The Rise and Fall of Caribbean Piracy: A Socio-Technical Analysis of the War of Spanish Succession, Maritime Innovation, and Edward Randolf’s Policy

This paper argues that the mode and historical context in which piracy ascended in the Caribbean after the War of the Spanish Succession, as well as the historical interrelation between maritime technology and pirate tactics, coalesced into a diachronic Damocles Sword that resulted in the downfall of piracy in the Golden Age. Sanctioning piratical enterprises as a subconventional maritime strategy displayed a geopolitical reliance on piracy by great powers. However, the depraved treatment conventional sailors received across all major European navies generated a social stratum that eventually bore the Golden Age of Piracy, while simultaneously contributing significantly to British naval supremacy in the eighteenth-century New World. The tactical, operational, and social technologies that this stratum of skilled seamen deployed initially overwhelmed national navies, leveraged popular support in peripheral communities, and ensured a dynamic supply and acquisitions system that granted pirate crews near immunity to the attrition of maritime operations. However, as pawns of history, they fell victim to their own success. At the turn of the mid-eighteenth Edward Randolph’s sophisticated anti-piracy policy, the obsolescence of pirate societies, and the promotion of the view that piratical endeavors are wholly parasitic, made both states and societies hunt them to extinction

Sleep staging and respiratory events in refractory epilepsy patients: Is there a first night effect?

Purpose:   We performed this analysis of possible first night effects (FNEs) on sleep and respiratory parameters in order to evaluate the need for two serial night polysomnograms (PSGs) to diagnose obstructive sleep apnea (OSA) in epilepsy patients. Methods:   As part of a pilot multicenter clinical trial investigating the effects of treating sleep apnea in epilepsy, two nights of PSG recording were performed for 40 patients with refractory epilepsy and OSA symptoms. Sleep architecture was examined in detail, along with respiratory parameters including apnea/hypopnea index (AHI) and minimum oxygen saturation. Analysis included two-tailed t -tests, Wilcox sign rank analysis, and Bland Altman measures of agreement. Results:   Total sleep time differed between the two nights (night 1,363.8 min + 59.4 vs. 386.3 min + 68.6, p = 0.05). Rapid eye movement (REM) sleep and percentage of REM sleep were increased during night two (night 1: 12.3% + 5.9 vs. night 2: 15.5% + 6.2, p = 0.007), and the total minutes of slow-wave sleep (SWS) were increased (night 1: 35.6 + 60.7 vs. night 2: 46.4 + 68.1, p = 0.01). No other sleep or respiratory variables differed between the two nights. Given an AHI inclusion criterion of five apneas per hour, the first PSG identified all but one patient with OSA. Discussion:   Respiratory parameters showed little variability between the first and second nights. Sleep architecture was mildly different between the first and second PSG night. Performing two consecutive baseline PSGs to diagnose OSA may not be routinely necessary in this population.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65717/1/j.1528-1167.2008.01681.x.pd

ST-Segment Elevation Myocardial Infarction vs. Hypothermia-Induced Electrocardiographic Changes: A Case Report and Brief Review of the Literature

BACKGROUND: Diagnosed ST-segment elevation myocardial infarction (STEMI) usually prompts rapid cardiac catheterization response. OBJECTIVE: Our aim was to raise awareness that hypothermia can cause electrocardiographic (ECG) changes that mimic STEMI. CASE REPORT: Emergency Medical Services (EMS) was called for altered mental status and lethargy in a 47-year-old man with a medical history of paraplegia. His history included hepatitis C, hypertension, seizures, anxiety, and recent pneumonia treated with i.v. antibiotics. When brought in by EMS, the patient was responsive only to painful stimuli. His blood glucose was 89 mg/dL; blood pressure was 80/50 mm Hg, and ECG showed ST elevations diffusely. His vital signs in the emergency department were heart rate 53 beats/min, blood pressure 134/79 mm Hg, respiratory rate 14 breaths/min, pulse oximetry of 100%, and a rectal temperature of 32.7°C (91°F). A second ECG showed diffuse ST elevation, sinus bradycardia with a rate of 56 beats/min, and a first-degree atrioventricular block. J waves were noted in V3-V6, I and II. There were no reciprocal changes or ST depressions. A bedside ultrasound showed no pericardial effusion. The patient underwent cardiac catheterization, which showed no coronary artery disease and a normal ejection fraction. Later, hypercapneic respiratory failure with bilateral pneumonia developed and was intubated. His ECG the following day, once he was rewarmed, showed complete resolution of ST elevation and almost complete resolution of J waves. CONCLUSION: Obtaining a complete set of vital signs is key to making a correct diagnosis. Hypothermia should be considered in the differential diagnosis of ST elevation

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Introduction: In 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines.Methods: This was a cohort study that took place from 2014-2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher’s exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461).Results: In 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016.Conclusion: A brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Introduction: In 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines.Methods: This was a cohort study that took place from 2014-2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher’s exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461).Results: In 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016.Conclusion: A brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients