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Zusammenfassung Hintergrund Im Jahr 2017 wurden weltweit etwa 4 Milliarden Menschen mit einem Flugzeug transportiert. Die International Air Transport Association (IATA) prognostiziert für Europa bis zum Jahr 2034 eine durchschnittliche jährliche Steigerung der Passagierzahlen von 2,7%. In der zivilen Luftfahrt treten Notfälle an Bord (sogenannte In-Flight Medical Emergencies, IFME) mit einer Häufigkeit von 1 pro 14 000 bis 1 pro 50 000 transportierte Passagiere auf. Belastbare Daten über die exakte Häufigkeit und Art von medizinischen Notfällen an Bord von Flugzeugen existieren nicht. Ein Herz-Kreislauf-Stillstand tritt statistisch gesehen nur in 0,3% der Notfälle an Bord auf. Dieses Ereignis ist jedoch mit einer Mortalität von 86% assoziiert und stellt daher Passagiere und Crew zugleich vor eine große Herausforderung. Mit der Leitlinie zum In-Flight Cardiac Arrest (IFCA) wurden 28 spezifische Empfehlungen erarbeitet. Ziel der Leitlinie war es, spezifische Handlungsempfehlungen für mitfliegende Ärzte, Kabinenpersonal (Cabin Crew) und auch Fluglinien zur Behandlung des Herz-Kreislauf-Stillstands an Bord von Luftfahrzeugen zu generieren.

ZusammenfassungIm Lichte zukünftiger Langzeitraumfahrtmissionen fernab der Erdumlaufbahn besitzt die Fähigkeit der Crew zur autonomen, medizinischen Versorgung einen besonderen Stellenwert. Hier ist insbesondere die Durchführung einer Anästhesie bei einer dringend notwendigen Operation von entscheidender Bedeutung, um unter Umständen die Mission weiter fortsetzen zu können. Bisher musste noch keine Allgemeinanästhesie in der Raumfahrt durchgeführt werden, sodass die praktische Erfahrung entsprechend limitiert ist. Es erscheint sinnvoll, in Umgebungen mit vergleichbaren medizinischen Versorgungssituationen nach Erfahrungswerten und Behandlungsstrategien zu suchen. Diese Umgebungen sollten über eine oder mehrere der Eigenschaften von Raumfahrtmissionen verfügen. Beispielsweise könnten dies Limitationen bei medizinischem Personal und Ausstattung oder die Unmöglichkeit einer zeitnahen Evakuierung zu einer höherwertigen Versorgungseinrichtung sein. Die vorliegende Übersichtsarbeit fasst die bisher zu diesem Thema publizierte Literatur zusammen und gibt einen Überblick über wichtige und bisher bekannte medizinische Maßnahmen in Schwerelosigkeit.

Objective: Severity of illness scores rest on the assumption that patients have normal physiologic values at baseline and that patients with similar severity of illness scores have the same degree of deviation from their usual state. Prior studies have reported differences in baseline physiology, including laboratory markers, between obese and normal weight individuals, but these differences have not been analyzed in the ICU. We compared deviation from baseline of pertinent ICU laboratory test results between obese and normal weight patients, adjusted for the severity of illness. Design: Retrospective cohort study in a large ICU database. Setting: Tertiary teaching hospital. Patients: Obese and normal weight patients who had laboratory results documented between 3 days and 1 year prior to hospital admission. Interventions: None. Measurements and Main Results: Seven hundred sixty-nine normal weight patients were compared with 1,258 obese patients. After adjusting for the severity of illness score, age, comorbidity index, baseline laboratory result, and ICU type, the following deviations were found to be statistically significant: WBC 0.80 (95% CI, 0.27–1.33) × 109/L; p = 0.003; log (blood urea nitrogen) 0.01 (95% CI, 0.00–0.02); p = 0.014; log (creatinine) 0.03 (95% CI, 0.02–0.05), p < 0.001; with all deviations higher in obese patients. A logistic regression analysis suggested that after adjusting for age and severity of illness at least one of these deviations had a statistically significant effect on hospital mortality (p = 0.009). Conclusions: Among patients with the same severity of illness score, we detected clinically small but significant deviations in WBC, creatinine, and blood urea nitrogen from baseline in obese compared with normal weight patients. These small deviations are likely to be increasingly important as bigger data are analyzed in increasingly precise ways. Recognition of the extent to which all critically ill patients may deviate from their own baseline may improve the objectivity, precision, and generalizability of ICU mortality prediction and severity adjustment models.

Artificial Intelligence (AI) as a novel tool to advance the field ofmedicine has rapidly become a subject of great interest and intense debate, lea ding many stakeholders to prospect on the future role of these technologies and relative responsibilities in decision-making [1–5].Furthermore, the complexity of some AI algorithms, theirlack of transparency and a widespread lack of prospective validation may serve to dishearten physicians. In this short piece, I will attempt to define what are some of the most common AI techniques with applications to intensive care, then I’ll discuss what barriers to implementation exist and why us, doctors, have not been superseded by robot-physicians.

In this Comment, we provide guidelines for reinforcement learning for decisions about patient treatment that we hope will accelerate the rate at which observational cohorts can inform healthcare practice in a safe, risk-conscious manner.

Pro Jahr reisen weltweit uber 3 Mrd. Menschen mit einem Luftfahrzeug. Bezogen auf die Anzahl transportierter Passagiere tritt ein medizinischer Notfall mit einer Haufigkeit von 1/14 000 bis 1/50 000 transportierten Passagieren auf. Der Herz-Kreislauf-Stillstand wahrend eines Fluges (in-flight cardiac arrest, IFCA) hat einen Anteil von 0,3 % an den Notfallen an Bord, besitzt aber andererseits eine Mortalitat von 86 %. Bisher existierte zum IFCA keine evidenzbasierte Leitlinie. Fur die Erstellung einer diesbezuglichen Leitlinie wurde eine Taskforce gegrundet, die publizierte Studien und die daraus abzuleitende Evidenz analysierte. Mittels systematischer Literaturanalyse und der Verwendung der Grade-, Rand- und Delphi-Methodik wurden spezifische Empfehlungen fur die Therapie des IFCA erstellt. Fur verschiedene Bereiche wurden spezifische Empfehlungen durch die Taskforce erarbeitet: Notfallausstattung an Bord, EKG, Reanimationstechniken, (Wiederholungs-)Training fur Besatzungen, Vorgehen nach „Return of Spontaneous Circulation“ (ROSC) und auserplanmasige Zwischenlandungen. Die Empfehlungen geben Arzten an Bord Hinweise, wie auf evidenzbasiertem Niveau mit IFCA-Patienten im Idealfall zu verfahren ist.

Purpose of review Missions to the Moon or more distant planets are planned in the next future, and will push back the limits of our experience in providing medical support in remote environments. Medical preparedness is ongoing, and involves planning for emergency surgical interventions and anaesthetic procedures. This review will summarize what principles of ambulatory anaesthesia on Earth could benefit the environment of a space mission with its unique constraints. Recent findings Ambulatory anaesthesia relies on several principles such as improved patient pathway, correct patient selection, optimized procedural strategies to hasten recovery and active prevention of postoperative complications. Severe limitations in the equipment available and the skills of the crew members represent the key factors to be taken into account when designing the on-board medical system for future interplanetary space missions. Summary The application of some of the key principles of ambulatory anaesthesia, as well as recent advances in anaesthetic techniques and better understanding of human adaptation to the space environment might allow nonanaesthesiologist physicians to perform common anaesthetic procedures, whilst maximizing crew safety and minimizing the impact of medical events on the mission.

Sepsis is the leading cause of mortality in the ICU. It is challenging to manage because individual patients respond differently to treatment. Thus, tailoring treatment to the individual patient is essential for the best outcomes. In this paper, we take steps toward this goal by applying a mixture-of-experts framework to personalize sepsis treatment. The mixture model selectively alternates between neighbor-based (kernel) and deep reinforcement learning (DRL) experts depending on patient’s current history. On a large retrospective cohort, this mixture-based approach outperforms physician, kernel only, and DRL-only experts.

Background and objective To develop a machine learning model to predict urine output (UO) in sepsis patients after fluid resuscitation. Methods We identified sepsis patients in the Multiparameter Intelligent Monitoring in Intensive Care-III v1.4 database according to the Sepsis-3 criteria. We focused on two outcomes: whether the UO decreased after fluid administration and whether oliguria (defined as UO less than the threshold of 0.5 mL/kg/h) developed. A gradient tree-based machine learning model implemented with an eXtreme Gradient Boosting algorithm was used to integrate relevant physiological parameters for predicting the aforementioned outcomes. A confusion matrix was computed. Results A total of 232,929 events in 19,275 patients were included. Using decreased UO as the outcome measure, the optimal model achieved an area under the curve (AUC) of 0.86; for predicting oliguria, most models achieved an AUC greater than 0.86, and the highest sensitivity was 92.2% when the model was applied to patients with baseline oliguria. Conclusions Machine learning could help clinicians evaluate fluid status in sepsis patients after fluid administration, thus preventing fluid overload-related complications.

Air travel during the COVID-19 pandemic is challenging for travellers, airlines, airports, health authorities, and governments. We reviewed multiple aspects of COVID peri-pandemic air travel, including data on traveller numbers, peri-flight prevention, and testing recommendations and in-flight SARS-CoV-2 transmission, photo-epidemiology of mask use, the pausing of air travel to mass gathering events, and quarantine measures and their effectiveness. Flights are reduced by 43% compared to 2019. Hygiene measures, mask use, and distancing are effective, while temperature screening has been shown to be unreliable. Although the risk of in-flight transmission is considered to be very low, estimated at one case per 27 million travellers, confirmed in-flight cases have been published. Some models exist and predict minimal risk but fail to consider human behavior and airline procedures variations. Despite aircraft high-efficiency filtering, there is some evidence that passengers within two rows of an index case are at higher risk. Air travel to mass gatherings should be avoided. Antigen testing is useful but impaired by time lag to results. Widespread application of solutions such as saliva-based, rapid testing or even detection with the help of "sniffer dogs" might be the way forward. The "traffic light system" for traveling, recently introduced by the Council of the European Union is a first step towards normalization of air travel. Quarantine of travellers may delay introduction or re-introduction of the virus, or may delay the peak of transmission, but the effect is small and there is limited evidence. New protocols detailing on-arrival, rapid testing and tracing are indicated to ensure that restricted movement is pragmatically implemented. Guidelines from airlines are non-transparent. Most airlines disinfect their flights and enforce wearing masks and social distancing to a certain degree. A layered approach of non-pharmaceutical interventions, screening and testing procedures, implementation and adherence to distancing, hygiene measures and mask use at airports, in-flight and throughout the entire journey together with pragmatic post-flight testing and tracing are all effective measures that can be implemented. Ongoing research and systematic review are indicated to provide evidence on the utility of preventive measures and to help answer the question "is it safe to fly?".

Simulation-based approaches to disease progression allow us to make counterfactual predictions about the effects of an untried series of treatment choices. However, building accurate simulators of disease progression is challenging, limiting the utility of these approaches for real world treatment planning. In this work, we present a novel simulation-based reinforcement learning approach that mixes between models and kernel-based approaches to make its forward predictions. On two real world tasks, managing sepsis and treating HIV, we demonstrate that our approach both learns state-of-the-art treatment policies and can make accurate forward predictions about the effects of treatments on unseen patients.

We study the problem of off-policy policy evaluation (OPPE) in RL. In contrast to prior work, we consider how to estimate both the individual policy value and average policy value accurately. We draw inspiration from recent work in causal reasoning, and propose a new finite sample generalization error bound for value estimates from MDP models. Using this upper bound as an objective, we develop a learning algorithm of an MDP model with a balanced representation, and show that our approach can yield substantially lower MSE in common synthetic benchmarks and a HIV treatment simulation domain., Comment: appeared at NeurIPS 18; updated style file

Travelling to the stars is a dream nearly as old as mankind itself. Nowadays, spaceflight is in many ways common business, becoming even accessible to space tourists. However, many problems remain to be solved before humanity can venture into deep space with an acceptable level of risk, and medical preparedness is one of them. The management of any severe medical emergency will be extremely challenging in this extreme environment, with limited resources in crew and equipment. Here, we discuss the case of a cardiac arrest occurring during spaceflight, and present challenges around the recognition, immediate management including delivering cardio-pulmonary resuscitation and secondary measures such as organ support or evacuation. Given the current treatment capabilities in space, the survivability of cardiac arrest is expected to be lower than on the ground.

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

Introduction In the near future, space programs will shift their focus toward long-duration interplanetary missions, in particular to the Moon and Mars. These exploration missions will be associated with an increased risk of acute medical problems, which will need to be handled by an autonomous crew operating in extreme isolation. An important skill in emergencies is represented by airway management. Many airway devices are available and it is unclear which one would be the most suitable in the context of a space mission. The aim of this systematic review was to analyze the existing literature on airway management in the special situation of weightlessness during space missions. Material and methods We performed a standardized review of published literature on airway management in spaceflight and analogue environments using the database PubMed. Results We identified a total of 3111 publications of which 3039 were initially excluded after evaluation. The screening identified three randomized comparative manikin studies, two of them in parabolic flights, one in a submerged setup. Under free-floating conditions, the insertion success rate of supraglottic airway devices (SGA) was excellent (91%-97%). The administration of artificial ventilation could be successfully achieved in weightlessness with SGA. The success rate of conventional laryngoscopy under free-floating conditions fluctuated between 15% and 86%. Conclusion It appears possible to safely manage the airway in weightlessness, provided that certain conditions are ensured, such as restraining the patient and operator for conventional orotracheal intubation. If airway protection is required with endotracheal intubation, both the operator and the patient should be restrained.

By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.

Die Behandlung schwerwiegender medizinischer Vorfalle wahrend eines Raumflugs stellt eine ausergewohnliche Herausforderung dar. Dank der intensiven medizinischen Untersuchungen in der Phase der Kandidatenauswahl sind signifikante medizinische Probleme wahrend des Trainings und der Weltraummissionen bisher selten, obwohl Raumfahrer kumuliert bereits 125 Personenjahre im All verbracht haben. Das Risiko schwerwiegender medizinischer Ereignisse ist dennoch erheblich, besonders bei Langzeitmissionen wie z. B. zum Mars. Es gibt noch viele Lucken in unserem Verstandnis der menschlichen Reaktion auf die Weltraumbedingungen und verschiedener kritischer Risiken der interplanetaren Raumfahrt, wie z. B. beim Schutz vor Strahlenexposition oder der autonomen medizinischen Versorgung. Sowohl die zu erwartenden medizinischen Beschwerden als auch die akute Versorgungskapazitat sind auf der Erde und im Weltraum grundsatzlich unterschiedlich. Wahrend die modernen medizinischen Moglichkeiten auf der Erde potenziell unbegrenzt sind, sind die Ausrustung und das unmittelbar verfugbare Know-how im Weltraum sehr begrenzt. Daher konzentriert man sich auf die Pravention von Notfallen. Selbst nach einer erfolgreichen initialen Stabilisation ware eine postreanimative Versorgung im erdnahen Orbit problematisch. Auf der internationalen Raumstation ISS ist eine lebenserhaltende Versorgung uber einen langeren Zeitraum unmoglich. Auserdem ist eine Evakuierung aus dem erdnahen Orbit mit den derzeitigen Moglichkeiten bei einem instabilen, kritisch erkrankten oder intubierten und beatmeten Patienten angesichts des begrenzten Volumens der Soyuz-Kapsel und der starken Verzogerung beim Wiedereintritt in die Atmosphare unter Umstanden nicht moglich. Kunftige Weltraum-Forschungsmissionen werden unsere Kenntnisse uber die Erhaltung von Gesundheit und Leistungsfahigkeit der Besatzungsmitglieder erweitern. Viele Fragen sind noch zu losen, bevor die Menschheit sich mit vertretbarem Risiko auf den Weg in die Tiefen des Weltalls machen kann.

The management of severe medical events during spaceflight represents an exceptional challenge. Thanks to the intense medical screening performed during astronaut selection, significant medical problems have remained uncommon during training and space missions, despite some 125 person-years of cumulated presence in space. The risk of severe medical events, particularly during long-term missions, e.g. to Mars, is nevertheless significant. Many gaps still remain in our understanding of the human response to the space environment and several critical risks associated with interplanetary space travel—such as protection against radiation exposure or delivery of autonomous medical care—remain unresolved. Both the expected medical conditions and the acute care capabilities differ greatly between Earth and space. While the options in modern medical facilities on the ground are potentially limitless, the equipment and immediate expertise available in space are very limited. For this reason, an emphasis is put on prevention of emergencies. Even after a successful initial stabilisation in low Earth orbit, postresuscitation care would prove problematic. The International Space Station (ISS) does not have the capability to deliver prolonged life support. Furthermore, evacuation from low Earth orbit with current capabilities may not be possible for an unstable, critically ill or intubated and ventilated patient, because of limited volume in the Soyuz capsule and the high deceleration profile. Future space exploration missions will push back the limits of human experience in maintaining health and performance of crew members. Many issues will have to be addressed before humanity can venture beyond low Earth orbit with an acceptable level of risk.

Background Pneumonia is responsible for approximately 230,000 deaths in Europe, annually. Comprehensive and comparable reports on pneumonia mortality trends across the European Union (EU) are lacking. Methods A temporal analysis of national mortality statistics to compare trends in pneumonia age-standardised death rates (ASDR) of EU countries between 2001 and 2014 was performed. International Classification of Diseases version 10 (ICD-10) codes were used to extract data from the World Health Organisation European Detailed Mortality Database and trends were analysed using Joinpoint regression. Results Median pneumonia mortality across the EU for the last recorded observation was 19.8 / 100,000 and 6.9 / 100,000 for males and females, respectively. Mortality was higher in males across all EU countries, most notably in Estonia and Lithuania where the ratio of male to female ASDR was 4.0 and 3.7, respectively. Gender mortality differences were lowest in the UK and Demark with ASDR ratios of 1.1 and 1.5, respectively. Pneumonia mortality across all countries decreased by a median of 31.0% over the observation period. Countries that demonstrated an increase in pneumonia mortality were Poland (males + 33.1%, females + 10.2%), and Lithuania (males + 6.0%). Conclusions Mortality from pneumonia is improving in most EU countries, however substantial variation in trends remains between countries and between genders. Electronic supplementary material The online version of this article (10.1186/s12931-018-0781-4) contains supplementary material, which is available to authorized users.

Supplemental Digital Content is available in the text., Objective: To determine the association of new-onset atrial fibrillation with outcomes, including ICU length of stay and survival. Design: Retrospective cohort of ICU admissions. We found atrial fibrillation using automated detection (≥ 90 s in 30 min) and classed as new-onset if there was no prior diagnosis of atrial fibrillation. We identified determinants of new-onset atrial fibrillation and, using propensity matching, characterized its impact on outcomes. Setting: Tertiary care academic center. Patients: A total of 8,356 consecutive adult admissions to either the medical or surgical/trauma/burn ICU with available continuous electrocardiogram data. Interventions: None. Measurements and Main Results: From 74 patient-years of every 15-minute observations, we detected atrial fibrillation in 1,610 admissions (19%), with median burden less than 2%. Most atrial fibrillation was paroxysmal; less than 2% of admissions were always in atrial fibrillation. New-onset atrial fibrillation was subclinical or went undocumented in 626, or 8% of all ICU admissions. Advanced age, acute respiratory failure, and sepsis were the strongest predictors of new-onset atrial fibrillation. In propensity-adjusted regression analyses, clinical new-onset atrial fibrillation was associated with increased hospital mortality (odds ratio, 1.63; 95% CI, 1.01–2.63) and longer length of stay (2.25 d; CI, 0.58–3.92). New-onset atrial fibrillation was not associated with survival after hospital discharge (hazard ratio, 0.99; 95% CI, 0.76–1.28 and hazard ratio, 1.11; 95% CI, 0.67–1.83, respectively, for subclinical and clinical new-onset atrial fibrillation). Conclusions: Automated analysis of continuous electrocardiogram heart rate dynamics detects new-onset atrial fibrillation in many ICU patients. Though often transient and frequently unrecognized, new-onset atrial fibrillation is associated with poor hospital outcomes.

L’exposition a l’apesanteur a des consequences sur la plupart des systemes physiologiques. Habituellement, les manifestations cliniques de la phase de transition, correspondant au space adaptation syndrome, demeurent relativement mineures. La comprehension du deconditionnement cardiovasculaire des astronautes est fondamentale dans l’eventualite de soins d’urgence. Cette atteinte est marquee par un remodelage arteriel et veineux et par des modifications de la volemie, de la performance cardiaque, des resistances vasculaires systemiques, du systeme nerveux autonome et de la regulation hormonale. Pour de nombreux experts, le nouvel etat atteint apres la phase d’ajustement ne correspond pas a un etat pathologique, mais simplement a un nouvel equilibre cardiovasculaire adapte a des conditions de charge reduites. Le retour a la gravite s’accompagne egalement d’une phase d’adaptation, qui se complique pour de nombreux astronautes de manifestations cliniques parfois serieuses. Parmi celles-ci, l’intolerance orthostatique et la reduction de la capacite a l’effort constituent des risques operationnels majeurs. Pendant le vol spatial et a son decours immediat, la tolerance hemodynamique de tout episode aigu surajoute (hypovolemie absolue ou relative, alteration de la fonction myocardique, induction anesthesique, ventilation mecanique) pourrait etre compromise. La difficulte des etudes en anesthesie et reanimation tient a l’absence de modele terrestre reproduisant precisement les modifications engendrees par l’apesanteur. Au cours des 78 personnes/annee de presence cumulee dans l’espace, les evenements medicaux graves (defaillances de vehicules exclues) ont ete exceptionnels, notamment grâce aux criteres extremement drastiques de selection medicale des astronautes. a l’avenir, ce tableau pourrait etre bouleverse par la multiplication des vols spatiaux commerciaux.

In spaceflight beyond low Earth's orbit, medical conditions requiring surgery are of a high level of concern because of their potential impact on crew health and mission success. Whereas surgical techniques have been thoroughly studied in spaceflight analogues, the research focusing on anesthesia is limited. To provide safe anesthesia during an exploration mission will be a highly challenging task. The research objective is thus to describe specific anesthesia procedures enabling treatment of pre-identified surgical conditions. Among the medical conditions considered by the NASA Human Research Program Exploration Medical Capability element, those potentially necessitating anesthesia techniques have been identified. The most appropriate procedure for each condition is thoroughly discussed. The substantial cost of training time necessary to implement regional anesthesia is pointed out. Within general anesthetics, ketamine combines the unique advantages of preservation of cardiovascular stability, the protective airway reflexes, and spontaneous ventilation. Ketamine side effects have for decades tempered enthusiasm for its use, but recent developments in mitigation means broadened its indications. The extensive experience gathered in remote environments, with minimal equipment and occasionally by insufficiently trained care providers, confirms its high degree of safety. Two ketamine-based anesthesia protocols are described with their corresponding indications. They have been designed taking into account the physiological changes occurring in microgravity and the specific constraints of exploration missions. This investigation could not only improve surgical care during long-duration spaceflights, but may find a number of terrestrial applications in isolated or austere environments.

In this chapter, the author will learn about the principles of model validation and how to conduct sensitivity analyses.

This case study describes common Markov models, their specific application in medical research, health economics and cost-effectiveness analysis.

In this chapter, the reader will learn about the most common tools available for exploring a dataset, which is essential in order to gain a good understanding of the features and potential issues of a dataset, as well as helping in hypothesis generation.

Introduction La recherche sur les techniques anesthesiques adaptees aux missions d’exploration spatiale est limitee, parce qu’il n’existe pas de modele humain reproduisant les variations physiologiques induites par l’apesanteur. L’objectif de ce travail etait de definir, grâce a la simulation et par l’avis d’experts, les protocoles d’anesthesie les plus adaptes aux contraintes physiologiques, techniques et humaines des missions d’exploration spatiale en cas de procedures chirurgicales. Materiel et methodes Ce travail prospectif a ete mene sur simulateur haute-fidelite HPS de CAE®. Cinq experts en anesthesie et en simulation medicale ont participe a l’etude. Le HPS a ete programme pour reproduire les perturbations physiologiques retrouvees chez les astronautes (deconditionnement cardiovasculaire). Deux types d’anesthesie generale (AG en ventilation spontanee et AG avec intubation orotracheale) ont ete testes sur 2 scenarios, en comparant 3 protocoles anesthesiques (propofol 1 mg/kg, etomidate 0,3 mg/kg et ketamine 2 mg/kg). Un des scenarios comprenait une hemorragie de 1000 mL surajoutee. Chaque scenario a ete repete 5 fois. La frequence cardiaque (FC), la pression arterielle moyenne (PAM) a la 60e seconde, les volumes de remplissage et le recours a la phenylephrine ont ete releves. La comparaison intergroupe a ete effectuee par un test de Kruskal-Wallis. Donnees presentees en mediane (Interquartile 25–75), p Resultats Les scenarii des groupes ketamine ( Fig. 1 ) s’accompagnait d’une meilleure stabilite tensionnelle. Les groupes propofol et etomidate necessitaient un remplissage significativement plus important que la ketamine (500 mL). Il n’y avait pas de difference significative pour l’administration de phenylephrine. Les experts approuvaient la ketamine comme agent anesthesique de choix. Discussion En reproduisant sur simulateur haute fidelite HPS les variations physiologiques induites par l’apesanteur, la ketamine s’est revelee comme l’agent anesthesique de choix en terme de tolerance hemodynamique pour l’induction en situation hemorragique ou non. Le positionnement de la ketamine en cas de procedure chirurgicale au cours des missions d’exploration spatiale est a considerer.

During future space exploration missions, the risk of medical events requiring surgery is significant, and will likely rely on anesthetic techniques. Available options during spaceflight include local, regional (nerve block) and general anesthesia. No actual invasive anesthesia was ever performed on humans in space or immediately after landing, and the safe delivery of such advanced medical care in this context is challenging. In the first section of this review, Human adaptation to the space environment is detailed, with a focus on the cardiovascular system, along with a discussion regarding which medical conditions may arise. The second part of the study focuses on discussing the extensive list of challenges associated with delivering an anesthetic procedure in space or on a foreign planetary surface. They schematically fall into two categories: missing technologies (generation of intravenous fluid, specific medical equipment, preservation of drugs…) and missing knowledge (human physiology in partial gravity, use of vasopressors, cardiovascular tolerance of general anesthesia and blood loss, choice of the most appropriate anesthetic technique, medical training). Future space exploration mis¬sions will push back the limits of human expe¬rience in maintaining health and performance of crew members in extreme settings. After more than five decades of research, our understanding of human physiology in weightlessness is advanced. Despite a number of challenges, the safe delivery of an anesthetic procedure on previously healthy individuals and given our current knowledge and technologies remains risky but could be possible even by non-anesthesiologists, and should not represent a showstopper for future space exploration missions.

Sepsis is the leading cause of mortality in the ICU. It is challenging to manage because individual patients respond differently to treatment. Thus, tailoring treatment to the individual patient is essential for the best outcomes. In this paper, we take steps toward this goal by applying a mixture-of-experts framework to personalize sepsis treatment. The mixture model selectively alternates between neighbor-based (kernel) and deep reinforcement learning (DRL) experts depending on patient's current history. On a large retrospective cohort, this mixture-based approach outperforms physician, kernel only, and DRL-only experts., Comment: AMIA 2018 Annual Symposium

As informatisation of hospitals continues to spread, increasing amounts of healthcare related data are being collected, and the ICU is no exception. Large datasets are being made available to the scientific community, and offer the potential to answer clinical questions and to develop the next generation of clinical tools. A demonstration of such a tool is presented here, built using data from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) open database.