Does a Nebulized Heparin/N-acetylcysteine Protocol Improve Outcomes in Adult Smoke Inhalation?

BACKGROUND: Smoke inhalation is a major source of morbidity and mortality. Heparin and N-acetylcysteine treatment has potential efficacy in inhalation injury. We investigated the impact of a heparin/N-acetylcysteine/albuterol nebulization protocol in adult patients with inhalation injury. METHODS: A retrospective review was performed of adult inhalation injury patients, admitted to a regional burn center between January 2011 and July 2012, who underwent a protocol of alternating treatments of heparin and N-acetylcysteine/albuterol nebulization every 4 hours. The study cohort was matched 1:1 by age, sex, and burn size to a control cohort admitted within 5 years before protocol implementation. RESULTS: The study (n = 20) and control cohorts (n = 20) were well matched, with nearly identical age (50 vs 49 years), sex distribution (70% male), burn size (total body surface area, 22% vs 21%), and inhalation injury, except grade I injuries (79% vs 47%, P = 0.01). The protocol did not change mortality (30% vs 25%, P = 0.72) or duration of mechanical ventilation (8.5 vs 8.8 days, P = 0.9). There was no difference in development of sepsis (40% vs 33%, P = 0.7) or acute respiratory distress syndrome (15% vs 10%, P = 1); however, those who received the protocol were more likely to develop pneumonia (45% vs 11%, P = 0.03). CONCLUSIONS: The implementation of a heparin/N-acetylcysteine/albuterol protocol did not reduce mortality or duration of mechanical ventilation in this cohort of adults with inhalation injury and resulted in a significant increase in pneumonia rates. Larger prospective studies are necessary, with close attention paid to minimizing the infection risk incurred from frequent administration of nebulized medications.

The exploration-exploitation dilemma: a multidisciplinary framework.

The trade-off between the need to obtain new knowledge and the need to use that knowledge to improve performance is one of the most basic trade-offs in nature, and optimal performance usually requires some balance between exploratory and exploitative behaviors. Researchers in many disciplines have been searching for the optimal solution to this dilemma. Here we present a novel model in which the exploration strategy itself is dynamic and varies with time in order to optimize a definite goal, such as the acquisition of energy, money, or prestige. Our model produced four very distinct phases: Knowledge establishment, Knowledge accumulation, Knowledge maintenance, and Knowledge exploitation, giving rise to a multidisciplinary framework that applies equally to humans, animals, and organizations. The framework can be used to explain a multitude of phenomena in various disciplines, such as the movement of animals in novel landscapes, the most efficient resource allocation for a start-up company, or the effects of old age on knowledge acquisition in humans.

Spatial instabilities untie the exclusion-principle constraint on species coexistence.

Using a spatially explicit mathematical model for water-limited vegetation we show that spatial instabilities of uniform states can lead to species coexistence under conditions where uniformly distributed species competitively exclude one another. Coexistence is made possible when water-rich patches formed by a pattern forming species provide habitats for a highly dispersive species that is a better competitor in uniform settings.

Periodic versus scale-free patterns in dryland vegetation.

Two major forms of vegetation patterns have been observed in drylands: nearly periodic patterns with characteristic length scales, and amorphous, scale-free patterns with wide patch-size distributions. The emergence of scale-free patterns has been attributed to global competition over a limiting resource, but the physical and ecological origin of this phenomenon is not understood. Using a spatially explicit mathematical model for vegetation dynamics in water-limited systems, we unravel a general mechanism for global competition: fast spatial distribution of the water resource relative to processes that exploit or absorb it. We study two possible realizations of this mechanism and identify physical and ecological conditions for scale-free patterns. We conclude by discussing the implications of this study for interpreting signals of imminent desertification.

Chronic pain treatment: a high moral imperative with offsetting personal risks for the physician--a medical student's perspective.

There is a clear need for physicians who specialize in the treatment of chronic pain, and these specialists must be empowered to use legally available and medically acceptable pain therapies, including opioids. However, prescribing opioids (or not prescribing them) for chronic pain treatment exposes pain physicians to medicolegal risks with serious personal consequences. This article summarizes, from a medical student's perspective, the basis for the specialization in pain medicine, and actions that place pain physicians at risk for serious professional harm. Regulatory issues of opioid prescription, physician litigation, and the ethical and legal implications on pain management from the perspective of a medical student are discussed. Existing data suggest that legal and regulatory issues have impacted and will continue to impact the treatment of pain. Creating uncertainty about legal issues and instilling fear in the prescribing physician are the best ways to discourage the use of opioids for legitimate medical purposes. In addition, the personal risks associated with the treatment of pain are likely to deter medical students from choosing pain management as their specialty. It is concluded that pain management is both a moral imperative and a moral obligation of clinicians that stems from the Hippocratic Oath. It is clear that there are many misconceptions and ethical concerns surrounding the use of opioids to treat pain. It is imperative that legal and regulatory issues do not discourage medical students from specializing in pain medicine.

An artist with extreme deuteranomaly.

BACKGROUND: There has been speculation about the colour vision of some artists of earlier generations based on the uncertain evidence of how they used colour, but it seems that no major artist has been shown to have a colour vision defect. A few lesser artists are known to have abnormal colour vision and its influence on their painting has been reported in the literature. However, there has been only one report of a deuteranomalous artist and no detailed report of one with extreme deuteranomaly. METHODS: An amateur artist was diagnosed as having extreme deuteranomaly using standard clinical tests. He was interviewed about his difficulty with colour when painting and the strategies he used to counter these problems. His work was studied to determine the colour palette he used and he was set the task of copying another painting to determine the nature of any errors he might make. RESULTS: The subject limits his palette to short-wave blues and blue-greens and long-wave yellow, orange and red. He avoids use of yellow-greens of which he is uncertain. He has adopted a few strategies that help him avoid mistakes in manipulating colour. Despite these difficulties, he is able to create attractive paintings. His early work tended toward monochrome but in his later work he has been able to create warm colourful effects with a limited palette. CONCLUSION: Defective colour vision is a handicap in those artistic activities using colour but it is not an insurmountable barrier. Optometrists should counsel patients with a colour deficiency who are considering a career in the graphic arts about the difficulties they will encounter and the strategies they can use to help minimise those problems.

The painter and handicapped vision.

A realist painter seeks to transform a three-dimensional stereoscopic image on to a two-dimensional surface, utilising one or more of the familiar cues to distance including linear and aerial perspective, relative size, overlap, tonal variation and use of colour. Sometimes this process can be jeopardised by one or more commonly occurring inherited and acquired vision problems, in particular errors of refraction, cataract, maculopathies, lack of binocularity and colour vision defects. Historically, several painters have been alleged to have suffered from one or more of these disorders to account for their particular style or changes in technique. The effects of these anomalies are discussed in relation to painters with particular emphasis on the ability for adaptation to occur.