Marine spatial planning makes room for offshore aquaculture in crowded coastal waters.

Marine spatial planning (MSP) seeks to reduce conflicts and environmental impacts, and promote sustainable use of marine ecosystems. Existing MSP approaches have successfully determined how to achieve target levels of ocean area for particular uses while minimizing costs and impacts, but they do not provide a framework that derives analytical solutions in order to co-ordinate siting of multiple uses while balancing the effects of planning on each sector in the system. We develop such a framework for guiding offshore aquaculture (bivalve, finfish, and kelp farming) development in relation to existing sectors and environmental concerns (wild-capture fisheries, viewshed quality, benthic pollution, and disease spread) in California, USA. We identify > 250,000 MSP solutions that generate significant seafood supply and billions of dollars in revenue with minimal impacts (often < 1%) on existing sectors and the environment. We filter solutions to identify candidate locations for high-value, low-impact aquaculture development. Finally, we confirm the expectation of substantial value of our framework over conventional planning focused on maximizing individual objectives.

The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature.

Individuals following vegetarian diets are at risk for developing vitamin B12 deficiency owing to suboptimal intake. As vitamin B12 is essential for the synthesis of nucleic acids, erythrocytes and in the maintenance of myelin, deficiency may result in a variety of symptoms. Some of these symptoms may be severe while others may be irreversible. The objective of this review was to assess vitamin B12 deficiency, based on reported serum vitamin B12, among individuals adhering to different types of vegetarian diets. A systematic literature search was carried out using multiple search engines including PubMed, Medline, CINAHL plus, ERIC, Nursing and Allied Health Collection and Nursing/Academic Edition. The inclusion criteria consisted of original studies that assessed serum vitamin B12, studies written in English, non-case studies and studies that reported actual percentages of vitamin B12 deficiency. Forty research studies were included. The deficiency prevalence among infants reached 45%. The deficiency among the children and adolescents ranged from 0 to 33.3%. Deficiency among pregnant women ranged from 17 to 39%, dependent on the trimester. Adults and elderly individuals had a deficiency range of 0-86.5%. Higher deficiency prevalence was reported in vegans than in other vegetarians. Thus, with few exceptions, the reviewed studies documented relatively high deficiency prevalence among vegetarians. Vegans who do not ingest vitamin B12 supplements were found to be at especially high risk. Vegetarians, especially vegans, should give strong consideration to the use of vitamin B12 supplements to ensure adequate vitamin B12 intake. Vegetarians, regardless of the type of vegetarian diet they adhere to, should be screened for vitamin B12 deficiency.

'How does that sound?': objective and subjective voice outcomes following CO2 laser resection for early glottic cancer.

OBJECTIVE: To investigate the effect of transoral laser microsurgery for early glottic cancer on subjective and objective vocal outcome measures. DESIGN: Prospective cohort study. SETTING: Tertiary care cancer centre. PARTICIPANTS: All patients scheduled for transoral laser microsurgery for untreated early primary glottic cancer over a 22-month period and offered voice assessment (31 patients; 19 tumour stage one, 12 tumour stage two). MAIN OUTCOME MEASURES: Fundamental frequency, maximum phonation time, calculated jitter, shimmer and subjective voice rating, analysed by tumour stage. RESULTS: Tumour stage T1 patients had significantly different fundamental frequencies and maximum phonation times at three months post-operatively, compared with pre-operative values; these differences resolved by 12 months. At 12 months, tumour stage T2 patients had significantly shorter maximum phonation times, and all patients reported significantly worse subjective voice ratings, compared with pre-operative values. CONCLUSION: We found no change in fundamental frequency, jitter and shimmer, one year post-operatively. Maximum phonation time deteriorated but stage one patients appeared to compensate, whereas stage two patients did not. Resection size may be a factor. All patients reported significantly worse subjective voice ratings at one year. Aerodynamic and subjective voice measures appear most sensitive to change in this patient group.

Transoral laser microsurgery outcomes with early glottic cancer: the Dalhousie University experience.

OBJECTIVE: To report the results of transoral laser microsurgery for the treatment of early glottic cancer at our institution. DESIGN: Cohort study. Retrospective review of charts of patients diagnosed with tumour stage 1 or 2 (early stage; no nodes or metastases), previously untreated, primary glottic cancer, treated with transoral laser microsurgery at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada. The minimum follow-up period was two years. SETTING: Tertiary care head and neck cancer centre. PARTICIPANTS: Fifty-three patients treated between January 2002 and November 2007. OUTCOME MEASURE: Kaplan-Meier survival analysis for disease-free survival, overall survival and laryngectomy-free survival, at five years. RESULTS: The group comprised 46 men and seven women, with a mean age of 66 years (range 30-84 years). Mean follow up was 40 months (range 12-89 months). There were four cases of complications (7.5 per cent). Kaplan-Meier survival analysis revealed a five-year disease-free survival (including salvage) of 96.2 per cent, a five-year overall survival (all causes) of 88.8 per cent and a five-year laryngectomy-free survival of 98.1 per cent. CONCLUSION: Transoral laser microsurgery is a safe and effective initial treatment for early laryngeal cancer, and has high rates of laryngeal preservation and disease-free survival.

Treatment-induced stable, moderate reduction in blood cell counts correlate to disease control in early rheumatoid arthritis.

BACKGROUND: Treatment of rheumatoid arthritis (RA) has become more intensive, thereby raising concerns regarding toxicities, including leucopenia. The objective was to analyse cell counts obtained as routine surveillance for adverse effects to assess the effect of intensive treatment and treatment dosage and to examine correlations to disease activity scores. METHODS: Patients with early RA were treated with combinations of disease-modifying anti-inflammatory drugs according to pre-defined rules, with dose adjustments contingent on residual disease activity and tolerance. RESULTS: Mean leucocyte, neutrophil and platelet counts fell with levels that correlated to disease activity scores. The strongest correlation was between platelets and disease activity scores. There was a modest, inverse correlation between methotrexate dose and monocyte and lymphocyte counts. No serious toxicity associated with the therapy was seen. CONCLUSION: Moderate reductions in cell counts are well tolerated in RA and appear to contribute to disease control.

'When will I see you again?' Using local recurrence data to develop a regimen for routine surveillance in post-treatment head and neck cancer patients.

OBJECTIVE: To develop an evidence-based regimen for routine surveillance of post-treatment head and neck cancer patients. DESIGN: Review of 10 years of prospectively collected patient data. MAIN OUTCOME MEASURES: Time of first presentation of 'new cancer event' (either first recurrence or second primary tumour). We did not evaluate whether or not the detected new cancer events were curable. RESULTS: Data from patients with primary squamous cell carcinoma of the larynx, oropharynx and hypopharynx were analysed. A total of 676 previously undiagnosed squamous cell carcinomas were recorded in these regions. In these patients there were 105 recurrences and 20 second primary cancers were recorded; 95(th) percentile of "time to a new cancer event" was calculated in years. These were for larynx 4.7 years, oropharynx 2.7 years, hypopharynx 2.3 years. The time to new cancer event was similar for early and late laryngeal cancers. Only 36 (47%) of the hypopharyngeal cancers were treated with curative intent and of these 36% had a previously undiagnosed cancer event. CONCLUSION: Local data and published evidence support a follow-up duration of 7 years for laryngeal primaries and 3 years for both oropharyngeal and hypopharyngeal primaries. Late stage oropharyngeal cancers may require longer follow up than early cancers. Patients who continue to smoke may need longer follow up. A change in local follow-up protocol to this regimen would save 10 patient slots every week with no detriment to patient care.

Endoscopic 'cold steel' versus laser dacryocystorhinostomy: completing the audit cycle.

INTRODUCTION: Dacryocystorhinostomy via an endonasal route has been adopted in our department. This audit study describes and compares our results for external, laser endonasal and 'cold steel' endonasal techniques. Success was defined as a subjective report of eye watering being 'better' or 'cured'. Data were obtained from a retrospective review of the medical records of all patients undergoing primary dacryocystorhinostomy in our department. 'Gold standard': External dacryocystorhinostomy performed by a consultant ophthalmologist was taken as our gold standard. In our study, the success rate for external dacryocystorhinostomy was 94 per cent. First cycle - laser-assisted endonasal dacryocystorhinostomy: Our initial results for endonasal laser-assisted dacryocystorhinostomy produced a success rate of 64 per cent, which was significantly worse than that for external dacryocystorhinostomy. These results have been previously published. CHANGE IN PRACTICE: Evidence suggested that cold steel endonasal dacryocystorhinostomy was more effective, and we adopted this as our technique of choice. Second cycle - cold steel endonasal dacryocystorhinostomy: Over a four-year period, 57 cases completed a full nine months' follow up. 93 per cent were completed as day cases and 39 per cent were performed under local anaesthetic. The success rate was 79 per cent (45/57). There was no difference in success rates when this procedure was compared with external dacryocystorhinostomy (p = 0.55). The type of anaesthetic used (i.e. local vs general) made no difference to the success rate (p = 0.93). CHANGE IN PRACTICE: Cold steel endonasal dacryocystorhinostomy was as effective as the gold standard, i.e. external dacryocystorhinostomy. Laser-assisted dacryocystorhinostomy was significantly less successful than external dacryocystorhinostomy. Due to the benefits of decreased operating time, lower morbidity and success under local anaesthetic, we recommend cold steel endonasal dacryocystorhinostomy as our procedure of choice for the treatment of epiphora.

Lesson plans in surgical training.

Lesson plans in surgery enable trainers and trainees to agree on goals that balance training needs with service commitments. Lesson plans are individualised to the trainee and encourage ownership of learning. They are based on SMART criteria and therefore have a sound educational footing. Most of the work in creating a lesson plan falls to the trainee. The total time for creation of each plan is approximately 20 min. Our use of lesson plans for surgical training has been met with favourable response from both trainer and trainees.

Silencing the snorers: no gain without pain?

OBJECTIVE: To compare the estimated effects of conservative surgery to those of a mandibular advancement splint (MAS) in the treatment of habitual snoring. METHOD: Prospective, observational, non-randomized cohort study. RESULTS: Adequate follow-up data were available for 88 participants (23 following coblation, 65 after provision of an MAS). The mean reduction in snoring symptoms inventory (SSI) score for the 23 subjects undergoing coblation was 9.83 (+/-standard deviation 11.43). Reported pain duration was greatest with uvula amputation, but uvula coblation did not always adequately reduce its bulk. Of the 65 MAS patients, 39 (60 per cent) used the device regularly, with a mean fall in SSI of 12 (+/-16.4, p=0.001). Approximately one in four patients in both groups achieved a significant fall in SSI (>15 points), and the measured effect sizes were close to 0.75 for both treatments. CONCLUSIONS: Mandibular advancement splints and coblation have similar efficacies. However, their efficacy does not match that of radical surgery.

Spontaneous growth hormone release in term infants: changes during the first four days of life.

Healthy term infants have higher umbilical cord GH levels compared to older infants and children. In the sheep, GH concentrations rapidly fall within an hour of birth; the physiology of GH release after parturition in the human term infant is less well known. The purpose of this study was to investigate spontaneous 12-h GH release in male and female term infants of varying postnatal ages. We studied 14 infants (7 males and 7 females). Subjects were divided into those studied earlier following delivery (28.2 +/- 3.4 h of age, mean +/- SE) and into those studied at a later time (74.8 +/- 3.5 h, P < 0.0005). The age at study was defined as the age (hours) when blood sampling began. There were eight infants studied at an early age (four males and four females) and six studied at a later age (three males and three females). Subjects were comparable with respect to gestational age, birth weight, and length; all were biochemically euthyroid. One infant was large for gestational age although his head circumference was in the normal range. Blood (0.1 mL) was taken every 30 min over a 12-h period from an indwelling umbilical catheter; no stress occurred during the blood withdrawal. GH was determined by a double-antibody RIA using 0.01 mL plasma. GH pulse detection was undertaken using Cluster, a computerized pulse detection algorithm. Total insulin-like growth factor I (IGF-I) was measured following separation of the IGFs from the serum binding proteins. Spontaneous pulsatile GH release was observed in all infants studied. No differences in GH characteristics were found between male and female subgroups in the early or late study groups. In subsequent analysis, the data for the males and females are combined. The GH pulse frequency per 12 h was greater in the earlier studied group, 5.1 +/- 0.9 (mean +/- SE) vs. 2.5 +/- 0.7 in the later group (P < 0.05). The maximal pulse amplitude was 47.1 +/- 7.9 micrograms/L in the early and 27.1 +/- 4.1 in the later studied group (P < 0.06). The incremental pulse amplitude was 26.4 +/- 3.4 micrograms/L in the early and 12.8 +/- 2.7 in the later group (P = 0.01). The pulse width was greater in the later studied group (202.8 +/- 71.1 min vs. 84.1 +/- 21.6, P < 0.06).(ABSTRACT TRUNCATED AT 400 WORDS)

Spontaneous and stimulated growth hormone release in adolescents with type I diabetes mellitus: effects of metabolic control.

Abnormalities in GH release have been found in adults with poorly controlled type I diabetes mellitus. During puberty, circulating GH concentrations transiently increase. To investigate in pubertal diabetic adolescents, the physiological relationship between metabolic control and GH release, we compared spontaneous and GH-releasing hormone (GHRH)-stimulated GH release in six pubertal subjects during poor (study A) and improved (study B) metabolic control. The subjects included two females and four males (mean age +/- SE, 15.5 +/- 1 yr; duration of diabetes, 8.6 +/- 0.9 yr; Tanner stages II-V). Serum samples for glucose and GH determinations were obtained at 20-min intervals over a 24-h period. Significant pulses of GH release were identified using a pulse detection algorithm (Cluster). Fourier expansion time series was used to document the occurrence of significant periodicities in the GH concentration-time data series. All subjects received 1.0 microgram/kg GHRH-44, iv, at 0800 h on the day after the 24-h monitoring for GH. After GHRH administration, samples were taken for glucose and GH determinations over 90 min. The overall mean glucose level (+/- SE) during the 24-h monitoring was 11.5 +/- 0.2 mmol/L during study A and 7.2 +/- 0.2 during study B (P = 0.0001). During the 4 weeks of improved control, glycated hemoglobin fell from 13.9 +/- 1.4% to 11.7 +/- 0.8% (mean +/- SE; P < 0.025). All subjects had significant pulses of GH release during poor or improved metabolic control. Relative to that at night, the daytime pulse frequency was higher in study A (P < 0.025). The overnight pulse frequency increased during study B (P < 0.01). Other pulse parameters, including maximal and incremental pulse amplitudes, pulse width, and interpulse valley mean, did not change during improved control. The mean +/- SE 24-h GH concentration was 4.1 +/- 0.7 micrograms/L during study A and 4.3 +/- 0.8 during study B. The amplitude of the circadian GH rhythm was not different by Fourier analysis. The overall mean glucose +/- SE after GHRH administration was 15.3 +/- 0.2 mmol/L in study A and 6.8 +/- 0.1 in study B. In spite of the marked hyperglycemia during study A, the GH responses were similar during studies A and B. Maximal GH levels were obtained at 15-30 min (mean +/- SE) and were 36.0 +/- 16.9 micrograms/L in study A and 38.7 +/- 18.9 in study B.(ABSTRACT TRUNCATED AT 400 WORDS)