The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay

OBJECTIVE

To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.

SUMMARY BACKGROUND DATA

ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain under-investigated.

METHODS

This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both pre- and post-intubation. Multivariable logistic regression analysis was performed to identify the modifiable and non-modifiable factors associated with PIH.

RESULTS

708 patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) and 71% were male. Median [IQR] arrival GCS was 7 [3-13]. Patients who developed PIH had a lower mean (SD) pre-intubation SBP (118 (46) vs. 138 (28), P<0.001) and higher median [IQR] ISS (27 [21-38] vs. 21 [9-26], P<0.001). Multivariable regression analysis identified BMI>25, increasing ISS, penetrating injury, spinal cord injury, Pre-intubation PRBC requirements, and diabetes mellitus as non-modifiable risk factors associated with increased odds of PIH. In contrast, pre-intubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH.

CONCLUSION

More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and non-modifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival.

LEVEL OF EVIDENCE

Level III, Prognostic Study.

Zircons reveal the history of fluctuations in oxidation state of crustal magmatism and supercontinent cycle

We apply a zircon redox index to a global compilation of detrital zircons to track the variation of oxidation state, expressed as ΔFMQ, through Earth's history. Those from I-type rocks, which comprise mantle and crustal igneous protoliths, including tonalite-trondhjemite-granodiorites (TTGs), generally have a high oxidation state (ΔFMQ > 0). In contrast, zircons from igneous rocks derived from supracrustal source rocks (S-type) are commonly reduced (ΔFMQ < 0). With the probability density function derived from the Gaussian-Kernel-Density-Estimation, we use the maximum likelihood estimation (MLE) to distinguish S-type from I-type zircons through Earth's history using zircon redox. Voluminous S-type magma production shows a ca. 600 Ma cyclicity that is closely related to the supercontinent cycle. We link a cyclic drop in redox values after 2.6 Ga to periodic S-type magma generation associated with burial and melting of metasedimentary rocks during supercontinent assembly and amalgamation. The ΔFMQ of the detrital zircons rise at ∼3.5 Ga followed by a consistent average ΔFMQ > 0 over the last 3 Ga. Given that the redox state of magmas is independent of crustal thickness and silica variation, and elevated values are likely more closely related to tectonic setting, we suggest that the consistent average ΔFMQ > 0 from ca. 3.5 Ga onwards relates to recycling of oceanic lithosphere back into the mantle in what eventually became established as subduction zones. The more reduced magmas associated with sedimentary sources, became established at 2.6 Ga, presumably in response to continental rocks rising above sea-level, and follow peaks of productivity associated with the supercontinent cycle.

Right Ventricular Dysfunction Patterns among Patients with COVID-19 in the Intensive Care Unit: A Retrospective Cohort Analysis

Rationale: Right ventricular (RV) dysfunction is common among patients hospitalized with coronavirus disease (COVID-19); however, its epidemiology may depend on the echocardiographic parameters used to define it. Objectives: To evaluate the prevalence of abnormalities in three common echocardiographic parameters of RV function among patients with COVID-19 admitted to the intensive care unit (ICU), as well as the effect of RV dilatation on differential parameter abnormality and the association of RV dysfunction with 60-day mortality. Methods: We conducted a retrospective cohort study of ICU patients with COVID-19 between March 4, 2020, and March 4, 2021, who received a transthoracic echocardiogram within 48 hours before to at most 7 days after ICU admission. RV dysfunction and dilatation, respectively, were defined by guideline thresholds for tricuspid annular plane systolic excursion (TAPSE), RV fractional area change, RV free wall longitudinal strain (RVFWS), and RV basal dimension or RV end-diastolic area. Association of RV dysfunction with 60-day mortality was assessed through logistic regression adjusting for age, prior history of congestive heart failure, invasive ventilation at the time of transthoracic echocardiogram, and Acute Physiology and Chronic Health Evaluation II score. Results: A total of 116 patients were included, of whom 69% had RV dysfunction by one or more parameters, and 36.3% of these had RV dilatation. The three most common patterns of RV dysfunction were the presence of three abnormalities, the combination of abnormal RVFWS and TAPSE, and isolated TAPSE abnormality. Patients with RV dilatation had worse RV fractional area change (24% vs. 36%; P = 0.001), worse RVFWS (16.3% vs. 19.1%; P = 0.005), higher RV systolic pressure (45 mm Hg vs. 31 mm Hg; P = 0.001) but similar TAPSE (13 mm vs. 13 mm; P = 0.30) compared with those with normal RV size. After multivariable adjustment, 60-day mortality was significantly associated with RV dysfunction (odds ratio, 2.91; 95% confidence interval, 1.01-9.44), as was the presence of at least two parameter abnormalities. Conclusions: ICU patients with COVID-19 had significant heterogeneity in RV function abnormalities present with different patterns associated with RV dilatation. RV dysfunction by any parameter was associated with increased mortality. Therefore, a multiparameter evaluation may be critical in recognizing RV dysfunction in COVID-19.

Transitioning from epicutaneous to oral peanut immunotherapy

Introduction

Epicutaneous immunotherapy (EPIT) has been tested in clinical trials for children with peanut allergy (PA) for its safety and efficacy in inducing desensitization. Aside from peanut avoidance and symptom management, oral immunotherapy (OIT) is another option for PA patients. However, OIT can be associated with adverse events and pose safety concerns to children and their caregivers.

Methods

This study assessed 27 children who successfully completed a peanut EPIT trial. 18 of them transitioned to peanut OIT with starting doses ranging from 10-600 mg of peanut protein. Our aim was to learn more about the EPIT to OIT experience through descriptive survey responses and to gather information that may support the sequential use of the two immunotherapies for safe and positive outcomes that may not be achieved by either alone.

Results

Overall, children and their caregivers had less anxiety about starting OIT after having had peanut exposure through EPIT. Most children who transitioned from EPIT to OIT had no or minor symptoms initially, with symptoms lessening later in OIT. Most were also able to maintain or increase their peanut dose over time, achieving maintenance doses of 60-2,000 mg.

Discussion

In comparison with current literature on OIT for PA in children, the reported symptoms appeared less severe and less prevalent in the EPIT to OIT group. However, there were 3 participants who withdrew from OIT due to the development of intolerable symptoms. This study provides initial data in support of EPIT to OIT, and larger randomized controlled trials assessing effectiveness of the two therapies together are warranted.

Association between Obesity and Length of COVID-19 Hospitalization: Unexpected Insights from the American Heart Association National COVID-19 Registry

Background

The mechanism for possible association between obesity and poor clinical outcomes from Coronavirus Disease 2019 (COVID-19) remains unclear.

Methods

We analyzed 22,915 adult COVID-19 patients hospitalized from March 2020 to April 2021 to non-intensive care using the American Heart Association National COVID Registry. A multivariable Poisson model adjusted for age, sex, medical history, admission respiratory status, hospitalization characteristics, and laboratory findings was used to calculate length of stay (LOS) as a function of body mass index (BMI). We similarly analyzed 5,327 patients admitted to intensive care for comparison.

Results

Relative to normal BMI subjects, overweight, class I obese, and class II obese patients had approximately half-day reductions in LOS (–0.469 days, P<0.01; –0.480 days, P<0.01; –0.578 days, P<0.01, respectively).

Conclusion

The model identified a dose-dependent, inverse relationship between BMI category and LOS for COVID-19, which was not seen when the model was applied to critically ill patients.

Anti-nucleocapsid antibody levels and pulmonary comorbid conditions are linked to post-COVID-19 syndrome

BACKGROUNDProlonged symptoms after SARS-CoV-2 infection are well documented. However, which factors influence development of long-term symptoms, how symptoms vary across ethnic groups, and whether long-term symptoms correlate with biomarkers are points that remain elusive.METHODSAdult SARS-CoV-2 reverse transcription PCR-positive (RT-PCR-positive) patients were recruited at Stanford from March 2020 to February 2021. Study participants were seen for in-person visits at diagnosis and every 1-3 months for up to 1 year after diagnosis; they completed symptom surveys and underwent blood draws and nasal swab collections at each visit.RESULTSOur cohort (n = 617) ranged from asymptomatic to critical COVID-19 infections. In total, 40% of participants reported at least 1 symptom associated with COVID-19 six months after diagnosis. Median time from diagnosis to first resolution of all symptoms was 44 days; median time from diagnosis to sustained symptom resolution with no recurring symptoms for 1 month or longer was 214 days. Anti-nucleocapsid IgG level in the first week after positive RT-PCR test and history of lung disease were associated with time to sustained symptom resolution. COVID-19 disease severity, ethnicity, age, sex, and remdesivir use did not affect time to sustained symptom resolution.CONCLUSIONWe found that all disease severities had a similar risk of developing post-COVID-19 syndrome in an ethnically diverse population. Comorbid lung disease and lower levels of initial IgG response to SARS-CoV-2 nucleocapsid antigen were associated with longer symptom duration.TRIAL REGISTRATIONClinicalTrials.gov, NCT04373148.FUNDINGNIH UL1TR003142 CTSA grant, NIH U54CA260517 grant, NIEHS R21 ES03304901, Sean N Parker Center for Allergy and Asthma Research at Stanford University, Chan Zuckerberg Biohub, Chan Zuckerberg Initiative, Sunshine Foundation, Crown Foundation, and Parker Foundation.

Constrictive Pericarditis Revealing Rare Case of ALH Amyloidosis With Underlying Lymphoplasmacytic Lymphoma (Waldenstrom Macroglobulinemia)

We present a case of pericardial amyloidosis with associated lymphoplasmacytic lymphoma in a patient with chronic worsening shortness of breath and cough. This case highlights the wide variation in the presentation of cardiac amyloidosis, and the rare occurrence of clinically significant light-chain and heavy-chain amyloidosis in the pericardium. (Level of Difficulty: Advanced.)

Virtual Reality Reduces Pediatric Anxiety During Food Allergy Clinical Trials: A Pilot Randomized, Pragmatic Study

Phlebotomy procedures required in food allergy (FA) diagnosis and clinical trials often induce fear and anxiety for pediatric patients. The primary aim of this study was to determine whether virtual reality (VR) applications were effective in reducing anxiety for pediatric FA patients undergoing phlebotomy during FA clinical trials. Secondary aims assessed fear, pain, procedural compliance, and adverse events. Participants undergoing phlebotomy were enrolled and randomized to a VR group or standard of care (SOC) group for this prospective pilot randomized, pragmatic study. Participants in the VR group played interactive applications on a customized Samsung Gear VR headset and those in the SOC group received the standard of care. Participants' anxiety, fear, and pain were assessed with the Children's Anxiety Meter, Children's Fear Scale, and FACES pain scale pre, during, and post phlebotomy procedure. Compliance was assessed using the modified Induction Compliance Checklist during the procedure and compared between two groups. Forty-nine participants were randomized to VR (n = 26) and SOC (n = 23) groups. Although both the VR and SOC groups experienced a decrease in anxiety and fear from pre- to post-procedure, those in the VR group experienced less anxiety and fear during the procedure than SOC participants. Similarly, both groups experienced an increase in pain from pre- to post-procedure; however, the VR group reported less pain during the procedure than SOC. Fewer symptoms of procedural non-compliance were reported in the VR group. Interactive VR applications may be an effective tool for reducing fear, anxiety, and pain during phlebotomy for FA clinical trials.

The social cost of methane: theory and applications

Methane emissions contribute to global warming, damage public health and reduce the yield of agricultural and forest ecosystems. Quantifying these damages to the planetary commons by calculating the social cost of methane (SCM) facilitates more comprehensive cost-benefit analyses of methane emissions control measures and is the first step to potentially incorporating them into the marketplace. Use of a broad measure of social welfare is also an attractive alternative or supplement to emission metrics focused on a temperature target in a given year as it incentivizes action to provide benefits over a broader range of impacts and timescales. Calculating the SCM using consistent temporal treatment of physical and economic processes and incorporating climate- and air quality-related impacts, we find large SCM values, e.g. ∼$2400 per ton and ∼$3600 per ton with 5% and 3% discount rates respectively. These values are ∼100 and 50 times greater than corresponding social costs for carbon dioxide. Our results suggest that ∼110 of 140 Mt of identified methane abatement via scaling up existing technology and policy options provide societal benefits that outweigh implementation costs. Within the energy sector, renewables compare far better against use of natural gas in electricity generation when incorporating these social costs for methane. In the agricultural sector, changes in livestock management practices, promoting healthy diets including reduced beef and dairy consumption, and reductions in food waste have been promoted as ways to mitigate emissions, and these are shown here to indeed have the potential to provide large societal benefits (∼$50-150 billion per year). Examining recent trends in methane and carbon dioxide, we find that increases in methane emissions may have offset much of the societal benefits from a slowdown in the growth rate of carbon dioxide emissions. The results indicate that efforts to reduce methane emissions via policies spanning a wide range of technical, regulatory and behavioural options provide benefits at little or negative net cost. Recognition of the full SCM, which has typically been undervalued, may help catalyze actions to reduce emissions and thereby provide a broad set of societal benefits.

Land-use emissions play a critical role in land-based mitigation for Paris climate targets

Scenarios that limit global warming to below 2 °C by 2100 assume significant land-use change to support large-scale carbon dioxide (CO₂) removal from the atmosphere by afforestation/reforestation, avoided deforestation, and Biomass Energy with Carbon Capture and Storage (BECCS). The more ambitious mitigation scenarios require even greater land area for mitigation and/or earlier adoption of CO₂ removal strategies. Here we show that additional land-use change to meet a 1.5 °C climate change target could result in net losses of carbon from the land. The effectiveness of BECCS strongly depends on several assumptions related to the choice of biomass, the fate of initial above ground biomass, and the fossil-fuel emissions offset in the energy system. Depending on these factors, carbon removed from the atmosphere through BECCS could easily be offset by losses due to land-use change. If BECCS involves replacing high-carbon content ecosystems with crops, then forest-based mitigation could be more efficient for atmospheric CO₂ removal than BECCS.

Land-based mitigation for meeting the Paris climate target must consider the carbon cycle impacts of land-use change. Here the authors show that when bioenergy crops replace high carbon content ecosystems, forest-based mitigation could be more effective for CO₂ removal than bioenergy crops with carbon capture and storage.

The effect of future ambient air pollution on human premature mortality to 2100 using output from the ACCMIP model ensemble

Ambient air pollution from ground-level ozone and fine particulate matter (PM_2.5) is associated with premature mortality. Future concentrations of these air pollutants will be driven by natural and anthropogenic emissions and by climate change. Using anthropogenic and biomass burning emissions projected in the four Representative Concentration Pathway scenarios (RCPs), the ACCMIP ensemble of chemistry-climate models simulated future concentrations of ozone and PM_2.5 at selected decades between 2000 and 2100. We use output from the ACCMIP ensemble, together with projections of future population and baseline mortality rates, to quantify the human premature mortality impacts of future ambient air pollution. Future air pollution-related premature mortality in 2030, 2050 and 2100 is estimated for each scenario and for each model using a health impact function based on changes in concentrations of ozone and PM_2.5 relative to 2000 and projected future population and baseline mortality rates. Additionally, the global mortality burden of ozone and PM_2.5 in 2000 and each future period is estimated relative to 1850 concentrations, using present-day and future population and baseline mortality rates. The change in future ozone concentrations relative to 2000 is associated with excess global premature mortality in some scenarios/periods, particularly in RCP8.5 in 2100 (316 thousand deaths/year), likely driven by the large increase in methane emissions and by the net effect of climate change projected in this scenario, but it leads to considerable avoided premature mortality for the three other RCPs. However, the global mortality burden of ozone markedly increases from 382,000 (121,000 to 728,000) deaths/year in 2000 to between 1.09 and 2.36 million deaths/year in 2100, across RCPs, mostly due to the effect of increases in population and baseline mortality rates. PM_2.5 concentrations decrease relative to 2000 in all scenarios, due to projected reductions in emissions, and are associated with avoided premature mortality, particularly in 2100: between -2.39 and -1.31 million deaths/year for the four RCPs. The global mortality burden of PM_2.5 is estimated to decrease from 1.70 (1.30 to 2.10) million deaths/year in 2000 to between 0.95 and 1.55 million deaths/year in 2100 for the four RCPs, due to the combined effect of decreases in PM_2.5 concentrations and changes in population and baseline mortality rates. Trends in future air pollution-related mortality vary regionally across scenarios, reflecting assumptions for economic growth and air pollution control specific to each RCP and region. Mortality estimates differ among chemistry-climate models due to differences in simulated pollutant concentrations, which is the greatest contributor to overall mortality uncertainty for most cases assessed here, supporting the use of model ensembles to characterize uncertainty. Increases in exposed population and baseline mortality rates of respiratory diseases magnify the impact on premature mortality of changes in future air pollutant concentrations and explain why the future global mortality burden of air pollution can exceed the current burden, even where air pollutant concentrations decrease.

Megacities and climate change - A brief overview

Cities have developed into the hotspots of human economic activity. From the appearance of the first cities in the Neolithic to 21st century metropolis their impact on the environment has always been apparent. With more people living in cities than in rural environments now it becomes crucial to understand these environmental impacts. With the immergence of megacities in the 20th century and their continued growth in both, population and economic power, the environmental impact has reached the global scale. In this paper we examine megacity impacts on atmospheric composition and climate. We present basic concepts, discuss various definitions of footprints, summarize research on megacity impacts and assess the impact of megacity emissions on air quality and on the climate at the regional to global scale. The intention and ambition of this paper is to give a comprehensive but brief overview of the science with regard to megacities and the environment.

NOTCH1 regulates matrix gla protein and calcification gene networks in human valve endothelium

Valvular and vascular calcification are common causes of cardiovascular morbidity and mortality. Developing effective treatments requires understanding the molecular underpinnings of these processes. Shear stress is thought to play a role in inhibiting calcification. Furthermore, NOTCH1 regulates vascular and valvular endothelium, and human mutations in NOTCH1 can cause calcific aortic valve disease. Here, we determined the genome-wide impact of altering shear stress and NOTCH signaling on human aortic valve endothelium. mRNA-sequencing of primary human aortic valve endothelial cells (HAVECs) with or without knockdown of NOTCH1, in the presence or absence of shear stress, revealed NOTCH1-dependency of the atherosclerosis-related gene connexin 40 (GJA5), and numerous repressors of endochondral ossification. Among these, matrix gla protein (MGP) is highly expressed in aortic valve and vasculature, and inhibits soft tissue calcification by sequestering bone morphogenetic proteins (BMPs). Altering NOTCH1 levels affected MGP mRNA and protein in HAVECs. Furthermore, shear stress activated NOTCH signaling and MGP in a NOTCH1-dependent manner. NOTCH1 positively regulated endothelial MGP in vivo through specific binding motifs upstream of MGP. Our studies suggest that shear stress activates NOTCH1 in primary human aortic valve endothelial cells leading to downregulation of osteoblast-like gene networks that play a role in tissue calcification.

Global air quality and climate

Emissions of air pollutants and their precursors determine regional air quality and can alter climate. Climate change can perturb the long-range transport, chemical processing, and local meteorology that influence air pollution. We review the implications of projected changes in methane (CH(4)), ozone precursors (O(3)), and aerosols for climate (expressed in terms of the radiative forcing metric or changes in global surface temperature) and hemispheric-to-continental scale air quality. Reducing the O(3) precursor CH(4) would slow near-term warming by decreasing both CH(4) and tropospheric O(3). Uncertainty remains as to the net climate forcing from anthropogenic nitrogen oxide (NO(x)) emissions, which increase tropospheric O(3) (warming) but also increase aerosols and decrease CH(4) (both cooling). Anthropogenic emissions of carbon monoxide (CO) and non-CH(4) volatile organic compounds (NMVOC) warm by increasing both O(3) and CH(4). Radiative impacts from secondary organic aerosols (SOA) are poorly understood. Black carbon emission controls, by reducing the absorption of sunlight in the atmosphere and on snow and ice, have the potential to slow near-term warming, but uncertainties in coincident emissions of reflective (cooling) aerosols and poorly constrained cloud indirect effects confound robust estimates of net climate impacts. Reducing sulfate and nitrate aerosols would improve air quality and lessen interference with the hydrologic cycle, but lead to warming. A holistic and balanced view is thus needed to assess how air pollution controls influence climate; a first step towards this goal involves estimating net climate impacts from individual emission sectors. Modeling and observational analyses suggest a warming climate degrades air quality (increasing surface O(3) and particulate matter) in many populated regions, including during pollution episodes. Prior Intergovernmental Panel on Climate Change (IPCC) scenarios (SRES) allowed unconstrained growth, whereas the Representative Concentration Pathway (RCP) scenarios assume uniformly an aggressive reduction, of air pollutant emissions. New estimates from the current generation of chemistry-climate models with RCP emissions thus project improved air quality over the next century relative to those using the IPCC SRES scenarios. These two sets of projections likely bracket possible futures. We find that uncertainty in emission-driven changes in air quality is generally greater than uncertainty in climate-driven changes. Confidence in air quality projections is limited by the reliability of anthropogenic emission trajectories and the uncertainties in regional climate responses, feedbacks with the terrestrial biosphere, and oxidation pathways affecting O(3) and SOA.

The effects of tropospheric ozone on net primary productivity and implications for climate change

Tropospheric ozone (O(3)) is a global air pollutant that causes billions of dollars in lost plant productivity annually. It is an important anthropogenic greenhouse gas, and as a secondary air pollutant, it is present at high concentrations in rural areas far from industrial sources. It also reduces plant productivity by entering leaves through the stomata, generating other reactive oxygen species and causing oxidative stress, which in turn decreases photosynthesis, plant growth, and biomass accumulation. The deposition of O(3) into vegetation through stomata is an important sink for tropospheric O(3), but this sink is modified by other aspects of environmental change, including rising atmospheric carbon dioxide concentrations, rising temperature, altered precipitation, and nitrogen availability. We review the atmospheric chemistry governing tropospheric O(3) mass balance, the effects of O(3) on stomatal conductance and net primary productivity, and implications for agriculture, carbon sequestration, and climate change.

Accretionary orogens through Earth history

Accretionary orogens form at intraoceanic and continental margin convergent plate boundaries. They include the supra-subduction zone forearc, magmatic arc and back-arc components. Accretionary orogens can be grouped into retreating and advancing types, based on their kinematic framework and resulting geological character. Retreating orogens (e.g. modern western Pacific) are undergoing long-term extension in response to the site of subduction of the lower plate retreating with respect to the overriding plate and are characterized by back-arc basins. Advancing orogens (e.g. Andes) develop in an environment in which the overriding plate is advancing towards the downgoing plate, resulting in the development of foreland fold and thrust belts and crustal thickening. Cratonization of accretionary orogens occurs during continuing plate convergence and requires transient coupling across the plate boundary with strain concentrated in zones of mechanical and thermal weakening such as the magmatic arc and back-arc region. Potential driving mechanisms for coupling include accretion of buoyant lithosphere (terrane accretion), flat-slab subduction, and rapid absolute upper plate motion overriding the downgoing plate. Accretionary orogens have been active throughout Earth history, extending back until at least 3.2 Ga, and potentially earlier, and provide an important constraint on the initiation of horizontal motion of lithospheric plates on Earth. They have been responsible for major growth of the continental lithosphere through the addition of juvenile magmatic products but are also major sites of consumption and reworking of continental crust through time, through sediment subduction and subduction erosion. It is probable that the rates of crustal growth and destruction are roughly equal, implying that net growth since the Archaean is effectively zero.

The Louisiana emergency department behavioral health challenge

Hurricane Katrina uncovered and exaggerated Louisiana's behavioral health crisis. Patients with mental illness are backlogged in emergency rooms across the state, unable to access inpatient psychiatric treatment. Post-Katrina, part of the department of psychiatry of the Louisiana State University (LSU) New Orleans was displaced to Huey P. Long Medical Center (HPLMC) in Pineville, Louisiana. While displaced, LSU wrote a grant to develop a psychiatric emergency room service at HPLMC and in the process experienced a number of barriers to optimal behavioral healthcare in the emergency department (ED). The ED plays an essential role in our state's system of care for the mentally ill. However, EDs throughout the nation traditionally have not had the provisions necessary for optimal behavioral healthcare. In this article, we will address barriers to implementing proper provisions for sound behavioral healthcare in the ED. We will outline an affordable and available mental health personnel infrastructure that integrates with the ED's medical model of care, and improves quality of care of the mentally ill and the functional level of the ED, as well as the morale and job satisfaction of ED healthcare providers.

Indirect radiative forcing of climate change through ozone effects on the land-carbon sink

The evolution of the Earth's climate over the twenty-first century depends on the rate at which anthropogenic carbon dioxide emissions are removed from the atmosphere by the ocean and land carbon cycles. Coupled climate-carbon cycle models suggest that global warming will act to limit the land-carbon sink, but these first generation models neglected the impacts of changing atmospheric chemistry. Emissions associated with fossil fuel and biomass burning have acted to approximately double the global mean tropospheric ozone concentration, and further increases are expected over the twenty-first century. Tropospheric ozone is known to damage plants, reducing plant primary productivity and crop yields, yet increasing atmospheric carbon dioxide concentrations are thought to stimulate plant primary productivity. Increased carbon dioxide and ozone levels can both lead to stomatal closure, which reduces the uptake of either gas, and in turn limits the damaging effect of ozone and the carbon dioxide fertilization of photosynthesis. Here we estimate the impact of projected changes in ozone levels on the land-carbon sink, using a global land carbon cycle model modified to include the effect of ozone deposition on photosynthesis and to account for interactions between ozone and carbon dioxide through stomatal closure. For a range of sensitivity parameters based on manipulative field experiments, we find a significant suppression of the global land-carbon sink as increases in ozone concentrations affect plant productivity. In consequence, more carbon dioxide accumulates in the atmosphere. We suggest that the resulting indirect radiative forcing by ozone effects on plants could contribute more to global warming than the direct radiative forcing due to tropospheric ozone increases.

The contribution from shipping emissions to air quality and acid deposition in Europe

A global three-dimensional Lagrangian chemistry-transport model STOCHEM is used to describe the European regional acid deposition and ozone air quality impacts along the Atlantic Ocean seaboard of Europe, from the SO2, NOx, VOCs and CO emissions from international shipping under conditions appropriate to the year 2000. Model-derived total sulfur deposition from international shipping reaches over 200 mg S m(-2) yr(-1) over the southwestern approaches to the British Isles and Brittany. The contribution from international shipping to surface ozone concentrations during the summertime, peaks at about 6 ppb over Ireland, Brittany and Portugal. Shipping emissions act as an external influence on acid deposition and ozone air quality within Europe and may require control actions in the future if strict deposition and air quality targets are to be met.

Nicotinamide adenine dinucleotide (phosphate) reduced:quinone oxidoreductase and glutathione S-transferase M1 polymorphisms and childhood asthma

Nicotinamide adenine dinucleotide (phosphate) reduced:quinone oxidoreductase (NQO1) and glutathione S-transferase (GST) M1 are phase II enzymes important in response to oxidative stress, such as occurs during exposure to ozone. We examined the relationship between functionally significant polymorphisms in NQO1 (Pro187Ser) and GSTM1 (homozygous deletion) and asthma risk in children with high lifetime exposure to ozone. We enrolled children with asthma from the allergy referral clinic at a public pediatric hospital in Mexico City, together with their parents. We assayed for the Pro187Ser polymorphism in NQO1 using a polymerase chain reaction-restriction fragment length polymorphism assay and for the presence of GSTM1 by polymerase chain reaction among 218 case-parent triads. We did not find strong evidence of an association between NQO1 genotype alone and asthma risk. However, among subjects with homozygous deletion of GSTM1, carriers of a serine allele were at significantly reduced risk of asthma compared with Pro/Pro homozygotes (relative risk = 0.4; 95% confidence interval, 0.2-0.8). The p value for difference in relative risk for NQO1 by GSTM1 genotype = 0.013. These data are consistent with a protective effect of the NQO1 Ser allele in this population of GSTM1-null children with high ozone exposure.

Directed mutagenesis of the Rhodobacter capsulatus puhA gene and orf 214: pleiotropic effects on photosynthetic reaction center and light-harvesting 1 complexes

Rhodobacter capsulatus puhA mutant strains containing either a nonpolar, translationally in-frame deletion or a polar insertion of an antibiotic resistance cartridge were constructed and evaluated for their photosynthetic growth properties, absorption spectroscopy profiles, and chromatophore protein compositions. Both types of mutants were found to be incapable of photosynthetic growth and deficient in the reaction center (RC) and light-harvesting 1 (LH1) complexes. The translationally in-frame puhA deletion strains were restored to the parental strain phenotypes by complementation with a plasmid containing the puhA gene, whereas the polar puhA mutants were not. Analogous nonpolar and polar disruptions of orf 214 (located immediately 3' of the puhA gene) were made, and the resultant mutant strains were evaluated as described above. The strain containing the nonpolar deletion of orf 214 exhibited severely impaired photosynthetic growth properties and had greatly reduced levels of the RC and LH1 complexes. Complementation of this strain with a plasmid that expressed orf 214 from the nifHDK promoter restored photosynthetic growth capability, as well as the RC and LH1 complexes. The polar disruption of orf 214 yielded cells that were incapable of photosynthetic growth and had even lower levels of the RC and LH1 complexes, and complementation in trans with orf 214 only marginally improved these deficiencies. These results indicate that orf 214 and at least one additional gene located 3' of orf 214 are required to obtain the RC and LH1 complexes, and transcription read-through from the puhA superoperon is necessary for optimal expression of these new photosynthesis genes.

Pilot clinical study of a fluoride resin and conditioning paste for desensitising dentine

The clinical trial was carried out on 34 'hypersensitive' teeth in 10 subjects. Dentine sensitivity was measured as the pain perception thresholds to controlled air and probe stimuli. In each subject, pairs of teeth of comparable initial sensitivity were randomly assigned to a test (T) or control (C) treatment. All teeth were cleaned and a conditioning paste applied. Group T was treated with a topically-applied light-cured resin; Group C received a placebo, sham light-cured. Air sensitivity was remeasured after treatment, and the procedures were repeated after 1, 2, and 3 weeks. When comparing air thresholds before and after treatment at each visit, the test agent caused significantly greater reduction in sensitivity than the control. The median increase in air threshold in the test group was 2.5 s at visit no. 1, 1.3 s at visit no. 2 and 0.8 s at visit no. 3. Comparisons of the initial thresholds at each visit showed no significant long-term changes in sensitivity in either group.

Effect of Kabatiella caulivora isolates and host growth stage on symptom expression and resistance in Trifolium subterraneum

Occasional severe clover scorch disease outbreaks from Kabatiella caulivora have occurred in the 2 partially resistant Trifolium subterraneum cultivars, Karridale and Meteora. All K. caulivora isolates screened, including isolates taken from severely damaged field swards of Karridale and Meteora, were highly pathogenic, but there was variation in the pathogenicity of some isolates and there was a significant cultivar x isolate interaction in 1 of 2 studies. Plant age affected development of disease. Cultivars Karridale, Mt Barker and Woogenellup were least susceptible when inoculated 10 weeks from sowing, and there was a strong plant age x cultivar interaction. However, there was no suggestion that severe disease in Karridale was due to increased susceptibility at a particular plant growth stage. In resistance screening studies, the resistance rankings of subterranean clover varieties sometimes changed markedly depending upon the test isolate, and in 1 of 2 studies, there was a significant cultivar x isolate interaction. While there was significant overall correlation between glasshouse and field data, this only accounted for 49.9 and 20.5%, respectively, of the variation. Glasshouse screening was not suitable for replacing field screening but it was useful for confirming the field resistance of some highly resistant genotypes.

Factors affecting diet selection by sheep. V. Observed and predicted preference ranking for six cultivars of subterranean clover

Samples from six cultivars of subterranean clover (Trifolium subterraneum) were harvested at two stages of maturity (vegetative and senescent) and one cultivar (Dinninup) at two additional stages. The samples were freeze dried to 90% dry matter, cut to 25 mm length and offered in pairs to trained sheep to determine their preference rankings. Within each stage of maturity, each cultivar was compared with every other cultivar. The vegetative clovers showed only a small (non significant) range in mean per cent preference (57-41), but the senescent material showed a much larger range (87-20). Preference for a forage was determined as the intake of that forage expressed as a per cent of the total intake of both forages on offer. Preference ranking changed with maturity and did not appear to be related to either oestrogenicity or length of growing season of the clovers in the vegetative stage. However, with the senescent material, clovers with a long growing season tended to have higher preference rankings (except for Dinninup). The 'palatability' of each cultivar of senescent herbage was quantified by comparing it in separate tests with a standard hay cut to several lengths. The preference ranking of the six cultivars predicted from this comparison with the standard hay was in close agreement with the observed rankings from the two-way preference tests. The agreement between the predicted and the observed rankings indicated that the method of establishing preference for forages relative to a standard hay (cut to several lengths) could be used to predict preference ranking between forages without performing a direct comparison. Seventeen of eighteen individual comparisons showed good agreement between predicted and observed preference. Preference ranking within the cultivar Dinninup decreased with maturity, and its ranking relative to the other clovers decreased markedly in the senescent stage comparisons. 'Palatability' and preference ranking may have major implications in the establishment and persistence of pastures, as well as influencing diet selection and subsequent nutrient intake by grazing animals.

Thresholds of hypersensitive teeth to 2 forms of controlled stimulation

2 new methods are described for measuring the sensitivity of dentine to mechanical (probe) and cold-air stimulation. The methods are suitable for clinical use and could be used in the evaluation of desensitising treatments. In addition to qualitative differences in the pattern of sensitivity of teeth to these stimuli, considerable variation was observed in the distribution of pain thresholds to probe and air stimulation. Thresholds were not significantly affected by the age or sex of the subjects, but mean thresholds of teeth sensitive to only one stimulus were significantly greater than thresholds of teeth sensitive to both stimuli; these differences were most marked in female subjects. Factors such as the qualitative differences in sensitivity to various stimuli and quantitative differences in the degree of sensitivity to the stimuli require to be considered in clinical evaluation of desensitizing treatments.

Spontaneous pneumothorax: report of a case in podiatric surgery

The authors have reviewed the literature concerning the subject of spontaneous pneumothoraces. Included in the review are the types of spontaneous pneumothoraces, such as: primary, secondary, tension, and catamenial. The symptomatology, diagnosis, and treatments were discussed. A case report of a catamenial spontaneous pneumothorax in a preoperative podiatric patient was presented.

Instrumentation for measurement of dental plaque thickness in situ

A commercial digital micrometer has been modified mechanically and electronically to allow the measurement, in situ, of the thickness of dental plaque. The device detects initial contact between a moving probe and the plaque, and measures subsequent probe displacement through to the tooth surface. Instrument accuracy is +/- 5 micron over a displacement range of 0-5 mm, with 1 micron resolution. In practice, after a short 'learning' phase, reliable clinical results can be obtained.

Identification of subterranean clover cultivars and their genetic relationships by isozyme analysis

Isozyme patterns for the 22 registered cultivars of Trifolium subterraneurn L. are described for 15 enzymes. The patterns discriminated among all cultivars except that Uniwager was isozymically identical with Geraldton, from which it was derived by deliberate mutation. The 17 cultivars which originally came from naturally occurring isolates, as well as Uniwager, appeared to be isozymically homogeneous, whereas three of the five bred cultivars (Nungarin, Esperance and Howard) were polymorphic for at least one locus. The cultivars indicated that T. subterraneum is highly polymorphic at isozyme loci. Excluding the complex esterase patterns, the species was polymorphic at 21 of 26 putative loci, with an average of 2.3 alleles detected per locus. Estimates of genetic distance between the cultivars stemming from natural isolates strongly supported the classification into three subspecies. In addition, the cultivar Woogenellup (syn Marrar) was well separated from all other cultivars of the subspecies subterraneum. Isozyme surveys should therefore provide critical evidence on the role such factors as introduction, natural selection, mutation and outcrossing have had in the origin of variation within subterranean clover in Australia.

Diels-Alder adducts of fulvenes and halogenated dienes. Synthesis and insecticidal activity

A series of eight adducts (1--8) of substituted fulvenes and polychlorinated cyclodienes was synthesized by Diels-Alder cyclization. The products isolated were the endo bicyclo adducts as determined by detailed 1H and 13C NMR spectral analysis. Steric hindrance of end-product bridge substituents coupled with bulky substituents at C6 of the fulvenes led to one isomeric product in most cases. Compounds 1--8 demonstrated weak insecticidal action in Musca domestica as determined by topical LD50 and oral LC50 assays.

Pulmonary vasculitis complicating childhood ulcerative colitis

A case of pulmonary vasculitis complicating ulcerative colitis is presented, and the literature is reviewed. Unexplained pulmonary problems complicating severe ulcerative colitis should prompt a review of rare etiologies to include pulmonary vasculitis, apical pulmonary fibrosis, and salicylazosulfapyridine-induced lung disease. Lung biopsy will establish a diagnosis of pulmonary vasculitis.

The influence of shading on seed yield in subterranean clover

Swards of three strains of subterranean clover (Woogenellup, Clare and Seaton Park) were subjected to three shading treatments (30%, 55% and 100% of daylight) from the beginning of flowering onwards. For the 100% daylight (unshaded) treatment the incoming daily solar radiation averaged between 20 and 30 MJ/m2. In the unshaded treatment, seed yields for the three strains ranged from about 120 to almost 200 g/m2. These yields were invariably decreased by shading. Moreover the evidence indicated a curvilinear relationship between seed yield and light supply such that at 50% of daylight there was a reduction of rather more than 50% in seed yield. Shading mainly affected the number of inflorescences produced per unit area, although other components of seed yield were also affected adversely. Even late shading (towards the end of flowering) led to lower seed yield, partly associated with lower inflorescence numbers and partly with lower seed numbers per burr. The results are considered to have significance for clover regeneration in mixed clover/grass pastures and also in the cloveritree associations of agro-forestry.

The interrelation of burr burial, seed yield and dormancy in strains of subterranean clover

Prevention of burr burial drastically reduced the yield of viable seed in subterranean clover. This occurred through reductions in total burr number, number of mature burrs, number of seeds per burr, individual seed weight and seed viability. Strains differed markedly in their ability to produce seed in unburied burrs. A simple selection criterion based on changes in individual seed weight was proposed as a guide to screening for this character. When this criterion was applied to a wide range of strains, it appeared that later-maturing types were the most capable at producing seed in unburied burrs. The initial level of hardseededness was lower in seed from unburied burrs; also the rate of breakdown of hardseededness was faster in this seed, although the size of the effect varied between strains. Defoliation during the flowering period increased the initial level of hardseededness in seed from both buried and unburied burrs. Seed produced in buried burrs generally had a faster rate of breakdown of embryo dormancy than seed from unburied burrs, although the response varied between strains. The implications of these findings for future breeding and improvement in subterranean clover are discussed.

Vernalization as a factor influencing the rate of development in subterranean clover (Trifolium subterraneum L.)

An investigation of the influence of vernalization on the rate of development in three cultivars of subterranean clover was conducted under controlled environmental conditions. Effects were evaluated in terms of the time from imbibition to flower initiation or flowering, i.e. including the time during which vernalization was imposed. In these terms, vernalization actually delayed flowering in the Yarloop and Mt. Barker cultivars, hastening it only in Tallarook. Some practical considerations are discussed. The effects of periods of higher temperatures after vernalization on the rate of development were also studied. No evidence was found for the occurrence of devernalization. If devernalization docs occur in subterranean clover, it is unlikely to be of practical consequence in normal field situations.