Themes and variations: An exploratory international investigation into resuscitation decision-making

AbstractBackgroundDo Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored.MethodsA questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire.Results78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions.ConclusionsThe majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation

An integrated map of structural variation in 2,504 human genomes

Structural variants are implicated in numerous diseases and make up the majority of varying nucleotides among human genomes. Here we describe an integrated set of eight structural variant classes comprising both balanced and unbalanced variants, which we constructed using short-read DNA sequencing data and statistically phased onto haplotype blocks in 26 human populations. Analysing this set, we identify numerous gene-intersecting structural variants exhibiting population stratification and describe naturally occurring homozygous gene knockouts that suggest the dispensability of a variety of human genes. We demonstrate that structural variants are enriched on haplotypes identified by genome-wide association studies and exhibit enrichment for expression quantitative trait loci. Additionally, we uncover appreciable levels of structural variant complexity at different scales, including genic loci subject to clusters of repeated rearrangement and complex structural variants with multiple breakpoints likely to have formed through individual mutational events. Our catalogue will enhance future studies into structural variant demography, functional impact and disease association. © 2015 Macmillan Publishers Limited. All rights reserved

A laboratory system for modeling hay storage

A simple system is described that uses a hinged metal baling unit and a hydraulic press to make 4.0 × 4.3 × 5.3 inch wire-tied, laboratory- scale, hay bales. A comparison of densities of conventional, small, alfalfa bales (15×18×37 inches) and laboratory bales was made over a wide range of moisture levels (15 to 36%) and conventional bale densities (10 to 25 lb/ft3). Laboratory bale densities were regressed against conventional bale densities and agreement was excellent. The system is inexpensive to build and easy to use and can be reproduced easily

Comparison of conventional and laboratory-scale alfalfa hay bales in small haystacks

A system for making laboratory-scale alfalfa hay bales was evaluated in two trials. In the first, conventional rectangular and laboratory-scale bales were made at each of seven different combinations of moisture and density. Laboratory bales were incubated between two parent conventional bales of identical moisture content and bale density. Laboratory bales remained different (P<.05) from parent conventional bales for most temperature-related storage traits. Agreement between bale types was better for most quality traits. To achieve closer agreement between bale types, a second experiment was conducted in which the laboratory bales were made at 1.0, 1.3, 1.6, and 2.0 times the density of the conventional bales. Agreement improved between laboratory bales of higher densities and conventional bales for most temperature traits. High-density laboratory bales had significantly greater acid detergent insoluble nitrogen values than conventional bales, particularly at the highest moisture level. These results implicate bale density as an important factor in heat damage to proteins in alfalfa hay

Relating quality changes to storage time for baled alfalfa

The relationships between storage time and several chemical indices for forage quality were established for alfalfa hay baled at two moisture levels (29.9 and 19.7%) in conventional and laboratory bale s made at 1.0, 1.5, and 2.0 times the density o f parent, conventional bales. Bales were sampled after 0, 4, 11, 22, and 60 days. For the high-moisture bales, most quality indices indicated substantial nutrient loss early in the storage period, particularly between days 4 and 11, with little change after 22 days. A nonlinear mathematical model was constructed to describe how neutral detergent fiber and several other quality indices changed with storage time. Acid detergent fiber was related poorly to storage time. Little change occurred in the low (19.7%) moisture bales

Evaluation of the potential of supplements to substitute for range forage

Thirteen, ruminally fistulated, Angus × Hereford, yearling steers were used to evaluate the effect of feeding different types and amounts of supplements on t h e likelihood of observing a substitution of supplement for range forage. Steers had ad libitum access to low-quality range forage and were fed a supplement comprised of sorghum grain (SG) and soybean meal (SBM ) that contained 18% CP (SG/SBM 18%), a SG/SBM supplement that contained 36% CP (SG/SBM 36%), long-stem alfalfa hay (18% CP), or alfalfa-pellets (18% CP) in amounts that provided .05, .10, and .15 % BW o f CP/day. In general, supplementation increase d the intake and digestibility of low-quality range forage. No substitution effect was observed for the SG/SBM 36% supplement or the alfalfa pellets. However, the SG/SBM 18% supplement did substitute for forage at the high level of supplementation. A similar trend appeared to exist for the long-stem alfalfa hay

Ketogenesis in the living rat followed by 13C-NMR spectroscopy : Infusion of [1,3-13C]octanoate

13C-NMR spectroscopy was used as a noninvasive approach to study the metabolism of [1,3-13C]octanoate in rat liver. Using a properly adjusted surface coil a liver selection of better than 90% was achieved in the intact animal without abdominal surgery. After infusion of [1,3-13C]octanoate via the jugular vein different patterns of metabolites were observed depending on the physiological state of the rat. In the fasted animal, the major metabolites were those of the Krebs cycle while in the diabetic animal ketogenic end products were predominant. As a fatty acid of medium chain length octanoate is imported into the inner mitochondrial space without control by the carnitine acyl transferase system. Hence, the metabolic differences observed between diabetic and fasted rats result from an intramitochondrial control mechanism. The in vivo 13C-NMR results therefore support previous biochemical in vitro studies which concluded that a major control of ketone body production occurs in the inner mitochondrial space, presumably via the redox potential of the liver. As an unexpected result, 13C-NMR provides evidence for the transitory esterification of the infused 13C-labeled octanoic acid. The corresponding 13C-NMR chemical shifts are typical for glycerides