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Summary: It is unclear if cardiopulmonary resuscitation is an aerosol‐generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out‐of‐hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time‐series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546–59,209 [1523–242,648]) particles.l‐1, which were 24‐fold greater than in control participants under general anaesthesia (744 (309–2106 [23–9099]) particles.l‐1, p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time‐averaged aerosol concentrations during ventilation were approximately 270‐fold higher than before cardiac arrest (19,410 (2307–41,017 [104–136,025]) vs. 72 (41–136 [23–268]) particles.l‐1, p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high‐risk pathogens, until the airway is secured with an airway device and breathing system with a filter. [ABSTRACT FROM AUTHOR]

A study was conducted to determine if air leakage around supraglottic airway devices (SADs) used during general anesthesia generates high concentrations of respiratory aerosol, which could pose a risk of airborne disease transmission to healthcare providers. The study involved monitoring aerosol levels during positive pressure ventilation with and without intentional leaks in two UK hospitals. The results showed that SADs did not generate high concentrations of respiratory aerosol, even with a large airway leak. These findings suggest that SADs should not be classified as aerosol-generating procedures and do not require additional airborne precautions. [Extracted from the article]

Summary: Aerosol‐generating procedures are medical interventions considered high risk for transmission of airborne pathogens. Tracheal intubation of anaesthetised patients is not high risk for aerosol generation; however, patients often perform respiratory manoeuvres during awake tracheal intubation which may generate aerosol. To assess the risk, we undertook aerosol monitoring during a series of awake tracheal intubations and nasendoscopies in healthy participants. Sampling was undertaken within an ultraclean operating theatre. Procedures were performed and received by 12 anaesthetic trainees. The upper airway was topically anaesthetised with lidocaine and participants were not sedated. An optical particle sizer continuously sampled aerosol. Passage of the bronchoscope through the vocal cords generated similar peak median (IQR [range]) aerosol concentrations to coughing, 1020 (645–1245 [120–48,948]) vs. 1460 (390–2506 [40–12,280]) particles.l-1 respectively, p = 0.266. Coughs evoked when lidocaine was sprayed on the vocal cords generated 91,700 (41,907–166,774 [390–557,817]) particles.l-1 which was significantly greater than volitional coughs (p < 0.001). For 38 nasendoscopies in 12 participants, the aerosol concentrations were relatively low, 180 (120–525 [0–9552]) particles.l-1, however, five nasendoscopies generated peak aerosol concentrations greater than a volitional cough. Awake tracheal intubation and nasendoscopy can generate high concentrations of respiratory aerosol. Specific risks are associated with lidocaine spray of the larynx, instrumentation of the vocal cords, procedural coughing and deep breaths. Given the proximity of practitioners to patient‐generated aerosol, airborne infection control precautions are appropriate when undertaking awake upper airway endoscopy (including awake tracheal intubation, nasendoscopy and bronchoscopy) if respirable pathogens cannot be confidently excluded. [ABSTRACT FROM AUTHOR]

Summary: The evidence base surrounding the transmission risk of 'aerosol‐generating procedures' has evolved primarily through quantification of aerosol concentrations during clinical practice. Consequently, infection prevention and control guidelines are undergoing continual reassessment. This mixed‐methods study aimed to explore the perceptions of practicing anaesthetists regarding aerosol‐generating procedures. An online survey was distributed to the Membership Engagement Group of the Royal College of Anaesthetists during November 2021. The survey included five clinical scenarios to identify the personal approach of respondents to precautions, their hospital's policies and the associated impact on healthcare provision. A purposive sample was selected for interviews to explore the reasoning behind their perceptions and behaviours in greater depth. A total of 333 survey responses were analysed quantitatively. Transcripts from 18 interviews were coded and analysed thematically. The sample was broadly representative of the UK anaesthetic workforce. Most respondents and their hospitals were aware of, supported and adhered to UK guidance. However, there were examples of substantial divergence from these guidelines at both individual and hospital level. For example, 40 (12%) requested respiratory protective equipment and 63 (20%) worked in hospitals that required it to be worn whilst performing tracheal intubation in SARS‐CoV‐2 negative patients. Additionally, 173 (52%) wore respiratory protective equipment whilst inserting supraglottic airway devices. Regarding the use of respiratory protective equipment and fallow times in the operating theatre: 305 (92%) perceived reduced efficiency; 376 (83%) perceived a negative impact on teamworking; 201 (64%) were worried about environmental impact; and 255 (77%) reported significant problems with communication. However, 269 (63%) felt the negative impacts of respiratory protection equipment were appropriately balanced against the risks of SARS‐CoV‐2 transmission. Attitudes were polarised about the prospect of moving away from using respiratory protective equipment. Participants' perceived risk from COVID‐19 correlated with concern regarding stepdown (Spearman's test, R = 0.36, p < 0.001). Attitudes towards aerosol‐generating procedures and the need for respiratory protective equipment are evolving and this information can be used to inform strategies to facilitate successful adoption of revised guidelines. [ABSTRACT FROM AUTHOR]

Manual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol-generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS-CoV-1 outbreak in 2003. There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation and facemask ventilation with an intentionally generated leak in anaesthetised patients. Recordings were made in ultraclean operating theatres and compared against the aerosol generated by tidal breathing and cough manoeuvres. Respiratory aerosol from tidal breathing in 11 patients was reliably detected above the very low background particle concentrations with median [IQR (range)] particle counts of 191 (77-486 [4-1313]) and 2 (1-5 [0-13]) particles.l-1 , respectively, p = 0.002. The median (IQR [range]) aerosol concentration detected during facemask ventilation without a leak (3 (0-9 [0-43]) particles.l-1 ) and with an intentional leak (11 (7-26 [1-62]) particles.l-1 ) was 64-fold (p = 0.001) and 17-fold (p = 0.002) lower than that of tidal breathing, respectively. Median (IQR [range]) peak particle concentration during facemask ventilation both without a leak (60 (0-60 [0-120]) particles.l-1 ) and with a leak (120 (60-180 [60-480]) particles.l-1 ) were 20-fold (p = 0.002) and 10-fold (0.001) lower than a cough (1260 (800-3242 [100-3682]) particles.l-1 ), respectively. This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, we argue facemask ventilation should not be considered an aerosol-generating procedure. [ABSTRACT FROM AUTHOR]

Summary: Many guidelines consider supraglottic airway use to be an aerosol‐generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real‐time aerosol monitoring (0.3–10‐µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0–3.1 [0–4.0]) particles.l−1) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3–11.0 [0–44]) particles.l−1, p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0–4.2 [0–6.2]) particles.l−1, n = 11), and removal (2.1 (0–17.5 [0–26.2]) particles.l−1, n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66–169 [33–326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non‐respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio‐aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways. [ABSTRACT FROM AUTHOR]

Background: Geant4 is a Monte Carlo code extensively used in medical physics for a wide range of applications, such as dosimetry, micro‐ and nanodosimetry, imaging, radiation protection, and nuclear medicine. Geant4 is continuously evolving, so it is crucial to have a system that benchmarks this Monte Carlo code for medical physics against reference data and to perform regression testing. Aims: To respond to these needs, we developed G4‐Med, a benchmarking and regression testing system of Geant4 for medical physics. Materials and Methods: G4‐Med currently includes 18 tests. They range from the benchmarking of fundamental physics quantities to the testing of Monte Carlo simulation setups typical of medical physics applications. Both electromagnetic and hadronic physics processes and models within the prebuilt Geant4 physics lists are tested. The tests included in G4‐Med are executed on the CERN computing infrastructure via the use of the geant‐val web application, developed at CERN for Geant4 testing. The physical observables can be compared to reference data for benchmarking and to results of previous Geant4 versions for regression testing purposes. Results: This paper describes the tests included in G4‐Med and shows the results derived from the benchmarking of Geant4 10.5 against reference data. Discussion: Our results indicate that the Geant4 electromagnetic physics constructor G4EmStandardPhysics_option4 gives a good agreement with the reference data for all the tests. The QGSP_BIC_HP physics list provided an overall adequate description of the physics involved in hadron therapy, including proton and carbon ion therapy. New tests should be included in the next stage of the project to extend the benchmarking to other physical quantities and application scenarios of interest for medical physics. Conclusion: The results presented and discussed in this paper will aid users in tailoring physics lists to their particular application. [ABSTRACT FROM AUTHOR]

This Special Report presents a description of Geant4‐DNA user applications dedicated to the simulation of track structures (TS) in liquid water and associated physical quantities (e.g., range, stopping power, mean free path…). These example applications are included in the Geant4 Monte Carlo toolkit and are available in open access. Each application is described and comparisons to recent international recommendations are shown (e.g., ICRU, MIRD), when available. The influence of physics models available in Geant4‐DNA for the simulation of electron interactions in liquid water is discussed. Thanks to these applications, the authors show that the most recent sets of physics models available in Geant4‐DNA (the so‐called “option4” and “option 6” sets) enable more accurate simulation of stopping powers, dose point kernels, and W‐values in liquid water, than the default set of models (“option 2”) initially provided in Geant4‐DNA. They also serve as reference applications for Geant4‐DNA users interested in TS simulations. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10–15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near‐infrared laparoscopy can minimize the rate of AL leak compared with conventional white‐light laparoscopy. Two mechanistic sub‐studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies. Method: IntAct is a prospective, unblinded, parallel‐group, multicentre, European, randomized controlled trial comparing surgery with intra‐operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end‐point is rate of clinical AL at 90 days following surgery. Secondary end‐points include all AL (clinical and radiological), change in planned anastomosis, complications and re‐interventions, use of stoma, cost‐effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days. Discussion: IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning. [ABSTRACT FROM AUTHOR]

We welcome the comments from Drs Yip and Cheung [1] related to our article investigating the risk of aerosol generation with supraglottic airway devices [2]. Placing an HME filter on the supraglottic airway before removal will reduce the low level of aerosol emission from a spontaneously-breathing patient no longer connected to an anaesthetic circuit but would not, of course, affect aerosol generated from a coughing patient after supraglottic airway removal. We agree that patient factors and anaesthetic techniques may influence the risk of patient coughing; however, there is a need to separate procedure-related aerosol generation from coughing-related aerosol generation [5]. [Extracted from the article]

Background Mast cells (MCs) have a central role in the induction of allergic inflammation, such as seen in asthma, and contribute to the severity of certain autoimmune diseases, such as rheumatoid arthritis. The MC thus represents an important inflammatory cell, and one which has resisted therapeutic attempts to alter its role in disease. Objective Because bone marrow-derived stromal cells (BMSC, also known as mesenchymal stem cells or MSCs) have been reported to alter allergic inflammation in vivo, we chose to study the interaction between mouse BMSC and mouse bone marrow-derived MCs. Methods MC degranulation, cytokine production and chemotaxis were evaluated in vitro following co-culture with BMSCs either in cell contact or a transwell. In addition, MC degranulation was assessed in vivo following administration of BMSCs in a model of passive cutaneous anaphylaxis and a peritoneal degranulation assay. Mechanisms of MC suppression by BMSCs were determined through use of inhibitors or antibodies to COX1, COX2, nitric oxide, indoleamine 2, 3-dioxygenase, EP1-4 receptors, TGF-β and IL-10. Lastly, we utilized either BMSCs or MCs deficient in COX1, COX2 or EP1-4 receptors to confirm the mechanisms of inhibition of MC function by BMSCs. Results We discovered that BMSCs will effectively suppress specific MC functions in vitro as well as in vivo. When MCs are cocultured with BMSCs to allow cell-to-cell contact, BMSCs suppressed MC degranulation, pro-inflammatory cytokine production, chemokinesis and chemotaxis. Similarly, MC degranulation within mouse skin or the peritoneal cavity was suppressed following in vivo administration of BMSCs. Further, we found that these inhibitory effects were dependent on up-regulation of COX2 in BMSCs; and were facilitated through the activation of EP4 receptors on MCs. Conclusion and Clinical Relevance These observations support the concept that BMSCs have the ability to suppress MC activation and therefore could be the basis for a novel cell based therapeutic approach in the treatment of MC driven inflammatory diseases. [ABSTRACT FROM AUTHOR]

Mast cells have long been recognized for their role in the genesis of allergic inflammation; and more recently for their participation in innate and acquired immune responses. Mast cells reside within tissues including the skin and mucosal membranes, which interface with the external environment; as well as being found within vascularized tissues next to nerves, blood vessels and glandular structures. Mast cells have the capability of reacting both within minutes and over hours to specific stimuli, with local and systemic effects. Mast cells express the high affinity IgE receptor (FcℇRI) and upon aggregation of FcℇRI by allergen-specific IgE, mast cells release and generate biologically active preformed and newly synthesized mediators which are involved in many aspects of allergic inflammation. While mast cells have been well documented to be essential for acute allergic reactions, more recently the importance of mast cells in reacting through pattern recognition receptors in innate immune responses has become recognized. Moreover, as our molecular understanding of the mast cell has evolved, novel targets for modulation have been identified with promising therapeutic potential. [ABSTRACT FROM AUTHOR]

Abstract The exotic shrub Scotch Broom (Cytisus scoparius) has invaded large areas of eucalypt woodland at Barrington Tops, New South Wales, where it forms dense stands that have significant impacts on vegetation structure, flora and fauna. Data are presented from four 25 m2 plots, which have been studied since 1985. Two plots were located in uniform broom thickets of different ages, and two were located across the margins of broom stands, which have since expanded to cover the entire plots. All broom plants in the plots (other than young seedlings, which were counted) were mapped, tagged and monitored annually. New seedlings appeared annually, but there was no relationship between their numbers (varying between years) and subsequent recruitment of older plants. The probability of seedlings reaching first flowering was less than 2%, and of surviving to mature size (>10 cm2 basal area) was negligible. Seedlings mainly died through suppression (shade). Individuals less than 50 cm high were also browsed. Recruitment occurred only where light levels were high, either before closure of the broom canopy or after senescence had led to canopy opening. From approximately 12–30 years after initial invasion, broom stands underwent self-thinning of mature plants, accelerated by collapse of plants on to each other. Recruitment of new, maturing plants, after this period produced a stand that was less dense than that found after initial invasion. Broom is creating more disturbance-prone environments due to its impacts on other biota, likely alterations to the fire regime, and by harbouring feral pigs. Further disturbance favours broom, and elsewhere it has resulted in massive seedling regeneration. While fire or other disturbance can be used to stimulate germination, and thereby reduce a large part of the soil seed bank, denser broom infestations are likely to result unless follow-up treatments can be applied over long time periods. A wiser... [ABSTRACT FROM AUTHOR]

This article presents results of a study of 11 communities covering a range of landform and soil types, fire ages and with some examination of the effects of presence of emergent trees. Southwestern Australia has long excited the interest of botanists and biogeographers, being a region rich in angiosperm species, many of which are endemic. In the setting of the relatively subdued topography of southwestern Australia, Tutanning Nature Reserve encompasses a diverse cross-section of the landscape with elevations ranging from 320 to 430 m.

Objective: Considerable evidence exists to suggest that tumor hypoxia results in radioresistance. Historically, it has been difficult to assess tumor oxygen tension levels reliably. These levels can now be assessed in head and neck malignancies using the Eppendorf pO2 histograph, which uses a fine-needle electrode and a computerized micromanipulator. This technology was used to compare the pretreatment tumor oxygen tension level in lymph node metastases of patients with head and neck cancer to measurements taken during nonsurgical treatment after a partial response had been achieved.Study Design: Prospective study.Methods: Oxygen tension levels were measured in the cervical lymph nodes of 10 patients with biopsy-proven head and neck squamous cell carcinoma and cervical metastases who were being treated with nonsurgical management. These levels were obtained using the Eppendorf pO2 histograph system. Measurements were taken before the start of treatment and were repeated when the size of the cervical metastatic node had decreased by 50%. Normal subcutaneous tissue was measured during the same session. The mean and median pO2 levels, as well as the percentage of measurements with pO2 less than 5 mm Hg were determined.Results: A mean of 72.6 measurements per session was taken from each lymph node. The median tumor pO2 measurement fell from a mean (+/-SD) of 13.9+/-8.0 mm Hg to 7.3+/-9.9 mm Hg. Even more dramatic, however, was the substantial increase in the percentage of values less than 5 mm Hg, a rise from 29% to 52%.Conclusions: While there is variability both in the pretreatment oxygenation of head and neck cervical metastases and in the change in tumor oxygen tension during treatment, there appears to be a decrease in the overall oxygenation of the tumors. The dramatic increase in very low oxygen measurements may reflect selective survival of radioresistant or chemoresistant hypoxic tumor cells. Cells at the very low level would be expected to be radiobiologically hypoxic (resistant to radiation-induced cell kill). [ABSTRACT FROM AUTHOR]

The issues arising from implementing an early intervention service, developed in the rural United States in the late 1960s in a range of different cultural contexts over a period of a quarter of a century, are explained. Services from India, Bangladesh, Jamaica and the United Kingdom are compared. As well as considering cross-cultural aspects of Portage, variability within one country, the United Kingdom, is considered by comparing one service in an inner-city area and one in a rural area. [ABSTRACT FROM AUTHOR]

Gibbs energy representations for ices II, III, V, and VI are reported. These were constructed using new measurements of volumes at high pressure over a range of low temperatures combined with calculated vibrational energies grounded in statistical physics. The collection of representations are released within the open source SeaFreeze program, together with the Gibbs representation already known for ice Ih and water. This program allows accurate determination of thermodynamics properties (phase boundaries, density, specific heat, bulk modulus, thermal expansivity, chemical potentials) and seismic wave velocities over the entire range of conditions encountered in hydrospheres in our solar system (130–500 K to 2,300 MPa). These comprehensive representations allow exploration of the rich spectrum of thermodynamic behavior in the H2O system. Although these results are broadly applicable in science and engineering, their use is particularly relevant to habitability analysis, interior modeling, and future geophysical sounding of water‐rich planetary bodies of our solar system and beyond. Key Points: New X‐Ray diffraction measurements covering the entire range of ice II, III, V and VI using state of the art high pressure techniquesThe first Gibbs energy equations of states for ice II, III, V and VI (and first equations of state for ice II, III and V)New open‐source code SeaFreeze allows to explore water and ices thermodynamic at all conditions found in solar system planetary hydrospheres [ABSTRACT FROM AUTHOR]

The article discusses the study conducted by N. J. Evans and colleagues which examines the association of treponemes with bovine ulcerative mammary dermatitis (UMD). It indicates the disease prevalence of UMD or mammary necrotic dermatitis which appear as lesions on the udder in dairy cows between the forequarters and ventral abdominal wall. The researchers have identified the strong association of the treponeme phylogroups to severe bovine digital dermatitis (BDD).

A letter to the editor is presented in response to the article "Validation of long-term survival prediction for scheduled abdominal aortic aneurysm repair with an independent calculator using only pre-operative variables," by J.B. Carlisle and colleagues, published in a 2015 issue.

The pain from insertion of two small cannulae was compared in 26 volunteers. Each subject was blindfolded and had both a 22 G and a 20 G cannula inserted in random order. One subject was rejected as cannulation was unsuccessful. Of the remaining 25 subjects, 12 found the 22 G more painful and 13 the 20 G. This difference was not significant (chi squared p > 0.1). [ABSTRACT FROM AUTHOR]

This study describes the association between bovine digital dermatitis (BDD) treponemes and three ‘non-healing’ bovine hoof horn lesions, namely, ‘toe necrosis’ (TN), ‘non-healing white line disease’ (nhWLD) and ‘non-healing sole ulcer’ (nhSU), which are disorders that involve penetration through the horn capsule to involve the corium. In this study, these non-healing disorders (n=44) were identified as foot lesions that exhibited a topical granular appearance, exuded a typical pungent smell, were severely painful to the animal involved, and typically originated from farms where BDD is endemic. Given the similarities between these ‘non-healing’ lesions and BDD, the authors subjected samples of diseased tissue to PCR assays to detect the presence of DNA of BDD treponemes. All the three characterised BDD treponeme groups were identified as present together in 84.2, 81.3 and 55.6 per cent of samples of TN (n=19), nhWLD (n=16) and nhSU (n=9), respectively. In contrast, healthy control horn samples from similar sites (n=16) were PCR-negative for the BDD treponemes. Hence, these non-healing hoof lesions were strongly associated with BDD treponemes. Samples from typical heel horn erosions (n=9) were also subjected to BDD treponeme PCR assays and no association could be identified between the BDD treponemes and this horn manifestation. [ABSTRACT FROM PUBLISHER]