Airway management in patients with suspected or confirmed cervical spine injury

Summary: Background: There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence‐based guidelines for practicing clinicians to support safe and effective airway management in this setting. Methods: An expert multidisciplinary, multi‐society working party conducted a systematic review of contemporary literature (January 2012–June 2022), followed by a three‐round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. Results: We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre‐oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front‐of‐neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre‐hospital care, military settings and principles in human factors. Conclusions: It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

ISSN exercise & sport nutrition review: research & recommendations

Sports nutrition is a constantly evolving field with hundreds of research papers published annually. For this reason, keeping up to date with the literature is often difficult. This paper is a five year update of the sports nutrition review article published as the lead paper to launch the JISSN in 2004 and presents a well-referenced overview of the current state of the science related to how to optimize training and athletic performance through nutrition. More specifically, this paper provides an overview of: 1.) The definitional category of ergogenic aids and dietary supplements; 2.) How dietary supplements are legally regulated; 3.) How to evaluate the scientific merit of nutritional supplements; 4.) General nutritional strategies to optimize performance and enhance recovery; and, 5.) An overview of our current understanding of the ergogenic value of nutrition and dietary supplementation in regards to weight gain, weight loss, and performance enhancement. Our hope is that ISSN members and individuals interested in sports nutrition find this review useful in their daily practice and consultation with their clients

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Paleohydrology and the origin of Jewel Cave

With more than 267 m (166 miles) of mapped cave passages, Jewel Cave is the third longest cave in the world. The passages are beneath an area of 775 ha (3 mi2), located almost entirely within the Hell Canyon drainage basin. The canyon itself is situated in the bottom of a south-plunging syncline and most of the cave passages are located within the east limb. A down-dip cross section shows the cave passages assuming the shape of an elongate lens, located just below the Pahasapa/Minnelusa contact. The lower boundary is a maximum of 75 m (250 feet) below the contact, but thins at each end, where the permeable, basal Minnelusa sandstone is exposed. Based on these observations, a conceptual model has been created to portray cave development as the result of local groundwater movement in geologically recent time. The apparent recharge was in the Pass Creek and Lithograph Canyon areas, and the discharge was in Hell Canyon. Groundwater initially moved through a shallow confined aquifer comprised of the basal Minnelusa sandstone, which was initially confined by the underlying Pahasapa Limestone and an overlying Minnelusa limestone. Although Laramide fractures provided secondary porosity, there is no evidence of sufficient connectivity to provide landscape-scale permeability. As water from the sandstone circulated into the discontinuous fractures of the Pahasapa, dissolutional enlargement integrated them to form the system of interconnected cave passages known today. The model precludes the need for direct recharge from rainfall, hydrothermal waters rising from below, or prior development of a Mississippian karst

Zambezi continental margin: allocyclic and antecedent controls on sediment transport in the Mozambique Channel.

Sediment delivery to the abyssal regions of the oceans is an integral process in the source to sink cycle of material derived from the hinterland. How sediments are transported down-slope, and where they are deposited has implications for the mass balance of the upper lithosphere, hydrocarbon reserves, climate archives and sequence stratigraphic models. The Zambezi River, the largest in southern Africa, delivers vast amounts of material to the continental shelf, submarine Sofala/Zambesia Bank. The Sofala/Zambesia Bank acts as a staging area for this riverine input prior to its redistribution toward the abyssal plains of the Mozambique Channel. Much of this material is said to be directed into the submarine Zambezi Valley and Channel. Until this study, however, the sediment transfer routes between the Sofala/Zambesia Bank and abyssal plains of the Mozambique Channel have been quite poorly understood and remain unconstrained. The aim of this contribution is to better constrain sediment transport pathways to the abyssal plains using the latest, regional, high resolution multibeam bathymetry data available, taking into account the effects of bottom water circulation, antecedent basin morphology and sea level change. Results show that sediment transport and delivery to the abyssal plains is discreetly partitioned into southern, central and northern domains. This sediment partitioning is primarily controlled by changes in continental shelf and shelf break morphology under the influence of a dynamic anticyclonic inshore circulation system. However, changes in base level have an overarching control on sediment delivery to particular domains at various sea levels. A direct consequence of these controlling factors is limited sediment delivery to the submarine Zambezi Valley and Channel under present-day conditions, with increased activity envisaged during regression. Furthermore, the “on-off” switching of discrete domains along strike is a sequence stratigraphic concept generally not previously considered in the shelf-slope-abyssal continuum. The proposed sediment transport routes, under varied sea level scenarios, provide a framework which relates shallow to mid depth studies with those focused on the deep regions of the Mozambique Channel providing the first inclusive account of shelf to abyssal sediment transport in the region

PERCEPTIONS AND PREVALENCE OF CAVING-SKILLS TRAINING IN THE UNITED STATES AND THE UNITED KINGDOM

Abstract: Results are presented of a study of perceptions of caving-skills training

Dynamic Climatologic Processes of Barometric Cave Systems Using the Example of Jewel Cave and Wind Cave in South Dakota, USA

Jewel and Wind Cave are two big barometric cave systems in SouthDakota, USA. The entrances of Jewel and Wind Cave are roughly 50 km apart, and until now it is unknown whether their entrances belong to two separate caves or to one muchlarger cave system. One possibility for testing these two competing hypotheses is to measure and analyse the climatic conditions in the vicinity of these entrances and within the caves in detail. In this context, the thermal conditions and air currents are crucial. These in turn can be characterised by the spatial and temporal patterns of the dynamics of air entering and leaving throughthe respective entrances; even thoughthese dynamics are coupled to atmospheric pressure fluctuations outside the caves, they differ for different cave systems and provide a “fingerprint” that has implications for the size and structure of individual cave systems. To give an example, Jewel and Wind Cave as the second and fourth-largest cave systems on earthshow some similarities, but many more noticeable differences regarding their climatological behaviour, despite their close proximity to eachother. The last big measurement campaigns on the climatic systems of the two barometric caves were carried out by Herb and Jan Conn in the 1960s, (Conn 1966). Despite their elementary work, the technical possibilities were very limited in those days. The self-constructed mechanical measurement equipment could only be used for basic measurements. Herb Conn was still able to identify the basic mechanism very clearly. He also carried out a number of different calculations on barometric air flow that remain important up to the present day. During the last 40 years, rapid electronic development has enabled us to use instruments that are far more precise and sensitive. The use of ultrasonic anemometers and dataloggers enables us to take more exact long term measurements. An extensive measurement programme was started in 2001 to fulfil several researchaims, and we are now in a position to decipher the different fingerpr

Dynamic Climatologic Processes of Barometric Cave Systems Using the Example of Jewel Cave and Wind Cave in South Dakota, USA

Jewel and Wind Cave are two big barometric cave systems in SouthDakota, USA. The entrances of Jewel and Wind Cave are roughly 50 km apart, and until now it is unknown whether their entrances belong to two separate caves or to one muchlarger cave system. One possibility for testing these two competing hypotheses is to measure and analyse the climatic conditions in the vicinity of these entrances and within the caves in detail. In this context, the thermal conditions and air currents are crucial. These in turn can be characterised by the spatial and temporal patterns of the dynamics of air entering and leaving throughthe respective entrances; even thoughthese dynamics are coupled to atmospheric pressure fluctuations outside the caves, they differ for different cave systems and provide a “fingerprint” that has implications for the size and structure of individual cave systems. To give an example, Jewel and Wind Cave as the second and fourth-largest cave systems on earthshow some similarities, but many more noticeable differences regarding their climatological behaviour, despite their close proximity to eachother. The last big measurement campaigns on the climatic systems of the two barometric caves were carried out by Herb and Jan Conn in the 1960s, (Conn 1966). Despite their elementary work, the technical possibilities were very limited in those days. The self-constructed mechanical measurement equipment could only be used for basic measurements. Herb Conn was still able to identify the basic mechanism very clearly. He also carried out a number of different calculations on barometric air flow that remain important up to the present day. During the last 40 years, rapid electronic development has enabled us to use instruments that are far more precise and sensitive. The use of ultrasonic anemometers and dataloggers enables us to take more exact long term measurements. An extensive measurement programme was started in 2001 to fulfil several researchaims, and we are now in a position to decipher the different fingerpr