Development of a prototype modeling system to estimate the GHG mitigation potential of forest and wildfire management

Having recently experienced the three worst wildfire seasons in British Columbia's history in 2017, 2018 and 2021, and anticipating more severe impacts in the future, a key Carbon (C) research priority is to develop reliable models to explore options and identify a portfolio of regionally differentiated solutions for wildfire and forest management. We contribute to this effort by developing a prototype integrated C modeling framework which includes future wildfires that respond to forest stand characteristics and wildfire history. Model validation evaluated net GHG emissions relative to a 'do-nothing' baseline for several management scenarios and included emissions from forest ecosystems, harvested wood products and substitution benefits from avoided fossil fuel burning and avoided emissions-intensive materials. Data improvements are needed to accurately quantify the baseline and scenario GHG emissions, and to identify trade-offs and uncertainties. • A Fire Tolerant scenario included post-fire restoration with planting of climatically suitable fire-resistant species and salvage harvest in place of clearcut harvest.

16 Pharmacological Interventions for Sialorrhoea in Parkinson’s Disease: A Systematic Review

Introduction

We looked at patients with Idiopathic Parkinson’s disease and reviewed articles that used any pharmacological therapy to attempt to reduce the volume or burden of sialorrhoea. The control was patients on placebo or receiving usual best care. The primary outcome was symptom burden of sialorrhoea.

Method

The review was registered on Prospero (CRD42016042470.) 7 electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS) were searched until April 2019 using search terms for sialorrhoea and Parkinson’s disease. We additional searched through the last 6 years of abstracts from the International Movement Disorder Conference, Movement Disorder Society International Congress and World Parkinson’s Congress. Hand searching was performed of published journals from the Movement Disorder Journal of the Movement Disorder Society and Neurology. Inclusion criteria included patients aged over 18; patients with a diagnosis of Idiopathic Parkinson’s disease; patients with the complication of sialorrhoea and any pharmacological therapy aimed at reducing sialorrhoea. All articles were assessed for risk of bias independently by two assessors using the Cochrane risk of bias tool.

Results

7 articles were included from the 1,015 screened citations. 3 studies used Botox B as an intervention with clear objective measures and low risk of bias. These studies did show a significant reduction in sialorrhoea however the largest study showed some reporting bias and the others had small numbers and a short follow up period. 1 study looked at Botox A which showed significant improvement in sialorrhoea but had short follow-up.

Conclusion

Most studies have very small numbers and were followed up for only 1 month. There was significant heterogeneity in outcome measures but little evidence of significant harm from from the treatments studied. Overall, more robust evidence is required in order to achieve a gold standard in the treatment of sialorrhoea.

Nasal Trauma: Who Nose what happens to the non-manipulated?

BACKGROUND

Nasal trauma is the most common facial injury worldwide. Prompt assessment allows for recognition of injuries requiring surgical intervention in the form of nasal bone manipulation. The literature is unclear to what extent patients undergoing conservative management subsequently require surgical intervention.

METHODS

A retrospective chart review of all patients presenting with nasal injury between July 2017 and July 2018 who underwent conservative and surgical management was undertaken. Re-referral and subsequent surgical intervention were documented.

RESULTS

In a cohort of 390 patients with nasal injury 229 patients underwent conservative management. Average age was 29 years. Males comprised 60% of our conservative cohort and 81% of the manipulated cohort. 8.3% of patients managed conservatively and 12% of those undergoing manipulation were re-referred.

CONCLUSION

Nasal trauma assessment is a significant workload for an ENT unit. Conservative management is appropriate following clinical assessment and does not lead to increased intervention compared with those who are surgically manipulated.

Hospital doctors' experiences of caring for dying patients

BACKGROUND

The aim of this study was to examine, by means of a postal questionnaire, the experience of all grades of doctors caring for patients dying in an acute hospital in Scotland.

METHOD

A postal questionnaire was sent to 306 doctors working in inpatient medical and surgical specialties, emergency medicine, anaesthetics and intensive care medicine in an acute hospital.

RESULTS

There was an overall 41% response rate (127/306). Of responding doctors 55% had cared for 10 or more patients in the previous year. A quarter of respondents had personal experience of bereavement outside of clinical practice within the previous year. A total of 65% of responding doctors agreed that their most memorable patient death had had a strong emotional impact upon them. Responding doctors reported benefit from peer support. There was no association between length of time as a doctor and difficulty rating for talking to patients about death (p-value: 0.203). There was no association between difficulty rating and length of time working as a doctor when talking to relatives about death and dying (p-value: 0.205). We considered the questionnaire responses in relation to Scottish Government policy and initiatives associated with the care of the dying, and the future training and support of doctors caring for this group of patients and their relatives.

CONCLUSION

Doctors describe similar experiences in terms of communication difficulties and emotional effects of caring for dying patients irrespective of their length of time working as a doctor.

Pain expectations in neuropathic pain: Is it best to be optimistic?

BACKGROUND

Pain expectancy may be an important variable that has been found to influence the effectiveness of treatments for pain. Much of the literature supports a self-fulfilment perspective where expectations for pain relief predict the actual pain experienced. However, in conditions such as neuropathic pain (NeP) where pain relief is difficult to attain, expectations for pain relief could be unrealistic. The objective of this study was to investigate the relationship between realistic/unrealistic expectations and 6-month, post-treatment outcomes.

METHODS

We performed a retrospective analysis of a large cohort of patients with NeP (n = 789) attending tertiary care centres to determine the association between unrealistic (both positive and negative) and realistic expectations with outcomes after multidisciplinary treatment. An expectation variable with three categories was calculated: realistic expectations were those whose expected reduction in pain was similar to the observed mean group reduction in pain, while optimistic and pessimistic expectations were those who over- or under-estimated the expected response to treatment, respectively. The association between baseline realistic/unrealistic expectations and 6-month pain-related disability, catastrophizing and psychological distress was assessed.

RESULTS

Univariable analyses suggested that realistic expectations were associated with lower levels of disability, catastrophizing and psychological distress, compared to unrealistic expectations. However, after adjustment for baseline symptom severity, multivariable analysis revealed that patients with optimistic expectations had lower levels of disability, than those with realistic expectations. Those with pessimistic expectations had higher levels of catastrophizing and psychological distress at follow-up.

CONCLUSIONS

These findings are largely congruent with the self-fulfilment perspective to expectations.

SIGNIFICANCE

This study defined realistic pain expectations with patient data. Examining the relationship between expectations between pain and disability in a large cohort of patients with neuropathic pain.

Isolated anterior mediastinal tuberculosis in an immunocompetent patient

Background

The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent.

Case presentation

This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis.

Conclusion

Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0175-7) contains supplementary material, which is available to authorized users.

Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.

Blood splash from different diathermy instruments during tonsillectomy

OBJECTIVE

To compare the potential risk of blood contamination of the surgeon's conjunctiva during tonsillectomy using disposable bipolar diathermy and reusable monopolar diathermy.

DESIGN

A prospective, single-blind, randomized, controlled trial.

METHODS

Elective tonsillectomy was performed using either disposable bipolar diathermy or reusable monopolar diathermy. The operating surgeon wore a ViewsafeTM protective eyeshield which was later examined under an operating microscope by a blinded observer and the number of blood spots counted.

RESULTS

One hundred and sixty-eight patients were enrolled. The relative risk of conjunctival contamination of the surgeon using disposable bipolar diathermy was 2.8 times that with reusable monopolar diathermy (chi-squared test, p < 0.0005). A previous history of peritonsillar abscess and additional adenoidectomy were associated with increased blood splatter.

CONCLUSION

The use of disposable bipolar diathermy for haemostasis during tonsillectomy poses a greater risk of conjunctival contamination for the surgeon than using reusable monopolar diathermy.

Rheology of aqueous carbon black dispersions

The interaction of carbon black with an acrylic resin has been investigated by rheology. Two carbon blacks, with similar particle size and surface characteristics but quite different particle morphologies, have been examined. These are somewhat arbitrarily denoted as "spherical" and "fractal" as shown by small-angle neutron scattering (SANS) and ultrasonic spectroscopy studies. In the absence of polymer, stable aqueous dispersions could not be obtained. Stable dispersions could be obtained, however, upon addition of polymer to a level corresponding to a ratio of 50 mg of polymer per 13 m2 (+/- m2) of surface area (i.e., 15 wt% particles). These stable dispersions exhibit flow typical of concentrated dispersions-Newtonian behavior up to some apparent "yield" or critical value, above which pronounced shear thinning is observed. The critical stress increases with increasing polymer concentration. When a significant amount of nonadsorbed polymer is also present, a second Newtonian plateau is superimposed on the shear-thinning behavior. This feature is observed for both particle types but is more pronounced for the fractal particle. When there is little or no nonadsorbed polymer, the viscosity of the fractal particle dispersions is greater than the viscosity of the spherical particle dispersions. At low polymer concentrations, the dispersions are predominantly viscous at low shear stresses. The phase angle decreases significantly over a narrow shear stress range and the rheology tends to more elastic behavior. At higher shear stresses, the dependence on particle morphology is weak.

Characteristics of Type 1 diabetes of over 50 years duration (the Golden Years Cohort)

BACKGROUND

Type 1 diabetes mellitus is associated with high levels of premature morbidity and mortality. Prolonged survival is possible, however, and some patients appear to be protected from the long-term complications of this condition.

METHODS

Diabetes UK awards medals to patients who have had Type 1 diabetes for 50 years or more. By examining medal-holders, we have established the clinical and biochemical features of a group of 400 subjects (54% male) with Type 1 diabetes of long duration.

RESULTS

Mean age of the subjects was 68.9 years and mean age-at-onset of diabetes 13.7 years. Features of long duration diabetes in this cohort include normal body mass (mean BMI 25.0 kg m-2), low insulin dose (mean 0.52 units kg-2) and greatly elevated HDL-cholesterol (mean 1.84 mmol/l). Mean HbA1c was 7.6% (normal range 3.8-5.0%) and no patient had a normal HbA1c at the time of venesection. As a group, they have long-lived parents and consume moderate amounts of alcohol. Medical contact has often been sporadic. A significant proportion (29%) were taking anti-hypertensive medication. Screening for micro- and macroalbuminuria was positive in 35.7%.

CONCLUSIONS

Patients with long-duration (> 50 years) Type 1 diabetes are relatively protected from clinical diabetic nephropathy and large vessel disease; our data are consistent with protection possibly being genetically determined in part via elevated HDL-cholesterol levels. An abnormal urinary albumin/creatinine ratio is common in these patients, despite their low risk of significant renal deterioration; this may have implications for microalbuminuria screening programmes.

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.

Refeeding syndrome: effective and safe treatment with Phosphates Polyfusor

BACKGROUND

Severe hypophosphataemia associated with refeeding syndrome requires treatment with intravenous phosphate to prevent potentially life-threatening complications. However, evidence for replacement regimens is limited and current regimens are complex and replace phosphate inadequately.

AIM

To assess the effectiveness and safety of 50 mmol intravenous phosphate infusion, given as a 'Phosphates Polyfusor', for the treatment of severe hypophosphataemia in refeeding syndrome.

METHODS

Patients with refeeding syndrome and normal renal function received a Phosphates Polyfusor infusion for the treatment of severe hypophosphataemia (< 0.50 mmol/L). The outcome measures were serial serum phosphate, creatinine and calcium concentrations for 4 days following phosphate infusion and adverse events.

RESULTS

Over 2 years, 30 patients were treated. Following treatment, 37% of cases had a normal serum phosphate concentration and 73% had a serum phosphate concentration of > 0.5 mmol/L within 24 h. Ten patients required more than one Phosphates Polyfusor infusion. Within 72 h, 93% of cases had achieved a serum phosphate concentration of > or = 0.50 mmol/L. No patient developed renal failure. Three episodes of transient mild hyperphosphataemia were recorded. Four patients developed mild hypocalcaemia.

CONCLUSIONS

This is the largest published series of the use of intravenous phosphate for the treatment of severe hypophosphataemia (< 0.50 mmol/L), and is the most effective regimen described. All patients had refeeding syndrome and were managed on general wards.

Pain measurement scales: a comparison of the visual analogue and faces rating scales in measuring pressure ulcer pain

OBJECTIVE

Although different pain scales often have been used interchangeably, it is not known whether interchanging them is appropriate. The purpose of this report was twofold: to better understand the statistical properties of the Faces Rating Scale (FRS) so it can be used appropriately in clinical settings and to describe the mathematical relationship between the Visual Analogue Scale (VAS) and the FRS when they are used to quantify pressure ulcer pain in hospitalized elderly patients.

DESIGN

Secondary data analyses were performed as part of a cross-sectional study.

SETTING AND SUBJECTS

A quality assurance program was undertaken to evaluate pressure ulcer pain perceived by elderly hospitalized patients. All patients without aphasia participated.

INSTRUMENTS

The VAS used was a 0 to 100 mm horizontal line demonstrated to have ratio scale properties with high validity and reproducibility, and the FRS used was 6 faces ordered horizontally from smiling to crying, labeled 0 to 5 beneath each face, respectively.

METHODS

Nonlinear least squares regression with a Gauss-Newton iterative procedure was used.

RESULTS

Among models with cubic, quadratic, and linear terms, only the quadratic term was significant (P <.05). With use of the equation derived, VAS = 3.33*(FRS)(2), the resulting reliability coefficient was r = 0.92.

CONCLUSIONS

The nonlinear relationship indicated high reliability between VAS and FRS for pain assessment in populations with diminished verbal and abstract thinking abilities. For readers who would like to translate results from one scale to another, a quadratic equation is provided.

Gene transfer of the Bcl-2 gene confers cytoprotection to isolated adult porcine pancreatic islets exposed to xenoreactive antibodies and complement

BACKGROUND

Exposing adult porcine pancreatic islets (PI) to xenoreactive natural antibodies (XNA) induces brisk inflammatory injury that involves activation of the complement system. Gene transfer of Bcl-2 has been shown to protect PI from apoptosis and necrosis in several models. In this study, we investigated the effect of Bcl-2 gene transfer on protection of PI from primate XNA and complement-mediated injury.

METHODS

The PI were isolated from adult female sows. Only islet preparations that exhibited >90% viability and purity were used. Fresh rhesus monkey serum served as the XNA source. Gene transfer of Bcl-2 was achieved with an adenoviral vector (AdBcl-2) at 500 particle forming units (pfu)/cell. The Bcl-2 expression was confirmed by Western blot technique. Untransfected and transfected PI were incubated in 50% fresh complete serum (CS) or heat-inactivated (HI) rhesus serum for 24 hours. The PI viability was analyzed with acridine orange and ethidium bromide staining. Antibody and complement-mediated cytotoxicity were tested by intracellular lactate dehydrogenase (LDH) release. The PI function was assessed in vitro by static incubation studies and in vivo after intraportal transplantation in diabetic severe combined immunodeficiency (SCID) mice.

RESULTS

The AdBcl-2 gene transfer resulted in Bcl-2 gene expression in >90% of PI cells. Following exposure to XNA, <15% of the untransfected cells were viable. Similar results were obtained in PI transfected with a similar recombinant adenovirus encoding the reporter gene E coli beta-galactosidase (AdLacZ), an irrelevant gene. A significant increase in LDH release was observed in control PI after exposure to CS compared with PI that overexpressed Bcl-2 (82.89% +/- 7.78% vs 34.31% +/- 5.4%, P <.005). Higher insulin release was observed in vitro in PI transfected with Bcl-2 compared with untransfected PI or islets transfected with AdLacZ (stimulation index of 0.9 +/- 0.31, 0.9 +/- 0.3 vs 2.67 +/- 0.4, respectively). Only PI treated with AdBcl-2 were able to achieve euglycemia after exposure to XNA and complement after transplantation.

CONCLUSIONS

Transfer of the antiapoptotic and antinecrotic Bcl-2 gene into PI can reduce primate XNA and complement-mediated lysis. Cytoprotection of PI with Bcl-2 has potential to improve survival of PI xenotransplants.

A tripartite anoikis-like mechanism causes early isolated islet apoptosis

BACKGROUND

This study examines the mechanisms of early isolated islet apoptosis (II-APO) and loss of functional islet mass.

METHODS

Rhesus islets were isolated for transplantation, and an aliquot was used for in vitro molecular studies of II-APO. These studies used Western blotting to examine caspase activation and perinuclear envelope protein cleavage that are associated with II-APO and used immunofluorescence analysis of Annexin V and mitochondrial permeability index to examine spontaneous and tripartite anoikis-like (TRAIL) mechanism--induced II-APO.

RESULTS

Caspase 6 was prominently activated in association with spontaneous II-APO, which occurred after overnight culture. In contrast, caspase 7, 8, and 9 were not activated. Cleavage of focal adhesion kinase and Lamin, substrates of caspase 6, was also evident in spontaneous II-APO. II-APO was exaggerated by the addition of the TRAIL mechanism. The TRAIL mechanism--induced II-APO was blocked by the caspase 6 inhibitor, VEID, and by the soluble fusion proteins, DR4 or DR5, which act as decoy receptors. In vivo studies in diabetic severe combined immunodeficiency disease mice showed that rhesus islets were cytoprotected by either ex vivo gene transfer of Bcl-2 or treatment of the isolated islet with VEID.

CONCLUSIONS

These studies suggest 3 major mechanisms involved in II-APO: caspase 6 activation, a TRAIL-induced apoptosis pathway, and the mitochondrial-associated apoptosis pathway. Inhibition of these II-APO pathways may improve isolated islet survival and reduce functional islet mass loss, which compromises the stable reversal of diabetes.

Creating order out of chaos: models of GNP practice with hospitalized older adults

It has been well documented that hospitalization of an older adult can trigger a cascade of events that negatively affect quality of life long after hospitalization. Three models of care directed by hospital-based geriatric nurse practitioners (GNPs) are described. The GNPs' roles include primary care provider, consultant, educator, researcher, and/or administrator. In one model, the GNP collaborated with a multi-disciplinary team to create a clinical pathway, the Functional Recovery Pathway. In the second model, the GNP and nurse manager addressed the issue of fall risk with an education program for the staff. As a result, the fall rate decreased 5.8%. In a third model, the GNP coordinated care of hospitalized nursing home residents in a "scatter bed" program. Working synergistically with a case management program, the length of stay for this group of patients decreased from a median of 12 days to 9 days in the first year to 6.8 days in the third year. All three models showed that the GNP facilitate change, improve resource utilization, and create innovative strategies to optimize care for hospitalized elders.