The classification of freezing cold injuries - a NATO research task group position paper

Introduction: Freezing cold injuries (FCI) are a common risk in extreme cold weather operations. Although the risks have long been recognised, injury occurrences tend to be sparse and geographically distributed, with relatively few cases to study in a systematic way. The first challenge to improve FCI medical management is to develop a common nomenclature for FCI classification. This is critical for the development of meaningful epidemiological reports on the magnitude and severity of FCI, for the standardisation of patient inclusion criteria for treatment studies, and for the development of clinical diagnosis and treatment algorithms. Methodology: A scoping review of the literature using PubMed and cross-checked with Google Scholar, using search terms related to freezing cold injury and frostbite, highlighted a paucity of published clinical papers and little agreement on classification schemes. Results: A total of 74 papers were identified, and 28 were included in the review. Published reports and studies can be generally grouped into four different classification schemes that are based on (1) injury morphology; (2) signs and symptoms; (3) pathophysiology; and (4) clinical outcome. The nomenclature in the different classification systems is not coherent and the discrete classification limits are not evidence based. Conclusions: All the classification systems are necessary and relevant to FCI medical management for sustainment of soldier health and performance in cold weather operations and winter warfare. Future FCI reports should clearly characterise the nature of the FCI into existing classification schemes for surveillance (morphology, symptoms, and appearance), identifying risk-factors, clinical guidelines, and agreed inclusion/exclusion criteria for a future treatment trial

Physician Orders for Life-Sustaining Treatment (POLST) Utilization in a Skilled Nursing Facility: An Educational Quality Initiative

According to expert reports and recent research, frequent clinician-patient conversations about individual end-of-life preferences are necessary to avoid unwanted treatment and to ensure that desired treatments are received. The ongoing diffusion of Physician Orders for Life-Sustaining Treatment (POLST) educational initiatives in skilled nursing facilities (SNFs) are vital to success of California’s POLST program, which is now recognized as only 1 of 3 mature POLST programs in the country. The purpose of this evidence-based practice project was to answer the question: Among staff in a skilled nursing facility, does implementing a formal POLST education program compared to current practice improve staff knowledge, comfort level and documentation of the POLST form? A pre- and post-education questionnaire was used. Results indicated a POLST education program significantly improved staff knowledge and promoted much-needed awareness of underutilized POLST educational resources (retrieved from the Coalition for Compassionate Care of California, www.caPOLST.org), available for SNF residents, families, practitioners and staff. As a result, these efforts provide higher quality end-of-life decision making which is essential with future uploading of these order forms into an electronic POLST registry (SB 19: e-POLST Registry Pilot) to be stored during nursing facility resident’s care transitions

Of “raisins” and “yeast”: mobilisation and framing in the East German revolution of 1989

There is no shortage of literature on the social movements that arose in East Germany in 1989. Numerous studies have shed light upon the nature, scale and dynamics of the uprising of that year. But on certain issues questions remain. No consensus exists, for example, on the relationship between the “civic groups” (New Forum, Democratic Awakening, etc.) and the street protests of the autumn of 1989. Were these simply two facets of a single movement? Or are they better characterised as two distinct streams within the same movement delta? Did the street protests push the civic movement activists into the limelight? Or is it more accurate to say, with Reinfried Musch, that “the civic movement brought the people onto the streets”?1 This paper considers two contrasting interpretations of these issues, and finds both wanting. An alternative interpretation is offered, one that draws upon Marc Steinberg's “dialogical” development of frame theory

Differences in the biological carbon pump at three subtropical ocean sites

We report primary production of organic matter and organic carbon removal from three subtropical open ocean time-series stations, two located in the Atlantic and one in the Pacific, to quantify the biological components of the oceanic carbon pump. We find that within subtropical gyres, export production varies considerably despite similar phytoplankton biomass and productivity. We provide evidence that the removal of organic carbon is linked to differences in nutrient input into the mixed layer, both from eddy induced mixing and dinitrogen fixation. These findings contribute to our knowledge of the spatial heterogeneity of the subtropical oceans, which make up more than 50% of all ocean area and are thought to spread in the course of CO2- induced global warming

Bacterial vs. zooplankton control of sinking particle flux in the ocean\u27s twilight zone

The downward flux of particulate organic carbon (POC) decreases significantly in the oceanÂs mesopelagic or ‘twilight’ zone due both to abiotic processes and metabolism by resident biota. Bacteria and zooplankton solubilize and consume POC to support their metabolism, but the relative importance of bacteria vs. zooplankton in the consumption of sinking particles in the twilight zone is unknown. We compared losses of sinking POC, using differences in export flux measured by neutrally buoyant sediment traps at a range of depths, with bacteria and zooplankton metabolic requirements at the Hawaii Ocean Time‐series station ALOHA in the subtropical Pacific and the Japanese times‐series site K2 in the subarctic Pacific. Integrated (150‐1,000 m) mesopelagic bacterial C demand exceeded that of zooplankton by up to 3‐fold at ALOHA, while bacteria and zooplankton required relatively equal amounts of POC at K2. However, sinking POC flux was inadequate to meet metabolic demands at either site. Mesopelagic bacterial C demand was 3‐ to 4‐fold (ALOHA), and 10‐fold (K2) greater than the loss of sinking POC flux, while zooplankton C demand was 1‐ to 2‐fold (ALOHA), and 3‐ to 9‐fold (K2) greater (using our ‘middle’ estimate conversion factors to calculate C demand). Assuming the particle flux estimates are accurate, we posit that this additional C demand must be met by diel vertical migration of zooplankton feeding at the surface and by carnivory at depth—with both processes ultimately supplying organic C to mesopelagic bacteria. These pathways need to be incorporated into biogeochemical models that predict global C sequestration in the deep sea

Peak oxygen uptake and left ventricular ejection fraction, but not depressive symptoms, are associated with cognitive impairment in patients with chronic heart failure

BACKGROUND: The aim of the present study was to assess cognitive impairment in patients with chronic heart failure (CHF) and its associations with depressive symptoms and somatic indicators of illness severity, which is a matter of controversy. METHODS AND RESULTS: Fifty-five patients with CHF (mean age 55.3 ± 7.8 years; 80% male; New York Heart Association functional class I-III) underwent assessment with an expanded neuropsychological test battery (eg, memory, complex attention, mental flexibility, psychomotor speed) to evaluate objective and subjective cognitive impairment. Depressive symptoms were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) and a self-report inventory (Hospital Anxiety and Depression Scale [HADS]). A comprehensive clinical dataset, including left ventricular ejection fraction, peak oxygen uptake, and a 6-minute walk test, was obtained for all patients. Neuropsychological functioning revealed impairment in 56% of patients in at least one measure of our neuropsychological test battery. However, the Mini Mental State Examination (MMSE) could only detect cognitive impairment in 1.8% of all patients, 24% had HADS scores indicating depressive symptoms, and 11.1% met SCID criteria for a depressive disorder. No significant association was found between depressive symptoms and cognitive impairment. Left ventricular ejection fraction was related to subjective cognitive impairment, and peak oxygen uptake was related to objective cognitive impairment. CONCLUSION: Cognitive functioning was substantially reduced in patients with CHF and should therefore be diagnosed and treated in routine clinical practice. Caution is advised when the MMSE is used to identify cognitive impairment in patients with CHF

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST

Changes in fecal pellet characteristics with depth as indicators of zooplankton repackaging of particles in the mesopelagic zone of the subtropical and subarctic North Pacific Ocean

Author Posting. © Elsevier B.V., 2008. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Deep Sea Research Part II: Topical Studies in Oceanography 55 (2008): 1636-1647, doi:10.1016/j.dsr2.2008.04.019.We investigated how fecal pellet characteristics change with depth in order to quantify the extent of particle repackaging by mesopelagic zooplankton in two contrasting open-ocean systems. Material from neutrally buoyant sediment traps deployed in the summer of 2004 and 2005 at 150, 300, and 500 m was analyzed from both a mesotrophic (Japanese time-series station K2) and an oligotrophic (Hawaii Ocean Time series-HOT station ALOHA) environment in the Pacific Ocean as part of the VERtical Transport In the Global Ocean (VERTIGO) project. We quantified changes in the flux, size, shape, and color of particles recognizable as zooplankton fecal pellets to determine how these parameters varied with depth and location. Flux of K2 fecal pellet particulate organic carbon (POC) at 150 and 300 m was 4-5 times higher than at ALOHA, and at all depths, fecal pellets were 2-5 times larger at K2, reflective of the disparate zooplankton community structure at the two sites. At K2, the proportion of POC flux that consisted of fecal pellets generally decreased with depth from 20% at 150 m to 5% at 500 m, whereas at ALOHA this proportion increased with depth (and was more variable) from 14% to 35%. This difference in the fecal fraction of POC with increasing depth is hypothesized to be due to differences in the extent of zooplankton-mediated fragmentation (coprohexy) and in zooplankton community structure between the two locations. Both regions provided indications of sinking particle repackaging and zooplankton carnivory in the mesopelagic. At ALOHA this was reflected in a significant increase in the mean flux of larvacean fecal pellets from 150 to 500 m of 3 to 46 μg C m-2 d-1, respectively, and at K2 a large peak in larvacean mean pellet flux at 300 m of 3.1 mg C m-2 d-1. Peaks in red pellets produced by carnivores occurred at 300 m at K2, and a variety of other fecal pellet classes showed significant changes in their distribution with depth. There was also evidence of substantially higher pellet fragmentation at K2 with nearly double the ratio of broken:intact pellets at 150 and 300 m (mean of 67% and 64%, respectively ) than at ALOHA where the proportion of broken pellets remained constant with depth (mean 35%). Variations in zooplankton size and community structure within the mesopelagic zone can thus differentially alter the transfer efficiency of sinking POC.This study was supported by grants from the U.S. National Science Foundation NSF OCE-0324402 (Biological Oceanography) to D.K.S and OCE-0301139 (Chemical Oceanography) to K.O.B

Predicting plankton net community production in the Atlantic Ocean

We present, test and implement two contrasting models to predict euphotic zone net community production (NCP), which are based on 14C primary production (PO14CP) to NCP relationships over two latitudinal (ca. 30°S–45°N) transects traversing highly productive and oligotrophic provinces of the Atlantic Ocean (NADR, CNRY, BENG, NAST-E, ETRA and SATL, Longhurst et al., 1995 [An estimation of global primary production in the ocean from satellite radiometer data. Journal of Plankton Research 17, 1245–1271]). The two models include similar ranges of PO14CP and community structure, but differ in the relative influence of allochthonous organic matter in the oligotrophic provinces. Both models were used to predict NCP from PO14CP measurements obtained during 11 local and three seasonal studies in the Atlantic, Pacific and Indian Oceans, and from satellite-derived estimates of PO14CP. Comparison of these NCP predictions with concurrent in situ measurements and geochemical estimates of NCP showed that geographic and annual patterns of NCP can only be predicted when the relative trophic importance of local vs. distant processes is similar in both modeled and predicted ecosystems. The system-dependent ability of our models to predict NCP seasonality suggests that trophic-level dynamics are stronger than differences in hydrodynamic regime, taxonomic composition and phytoplankton growth. The regional differences in the predictive power of both models confirm the existence of biogeographic differences in the scale of trophic dynamics, which impede the use of a single generalized equation to estimate global marine plankton NCP. This paper shows the potential of a systematic empirical approach to predict plankton NCP from local and satellite-derived P estimates

VERTIGO (VERtical Transport In the Global Ocean) : a study of particle sources and flux attenuation in the North Pacific

Author Posting. © Elsevier B.V., 2008. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Deep Sea Research Part II: Topical Studies in Oceanography 55 (2008): 1522-1539, doi:10.1016/j.dsr2.2008.04.024.The VERtical Transport In the Global Ocean (VERTIGO) study examined particle sources and fluxes through the ocean’s “twilight zone” (defined here as depths below the euphotic zone to 1000 m). Interdisciplinary process studies were conducted at contrasting sites off Hawaii (ALOHA) and in the NW Pacific (K2) during 3 week occupations in 2004 and 2005, respectively. We examine in this overview paper the contrasting physical, chemical and biological settings and how these conditions impact the source characteristics of the sinking material and the transport efficiency through the twilight zone. A major finding in VERTIGO is the considerably lower transfer efficiency (Teff) of particulate organic carbon (POC), POC flux 500 / 150 m, at ALOHA (20%) vs. K2 (50%). This efficiency is higher in the diatom-dominated setting at K2 where silica-rich particles dominate the flux at the end of a diatom bloom, and where zooplankton and their pellets are larger. At K2, the drawdown of macronutrients is used to assess export and suggests that shallow remineralization above our 150 m trap is significant, especially for N relative to Si. We explore here also surface export ratios (POC flux/primary production) and possible reasons why this ratio is higher at K2, especially during the first trap deployment. When we compare the 500 m fluxes to deep moored traps, both sites lose about half of the sinking POC by >4000 m, but this comparison is limited in that fluxes at depth may have both a local and distant component. Certainly, the greatest difference in particle flux attenuation is in the mesopelagic, and we highlight other VERTIGO papers that provide a more detailed examination of the particle sources, flux and processes that attenuate the flux of sinking particles. Ultimately, we contend that at least three types of processes need to be considered: heterotrophic degradation of sinking particles, zooplankton migration and surface feeding, and lateral sources of suspended and sinking materials. We have evidence that all of these processes impacted the net attenuation of particle flux vs. depth measured in VERTIGO and would therefore need to be considered and quantified in order to understand the magnitude and efficiency of the ocean’s biological pump.Funding for VERTIGO was provided primarily by research grants from the US National Science Foundation Programs in Chemical and Biological Oceanography (KOB, CHL, MWS, DKS, DAS). Additional US and non-US grants included: US Department of Energy, Office of Science, Biological and Environmental Research Program (JKBB); the Gordon and Betty Moore Foundation (DMK); the Australian Cooperative Research Centre program and Australian Antarctic Division (TWT); Chinese NSFC and MOST programs (NZJ); Research Foundation Flanders and Vrije Universiteit Brussel (FD, ME); JAMSTEC (MCH); New Zealand Public Good Science Foundation (PWB); and internal WHOI sources and a contribution from the John Aure and Cathryn Ann Hansen Buesseler Foundation (KOB)