Global Vertical Distribution of Water Vapor on Mars: Results From 3.5 Years of ExoMars-TGO/NOMAD Science Operations.

We present water vapor vertical distributions on Mars retrieved from 3.5 years of solar occultation measurements by Nadir and Occultation for Mars Discovery onboard the ExoMars Trace Gas Orbiter, which reveal a strong contrast between aphelion and perihelion water climates. In equinox periods, most of water vapor is confined into the low-middle latitudes. In aphelion periods, water vapor sublimated from the northern polar cap is confined into very low altitudes-water vapor mixing ratios observed at the 0-5 km lower boundary of measurement decrease by an order of magnitude at the approximate altitudes of 15 and 30 km for the latitudes higher than 50°N and 30-50°N, respectively. The vertical confinement of water vapor at northern middle latitudes around aphelion is more pronounced in the morning terminators than evening, perhaps controlled by the diurnal cycle of cloud formation. Water vapor is also observed over the low latitude regions in the aphelion southern hemisphere (0-30°S) mostly below 10-20 km, which suggests north-south transport of water still occurs. In perihelion periods, water vapor sublimated from the southern polar cap directly reaches high altitudes (>80 km) over high southern latitudes, suggesting more effective transport by the meridional circulation without condensation. We show that heating during perihelion, sporadic global dust storms, and regional dust storms occurring annually around 330° of solar longitude (L S) are the main events to supply water vapor to the upper atmosphere above 70 km.

Bespoke regional blocks for axillary sentinel node biopsy.

INTRODUCTION: Axillary sentinel node biopsy for melanoma is routinely performed under general anaesthesia. Emerging evidence has shown general anaesthetics are associated with increased mortality in the context of the COVID-19 pandemic. In the interest of patient safety, we have designed a series of bespoke axillary regional blocks enabling surgeons to remove nodes up to and including level III without the need for a general anaesthetic. The aim of this study was to assess the feasibility of performing axillary sentinel node biopsy under such blocks. METHODS: Approval was granted by the Joint Study Review Committee on behalf of the Research and Ethics Department. Ten consecutive patients having axillary sentinel node biopsy for melanoma were included in this prospective study. Patients completed a Quality of Recovery-15 (QoR15) questionnaire preoperatively and 24 h postoperatively. DISCUSSION: One patient had a positive sentinel node, the remining were negative. A significant reduction in time spent in hospital post-operatively (p = 0.0008) was observed. QoR15 patient reported outcome measures demonstrated high levels of satisfaction evidenced by lack of statistical difference between pre and post-operative scores (p = 0.0118). 80% of patients were happy to have a regional block and 90% were happy to attend hospital during the pandemic. CONCLUSION: ASNB under regional block is safe, negates risks associated with performing GAs during the COVID-19 pandemic and facilitates quicker theatre turnover and discharge from hospital. Collaboration between anaesthetic and surgical teams has enabled this change in practice. There is a learning curve with both patient selection, education and development of technique.

Mars Perihelion Cloud Trails as revealed by MARCI: Mesoscale Topographically Focussed Updrafts and Gravity Wave Forcing of High Altitude Clouds.

Daily, global wide angle imaging of Mars clouds in MARCI (MARs Color Imager, (Malin et al., 2008)) ultraviolet and visible bands reveals the spatial/seasonal distributions and physical characteristics of perihelion cloud trails (PCT); a class of high altitude (40-50 km), horizontally extended (200-1000 km, trending W to WSW) water ice clouds formed over specific southern low-to-mid latitude (5S-40S), mesoscale (~50 km) locations during the Mars perihelion, southern summer season. PCT were first reported in association with rim regions of Valles Marineris (Clancy et al., 2009). The current study employs MARCI 2007-2011 imaging to sample the broader distributions and properties of PCT; and indicates several distinct locations of peak occurrences, including SW Arsia Mons, elevated regions of Syria, Solis, and Thaumasia Planitia, along Valles Marineris margins, and the NE rim of Hellas Basin. PCT are present over Mars solar longitudes (L S ) of 210-310°, in late morning to mid afternoon hours (10am-3pm), and are among the brightest and most distinctive clouds exhibited during the perihelion portion of the Mars orbit. Their locations (i.e., eastern margin origins) correspond to strong local elevation gradients, and their timing to peak solar heating conditions (perihelion, subsolar latitudes and midday local times). They occur approximately on a daily basis among all locations identified (i.e., not daily at a single location). Based on cloud surface shadow analyses, PCT form at 40-50 km aeroid altitudes, where water vapor is generally at near-saturation conditions in this perihelion period (e.g. Millour et al., 2014). They exhibited notable absences during periods of planet encircling and regional dust storm activity in 2007 and 2009, respectively, presumably due to reduced water saturation conditions above 35-40 km altitudes associated with increased dust heating over the vertically extended atmosphere (e.g., Neary et al., 2019). PCT exhibit smaller particle sizes (R eff =0.2-0.5µm) than typically exhibited in the lower atmosphere, and incorporate significant fractions of available water vapor at these altitudes. PCT ice particles are inferred to form continuously (over ~4 hours) at their PCT eastern origins, associated with localized updrafts, and are entrained in upper level zonal/meridional winds (towards W or WSW with ~50 m/sec speeds at 40-50 km altitudes) to create long, linear cloud trails. PCT cloud formation is apparently forced in the lower atmosphere (≤10-15 km) by strong updrafts associated with distinctive topographic gradients, such as simulated in mesoscale studies (e.g., Tyler and Barnes, 2015) and indicated by the surface-specific PCT locations. These lower scale height updrafts are proposed to generate vertically propagating gravity waves (GW), leading to PCT formation above ~40 km altitudes where water vapor saturation conditions promote vigorous cloud ice formation. Recent mapping of GW amplitudes at ~25 km altitudes, from Mars Climate Sounder 15 µm radiance variations (Heavens et al., 2020), in fact demonstrates close correspondences to the detailed spatial distributions of observed PCT, relative to other potential factors such as surface albedo and surface elevation (or related boundary layer depths).

Restitution of the NHS breast reconstruction service during the recovery phase of the Covid 19 pandemic.

During the recovery restitution phase of the coronavirus pandemic, breast reconstruction teams have faced particular challenges to restarting this essential service. This is due to the length and complexity of the surgery, along with the demands on healthcare staff. The Royal College of Surgeons have classified immediate breast reconstruction as priority 2 and the National Institute for Health and Care Excellence have provided a pre-operative pathway for resumption of elective procedures. We therefore describe our experience in restarting our service for providing a breast reconstruction service from the 29th June 2020.

Personal protective equipment for surgeons during COVID-19 pandemic: systematic review of availability, usage and rationing.

BACKGROUND: Surgeons need guidance regarding appropriate personal protective equipment (PPE) during the COVID-19 pandemic based on scientific evidence rather than availability. The aim of this article is to inform surgeons of appropriate PPE requirements, and to discuss usage, availability, rationing and future solutions. METHODS: A systematic review was undertaken in accordance with PRISMA guidelines using MEDLINE, Embase and WHO COVID-19 databases. Newspaper and internet article sources were identified using Nexis. The search was complemented by bibliographic secondary linkage. The findings were analysed alongside guidelines from the WHO, Public Health England, the Royal College of Surgeons and specialty associations. RESULTS: Of a total 1329 articles identified, 95 studies met the inclusion criteria. Recommendations made by the WHO regarding the use of PPE in the COVID-19 pandemic have evolved alongside emerging evidence. Medical resources including PPE have been rapidly overwhelmed. There has been a global effort to overcome this by combining the most effective use of existing PPE with innovative strategies to produce more. Practical advice on all aspects of PPE is detailed in this systematic review. CONCLUSION: Although there is a need to balance limited supplies with staff and patient safety, this should not leave surgeons treating patients with inadequate PPE.

Salivary dysbiosis and the clinical spectrum in anti-Ro positive mothers of children with neonatal lupus.

Mothers giving birth to children with manifestations of neonatal lupus (NL) represent a unique population at risk for the development of clinically evident pathologic autoimmunity since many are asymptomatic and only become aware of anti-SSA/Ro positivity (anti-Ro+) based on heart block in their fetus. Accordingly, we hypothesized that the microbiome in saliva is associated with the development of autoreactivity and in some cases the progression in health status from benign to overt clinical disease including Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE). The study comprised a clinical spectrum of anti-Ro+ mothers, all of whom gave birth to a child with NL: 9 were asymptomatic or had an undifferentiated autoimmune disease (Asym/UAS) and 16 fulfilled criteria for SS and/or SLE. Microbial diversity was reduced across all levels from kingdom to species for the anti-Ro+ mothers vs healthy controls; however, there were no significant differences between Asym/UAS and SS/SLE mothers. Relative abundance of Proteobacteria and more specifically class Betaproteobacteria decreased with clinical severity (healthy controls < Asym/UAS < SS/SLE). These ordered differences were maintained through the taxonomic hierarchy to three genera (Lautropia, Comamonas, and Neisseria) and species within these genera (L. mirabilis, N. flavescens and N. oralis). Biometric analysis comparing von Willebrand Factor domains present in human Ro60 with L. mirabilis proteins support the hypothesis of molecular mimicry. These data position the microbiome in the development of anti-Ro reactivity and subsequent clinical spectrum of disease.

Martian dust storm impact on atmospheric H2O and D/H observed by ExoMars Trace Gas Orbiter.

Global dust storms on Mars are rare1,2 but can affect the Martian atmosphere for several months. They can cause changes in atmospheric dynamics and inflation of the atmosphere3, primarily owing to solar heating of the dust3. In turn, changes in atmospheric dynamics can affect the distribution of atmospheric water vapour, with potential implications for the atmospheric photochemistry and climate on Mars4. Recent observations of the water vapour abundance in the Martian atmosphere during dust storm conditions revealed a high-altitude increase in atmospheric water vapour that was more pronounced at high northern latitudes5,6, as well as a decrease in the water column at low latitudes7,8. Here we present concurrent, high-resolution measurements of dust, water and semiheavy water (HDO) at the onset of a global dust storm, obtained by the NOMAD and ACS instruments onboard the ExoMars Trace Gas Orbiter. We report the vertical distribution of the HDO/H2O ratio (D/H) from the planetary boundary layer up to an altitude of 80 kilometres. Our findings suggest that before the onset of the dust storm, HDO abundances were reduced to levels below detectability at altitudes above 40 kilometres. This decrease in HDO coincided with the presence of water-ice clouds. During the storm, an increase in the abundance of H2O and HDO was observed at altitudes between 40 and 80 kilometres. We propose that these increased abundances may be the result of warmer temperatures during the dust storm causing stronger atmospheric circulation and preventing ice cloud formation, which may confine water vapour to lower altitudes through gravitational fall and subsequent sublimation of ice crystals3. The observed changes in H2O and HDO abundance occurred within a few days during the development of the dust storm, suggesting a fast impact of dust storms on the Martian atmosphere.

Publisher Correction: Martian dust storm impact on atmospheric H2O and D/H observed by ExoMars Trace Gas Orbiter.

The surname of author Cathy Quantin-Nataf was misspelled 'Quantin-Nata' , authors Ehouarn Millour and Roland Young were missing from the ACS Science Team list, and minor changes have been made to the author and affiliation lists; see accompanying Amendment. These errors have been corrected online.

Multi-site placebo-controlled randomised clinical trial to assess protection following oral immunisation with inactivated non-typeable Haemophilus influenzae in chronic obstructive pulmonary disease.

BACKGROUND: Previous studies identified factors that modify response to an oral non-typeable Haemophilus influenzae (NTHi) vaccine in chronic obstructive pulmonary disease (COPD): severe COPD, moderate-severe exacerbations as end-point and a threshold prevalence of NTHi in the study population. More data are needed to confirm parameters that influence clinical outcomes. AIMS: The primary aim was to determine the efficacy of an oral NTHi vaccine (HI-164OV) in reducing the rate of exacerbations requiring systemic corticosteroids or hospitalisation in COPD. Secondary aims included effect on the proportion of patients experiencing such exacerbations, severity of infections and quality of life (St George Respiratory Questionnaire for COPD patients (SGRQ-C)). METHODS: This multi-centre, double-blind, placebo-controlled study was conducted at 21 Australian sites for 9 months in 2011. RESULTS: Three-hundred and twenty subjects with COPD, FEV1 <60% predicted and ≥1 moderate-severe exacerbations in the previous 12 months were recruited. The primary and secondary end-points for the intention-to-treat population aged 40-88 years were not achieved, and only 5% of subjects had an H. influenzae-positive sputum sample. Subsequent exploratory analysis of patients <65 years (91 subjects) indicated protection with respect to the primary and most of the secondary end-points, with SGRQ-C symptom scores lower at 3 and 6 months. CONCLUSION: Patients aged 40-88 years with moderate to severe COPD and low rates of H. influenzae-positive sputum were not protected against exacerbations by HI-1640V. Further studies are needed to confirm protection in subjects aged <65 years. Older age and low colonisation rates appear to affect adversely response to this vaccine.

A rectal bleeding algorithm can successfully reduce emergency admissions.

AIM: Acute lower gastrointestinal bleeding (LGIB) is a common cause of emergency admissions yet rarely requires blood transfusion or radiological/surgical intervention. We aimed to develop a risk assessment tool to identify patients with acute LGIB who can be safely managed in primary care. METHOD: We retrospectively applied an existing nomogram to 20 admissions to obtain criteria that could predict the need for transfusion. We simplified the algorithm to three criteria and developed an associated care pathway. If haemoglobin was > 13 g/dl, systolic blood pressure > 115 mmHg and the patient was not anticoagulated, admission could be avoided. These criteria were then applied to 57 prospective patients attending during a 16-week period. This was implemented with education of primary and secondary care staff, access to an emergency clinic and provision of patient information. RESULTS: We applied our algorithm and care pathway to 57 patients with uncomplicated rectal bleeding. Thirty-five per cent (20/57) of potential admissions were avoided. Instead, patients received written information and underwent flexible sigmoidoscopy as outpatients within 6 weeks. One discharged patient was readmitted from endoscopy with severe colitis. There were no other readmissions or complications. Of the 36 patients for whom the algorithm predicted admission was needed, 33% (12/36) were anticoagulated, 94% (34/36) had haemoglobin < 13 g/dl and 42% (15/36) had a systolic blood pressure < 115 mmHg. Only one admission (1.8%) did not fulfil the admission criteria and could have potentially been avoided. Avoidable admissions reduced from 50 to 1.8%. CONCLUSION: The application of a simple rectal bleeding algorithm can safely prevent unnecessary admissions.

Single incision laparoscopic adjustable gastric band: technique, feasibility, safety and learning curve.

INTRODUCTION: Single incision laparoscopic surgery (SILS) is established in many procedures but not in bariatric surgery. One explanation may be that SILS is technically demanding in morbidly obese patients. This report describes our technique and experience with single incision laparoscopic adjustable gastric banding (SILAGB). METHODS: Prospective data collection was performed on consecutive obese patients who underwent SILAGB between November 2009 and February 2011. A single 3 cm transverse incision in the right upper quadrant was used for a Covidien SILS™ multichannel access port. The technique is described with a standard pars flaccida approach and the 'tips and tricks' needed for a wide range of candidates using standard laparoscopic equipment. RESULTS: A total of 29 patients (27 female) with a median body mass index of 41 kg/m(2) (range: 35-52 kg/m(2)) and median age of 44 years (range: 22-57 years) underwent SILAGB. There were no 'conversions' to a standard laparoscopic technique. Two cases required the addition of one single 5 mm port. The only complications were two postoperative wound infections (one with a port site infection requiring replacement of the port) and one faulty band requiring replacement. There were therefore two returns to theatre and no 30-day deaths. All patients were discharged on the first postoperative day. In this series, operative times reduced significantly to be comparable with the conventional laparoscopic approach. CONCLUSIONS: SILAGB is safe and feasible in the morbidly obese. Proficiency in this technique using conventional laparoscopic equipment can be achieved with a short learning curve.

Towards a vaccine for chronic obstructive pulmonary disease.

This review discusses chronic obstructive pulmonary disease as an outcome of two pathogenic pathways: the first resulting from inhalation of toxins and the second a consequence of bacterial colonisation of damaged airways. Earlier assessment of the role played by bacteria in acute exacerbations was compromised by a deficiency of quality data and the use of parameters more relevant to invasive infection. Data are reviewed to support a hypothesis that states intrabronchial inflammation reflects an excessive and inappropriate host response (largely mediated by Th17 cells derived from gut-associated lymphoid tissues) to colonising bacteria acting as an 'antigen sump' (in essence, a hypersensitivity reaction). It is proposed that both viral and bacterial infections exacerbate inflammation through a common pathway that involves colonising bacteria. An oral vaccine containing inactivated non-typeable Haemophilus influenzae augments a protective loop that involves the aspiration of bronchus content into the gut and reduces the severity of acute exacerbations including the need for hospital admission by reducing the 'load' of bacteria comprising this final common path. The positive clinical results from trials using oral NTHi support both the concept that bacterial colonisation of damaged airways is a potent second pathogenic pathway and that oral immunotherapy provides a significant therapeutic advance in limiting damage in chronic obstructive pulmonary disease.

Nonconvulsive seizures are common in critically ill children.

BACKGROUND: Retrospective studies have reported the occurrence of nonconvulsive seizures in critically ill children. We aimed to prospectively determine the incidence and risk factors of nonconvulsive seizures in critically ill children using predetermined EEG monitoring indications and EEG interpretation terminology. METHODS: Critically ill children (non-neonates) with acute encephalopathy underwent continuous EEG monitoring if they met institutional clinical practice criteria. Study enrollment and data collection were prospective. Logistic regression analysis was utilized to identify risk factors for seizure occurrence. RESULTS: One hundred children were evaluated. Electrographic seizures occurred in 46 and electrographic status epilepticus occurred in 19. Seizures were exclusively nonconvulsive in 32. The only clinical risk factor for seizure occurrence was younger age (p=0.03). Of patients with seizures, only 52% had seizures detected in the first hour of monitoring, while 87% were detected within 24 hours. CONCLUSIONS: Seizures were common in critically ill children with acute encephalopathy. Most were nonconvulsive. Clinical features had little predictive value for seizure occurrence. Further study is needed to confirm these data in independent high-risk populations, to clarify which children are at highest risk for seizures so limited monitoring resources can be allocated optimally, and to determine whether seizure detection and management improves outcome.

Providing nicotine dependence treatment to psychiatric inpatients: the views of Australian nurse managers.

The prevalence of smoking in psychiatric settings remains high. This study aims to describe the views of nurse managers in psychiatric inpatient settings regarding the provision of nicotine dependence treatment, and whether there were associations between such views and the provision of nicotine dependence treatment. A cross-sectional survey was mailed to all public psychiatric inpatient units in New South Wales, Australia, for completion by nurse managers. Of the identified 131 service units, 123 completed questionnaires were returned (94%). Patient-related factors were considered to have a high level of influence on the provision of nicotine dependence treatment: patients requesting assistance to quit (58%), patients being receptive to interventions (52%), and patient health improving with quitting (45%). Units where the respondent reported that nicotine dependence treatment was as important as other roles were more likely to provide nicotine dependence treatment compared to units whose respondents did not hold this view (OR = 0.257, d.f. = 1, P < 0.01). While the results indicate strong support for the provision of nicotine dependence treatment, this support appears qualified by perceived patient readiness to quit, suggesting care is provided selectively rather than systematically. Positioning smoking as an addiction requiring treatment within a traditional curative approach may lead to a health service more conducive to the routine provision of nicotine dependence treatment.

Oral non-typable Haemophilus influenzae enhances physiological mechanism of airways protection.

Oral immunotherapy with inactivated non-typeable Haemophilus influenzae (NTHi) prevents exacerbations of chronic obstructive pulmonary disease, but the mechanism is unclear. The aim of this study was to determine the mechanism of protection. This was a placebo versus active prospective study over 3 months in 64 smokers. The active treatment was three courses of oral NTHi given at monthly intervals, followed by measurement of bacteriological and immunological parameters. The results can be summarized: (i) NTHi-specific T cells increased in the placebo treatment group over time (P<0.05); (ii) the T cell response in the oral NTHi group started earlier than that in the placebo group (P<0.05); and (iii) serum NTHi-specific immunoglobulin (Ig)G had significantly greater variation in the placebo group (P<0.0001). The increase in antibody in placebos over time correlated with exposure to live H. influenzae (P<0.05) determined from culture of gargles; (iv) reduction in saliva lysozyme over time (P<0.05) was detected only in the oral NTHi treatment group. These data are consistent with T cell priming of gut lymphoid tissue by aspiration of bronchus content into the gut, with oral immunotherapy augmenting this process leading to enhanced bronchus protection. The evidence for protection was a stable IgG antibody level through the study in the oral NTHi treatment group, contrasting with an increase in antibody correlating with exposure of the airways to H. influenzae in the placebo group. Saliva lysozyme was a useful biomarker of mucosal inflammation, falling after oral NTHi consistent with a reduction in the level of intralumenal inflammation.

Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest.

BACKGROUND: Hypoxic ischemic brain injury secondary to pediatric cardiac arrest (CA) may result in acute symptomatic seizures. A high proportion of seizures may be nonconvulsive, so accurate diagnosis requires continuous EEG monitoring. We aimed to determine the safety and feasibility of long-term EEG monitoring, to describe electroencephalographic background and seizure characteristics, and to identify background features predictive of seizures in children undergoing therapeutic hypothermia (TH) after CA. METHODS: Nineteen children underwent TH after CA. Continuous EEG monitoring was performed during hypothermia (24 hours), rewarming (12-24 hours), and then an additional 24 hours of normothermia. The tolerability of these prolonged studies and the EEG background classification and seizure characteristics were described in a standardized manner. RESULTS: No complications of EEG monitoring were reported or observed. Electrographic seizures occurred in 47% (9/19), and 32% (6/19) developed status epilepticus. Seizures were nonconvulsive in 67% (6/9) and electrographically generalized in 78% (7/9). Seizures commenced during the late hypothermic or rewarming periods (8/9). Factors predictive of electrographic seizures were burst suppression or excessively discontinuous EEG background patterns, interictal epileptiform discharges, or an absence of the expected pharmacologically induced beta activity. Background features evolved over time. Patients with slowing and attenuation tended to improve, whereas those with burst suppression tended to worsen. CONCLUSIONS: EEG monitoring in children undergoing therapeutic hypothermia after cardiac arrest is safe and feasible. Electrographic seizures and status epilepticus are common in this setting but are often not detectable by clinical observation alone. The EEG background often evolves over time, with milder abnormalities improving and more severe abnormalities worsening.