Inadequate Reductions Research Articles

Substantial reductions in non-CO2 greenhouse gas emissions reductions implied by IPCC estimates of the remaining carbon budget

Carbon budgets are quantifications of the total amount of carbon dioxide that can ever be emitted while keeping global warming below specific temperature limits. However, estimates of these budgets for limiting warming to 1.5 °C and well-below 2 °C include assumptions about how much warming can be expected from non-CO2 emissions. Here, we uncover the non-CO2 emissions assumptions that underlie the latest remaining carbon budget estimates by the Intergovernmental Panel on Climate Change and quantify the implication of the world pursuing alternative higher or lower emissions. We consider contributions of methane, nitrous oxide, fluorinated gases, and aerosols and show how pursuing inadequate methane emission reductions causes remaining carbon budgets compatible with the Paris Agreement temperature limits to be exhausted today, effectively putting achievement of the Paris Agreement out of reach.

Navigation-guided surgery in orbital trauma

There are times in an orbital surgeon's life when experience and instincts seem inadequate and there is a need for some extra guidance and technical support. High-velocity injuries with shattered orbits are one such instance. In these cases, the entire orbit is disrupted and there are no bony landmarks to guide placement of implants and restoration of volume. Orbital walls have complex curvatures and it is extremely difficult to reestablish and symmetrize this complex three-dimensional (3D) anatomy. Inadequate reductions and poor implant placements are common causes of postoperative persistent enophthalmos. Intraoperative navigation guidance has greatly aided in accurate localization of bony landmarks, in planning complex reconstructions and verifying adequate reconstruction and symmetry, and in planning patient-specific or customized 3D-printed implants. It has brought in a revolution in the treatment of orbital trauma in current times.

Stepped Treatment for Attention-Deficit/Hyperactivity Disorder and Aggressive Behavior: A Randomized, Controlled Trial of Adjunctive Risperidone, Divalproex Sodium, or Placebo After Stimulant Medication Optimization

Stimulant medications are the most prevalent first-line pharmacotherapy for attention-deficit/hyperactivity disorder, but children with aggressive behavior often receive multiagent treatment. There is sparse evidence for the benefits of adjunctive medications when stimulant monotherapy provides inadequate benefit for aggressive behavior, yet the adverse effects of common adjuncts are well established. This study compared the efficacy in reducing aggressive behavior of risperidone (RISP), divalproex sodium (DVPX), and placebo (PBO) added to stimulant medication among childrenwhose symptoms persisted after individually optimized stimulant treatment. This trial enrolled 6- to 12-year-old with attention-deficit/hyperactivity disorder, a disruptive disorder, significant aggressive behavior, and prior stimulant treatment. Open, systematically titrated stimulant treatment identified patients with inadequate reductions in aggressive behavior, who were then randomly assigned to receive adjunctive RISP, DVPX, or PBO under double-blinded conditions for 8 weeks. Family-based behavioral treatment was offered throughout the trial. The primary outcome was the parent-completed Retrospective Modified Overt Aggression Scale. Participants included 175 children (mean [SD] age 9.48 [2.04] years, 19% female). Of participants, 151 completed the stimulant optimization phase, with aggression remitting among 96 (63%), and 45 were randomly assigned to adjunctive treatment groups. The adjunctive RISP group showed greater reductions in aggression ratings than the PBO group (least squares means difference [ΔLSM],-2.33; 95% CI,-3.83 to-0.82; effect size [ES],-1.32), as did the DVPX group (ΔLSM,-1.60; 95% CI,-3.18 to-0.03; ES,-0.91). Mean standardized body mass index scores increased more among RISP-treated participants than participants receiving PBO (ΔLSM, 1.54; 95% CI, 0.68 to 2.40; ES, 0.58). High response rate during the trial's open stimulant optimization phase suggests that rigorous titration of stimulant medication and concurrent behavioral therapy may avert the need for additional medications. Among nonremitters, RISP and DVPX were efficacious adjunctive treatments, although RISP was associated with weight gain. Effectiveness of Combined Medication Treatment for Aggression in Children With Attention Deficit With Hyperactivity Disorder (The SPICY Study); https://www.clinicaltrials.gov; NCT00794625.

Quantifying human error probability in independent protection layers for a batch reactor system using dynamic simulations

The batch processing facilities with features involving in large-scale human intervention are generally considered to be relatively hazardous processes due to frequent change in operating conditions. Therefore, sufficient protection layers should be implemented against the hazards inherent in the batch processing facilities, especially for batch reactor systems. The human operations involved in the batch process play an important role to maintain process production and also take responsibility for reducing risks in specific possible accident scenarios. However, in practice, a number of companies initially did not take any credits for human actions in Layer of Protection Analysis (LOPA) or were overly optimistic in a few cases, which result in unwarranted safety expenditures or inadequate risk reductions. In this study, we propose a simulation-oriented methodology for quantifying human error probability (HEP) in independent protection layers (IPLs). The methodology integrates dynamic simulations with human reliability analysis (HRA) to give a comprehensive analysis of human actions. Case study for a batch reactor system shows that risk reductions of human response are expected to be greater than that determined using other methods. The present study provides a solution for analyzing the risk reductions of human elements within the IPL and serves as a reference for improving the emergency response for operators.

Computed tomography versus plain radiography assessment of acetabular fracture reduction is more predictive for native hip survivorship

IntroductionComputed tomography (CT) is more accurate than plain pelvic radiography (PXR) for evaluating acetabular fracture reduction. As yet unknown is whether CT-based assessment is more predictive for clinical outcome. We determined the independent association between reduction quality according to both methods and native hip survivorship following acetabular fracture fixation.Materials and methodsRetrospectively, 220 acetabular fracture patients were reviewed. Reductions on PXR were graded as adequate or inadequate (0–1 mm or > 1 mm displacement) (Matta’s criteria). For CT-based assessment, adequate reductions were defined as < 1 mm step and < 5 mm gap, and inadequate reductions as ≥ 1 mm step and/or ≥ 5 mm gap displacement. Predictive values and Kaplan–Meier hip survivorship curves were compared and risk factors for conversion to total hip arthroplasty (THA) were identified.ResultsMean follow-up was 8.9 years (SD 5.6, range 0.5–23.3 years), and 52 patients converted to THA (24%). Adequate reductions according to CT versus PXR assessment were associated with higher predictive values for native hip survivorship (92% vs. 82%; p = 0.043). Inadequate reductions were equally predictive for conversion to THA (33% for CT and 30% for PXR; p = 0.623). For both methods, survivorship curves of adequate versus inadequate reductions were significantly different (p = 0.030 for PXR, p < 0.001 for CT). Only age ≥ 50 years (p < 0.001) and inadequate reductions as assessed on CT (p = 0.038) were found to be independent risk factors for conversion to THA. Reduction quality as assessed on PXR was not found to be independently predictive for this outcome (p = 0.585).ConclusionNative hip survivorship is better predicted based on postoperative CT imaging as compared to PXR assessment. Predicting need for THA in patients with inadequate reductions based on both assessment methods remains challenging. While both PXR and CT-based methods are associated with hip survivorship, only an inadequate reduction according to CT assessment was an independent risk factor for conversion to THA.

Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images

ObjectiveEmergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy. MethodsWe prospectively enrolled ED patients 0–17 years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist. ResultsThe 58 patients were 7.9 ± 3.5 years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°–3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92–93% specificity. ConclusionsBlinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED.

Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India.

BackgroundImprovements in continuum of care (CoC) utilization are needed to address inadequate reductions in neonatal and infant mortality in India and elsewhere. This study examines the effect of Ananya, a health system training and community outreach intervention, on reproductive, maternal and newborn health continuum of care (RMNH CoC) utilization in Bihar, India, and explores whether that effect is moderated by gender equity factors (child marriage, restricted mobility and low decision-making control).MethodsA two-armed quasi-experimental design compared districts in Bihar that did/did not implement Ananya. Cross-sections of married women aged 15–49 with a 0–5 month old child were surveyed at baseline and two year follow-up (baseline n = 7191 and follow-up n = 6143; response rates 88.9% and 90.7%, respectively). Difference-in-difference analyses assessed program impact on RMNH CoC co-coverage, defined by 9 health services/behaviors for the index pregnancy (e.g., antenatal care, skin-to-skin care). Three-way interactions assessed gender equity as a moderator of Ananya’s impact.FindingsParticipants reported low RMNH CoC co-coverage at baseline (on average 3.2 and 3.0 of the 9 RMNH services/behaviors for Ananya and control groups, respectively). The Ananya group showed a significantly greater increase in RMNH CoC co-coverage (.41 services) compared with the control group over time (p<0.001), with the primary drivers being increases in clean cord care, skin-to-skin care and postpartum contraceptive use. Gender equity interaction analyses revealed diminished intervention effects on antenatal care, skilled birth attendance and exclusive breastfeeding for women married as minors.ConclusionAnanya improved RMNH CoC co-coverage among these recent mothers, largely through positive health behavior changes. Child marriage attenuated Ananya’s impact on utilization of key health services and behaviors. Supporting the health system with training and community outreach can be beneficial to RMNH CoC utilization; additional support is needed to adequately address the unique issues faced by women married as minors.

Chemical and Microbiological Quality of Effluents from Different On-Site Wastewater Treatment Systems across Finland and Sweden

Domestic wastewaters, which cannot be disposed through sewage networks, must be treated with different on-site treatment systems; these are usually commercial, small-scale treatment plants or built sand filters. These systems are usually maintained by the house’s inhabitants. This study was achieved by analysing the chemical and microbiological data of 717 effluents collected in Finland and Sweden. There were inadequate reductions in 31% of phosphorus effluents, 22% of nitrogen effluents and 5% of biological oxygen demand compounds. The addition of a coagulant capable of precipitating phosphorus improved the performance of sand filters and biorotors. There are no legally binding limitations on the number of enteric microorganisms that can be present in an effluent, but the number of Escherichia coli and enterococci exceeded more than 100 colony forming units per 100 mL in 59% and 53% effluents studied, with the highest numbers for these indicators being more than 100,000 cfu per 100 mL. The number of E. coli and enterococci were lower when the concentration of phosphorus in effluent was less than 1 mg/L. The treatment efficiency varied extensively, even between similar plant models, possibly due to either irregular use, or after long pauses, when they were not being used. In addition, it is possible that the end users are not capable of properly maintaining these wastewater treatment plants.

English

The increasing rate of disease incidence resulting from devastating effects of plant pathogens, limits crop productivity globally, thus affecting food security. The current global population growth with many mouths to feed is dependent on vibrant agricultural productivity. The effects of globalization, climate change, evolution of pathogens and vectors to mention a few, have combined to increase spread of invasive plant pathogens. Consequently, early detection of pathogens, accurate diagnosis and assessment and surveillance are imperative to predicting disease outbreaks and ample time to develop and apply appropriate mitigation measures for crop protection and enhanced productivity. Diagnosis is the process to determine cause of disease, while detection deals with knowing pathogen. Both disease diagnosis and pathogen detection are central to protecting crops and natural plant systems, as well as crucial prelude to undertaking prevention and management measures. Visual assessments of disease in plants populations are unreliable and subjective, arising from human limitations. Failure in pathogen detection and disease diagnosis lead directly to inadequate disease control and reductions in crop production and quality. Geographic Information Systems (GIS) and Digital Imaging (DI) have been applied in plant pathology to improve speed and accuracy of disease assessment, diagnostics and pathogen detection. These new technologies have assisted in collection and analysis of field data in ways that were not possible before advent of computer and thus, minimize human errors. This paper presents a brief review on application of both emerging technologies in plant disease diagnosis and detection. Key words: Geographic information systems, imaging, plant disease, detection, diagnosis.

Bedside ultrasonography for verification of shoulder reduction: A long way to go

PurposeShoulder dislocation is a common joint dislocation managed by the emergency physicians in the emergency departments. Pre- and post-reduction radiographic examinations have long been the standard practice to confirm the presence of dislocation and the successful reduction. However, shoulder ultrasonography has recently been proposed as an alternative to the radiographic examination. This study aimed to assess the accuracy of ultrasonography in evaluating proper reduction of the dislocated joint. MethodsThis was a prospective observational study. All patients with confirmed anterior shoulder dislocation were examined by both ultrasonography and radiography after the attempt for reduction of the dislocated joint. The examiners were blinded to the result of the other imaging modality. Results of the two methods were then compared. ResultsOverall, 108 patients with confirmed anterior shoulder dislocation were enrolled in the study. Ninety-one (84.3%) of the patients were males. Mean age of the participants was (30.11 ± 11.41) years. The majority of the patients had a recurrent dislocation. Bedside ultrasonography showed a sensitivity of 53.8% (95% CI: 29.1%–76.8%) and a specificity of 100% (95% CI: 96.1%–100%) in detecting inadequate reductions. The results of ultrasonography had a statistically significant agreement with the results of radiography (Kappa = 0.672, p < 0.001). ConclusionThe results suggest that the sensitivity of post-reduction ultrasound is not sufficient for it to serve as a substitute for radiography.

Accuracy of Ultrasonography for Determining Successful Realignment of Pediatric Forearm Fractures

The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures. The secondary objective is to determine the rate of agreement of ultrasonography and fluoroscopy in real-time by the treating physician. A cross-sectional study was conducted in children younger than 18 years and presenting to an academic emergency department with forearm fractures requiring realignment of a single bone. Physicians performed closed reductions with ultrasonographic assessment of realignment until the best possible reduction was achieved. Fluoroscopy was then immediately performed and images were saved. A positive test result was defined as an inadequately reduced fracture on fluoroscopy by a blinded pediatric orthopedic surgeon (reference standard) and on ultrasonography (index test) and fluoroscopy in real-time by the treating physician. One hundred patients were enrolled (median age 12.1 years; 74% male patients); the radius was involved in 98%, with 27% involving the growth plate. The sensitivity, specificity, positive predictive value, and negative predictive value were 50% (95% confidence interval [CI] 15.4% to 84.6%), 89.1% (95% CI 82.8% to 95.5%), 28.6% (95% CI 4.9% to 52.2%), and 95.3% (95% CI 90.9% to 99.8%), respectively. The treating physicians' agreement rate of the real-time images was 98%. Point-of-care ultrasonography can help emergency physicians determine when pediatric forearm fractures have been adequately realigned, but inadequate reductions should be confirmed by other imaging modalities.

Intraoperative Use of the Pelvic c-clamp as an Aid in Reduction for Posterior Sacroiliac Fixation

Posterior pelvic ring injuries with dissociation of the sacroiliac joint can be a therapeutic challenge. Open procedures for reduction have a significant risk for wound complications although inadequate reductions using percutaneous methods can have poor long-term outcomes. Several indirect reduction methods have been previously described for closed reduction of the sacroiliac joint. We present our technique for the intraoperative use of the pelvic c-clamp as a reduction aid for the posterior pelvis in conjunction with percutaneous iliosacral screw fixation. This technique has been used routinely in our patients who sustain injuries to the sacroiliac joint and are candidates for closed reduction and percutaneous fixation. Our objective is to provide orthopedic surgeons an additional means by which to reduce sacroiliac disruptions by percutaneous means.

Correlates of Bleeding Events Among Moderate- to High-Risk Patients Undergoing Percutaneous Coronary Intervention and Treated With Eptifibatide: Observations From the PROTECT–TIMI-30 Trial

Correlates of Bleeding Events Among Moderate- to High-Risk Patients Undergoing Percutaneous Coronary Intervention and Treated With Eptifibatide: Observations From PROTECT–TIMI-30 Trial Ajay J. Kirtane, Gregory Piazza, Sabina A. Murphy, Daniela Budiu, David A. Morrow, David J. Cohen, Eric Peterson, Nasser Lakkis, Howard C. Herrmann, Theresa M. Palabrica, C. Michael Gibson, for the TIMI Study Group Among non–ST-segment elevation acute coronary syndrome percutaneous coronary intervention patients treated with eptifibatide, increased age was the only independent correlate of bleeding events. Although creatinine clearance (CrCl) was also associated with bleeding, that appeared to be related to the incorporation of age in the estimate of CrCl; reliance on serum creatinine alone as an estimate of renal function may yield inadequate dose reductions of eptifibatide. We aimed to identify correlates of Thrombolysis In Mycocardial Infarction (TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention (PCI). Evaluation of bleeding predictors among patients treated with glycoprotein IIb/IIIa receptor inhibition might aid in the identification of targets to reduce bleeding risk. Data were analyzed from 567 moderate- to high-risk PCI patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) treated with eptifibatide/reduced-dose unfractionated heparin or eptifibatide/reduced-dose enoxaparin enrolled in the Randomized Trial to Evaluate the Relative Protection Against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia Among Anti-Platelet and Anti-Thrombotic Agents–Thrombolysis In Myocardial Infarction-30 (PROTECT–TIMI-30). The incidence of significant bleeding was 3.2% with a median time to event of 7.0 h after the first eptifibatide bolus. Increased age was the only independent correlate of bleeding events. Among patients with reduced creatinine clearance (CrCl), lack of adjustment of the maintenance infusion for CrCl ≤50 ml/min occurred frequently (15 of 33 patients, or 45%) and was associated with a high rate of bleeding (20%). The association of CrCl with bleeding appeared to be largely mediated by the incorporation of age in the estimation of CrCl. Patient gender, Cr, weight, and the peak activated clotting time were not associated with bleeding. Among NSTEACS PCI patients treated with eptifibatide, increased age was a significant correlate of bleeding events and appeared to explain the association between low CrCl and bleeding. The more widespread use of CrCl or other estimates of renal function over Cr may lead to more appropriate dose adjustments of eptifibatide.

Intramedullary Fixation of Intertrochanteric Fractures with the Proximal Femoral Nail (PFN)

Minimally invasive internal fixation of interand subtrochanteric fractures allowing early weight bearing. Restoration of shape and early return to function of the lower limb. All inter- and subtrochanteric fractures of AO type 31.A. Femoral neck and intertrochanteric fractures; associated with proximal femoral fractures; in these instances, a longer nail is used. Marked ipsilateral coxofemoral osteoarthritis. Open physes. Reduction of fracture on fracture table. Stab incision. Unreamed intramedullary nailing. Insertion of femoral neck and antirotation screws over guide wires for dynamic fixation of femoral neck/head fragment ensuring stability in rotation. Possibility of dynamic or static locking at diaphyseal level. Between January 1, 1996 and March 31, 1999, the described system was used in 231 patients (74.2% women, 25.8 men, average age 78.1 years). 2.1% intraoperative complications: three inadequate reductions, one antirotation screw implanted too deeply, one wrong placement of distal femoral drill hole. 9.5% postoperative complications related to surgery: three avulsions of implant, one femoral fracture, 14 hematomas or seromas, four deep infections. Followup after 12 months in 76.3% of patients: 63.4% personal postoperative assessment, 12.9% information supplied by family physician. Mortality: 17.5%. Impossible to reach: 6.2% of patients. Late complications in 6.2% of followed-up patients: nine migrating antirotation screws, two late infections. Bony consolidation in all patients, no nonunion. Merle d’Aubigne score: 34.2% excellent, 49.3% good, 13.7% satisfactory, 2.7% poor.

Magnetic resonance imaging after reduction for congenital dislocation of the hip.

Reliable concentric reduction of the femoral head and subsequent retention in a centred position are indispensable preconditions for the remodelling of the acetabulum in developmental dysplasia of the hip (DDH) and to prevent damage to the hip joint, i.e. avascular necrosis. The objective of this study is to evaluate the necessity of verifying the reduced position of the articulation in the plaster cast. MRI was carried out in 15 infants with 21 unstable hip joints after reduction under arthrographic control and fixation in a plaster cast in the 'human' position with the hips flexed above 90 degrees and abducted to 50 degrees or 60 degrees. When the reduction was found to be inadequate-the hip still partially or completely dislocated-the plaster cast was removed, reduction repeated, a new cast applied, and MRI carried out again. After primary reduction, 1 of 21 hips was dislocated, and 2 showed unsatisfactory reduction. Three hip joints out of 21 (14.3%) were not fixed in the plaster cast in the optimal centred position. In view of the number of inadequate reductions in plaster casts, we recommend verifying the position of the hip joint by MRI. This MRI documentation should be established as a standard examination post-reduction.

Gradients in ecological systems

In this paper, the potentials of a holistic and hierarchical gradient approach to ecosystem analysis and ecosystem theory are discussed, using some examples from the ecosystem research project in the Bornhöved Lakes Region (Northern Germany). In the gradient concept, which originates in the thermodynamic non-equilibrium principle, structural ecosystem properties are comprehended as concentration gradients in space and time. They build up potentials to carry out mechanical work, chemical reactions, or biological interactions. Ecosystem function is defined as the general characteristic of the systems' gradients dynamics. The gradient concept is theoretically discussed as an integrating tool for the aspects of thermodynamics, self-organization, and hierarchy theory. It helps to avoid inadequate reductions from holistic data sets to non-representative theoretical variables. Also, it can be used as an indicator to test theoretical hypotheses which are often based on non-measureable variables, and it may improve the cooperation between theoreticians and empirical ecologists. The necessary interfaces between this strategy and important ecosystem theoretical ideas are briefly described in this text. As an illustration, three aspects of the gradient concept are presented in empirical case studies: spatial, temporal, and functional gradients. In these examples, the gradient systems of nature-near ecosystems are compared with those of stressed ecosystems. On this basis, the applicability of the gradient concept in theory and practice is discussed.

Treatment of tibial plateau fractures by limited internal fixation.

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.