Considerazioni etico-giuridiche sui criteri di priorità di cura per i pazienti in terapia intensiva durante la pandemia di COVID-19 / Consideracions ètic-jurídiques sobre els criteris de prioritat de cura pels pacients en teràpia intensiva durant la pandèmia de la COVID-19 / Consideraciones ético-jurídicas sobre los criterios de prioridad de atención para los pacientes en terapia intensiva durante la pandemia de COVID-19 / Ethical-legal considerations on priority care criteria for patients in intensive therapy during the COVID-19 pandemic

Ci si è chiesti se la pandemia abbia modificato il modo in cui la morte e il morire vengano pensati. L’incontrollata diffusione del contagio e la mancanza di un’adeguata risposta organizzativa in termini di sanità pubblica ha determinato ben presto nelle TI una sproporzione tra domanda di assistenza (insufficienza respiratoria acuta) e risorse disponibili (personale formato, posti-letto, ventilatori meccanici). I clinici si sono così trovati nella condizione di dover decidere quali pazienti ammettere in TI e quali escludere. Sia in Italia che in Spagna si è fatto ricorso al triage: sono state elaborate alcune raccomandazioni che hanno destato perplessità e critiche nell’ambito medico ed etico-giuridico.(AU)

En aquest article es reflexiona sobre la forma en què la pandèmia derivada de la COVID-19 ha alterat determinats processos assistencials davant de la mort. La ràpida propagació incontrolada de la malaltia i la manca de resposta organitzativa en termes de salut pública aviat van conduir a una desproporció entre la demanda assistencial en cures intensives i els recursos humans imaterials per satisfer-la. En ocasions, els metges s'han vist en el dilema de decidir quins pacients tractar i quins excloure a les unitats de cures intensives. Tant a Espanya com a Itàlia s'ha fet servir el triatge i s'han publicat algunes recomanacions que han suscitat algunes crítiques en l'àmbit mèdic, ètic i legal. Es planteja el dubte de si aquestes mesures excepcionals es poden aplicar quan es recupera la normalitat sociosanitària.(AU)

En este artículo se reflexiona sobre la forma en que la pandemia derivada del COVID-19 ha alterado determinados procesos asistenciales frente a la muerte. La rápida propagación incontrolada de la enfermedad y la faltade respuesta organizativa en términos de salud pública pronto condujeron a una desproporción entre la demanda asistencial en cuidados intensivos y los recursos humanos y materiales para satisfacerla. En ocasiones, los médicos se han visto en el dilema de decidir qué pacientes tratar y cuales excluir en las unidades de cuidados intensivos. Tanto en España como en Italia se ha usado el triaje y se han publicado algunas recomendaciones que han suscitado ciertas críticas en el ámbito médico, ético y legal. Se plantea el interrogante de que estas medidas excepcionales se puedan aplicar cuando se recupera la normalidad socio sanitaria.(AU)

This paper reflects on the way in which the pandemic derived from COVID-19 has altered certain care processes in the face of death. The rapid uncontrolled spread of the disease, and the lack of organizational response in terms of public health soon led to a disproportion between the demand for intensive care and the human and material resources to meet it. At times, doctors have been faced with the dilemma of deciding which patients to treat and which to exclude in intensive care units. Both in Spain and Italy triage has been used and some recommendations have been published that have provoked some criticism in the medical, ethical and legal field. The question arises whether these exceptional measures can be applied when socio-sanitary normality is restored.(AU)

Pérdida gestacional y el proceso de su duelo. Lo que comparten las mujeres y sus parejas / Pèrdua gestacional i el procés del dol. El que comparteixen les dones i les seves parelles / Pregnancy loss and the grieving process. What women and their partners share

La interrupción del embarazo,ya sea espontánea como voluntaria, supone un impacto emocional intenso tanto en la mujer como en su pareja que alterasu mundo emocional. El elevado porcentaje de mujeres que sufren una pérdida perinatal y las repercusiones emocionalesque conlleva a corto y largo plazo hace necesario replantear el trabajo de las especialidades que atienden a población pe-rinatal (psicología, pediatría, ginecología, obstetricia, psiquiatría, etc.) para conceder la importancia que tiene un procesode duelo frecuente y especialmente silenciado. Nos centraremos en las pérdidas perinatales que ocurren a lo largo de lagestación, un proceso de duelo con idas y vueltas, con sintomatología propia y que requiere una atención, formación yescucha terapéutica también propia. Desde la reflexión y la práctica clínica abordaremos aspectos relevantes que ocurrendurante este proceso terapéutico. Este acompañamiento profesional, necesario y escaso, tiene como objetivo que la mujery su pareja, en caso de tenerla, puedan elaborar suficientemente el duelo, aliviar la sintomatología actual y, caso de una si-guiente gestación, disminuir el riesgo de desajuste emocional tanto en la madre, como en su pareja y en el futuro bebé, quepuede desembocar en una depresión perinatal en los padres o en problemas de desarrollo emocional en el bebé. (AU)

The termination of pregnancy,whether spontaneous or voluntary, involves an intense emotional impact on both the woman and her partner which al-ters their emotional world. The high percentage of women who suffer a perinatal loss, and the emotional repercussions itentails in both the short and long term, make it necessary to rethink the work of the specialties which attend the perinatalpopulation (psychology, pediatrics, gynecology, obstetrics, psychiatry …) to acknowledge the importance of a frequentyet particularly silenced grieving process. In this article focus will be placed on the perinatal losses which occur duringgestation, a mourning process which ebbs and flows, which has its own symptomatology and one which also requires itsown bespoke attention, training, and therapeutic listening. From reflection and clinical practice, relevant aspects whichoccur during this therapeutic process will be addressed. This professional accompaniment, which is necessary yet scarce,aims to enable the woman and her partner to sufficiently work through their grief, alleviate the current symptomatologyand, in the case of a subsequent pregnancy, reduce the risk of emotional imbalance in the mother, her partner and thefuture baby, which can lead to perinatal depression in the parents or emotional development problems in the baby. (AU)

La interrupció de l’embaràsja sigui espontània o voluntària suposa un impacte emocional intens tant en la dona com en la parella que altera el seumón emocional. L'elevat percentatge de dones que pateixen una pèrdua perinatal i les repercussions emocionals quecomporta a curt i llarg termini fan necessari replantejar el treball de les especialitats que atenen la població perinatal(psicologia, pediatria, ginecologia, obstetrícia, psiquiatria, etc.) per concedir la importància que té a un procés de dolfreqüent i especialment silenciat. Ens centrarem en les pèrdues perinatals que esdevenen al llarg de la gestació, unprocés de dol amb anades i tornades, amb simptomatologia pròpia i que requereix una atenció, formació i escoltaterapèutica també pròpia. Des de la reflexió i la pràctica clínica abordarem aspectes rellevants que tenen lloc durantaquest procés terapèutic. Aquest acompanyament professional, necessari i escàs, té com a objectiu que la dona i laseva parella, en cas de tenir-la, puguin elaborar prou el dol, alleujar la simptomatologia actual i, en cas d'una següentgestació, disminuir el risc de desajust emocional tant en la mare, com en la seva parella i en el futur nadó, que pot des-embocar en una depressió perinatal als pares o en problemes de desenvolupament emocional al nadó.(AU)

Suppression of Bile Acid Synthesis in a Preterm Infant Receiving Prolonged Parenteral Nutrition.

Bile acid metabolism is altered in neonates on parenteral nutrition (PN), predisposing them to parenteral nutrition-associated liver disease. Cholesterol 7α-hydroxylase (CYP7A1), the rate-limiting enzyme in the bile acid synthesis pathway, is repressed by fibroblast growth factor 19 (FGF19) and phytosterols (PS). We describe a case of a preterm infant who developed necrotizing enterocolitis (NEC) and received exclusive PN for over 2 months. Our objective was to serially assess CYP7A1 activity and plasma FGF19 and PS concentrations in this infant case compared to five healthy preterm infants. We found that CYP7A1 activity increased during the first 2 weeks of life in control infants but was undetectable in the infant case. FGF19 concentrations were high at birth in all infants and subsequently declined and did not differ between the case and control infants. As expected, PS concentrations were elevated in the infant case and continued to increase despite lipid minimization. In conclusion, CYP7A1 activity was gradually upregulated in healthy preterm infants but remained suppressed in the infant requiring prolonged PN. Preterm infants also had elevated FGF19 concentrations at birth, which decreased with advancing postnatal age.

Variable disease manifestations and metabolic management within a single family affected by ornithine transcarbamylase deficiency.

We report on a family with ornithine transcarbamylase (OTC) deficiency, an X-linked urea cycle disorder, with variable disease severity and tailored management strategies based on each family member's biochemical profile and clinical presentation. Our primary patient is a female monozygotic twin who presented to medical care at 10 months of age with acute liver failure, gastrointestinal symptoms, altered mental status, hypoglycemia, and hyperammonemia. The patient's older brother, known to have hemizygous OTC deficiency, died at 8 months of age from cardiac arrest after complications secondary to his diagnosis. Despite her family history, manifestation of symptoms of heterozygous (partial) OTC deficiency went unrecognized by multiple providers based on misconceptions regarding a female's risk for X-linked disease. Despite barriers related to the family's low socioeconomic status, follow-up care by a multidisciplinary metabolic care team, including moderate protein restriction and nitrogen scavenger therapy, led to positive outcomes for the patient. Her twin sister and mother are also heterozygous for variants in OTC and remain controlled on moderate protein restriction. This case illustrates the importance of genotyping all individuals with genetic risk factors for OTC deficiency and the variability in disease manifestation that necessitates tailored treatment approaches for individuals with partial OTC deficiency.

The Long-Term Mechanical Properties of BS Perpendicular to the Grain.

As a modern bamboo composite with good mechanical properties, bamboo scrimber (BS) has achieved prominence in the sustainable architecture field. When used as a structural material, it is inevitably under continual tension perpendicular to the grain, therefore its mechanical response under long-term loading is significant for structural design. In this study, tensile tests were conducted on BS under short-term and long-term loads perpendicular to the grain. The duration of load (DOL) effect on BS perpendicular to grain and its creep effect were analyzed. Compared with BS parallel to the grain, the DOL effect on BS perpendicular to the grain was less severe, and the capacity for creep resistance was weaker. The threshold stress ratio and relative creep strain of BS perpendicular to the grain were 0.40 and 0.87, respectively. It was found that the DOL models and the viscoelastic model accurately predicted the DOL factor and creep strain. This study provides a scientific reference for the safe lifetime service of BS in practical engineering.

Uso fuera de indicación de la combinación a dosis fija de tramadol/dexketoprofeno en atención primaria de salud: ¿Basado en la evidencia científica o motivo de preocupación? / Off-label use of fixed-dose combination of tramadol and dexketoprofen in primary health care. Evidence-based or cause for concern?

Introducción: La utilización de la combinación a dosis fija de tramadol/dexketoprofeno en España y en otros países ha aumentado de forma conside-rable. La indicación terapéutica autorizada de este medicamento es el tratamiento sintomático a corto plazo del dolor agudo de moderado a intenso en pacientes adultos. El objetivo de este estudio fue describir el patrón de uso de tramadol/dexketopro-feno en el ámbito de la atención primaria de salud.Método: Se realizó un estudio transversal, descrip-tivo y multicéntrico. La población de estudio incluyó a todos los pacientes de una Dirección de Atención Primaria (53 equipos de Atención Primaria) que tenían activa la prescripción de tramadol/dexke-toprofeno el 28 de marzo de 2018. La población diana fueron aquellos pacientes a los que se les prescribió tramadol/dexketoprofeno durante más de 20 días.Resultados: Un total de 176 pacientes tenía activa la prescripción de tramadol/dexketoprofeno. Todos los pacientes (100%) tuvieron una duración del tratamiento superior a 5 días y el 72,7% (N=128) su-perior a 20 días. La duración media del tratamiento fue de 14±160,9 días en pacientes que tenían me-nos de 20 días de tratamiento y de 224±160,8 días en pacientes que tenían más de 20 días de trata-miento. El 35,1% de los pacientes estaban tratados con más de 2 medicamentos para aliviar el dolor de forma concomitante con tramadol/dexketoprofeno. El médico de atención primaria inició un 65,6% de las prescripciones.Conclusiones: La combinación a dosis fija de tramadol/dexketoprofeno se utilizó con frecuencia fuera de indicación, de acuerdo con la ficha técnica y la evidencia científica disponible. Este estudio alerta sobre los riesgos potenciales asociados a la utilización de este medicamento en la práctica clíni-ca, como son la falta de efectividad y/o la aparición de efectos adversos. (AU)

Introduction: The use of the fixed-dose combi-nation of tramadol/dexketoprofen in Spain and in other countries has increased considerably. The authorized therapeutic indication for this medicinal product is the short-term symptomatic treatment of moderate to severe acute pain in adult patients. The objective of this study was to describe the pat-tern of use of tramadol/dexketoprofen in the field of primary health care.Method: A cross-sectional, descriptive and mul-ticenter study was carried out. The study popu-lation included all patients from a Primary Care Department (53 Primary Care teams) with an active prescription of tramadol/dexketoprofen on March 28, 2018. The target population was those patients who were prescribed tramadol/dexketoprofen. dexketoprofen for >20 days.Results: A total of 176 patients had an active pre-scription for tramadol/dexketoprofen. All patients (100%) had a duration of treatment greater than 5 days and 72.7% (N=128) greater than 20 days. The mean duration of treatment was 14±160.9 days in patients who had less than 20 days of treatment and 224±160.8 days in patients who had more than 20 days of treatment. 35.1% of the patients were treated with >2 pain medications and concomi-tantly with tramadol/dexketoprofen. The general practitioner initiated 65.6% of the prescriptions.Conclusions: The fixed-dose combination of tra-madol/dexketoprofen was frequently used off-la-bel, according to the product characteristics and the available scientific evidence. This study warns about the potential risks associated with the use of this drug in clinical practice, such as lack of effec-tiveness and/or the appearance of adverse effects (AU)

El proceso de duelo en la familia que emigra: del «Síndrome de Ulises» a la patología / El procés de dol en la família que emigra: de la “síndrome d'Ulisses” a la patologia / The grieving process in the migrant family: from the "Ulysses Syndrome" to pathology

En este artículo des-cribiremos la migración como un proceso en el cual aparecen profundas pérdidas. La reacción ante la pérdidaconstituye un proceso de duelo, que empieza antes de partir con la ambivalencia y termina con la reintroyec-ción del objeto cuando aparece la integración de la familia en la sociedad de acogida. Dependiendo de cómo serealiza la migración podrá elaborarse el duelo (migración normal), generará dificultades como el Síndrome delInmigrante con Estrés Crónico y Múltiple (Ulysses Sindrome) o fracasará la elaboración, apareciendo entoncessituaciones de riesgo por las que la familia puede desorganizarse y enfermar.(AU)

In this article, we willdescribe migration as a process in which profound losses occur. The reaction to the loss constitutes a mourningprocess, which begins before the migration with ambivalence and ends with the reintroduction of the objectwhen the integration of the family into the host society takes place. Depending on how the migration is carriedout, the mourning can be elaborated (normal migration), it will generate difficulties such as the Chronic andMultiple Stress Migrant Syndrome (Ulysses Syndrome) or the elaboration will fail, thus creating risk situations inwhich the family can become disorganised and become ill.(AU)

En aquest article descriuremla migració com un procés en el qual apareixen profundes pèrdues. La reacció davant la pèrdua constitueix unprocés de dol, que comença abans de marxar amb l'ambivalència i acaba amb la reintrojecció de l'objecte quanapareix la integració de la família en la societat d'acollida. Depenent de com es realitza la migració es pot ela-borar el dol (migració normal), generarà dificultats com la síndrome de l'immigrant amb estrès crònic i múltiple(Ulysses Sindrome) o fracassarà l'elaboració, amb l’aparició llavors de situacions de risc per les quals la famíliapot desorganitzar-se i emmalaltir.(AU)

Occlusive Pulmonary Artery Thrombosis in a Healthy Neonate With No Identifiable Risk Factors.

Pulmonary artery thrombosis is reported in neonates with risk factors for hypercoagulability. No consensus exists regarding standard therapy for this condition. We present a neonate, with no risk factors for thrombosis, who was admitted after birth to the Pediatric Cardiac Intensive Care Unit with an occlusive left pulmonary artery thrombus. (Level of Difficulty: Intermediate.).

Recurrent Atrial Flutter Requiring Multiple Cardioversions in a Preterm Infant.

We describe the first case of atrial flutter requiring multiple cardioversions in a preterm infant. Direct current cardioversion is one of the best-understood treatment options, with a first-time success rate higher than 96%. The electrocardiograms provided reveal a second run of atrial flutter occurring after successful cardioversion. (Level of Difficulty: Intermediate.).

Arginine to ornithine ratio as a diagnostic marker in patients with positive newborn screening for hyperargininemia.

Arginase deficiency is a rare inborn error of metabolism that interrupts the final step of the urea cycle. Untreated individuals often present with episodic hyperammonemia, developmental delay, cognitive impairment, and spasticity in early childhood. The newborn screening (NBS) algorithms for arginase deficiency vary between individual states in the US but often include hyperargininemia and elevated arginine to ornithine (Arg/Orn) ratio. Here, we report 14 arginase deficiency cases, including two patients with positive NBS for hyperargininemia in whom the diagnosis of arginase deficiency was delayed owing to normal or near normal plasma arginine levels on follow-up testing. To improve the detection capability for arginase deficiency, we evaluated plasma Arg/Orn ratio as a secondary diagnostic marker in positive NBS cases for hyperargininemia. We found that plasma Arg/Orn ratio combined with plasma arginine was a better marker than plasma arginine alone to differentiate patients with arginase deficiency from unaffected newborns. In fact, elevated plasma arginine in combination with an Arg/Orn ratio of ≥1.4 identified all 14 arginase deficiency cases. In addition, we examined the impact of age on plasma arginine and ornithine levels. Plasma arginine increased 0.94 µmol/L/day while ornithine was essentially unchanged in the first 31 days of life, which resulted in a similar increasing trend for the Arg/Orn ratio (0.01/day). This study demonstrated that plasma Arg/Orn ratio as a secondary diagnostic marker improved the detection capability for arginase deficiency in newborns with hyperargininemia, which will allow timely detection of arginase deficiency and hence initiation of treatment before developing symptoms.

Clinical update on the hybrid comprehensive stage II operation.

Objective: We previously described the hybrid comprehensive stage II operation as an alternate surgical procedure for a subset of patients with single ventricle congenital heart disease with adequate native ascending aortic outflow. Here we provide a clinical update on the 4 patients who have undergone this procedure. Methods: After undergoing a hybrid approach to the stage I Norwood palliation, the hybrid comprehensive stage II procedure was performed with an incision to the main pulmonary artery (PA), dilation of the ductal stent, creation of a stented baffle between the branch PAs, and a bidirectional Glenn connection. With this approach, dissection of the distal arch and creation of a Damus-Kaye-Stansel anastomosis was avoided. A standard Fontan procedure was planned after the usual period of growth. Results: The first patient, who had trisomy 21 and elevated PA pressures, died postoperatively due to left PA thrombosis. The subsequent 3 patients survived the procedure and remain clinically well. All have required catheterizations for reintervention on their stented intrapulmonary baffles and ductal arches, and all have undergone successful completion of their Fontan procedures. Conclusions: The hybrid comprehensive stage II is a feasible, less complex alternative to the conventional comprehensive stage II operation in a subset of patients with single ventricle physiology. Early postoperative anticoagulation therapy to avoid PA thrombosis is recommended, and restenting of the ductal arch is anticipated. Although the long-term consequences of separate outflow tracts supplying the upper and lower body is unknown, the 3 surviving patients with this circulation are doing well with their Fontan circulation at midterm follow-up.

Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives.

The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.

A miniature Ordovician hurdiid from Wales demonstrates the adaptability of Radiodonta.

Originally considered as large, solely Cambrian apex predators, Radiodonta-a clade of stem-group euarthropods including Anomalocaris-now comprises a diverse group of predators, sediment sifters and filter feeders. These animals are only known from deposits preserving non-biomineralized material, with radiodonts often the first and/or only taxa known from such deposits. Despite the widespread and diverse nature of the group, only a handful of radiodonts are known from post-Cambrian deposits, and all originate from deposits or localities rich in other total-group euarthropods. In this contribution, we describe the first radiodont from the UK, an isolated hurdiid frontal appendage from the Tremadocian (Lower Ordovician) Dol-cyn-Afon Formation, Wales, UK. This finding is unusual in two major aspects: firstly, the appendage (1.8 mm in size) is less than half the size of the next smallest radiodont frontal appendage known, and probably belonged to an animal between 6 and 15 mm in length; secondly, it was discovered in the sponge-dominated Afon Gam Biota, one of only a handful of non-biomineralized total-group euarthropods known from this deposit. This Welsh hurdiid breaks new ground for Radiodonta in terms of both its small size and sponge-dominated habitat. This occurrence demonstrates the adaptability of the group in response to the partitioning of ecosystems and environments in the late Cambrian and Early Ordovician world.

Enhancement of phenol biodegradation: Metabolic division of labor in co-culture of Stenotrophomonas sp. N5 and Advenella sp. B9.

The aim of this work is to study the synergistic effect of Stenotrophomonas sp. N5 and Advenella sp. B9 co-culture (COC) on enhancement of phenol biodegradation. These two strains utilizing phenol as sole carbon and energy source were isolated from phenol-containing coking wastewater. The results of biodegradation experiment showed the COC of N5 and B9 has stronger capability to degrade phenol than either of mono-culture (MOC). Growth kinetics studies indicated inhibitory effect of phenol on COC was reduced by the interaction of N5 and B9 in COC. The RNA-Seq results demonstrated that phenol biodegradation was enhanced by metabolic division of labor (DOL) in COC based on the expression of key genes for phenol degradation. GO enrichment analysis of differentially expressed genes (DEGs) indicated DEGs between COC and MOC degradation systems are mainly concentrated in the synthesis of cell components, microbial growth and metabolism, and catalytic activity. The expression of 3 transcriptional factors (LysR, Two-component system response regulator, and TetR families) which can regulate degradation of aromatic compounds, was identified beneficial to phenol degradation.

Williams Syndrome and Neonatal Cardiac Surgery for Congenital Single Ventricle.

Williams syndrome (WS) is an arteriopathic derangement associated with supravalvular aortic stenosis and branch pulmonary stenosis. We describe double-outlet right ventricle with mitral atresia and aortic arch hypoplasia in an infant with WS. This case demonstrates the difficulty in managing patients with WS with complex cardiac defects. To our knowledge, this is the first reported single-ventricle physiology in a patient with WS. (Level of Difficulty: Advanced.).

A working method for estimating dynamic shear velocity in the montney formation.

In this paper, we present a customized method for estimating sonic shear velocity (Vs) from compressional velocity (Vp) logs in the Montney Formation, in wells lacking dipole sonic data. Following a multi-scenario analysis that comprised of assessing empirical Vs estimation relations [including lithology, porosity (Ø), and volume of clay (Vsh)-based Vs estimation techniques], bivariate statistics, and machine learning, we found that the Greenberg & Castagna (1992) shale lithology constants yield Vs log estimates that best match the measured Montney Formation Vs in our study area, with a regional correlation coefficient of 0.8. We have therefore customized the Vs estimation method in our study to use the Greenberg & Castagna (1992) shale lithology constants. Our working method: •Improves the efficacy of Vs log estimation from Vp logs in the study area•Demonstrates the importance of calibrating empirical relations for Vs estimation to a specific formation, and•Provides a more accurate complementary Vs log dataset for subsequent regional reservoir characterization studies.

A phase 2 trial of N-Acetylcysteine in Biliary atresia after Kasai portoenterostomy.

BACKGROUND: Biliary atresia (BA) is a life-threatening liver disease of infancy, characterized by extrahepatic biliary obstruction, bile retention, and progressive liver injury. The Kasai portoenterostomy (KP) is BA's only nontransplant treatment. Its success is variable and depends on restoration of hepatic bile flow. Many adjunctive therapeutics have been studied to improve outcomes after the KP, but none demonstrate effectiveness. This study tests if N-acetylcysteine (NAC), a precursor to the choleretic glutathione, improves bile flow after KP. METHODS: This report describes the design of an open-label, single center, Phase 2 study to determine the effect of NAC following KP on markers of bile flow and outcomes in BA. The intervention is intravenous NAC (150 mg/kg/day) administered continuously for seven days starting 0-24 h after KP. The primary outcome is normalization of total serum bile acid (TSBA) concentrations within 24 weeks of KP. The secondary objectives are to describe NAC therapy's effect on other clinical parameters followed in BA for 24 months and to report adverse events occurring with therapy. This study follows the "minimax" clinical trial design. DISCUSSION: This is the first clinical trial to test NAC's effectiveness in improving bile flow after KP in BA. It introduces three important concepts for future BA therapeutic trials: (1) the "minimax" study design, a pertinent design for rare diseases because it detects potential effects quickly with small subject size; (2) the more sensitive bile flow marker, TSBAs, which may correlate with positive long-term outcomes better than traditional bile flow markers such as serum bilirubin; and (3) liver enzyme changes immediately after KP, which can be a guideline for potential drug-induced liver injury in other BA peri-operative adjunctive therapeutic trials.

Flexible Artificial Solid Electrolyte Interphase Formed by 1,3-Dioxolane Oxidation and Polymerization for Metallic Lithium Anodes.

Lithium-tin (Li-Sn) alloys are perfect substrate materials for anodes in high-energy density lithium metal secondary batteries. A new approach is proposed to further prevent the Li deposit on Li-Sn alloy substrates from reaction with electrolytes using an artificial solid electrolyte interphase (ASEI) based on electrochemical oxidation and polymerization of 1,3-dioxolane precursor with LiTFSI additive. This ASEI layer is flexible, stable, ion conductive, and electrically insulating, which can provide very stable cycling of Li-Sn alloy substrate anodes for Li deposition/stripping with an average Coulombic efficiency of 98.4% at a current density of 1 mA cm-2. The Li-Sn alloy substrate is kept uniform and smooth without any dendrites and cracks after cycles. When the Li-Sn alloy substrate protected by ASEI is used as the anode of lithium-sulfur full cell, the cell shows much higher discharge capacity and better cycleability. This innovative and facile strategy of ASEI formation demonstrates a new and promising approach to the solution of the tough problems of Li dendrites in Li metal batteries.

The Demographics and Education of Emergency Medical Services (EMS) Professionals: A National Longitudinal Investigation.

OBJECTIVES: The objectives of this study were to assess longitudinal and cross-sectional changes in Emergency Medical Technician (EMT)-Basics and Paramedics: (1) demographics, (2) employment characteristics, and (3) initial Emergency Medical Services (EMS) education. METHODS: These data were collected between 1999 and 2008 employing survey techniques aimed at collecting valid data. A random, stratified sample was utilized to allow results to be generalizable to the nationally certified EMS population. Survey weights that were adjusted for each stratum's response were estimated. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted when the CIs did not overlap. RESULTS: In all 10 years of data collection, the proportion of EMT-Paramedics who were male was greater than the proportion of EMT-Basics who were male. A substantial proportion of respondents performed EMS services for more than one agency: between 39.8% and 43.5% of EMT-Paramedics and 18.4% and 22.4% of EMT-Basic respondents reported this. The most common type of employer for both EMT-Basics and EMT-Paramedics was fire-based organizations. About one-third of EMT-Basics (32.3%-40.1%) and almost one-half of EMT-Paramedics (43.1%-45.3%) reported that these organizations were their main EMS employer. Rural areas (<25,000 residents) were the most common practice settings for EMT-Basics (52.1%-63.7%), while more EMT-Paramedics worked in urban settings (65.2%-77.7%). CONCLUSIONS: This analysis serves as a useful baseline to measure future changes in the EMS profession. This study described the demographic and work-life characteristics of a cohort of nationally certified EMT-Basics and Paramedics over a 10-year period. This analysis also summarized initial EMS education changes over time. Bentley MA , Shoben A , Levine R . The demographics and education of Emergency Medical Services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(Suppl. 1):s18-s29.

Holocarboxylase synthetase deficiency pre and post newborn screening.

Holocarboxylase synthetase deficiency is an autosomal recessive disorder of biotin metabolism resulting in multiple carboxylase deficiency. The typical presentation described in the medical literature is of neonatal onset within hours to weeks of birth with emesis, hypotonia, lethargy, seizures, metabolic ketolactic acidosis, hyperammonemia, developmental delay, skin rash and alopecia. The condition is screened for by newborn screening (NBS) tandem mass spectroscopy by elevated hydroxypentanoylcarnitine on dried blood spots. Urine organic acid profile may demonstrate elevated lactic, 3-OH isovaleric, 3-OH propionic, 3-MCC, methylcitric acids, and tiglylglycine consistent with loss of function of the above carboxylases. Here we describe a cohort of patients, 2 diagnosed pre-NBS and 3 post-NBS with broad differences in initial presentation and phenotype. In addition, prior to the advent of NBS, there are isolated reports of late-onset holocarboxylase synthetase deficiency in the medical literature, which describe patients diagnosed between 1 and 8 years of life, however to our knowledge there are no reports of late-onset HCLS being missed by NBS. Also we report two cases, each with novel pathogenic variants HCLS, diagnosed at age 3 years and 21 months respectively. The first patient had a normal newborn screen whilst the second had an abnormal newborn screen but was misdiagnosed as 3-methylcrotonylcarboxylase (3-MCC) deficiency and subsequently lost to follow-up until they presented again with severe metabolic acidosis.