Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient.

BACKGROUND: The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device. METHODS: This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV). RESULTS: A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001). CONCLUSIONS: Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

Commercial surrogacy: Landscapes of empowerment or oppression explored through integrative review.

The surge in demand for surrogacy treatments, combined with regulatory loopholes, has spurred the widespread adoption of global commercial surrogacy. This phenomenon poses potential risks to all involved parties, including surrogates and children, encompassing ethical, legal, physical, and psychological concerns. Although commercial surrogacy is under discussion in various jurisdictions, some countries may reintroduce legislation on the matter. In addressing this intricate landscape, the researchers performed an integrative review of existing literature with the intention of providing guidance to researchers and policymakers. The researchers emphasized notable legal and ethical challenges linked to commercial surrogacy. Surrogates often experience disempowerment and oppression, exacerbated by the contractual nature of these arrangements, perpetuating structural inequalities. Children born through commercial surrogacy, especially internationally, risk losing cultural heritage and future benefits. Banning commercial surrogacy may drive it underground, harming surrogates. Reconsidering prohibitions without penalizing surrogates could mitigate downstream issues and safeguard them from exploitation.

Agent-Based Life Cycle Assessment enables joint economic-environmental analysis of policy to support agricultural biomass for biofuels.

Production of agricultural biofuels is expected to rise due to increasing climate change mitigation ambitions. Policy interventions promoting targeted bioenergy solutions can be motivated by the large environmental externalities present in agricultural systems and the local context of biomass production co-benefits. Introducing energy crops in crop rotations in arable land with depleted Soil Organic Carbon (SOC) levels offers the potential to increase SOC stocks and future crop yields as a step towards more sustainable agricultural systems. However, the environmental performance of a policy incentive for energy crops with SOC co-benefits is less evident when considering its land-use effects within and outside of the target agricultural system. We study the potential impacts of a change in agricultural policy on regional agricultural structure and production, and the environment with an Agent-Based Life Cycle Assessment approach. We simulate a policy payment that would achieve adoption of grass leys in crop rotations corresponding to 25 % of the highly productive land in an intensive farming region of southern Sweden. Although enhancing soil health in SOC-depleted farming regions is a desirable environmental objective, its significance is limited within the life-cycle performance of the payment. Instead, crop-displacement impacts and the grass potential as biofuel feedstock are the main drivers. The active utilisation of grasses for biofuel purposes is key in reaching a positive environmental evaluation of the policy instrument. Our environmental evaluation is likely generalisable to other regions with similar technological levels and farming intensity, while our analysis on structural shifts is specific to the policy instrument and agricultural production system under study. Overall, our work provides a method to contrast regional effects and global environmental impacts of policy instruments supporting agricultural biomass for biofuels prior to implementation. This contributes to the environmental assessment of land-based biofuels at a time when their sustainability is highly debated.

Deep learning-based analysis of COVID-19 X-ray images: Incorporating clinical significance and assessing misinterpretation.

COVID-19, pneumonia, and tuberculosis have had a significant effect on recent global health. Since 2019, COVID-19 has been a major factor underlying the increase in respiratory-related terminal illness. Early-stage interpretation and identification of these diseases from X-ray images is essential to aid medical specialists in diagnosis. In this study, (COV-X-net19) a convolutional neural network model is developed and customized with a soft attention mechanism to classify lung diseases into four classes: normal, COVID-19, pneumonia, and tuberculosis using chest X-ray images. Image preprocessing is carried out by adjusting optimal parameters to preprocess the images before undertaking training of the classification models. Moreover, the proposed model is optimized by experimenting with different architectural structures and hyperparameters to further boost performance. The performance of the proposed model is compared with eight state-of-the-art transfer learning models for a comparative evaluation. Results suggest that the COV-X-net19 outperforms other models with a testing accuracy of 95.19%, precision of 96.49% and F1-score of 95.13%. Another novel approach of this study is to find out the probable reason behind image misclassification by analyzing the handcrafted imaging features with statistical evaluation. A statistical analysis known as analysis of variance test is performed, to identify at which point the model can identify a class accurately, and at which point the model cannot identify the class. The potential features responsible for the misclassification are also found. Moreover, Random Forest Feature importance technique and Minimum Redundancy Maximum Relevance technique are also explored. The methods and findings of this study can benefit in the clinical perspective in early detection and enable a better understanding of the cause of misclassification.

Emergency Medical Services Responder Manual Ventilation Performance.

OBJECTIVE: Manual ventilation is a basic skill that every emergency medical services (EMS) responder is expected to perform proficiently. Improper manual ventilation may result in significant morbidity; however, there is no feedback mechanism or method of control for the volume, pressure, or frequency during manual ventilation. In this study, we aimed to quantify the volume and peak pressures of manually delivered breaths using a simulated lung. METHODS: One hundred ninety-nine volunteer EMS responders from the EMS World Expo 2019 and EMS Today 2020 participated in this study. Each volunteer manually ventilated a simulated lung using a bag-valve-mask (BVM) for 18 breaths. Descriptive statistics were computed for peak pressures (Ppeak) and tidal volumes (VT)), and a multivariable linear regression was conducted to determine whether there was an independent correlation between Ppeak or VT and seven different variables. RESULTS: Both Ppeak and VT delivered by EMS responders had a high level of variability; 82.9% of clinicians delivered at least one breath exceeding the recommended safety thresholds; and 98.0% delivered at least one breath that was inadequate or excessive. Our results showed no likely clinical significant role of sex, hand size, frequency of use, or years of experience in determining Ppeak and VT. Tidal volumes were significantly higher in males (p < 0.001), those using two-hand manual ventilation (p < 0.001), shorter hand length (p = 0.013), higher confidence (p < 0.001), and more years of experience (p < 0.001). Peak pressures were significantly higher in those using two-hand manual ventilation (p < 0.001), wider hand width (p = 0.004), higher confidence (p < 0.001), less frequent use of the BVM per month (p < 0.001), more experience (p < 0.001). CONCLUSIONS: Our study demonstrated large variability of VT and Ppeak within and, to a lesser degree, between clinicians. Of the seven variables that might have affected tidal volume or peak pressures, only the use of two hands versus one hand had a potentially clinically significant effect. Our study identifies a clear need for BVM improvement to ensure every practitioner can deliver breaths at appropriate volumes and safe pressures.

Entropy-Based Emotion Recognition from Multichannel EEG Signals Using Artificial Neural Network.

Humans experience a variety of emotions throughout the course of their daily lives, including happiness, sadness, and rage. As a result, an effective emotion identification system is essential for electroencephalography (EEG) data to accurately reflect emotion in real-time. Although recent studies on this problem can provide acceptable performance measures, it is still not adequate for the implementation of a complete emotion recognition system. In this research work, we propose a new approach for an emotion recognition system, using multichannel EEG calculation with our developed entropy known as multivariate multiscale modified-distribution entropy (MM-mDistEn) which is combined with a model based on an artificial neural network (ANN) to attain a better outcome over existing methods. The proposed system has been tested with two different datasets and achieved better accuracy than existing methods. For the GAMEEMO dataset, we achieved an average accuracy ± standard deviation of 95.73% ± 0.67 for valence and 96.78% ± 0.25 for arousal. Moreover, the average accuracy percentage for the DEAP dataset reached 92.57% ± 1.51 in valence and 80.23% ± 1.83 in arousal.

Experimental testing of fracture fixation plates: A review.

Metal and its alloys have been predominantly used in fracture fixation for centuries, but new materials such as composites and polymers have begun to see clinical use for fracture fixation during the past couple of decades. Along with the emerging of new materials, tribological issues, especially debris, have become a growing concern for fracture fixation plates. This article for the first time systematically reviews the most recent biomechanical research, with a focus on experimental testing, of those plates within ScienceDirect and PubMed databases. Based on the search criteria, a total of 5449 papers were retrieved, which were then further filtered to exclude nonrelevant, duplicate or non-accessible full article papers. In the end, a total of 83 papers were reviewed. In experimental testing plates, screws and simulated bones or cadaver bones are employed to build a fixation construct in order to test the strength and stability of different plate and screw configurations. The test set-up conditions and conclusions are well documented and summarised here, including fracture gap size, types of bones deployed, as well as the applied load, test speed and test ending criteria. However, research on long term plate usage was very limited. It is also discovered that there is very limited experimental research around the tribological behaviour particularly on the debris' generation, collection and characterisation. In addition, there is no identified standard studying debris of fracture fixation plate. Therefore, the authors suggested the generation of a suite of tribological testing standards on fracture fixation plate and screws in the aim to answer key questions around the debris from fracture fixation plate of new materials or new design and ultimately to provide an insight on how to reduce the risks of debris-related osteolysis, inflammation and aseptic loosening.

Phase III Randomized Trial of Maintenance Taxanes Versus Surveillance in Women With Advanced Ovarian/Tubal/Peritoneal Cancer: A Gynecologic Oncology Group 0212:NRG Oncology Study.

PURPOSE: To compare taxane maintenance chemotherapy, paclitaxel (P) and paclitaxel poliglumex (PP), with surveillance (S) in women with ovarian, peritoneal, or fallopian tube (O/PC/FT) cancer who attained clinical complete response after first-line platinum-taxane therapy. METHODS: Women diagnosed with O/PC/FT cancer who attained clinical complete response after first-line platinum-taxane-based chemotherapy were randomly allocated 1:1:1 to S or maintenance, P 135 mg/m2 once every 28 days for 12 cycles, or PP at the same dose and schedule. Overall survival (OS) was the primary efficacy end point. RESULTS: Between March 2005 and January 2014, 1,157 individuals were enrolled. Grade 2 or worse GI adverse events were more frequent among those treated with taxane (PP: 20%, P: 27% v S: 11%). Grade 2 or worse neurologic adverse events occurred more often with taxane treatment (PP: 46%, P: 36% v S: 14%). At the fourth scheduled interim analysis, both taxane regimens passed the OS futility boundary and the Data Monitoring Committee approved an early release of results. With a median follow-up of 8.1 years, 653 deaths were reported; none were attributed to the study treatment. Median survival durations were 58.3, 56.8, and 60.0 months for S, P, and PP, respectively. Relative to S, the hazard of death for P was 1.091 (95% CI, 0.911 to 1.31; P = .343) and for PP, it was 1.033 (95% CI, 0.862 to 1.24; P = .725). The median times to first progression or death (PFS) were 13.4, 18.9, and 16.3 months for S, P, and PP, respectively. Hazard ratio = 0.801; 95% CI, 0.684 to 0.938; P = .006 for P and hazard ratio = 0.854; 95% CI, 0.729 to 1.00; P = .055 for PP. CONCLUSION: Maintenance therapy with P and PP did not improve OS among patients with newly diagnosed O/tubal/peritoneal cancer, but may modestly increase PFS. GI and neurologic toxicities were more frequent in the taxane treatment arms.

Automated Computational Detection of Disease Activity in ANCA-Associated Glomerulonephritis Using Raman Spectroscopy: A Pilot Study.

Biospectroscopy offers the ability to simultaneously identify key biochemical changes in tissue associated with a given pathological state to facilitate biomarker extraction and automated detection of key lesions. Herein, we evaluated the application of machine learning in conjunction with Raman spectroscopy as an innovative low-cost technique for the automated computational detection of disease activity in anti-neutrophil cytoplasmic autoantibody (ANCA)-associated glomerulonephritis (AAGN). Consecutive patients with active AAGN and those in disease remission were recruited from a single UK centre. In those with active disease, renal biopsy samples were collected together with a paired urine sample. Urine samples were collected immediately prior to biopsy. Amongst those in remission at the time of recruitment, archived renal tissue samples representative of biopsies taken during an active disease period were obtained. In total, twenty-eight tissue samples were included in the analysis. Following supervised classification according to recorded histological data, spectral data from unstained tissue samples were able to discriminate disease activity with a high degree of accuracy on blind predictive modelling: F-score 95% for >25% interstitial fibrosis and tubular atrophy (sensitivity 100%, specificity 90%, area under ROC 0.98), 100% for necrotising glomerular lesions (sensitivity 100%, specificity 100%, area under ROC 1) and 100% for interstitial infiltrate (sensitivity 100%, specificity 100%, area under ROC 0.97). Corresponding spectrochemical changes in paired urine samples were limited. Future larger study is required, inclusive of assigned variables according to novel non-invasive biomarkers as well as the application of forward feature extraction algorithms to predict clinical outcomes based on spectral features.

Olaparib With or Without Cediranib Versus Platinum-Based Chemotherapy in Recurrent Platinum-Sensitive Ovarian Cancer (NRG-GY004): A Randomized, Open-Label, Phase III Trial.

PURPOSE: Platinum-based chemotherapy is the standard of care for platinum-sensitive ovarian cancer, but complications from repeated platinum therapy occur. We assessed the activity of two all-oral nonplatinum alternatives, olaparib or olaparib/cediranib, versus platinum-based chemotherapy. PATIENTS AND METHODS: NRG-GY004 is an open-label, randomized, phase III trial conducted in the United States and Canada. Eligible patients had high-grade serous or endometrioid platinum-sensitive ovarian cancer. Patients were randomly assigned 1:1:1 to platinum-based chemotherapy, olaparib, or olaparib/cediranib. The primary end point was progression-free survival (PFS) in the intention-to-treat population. Secondary end points included activity within germline BRCA-mutated or wild-type subgroups and patient-reported outcomes (PROs). RESULTS: Between February 04, 2016, and November 13, 2017, 565 eligible patients were randomly assigned. Median PFS was 10.3 (95% CI, 8.7 to 11.2), 8.2 (95% CI, 6.6 to 8.7), and 10.4 (95% CI, 8.5 to 12.5) months with chemotherapy, olaparib, and olaparib/cediranib, respectively. Olaparib/cediranib did not improve PFS versus chemotherapy (hazard ratio [HR] 0.86; 95% CI, 0.66 to 1.10; P = .077). In women with germline BRCA mutation, the PFS HR versus chemotherapy was 0.55 (95% CI, 0.32 to 0.94) for olaparib/cediranib and 0.63 (95% CI, 0.37 to 1.07) for olaparib. In women without a germline BRCA mutation, the PFS HR versus chemotherapy was 0.97 (95% CI, 0.73 to 1.30) for olaparib/cediranib and 1.41 (95% CI, 1.07 to 1.86) for olaparib. Hematologic adverse events occurred more commonly with chemotherapy; however, nonhematologic adverse events were higher with olaparib/cediranib. In 489 patients evaluable for PROs, patients receiving olaparib/cediranib scored on average 1.1 points worse on the NFOSI-DRS-P subscale (97.5% CI, -2.0 to -0.2, P = .0063) versus chemotherapy; no difference between olaparib and chemotherapy was observed. CONCLUSION: Combination olaparib/cediranib did not improve PFS compared with chemotherapy and resulted in reduced PROs. Notably, in patients with a germline BRCA mutation, both olaparib and olaparib/cediranib had significant clinical activity.

How unnecessarily high abatement costs and unresolved distributional issues undermine nutrient reductions to the Baltic Sea.

This paper systematically reviews the literature on how to reduce nutrient emissions to the Baltic Sea cost-effectively and considerations for allocating these costs fairly among countries. The literature shows conclusively that the reduction targets of the Baltic Sea Action Plan (BSAP) could be achieved at considerably lower cost, if countries would cooperate to implement the least costly abatement plan. Focusing on phosphorus abatement could be prudent as the often recommended measures-wastewater treatment and wetlands-abate nitrogen too. An implication of our review is that the potential for restoring the Baltic Sea to good health is undermined by an abatement strategy that is more costly than necessary and likely to be perceived as unfair by several countries. Neither the BSAP nor the cost-effective solution meet the surveyed criteria for fairness, implying a need for side-payments.

Strengthening the policy framework to resolve lax implementation of the Baltic Sea Action Plan for agriculture.

In this perspective article, we provide recommendations for strengthening the policy framework for protecting the Baltic Sea from agricultural nutrient pollution. The most striking weakness is the lax implementation of prescribed abatement measures, particularly concerning manure management, in most countries. Institutions of the EU should also be leveraged for achieving Baltic Sea Action Plan (BSAP) goals. In contrast to the Helsinki Convention, the European Union has economic, political and legal mandates to further implementation and compliance. Equally important is the need for strengthening of local institutions, particularly Water Boards and independent agricultural advisory services in the eastern Baltic Sea Region countries. There is also an urgent need for implementation of voluntary land-use measures where EU funding available to farmers is more broadly and effectively used by providing it on the basis of estimated abatement performance, which can be realized through modelling. The enormous potential for funding performance-based schemes, manure management infrastructure and advisory services through the EU's Common Agricultural Policy are currently underutilized.

Promise and performance of agricultural nutrient management policy: Lessons from the Baltic Sea.

Following decades of international collaboration to restore the Baltic Sea, we provide an assessment of the domestic implementation of measures agreed to limit diffuse agricultural pollution and the patterns of policy instruments applied. Despite the Helsinki Convention being unusually specific in detailing what measures countries should introduce, we find many shortcomings. These are most pronounced in the larger countries (Poland, Germany and Russia), while smaller countries perform better, notably Sweden and Estonia. The patterns of policy instruments applied differ, influenced by domestic politics. The limited use of complementary policy instruments suggests that other priorities overrule full and effective implementation, with engagement mirroring the advantages that a restored Baltic Sea can bring to countries. Using the European Agricultural Fund for Rural Development to support farmers in managing nutrients, particularly advisory services and investments in modern manure management technologies, represents a significant opportunity for reducing agricultural pollution in most countries.

Prognostic significance of ethnicity and age in advanced stage epithelial ovarian cancer: An NRG oncology/gynecologic oncology group study.

BACKGROUND: Age and ethnicity are among several factors that influence overall survival (OS) in ovarian cancer. The study objective was to determine whether ethnicity and age were of prognostic significance in women enrolled in a clinical trial evaluating the addition of bevacizumab to front-line therapy. METHODS: Women with advanced stage ovarian, primary peritoneal, or fallopian tube cancer were enrolled in a phase III clinical trial. All women had surgical staging and received adjuvant chemotherapy with one of three regimens. Cox proportional hazards models were used to evaluate the relationship between OS with age and race/ethnicity among the study participants. RESULTS: One-thousand-eight-hundred-seventy-three women were enrolled in the study. There were 280 minority women and 328 women over the age of 70. Women age 70 and older had a 34% increase risk for death when compared to women under 60 (HR = 1.34; 95% CI 1.16-1.54). Non-Hispanic Black women had a 54% decreased risk of death with the addition of maintenance bevacizumab (HR = 0.46, 95% CI:0.26-0.83). Women of Asian descent had more hematologic grade 3 or greater adverse events and a 27% decrease risk of death when compared to non-Hispanic Whites (HR = 0.73; 95% CI: 0.59-0.90). CONCLUSIONS: Non-Hispanic Black women showed a decreased risk of death with the addition of bevacizumab and patients of Asian ancestry had a lower death rate than all other minority groups, but despite these clinically meaningful improvements there was no statistically significant difference in OS among the groups.

Home-based exercise for people living with frailty and chronic kidney disease: A mixed-methods pilot randomised controlled trial.

BACKGROUND: Frailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD. METHODS: Participants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability. RESULTS: Six hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence. CONCLUSIONS: This pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exercise may be beneficial for people living with frailty and CKD. TRIAL REGISTRATION: ISRCTN87708989; https://clinicaltrials.gov/.

A harmonized and spatially explicit dataset from 16 million payments from the European Union's Common Agricultural Policy for 2015.

The Common Agricultural Policy (CAP) is the largest budget item in the European Union, but varied data reporting hampers holistic analysis. Here we have assembled the first dataset to our knowledge to report individual CAP payments by standardized CAP funding measures and geolocation. We created this dataset by translating, geolocating to the county or province (NUTS3) level, and consistently harmonizing payment measures for over 16 million payments from 2015, originally reported by EU member states and compiled by the Open Knowledge Foundation Germany. This dataset and code allow in-depth analysis of over €60 billion in public spending by purpose and location for the first time, which enables both individual payment tracing and analysis by aggregation. These data are representative of the distribution of annual CAP payments from 2014 to 2020 and are of interest to researchers, policy makers, non-governmental organizations, and journalists for evaluating the distribution and impacts of CAP spending.