Dynamical and surface impacts of the January 2021 sudden stratospheric warming in novel Aeolus wind observations, MLS and ERA5

Major sudden stratospheric warmings (SSWs) are extreme dynamical events where the usual strong westerly winds of the stratospheric polar vortex temporarily weaken or reverse and polar stratospheric temperatures rise by tens of kelvins over just a few days and remain so for an extended period. Via dynamical modification of the atmosphere below them, SSWs are believed to be a key contributor to extreme winter weather events at the surface over the following weeks. SSW-induced changes to the wind structure of the polar vortex have previously been studied in models and reanalyses and in localised measurements such as radiosondes and radars but have not previously been directly and systematically observed on a global scale because of the major technical challenges involved in observing winds from space. Here, we exploit novel observations from ESA's flagship Aeolus wind-profiler mission, together with temperature and geopotential height data from NASA's Microwave Limb Sounder and surface variables from the ERA5 reanalysis, to study the 2021 SSW. This allows us to directly examine wind and related dynamical changes associated with the January 2021 major SSW. Aeolus is the first satellite mission to systematically and directly acquire profiles of wind, and therefore our results represent the first direct measurements of SSW-induced wind changes at the global scale. We see a complete reversal of the zonal winds in the lower to middle stratosphere, with reversed winds in some geographic regions reaching down to the bottom 2 km of the atmosphere. These altered winds are associated with major changes to surface temperature patterns, and in particular we see a strong potential linkage from the SSW to extreme winter weather outbreaks in Greece and Texas during late January and early February. Our results (1) demonstrate the benefits of wind-profiling satellites such as Aeolus in terms of both their direct measurement capability and use in supporting reanalysis-driven interpretation of stratosphere–troposphere coupling signatures, (2) provide a detailed dynamical description of a major weather event, and (3) have implications for the development of Earth-system models capable of accurately forecasting extreme winter weather.

Postoperative Management for the Obese Patient

Obesity results in physiologic changes that effect nearly every organ system, including respiratory, cardiovascular, gastrointestinal, endocrine, genitourinary, and neuropsychiatric. These changes are associated with complications in the postoperative period that the anesthesia provider must take into account when planning the anesthetic of the obese patient. Obesity is associated with obstructive sleep apnea, obesity hypoventilation syndrome, and restrictive-type changes in lung volumes that decrease the obese patient’s ability to compensate for the changes that take place with anesthesia. The anesthetic provider should conduct a thorough preoperative evaluation, ensure complete reversal of neuromuscular blockade prior to extubation to prevent obstruction, ensure adequate pain control without compromising respiratory function, and consider use of Continuous positive airway pressure (CPAP) machines for patients on home CPAP. Obesity is also associated with an increased risk of perioperative arrhythmias, thrombotic events, impaired wound healing, decreased kidney function, and postoperative cognitive decline. Anesthetic providers should make every effort to take steps in order to prevent these complications and be knowledgeable about their management should they occur. This review contains 3 figures, 2 tables, 37 references

Postoperative Management for the Obese Patient

Obesity results in physiologic changes that effect nearly every organ system, including respiratory, cardiovascular, gastrointestinal, endocrine, genitourinary, and neuropsychiatric. These changes are associated with complications in the postoperative period that the anesthesia provider must take into account when planning the anesthetic of the obese patient. Obesity is associated with obstructive sleep apnea, obesity hypoventilation syndrome, and restrictive-type changes in lung volumes that decrease the obese patient’s ability to compensate for the changes that take place with anesthesia. The anesthetic provider should conduct a thorough preoperative evaluation, ensure complete reversal of neuromuscular blockade prior to extubation to prevent obstruction, ensure adequate pain control without compromising respiratory function, and consider use of Continuous positive airway pressure (CPAP) machines for patients on home CPAP. Obesity is also associated with an increased risk of perioperative arrhythmias, thrombotic events, impaired wound healing, decreased kidney function, and postoperative cognitive decline. Anesthetic providers should make every effort to take steps in order to prevent these complications and be knowledgeable about their management should they occur. This review contains 3 figures, 2 tables, 37 references

Renal Recovery after the Implementation of an Electronic Alert and Biomarker-Guided Kidney-Protection Strategy Following Major Surgery

Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by >25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p < 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery.

Ciraparantag reverses the anticoagulant activity of apixaban and rivaroxaban in healthy elderly subjects

Aims Ciraparantag is a reversal agent for anticoagulants including direct oral anticoagulants. The aim was to evaluate the efficacy and safety of ciraparantag to reverse anticoagulation induced by apixaban or rivaroxaban in healthy elderly adults. Methods and results Two randomized, placebo-controlled, dose-ranging trials conducted in healthy subjects aged 50–75 years. Subjects received apixaban (Study 1) 10 mg orally twice daily for 3.5 days or rivaroxaban (Study 2) 20 mg orally once daily for 3 days. At steady-state anticoagulation subjects were randomized 3:1 to a single intravenous dose of ciraparantag (Study 1: 30, 60, or 120 mg; Study 2: 30, 60, 120, or 180 mg) or placebo. Efficacy was based on correction of the whole blood clotting time (WBCT) at multiple timepoints over 24 h. Subjects and technicians performing WBCT testing were blinded to treatment. Complete reversal of WBCT within 1 h post-dose and sustained through 5 h (apixaban) or 6 h (rivaroxaban) was dose related and observed with apixaban in 67%, 100%, 100%, and 17% of subjects receiving ciraparantag 30 mg, 60 mg, 120 mg, or placebo, respectively; and with rivaroxaban in 58%, 75%, 67%, 100%, and 13% of subjects receiving ciraparantag 30 mg, 60 mg, 120 mg, 180 mg, or placebo, respectively. Adverse events related to ciraparantag were mild, transient hot flashes or flushing. Conclusions Ciraparantag provides a dose-related reversal of anticoagulation induced by steady-state dosing of apixaban or rivaroxaban. Sustained reversal was achieved with 60 mg ciraparantag for apixaban and 180 mg ciraparantag for rivaroxaban. All doses of ciraparantag were well tolerated.

Applications of Mesenchymal Stem Cells in Liver Fibrosis: Novel Strategies, Mechanisms, and Clinical Practice

Liver fibrosis is a common result of most chronic liver diseases, and advanced fibrosis often leads to cirrhosis. Currently, there is no effective treatment for liver cirrhosis except liver transplantation. Therefore, it is important to carry out antifibrosis treatment to reverse liver damage in the early stage of liver fibrosis. Mesenchymal stem cells (MSCs) are the most widely used stem cells in the field of regenerative medicine. The preclinical and clinical research results of MSCs in the treatment of liver fibrosis and cirrhosis show that MSC administration is a promising treatment for liver fibrosis and cirrhosis. MSCs reverse liver fibrosis and increase liver function mainly through differentiation into hepatocytes, immune regulation, secretion of cytokines and other nutritional factors, reduction of hepatocyte apoptosis, and promotion of hepatocyte regeneration. Recently, many studies provided a variety of new methods and strategies to improve the effect of MSCs in the treatment of liver fibrosis. In this review, we summarized the current effective methods and strategies and their potential mechanisms of MSCs in the treatment of liver fibrosis, as well as the current research progress in clinical practice. We expect to achieve complete reversal of liver injury with MSC-based therapy in the future.

Ivabradine: A Potential Therapeutic for Children With Refractory SVT

Background: In April 2015, ivabradine was approved by the Food and Drug Administration for the treatment of patients with coronary artery disease and heart failure (HF). The use of this medication has been linked with improved clinical outcomes and reduced rates of hospitalization in patients with symptomatic HF and a baseline heart rate of 70 bpm and above. Nonetheless, little is known about the use of ivabradine in pediatric patients with supraventricular tachycardia (SVT). This use is not well-studied and is only endorsed by a few case reports and case series.Aim: This study discusses the off-label utilization of ivabradine in pediatric patients with SVT, and highlights its efficacy in treating treatment-resistant (refractory) SVT.Methods: We conducted a retrospective single-center observational study involving pediatric patients with SVT treated at our center between January 2016 and October 2020. We identified the total number of patients with SVT, and the number of patients with refractory SVT treated with Ivabradine. Similarly, we performed a thorough review of the databases of PubMed, Medline and Google Scholar to compare the clinical course of our patients to those described in the literature.Results: Between January 2016 and October 2020, 79 pediatric patients with SVT were seen and treated at our center. A treatment-resistant SVT was noted only in three patients (4%). Ivabradine was used in these patients as a single or combined therapy. The rest (96%) were successfully treated with conventional anti-arrhythmics such as β-blockers, flecainide, and other approved medications. In the ivabradine group, successful reversal to sinus rhythm was achieved in two of the three patients (66%), one patient was treated with a combination therapy of amiodarone and ivabradine, and the other patient was treated only with ivabradine.Conclusion: Overall, promissory results are associated with the use of ivabradine in pediatric patients with refractory SVT. Ivabradine appears to be a safe and well-tolerated medication that can induce adequate suppression of SVT, complete reversal to sinus rhythm, and effective enhancement of left ventricular function.

Acute Neonatal Upper Limb Ischemia: Topical Vasodilation, Anticoagulation and Physical Therapy-A new option for complete reversal of ischemia

Acute upper limb ischemia in neonates is extremely rare and oftenassociated with disastrous outcomes including digital gangrene, chroniclimb ischemia, sepsis and limb loss. It is usually seen in the contextof intra-arterial catheters in the preterm neonates but it can be alsoseen in cases of difficult or traumatic deliveries as well as in infantswith coagulation deficits but can also be spontaneous with no obviousaetiology. Treatment options include topical vasodilators, systemicanticoagulation and in some instances, surgical intervention. We reportthree cases of acute limb ischemia in preterm neonates in which anew treatment option was introduced. The neonates responded to acombination of topical nitro-glycerine cream, systemic anticoagulationwith heparin and physical light massaging of the area just proximalto the site of reduced flow in the vessel assuming some degree ofvasospasm of the vessel occurs with or without thrombosis.Keywords: neonatal ischemia, management of neonatal ischemia, topicalvasodilators, systemic anticoagulation, massage therapy, surgicalintervention

After the “service”Time to party in ţigănie

This chapter describes the parties that take place in the Roma neighborhood of Ceuaş when professional musicians come back from the “service.” Both familial celebrations and an opportunity to rehearse, these “after-parties” arouse intense emotions in the musicians themselves. These gatherings mark a complete reversal in the musicians’ attitudes and relationships: after serving their customers and arousing their emotions, the musicians now shift their focus onto their own personal lived experiences and memories.

Thromboelastography utilization for dabigatran reversal in a patient with acute kidney injury

Purpose This case report describes utilization of thromboelastography (TEG) in the setting of an acute major bleed in a patient on dabigatran who had concomitant acute kidney injury. Summary An 80-year-old female presented to the emergency department after a fall with complaints of pain in her knee, shoulder, and hip. Her medical history was significant for coronary artery disease, for which she took clopidogrel 75 mg daily, and atrial fibrillation, for which she took dabigatran 150 mg twice daily. The physical exam was remarkable for pain within the shoulder, hip, and knee, which had swelling and ecchymosis that extended into the right thigh. Given the possibility of compartment syndrome with multiple possible etiologies of coagulopathy, TEG and computed tomography angiography (CTa) of the right lower extremity were performed. The initial TEG showed prolonged R time and activated clotting time, indicating clotting factor dysfunction with no additional coagulopathy noted, including antiplatelet effects. On the basis of the TEG and CTa findings, it was decided to reverse dabigatran with 5 grams of idarucizumab. Approximately 1 hour after administration of idarucizumab, the patient was taken to interventional radiology where a limited angiogram of the right lower extremity showed no active extravasation. Because of the patient’s renal dysfunction and the possibility of rebound hypercoaguability, repeat TEG tests were ordered at 4 and 8 hours after the initial reversal to ensure clearance of idarucizumab-dabigatran complexes. The repeat TEG values showed complete reversal of the initial coagulopathy noted. During the admission, the patient required no blood transfusions or surgical interventions and all her initial laboratory results improved. Conclusion Serial TEG testing was successful at managing multiple coagulopathies in a patient at risk for trauma-induced compartment syndrome.