A vanguard randomised feasibility trial comparing three regimens of peri-operative oxygen therapy on recovery after major surgery.

International recommendations encourage liberal administration of oxygen to patients having surgery under general anaesthesia, ostensibly to reduce surgical site infection. However, the optimal oxygen regimen to minimise postoperative complications and enhance recovery from surgery remains uncertain. The hospital operating theatre randomised oxygen (HOT-ROX) trial is a multicentre, patient- and assessor-blinded, parallel-group, randomised clinical trial designed to assess the effect of a restricted, standard care, or liberal peri-operative oxygen therapy regimen on days alive and at home after surgery in adults undergoing prolonged non-cardiac surgery under general anaesthesia. Here, we report the findings of the internal vanguard feasibility phase of the trial undertaken in four large metropolitan hospitals in Australia and New Zealand that included the first 210 patients of a planned overall 2640 trial sample, with eight pre-specified endpoints evaluating protocol implementation and safety. We screened a total of 956 participants between 1 September 2019 and 26 January 2021, with data from 210 participants included in the analysis. Median (IQR [range]) time-weighted average intra-operative Fi O2 was 0.30 (0.26-0.35 [0.20-0.59]) and 0.47 (0.44-0.51 [0.37-0.68]) for restricted and standard care, respectively (mean difference (95%CI) 0.17 (0.14-0.20), p < 0.001). Median time-weighted average intra-operative Fi O2 was 0.83 (0.80-0.85 [0.70-0.91]) for liberal oxygen therapy (mean difference (95%CI) compared with standard care 0.36 (0.33-0.39), p < 0.001). All feasibility endpoints were met. There were no significant patient adverse events. These data support the feasibility of proceeding with the HOT-ROX trial without major protocol modifications.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. The aim is that they will be used as a basis for instilling good practice.

[Sleep disorders and fatigue syndrome in long COVID syndrome: case-based experiences from neurological/sleep medicine rehabilitation]. / Schlafstörungen und Erschöpfungssyndrom bei Long-COVID-Syndrom: Fallbasierte Erfahrungen aus der neurologischen/schlafmedizinischen Rehabilitation.

Sleep disturbances and clinically significant fatigue syndrome are regularly described for long COVID syndrome. The pathophysiological correlations remain unknown. The clinical presentation is variable and must be considered individually. Four case studies will be used to illustrate the symptoms that constitute long COVID syndrome and the treatment options available. Multimodal individualized rehabilitation seems to be suitable to return those affected to their premorbid performance and to achieve a considerable reduction in insomniac complaints.

Clinical presentation of verruca vulgaris in HIV.

BACKGROUND: Immunocompromised patients, including those with human immunodeficiency virus (HIV), have been observed to have verrucae that are more extensive and treatment-resistant compared to those in immunocompetent patients. However, there is a critical lack of data in the current literature on the characteristics of verruca vulgaris in individuals with HIV. METHODS: This retrospective chart review included a cohort of HIV-positive individuals and a control group of immunocompetent individuals presenting to an outpatient, county hospital-based dermatology clinic for evaluation of verruca vulgaris between the years of 2016 and 2018. Clinical characteristics, including gender, age, last CD4 count, viral load, antiretroviral therapy adherence, and total number and location of lesions were recorded. RESULTS: A total of 66 patients (33 HIV-positive, 33 immunocompetent) were included in the study. HIV-positive status was significantly associated with a higher total number of lesions (42% of immunocompromised patients versus 21% of immunocompetent patients presented with four or more lesions, P=0.04) as well as location of lesions on the face, scalp, and neck (51.5% versus 9.1%, P<0.001). CONCLUSIONS: HIV-positive status may be associated not only with a higher burden of verruca vulgaris lesions but also a higher number of lesions in locations at or above the neck.

Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline.

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.

Combining experimental and computational techniques to understand and improve dry powder inhalers.

INTRODUCTION: Dry Powder Inhalers (DPIs) continue to be developed to deliver an expanding range of drugs to treat an ever-increasing range of medical conditions; with each drug and device combination needing a specifically designed inhaler. Fast regulatory approval is essential to be first to market, ensuring commercial profitability. AREAS COVERED: In vitro deposition, particle image velocimetry, and computational modeling using the physiological geometry and representative anatomy can be combined to give complementary information to determine the suitability of a proposed inhaler design and to optimize its formulation performance. In combination, they allow the entire range of questions to be addressed cost-effectively and rapidly. EXPERT OPINION: Experimental techniques and computational methods are improving rapidly, but each needs a skilled user to maximize results obtained from these techniques. Multidisciplinary teams are therefore key to making optimal use of these methods and such qualified teams can provide enormous benefits to pharmaceutical companies to improve device efficacy and thus time to market. There is already a move to integrate the benefits of Industry 4.0 into inhaler design and usage, a trend that will accelerate.

Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists.

This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the UK and Ireland, but it is recognised that these guidelines may also be of use in other areas of the world. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and during transfer. There are new sections specifically discussing capnography, sedation and regional anaesthesia. In addition, the indications for processed electroencephalogram and neuromuscular monitoring have been updated.

Environmental effects of stratospheric ozone depletion, UV radiation, and interactions with climate change: UNEP Environmental Effects Assessment Panel, Update 2020.

This assessment by the Environmental Effects Assessment Panel (EEAP) of the United Nations Environment Programme (UNEP) provides the latest scientific update since our most recent comprehensive assessment (Photochemical and Photobiological Sciences, 2019, 18, 595-828). The interactive effects between the stratospheric ozone layer, solar ultraviolet (UV) radiation, and climate change are presented within the framework of the Montreal Protocol and the United Nations Sustainable Development Goals. We address how these global environmental changes affect the atmosphere and air quality; human health; terrestrial and aquatic ecosystems; biogeochemical cycles; and materials used in outdoor construction, solar energy technologies, and fabrics. In many cases, there is a growing influence from changes in seasonality and extreme events due to climate change. Additionally, we assess the transmission and environmental effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the COVID-19 pandemic, in the context of linkages with solar UV radiation and the Montreal Protocol.

Examining Psychological Self-Sufficiency Among Low-Income Jobseekers with Mental Health Barriers.

The study is to investigate psychological self-sufficiency-the force within someone that activates cognitive and non-cognitive process of shifting perceived barriers into hope actions-as it relates to economic self-sufficiency among jobseekers with mental health barriers. Among a sample of 2455 low-income jobseekers in job readiness programs at six community-based agencies in Chicago, a subsample of 424 who self-identified as having mental illness barriers are selected to analyze the relationships between employment hope, employment barriers, and economic self-sufficiency using structural equation modeling. Results indicate that employment hope mediates the path between perceived employment barriers and economic self-sufficiency. The study further highlights the positive effects of employment barriers on employment hope among jobseekers with perceived mental illnesses. The findings support growing evidence that psychological self-sufficiency is positively associated with gaining economic self-sufficiency in workforce development programs.

Neuromuscular blockade in patients with ARDS: a rapid practice guideline.

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.

Effectiveness of an mHealth application to improve hypertension health literacy in India.

AIM: The purpose of this research was to determine the effectiveness of a mobile health or mHealth application to improve hypertension health literacy among vulnerable populations in India. Additionally, we sought to estimate relationships between participant knowledge on hypertension and sociodemographic variables. BACKGROUND: The World Health Organization advocates for the use of mobile technology to improve public health outcomes. INTRODUCTION: The incidence of hypertension is on the rise in India, and effective and sustainable interventions are needed. METHODS: A quantitative single arm pre-test post-test interventional and correlational design was used to test the hypertension mHealth application among participants in a limited resource setting. A paired t-test was performed to compare pre- and post-test results after participant use of the mHealth application. A regression model was used to estimate relationships between participant hypertension health literacy and sociodemographic variables. RESULTS: A statistically significant improvement in test scores among participants after use of the mHealth app was found. Sociodemographic characteristics such as living in an urban environment, married, increased number of people living in household and alcohol use were determined to have a statistically significant effect on improvement of test score. DISCUSSION: Results indicated the application was effective among participants with varied literacy and health literacy levels. These findings contribute to the potential widespread scalability of the app among populations with varied demographics. CONCLUSION: This application provides an effective and valuable culturally tailored educational resource for nurses and other health providers to use to improve hypertension health literacy among vulnerable populations in India. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY: This study contributes to nursing and health policy by answering a call from the World Health Organization to implement and research mHealth interventions to improve health outcomes, particularly in a low and middle income country where preventive health access is limited.

[Management of diagnostic procedures and treatment of sleep related breathing disorders in the context of the coronavirus pandemic]. / Diagnostik und Therapie schlafbezogener Atmungsstörungen im Zusammenhang mit der Corona­Pandemie: Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP), Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM).

When providing sleep medical services special aspects must be taken into account in the context of the coronavirus pandemic. Despite all prevention, due to the high number of unrecognized cases, SARS-CoV2 contacts in the sleep laboratory must be expected and appropriate precautions are necessary. Nevertheless, the continuation or resumption of sleep medical services under the appropriate hygiene measures is strongly recommended to avoid medical and psychosocial complications. There is no evidence for a deterioration of COVID-19 through CPAP therapy. In principle, the application of positive pressure therapy via various mask systems can be accompanied by the formation of infectious aerosols. In the case of confirmed infection with SARS-CoV2, a pre-existing PAP therapy should be continued in an outpatient setting in accordance with the local guidelines for home isolation, since discontinuation of PAP therapy is associated with additional cardiopulmonary complications due to the untreated sleep-related breathing disorder. According to the current state of knowledge inhalation therapy, nasal high-flow (NHF), and PAP therapy can be carried out without increased risk of infection for health care workers (HCW) as long as appropriate personal protective equipment (eye protection, FFP2 or FFP-3 mask, gown) is being used.This position paper of the German Society for Pneumology and Respiratory Medicine (DGP) and the German Society for Sleep Medicine (DGSM) offers detailed recommendations for the implementation of sleep medicine diagnostics and therapy in the context of the coronavirus pandemic.