Examining the Relationship between Adult Attention Deficit and Emotional Intelligence: Exploration of fundamental Univariate and Multi-Variate Relationships - Juniper Publishers

Intellectual & Developmental Disabilities - Juniper Publishers

Abstract

This research study examines the associations between dimensions of emotional intelligence (EQ) and adult attention deficit (AAD) in order to provide a framework for future research. A total of 219 management students completed three measures of AAD and a multi-dimensional measure of EQ (Bar-on EQI). Product moment correlations were used to examine the univariate associations between dimensions of EQ and AAD, and multiple regression examined the simultaneous multivariate relationship. Both the global measure of EQ and the all the sub-dimensions of EQ were significantly correlated with three established measures of AAD (College ADHD Response Evaluation, Brown AAD Scale and the DSM-V items used to identify inattention), except for non-significant univariate relationships between Brown-AAD and both empathy and social responsibility. Self-regard, self-actualization, reality-testing and stress-tolerance displayed the strongest univariate correlations, while self-actualization, reality-testing, happiness and stress tolerance remained significant when a composite score of the standardized scores from the 3 measures of AAD was simultaneously regressed on all the dimensions of EQ. Further research is required to confirm the directionality of the associations which will help to address the question of whether enhancing emotional competency will help reduce AAD symptoms and associated performance challenges.

Keywords: Emotional intelligence; Adult attention deficit; Adult attention deficit hyperactivity disorder

Introduction

Much of the traditional research on intelligence and performance has focused on the role of cognitive intelligence (IQ), which is defined as the capacity to understand, learn, recall, think rationally and solve problems [1]. Gardner [2], expanded on the concept of cognitive intelligence by suggesting that intelligence encompasses both cognitive and personal (emotional) elements. The personal (emotional) component includes two general components referred to as intrapsychic and interpersonal skills. Salovey and Mayer [3], referred to these components as emotional intelligence (EQ). Goleman [4], popularized the concept and suggested that EQ might be a better predictor of individual performance than IQ in a wide range of situations [5]. Goleman [4], generally defines EQ as the capacity to recognize and manage emotions in oneself and others.

Emotional intelligence is typically measured using either an omnibus test (e.g. Schutte Test) or tests that explicitly measure various dimensions of the construct (e.g. Bar-on EQI). Bar-on [6], developed a measure of EQ that contains fifteen dimensions of EQ and is considered to be one of the more comprehensive measures. The total score is referred to as the global emotional intelligence quotient (EQI). Bar-on [7], defines emotional intelligence as an “array of non-cognitive capabilities, competencies, and skills that influence one’s ability to succeed in coping with environmental demands and pressures.” The Bar-on measure of EQ is comprised of five core elements each with their own sub-dimensions. The five core components are intrapersonal capacities, adaptability, general mood, interpersonal capacities and stress management. The intrapersonal component includes self-regard, emotional selfawareness, assertiveness, independence and self-actualization. The adaptability component includes reality-testing, flexibility and problem-solving, and the general mood component includes optimism and happiness. The interpersonal component includes empathy, social-responsibility and interpersonal-relationships, and the stress-management component includes stress- tolerance and impulse-control.

Research has shown that EQ has a positive impact on individual performance (Kelley & Caplan, 1993), team performance [8-10], and organizational performance [11]. Research has also shown a positive impact on employee satisfaction [12], customer service [13], customer satisfaction [14], sales success [15], leadership [16,17], organizational change [18] and conflict management [19]. Goleman [20], suggests that unlike IQ, EQ can change throughout a person’s life, and is therefore a competency that should be the targeted in training programs and interventions aimed at improving performance in the workplace.

The above research highlights the importance of identifying personal and organizational factors that influence the development of EQ. A recent study on brain activity found that low EQ is related to underarousal of the left-frontal cortex, a condition that is also associated with attention deficit disorder [21]. A recent Harvard Business Review paperback [22], on bringing the whole self to work included articles by Edward Hallowell, Herbert Benson, Daniel Goleman, and Manfred Kets de Vries on how increased emotional intelligence can help to overcome attention deficit problems. This suggests a link between emotional intelligence and adult attention deficit.

Adult attention deficit

A recent national survey found that 4.2 percent of US workers had adult attention deficit and hyperactivity disorder (ADHD) resulting in $19.5 billion in lost human capital per annum [23]. Lifespan research suggests that the majority of children with ADHD continue to experience symptoms as adults [24- 29]. Prevalence estimates of ADHD among adults in the United States vary according to the measurement criteria used, with estimates ranging from less than 10 percent to as high as 70 percent [24,26,27,30]. A recent population screen of 966 adults in the United States suggests prevalence rates of 2.9 percent for narrowly defined ADHD and 16.4 percent using a more broad definition [31]. Kessler et al., [23], concludes that adult attention deficit disorders are a common and costly problem within the US workforce.

The Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (DSM-IV) defines ADHD (attention deficit and hyperactivity disorder) as “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development” [32]. A recent national survey by Harris Interactive (2004) found that the majority of adults with ADHD believed that the disorder had constrained them from achieving both short and long term goals. Research has confirmed that adults with ADHD attain lower occupational ranking, socioeconomic status and social class standing when compared with their peers [26,33]. Research by Biederman et al., [33], found that, on average, adults with ADHD have household incomes that are $10,791 lower for high school graduates and $4,334 lower for college graduates. Annual income loss for adults with ADHD in the United States is estimated at $77 billion, which is similar to income loss estimates for drug abuse ($58 billion) and alcohol abuse ($86 billion). Research has also established a link between ADHD and substance abuse [33].

A recent study using data from Fortune 200 companies found that absenteeism and medical costs for employees diagnosed with ADHD were 48 percent higher [34]. Adults with ADHD were also more likely to change jobs [35,36], engage in part time employment [33], and seek out jobs that don’t require concentration over long periods of time [37]. They also avoid jobs that require close supervision, repetitive tasks and sedentary performance conditions [26]. The disorder is also associated with higher accident rates and lower productivity [38,39]. Adults with ADHD are perceived by their employers as requiring more supervision and less able to complete assignments [40]. Research also suggests that team members with attention disorders have lower efficacy for working in teams [41]. Adults with ADHD have difficulty focusing on their problem behavior and without help will often fall into a chain of failures [42]. Barkley [40], suggests that depression, anxiety and diminished hopes of future success may help to develop and exacerbate the symptoms of adult ADHD. This suggests that without intervention, adults with attention disorders may find themselves trapped in a self reinforcing and debilitating cycle between strengthening symptoms and ongoing failures.

ADHD may also be associated with positive behaviors like ingenuity, creativity and determination [26], which may explain why entrepreneurs appear to have relatively higher levels of the disorder [43]. In fast paced work environments, adults with ADHD may perform just as well, if not better, than non-ADHD employees [44]. Hartman [45], encourages a more encompassing view of adult workers with ADHD by suggesting that employers consider both the negative and positive behaviors associated with the condition.

Research on adult ADHD suggests that the hyperactivity/ impulsivity component of the disorder may disappear or not exist, [28,46], whereas the inattention component and related cognitive symptoms, referred to as adult attention deficit (AAD), are more likely to persist or develop [47]. Brown [48], suggests that measures of AAD should exclude hyperactivity/impulsivity due to the inconsistency with which these symptoms appear in adults with attention disorders. Brown [48] also suggests that strict reference to the symptoms of inattention may not capture all of the key symptoms. Brown [48], proposes five clusters of symptoms all of which seem to commonly occur among adults with AADs. The five symptom clusters include difficulties with activation, concentration, effort, managing emotional interference and accessing memory. This suggests that AAD, as opposed to ADHD, may be a more prevalent problem for adult workers and that some of the key symptoms associated with the disorder are not sufficiently represented within the inattention component of traditional measures of ADHD.

Researchers have also expressed concern about strictly treating attention deficit disorder as a categorical diagnosis, as opposed to a dimensional construct with varying levels of severity [49,50]. Categorical diagnosis promotes simplistic use and interpretation of the construct. In order to overcome this limitation, Brown [48], suggests that measures of attention deficit disorder need to capture varying levels of severity and provide cut scores that separate out clinical vs. non-clinical sub-groups. This research defines adult attention deficit (AAD) as a persistent pattern of inattention and related cognitive symptoms that occur with varying levels of severity. AAD creates additional challenges within the academic, work and social life of adults.

Although empirical research on the impact of attention disorders on organizational behavior is limited, research to date suggests that AAD is having a wide range of negative consequences in the workplace [23]. Research also suggests that employees with attention related disorders may excel on certain tasks and in certain work environments. This highlights the importance of identifying the particular competencies, tasks and work situations that are negatively affected by AAD.

Emotional intelligence and adult attention deficit

This research study will examine the influence of AAD deficit on the fifteen elements of EQ proposed by Bar-on [7]. The intrapersonal core component includes self-regard, emotional self-awareness, assertiveness, independence and selfactualization. Difficulties with activation, concentration, effort, managing emotional interference and use of short term memory will undermine attempts at mastering key life tasks. Persistent difficulties with mastery will undermine general efficacy, selfregard and eventually assertiveness. Assertiveness in face of persistent failures will produce escalating dissonance which should ultimately lower expectations and proactive behavior if success is not available. The inability to concentrate, sustain effort and manage emotional interference will constrain emotional awareness and increase emotional dependence on others. All of the elements of AAD represent considerable barriers to realizing one’s full potential and living a meaningful and satisfying life, therefore AAD represents a significant barrier to self-actualization.

H1: Self-regard will be negatively associated with adult attention deficit
H2: Emotional self-awareness will be negatively associated with adult attention deficit
H3: Assertiveness will be negatively associated with adult attention deficit
H4: Independence will be negatively associated with adult attention deficit
H5: Self-actualization will be negatively associated with adult attention deficit

The adaptability core component includes reality testing, flexibility and problem solving. The ability to assess the correspondence between what is experienced and what objectively exists will be constrained by difficulties with concentration, emotional interference and accessing short term memory. Difficulties with concentration, effort and emotional interference will limit the extent to which someone is able to adjust their emotions, thoughts and behavior to changing situations and conditions. The process of identifying, analyzing and taking actions to remove problems requires concentration and effort. This suggests that adults with AAD will have difficulty with problem solving.

H6: Reality testing will be negatively associated with adult attention deficit
H7: Flexibility will be negatively associated with adult attention deficit
H8: Problem solving will be negatively associated with adult attention deficit

The general mood core component includes optimism and happiness. The ability to look on the brighter side of life and remain hopeful in the face of adversity is difficult to do when afflicted with significant cognitive and emotional constraints. Difficulty achieving personally valued outcomes and states will limit enjoyment and satisfaction.

H9: Optimism will be negatively associated with adult attention deficit
H10: Happiness will be negatively associated with adult attention deficit

The interpersonal core component includes empathy, social responsibility and interpersonal relationships. Difficulties achieving a sense of personal value and efficacy should increase preoccupation with self. Heightened self-preoccupation coupled with emotion interference and the inability to concentrate, will reduce the ability to empathize with others. All of the symptoms of AAD will constrain a person’s ability to be a cooperative, contributing and constructive member of a group. This does not mean that group members with AAD have anti-social intent, rather it means that ongoing difficulties and preoccupation with self makes it difficult to display higher levels of social responsibility. Adults with AAD will have difficulty establishing and maintaining mutually satisfying relationships characterized by intimacy and the exchange of affection. Intimacy and the exchange of affection requires attentiveness, effort and non-reactive expression of difficult emotions. AAD will limit such abilities, and in doing so, will undermine the process of establishing and maintaining healthy interpersonal relationships.

H11: Empathy will be negatively associated with adult attention deficit
H12: Social responsibility will be negatively associated with adult attention deficit
H13: Interpersonal relationships will be negatively associated with adult attention deficit

The stress management core component includes stress tolerance and impulse control. The ability to tolerate stress and control reactive behavior requires concentration, emotional control and effort. This suggests that adults with AAD will have difficulty with stress and controlling impulsive behavior.

H14: Stress tolerance will be negatively associated with adult attention deficit
H15: Impulse control will be negatively associated with adult attention deficit

All of the elements of EQ are potentially constrained by difficulties with activation, concentration, effort , managing emotional difficulties and memory. Therefore, total or global EQ should be negatively associated with AAD.

H16: Global emotional intelligence will be negatively associated with adult attention deficit

Methods

Subjects and procedures

The subjects were two hundred and nineteen university students enrolled in two business courses at public universities in the Northwestern United States. The subjects completed two measures of adult attention deficit and a multi-dimensional measure of EQ during the course of the semester. The hypotheses regarding associations between emotional intelligence and adult attention deficit were tested using Pearson product moment correlations.

Measures

Bar-on Emotional Intelligence Quotient (EQI). Emotional intelligence was measured using the Bar-on EQI [7]. The Baron EQI is a comprehensive instrument that measures fifteen conceptual components of emotional intelligence that are group into five core components. The following definitions of each of the fifteen conceptual components were taken from the professional manual accompanying the Bar-on EQI measure. The intrapersonal core component includes self-regard, emotional self awareness, assertiveness, independence and self actualization. Self regard is defined as the ability to respect and accept oneself as basically good, and an example item is: “I’m happy with the type of person that I am.” Emotional self awareness is defined as the ability to recognize one’s feelings, and an example item is: “It’s hard for me to describe my feelings.” Assertiveness is the ability to express feelings, beliefs, and thoughts, and defend one’s rights in a nondestructive way. An example item is: “It’s hard for me to say no when I want to.” Independence is the ability to be self-directed and self-controlled in one’s thinking and actions, and to be free of emotional dependency. An example item is: “I tend to cling to others.” Self actualization is the ability to realize one’s potential capabilities, and an example item is: “I don’t have a good idea of what I want to do in life.”

The adaptability core component includes reality testing, flexibility and problem solving. Reality testing is the ability to assess the correspondence between what is experienced and what objectively exists. An example item is: “I tend to exaggerate.” Flexibility is the ability to adjust one’s emotions, thoughts and behavior to changing situations and conditions, and an example item is: “It’s easy for me to adjust to new conditions.” Problem solving is the ability to identify and define problems as well as to generate and implement potentially effective solutions. An example item is: “I generally get stuck when thinking about different ways of solving problems.”

The general mood core component includes optimism and happiness. Optimism is the ability to look at the brighter side of life and to maintain a positive attitude even in the face of adversity. An example item is: “I generally expect that things will turn out alright, despite setbacks from time to time.” Happiness is the ability to feel satisfied with one’s life, to enjoy oneself and others, and to have fun. An example item is: “I’m a fairly cheerful person.”

The interpersonal core component includes empathy, social responsibility and interpersonal relationships. Empathy is the ability to be aware of, to understand, and to appreciate the feelings of others, and an example item is: “I’m good at understanding the way other people feel.” Social responsibility is the ability to demonstrate oneself as a cooperative, contributing, and constructive member of one’s social group, and an example item is: “It doesn’t bother me to take advantage of other people, especially if they deserve it.” Interpersonal relationships is the ability to establish and maintain mutually satisfying relationships that are characterized by intimacy and by giving and receiving affection. An example item is: “I don’t keep in touch with friends.”

The stress management core component includes stress tolerance and impulse control. Stress tolerance is the ability to withstand adverse events and stressful situations without falling apart by actively and positively coping with the stress. An example item is: “I know how to keep calm in difficult situations.” Impulse control is the ability to resist or delay an impulse, drive, or temptation to act, and an example item is: “I tend to explode with anger easily.”

The measure contains one hundred and seventeen items that are answered using a five point scale (1=very seldom or not true of me, 2=seldom true of me, 3=sometimes true of me, 4=often true of me, 5=very often true of me or true of me).

Adult Attention Deficit (AAD): The Brown [48], attention deficit disorder scales were used to measure adult attention deficit. The instrument has been designed and tested for use with adults eighteen years and older. The forty self-report items on the Brown AAD scales are grouped into five clusters of conceptually related symptoms of AAD. Organizing and activating to work (cluster 1) measures difficulty in getting organized and started on tasks. An example item is: I am disorganized; I have excessive difficulty keeping track of plans, money, or time. Sustaining concentration (cluster2) measures problems in sustaining attention while performing tasks. An example item is: I listen and try to pay attention (e.g., in a meeting, lecture, or conversation) but my mind often drifts; I miss out on desired information. Sustaining energy and effort (cluster 3) measures problems in keeping up consistent energy and effort while performing tasks. An example item is: I “run out of steam” and don’t follow through; my effort fades quickly. Managing affective interference (cluster 4) measures difficulty with moods and sensitivity to criticism. An example item is: I become irritated easily; I am “short-fused” with sudden outbursts of anger. Utilizing working memory and accessing recall (cluster 5) measures forgetfulness in daily routines and problems in recall of learned material. An example item is: I intend to do things but forget (e.g., turn off appliances, get things from store, return phone calls, keep appointments, pay bills, do assignments).

College ADHD Response Evaluation: In addition to the Brown measure of adult attention deficit, a measure of inattention was taken from the college adult attention deficit and hyperactivity response evaluation (CARE) [51]. The CARE measure also included a separate inattention scale containing the DSM-IV items used to identify the inattention component of ADHD. The CARE measure of inattention was developed to assist with the increasing number of requests for academic accommodations for college students with ADHD. It is the first measure of ADHD expressly designed for individuals at the university level. Twenty-one items were used to measure the inattention component of the CARE, and an example item is: “I notice important details on an assignment.” There are nine DSM-IV items used to identify the inattention component of ADHD, and an example item is: “I avoid, dislike or am reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).” For both the CARE and the DSM-IV inattention scales, subjects rated their level of agreement with each item using a three point scale (0=disagree, 1=undecided, 2=agree).

Results

Descriptive statistics

Means, standard deviations, internal reliabilities and correlations appear in table one. All variable distributions are approximately normal and demonstrate reasonable variation across their respective scales. Cronbach alpha coefficients ranged from α=0.73 to α=0.90 suggesting good internal reliabilities. No univariate or bivariate outliers were considered problematic and the product moment correlations revealed significant associations between the variables (Table 1).

Empirical tests of hypotheses

Unless stated otherwise, all hypothesized correlations were in the expected direction, and all reported statistical probabilities are based on two tailed tests (α=0.05). Given the sample size and the use of two-tailed significance tests, correlations above 0.14 are statistically significant.

Hypothesis 1: The correlations between self-regard and adult attention deficit were statistically significant (Brown r = -0.38, Care r = -0.33, DSM-IV r = -0.41). This provides support for the hypothesis that self-regard is negatively associated with adult attention deficit.
Hypothesis 2: The correlations between emotional selfawareness and adult attention deficit were statistically significant (Brown r = -0.33, Care r = -0.30, DSM-IV r = -0.34). This provides support for the hypothesis that emotional self-awareness is negatively associated with adult attention deficit.
Hypothesis 3: The correlations between assertiveness and adult attention deficit were statistically significant (Brown r = -0.36, Care r = -0.20, DSM-IV r = -0.33). This provides support for the hypothesis that assertiveness is negatively associated with adult attention deficit.
Hypothesis 4: The correlations between independence and adult attention deficit were statistically significant (Brown r = -0.34, Care r = -0.18, DSM-IV r = -0.28). This provides support for the hypothesis that independence is negatively associated with adult attention deficit.
Hypothesis 5: The correlations between self-actualization and adult attention deficit were statistically significant (Brown r = -0.39, Care r = -0.34, DSM-IV r = -0.40). This provides support for the hypothesis that self-actualization is negatively associated with adult attention deficit.
Hypothesis 6: The correlations between reality testing and adult attention deficit were statistically significant (Brown r = -0.42, Care r = -0.44, DSM-IV r = -0.44). This provides support for the hypothesis that reality testing is negatively associated with adult attention deficit.
Hypothesis 7: The correlations between flexibility and adult attention deficit were statistically significant (Brown r = -0.25, Care r = -0.15, DSM-IV r = -0.24). This provides support for the hypothesis that flexibility is negatively associated with adult attention deficit.
Hypothesis 8: The correlations between problem solving and adult attention deficit were statistically significant (Brown r = -0.20, Care r = -0.25, DSM-IV r = -0.19,). This provides support for the hypothesis that problem solving is negatively associated with adult attention deficit.
Hypothesis 9: The correlations between optimism and adult attention deficit were statistically significant (Brown r = -0.29, Care r = -0.25, DSM-IV r = -0.33). This provides support for the hypothesis that optimism is negatively associated with adult attention deficit.
Hypothesis 10: The correlations between happiness and adult attention deficit were statistically significant (Brown r = -0.22, Care r = -0.22, DSM-IV r = -0.25). This provides support for the hypothesis that happiness is negatively associated with adult attention deficit.
Hypothesis 11: The correlations between empathy and adult attention deficit were mostly statistically significant (Brown r = -0.02, Care r = -0.19, DSM-IV r = -0.16) except for the correlation with Brown AAD which was non-significant. This provides some support for the hypothesis that empathy is negatively associated with adult attention deficit.
Hypothesis 12: The correlations between social responsibility and adult attention deficit were mostly statistically significant (Brown r = -0.04, Care r = -0.28, DSM-IV r = -0.24), except for the correlation with Brown AAD which was non-significant. This provides some support for the hypothesis that social responsibility is negatively associated with adult attention deficit.
Hypothesis 13: The correlations between interpersonal relationships and adult attention deficit were statistically significant (Brown r = -0.20, Care r = -0.21, DSM-IV r = -0.28). This provides support for the hypothesis that interpersonal relationships is negatively associated with adult attention deficit.
Hypothesis 14: The correlations between stress tolerance and adult attention deficit were statistically significant (Brown r = -0.41, p = 0.00; Care r = -0.31, p = 0.00; DSM-IV r = -0.40, p = 0.00). This provides support for the hypothesis that stress tolerance is negatively associated with adult attention deficit.
Hypothesis 15: The correlations between impulse control and adult attention deficit were statistically significant (Brown r = -0.22, Care r = -0.35, DSM-IV r = -0.25). This provides support for the hypothesis that impulse control is negatively associated with adult attention deficit.
Hypothesis 16: The correlations between total EQ and adult attention deficit were statistically significant (Brown r = -0.39, Care r = -0.39, DSM-IV r = -0.44). This provides support for the hypothesis that impulse control is negatively associated with adult attention deficit.

Multivariate Exploration

A multivariate exploration of the relationship between the dimensions of EQ and a composite measure of AAD, derived by adding the standardized scores from the three measures of AAD (Brown, CARE and DSM-V) is contained in table 2. After simultaneously entering all the dimensions of EQ into the regression, self-actualization (p=0.03), reality-testing (p=0.00), happiness (p=0.00) and stress tolerance (p=0.05) remained significant. This suggests that the EQ dimensions of selfactualization, reality-testing, happiness and stress tolerance demonstrate independent and significant associations with AAD [52-57].

Discussion

The global measure of EQ (Bar-on EQI) is significantly negatively correlated with adult attention deficit. In general, this suggests that adult attention deficit is associated with a variety of emotional challenges ranging from assertiveness to self-actualization. The EQ dimensions of self-regard, selfactualization, reality-testing and stress-tolerance displayed the strongest univariate correlations, and all remained significant except for self-regard (p=0.08) when simultaneously controlling for the influence of the other dimensions of EQ. The results suggest that AAD is a potential constraint within the process of developing accurate representations of external situations (reality testing) and may evoke defensive reality distorting processes arising from experienced threats to self-efficacy. The significant association with poor stress tolerance supports the increased likelihood of performance disruption and reduction in self-efficacy. From a higher-order perspective, the results suggest that AAD is associated with experiential challenges including difficulty attaining general happiness and achieving a sense of self-actualization. In general, the results suggest that AAD is associated with both lower order challenges like situational assessment and stress management, and experiential challenges like general happiness and self-actualization. The directionality of the relationship between EQ and AAD requires further exploration to determine potential types of intervention and assistance. To the extent that EQ contributes to AAD, activities that emphasize improvement in emotional competency may assist in reducing or constraining the symptoms and associated performance challenges associated with AAD. To the extent that AAD contributes to EQ, addressing the key dimensions of AAD like difficulty activating to work and sustaining attention on required tasks may support significant emotional dynamics like stress tolerance, and ultimately contribute to greater self-actualization and happiness.

Suggestions for Future Research and Limitations

In order to overcome potential limitations to external validity resulting from the use of university students, future studies need to draw samples from a wider variety of adults. More complex modeling and empirical assessment of the network of relationships between AAD and EQ is required to better specific the nomological network, identify key mediators and moderators, and clarify the directionality of the relationship.

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Evolution and the Chemistry of Life - Juniper Publishers

Organic & Medicinal Chemistry - Juniper Publishers

Abstract

In this paper, we show the physics and chemistry of how life may have begun up to the stage of producing three amino acids and sugar. The reaction is telescopic to produce even more proteins. We use the parameters from Astro theology Mathematics covered extensively in other papers by this author.

Keywords: Chromium; Life Chemistry; Amino Acids, Butanoic Acid; Tryptophan; Cystene; L- Glutathione

Introduction

In this brief paper, we develop the balanced chemical equation that shows that life began from three amino acids which produced sugar. We show how Physics, or Astroheology, melds with Chemistry, the Periodic Table.
G/Coulomb= Chromium
6.67/1.602=24=Cr
Mass Cr=55.996 +26e-=1/54=t
t=e^M=1/54=3.989≈4=M
24(938)=2.25=9/4=c²/M
24 x938+26(5.1099)=1/4.416=1/148
Ln 148=5.0=E ⇒y=y′ t=3
51.996 x 24=1.2479≈1.25=Emin
t=0.801

2(5.1099)(26=265.7
Butanoic Acid implies L-Tryptophan
C₂H₄O m mass
44.0262 x 6.023=265.7

Butanoic acid results from L-Tryptophan. It is a n immune response for Ble Green Algae Cyanobacteria – one of the oldest life forms on Earth. Cyanobacteria forms Vitamin B12 (Figure 1).

NaCl + HOH = Na(OH) + HCl
Zn(OH) + HCl = HOH + ZnCl
HOH = H + OH
2 ZnCl + H₂O + C₆H₁₂O₂ = 2Zn + 2HCl + 3C₂H₄O
Zinc +Water + Sugar =Zinc Mineral +Stomach Acid+ Butanoic
Acid
2(100.83)+1(18.02)+1(116.16)=2022=H2 acid
C₁₀H₁₂N₃O₆S + 24 H₂O = 10 CO₂ + H₂SO₄ + 3 NO₂ + 29 H₂
L- glutathione
24 (18.02)+1(302.28)=734.28 -100=265
Ethylene Oxide
C₂H₄O 44.05(6.023)=265=SF
t=e^M=e^2.65=1.415=sqrt2=E=sin 45+cos 45
For glutathione we need cystine and glutamate.
s=E ×t=|E||t|sinn θ
sin θ =s/[Et]
y=y′ ⇒E=5, t=3
Et=15
s=Et
s=E²Et sin θ
sin θ =s/E²=tan θ =sin θ /cos θ
sinθcos θ =sin θ
cos θ =1
θ =0, π =t
π² - π -1=57.29°=1 rad=E
3²+x²=15²
x²=225/9
x²=25=E² Perfect Square
t=E

Cyanobacteria leads to Butanoic Acid which leads to Iron and red blood cells and oxygen metabolism. It also leads to Zinc. Butanoic acid also leads to H₂ Acid. Cysteine leads to Sulphur.

Try Mo M=204.29
Cys Mol/ M=121.15
SUM325.44 x 6.023=1960 = infinity divergent
Immunoglobulins evolved from Cys, Try, and Glu (Figure 2)

6 C₁₇H₂₃N₃₀₇S + 5652 H₂O =5613 H₂ +17 C₆H₁₂O₆ + 6 H₂SO₄ + 1842 NO₃ Cys-Glu-Try  Sugar +Volcanos. 413.4 x 6.023=2489=1/402=1/Re 1/Re=VF/IF =1/2rhov^2/[Ma] =1/2(4/Pi)v^2=[4 x 1/sqrt2] V=148.7 M= Ln 148.7=5.00=E

Conclusion

We have shown that life began with a combination of three amino acids (Cys-Glu-Tyr) which produced acid and sugar.

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A Book Review of Exporting Chinese Architecture: History, Issues and “One Belt One Road” - Juniper Publishers

 Civil Engineering Research - Juniper Publishers

Abstract

Power devices are used in various industrial applications, including energy transfer (grid, wind), industrial applications (rail, photovoltaic systems) and civil equipments (electric vehicles, battery charges, home appliance). Power switches reliability may be affected by their high switching frequency, causing strong thermal fluctuations. Therefore, an electro-thermal analysis is essential to improve their reliability and to ensure continuous operation. The device aging phenomenon is taken in consideration for lifetime estimation.

Keywords: Power device; Thermal stress; Junction temperature; Electro-thermal model; Lifetime; Aging

Introduction

The first two decades of the twentieth-first century have witnessed the growing scholarly attention paid to the history of transnational architectural production, which demonstrated the dynamic flow of people, ideas, goods, and technical know-how, especially from the Second World to the Third World during the Cold War [1-5]. Exporting Chinese Architecture is the first English monograph on the subject of China-aided architecture built in the rest of the world, providing international readers with a window through which to understand the contexts, practices, and consequences of China’s engagement with the globe through material constructions. The editors Charlie Xue and Guanghui Ding worked together with 20 other scholars to conduct a comprehensive and systematic review of China’s aid construction process from multiple perspectives. The collected 13 articles are organized into three parts, namely “Historical Narrative”, “Cross-Border Design and Construction” and “One Belt and Road”. According to the editors’ statistics, over the past 60 years, more than 1,500 buildings were subsidized by the Chinese government and built by Chinese professionals in more than 160 countries, involving an investment equivalent to more than 100 billion US dollars. Sixty years (1958-2018) of construction assistance and cooperation are all connected and underlined by “transformational modernism” put forward by the editors. This “transformational modernism” changed the face of many cities in developing countries, and also Chinese architecture itself.

Xue and Ding had already analyzed the role of design institutes in offering foreign aid under the chapter “Architectural Export from China’s Design Institutes “ in their earlier book A History of Design Institutes in China: from Mao to market. In the short review of the book, Kenneth Frampton expressed his interest in “how Chinese modern culture spreads to the developing countries through design institutes, especially in Africa and Southeast Asian countries”. As an expansion of the topic mentioned by Frampton, Exporting Chinese Architecture explains the background, motives, principles, and features of China’s aided constructions, and takes five questions as a guide to uncover the stories behind the production of foreign-aided buildings, including the international situation, diplomatic relationship, society, cultures, and economic situations. In addition, the local attitudes and evaluations towards China-aided buildings have also enriched the understanding of China’s aided constructions. Ultimately, the editors believe that building quality is eventually the pursuit of the goal of China’s exported architecture when designers and constructors face the tasks.

The first part is the interpretation of the historical context at the macro level. The evolution of architectural forms, materials, technologies, and aesthetics is a visible expression of the changing politics, economy, technology, foreign policy, and diplomatic relations in China. China’s architectural aid has experienced three periods Woods [6]: 1) Free aid (1956-1978): To meet the local needs for modern industrialization and political performance, China assisted to build industrial facilities and public buildings in Mongolia, North Korea, Vietnam, Laos, Cambodia, Indonesia, Guinea, Ghana, Sri Lanka, Pakistan, etc. 2) Reasonable aid (1979- 1995): Under the market-oriented policy, Chinese government carried out rationalization reforms on aided construction, pursuing effective, fast, and low-cost works. 3) Institutionalized aid (1996-2018). The style, technology, and standards of aided construction are the factors that Chinese architects focused on. In Chapter 4, Amoah uses “Architecture diplomacy” to discuss space and rights with the National Theatre of Ghana as an example. He believes that the political factors of China’s aided architecture are overwhelming and points out the contradictions of the implementation process. While Chinese architects introduced local elements to express Ghanaian cultural attributes, Amoah was concerned about the lack of opportunity by local architects to participate in architectural design and the damage to the rural landscape, and ecological environment, arguing that Chinese engagement gave rise to what he called a “deformational modernism”.

The second part is a detailed study of specific architectural types at the medium level. The local influence in combination with research and evaluation also be discussed. This part is a collection of four papers, the first three are special analyses of aided medical buildings (Tang, et al.), conference buildings Zhang et al. [7], and educational buildings [8]. The last chapter Zhang et al. [7] enlarges the view of the city and discusses the role of China’s aided construction in the urban development of Djibouti and Addis Ababa. Overall, “designed in China, adapted to overseas” is the basic principle of architectural aid. China’s foreign aid construction is generally based on the various development goals of the recipient countries and built to show China’s positive image and enhance its soft power. The aided medical and health projects are deeply supported by the local people, improving the level of medical infrastructure, and having a positive social impact; while the parliament buildings, (international) conference centers, and stadiums are conducive to shaping the image of the recipient country as a landmark [9]. Such projects are the basis for the recipient country to be qualified to host international conferences and events, which in turn attract foreign investment for urban development [10]. However, these aided political edifices have received mixed reviews internationally. In contrast, education aid projects are more likely to gain respect and acclaim due to their international feature, humanitarian nature, and public benefit. These aid programs have created only a fragmented picture of the modern city, with limited impact on urban life, however.

The third part, focusing on the “One Belt, One Road” initiative, is the consideration of cases on a micro level under the policy guidance. This section shows how Chinese professionals have in recent decade engaged with the international world through architectural design and construction. In addition to traditional state-owned design institutes, design institutes such as IPPR and CCDI have also captured a portion of the market share of aided construction [11]. A series of events in the 21st century point to an international opportunity for greater integration. The overseas design practice is changing from the “philanthropic project” that emphasizes assistance to the “compound output” that realizes win-win value, with a shift from “project export” to “investment export” (Ai). This is completely consistent with China’s current national strategy of “the One Belt and One Road” Initiative. Throughout the construction industry, promoting multilateral mechanisms with developing countries and actively developing cooperative partnerships is the trend of China’s overall policy in the future [7]. The history of aided construction proves China’s construction strength, technology, and international cooperation capabilities. As an unpredictable “blue ocean”—unexplored new market areas, the overseas business and special features of Chinese large design enterprises still deserve further study and exploration [12].

In general, hundreds of projects mentioned and more than forty projects analyzed in this book can be summed up in two basic issues: first is the discussion and analysis of the Chinese model of foreign aid. In the international context, the relationship between “China, the West, Soviet socialism, and locality” is complex and intertwined. There is a worship of authority, but also a certain sense of common humanity and humanism. The authors concretize the abstract relationship between them, among which political preferences, tropical modernism, standard issues, and economic rationality are the focus of discussion. Second is an in-depth inquiry into how influential factors, especially non-architectural ones, are reflected in architectural entities. The development of aided architecture is undoubtedly related to external factors such as politics, economy, society, and culture. But this transformation is a multi-level and non-simultaneous complex process. In addition, the changes and continuity of Asian-African relations are evident throughout the history of China’s architectural aid. Africa has more than 70% of aided projects and occupies an important position in China’s foreign aid construction [13]. Following Asia, and Latin America, Africa began its modernization, rapid urbanization, and social reform. After independence, many African countries are highly dependent on foreign aid. Although African countries have their history and glorious native civilization, the uniqueness is missing due to the constraint of economic, colonial control, and political turmoil. In such a situation, aid eager for instant benefit would worsen the state, causing recipient countries to alleviate poverty but lose their vitality and identity [14]. Therefore, a reasonable and moderate model as well as a healthy cooperative construction relationship have always been the goals pursued by Chinese construction professionals.

Although this book provides a systematic and comprehensive review of the history of construction aid and conducts in-depth research on architectural cases, it lacks an overview of building types at the middle level. Perhaps due to the limited length of the introduction, the editors did not fully describe “more than 1,500 buildings subsidized by the Chinese government and built by Chinese professionals in more than 160 countries, including railways, stations, factories, theaters, stadiums, schools, hospitals, and government buildings.”, and only three of these types were expanded. Other types of aid construction are also mentioned in the first and third parts of this book. The study of respective emergence, duration, quantity, and regional distribution of these types is likely to corroborate the shifts in bilateral international relations, political and economic policies, and development needs of recipient countries.

The practical significance of studying China’s aided architecture is not to create a new field, rather, it is to integrate the research on “Third-world” countries into existing Chinese architectural research and practice, with the implication of rethinking Chinese contemporary architecture within a broader world network, thus avoiding isolated thinking and simplified operations [8]. As part of international development assistance, China’s exported construction is a transnational practice shaped by geopolitics, power competition and cooperation, knowledge transfer, and the movement of people, capital, goods, and ideas [15]. Therefore, there is a need to look at Chinese aid issues from a global perspective and to combine common human standards of environmental values with the differentiated development paths adhered to by different regions. This stance of respect, civilization, fraternity, and sharing is rooted in the contemporary reflection of ancient Chinese wisdom.

Overall, Exporting Chinese Architecture is a fascinating and in-depth introduction to the process of China’s construction aid. It is suitable not only for students and faculties of architecture but also for other readers interested in political history, social history, cultural history, art history, diplomacy and international relations, cross-cultural studies, etc. The book’s informative historical materials, diverse protagonists, rich on-site surveys and photographs, and diverse perspectives provide a multifaceted record depicting the history of China’s aid construction, like a piece of the puzzle, complementing the historical and theoretical discussion on China’s modern and contemporary architecture. The authors strive to use interdisciplinary methods to achieve factual research, data statistics, text interpretation, formal analysis, and even cross- cultural comparison, adding new contexts and perspectives to stimulate the reader’s thinking. Regardless of race, people from different political systems and cultures share the desire for a better life. Promoting the building of a world of common prosperity is not only the goal pursued by great power diplomacy with Chinese characteristics but also the common mission of the international community. From this point of view, what will go out in the future is no longer a narrowly defined “Chinese design”, but a closer and more diversified relationship between “China and the world”.

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Does the Timing of Intubation and IMV Impact Clinical Outcomes in Adult COVID-19 Patients with ARDS: A Systematic Review and Meta-Analysis - Juniper Publishers

 Pediatrics & Neonatology - Juniper Publishers

Abstract

Background/Aim: COVID-19 can rapidly develop into acute lung injury, and even acute respiratory distress syndrome (ARDS), which has a high risk of death. Patients with ARDS often require intubation. However, the timing of intubation and its effect on clinical outcomes in COVID-19 ARDS (CARDS) patients remains unclear. Thus, the authors explored the impact of intubation time on clinical outcomes in COVID-19 patients with ARDS through a systematic review and meta-analysis.

Materials and Methods: Research articles from PUBMED, CINAHL, MEDLINE, ProQuest Covid database, and Web of Science were searched through December 2021. All patients in the research met the Berlin criteria for ARDS. For the purposes of this review, “Early” intubation was defined as intubation within 24 hours of an ARDS diagnosis, while “Late” was defined as 24 or more hours after diagnosis. The primary outcome was ICU mortality, and secondary measures included length of ICU stay and duration of mechanical ventilation. The meta-analysis was performed using a random-effects model. The quality of cohort studies was assessed using the Newcastle-Ottawa Scale. The methodological quality of the overall evidence in this review was evaluated using the GRADE approach.

Results: After an extensive search, six cohort studies were ultimately included in the systematic review, altogether encompassing 2,739 patients with CARDS. A meta-analysis revealed statistically significant differences in mortality [risk ratio (RR)=0.78; 95% confidence interval (CI),0.69-0.88; Z=3.91, P < 0.0001)]. The mortality rate was 36.2% (817 deaths) in the early group and 48.2% (229 deaths) in the late group, respectively. Results of the narrative analysis showed that early intubation resulted in shorter ICU stays, which was statistically significant. However, no statistical difference was found in the duration of mechanical ventilation.

Conclusions: Early intubation can reduce mortality and length of ICU stay in adult COVID-19 patients with ARDS. However, the timing of intubation did not affect the duration of continuous mechanical ventilation.

Keywords: COVID-19; ARDS; Timing of Intubation; Invasive Mechanical Ventilator; Systematic Review; Mortality

Introduction

In December 2019, COVID-19 was identified as a new clinical syndrome caused by a novel coronavirus. The virus is transmittable through the respiratory tract and is highly contagious. Despite significant efforts to control the spread of COVID-19, it triggered a global pandemic [1-4], an epidemic of scale across international borders [5]. COVID-19 pneumonia may develop rapidly into acute respiratory distress syndrome (ARDS) with a high risk of death [6]. ARDS is an acute respiratory failure caused by increased pulmonary capillary permeability secondary to inflammatory oedema. It leads to alveolar flooding and subsequent deep hypoxemia, in which intrapulmonary shunt is the most important underlying mechanism [7]. However, ARDS caused by COVID-19 is different from ARDS with any other underlying cause. According to Huang et al. (2020) [8], the onset of ARDS associated with COVID-19 is between 8-12 days. There are two distinct phenotypes of COVID-19-associated ARDS (CARDS), L-type and H-type. Type L presents as pneumonia and is limited to mild inflammation of the subpleural interstation.

It is characterized by low elasticity, atelectasis, normal compliance, and low lung weight. On the other hand, patients with Type H meet typical ARDS criteria, including decreased lung compliance, hypoxemia, bilateral lung infiltration, and increased lung weight [9]. Li and Ma [10] have been reporting on respiratory support strategies for patients with CARDS during the past two years, but how exactly the timing of tracheal intubation and use of invasive mechanical ventilation impacts clinical outcomes is still unclear in patients with CARDS. Delayed intubation can cause autologous lung injury (SILI) due to high respiratory drive pressure [11]. However, intubating patients too early can also be associated with some complications, including ventilatorassociated pneumonia, airway injury, ventilator-induced lung injury, and hemodynamic disorders due to positive pressure ventilation [12]. Six primary studies [13-18] have indicated different results regarding the timing of intubation for patients with CARDS, and currently there is no systematic review relevant to this topic. Therefore, a systematic review is necessary to further explore how the timing of intubation impacts outcomes for these patients.

Materials and Methods

The PRISMA statement, which contains a 27-item checklist and four-phase flow chart [19], is used to help authors report systematic reviews and meta-analyses.

Eligibility Criteria

The population included in this systematic review was defined as adult patients (≥18 years old) with PCR-confirmed COVID-19 diagnoses who also had ARDS. ARDS was defined by the Berlin Criteria or American-European Consensus Conference (Table 1) [20]. Early intubation was defined as being intubated within 24 hours of being diagnosed with ARDS; Late intubation was defined as being intubated 24 or more hours after an ARDS diagnosis. The timing of intubation was also defined by authors of four original studies [21]. Systematic reviews and meta-analyses are in the upper echelon of the evidence-based medicine hierarchy of evidence, followed by randomized, controlled, double-blind studies, followed by cohort studies, case-control studies, case series, and case reports [2] (Figure 1). Randomized trial studies were not permitted due to potential ethical issues regarding the timing of intubation of COVID-19 ARDS patients [22]. Therefore, existing cohort studies and case-control studies were sought out to provide high-quality research evidence for this systematic review [23], (Figure 1).

Search Strategy

The authors only searched relevant scientific databases, which included PUBMED, CINAHL, MEDLINE, ProQuest Covid Databases, and Web of Science. Articles were retrieved from December 2019 to December 2021, and the language was restricted to English. In this systematic review, the search strategy developed by the authors consisted of a combination of keywords, medical subject headings (MeSH), free-text words, wildcards, acronyms, synonyms, and transatlantic terms. Boolean operators (“AND” “OR” and “NOT”) were used to combine the terms entered in each search field. Search strategy and keywords are described as follows (Table 2).

Study Selection

Two authors independently searched for relevant literature by executing the above search strategy and browsing abstracts or full texts to find potential articles. Detailed inclusion and exclusion criteria were used to screen the articles, and six primary research articles were finally selected as suitable for review.

Data Extraction and Risk of Bias Assessment

Two reviewers independently extracted and examined data from each included study. Extracted data included article title, author name(s), the date of publication, language, country, characteristics of participants, type of study, and data pertaining to the study’s outcome. Outcomes included mortality, length of ICU stay, and duration of ventilator use. The Newcastle-Ottawa Scale (NOS), developed by the University of Newcastle in Australia and the University of Ottawa in Canada, is a quality assessment tool for the systematic evaluation of non-randomized studies, especially for cohort and case-control studies [24]. The NOS cohort study version consists of eight multiple-choice questions involving topic selection and comparability, as well as outcome assessment or exposure. A star rating system is used to indicate the quality of the study, up to a maximum rating of nine stars. One star is awarded for each criterion if the reporting methodology is appropriate. Separate scales have been developed for cohort and case-control studies, which can help authors identify low-quality studies and inform sensitivity analyses or meta-regression [25]. NOS developers have examined NOS face and standard validity, reliability among evaluators, and evaluator burden. Surface validity has been assessed as strong by comparing each assessment item with its stem problem [26]. Therefore, NOS can be a helpful tool in assessing the quality of studies included in systematic reviews.

Data Synthesis

Stroup et al. published criteria for conducting and reporting meta-analyses of observational studies to improve the quality of reporting. Dichotomous data and risk ratio (RR) were chosen for data synthesis. The most common, a 95% confidence interval, is used to analysed mortality and favourable outcomes. Narrow confidence intervals are used to indicate that treatment estimates are relatively accurate [27]. In the second stage, the pooled (combined) intervention effect estimates are calculated as a weighted average of the estimated intervention effects in a single study. There are four methods for binary results meta-analysis, including three fixed-effect methods (Mantel-Haenszel, Peto, and inverse variance) and one random-effects method (Der Simonian and Laird inverse variance) [28]. For this systematic review, Rev Man software from the Cochrane Review was used for data analysis. The results were presented using forest maps.

Results

Study Selection.

Assessment Quality

The Newcastle-Ottawa Scale was used to evaluate the quality of the six studies [32] (see Appendix 3). There are detailed evaluation records for each study, as well as summary tables for each of the six studies. The traffic-light plots and summary bar plots were created using the robvis tool (Figure 3), which is a web application for visualizing deviation risk assessment as part of a system assessment [33]. Selection criteria, comparability, and outcome (cohort) or exposure (case-control) were scored on a scale up to 9 (Figure 3).

Main Outcome

The forest plot showed that 2,731 participants across six studies were included in the meta-analysis with a combined RR = 0.78 (95% CI 0.69 to 0.88, Z=3.91, P < 0.0001) (Figure 4). Overall, the results showed that the mortality of the early intubation group was lower than the late intubation group, and the difference was statistically significant. Significant heterogeneity was observed (I2=63%), which indicated a large degree of variation between effect sizes in the included studies (Figure 4).

Length of ICU Stay

Schmidt et al. failed to extract the length of ICU stay of participants. No statistically significant differences were found between groups regarding the number of days spent in the ICU in three of the other studies (P > 0.05) [34,35]. Two studies indicated that there were significant differences between the groups (P< 0.05). Overall, since analysis found that early intubation results in shorter ICU stays, this was seen as statistically significant (Table 5).

Duration of Ventilation

Ventilation time was not extracted for the participants in one study Schmidt et al. The other five studies reported no significant difference in the duration of mechanical ventilation between the early intubation group and the late intubation group (P＞0.05). Overall, the timing of intubation does not appear to impact the duration of mechanical ventilation of CARDS patients in the ICU (Table 5).

Complications

Patient complications were not reported separately in one study. Lee et al. observed that among patients treated with MV, the incidence of ventilator-associated pneumonia (VAP) in the early intubation group was often higher than that in the late intubation group, but no statistical significance was found (30.4%; N = 7 vs 6.2%; N = 1; P = 0.109). In research by the secondary infection rate was 13.3% in the early intubation group, while it was 22.2% in the late intubation group (P = 0.6). Additionally, AKI/RENAL failure was 21.3% in the early group and 18% in the late group (P = 0.1). A total of 16% of patients underwent tracheostomy in the early group, while the percentage rose to 25% in the late group (P = 0.1). Therefore, no statistically significant differences were found regarding secondary infection, Acute kidney injury (AKI), and interventional tracheotomy between intubation within 48 hours (early group) and intubation 48 hours after ICU admission (late group). Two studies did not describe patient complications.

Discussion

The purpose of this systematic review was to explore the effects of intubation time on clinical outcomes in COVID-19 patients with ARDS. Questions to investigate included whether late intubation increases ICU mortality, length of ICU stay, and duration of ventilator use. Results indicated that early intubation could reduce mortality and length of ICU stay in patients with CARDS. However, intubation time did not affect the duration of continuous mechanical ventilation in patients. There were obvious differences between the definitions of early intubation and late intubation in the six included studies. In three studies early intubation was defined as intubation within 24 hours after diagnosis of ARDS. Two studies defined early intubation as within 48 hours of diagnosis, while defined it as within 1.27 days. Most studies defined the early intubation time as within 24 hours after admission to an ICU [36,37]. However, according to the systematic review reported by the definition of early/late intubation time had no statistical difference in all-cause mortality between the two groups and did not influence the clinical outcomes of COVID-19 patients. Therefore, for the sake of homogeneity, early intubation group and late intubation group data was extracted for analysis according to the respective definitions included in the current study. However, the definition of early/late intubation time directly affected the number of participants between the two groups.

The Effects of Early and Late Intubation

The high mortality associated with late intubation may be related to lung injuries (P-SILI) unintentionally caused by the patients themselves. When COVID-19 patients’ respiratory support was insufficient, their lung function deteriorated in the first week [38]. ARDS is characterized by non-cardiogenic pulmonary oedema, decreased exchange volume of hypoxic blood, and normal gas related to V/Q imbalance, which leads to low respiratory compliance. Hypoxemia may cause patients to inhale spontaneously and violently, leading to lung injury caused by high trans-pulmonary pressure. Early intubation with pulmonary protective ventilation can prevent P-SILI [39]. In a study including 457 ARDS patients, the 60-day mortality rate of the late intubation subgroup (56%) was significantly higher than that of the early intubation group (36%) [40]. The mortality rate of the late intubation group continued to rise during the 2-year follow-up period, which was consistent with the results of the current study.

Chinese critical care experts also suggested that tracheal intubation should be done when critically ill patients are asymptomatic (persistent respiratory distress and/or hypoxemia) after standard oxygen therapy, which was also referred to in the COVID-19 guidelines for patient treatment [41]. Given the high risk of non-invasive respiratory support failure and the risk of virus particle atomization [42], Brown et al. also recommended that early tracheal intubation be performed for patients with respiratory failure who need ventilation support. Other factors influencing death included BMI, age, Sequential Organ Failure Assessment (SOFA) Score, and (Acute Physiology, Age, and Chronic Health Evaluation Ⅱ(APACHEⅡ)); however, no statistical difference was found between the two groups in the early/late stage. In a study by Pandya et al. The included population was characterized by a nasopharyngeal swab-confirmed COVID-19 patient with a mean age of 65 years. A median BMI of 31 was observed in the study, and all patients were more than 50% of the standard BMI and could be categorized as ‘obese’.

These were risk factors associated with mortality. In this study, the mortality rate of patients with mechanical ventilation was as high as 49%. The median age of non-survivors was higher than that of survivors (70 VS 59, p = 0.0006). The median ages of patients in the six included studies were 70, 63, 60, 59, 65, and 61.5, all of which were higher than 59. Therefore, elderly COVID ADRS patients were found to have a higher mortality rate. Compared with the United States, whose patients had a mortality rate of 16.6%, India’s mortality rate was much higher at 68.7%, which may be related to the level of economic development and medical care [43]. Overall, this systematic review found that patients with early intubation were prone to more severe illness, organ dysfunction, and higher SOFA and APACHE scores when diagnosed with ARDS compared to those with late intubation. These results may have great significance in clinical practice, by providing strong evidence for researchers and clinicians to consider when choosing when to intubate COVID-19 ARDS patients. This can assist in rationalizing the allocation of medical resources and reduce the mortality of patients.

Agreements and Disagreements with Other Studies and Reviews

No similar systematic reviews were found pertaining to the topic of this article. Navas-Blanco and Dudaryk (2020) agreed that early intubation can prevent adverse consequences due to delayed intubation in patients with CARDS. Two studies recommend early intubation for COVID-19 ARDS patients. However, a recent review by Papoutsi et al. found no statistically detectable difference in allcause mortality between patients undergoing either early or late intubation (3981 deaths; 45.4% versus 39.1%; RR 1.07，95% CI 0.99-1.15 p = 0.08). The same was true of MV duration (1892; MD- 0.58 days, 95% CI -3.06 to 1.89 days, p = 0.65). Intubation time may have had no effect on the mortality and morbidity of critically ill COVID-19 patients, which was inconsistent with the results summarized in this systematic review. In a study by Papoutsi et al. (2021), participants were critically ill patients with COVID-19. However, the population in this systematic review included ARDS patients with COVID-19.

Critique and Limitation

There are a few notable limitations to this study. For one, the reviewers only searched English-language articles, which can potentially lead to language bias. There may perhaps be articles related to this topic in other languages, but if so, these would have been excluded from the current review. In terms of secondary outcome data extraction, we contacted the authors of the six included studies by email, but failed to obtain specific data on length of ICU stays and MV duration. Therefore, the reliability of secondary measurement results may be reduced.

Conclusion

The findings of this systematic review conclude that early intubation for mechanical ventilation is beneficial to patients with COVID-19 ARDS. However, it appears that early intubation cannot reduce the overall duration of mechanical ventilation. The authors recommend immediate tracheal intubation for patients with moderate to severe COVID-19 ARDS. The treatment and management strategies of ARDS patients have been the continuing focus of researchers. In the face of COVID-19 pandemic, decreasing COVID-19 ARDS patients’ mortality remains an unsolved problem that needs further investigation. Further work is needed to improve research design and solve the problem of high heterogeneity and provide higher quality evidence.

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A Case of Successful Cardiopulmonary Resuscitation in a Pregnant Woman with Eisenmenger’s Syndrome - Juniper Publishers

 Anesthesia & Intensive Care Medicine - Juniper Publishers

Abstract

Patients with Eisenmenger’s syndrome (ES) are advised to avoid pregnancy due to high maternal mortality, reaching 30 - 50%. A 37-year-old pregnant patient, at a gestational age of 14/15 weeks, was admitted to the Medical Center for abortion due to ES. Due to the complete presentation of the chorion, it was planned to perform curettage of the uterine cavity. After introduction of antibacterial drug in the perioperative period, acute decompensation of heart failure was observed, which required cardiopulmonary resuscitation and ECMO. This condition was assessed as an anaphylactic shock. It was possible to stabilize the patient after switching to ECMO. On the next day the patient was extubated and the ECMO system was explained on the 5th day. On the 29-th day the patient was discharged.

Keywords: Eisenmenger’s syndrome; Anaphylactic Shock; ECMO; Cardiopulmonary Resuscitation; Pregnancy

Introduction

Unfortunately, there are still several adult patients who did not manage proper cardiac surgical care in childhood and subsequent development of severe hemodynamic disorders later in their lives, up to the formation of Eisenmenger's syndrome (ES). ES is marked by the development of a shunt of blood from the right side to the left side of the heart, resulting in defects of systemic and pulmonary circulation, which occur due to the formation of severe pulmonary arterial hypertension (PAH). Patients with ES are advised to avoid pregnancy due to high maternal mortality [1], reaching 30 - 50% [2]. In accordance with current international clinical guidelines, pregnant women with ES should be treated in the following way. During pregnancy women with ES should be observed by a multidisciplinary team, in reference centers; specific therapy for PAH should be evaluated and possibly modified. Operative abdominal delivery is recommended. In the respective literature, several clinical cases of cardiopulmonary resuscitation (CPR) in patients with ES [3-6] are described. However, only one publication demonstrates a successful case of CPR [7]. The reason for the low effectiveness of CPR is associated with the pathophysiological features of ES. During heart massage, venous blood from the right chamber enters the left chamber of the heart, following into the systemic circulation.

Case Presentation

Patient M, 37 years old, pregnant, at a gestational age of 14/15 weeks, was admitted to the Almazov centre on June 27^th of, 2022 for abortion due to ES. Informed consent was obtained from the people who participated in this clinical case.

Preoperative Management

From the anamnesis: patient is aware of her heart disease - ventricular septal defect (VSD) - since the age of 14. Patient has been repeatedly examined in cardiac surgery clinics, with surgical treatment denied due to high PAH. PAH-specific therapy was initiated (Bosentan was taken irregularly, and patient didn't switch to Sildenafil therapy).

Allergies: All antibacterial drugs that she received prior to her current hospitalization were well tolerated, without any anaphylactoid reactions. The patient’s weight was 52 kg, height was 149 cm. Blood pressure (BP) was 120/70 mm Hg. SpO₂ was 78 - 81% at rest on atmospheric air.

The Main TTE Parameters: Left Atrium -35 mm; End-Diastolic Volume of the Left Ventricle (LV) - 51 ml; End-Systolic Volume of the LV- 21 ml; Stroke Volume - 30 ml; Ejection Fraction of the LV - 59%. Right Ventricular (RV) (4-chamber position) - 32 mm; RV Front Wall- 10 mm; TAPSE -1,8 cm; Right Atrium- 41\42 mm. Pulmonary Artery (PA) – 24 mm; PA Systolic Pressure - 139 mm Hg. There were no significant valvular disorders. D - deformation of the Interventricular Septum (IVS). There was a defect in the membranous part of the IVS up to 13 mm with a right to left shunt.

The Results of Main Biochemical Tests: ALT - 13 U/l, AST - 22 U/l, bilirubin - 11 µmol/l, creatinine - 36 µmol/l, lactate - 1.0 mmol/l, hemoglobin - 133 g/l. NT-proBNP - 99.52 pg/ml. According to the ultrasound of the pelvic organs the chorion has been detected on the anterior wall. The edge of the chorion was in the region of the internal so extended to 1/3 of the cervix. Fetus was in transverse presentation.

Preoperative PAH Specific Therapy Was Adjusted: it was recommended to take Sildenafil 20 mg TID. Surgical termination of pregnancy was recommended due to full chorion presentation. Additionally, temporary embolization of the uterine arteries was recommended to minimize blood loss. Epidural anesthesia with invasive monitoring, including catheterization of the radial artery and internal jugular vein, has been chosen.

Surgical procedure anesthesia CPR: 06/30/2022 09:40-10:20. The patient was prepared for surgical procedure in the cath-lab according to standard methods. 10:25. Antibacterial prophylaxis with Ampicillin + Sulbactam, (Ampicillin+Sulbactam 1,0g +0,5g; Krasfarma, Russia) 3000 mg was initiated. However, during infusion of 1000 mg of antibiotics, the patient's condition worsened (vomiting, agitation, loss of consciousness, hemodynamic depression up to 60/40 mm Hg, tachycardia up to 145 beats/min, SpO₂ decreased to 56%). 10:25-10:45. Intensive therapy was started: orotracheal intubation and controlled mechanical ventilation and hemodynamic support including chest compressions. As anaphylaxis was suspected, Epinephrine bolus 100 μg was given IV, further followed by infusion 0.1 - 0.3 μg/kg/min, Infusion therapy and correction of acid-base balance were carried out, methylprednisolone 120 mg was administered. To reduce PVR and improve the hemodynamic profile, nitric oxide (NO) was inhaled at a dose of 60 ppm (synthesis from atmospheric air with he "Tianox" device, Russia). TTE and chest x-ray were performed, left ventricular injury, hemopericardium, pneumothorax and hemothorax were excluded.

ECMO Procedure: 10:45. Patient displayed arterial hypotension - 40/20 mm Hg. Due to the lack of effectiveness of CPR, the team decided to start veno-arterial ECMO. 10:45-11:30. Venous and arterial cannula implantations were performed, and an ECMO circuit was prepared. 11:30. ECMO-flow 3 l/min was initiated. It allowed to achieve stabilization of hemodynamics, an increase SaO₂ up to 98%. 15:15. A spontaneous miscarriage occurred while the patient was in the ICU. The patient received Carbetocin 100 mcg to prevent bleeding. No bleeding from the genital tract was observed. The infusion of unfractionated Heparinum (UFH) required for ECMO was not carried out. 07/01/2022 00:15. Infusion of UFH 500 U/h was started. The patient underwent a course of antibiotic prophylaxis: Vancomycin 1gr BID i/v, Clindamycin 300 mg TID i/v 10:00.

The patient was extubated. 07/01/22-07/04/2022. The PAH therapy was adjusted: sildenafil (20 mg TID); bosentan (125 mg BID); selexipag (was started at dose 200 μg BID); NO inhalation at dose 40 ppm. 07/08/2022. Inhalation of NO using «Tianox» deviceis turned off. The physical activation and rehabilitation program has been upgraded. 07/11/2022.The patient was discharged from the ICU and transferred to the cardiology department. 07/29/2022 The patient was hemodynamically and clinically stable against the background of three-component PAH-specific therapy: Sildenafil (20 mg TID), Ambrizentan (10 mg OID), Bosentan (125 mg BID), Selexipag (was titrated to the maximum tolerated dose - 1600 μg BID. The patient was discharged from the Almazov center with a moderate decrease in physical status.

Discussion

We found only one publication about case of successful CPR in a pregnant woman with ES [7]. In this case, the ECMO system was available, but was not installed, since the cardiac arrest occurred due to ventricular fibrillation, which was rapidly stopped by defibrillation.

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What A Drag It Is Growing Old - Personal Reflections on Ways to Cope with Changing Physical Capabilities as We Age - Juniper Publishers

 Complementary Medicine & Alternative Healthcare - Juniper publishers

Abstract

In this brief article we discuss successful and authentic aging, emphasizing that rather than seeing aging as a drag we should embrace it. Through anecdotes that embed ideas, the authors present ways that we each are coming to terms with our own constantly changing physical appearance and capabilities and discuss some of the ways that each of has coped with these as we continue to age.

Keywords:Health Maintenance; Successful Aging; Authentic Aging; Happiness; Taoism; Tai Chi; Yoga; Qigong; Age-Appropriate Exercise; Diet; Positive Psychology

What a drag it is getting old [1]

The (Wo)Man in The Mirror

We know from fairy tales that mirrors can be important elements in the past, present and future of the characters who gaze into them. But everywhere I go, whenever I look in a mirror, I am shocked to see an old fat person looking back at me. Who is this strange person invading my mirror and why are they following me?

Is there anything I can do about this intrusion on my self-image? How may I reframe my perceptions to make that image more welcoming? How can I become more content with who I am right now.

In this article, through anecdotes that embed ideas, the authors seek to present the ways that we each are coming to terms with our own constantly changing physical appearance and capabilities and discuss some of the ways that each of has coped with these as we continue to age.

The Changing Nature of Time [2]

“Sometimes you will never know the value of a moment until it becomes a memory.”

Dr Seuss No matter how much the anti-aging industry may try to persuade us differently, ultimately, we cannot outrun aging or death. For unlike Sisyphus, who did so twice [3], we are unlikely to cheat death. And although we mortals may escape pushing boulders up hills for eternity, nevertheless, as Franklin once quipped, nothing is certain except death and taxes. When we are working, we are kept busy dealing with day-to-day necessities. But as we age, especially if we are lucky enough to retire, time is a contradiction. For while each day is a gift, full of opportunities, there is often next to nothing on a retiree’s calendar, and the number of days left in life is diminishing. This, coupled with dealing with the unexpected deaths of old friends, may sometimes sadden and remind us of our own mortality. So, as we age how do we avoid the Marcel Proust trap: constantly seeking solace and meaning in our life by reflecting on experiences and memories from our past ‘glory days’ to avoid our world ending, “not with a bang but with a whimper” [4]. How do we keep each day interesting for ourselves?

Authentic Aging - Being Content with Your Life as It Is.

Authentic Aging [5] reframes ideas about Successful Aging [6] which suggests as we age we aim for optimal physical and cognitive health with an absence of disease/disability and full engagement with social life. These ideas have permeated societal thought about aging and created an atmosphere that puts the onus on all of us as individuals to take care of our own health and treat it as a choice [7]. Authentic aging suggests that everyone has value simply in being, as we are, no matter what our life choices, or even an inability to choose.

This links to Taoist philosophy which sees life as a river that continually flows forward [8]. From a Taoist perspective it is not that we should forget the lessons of the past, nor abdicate planning for the future but ultimately, we must live in this moment and experience it fully. For it is the only moment we can be sure about.
• In accepting this each of us must:
• Acknowledge our journey and its successes and failures; moments of happiness and grief; and even those moments of boredom or depression.
• Accept who we are now - that we are the sum of all the moments that went before and led to THIS moment.
• Live fully in this moment
• As we age, even when living fully in each moment, there are times you may feel a need to look forward, to and plan for:
• Seeing children / grandchildren
• Trips to places or friends
• Weekly events e.g., bingo
• Weddings / reunions

Trying To Stay Healthy - Coping with Changing Circumstances

A friend recently quipped, “I’m supposed to have bad hearing, bad vision, and nothing to say. So, from now on, I’m practicing selective hearing, not paying attention and no filters on talking!”

After giving me a couple of simple exercises for a sore shoulder, the physiotherapist saw I could painfully reach to the level of my head. He said, “You have functional movement. What more do you want?” Instead of warnings to ‘stay vigilant’, these biases can catapult us into decline.

Our mindset, our self-talk, our attitude is often our greatest obstacle to enjoying life to its fullest. There are simple, easy ways to improve our lives despite all variables. How we think about ourselves, or a situation affects everything. When I (GMF) first met my trainer [9] and commented that “at my age, I wanted to avoid ‘overworking”, she agreed, but reminded me that: “your muscles don’t know what age they are! They want to be worked.” This is pivotal information!

I’ve (GMF) found that when angst, panic, dread, worry begin to creep up, one of Bernie’s trademark pieces of advice: just “breath and smile” - becomes the best ‘medicine’. It provides me with momentary relief and starts to become a way of improving the quality of the moment and the day.

Improving Quality of Life

• If you are happy as you are now.
• Accept this and stick to the path you are on.
• IF you feel a need to make changes to your lifestyle to achieve specific goals
• Make an age appropriate and realistic plan.
• Start on that path until you feel the desire to change it.

If you decide you want to make changes here are some suggestions.

Diet/Cooking – Some Notes

To Reduce Ill Health from dietary sources • Identifying your food triggers/cravings e.g.:
• Do you have specific stressors?
• Do you crave sugary or salty foods?
• Do you over fill your plate?
• Do you always go back for second or third helpings?

If you prepare your own meals:
• Plan colourful & balanced meals / weekly menus!
• Even if you’re not vegetarian, add lots of different coloured vegetables/fruits to your meals.
• Rotate starches / proteins.
• Choose healthy snacks.
• Add teas (especially oolong or green) to your diet.
• Drink lots of water
• Reduce alcohol and sodas to a minimum.

Exercise - Some Notes

Setting Realistic and Age-Appropriate Goals
• WHY? Am I doing this e.g., stay healthy / going to a wedding etc.
• Make whatever you choose to do enjoyable.
• ENJOYMENT  Motivation - THE key to sustainable goals

Bert Amies always used to say that motivation is the key to success [10] - however, enjoyment is a key to staying motivated and achieving sustainable goals.

Choose age and ability appropriate enjoyable routines and activities, you can accomplish.
• There are many great exercises and ideas on Instagram/ Internet, however, be aware that:
• Most videos are NOT targeting older adults or addressing specific physical restrictions.
• The number of repetitions / speeds NOT doable for most people and more importantly
• Start at your own pace and only do what you can do.
• IF you wish slowly build up the number of repetitions and speed

Pay attention to any diminished physical capability. If it is due to injury or illness or a particular action… is there something you might do to avoid or reverse the situation? If there isn’t then work within your capabilities, with the one caveat - do not use your restrictions not to try.

A friend in her 90’s complained that she and her retirement home friends were falling. They collectively wondered ‘why we lose our legs first?’ A recent study [11] showed that legs can be strengthened with simple exercises done at home. Likewise, before turning to ‘waddling’, limping, canes, or walkers too soon, realize that aches, pains, niggles can often disappear with a little attention and targeted work.

Coping with Changing Circumstances – Some Suggestions

In a recent article [12], I (BW) documented my struggles with the changes to my health upon my retirement. I also identified that I stubbornly wish to continue to take ownership of my own health and not abdicate this responsibility solely to physicians and big Pharma.

In the seven years since leaving work this struggle has continued but remained manageable. However, our middle daughter’s destination wedding in October 2022, created a tsunami of problems for me precipitating a major health crisis.

The wedding created financial hardship and emotional stress. Like many others during the pandemic lockdown, I had been cooking and eating a lot, and my weight had been slowly creeping up. However, the wedding preparations precipitated stress eating, and the week itself presented excesses of food and drink.

Upon return I attended a regular doctor’s appointment. I discovered that my weight had skyrocketed 20+lbs (10Kilos), I had elevated blood pressure and unhealthy cholesterol numbers. After a good deal of discussion, my physician agreed to let me design a Self-Directed Program to control my BP and Cholesterol and so avoid use of medications. And that we would revisit the numbers in a few months.

My plan was simple but not easy. Identify dietary factors that were affecting my health and change my diet accordingly. To this end I:
• Continued my healthy menu planning and healthy eating [13], but
• Cut out ALL added salt![14]
• Cut out butter!
• Reduced my alcohol consumption by 60% (0-3 standard drinks a day).
• Increased my consumption of milk oolong tea, and water.
• Researched dietary supplements to help reduce my BP/ Cholesterol/Triglyceride levels. To this end I started taking Red Rice Yeast [15]; Organic Beetroot Capsules [16]; and increased my Omega 3 intake [17].
• In addition,
• I worked to reduce my stress by focussing on the positive and on reducing negative thoughts and actions.
• I increased my physical activity.
• Added isometric hand grip training [18]
• Added swimming laps to my routine (10-20 mins at least 4 times a week)
• Continued with:
• My daily martial arts practice (30-45 mins per day) [19].
• Regular floor-based yoga (3-4 times a week) [19].
• Walking for groceries to stores (7-10 miles a week).
• Walking up and down 6 flights of stairs daily.

I am happy to report that over 4 months I lost 22lbs and 2.5 inches from my waist. Most importantly my BP and cholesterol came down within normal parameters for my age. [20] and I am continuing with this program in consultation with my physician, and continue to closely watch my BP, Cholesterol and Triglyceride numbers.

Maintaining / Building Circles of Friends

Sometimes, in an effort to stay on top of health, our medical appointments can become our social lives. But it’s interactions with friends that can have a most profound impact on our health and outlook. What researchers of aging and gerontology have found is that most people are resilient. They find ways to create connections with others, which helps them cope in changing life situations such as: finding that one can rely on same age friends after loss [21]; finding new relationships with others after institutionalization [22]; and seeking new companionship through online dating [23,24].

A few other thoughts on finding useful health information:
• Don’t be afraid to talk to a friendly pharmacist: they are often spot on and have some excellent advice.
• Talk to friends about their experiences.
• If you don’t have a computer, good watch or even iPad, talk to friends who do or go to a library as they usually have computers available.

Looking Forwards – Embracing Aging

While researching for my PhD I (CH) was struck by how many writers have discussed viewing photos of themselves, in their young lives and being taken aback by those images and their lack of wrinkles. A common refrain was, “This is me. But it is not me.” I am still the person in that image but have evolved into being a different person at the same time.

It seems that the struggle is finding balance and congruence between temporal states in our lives, as having a past (but not living exclusively in nostalgia), having a present (an appreciation of each breath without remaining static), and a future with possibilities and growth (without putting off living until tomorrow).

But how do we do this? How do we fight against urges to withdraw, outrun age by staying perpetually busy, or conceal it through altering ourselves to meet unrealistic ideals?

The key may be to get over these impulses and realize that we are doing the best with what we have and overcome our own ego to embrace this time in our lives. Relish the opportunity to fully experience it. We can go beyond social and self-acceptance in aging and move to a place where we embrace this time in life as aspirational.

The secret seems to be in always having something to look forward to. Be it a small thing such as lunch or a television program or going to a weekly social event like attending bingo on a Monday, to larger things like celebrations. Even an afterlife can be part of this future orientation.

We can overcome our own ego and take the photo, eat the cake, recognize change and do it anyway. Be visible and show up for our lives by planning for one small achievable step. Don’t be afraid to be visible and take up the space you need to make connections, be it talking with a cashier at a drugstore, or making a phone call to someone you haven’t spoken to in a while. Realize that moving to self-acceptance and expression in aging is a process of these small steps, not a single result.

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