Respiratory Health Associated with Systemic Metal Exposure in Post 9/11 Veterans in the Department of Veterans Affairs Toxic Embedded Fragment Registry.

OBJECTIVE: Adverse respiratory outcomes in post-9/11 Veterans with elevated urinary metal measures and enrolled in the VA's Toxic Embedded Fragment registry were compared to those without elevated urinary metals. METHODS: Veterans completed questionnaires, pulmonary physiology tests (pulmonary function and oscillometry) and provided urine samples for analysis of 13 metals. Respiratory symptoms, diagnoses and physiology measures were compared in Veterans with ≥1 urine metal elevation to those without metal elevations, adjusted for covariates, including smoking. RESULTS: Among 402 study participants, 24% had elevated urine metals, often just exceeding upper limits of reference values. Compared to Veterans without elevated metals, those with elevated metals had had higher FEV1 values but similar frequencies of respiratory symptoms and diagnoses and abnormalities on pulmonary physiology tests. CONCLUSIONS: Mild systemic metal elevations in post 9/11 Veterans are not associated with adverse respiratory health outcomes.

Carer involvement in medication adherence: carer views and experiences of facilitating medication adherence using pharmacy-filled multi-compartment medication compliance aids and other methods of adherence support-a questionnaire survey.

INTRODUCTION: Unpaid carers are an increasing proportion of the UK population. One of the many ways in which they help those they care for is assisting with medication adherence. Many older adults have medicines dispensed in pharmacy-filled multi-compartment medication compliance aids (pMCAs). However, evidence suggests that pMCAs may increase medication-related harm, and little is known about the interaction between the user, medication adherence systems and the carer. AIM: To explore the views of carers supporting older adults to manage their medications with and without a pMCA. METHOD: A researcher-administered questionnaire survey of carers supporting older adults to manage their medicines with or without a pMCA. Participants were recruited from inpatient wards, outpatient clinics and community services in central London. Responses were analysed by two independent researchers to identify overarching themes. RESULTS: Eighty-eight unpaid carers were interviewed and responses were categorised according to the medication adherence method used; 47 supported a user with a pMCA and 41 supported without a pMCA. The main themes were: Time, Responsibility and Mistakes, Waste and Sustainability, and Polypharmacy, with sub-themes of design of multi-compartment medication compliance aids, organisation and reassurance. CONCLUSION: Supporting medication adherence puts considerable burden on carers regardless of whether a self- or pharmacy-filled medication compliance aid is used or not. Prescribers could alleviate this burden through regular medication review by considering the prescribing frequency and duration and medication rationalisation. Redesign of both pMCAs and systems surrounding their use could also help reduce carer's burden and environmental burden.

Self-reported respiratory outcomes associated with blast exposure in post 9/11 veterans.

BACKGROUND: Blast lung overpressure has received interest as a cause of chronic respiratory disease in Service members who deployed in support of U.S. military operations in Southwest Asia and Afghanistan since 2001. We studied whether veterans who experienced blast exposure report more chronic respiratory symptoms and diagnoses compared to deployed veterans who did not. METHODS: 9,000 veterans included in the Department of Veterans Affairs Toxic Embedded Fragment Registry were invited to complete a survey assessing chronic respiratory symptoms, diagnoses, and exposures. Blast exposure was assessed using the Brief Traumatic Brain Injury Screen and by presence of other symptoms such as blast-induced loss of consciousness. RESULTS: Participants (n = 2147) were predominantly <40 years old, served in the Army, and injured on average 12.8 years previously. 91% reported blast exposure. Blast-exposed veterans were significantly more likely to report cough (OR 1.8), wheeze (OR 2.4), and dyspnea (OR 1.8), even after adjustment for covariates including smoking and occupational exposures to dust, fume, and gas. Veterans reporting higher severity of blast impact, such as traumatic brain injury or loss of consciousness, were more likely to report cough, wheeze, or dyspnea. Veterans with higher severity of blast impact by multiple measures were also more likely to report having COPD. Those reporting a physician-diagnosis of traumatic brain injury were significantly more likely to report having both asthma (OR 1.5) and COPD (OR 1.5). CONCLUSIONS: Blast exposure is associated with respiratory symptoms and COPD. Respiratory system evaluation may warrant inclusion as a standard part of barotrauma health assessment.

Effects of simulation dimensionality on laser-driven electron acceleration and photon emission in hollow microchannel targets.

Using two-dimensional (2D) and three-dimensional (3D) kinetic simulations, we examine the impact of simulation dimensionality on the laser-driven electron acceleration and the emission of collimated γ-ray beams from hollow microchannel targets. We demonstrate that the dimensionality of the simulations considerably influences the results of electron acceleration and photon generation owing to the variation of laser phase velocity in different geometries. In a 3D simulation with a cylindrical geometry, the acceleration process of electrons terminates early due to the higher phase velocity of the propagating laser fields; in contrast, 2D simulations with planar geometry tend to have prolonged electron acceleration and thus produce much more energetic electrons. The photon beam generated in the 3D setup is found to be more diverged accompanied with a lower conversion efficiency. Our paper concludes that the 2D simulation can qualitatively reproduce the features in 3D simulation, but for quantitative evaluations and reliable predictions to facilitate experiment designs 3D modeling is strongly recommended.

Remote Clinics During Coronavirus Disease 2019: Lessons for a Sustainable Future.

Background The coronavirus disease 2019 (COVID-19) pandemic has led to a focus on non-face-to-face (NF2F) orthopedic clinics. In this study, our aim was to establish whether NF2F clinics are sustainable according to the "triple bottom line" framework by taking into account the impact on patients, the planet, and the financial cost. Methodology This retrospective cohort study was carried out at a large district general hospital with 261 patients identified as having undergone face-to-face (F2F) or NF2F orthopedic consultations (April 2020). These patients were contacted by telephone to establish their experience, mode of transport, and preference for future consultations. Data were also collected relating to environmental and financial costs to the patient and the trust. Results The final analysis included 180 (69%) patients: 42% had an F2F consultation and 58% NF2F consultation. There was no significant difference between each group in terms of convenience, ease of communication, subjective patient safety, or overall satisfaction rating (p > 0.05). Overall, 80% of NF2F patients would be happy with virtual consultations in the future. The mean journey distance was 18.6 miles leading to a reduction in total carbon emissions of 563.9 kgCO2e (66%), equating to 2,106 miles in a medium-sized car. The hospital visit carbon cost (heating, lighting, and waste generation) was reduced by 3,967 kgCO2e (58%). The financial cost (petrol and parking) was also reduced by an average of £8.96 per person. Conclusions NF2F consultations are aligned to the National Health Service's "Long Term Plan": (i) delivering high patient satisfaction with equivalent outcomes as F2F consultations; (ii) reducing carbon emissions from transportation and hospital running; and (iii) becoming cheaper.

Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic.

The coronavirus severe acute respiratory syndrome (COVID-19) pandemic has placed increased stress on healthcare workers (HCWs). While anxiety and post-traumatic stress have been evaluated in HCWs during previous pandemics, moral injury, a construct historically evaluated in military populations, has not. We hypothesized that the experience of moral injury and psychiatric distress among HCWs would increase over time during the pandemic and vary with resiliency factors. From a convenience sample, we performed an email-based, longitudinal survey of HCWs at a tertiary care hospital between March and July 2020. Surveys measured occupational and resilience factors and psychiatric distress and moral injury, assessed by the Impact of Events Scale-Revised and the Moral Injury Events Scale, respectively. Responses were assessed at baseline, 1-month, and 3-month time points. Moral injury remained stable over three months, while distress declined. A supportive workplace environment was related to lower moral injury whereas a stressful, less supportive environment was associated with increased moral injury. Distress was not affected by any baseline occupational or resiliency factors, though poor sleep at baseline predicted more distress. Overall, our data suggest that attention to improving workplace support and lowering workplace stress may protect HCWs from adverse emotional outcomes.

Statistical analysis of trace contaminants measured in biogas.

Biogas is a renewable energy fuel that can be treated to increase purity so that the resulting "biomethane" can be injected into the natural gas pipeline grid. The trace contaminants in biogas and biomethane make up a small fraction of the total gas but they still have the potential to cause adverse health effects and pipeline corrosion. This study investigates the statistical distributions of 17 trace metals, six mercaptans, hydrogen sulfide, ammonia, and six additional trace organic compounds. Twelve of these 31 trace contaminants have been previously identified as constituents of concern based on their toxicity profiles and through health risk assessment studies. Untreated and treated samples of biogas were collected from 12 different biogas production facilities using diverse feedstocks throughout California. Results show that most biogas trace contaminants follow a single log-normal distribution or a bi-modal lognormal distribution depending on the type of production facility. Treatment of biogas demonstrates some removal for all trace contaminants, but four constituents of concern (copper, lead, hydrogen sulfide, and methyl mercaptan) are predicted to have a >1% probability of exceeding trigger levels even after common treatments. This finding suggests that enhanced monitoring may be warranted for these contaminants. Several trace metals and volatile organic compounds (VOCs) were found to have seasonal trends with greater concentrations in the summer and lower concentrations in the winter suggesting that seasonal variation should be considered in future monitoring plans.

Caries risk assessment.

Caries remains the most common chronic disease affecting both children and adults in the United States. High rates of primary and secondary caries in at-risk populations result in significant lifetime costs. Dental providers should be skilled in assessing an individual patient's risk for dental caries so that effective and minimally invasive preventive strategies can be employed to address the etiology of dental caries. Validated assessment strategies, such as the caries risk assessment model, allow dental providers to implement a systematic and evidence-based approach to astutely assess and record changes in the caries risk status of patients in an effort to prevent disease.

Resolution of obstructive sleep apnea after mandibular distraction osteogenesis in setting of delayed tongue-lip adhesion takedown: A case report.

RATIONALE: There is a high prevalence of obstructive sleep apnea (OSA) in patients with Pierre Robin sequence (PRS), and treatment approaches are highly variable. One approach is a temporary tongue-lip adhesion (TLA) that acts as a temporizing measure while the mandible continues to grow and is usually taken down at 1 year of age. PATIENT CONCERNS: Side effects of prolonged tongue-lip adhesion and optimal workup and treatment of persistent OSA in the setting of a tongue-lip adhesion. DIAGNOSES: Pierre Robin sequence (PRS), persistent obstructive sleep apnea (OSA), and tongue-lip adhesion (TLA). INTERVENTIONS: Mandibular distraction osteogenesis (MDO), adenotonsillectomy, and tongue-lip adhesion takedown. OUTCOMES: Resolution of OSA. LESSONS: This case puts into question the efficacy of isolated TLA in infants with Pierre Robin sequence and OSA, and places emphasis on the importance of considering an earlier workup of other potential causes of obstruction and the potential need for MDO as a primary or adjunctive approach to treatment.

Ketamine Infusion for Adjunct Sedation in Mechanically Ventilated Adults.

BACKGROUND: Many critically ill patients receive ketamine for adjunct sedation despite a paucity of evidence on its use, dosing, and monitoring in this setting. OBJECTIVE: To describe the dosing and safety considerations of ketamine for adjunct sedation in a population of mechanically ventilated critically ill patients targeting light sedation. METHODS: We conducted a retrospective review of mechanically ventilated patients receiving continuous ketamine infusion between January 2012 and April 2016. Data included dosing, effect of ketamine on other sedatives, total sedative use, Riker Sedation-Agitation Scale (SAS) scores, adverse drug reactions (ADRs), and hemodynamic variables. RESULTS: Ninety-one patients were included in the analysis. Ketamine was infused at a median dosage of 0.41 mg/kg/hour (range 0.04-2.5 mg/kg/hr) for up to 14.7 days (median 2.8 days). Concomitant sedatives were reduced or discontinued, without the initiation of an additional sedative, in 57 patients (63%) within 24 hours of initiating ketamine. Propofol was most commonly discontinued (16 patients, 36%), followed by benzodiazepines (12 patients, 27%). There was an increase in the number of SAS scores documented in goal in the 24-hour period after ketamine initiation compared with the immediate 24 hours before (61% vs 55%, p=0.001). Patients were less frequently agitated, defined as SAS >4, after the initiation of ketamine (27% vs 33%, p=0.005). Seven patients (7.7%) required discontinuation of ketamine infusion for an ADR. There were no significant changes in hemodynamic variables after the initiation of ketamine. CONCLUSIONS: Continuous ketamine infusion for adjunct light sedation was well tolerated in a cohort of critically ill adults, with an acceptable safety profile. Prospective studies of ketamine infusion are warranted to further establish its efficacy as a sedative in this population.

Effect of administration of neuromuscular blocking agents in children with severe traumatic brain injury on acute complication rates and outcomes: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia.

OBJECTIVE: To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury. DESIGN: A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. SETTING: Seventeen hospitals in the United States, Australia, and New Zealand. PATIENTS: Children (< 18 yr) with severe traumatic brain injury. INTERVENTIONS: None for this secondary analysis. MEASUREMENTS AND MAIN RESULTS: Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups. CONCLUSIONS: Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.

The design and fabrication of three-chamber microscale cell culture analog devices with integrated dissolved oxygen sensors.

Whole animal testing is an essential part in evaluating the toxicological and pharmacological profiles of chemicals and pharmaceuticals, but these experiments are expensive and cumbersome. A cell culture analog (CCA) system, when used in conjunction with a physiologically based pharmacokinetic (PBPK) model, provides an in vitro supplement to animal studies and the possibility of a human surrogate for predicting human response in clinical trials. A PBPK model mathematically simulates animal metabolism by modeling the absorption, distribution, metabolism, and elimination kinetics of a chemical in interconnected tissue compartments. A CCA uses mammalian cells cultured in interconnected chambers to physically represent the corresponding PBPK. These compartments are connected by recirculating tissue culture medium that acts as a blood surrogate. The purpose of this article is to describe the design and basic operation of the microscale manifestation of such a system. Microscale CCAs offer the potential for inexpensive, relatively high throughput evaluation of chemicals while minimizing demand for reagents and cells. Using microfabrication technology, a three-chamber ("lung"-"liver"-"other") microscale cell culture analog (microCCA) device was fabricated on a 1 in. (2.54 cm) square silicon chip. With a design flow rate of 1.76 microL/min, this microCCA device achieves approximate physiological liquid-to-cell ratio and hydrodynamic shear stress while replicating the liquid residence time parameters in the PBPK model. A dissolved oxygen sensor based on collision quenching of a fluorescent ruthenium complex by oxygen molecules was integrated into the system, demonstrating the potential to integrate real-time sensors into such devices.

Serum mepivacaine concentrations after intraoral injection in young children.

The authors measured plasma concentrations of mepivacaine in 36 children from the ages of 2 to 5 years who received dental care under light general anesthesia. The subjects were randomly assigned to receive either 2 percent mepivacaine hydrochloride with 1:20,000 levonordefrin or 3 percent mepivacaine hydrochloride without vasoconstrictor. The volume of anesthetic injected depended on the planned procedures for each patient. Blood samples (3 mL) were drawn from an intravenous line before and 5, 10, 20, 30, 45, and 60 minutes after mepivacaine injection. The serum was collected and analyzed by gas-liquid chromatography. Mean serum concentrations, normalized to a dose of 1 mg/kg body weight, reached a peak of 0.67 +/- 0.42 microgram/mL (mean +/- SD) after 3 percent mepivacaine and 0.63 +/- 0.21 microgram/mL after 2 percent mepivacaine with levonordefrin. Levonordefrin had no significant effect on the plasma concentrations. However, because of the higher concentration of mepivacaine in the 3 percent formulation, it was potentially 1.5 times as toxic (P < 0.002) on a volume basis. Statistical analysis also suggested that the maximum recommended dose of 3 mg/lb could result in potentially toxic blood concentrations in a small percentage of pediatric patients. The authors conclude that 3 percent mepivacaine should not be used when relatively large volumes of local anesthetic must be administered to small children and recommend that the maximum dose of mepivacaine not exceed 5 mg/kg.