Trace Organic Contaminant Removal from Municipal Wastewater by Styrenic ß-Cyclodextrin Polymers.

Trace organic contaminants (TrOCs) present major removal challenges for wastewater treatment. TrOCs, such as perfluoroalkyl and polyfluoroalkyl substances (PFAS), are associated with chronic toxicity at ng L-1 exposure levels and should be removed from wastewater to enable safe reuse and release of treated effluents. Established adsorbents, such as granular activated carbon (GAC), exhibit variable TrOC removal and fouling by wastewater constituents. These shortcomings motivate the development of selective novel adsorbents that also maintain robust performance in wastewater. Cross-linked ß-cyclodextrin (ß-CD) polymers are promising adsorbents with demonstrated TrOC removal efficacy. Here, we report a simplified and potentially scalable synthesis of a porous polymer composed of styrene-linked ß-CD and cationic ammonium groups. Batch adsorption experiments demonstrate that the polymer is a selective adsorbent exhibiting complete removal for six out of 13 contaminants with less adsorption inhibition than GAC in wastewater. The polymer also exhibits faster adsorption kinetics than GAC and ion exchange (IX) resin, higher adsorption affinity for PFAS than GAC, and is regenerable by solvent wash. Rapid small-scale column tests show that the polymer exhibits later breakthrough times compared to GAC and IX resin. These results demonstrate the potential for ß-CD polymers to remediate TrOCs from complex water matrices.

The application of a surgical face mask over different oxygen delivery devices; a crossover study of measured end-tidal oxygen concentrations.

BACKGROUND: The application of a surgical face mask over oxygen delivery devices is now a widespread recommendation in the setting of the Coronavirus disease pandemic. This addition is designed to reduce droplet spread, but this also changes the nature of these devices, and may alter the amount of oxygen delivered to a patient. This research investigated how placing a surgical face mask over both a simple plastic mask ("Hudson mask") and nasal cannula altered the concentration of available oxygen measured at the nares. METHODS: We measured the inspired and end-tidal oxygen concentrations of five healthy non-smoking volunteers. Oxygen was delivered via nasal cannula and also a simple plastic face mask, at flow rates of 2, 4, 6 and 8 l per minute, with and without an overlying surgical face mask. RESULTS: Adding a surgical mask over nasal cannula caused an appreciable rise in the end-tidal oxygen concentrations at all the measured oxygen flow rates 2, 4, 6, 8 L/minute. With the Hudson mask, there was a rise in oxygen concentration at 4 and 6 L/minute. For example, at a flow rate of 4 l/min via nasal cannula, available oxygen concentration increased from 24 to 36%, and via the Hudson mask the concentration rose from 27 to 38%. CONCLUSIONS: The addition of a surgical face mask over both nasal cannula and a Hudson mask resulted in an increased available oxygen concentration. This may be valuable where more advanced oxygen devices are not available, or alternatively providing adequate supplemental oxygen at lower flow rates and thus making critical savings in oxygen usage.

Metabolic heat loss in southern elephant seals (Mirounga leonina) differs with stage of moult and between habitats.

The moult in southern elephant seals (Mirounga leonina) represents an especially energetically demanding period during which seals must maintain high skin temperature to facilitate complete replacement of body fur and upper dermis. In this study, heat flux from the body surface was measured on 18 moulting southern elephant seals to estimate metabolic heat loss in three different habitats (beach, wallow and vegetation). Temperature data loggers were also deployed on 10 southern elephant seals to monitor skin surface temperature. On average, heat loss of animals on the beach was greater than in wallows or vegetation, and greater in wallows than in vegetation. Heat loss across all habitats during the moult equated to 1.8 x resting metabolic rate (RMR). The greatest heat loss of animals was recorded in the beach habitat during the late moult, that represented 2.3 x RMR. Mass loss was 3.6 ± 0.3 kg day-1, resulting in changes in body condition as the moult progressed. As body condition declined, skin surface temperature also decreased, suggesting that as animals approached the end of the moult blood flow to the skin surface was no longer required for hair growth.

Airway Management in the Operating Room and Interventional Suites in Known or Suspected COVID-19 Adult Patients: A Practical Review.

Current evidence suggests that coronavirus disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 µm) and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology, and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures, when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.

LMA® Gastro™ Airway for endoscopic retrograde cholangiopancreatography: a retrospective observational analysis.

BACKGROUND: Various airway techniques have been employed for endoscopic procedures, with an aim to optimise patient outcomes by improving airway control and preventing hypoxia whilst avoiding the need for intubation. The LMA® Gastro™ Airway, a novel dual channel supraglottic airway technique, has been described as such a device. Its utility alongside sedation with low flow nasal cannula and general anaesthesia (GA) with intubation for endoscopic retrograde cholangiopancreatography (ERCP) procedures was evaluated. METHODS: Details of all the ERCPs performed in our institution from March 2017 to June 2018 were carefully recorded in the patients' electronic case records. Data on the successful completion of ERCP through LMA® Gastro™ Airway; any difficulty encountered by the gastroenterologists; and adverse events were recorded. Episodes of hypoxia (SpO2 < 92%) and haemodynamic parameters were compared across the three groups: LMA® Gastro™ vs. sedation with low flow nasal cannula vs. GA with an endotracheal tube (ETT). RESULTS: One hundred seventy-seven ERCP procedures were performed during the study period. The LMA® Gastro™ Airway was employed in 64 procedures (36%) on 59 patients. Of these 64 procedures, ERCP was successfully completed with LMA® Gastro™ Airway in 63 (98%) instances, with only one case requiring conversion to an endotracheal tube. This instance followed difficulty in negotiating the endoscope through LMA® Gastro™ Airway. No episodes of hypoxia or hypercapnia were documented in both LMA® Gastro™ and GA with ETT groups. One sedation case with nasal cannula was noted to have hypoxia. Adverse intraoperative events were recognised in 2 cases of LMA® Gastro™: one had minimal blood stained secretions from the oral cavity that resolved with suctioning; the other developed mild laryngospasm which resolved spontaneously within a few minutes. CONCLUSION: In patients undergoing ERCP, the LMA® Gastro™ airway demonstrated a high success rate for ERCP completion. Ventilation was well maintained with minimal intraoperative and postoperative adverse events. This technique may have a role in higher risk groups such as high ASA (American Society of Anesthesiologists) status, or those with potential airway difficulties such as high body mass index and those with known or suspected sleep apnoea.

The intraoperative use of non-opioid adjuvant analgesic agents: a survey of anaesthetists in Australia and New Zealand.

BACKGROUND: Opioids have long been the mainstay of drugs used for intra-operative analgesia. Due to their well-known short and long term side effects, the use of non-opioid analgesics has often been encouraged to decrease the dose of opioid required and minimise these side effects. The trends in using non-opioid adjuvants among Australian Anaesthetists have not been examined before. This study has attempted to determine the use of non-opioid analgesics as part of an opioid sparing practice among anaesthetists across Australia and New Zealand. METHODS: A survey was distributed to 985 anaesthetists in Australia and New Zealand. The questions focused on frequency of use of different adjuvants and any reasons for not using individual agents. The agents surveyed were paracetamol, dexamethasone, non-steroidal anti-inflammatory agents (NSAIDs), tramadol, ketamine, anticonvulsants, intravenous lidocaine, systemic alpha 2 agonists, magnesium sulphate, and beta blockers. Descriptive statistics were used and data are expressed as a percentage of response for each drug. RESULTS: The response rate was 33.4%. Paracetamol was the most frequently used; with 72% of the respondents describing frequent usage (defined as usage above 70% of the time); followed by parecoxib (42% reported frequent usage) and dexamethasone (35% reported frequent usage). Other adjuvants were used much less commonly, with anaesthetists reporting their frequent usage at less than 10%. The majority of respondents suggested that they would never consider dexmedetomidine, magnesium, esmolol, pregabalin or gabapentin. Perceived disincentives for the use of analgesic adjuvants varied. The main concerns were side effects, lack of evidence for benefit, and anaesthetists' experience. The latter two were the major factors for magnesium, dexmedetomidine and esmolol. CONCLUSION: The uptake of tramadol, lidocaine and magnesium amongst respondents from anaesthetists in Australia and New Zealand was poor. Gabapentin, pregabalin, dexmedetomidine and esmolol use was relatively rare. Most anaesthetists need substantial evidence before introducing a non-opioid adjuvant into their routine practice. Future trials should focus on assessing the opioid sparing benefits and relative risk of using individual non-opioid adjuvants in the perioperative period for specific procedures and patient populations.

Insights into toxic Prymnesium parvum blooms: the role of sugars and algal viruses.

Prymnesium parvum is a toxin-producing microalga that causes harmful algal blooms globally, which often result in large-scale fish kills that have severe ecological and economic implications. Although many toxins have previously been isolated from P. parvum, ambiguity still surrounds the responsible ichthyotoxins in P. parvum blooms and the biotic and abiotic factors that promote bloom toxicity. A major fish kill attributed to P. parvum occurred in Spring 2015 on the Norfolk Broads, a low-lying set of channels and lakes (Broads) found on the East of England. Here, we discuss how water samples taken during this bloom have led to diverse scientific advances ranging from toxin analysis to discovery of a new lytic virus of P. parvum, P. parvum DNA virus (PpDNAV-BW1). Taking recent literature into account, we propose key roles for sialic acids in this type of viral infection. Finally, we discuss recent practical detection and management strategies for controlling these devastating blooms.

Anaesthetic management for endobronchial valve insertion: lessons learned from a single centre retrospective series and a literature review.

BACKGROUND: Endoscopic lung volume reduction using one or more endobronchial valves is a treatment option for a select group of patients with severe emphysema. Patients presenting for this procedure pose various challenges to the anaesthetist; in addition to their lung condition, they are often elderly with multiple comorbidities. The procedure is usually performed outside the operating room. Monitored anaesthesia care with intravenous sedation, and general anaesthesia with an endotracheal tube have both been described for these procedures, aiming for adequate ventilation and haemodynamic stability. METHODS: We present our experience on 20 of these procedures in relation to the anaesthetic techniques employed and discuss the perioperative challenges involved in managing these cases. RESULTS: Twenty one planned endobronchial valve insertion procedures were identified on 18 patients. There were ten cases of monitored anaesthesia care with sedation and 10 cases which used general anaesthesia with an endotracheal tube. Two have been excluded; one had features of anaphylaxis and the procedure was abandoned, and the other required conversion from monitored anaesthesia care to general anaesthesia with endotracheal tube. CONCLUSIONS: Both monitored anaesthesia care with sedation and general anaesthesia with endotracheal tube were well tolerated during endobronchial valve insertion procedures. General anaesthesia with endotracheal tube may offer better interventional conditions, patient comfort and reduced anaesthetic time.

Combination paracetamol and ibuprofen for pain relief after oral surgery: a dose ranging study.

PURPOSE: Combined paracetamol and ibuprofen has been shown to be more effective than either constituent alone for acute pain in adults, but the dose-response has not been confirmed. The aim of this study was to define the analgesic dose-response relationship of different potential doses of a fixed dose combination containing paracetamol and ibuprofen after third molar surgery. METHODS: Patients aged 16 to 60 years with moderate or severe pain after the removal of at least two impacted third molars were randomised to receive double-blind study medication as two tablets every 6 h for 24 h of either of the following: two tablet, combination full dose (paracetamol 1000 mg and ibuprofen 300 mg); one tablet, combination half dose (paracetamol 500 mg and ibuprofen 150 mg); half a tablet, combination quarter dose (paracetamol 250 mg and ibuprofen 75 mg); or placebo. The primary outcome measure was the time-adjusted summed pain intensity difference over 24 h (SPID 24) calculated from the 100-mm VAS assessments collected over multiple time points for the study duration. RESULTS: Data from 159 patients were included in the analysis. Mean (SD) time-adjusted SPID over 24 h were full-dose combination 20.1 (18.0), half dose combination 20.4 (20.8), quarter dose combination 19.3 (20.0) and placebo 6.6 (19.8). There was a significant overall effect of dose (p = 0.002) on the primary outcome. Planned pairwise comparisons showed that all combination dose groups were superior to placebo (full dose vs. placebo p = 0.004, half dose vs. placebo p = 0.002, quarter dose vs. placebo p = 0.002). The overall effect of dose was also significant for maximum VAS pain intensity score (p = 0.048), response rate (p = 0.0094), percentage of participants requiring rescue (p = 0.025) and amount of rescue (p < 0.001). No significant dose effect was found for time to peak reduction in VAS or time to meaningful pain relief. The majority of adverse events recorded were of mild (52.75%) or moderate (40.16%) severity and not related (30.7%) or unlikely related (57.5%) to the study medication. CONCLUSION: All doses of the combination provide safe superior pain relief to placebo in adult patients following third molar removal surgery.

The use of hyperbaric oxygen for avascular necrosis of the femoral head and femoral condyle: a single centre's experience over 30 years.

Introduction: Avascular necrosis (AVN) is a rare progressive degenerative disease leading to bone and joint destruction. Patients often require surgical intervention. Femoral AVN is the most common anatomical location. Hyperbaric oxygen treatment (HBOT) has been shown to be effective in AVN. We present data collected from one centre over a 30-year period and compare the results with other published data. Methods: A retrospective chart review of all patients receiving HBOT for AVN at Fremantle and Fiona Stanley Hospitals since 1989 was performed. The primary outcome was radiological appearance using the Steinberg score, with secondary outcomes being subjective improvement, the need for joint replacement surgery and rates of complications. Results: Twenty-one joints in 14 patients (14 femoral heads and seven femoral condyles) were treated with HBOT since 1989. Two patients were excluded. Within the femoral head group, nine of the 14 joints (64%) had stable or improved magnetic resonance imaging (MRI) scans post treatment and at six months (minimum); 10 joints (71%) had good outcomes subjectively, three joints required surgical intervention, and three patients developed mild aural barotrauma. Within the femoral condyle group, all five joints had stable or improved post-treatment MRI scans (four had visible improvement in oedema and/or chondral stability), four joints reported good outcomes subjectively, none of the patients required surgical intervention (follow-up > six months). Conclusions: This single centre retrospective study observed prevention of disease progression in femoral AVN with the use of HBOT, comparable to other published studies. This adds to the body of evidence that HBOT may have a significant role in the treatment of femoral AVN.

Increased Metabolic Rate of Hauled-Out Harbor Seals (Phoca vitulina) during the Molt.

AbstractHarbor seals (Phoca vitulina) live in cold temperate or polar seas and molt annually, renewing their fur over a period of approximately 4 wk. Epidermal processes at this time require a warm skin; therefore, to avoid an excessive energy cost at sea during the molt, harbor seals and many other pinnipeds increase the proportion of time they are hauled out on land. We predicted that metabolic rate during haul-out would be greater during the molt to sustain an elevated skin temperature in order to optimize skin and hair growth. To examine this, we measured post-haul-out oxygen consumption (V˙O2) in captive harbor seals during molt and postmolt periods. We recorded greater V˙O2 of seals while they were molting than when the molt was complete. Post-haul-out V˙O2 increased faster and reached a greater maximum during the first 40 min. Thereafter, V˙O2 decreased but still remained greater, suggesting that while metabolic rate was relatively high throughout haul-outs, it was most pronounced in the first 40 min. Air temperature, estimated heat increment of feeding, and mass also explained 15.5% of V˙O2 variation over 180 min after haul-out, suggesting that the environment, feeding state, and body size influenced the metabolic rate of individual animals. These results show that molting seals have greater metabolic rates when hauled out, especially during the early stages of the haul-out period. As a consequence, human disturbance that changes the haul-out behavior of molting seals will increase their energy costs and potentially extend the duration of the molt.

High-flow nasal cannula versus standard oxygen therapy assisting sedation during endoscopic retrograde cholangiopancreatography in high risk cases (OTHER): study protocol of a randomised multicentric trial.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly common intervention in the treatment of pancreaticobiliary disorders. Patients are often elderly with complex co-morbidities. While monitored anaesthesia care with sedation is commonly used for most cases, few would require general anaesthesia with an endotracheal tube. Both low-flow and high-flow nasal cannulas (HFNC) are established ways of delivering supplemental oxygen, but it is unclear whether one technique is better than the other. HFNC seems a promising tool for advanced procedures but evidence to support its application in high-risk ERCP cases is limited. The rate of oxygen desaturation during endoscopy has been reported to be as high as 11%-50% and the method of oxygen delivery for ERCP merits further study. METHODS/DESIGN: This is a prospective, randomised, multicentre trial comparing the efficacy of oxygen supplementation through HFNC versus low-flow nasal cannula during ERCP, in a cohort of patients at risk of adverse respiratory events. A total of 132 patients will be recruited across three sites and randomly assigned to either the low-flow or the HFNC group. The primary outcome is the proportion of patients experiencing hypoxia, defined by any event of SpO2 < 90%. The secondary outcomes include parameters centred on oxygenation, requirement of airway manoeuvres, successful completion of procedure, perioperative complications, patient satisfaction and cost analysis of the consumables. An intention-to-treat principle will be applied while analysing. DISCUSSION: The demand for ERCPs is likely to increase in the future with the aging population. Our study results may lead to improved outcomes and reduce airway-related complications in patients undergoing ERCPs. The results will be presented at national and international meetings and published in peer-reviewed journals. TRIAL REGISTRATION: www.ANZCTR.org.au, CTRN12619000397112. Registered on 12 March 2019.

Stress and pain relief in the care of the surgical neonate.

In recent years, there has been a major change in our thinking about the way neonates experience stress. This understanding has led to advances in anesthetic technique and the pre- and postoperative care of the surgical neonate. Stress can develop before birth due to placental insufficiency. This can lead to preterm delivery, and the preterm infant is much more vulnerable to stressful stimulus. Stress is detrimental to the neonate in the short term and can also have adverse effects on the future wellbeing of the child. Limiting stress is not just about good pain control. The nursing environment is vitally important. Much can be achieved with good attention to detail in this respect. The effects of stress and the ways they can be minimized are discussed.

Adenosarcoma arising in inguinal endometriosis.

BACKGROUND: Adenosarcoma arising in inguinal endometriosis is a rare clinical entity. CASE: A 47-year-old nulligravida presented with a persistent and enlarged right groin mass. Sixteen years earlier she had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis and was placed on estrogen therapy. Surgical en bloc excision of the 12 x 4 cm inguinal mass revealed adenosarcoma arising in endometriosis. CONCLUSION: Although a rare entity, adenosarcoma arising in inguinal endometriosis should be included in the differential diagnosis for those patients with a history of endometriosis and chronic unopposed estrogen therapy who present with a groin mass.

Effects of methylphenidate on cognitive functions in children and adolescents with attention-deficit/hyperactivity disorder: evidence from a systematic review and a meta-analysis.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with a broad range of neuropsychological impairments. The relationship between these neuropsychological deficits and the defining symptoms of ADHD seems more complex than originally thought. Methylphenidate (MPH) is an effective treatment for ADHD symptoms, but its impact on cognition is less clearly understood. METHODS: With a common systematic search strategy and a rigorous coding and data extraction strategy across domains, we searched electronic databases to identify published placebo controlled trials that compared MPH and placebo on executive and nonexecutive memory, reaction time, reaction time variability and response inhibition in children and adolescents (5-18 years) with a formal diagnosis of ADHD. RESULTS: Sixty studies were included in the review, of which 36 contained sufficient data for meta-analysis. Methylphenidate was superior to placebo in all five meta-analyses: executive memory, standardized mean difference (SMD) .26, 95% confidence interval (CI): -.39 to -.13; non-executive memory, SMD .60, 95% CI: -.79 to -.41; reaction time, SMD .24, 95% CI: -.33 to -.15; reaction time variability, SMD .62, 95% CI: -.90 to -.34; response inhibition, SMD .41, 95% CI: -.55 to -.27. CONCLUSIONS: These data support the potentially important effects of MPH on various aspects of cognition known to be associated with ADHD. Consideration should be given to adding cognitive outcomes to the assessment of treatment outcome in ADHD, considering the complexity of the relationship between ADHD symptoms and cognition.

Abdominal extraperitoneal excision of a foreign body in the pararectal space.

Permanent suture material and synthetic grafts can be used as part of pelvic organ prolapse surgery. These materials are often attached to the sacrospinous ligament or passed in retroperitoneal spaces. There is a risk for erosion and granulation tissue formation with any of these materials. Typically, this is managed through a transvaginal incision.We present a case of a postmenopausal woman with persistent granulation tissue and a sinus tract from a braided polyester (Ethibond) suture placed in the right sacrospinous ligament fixation. After failing several attempts at treating this granulation tissue through a vaginal incision, we managed this via an abdominal retroperitoneal approach.

New tools in the treatment of motility disorders in children.

Gastrointestinal motility disorders can develop in neurologically impaired children and those with congenital malformations of the gut. It is characterized by moderate to severe abdominal pain, vomiting, and failure to thrive. Antral dysmotility after fundoplication and increased sympathetic over activity are 2 factors associated with this condition that make it difficult to treat. This paper proposes a management strategy using metoclopramide, celiac plexus blockade, and thoracic splanchnectomy. It reviews our experience with 11 patients.