Mallampati score is a good and independent predictive factor for obstructive sleep apnoea (OSA)

published_or_final_versio

Replacing Conventional PFAS Water Treatment by GAC with Plasma Treatment to Improve Sustainability

Per and poly-fluoroalkylated substances (PFAS) are carcinogenic compounds which make their way into water systems and are difficult to remove. Currently, PFAS is removed from drinking water at an industrial scale using granular activated carbon (GAC), a solid particulate which removes PFAS from water through adsorption. However, in recent years, a new method utilizing a plasma reactor to mineralize the PFAS has been designed and tested at small scales. This project aims to increase the scale of existing plasma reactor designs to treat the same volumes of water that traditional GAC plants are capable of treating. A specific well in New Castle County, Delaware was identified as the treatment site, and both processes were designed to treat 2.33 million gallons of water per day by reducing the PFAS concentration from 4,500 parts per trillion to the US EPA health advisory level of 70 parts per trillion. The GAC process was estimated to have a capital cost of $6.73 million and an operational cost of$6.32 million each year. The plasma process was estimated to have a capital cost of $14.8 million and an operational cost of$5.93 million each year. Based on a number of economic and environmental factors, this project found that the plasma system was a more effective and sustainable method for achieving the desired reduction in PFAS concentration

Green Infrastructure System Map & Gap Analysis for Maunalua Bay Watersheds, Oʻahu

A collection of resources important to green infrastructure research and projects in Maunalua, Oʻahu.In Maunalua's urban environment, excess stormwater causes flooding, property damage, eutrophication, and pollution of coastal areas that threatens the biodiversity, natural resources, and quality of life. Thus, effective implementation of green infrastructure is critical for Maunalua communities to successfully mitigate extreme wet weather impacts and create a healthy urban environment. The project goal was to create a system map to understand the network of entities surrounding green infrastructure, and a gap analysis to identify inefficiencies and leverage points within the system. A final document is also included to synthesize all resources and findings. Furthermore, additional resources are included to aid future research and projects in green infrastructure in Maunalua Bay and other urban cities in Hawaiʻi

Escaping the Shadow

Photo by Karl Raymund Catabas on Unsplash  “After Buddha was dead, they still showed his shadow in a cave for centuries – a tremendous, gruesome shadow. God is dead; but given the way people are, there may still for millennia be caves in which they show his shadow. – And we – we must still defeat his shadow as well!” –  Friedrich Nietzsche[1] INTRODUCTION Friedrich Nietzsche famously declared that “God is dead!”[2] but lamented that his contemporaries remained living in the shadow of God. For Nietzsche, the morality of his time was still based in the Christian tradition, even though faith in God was waning. Bioethics lives under a similar shadow: the shadow of Enlightenment Era-rationalism. Bioethics curricula focus on principles derived from Kantian deontology and utilitarianism. The allure of maintaining a moral framework that provides a rational method that can be handily applied to any situation remains strong. The principlist approach advanced by Tom Beauchamp and James Childress is taught to nearly all medical students in the United States,[3] and is essentially the canonical ethical framework of bioethics. In this model, the principle of autonomy is Kantian in nature, and the principles of beneficence and non-maleficence are utilitarian in nature.[4] Moreover, the presented framework is an approach that, when applied rationally to any healthcare scenario, will yield an outcome “considered moral.”[5] This reflects a faulty conception of philosophy that plagues much of bioethics, wherein the only contribution of philosophy pertinent to bioethics is moral philosophy elucidated by European thinkers in the Enlightenment Era. The landscape of moral philosophy has evolved significantly from the 18th century. However, the bioethical world has not kept up with the philosophical world, remaining instead in the shadow of antiquated moral thinking. Also lacking in bioethics are other disciplines of philosophy, such as philosophy of language, existentialism, and aesthetics, which are often given no consideration at all. The inclusion of both modern moral philosophy and other philosophical fields is necessary if bioethics is to survive its transition into modernity. l.     The Shadow of Enlightenment Enlightenment Era philosophers such as Immanuel Kant argued that one need only employ reason to obtain knowledge; emotion bore no relevance when determining ethical behavior. Kant’s moral theories thus privileged a duty to act according to moral imperatives over feelings. Other Enlightenment Era philosophers such as John Locke developed systems that attempted to quantify human goods and human ills. This quantification potentially reduces human welfare and suffering to utility. Today, in the world of philosophy, such a “neutral analysis,” as Cora Diamond noted, is “dead or moribund.”[6] Bernard Williams remarked that such moral philosophy is “empty and boring,”[7] and G. E. M. Anscombe stated that it “no longer generally survives.”[8] And yet, just as the atheists in Nietzsche’s world dwelt in the moral code of a dead God, bioethicists still pursue a unified moral system that takes an input, applies some moral rules, and generates a moral outcome, like the four principles approach that Beauchamp and Childress laid out.[9]  Some detractors of principlism take issue with their approach for not being unified enough and want to replace it with a procedural framework that is even more systematic and complicated. They argue that the resulting moral framework would be a “comprehensive decision procedure for arriving at answers”[10] that retains the “impartiality that is an essential part of morality.”[11] The shadow of rationalist morality has caused bioethical decision making to become detached and rigid when bioethics should concern itself with the humans whose lives it affects. A rational, divorced-from-emotion way of thinking ultimately fails to yield satisfactory results when decisions are made by and for emotional beings. Dr. Paul Farmer, among others, championed the idea that bioethics should be de-philosophized, as philosophy, cold and calculated, fails to adequately respond to the realities of those worst off.[12] Instead, Dr. Farmer emphasized the inclusion of the social sciences, like sociology and anthropology, in bioethics. Undoubtedly, Dr. Farmer was on the right track; bioethics should certainly engage directly with the people whom its decisions involve. If the narrow band of moral philosophy currently found in bioethics – that of stringent rationalism – were all that philosophy had to offer, I, too, would advocate for a de-philosophization. Ludwig Wittgenstein notes that to attempt to capture the complexity of moral thinking in a manner that employs reason alone and casts aside emotion is a “hopeless task,” like reconstructing a sharp image “from a blurred one.”[13] Unfortunately, bioethics is mired in the remnants of this hopeless task. To Dr. Farmer, the dominant moral framework was too restrictive and was unresponsive to the social and humanitarian needs of those whom bioethics is meant to help. As such, he wished to free bioethics from the shadow of a morality derived from rationalist thinkers. ll.     Beyond Rationalism Like Nietzsche, who tried to resolve Europe’s post-religion vacuum by providing his society with a new way to live, Dr. Farmer wanted to replace the rationalist philosophy upon which bioethics was built with a “resocialization” of the field.[14] I agree with Dr. Farmer’s call for resocialization, as well as his denouncement of philosophy as it exists in bioethics. Evaluating risks and benefits along a predetermined array of moral principles is far too rigid and impersonal to guide what are often the most important decisions one will make. For Dr. Farmer, the most needed change was restoring the social element of bioethics. However, in advocating for this resocialization, Dr. Farmer casts philosophy as the antithesis of social science, noting that “few would regard philosophy … as a socializing discipline.”[15] I disagree. Rationalist moral philosophy may be lacking in socializing force, but there are other fields of philosophy that are responsive to our social reality. Rather than de-philosophizing bioethics, it makes more sense to replace the antisocial philosophies predominant in bioethics with prosocial philosophies better suited to it. Of course, the contribution of philosophy to bioethics is more than moral theories from the Enlightenment Era. There are more recent philosophical contributions from outside the field of moral philosophy that have roused bioethical interest.  Jennifer Blumenthal-Barby, et al., argue for philosophy’s continued place in bioethics, citing Derek Parfit’s “non-identity problem,” which altered the landscape of reproductive ethics, and David Chalmers’ contributions to philosophy of consciousness, which have implications for the moral status of brain organoids.[16] Still, these are narrow applications of philosophy to highly specialized areas of bioethics, which not all bioethicists are inclined to delve into. Philosophy in bioethics should not be confined to niche applications in specialist fields but should influence all bioethical thought. Fortunately, there remains untapped a wealth of philosophical disciplines that pertains to exactly this. Philosophy of language investigates the nature of meaning and understanding in communication, which is a necessary social action. Successfully deciphering and conveying moral values in discourse is a bioethicist’s bread and butter, as is resolving disagreements and reaching agreements. Indeed, it is often the case that miscommunication lies at the root of an impasse between a doctor and a patient. An understanding of the nature of the disagreement would help resolve the conflict, as different types of disagreements require different interventions for resolution. For instance, a “substantive disagreement,”[17] in which two parties use the same terms in the same ways and have a fundamental disagreement on which outcome is more desirable, can be resolved only if one party yields to the other. On the other hand, a “merely verbal dispute,”[18] in which two parties use the same terms to represent entirely different concepts and values, requires standardization of terminological usage for its resolution. As such, no one can overstate the moral importance of successful communication in bioethics, and an exploration of language itself would prove invaluable to a bioethicist’s training. Existentialism is another subset of philosophy that acknowledges the social nature of human existence, noting that one’s being in the universe is concomitant with the existence of others sharing the same universe.[19] Thus, there is the recognition that whatever existence is, it is not complete without the existence of others. With this as a starting point, existentialists examined how to live meaningfully with others in this world. Since ethics crucially involves others, it is no surprise that existentialists pondered how to live moral lives. Existentialist conceptions of morality did not revolve around acting in accordance with a set of rules, but rather, recognized individual freedom in choosing how to act and emphasized acting authentically. In this vein, bioethicists should commit to doing what is right rather than committing to applying a set of principles. Existentialism, while part of the broader bioethics literature, is less common throughout bioethics curricula and deserves more prominence. Martin Heidegger, for instance, emphasized the difference between two types of thinking: “calculative thinking” and “meditative thinking.” Heidegger characterizes calculative thinking as a computation, wherein from some given starting conditions “definite results”[20] are determined, and contrasts this with meditative thinking, which he describes as “thinking which contemplates the meaning which reigns in everything that is.”[21] Heidegger was critical of the pervasiveness of calculative thinking, seeing it as the “ground of thoughtlessness,”[22] in which we only relate to the world in a meaningless, mechanical way. This is the emphasized type of thinking in rationalist conceptions of morality popular in bioethics; from a set of starting conditions, a series of rules are applied, and a moral outcome is calculated. Such a technique, however, discounts the personal meaning individuals place on the aspects of their lives relevant to their decision making, as well as the meaning in committing to doing what is right. Under calculative thinking, such a commitment is reduced to rote rule-following. A turn to meditative thinking would ensure that bioethical decisions comport with living meaningful lives. Even aesthetics, a discipline devoted to examining beauty and taste,[23] has a place in bioethics. Just as the viewing of a painting, the listening of a song, or the reading of a book elicits an effective response, hearing a patient’s story leaves an emotional imprint. The recounting of a traumatic moment imparts sadness, and a joyous occasion begets joy in the listener as well. As acknowledged in the field of everyday aesthetics, these aesthetic experiences often spur us to act:[24] The unsightly appearance of a polluted riverbank drives us to remove the trash; the presence of sorrow in one’s life drives us to ameliorate it. To be mindful of aesthetic experiences and allow them to affect us emotionally is paramount to the motivation of a bioethicist to serve the patient, not out of an obligation to a job description, but out of a desire to truly avail the patient of their anguish. For example, the new field of narrative medicine utilizes critical reading and literary techniques to train clinicians and bioethicists in emotional understanding and listening skills that stress the social aspects of medicine beyond rational analysis and decision making. CONCLUSION Dr. Farmer is absolutely correct; bioethics is in dire need of resocialization. It should not be the case that the justification for a moral action is essentially that “the rules say so,” or that simply by teaching such rules to medical students, the very act of making bioethical decisions that diverge from those determined by principles can be seen as an act of “bad faith … hubris or, worse, malpractice.”[25] As bioethicists are coming to realize, the rationalist philosophical traditions that bioethics was founded upon are past their expiry, and the time for change is now. Indeed, as Dr. Farmer urges, “socializing disciplines” like anthropology, history, political economy, and sociology are necessary to humanize the field of bioethics.[26] So too, however, can philosophy be a socializing discipline, if we know where to look. Bioethics should evolve. Its new goal should be to focus on meaningful human relationships, and to phase out rigid, impersonal modes of moral thinking. The limited sampling of unsatisfying moral theories from hundreds of years ago leaves many bioethics students cold, and it is easy to see why bioethicists are ready to part ways with philosophy. I believe this is a move in the wrong direction; there is a place for philosophy in the future of bioethics. Just as bioethics needs a resocialization, it is also needs of a re-philosophization. These enrichments complement one another. There is more to bioethics than mechanically determining the right course of action in a healthcare setting. Bioethics engages with the most ancient of philosophical questions: questions of what makes human existence meaningful, what makes us who we are, how we want to relate to others, how and why we feel, what our place in the world is, how we can communicate what we think, and why our moral intuitions are so compelling. We would be remiss if we did not begin to investigate additional contributions to morality from a wider range of philosophies that try to provide answers to such questions, as they offer a richness to moral thinking that cannot be gleaned from traditional bioethical approaches alone. - [1] Friedrich Wilhelm Nietzsche, The Gay Science: With a Prelude in German Rhymes and an Appendix of Songs, ed. Bernard Williams, Josefine Nauckhoff, and Adrian Del Caro, Cambridge Texts in the History of Philosophy (Cambridge, U.K. ; New York: Cambridge University Press, 2001), 109. [2] Nietzsche, 120. [3] Daniel C O’Brien, “Medical Ethics as Taught and as Practiced: Principlism, Narrative Ethics, and the Case of Living Donor Liver Transplantation,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 47, no. 1 (February 1, 2022): 97, https://doi.org/10.1093/jmp/jhab039. [4] K. D. Clouser and B. Gert, “A Critique of Principlism,” Journal of Medicine and Philosophy 15, no. 2 (April 1, 1990): 219–36, https://doi.org/10.1093/jmp/15.2.219. [5] O’Brien, “Medical Ethics as Taught and as Practiced,” 97. [6] Cora Diamond, “Having a Rough Story about What Moral Philosophy Is,” New Literary History 15, no. 1 (1983): 168, https://doi.org/10.2307/468998. [7] Bernard Williams, Morality: An Introduction to Ethics, Canto ed (Cambridge ; New York: Cambridge University Press, 1993), xvii. [8] G. E. M. Anscombe, “Modern Moral Philosophy,” Philosophy 33, no. 124 (January 1958): 1, https://doi.org/10.1017/S0031819100037943. [9] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed (New York: Oxford University Press, 2013), 13. [10] Clouser and Gert, 233. [11] Clouser and Gert, “A Critique of Principlism,” 235. [12] Paul Farmer and Nicole Gastineau Campos, “Rethinking Medical Ethics: A View from Below,” Developing World Bioethics 4, no. 1 (May 2004): 17–41, https://doi.org/10.1111/j.1471-8731.2004.00065.x. [13] Ludwig Wittgenstein, Philosophical Investigations, ed. Joachim Schulte, trans. P. M. S. Hacker, 4th edition (Chichester, West Sussex, U.K. ; Malden, MA: Wiley-Blackwell, 2009), 40. [14] Farmer and Campos, “Rethinking Medical Ethics,” 20. [15] Farmer and Campos, 20. [16] Jennifer Blumenthal-Barby et al., “The Place of Philosophy in Bioethics Today,” The American Journal of Bioethics: AJOB, June 30, 2021, 3–5, https://doi.org/10.1080/15265161.2021.1940355. [17] Brendan Balcerak Jackson, “Verbal Disputes and Substantiveness,” Erkenntnis 79, no. S1 (March 2014): 31–54, https://doi.org/10.1007/s10670-013-9444-5. [18] C. S. I. Jenkins, “Merely Verbal Disputes,” Erkenntnis 79, no. 1 (March 1, 2014): 11–30, https://doi.org/10.1007/s10670-013-9443-6. [19] Steven Crowell, “Existentialism,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Summer 2020 (Metaphysics Research Lab, Stanford University, 2020), https://plato.stanford.edu/archives/sum2020/entries/existentialism/; Anita Avramides, “Other Minds,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2020 (Metaphysics Research Lab, Stanford University, 2020), https://plato.stanford.edu/archives/win2020/entries/other-minds/. [20] Martin Heidegger, Discourse on Thinking, Harper Torchbooks (New York, NY: Harper & Row, 1969), 46. [21] Heidegger, 46. [22] Heidegger, 45. [23] Nick Zangwill, “Aesthetic Judgment,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2021 (Metaphysics Research Lab, Stanford University, 2021), https://plato.stanford.edu/archives/win2021/entries/aesthetic-judgment/. [24] Yuriko Saito, “Aesthetics of the Everyday,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Spring 2021 (Metaphysics Research Lab, Stanford University, 2021), https://plato.stanford.edu/archives/spr2021/entries/aesthetics-of-everyday/. [25] O’Brien, “Medical Ethics as Taught and as Practiced,” 112. [26] Farmer and Campos, “Rethinking Medical Ethics,” 20

Intracranial arachnoid cysts: Pediatric neurosurgery update

Background: With the greater worldwide availability of neuroimaging, more intracranial arachnoid cysts (IACs) are being found in all age groups. A subset of these lesions become symptomatic and requires neurosurgical management. The clinical presentations of IACs vary from asymptomatic to extremely symptomatic. Here, we reviewed the clinical presentation and treatment considerations for pediatric IACs. Case Description: Here, we presented three cases of IAC, focusing on different clinical and treatment considerations. Conclusion: IACs can be challenging to manage. There is no Class I Evidence to guide how these should be treated. We suggest clinical decision-making framework as to how to treat IACs based on our understanding of the natural history, risks/benefits of treatments, and outcomes in the future, require better patient selection for the surgical management of IACs will be warranted

Stream Fish Assemblages Around the Clemson Experimental Forest

The southeastern USA harbors high aquatic diversity in the temperate region. Yet, stream fish suffer high imperilment rates due to anthropogenic activities such as habitat loss and water quality degradation. From the biodiversity conservation perspective, it is important to document what and where species occur in a landscape. The purpose of this Creative Inquiry project was to survey stream fish assemblages in and around the Clemson Experimental Forest. We surveyed local streams using electrofishing and seining techniques in Fall 2014 and recorded abundance of fish species captured. We collected common species such as bluehead chub (Nocomis leptocephalus) and yellowfin shiner (Notropis lutipinnis), as well as locally rare species such as blackbanded darter (Percina nigrofasciata). Although we hypothesized that larger streams would contain higher species richness than smaller streams, our data did not support this hypothesis based on a linear regression analysis. Our study showed that fish fauna around campus is diverse and we should be aware of these important water resources for conservation

Evaluating snow microbial assemblages

Psychrophiles are organisms that grow optimally below 20C (1). The US Great Basin is home to many mountain peaks with an abundance of alpine snow environments perfect for psychrophilic habitation. We analyzed samples from three different locations, Wheeler Peak, Pacific Crest Trail, and Mount Conness, characterizing and comparing the psychrophilic communities at varying depth intervals in the snow. Polymerase chain reaction (PCR) and denaturing gradient gel electrophoresis (DGGE) showed no notable difference in community structure with depth, but there was a distinct difference when comparing different snow environments (i.e. shaded vs. full sun exposure). The chlorophyll concentration decreased as the depth of the snow increased. By creating a clone library and utilizing DNA sequencing technology we were able to obtain 16S and 18S rRNA gene sequences from samples collected from Mount Conness, which allowed us to identify microbes living in the ecosystem. This information enabled us to produce bacterial and eukaryl phylogenetic trees, giving us a clear look into the diversity of this psychrophilic community. Out of seventy bacterial results there were fifty‐three ‐Proteobacteria, thirteen Sphingobacteria, and only three Actinobacteria, with one unclassified bacteria as well. These results will guide us in our future plans for experimentation

Toward a Millimeter-Scale Tendon-Driven Continuum Wrist with Integrated Gripper for Microsurgical Applications

Microsurgery is a particularly impactful yet challenging form of surgery. Robot assisted microsurgery has the potential to improve surgical dexterity and enable precise operation on such small scales in ways not previously possible. Intraocular microsurgery is a particularly challenging domain in part due to the lack of dexterity that is achievable with rigid instruments inserted through the eye. In this work, we present a new design for a millimeter-scale, dexterous wrist intended for microsurgery applications. The wrist is created via a state-of-the-art two-photon-polymerization (2PP) microfabrication technique, enabling the wrist to be constructed of flexible material with complex internal geometries and critical features at the micron-scale. The wrist features a square cross section with side length of 1.25 mm and total length of 3.75 mm. The wrist has three tendons routed down its length which, when actuated by small-scale linear actuators, enable bending in any plane. We present an integrated gripper actuated by a fourth tendon routed down the center of the robot. We evaluate the wrist and gripper by characterizing its bend-angle. We achieve more than 90 degrees bending in both axes. We demonstrate out of plane bending as well as the robot's ability to grip while actuated. Our integrated gripper/tendon-driven continuum robot design and meso-scale assembly techniques have the potential to enable small-scale wrists with more dexterity than has been previously demonstrated. Such a wrist could improve surgeon capabilities during teleoperation with the potential to improve patient outcomes in a variety of surgical applications, including intraocular surgery.Comment: 2 pages, 3 figures, submitted to the 2023 Hamlyn Symposium on Medical Robotics conferenc