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Nutrient enrichment is a significant cause of ecosystem change in coastal habitats worldwide. This study focuses on the change in a benthic macroinvertebrate community and environmental quality as assessed through different biotic indices following the construction of a sewage outfall pipe in the west of Scotland, from first implementation to seven years after operation of the pipe. Benthic macroinvertebrates are an important part of marine ecosystems because they mediate ecosystem processes and functions, are a key part of food webs and they provide many ecosystem services. Results indicated a clear change in benthic communities over time with an increase in species richness and changes to benthic community composition (specifically feeding type, bioturbation mode and ecological group) towards those indicative of organic enrichment. No clear spatial zonation was observed because organic carbon content increased over the entire area. According to a suite of benthic indices calculated, some negative changes were detectable following the start of sewage disposal, but largely negative community changes, and a change from ‘good’ to ‘moderate’ quality, only occurred seven years after implementation. The increase in species richness in response to increasing disturbance reduced the utility of a multi-metric index, the Infaunal Quality Index, which, instead of amplifying the signal of negative impact, dampened it. We suggest that any change in communities, regardless of direction, should be heeded, and species richness is a particularly sensitive and early warning indicator for this, but a suite of approaches is required to understand benthic community changes.
To investigate the percentage of patients who commenced smoking after transferring out of a non-smoking forensic psychiatric unit, the corresponding clozapine dose adjustments, the effects on plasma clozapine/norclozapine concentrations and observed changes in mental state. We reviewed the notes and plasma clozapine/norclozapine concentrations of 46 patients transferred to medium secure units between July 2008 and December 2013.
Thirty-five patients commenced smoking. Their median clozapine dose was increased by 50 mg/d. In the non-smokers, the median clozapine dose remained unchanged. Plasma clozapine/norclozapine concentrations were significantly reduced in smokers despite dosage adjustment. Eighteen patients experienced deterioration in mental state after transfer; almost all these patients were smokers.
Approximately three-quarters of patients who were non-smokers by virtue of being in a secure non-smoking environment commenced smoking after transfer. Monitoring of clozapine serum levels and assessment of mental state in the immediate period after a change in smoking status is indicated.
To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data.
A retrospective, population-based, propensity-score–matched cohort study.
Acute-care facilities in Alberta, Canada.
Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016.
Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars.
Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21–1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312–$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07–1.19), which corresponds to an extra 5.6 days (95% CI, 3.10–8.06) in length of hospital stay per HA-CDI case.
In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.
Despite United States national learning objectives referencing research fundamentals and the critical appraisal of medical literature, many paramedic programs are not meeting these objectives with substantive content.
The objective was to develop and implement a journal club educational module for paramedic training programs, which is all-inclusive and could be distributed to Emergency Medical Services (EMS) educators and EMS medical directors to use as a framework to adapt to their program.
Four two-hour long journal club sessions were designed. First, the educator provided students with four types of articles on a student-chosen topic and discussed differences in methodology and structures. Next, after a lecture about peer-review, students used search engines to verify references of a trade magazine article. Third, the educator gave a statistics lecture and critiqued the results section of several articles found by students on a topic. Finally, students found an article on a topic of personal interest and presented it to their classmates, as if telling their paramedic partner about it at work. Before and after the series, students from two cohorts (2017, 2018) completed a survey with questions about demographics and perceptions of research. Students from one cohort (2017) received a follow-up survey one year later.
For the 2016 cohort, 13 students participated and provided qualitative feedback. For the 2017 and 2018 cohorts, 33 students participated. After the series, there was an increased self-reported ability to find, evaluate, and apply medical research articles, as well as overall positive trending opinions of participating in and the importance of prehospital research. This ability was demonstrated by every student during the final journal club session. McNemar’s and Related-Samples Cochran’s Q testing of questionnaire responses suggested a statistically significant improvement in student approval of exceptions from informed consent.
The framework for this paramedic journal club series could be adapted by EMS educators and medical directors to enable paramedics to search for, critically appraise, and discuss the findings of medical literature.
Even though Southeast Asia is one of the most densely populated regions of the world, its rock art is relatively unknown, and the rock art of Micronesia is even less so. As a starting point for comparing Philippine rock art within the region, a systematic quantitative literature review (SQLR) was conducted to assess the current body of accessible publications. The SQLR resulted in 126 viable references, and characteristics of those references were quantified and analyzed to ascertain the qualities of research published to date. The SQLR results show that scholarship in Southeast Asian rock art is increasing and that the research is dominated by Australia-affiliated scholars. It also quantitatively affirmed that the most noted color for rock art in the region is red and the most commonly identified motif is anthropomorphic. Many motifs found elsewhere in Southeast Asia are notably absent in the known corpus of Philippine rock art. Finally, we discuss SQLR methodology and propose integrating collaborative semantic web applications to increase efficiency and relevance.
The Arctic is warming faster than anywhere else of comparable size on Earth, impacting global climate feedbacks and the Arctic biota. However, a warm Arctic is not novel. The Late Cretaceous fossil record of the region enables a detailed reconstruction of polar environmental conditions, and a thriving extinct ecosystem, during a previous 'hothouse’ global climate. Using leaf form (physiognomy) and tree ring characteristics we reconstruct Cenomanian to Coniacian polar thermal and hydrological regimes over an average annual cycle at eight locations in NE Russia and northern Alaska. A new high spatial resolution (∼1 km) WorldClim2 calibration of the Climate Leaf Analysis Multivariate Program (CLAMP) yields results similar to, but often slightly warmer than, previous analyses, but also provides more detailed insights into the hydrological regime through the return of annual and seasonal vapour pressure deficit (VPD), potential evapotranspiration (PET) estimates and soil moisture, as well as new thermal overviews through measures of thermicity and growing degree days. The new results confirm the overall warmth of the region, particularly close to the Arctic Ocean, but reveal strong local differences that may be related to palaeoelevation in the Okhotsk–Chukotka Volcanogenic Belt in NE Russia. While rainfall estimates have large uncertainties due to year-round wet soils in most locations, new measures of VPD and PET show persistent high humidity, but with notably drier summers at all the Arctic sites.
Workforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression.
Those most likely to apply were White, privately educated older doctors with below average performance at medical school.
To reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.
Synthetic biology has a huge potential to produce the next generation of advanced materials by accessing previously unreachable (bio)chemical space. In this prospective review, we take a snapshot of current activity in this rapidly developing area, focusing on prominent examples for high-performance applications such as those required for protective materials and the aerospace sector. The continued growth of this emerging field will be facilitated by the convergence of expertise from a range of diverse disciplines, including molecular biology, polymer chemistry, materials science, and process engineering. This review highlights the most significant recent advances and addresses the cross-disciplinary challenges currently being faced.
Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.
The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.
Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).
Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001).
In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.
Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175–181
The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions.
We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality.
Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = −0.90 (CBT; k = 27, 95% CI −1.11 to −0.68; moderate quality) to g = −1.26 (EMDR; k = 4, 95% CI −2.01 to −0.51; low quality). CBT and EA each had moderate–large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate–large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome.
The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.
X-ray diffraction techniques were utilized to study the film stress effects in silicon wafers subjected to several processing conditions. The wafer processing matrix consisted of three thicknesses of polysilicon deposited on (100) silicon with a 25 nm layer of Si02. The polysilicon was doped with phosphorous and arsenic after which the samples were implanted with fluorine at 30 KeV at a dose of 6 × 1015 cm2. A synchrotron radiation source at Brookhaven National Laboratory on beamline X-14 was employed to determine the residual stresses in the polysilicon film by a powder diffraction technique ordinarily used on poly crystal line material X-ray rocking curve experiments were employed to determine the stress in the film from measurements of the curvature of the substrate. These two stress measurements allow the estimation of the stress gradient in the intermediate amorphous oxide layer. Correlations are made between the stress gradients, the fluorine distribution in the wafer and the electrical characteristics of the structures.
Deficits in frontal lobe perfusion have been demonstrated in late-life depression; however, studies to date have generally involved small numbers, used neuroimaging rather than bedside testing and have not controlled for important covariates.
We aimed to examine the association between depressive symptoms and frontal lobe perfusion during standing, in a large cohort of community-dwelling older people.
Participants aged ≥50 years underwent continuous measurement of orthostatic blood pressure by finometry, and frontal lobe perfusion by near-infrared spectroscopy. Depressive symptoms were assessed by the eight-item Centre for Epidemiological Studies Depression Scale. Real-time frontal lobe cerebral oxygenation was measured by the Portalite System, detecting changes in frontal lobe perfusion and reporting a tissue saturation index score.
Almost 8% (209 out of 2616) had clinically significant depressive symptoms. Multilevel models demonstrated a significantly lower tissue saturation index in participants with depressive symptoms at both 60 and 90 s post-stand, with coefficients of −0.43 (95% CI −0.63 to −0.22) and −0.37 (95% CI −0.57 to −0.16), respectively. Controlling for relevant covariates did not significantly attenuate these associations. After addition of systolic blood pressure this association was no longer significant, suggesting lower blood pressure may modify this relationship.
This study demonstrates that lower frontal lobe perfusion, related to lower values of baseline systolic blood pressure, is associated with clinically significant depressive symptoms in a cohort of community-dwelling older people. Given the recognised longitudinal association between lower blood pressure and depression in older people, this may represent a potential therapeutic target for prevention of incident depression.
Current practice in cost-effectiveness analysis (CEA) involves the estimation of the incremental cost-effectiveness ratio (ICER) between a new intervention and one alternative comparator reflecting the standard of care. As this focuses on pairwise comparisons, rather than considering the whole range of available alternatives at any given time, this method fails to capture the full impact of bringing the new intervention to market.
A multi-comparator ICER (MC-ICER) evaluating the impact of the new technology on patients treated with all comparators used in clinical practice, rather than a theoretical ‘second-best’ alternative only, was estimated. This can be achieved by weighting the incremental costs and benefits for each comparator by its change in market share to generate an MC-ICER. This is shown using a stylized example with three comparators.
The traditional ICER against the second-best alternative was USD 200,000 per QALY, while the estimated multi-comparator ICER is USD 133,548 per QALY, corresponding to a 33 percent decrease. This reflects the fact that patients who switch to the new intervention are not only those who had been previously treated with one particular comparator, as is assumed in a traditional CEA. The difference between the traditional ICER and the MC-ICER depends on how the new intervention impacts on the uptake of each comparator.
Results show that, when comparator selection was made excluding dominated and extendedly-dominated alternatives, the MC-ICER, produced using the method described above, is lower than the traditional ICER comparing the new intervention to the second-best comparator. This captures the fact that patients may switch to the new intervention not only from the second-best comparator, but from the whole range of alternative treatments. Such patient movements determine the real impact, or opportunity cost, of the new intervention on the healthcare system and, therefore, should be captured in CEA alongside traditional one-way ICERs.