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Snakebite pain can be challenging to control. We describe our experience managing intolerable pain after conventional treatment failed. A 35-year-old man, presented after a viper snakebite, suffering from intolerable pain in the affected extremity. He had no significant past medical history. All attempts to control the pain conventionally were unsuccessful. Treatment with a supraclavicular nerve block resulted in immediate relief. After the block receded, only a dull pain remained, which later disappeared without recurrence. This experience illustrates the need for personalized pain treatment to avoid subsequent complications., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

The scope of this work is to discuss the proper choice of macrodispersion coefficients in modeling contaminant transport through the advection dispersion equation (ADE). It is common to model solute concentrations in transport by groundwater with the aid of the ADE. Spreading is quantified by macrodispersivity coefficients, which are much larger than the laboratory observed pore-scale dispersivities. In the frame of stochastic theory, longitudinal macrodispersivity is related to the hydraulic conductivity spatial variability via its statistical moments (mean, variance, integral scales), which are generally determined by geostatistical analysis of field measurements. In many cases, especially for preliminary assessment of contaminant spreading, these data are not available and ad hoc values are adopted by practitioners. The present study aims at recommending dispersivity values based on a thorough analysis of tens of field experiments. Aquifers are classified as of weak, medium, and high heterogeneity and for each class a range of macrodispersivity values is recommended. Much less data are available for the transverse macrodispersivities, which are significantly smaller than the longitudinal one. Nevertheless, a few realistic values based on field data, are recommended for applications. Transport models using macrodispersivities can predict mean concentrations, different from the local ones. They can be used for estimation of robust measures, like plumes spatial moments, longitudinal mass distribution and breakthrough curves at control planes., (© 2022 The Authors. Groundwater published by Wiley Periodicals LLC on behalf of National Ground Water Association.)

Background : Cardiogenic shock (CS) continues to be a severe and fatal complication of acute coronary syndrome (ACS). CS patients have a high mortality rate despite significant progress in primary reperfusion, the management of heart failure and the expansion of mechanical circulatory support strategies. The present study addressed the clinical characteristics, management, and outcomes of ACS patients complicated with CS. Methods: We performed an observational study, using the 2000-2013 Acute Coronary Syndrome Israeli Surveys (ACSIS) database and identified hospitalizations of ACS patients complicated with CS. Patients' demographics and clinical characteristics, complications and outcomes were evaluated. We assessed the outcomes of ACS patients with CS at arrival (on the day of admission) compared with ACS patients who arrived without CS and developed CS during hospitalization. Results: The cohort included 13,434 patients with ACS diagnoses during the study period. Of these, 4.2% were complicated with CS; 224 patients were admitted with both ACS and CS; while 341 ACS patients developed CS only during the hospitalization period. The latter patients had significantly higher rates of MACEs compared with the group of ACS patients who presented with CS at arrival (73% vs. 51%; p < 0.0001). Similarly, the rates of in-hospital mortality (55% vs. 36%; p < 0.0001), 30-day mortality (64% vs. 50%; p = 0.0013) and 1-year mortality (73% vs. 59%; p = 0.0016) were higher in ACS patients who developed CS during hospitalization vs. ACS patients with CS at admission. There was a significant decrease in 1-year mortality trends during the 13 years of this study presented in ACS patients from both groups. Conclusions: Patients who developed CS during hospitalization had higher mortality and MACE rates compared with those who presented with CS at arrival. Further studies should focus on this subgroup of high-risk patients.

Language evolution is driven by pressures for simplicity and informativity; however, the timescale on which these pressures operate is debated. Over several generations, learners' biases for simple and informative systems can guide language evolution. Over repeated instances of dyadic communication, the principle of least effort dictates that speakers should bias systems towards simplicity and listeners towards informativity, similarly guiding language evolution. At the same time, it has been argued that learners only provide a bias for simplicity and, thus, language users must provide a bias for informativity. To what extent do languages evolve during acquisition versus use? We address this question by formally defining and investigating the communicative efficiency of acquisition trajectories. We illustrate our approach using colour-naming systems, replicating the communicative efficiency model of Zaslavsky, Kemp, Regier & Tishby (2018, PNAS ) and the acquisition model of Beekhuizen & Stevenson (2018, Cogn. Sci. ). We find that to the extent that language is iconic, learning alone is sufficient to shape language evolution. Regarding colour-naming systems specifically, we find that incorporating learning biases into communicative efficiency accounts might explain how speakers and listeners trade off communicative effort.

Clouds are a key player in the global climate system, affecting the atmospheric water and energy budgets, and they are strongly coupled to the large-scale atmospheric circulation. Here, we examine the co-variability of the atmospheric energy and water budget imbalances in three different global model configurations-radiative-convective equilibrium, aqua-planet, and global simulations with land. The gradual increase in the level of complexity of the model configuration enables an investigation of the effects of rotation, meridional temperature gradient, land-sea contrast, and seasonal cycle on the co-variability of the water and energy imbalances. We demonstrate how this co-variability is linked to both the large-scale tropical atmospheric circulation and to cloud properties. Hence, we propose a co-variability-based framework that connects cloud properties to the large-scale tropical circulation and climate system and is directly linked to the top-down constrains on the system-the water and energy budgets. In addition, we examine how the water and energy budget imbalances co-variability depends on the temporal averaging scale, and explain its dependency on how stationary the circulation is in the different model configurations. Finally, we demonstrate the effect of an idealized global warming and convective aggregation on this co-variability., Competing Interests: The authors declare no conflicts of interest relevant to this study., (© 2022 The Authors. Journal of Advances in Modeling Earth Systems published by Wiley Periodicals LLC on behalf of American Geophysical Union.)

The Sahel rainfall has a close teleconnection with North Atlantic sea surface temperature (NASST) variability, which has separately been shown to be affected by aerosols. Therefore, changes in regional aerosols emission could potentially drive multidecadal Sahel rainfall variability. Here we combine ensembles of state-of-the-art global climate models (the CESM and CanESM large ensemble simulations and CMIP6 models) with observational data sets to demonstrate that anthropogenic aerosols have significantly impacted 20th-century detrended Sahel rainfall multidecadal variability through modifying NASST. We show that aerosol-induced multidecadal variations of downward solar radiative fluxes over the North Atlantic cause NASST variability during the 20th century, altering the ITCZ position and dynamically linking aerosol effects to Sahel rainfall variability. This process chain is caused by aerosol-induced changes in radiative surface fluxes rather than changes in ocean circulations. CMIP6 models further suggest that aerosol-cloud interactions modulate the inter-model uncertainty of simulated NASST and potentially the Sahel rainfall variability., Competing Interests: The authors declare no conflicts of interest relevant to this study., (© 2021. The Authors.)

Aerosol-cloud interactions (ACIs) are considered to be the most uncertain driver of present-day radiative forcing due to human activities. The nonlinearity of cloud-state changes to aerosol perturbations make it challenging to attribute causality in observed relationships of aerosol radiative forcing. Using correlations to infer causality can be challenging when meteorological variability also drives both aerosol and cloud changes independently. Natural and anthropogenic aerosol perturbations from well-defined sources provide "opportunistic experiments" (also known as natural experiments) to investigate ACI in cases where causality may be more confidently inferred. These perturbations cover a wide range of locations and spatiotemporal scales, including point sources such as volcanic eruptions or industrial sources, plumes from biomass burning or forest fires, and tracks from individual ships or shipping corridors. We review the different experimental conditions and conduct a synthesis of the available satellite datasets and field campaigns to place these opportunistic experiments on a common footing, facilitating new insights and a clearer understanding of key uncertainties in aerosol radiative forcing. Cloud albedo perturbations are strongly sensitive to background meteorological conditions. Strong liquid water path increases due to aerosol perturbations are largely ruled out by averaging across experiments. Opportunistic experiments have significantly improved process-level understanding of ACI, but it remains unclear how reliably the relationships found can be scaled to the global level, thus demonstrating a need for deeper investigation in order to improve assessments of aerosol radiative forcing and climate change., Competing Interests: Competing interests. At least one of the (co-)authors is a member of the editorial board of Atmospheric Chemistry and Physics. The peer-review process was guided by an independent editor, and the authors also have no other competing interests to declare.

Tropical deep convection can aggregate into large clusters, which can have impacts on the local humidity and precipitation. Sea surface temperature (SST) gradients have been shown to organize convection, yet there has been little work done to investigate the impact of diabatic heating perturbations in the atmosphere on the aggregation of convection. Here we investigate how anomalous diabatic heating of the atmospheric column, through an idealized aerosol plume, affects the existence and mechanisms of convective aggregation in non-rotating, global radiative-convective equilibrium simulations. We show that the aerosol forcing has the ability to increase the degree of aggregation, especially at lower SSTs. Detailed investigation shows that the diabatic heating source incites a thermally driven circulation, forced by the shortwave perturbation. The increase in aggregation is caused in part by this circulation, and in part by the longwave heating anomalies occurring due to the surface convergence of moisture and convection. At higher SSTs, longwave feedbacks are crucial for the aggregation of convection, even with the shortwave heating perturbation. At lower SSTs, convection is able to aggregate with the shortwave perturbation in the absence of longwave feedbacks. These perturbations provide a link to studying the effects of absorbing aerosol plumes on convection, for example during the Indian monsoon season. We argue that, as there is aggregation for plumes with realistic aerosol absorption optical depths, this could be an analogue for real-world organization in regions with high pollution., (© 2021 The Authors. Journal of Advances in Modeling Earth Systems published by Wiley Periodicals LLC on behalf of American Geophysical Union.)

Sea spray aerosol (SSA) formation have a major role in the climate system, but measurements at a global-scale of this micro-scale process are highly challenging. We measured high-resolution temporal patterns of SSA number concentration over the Atlantic Ocean, Caribbean Sea, and the Pacific Ocean covering over 42,000 km. We discovered a ubiquitous 24-hour rhythm to the SSA number concentration, with concentrations increasing after sunrise, remaining higher during the day, and returning to predawn values after sunset. The presence of dominating continental aerosol transport can mask the SSA cycle. We did not find significant links between the diel cycle of SSA number concentration and diel variations of surface winds, atmospheric physical properties, radiation, pollution, nor oceanic physical properties. However, the daily mean sea surface temperature positively correlated with the magnitude of the day-to-nighttime increase in SSA concentration. Parallel diel patterns in particle sizes were also detected in near-surface waters attributed to variations in the size of particles smaller than ~1 µm. These variations may point to microbial day-to-night modulation of bubble-bursting dynamics as a possible cause of the SSA cycle., (© 2021. The Author(s).)

Six conceptually different transport models were applied to the macrodispersion experiment (MADE)-1 field tracer experiment as a first major attempt for model comparison. The objective was to show that complex mass distributions in heterogeneous aquifers can be predicted without calibration of transport parameters, solely making use of structural and flow data. The models differ in their conceptualization of the heterogeneous aquifer structure, computational complexity, and use of conductivity data obtained from various observation methods (direct push injection logging, DPIL, grain size analysis, pumping tests and flowmeter). They share the same underlying physical transport process of advection by the velocity field solely. Predictive capability is assessed by comparing results to observed longitudinal mass distributions of the MADE-1 experiment. The decreasing mass recovery of the observed plume is attributed to sampling and no physical process like mass transfer is invoked by the models. Measures like peak location and strength are used in comparing the modeled and measured plume mass distribution. Comparison of models reveals that the predictions of the solute plume agree reasonably well with observations, if the models are underlain by a few parameters of close values: mean velocity, a parameter reflecting log-conductivity variability, and a horizontal length scale related to conductivity spatial correlation. The robustness of the results implies that conservative transport models with appropriate conductivity upscaling strategies of various observation data provide reasonable predictions of plumes longitudinal mass distribution, as long as key features are taken into account., (© 2021. The Authors.)

Background: Acute coronary syndrome (ACS) at a young age is uncommon. Limited data regarding the long-term follow-up and prognosis in this population are available. Our objectives were to evaluate the long-term clinical outcomes of patients presenting with ACS at a young age and to assess factors that predict long-term prognosis., Methods: A retrospective analysis of consecutive young patients (male below 40 and female below 50 years old) that were admitted with ACS and underwent percutaneous coronary intervention (PCI) between the years 1997 and 2009. Demographics, clinical characteristics, and clinical outcomes including major cardiovascular (CV) events and mortality were analyzed. Multivariable cox proportional hazard model was performed to identify predictors of long-term prognosis., Results: One-hundred sixty-five patients were included with a mean follow-up of 9.1±4.6 years. Most patients were men (88%), and mean age (years) was 36.8±4.2. During follow-up, 15 (9.1%) died, 98 (59.4%) patients had at least one major CV event, 22 (13.3%) patients had more than two CV events, and the mean number of recurrent CV events was 1.4±1.48 events per patient. In multivariate analysis, the strongest predictors of major CV events and/or mortality were coronary intervention without stent insertion (HR1.77; 95% CI 1.09-2.9), LAD artery involvement (HR 1.59; 95% CI 1.04-2.44) and hypertension (HR 1.6; 95% CI 1.0-2.6)., Conclusion: Patients with ACS in young age are at high risk for major CV and/or mortality in long-term follow-up with a high rate of recurrent CV events. Close follow-up and risk factor management for secondary prevention have a major role, particularly in this population., (© 2021 Yagel et al.)

The North Atlantic warming hole (NAWH) is referred to as a reduced warming, or even cooling, of the North Atlantic during an anthropogenic-driven global warming. A NAWH is predicted by climate models during the 21st century, and its pattern is already emerging in observations. Despite the known key role of the North Atlantic surface temperatures in setting the Northern Hemisphere climate, the mechanisms behind the NAWH are still not fully understood. Using state-of-the-art climate models, we show that anthropogenic aerosol forcing opposes the formation of the NAWH (by leading to a local warming) and delays its emergence by about 30 years. In agreement with previous studies, we also demonstrate that the relative warming of the North Atlantic under aerosol forcing is due to changes in ocean heat fluxes, rather than air-sea fluxes. These results suggest that the predicted reduction in aerosol forcing during the 21st century may accelerate the formation of the NAWH., (©2020. The Authors.)

Global mean precipitation changes due to climate change were previously shown to be relatively small and well constrained by the energy budget. However, local precipitation changes can be much more significant. In this paper we propose that for large enough scales, for which the water budget is closed (precipitation [ P ] roughly equals evaporation [ E ]), changes in P approach the small global mean value. However, for smaller scales, for which P and E are not necessarily equal and convergence of water vapor still plays a role, changes in P could be much larger due to dynamical contributions. Using 40 years of two reanalysis data sets, 39 Coupled Model Intercomparison Project Phase 5 (CMIP5) models and additional numerical simulations, we identify the scale of transition in the importance of the different terms in the water budget to precipitation to be ~3,500-4,000 km and demonstrate its relation to the spatial scale of precipitation changes under climate change., (©2019. The Authors.)

Precipitation plays a crucial role in the Earth's energy balance, the water cycle, and the global atmospheric circulation. Aerosols, by direct interaction with radiation and by serving as cloud condensation nuclei, may affect clouds and rain formation. This effect can be examined in terms of energetic constraints, that is, any aerosol-driven diabatic heating/cooling of the atmosphere will have to be balanced by changes in precipitation, radiative fluxes, or divergence of dry static energy. Using an aqua-planet general circulation model (GCM), we show that tropical and extratropical precipitation have contrasting responses to aerosol perturbations. This behavior can be explained by contrasting ability of the atmosphere to diverge excess dry static energy in the two different regions. It is shown that atmospheric heating in the tropics leads to large-scale thermally driven circulation and a large increase in precipitation, while the excess energy from heating in the extratropics is constrained due to the effect of the Coriolis force, causing the precipitation to decrease., (©2019. The Authors.)

Transverse dispersion, or tracer spreading orthogonal to the mean flow direction, which is relevant e.g, for quantifying bio-degradation of contaminant plumes or mixing of reactive solutes, has been studied in the literature less than the longitudinal one. Inferring transverse dispersion coefficients from field experiments is a difficult and error-prone task, requiring a spatial resolution of solute plumes which is not easily achievable in applications. In absence of field data, it is a questionable common practice to set transverse dispersivities as a fraction of the longitudinal one, with the ratio 1/10 being the most prevalent. We collected estimates of field-scale transverse dispersivities from existing publications and explored possible scale relationships as guidance criteria for applications. Our investigation showed that a large number of estimates available in the literature are of low reliability and should be discarded from further analysis. The remaining reliable estimates are formation-specific, span three orders of magnitude and do not show any clear scale-dependence on the plume traveled distance. The ratios with the longitudinal dispersivity are also site specific and vary widely. The reliability of transverse dispersivities depends significantly on the type of field experiment and method of data analysis. In applications where transverse dispersion plays a significant role, inference of transverse dispersivities should be part of site characterization with the transverse dispersivity estimated as an independent parameter rather than related heuristically to longitudinal dispersivity., (© 2018, National Ground Water Association.)

Aerosol effects on convective clouds and associated precipitation constitute an important open-ended question in climate research. Previous studies have linked an increase in aerosol concentration to a delay in the onset of rain, invigorated clouds and stronger rain rates. Here, using observational data, we show that the aerosol effect on convective clouds shifts from invigoration to suppression with increasing aerosol optical depth. We explain this shift in trend (using a cloud model) as the result of a competition between two types of microphysical processes: cloud-core-based invigorating processes vs. peripheral suppressive processes. We show that the aerosol optical depth value that marks the shift between invigoration and suppression depends on the environmental thermodynamic conditions. These findings can aid in better parameterizing aerosol effects in climate models for the prediction of climate trends.

Little is known regarding the management of direct oral anticoagulants (DOACs) in patients with enzyme-inducing drugs (EID). The use of EID may lead to sub-therapeutic concentrations of DOACs and to treatment failure. Thus, many patients on EIDs cannot benefit from the advantages of DOACs. This was a retrospective study, evaluating the management of hospitalized patients with DOACs. Characteristics of hospitalized patients with a prescription for DOACs, with and without EIDs, were summarized and evaluated, and management strategies addressing the potential interaction were documented, including the use of DOAC concentration monitoring. During the period evaluated, 1596 hospitalized patients with prescriptions for DOACs were identified. Most patients received apixaban (n = 1227, 77%), followed by rivaroxaban (240, 15%), and dabigatran (129, 8%). Twenty-two patients (1.4%) had concomitant EIDs. Demographic and clinical characteristics of hospitalized patients with DOACs were similar in those receiving EID and those not. Management strategies included stopping DOAC or EID (41%), and DOAC dose increase (14%). During management of these interactions, DOAC concentrations were measured for 11 of 22 patients and were below the 5th percentile of expected concentration for six of these patients. The management of patients with DOAC concentration measurement differed significantly from those without (p = 0.005), as they were much less likely to have one of the medications stopped and more often had the DOACs' dose increased. Among hospitalized patients with DOACs, EIDs are not rare. DOAC concentrations are often low in the presence of EIDs. DOAC concentration monitoring may be useful in settings requiring both DOAC and EIDs.

Clouds control much of the Earth's energy and water budgets. Aerosols, suspended in the atmosphere, interact with clouds and affect their properties. Recent studies have suggested that the aerosol effect on warm convective cloud systems evolve in time and eventually approach a steady state for which the overall effects of aerosols can be considered negligible. Using numerical simulations, it was estimated that the time needed for such cloud fields to approach this state is >24 hr. These results suggest that the typical cloud field lifetime is an important parameter in determining the total aerosol effect. Here, analyzing satellite observations and reanalysis data (with the aid of numerical simulations), we show that the characteristic timescale of warm convective cloud fields is less than 12 hr. Such a timescale implies that these clouds should be regarded as transient-state phenomena and therefore can be highly susceptible to changes in aerosol properties., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Current guidance recommends avoiding concomitant use of direct-acting oral anticoagulants and enzyme-inducing antiepileptic drugs because of theoretical drug interactions potentially leading to subtherapeutic drug concentrations and treatment failure. We describe a case documenting a significant interaction between phenobarbital and rivaroxaban, and then apixaban. This case illustrates and supports the concerns regarding concomitant use of these medications. Additionally, in this case the interaction was managed with concentration-guided dosing of apixaban, suggesting this approach may represent a feasible strategy for managing patients requiring treatment with direct-acting oral anticoagulants and enzyme-inducing antiepileptic drugs., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Convective cloud formation and evolution strongly depend on environmental temperature and humidity profiles. The forming clouds change the profiles that created them by redistributing heat and moisture. Here we show that the evolution of the field's thermodynamic properties depends heavily on the concentration of aerosol, liquid or solid particles suspended in the atmosphere. Under polluted conditions, rain formation is suppressed and the non-precipitating clouds act to warm the lower part of the cloudy layer (where there is net condensation) and cool and moisten the upper part of the cloudy layer (where there is net evaporation), thereby destabilizing the layer. Under clean conditions, precipitation causes net warming of the cloudy layer and net cooling of the sub-cloud layer (driven by rain evaporation), which together act to stabilize the atmosphere with time. Previous studies have examined different aspects of the effects of clouds on their environment. Here, we offer a complete analysis of the cloudy atmosphere, spanning the aerosol effect from instability-consumption to enhancement, below, inside and above warm clouds, showing the temporal evolution of the effects. We propose a direct measure for the magnitude and sign of the aerosol effect on thermodynamic instability.

Among all cloud-aerosol interactions, the invigoration effect is the most elusive. Most of the studies that do suggest this effect link it to deep convective clouds with a warm base and cold top. Here, we provide evidence from observations and numerical modeling of a dramatic aerosol effect on warm clouds. We propose that convective-cloud invigoration by aerosols can be viewed as an extension of the concept of aerosol-limited clouds, where cloud development is limited by the availability of cloud-condensation nuclei. A transition from pristine to slightly polluted atmosphere yields estimated negative forcing of ~15 watts per square meter (cooling), suggesting that a substantial part of this anthropogenic forcing over the oceans occurred at the beginning of the industrial era, when the marine atmosphere experienced such transformation., (Copyright © 2014, American Association for the Advancement of Science.)

It is common to determine the effective conductivity of heterogeneous media by assuming stationarity of the random local properties. This assumption is not obeyed in a boundary layer of a body of finite size. The effect of different types of boundaries is examined for a two-phase medium with spherical inclusions of given conductivity distributed randomly in a matrix of a different conductivity. Exact solutions are derived for the apparent conductivity and the boundary layer thickness. The interaction between the spheres and the boundaries is fully incorporated in the solutions using a spherical harmonics expansion and the method of images. As applications, the corrections for the effective conductivity are given for two cases of finite bodies: the Maxwell sphere and a cylinder of flow parallel to the axis.

Determination of hydraulic head, H, as a function of spatial coordinates and time, in ground water flow is the basis for aquifer management and for prediction of contaminant transport. Several computer codes are available for this purpose. Spatial distribution of the transmissivity, T(x,y), is a required input to these codes. In most aquifers, T varies in an erratic manner, and it can be characterized statistically in terms of a few moments: the expected value, the variance, and the variogram. Knowledge of these moments, combined with a few measurements, permits one to estimate T at any point using geostatistical methods. In a review of transmissivity data from 19 unconsolidated aquifers, Hoeksema and Kitanidis (1985) identified two types of the logtransmissivity Y= ln(T) variations: correlated variations with variance sigma2Yc and correlation scale, I(Y), on the order of kilometers, and uncorrelated variations with variance sigma2Yn. Direct identification of the logtransmissivity variogram, Gamma(Y), from measurements is difficult because T data are generally scarce. However, many head measurements are commonly available. The aim of the paper is to introduce a methodology to identify the transmissivity variogram parameters (sigma2Yc, I(Y), and sigma2Yn) using head data in formations characterized by large logtransmissivity variance. The identification methodology uses a combination of precise numerical simulations (carried out using analytic element method) and a theoretical model. The main objective is to demonstrate the application of the methodology to a regional ground water flow in Eagle Valley basin in west-central Nevada for which abundant transmissivity and head measurements are available.

Determining the effective conductivity of heterogeneous media is a central problem in different fields of physics. The medium considered here contains cylinders (inclusions) of random conductivities that are distributed at random in an embedding matrix. For random systems, widely encountered in applications, we derive an approximative analytical solution that applies to significantly denser configurations than Maxwell first-order approximations. The analytic solution is tested against accurate numerical simulations. The widely used effective medium approach is shown to be exact for symmetric conductivity distributions and quite accurate for asymmetrical cases.