Acute care for patients exposed to a chemical attack: protocol for an international multicentric observational study.

INTRODUCTION: The use of weapons of mass destruction against civilian populations is of serious concern to public health authorities. Chemical weapons are of particular concern. A few studies have investigated medical responses in prehospital settings in the immediate aftermath of a chemical attack, and they were limited by the paucity of clinical data. This study aims to describe the acute management of patients exposed to a chemical attack from the incident site until their transfer to a medical facility. METHODS AND ANALYSIS: This international multicentric observational study addresses the period from 1970 to 2036. An online electronic case report form was created to collect data; it will be hosted on the Biomedical Telematics Laboratory Platform of the Quebec Respiratory Health Research Network. Participating medical centres and their clinicians are being asked to provide contextual and clinical information, including the use of protective equipment and decontamination capabilities for the medical evacuation of the patient from the incident site of the chemical attack to the moment of admission at the medical facility. In brief, variables are categorised as follows: (1) chemical exposure (threat); (2) prehospital and hospital/medical facility capabilities (staffing, first aid, protection, decontamination, disaster plans and medical guidelines); (3) clinical interventions before hospital admission, including the use of protection and decontamination and (4) outcomes (survivability vs mortality rates). Judgement criteria focus on decontamination drills applied to any of the patient's conditions. ETHICS AND DISSEMINATION: The Sainte-Justine Research Centre Ethics Committee approved this multicentric study and is acting as the main evaluating centre. Study results will be disseminated through various means, including conferences, indexed publications in medical databases and social media. TRIAL REGISTRATION NUMBER: NCT05026645.

Defoliation-induced changes in foliage quality may trigger broad-scale insect outbreaks.

Top-down effects, like predation, are drivers of insect outbreaks, but bottom-up effects, like host nutritional quality, also influence outbreaks and could in turn be altered by insect-caused defoliation. We evaluated the prediction that herbivory leads to a positive feedback on outbreak severity as nutrient concentration in plant tissues increases through improved soil nutrient availability from frass and litter deposition. Over seven years of a spruce budworm outbreak, we quantified litter nutrient fluxes, soil nitrogen availability, and host tree foliar nutrient status along a forest susceptibility gradient. As the outbreak progressed, both soil nutrient fluxes and availability increased which, in turn, improved foliage quality in surviving host trees. This is consistent with boosted insect fitness and increased population density and defoliation as outbreaks grow. Our results suggest that a positive bottom-up feedback to forest ecosystems from defoliation may result in conditions favorable to self-amplifying population dynamics in insect herbivores that can contribute to driving broad-scale outbreaks.

Gaps in Prehospital Care for Patients Exposed to a Chemical Attack - A Systematic Review.

INTRODUCTION: The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals. METHODS: This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient's health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination). RESULTS: Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis. CONCLUSIONS: This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

Improved performance of the eastern spruce budworm on black spruce as warming temperatures disrupt phenological defences.

Phenological shifts, induced by global warming, can lead to mismatch between closely interacting species. The eastern spruce budworm, Choristoneura fumiferana, an important outbreaking insect defoliator in North America, mainly feeds on balsam fir, Abies balsamea, which has historically been well synchronized with the insect. But as climate change pushes the northern range limit of the budworm further north into the boreal forest, the highly valuable black spruce, Picea mariana, historically protected against the budworm by its late budburst phenology, is suffering increased defoliation during the current outbreak. We tested the hypothesis that rising temperatures can lead, not to a mismatch, but to an improved match between the budworm and black spruce through differential phenological advancement. For 3 years, eastern spruce budworm larvae were reared from instar 2 to pupae, on both black spruce and balsam fir, in a temperature free-air controlled enhancement experiment (T-FACE) consisting in 24 field plots, half of which were heated at +2°C from March to October. Our results show that every year, larval development was faster on heated trees and pupation was earlier than on unheated trees. Bud development was also accelerated in heated trees of both species. However, there was no difference in mass between pupae that developed at +2°C and controls at the end of the season. Finally, we found no difference either in development rate or pupal mass between larvae reared on black spruce and those reared on balsam fir. This suggests that under higher temperature regimes, eastern spruce budworm will be as successful on black spruce as on balsam fir, as black spruce budburst becomes better synchronized with the insect's emergence from diapause. This could lead to critical changes in outbreak dynamics and severity with important ecological state shifts at the landscape level.

Oxygen Conservation Methods With Automated Titration.

BACKGROUND: Oxygen titration is recommended to avoid hyperoxemia and hypoxemia. Automated titration, as well as the [Formula: see text] target, may have an impact on oxygen utilization, with potential logistical effects in emergency and military transportation. We sought to assess the oxygen flow required for different [Formula: see text] targets in spontaneously breathing subjects, and to evaluate individualized automated oxygen titration to maintain stable oxygenation in subjects with COPD and healthy subjects with induced hypoxemia. METHODS: In the first part of the study, oxygen flow was evaluated in hospitalized subjects for different [Formula: see text] targets from 90% to 98%. Oxygen requirements to reach these targets were determined using a device that automatically adjusts oxygen flow every second on the basis of the [Formula: see text] target. In the second part of the study, the same automated oxygen titration method was used to correct hypoxemia in subjects with COPD and in healthy subjects with induced hypoxemia while the subjects wore a gas mask. Oxygen flow, [Formula: see text], and heart rate were continuously recorded. RESULTS: Thirty-six spontaneously breathing hospitalized subjects were included in the first part of the study. Oxygen flow was reduced more than 6-fold when the [Formula: see text] target was decreased from 98% to 90%. The second part of the study included 15 healthy and 9 subjects with stable COPD. In healthy subjects, heterogeneous oxygen flows were required to correct induced hypoxemia (0.2-2.5 L/min). In subjects with COPD, oxygen flow varied from 0 L/min (in 9 of 18 tested conditions) to 2.9 L/min. CONCLUSIONS: Significant reductions in the amount of oxygen delivered could be obtained with optimized [Formula: see text] targets. Oxygen delivery through a gas mask to correct hypoxemia is feasible, and automated oxygen titration may help individualize oxygen administration and reduce oxygen utilization. (ClinicalTrials.gov registration: NCT02782936, NCT02809807.).

Impact of Gas Masks on the Work of Breathing and Breathing Pattern in Subjects With Stable COPD.

BACKGROUND: The gas mask constitutes the main respiratory protective equipment in a chemical, biological, radiological, or nuclear environment. The aim of the study was to evaluate the impact of the gas mask on respiratory pattern, gas exchange, and indexes of respiratory effort in patients with moderate to severe stable COPD. METHODS: Crossover evaluation with 3 randomized-order, 10-min conditions: at rest and with and without a gas mask using 2 different filtered cartridges, each with a distinct inspiratory resistance (cartridge A = 3.5 cm H2O; cartridge B = 2.2 cm H2O, both at 1 L/s). The study involved 8 subjects with COPD, and breathing patterns, indexes of respiratory effort, and capillary blood gases were evaluated. Comparisons of these parameters were made between the tested conditions. RESULTS: Mean subject age was 69 y, and mean FEV1 = 1.3 L (47% predicted). Short-term utilization of the gas mask was associated with a significant increase in the indexes of effort in comparison to baseline without a mask. The esophageal product-time product significantly increased in comparison with baseline (cartridge A = 281 ± 65 cm H2O/s/min, cartridge B = 253 ± 47 cm H2O/s/min, and baseline = 184 ± 46 cm H2O/s/min, P < .001). There were negligible changes in the breathing pattern and gas exchange. CONCLUSIONS: Indexes of respiratory effort increased slightly in subjects with stable COPD while using a gas mask. This effect was likely related to increased inspiratory resistance when the mask was worn. These data are reassuring for the potential short-duration use of such protection for patients with moderate to severe COPD.

Natural succession and clearcutting as drivers of environmental heterogeneity and beta diversity in North American boreal forests.

Clear-cutting alters natural ecosystem processes by reducing landscape heterogeneity. It is the dominant harvesting technique across the boreal zone, yet understanding of how environmental heterogeneity and beta diversity are structured in forest ecosystems and post-clear cut is lacking. We use ground-dwelling arthropods as models to determine how natural succession (progression from deciduous to mixed to coniferous cover types) and clear-cutting change boreal forests, exploring the role of environmental heterogeneity in shaping beta diversity across multiple spatial scales (between-cover types and between-stands of the same cover type (1600 to 8500 m), between-plots (100 to 400 m) and within-plots (20 to 40 m)). We characterise environmental heterogeneity as variability in combined structural, vegetational and soil parameters, and beta diversity, as variability in assemblage composition. Clear-cutting homogenised forest environments across all spatial scales, reducing total environmental heterogeneity by 35%. Arthropod beta diversity reflected these changes at larger scales suggesting that environmental heterogeneity is useful in explaining beta diversity both between-cover types and between-stands of the same cover type. However, at smaller scales, within- and between-plots spider beta diversity reflected the lower environmental heterogeneity in regenerating stands, whereas staphylinid and carabids assemblages were not homogenised 12 years post-harvest. Differences in environmental heterogeneity and staphylinid beta diversity between cover types were also important at small scales. In regenerating stands, we detected a subtle yet notable effect of pre-felling cover type on environmental heterogeneity and arthropods, where pre-felling cover type accounted for a significant amount of variance in beta diversity, indicating that biological legacies (e.g. soil pH reflecting pre-harvest conditions) may have a role in driving beta diversity even 12 years post-harvest. This study highlights the importance of understanding site history when predicting impacts of change in forest ecosystems. Further, to understand drivers of beta diversity we must identify biological legacies shaping community structure.

Impact of Gas Masks on Work of Breathing, Breathing Patterns, and Gas Exchange in Healthy Subjects.

BACKGROUND: The gas mask is used to protect military and non-military personnel exposed to respiratory hazards (chemical, biologic, radiologic, and nuclear agents). The objective was to evaluate the impact of the gas mask on indexes of respiratory effort and breathing patterns in a human model because no data exist. METHODS: The design of the study was a crossover evaluation with four 10-min conditions in a randomized order: with and without wearing the gas mask when at rest and when exerting a standardized effort. During the studied conditions, 14 healthy subjects were evaluated for breathing patterns, indexes of respiratory effort (work of breathing, pressure-time product for esophageal pressure, and esophageal pressure swing) and capillary blood gases. Continuous SpO2 was recorded during the tested conditions. RESULTS: The indexes of respiratory effort significantly increased when subjects wore the gas mask under the tested conditions (at rest and during effort). The work of breathing was significantly augmented with the mask (at rest, 0.40 ± 0.32 J/cycle vs 0.25 ± 0.10 J/cycle; effort, 5.96 ± 3.32 J/cycle vs 4.43 ± 2.50 J/cycle; P < .001). The other indexes of effort (esophageal pressure-time product and esophageal swing were all significantly increased, from 30 to 60%, with a gas mask in comparison with at baseline without a gas mask). The impact on breathing patterns and PaCO2 was limited, without significant differences. Moderate hypoxemia was present during effort and was not increased by the gas mask. CONCLUSIONS: This study demonstrated a substantial increase in the indicies of respiratory effort both at rest and during exercise with a gas mask. Our measurements and findings may be referred in future research and development studies in this field. (ClinicalTrials.gov registration NCT02782936.).

Wing-dimorphism and population expansion of Pterostichus melanarius (Illiger, 1798) at small and large scales in central Alberta, Canada (Coleoptera, Carabidae, Pterostichini).

A study spanning ten years revealed changes in wing-morph ratios corroborating the hypothesis that the wing-dimorphic introduced carabid, Pterostichus melanarius Ill.,is spreading through flight, from the city of Edmonton, Canada and establishing populations in natural aspen forest of more rural areas 45-50 km to the East. Comparison of wing-morph ratios between Pterostichus melanarius and the native wing dimorphic species Agonum retractum LeConte suggests that the spatial variation in ratios for Pterostichus melanarius does not reflect underlying environmental variation, but instead the action of selective forces on this wing-dimorphic species. About ten years after its earliest detection in some rural sites the frequency of macropterous individuals in Pterostichus melanarius has decreased c. five-fold, but it is still above the level seen in European populations in which the two wing-morphs are thought to exist in equilibrium. Pterostichus melanarius is expanding its range in native aspen forest much faster than three other introduced species Clivina fossor L.), Carabus granulatus O.F. Müllerand Clivina fossor L also encountered in this study. The two Carabus species are flightless, but Carabus fossor can be dimorphic. Although these four non-native ground beetle species comprise >85% of the carabids collected at sites in urban Edmonton, activity-density of native carabids was similar across the urban-rural gradient, suggesting little direct impact of introduced species on the local abundance of native species. In a second study conducted at a smaller scale near George Lake, Alberta, macropterous individuals of Pterostichus melanarius have penetrated furthest and most rapidly into native aspen forest. Furthermore, the percentage of micropterous individuals has increased markedly in areas first colonized a decade previously. Overall, these studies support the idea that macropterous beetles in wing-d dimorphic species are important vanguards for early colonization of unexploited territory, but that flightless individuals replace the flying morph relatively rapidly once populations are established.