Πέμπτη, 22 Μαρτίου 2018

Local Anesthetic Injection Speed and Common Peroneal Nerve Block Duration: A Randomized Controlled Trial in Healthy Volunteers

Background and Objectives The speed of local anesthetic (LA) injections in peripheral regional anesthesia ranges from slow continuous infusions (3–12 mL/h) to rapid manual injections (>7500 mL/h). Optimizing injection speed could augment the spread of LA toward the targeted nerves and influence nerve block characteristics. The objective of this study was to investigate whether injection speed of a single dose of LA affects peripheral nerve block duration. Methods After approval from the Danish Regional Scientific Ethics Committee, we enrolled 60 healthy adult volunteers. We used an ultrasound-guided catheter-based technique to perform a common peroneal nerve block. Participants were randomized to receive 4.0 mL of ropivacaine 0.2% with 1 of 5 injection speeds: 12, 60, 300, 600, or 1800 mL/h. Investigators and participants were blinded to group assignment and intervention. Primary outcome was duration of sensory nerve block defined by insensitivity toward cold. Secondary outcomes were duration of motor nerve block, time to onset of sensory nerve block, and grades of sensory and motor nerve block. Intergroup differences were tested by one-way analysis of variance. Results We found no differences in sensory block duration between the 5 groups. Durations were median [range]: 11 [6–14], 12 [9–14], 10.5 [2–15], 11 [8–17], and 12 [9–18] hours, respectively (P = 0.294). In addition, we found no differences in secondary outcomes. Conclusions Injection speed of LA in the range of 12 to 1800 mL/h did not affect common peroneal nerve block duration. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02801799. Accepted for publication November 13, 2017. Address correspondence to: Mikkel Herold Madsen, MD, Department of Anesthesiology, Nordsjællands Hospital Hillerød, Dyrehavevej 29, Building 52B, 4th Floor, DK-3400 Hillerød, Denmark (e-mail: mhmadsen@gmail.com). This work was funded by Innovation Fund Denmark and by Nordsjællands Hospital Hillerød. This work was presented in part at the American Society of Regional Anesthesia and Pain Medicine 42nd Annual Regional Anesthesiology and Pain Medicine Meeting; San Francisco, CA; April 6 to 8, 2017. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Antibiotic Susceptibility of Non-Cholera Vibrios Isolated from Farmed and Wild Marine Fish (Argyrosomus japonicus), Implications for Public Health

Microbial Drug Resistance, Ahead of Print.


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Molecular Epidemiology and Virulence Features of Staphylococcus aureus Bloodstream Isolates in a Regional Burn Center in China, 2012–2016

Microbial Drug Resistance, Ahead of Print.


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Genomic Identity of Fluoroquinolone-Resistant blaCTX-M-15-Type ESBL and pMAmpC β-Lactamase Producing Klebsiella pneumoniae from Buffalo Milk, India

Microbial Drug Resistance, Ahead of Print.


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Prevalence of Extended-Spectrum Beta-Lactamase and Carbapenemase Genes in Clinical Isolates of Escherichia coli in Myanmar: Dominance of blaNDM-5 and Emergence of blaOXA-181

Microbial Drug Resistance, Ahead of Print.


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Risk Factors for Community-Onset Pneumonia Caused by Levofloxacin-Nonsusceptible Streptococcus pneumoniae

Microbial Drug Resistance, Ahead of Print.


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Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database

Adult spinal deformity surgery (ASD) is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and over $1.7 billion in charges for managed care population in the last decade. Given the recent move towards bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component towards the bundled payment.

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Spontaneous correction of coronal imbalance after selective thoracolumbar/lumbar fusion in patients with lenke-5c adolescent idiopathic scoliosis

Coronal imbalance is a complication of corrective surgeries in AIS. However, few studies about immediate coronal decompensation in Lenke-5C curves have reported its incidence, prognosis, and related factors.

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Reply to “Relationship between age and nerve dimensions in Charcot-Marie-Tooth disease. Do we know the reality?”

We read with great interest the letter by Coraci and collaborators (2018) in response to our recent electrodiagnostic, nerve ultrasound and histological study on Charcot-Marie-Tooth disease (CMT) due to myelin protein zero (Fabrizi et al., 2018). In an attempt to reconcile discrepancies on the relationship between age and nerve size in previous reports, Coraci and coworkers explored the correlation between age and cross sectional area (CSA) in a group of 49 patients with genetically confirmed CMT, namely 27 CMT1 and 22 CMT2 patients with local polynomial regression fitting (LOESS), a very flexible non-parametric regression analysis method that does not require the specification of a function to fit a model to all of the data in the sample, making it ideal for modelling complex processes for which no theoretical models exist (NIST, 2018).

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Reply to DR. De Cassai et al.

We appreciate Dr De Cassai and colleagues [1] for their interest in our recent publication on bilateral ultrasound-guided erector spinae plane (ESP) block in breast surgery [2].

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Raymond E. Meyn, Jr., Ph.D.; 1942–2017

Radiation Research, Volume 189, Issue 4, Page 447-448, April 2018.


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Response to the ‘Comments on “Cellular Therapies for Treatment of Radiation Injury after a Mass Casualty Incident” (Radiat Res 2017; 188:242-45)' by Drouet et al. (Letters to the Editor, Radiat Res 2017; 188:463)

Radiation Research, Volume 189, Issue 4, Page 446-446, April 2018.


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An Assessment of Radiation-Associated Risks of Mortality from Circulatory Disease in the Cohorts of Mayak and Sellafield Nuclear Workers

Radiation Research, Volume 189, Issue 4, Page 371-388, April 2018.


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Median Nerve Area Measurements Using Ultrasound: Importance of Proper Technique and Interpretation

imageNo abstract available

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Interventional Pain Procedures in Physical Medicine and Rehabilitation Residencies

imageExposure to interventional pain procedures is now a required component of training in physical medicine and rehabilitation residencies as mandated by the Accreditation Council for Graduate Medical Education. Data regarding resident exposure and competency in these procedures remain limited. Objectives were to determine the volume and type of exposure physical medicine and rehabilitation residents have to interventional pain procedures and to obtain faculty-perceived opinions regarding competency of incoming fellows as it pertains to interventional pain management. Online surveys were sent to program directors of physical medicine and rehabilitation residencies and fellowship directors of interventional spine, sports medicine, and pain medicine fellowships. Surveys inquired about educational methods, the volume of procedures in which residents actively participate, and faculty-perceived competency of trainees performing procedures. Thirty-nine residency programs and 27 fellowships responded to the surveys. Of the 39 residencies that responded, there was great variation in the exposure residents receive. Most programs reported that residents have moderate exposure to common procedures such as ultrasound-guided knee injections and lumbar epidural injections. In addition, while most residency program directors report graduates to be "fairly prepared" (33%) to "well prepared" (20.5%) with regard to spine procedures, most fellowship directors (63%) describe incoming fellows to be at the "beginner" level.

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Probabilistic Matching of Deidentified Data From a Trauma Registry and a Traumatic Brain Injury Model System Center: A Follow-up Validation Study

imageIn a previous study, individuals from a single Traumatic Brain Injury Model Systems and trauma center were matched using a novel probabilistic matching algorithm. The Traumatic Brain Injury Model Systems is a multicenter prospective cohort study containing more than 14,000 participants with traumatic brain injury, following them from inpatient rehabilitation to the community over the remainder of their lifetime. The National Trauma Databank is the largest aggregation of trauma data in the United States, including more than 6 million records. Linking these two databases offers a broad range of opportunities to explore research questions not otherwise possible. Our objective was to refine and validate the previous protocol at another independent center. An algorithm generation and validation data set were created, and potential matches were blocked by age, sex, and year of injury; total probabilistic weight was calculated based on of 12 common data fields. Validity metrics were calculated using a minimum probabilistic weight of 3. The positive predictive value was 98.2% and 97.4% and sensitivity was 74.1% and 76.3%, in the algorithm generation and validation set, respectively. These metrics were similar to the previous study. Future work will apply the refined probabilistic matching algorithm to the Traumatic Brain Injury Model Systems and the National Trauma Databank to generate a merged data set for clinical traumatic brain injury research use.

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Limbic and Basal Ganglia Neuroanatomical Correlates of Gait and Executive Function: Older Adults With Mild Cognitive Impairment and Intact Cognition

imageObjective This study aimed to examine differences in spatiotemporal gait parameters between older adults with amnestic mild cognitive impairment and normal cognition and to examine limbic and basal ganglia neural correlates of gait and executive function in older adults without dementia. Design This was a cross-sectional study of 46 community-dwelling older adults, ages 70–95 yrs, with amnestic mild cognitive impairment (n = 23) and normal cognition (n = 23). Structural magnetic resonance imaging was used to attain volumetric measures of limbic and basal ganglia structures. Quantitative motion analysis was used to measure spatiotemporal parameters of gait. The Trail Making Test was used to assess executive function. Results During fast-paced walking, older adults with amnestic mild cognitive impairment demonstrated significantly slower gait speed and shorter stride length compared with older adults with normal cognition. Stride length was positively correlated with hippocampal, anterior cingulate, and nucleus accumbens volumes (P

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Distribution Patterns of the Vulnerable Vessels Around Cervical Nerve Roots: A Computed Tomography-Based Study

imageObjective The aim of the study was to evaluate the prevalence of vulnerable vessels around the target of cervical transforaminal epidural steroid injection at the C3-C7 cervical nerve root levels in a clinical setting. Design Retrospective, cross-sectional study was conducted. Participants Patients complaining of neck or arm pain with no previous surgical history and who had undergone both precontrast and contrast-enhanced neck computed tomography were included retrospectively. Results In 26 (21.0%) of 124 patients, none of the vulnerable vessels around the target of cervical transforaminal epidural steroid injection around both sides of the C3-C7 nerve roots were observed. Of 248 cervical root levels, the C3 level had 103 vessels (41.5%), the C4 level had 110 vessels (44.4%), the C5 level had 98 vessels (39.5%), the C6 level had 59 vessels (23.8%), and the C7 level had 34 vessels (13.7%) close to each target nerve root. In addition, variations of the vertebral artery at the C4-C7 level were observed in 11 (8.9%) of 124 patients. Conclusions To prevent unexpected critical complications involving injury to vulnerable vessels during cervical transforaminal epidural steroid injection, it is recommended to routinely evaluate the vulnerable vessels around the cervical nerve root with computed tomography or Doppler ultrasound before cervical transforaminal epidural steroid injection, especially for the upper cervical nerve root level.

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Association of Need for Tracheotomy With Decreasing Mechanical In-Exsufflation Flows in Amyotrophic Lateral Sclerosis

imageAlthough patients with lower motor neuron and myopathic disorders can prolong their lives by depending on continuous noninvasive ventilatory support, most patients with amyotrophic lateral sclerosis (ALS) cannot and must use tracheostomy mechanical ventilation to prolong survival. This case demonstrates that this occurs because amyotrophic lateral sclerosis patients' upper motor neuron reflex laryngeal closure and stridor cause upper airway collapse that renders mechanical insufflation-exsufflation (MIE) ineffective in expulsing airway secretions as well as for permitting continuous noninvasive ventilatory support. A decrease in MIE-exsufflation flows is a marker for a decrease in upper airway patency that renders MIE ineffective. As airway secretions accumulate and baseline oxyhemoglobin saturation decreases, tracheotomy becomes necessary for further survival. This case demonstrates an association between diminishing MIE-exsufflation flow and need to resort to tracheotomy.

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Effects of Platelet-Rich Plasma on Pain and Muscle Strength in Patients With Knee Osteoarthritis

imageObjective No studies comparing the effects of platelet-rich plasma (PRP) injection and placebo injection in bilateral knee osteoarthritis in the same patient, or discussing muscle strength after PRP injection, have been published. Design Twenty patients with bilateral knee osteoarthritis were eligible, and 40 knees were randomized into two groups: PRP (knees [right or left by a coin toss] receiving a single intra-articular PRP injection) and saline group (the contralateral knee of the same patient, into which single 4-mL intra-articular injection of normal saline was administered). The primary outcome measure was Western Ontario and McMaster's Universities Osteoarthritis Index and the secondary included isokinetic test results. The evaluation was at baseline and at 2 wks, 1, 3, and 6 mos after injection. Results The PRP group showed a significant reduction in the Western Ontario and McMaster's Universities Osteoarthritis Index pain and total scores compared with normal saline group (P flexor) was found in the PRP group during a longer follow-up period, PRP treatment resulted in insignificant differences in muscle strength compared with normal saline. Conclusions Platelet-rich plasma treatment significantly improves pain, stiffness, and disability in patients with knee osteoarthritis compared with normal saline treatment. Additional strength training is recommended to enhance muscle strength recovery.

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Change of an Injured Corticospinal Tract During 3 Weeks' Rehabilitation After Putaminal Hemorrhage

imageNo abstract available

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Objectively Measured Physical Activity and Falls in Well-Functioning Older Adults: Findings From the Baltimore Longitudinal Study of Aging

imageObjective Previous work demonstrates the consequences of falling in older adults and the potential of physical activity (PA) to reduce falls, but few studies have used accelerometer-measured PA to compare overall and time-of-day activity patterns of nonfallers, fallers, or subgroups of fallers. Methods In 840 participants (mean age, 66.7; s = 13.2; range, 26–97) of the Baltimore Longitudinal Study of Aging between 2007 and 2014, PA was measured objectively with Actiheart accelerometers and falling status (faller/nonfaller) was assessed during an in-person interview. Differences in daily PA and PA by time-of-day were assessed using multiple linear regression. Differences in PA (multiple linear regression), and functional status (χ2) were further examined in subgroups of "risky" or "normal" fallers. Results Overall, fallers and nonfallers exhibited similar daily (β = 22.6, P = 0.48) and time-specific PA; however, those who fell doing risky activities were more active overall (β = 243.8, P = 0.002), during the morning (β = 77.3, P = 0.004), afternoon (β = 78.4, P = 0.001), and late afternoon/evening (β = 56.3, P = 0.006) than those who fell doing normal activities. Risky fallers were significantly higher functioning than normal fallers. Conclusions Persons who fell while engaging in normal activities exhibited lower PA overall and throughout most of the day, and were of lower functional status than persons who fell while engaging in risky or unusual activities, suggesting that engagement in risky or unusual PA is associated with higher functional ability and lower falls risk in older persons.

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Feasibility and Effect of Cervical Resistance Training on Head Kinematics in Youth Athletes: A Pilot Study

imageGreater neck girth and strength may be associated with a lower risk of sport-related concussion due to mitigation of head accelerations by the neck. However, neck strengthening exercise remains unstudied in youth athletes. Therefore, this pilot study assessed the feasibility and effect of targeted neck strengthening exercises in youth athletes. Seventeen participants were allocated to perform 8-wk manual resistance-based neck strengthening (n = 13) or control resistance exercise (n = 4) programs. Before and after the intervention, participants completed laboratory-based assessments of neck size, strength, and head kinematics during standardized test loading in each plane of motion. Descriptive statistics were calculated to compare pre-post changes between the two groups. All participants safely and successfully completed the intervention. Neck girth and strength increased in both groups, with greater increases in the neck strengthening group. Across all planes of motion, overall changes in head linear and angular velocity decreased in both groups, with greater decreases in ΔV in the neck strengthening group and greater decreases in Δω in controls. These results suggest the potential for resistance exercise training to reduce youth athletes' risk for sport-related concussion by increasing neck girth and strength. Additional research is needed to determine optimal neck strengthening programs.

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Efficacy of Noninvasive Brain Stimulation on Unilateral Neglect After Stroke: A Systematic Review and Meta-analysis

imageObjective Unilateral neglect (UN) is a common debilitating consequence of stroke. This review focused on the effect of noninvasive brain stimulation (NIBS) techniques in the recovery of UN in poststroke patients. Methods Relevant databases were comprehensively searched, including Cochrane Central Register of Controlled Trials, Medline, Embase, the Web of Knowledge, and relevant websites. All randomized controlled trials were identified which used NIBS for poststroke UN. The methodological quality and risk of bias were systematically evaluated. Results Twelve studies were included, and 11 randomized controlled trials were made further meta-analysis. Participants who were randomized to active transcranial direct current stimulation (effect size [ES], −0.51; 95% confidence interval [CI], −1.02 to −0.01; P = 0.04) and repetitive transcranial magnetic stimulation (ES, −1.76; 95% CI, −2.40 to −1.12; P

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Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty The HIHO Randomized Clinical Trial

imageNo abstract available

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Low-Intensity Pulsed Ultrasound Stimulation for Tendon-Bone Healing: A Dose-Dependent Study

imageObjective The aim of the study was to evaluate the dosage effect of low-intensity pulsed ultrasound stimulation on tendon-bone healing. Design Standard partial patellectomies were performed on 120 mature New Zealand rabbits randomly assigned into the following three groups: a control group (daily mock sonication, 20 mins), a qd group (daily ultrasonication, 20 mins), and a bid group (ultrasonication twice a day, 20 mins each time). The rabbits were killed 8 or 16 wks postoperatively, and the microarchitectural, histological, and mechanical properties of the patella-patellar tendon interface were evaluated. Results Microcomputed tomography analysis showed that the bid group exhibited more new bone formation and mineralization than the other groups in the tendon-bone healing position at both 8 and 16 wks postoperatively. Histological assessments confirmed that the bid group exhibited a significantly better patella-patellar tendon interface than the other groups, as shown by the increased formation and remodeling of newly formed bone and a fibrocartilage layer. The biomechanical properties of the regenerated patella-patellar tendon interface significantly improved in the bid group. Conclusions Low-intensity pulsed ultrasound stimulation treatment twice a day was more effective than the once-a-day treatment on tendon-bone healing.

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Cauda Equina Syndrome Due to Vigorous Back Massage With Spinal Manipulation in a Patient With Pre-Existing Lumbar Disc Herniation: A Case Report and Literature Review

imageCauda equina syndrome (CES) resulting from acute lumbar disc herniation due to spinal massage is extremely rare. We present a case of CES caused by the acute worsening of a lumbar disc herniation after a vigorous back massage that included spinal manipulation. After vigorous back massage with spinal manipulation performed by a massage therapist, a 38-yr-old male patient experienced CES with severe numbness in both lower limbs, inability to walk due to weakness of bilateral lower limbs, and incontinence of urine and feces. The magnetic resonance imaging and computer tomography scan results showed that the L4–5 disc herniated down into the spinal canal, extensively compressing the ventral dural sac. The patient was successfully treated with an emergency operation including laminectomy, spinal canal decompression, discectomy, interbody fusion, and pedicle screw fixation. The muscle power in both lower limbs of the patient recovered rapidly to support standing only 1 wk later. Moreover, he regained continence of urine and feces. In conclusion, this case brings us novel knowledge that spinal massage or manipulation may worsen pre-existing disc herniation causing CES, and a timely emergency surgery is necessary and effective for treatment of CES-related symptoms.

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Intra-articular Triamcinolone Versus Hyaluronate Injections for Low Back Pain With Symptoms Suggestive of Lumbar Zygapophyseal Joint Arthropathy: A Pragmatic, Double-Blind Randomized Controlled Trial

imageObjective The aim of the study was to compare hyaluronate with triamcinolone injections in treating chronic low back pain suggestive of lumbar zygopophyseal joint arthropathy. Design This was a prospective, double-blind, randomized controlled trial. Thirty subjects were randomly assigned to receive bilateral L3-S1 lumbar zygopophyseal joint injections with triamcinolone (KA) or Synvisc-One (HA). Pain (visual analog scale) and Pain Disability Questionnaire scores at 1, 3, and 6 mos were evaluated. Results No significant intergroup differences (P > 0.05) in outcomes were noted in the 30 recruited subjects. For KA/HA (baseline; 1 mo; 3 mos; 6 mos), visual analog scale scores were the following: 70 (15)/74 (10); 58 (29)/45 (25); 58 (29)/56 (25); and 59 (28)/63 (24), respectively. Pain Disability Questionnaire scores were the following: 100 (23)/102 (28); 77 (30)/74 (34); 87 (26)/74 (36); and 96 (25)/79 (25). Overall percent improvement at 6 mos for KA was 51 (35) and for HA was 42 (33) (P = 0.51). Synvisc-One group visual analog scale scores improved significantly (70 [20]–45 [25] at 1 mo, P = 0.008). Pain Disability Questionnaire scores improved at 1 mo (100 [23]–77 [30], P = 0.009) in the KA group and at all time points in the HA group (102 [28]–74 [34] at 1 mo, P = 0.002; 74 [36] at 3 mos, P = 0.037; 79 at 6 mos [median = 52–99.5], P

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Reply

No abstract available

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Ultrasound Imaging and Guided Injection for the Lateral and Posterior Hip

imageUltrasound has emerged as one of the most utilized tools to diagnose musculoskeletal disorders and to assist in interventions. Traditionally, sonographic examination of the hip joint has been challenging because most of the major structures are deeply situated, thus requiring the use of curvilinear transducer for better penetrance. The posterior lateral hip is a frequent area for musculoskeletal pain and nerve entrapments. Common disorders include greater trochanteric pain syndrome, gluteus medius tendinopathy, piriformis syndrome, pudendal neuralgia, and proximal hamstring tendinopathy. The present review article aims to delineate sonoanatomy of the posterior lateral hip and to exemplify several common ultrasound guided procedures at the greater trochanteric, gluteal, and ischial tuberosity regions.

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Perilesional Reorganization in a Patient With Brain Tumor

imageNo abstract available

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EMS From a Distance: Language and prose on the offensive

Long before I recorded my first blood pressure as an EMT, I was a hockey writer for a now-defunct monthly magazine. Our 1973 Stanley Cup Playoffs issue included my predictions about which players would disappoint. Non-clairvoyants like me who write such nonsense guess wrong a lot, like when I said New York Rangers' goaltender Ed Giacomin would be the "goat" of his team's opening ...

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Innovative Training Framework for Additive Manufacturing Ecosystem to Accelerate Adoption of Three-Dimensional Printing Technologies

3D Printing and Additive Manufacturing, Ahead of Print.


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Medic Mindset Podcast: A flight medic's passion for free medical education

In this episode of Medic Mindset, Ginger Locke interviews Tyler Christifulli. Christifulli is a flight medic, an EMS educator and an EMS podcast creator. He and Ginger share a passion for podcasting and free online access medical education (FOAMed). In this episode, they discuss: The three signs that indicate cardiac arrest is imminent. What five medications Christifulli would want on his ambulance/helicopter ...

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Collision activity during training increases total energy expenditure measured via doubly labelled water

Abstract

Purpose

Collision sports are characterised by frequent high-intensity collisions that induce substantial muscle damage, potentially increasing the energetic cost of recovery. Therefore, this study investigated the energetic cost of collision-based activity for the first time across any sport.

Methods

Using a randomised crossover design, six professional young male rugby league players completed two different 5-day pre-season training microcycles. Players completed either a collision (COLL; 20 competitive one-on-one collisions) or non-collision (nCOLL; matched for kinematic demands, excluding collisions) training session on the first day of each microcycle, exactly 7 days apart. All remaining training sessions were matched and did not involve any collision-based activity. Total energy expenditure was measured using doubly labelled water, the literature gold standard.

Results

Collisions resulted in a very likely higher (4.96 ± 0.97 MJ; ES = 0.30 ± 0.07; p = 0.0021) total energy expenditure across the 5-day COLL training microcycle (95.07 ± 16.66 MJ) compared with the nCOLL training microcycle (90.34 ± 16.97 MJ). The COLL training session also resulted in a very likely higher (200 ± 102 AU; ES = 1.43 ± 0.74; p = 0.007) session rating of perceived exertion and a very likely greater (− 14.6 ± 3.3%; ES = − 1.60 ± 0.51; p = 0.002) decrease in wellbeing 24 h later.

Conclusions

A single collision training session considerably increased total energy expenditure. This may explain the large energy expenditures of collision-sport athletes, which appear to exceed kinematic training and match demands. These findings suggest fuelling professional collision-sport athletes appropriately for the "muscle damage caused" alongside the kinematic "work required".



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Perfusion dynamics assessment with Power Doppler ultrasound in skeletal muscle during maximal and submaximal cycling exercise

Abstract

Purpose

Assessment of limitations in the perfusion dynamics of skeletal muscle may provide insight in the pathophysiology of exercise intolerance in, e.g., heart failure patients. Power doppler ultrasound (PDUS) has been recognized as a sensitive tool for the detection of muscle blood flow. In this volunteer study (N = 30), a method is demonstrated for perfusion measurements in the vastus lateralis muscle, with PDUS, during standardized cycling exercise protocols, and the test–retest reliability has been investigated.

Methods

Fixation of the ultrasound probe on the upper leg allowed for continuous PDUS measurements. Cycling exercise protocols included a submaximal and an incremental exercise to maximal power. The relative perfused area (RPA) was determined as a measure of perfusion. Absolute and relative reliability of RPA amplitude and kinetic parameters during exercise (onset, slope, maximum value) and recovery (overshoot, decay time constants) were investigated.

Results

A RPA increase during exercise followed by a signal recovery was measured in all volunteers. Amplitudes and kinetic parameters during exercise and recovery showed poor to good relative reliability (ICC ranging from 0.2–0.8), and poor to moderate absolute reliability (coefficient of variation (CV) range 18–60%).

Conclusions

A method has been demonstrated which allows for continuous (Power Doppler) ultrasonography and assessment of perfusion dynamics in skeletal muscle during exercise. The reliability of the RPA amplitudes and kinetics ranges from poor to good, while the reliability of the RPA increase in submaximal cycling (ICC = 0.8, CV = 18%) is promising for non-invasive clinical assessment of the muscle perfusion response to daily exercise.



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Wife saves her firefighter husband's life with CPR

Jessica Pichette said she thought her husband, Capt. Luke Pichette, was having a stroke when he began making strange noises before bed

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How Children’s Hospital of Omaha achieved interoperability between EMS and hospital patient data

Struggling with a documentation system that left providers with incomplete data, one EMS leader found a solution that works for both her team and her hospital

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Intra-operative lidocaine in the prevention of vomiting after elective tonsillectomy in children: A randomised controlled trial

BACKGROUND Postoperative vomiting (POV) is a frequent complication of tonsillectomy in children. In adult patients undergoing abdominal surgeries, the use of intravenous lidocaine infusion can prevent POV. OBJECTIVE To evaluate the anti-emetic effect of an intravenous lidocaine infusion used as an adjuvant to general anaesthesia, in children undergoing elective ear, nose and throat surgery. DESIGN Double-blind, randomised, controlled study. SETTING Hospital-based, single-centre study in Chile. PATIENTS ASA I-II children, aged 2 to 12 years, scheduled for elective tonsillectomy. INTERVENTION We standardised the induction and maintenance of anaesthesia. Patients were randomly allocated to lidocaine (1.5 mg kg−1 intravenous lidocaine over 5 min followed by 2 mg kg−1 h−1) or 0.9% saline (at the same rate and volume). Infusions were continued until the end of the surgery. MAIN OUTCOME MEASURES Presence of at least one episode of vomiting, retching or both in the first 24 h postoperatively (POV). SECONDARY OUTCOMES Plasma concentrations of lidocaine and postoperative pain. RESULTS Ninety-two children were enrolled. Primary outcome data were available for 91. In the Lidocaine group, 28 of 46 patients (60.8%) experienced POV, compared with 37 of 45 patients (82.2%) in the Saline group [difference in proportions 21.3% (95% confidence interval (CI) 2.8 to 38.8), P = 0.024]. The intention-to-treat analysis showed that when we assumed that the patient in the Saline group lost to follow-up did not have POV, the difference in proportions decreased to 19.6% (95% CI, 0.9 to 37.2), with an unadjusted odds ratio of 0.38 (95% CI, 0.15 to 0.97, P = 0.044). The odds of having POV were 62% less likely in those patients receiving lidocaine compared with patients in the Saline group. The mean lidocaine plasma concentration was 3.91 μg ml−1 (range: 0.87 to 4.88). CONCLUSION Using an intravenous lidocaine infusion as an adjuvant to general anaesthesia decreased POV in children undergoing elective tonsillectomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01986309. Correspondence to Fernando R. Altermatt, MD, MHSc, MBA, Department of Anaesthesiology, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 367, 8330024 Santiago, Chile Tel: +56 2 2354 3270; fax: +56 2 2632 7620; e-mail: falterma@med.puc.cl © 2018 European Society of Anaesthesiology

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Specificity of spontaneous EEG associated with different levels of cognitive and communicative dysfunctions in children

Publication date: Available online 22 March 2018
Source:International Journal of Psychophysiology
Author(s): Nadezhda Ju. Kozhushko, Zhanna V. Nagornova, Sergey A. Evdokimov, Natalia V. Shemyakina, Valery A. Ponomarev, Ekaterina P. Tereshchenko, Jury D. Kropotov
This study aimed to reveal electrophysiological markers of communicative and cognitive dysfunctions of different severity in children with autism spectrum disorder (ASD). Eyes-opened electroencephalograms (EEGs) of 42 children with ASD, divided into two groups according to the severity of their communicative and cognitive dysfunctions (24 with severe and 18 children with less severe ASD), and 70 age-matched controls aged 4–9 years were examined by means of spectral and group independent component (gIC) analyses. A predominance of theta and beta EEG activity in both groups of children with ASD compared to the activity in the control group was found in the global gIC together with a predominance of beta EEG activity in the right occipital region. The quantity of local gICs with enhanced slow and high-frequency EEG activity (within the frontal, temporal, and parietal cortex areas) in children 4–9 years of age might be considered a marker of cognitive and communicative dysfunction severity.



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Individual differences in self-reported reward-approach tendencies relate to resting-state and reward-task-based fMRI measures

Publication date: Available online 21 March 2018
Source:International Journal of Psychophysiology
Author(s): Guangheng Dong, Hui Li, Yifan Wang, Marc N. Potenza
In this study, we investigated neural responses during resting-state and reward-task-based fMRI and how these related to individual differences in self-reported reward sensitivity. Resting-state fMRI data were collected from 191 college students, and 60 of these individuals further finished a reward-related fMRI task. Self-reported reward-approach tendencies were assessed using the behavioral activation scale. Behavioral activation scale scores were positively correlated with brain activations in the striatum bilaterally during reward processing. During rest, behavioral activation scale scores were positively correlated with functional connectivity between the left and right striatum and with functional connectivity between the right striatum and right middle frontal gyrus. Positive correlations were found between task-based striatal activations and the functional connectivity between the left and right striatum at rest. These results suggest a relationship between striatal task-based reward-related activations and resting connectivity strengths that relate to individual differences in reward-approach tendencies.



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Reduced distractor interference during vagus nerve stimulation

Publication date: Available online 21 March 2018
Source:International Journal of Psychophysiology
Author(s): Marlies E. van Bochove, Leen De Taeye, Robrecht Raedt, Kristl Vonck, Alfred Meurs, Paul Boon, Ine Dauwe, Wim Notebaert, Tom Verguts
Suppressing irrelevant information in decision making is an essential everyday skill. We studied whether this ability could be improved in epileptic patients during vagus nerve stimulation (VNS). VNS is known to increase norepinephrine (NE) in the brain. NE is thought to improve several aspects of cognitive control, including the suppression of irrelevant information. Nineteen epileptic VNS patients executed the Eriksen flanker task twice, both during on and off stimulation. Distractor interference was indexed by the congruency effect, a standard empirical marker of cognitive control. We found a reduced congruency effect during stimulation, which indicates an improved ability to suppress distractor interference. This effect was only found in patients that are clinically determined VNS-responders (n = 10). As VNS increases NE in VNS-responders, our finding suggests a beneficial role of NE in cognitive control. At the same time, it suggests that VNS does not only reduce seizure frequency in epileptic patients, but also improves cognitive control.



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How clinicians and pathologists interact concerning inflammatory bowel disease in Italy: an IG-IBD survey



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How clinicians and pathologists interact concerning inflammatory bowel disease in Italy: an IG-IBD survey



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All Blood Counts: A Manual for Blood Conservation and Patient Blood Management

No abstract available

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Advanced Perioperative Crisis Management

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No abstract available

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Incidence and Risk Factors for Chronic Postoperative Opioid Use After Major Spine Surgery: A Cross-sectional Study With Longitudinal Outcome

BACKGROUND: Chronic opioid use is a significant public health concern. Surgery is a risk factor for developing chronic opioid use. Patients undergoing major spine surgery frequently are prescribed opioids preoperatively and may be at risk for chronic opioid use postoperatively. The aim of this study was to investigate the incidence of and perioperative risk factors associated with chronic opioid use after major spine surgery. METHODS: The records of patients who underwent elective major spine surgery at the University of Virginia between March 2011 and February 2016 were retrospectively reviewed. The primary outcome was chronic opioid use through 12 months postoperatively. Demographic data, medical comorbidities, preoperative pain scores, and medication use including daily morphine-equivalent (ME) dose, intraoperative use of lidocaine and ketamine, estimated blood loss, postoperative pain scores and medication use, and postoperative opioid use were collected. Logistic regression models were used to examine factors associated with chronic opioid use. RESULTS: Of 1477 patient records reviewed, 412 patients (27.9%) were opioid naive and 1065 patients (72.3%) used opioids before surgery. Opioid data were available for 1325 patients, while 152 patients were lost to 12-month follow-up and were excluded. Of 958 preoperative opioid users, 498 (52.0%) remained chronic users through 12 months. There was a decrease in opioid dosage (mg ME) from preoperative to 12 months postoperatively with a mean difference of -14.7 mg ME (standard deviation, 1.57; 95% confidence interval [CI], -17.8 to -11.7). Among 367 previously opioid-naive patients, 67 (18.3%) became chronic opioid users. Factors associated with chronic opioid use were examined using logistic regression models. Preoperative opioid users were nearly 4 times more likely to be chronic opioid users through 12 months than were opioid-naive patients (odds ratio, 3.95; 95% CI, 2.51–6.33; P

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Introduction to Bronchoscopy, 2nd ed

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No abstract available

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Opioid Use Disorders and the Risk of Postoperative Pulmonary Complications

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BACKGROUND: As the rate of opioid use disorders continues to rise, perioperative physicians are increasingly faced with the challenge of providing analgesia to these patients after surgery. Due to the likelihood of opioid dose escalation in the perioperative period, we hypothesized that opioid-dependent patients would be at increased risk for postoperative pulmonary complications. METHODS: A retrospective cross-sectional analysis of patients undergoing 6 representative elective surgical procedures was performed using the Nationwide Inpatient Sample from 2002 to 2011. The primary outcome was a composite including prolonged mechanical ventilation, reintubation, and acute respiratory failure. Secondary outcomes were length of stay, in-hospital mortality, and total hospital costs. Both multivariable logistic regression and propensity score matching were used to determine the impact of opioid use disorder on outcomes. RESULTS: The total sample-weighted cohort consisted of 7,533,050 patients. Patients with opioid use disorders were more likely to suffer pulmonary complications, with a frequency of 4.2% compared to 1.6% in the nonopioid-dependent group (P

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Neural Invasion Spreads Macrophage-Related Allodynia via Neural Root in Pancreatic Cancer

BACKGROUND: Neural invasion (N-inv) induces the neural damage and pain in pancreatic cancer (PCa). Benign nerve injury evokes allodynia through neuroinflammation in the neural root, which might be seen in PCa. Macrophages have the potential to release excitatory cytokines after nerve injury and so may play a role in the generation of chronic neuropathic pain. The aim of this study is to represent N-inv–induced allodynia in patients with PCa and to characterize allodynia-related neuroinflammation as macrophage accumulation on dorsal root ganglion (DRG) in the N-inv animal model (N-inv model). METHODS: Treatment-naïve patients with advanced PCa with no opioid use were enrolled in the clinical study. To evaluate allodynia, the current perception threshold on epigastric skin and pain score from questionnaire were measured. The association between the degrees of radiological N-inv and allodynia was evaluated. In the animal experiments, we used the N-inv model, which is established by the inoculation of the human PCa cell line into the left sciatic nerve of mice and mimics the invasion behavior of human PCa. The change of sensation was weekly measured at right hind paw, and the expressions of mRNA and protein were investigated on DRG at 6 weeks in the N-inv and sham models. The effect of macrophage depletion using liposome-encapsulated clodronate (Lp-CLD) was evaluated in the N-inv model. Tumor size and the degree of macrophage accumulation on DRG or around the tumor were investigated. RESULTS: In the clinical study, 43 patients were analyzed. The threshold of epigastric skin at 2000 Hz touch and pressure sensation was decreased in patients with severe N-inv, compared to patients without severe N-inv. Patients with severe N-inv showed a high pain score. In the animal experiments, the N-inv model decreased the threshold of right hind paw at 5 and 6 weeks. The macrophage-related gene expression and F4/80-positive macrophages were increased in the left DRG. Lp-CLD–induced macrophage depletion induced an increase of the threshold in the right hind paw and a decrease of CD206-positive macrophages accumulation in the left DRG. Lp-CLD had no effect for tumor size. CONCLUSIONS: The present study first showed that the N-inv–induced allodynia was spread in patients with PCa and in the N-inv model. Allodynia was related to the amount of macrophages at DRG in the N-inv model. The neuroinflammation may be a target for researching the N-inv-induced pain mechanism and developing novel analgesics. Accepted for publication November 16, 2017. Funding: Supported by Grants-in-Aid for Cancer Research and for the Third-Term Comprehensive 10-Year Strategy for Cancer Control from the Ministry of Health, Labour and Welfare of Japan; JSPS KAKENHI Grant Number 22790624; the National Cancer Center Research and Development Fund (23-A-2); Third-Term Comprehensive Control Research for Cancer from the Ministry of Health, Labour and Welfare of Japan; and Chugai Pharmacology Co, Ltd. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Shuichi Mitsunaga, MD, PhD, Division of Biomarker Discovery, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277–8577, Japan. Address e-mail to smitsuna@east.ncc.go.jp. © 2018 International Anesthesia Research Society

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Isoflurane Impacts Murine Melanoma Growth in a Sex-Specific, Immune-Dependent Manner: A Brief Report

The impact of volatile anesthetics on cancer progression has been observed for decades, but sex differences have not been described. Male and female immune systems vary considerably, and the immune system plays an important role in limiting cancer growth. Currently, mouse models describing the impact of volatile anesthetics on cancer growth are limited to same-sex models. In this brief report, we describe a sex-specific impact of isoflurane on melanoma growth observed in wild-type but not in immune-deficient mice. Future experimental designs related to anesthesia and cancer should evaluate the biological variable of sex in a systematic manner. Accepted for publication February 1, 2018. Funding: A. Meier is supported by a grant from the International Anesthesia Research Society and was supported by a grant from the University of California, San Diego Faculty Senate. J. D. Bui is supported by grants from the NCI (CA157885) and The Hartwell Foundation. X. M. Tu and T. Lin are supported by the National Institutes of Health (NIH), grant UL1TR001442 of CTSA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Angela Meier, MD, PhD, Department of Anesthesiology, University of California San Diego, 200 W Arbor Dr, San Diego, CA 92103. Address e-mail to anmeier@ucsd.edu. © 2018 International Anesthesia Research Society

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Cost-Effectiveness Research in Anesthesiology

Perioperative interventions aimed at decreasing costs and improving outcomes have become increasingly popular in recent years. Anesthesiologists are often faced with a choice among different treatment strategies with little data available on the comparative cost-effectiveness. We performed a systematic review of the English language literature between 1980 and 2014 to identify cost-effectiveness analyses of anesthesiology and perioperative medicine interventions. We excluded interventions related to critical care or pediatric anesthesiology, and articles on interventions not normally ordered or performed by anesthesiologists. Of the >5000 costeffectiveness analyses published to date, only 28 were applicable to anesthesiology and perioperative medicine and met inclusion criteria. Multidisciplinary interventions were the most cost-effective overall; 8 of 8 interventions were "dominant" (improved outcomes, reduced cost) or cost-effective, including accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles. Intraoperative measures were dominant in 3 of 5 cases, including spinal anesthesia for benign abdominal hysterectomy. With regard to prevention of perioperative infection, methicillin-resistant Staphylococcus aureus (MRSA) decolonization was dominant or cost-effective in 2 of 2 studies. Three studies assessing various antibiotic prophylaxis regimens had mixed results. Autologous blood donation was not found to be cost-effective in 5 of 7 studies, and intraoperative cell salvage therapy was also not cost-effective in 2 of 2 reports. Overall, there remains a paucity of cost-effectiveness literature in anesthesiology, particularly relating to intraoperative interventions and multidisciplinary perioperative interventions. Based on the available studies, multidisciplinary perioperative optimization interventions such as accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles tended to be most cost-effective. Our review demonstrates that there is a need for more rigorous cost-effective analyses in many areas of anesthesiology and that anesthesiologists should continue to lead collaborative, multidisciplinary efforts in perioperative medicine. Accepted for publication February 9, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Bijan J. Teja, MD, MBA, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Address e-mail to bijanteja@gmail.com. © 2018 International Anesthesia Research Society

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Comparison of catheter-over-needle and catheter-through-needle on leakage from the catheter insertion site during continuous femoral nerve block

Abstract

The aim of this study was to compare the incidences of leakage from the catheter insertion site during continuous femoral nerve block when using the catheter-through-needle, Contiplex Touhy™ (CT) and the newly developed catheter-over-needle, Contiplex C™ (CC). Forty adult patients who were scheduled to undergo continuous femoral nerve block for pain control following knee surgery were enrolled and were randomly assigned to a CT group or a CC group. After finishing surgery, a catheter for continuous femoral nerve block was placed using ultrasound. A catheter was advanced along the femoral nerve 5–6 cm beyond the needle tip. Then 0.25% levobupivacaine was continuously administered at a rate of 5 ml/h until 9:00 am on postoperative day 1. The incidence of leakage of the local anesthetic from the insertion site in the CT group was significantly higher than that in the CC group. In the CT group, leakage from the catheter insertion site was observed in 11 of 20 patients during the observation period. On the other hand, none of the patients in the CC group showed leakage. Contiplex C™ is more effective than Contiplex Touphy™ for prevention of leakage of local anesthetics from the insertion site during continuous femoral nerve block.



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Numerical modeling of the sources and behaviors of 222Rn, 220Rn and their progenies in the indoor environment—A review

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Publication date: September 2018
Source:Journal of Environmental Radioactivity, Volume 189
Author(s): Jun Hu, Guosheng Yang, Miklós Hegedűs, Kazuki Iwaoka, Masahiro Hosoda, Shinji Tokonami
222Rn, 220Rn and their short-lived progenies are well known radioactive indoor pollutants, identified as the leading environmental cause of lung cancer next to smoking. Apart from the conventional measurement methods, numerical modeling methods are developed to simulate their physical and decay processes in 222Rn and 220Rn's life cycle, estimate their levels, concentration distributions, as well as effects of control strategies in the indoor environment. In this article, we summarized the numerical models used to illustrate the physical processes of each source of 222Rn and 220Rn entry into the indoor environment, and the application of Jacobi room models and CFD (Computational Fluid Dynamic) models used to present the behaviors of indoor 222Rn, 220Rn and their progenies. Furthermore, we consider that the development of numerical modeling of 222Rn and 220Rn would have a bright prospect in the directions of stochastic methods based on a steady-state model, the fine simulation of the time-dependent model as well as the multi-dimension model.



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Whole organism to tissue concentration ratios derived from an Australian tropical dataset

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Publication date: September 2018
Source:Journal of Environmental Radioactivity, Volume 189
Author(s): Che Doering, Peter Medley, Blake Orr, David Urban
Whole organism to tissue concentration ratios (CRwo-tissue) were derived for six wildlife groups (freshwater birds, freshwater bivalves, freshwater fishes, freshwater reptiles, freshwater vascular plants and terrestrial mammals). The wildlife groups and data represented species common to tropical northern Australia. Values of CRwo-tissue were derived for between 6 and 34 elements, depending upon wildlife group. The values were generally similar to international reference values. However, differences for some element-tissue combinations could affect radiation dose estimates for wildlife in certain environmental exposure situations, including uranium mining, where these data are intended to be applied.



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