The global loss of avian functional and phylogenetic diversity from anthropogenic extinctions.

Humans have been driving a global erosion of species richness for millennia, but the consequences of past extinctions for other dimensions of biodiversity-functional and phylogenetic diversity-are poorly understood. In this work, we show that, since the Late Pleistocene, the extinction of 610 bird species has caused a disproportionate loss of the global avian functional space along with ~3 billion years of unique evolutionary history. For island endemics, proportional losses have been even greater. Projected future extinctions of more than 1000 species over the next two centuries will incur further substantial reductions in functional and phylogenetic diversity. These results highlight the severe consequences of the ongoing biodiversity crisis and the urgent need to identify the ecological functions being lost through extinction.

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: A Blinded Observational Feasibility Study.

BACKGROUND: Minimally invasive thoracic surgical techniques require effective lung isolation using one-lung ventilation (OLV). Verification of lung isolation may be confirmed by auscultation, visual confirmation using fiberoptic bronchoscopy (FOB), or more recently, point-of-care ultrasound (POCUS). The aim of this study was to prospectively compare lung ultrasound with clinical auscultation to confirm OLV before thoracic surgery in pediatric patients. METHODS: This prospectively blinded feasibility study included 40 patients ranging in age from 0 to 20 years. After confirmation of lung separation by the primary anesthesia team using FOB, the sonographer and the auscultator, both blinded to the laterality of surgery and lung separation, entered the operating room. The sonographer evaluated for pleural lung sliding and the auscultator listened for breath sounds. Successful lung separation was definitively confirmed by direct visualization of lung collapse during the operation. RESULTS: In confirming effective single-lung ventilation, lung ultrasound had a diagnostic accuracy of 95% (95% confidence interval [CI], 82.7%-98.5%). In contrast, auscultation could only reliably confirm lung isolation with 68% accuracy (95% CI, 51.5%-80.4%). The McNemar test showed a statistically significant difference between the use of lung ultrasound and auscultation (P < .001). The median time to perform ultrasonography was 67 seconds (interquartile range [IQR], 46-142) and the median time to perform auscultation was 21 seconds (IQR, 10-32). CONCLUSIONS: Based on the initial results of our feasibility trial, lung ultrasound proved to be a fast and reliable method to verify single-lung ventilation in pediatric patients presenting for thoracic surgery with a high degree of diagnostic accuracy.

Peptide Receptor Radionuclide Therapy versus Capecitabine/Temozolomide for the Treatment of Metastatic Pancreatic Neuroendocrine Tumors.

Background: Peptide Receptor Radionuclide Therapy (PRRT), a form of Radioligand Therapy (RLT), and Capecitabine/Temozolomide (CAPTEM) are cornerstones of systemic therapy for metastatic pancreatic neuroendocrine tumors (PNETs). Data regarding comparative efficacy are lacking. Herein, we compare the efficacy of PRRT vs. CAPTEM as second-line/beyond regimens and treatment sequencing. Methods: Clinicopathologic, radiographic, and genomic data were captured for metastatic PNETs seen in our multi-disciplinary NET clinic between 2013 and 2023. The primary outcome was progression-free survival (PFS) after progression on a previous line of systemic therapy. The secondary outcomes were objective response rate (ORR), time to response (TTR), and overall survival (OS). Results: Fifty-nine cases were included. PFS was similar in the PRRT (n = 29) and CAPTEM (n = 30) groups (PRRT = 21.90 months vs. CAPTEM = 20.03 months; HR 0.99; p = 0.97). On subgroup analysis, PRRT had longer PFS in cases without extrahepatic metastases (26.47 months vs. 17.67 months; p = 0.03) and cases with a mutation in the MEN1, DAXX, and/or ATRX genes (28.43 months vs. 18.67 months; p = 0.03). PRRT had reduced PFS in patients with grade 3 disease (7.83 months vs. 16.33 months; p = 0.02). ORR did not vary significantly (34.78% vs. 40.91%; p = 0.67). CAPTEM responders showed shorter TTR (6.03 months vs. 11.15 months; p = 0.03). In patients who received both, OS did not vary based on the sequence (HR 1.20; p = 0.75). Conclusions: PFS, ORR, and OS are similar when using PRRT vs. CAPTEM as second-line-and-beyond therapy for patients with metastatic PNETs. However, patients with MEN1, DAXX, and/or ATRX mutations or without extrahepatic metastases might better benefit from PRRT and patients with grade 3 disease from CAPTEM. Candidates for surgical debulking or with tumor-induced symptoms may benefit from initial treatment with CAPTEM due to shorter TTR.

Preoperative neurologic comorbidity and unanticipated early postoperative reintubation: a multicentre cohort study.

BACKGROUND: The risk of respiratory complications is highest in the first 72 h post-surgery. Postoperative respiratory events can exacerbate pre-existing respiratory compromise and lead to reintubation of the trachea, particularly in patients with neurologic disorders. This study examined the association between neurologic comorbidities and unanticipated early postoperative reintubation in children. METHODS: This multicentre, 1:1 propensity score-matched study included 420 096 children who underwent inpatient, elective, noncardiac surgery at National Surgical Quality Improvement Program reporting hospitals in 2012-22. The primary outcome was unanticipated early postoperative reintubation within 72 h after surgery. The secondary outcome was prolonged postoperative mechanical ventilation, defined as ventilator use >72 h. We also evaluated 30-day mortality in patients requiring reintubation. RESULTS: Cerebral palsy was associated with the highest risk of early reintubation (adjusted relative risk [RRadj]: 1.97, 95% confidence interval [CI]: 1.44-2.69; P<0.01), followed by seizure disorders (RRadj: 1.87, 95% CI: 1.50-2.34; P<0.01), neuromuscular disorders (RRadj: 1.76, 95% CI: 1.41-2.19; P<0.01), and structural central nervous system abnormalities (RRadj: 1.35, 95% CI: 1.13-1.61; P<0.01). Unanticipated early postoperative reintubation was associated with an eight-times increased risk of 30-day mortality (adjusted hazard ratio: 8.1, 95% CI: 6.0-11.1; P<0.01). Risk of prolonged postoperative mechanical ventilation was also increased with neurologic comorbidities, particularly seizure disorders (RRadj: 1.73, 95% CI: 1.55-1.93; P<0.01). CONCLUSIONS: Children with neurologic comorbidities have an increased risk of unanticipated early postoperative reintubation and prolonged mechanical ventilation. Given the high mortality risk associated with these outcomes, children with neurologic comorbidities require heightened monitoring and risk assessment.

Association of Previous Cardiac Surgery With Postoperative Pneumonia in Infants Undergoing Abdominal Operations: A Cohort Study.

BACKGROUND: Children with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery. METHODS: A 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort). RESULTS: Of the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001). CONCLUSIONS: A history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery. LEVEL OF EVIDENCE: II.

Respiratory Compromise Related to Primary Histoplasmosis Infection in Two Pediatric Patients.

Primary infection related to the fungus, histoplasmosis, is generally asymptomatic in immunocompetent hosts. Calcified granulomas may be noted incidentally on radiologic imaging such as chest radiographs or computed tomography imaging. However, even in immunocompetent hosts, these primary infections occasionally result in end-organ involvement including respiratory compromise. Histoplasmosis should be included in the differential diagnosis of patients presenting with respiratory involvement and mediastinal adenopathy. We present two pediatric-aged patients who developed pulmonary involvement related to a primary histoplasmosis infection that resulted in mediastinal and tracheal lymphadenopathy. These led to respiratory compromise due to pleural effusion in the first patient and tracheal compression in the second. In this paper, the basic microbiology of Histoplasma capsulatum is presented, previous reports of primary respiratory involvement presented, and diagnostic and therapeutic options discussed.

Operating Room Noise Environment and Behavior in Children Undergoing General Anesthesia: A Randomized Controlled Trial.

Background: Excessive operating room noise impairs communication, distracts from monitoring equipment, and may increase patient and provider stress. Aim: This study investigates the effects of reduced noise on perioperative behavior in children undergoing general anesthesia and on anesthesia provider response time. Methods: Healthy children (the American Society of Anesthesiologists class I-II), 2-8 years of age, and their anesthesia providers were randomized into a control or treatment group exposed to reduced stimulation during induction and emergence. Primary outcomes were patient behavior and provider response time. Secondary outcomes were postoperative pain scores, provider responses exceeding 30 seconds, and median and maximum noise exposure. Results: 64 children (27 females and 37 males) were randomized into a control or treatment group, of whom 32 (50%) underwent tonsillectomy/adenoidectomy and 32 (50%) underwent dental procedures. The average age was 4.6 (SD 1.43) years. Children exposed to reduced noise were less likely to be "fussy about eating" (p=0.042), more "interested in what goes on around them" (p=0.008), and had fewer temper tantrums (p=0.004) on postoperative day one or two and on postoperative day five, six, or seven. No other differences were found between groups in behavioral assessment scores or provider response times. Conclusions: Our study is the first to show that a low-stimulus environment improves postdischarge behavior. Provider response time was unaffected by reduced noise, and the average and peak noise exposure levels did not exceed national safety guidelines. This trial is registered with NCT03507855 and NCT03504553.

MEN1/DAXX/ATRX mutations enhance progression-free survival in gastroenteropancreatic neuroendocrine tumors treated with peptide receptor radionuclide therapy.

Pre-clinical data suggest that mutations in the MEN1, DAXX, and/or ATRX genes may potentially increase radiation efficacy in cancer cells. Herein, we explore the association between response to peptide receptor radionuclide therapy (PRRT) and those mutations in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs). We analyzed tissue-based next generation sequencing (NGS) assay results and clinicopathologic data from 28 patients with GEP-NETs treated with PRRT. Findings were correlated with progression-free survival (PFS) and objective response rate (ORR). Patients with mutations in MEN1, DAXX, and/or ATRX (n = 13) had a longer median PFS (26.47 vs 12.13 months; P = 0.014) than wild-type (n = 15) patients when adjusted for surgery prior to PRRT, tumor grade, and presence of TP53 mutation. Alterations in MEN1 along with a concurrent mutation in either DAXX or ATRX (n = 6) trended toward longer PFS compared to patients without concurrent mutations (31.53 vs 17.97 months; P = 0.09). ORR was higher in patients with a mutation in MEN1, DAXX, or ATRX (41.67% vs 15.38%). In pancreatic NET patients, these target mutations also showed a longer PFS (28.43 vs 9.83 months; P = 0.04). TP53 alterations showed a shorter PFS than wild-type cases (11.17 vs 20.47 months; P = 0.009). Mutations in MEN1/DAXX/ATRX are associated with improved PFS in patients with GEP-NETs receiving PRRT and might be used as a biomarker for treatment response.

Unravelling the complexities of biotic homogenization and heterogenization in the British avifauna.

Biotic homogenization is a process whereby species assemblages become more similar through time. The standard way of identifying the process of biotic homogenization is to look for decreases in spatial beta-diversity. However, using a single assemblage-level metric to assess homogenization can mask important changes in the occupancy patterns of individual species. Here, we analysed changes in the spatial beta-diversity patterns (i.e. biotic heterogenization or homogenization) of British bird assemblages within 30 km × 30 km regions between two periods (1988-1991 and 2008-2011). We partitioned the change in spatial beta-diversity into extirpation and colonization-resultant change (i.e. change in spatial beta-diversity within each region resulting from both extirpation and colonization). We used measures of abiotic change in combination with Bayesian modelling to disentangle the drivers of biotic heterogenization and homogenization. We detected both heterogenization and homogenization across the two time periods and three measures of diversity (taxonomic, phylogenetic, and functional). In addition, both extirpation and colonization contributed to the observed changes, with heterogenization mainly driven by extirpation and homogenization by colonization. These assemblage-level changes were primarily due to shifting occupancy patterns of generalist species. Compared to habitat generalists, habitat specialists had significantly (i) higher average contributions to colonization-resultant change (indicating heterogenization within a region due to colonization) and (ii) lower average contributions to extirpation-resultant change (indicating homogenization from extirpation). Generalists showed the opposite pattern. Increased extirpation-resultant homogenization within regions was associated with increased urban land cover and decreased habitat diversity, precipitation, and temperature. Changes in extirpation-resultant heterogenization and colonization-resultant heterogenization were associated with differences in elevation between regions and changes in temperature and land cover. Many of the 'winners' (i.e. species that increased in occupancy) were species that had benefitted from conservation action (e.g. buzzard (Buteo buteo)). The 'losers' (i.e. those that decreased in occupancy) consisted primarily of previously common species, such as cuckoo (Cuculus canorus). Our results show that focusing purely on changes in spatial beta-diversity over time may obscure important information about how changes in the occupancy patterns of individual species contribute to homogenization and heterogenization.

An in vitro technique to measure resistance to compression and kinking of endotracheal tubes.

Background: During intraoperative care, ventilatory parameters including peak inflating pressure (PIP) and exhaled tidal volumes are continuously monitored to assess changes in respiratory resistance and compliance. Changes in these parameters, such as an increase in PIP or a decrease in the exhaled tidal volume, may indicate various pathologic processes that may require immediate attention to prevent inadequate ventilation resulting in hypoxemia or hypercarbia. A kinked endotracheal tube (ETT) may mimic other pathologic processes including bronchospasm, mainstem intubation, or ventilator malfunction. As newer ETTs are developed, a key factor in their design should be resistance to kinking or occlusion due to patient positioning. Methods: The current project developed and describes the process for using a repeatable in vitro mechanical test to determine resistance to kinking by an ETT. Results: The mechanical testing procedure can be used to determine the compression force and distance required to kink an ETT under different conditions including temperature. The force required to induce devastating kink failure was lower during heated testing conditions. The addition of airflow through the ETTs during compression testing confirms the occurrence of airway obstruction at approximately the same time a mechanical kink is observed on the force-versus-distance curves. Conclusions: These procedures may be used to characterize and evaluate ETT designs under in vitro conditions mimicking those in the clinical practice.

Endotracheal tube cuff position in relationship to the walls of the trachea: A retrospective computed tomography-based analysis.

Background: The use of cuffed endotracheal tubes (ETTs) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: The study included patients ranging in age from 1 month to 10 years who underwent neck and chest CT imaging that required general anesthesia and endotracheal intubation. The location of the ETT and of the cuff within the airway was determined from axial CT images at three levels (proximal, middle, and distal). Anatomical orientations were tabulated, and percent chances of each orientation were determined for the ETT and the cuff. Results: The study cohort included 42 patients ranging in age from 1 to 114 months. An ETT with a polyvinylchloride cuff was used in 24 patients, and an ETT with a polyurethane cuff was used in 18 patients. The ETT was located near the posterior wall of the trachea in approximately 24-38% of patients, being most likely to be centrally located at the proximal end and at its mid-portion. The middle part of the cuff was most likely to be positioned in the mid-portion of the trachea but tended to skew anteriorly at both the proximal and distal ends. Conclusion: This is the first study using CT imaging to identify the uniformity of cuff inflation within the trachea in children. With commonly used cuffed ETTs, cuff inflation and the final position of ETT cuff within the tracheal lumen were not uniform. Future investigations are needed to determine the reasons for this asymmetry and its clinical implications.

Anesthesia considerations for pediatric metabolic and bariatric surgery.

Childhood obesity is a rapidly growing global health issue, linked to significant lifelong morbidity and mortality. Its impact on various organ systems increases perioperative complications. Obesity treatment in children and adolescents involves lifestyle, dietary, and behavioral modifications, as well as pharmacologic interventions that targets hormonal, metabolic, and neurochemical abnormalities. Metabolic and bariatric surgery, proven safe and effective for adults with severe obesity (class 2 or higher), is now being recommended for adolescents. Key anesthetic considerations for these surgeries include preoperative optimization, advanced airway management, targeted ventilation strategies, and opioid-sparing analgesic regimens. Comprehensive presurgical evaluations must address co-morbid conditions such as hypertension, obstructive sleep apnea, asthma, and impaired glycemic control. Preoperative management should also consider the effects of antiobesity medications on gastric emptying and hemodynamic stability. Ventilation strategies should prevent atelectasis while avoiding barotrauma, and drug dosages must be adjusted for altered pharmacokinetics due to increased adipose tissue. Employing enhanced recovery after surgery protocols may reduce perioperative complications, shorten postsurgical stays, and improve outcomes.

Clinical experience with remimazolam in pediatric anesthesiology: An educational focused review.

Remimazolam is a novel ultrashort-acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma-amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half-life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA-approval in pediatric-aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric-aged patients, and discusses dosing parameters and clinical use in this population.

Exploring the Macroevolutionary Signature of Asymmetric Inheritance at Speciation.

Popular comparative phylogenetic models such as Brownian Motion, Ornstein-Ulhenbeck, and their extensions, assume that, at speciation, a trait value is inherited identically by two descendant species. This assumption contrasts with models of speciation at a micro-evolutionary scale where descendants' phenotypic distributions are sub-samples of the ancestral distribution. Different speciation mechanisms can lead to a displacement of the ancestral phenotypic mean among descendants and an asymmetric inheritance of the ancestral phenotypic variance. In contrast, even macro-evolutionary models that account for intraspecific variance assume symmetrically conserved inheritance of ancestral phenotypic distribution at speciation. Here we develop an Asymmetric Brownian Motion model (ABM) that relaxes the assumption of symmetric and conserved inheritance of the ancestral distribution at the time of speciation. The ABM jointly models the evolution of both intra- and inter-specific phenotypic variation. It also infers the mode of phenotypic inheritance at speciation, which can range from a symmetric and conserved inheritance, where descendants inherit the ancestral distribution, to an asymmetric and displaced inheritance, where descendants inherit divergent phenotypic means and variances. To demonstrate this model, we analyze the evolution of beak morphology in Darwin finches, finding evidence of displacement at speciation. The ABM model helps to bridge micro- and macro-evolutionary models of trait evolution by providing a more robust framework for testing the effects of ecological speciation, character displacement, and niche partitioning on trait evolution at the macro-evolutionary scale.

Thresholds for adding degraded tropical forest to the conservation estate.

Logged and disturbed forests are often viewed as degraded and depauperate environments compared with primary forest. However, they are dynamic ecosystems1 that provide refugia for large amounts of biodiversity2,3, so we cannot afford to underestimate their conservation value4. Here we present empirically defined thresholds for categorizing the conservation value of logged forests, using one of the most comprehensive assessments of taxon responses to habitat degradation in any tropical forest environment. We analysed the impact of logging intensity on the individual occurrence patterns of 1,681 taxa belonging to 86 taxonomic orders and 126 functional groups in Sabah, Malaysia. Our results demonstrate the existence of two conservation-relevant thresholds. First, lightly logged forests (<29% biomass removal) retain high conservation value and a largely intact functional composition, and are therefore likely to recover their pre-logging values if allowed to undergo natural regeneration. Second, the most extreme impacts occur in heavily degraded forests with more than two-thirds (>68%) of their biomass removed, and these are likely to require more expensive measures to recover their biodiversity value. Overall, our data confirm that primary forests are irreplaceable5, but they also reinforce the message that logged forests retain considerable conservation value that should not be overlooked.

Race, Ethnicity, and Pediatric Postsurgical Mortality: Current Trends and Future Projections.

BACKGROUND: No study has contextualized the aggregate human costs attributable to disparities in pediatric postsurgical mortalities in the United States, a critical step needed to convey the scale of racial inequalities to clinicians, policymakers, and the public. METHODS: We conducted a population-based study of 673 677 children from US hospitals undergoing intermediate to high-risk surgery between 2000 and 2019. We estimated the excess deaths that could be avoided if Black and Hispanic children had comparable mortality rates to white children. We estimated the mortality reduction required to eliminate disparities within the next decade. We finally evaluated the impact of policy changes targeting a modest annual 2.5% reduction in disparity-attributable mortality. RESULTS: During 2000 to 2019, risk-adjusted postoperative mortality trended consistently higher for both Black (adjusted RR [aRR]: 1.42, 95% confidence interval [CI]: 1.36-1.49) and Hispanic children (aRR: 1.22, 95% CI: 1.17-1.27) than for white children. These disparity gaps were driven by higher mortality in Black and Hispanic children receiving surgery in nonteaching hospitals (Black versus white aRR: 1.63, 95% CI: 1.38-1.93; Hispanic versus white aRR: 1.50, 95% CI: 1.33-1.70). There were 4700 excess deaths among Black children and 5500 among Hispanic children, representing. 10 200 (average: 536 per year) excess deaths among minoritized children. Policy changes achieving an annual 2.5% reduction in postoperative mortality would prevent approximately 1100 deaths among Black children in the next decade. CONCLUSIONS: By exploring the solution, and not just the problem, our study provides a framework to reduce disparities in pediatric postoperative mortality over the next decade.

Birds optimize fruit size consumed near their geographic range limits.

Animals can adjust their diet to maximize energy or nutritional intake. For example, birds often target fruits that match their beak size because those fruits can be consumed more efficiently. We hypothesized that pressure to optimize diet-measured as matching between fruit and beak size-increases under stressful environments, such as those that determine species' range edges. Using fruit-consumption and trait information for 97 frugivorous bird and 831 plant species across six continents, we demonstrate that birds feed more frequently on closely size-matched fruits near their geographic range limits. This pattern was particularly strong for highly frugivorous birds, whereas opportunistic frugivores showed no such tendency. These findings highlight how frugivore interactions might respond to stressful conditions and reveal that trait matching may not predict resource use consistently.

The Use of Remimazolam During Awake Craniotomy for Seizure Foci Resection in Adolescents: A Case Series.

Remimazolam is a novel benzodiazepine with sedative, anxiolytic, and amnestic properties similar to midazolam. Metabolism by tissue esterases results in a short clinical half-life of 5 - 10 min and a limited context sensitive half-life. We present initial retrospective clinical experience with the use of remimazolam as an intraoperative adjunct to sedation during awake craniotomy in a cohort of three adolescent patients. A remimazolam infusion was added to a combination of dexmedetomidine and remifentanil to deepen the level of sedation during surgical incision, craniotomy, duraplasty, and surgical dissection for exposure of the seizure foci. The remimazolam infusion was discontinued 30 min prior to the planned awake assessments and electrophysiology testing. The patients emerged calmly and were able to follow commands for intraoperative testing. Our anecdotal experience supports the efficacy of remimazolam for awake craniotomy and tumor resection using a standard asleep-awake-asleep technique. We noted adequate sedation, maintenance of spontaneous respiration, rapid awakening, and no limitations to intraoperative neuromonitoring or awake assessment in our three patients.

Disentangling the drivers of urban bird diversity in the non-breeding season: A general synthesis.

Current knowledge about the impacts of urbanisation on bird assemblages is based on evidence from studies partly or wholly undertaken in the breeding season. In comparison, the non-breeding season remains little studied, despite the fact that winter conditions at higher latitudes are changing more rapidly than other seasons. During the non-breeding season, cities may attract or retain bird species because they offer milder conditions or better feeding opportunities than surrounding habitats. However, the range of climatic, ecological and anthropogenic mechanisms shaping different facets of urban bird diversity in the non-breeding season are poorly understood. We explored these mechanisms using structural equation modelling to assess how urbanisation affects the taxonomic, phylogenetic and functional diversity of avian assemblages sampled worldwide in the non-breeding season. We found that minimum temperature, elevation, urban area and city age played a critical role in determining taxonomic diversity while a range of factors-including productivity, precipitation, elevation, distance to coasts and rivers, socio-economic (as a proxy of human facilitation) and road density-each contributed to patterns of phylogenetic and functional diversity. The structure and function of urban bird assemblages appear to be predominantly shaped by temperature, productivity and city age, with effects of these factors differing across seasons. Our results underline the importance of considering multiple hypotheses, including seasonal effects, when evaluating the impacts of urbanisation on biodiversity.