Interstate Air Pollution Governance in the United States: Exploring Clean Air Act Section 126.

Air pollution is arguably the most pressing human health concern today, accounting for approximately 7-9 million premature deaths worldwide. In the United States, more than 40% of early deaths caused by air pollution are assessed to be caused by emissions produced by neighboring states. This article examines one of the governance mechanisms used by the U.S. to address this issue: section 126 of the Clean Air Act. Critical factors including case length, evidence used, and case outcome are compiled for the population of section 126 petitions submitted from 2000-2022. This evidence is assessed using comparative case analysis. The findings reinforce two issues with the petition process already identified in the literature-the use of cost as a proxy for significance and the excessive and unclear burden of proof placed on downwind states-adding texture to the latter issue by examining the modeling techniques used by downwind states. This analysis identifies lengthy response timelines as an additional issue and calls to attention the infrequency with which the EPA has formally accepted petitions. Collectively, these issues increase the cost, complexity, and unpredictability of filing a section 126 petition.

Battling Alarm Fatigue in the Pediatric Intensive Care Unit.

Pediatric intensive care unit nurses can be exposed to hundreds of alarms per patient they care for each shift. The exposure to so many alarms can cause nurses to be desensitized to future alarms and thus increase the time to respond to alarms. This is one of the largest patient safety concerns within health care today. Steps should be taken to mitigate the number of alarms nurses experience so that they can properly respond to actionable alarms.

Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care.

OBJECTIVES: Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months. DESIGN: Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU. SETTING: This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021. PATIENTS: Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery. INTERVENTIONS: Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure. MEASUREMENTS AND MAIN RESULTS: Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures. CONCLUSIONS: A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.

Oral Cavity Movements of the Tongue During Large Interval Slurs in High-Level Horn Players: A Descriptive Study.

OBJECTIVE: Recent publications describing lingual movement strategies within the oral cavity of brass players have established the existence of efficient and predictable movement patterns in healthy performers for a variety of performance tasks. In this study we extend the research to include the playing of large interval slurs in horn players. METHODS: Real-time MRI films at 40-msec resolution were simultaneously obtained in the sagittal and coronal planes in 9 professional horn players as they performed 2 repetitions each of 3 slur sequences spanning 1 octave, 1 octave + 3rd, and 1 octave + 5th at a mezzo forte dynamic level. Nine profile lines were overlaid on the images allowing the measurement of dorsal tongue edge movement using a customized MATLAB toolkit. Movement along lines representing the anterior, middle, and posterior oral cavity in the sagittal plane, as well as the vertical height of an air channel observed in the coronal plane, are reported. RESULTS: Both sagittal and coronal views demonstrate patterned tongue movements that narrow and widen the air channel during ascending and descending slurs, respectively. The magnitude of these movements is greater during larger intervals, though not perfectly consistent within each slur sequence. Additionally, the tongue position during notes tends to drift in the direction of the subsequent note in each sequence. We suggest that the observed movements may help to modulate air speed through the lips, possible attenuating embouchure muscle tension changes by assisting changes in lip vibration frequency.

The large footprint of small-scale artisanal gold mining in Ghana.

Gold mining has played a significant role in Ghana's economy for centuries. Regulation of this industry has varied over time and while industrial mining is prevalent in the country, the expansion of artisanal mining, or Galamsey has escalated in recent years. Many of these artisanal mines are not only harmful to human health due to the use of Mercury (Hg) in the amalgamation process, but also leave a significant footprint on terrestrial ecosystems, degrading and destroying forested ecosystems in the region. In this study, the Landsat image archive available through Google Earth Engine was used to quantify the total footprint of vegetation loss due to artisanal gold mines in Ghana from 2005 to 2019 and understand how conversion of forested regions to mining has changed over a decadal period from 2007 to 2017. A combination of machine learning and change detection algorithms were used to calculate different land cover conversions and the timing of conversion annually. Within the study area of southwestern Ghana, our results indicate that approximately 47,000 ha (⨦2218 ha) of vegetation were converted to mining at an average rate of ~2600 ha yr-1. The results indicate that a high percentage (~50%) of this mining occurred between 2014 and 2017. Around 700 ha of this mining occurred within protected areas as mapped by the World Database of Protected Areas. In addition to deforestation, increased artisanal mining activity in recent years has the potential to affect human health, access to drinking water resources and food security. This work expands upon limited research into the spatial footprint of Galamsey in Ghana, complements mapping efforts by local geographers, and will support efforts by the government of Ghana to monitor deforestation caused by artisanal mining.

Turn the beat around: Commentary on "Slow and fast beat sequences are represented differently through space" (De Tommaso & Prpic, 2020, in Attention, Perception, & Psychophysics).

There has been increasing interest in the spatial mapping of various perceptual and cognitive magnitudes, such as expanding the spatial-numerical association of response codes (SNARC) effect into domains outside of numerical cognition. Recently, De Tommaso and Prpic (Attention, Perception, & Psychophysics, 82, 2765-2773, 2020) reported in this journal that only fast tempos over 104 beats per minute have spatial associations, with more right-sided associations and faster responses for faster tempos. After discussing the role of perceived loudness and possible response strategies, we propose and recommend methodological improvements for further research.

Reduction of bacterial load with the addition of ultraviolet-C disinfection inside the hyperbaric chamber.

INTRODUCTION: Healthcare acquired infections (HAIs) are associated with increased mortality, morbidity and prolonged hospital stays. Microbiological contamination of the hospital environment directly contributes to HAIs. Optimising environmental cleaning reduces transmission of HAIs. The hyperbaric chamber poses a specific challenge for infection control as certain disinfectants and alcohol-based hand sanitisers are prohibited due to fire risk. Patients often possess multiple risk factors for HAIs. This study compared the bacteria remaining on a surface (bioburden) after a standard clean and after adjunctive disinfection with an ultraviolet-C (UV-C) robot. METHODS: Internal hyperbaric chamber surfaces were first manually cleaned with Clinell® universal wipes and the floor was mopped with Whiteley neutral detergent. Allocated surfaces were swabbed using sterile cotton swabs and processed using a standard microbial culture and a bacteria-specific rapid metabolic assay. Bacterial contamination was also measured by direct contact plating on flat surfaces. The plexiglass ports were covered to protect from potential UV-C mediated damage and used as a negative control. A UV-C disinfection robot was then used to disinfect the chamber for 30 min, whereafter surfaces were swabbed again. RESULTS: There was a significantly greater mean reduction in bioburden following adjunctive UV-C disinfection than with standard cleaning alone. The surfaces not routinely manually cleaned (e.g., bench, phone) showed greatest reduction in bacterial load following UV-C cleaning. CONCLUSIONS: There was a significant reduction in the bacterial load in the chamber following an adjunctive UV-C clean compared with that of a standard clean. Adjunctive cleaning of the hyperbaric chamber environment with a non-touch UV-C device shows promise as a method to reduce HAIs.

Topical Nanofat Biocrème Improves Aesthetic Outcomes of Nonablative Fractionated Laser Treatment: A Preliminary Report.

BACKGROUND: Improvements in skin erythema and elasticity have been observed with topical application of platelet-rich plasma after fractional laser (FXD) treatment. Injections of nanofat via small needles into the dermis improves tissue thickness, discoloration and wrinkle depth. OBJECTIVES: The aim of this study was to evaluate improvements in skin following a nonablative FXD treatment combined with the application of a novel topical nanofat biocrème, called neo-U. METHODS: Fifty patients were treated with a nonablative FXD followed by application of a topical nanofat biocrème. Harvested fat was processed into nanofat, which was compounded with a transdermal liposomal delivery vector to produce a topical biocrème. In 2 patients, postauricular skin punch biopsies were performed before and after treatment and examined for histologic changes. Photographs of a historical group treated with only the FXD were compared with photographs of patients treated with a combination of topical nanofat biocrème and FXD. Skin types were evaluated for improvements in nasolabial folds, wrinkles, and skin texture. RESULTS: Findings from postauricular skin biopsies show the skin exposed to FXD with nanofat biocrème had more elastin fibers and a slight increase in the thickness of the epidermis. Patients treated with FXD plus nanofat biocrème had a statistically significant improvement in the degree of wrinkles, nasolabial fold depth, and texture compared with historical controls. CONCLUSIONS: Transdermal delivery of nanofat topical biocrème applied after FXD treatment can serve as a delivery system to improve fine lines, nasolabial fold depth, and overall texture of the tissue to a greater degree than laser resurfacing alone.

Comparison of Oral and Axillary Temperatures in Intubated Pediatric Patients.

PURPOSE: Accurate body temperature measurement is essential in providing timely care to critically ill patients. Current practice within the Pediatric ICU (PICU) at a Midwestern academic medical center is to obtain axillary temperatures in endotracheally intubated patients. According to research, axillary temperatures have greater variance than other forms of temperature measurement. Research in adult patients show that oral temperature measurement in endotracheally intubated patients is acceptable as the heated gases from the ventilator has no significant effect on measured temperatures. This study sought to determine if the same is true in pediatrics. DESIGN AND METHODS: Oral and axillary temperatures of endotracheally intubated pediatric patients were obtained during unit prescribed vital assessment intervals. Patients were divided into neonate, infant, and children age groups with 25 sets of temperatures obtained for each group. Descriptive statistics and Bland-Altman plot interpretation were performed to determine confidence intervals for each age group. RESULTS: Bland-Altman plot analysis of oral and axillary routes of temperature measurement showed a high positive correlation within all age groups studied. The infant age group showed lower correlation in comparison to neonates and children. The infant age group also had an outlier of data sets with lower oral temperatures as compared to the axilla. CONCLUSIONS: Oral temperature measurement is a viable alternative to axillary temperature measurement in endotracheally intubated pediatric patients. Correction factors for age groups were calculated for prediction of axillary temperature based on measured oral temperature. PRACTICAL IMPLICATIONS: This study serves as evidence for practice change within the studied unit.

ADHD medication overdose and misuse: the NSW Poisons Information Centre experience, 2004-2014.

OBJECTIVES: To describe Australian trends in overdoses with medications used to treat attention deficit hyperactivity disorder (ADHD). DESIGN, SETTING AND PARTICIPANTS: This was a retrospective observational study of intentional exposures to methylphenidate, dexamphetamine, modafinil and atomoxetine reported to the New South Wales Poisons Information Centre (NSWPIC) from 1 January 2004 to 31 December 2014. The NSWPIC takes calls from New South Wales, Tasmania and the Australian Capital Territory between 6 am and midnight each day, and, as part of a national after-hours roster, from all Australian states between midnight and 6 am on seven nights each fortnight. The target population included Australian residents aged 10-75 years. MAIN OUTCOME MEASURES: Demographic characteristics of the patients, changes in numbers of exposures with time, co-ingestants, route of exposure, and disposition of patients. RESULTS: During the 11-year study period, 1735 intentional exposures to the four medications were reported to NSWPIC. There was a 210% increase in intentional exposures to methylphenidate over this period, whereas the number of dexamphetamine exposures declined by 25%. Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429% across the study period. At least 93% of overdose patients required hospitalisation. Trends in exposures paralleled trends in the dispensing of these medications, as recorded in Pharmaceutical Benefits Scheme data. CONCLUSIONS: NSWPIC data show a dramatic increase in intentional exposures to ADHD medications between 2004 and 2014, mainly to methylphenidate. Further, the data suggest that illicit use of these substances is increasing. The potential harm related to misuse of prescription stimulants and the close correlation between these exposures and the prescribing of these drugs causes concerns about their diversion, and highlights the importance of the quality use of medicines (ie, ensuring that they are used safely, appropriately and in an evidence-based manner, including considering non-medical or non-stimulant alternatives) and of risk assessment for misuse when prescribing ADHD drugs.

Drug diversion.

Prescription drug diversion has significant health, legal and social implications. Deaths from misuse of prescription drugs account for a significant proportion of overdose deaths. The drugs most commonly involved are analgesics, particularly opioids, and psychoactive drugs, particularly benzodiazepines. Diverted drugs are most often sourced from a family member or friend, but are also sourced from overseas pharmacies or laboratories, or bought from drug dealers. Drug diversion can be mitigated by good prescribing practices. Systems for monitoring the prescribing and dispensing of medicines are being instituted across Australia.

Improving voluntary environmental management programs: facilitating learning and adaptation.

Environmental planners and managers face unique challenges understanding and documenting the effectiveness of programs that rely on voluntary actions by private landowners. Programs, such as those aimed at reducing nonpoint source pollution or improving habitat, intend to reach those goals by persuading landowners to adopt behaviors and management practices consistent with environmental restoration and protection. Our purpose with this paper is to identify barriers for improving voluntary environmental management programs and ways to overcome them. We first draw upon insights regarding data, learning, and adaptation from the adaptive management and performance management literatures, describing three key issues: overcoming information constraints, structural limitations, and organizational culture. Although these lessons are applicable to a variety of voluntary environmental management programs, we then present the issues in the context of on-going research for nonpoint source water quality pollution. We end the discussion by highlighting important elements for advancing voluntary program efforts.