Duration to Establish an Emergency Vascular Access and How to Accelerate It: A Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms

Objectives: To compare the duration to establish an umbilical venous catheter and an intraosseous access in real hospital delivery rooms and as a secondary aim to assess delaying factors during establishment and to provide recommendations to accelerate vascular access in neonatal resuscitation. Design: Retrospective analysis of audio-video recorded neonatal simulation training. Settings: Simulation training events in exact replications of actual delivery/resuscitation rooms of 16 hospitals with different levels of care (Austria and Germany). Equipment was prepared the same way as for real clinical events. Subjects: Medical teams of four to five persons with birth-related background (midwives, nurses, neonatologists, and anesthesiologists) in a realistic team composition. Interventions: Audio-video recorded mannequin-based simulated resuscitation of an asphyxiated newborn including the establishment of either umbilical venous catheter or intraosseous access. Measurements and Main Results: The duration of access establishment (time from decision to first flush/aspiration), preparation (decision to start of procedure), and the procedure itself (start to first flush/aspiration) was significantly longer for umbilical venous catheter than for intraosseous access (overall duration 199 vs 86 s). Delaying factors for umbilical venous catheter establishment were mainly due to the complex approach itself, the multitude of equipment required, and uncertainties about necessary hygiene standards. Challenges in intraosseous access establishment were handling of the unfamiliar material and absence of an intraosseous access kit in the resuscitation room. There was no significant difference between the required duration for access establishment between large centers and small hospitals, but a trend was observed that duration for umbilical venous catheter was longer in small hospitals than in centers. Duration for intraosseous access was similar in both hospital types. Conclusions: Vascular access establishment in neonatal resuscitation could be accelerated by infrastructural improvements and specific training of medical teams. In simulated in situ neonatal resuscitation, intraosseous access is faster to establish than umbilical venous catheter. Future studies are required to assess efficacy and safety of both approaches in real resuscitation settings

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.Peer reviewe

Structure of the human κ-opioid receptor in complex with JDTic

Opioid receptors mediate the actions of endogenous and exogenous opioids on many physiological processes, including the regulation of pain, respiratory drive, mood, and—in the case of κ-opioid receptor (κ-OR)—dysphoria and psychotomimesis. Here we report the crystal structure of the human κ-OR in complex with the selective antagonist JDTic, arranged in parallel dimers, at 2.9 Å resolution. The structure reveals important features of the ligand-binding pocket that contribute to the high affinity and subtype selectivity of JDTic for the human κ-OR. Modelling of other important κ-OR-selective ligands, including the morphinan-derived antagonists norbinaltorphimine and 5′-guanidinonaltrindole, and the diterpene agonist salvinorin A analogue RB-64, reveals both common and distinct features for binding these diverse chemotypes. Analysis of site-directed mutagenesis and ligand structure–activity relationships confirms the interactions observed in the crystal structure, thereby providing a molecular explanation for κ-OR subtype selectivity, and essential insights for the design of compounds with new pharmacological properties targeting the human κ-OR

Multivariate Disease Mapping of Seven Prevalent Cancers in Iran Asian Pacific

Abstract Background: The aim of this study was to model the geographical variation in incidence and risk factors of seven prevalent cancers in Iran. Methods: The data for cancers of esophagus, stomach, bladder, colorectal, lung, prostate, and female breast along with their risk factors in all 30 provinces of Iran for the year 2007 were included into study. Smoking, overweight, inadequate consumption of fruits and vegetables, socioeconomic status and low physical activity were studied as risk factors. Standardized incidence ratios were estimated using full Bayesian model. In addition, the shared component model was used to explore the spatial pattern of the cancers and to estimate the relative importance of their corresponding risk factors. Results: Fars and the Northwestern provinces were observed as high risk areas and Hormozgan (a Persian Gulf coastal province), Sistan and Baluchestan, South Khorasan, and Kerman provinces located in Southeast were areas of low risk for most cancers. For all five risk factors, larger effects on incidence of the relevant cancers were found in the Northern provinces compared to other areas. Smoking, overweight, inadequate consumption of fruit and vegetable, socioeconomic status, and low physical activity were found to have more effects on incidence of stomach, breast, esophagus, and breast cancers, respectively. Conclusions: Most of the high risk areas for seven cancers were in accordance with the results for spatial patterns of related risk factors and their relative weights on relevant cancers. The multivariate shared component model of the seven cancers achieves a considerable improvement in terms of Deviance Information Criterion over the individual modeling of diseases

Questioni di diritto sostanziale e tributario connesse al riconoscimento del trust nell'ordinamento italiano. Parte seconda

in "Fiducia e trust" n. 2/2002, allegato a "Il fisco" n. 34/200

Maternal age at birth and childhood type 1 diabetes: a pooled analysis of 30 observational studies

WSTĘP. Celem badania było sprawdzenie, czy u dzieci urodzonych przez starsze matki występuje większe ryzyko zachorowania na cukrzycę typu 1, poprzez łączną analizę wcześniejszych badań z użyciem indywidualnych danych pacjentów dla skorygowania względem znanych czynników błędu. MATERIAŁ I METODY. Odpowiednie badania, opublikowane przed czerwcem 2009 roku, zostały zidentyfikowane w bazach MEDLINE, Web of Science i EMBASE. Skontaktowano się z autorami analiz i poproszono o dostarczenie indywidualnych danych pacjentów lub przeprowadzenie wcześniej określonych analiz. Dla każdej z analiz oszacowano ryzyko wystąpienia cukrzycy typu 1 względem wieku matki zarówno przed, jak i po uwzględnieniu potencjalnych czynników błędu. W celu uzyskania złożonych ilorazów szans i zbadania różnic między badaniami zastosowano metody oparte na metaanalizie. WYNIKI. Dostępne dane pochodziły z 5 badań kohortowych i 25 badań porównawczych, obejmujących 14 724 przypadki cukrzycy typu 1. Ogółem, prawdopodobieństwo wystąpienia cukrzycy typu 1 w dzieciństwie wzrosło średnio o 5% (95% CI 2–9) na każde 5 lat wieku matki (p = 0,006), ale wyniki badań nie były jednorodne (niejednorodność I2 = 70%). W badaniach z małym ryzykiem błędu wyraźnie było widać wzrost szans na wystąpienie cukrzycy — 10% na każde 5 lat wieku matki. Uwzględnienie potencjalnych czynników błędu tylko nieznacznie wpłynęło na te szacunki. WNIOSKI. Wykazano niewielki, ale istotny, liniowy wzrost ryzyka występowania dziecięcej cukrzycy typu 1 wraz z wiekiem matki, ale siła tego skojarzenia różniła się między badaniami. Niewielki odsetek przypadków wzrostu występowania dziecięcej cukrzycy typu 1 w ostatnich latach można by wytłumaczyć rosnącym wiekiem matek. (Diabet. Prakt. 2010; 11, 5: 181–193)OBJECTIVE. The aim if the study was to investigate whether children born to older mothers have an increased risk of type 1 diabetes by performing a pooled analysis of previous studies using individual patient data to adjust for recognized confounders. MATERIAL AND METHODS. Relevant studies published before June 2009 were identified from MEDLINE, Web of Science, and EMBASE. Authors of studies were contacted and asked to provide individual patient data or conduct prespecified analyses. Risk estimates of type 1 diabetes by maternal age were calculated for each study, before and after adjustment for potential confounders. Meta-analysis techniques were used to derive combined odds ratios and to investigate heterogeneity among studies. RESULTS. Data were available for 5 cohort and 25 casecontrol studies, including 14,724 cases of type 1 diabetes. Overall, there was, on average, a 5% (95% CI 2–9) increase in childhood type 1 diabetes odds per 5-year increase in maternal age (P = 0.006), but there was heterogeneity among studies (heterogeneity I2 = 70%). In studies with a low risk of bias, there was a more marked increase in diabetes odds of 10% per 5-year increase in maternal age. Adjustments for potential confounders little altered these estimates. CONCLUSIONS. There was evidence of a weak but significant linear increase in the risk of childhood type 1 diabetes across the range of maternal ages, but the magnitude of association varied between studies. A very small percentage of the increase in the incidence of childhood type 1 diabetes in recent years could be explained by increases in maternal age. (Diabet. Prakt. 2010; 11, 5: 181–193