The Effectiveness of Using the Anatomage Table as a Learning Adjunct to Peripheral Nerve Blocks Among Student Registered Nurse Anesthetists

Abstract In anesthesia programs across the country, learning advanced level human anatomy and physiology concepts provides a large foundation for which skills used in clinical application are learned. Student registered nurse anesthetists (SRNAs) are clinically trained to perform a variety of invasive procedures in practice including peripheral nerve blocks (PNBs). This project aimed to implement a supplemental, hands-on learning activity to improve overall PNB education, ultimately improving patient care and safety. A series of guided lessons were created to help the students walk through the anatomy of PNBs utilizing the Anatomage table (AT). SRNAs attended a workshop where they went through these lessons and then applied their knowledge to ultrasound images. An anonymous survey was given to students prior to and after the workshop to assess their confidence with the blocks. The pre-survey revealed that only 24.1% of students were confident in completing a PNB with guidance. Student confidence rose to 82.8% after attending the AT workshop. Incorporating the AT in an ultrasound guided PNB lab improved knowledge of the anatomy associated with each block. Having resources, such as these, available to SRNAs will lead to the production of strong nurse anesthesiologists, proficient in regional anesthesia

Diversity and Ecological Correlates of Red Fluorescence in Marine Fishes

Marine environments at depths below -10 to -25 m are almost devoid of ambient red sunlight because water quickly attenuates long wavelengths. This stenospectral light environment presents unique opportunities for organisms that can transform ambient blue-green light into red light by fluorescence. Numerous marine fish species display intricate patterns of fluorescence. Because color vision is a key component of fish sensory ecology, several putative visual functions of red fluorescence have been proposed but are difficult to test experimentally. Here, we follow a comparative approach to assess the consistency between the phylogenetic distribution of red fluorescence with its presumed functions. We collected and analyzed the largest data set of red fluorescence in fishes to date, consisting of confirmed cases in 272 primarily diurnal fish species from 49 out of 90 surveyed fish families and 12 out of 21 surveyed fish orders, contrasted to 393 fish species with confirmed absence of red fluorescence. Based on a priori hypotheses on adaptive function, we compare the prevalence of red fluorescence among pre-defined sets of species based on ecological or biological characteristics while controlling for shared ancestry. When comparing between species, we find no evidence that red fluorescence is more prevalent in deep-water species, contrasting with our recent finding that fluorescence brightness increases with depth within species. There is also no evidence for a role in group-driven communication. Phylogenetic patterns are consistent, however, with three other predictions. First, fluorescence with a rather patchy distribution across the body occurred significantly more often among sit-and-wait predators or otherwise sedentary fish than in more mobile species, consistent with background matching for camouflage. Second, small, predatory fishes tended to show red fluorescent irides disproportionally often consistent with a proposed function in prey localization. Finally, sexually dimorphic species showed fluorescent fins more often, as predicted if relevant in sexual communication. From these findings, we derive predictions for experimental investigations of the presumed functions of red fluorescence

Optimizing CoMag® System Operations Billerica, MA Wastewater Treatment Plant

The Billerica, MA Wastewater Treatment Plant uses alum addition with CoMag® treatment for phosphorus removal before discharging to the Concord River. The plant\u27s NPDES permit constrains levels of total phosphorus to 0.2 mg/L and total aluminum to 171 µg/L in the summer effluent water.The goal of this project was to determine the optimal parameters of the CoMag® system, while meeting NPDES permit total phosphorus and total aluminum levels.A bench- scale, batch system was developed in the laboratory to simulate the multi-step CoMag® system.The most significant trend, found through bench-scale testing, was that lower sludge recycle concentrations yielded higher total phosphorus and total aluminum removal

Vitamin B6 Deficiency A Potential Cause of Refractory Seizures in Adults

Objective: In children, vitamin B6 (pyridoxine) deficiency has been described as a cause of seizures that are refractory to conventional antiepileptic medications. We describe the clinical presentation of 3 adults with refractory seizures (later diagnosed with vitamin B6 deficiency) that resolved after pyridoxine treatment. Design: Case series. Setting: Tertiary care surgical intensive care unit. Patients: In the first case, a 54-year-old male with history of alcoholic cirrhosis developed new-onset seizures refractory to phenytoin and levetiracetam 8 days after liver transplantation. In the second case, a 59-year-old male with hepatitis C infection developed intracranial hemorrhage and new-onset seizures refractory to phenytoin, levetiracetam, and pentobarbital. The third patient is a 78-year-old male with a history of alcohol dependence who was admitted for an intraventricular bleed and developed new onset of refractory seizures. Interventions: Intravenous pyridoxine followed by oral pyridoxine. Measurement and Main Results: In all 3 cases, seizures persisted despite escalation of conventional antiepileptic medications but resolved within 2 days of pyridoxine supplementation. In each case, low serum pyridoxal 5′-phosphate concentrations normalized with pyridoxine administration. Conclusions: Although refractory seizures caused by vitamin B6 deficiency are rare in adults, it should be considered in critically ill adult patients with refractory seizures

Vitamin B6 Deficiency A Potential Cause of Refractory Seizures in Adults

Objective: In children, vitamin B6 (pyridoxine) deficiency has been described as a cause of seizures that are refractory to conventional antiepileptic medications. We describe the clinical presentation of 3 adults with refractory seizures (later diagnosed with vitamin B6 deficiency) that resolved after pyridoxine treatment. Design: Case series. Setting: Tertiary care surgical intensive care unit. Patients: In the first case, a 54-year-old male with history of alcoholic cirrhosis developed new-onset seizures refractory to phenytoin and levetiracetam 8 days after liver transplantation. In the second case, a 59-year-old male with hepatitis C infection developed intracranial hemorrhage and new-onset seizures refractory to phenytoin, levetiracetam, and pentobarbital. The third patient is a 78-year-old male with a history of alcohol dependence who was admitted for an intraventricular bleed and developed new onset of refractory seizures. Interventions: Intravenous pyridoxine followed by oral pyridoxine. Measurement and Main Results: In all 3 cases, seizures persisted despite escalation of conventional antiepileptic medications but resolved within 2 days of pyridoxine supplementation. In each case, low serum pyridoxal 5′-phosphate concentrations normalized with pyridoxine administration. Conclusions: Although refractory seizures caused by vitamin B6 deficiency are rare in adults, it should be considered in critically ill adult patients with refractory seizures

Red fluorescence increases with depth in reef fishes, supporting a visual function, not UV protection

Why do some marine fishes exhibit striking patterns of natural red fluorescence? In this study, we contrast two non-exclusive hypotheses: (i) that UV absorption by fluorescent pigments offers significant photoprotection in shallow water, where UV irradiance is strongest; and (ii) that red fluorescence enhances visual contrast at depths below −10 m, where most light in the ‘red’ 600–700 nm range has been absorbed. Whereas the photoprotection hypothesis predicts fluorescence to be stronger near the surface and weaker in deeper water, the visual contrast hypothesis predicts the opposite. We used fluorometry to measure red fluorescence brightness in vivo in individuals belonging to eight common small reef fish species with conspicuously red fluorescent eyes. Fluorescence was significantly brighter in specimens from the −20 m sites than in those from −5 m sites in six out of eight species. No difference was found in the remaining two. Our results support the visual contrast hypothesis. We discuss the possible roles fluorescence may play in fish visual ecology and highlight the possibility that fluorescent light emission from the eyes in particular may be used to detect cryptic prey

Does Delaying Early Intravenous Fat Emulsion during Parenteral Nutrition Reduce Infections during Critical Illness?

Background: Because early administration of intravenous fat emulsions (IVFEs) has been linked to infectious complications in trauma patients, we began withholding IVFE for the first seven to ten days of parenteral nutrition (PN) in all surgical intensive care unit (SICU) patients. Prior to this, IVFE had been infused from the start of PN. Purpose: To evaluate the influence of delaying IVFE on infectious complications in SICU patients. Methods: Retrospective review from October 2006 to June 2009 of SICU patients before and after a change in IVFE practice patterns in a 44-bed SICU at an academic medical center. Adult patients who received PN for more than six days were included. Patients receiving PN with IVFE prior to SICU admission or being given other lipid emulsion therapy were excluded. The data collected included demographics, transfusion requirements, nutritional assessments, and laboratory and microbiology results. The infectious complications studied were pneumonia, urinary tract infections (UTIs), blood stream infections (BSIs), and catheter-related blood stream infections (CRBSIs). Results: Sixty-four patients received IVFE; 30 at initiation of PN and 34 starting after seven to ten days. The two groups had similar demographics, severity of illness, transfusion requirements, and duration of PN. Infectious complications occurred in 65.6% of patients (63.3% having immediate IVFE vs. 67.6% having delayed IVFE; p = 0.79). Seventeen patients developed BSI or CRBSI while receiving PN (26.7% immediate IVFE vs. 26.5% delayed IVFE; p \u3e 0.99). The mortality rates were 63.3% and 55.9%, respectively (p = 0.63). Conclusions: Withholding IVFE therapy during the first seven to ten days of PN did not influence infectious complications or the mortality rate in SICU patients. The benefits of delaying IVFE therefore may not be generalizable to all critically ill patients