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"Wells, Adam"
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A little bit of heaven
Marley is a young, beautiful, and funny, but she's afraid of opening herself up to true love. A life-changing visit to her doctor sends both of them on an eye-opening adventure of mutual discovery, leading to revelations neither thought possible.
DVD
The weakness of fragility index exposed in an analysis of the traumatic brain injury management guidelines: A meta-epidemiological and simulation study
To perform fragility index (FI) analysis on the evidence that forms the basis of the guidelines for the management of severe traumatic brain injury (TBI), and develop a deeper understanding of the pitfalls associated with FI.
Meta-epidemiological analysis and numerical simulations.
The Brain Trauma Foundation guidelines (4th edition) for management of severe TBI were used to identify relevant randomised controlled trials (RCTs). FI based on Fisher's exact test and relative risk was performed on eligible RCTs. The relationship between FI, event counts and P values was explored by exhaustively considering different combinations of outcomes for studies of total size ranging from 80 to 10000. Sample size calculations were also performed for a range of power, baseline risk and relative risk, to determine the influence of study design on FI.
FI analysis of the severe TBI management guidelines revealed that most studies were associated with a low FI. In the majority of studies, FI was of a similar magnitude to the number lost to follow-up. The simulations revealed that while FI was inversely related to P value, a wide range of FI may be associated with a given P value. FI is also affected by sample size, baseline risk and effect size. Sample size calculations suggest that aside from very high-powered studies, most are likely to yield low FI values in the range typically encountered in the literature.
Many studies are underpowered and are expected to be associated with a small FI. Furthermore, FI over-simplifies the complex, non-linear relationships between sample size, effect size and P value, which hinder comparisons of FI between studies. FI places undue importance on the \"significance\" of P values and accordingly should only be used sparingly.
Journal Article
The therapeutic efficacy of adjunct therapeutic plasma exchange for septic shock with multiple organ failure: a single-center experience
Background
Sepsis remains a common condition with high mortality when multiple organ failure develops. The evidence for therapeutic plasma exchange (TPE) in this setting is promising but inconclusive. Our study aims to evaluate the efficacy of adjunct TPE for septic shock with multiple organ failure compared to standard therapy alone.
Methods
A retrospective, observational chart review was performed, evaluating outcomes of patients with catecholamine-resistant septic shock and multiple organ failure in intensive care units at a tertiary care hospital in Winston-Salem, NC, from August 2015 to March 2019. Adult patients with catecholamine-resistant septic shock (≥ 2 vasopressors) and evidence of multiple organ failure were included. Patients who received adjunct TPE were identified and compared to patients who received standard care alone. A propensity score using age, gender, chronic co-morbidities (HTN, DM, CKD, COPD), APACHE II score, SOFA score, lactate level, and number of vasopressors was used to match patients, resulting in 40 patients in each arm.
Results
The mean baseline APACHE II and SOFA scores were 32.5 and 14.3 in TPE patients versus 32.7 and 13.8 in control patients, respectively. The 28-day mortality rate was 40% in the TPE group versus 65% in the standard care group (
p
= 0.043). Improvements in baseline SOFA scores at 48 h were greater in the TPE group compared to standard care alone (
p
= 0.001), and patients receiving adjunct TPE had a more favorable fluid balance at 48 h (
p
= 0.01). Patients receiving adjunct TPE had longer ICU and hospital lengths of stay (
p
= 0.003 and
p
= 0.006, respectively).
Conclusions
Our retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone. Hemodynamics, organ dysfunction, and fluid balance all improved with adjunct TPE, while lengths of stay were increased in survivors. The study design does not allow for a generalized statement of support for TPE in all cases of sepsis with multiple organ failure but offers valuable information for a prospective, randomized clinical trial.
Journal Article
Phenomenologies of Scripture
Phenomenologies of Scripture addresses two increasingly convergent disciplines: philosophy and biblical studies. On the one hand, the recent “theological turn” in phenomenology has established religion as a legitimate area of phenomenological inquiry. If that turn is to be enduringly successful, phenomenology must pay attention to the scriptures on which religious life, practice, and thought are based. On the other hand, biblical studies finds itself in a methodological morass. Contemporary approaches to scripture have raised important questions about the meaning and function of scriptural texts that phenomenology is uniquely positioned to answer: How is the meaning of a text constructed or gleaned? How can the divine be present in human words? Is a scientific approach to the Bible still possible?
Bringing together essays by eight of today’s most prominent philosophers of religion with responses by two leading biblical scholars, Phenomenologies of Scripture reestablishes the possibility of fruitful, dialectical exchange between fields that demand to be read together.
eBook
Habitat selection by Dall’s sheep is influenced by multiple factors including direct and indirect climate effects
Arctic and boreal environments are changing rapidly, which could decouple behavioral and demographic traits of animals from the resource pulses that have shaped their evolution. Dall’s sheep ( Ovis dalli dalli ) in northwestern regions of the USA and Canada, survive long, severe winters and reproduce during summers with short growing seasons. We sought to understand the vulnerability of Dall’s sheep to a changing climate in Lake Clark National Park and Preserve, Alaska, USA. We developed ecological hypotheses about nutritional needs, security from predators, energetic costs of movement, and thermal shelter to describe habitat selection during winter, spring, and summer and evaluated habitat and climate variables that reflected these hypotheses. We used the synoptic model of animal space use to estimate parameters of habitat selection by individual females and calculated likelihoods for ecological hypotheses within seasonal models. Our results showed that seasonal habitat selection was influenced by multiple ecological requirements simultaneously. Across all seasons, sheep selected steep rugged areas near escape terrain for security from predators. During winter and spring, sheep selected habitats with increased forage and security, moderated thermal conditions, and lowered energetic costs of movement. During summer, nutritional needs and security influenced habitat selection. Climate directly influenced habitat selection during the spring lambing period when sheep selected areas with lower snow depths, less snow cover, and higher air temperatures. Indirectly, climate is linked to the expansion of shrub/scrub vegetation, which was significantly avoided in all seasons. Dall’s sheep balance resource selection to meet multiple needs across seasons and such behaviors are finely tuned to patterns of phenology and climate. Direct and indirect effects of a changing climate may reduce their ability to balance their needs and lead to continued population declines. However, several management approaches could promote resiliency of alpine habitats that support Dall’s sheep populations.
Journal Article
Resistance training does not induce uniform adaptations to quadriceps
Resistance training may differentially affect morphological adaptations along the length of uni-articular and bi-articular muscles. The purpose of this study was to compare changes in muscle morphology along the length of the rectus femoris (RF) and vastus lateralis (VL) in response to resistance training. Following a 2-wk preparatory phase, 15 resistance-trained men (24.0 ± 3.0 y, 90.0 ± 13.8 kg, 174.9 ± 20.7 cm) completed pre-training (PRE) assessments of muscle thickness (MT), pennation angle (PA), cross-sectional area (CSA), and echo-intensity in the RF and VL at 30, 50, and 70% of each muscle's length; fascicle length (FL) was estimated from respective measurements of MT and PA within each muscle and region. Participants then began a high intensity, low volume (4 x 3-5 repetitions, 3min rest) lower-body resistance training program, and repeated all PRE-assessments after 8 weeks (2 d ∙ wk-1) of training (POST). Although three-way (muscle [RF, VL] x region [30, 50, 70%] x time [PRE, POST]) repeated measures analysis of variance did not reveal significant interactions for any assessment of morphology, significant simple (muscle x time) effects were observed for CSA (p = 0.002) and FL (p = 0.016). Specifically, average CSA changes favored the VL (2.96 ± 0.69 cm2, p < 0.001) over the RF (0.59 ± 0.20 cm2, p = 0.011), while significant decreases in average FL were noted for the RF (-1.03 ± 0.30 cm, p = 0.004) but not the VL (-0.05 ± 0.36 cm, p = 0.901). No other significant differences were observed. The findings of this study demonstrate the occurrence of non-homogenous adaptations in RF and VL muscle size and architecture following 8 weeks of high-intensity resistance training in resistance-trained men. However, training does not appear to influence region-specific adaptations in either muscle.
Journal Article
The effect of training volume and intensity on improvements in muscular strength and size in resistance‐trained men
This investigation compared the effect of high‐volume (VOL) versus high‐intensity (INT) resistance training on stimulating changes in muscle size and strength in resistance‐trained men. Following a 2‐week preparatory phase, participants were randomly assigned to either a high‐volume (VOL; n = 14, 4 × 10–12 repetitions with ~70% of one repetition maximum [1RM], 1‐min rest intervals) or a high‐intensity (INT; n = 15, 4 × 3–5 repetitions with ~90% of 1RM, 3‐min rest intervals) training group for 8 weeks. Pre‐ and posttraining assessments included lean tissue mass via dual energy x‐ray absorptiometry, muscle cross‐sectional area and thickness of the vastus lateralis (VL), rectus femoris (RF), pectoralis major, and triceps brachii muscles via ultrasound images, and 1RM strength in the back squat and bench press (BP) exercises. Blood samples were collected at baseline, immediately post, 30 min post, and 60 min postexercise at week 3 (WK3) and week 10 (WK10) to assess the serum testosterone, growth hormone (GH), insulin‐like growth factor‐1 (IGF1), cortisol, and insulin concentrations. Compared to VOL, greater improvements (P < 0.05) in lean arm mass (5.2 ± 2.9% vs. 2.2 ± 5.6%) and 1RM BP (14.8 ± 9.7% vs. 6.9 ± 9.0%) were observed for INT. Compared to INT, area under the curve analysis revealed greater (P < 0.05) GH and cortisol responses for VOL at WK3 and cortisol only at WK10. Compared to WK3, the GH and cortisol responses were attenuated (P < 0.05) for VOL at WK10, while the IGF1 response was reduced (P < 0.05) for INT. It appears that high‐intensity resistance training stimulates greater improvements in some measures of strength and hypertrophy in resistance‐trained men during a short‐term training period. We investigated the effect of 8 weeks of resistance training that focused on high‐volume or high‐intensity training on stimulating changes in muscle strength and size in resistance‐trained men. Our biochemical analysis revealed greater growth hormone and cortisol responses to exercise in the high‐volume group, while no group differences were observed in the testosterone, insulin‐like growth factor‐1, or insulin responses. Nevertheless, we observed greater changes in upper body strength and size following high‐intensity training, while lower body changes were equal between groups.
Journal Article
Characterizing fire history on military land using machine learning and landsat imagery
BackgroundIn the past several decades, United States wildland fire occurrences have increased due to anthropogenic activities, shifts in precipitation and temperature patterns, and long-term fire suppression policies. Detailed records of local fire histories are needed to further understand ignition sources and the interaction between human activity, weather patterns and fire occurrences.AimTo estimate local fire histories, we delineate burned area on military installations over decadal time series (1984–2023) of Landsat imagery using random forest and boosted regression tree algorithms.MethodsWe trained and tested each model with 10 images from a manually delineated burned area dataset and applied them to Landsat images acquired from 1984 to 2023. We validated the model’s yearly summaries with the remaining manually delineated burned area dataset and compared success rates through confusion matrices, omission/commission error, sensitivity and specificity.Key resultsThe mean accuracy for the random forest models across all four installations was 0.941, while the mean accuracy of boosted regression models was 0.935. There was no significant difference between random forest and boosted regression model performance.ConclusionsWe present a methodology which can be utilized by other Army personnel and local land managers to develop fire histories for local-scale management units, particularly those geared towards national defense institutions.
Journal Article