Coexisting Cardiac and Hematologic Disorders.

Patients with concomitant cardiac and hematologic disorders presenting for noncardiac surgery are challenging. Anemic patients with cardiac disease should be approached in a methodical fashion. Transfusion triggers and target should be based on underlying symptomatology. The approach to anticoagulation management in patients with artificial heart valves, cardiac devices, or severe heart failure in the operative setting must encompass a complete understanding of the rationale of a patient\u27s therapy as well as calculate the risk of changing this regimen. This article focuses common disorders and discusses strategies to optimize care in patients with coexisting cardiac and hematologic disease

Homage to Richard M. Elliott

No abstract available

Type 2 diabetes mellitus and the cardiometabolic syndrome: impact of incretin-based therapies

The rates of type 2 diabetes mellitus, obesity, and cardiovascular disease (CVD) continue to increase at epidemic proportions. It has become clear that these disease states are not independent but are frequently interrelated. By addressing conditions such as obesity, insulin resistance, stress hyperglycemia, impaired glucose tolerance, and diabetes mellitus, with its micro- and macrovascular complications, a specific treatment strategy can be developed. These conditions can be addressed by early identification of patients at high risk for type 2 diabetes, prompt and aggressive treatment of their hyperglycemia, recognition of the pleiotropic and synergistic benefits of certain antidiabetes agents on CVD, and thus, avoiding potential complications including hypoglycemia and weight gain. Incretin-based therapies, which include glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-IV (DPP-IV) inhibitors, have the potential to alter the course of type 2 diabetes and associated CVD complications. Advantages of these therapies include glucose-dependent enhancement of insulin secretion, infrequent instances of hypoglycemia, weight loss with GLP-1 receptor agonists, weight maintenance with DPP-IV inhibitors, decreased blood pressure, improvements in dyslipidemia, and potential beneficial effects on CV function

Firm foundations: The statistical footprint of multinational corporations as a problem for political economy

The discipline of comparative political economy (CPE) relies heavily on aggregate, country-level economic indicators. However, the practices of multinational corporations have increasingly undermined this approach to measurement. The problem of indicator drift is well documented by a growing critical literature and calls for systematic methodological attention in CPE. We present the case for a rocky but ultimately rewarding middle road between indicator fatalism and indicator faith. We illustrate our argument by examining two important cases—Sweden’s recent export success and the financialization of non-financial corporations in France. A careful parsing of the data suggests corrections to common characterizations of the two cases. Swedish exports have been reshaped by intragroup trade among foreign subsidiaries of domestic corporations. The growth of financial assets held by French firms is attributable to the growth of foreign direct investment and to cumulative revaluation effects, while what remains of financialization is concentrated among the very largest firms. Based on these findings, we propose a methodological routine that parses data by zooming in on the qualitative specifics of countries, sectors, and firms, while using all available options for disaggregation

Competing Saints in late medieval Padua

This article addresses the question of the evolution of civic ritual in late medieval Europe between the early thirteenth and early fifteenth centuries. Arguing for the importance of the participants as well as the planners of civic ritual, and for the need to contextualize the forms of ritual behaviour, it also offers a new case study: the changing civic calendar and the celebration of feast days in the northern Italian city of Padua. It publishes for the first time documentary evidence for the patronage and iconography of saints’ days in Padua, drawing heavily on the city’s statutes, and aims to interpret what it was that religious and civic officials – as well as Padua’s citizens and inhabitants – intended and experienced. It not only throws light on the reverence for universal and local saints in the Paduan Christian calendar, but also focuses on the festivals, holidays, fairs, parish life and churches of late medieval Padua and its contado

Discerning the spatio-temporal disease patterns of surgically induced OA mouse models

Osteoarthritis (OA) is the most common cause of disability in ageing societies, with no effective therapies available to date. Two preclinical models are widely used to validate novel OA interventions (MCL-MM and DMM). Our aim is to discern disease dynamics in these models to provide a clear timeline in which various pathological changes occur. OA was surgically induced in mice by destabilisation of the medial meniscus. Analysis of OA progression revealed that the intensity and duration of chondrocyte loss and cartilage lesion formation were significantly different in MCL-MM vs DMM. Firstly, apoptosis was seen prior to week two and was narrowly restricted to the weight bearing area. Four weeks post injury the magnitude of apoptosis led to a 40–60% reduction of chondrocytes in the non-calcified zone. Secondly, the progression of cell loss preceded the structural changes of the cartilage spatio-temporally. Lastly, while proteoglycan loss was similar in both models, collagen type II degradation only occurred more prominently in MCL-MM. Dynamics of chondrocyte loss and lesion formation in preclinical models has important implications for validating new therapeutic strategies. Our work could be helpful in assessing the feasibility and expected response of the DMM- and the MCL-MM models to chondrocyte mediated therapies

Evaluation and Enhancement of an Intraoperative Insulin Infusion Protocol via In-Silico Simulation

Intraoperative glycemic control, particularly in cardiac surgical patients, remains challenging. Patients with impaired insulin sensitivity and/or secretion (i.e., type 1 diabetes mellitus) often manifest extremely labile blood glucose measurements during periods of stress and inflammation. Most current insulin infusion protocols are developed based on clinical experiences and consensus among a local group of physicians. Recent advances in human glucose metabolism modeling have established a computer model that invokes algorithms representing many of the pathways involved in glucose dysregulation for patients with diabetes. In this study, we used an FDA approved glucose metabolism model to evaluate an existing institutional intraoperative insulin infusion protocol via closedloop simulation on the virtual diabetic population that comes with the computer model. A comparison of simulated responses to actual retrospective clinical data from 57 type 1 diabetic patients undergoing cardiac surgery managed by the institutional protocol was performed. We then designed a proportional-derivative controller that overcomes the weaknesses exhibited by our old protocol while preserving its strengths. In-silico evaluation results show that our proportional-derivative controller more effectively manages intraoperative hyperglycemia while simultaneously reducing hypoglycemia and glycemic variability. By performing insilico simulation on intraoperative glucose and insulin responses, robust and seemingly efficacious algorithms can be generated that warrant prospective evaluation in human subjects

Telemedicine coverage for post-operative ICU patients.

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group ( n = 6652), patients in the VICU group ( n = 1037) were slightly older (median age 60 (IQR 47-69) versus 58 (IQR 44-70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7-14) versus 15 (IQR 11-21), p \u3c 0.001). The average amount of time patients spent in the VICU was 13.7 + /-9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation

Transport mechanisms of hydrothermal convection in faulted tight sandstones

Motivated by the unknown reasons for a kilometre-scale high-temperature overprint of 270–300 ∘C in a reservoir outcrop analogue (Piesberg quarry, northwestern Germany), numerical simulations are conducted to identify the transport mechanisms of the fault-related hydrothermal convection system. The system mainly consists of a main fault and a sandstone reservoir in which transfer faults are embedded. The results show that the buoyancy-driven convection in the main fault is the basic requirement for elevated temperatures in the reservoir. We studied the effects of permeability variations and lateral regional flow (LRF) mimicking the topographical conditions on the preferential fluid-flow pathways, dominant heat-transfer types, and mutual interactions among different convective and advective flow modes. The sensitivity analysis of permeability variations indicates that lateral convection in the sandstone and advection in the transfer faults can efficiently transport fluid and heat, thus causing elevated temperatures (≥269 °C) in the reservoir at a depth of 4.4 km compared to purely conduction-dominated heat transfer (≤250 °C). Higher-level lateral regional flow interacts with convection and advection and changes the dominant heat transfer from conduction to advection in the transfer faults for the low permeability cases of sandstone and main fault. Simulations with anisotropic permeabilities detailed the dependence of the onset of convection and advection in the reservoir on the spatial permeability distribution. The depth-dependent permeabilities of the main fault reduce the amount of energy transferred by buoyancy-driven convection. The increased heat and fluid flows resulting from the anisotropic main fault permeability provide the most realistic explanation for the thermal anomalies in the reservoir. Our numerical models can facilitate exploration and exploitation workflows to develop positive thermal anomaly zones as geothermal reservoirs. These preliminary results will stimulate further petroleum and geothermal studies of fully coupled thermo–hydro–mechanical–chemical processes in faulted tight sandstones

Alfven Wave Reflection and Turbulent Heating in the Solar Wind from 1 Solar Radius to 1 AU: an Analytical Treatment

We study the propagation, reflection, and turbulent dissipation of Alfven waves in coronal holes and the solar wind. We start with the Heinemann-Olbert equations, which describe non-compressive magnetohydrodynamic fluctuations in an inhomogeneous medium with a background flow parallel to the background magnetic field. Following the approach of Dmitruk et al, we model the nonlinear terms in these equations using a simple phenomenology for the cascade and dissipation of wave energy, and assume that there is much more energy in waves propagating away from the Sun than waves propagating towards the Sun. We then solve the equations analytically for waves with periods of hours and longer to obtain expressions for the wave amplitudes and turbulent heating rate as a function of heliocentric distance. We also develop a second approximate model that includes waves with periods of roughly one minute to one hour, which undergo less reflection than the longer-period waves, and compare our models to observations. Our models generalize the phenomenological model of Dmitruk et al by accounting for the solar wind velocity, so that the turbulent heating rate can be evaluated from the coronal base out past the Alfven critical point - that is, throughout the region in which most of the heating and acceleration occurs. The simple analytical expressions that we obtain can be used to incorporate Alfven-wave reflection and turbulent heating into fluid models of the solar wind.Comment: 9 pages, 9 figures, accepted for publication in Ap