UNM Sandoval Regional Medical Center

OBJECTIVE: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. DESIGN/METHODS: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. RESULTS: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). CONCLUSIONS: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

OBJECTIVE: To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). PARTICIPANTS: A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES: Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. RESULTS: Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. CONCLUSIONS: Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.

At the beginning of the thirteenth century A.D., the Mesa Verde region was densely inhabited by Ancestral Pueblo peoples. By the end of that century, Ancestral Pueblo peoples no longer permanently inhabited the region. We present detailed reconstructions of precipitation based on tree rings from five geographic subregions of Ancestral Pueblo occupation (Mesa Verde, Tsegi/Kayenta, Chama, Cibola, and Santa Fe) and a consideration of distributions of archaeological ceramic styles and types from four corresponding Ancestral Pueblo subculture areas (Mesa Verde, Kayenta, Cibola, and the Northern Rio Grande) in order to explore Ancestral Pueblo strategies of adaptation to farming under conditions of often inadequate precipitation. Our analyses examine and corroborate the notion that Ancestral Pueblo peoples of the Mesa Verde region maintained long-term relationships of social interaction primarily with groups that were proximate and also experienced different and complementary patterns of precipitation. These social relationships, along with development of a marked gradient in precipitation, may have facilitated eventual migration pathways from the Mesa Verde region to the northern Rio Grande.

Large differences between the concentrations of serum total carbon dioxide (TCO2) and blood gas bicarbonate (HCO3 (-)) were observed in two consecutive simultaneously drawn sets of samples of serum and arterial blood gases in a patient who presented with severe carbon dioxide retention and profound acidemia. These differences could not be explained by the effect of the high partial pressure of carbon dioxide on TCO2, by variations in the dissociation constant of the carbonic acid/bicarbonate system or by faults caused by the algorithms of the blood gas apparatus that calculate HCO3 (-). A recalculation using the Henderson-Hasselbach equation revealed arterial blood gas HCO3 (-) values close to the corresponding serum TCO2 values and clarified the diagnosis of the acid-base disorder, which had been placed in doubt by the large differences between the reported TCO2 and HCO3 (-) values. Human error in the calculation of HCO3 (-) was identified as the source of these differences. Recalculation of blood gas HCO3 (-) should be the first step in identifying the source of large differences between serum TCO2 and blood gas HCO3 (-).

Abstract Public agencies at all levels of government and other organizations that manage archaeological resources often face the problem of many undertakings that collectively impact large numbers of individually significant archaeological resources. Such situations arise when an agency is managing a large area, such as a national forest, land management district, park unit, wildlife refuge, or military installation. These situations also may arise in regard to large-scale development projects, such as energy developments, highways, reservoirs, transmission lines, and other major infrastructure projects that cover substantial areas. Over time, the accumulation of impacts from small-scale projects to individual archaeological resources may degrade landscape or regional-scale cultural phenomena. Typically, these impacts are mitigated at the site level without regard to how the impacts to individual resources affect the broader population of resources. Actions to mitigate impacts rarely are designed to do more than avoid resources or ensure some level of data recovery at single sites. Such mitigation activities are incapable of addressing research question at a landscape or regional scale.

We review advancements in silicon photonic (SiPh) devices and integrated circuits (SiPICs) to enable high density, low power, multi-Tb/s optical solutions for next-generation Ethernet networking and compute connectivity.

ABSTRACT Over the past several years, we have seen many attacks on publicly funded and mandated archaeology in the United States. These attacks occur at the state level, where governors and state legislatures try to defund or outright eliminate state archaeological programs and institutions. We have also seen several attacks at the federal level. Some members of Congress showcase archaeology as a waste of public tax dollars, and others propose legislation to move federally funded or permitted projects forward without consideration of impacts on archaeological resources. These attacks continue to occur, and we expect them to increase in the future. In the past, a vigilant network of historic preservation and archaeological organizations was able to thwart such attacks. The public, however, largely remains an untapped ally. As a discipline, we have not built a strong public support network. We have not demonstrated the value of archaeology to the public, beyond a scattering of educational and informational programs. In this article, we—a group of archaeologists whose work has focused on public engagement—provide a number of specific recommendations on how to build a strong public constituency for the preservation of our nation's archaeological heritage.

This guideline replaces/updates the 2008 recommendations regarding the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. In CIRCI, inadequate glucocorticoid-mediated anti-inflammatory activity is observed in relation to the severity of the critical illness due to somehow disrupted HPA axis, cortisol and receptor to signalling transduction; but the exact mechanism is only poorly understood. The recommendation was achieved by a multispecialty team of 16 international specialists (including endocrinologists and a paediatrician) reviewing the literature and grading its relevance according to established standards (GRADE method). It recommends two possible lab tests for diagnosing CIRCI, e.g. either a random plasma cortisol of < 10 μg/dL (276 nmol/L) or a 60 min-cortisol response to high-dose (250 μg) of ACTH of < 9 μg/dL (248 nmol/L). Experts recommend against the use of corticosteroids in sepsis without shock and suggest its use only in patients with septic shock that does not respond to fluid and vasopressor therapy. In addition, the use of corticosteroids is recommended for hospitalized adult patients with moderate to severe acute respiratory distress syndrome, but not in patients with major trauma/non-septic inflammatory response syndrome. Of note, this guideline was published before the results of the two most-comprehensive studies so far reported on mortality outcomes of hydrocortisone (HC) treatment in septic shock patients (14, 15). However, as discussed below (8.12), even these studies were not able to give a clear answer about the possible benefit or harm of HC. Therefore, the current guidelines may still remain valid.

This article provides an overview of the components of the informed consent process for surgery including the components specific to hysterectomy. Shared decision making and informed consent for hysterectomy rely on a mutual understanding by the patient and surgeon of the goals, risks, benefits, and alternatives as well as the choice of hysterectomy technique. The importance of a patient-centered approach is emphasized with an explanation of several communication methods and resources for decision aids that will help to ensure that patients have a good understanding of the items listed above and are able to provide informed consent.

Increasing water scarcity has made nontraditional water reuse a critical strategy for enhancing water supply in the United States. This study investigated public perceptions of nontraditional water reuse, particularly oil and gas–oil and gas produced water reuse, in New Mexico, using valid responses from 657 statewide survey participants. Results showed substantial public support (up to 68.5%) for reusing various nontraditional water sources, including produced water. Awareness gaps were identified, particularly among younger individuals, those with lower educational attainment, and residents in less drought severe counties. Statistical analysis revealed significantly greater support for nontraditional water reuse (>74%) in severely drought-stricken counties with an average drought severity and coverage index (DSCI) >300 compared to those in milder drought conditions (>62.1%, average DSCI < 200), highlighting the influence of direct experience with water scarcity on public attitudes. Increased public awareness correlated with stronger support for reuse initiatives, highlighting the need for targeted education and outreach efforts. Concerns about the safety of produced water reuse emphasized the importance of transparent communication on treatment processes, monitoring, and regulatory oversight to ensure safe reuse. These findings offer valuable guidance for policymakers to develop effective water reuse strategies and bolster public support for sustainable water management practices.

Prosthetic joint infection (PJI) and metallosis are known complications of total hip arthroplasty (THA) and are causes for revision surgeries. Articulating metal surfaces in total hip arthroplasty with corrosion at modular junctions can lead to the release of metal ions that can cause an immune-mediated biological reaction. There are few cases in the literature of both coinciding together. We describe a case of chronic Cutibacertium acnes PJI and metallosis co-occurring in a 64-year-old female after THA with a dual mobility construct. After undergoing uncomplicated left THA through a modified Hardinge approach, the patient dislocated anteriorly after four weeks and required revision of her acetabular component to a less anteverted position. Nine months later, she presented with hip pain and was found to have medial wall fragmentation and cystic changes around the greater trochanter on radiographs, elevated serum cobalt and chromium levels, and a benign noninfected hip aspiration. During her revision procedure, intraoperative histopathology showed over 20 neutrophils per high power field in multiple samples and fluid aspirates demonstrating Gram-positive rods. She was also found to have pseudotumor formation with the erosion of the anterior and posterior capsules with black debris on the femoral stem trunnion and the backside of the modular dual mobility liner. An antibiotic spacer was placed and her cultures grew into C. acnes. She completed six weeks of intravenous ceftriaxone and, during her "drug holiday," she dislocated her spacer and was found to have a lateral femoral diaphyseal stress fracture at the distal end of her spacer. She underwent stage II of her revision, and while the plan was to continue her antibiotics, she had an adverse reaction and was transitioned to oral antibiotics for six months. Due to delayed healing, she underwent additional irrigation and debridement with head and liner exchange. Her wound then healed, and at her one-year final follow-up, she was able to ambulate without pain, and her serum inflammatory and metal ion levels were within normal limits. Concurrent PJI and metallosis from articulating metal interfaces can occur, and a high index of suspicion is necessary to properly manage both conditions.

CONTEXT: Abnormal knee frontal plane projection angles (FPPA) during movement have been associated with patellofemoral pain. As such, clinicians are interested in valid and reliable instruments suitable for broad-based clinical use that allow them to objectively measure such variables. Therefore, the purpose of the current study was to examine the criterion validity and reliability of knee FPPA measures obtained by clinicians using a free tablet application called Technique. DESIGN: Validity/reliability study. METHODS: To examine validity, the same raters measured 10, two-dimensional criterion reference angles at the first testing session. To examine reliability, the knee FPPA of 16 subjects was measured by 6 raters (3 physical therapists and 3 student physical therapists) on 2 separate occasions while performing a single-limb step-down task. Validity was investigated by calculating the 95% limits of agreement, mean absolute differences, and Bland-Altman plots. Reliability was examined by calculating intraclass correlation coefficients and the SE of measure. RESULTS: For validity, the mean absolute difference between rater and criterion reference angle measures ranged from 0.20° to 0.90°. Ninety-five percent of expected errors between rater and criterion reference angle measures were 2.04° or less. For reliability, the intraclass correlation coefficient values for interrater and intrarater reliability were excellent ranging from .994 to .998 with SE of measure ranging from 0.44° to 0.84°. CONCLUSIONS: These findings indicate that knee FPPA measures obtained during a single-limb step-down task using the Technique tablet application are valid and reliable, and suitable for clinical use.

We demonstrate an isolator-free 128 Gb/s PAM4 data transmission using a silicon microring modulator and a heterogeneous III-V/Si quantum dot laser in the presence of optical feedback of up to -13dB.

e13060 Background: Lung cancer is the leading cause of overall cancer-related deaths in both men and women in the United States. In 2009, cancer surpassed cardiovascular disease as the leading cause of death in North Carolina. Between 2010-2014, the age-adjusted incidence rate for lung and bronchus cancers in North Carolina was 70 per 100000 persons per year. Between 2010-2014, the age-adjusted mortality rate for lung and bronchus cancers in North Carolina was 50.6 per 100000 persons per year. It is documented that about half of lung and bronchus cancer cases were diagnosed at the distant stage and about 60 percent of deaths occurred in adults ages 65-84. In 2011, 32 percent of cancer death was from lung/bronchus cancer in Robeson County. A chart review in a rural primary care clinic identified patients not being appropriately screened for targeted intervention. Methods: Our retrospective chart review at Lumberton Medical Clinic, a rural outpatient Internal Medicine Clinic, reviewed 91 records from adults aged 55 to 80 years old during the timeframe of September 2017 through August 2018. Patients with a known history of lung cancer were excluded from this study. Patient records were assessed for compliance with USPTF lung cancer screening guidelines. USPTF recommends adults aged 55 to 80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years to have an annual low-dose computed tomography of the chest to screen for lung cancer. Results: The review showed that during the timeframe studied, 42% of patients who qualified received appropriate screening, while 58% of those qualified were found to have no documentation of screening. Following data analysis, intervention to increase screening rates has been initiated. This involves provider education, posters, and individualized letters mailed to patients found deficient during the study. The success of this direct patient outreach effort will be measured over six months. Conclusions: It is the responsibility of providers to emphasize the importance of proper lung cancer screening. This retrospective review found that a large percentage (58%) of adults were not being adequately screened in our rural clinic. Direct outreach is underway to increase compliance rates in this high-risk population served by our rural clinic.

We present a rare case of emphysematous pyelonephritis complicated by secondary emphysematous osteomyelitis, likely resulting from the hematogenous spread of Escherichia coli in a patient with multiple comorbid conditions. Early identification of computed tomography findings and prompt initiation of therapy resulted in a favorable outcome. This case underscores the importance of rapid diagnosis and intervention in patients with complex comorbid conditions, because early treatment can significantly improve outcomes.

Neurosensory disorders (ND) following the placement of dental implants (DI) in the posterior mandibular region are a potential complication due to their proximity to the inferior alveolar nerve (IAN). Paresthesia and dysesthesia are the most commonly reported symptoms, affecting quality of life and requiring an effective therapeutic approach. This case report describes the management of ND using adjunctive laser therapy (LT) combined with B-complex vitamins (B-Vit). A 57-year-old female patient presented with persistent hypoesthesia and spontaneous episodes of electric shock-like sensations after the placement of three dental implants in the posterior right mandibular region. Clinical examination confirmed a lack of soft tissue sensation and pain rated 8/10 on the Visual Analog Scale (VAS) at the depth of the sulcus. Tomographic imaging revealed compression of the IAN by all three DI. A diagnosis of paresthesia with dysesthesia secondary to nerve compression was established. With informed consent, the dental implants were explanted, followed by guided bone regeneration. As adjunctive therapy, low-level laser therapy (LLLT) at wavelengths of 650 nm and 976 nm was applied, along with B-Vit administered every 8 hours for 15 days. By the third session, the patient reported recovered sensation and a pain score of 0/10 on the VAS, leading to the conclusion of treatment. Subsequent tomographic imaging showed the bone neoformation. This case suggests that the combination of LLLT with B-Vit may serve as an adjunctive therapeutic alternative for the management of dysesthesia and paresthesia following the explantation of implants compressing the IAN.

Fusion energy addresses the 21st-century challenge of developing sustainable, ubiquitous, and safer energy sources. Achieving practical fusion energy remains complex, with multiple pathways and no one dominant reactor design. Private and public funding is accelerating research. This effort focuses on advancing pulsed power technology, a critical subsystem common to many different fusion energy reactors, that is essential to making fusion commercially viable.

:maqolada rus folklorshunosi Vladimir Propp tomonidan ishlab chiqilgan “Ertak morfologiyasi” nazariyasi asosida o‘zbek xalq sehrli ertaklarining tuzilishi va funksional tarkibi tahlil qilinadi. Tadqiqot davomida Proppning 31 ta funksiyasi hamda qahramonlarning tipik rollari o‘zbek sehrli ertaklari misolida ko‘rib chiqilib, ularning syujet qurilishidagi o‘rni aniqlanadi. Shuningdek, “Zumrad va Qimmat”, “Bahodir va ajdarho”, “Boy va kambag‘al” kabi mashhur o‘zbek sehrli ertaklarida uchraydigan syujet unsurlari, sehrli yordamchilar, sinovlar, konflikt va yechim bosqichlari Propp modeli bilan taqqoslab o‘rganiladi.

e13054 Background: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Between 2012-2016, the age adjusted mortality rate was 18-25 per 100,000 persons in Robeson County, North Carolina. During this timeframe, it is estimated that if all people aged 50 and older in NC were routinely screened, 40 out of 100 deaths from late stage CRC can be prevented. A chart review in a rural primary care clinic identified patients not being appropriately screened for targeted intervention. Methods: Our retrospective chart review at Lumberton Medical Clinic, a rural outpatient Internal Medicine Clinic, reviewed 1622 records from adults 50-75 years old during the timeframe September 2017 through August 2018. Patients with history of CRC or status-post colectomy for other reasons were excluded from this study. Patient records were assessed for compliance with USPTF CRC screening guidelines. USPTF recommends adults aged 50 to 75 years receive screening as follows: 1) Fecal occult blood testing (FOBT) annually 2) Flexible sigmoidoscopy every 5 years 3) Colonoscopy every 10 years OR 4) Combined FOBT (every 3 years) plus flexible sigmoidoscopy (every 5 years). Results: The review showed that during the timeframe studied, 56% of patients received appropriate screening, 44% were found with no documentation of screening, and 17% were never offered screening or informed about current guidelines. Following data analysis, intervention to increase screening rates has been initiated. This involves provider education, posters in clinic, and individualized letters mailed to patients found deficient during the study. The success of this direct patient outreach effort will be measured over six months. Conclusions: The mortality rate from CRC cancer is higher in Robeson County compared to the NC state rate. Additionally, 40% of deaths from late-stage CRC may be prevented by doing a routine screening. It is the responsibility of providers to emphasize the importance of proper screening. This retrospective review found that a large percentage (44%) of adults are not being adequately screened in our rural clinic. Direct outreach is underway to increase compliance rates in this high-risk population served by our rural clinic.

Abstract Relativistic electrons are an important space weather hazard, being a major source of radiation damage to satellites and posing a risk to humans in space. We use approximately 20 years of data from the US Global Positioning System (GPS) satellite NS41 to determine the characteristics of the geomagnetic storms that lead to the largest relativistic electron fluxes in GPS orbit. The largest coronal mass ejection (CME)‐driven events are associated with the solar wind having negative excursions of the IMF with minimum values of −14 nT two hours prior to zero epoch, defined as the time of the minimum in the index, and strong minima, reaching −130 nT at zero epoch. In contrast, events driven by high speed solar wind streams (HSSs) are associated with smaller negative excursions of IMF with minimum values of −4 nT one to two hours prior to zero epoch and moderate minima, reaching −60 nT at zero epoch. Compared with HSS‐driven events, peak = 2.0 MeV fluxes associated with CME‐driven events are larger by factors of 1.3 at = 4.5 and 2.4 at = 6.5. Both the CME‐ and HSS‐driven events are associated with enhancements in the solar wind number density and pressure prior to zero epoch. Following zero epoch the solar wind number density and pressure become low and substorm activity is enhanced for several days.