Mobile Anesthesia Applications as Point-of-Care Tools for CRNAs in Clinical Practice

Background: The practice of anesthesia requires knowledge of procedures, patient conditions, comorbidities, and medications, as well as the ability to continually assess and respond to the patient’s status. The use of mobile anesthesia applications (apps) has become increasingly common among Certified Registered Nurse Anesthetists (CRNAs) to provide immediate access to current information regarding anesthesia administration and to support optimal patient care.The purpose of this study was to assess the use of mobile anesthesia apps used by CRNAs as point-of-care (POC) tools in their anesthesia practice.Methodology: We report data collected from a survey designed to sample CRNAs who have been in practice for three years or less (“recent” graduates) and who utilize mobile anesthesia apps. The survey was offered to members of a Facebook group called CRNAs and SRNAs.Results: A total of 160 CRNAs in practice three years or less completed the survey and reported the ways they currently use a mobile anesthesia app. In this report we quantify the various ways such apps are used and conclude that mobile apps are widely used among student and/or recent graduate CRNAs as point-of-care tools and who believe they improve the safety and efficacy of their anesthesia practice.Conclusions: The benefits to practice that users report should be encouraging to the developers of mobile health care apps and a motivating factor for more practitioners to utilize them

Scalable iterative methods for sampling from massive Gaussian random vectors

Sampling from Gaussian Markov random fields (GMRFs), that is multivariate Gaussian ran- dom vectors that are parameterised by the inverse of their covariance matrix, is a fundamental problem in computational statistics. In this paper, we show how we can exploit arbitrarily accu- rate approximations to a GMRF to speed up Krylov subspace sampling methods. We also show that these methods can be used when computing the normalising constant of a large multivariate Gaussian distribution, which is needed for both any likelihood-based inference method. The method we derive is also applicable to other structured Gaussian random vectors and, in particu- lar, we show that when the precision matrix is a perturbation of a (block) circulant matrix, it is still possible to derive O(n log n) sampling schemes.Comment: 17 Pages, 4 Figure

Solving the CSO Conundrum: Green Infrastructure and the Unfulfilled Promise of Federal-Municipal Cooperation

Faced with mounting infrastructure construction costs and more frequent and severe weather events due to climate change, cities across the country are managing the water pollution challenges of stormwater runoff and combined sewer overflows through new and innovative green infrastructure mechanisms that mimic, maintain, or restore natural hydrological features in the urban landscape. When utilized properly, such mechanisms can obviate the need for more expensive pipes, storage facilities, and other traditional grey infrastructure features, so named to acknowledge the vast amounts of concrete and other materials with high embedded energy necessary in their construction. Green infrastructure can also provide substantial co-benefits to city dwellers, such as cleaner air, reduced urban temperatures, and quality of life improvements associated with recreation areas and wildlife habitats. This Article examines the opportunities and challenges presented by municipal green infrastructure programs in the context of Clean Water Act ( CWA ) enforcement by the U.S. Environmental Protection Agency ( EPA ). First, it explores new thinking in urban sustainability and identifies opportunities for greater federal-municipal cooperation in the management of environmental problems, including stormwater runoff. Second, it unpacks the challenges presented by the relative inflexibility of federal environmental enforcement in the context of urban stormwater management under the CWA, and compares the differences between traditional federal approaches and newer local initiatives in terms of adaptability, responsiveness to community needs, preferences and trade-offs, cost effectiveness, and innovation. Third, it describes a recent consent agreement between New York State and New York City, identifying key features and best practices that can be readily replicated in other jurisdictions. In recent years, EPA has taken big steps forward to encourage and support municipal green infrastructure initiatives, including the release of its Integrated Municipal Stormwater and Wastewater Planning Approach Framework. The Article concludes with a specific proposal for further regulatory and policy reform that would build upon this framework to develop truly comprehensive, municipally-led plans to prioritize infrastructure investments that improve public health and the environment

Type-Ia Supernova-driven Galactic Bulge Wind

Stellar feedback in galactic bulges plays an essential role in shaping the evolution of galaxies. To quantify this role and facilitate comparisons with X-ray observations, we conduct 3D hydrodynamical simulations with the adaptive mesh refinement code, FLASH, to investigate the physical properties of hot gas inside a galactic bulge, similar to that of our Galaxy or M31. We assume that the dynamical and thermal properties of the hot gas are dominated by mechanical energy input from SNe, primarily Type Ia, and mass injection from evolved stars as well as iron enrichment from SNe. We study the bulge-wide outflow as well as the SN heating on scales down to ~4 pc. An embedding scheme that is devised to plant individual SNR seeds, allows to examine, for the first time, the effect of sporadic SNe on the density, temperature, and iron ejecta distribution of the hot gas as well as the resultant X-ray morphology and spectrum. We find that the SNe produce a bulge wind with highly filamentary density structures and patchy ejecta. Compared with a 1D spherical wind model, the non-uniformity of simulated gas density, temperature, and metallicity substantially alters the spectral shape and increases the diffuse X-ray luminosity. The differential emission measure as a function of temperature of the simulated gas exhibits a log-normal distribution, with a peak value much lower than that of the corresponding 1D model. The bulk of the X-ray emission comes from the relatively low temperature and low abundance gas shells associated with SN blastwaves. SN ejecta are not well mixed with the ambient medium, at least in the bulge region. These results, at least partly, account for the apparent lack of evidence for iron enrichment in the soft X-ray-emitting gas in galactic bulges and intermediate-mass elliptical galaxies.[...]Comment: 37 pages, 19 figures, submitted to MNRAS; comments are welcom

Functional evolution of IGF2:IGF2R domain 11 binding generates novel structural interactions and a specific IGF2 antagonist

Among the 15 extracellular domains of the mannose 6-phosphate/insulin-like growth factor-2 receptor (M6P/IGF2R), domain 11 has evolved a binding site for IGF2 to negatively regulate ligand bioavailability and mammalian growth. Despite the highly evolved structural loops of the IGF2:domain 11 binding site, affinity-enhancing AB loop mutations suggest that binding is modifiable. Here we examine the extent to which IGF2:domain 11 affinity, and its specificity over IGF1, can be enhanced, and we examine the structural basis of the mechanistic and functional consequences. Domain 11 binding loop mutants were selected by yeast surface display combined with high-resolution structure-based predictions, and validated by surface plasmon resonance. We discovered previously unidentified mutations in the ligand-interacting surface binding loops (AB, CD, FG, and HI). Five combined mutations increased rigidity of the AB loop, as confirmed by NMR. When added to three independently identified CD and FG loop mutations that reduced the koff value by twofold, these mutations resulted in an overall selective 100-fold improvement in affinity. The structural basis of the evolved affinity was improved shape complementarity established by interloop (AB-CD) and intraloop (FG-FG) side chain interactions. The high affinity of the combinatorial domain 11 Fc fusion proteins functioned as ligand-soluble antagonists or traps that depleted pathological IGF2 isoforms from serum and abrogated IGF2-dependent signaling in vivo. An evolved and reengineered high-specificity M6P/IGF2R domain 11 binding site for IGF2 may improve therapeutic targeting of the frequent IGF2 gain of function observed in human cancer

Impact of socioeconomic deprivation on rate and cause of death in severe mental illness

Background: Socioeconomic status has important associations with disease-specific mortality in the general population. Although individuals with Severe Mental Illnesses (SMI) experience significant premature mortality, the relationship between socioeconomic status and mortality in this group remains under investigated.<p></p> Aims: To assess the impact of socioeconomic status on rate and cause of death in individuals with SMI (schizophrenia and bipolar disorder) relative to the local (Glasgow) and wider (Scottish) populations.<p></p> Methods: Cause and age of death during 2006-2010 inclusive for individuals with schizophrenia or bipolar disorder registered on the Glasgow Psychosis Clinical Information System (PsyCIS) were obtained by linkage to the Scottish General Register Office (GRO). Rate and cause of death by socioeconomic status, measured by Scottish Index of Multiple Deprivation (SIMD), were compared to the Glasgow and Scottish populations.<p></p> Results: Death rates were higher in people with SMI across all socioeconomic quintiles compared to the Glasgow and Scottish populations, and persisted when suicide was excluded. Differences were largest in the most deprived quintile (794.6 per 10,000 population vs. 274.7 and 252.4 for Glasgow and Scotland respectively). Cause of death varied by socioeconomic status. For those living in the most deprived quintile, higher drug-related deaths occurred in those with SMI compared to local Glasgow and wider Scottish population rates (12.3% vs. 5.9%, p = <0.001 and 5.1% p = 0.002 respectively). A lower proportion of deaths due to cancer in those with SMI living in the most deprived quintile were also observed, relative to the local Glasgow and wider Scottish populations (12.3% vs. 25.1% p = 0.013 and 26.3% p = <0.001). The proportion of suicides was significantly higher in those with SMI living in the more affluent quintiles relative to Glasgow and Scotland (54.6% vs. 5.8%, p = <0.001 and 5.5%, p = <0.001). Discussion and conclusions: Excess mortality in those with SMI occurred across all socioeconomic quintiles compared to the Glasgow and Scottish populations but was most marked in the most deprived quintiles when suicide was excluded as a cause of death. Further work assessing the impact of socioeconomic status on specific causes of premature mortality in SMI is needed

The Circum-Galactic Medium of Massive Spirals. II. Probing the Nature of Hot Gaseous Halo around the Most Massive Isolated Spiral Galaxies

We present the analysis of the XMM-Newton data of the Circum-Galactic Medium of MASsive Spirals (CGM-MASS) sample of six extremely massive spiral galaxies in the local universe. All the CGM-MASS galaxies have diffuse X-ray emission from hot gas detected above the background extending \sim (30\mbox{--}100)\,\mathrm{kpc} from the galactic center. This doubles the existing detection of such extended hot CGM around massive spiral galaxies. The radial soft X-ray intensity profile of hot gas can be fitted with a β-function, with the slope typically in the range of \beta =0.35\mbox{--}0.55. This range, as well as those β values measured for other massive spiral galaxies, including the Milky Way (MW), are in general consistent with X-ray luminous elliptical galaxies of similar hot gas luminosity and temperature, and with those predicted from a hydrostatic-isothermal gaseous halo. Hot gas in such a massive spiral galaxy tends to have temperature comparable to its virial value, indicating the importance of gravitational heating. This is in contrast to lower mass galaxies, where hot gas temperature tends to be systematically higher than the virial one. The ratio of the radiative cooling to free fall timescales of hot gas is much larger than the critical value of ~10 throughout the entire halos of all the CGM-MASS galaxies, indicating the inefficiency of gas cooling and precipitation in the CGM. The hot CGM in these massive spiral galaxies is thus most likely in a hydrostatic state, with the feedback material mixed with the CGM, instead of escaping out of the halo or falling back to the disk. We also homogenize and compare the halo X-ray luminosity measured for the CGM-MASS galaxies and other galaxy samples and discuss the "missing" galactic feedback detected in these massive spiral galaxies

Evidence for divergent patterns of local selection driving venom variation in Mojave Rattlesnakes (\u3ci\u3eCrotalus scutulatus\u3c/i\u3e)

Snake venoms represent an enriched system for investigating the evolutionary processes that lead to complex and dynamic trophic adaptations. It has long been hypothesized that natural selection may drive geographic variation in venom composition, yet previous studies have lacked the population genetic context to examine these patterns. We leverage range-wide sampling of Mojave Rattlesnakes (Crotalus scutulatus) and use a combination of venom, morphological, phylogenetic, population genetic, and environmental data to characterize the striking dichotomy of neurotoxic (Type A) and hemorrhagic (Type B) venoms throughout the range of this species. We find that three of the four previously identified major lineages within C. scutulatus possess a combination of Type A, Type B, and a ‘mixed’ Type A + B venom phenotypes, and that fixation of the two main venom phenotypes occurs on a more fine geographic scale than previously appreciated. We also find that Type A + B individuals occur in regions of inferred introgression, and that this mixed phenotype is comparatively rare. Our results support strong directional local selection leading to fixation of alternative venom phenotypes on a fine geographic scale, and are inconsistent with balancing selection to maintain both phenotypes within a single population. Our comparisons to biotic and abiotic factors further indicate that venom phenotype correlates with fang morphology and climatic variables. We hypothesize that links to fang morphology may be indicative of co-evolution of venom and other trophic adaptations, and that climatic variables may be linked to prey distributions and/or physiology, which in turn impose selection pressures on snake venoms

Neuroserpin polymorphisms and stroke risk in a biracial population: the stroke prevention in young women study

<p>Abstract</p> <p>Background</p> <p>Neuroserpin, primarily localized to CNS neurons, inhibits the adverse effects of tissue-type plasminogen activator (tPA) on the neurovascular unit and has neuroprotective effects in animal models of ischemic stroke. We sought to evaluate the association of neuroserpin polymorphisms with risk for ischemic stroke among young women.</p> <p>Methods</p> <p>A population-based case-control study of stroke among women aged 15–49 identified 224 cases of first ischemic stroke (47.3% African-American) and 211 age-matched control subjects (43.1% African-American). Neuroserpin single nucleotide polymorphisms (SNPs) chosen through HapMap were genotyped in the study population and assessed for association with stroke.</p> <p>Results</p> <p>Of the five SNPs analyzed, the A allele (frequency; Caucasian = 0.56, African-American = 0.42) of SNP rs6797312 located in intron 1 was associated with stroke in an age-adjusted dominant model (AA and AT vs. TT) among Caucasians (OR = 2.05, p = 0.023) but not African-Americans (OR = 0.71, p = 0.387). Models adjusting for other risk factors strengthened the association. Race-specific haplotype analyses, inclusive of SNP rs6797312, again demonstrated significant associations with stroke among Caucasians only.</p> <p>Conclusion</p> <p>This study provides the first evidence that neuroserpin is associated with early-onset ischemic stroke among Caucasian women.</p