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The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
Accurate low-dimensional models for the dynamics of falling liquid films subject to localized or time-varying heating are essential for applications that involve patterning or control. However, existing modelling methodologies either fail to respect fundamental thermodynamic properties or else do not accurately capture the effects of advection and diffusion on the temperature profile. We argue that the best-performing long-wave models are those that give the surface temperature implicitly as the solution of an evolution equation in which the wall temperature alone (and none of its derivatives) appears as a source term. We show that, for both flat and non-uniform films, such a model can be rationally derived by expanding the temperature field about its free-surface values. We test this model in linear and nonlinear regimes, and show that its predictions are in remarkable quantitative agreement with full Navier–Stokes calculations regarding the surface temperature, the internal temperature field and the surface displacement that would result from temperature-induced Marangoni stresses.
Every year statistics seem to demonstrate another decline in the quality of life in Southern Africa. The annual growth rate per capita of agricultural production in the region deteriorated to -1.04 percent from 1978-85. In March 1987, UNICEF reported that every four minutes a child under 5 years dies in Angola and Mozambique, the highest death rate among children in the world. International agencies like UNICEF now cite the major cause of this devastation: war waged by South Africa against its neighbors.
Childhood maltreatment (CM) plays an important role in the development of major depressive disorder (MDD). The aim of this study was to examine whether CM severity and type are associated with MDD-related brain alterations, and how they interact with sex and age.
Within the ENIGMA-MDD network, severity and subtypes of CM using the Childhood Trauma Questionnaire were assessed and structural magnetic resonance imaging data from patients with MDD and healthy controls were analyzed in a mega-analysis comprising a total of 3872 participants aged between 13 and 89 years. Cortical thickness and surface area were extracted at each site using FreeSurfer.
CM severity was associated with reduced cortical thickness in the banks of the superior temporal sulcus and supramarginal gyrus as well as with reduced surface area of the middle temporal lobe. Participants reporting both childhood neglect and abuse had a lower cortical thickness in the inferior parietal lobe, middle temporal lobe, and precuneus compared to participants not exposed to CM. In males only, regardless of diagnosis, CM severity was associated with higher cortical thickness of the rostral anterior cingulate cortex. Finally, a significant interaction between CM and age in predicting thickness was seen across several prefrontal, temporal, and temporo-parietal regions.
Severity and type of CM may impact cortical thickness and surface area. Importantly, CM may influence age-dependent brain maturation, particularly in regions related to the default mode network, perception, and theory of mind.
Introduction: Little is known about the variety of roles volunteers play in the emergency department (ED), and the potential impact they have on patient experience. The objective of this scoping review was to identify published and unpublished reports that described volunteer programs in EDs, and determine how these programs impacted patient experiences or outcomes. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. A grey literature search was also conducted (Web of Science, ProQuest, Canadian Business and Current Affairs Database ProQuest Dissertations and Theses Global). Two reviewers independently screened titles and abstracts, reviewed full text articles, and extracted data. Results: The search strategy yielded 4,589 potentially relevant citations. After eliminating duplicate citations and articles that did not meet eligibility criteria, 87 reports were included in the review. Of the included reports, 18 were peer-reviewed articles, 6 were conference proceedings, 59 were magazine or newspaper articles, and 4 were graduate dissertations or theses. Volunteer activities were categorized as non-clinical tasks (e.g., provision of meals/snacks, comfort items and mobility assistance), navigation, emotional support/communication, and administrative duties. 52 (59.8%) programs had general volunteers in the ED and 35 (40.2%) had volunteers targeting a specific patient population, including pediatrics, geriatrics, patients with mental health and addiction issues and other vulnerable populations. 20 (23.0%) programs included an evaluative component describing how ED volunteers affected patient experiences and outcomes. Patient satisfaction, follow-up and referral rates, ED and hospital costs and length of stay, subsequent ED visits, medical complications, and malnutrition in the hospital were all reported to be positively affected by volunteers in the ED. Conclusion: This scoping review demonstrates the important role volunteers play in enhancing patient and caregiver experience in the ED. Future volunteer engagement programs implemented in the ED should be formally described and evaluated to share their success and experience with others interested in implementing similar programs in the ED.
Introduction: Hydronephrosis is the de facto measure of obstructive uropathy (OU) and can be evaluated using renal Point of Care Ultrasound (rPOCUS). This educational initiative aimed to develop an effective one-day rPOCUS curriculum and evaluate if feedback/quality assurance (QA), leads to an improvement in image acquisition and interpretation of hydronephrosis as well as comfort with the technique. Methods: Physicians were randomized into a QA or control group (NQA) and all attended a one day training session which involved acquiring rPOCUS scans with one-on-one instruction. Participants then performed POCUS scans on all ED patients where formal renal US was deemed clinically indicated. The QA group received feedback on every scan from qualified ED physicians. Overall sensitivity and specificity were calculated compared to formal scans using a chi-square test. Written QA was reviewed for future improvements. Crossover occurred at 10 weeks to allow for equal learning opportunity but analyses focused on pre-crossover data. Participants completed surveys at study start and end focusing on initiative effectiveness and barriers/comfort with POCUS measured with a likert scale (Not at all (1)-Very (7)). Results: Fourteen ED physicians participated. The most common cited barrier to utilizing rPOCUS was lack of knowledge/training (78.6%). A total of 63 POCUS scans were reviewed. Common feedback included breath-holding (69.7%), use of color doppler (48.5%) and including a transverse sweep (36.4%). Sensitivity and specificity were better in the QA versus NQA group though the difference was not significant (Se- 75.0% vs 50.0%, 95%CI: −34.0-73.4%; Sp- 89.3% vs 73.9%, 95% CI: 8.2-39.2%). Ten physicians completed the post survey; all reported improved comfort with rPOCUS in assessment of hydronephrosis (median [IQR]: Δ+2 [1-3]). At study end, the comfort rating for using only POCUS and not formal scan remained low (median [IQR]: 3.50 [1.8-4.2]). The training initiative was rated highly with a median [IQR] rating of 5.50 [4.8-7.0]. Conclusion: Although the initiative was rated highly effective and resulted in improved comfort with renal POCUS, physicians did not feel comfortable solely using POCUS without formal scan to diagnose OU. Despite the initiative's success, further educational programs are needed before rPOCUS can be safely used as the primary investigation. In the future, a greater emphasis should be placed on the commonly noted areas of improvement.
Introduction: Choosing Wisely Canada guidelines suggest that in the absence of red flags or clinical indicators suggestive of serious underlying conditions, physicians should not order radiological images for patients presenting with non-specific low back pain, and current recommendations do not endorse routine prescribing of opioids for this condition. The objective of this study was to determine how many patients presenting to the ED with non-traumatic low back pain have spinal imaging and how many are discharged home on opioids. Methods: We conducted a retrospective medical record review for adult (>17 years) patients presenting to an academic tertiary care ED with non-traumatic low back pain from April 1st 2014 to March 31st 2015 (pre-guideline) and April 1st 2017 to March 31st 2018 (post-guideline). Patients were excluded if they were >70 years old, were not discharged home, had a traumatic injury, features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, first episode of low back pain over 50 years of age, abnormal reflexes, loss of motor strength or loss of sensation in the legs. Results: 1060 (545 pre-guideline, 515 post-guideline) were included. Mean (SD) age was 39.6 (12.3) years and 549 (51.8%) were female. Pre-guideline, 45 (8.3%) patients had spinal imaging, compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% CI: −2.6% to 4.0%). Of the 84 (7.9%) patients who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline, compared to 10 (25.6%) patients post-guideline. The proportion of patients discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines (40.9% vs. 11.1%; Δ29.8%; 95% CI: 24.8% to 34.7%). Conclusion: Choosing Wisely Canada guidelines did not appear to alter the rate of imaging for patients presenting to the ED with non-traumatic low back pain. Overall the rate of spinal imaging was lower than expected. The proportion of patients who were discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines, however we don't know if this represents an overall trend in the reduction of opioid prescribing, or a specific change in practice related to the ED management of low back pain.
Depression is a common, serious, but under-recognised problem in multiple sclerosis (MS). The primary objective of this study was to assess whether a rapid visual analogue screening tool for depression could operate as a quick and reliable screening method for depression, in patients with MS.
Patients attending a regional MS outpatient clinic completed the Emotional Thermometer 7 tool (ET7), the Hospital Anxiety and Depression Scale – Depression Subscale (HADS-D) and the Major Depression Inventory (MDI) to establish a Diagnostic and Statistical Manual, 4th edition (DSM-IV) diagnosis of Major Depression. Full ET7, briefer subset ET4 version and depression and distress thermometers alone were compared with HADS-D and MDI. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curve were calculated to compare the performance of all the screening tools.
In total, 190 patients were included. ET4 performed well as a ‘rule-out’ screening step (sensitivity 0.91, specificity 0.72, NPV 0.98, PPV 0.32). ET4 performance was comparable to HADS-D (sensitivity 0.96, specificity 0.77, NPV 0.99, PPV 0.37) without need for clinician scoring. The briefer ET4 performed as well as the full ET7.
ET are quick, sensitive and useful screening tools for depression in this MS population, to be complemented by further questioning or more detailed psychiatric assessment where indicated. Given that ET4 and ET7 perform equally well, we recommend the use of ET4 as it is briefer. It has the potential to be widely implemented across busy neurology clinics to assist in depression screening in this under diagnosed group.
Depression frequently co-occurs with disorders of glucose and insulin homeostasis (DGIH) and obesity. Low-grade systemic inflammation and lifestyle factors in childhood may predispose to DGIH, obesity and depression. We aim to investigate the cross-sectional and longitudinal associations among DGIH, obesity and depression, and to examine the effect of demographics, lifestyle factors and antecedent low-grade inflammation on such associations in young people.
Using the Avon Longitudinal Study of Parents and Children birth cohort, we used regression analyses to examine: (1) cross-sectional and (2) longitudinal associations between measures of DGIH [insulin resistance (IR); impaired glucose tolerance] and body mass index (BMI) at ages 9 and 18 years, and depression (depressive symptoms and depressive episode) at age 18 years and (3) whether sociodemographics, lifestyle factors or inflammation [interleukin-6 (IL-6) at age 9 years] confounded any such associations.
We included 3208 participants. At age 18 years, IR and BMI were positively associated with depression. These associations may be explained by sociodemographic and lifestyle factors. There were no longitudinal associations between DGIH/BMI and depression, and adjustment for IL-6 and C-reactive protein did not attenuate associations between IR/BMI and depression; however, the longitudinal analyses may have been underpowered.
Young people with depression show evidence of DGIH and raised BMI, which may be related to sociodemographic and lifestyle effects such as deprivation, smoking, ethnicity and gender. In future, studies with larger samples are required to confirm this. Preventative strategies for the poorer physical health outcomes associated with depression should focus on malleable lifestyle factors.
X-ray microscopy is a field that has developed rapidly in recent years. Two different approaches have been used. Zone plates have been employed to produce focussed beams with sizes as low as 0.07 pm for x-ray energies below 1 keV. Images of biological materials and elemental maps for major and minor low Z have been produced using above and below absorption edge differences. At higher energies collimators and focussing mirrors have been used to make small diameter beams for excitation of characteristic K— or L-x rays of all elements in the periodic
Isoconcentration surfaces are commonly used to delineate phases in atom probe datasets. These surfaces then provide the spatial and compositional reference for proximity histograms, the number density of particles, and the volume fraction of particles within a multiphase system. This paper discusses the influence of the isoconcentration surface selection value on these quantitative outputs, using a simple oxide dispersive strengthened alloy, Fe91Ni8Zr1, as the case system. Zirconium reacted with intrinsic oxygen impurities in a consolidated ball-milled powder to precipitate nanoscale zirconia particles. The zirconia particles were identified by varying the Zr-isoconcentration values as well as by the maximum separation data mining method. The associated outputs mentioned above are elaborated upon in reference to the variation in this Zr isosurface value. Considering the dataset as a whole, a 10.5 at.% Zr isosurface provided a compositional inflection point for Zr between the particles and matrix on the proximity histogram; however, this value was unable to delineate all of the secondary oxide particles identified using the maximum separation method. Consequently, variations in the number density and volume fraction were observed as the Zr isovalue was changed to capture these particles resulting in a loss of the compositional accuracy. This highlighted the need for particle-by-particle analysis.
Atom probe tomography (APT) of a nanocrystalline Cu–7 at.% V thin film annealed at 400°C for 1 h revealed chemical partitioning in the form of solute segregation. The vanadium precipitated along high angle grain boundaries and at triple junctions, determined by cross-correlative precession electron diffraction of the APT specimen. Upon field evaporation, the V2+/(V1+ + VH1+) ratio from the decomposed ions was ~3 within the matrix grains and ~16 within the vanadium precipitates. It was found that the VH1+ complex was prevalent in the matrix, with its presence explained in terms of hydrogen's ability to assist in field evaporation. The change in the V2+/(V1+ + VH1+) charge-state ratio (CSR) was studied as a function of base temperature (25–90 K), laser pulse energy (50–200 pJ), and grain orientation. The strongest influence on changing the CSR was with the varied pulse laser, which made the CSR between the precipitates and the matrix equivalent at the higher laser pulse energies. However, at these conditions, the precipitates began to coarsen. The collective results of the CSRs are discussed in terms of field strengths related to the chemical coordination.
Limited research has suggested that higher lambing densities increase interference from foreign ewes at lambing which disrupts the ewe-lamb bond and compromises lamb survival. This may be particularly evident in mobs of twin-bearing ewes compared to single-bearing ewes because a greater number of lambs are born per day. Therefore, we hypothesised that; (i) decreasing the mob size of ewes at lambing has a greater impact on the survival of twin-born lambs than single-born lambs; (ii) the relationship between mob size and lamb survival can be explained by differences in the rate of interaction with foreign ewes and lambs at lambing; and (iii) ewes will utilise a limited area of the paddock at lambing and thus lambing density will be defined by the distribution of ewes in the paddock rather than the paddock area. Merino ewes were allocated into a 2×2 factorial combination of ewe pregnancy status (single- or twin-bearing) and mob size (high (n=130 ewes) or low (n=50 ewes)) on day 140 from the start of joining. Each treatment had two replicates excepting the low mob size for twins which had a third replicate. Ewes lambed at a stocking rate of 11 ewes/ha. Feed-on-offer during lambing exceeded 2400 kg dry matter (DM)/ha. Ewe-lamb behaviour was observed and dead lambs were autopsied over 11 days during the peak of lambing. The distribution of ewes in each paddock was recorded every 2 h during daylight hours by counting the number of ewes occupying 2500 m2 grids. The proportion of ewes and their newborn progeny which interacted with foreign ewes at lambing did not differ between the high and low mob sizes for single- (24.9% v. 20.8%) or twin-bearing ewes (14.3% v. 19.6%; P=0.74). Similarly, interaction with foreign lambs did not differ between the high and low mob sizes for single- (14.5% v. 25.2%) and twin-bearing ewes (34.5% v. 26.4%; P=0.44). The distribution of ewes within the paddock did not differ between treatments (P=0.95). On average, single-bearing ewes which lambed at the high and low mob sizes occupied 34% and 36% of the paddock during daylight hours, and the corresponding values for twin-bearing ewes were 40% and 43%. Survival of twin-born lambs was lower than single-born lambs (75.3% v. 87.9%; P<0.01), however, lamb survival was not influenced by mob size regardless of birth type. These results suggest that higher mob sizes may not compromise lamb survival when feed-on-offer during lambing exceeds 2400 kg DM/ha.
Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.
Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3–18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.
We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.
Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.
Background:ATP8A2 mutations have only recently been associated with human disease. We present the clinical features from the largest cohort of patients with this disorder reported to date. Methods: An observational study of 9 unreported and 2 previously reported patients with biallelic ATP8A2 mutations was carried out at multiple centres. Results: The mean age of the cohort was 9.4 years old (range: 2.5-28 yrs). All patients demonstrated developmental delay, severe hypotonia and movement disorders: chorea/choreoathetosis (100%), dystonia (27%) or facial dyskinesia (18%). Hypotonia was apparent at birth (70%) or before 6 months old (100%). Optic atrophy was observed in 75% of patients who had a funduscopic examination. MRI of the brain was normal for most patients with a small proportion showing mild cortical atrophy (30%), delayed myelination (20%) and/or hypoplastic optic nerves (20%). Epilepsy was seen in two older patients. Conclusions:ATP8A2 gene mutations have emerged as a cause of a novel phenotype characterized by developmental delay, severe hypotonia and hyperkinetic movement disorders. Optic atrophy is common and may only become apparent in the first few years of life, necessitating repeat ophthalmologic evaluation. Early recognition of the cardinal features of this condition will facilitate diagnosis of this disorder.
Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.
Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.