Lake Superior's summer cooling of shorelines and adjacent inland forests: Implications for refugia of boreal forests and disjunct arctic-alpine plants

Climate refugia can serve as remnant habitat for cold-adapted species and delay forest transitions. The world's largest freshwater lake by surface area, Lake Superior, serves as a model system for understanding cooling-mediated refugia effects, as its cool summer water temperatures have maintained disjunct populations of arctic-alpine plants on its shoreline since deglaciation. It is known to affect local inland climates by providing a summer cooling effect; however, the inland temperature gradient and spatial patterns of cooling have not been well quantified. Here, we describe the extent, degree, and patterns of temperature buffering and examine drivers of buffering and disjunct plant occurrence for Lake Superior's north shore over a 3-year period at distances of 10, 100 m, 1, 10, and 100 km inland. We analyzed temperature data by year, month, summer maximum (July), and growing degree days (GDD0) for each site. Average summertime cooling at shore sites (10 m) was ~5°C cooler than reference sites (100 km inland), with a maximum difference of -19.2°C. The magnitude of cooling varied geographically, with sites further west and southeast showing little to no cooling effect, while the exposed north-central shore showed the highest degree of buffering (5.8°C cooler) and had a shorter growing season than reference sites. Finally, north-central shorelines had fewer days above 16°C, a threshold above which disjunct plants are unlikely to grow. These sites also showed the highest proportion of disjunct arctic-alpine species, reflecting the highest buffering from inland sites. On north-central shores, sites up to 10 km inland had less than 10 days per year warmer than 20°C, a threshold identified for boreal forest transition. An understanding of the extent of lake-mediated cooling on adjacent forests can better inform the risk to disjunct species, inland forests, and vegetation transition models on Lake Superior's north shore.

The precariousness of living with, and caring for people with, dementia: Insights from the IDEAL programme

This paper uses precarity as a framework to understand the vulnerabilities experienced by those living with or caring for someone living with dementia. Drawing on qualitative interview data from the Improving the Experience of Dementia and Enhancing Active Life (IDEAL) programme, we attend to our participants' reflections on how they manage the condition and the wider circumstances in which this occurs. To interrogate the utility of precarity, we focus on our participants' descriptions of needs and challenges and set these alongside both the wider contexts in which they seek or offer care (formal and informal) and the sets of values attributed to different ways of living with dementia. Building on the work of Portacolone, our analysis identified four interconnected themes: uncertainty; experiences of support and services; independence and personhood; and cumulative pressures and concerns. We develop this analysis by reviewing how our themes reflect, extend, or depart from previously identified markers of precarity and consider the specific ways in which these markers shape the lives of those living with dementia.

Clinical evaluation of BioFire® multiplex-PCR panel for acute undifferentiated febrile illnesses in travellers: a prospective multicenter study

BACKGROUND

Identifying the causes of Acute Undifferentiated Febrile Illness(AUFI) is key to improve the management of returning travellers with fever. We evaluated a BioFire®FilmArray® prototype panel of multiplex nucleic acid amplification tests(NAAT) targeting different relevant pathogens in travellers returning with fever.

METHODS

Prospective, multicenter study to evaluate a prototype panel in whole blood samples of adult international travellers presenting with AUFI in three European travel Clinics/Hospitals (November2017-November2019). We evaluated 15 target analytes: Plasmodium spp., P.falciparum, P.knowlesi, P.malariae, P.ovale, P.vivax, chikungunya virus, dengue virus, Zika virus, Anaplasma phagocytophilum, Borrelia spp., Leptospira spp., Orientia tsutsugamushi, Rickettsia spp., Salmonella spp. Results were compared with composite reference standards(CRS) for each target infection, including direct methods (smear microscopy, rapid diagnostic test(RDT), reference NAAT, blood cultures) and indirect methods(paired serology).

FINDINGS

Among 455 travellers with AUFI, 229 target infections were diagnosed; the prototype panel detected 143 (overall sensitivity and specificity of 62.5% and 99·8%, respectively). The panel identified all Plasmodium infections(n = 82). Sensitivity for dengue(n = 71) was 92·9%; 80·8% and 68·5% compared to RDT, NAAT and CRS. Compared to direct methods and CRS, respectively, the prototype panel detected 4/4 and 4/6 chikungunya, 2/2 and 4/29 Leptospira spp., 1/1 and 1/6 O.tsutsugamushi, 2/2 and 2/55 Rickettsia spp., but 0/2 and 0/10 Zika, 0/1 and 0/11 A.phagocytophylum, 0/3 Borrelia spp. diagnosed by serology and 1/7 Salmonella spp. diagnosed by blood cultures. 77/86 (89·5%) infections not detected by the panel were diagnosed by serology.

INTERPRETATION

The prototype panel allowed rapid and reliable diagnosis for malaria, dengue and chikungunya. Further improvements are needed to improve its sensitivity for Zika and important travel-related bacterial infections.

The black summer bushfires: impacts and risk factors for livestock bushfire injury in south-eastern Australia

Background

The 2019/2020 Australian bushfires were the largest bushfire event in modern Australian history. While actions to mitigate risk to homes from bushfires are well reported, there is very little research reported on the impacts of bushfires on livestock. With an increasing incidence of bushfires predicted, there is an urgent need to identify how farmers can best protect their livestock.

Objectives

Compare bushfire affected farms with and without injured livestock to identify associations between risk factors and bushfire injury. Infer management approaches that can be used to reduce bushfire injury in livestock.

Method

A case‐control study using a structured interview questionnaire, delivered in late 2020 to cattle and sheep farmers in south‐eastern Australia (New South Wales and Victoria) whose farmland was burnt in the 2019/2020 Australian bushfires. Case farms were farms with bushfires injured or killed livestock. Control farms were farms that had no bushfire injured livestock but that still had fire present on the farm. Interview responses were summarised and information theoretical approaches were used to identify potential risk factors for livestock bushfire injury and protective actions that could inform future fire‐preparation recommendations.

Results and discussion

Of 46 farms in the case‐control study, 21 (46%) reported bushfire injured or killed livestock. Apparent protective factors identified included: preparation (having a bushfire plan and more than two farm bushfire fighting units), backburning and receiving assistance from fire authorities. Combined beef and sheep grazing enterprises appeared to have an increased risk of bushfire injury to livestock.

Implementation of a pharmacy-led virtual academic detailing program at the US Veterans Health Administration

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To provide a summary of the implementation of a virtual academic detailing pilot program at the US Department of Veterans Affairs (VA).

SUMMARY

In September 2018, VA Pharmacy Benefits Management implemented a virtual academic detailing ("e-Detailing") pilot program across three regional networks. Academic detailing involves multifaceted collaborative outreach delivered by trained healthcare clinicians to other clinicians using targeted educational interventions that improve clinical decision-making. Across VA, academic detailing programs are primarily staffed by specially trained clinical pharmacist specialists. Implementation began with an in-person meeting to train academic detailers on using the virtual academic detailing platform (VA Video Connect) and virtual soft skills, which was followed by regular facilitation meetings to address issues and share experiences. During e-Detailing program implementation, the coronavirus disease 2019 (COVID-19) emerged, prompting the US Department of Health and Human Services to declare a public health emergency. VA followed with restrictions on nonessential travel for all employees, thus hampering in-person academic detailing activities. Fortunately, e-Detailing provided an alternative channel for academic detailers across VA to continue delivering critical outreach to providers during the pandemic. Qualitative assessment of academic detailers' and providers' perceptions on e-Detailing highlighted the need for local leadership support for e-Detailing and telehealth, the efficiency of virtual compared to in-person visits, and potential time savings resulting from avoidance of long commutes.

CONCLUSION

The timing of e-Detailing implementation during the COVID-19 pandemic illustrates the need and potential for a virtual platform to deliver timely provider outreach.

Student pharmacist experiences as inpatient psychiatry medication education group leaders during an early immersion program

BACKGROUND AND PURPOSE

While research suggests that pharmacists generally hold positive attitudes toward consumers of psychiatric medications, they often feel less comfortable talking about these medications and providing services for patients with mental illness. The purpose of this program was to train second and third year student pharmacists as psychiatry medication education groups leaders and to examine resulting student self-efficacy and mental health stigma.

EDUCATIONAL ACTIVITY AND SETTING

In partnership with the University of North Carolina (UNC) Eshelman School of Pharmacy, the inpatient psychiatry service at UNC Medical Center expanded weekly medication education groups with the help of trained student pharmacists. All second- and third-year student pharmacists were invited to participate. Pre/post surveys and reflection statements were collected from 13 students that received training, provided informed consent, and participated in one or more medication education groups. Data were analyzed with a mixed methods approach.

FINDINGS

Student responses revealed an increase in student self-efficacy (p < 0.05), improved understanding of mental illness, and new strategies for engaging in direct patient care.

DISCUSSION AND SUMMARY

Results from this study suggest that students gained an appreciation for pharmacists and the workplace while developing self-efficacy and strategies for engaging with patients with mental illness as a part of medication education groups.

Stigmatizing beliefs: How leading patient medication education groups on an inpatient psychiatric unit impacts pharmacy learners

Introduction

Stigma is an important challenge facing patients with mental illness. Stigmatizing attitudes may impact the quantity and quality of care patients receive. Interaction with these patients may reduce stigmatizing attitudes in pharmacy learners. Patient medication education groups (PMEGs) provide learners with an opportunity for this interaction. The objectives of the study were to evaluate pharmacy learner's attitudes toward patients with mental illness and their comfort and ability to provide pharmaceutical services to this population before and after leading a PMEG on an adolescent inpatient psychiatric unit and to evaluate the feasibility of a larger, future trial.

Methods

Third- or fourth-year student pharmacists or first-year pharmacy residents observed a postgraduate year-2 (PGY2) pharmacy specialty resident in psychiatry leading PMEGs on the adolescent unit of an inpatient psychiatric hospital. Then, they discussed their own ideas for design and delivery of a group (with feedback from the PGY2 resident) and, under observation of the PGY2, led their own group. The study used a mixed-methods approach consisting of a presurvey and postsurvey learning experience survey as well as reflective statements. The presurvey consisted of 2 previously validated measures that evaluate stigma toward people with mental illness—the Social Distance Scale (SDS) and the Opening Minds Scale for Health Care Providers (OMS-HC). The postsurvey also consisted of the SDS and OMS-HC and included program evaluation questions that examined the learners' impression of patients with mental illness, their ability and comfort with providing pharmaceutical services to patients with mental illness, and their reflections on the experience.

Results

Seven pharmacy learners participated, and 5 completed both the prelearning and postlearning experience survey for a 71% response rate. There was a median decrease in stigmatizing beliefs of 1 point on the SDS, and a median 5-point drop in the OMS-HC scale. The postintervention questions yielded results primarily of strongly agree or agree with the statements evaluating the other objectives, and the reflection statements brought up the additional value of the educational intervention. Finally, the feasibility and value of a larger trial were confirmed.

Discussion

The value of pharmacy learners teaching PMEGs on stigmatizing beliefs toward patients with mental illness was confirmed. The effectiveness of a model of observing, designing, and delivering a PMEG was also postulated and will be further examined with a larger trial. Future research will also focus on examining the impact of this model on patient outcomes.

Experiencing rights within positive, person-centred support networks of people with intellectual disability in Australia

BACKGROUND

This research describes issues related to human rights as they arose within the everyday lives of people in nine personal support networks that included adult Australians with an intellectual disability (ID).

METHOD

The research was part of a wider 3-year ethnographic study of nine personal support networks. A major criterion for recruitment was that people in these networks were committed to actively developing the positive, meaningful future of an adult family member with an ID. Data were collected from November 2007 to March 2011 via interviews, participant observations and analysed within the framework of situational analysis. Findings were checked with network members.

RESULTS

The issue of rights was challenging to network members. Subtle rights violations could have a major impact on an individual with a disability. Network members worked to protect the rights of people with ID by building and maintaining an empathic and respectful support network, developing the person's self-confidence and autonomy and ensuring that the person with an ID was an active member of the personal support network.

CONCLUSION

The maintenance of rights within a supportive environment remains a difficult task. It can be facilitated by a deep knowledge and respect for the person being supported, the promotion of his or her active participation in the planning and provision of support, and an experimental and reflective approach.

The role of informal networks in providing effective work opportunities for people with an intellectual disability

Being in paid employment is socially valued, and is linked to health, financial security and time use. Issues arising from a lack of occupational choice and control, and from diminished role partnerships are particularly problematic in the lives of people with an intellectual disability. Informal support networks are shown to influence work opportunities for people without disabilities, but their impact on the work experiences of people with disability has not been thoroughly explored. The experience of 'work' and preparation for work was explored with a group of four people with an intellectual disability (the participants) and the key members of their informal support networks (network members) in New South Wales, Australia. Network members and participants were interviewed and participant observations of work and other activities were undertaken. Data analysis included open, conceptual and thematic coding. Data analysis software assisted in managing the large datasets across multiple team members. The insight and actions of network members created and sustained the employment and support opportunities that effectively matched the needs and interests of the participants. Recommendations for future research are outlined.

Brain tissue oxygen monitoring for assessment of autoregulation: preliminary results suggest a new hypothesis

Brain tissue oxygen monitoring (P(ti)O2 (Neurotrend, Codman, Germany) was employed in addition to standard intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring in seven patients with severe neuronal damage of heterogeneous etiology. The correlation between P(ti)O2 changes and CPP fluctuations during periods of 30 minutes were analyzed, when CPP was above 70 mmHg and lower than 100 mmHg. A new ratio, the CPP-oxygen-reactivity (COR) index was calculated as COR=delta p(ti)O2 %/delta CPP%. The patient COR values were compared to those found in the brain of six noninjured anesthetized piglets. The analysis was performed to determine the significance of synchronous fluctuations of CPP and P(ti)O2, when CPP is above the lower threshold of autoregulation. The correlation between CPP variations and p(ti)O2 variations was found to be strong (R(mean)) = 0.74 +/- 0.17) in the patients and was weak in the uninjured animals (R(mean)) =0.38 +/- 0.43). The COR (mean) was 2.05 +/- 0.57 in patients and 0.78 +/- 0.6 in the animals. In the injured brain of our patients, we observed an unexpectedly close correlation between P(ti)O2 and CPP variations when CPP levels were within a therapeutically targeted range (70 to 100 mmHg). In a porcine model, we could not find this relationship in the noninjured brain. We speculate that an increased COR might be indicative for an impaired local pressure autoregulation. The preliminary data suggest that COR values above "1" might be pathologic. However, the reported sample sizes are too small to provide sufficient statistical power to justify inferential statistical analyses. As such, results are presented with descriptive statistics only, and should be regarded as a hypothesis.

Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome

OBJECTIVE

To examine the impact of providing a specialist addictions trained psychiatric nurse on outcome of alcohol treatment in patients presenting to general medical and surgical wards of a district general hospital. Before introducing the specialist alcohol liaison service, a range of staff including a consultant liaison psychiatrist, junior psychiatrists and community psychiatric nurses trained in liaison psychiatry assessed this patient group.

METHOD

A retrospective review of all alcohol liaison referrals with ICD-10 defined alcohol misuse was performed for one year. Comparison data for the first 100 referrals to the specialist alcohol liaison service were obtained prospectively. Indicators included diagnosis at referral, and engagement in and completion of alcohol rehabilitation.

RESULTS

The rates of completion of a four to six week period of alcohol rehabilitation were significantly better after introduction of the Specialist Alcohol Liaison Service. Of those who commenced alcohol rehabilitation, 88% completed, compared to 40% in the traditional assessment service (p < 0.0001).

CONCLUSION

Specialist addictions trained staff in the assessment and management of alcohol dependent patients in medical and surgical wards produce a better immediate outcome than their non-specialist colleagues. This may have implications for service design.

Limitations in the use of gamma-glutamyl transferase estimations in alcohol-dependent subjects

This paper studies a cohort of randomly selected attenders at a district alcohol treatment service and examines the relationship between clinical assessments and laboratory markers currently in use in the unit. It measures in particular the rate of change of serial gamma-glutamyl transferase (GGT) during abstinence throughout an alcohol treatment programme in alcohol-dependent subjects. The results show that GGT is less often elevated in alcohol-dependent patients than was previously thought. Its predictive value changes little with respect to the age of the subject and length of drinking history. Measurement of GGT adds little to the diagnostic sensitivity of careful history taking. In the alcohol-dependent population, GGT estimation is of little value and a normal GGT does not exclude chronic alcohol dependence.

No association between the c2 allele at the cytochrome P450IIE1 gene and alcohol induced liver disease, alcohol Korsakoff's syndrome or alcohol dependence syndrome

Cytochrome P450IIE1 metabolises, and is induced by ethanol. The 5' regulatory sequence of the gene is polymorphic; that identified by the c2 allele has been shown by transfection studies to confer an increased rate of transcription. A recent report indicating an association between this allele and alcohol induced cirrhosis suggests that it may contribute to the genetic vulnerability to this disease. We have examined this polymorphism in patients of western European origin with alcohol induced cirrhosis, alcohol Korsakoff's syndrome and alcohol dependence syndrome. We were unable to detect any association between this allele and any of these diseases.

Primary care physician turnover in HMOs

OBJECTIVE

We assess whether physician turnover stems from incorrect physician expectations about the practice environment or from actual constraints or rewards in that environment.

DATA SOURCES

Our primary data source contains information about individual HMOs' primary care physicians incentive mechanisms and general HMO characteristics. Our secondary data source is the area resource file (ARF), which contains countywide information about the HMOs' market areas, including physician characteristics, population characteristics, and other market characteristics.

DATA COLLECTION

Our primary data source is from a nationwide survey of all HMOs in operation in 1987-1988, as reported to Interstudy.

PRINCIPAL FINDINGS

We find that turnover is higher on the part of physicians whose HMO enrollment comprises a greater percentage of their total practice. Our results further indicate that physicians whose compensation is dependent on the behavior of a group of other physicians are more likely to leave the plan than those who bear the risk (and control it) more directly. On the other hand, turnover is increased by basing bonuses on individual productivity and by not sharing surpluses among a group. Market characteristics also are significant in explaining physician turnover in HMOs.

CONCLUSIONS

It appears that physicians accurately forecast how they will react to individual financial risk, although they dislike restrictions imposed by HMOs.

Cost-effectiveness opportunities for new antibiotics

Antibacterial drugs account for between 6 and 21% of the drug market in various countries, or between 3 and 25% of the total prescriptions. Given the high usage of these agents, they are appropriate candidates for economic appraisal in the near future. It is probable that the marketplace and healthcare reform will give managed care the dominant position in the US healthcare system. Cost-effectiveness analyses of managed care organisations are based on both hospital and outpatient costs, and they are increasingly being aimed at formulary decisions regarding pharmaceuticals. Appropriate outcome parameters, long term follow-up, and phase IV trials to determine costs and outcomes relating to actual clinical use are needed to assess cost-effectiveness. Unbiased pharmacoeconomic research is needed to accurately answer questions on the economic viability of new products, and to avoid scepticism on the part of the purchasers of healthcare. The ultimate challenge for research and development of new antibiotics will be to reconcile the needs of the patient with the economic needs of society, within the cost-effectiveness paradigm.