Perioperative Management in Neuromuscular Diseases: A Narrative Review.

Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.

Phenology and ecological role of aerobic anoxygenic phototrophs in freshwaters.

BACKGROUND: Aerobic anoxygenic phototrophic (AAP) bacteria are heterotrophic bacteria that supply their metabolism with light energy harvested by bacteriochlorophyll-a-containing reaction centers. Despite their substantial contribution to bacterial biomass, microbial food webs, and carbon cycle, their phenology in freshwater lakes remains unknown. Hence, we investigated seasonal variations of AAP abundance and community composition biweekly across 3 years in a temperate, meso-oligotrophic freshwater lake. RESULTS: AAP bacteria displayed a clear seasonal trend with a spring maximum following the bloom of phytoplankton and a secondary maximum in autumn. As the AAP bacteria represent a highly diverse assemblage of species, we followed their seasonal succession using the amplicon sequencing of the pufM marker gene. To enhance the accuracy of the taxonomic assignment, we developed new pufM primers that generate longer amplicons and compiled the currently largest database of pufM genes, comprising 3633 reference sequences spanning all phyla known to contain AAP species. With this novel resource, we demonstrated that the majority of the species appeared during specific phases of the seasonal cycle, with less than 2% of AAP species detected during the whole year. AAP community presented an indigenous freshwater nature characterized by high resilience and heterogenic adaptations to varying conditions of the freshwater environment. CONCLUSIONS: Our findings highlight the substantial contribution of AAP bacteria to the carbon flow and ecological dynamics of lakes and unveil a recurrent and dynamic seasonal succession of the AAP community. By integrating this information with the indicator of primary production (Chlorophyll-a) and existing ecological models, we show that AAP bacteria play a pivotal role in the recycling of dissolved organic matter released during spring phytoplankton bloom. We suggest a potential role of AAP bacteria within the context of the PEG model and their consideration in further ecological models.

Using technology to reduce critical deterioration (the DETECT study): a cost analysis of care costs at a tertiary children's hospital in the United Kingdom.

BACKGROUND: Electronic early warning systems have been used in adults for many years to prevent critical deterioration events (CDEs). However, implementation of similar technologies for monitoring children across the entire hospital poses additional challenges. While the concept of such technologies is promising, their cost-effectiveness is not established for use in children. In this study we investigate the potential for direct cost savings arising from the implementation of the DETECT surveillance system. METHODS: Data were collected at a tertiary children's hospital in the United Kingdom. We rely on the comparison between patients in the baseline period (March 2018 to February 2019) and patients in the post-intervention period (March 2020 to July 2021). These provided a matched cohort of 19,562 hospital admissions for each group. From these admissions, 324 and 286 CDEs were observed in the baseline and post-intervention period, respectively. Hospital reported costs and Health Related Group (HRG) National Costs were used to estimate overall expenditure associated with CDEs for both groups of patients. RESULTS: Comparing post-intervention with baseline data we found a reduction in the total number of critical care days, driven by an overall reduction in the number of CDEs, however without statistical significance. Using hospital reported costs adjusted for the Covid-19 impact, we estimate a non-significant reduction of total expenditure from £16.0 million to £14.3 million (corresponding to £1.7 million of savings - 11%). Additionally, using HRG average costs, we estimated a non-significant reduction of total expenditure from £8.2 million to £ 7.2 million (corresponding to £1.1 million of savings - 13%). DISCUSSION AND CONCLUSION: Unplanned critical care admissions for children not only impose a substantial burden on patients and families but are also costly for hospitals. Interventions aimed at reducing emergency critical care admissions can be crucial to contribute to the reduction of these episodes' costs. Even though cost reductions were identified in our sample, our results do not support the hypothesis that reducing CDEs using technology leads to a significant reduction on hospital costs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61279068, date of registration 07/06/2019, retrospectively registered.

Artificial neural network analysis of microbial diversity in the central and southern Adriatic Sea.

Bacteria are an active and diverse component of pelagic communities. The identification of main factors governing microbial diversity and spatial distribution requires advanced mathematical analyses. Here, the bacterial community composition was analysed, along with a depth profile, in the open Adriatic Sea using amplicon sequencing of bacterial 16S rRNA and the Neural gas algorithm. The performed analysis classified the sample into four best matching units representing heterogenic patterns of the bacterial community composition. The observed parameters were more differentiated by depth than by area, with temperature and identified salinity as important environmental variables. The highest diversity was observed at the deep chlorophyll maximum, while bacterial abundance and production peaked in the upper layers. The most of the identified genera belonged to Proteobacteria, with uncultured AEGEAN-169 and SAR116 lineages being dominant Alphaproteobacteria, and OM60 (NOR5) and SAR86 being dominant Gammaproteobacteria. Marine Synechococcus and Cyanobium-related species were predominant in the shallow layer, while Prochlorococcus MIT 9313 formed a higher portion below 50 m depth. Bacteroidota were represented mostly by uncultured lineages (NS4, NS5 and NS9 marine lineages). In contrast, Actinobacteriota were dominated by a candidatus genus Ca. Actinomarina. A large contribution of Nitrospinae was evident at the deepest investigated layer. Our results document that neural network analysis of environmental data may provide a novel insight into factors affecting picoplankton in the open sea environment.

Relationship of grit and resilience to dental students' academic success.

OBJECTIVES: This study assesses the levels of grit (the perseverance and passion for long-term goals), and resilience (the ability to bounce back or recover from stress), reported by U.S. dental students, and its possible association with academic achievements. METHODS: An anonymous 27 question cross-sectional online survey with sections on demographics, grit, resilience, and academic achievement was e-mailed to all dental students in the U.S. The Short Grit and Brief Resilience scales were used. Scores for both scales ranged from 1 to 5, and were grouped into low, moderate, and high tertiles based on distribution. Dental school grade point average (GPA), and class rank were used to measure academic achievement, and were similarly grouped. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from multinomial logistic regression models assessing the relationship of grit and resilience to the outcomes adjusting for gender, dental school year, race, geographic origin, and a variable combining education and income. RESULTS: Of the 3292 (17%) respondents, 58% were female. Hispanics reported significantly higher grit and resilience scores while Asian students reported the lowest. 18% of Hispanics were ranked in the top 20 percentile versus 37% of whites. CONCLUSION: Results indicate that dental students with high grit (high vs. low scores: OR [95% CI]: 2.06 [1.57-2.72]) and resilience (high vs. low scores: 1.36 [1.04-1.76]) achieved higher GPA and better class ranks. Therefore, it is crucial for students wanting to achieve academic success to consider the value that these non-cognitive characteristics might have on their overall progress.

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department.

BACKGROUND: Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. METHODS: We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. RESULTS: Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. CONCLUSION: The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.

Oral and Maxillofacial Surgery Resident Perception of Personal Achievement and Anxiety: A Cross-Sectional Analysis.

PURPOSE: Anxiety is prevalent among medical residents and is associated with fatigue, psychological dysfunction, and burnout. A low personal achievement level is a characteristic of burnout, which-if unaddressed-may lead to medical error and decrease the quality of patient care. This study aimed to assess both personal achievement levels and anxiety levels in current oral and maxillofacial surgery (OMS) residents and to discern a relationship between anxiety severity and perceived personal achievement level among residents. MATERIALS AND METHODS: An anonymous 20-question cross-sectional online survey was developed using the anxiety component of the Hospital Anxiety and Depression Scale and the personal Maslach Burnout Inventory. The survey was sent to all the OMS residents enrolled in programs affiliated with the American Association of Oral and Maxillofacial Surgeons in 2017. Univariate and bivariate analyses were conducted to obtain summary measures of the predictor (anxiety) and the outcome (personal achievement) stratified by age, gender, marital status, program type (4- or 6-year program), and year of residency. Multinomial logistic regression models were obtained to evaluate the association between anxiety and personal achievement. A 2-sided P < .05 was considered statistically significant. RESULTS: We received 238 responses (20% response rate); 58% of respondents had moderate or severe levels of anxiety, and nearly half of respondents reported moderate or low levels of personal achievement. Women were more likely to have severe anxiety than men (60% vs 37%, P < .01). Residents with severe anxiety were 91% more likely to report low levels of personal achievement than residents with low anxiety (odds ratio, 0.09; 95% confidence interval, 0.03 to 0.22; P < .0001). The results suggest the presence of an inverse relationship between personal achievement level and anxiety. CONCLUSIONS: More than half of OMS residents in the United States report moderate to severe anxiety. Higher levels of anxiety are associated with lower personal achievement levels. It is important to understand the negative impact anxiety has on trainees, including the unintended consequences.

Phosphatidylglycerol is implicated in divisome formation and metabolic processes of cyanobacteria.

Phosphatidylglycerol is an essential phospholipid for photosynthesis and other cellular processes. We investigated the role of phosphatidylglycerol in cell division and metabolism in a phophatidylglycerol-auxotrophic strain of Synechococcus PCC7942. Here we show that phosphatidylglycerol is essential for the photosynthetic electron transfer and for the oligomerisation of the photosynthetic complexes, notably, we revealed that this lipid is important for non-linear electron transport. Furthermore, we demonstrate that phosphatidylglycerol starvation elevated the expressions of proteins of nitrogen and carbon metabolism. Moreover, we show that phosphatidylglycerol-deficient cells changed the morphology, became elongated, the FtsZ ring did not assemble correctly, and subsequently the division was hindered. However, supplementation with phosphatidylglycerol restored the ring-like structure at the mid-cell region and the normal cell size, demonstrating the phosphatidylglycerol is needed for normal septum formation. Taken together, central roles of phosphatidylglycerol were revealed; it is implicated in the photosynthetic activity, the metabolism and the fission of bacteria.

Nonlinear effect of irradiance on photoheterotrophic activity and growth of the aerobic anoxygenic phototrophic bacterium Dinoroseobacter shibae.

Aerobic anoxygenic photosynthetic bacteria are an important component of marine microbial communities. They produce energy in light using bacteriochlorophyll a containing photosystems. This extra energy provides an advantage over purely heterotrophic bacteria. One of the most intensively studied AAP bacteria is Dinoroseobacter shibae, a member of the environmentally important Roseobacter clade. Light stimulates its growth and metabolism, but the effect of light intensity remains unclear. Here, we show that an increase in biomass along an irradiance gradient followed the exponential rise to the maximum curve, with saturation at about 300 µmol photons m-2 s-1 , without any inhibition at light intensities up to 600 µmol photons m-2 s-1 . The cells adapted to higher irradiance by reducing pigmentation and increasing the electron transfer rate. This additional energy allowed D. shibae to redirect the metabolism of organic carbon sources such as glucose, leucine, glutamate, acetate and pyruvate toward anabolism, resulting in a twofold increase of their assimilation rates. We provide equations that can be feasibly incorporated into the existing model of D. shibae metabolism to further advance our understanding of the role of photoheterotrophy in the ocean.

The neurobiology of depression: An integrated view.

Major Depressive Disorder (MDD) is one of the most common and debilitating mental disorders; however, its etiology remains unclear. This paper aims to summarize the major neurobiological underpinnings of depression, synthesizing the findings into a comprehensive integrated view. A literature review was conducted using Pubmed. Search terms included "depression" or "MDD" AND "biology", "neurobiology", "inflammation", "neurogenesis", "monoamine", and "stress". Articles from 1995 to 2016 were reviewed with a focus on the connection between different biological and psychological models. Some possible pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction. All of these proposed mechanisms are integrally related and interact bidirectionally. In addition, psychological factors have been shown to have a direct effect on neurodevelopment, causing a biological predisposition to depression, while biological factors can lead to psychological pathology as well. The authors suggest that while it is possible that there are several different endophenotypes of depression with distinct pathophysiological mechanisms, it may be helpful to think of depression as one united syndrome, in which these mechanisms interact as nodes in a matrix. Depressive disorders are considered in the context of the RDoC paradigm, identifying the pathological mechanisms at every translational level, with a focus on how these mechanisms interact. Finally, future directions of research are identified.

What a Shame: Increased Rates of OMS Resident Burnout May Be Related to the Frequency of Shamed Events During Training.

PURPOSE: Shame is an ineffective tool in residency education that often results in depression, isolation, and worse patient care. This study aimed to assess burnout, depersonalization, and personal achievement levels in current oral and maxillofacial surgery (OMS) residents, to assess the prevalence of the use of shame in OMS residency training, and to determine whether there is a relation between shame exposure and resident burnout, depersonalization, and personal achievement levels. MATERIALS AND METHODS: An anonymous 20-question cross-sectional survey was developed incorporating the Maslach Burnout Index and a previously validated shame questionnaire and sent to all OMS program directors affiliated with the American Association of Oral and Maxillofacial Surgeons for distribution among their respective residents in 2016. Univariate analyses were used to determine the distribution of the predictor (shame) and outcome (burnout) by gender and by frequency of shaming events. Multivariable logistic regression analysis was used to assess the relation of shame to burnout. A 2-sided P value less than .05 was considered statistically significant. RESULTS: Two hundred seventeen responses were received; 82% of respondents were men (n = 178), 95% were 25 to 34 years old (n = 206), and 58% (n = 126) were enrolled in a 4-year program. Frequently shamed residents were more likely to have depression (58 vs 22%; P < .0001), isolation (55 vs 22%; P < .0001), and poor job performance (50 vs 30%; P < .0001). Residents who were frequently shamed were more likely to experience moderate to severe burnout (odds ratio = 4.6; 95% confidence interval, 2.1-10.0; P < .001) and severe depersonalization (odds ratio = 5.1; 95% confidence interval, 2.1-12.0; P < .0001) than residents who had never or infrequently been shamed. CONCLUSION: There is a clear relation between the number of shame events and burnout and depersonalization levels. It is important to understand the negative impact that the experience of shame has on residents, including its unintended consequences.

Psychoanalysis as a Philosophical Revolution: Freud's Divergence From the Philosophy of Kant, Schopenhauer, and Nietzsche.

In his classic, The Birth of Tragedy, Nietzsche described a philosophical worldview that has many similarities to Freudian metapsychology. This paper uses Freud's theories to analyze The Birth of Tragedy, discussing the similarities and differences between Nietzsche's philosophy and Freudian metapsychology. The author suggests that while psychoanalysis was born from the spirit of German philosophy, in that it based itself on a similar concept of the unconscious, Freud diverged from his predecessors to create a new worldview, based on the acceptance and integration of unconscious desire. This revolutionary theory provided a new approach to humanity's moral and existential issues.

Corrigendum: Barriers, Benefits, and Beliefs of Brain Training Smartphone Apps: An Internet Survey of Younger US Consumers.

[This corrects the article on p. 180 in vol. 10, PMID: 27148026.].

Barriers, Benefits, and Beliefs of Brain Training Smartphone Apps: An Internet Survey of Younger US Consumers.

BACKGROUND: While clinical evidence for the efficacy of brain training remains in question, numerous smartphone applications (apps) already offer brain training directly to consumers. Little is known about why consumers choose to download these apps, how they use them, and what benefits they perceive. Given the high rates of smartphone ownership in those with internet access and the younger demographics, we chose to approach this question first with a general population survey that would capture primarily this demographic. METHOD: We conducted an online internet-based survey of the US population via mTurk regarding their use, experience, and perceptions of brain training apps. There were no exclusion criteria to partake although internet access was required. Respondents were paid 20 cents for completing each survey. The survey was offered for a 2-week period in September 2015. RESULTS: 3125 individuals completed the survey and over half of these were under age 30. Responses did not significantly vary by gender. The brain training app most frequently used was Lumosity. Belief that a brain-training app could help with thinking was strongly correlated with belief it could also help with attention, memory, and even mood. Beliefs of those who had never used brain-training apps were similar to those who had used them. Respondents felt that data security and lack of endorsement from a clinician were the two least important barriers to use. DISCUSSION: RESULTS suggest a high level of interest in brain training apps among the US public, especially those in younger demographics. The stability of positive perception of these apps among app-naïve and app-exposed participants suggests an important role of user expectations in influencing use and experience of these apps. The low concern about data security and lack of clinician endorsement suggest apps are not being utilized in clinical settings. However, the public's interest in the effectiveness of apps suggests a common theme with the scientific community's concerns about direct to consumer brain training programs.