Clarification of the circulatory patho-physiology of anaesthesia - Implications for high-risk surgical patients

AbstractThe paper examines the effects of anaesthesia on circulatory physiology and their implications regarding improvement in perioperative anaesthetic management. Changes to current anaesthetic practice, recommended recently, such as the use of flow monitoring in high risk patients, are already beginning to have an impact in reducing complications but not mortality [1]. Better understanding of the patho-physiology should help improve management even further. Analysis of selected individual clinical trials has been used to illustrate particular areas of patho-physiology and how changes in practice have improved outcome. There is physiological support for the importance of achieving an appropriate rate of oxygen delivery (DO2), particularly following induction of anaesthesia. It is suggested that ensuring adequate DO2 during anaesthesia will avoid development of oxygen debt and hence obviate the need to induce a high, compensatory, DO2 in the post-operative period. In contrast to the usual assumptions underlying strategies requiring a global increase in blood flow [1] by a stroke volume near maximization strategy, blood flow control actually resides entirely at the tissues not at the heart. This is important as the starting point for understanding failed circulatory control as indicated by ‘volume dependency’. Local adjustments in blood flow at each individual organ – auto-regulation – normally ensure the appropriate local rate of oxygen supply, i.e. local DO2. Inadequate blood volume leads to impairment of the regulation of blood flow, particularly in the individual tissues with least capable auto-regulatory capability. As demonstrated by many studies, inadequate blood flow first occurs in the gut, brain and kidney. The inadequate blood volume which occurs with induction of anaesthesia is not due to blood volume loss, but probably results from redistribution due to veno-dilation. The increase in venous capacity renders the existing blood volume inadequate to maintain venous return and pre-load. Blood volume shifted to the veins will, necessarily, also reduce the arterial volume. As a result stroke volume and cardiac output fall below normal with little or no change in peripheral resistance. The resulting pre-load dependency is often successfully treated with colloid infusion and, in some studies, ‘inotropic’ agents, particularly in the immediate post-operative phase. Treatment during the earliest stage of anaesthesia can avoid the build up of oxygen debt and may be supplemented by drugs which maintain or restore venous tone, such as phenylephrine; an alternative to volume expansion. Interpretation of circulatory patho-physiology during anaesthesia confirms the need to sustain appropriate oxygen delivery. It also supports reduction or even elimination of supplementary crystalloid maintenance infusion, supposedly to replace the “mythical” third space loss. As a rational evidence base for future research it should allow for further improvements in anaesthetic management

Dugout Canoes from Lakes of the Adirondack Uplands

We describe here four dugout canoes that have been retrieved from three water bodies in the Adirondack uplands during the last half century. Two dugouts from Lake Placid and Lake Ozonia, which are kept at the Six Nations Iroquois Cultural Center and Adirondack Experience, respectively, were made by Indigenous or Euro-American people equipped with metal tools and are probably no more than 4 centuries old. Two other dugouts under private ownership that were retrieved from Twin Ponds were almost certainly made by Indigenous artisans with traditional methods. The larger of the two is 6 m long and up to 5 centuries old, possibly the oldest boat known thus far from the Adirondack uplands. All of these dugouts were probably built, used, and stored at the lakes they were found in. The great size and weight of the larger Twin Ponds dugout in particular suggests long-term use at the discovery site and therefore challenges persistent claims that Indigenous people did not live in the Adirondack uplands

Arterial Oxygen Saturation During Ascent to 5010 m: Heart Rate and AMS Scores

The hypothesis here is that tissues exposed to the hypoxia of altitude have increased blood flow so that the rate of arrival of oxygen is as rapid as normal. If the ascent is too rapid, the system starts to fail. The study involves an ascent to high altitude (5010 m) during which 59 subjects recorded their resting arterial oxygen saturation (SaO2), heart rate (HR) and Lake Louise acute mountain sickness (AMS) scores, twice daily. During the major ascent SaO2 fell progressively. In 42 subjects, HR increased in a highly significant, negative, relationship to SaO2. In 10 subjects heart rate (HR) remained unchanged. Three subjects showed extreme HR variability. Data were incomplete in four subjects. For nine of the subjects, showing the progressive HR versus SaO2 correlation during ascent, the sequence terminated with a lower HR than would be expected from the correlation so far. Individual AMS scores showed no correlation with SaO2 but averaged values from 19 of the subjects from each ‘one night’ stopover; showed a strong, negative, correlation. Average stopover HR values correlated negatively with the average SaO2 values. Cardiac output (CO) is likely to have increased during ascent as HR increased, since there is a progressive relationship between HR and cardiac output (CO). Hence, despite the progressive fall in SaO2, tissue oxygen delivery (DO2) would have remained close to normal in the 42 subjects who showed the significant HR: SaO2 relationship

Radiative absorption enhancements by black carbon controlled by particle-to-particle heterogeneity in composition.

Black carbon (BC) absorbs solar radiation, leading to a strong but uncertain warming effect on climate. A key challenge in modeling and quantifying BC's radiative effect on climate is predicting enhancements in light absorption that result from internal mixing between BC and other aerosol components. Modeling and laboratory studies show that BC, when mixed with other aerosol components, absorbs more strongly than pure, uncoated BC; however, some ambient observations suggest more variable and weaker absorption enhancement. We show that the lower-than-expected enhancements in ambient measurements result from a combination of two factors. First, the often used spherical, concentric core-shell approximation generally overestimates the absorption by BC. Second, and more importantly, inadequate consideration of heterogeneity in particle-to-particle composition engenders substantial overestimation in absorption by the total particle population, with greater heterogeneity associated with larger model-measurement differences. We show that accounting for these two effects-variability in per-particle composition and deviations from the core-shell approximation-reconciles absorption enhancement predictions with laboratory and field observations and resolves the apparent discrepancy. Furthermore, our consistent model framework provides a path forward for improving predictions of BC's radiative effect on climate

Integrated Multiparametric Radiomics and Informatics System for Characterizing Breast Tumor Characteristics with the OncotypeDX Gene Assay

Optimal use of multiparametric magnetic resonance imaging (mpMRI) can identify key MRI parameters and provide unique tissue signatures defining phenotypes of breast cancer. We have developed and implemented a new machine-learning informatic system, termed Informatics Radiomics Integration System (IRIS) that integrates clinical variables, derived from imaging and electronic medical health records (EHR) with multiparametric radiomics (mpRad) for identifying potential risk of local or systemic recurrence in breast cancer patients. We tested the model in patients (n = 80) who had Estrogen Receptor positive disease and underwent OncotypeDX gene testing, radiomic analysis, and breast mpMRI. The IRIS method was trained using the mpMRI, clinical, pathologic, and radiomic descriptors for prediction of the OncotypeDX risk score. The trained mpRad IRIS model had a 95% and specificity was 83% with an Area Under the Curve (AUC) of 0.89 for classifying low risk patients from the intermediate and high-risk groups. The lesion size was larger for the high-risk group (2.9 ± 1.7 mm) and lower for both low risk (1.9 ± 1.3 mm) and intermediate risk (1.7 ± 1.4 mm) groups. The lesion apparent diffusion coefficient (ADC) map values for high- and intermediate-risk groups were significantly (p \u3c 0.05) lower than the low-risk group (1.14 vs. 1.49 × 10−3 mm2/s). These initial studies provide deeper insight into the clinical, pathological, quantitative imaging, and radiomic features, and provide the foundation to relate these features to the assessment of treatment response for improved personalized medicine

Psychology as a natural science in the eighteenth century

Psychology considered as a natural science began as Aristotelian "physics" or "natural philosophy" of the soul. C. Wolff placed psychology under metaphysics, coordinate with cosmology. Scottish thinkers placed it within moral philosophy, but distinguished its "physical" laws from properly moral laws (for guiding conduct). Several Germans sought to establish an autonomous empirical psychology as a branch of natural science. British and French visual theorists developed mathematically precise theories of size and distance perception; they created instruments to test these theories and to measure visual phenomena such as the duration of visual impressions. These investigators typically were dualists who included mental phenomena within nature

Interstellar Deuterium, Nitrogen, and Oxygen Abundances Toward GD 246, WD 2331−-475, HZ 21, and Lan 23: Results from the FUSE Mission

The interstellar abundances of D I, N I, and O I in the local ISM are studied us ing high-resolution spectra of four hot white dwarfs. The spectra of GD 246, WD 2331$-$475, HZ 21, and Lan 23 were obtained with the {\it Far Ultraviolet Spectroscopic Explorer} FUSE in the wavelength range 905-1187 A. The line of sight to GD 246 probes the Local Interstellar Cloud and at least one other H I cloud inside the Local Bubble, which contains most of the gas seen al ong this line of sight. The column densities of H I, C II*, S II, and Si II are measured using archival STIS echelle-mode observations. The H I column density is determined by fitting the strong damping wings of inte rstellar Lyman alpha using a model atmosphere to account for the stellar continuum. We combine the different abundance ratios computed here with previous published values to produce revised FUSE abundance ratios for DI/HI, OI/HI, NI/HI, DI/NI, DI/OI, and OI/NI.Comment: 12 figures, 48 page