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As a key component of a circular economy, remanufacturing is gaining popularity across various sectors. This paper focuses on the wind energy sector, a major player in renewable technologies, which is gradually recognizing its increasing resource-intensive material usage. We present a case study outlining a method for selecting parts from an industrial supply chain partner’s inventory. This strategy is further employed to streamline the manufacturing processes for the chosen part. We utilized the Weighted Sum method, a multi-criteria decision-making strategy, in both instances. We discuss how expertise of process specialists and multi-criteria decision-making techniques could be synthesised for adopting a remanufacturing approach. Data from the commercial partners was collected and any identifying information was stripped. From this, we discovered that the Yaw gear pinion shaft is the top candidate for remanufacturing due to its high commercial value. After comparing various additive manufacturing technologies, Arc Directed Energy Deposition stands out as the best fit for remanufacturing this particular pinion shaft. Although our initial aim was to consider additive manufacturing technologies as solutions for remanufacturing, we show how even conventional manufacturing processes, such as friction welding, could emerge as strong contenders.

Abstract Background Neuroimaging researchers have developed rigorous community data and metadata standards that encourage meta-analysis as a method for establishing robust and meaningful convergence of knowledge of human brain structure and function. Capitalizing on these standards, the BrainMap project offers databases, software applications, and other associated tools for supporting and promoting quantitative coordinate-based meta-analysis of the structural and functional neuroimaging literature. Findings In this report, we describe recent technical updates to the project and provide an educational description for performing meta-analyses in the BrainMap environment. Conclusions The BrainMap project will continue to evolve in response to the meta-analytic needs of biomedical researchers in the structural and functional neuroimaging communities. Future work on the BrainMap project regarding software and hardware advances are also discussed.

Purpose: Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation., Methods: A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival., Results: Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294)., Conclusion: While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Cocaine has a short biological half-life, but inactive urine metabolites may be detectable for a week following use. It is unclear if patients who test positive for cocaine but have a normal electrocardiogram and vital signs have a greater percentage of hemodynamic events intraoperatively., Methods: A total of 328 patients with a history of cocaine use who were scheduled for elective noncardiac surgery under general anesthesia were enrolled. Patients were categorized into cocaine-positive versus cocaine-negative groups based on the results of their urine cocaine toxicology test. The primary aim of this study was to evaluate whether asymptomatic cocaine-positive patients had similar percentages of intraoperative hemodynamic events, defined as (1) a mean arterial blood pressure (MAP) of <65 or >105 mm Hg and (2) a heart rate (HR) of <50 or >100 beats per minute (bpm) compared to cocaine-negative patients. The study was powered to assess if the 2 groups had an equivalent mean percent of intraoperative hemodynamic events within specific limits using an equivalence test of means consisting of 2 one-sided tests., Results: The cocaine-positive group had a blood pressure (BP) that was outside the set limits 19.4% (standard deviation [SD] 17.7%) of the time versus 23.1% (SD 17.7%) in the cocaine-negative group (95% confidence interval [CI], 0.5-7.0). The cocaine-positive group had a HR outside the set limits 9.6% (SD 16.2%) of the time versus 8.2% (SD 14.9%) in the cocaine-negative group (95% CI, 4.3-1.5). Adjusted for age, sex, body mass index (BMI), smoking status, and the presence of comorbid hypertension, renal disease, and psychiatric illness, the cocaine-positive and cocaine-negative patients were similar within a 7.5% margin of equivalence for MAP data (β coefficient = 2%, P = .003, CI, 2-6) and within a 5% margin of equivalence for HR data (β coefficient = 0.2%, P < .001, CI, 4-3)., Conclusions: Asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia have similar percentages of intraoperative hemodynamic events compared to cocaine-negative patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Study Objective: This objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus neostigmine results in a decreased number of hypoxic episodes in the early postoperative period in patients undergoing thoracic surgery with single lung ventilation., Design: Single-center, randomized, double-blind, two-arm clinical trial., Setting: Operating room and postanesthesia care unit., Patients: 92 subjects aged ≥18, American Society of Anesthesiologists physical status II-IV, and undergoing a thoracic operation necessitating single lung ventilation., Interventions: Subjects received either 2 mg/kg sugammadex or 50 μg/kg neostigmine with 8 μg/kg glycopyrrolate for reversal of moderate neuromuscular blockade., Measurements: For the first 90 min postoperatively, all episodes of hypoxia were recorded. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch® SX) and the train of four (TOF) was recorded at 2, 5, 10, and 15 min after administration of the neuromuscular reversal agent., Main Results: Subjects who received neostigmine had a median of 1 episode (interquartile range IQR: 0-2.2) of hypoxia versus subjects who received sugammadex who had a median of 0 episodes (IQR: 0-1) (p = 0.009). The mean time to recovery of TOF ≥ 0.9 was significantly faster with sugammadex at 10 min (95% confidence interval CI: 5-15) compared with neostigmine at 40 min (95% CI: 15-53) (p < 0.001)., Conclusions: In thoracic surgical patients necessitating single lung ventilation, sugammadex provides faster reversal of moderate neuromuscular blockade and results in a decreased number of postoperative hypoxic episodes compared with neostigmine., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Disclosures Supported in part by a research grant from the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp., (Copyright © 2020. Published by Elsevier Inc.)

Background: Obese patients have a propensity to desaturate during induction of general anesthesia secondary to their reduced functional residual capacity and increased oxygen consumption. Apneic oxygenation can provide supplemental oxygen to the alveoli, even in the absence of ventilation, during attempts to secure the airway. In this study, we hypothesized that oxygen administration through a nasopharyngeal airway and standard nasal cannula during a simulated prolonged laryngoscopy would significantly prolong the safe apneic duration in obese patients., Methods: One hundred thirty-five obese patients undergoing non-emergent surgery requiring general anesthesia were randomized to either the control group or to receive apneic oxygenation with air versus oxygen. All patients underwent a standard intravenous induction. For patients randomized to receive apneic oxygenation, a nasopharyngeal airway and standard nasal cannula were inserted. A simulated prolonged laryngoscopy was performed to determine the duration of the safe apneic period, defined as the beginning of laryngoscopy until the peripheral oxygen saturation (SpO 2 ) reached 95%., Results: The oxygen group had a median safe apneic duration that was 103 s longer than the control group. The lowest mean SpO 2 value during the induction period was 3.8% higher in the oxygen group compared to the control group. Following intubation, patients in the oxygen group had a mean end tidal carbon dioxide (ETCO 2 ) level that was 3.0 mmHg higher than patients in the control group., Conclusions: In obese patients, oxygen insufflation at 15 L/min through a nasopharyngeal airway and standard nasal cannula can significantly increase the safe apneic duration during induction of anesthesia.

Study Objective: To evaluate the intraoperative hemodynamics and medication requirements of cocaine-positive patients compared to matched cocaine-negative controls., Design: Retrospective cohort study., Setting: Public county hospital., Patients: 821 patients undergoing general anesthesia., Measurements: Incidence of hemodynamic events, defined by a mean arterial pressure of <65 mmHg or >105 mmHg or a heart rate of <50 beats per minute or >100 beats per minute., Main Results: Cocaine-positive patients did not experience a higher incidence of hemodynamic events when compared with matched cocaine-negative patients. Cocaine-positive patients were not more likely to be administered vasopressors intraoperatively but did receive more anti-hypertensive agents. The minimum alveolar concentration of anesthetics used was similar between the two groups. Anesthesia duration, length of stay, and in-hospital mortality did not significantly differ between the two cohorts., Conclusions: Cocaine-positive patients did not demonstrate more intraoperative hemodynamic events or adverse short-term outcomes as compared to matched cocaine-negative controls., (Published by Elsevier Inc.)

Purpose: To determine the influence of morbid obesity on the incidence of difficult mask ventilation and difficult intubation., Methods: Over a 6-year period, all tracheal intubations in the operating room of a large tertiary teaching hospital were analyzed. A modified version of the intubation difficulty scale (mIDS) was used to define easy versus difficult intubation, where a score of two or greater was defined as difficult intubation. Difficult mask ventilation was defined as the use of one or more adjuncts to achieve successful mask ventilation., Results: Of 45,447 analyzed cases, 1893 (4.2%) were classified as difficult intubations. Morbidly obese patients were not more likely to have difficult intubation [Odds Ratio (OR) = 1.131, 95% confidence interval (CI): 0.958, 1.334, p = 0.146]. Factors that were associated with difficult intubation included patient age > 46 years, male sex, Mallampati 3-4, thyromental distance < 6 cm, and the presence of intact dentition. Of 37,016 cases in which mask ventilation was attempted, 1069 (2.9%) were difficult. Morbidly obese patients were more likely to have difficult mask ventilation (OR = 3.785, 95% CI: 3.188, 4.493, p < 0.0001). Other factors associated with difficult mask ventilation included patient age > 46 years, male sex, Mallampati 3-4, and a history of obstructive sleep apnea. Having intact dentition decreased the likelihood of difficult mask ventilation., Conclusion: Morbidly obese patients do not have a higher incidence of difficult intubation compared to non-morbidly obese patients. However, they have a significantly higher incidence of difficult mask ventilation. Other factors that are predictive of both difficult mask ventilation and difficult intubation include age > 46 years, male sex, and Mallampati 3-4.

Study Objective: To evaluate the efficacy of a bundled intervention to improve the quality of the operating room to intensive care unit (ICU) clinical handover., Design: Prospective, interventional study., Setting: An urban, public teaching hospital with more than 1500 direct postoperative ICU admissions each year., Interventions: A bundled intervention to include the addition of a direct anesthesia provider to ICU nurse telephone report, a mnemonic to standardize the handover process, and improved template for postoperative documentation by the anesthesia team., Measurements: Preintervention (baseline) and postintervention survey data were solicited from key stakeholders, which included anesthesia providers and ICU nursing staff., Main Results: Anesthesia provider and ICU nursing staff satisfaction levels rose significantly following implementation of the bundled intervention. In addition, perceived effectiveness of the handover process and note increased significantly. The satisfaction level of the ICU nurses with respect to the phone report received before patient arrival in the ICU nearly doubled., Conclusions: The implementation of a bundled handover intervention was associated with increased stakeholder satisfaction as well as a perception of increased efficacy and quality of the overall handover process and postoperative anesthesia documentation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Contagious equine metritis (CEM) is a highly contagious venereal disease of horses caused by Taylorella equigenitalis. During testing for semen export purposes, a stallion in Kentucky was found to be T. equigenitalis culture positive in December of 2008. This finding triggered an extensive regulatory investigation to search for additional positive horses, determine the extent of the outbreak, identify the potential source of the outbreak, and ultimately return the United States to CEM-free status. The investigation included over 1000 horses located in 48 states. Diagnostic testing found a total of 22 stallions, 1 gelding and 5 mares culture positive for T. equigenitalis. Epidemiologic analysis indicated that all of the positive horses were linked to a single common source, most likely a Fjord stallion imported into the United States in 2000. The T. equigenitalis strain subsequently spread to other stallions via undetermined indirect mechanisms at shared breeding facilities, and to mares via artificial insemination and live breeding. This CEM outbreak and investigation represent the largest ever in the United States based on the number of exposed horses tested and their geographic distribution., (Published by Elsevier B.V.)

Introduction: West Nile virus (WNV) and La Crosse virus (LAC) are the primary mosquito-borne arboviruses associated with human disease in Wisconsin. We examined WNV and LAC human illness surveillance data collected during 2002 through 2006., Methods: ELISA-based tests developed by the Centers for Disease Control and Prevention (CDC) were used to detect acute WNV and LAC infection in patient sera or cerebral spinal fluid. Public health personnel conducted patient follow-up using standard arbovirus reporting forms. CDC/Council of State and Territorial Epidemiologists definitions were used to determine cases., Results: From 2002 through 2006, 114 confirmed human cases of WNV illness were reported in Wisconsin residents; 82% of illness onsets occurred during August or September. Median age of WNV case patients was 51 years, 49% reported neuroinvasive disease, 56% were hospitalized, and 7 cases were fatal. Confirmed LAC illnesses declined from a high of 27 cases during 2003 to a low of 3 cases during 2005 and 2006. Most LAC illnesses occurred in residents of Western Wisconsin; median age of LAC cases was 9 years. Mean annual incidences of reported confirmed WNV illnesses calculated for high, medium, and low population density groupings were very similar (range: 0.40-0.46 cases/100,000 population)., Conclusions: Humans are at risk for mosquito-borne diseases in Wisconsin. Protection and prevention measures are important statewide, especially during July through September when the risk is greatest.

The New York 1999 strain of West Nile virus (WNV) is nearly 100% fatal in the American crow (Corvus brachyrhynchos). We evaluated four WNV vaccine formulations in American crows, including intramuscular (i.m.) DNA vaccine, i.m. DNA vaccine with adjuvant, orally administered microencapsulated DNA vaccine, and i.m. killed vaccine. Neutralizing antibodies developed in approximately 80% of crows that received the DNA vaccine i.m. (with or without adjuvant), and in 44% that received the killed vaccine. However, no crows that received the oral microencapsulated DNA vaccine or the placebo developed WNV antibodies. All crows were challenged 10 wk after initial vaccination. No unvaccinated crows survived challenge, and survival rates were 44% (i.m. DNA vaccine), 60% (i.m. DNA vaccine with adjuvant), 0% (oral microencapsulated DNA vaccine), and 11% (killed vaccine). Peak viremia titers in the birds that survived were significantly lower as compared to titers in birds that died. Parenteral administration of a WNV DNA vaccine was associated with reduced mortality but did not provide sterile immunity.

To better understand the potential environmental health risk presented by West Nile virus (WNV)-contaminated feces, we quantified the amount of WNV present in the feces of experimentally infected American crows (Corvus brachyrhynchos) and fish crows (Corvus ossifragus). Peak fecal titers ranged from 10(3.5) to 10(8.8) plaque-forming units (PFU)/g for 10 American crows and from 10(2.3) to 10(6.4) PFU/g for 10 fish crows. The presence of infectious WNV in bird feces indicates a potential for direct transmission of WNV. Thus, handlers of sick or dead birds should take appropriate precautions to avoid exposure to fecal material.

Many of the techniques used in newborn intensive care damage the skin and may lead to scarring. We have investigated a cohort of consecutive survivors of newborn intensive care for the presence of scars. Ninety of the original 100 children between the ages of 8 and 9 years were examined in detail by a single observer--the number, site and severity of the scars were noted and compared with the findings when the children were 2 years old. There was an overall reduction in the number of scars with time, regardless of gestational age. Scars from needlemarks were reduced by 41% and those from intravenous accidents by 70%, compared with those seen at 2 years. Scars from chest drains were still visible, in two cases requiring corrective surgery. Nine children and their families found that the scars caused them embarrassment. The only scars which did not usually improve with time and which were often judged to be worse cosmetically were those caused by surgery.

Many techniques used in neonatal intensive care are invasive and the risk of producing skin damage is high. To investigate this, 100 consecutive survivors of neonatal intensive care (gestation 26-42 weeks, median 32) were examined in detail by a single observer at 16-29 months of age, and the scar severity, site and likely cause noted. Scarring was present in all infants although it was usually trivial. The total number of scars was inversely related to gestational age and directly related to the duration of intensive care. Eleven children had cosmetically or functionally significant lesions caused by chest drain insertion, extravasation of intravenous fluid or skin stripping by adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to be aware that many routine procedures may lead to long term scarring. In particular, more careful wound closure after chest drain removal is needed.