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Image captioning is a brand-new study area in the science of computer vision. The primary goal of picture captioning is to create a natural language description for the input image. In recent years, research on natural language processing and computer vision has become increasingly interested in the problem of automatically synthesising descriptive phrases for photos. Image captioning is a crucial task that demands both the ability to create precise and accurate description phrases as well as a semantic understanding of the images. Long Short Term Memory (LSTM) is used to precisely organise data using the available keywords to form meaningful sentences. The authors of this research propose a hybrid system based on multilayer Convolutional Neural Networks to create a lexicon for characterising the visuals. The convolutional neural network employs trained captions to deliver an accurate description after comparing the target image to a sizable dataset of training images. We demonstrate the effectiveness of our suggested methodology using the Flickr 8K datasets.

Amorphous solid dispersions (ASDs) are popular for enhancing the solubility and bioavailability of poorly water-soluble drugs. Various approaches have been employed to produce ASDs and novel techniques are emerging. This review provides an updated overview of manufacturing techniques for preparing ASDs. As physical stability is a critical quality attribute for ASD, the impact of formulation, equipment, and process variables, together with the downstream processing on physical stability of ASDs have been discussed. Selection strategies are proposed to identify suitable manufacturing methods, which may aid in the development of ASDs with satisfactory physical stability., Graphical abstract The review provides an updated overview of amorphous solid dispersion (ASD) manufacturing techniques. The impact of manufacturing variables of each method and downstream processing on the critical physical stability of ASDs are discussed.Image 1

World Health Organization estimates that worldwide annually there are about one billion infections, 3-5 million severe illnesses, and 300,000-500,000 deaths (10.1038/s41572-018-0002-y). Influenza is caused primarily by influenza A and influenza B viruses. Influenza A is the cause of pandemics.

Personal Digital Health Assistants (PDHA) are applications that can run on virtually any computer or mobile device including a smart phone/ personal digital assistant (PDA). A PDHA acquires, stores, and analyzes health related information of an individual. It usually communicates with remote servers of a large organization which can connect it to various resources. PDHAs are an integral part of telehealth. Their utility has increased manyfold since the start of the pandemic. The systems are increasingly more complex and are involved in all aspects of care. The PDHA are usually utilized by patients or their caregivers with assistance from professionals. Many automated systems can be utilized free of charge. Some are available as part of a prepaid health plan.

The COVID-19 pandemic that first became apparent in Wuhan, China, is now infecting millions all over the world. This is a review of COVID-19's extensive effects on virtually all the organs. It causes inflammation, endotheliitis, vasoconstriction, hypercoagulability, and edema. Lymphocytopenia, elevated D-dimer, elevated fibrin degradation products (FDPs), and disseminated intravascular coagulation (DIC) are observed. Deep vein thrombosis (DVT), venous thromboembolism, pulmonary embolism (PE), systemic and pulmonary arterial thrombosis and embolism, ischemic stroke, and myocardial infarction (MI) are reported. In the heart it can cause acute coronary syndrome, congestive heart failure, myocarditis, and arrhythmias. Kidney injury is usually secondary to systemic abnormalities. Stroke occurs even in young patients. Delirium and seizures are common. Anosmia and impaired sense of taste are reported. Psychological problems are common among patients as well as providers. Stool may contain virus. Lactate dehydrogenase may be elevated. Various skin manifestations including patchy erythematous rash are reported.

The supply of personal protective equipment (PPE) is inadequate throughout the United States and the world This is especially true of N95 respirators The cost of PPE is high There are numerous cases of providers working with inadequate PPE and being disciplined on complaining In the United States, thousands of providers have contracted COVID-19, in part due to inadequate PPE Extended use and reuse of N95 respirators has been permitted by the Centers for Disease Control and Prevention (CDC) The N95 respirators can be sterilized utilizing vaporized hydrogen peroxide, ultraviolet germicidal irradiation, or dry heat at 70 degrees C-80 degrees C The risk to providers due to inadequate PPE increases with their age and presence of comorbidities African-Americans and Latinos are at a greater risk CDC recommends that in the absence of appropriate PPE, "exclude healthcare personnel at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients " Providing care without appropriate PPE should not be a condition of employment for any provider, especially for the ones in high-risk category

The paper reports findings related to perceived worldviews and risk associated with environmental problems by the residents of urban neighborhoods. Unhygienic environmental conditions are common in residential areas of medium-size cities like Allahabad, India. The respondents were 102 men and 102 women of four residential neighborhoods which varied in population, layout planning (congested vs. wide-streets) and pollutions (noise, garbage, drainage). In addition to background information, they completed the worldviews scale, rated perceived seriousness of local environmental problems and risk impact on self, family, rich, poor, plants and animals. They also rated attribution of responsibility for environmental problems and pro-environmental behavior. Probably, due to cultural homogeneity no significant differences were found for worldviews across four neighborhoods. Men and women did not differ in their worldviews except for the fatalistic worldviews with men perceiving themselves less fatalistic than women. With a few exceptions, the residents of four localities did not differ significantly on perception of environmental problems and attribution of responsibility. Correlations of worldviews with perception of environmental problems, risk impact, attribution of responsibility and inactions are discussed. Nature of correlations of environmental conditions with physical and psychological health is also discussed.

There is a lack of evidence-based approach regarding the best practice for airway management in patients with a traumatized airway. General recommendations for the management of the traumatized airway are summarized in table 5. Airway trauma may not be readily apparent, and its evaluation requires a high level of suspicion for airway disruption and compression. For patients with facial trauma, control of the airway may be significantly impacted by edema, bleeding, inability to clear secretions, loss of bony support, and difficulty with face mask ventilation. With the airway compression from neck swelling or hematoma, intubation attempts can further compromise the airway due to expanding hematoma. For patients with airway disruption, the goal is to pass the tube across the injured area without disrupting it or to insert the airway distal to the injury using a surgical approach. If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach. Alternatively, if orotracheal intubation is chosen, spontaneous ventilation may be maintained or RSI may be performed. RSI is a common approach. Thus, some of the patients intubated may subsequently require tracheostomy. A stable patient with limited injuries may not require intubation but should be watched carefully for at least several hours. Because of a paucity of evidence-based data, the choice between these approaches and the techniques utilized is a clinical decision depending on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment. Inability to obtain a definitive airway is always an absolute indication for an emergency cricothyroidotomy or surgical tracheostomy.

After cardiac surgery, major morbidities known to be primary contributors to perioperative mortality are cardiac failure, respiratory failure, renal failure, and the need for mediastinal exploration. The first aim of this study was to ascertain long-term survival in cardiac surgery patients with and without the occurrence of major morbidities to investigate if long-term survival was comparable. The second aim of this study was to evaluate the prevalences and risk factors related to the four major morbidities in this patient population.Retrospective observational outcome study.Cardiothoracic intensive care unit at a university hospital.We included 2,683 of 3,253 consecutive cardiac surgery patients cared for in a uniform fashion.Perioperative mortality was significantly increased by the occurrence of major morbidity. In-hospital mortality was 0.7% in the absence of major morbidity compared with 72% when all major morbidities occurred. Three-year mortality for the entire study population was 15%, whereas the 3-yr long-term survival was significantly less for patients with morbidities compared with those without. Various independent perioperative risk factors were found for perioperative major morbidity and mortality.Successful acute treatment and measures to identify and reduce the risk of major morbidities are necessary to improve outcome. In addition, long-term follow-up and management of morbidities are necessary to possibly improve long-term survival.

Early diagnosis and treatment of infection after cardiac surgery with cardiopulmonary bypass (CPB) improves outcome. Conventional laboratory tests, such as C-reactive protein and white blood cell count can not distinguish patients with early infection from those with systemic inflammatory response syndrome but without infection. After CPB, there is a systemic release of proinflammatory and antiinflammatory cytokines, including tumor necrosis factor-alpha, interleukin (IL)-6, and IL-10. We investigated the predictive ability of these variables for infection after cardiac surgery. Forty-six patients with impaired left ventricular ejection fraction (

Normothermic, nonpulsatile cardiopulmonary bypass (CPB) impairs systemic and splanchnic oxygen transport and increases gastrointestinal permeability. It is an important therapeutic goal to avoid splanchnic dysoxia during CPB. Small-dose prostacyclin therapy improves splanchnic oxygen transport and microcirculation in septic patients. In this study, we sought to determine if during cardiac surgery, the prostacyclin analog epoprostenol improves the balance of systemic and splanchnic oxygen transport. Eighteen patients undergoing cardiac valve replacement were randomized to receive either epoprostenol (3 ng x kg(-1) x min(-1)) or placebo during, and for 1 hour after, surgery. Systemic and splanchnic oxygen delivery, consumption, and extraction and arterial, mixed venous, and hepato-venous lactate concentrations were measured before, during, and after CPB. Gastrointestinal permeability was measured 1 day before and 1 day after surgery using the triple sugar permeability test. During CPB, the epoprostenol group had decreased systemic oxygen consumption and splanchnic oxygen extraction (P = 0.024). These effects were not present 1 hour after the end of epoprostenol infusion. The study was not adequately powered to determine whether epoprostenol altered the trend towards increased lactate metabolism and increased postoperative gastrointestinal permeability, nor could we demonstrate any differences between groups in clinically relevant end-points. In conclusion, these findings suggest that during normothermic CPB, small-dose epoprostenol therapy may reduce systemic oxygen consumption and splanchnic oxygen extraction.

UNLABELLED Postoperative myocardial ischemia (POMI) is prevalent among patients after major noncardiac surgery. Surgery, as well as POMI, may modulate the immune system, potentially worsening patient outcome. We sought to investigate the modulation of soluble interleukin (IL)-6 and IL-10 by POMI and its association with increased postoperative infection rates. Two-hundred-three patients undergoing elective major abdominal, vascular, and orthopedic surgery participated in this prospective observational study. Perioperative management was standardized. Hemodynamic variables were kept within 20% of baseline. POMI was assessed by Holter electrocardiography starting at least 8 h before the induction of anesthesia and continued until 96 h after surgery. Twelve-lead electrocardiograms, cardiac enzymes, and immune variables were obtained at the time of admission to the hospital, before surgery, before the induction of anesthesia, after surgery, at the time of admission to the intensive care unit, and 6, 12, 18, 24, 36, 48, 72, 96, 120, 144, and 168 h after surgery. Infections were diagnosed according to the Centers for Disease Control criteria. The incidence of POMI was 27%, and the majority of cases (76%) occurred within the first 24 h after surgery. IL-6 and IL-10 levels significantly increased during surgery but did not differ between the POMI and Non-POMI groups. However, in the subset of patients who developed severe infections or sepsis (n = 47) a median of 3 days (range, 1-8 days) after surgery, the intraoperative increases of IL-6 and IL-10 in the POMI group were, respectively, 3 and 10 times higher compared with the increase in the Non-POMI group. By using a multifactorial analysis in these patients with severe infections, the type of surgical trauma was associated with an increased IL-6 response, whereas the increase in IL-10 was attributed to POMI. These findings suggest that immediate cytokine responses due to POMI and type of surgery might be relevant for the later onset of severe infections and sepsis. IMPLICATIONS Postoperative myocardial ischemia (POMI) occurred in 27% of patients after major noncardiac surgery. This was associated with an immediate augmented cytokine response in the first 12 h after surgery in patients who developed severe infections or sepsis 3 days later. POMI was associated with an increased interleukin (IL)-10 response, whereas IL-6 was associated with the type of surgery.

Objectives: No data exist regarding “the best” hematocrit value after coronary artery bypass graft surgery. Transfusion practice varies, because neither an optimal hematocrit value nor a uniform transfusion trigger criterion has been determined. Methods: To investigate the optimal hematocrit value, we studied 2202 patients undergoing coronary bypass. The hematocrit value on entry into the intensive care unit (IHCT) was categorized into three groups: high (≥34%), medium (25% to 33%), and low (24%). Characteristics and adverse events (outcomes) were compared, and the effect of IHCT on the risk of myocardial infarction was determined by logistic regression. Results: High IHCT (≥34%) was associated with an increased rate of myocardial infarction (8.3% vs 5.5% vs 3.6%; P 0.03, high, medium vs low) and with more severe left ventricular dysfunction (11.7% vs 7.4% and 5.7%; P = 0.006, high, medium vs low). Mortality rate increased with higher IHCT when all the high-risk subgroups were combined (8.6% vs 4.5% vs 3.2%; P < 0.001, high, medium vs low). By multivariate analysis, IHCT remained the most significant predictor of adverse outcomes (relative risk high vs low 2.22, 95% confidence interval: 1.04 to 4.76). No characteristic, event, medication, or transfusion therapy confounded the relationship between IHCT and outcome. Conclusion: High IHCT is associated with a higher rate of myocardial infarction and is an independent predictor of infarction. On the basis of the risk of myocardial infarction, there is no rationale for transfusion to an arbitrary level after coronary artery bypass grafting. (J Thorac Cardiovasc Surg 1998;116:460-7)

Study Objectives: To evaluate the automated determination of onset and offset times and amplitudes of all the PQRST waves from simultaneously recorded surface electrocardiogram (SECG) and unipolar esophageal ECG (EsECG). The occurrence of ST segment deviation is also examined. Design: Prospective, observational study. Setting: University hospital. Patients: 30 patients undergoing coronary artery bypass graft (CABG) surgery. Interventions: SECG and two-lead unipolar EsECG were recorded after induction of anesthesia and before cardiopulmonary bypass (CPB). Measurements and Main Results: The amplitudes of the P and T waves and the ST segment deviation were measured. EsECG had more noise than SECG. Slight movement of the esophageal electrodes occasionally caused substantial changes in the wave amplitudes and ST segment deviation in the unipolar EsECG. The maximum P wave amplitude in EsECG was, on average, 97% greater than the maximum P wave amplitude in SECG. ST segment deviation in EsECG was observed in the absence of ST segment deviation in SECG and vice versa. Conclusions: The recognition and measurement of all the PQRST waves can be improved and automated by simultaneous use of EsECG and SECG. The P wave amplitude is greater in EsECG than in SECG, which may facilitate the identification of supraventricular versus ventricular arrhythmias. ST segment deviation in the unipolar EsECG may not be suitable for the routine detection of ischemia.

Background Electrocardiographic (ECG) changes during coronary artery bypass graft surgery have not been described in detail in a large multicenter population. The authors describe these ECG changes and evaluate them, along with demographic and clinical characteristics and intraoperative hemodynamic alterations, as predictors of myocardial infarction (MI) as defined by two sets of criteria. Methods Data from 566 patients at 20 clinical sites, collected as part of a clinical trial to evaluate the efficacy of acadesine for reducing MI, were analyzed at core laboratories. Perioperative ECG changes were identified using continuous three-lead Holter ECG. Systolic blood pressure, diastolic blood pressure, and heart rate were recorded each minute during operation. The occurrence of MI by Q wave or myocardial fraction of creatine kinase (CK-MB) or autopsy criteria, and by (Q wave and CK-MB) or autopsy criteria was determined. Results During perioperative Holter monitoring, episodes of ST segment deviation, major cardiac conduction changes > or = 30 min, or use of ventricular pacing > or = 30 min occurred in 58% patients, primarily in the first 8 h after release of aortic occlusion. Of the 25% patients who met the Q wave or CK-MB or autopsy criteria for MI, 19% had increased CK-MB as well as ECG changes. (Q wave and CK-MB) or autopsy criteria for MI were met by 4% of patients. The CK-MB concentration generally peaked by 16 h after release of aortic occlusion. In patients with (n = 187) and without a perioperative episode of ST segment deviation, the incidence of MI was 36% and 19%, respectively (P < 0.01), by Q wave or CK-MB or autopsy criteria, and 6% and 3%, respectively (P = 0.055), by (Q wave and CK-MB) or autopsy criteria. Multiple logistic regression analysis showed that intraoperative ST segment deviation, intraventricular conduction defect, left bundle branch block, duration of hypotension (systolic blood pressure < 90 mmHg) after cardiopulmonary bypass, and duration of cardiopulmonary bypass are independent predictors of Q wave or CK-MB or autopsy MI. The independent predictors of (Q wave and CK-MB) or autopsy MI are intraoperative ST segment deviation and duration of aortic occlusion. Conclusions Major ECG changes occurred in 58% of patients during coronary artery bypass graft surgery, primarily within 8 h after release of aortic occlusion. Multicenter data collection revealed a substantial variation in the incidence of MI and an overall incidence of up to 25%, with most MI occurring within 16 h after release of aortic occlusion. Intraoperative monitoring of ECG and hemodynamics has incremental value for predicting MI.

Background The use of target-controlled infusions of anesthetics for coronary artery bypass graft surgery has not been studied in detail. The effects of target-controlled infusions of propofol or sufentanil, supplemented by infusions of sufentanil or midazolam, respectively, were evaluated and compared. Methods At 14 clinical sites, 329 patients were given a target-controlled infusion of propofol (n = 165) to produce effect-site concentration (Ce) of > or = 3-micrograms/ml or a target-controlled infusion of sufentanil (n = 164). Sufentanil or midazolam, respectively, also were infused. Systolic hypertension, hypotension, tachycardia, and bradycardia were assessed by measuring heart rate and blood pressure every minute during operation. Myocardial ischemia was assessed perioperatively by monitoring ST segment deviation via continuous three-lead Holter electrocardiography, and it was evaluated during operation by monitoring left ventricular wall motion abnormality via transesophageal echocardiography. Results The measured cardiovascular parameters were satisfactory and usually similar for the patients receiving propofol-sufentanil or sufentanil-midazolam. The primary endpoint of the percentage of patients with intraoperative ST segment deviation (23 +/- 6% vs. 24 +/- 6%, P = 0.86) did not differ significantly between the two groups. The incidence of left ventricular wall motion abnormality shown on transesophageal echocardiography before (19 +/- 4% vs. 26 +/- 4%, P = 0.25) and after (23 +/- 4% vs. 31 +/- 5%, P = 0.32) cardiopulmonary bypass also did not differ significantly for the two groups. Changes in intraoperative target concentration were more frequent with propofol-sufentanil anesthetic than with sufentanil-midazolam (11.7 +/- 7.1 vs. 7.3 +/- 3.6, P < 0.001). The incidence of intraoperative hypotension (77% vs. 55%, P < 0.001), the use of inotropic/vasopressor medications (93% vs. 84%, P = 0.01), and the administration of crystalloids (2.8 +/- 1.4 L vs. 2.4 +/- 1.2 L, P < 0.001) were significantly greater in the propofol-sufentanil group. Conversely, the incidence of intraoperative hypertension (43% vs. 54%, P = 0.05) and the use of antihypertensive/vasodilator medications (70% vs. 90%, P < 0.001) were significantly less in the propofol-sufentanil group. Conclusions Target-controlled infusions of propofol or sufentanil, supplemented by infusions of sufentanil or midazolam, respectively, were suitable to provide anesthesia for coronary artery bypass graft surgery. Continuous monitoring revealed a high prevalence of hemodynamic abnormalities. Despite greater hypotension in the propofol-sufentanil group and greater hypertension in the sufentanil-midazolam group, episodes of myocardial ischemia were similar for both groups and were not temporally related to episodes of hemodynamic abnormalities.

Background Propofol sedation offers advantages for titration and rapid emergence in the critically ill patient, but concern for adverse hemodynamic effects potentially limits its use in these patients. The current study compares the cardiovascular effects of sedation with propofol versus midazolam during the first 12 h after coronary revascularization. Methods Three hundred fifty-one patients undergoing coronary revascularization were anesthetized using a standardized sufentanil/midazolam regimen, and assigned randomly to 12 h of sedation with either propofol or midazolam while tracheally intubated. The incidence and characteristics of hemodynamic episodes, defined as heart rate less than 60 or greater than 100 beats/min or systolic blood pressure greater than 140 or less than 90 mmHg, were determined using data electronically recorded at 1-min intervals. The presence of myocardial ischemia was determined using continuous three-channel Holter electrocardiography (ECG) and of myocardial infarctions (MI) using 12-lead ECG (Q wave MI, Minnesota Code) or creatine kinase isoenzymes (CK-MB) analysis (non-Q wave MI, peak CK-MB > 70 ng/ml, or CK-MB > 70 IU/I). Results Ninety-three percent of patients in both treatment groups had at least one hemodynamic episode during the period of postoperative sedation. Propofol sedation resulted in a 17% lower incidence of tachycardia (58% vs. 70%, propofol vs. midazolam; P = 0.04), a 28% lower incidence of hypertension (39% vs. 54%; P = 0.02), and a greater incidence of hypotension (68% vs. 51%; P = 0.01). Despite these hemodynamic effects, the incidence of myocardial ischemia did not differ between treatment groups (12% propofol vs. 13% midazolam; P = 0.66), nor did its severity, as measured by ischemic minutes per hour monitored (8.7 +/- 5.8 vs. 6.2 +/- 4.6 min/h, propofol vs. midazolam; P = 0.19) or ischemic area under the curve (6.8 +/- 4.0 vs. 5.3 +/- 4.2; P = 0.37). The incidence of cardiac death (one per group), Q wave MI (propofol, n = 7; midazolam, n = 3; P = 0.27), or non Q wave MI (propofol, n = 16; midazolam, n = 18; P = 0.81) did not differ between treatment groups. Conclusions Hemodynamic episodes occur frequently in the first 12 h after coronary revascularization. Compared with a standard sedation regimen (midazolam), propofol sedation appears to modulate postoperative hemodynamic responses by reducing the incidence and severity of tachycardia and hypertension and increasing the incidence of hypotension. Both sedation regimens appear similarly safe with respect to myocardial ischemia. These findings indicate that propofol infusion provides effective sedation without deleterious hemodynamic effects in patients recovering from cardiac surgery.

This article, the first in the new DCCN department for acute-care nurse practitioners, clinical nurse specialists, and advanced practice nurses, focuses on the pharmacodynamics of propofol. The advanced practice nurse working in the ICU is likely to institute propofol protocols, teach staff about the drug, and collaborate with the bedside nurse on the patient's outcome to this treatment.

Study Objectives: To identify the optimal subset of two electrocardiographic (ECG) leads for monitoring of ischemic ST depression and elevation during coronary artery bypass grafting (CABG) surgery. Design: Prospective observational clinical study. Setting: University hospital cardiac surgery operating room. Patients: 120 patients undergoing primary surgery or reoperation for CABG. Interventions: All six ECG limb leads and a precordial matrix of four leads were recorded intraoperatively approximately every 3 minutes. The limb leads were placed on the torso in modified Mason-Likar positions. The precordial leads were placed at V 4 , V 5 , and one interspace below them. Measurements and Main Results: New ischemic 1 mm ST depression and elevation episodes were determined. New ST deviation episodes attributed to nonischemic causes such as cooling at the onset of cardiopulmonary bypass (CPB), defibrillation at the end of CPB, new cardiac conduction changes after CPB, and postoperative pericarditis were excluded. Fixed ST deviation that did not change by 1 mm in the perioperative period was also excluded. Leads V 5 and III constituted the best two-lead set. These leads recorded 15 of the 16 ischemic ST elevation episodes and all 8 ischemic ST depression episodes. One ST elevation episode was not recorded intraoperatively but was recorded in lead V 1 in the immediate postoperative ECG. Leads V 5 and II recorded 13 of the 16 ischemic ST elevation episodes and all 8 ischemic ST depression episodes. Lead V 5 alone missed 8 episodes of ischemic ST elevation and one episode of ischemic ST depression. Conclusions: For monitoring of ischemia during CABG, leads V 5 and III are preferable to other two-lead sets, including the commonly used V 5 and II. No single lead is adequate. Lead V 5 alone missed approximately one half the episodes of ST elevation that were recorded by lead III or another inferior lead.

Background Dexmedetomidine, a highly selective alpha 2-adrenergic agonist, increases perioperative hemodynamic stability in healthy patients but decreases blood pressure and heart rate. The goal of this study was to evaluate, in a preliminary manner, the hemodynamic effects of perioperatively administered dexmedetomidine in surgical patients at high risk for coronary artery disease. Methods Twenty-four vascular surgery patients received a continuous infusion of placebo or one of three doses of dexmedetomidine, targeting plasma concentrations of 0.15 ng/ml (low dose), 0.30 ng/ml (medium dose), or 0.45 ng/ml (high dose) from 1 h before induction of anesthesia until 48 h postoperatively. All patients received standardized anesthesia and hemodynamic management. Blood pressure, heart rate, and Holter ECG were monitored; additional monitoring included continuous 12-lead ECG preoperatively, anesthetic concentrations and myocardial wall motion (echocardiography) intraoperatively, and cardiac enzymes postoperatively. Results Preoperatively, there was a decrease in heart rate (low dose 11%, medium dose 5%, high dose 20%) and systolic blood pressure (low dose 3%, medium dose 12%, high dose 20%) in patients receiving dexmedetomidine. Intraoperatively, dexmedetomidine groups required more vasoactive medications to maintain hemodynamics within predetermined limits. Postoperatively, demedetomidine groups had less tachycardia (minutes/monitored hours) than the placebo group (placebo 23 min/h; low dose 9 min/h, P = 0.006; medium dose 0.5 min/h, P = 0.004; high dose 2.3 min/h, P = 0.004). Bradycardia was rare in all groups. There were no myocardial infarctions or discernible trends in the laboratory results. Conclusions Infusion of dexmedetomidine up to a targeted plasma concentration of 0.45 ng/ml appears to benefit perioperative hemodynamic management of surgical patients undergoing vascular surgery but required greater intraoperative pharmacologic intervention to support blood pressure and heart rate.

Critiquing the positivist-empiricist models ofresearch on emotions within mainstream psychology, the present paper highlights the constructionist approach. The paper emphasises the need to look at emotions in terms of culturally specific models and theories of beliefs. In this light, a classical Indian theory of meta-emotions is examined and its implications for a cultural psychology of emotion are discussed.

Many modalities are available for monitoring for ischemia. Electrocardiography (ECG) is the most suitable modality for monitoring for perioperative ischemia. The detection and monitoring of myocardial stunning is more difficult. T wave inversion or peaking may be caused by ischemia. However, numerous nonischemic causes may lead to perioperative T wave changes. Inverted T waves may also indicate myocardial stunning. ST deviation is the most commonly used feature of ischemia. ST depression may be indicative of subendocardial ischemia while ST elevation may be associated with transmural ischemia or injury. Perioperatively, ST deviation may be caused by many nonischemic causes. Fixed ST deviation may be caused by left ventricular hypertrophy (LVH), cardiac conduction changes, old MI, coronary artery disease, and other causes such as drugs, including digitalis. New ST deviation may be caused by changes in body position. During cardiopulmonary bypass, ST deviation may be caused by hypothermia and defibrillation. ST deviation may be caused by new cardiac conduction changes and pericarditis. Ischemia may cause changes in other features of the ECG including the R wave, Q wave, U wave, QRS axis, and the angle between QRS axis and T wave axis. However, the specificity of these features for ischemia is even lower than that of the ST segment.

Measures of reported crowding and comfortable interpersonal distance were obtained in India for 480 husband-wife pairs equally drawn from four levels of density and three income groups. It was expected that reported crowding would vary according to level of density, but that gender and income would not be influential and that density, income, and gender would affect preferred comfortable distance. These predictions were supported.

Myocardial stunning commonly occurs after cardiopulmonary bypass (CPB). Myocardial stunning can be cardioprotective under some conditions, but in other situations may actually contribute to myocardial infarction (MI). Vascular endothelial stunning may be one of the mechanisms by which myocardial stunning can cause MI. It has been found that 15 minutes of reversible ischemia is enough to cause elevations in vascular resistance and impairment of vasodilator responsiveness. However, no correlation between contractile dysfunction and microvascular stunning has been observed. Transduction defects (increased oxygen extraction and consumption despite normal regional oxygen blood flow and delivery) may be another mechanism by which stunning predisposes to MI, indicating uncoupling of substrate utilization from energy production. In addition, abnormalities in wall motion, oxygen free radical toxicity, hypotension, use of inotropic agents (leading to increased oxygen consumption, high heart rates, and arrhythmias) increase the risk of cellular necrosis. Following CPB, flow limitations due to diffuse atherosclerosis in some areas may result in poor contractility, and newly grafted areas have a high probability of becoming ischemic and stunned. These areas are likely to contribute to MI.

P ERIOPERATIVE myocardial infarction (PMI) is one of the major problems during coronary artery bypass grafting surgery (CABG). Its incidence is reported to be between 2% and 82%.lJ This wide variation can be attributed to different tests and criteria for the detection of PMI, the patient population,3-s and the quality of care.” Some previous reviews of the literature in this area exist. l”-ih This review concentrates on significant new information. The literature on PM1 during noncardiac surgery has been extensively reviewed.r4 Literature on PM1 during cardiac surgery other than CABG is limited, and is not reviewed.

Previous studies with perzinfotel (1), a potent, selective, competitive NMDA receptor antagonist, showed it to be efficacious in inflammatory and neuropathic pain models. To increase the low oral bioavailability of 1 (3−5%), prodrug derivatives (3a−h) were synthesized and evaluated. The oxymethylene-spaced diphenyl analogue 3a demonstrated good stability at acidic and neutral pH, as well as in simulated gastric fluid. In rat plasma, 3a was rapidly converted to 1 via 2a. Pharmacokinetic studies indicated that the amount of systemic exposure of 1 produced by a 10 mg/kg oral dose of 3a was 2.5-fold greater than that produced by a 30 mg/kg oral dose of 1. Consistent with these results, 3a was significantly more potent and had a longer duration of activity than 1 following oral administration in a rodent model of inflammatory pain. Taken together, these results demonstrate that an oxymethylene-spaced prodrug approach increased the bioavailability of 1.

SAR on HTS hits 1 and 2 led to the potent, Notch-1-sparing GSI 9, which lowered brain Abeta in Tg2576 mice at 100 mg/kg po. Converting the metabolically labile methyl groups in 9 to trifluoromethyl groups afforded the more stable analogue 10, which had improved in vivo potency. Further side chain modification afforded the potent Notch-1-sparing GSI begacestat (5), which was selected for development for the treatment of Alzheimer's disease.

Objective: Analysis of safety and efficacy of recombinant activated factor VII (rFVIIa) used as the last resort for refractory bleeding after cardiac surgery. Design: Retrospective cohort analysis and matched pairs analysis with historic controls were performed. In the rFVIIa group, which also received conventional hemostatic therapy, data were collected for a median of 14 hrs from admission to the intensive care unit (ICU) to the administration of rFVIIa and for the following 24 hrs. In the control group, which received only conventional hemostatic therapy, data were collected for 14 and then for 24 hrs after admission to the ICU. Setting: University hospital. Patients: Twenty-four patients matched with historic controls. Interventions: None. Measurements and Main Results: No thromboembolic complications were observed in the rFVIIa group. Blood loss and transfusion requirements were significantly reduced in the period after the administration of rFVIIa. However, in the 24-hr period after rFVIIa administration, blood loss (p = .140) and transfusion of packed red blood cells (p = .442) and fresh frozen plasma (p = .063) were not different between the rFVIIa and control groups. Platelet concentrates (p = .004) were transfused less in the control group. Mortality and 6-month survival rates were not different between the groups. Conclusions: When used as a last resort, rFVIIa was safe but not incrementally efficacious over conventional hemostatic therapy.

We synthesized and evaluated a novel series of 2-carboxylic acid indole-based inhibitors of plasminogen activator inhibitor-1 (PAI-1). Systematic modification of the N-1 position and the 5-position of the indole scaffold resulted in the identification of several compounds that showed good potency against PAI-1 in the spectrophotometric assay. This potency did not always translate to the antibody assay. Solubility and serum protein binding studies on selected analogs revealed that protein binding might be a factor in the poor correlation between the two assays.

We describe experiments demonstrating the feasibility of human iris recognition at up to 10 m distance between subject and camera. The iris images of 250 subjects were captured with a telescope and infrared camera, while varying distance, capture angle, environmental lighting, and eyewear. Automatic iris localization and registration algorithms, in conjunction with a local correlation based matcher, were used to obtain a similarity score between gallery and probe images. Both the area under the receiver operating characteristic (ROC) curve and the Fisher Linear Discriminant were used to measure the distance between authentic and imposter distributions. Among variables studied, database wide experiments reveal no performance degradation with distance, and minor performance degradation with, in order of increasing effect, time (one month), capture angle, and eyewear.

We present a probabilistic description of the harmonic plus noise model (HNM) for speech signals. This probabilistic formulation permits maximum likelihood (ML) parameter estimation and speech synthesis becomes a straightforward sampling from a distribution. It also permits the development of a Kalman filter that tracks model parameters such as pitch, harmonic amplitudes, and autoregressive coefficients. We focus here on pitch tracking for which the estimator is highly non-linear. As a result it is necessary to develop an approximate Kalman filter that goes beyond extended Kalman filtering.

Worldwide, approximately 750,000 cardiac surgeries are being performed annually. No fundamental differences have been demonstrated between anesthesia for cardiac versus noncardiac surgery.* If used appropriately, virtually all available anesthetics are suitable for cardiac surgery. To achieve adequate general anesthesia, a minimum of two different classes of anesthetic drugs is usually required.* In patients with cardiac disease, the maintenance of hemodynamic stability is considered important for reducing the incidence of adverse cardiovascular outcomes. Because opioids are associated with relative hemodynamic stability, they are the most commonly used primary anesthetics during cardiac surgery. Supplementation with potent inhalational anesthetics, benzodiazepines, or other anesthetics is required. Opioid anesthesia is associated with a small incidence of hypotension, especially on induction of anesthesia. Intraoperative hypertension also may occur. Potent inhalational anesthetics and intravenous (IV) sedative-hypnotics such as benzodiazepines are also used as the prirnary anesthetics for cardiac surgery. Other sedative-hypnotics such as propofol are being used during cardiac surgery. Compared with most anesthetics, propofol allows easier titratability and more rapid emergence.s-5 Su pplementation of propofol with an opioid leads to a synergistic interaction.* Propofol can be used for preoperative sedation as an anesthetic and for postoperative sedation. Propofol has certain disadvantages. It may contribute to hypotension and bradycardia.3-6 This may be especially true for cardiac surgery patients who are often given antihypertensive, antiischemic, and vasodilator medications such as beta-blockers and calcium-channel blockers. Anesthetics including propofol and opioids cause hypotension because of loss of sympathetic tone. In addition, propofol also has a dose-dependent hypotensive effect. This leads to lesser hemoclynamic stability and greater need for titration when propofol is used. Propofol infusion may have 70 be titrated frequently and skillfully to avoid hypotension on one hand and light anesthesia on the other. The bradycardiac effects *Assistant Professor of Anesthesia

Intraoperatively, myocardial ischemia is more common after cardiopulmonary bypass (CPB) than before CPB. Ischemia associated with coronary vasospasm and thrombosis may be much more common toward the end of surgery and early in the postoperative period than previously appreciated. This may be because the coagulation system is altered during CPB, and the coronary endothelium is damaged significantly as a result of cardioplegic arrest followed by reperfusion. In this milieu, vasospasm and thrombosis may be caused by the administration of protamine. Some of the ischemia observed in this period actually is not reversible and is associated with myocardial injury and infarction. It may be ameliorated by the administration of calcium channel blockers, aspirin, and anticoagulants. Electrocardiography may be the most suitable modality for the detection of ischemia after CPB and postoperatively. During this period, many episodes of ST deviation are of a nonischemic etiology, and the ECG needs careful interpretation. Transesophageal echocardiography is suitable for use intraoperatively and early on in the intensive care unit.