preoperative blood urea nitrogen, previous percutaneous coronary intervention, dyspnea at rest, and history of prior myocardial infarction. The C-statistic for this model was 0.773 while the bootstrap-validated C-statistic was 0.750. The Hosmer-Lemeshow test had a p-value of 0.675, suggesting the model does not overfit the data. CONCLUSIONS: The American College of Surgeons National Surgical Quality Improvement Program risk model has good discrimination for 30-day mortality following coronary artery bypass graft surgery. The model employs six independent variables, making it easy to use in the clinical setting.

Biological Response of Positron Emission Tomography Scan Exposure and Adaptive Response in Humans.

The biological effects of exposure to radioactive fluorodeoxyglucose ((18)F-FDG) were investigated in the lymphocytes of patients undergoing positron emission tomography (PET) procedures. Low-dose, radiation-induced cellular responses were measured using 3 different end points: (1) apoptosis; (2) chromosome aberrations; and (3) γH2AX foci formation. The results showed no significant change in lymphocyte apoptosis, or chromosome aberrations, as a result of in vivo (18)F-FDG exposure, and there was no evidence the PET scan modified the apoptotic response of lymphocytes to a subsequent 2 Gy in vitro challenge irradiation. However, lymphocytes sampled from patients following a PET scan showed an average of 22.86% fewer chromosome breaks and 39.16% fewer dicentrics after a subsequent 2 Gy in vitro challenge irradiation. The effect of (18)F-FDG exposure on phosphorylation of histone H2AX (γH2AX) in lymphocytes of patients showed a varied response between individuals. The relationship between γH2AX foci formation and increasing activity of (18)F-FDG was not directly proportional to dose. This variation is most likely attributed to differences in the factors that combine to constitute an individual's radiation response. In summary, the results of this study indicate(18)F-FDG PET scans may not be detrimental but can elicit variable responses between individuals and can modify cellular response to subsequent radiation exposures.

Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery†.

Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovah's Witness patient following emergent colectomy. The patient's hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patient's lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patient's course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.