Objective To evaluate the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. Methods This was a quasi-experimental, before-after study that consisted of a pre-intervention period, a run-in period of approximately six months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure (PEEP), rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. Results A total of 1,192 patients in the pre-intervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n= 490 in each group), the primary outcome occurred in 71 patients (14.5%) in the pre-intervention group, as compared with 36 patients (7.4%) in the intervention group [adjusted OR, 0.47 (0.31–0.71)]. There was an increase in ventilator-free days (mean difference 3.7, 95% CI 2.3–5.1), ICU-free days (mean difference 2.4, (95% CI 1.0–3.7), and hospital-free days (mean difference 2.4, 95% CI 1.2–3.6) associated with the intervention. The mortality rate was 34.1% in the pre-intervention group and 19.6% in the intervention group, adjusted OR 0.47 (0.35–0.63). Conclusions Implementing a mechanical ventilator protocol in the ED is feasible, and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.

These data suggest that an extract of this leguminous plant may be a useful adjunct in reducing alcohol intake in a naturalistic setting.

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Early deep sedation is common in mechanically ventilated ED patients and is associated with worse mortality. These data suggest that ED-based sedation is a modifiable variable that could be targeted to improve outcome.

Oral naltrexone reduces heavy drinking, but is less consistent as an abstinence promoter, whereas once-monthly extended-release naltrexone (XR-NTX) also maintains abstinence. The present study sought to determine if alcohol cue reactivity is attenuated by XR-NTX. Twenty-eight detoxified alcohol-dependent adult male and female volunteers received a single i.m. injection of either XR-NTX or placebo under double-blind conditions. An fMRI/cue reactivity procedure was conducted immediately before and two weeks after injection. At baseline, alcohol-related visual and olfactory cues elicited significant increases in orbital and cingulate gyri, inferior frontal and middle frontal gyri. Subsequently, brain activation was significantly altered in XR-NTX-treated individuals. These affected brain regions are associated with the integration of emotion, cognition, reward, punishment, and learning/memory, suggesting that XR-NTX attenuates the salience of alcohol-related cues. Such an effect on brain function may interrupt the processes associated with "slips" and relapse, which may account for XR-NTX's ability to maintain abstinence.

Objective To evaluate the impact of an emergency department (ED) mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome (ARDS). Design Quasi-experimental, before-after trial. Setting ED and intensive care units (ICU) of an academic center. Patients Mechanically ventilated ED patients experiencing ARDS while in the ED or after admission to the ICU. Interventions An ED ventilator protocol which targeted parameters in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume; 2) appropriate setting of positive end-expiratory pressure (PEEP); 3) oxygen weaning; and 4) head-of-bed elevation. Measurements and Main Results A total of 229 patients (186 pre-intervention group, 43 intervention group) were studied. In the ED, the intervention was associated with significant changes (P < 0.01 for all) in tidal volume, PEEP, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in ED tidal volume from 8.1 mL/kg PBW (7.0 – 9.1) to 6.4 mL/kg PBW (6.1 – 6.7), and an increase in lung-protective ventilation from 11.1% to 61.5%, P < 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (OR 0.38, 95% CI 0.17 – 0.83, P = 0.02), and a 3.9 day increase in ventilator-free days, P = 0.01. Conclusions This before-after study of mechanically ventilated patients with ARDS demonstrates that implementing a mechanical ventilator protocol in the ED is feasible, and associated with improved clinical outcomes.

The diversity and abundance of native invertebrates is declining globally, which could have significant consequences for ecosystem functioning. Declines are likely to be at least as severe as those observed for vertebrates, although often are difficult to quantify due to a lack of historic baseline data and limited monitoring effort. The Lepidoptera are well studied in Australia compared with other invertebrates, so we know that some species are imperilled or declining. Despite this, few butterfly taxa are explicitly listed for protection by legislation. Here we aim to identify the butterfly taxa that would most benefit from listing by determining the Australian butterflies at most immediate risk of extinction. We also identify the research and management actions needed to retain them. For 26 taxa identified by experts and various conservation schedules, we used structured expert elicitation to estimate the probability of extinction within 20 years (i.e. by 2040) and to identify key threatening processes, priority research and management needs. Collation and analysis of expert opinion indicated that one taxon, the laced fritillary (Argynnis hyperbius inconstans), is particularly imperilled, and that four taxa (Jalmenus eubulus, Jalmenus aridus, Hypochrysops piceatus and Oreisplanus munionga larana) have a moderate–high (>30%) risk of extinction by 2040. Mapped distributions of the 26 butterflies revealed that most are endemic to a single state or territory, and that many occupy narrow ranges. Inappropriate fire regimes, habitat loss and fragmentation (through agricultural practices), invasive species (mostly through habitat degradation caused by weeds and rabbits) and climate change were the most prevalent threats affecting the taxa considered. Increased resourcing and management intervention will be required to prevent these extinctions. We provide specific recommendations for averting such losses.

Purpose of review Ketogenic diets, which have been used to treat drug-refractory paediatric epilepsy for over 100 years, are becoming increasingly popular for the treatment of other neurological conditions, including mental illnesses. We aim to explain how ketogenic diets can improve mental illness biopathology and review the recent clinical literature. Recent findings Psychiatric conditions, such as schizophrenia, depression, bipolar disorder and binge eating disorder, are neurometabolic diseases that share several common mechanistic biopathologies. These include glucose hypometabolism, neurotransmitter imbalances, oxidative stress and inflammation. There is strong evidence that ketogenic diets can address these four fundamental diseases, and now complementary clinical evidence that ketogenic diets can improve the patients’ symptoms. Summary It is important that researchers and clinicians are made aware of the trajectory of the evidence for the implementation of ketogenic diets in mental illnesses, as such a metabolic intervention provides not only a novel form of symptomatic treatment, but one that may be able to directly address the underlying disease mechanisms and, in so doing, also treat burdensome comorbidities (see Video, Supplementary Digital Content 1, http://links.lww.com/COE/A16, which summarizes the contents of this review).