Medical

Latar belakang: Kelelahan penerbang sipil, termasuk pada penerbangan jarak dekat, dapat mempengaruhi fungsi kognitif penerbang sehingga membahayakan keselamatan penerbangan. Tujuan penelitian ini untuk mengidentifikasi faktor-faktor yang mempengaruhi kelelahan penerbang sipil pada penerbangan jarak dekat di Indonesia. Metode: Desain penelitian potong lintang dengan purposive sampling dilakukan di antara penerbang jarak dekat dengan rating Boeing 737 series yang melaksanakan pengujian kesehatan di Balai Kesehatan Penerbangan periode 5-26 Mei, 2014. Kelelahan diukur dengan Self-Reporting Questionnaire, Fatigue Severity Scale (FSS). Data dikumpulkan dengan pengisian kuesioner oleh subyek yang meliputi demografi, pekerjaan, kehilangan waktu tidur (Epworth Sleepiness Scale-ESS), faktor personal, dukungan manajemen, dan FSS. Analisis regresi linear dipakai untuk menganalisis faktor-faktor dominan berkaitan kelelahan. Hasil: Di antara 785 penerbang yang melaksanakan pengujian kesehatan, 382 bersedia berpartisipasi, dan 239 penerbang yang memenuhi kriteria. Rata-rata skala kelelahan adalah 4,66 (standar deviasi 1,202). Faktor-faktor dominan yang mempertinggi skala kelelahan adalah jumlah sektor 24 jam terakhir, jam terbang penugasan di luar jadwal, dan kehilangan waktu tidur. Setiap penambahan 1 sektor dalam 24 jam terakhir meningkatkan 0,371 skala kelelahan [koefisien regresi (β) = 0,371; P = 0,000]. Selanjutnya setiap penambahan 1 jam terbang penugasan di luar jadwal mempertinggi 0,033 skala kelelahan (β = 0

Objectives: To provide Canadian physicians with a standard definition of hypertension in pregnancy, recommendations for laboratory investigations and tests for the assessment and management of hypertensive disorders in pregnancy, and a classification of such disorders. Options: To improve or not improve Canadian uniformity and standardization in the investigation and classification of hypertensive disorders in pregnancy. Outcomes: 1) Accuracy, reliability and practicality of diagnostic clinical criteria for hypertensive disorders in pregnancy. 2) Laboratory tests useful to determine severity and prognosis of disorders as measured by maternal and neonatal adverse outcomes. 3) A classification of disorders for use by Canadian physicians to facilitate uniformity and diffusion of research through a common language. Evidence: Articles on hypertensive disorders in pregnancy published from 1966 to 1996, retrieved through MEDLINE search, related to definitions, tests, diagnostic criteria and classification, as well as documents on diagnosis and classification from authorities in the United States, Europe and Australia and from special interest groups. Values: High priority was given to the principle of preventing adverse maternal and neonatal outcomes through the provision of diagnostic criteria for severity and prognosis and through dissemination of reliable and pertinent information and research results using a common language. Benefits, harms and cost: Higher degree of vigilance in diagnosing hypertensive disorders in pregnancy, allowing for earlier assessment and intervention, and more efficient dissemination of comparative information through common language. No harm or added cost is perceived at this time. Recommendations: (1) A diastolic blood pressure of 90 mm Hg or more should be the criterion for a diagnosis of hypertension in pregnancy and should trigger investigation and management. Except for very high diastolic readings (110 mm Hg or more), all diastolic readings of 90 mm Hg or more should be confirmed after 4 hours. (2) A regularly calibrated mercury sphygmomanometer, with an appropriate-sized cuff, is the instrument of choice. A rest period of 10 minutes should be allowed before taking the blood pressure. The woman should be sitting upright and the cuff positioned at the level of the heart. (3) Both Korotkoff phase IV and V sounds should be recorded, but the phase IV sound should be used for initiating clinical investigation and management. (4) A urine protein level of more than 0.3 g/d should be the criterion for a diagnosis of proteinuria; 24-hour urine collection should be the standard method for determining proteinuria. (5) Edema and weight gain should not be used as diagnostic criteria. (6) Hypertensive disorders diagnosed during pregnancy should be classified as pre-existing hypertension; gestational hypertension with or without proteinuria; pre-existing hypertension with superimposed gestational hypertension with proteinuria; and unclassifiable antenatally but final classification 42 days after delivery. Validation: Except for expert opinions and reviews solicited for this project, these recommendations need to be field tested and validated in Canada. Guidelines en

Neutrophils play important roles in host defense against all classes of infectious agents but, paradoxically, they are also involved in the pathology of vanous inflammatory conditions. Their microbicidal armory consists of oxidative and nonoxidative processes that are activated simultaneously upon phagocytosis. Although destruction of infectious agents occurs intracellulanly, release of cytotoxic molecules into the extracellulan milieu can damage body tissues. Neutrophils are heterogeneous. Subpopulations exist in various stages from dormant to primed to fully activated. The activities of neutrophils are regulated locally in microenvironments and systemically by a plethora of mediators including cytokines, "classical" neuroendocrine hormones, and bioactive lipids. The net response depends on a complex balance of stimulatory and inhibitory pathways that are regulated by these mediators. Although some effector and regulatory pathways are vital, considerable redundancy is also evident. Identification of the essential mediators and the unraveling of any interactions may be the keys to understanding the neutrophil paradox and developing thenapeutic strategies that optimize microbial killing and minimize host tissue damage. Finally, reports that neutrophils can act as drug delivery vectors and that their function is influenced by stress and other lifestyle factors suggest that new homeostatic functions for these cells, outside their traditional roles in host defense and inflammation, remain to be identified: some are speculated on here.J.

It is commonly assumed that identification with a social group is constant throughout the play of a one-shot game in the absence of feedback. We provide evidence which challenges this assumption. We direct subjects to play one of two versions of the prisoner's dilemma game. These versions are distinguished by the relative attractiveness of the uncooperative action. We refer to the version with a relatively attractive uncooperative action as the Easy Game and the other as the Difficult Game. We find that for the subjects who play the Difficult ...

N utritional support is vital for critically ill patients, and important developments include early enteral nutrition, immunonutrition, postpyloric feeding, and an increasingly scientific, evidencebased approach. However, there are still many unanswered questions, and new insights about specific nutrients or nutrient combinations are tantalizing rather than definite. Clinical trials of enteral nutrition in the critically ill are difficult, given the size of trial necessary to minimize population heterogeneity and demonstrate efficacy in severe sepsis and acute lung injury (1, 2). A specific problem is the inability to deliver feed effectively in a proportion of subjects due to variations in enteral tolerance with patient and disease type. High-quality clinical care, employing feeding protocols, avoiding excessive sedation, and using aperients and prokinetics early, substantially minimizes the problem, but fullvolume enteral feeding is still difficult or impossible to achieve early in some intensive care unit (ICU) patients (3). An important motive for feeding critically ill patients early is that the gutassociated lymphoid tissue comprises the largest collection of immune cells in the body, and their turnover and the vulnerability of the gut to ischemia/reperfusion Objective: To assess the safety and efficacy of an early enteral pharmaconutrition supplement containing glutamine dipeptides, antioxidative vitamins and trace elements, and butyrate in critically ill, septic patients. Design: A prospective, randomized, controlled, double-blind clinical trial. Setting: Adult intensive care unit in a university hospital. Patients: Fifty-five critically ill, septic patients requiring enteral feeding. Interventions: Patients received either an enteral supplement (500 mL of Intestamin, Fresenius Kabi) containing conditionally essential nutrients or a control solution via the nasogastric route for up to 10 days. Inclusion occurred within 24 hrs of intensive care unit admission. Additionally, patients received enteral feeding with an immunonutrition formula (experimental group) or standard formula (control group) initiated within 48 hrs after enrollment. Measurements and Main Results: Organ dysfunction was assessed by daily total Sequential Organ Failure Assessment (SOFA) score over the 10-day study period in both patient groups. Patients receiving the experimental supplement showed a significantly faster decline in the regression slopes of delta daily total SOFA score over time compared with control. The difference between the regression coefficients of the two slopes was significant irrespective of the level of analysis: intent to treat ؊0.32 vs. ؊0.14, p < .0001; per protocol ؊0.34 vs. ؊0.14, p < .0001; and completers (patients receiving >80% of the calculated caloric target over a period of 6 days), ؊0.26 vs. ؊0.16, p ‫؍‬ .0005. Vitamin C, as a marker of supplement absorption, increased from 10.6 (1.9-159.4) mol/L (normal range 20-50 mol/L) on day 1 to 58.7 (5.4-189.9) mol/L by day 3 (p ‫؍‬ .002) in the intervention group but remained below the normal range in the control group 17.0 (2.8-78.5) on day 1 and 14.3 (2.4-179.6) on day 3. Serum levels of glycine, serine, arginine, ornithine, vitamin E, and ␤-carotene all increased significantly with treatment in the supplementation group. Conclusions: In medical patients with sepsis, early enteral pharmaconutrition with glutamine dipeptides, vitamin C and E, ␤-carotene, selenium, zinc, and butyrate in combination with an immunonutrition formula results in significantly faster recovery of organ function compared with control.

The naturally occurring radionuclide 234Th (tl/2-24.1 days) was used to examine the organic carbon cycle in the Gulf of Maine. A seasonal study (March, June, and September 1995) was conducted in the central Gulf of Maine in Wilkinson and Jordan Basins, and a regional survey, which included the Scotian Shelf, was conducted during August-September 1997. Particulate organic carbon (POC) export (particulate export production) was estimated from a three-dimensional steady state model of 234Th flux combined with measurements of the POC/234Th ratio on >53-gm particles. The POC export for this region was seasonally variable; average values ranged from 15 to 34 mmol C m-2 d-1, between 11% and 25% of the regionally integrated primary production. The Gulf of Maine was a net source (to the Mid-Atlantic Bight) of dissolved organic carbon (2.4 mmol C m-2 d-1) amounting to-2% of carbon uptake rates. Organic carbon burial in the sediments was a minor fraction of the primary production, averaging 1.6 mmol C m-2 d-1. Though only a fraction of total export production was buried in the sediments, these estimates close the budget for organic carbon in the Gulf of Maine. An implication is that off-shelf export may not be as important as previously estimated in this shelf region. POC export was empirically linked to the 234Th deficit via the POC/234Th ratio of sinking particulate matter [Buesseler et

The whisper and croak modes of phonation provide convenient broad band excitation of the vocal tract and thus give relatively precise information about tract resonances. How closely do the measured resonances for these mechanisms approximate those of normal speech? We measured the frequencies of the first four resonances (R1-R4) in normal, whisper and croak phonation. Subjects produced pairs of these phonations in the same vocal gesture. Formants were used to measure the frequencies (R1-R4) for the non-periodic phonations and broad band excitation at the mouth was used to measure them with similar precision in normal speech. For R1 to R4 respectively, whispering raised the resonant frequencies by 255±90 Hz (92)*, 115±105 Hz (119)*, 125±125 Hz (109)* and 75±120 Hz (118)*, (mean ± standard deviation (n), asterisks show significance at the 5% level). These values, and their decrease with increasing frequency, are consistent with the effect of the increased glottal opening in whispering only if the increased opening is large. A supra-glottal narrowing in the tract could also help raise the frequencies of resonance. Croak phonation raises the resonant frequencies respectively by 45±50 Hz (121)*, 10±60 Hz (124), 65±120 Hz (109)* and 15±110 Hz (108).

A nine-aperture, wide-field Fizeau imaging telescope has been built at the Lockheed-Martin Advanced Technology Center. The telescope consists of nine, 125 mm diameter collector telescopes coherently phased and combined to form a diffraction-limited image with a resolution that is consistent with the 610 mm diameter of the telescope. The phased field of view of the array is 1 rad. The measured rms wavefront error is 0.08 waves rms at 635 nm. The telescope is actively controlled to correct for tilt and phasing errors. The control sensing technique is the method known as phase diversity, which extracts wavefront information from a pair of focused and defocused images. The optical design of the telescope and typical performance results are described.

Plasma ~-hydroxybutyrate concentrations were measured in the offspring of rats that were fed either a control (20% protein) diet or low-protein (8% protein) diet during pregnancy and lactation. Low-protein offspring had significantly lower plasma ~-hydroxybutyrate compared with controls in the fed state (P < .04) and after fasting for 24 hours (P < .001) and 48 hours (P < .04). There were no differences in blood glucose, acetoacetate, plasma glucagon, cholesterol, or glycerol between control and low-protein offspring. However, plasma nonesterified fatty acids (NEFAs) were significantly higher in low-protein offspring in the fed state (P < .05). In contrast, plasma triglycerides and insulin were significantly lower in low-protein offspring compared with controls when fed (P < .001) and after a 24-hour fast (P < ,001). These results suggest that poor maternal and early postnatal nutrition can have long-term effects on ketone body metabolism in the offspring during adulthood. This apparent ketosis resistance is similar to that observed in some forms of human diabetes.

N utritional support is vital for critically ill patients, and important developments include early enteral nutrition, immunonutrition, postpyloric feeding, and an increasingly scientific, evidencebased approach. However, there are still many unanswered questions, and new insights about specific nutrients or nutrient combinations are tantalizing rather than definite. Clinical trials of enteral nutrition in the critically ill are difficult, given the size of trial necessary to minimize population heterogeneity and demonstrate efficacy in severe sepsis and acute lung injury (1, 2). A specific problem is the inability to deliver feed effectively in a proportion of subjects due to variations in enteral tolerance with patient and disease type. High-quality clinical care, employing feeding protocols, avoiding excessive sedation, and using aperients and prokinetics early, substantially minimizes the problem, but fullvolume enteral feeding is still difficult or impossible to achieve early in some intensive care unit (ICU) patients (3). An important motive for feeding critically ill patients early is that the gutassociated lymphoid tissue comprises the largest collection of immune cells in the body, and their turnover and the vulnerability of the gut to ischemia/reperfusion Objective: To assess the safety and efficacy of an early enteral pharmaconutrition supplement containing glutamine dipeptides, antioxidative vitamins and trace elements, and butyrate in critically ill, septic patients. Design: A prospective, randomized, controlled, double-blind clinical trial. Setting: Adult intensive care unit in a university hospital. Patients: Fifty-five critically ill, septic patients requiring enteral feeding. Interventions: Patients received either an enteral supplement (500 mL of Intestamin, Fresenius Kabi) containing conditionally essential nutrients or a control solution via the nasogastric route for up to 10 days. Inclusion occurred within 24 hrs of intensive care unit admission. Additionally, patients received enteral feeding with an immunonutrition formula (experimental group) or standard formula (control group) initiated within 48 hrs after enrollment. Measurements and Main Results: Organ dysfunction was assessed by daily total Sequential Organ Failure Assessment (SOFA) score over the 10-day study period in both patient groups. Patients receiving the experimental supplement showed a significantly faster decline in the regression slopes of delta daily total SOFA score over time compared with control. The difference between the regression coefficients of the two slopes was significant irrespective of the level of analysis: intent to treat ؊0.32 vs. ؊0.14, p < .0001; per protocol ؊0.34 vs. ؊0.14, p < .0001; and completers (patients receiving >80% of the calculated caloric target over a period of 6 days), ؊0.26 vs. ؊0.16, p ‫؍‬ .0005. Vitamin C, as a marker of supplement absorption, increased from 10.6 (1.9-159.4) mol/L (normal range 20-50 mol/L) on day 1 to 58.7 (5.4-189.9) mol/L by day 3 (p ‫؍‬ .002) in the intervention group but remained below the normal range in the control group 17.0 (2.8-78.5) on day 1 and 14.3 (2.4-179.6) on day 3. Serum levels of glycine, serine, arginine, ornithine, vitamin E, and ␤-carotene all increased significantly with treatment in the supplementation group. Conclusions: In medical patients with sepsis, early enteral pharmaconutrition with glutamine dipeptides, vitamin C and E, ␤-carotene, selenium, zinc, and butyrate in combination with an immunonutrition formula results in significantly faster recovery of organ function compared with control.

SUMMARYThe accumulation of deleterious mutations in a finite diploid selfing population is investigated. It is shown that the conditions for accumulation are very similar to those for the accumulation of mutations in an asexual population by ‘Muller&#39;s ratchet’. The ratchet is likely to operate in both types of population if there is a large class of slightly deleterious mutations.

The whisper and croak modes of phonation provide convenient broad band excitation of the vocal tract and thus give relatively precise information about tract resonances. How closely do the measured resonances for these mechanisms approximate those of normal speech? We measured the frequencies of the first four resonances (R1-R4) in normal, whisper and croak phonation. Subjects produced pairs of these phonations in the same vocal gesture. Formants were used to measure the frequencies (R1-R4) for the non-periodic phonations and broad band excitation at the mouth was used to measure them with similar precision in normal speech. For R1 to R4 respectively, whispering raised the resonant frequencies by 255±90 Hz (92)*, 115±105 Hz (119)*, 125±125 Hz (109)* and 75±120 Hz (118)*, (mean ± standard deviation (n), asterisks show significance at the 5% level). These values, and their decrease with increasing frequency, are consistent with the effect of the increased glottal opening in whispering only if the increased opening is large. A supra-glottal narrowing in the tract could also help raise the frequencies of resonance. Croak phonation raises the resonant frequencies respectively by 45±50 Hz (121)*, 10±60 Hz (124), 65±120 Hz (109)* and 15±110 Hz (108).

Plasma ~-hydroxybutyrate concentrations were measured in the offspring of rats that were fed either a control (20% protein) diet or low-protein (8% protein) diet during pregnancy and lactation. Low-protein offspring had significantly lower plasma ~-hydroxybutyrate compared with controls in the fed state (P < .04) and after fasting for 24 hours (P < .001) and 48 hours (P < .04). There were no differences in blood glucose, acetoacetate, plasma glucagon, cholesterol, or glycerol between control and low-protein offspring. However, plasma nonesterified fatty acids (NEFAs) were significantly higher in low-protein offspring in the fed state (P < .05). In contrast, plasma triglycerides and insulin were significantly lower in low-protein offspring compared with controls when fed (P < .001) and after a 24-hour fast (P < ,001). These results suggest that poor maternal and early postnatal nutrition can have long-term effects on ketone body metabolism in the offspring during adulthood. This apparent ketosis resistance is similar to that observed in some forms of human diabetes.

Neutrophils play important roles in host defense against all classes of infectious agents but, paradoxically, they are also involved in the pathology of various inflammatory conditions. Their microbicidal armory consists of oxidative and nonoxidative processes that are activated simultaneously upon phagocytosis. Although destruction of infectious agents occurs intracellularly, release of cytotoxic molecules into the extracellular milieu can damage body tissues. Neutrophils are heterogeneous. Subpopulations exist in various stages from dormant to primed to fully activated. The activities of neutrophils are regulated locally in microenvironments and systemically by a plethora of mediators including cytokines, &quot;classical&quot; neuroendocrine hormones, and bioactive lipids. The net response depends on a complex balance of stimulatory and inhibitory pathways that are regulated by these mediators. Although some effector and regulatory pathways are vital, considerable redundancy is al...

Because most newly arising mutations are neutral or deleterious, it has been argued that the mutation rate has evolved to be as low as possible, limited only by the cost of error-avoidance and error-correction mechanisms. But up to one per cent of natural bacterial isolates are &#39;mutator&#39; clones that have high mutation rates. We consider here whether high mutation rates might play an important role in adaptive evolution. Models of large, asexual, clonal populations adapting to a new environment show that strong mutator genes (such as those that increase mutation rates by 1,000-fold) can accelerate adaptation, even if the mutator gene remains at a very low frequency (for example, 10[-5]). Less potent mutators (10 to 100-fold increase) can become fixed in a fraction of finite populations. The parameters of the model have been set to values typical for Escherichia coli cultures, which behave in a manner similar to the model in long-term adaptation experiments.