Refining the role of phenology in regulating gross ecosystem productivity across European peatlands.

The role of plant phenology as a regulator for gross ecosystem productivity (GEP) in peatlands is empirically not well constrained. This is because proxies to track vegetation development with daily coverage at the ecosystem scale have only recently become available and the lack of such data has hampered the disentangling of biotic and abiotic effects. This study aimed at unraveling the mechanisms that regulate the seasonal variation in GEP across a network of eight European peatlands. Therefore, we described phenology with canopy greenness derived from digital repeat photography and disentangled the effects of radiation, temperature and phenology on GEP with commonality analysis and structural equation modeling. The resulting relational network could not only delineate direct effects but also accounted for possible effect combinations such as interdependencies (mediation) and interactions (moderation). We found that peatland GEP was controlled by the same mechanisms across all sites: phenology constituted a key predictor for the seasonal variation in GEP and further acted as a distinct mediator for temperature and radiation effects on GEP. In particular, the effect of air temperature on GEP was fully mediated through phenology, implying that direct temperature effects representing the thermoregulation of photosynthesis were negligible. The tight coupling between temperature, phenology and GEP applied especially to high latitude and high altitude peatlands and during phenological transition phases. Our study highlights the importance of phenological effects when evaluating the future response of peatland GEP to climate change. Climate change will affect peatland GEP especially through changing temperature patterns during plant phenologically sensitive phases in high latitude and high altitude regions.

Urban landscapes and legacy industry provide hotspots for riverine greenhouse gases: A source-to-sea study of the River Clyde.

There is growing global concern that greenhouse gas (GHG) emissions from water bodies are increasing because of interactions between nutrient levels and climate warming. This paper investigates key land-cover, seasonal and hydrological controls of GHGs by comparison of the semi-natural, agricultural and urban environments in a detailed source-to-sea study of the River Clyde, Scotland. Riverine GHG concentrations were consistently oversaturated with respect to the atmosphere. High riverine concentrations of methane (CH4) were primarily associated with point source inflows from urban wastewater treatment, abandoned coal mines and lakes, with CH4-C concentrations between 0.1 - 44 µg l-1. Concentrations of carbon dioxide (CO2) and nitrous oxide (N2O) were mainly driven by nitrogen concentrations, dominated by diffuse agricultural inputs in the upper catchment and supplemented by point source inputs from urban wastewater in the lower urban catchment, with CO2-C concentrations between 0.1 - 2.6 mg l-1 and N2O-N concentrations between 0.3 - 3.4 µg l-1. A significant and disproportionate increase in all GHGs occurred in the lower urban riverine environment in the summer, compared to the semi-natural environment, where GHG concentrations were higher in winter. This increase and change in GHG seasonal patterns points to anthropogenic impacts on microbial communities. The loss of total dissolved carbon, to the estuary is approximately 48.4 ± 3.6 Gg C yr-1, with the annual inorganic carbon export approximately double that of organic carbon and four times that of CO2, with CH4 accounting for 0.03%, with the anthropogenic impact of disused coal mines accelerating DIC loss. The annual loss of total dissolved nitrogen to the estuary is approximately 4.03 ± 0.38 Gg N yr-1 of which N2O represents 0.06%. This study improves our understanding of riverine GHG generation and dynamics which can contribute to our knowledge of their release to the atmosphere. It identifies where action could support reductions in aquatic GHG generation and emission.

MAKING WAVES: Effluent to estuary: Does sunshine or shade reduce downstream footprints of cities?

Riparian tree canopies are key components of river systems, and influence the provision of many essential ecosystem services. Their management provides the potential for substantial control of the downstream persistence of pollutants. The recent advent of new advances in mass spectrometry to detect a large suite of emerging contaminants, high-frequency observations of water quality and gas exchange (e.g., aquatic eddy covariance), and improved spatial resolution in remote sensing (e.g., hyperspectral measurements and high-resolution imagery), presents new opportunities to understand and more comprehensively quantify the role of riparian canopies as Nature-based Solutions. The paper outlines how we may now couple these advances in observational technologies with developments in water quality modelling to integrate simulation of eutrophication impacts with organic matter dynamics and fate of synthetic toxic compounds. In particular regarding solar radiation drivers, this enables us to scale-up new knowledge of canopy-mediated photodegradation processes at a basin level, and integrate it with ongoing improvements in understanding of thermal control, eutrophication, and ecosystem metabolism.

Anthropogenic-estuarine interactions cause disproportionate greenhouse gas production: A review of the evidence base.

Biologically productive regions such as estuaries and coastal areas, even though they only cover a small percentage of the world's oceans, contribute significantly to methane and nitrous oxide emissions. This paper synthesises greenhouse gas data measured in UK estuary studies, highlighting that urban wastewater loading is significantly correlated with both methane (P < 0.001) and nitrous oxide (P < 0.005) concentrations. It demonstrates that specific estuary typologies render them more sensitive to anthropogenic influences on greenhouse gas production, particularly estuaries that experience low oxygen levels due to reduced mixing and stratification or high sediment oxygen demand. Significantly, we find that estuaries with high urban wastewater loading may be hidden sources of greenhouse gases globally. Synthesising available information, a conceptual model for greenhouse gas concentrations in estuaries with different morphologies and mixing regimes is presented. Applications of this model should help identification of estuaries susceptible to anthropogenic impacts and potential hotspots for greenhouse gas emissions.

Greenhouse gas budgets of severely polluted urban lakes in India.

Inland waters are important sources of greenhouse gases and emissions from polluted subtropical systems may be contributing to the observed global increase in atmospheric methane concentrations. Here we detail a scoping study where dissolved concentrations of greenhouse gases methane (CH4), carbon dioxide (CO2) and nitrous oxide (N2O) were measured in two contrasting urban lakes in Bangalore (Bengaluru), Karnataka, India, from June 2018 to February 2020. Bellandur Lake is a severely polluted system whilst Jakkur Lake has been subject to partial restoration via treatment of organic matter inputs. Methane concentrations in Bellandur Lake were three orders of magnitude higher than in Jakkur Lake, with a mean concentration of 3.02 ± 1.57 mg CH4-C L-1 compared to 1.72 ± 1.22 µg CH4-C L-1. At Bellandur Lake, dissolved CO2 concentrations were of the same order of magnitude as for CH4, whereas at Jakkur Lake dissolved CO2 concentrations were two orders of magnitude greater than for CH4. Concentrations of N2O were negligible in both lakes. Extrapolating our data to estimate greenhouse gas fluxes, mean daily methane fluxes from Bellandur Lake were consistently in excess of 1000 mg CH4 m2 d-1, rendering the lake a source of GHGs to the order of 148,350 ± 21,790 ton yr-1 CO2-e yr-1, compared to 100 ± 37 ton CO2-e yr-1 from Jakkur Lake, with CH4 contributing primarily to this difference. We propose that the contribution of severely polluted urban lakes to global CH4 production warrants further investigation, particularly as our evidence suggests that standard secondary wastewater treatment to support restoration of these systems has the potential to significantly reduce CH4 emissions.

Important aspects of end-of-life care among veterans: implications for measurement and quality improvement.

To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments (n=174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits (n=36; 55%), inpatient care (n=36; 55%), access to care (n=33; 50%), transitions in care (n=32; 48%), care that the veteran received at the time of death (n=31; 47%), home care (n=26; 40%), health care facilities (n=12; 18%), and mistakes and complications (n=18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.

A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life.

OBJECTIVES: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN: Nationwide telephone survey. SETTING: Five VA medical centers. PARTICIPANTS: Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS: The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items). RESULTS: Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS: The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Epidemiology of drug-resistant malaria.

Since the first reports of chloroquine-resistant falciparum malaria in southeast Asia and South America almost half a century ago, drug-resistant malaria has posed a major problem in malaria control. By the late 1980s, resistance to sulfadoxine-pyrimethamine and to mefloquine was also prevalent on the Thai-Cambodian and Thai-Myanmar (Thai-Burmese) borders, rendering them established multidrug-resistant (MDR) areas. Chloroquine resistance spread across Africa during the 1980s, and severe resistance is especially found in east Africa. As a result, more than ten African countries have switched their first-line drug to sulfadoxine-pyrimethamine. Of great concern is the fact that the efficacy of this drug in Africa is progressively deteriorating, especially in foci in east Africa, which are classified as emerging MDR areas. Urgent efforts are needed to lengthen the lifespan of sulfadoxine-pyrimethamine and to identify effective, affordable, alternative antimalarial regimens. Molecular markers for antimalarial resistance have been identified, including pfcrt polymorphisms associated with chloroquine resistance and dhfr and dhps polymorphisms associated with sulfadoxine-pyrimethamine resistance. Polymorphisms in pfmdr1 may also be associated with resistance to chloroquine, mefloquine, quinine, and artemisinin. Use of such genetic information for the early detection of resistance foci and future monitoring of drug-resistant malaria is a potentially useful epidemiological tool, in conjunction with the conventional in-vivo and in-vitro drug-sensitivity assessments. This review describes the various features of drug resistance in Plasmodium falciparum, including its determinants, current status in diverse geographical areas, molecular markers, and their implications.

Co-infection with malaria and leptospirosis.

Malaria and leptospirosis are both common in the tropics. Simultaneous infections are possible, although not previously reported. We report two cases of malaria from an area of Thailand on the Thailand-Myanmar border with compelling serologic evidence of simultaneous acute leptospirosis. One was a case of infection with Plasmodium falciparum with acute and convalescent microscopic agglutination test (MAT) titers for Leptospira serovar icterohaemorrhagiae of 1:200 and 1:1,600, respectively. The other was a case of infection with P. vivax that seroconverted to a titer of 1:3,200 for Leptospira serovar bataviae. Additionally, there were five probable cases of leptospirosis with patent malaria parasitemia (three P. falciparum and two P. vivax) detected. Management of dual infections is complicated by their similar clinical presentations, and because the confirmatory diagnosis of malaria is readily available as opposed to that of leptospirosis. Treatment focusing on malaria mono-infections instead of dual infections could result in a delay of specific therapy for leptospirosis and possible consequences of serious complications.

Recrudescence in artesunate-treated patients with falciparum malaria is dependent on parasite burden not on parasite factors.

Artemisinin derivatives are first-line antimalarial drugs in Thailand. No firm evidence of clinically relevant artemisinin resistance exists. When used as monotherapy, artesunate has been associated with a high treatment failure (recrudescence) rate, which could be due to low-level artemisinin resistance. To understand the causes of recrudescence, we retrospectively studied a cohort of 104 malaria patients treated with artesunate monotherapy, 32 of whom recrudesced. There was no difference in in vitro artesunate sensitivities between 6 nonrecrudescent isolates and 16 paired admission and recrudescent isolates. Paired admission and recrudescent isolates from 10 patients were genotyped; only 3 had pfmdr1 mutations. Patients with admission parasitemias >10,000 per microl had a 9-fold higher likelihood of recrudescence (adjusted odds ratio) compared with patients with lower parasitemias. This study suggests (1) recrudescence after treatment with artesunate is not the result of inherent parasite resistance, and (2) admission parasitemia may be useful in choosing therapeutic options.

A study of'febrile illnesses on the Thai-Myanmar border: predictive factors of rickettsioses.

We have performed a case-control analysis to determine the significance of clinical, laboratory and epidemiological features as predictive factors of rickettsioses among patients in Sangkhla Buri, Thailand (Thai-Myanmar border). Fifteen serologically-confirmed rickettsiosis patients including Spotted Fever Group (SFG) rickettsioses, scrub typhus, and murine typhus were classified as 'cases'; one hundred and sixty-three acutely febrile patients presenting to the same hospital during the same time period, who had no serological evidence of acute rickettsiosis, were classified as 'controls'. Patients' report of rash/arthropod bite [Odds ratio (OR) 22.90, 95% CI (confidence interval) 6.23, 84.13] and history of jungle trips (OR 5.30, 95% CI 1.69-16.62) were significant risk factors. Elevated ALT (OR 3.04, 95% CI 1.04, 8.88) and depressed platelet count (OR 3.38, 95% CI 1.13, 10.10) were also useful differentiating markers of rickettsioses in this population. Definitive diagnosis of rickettsioses is difficult without specialized diagnostic capabilities that are rarely available in remote areas such as Sangkhla Buri, where other acute febrile illnesses with similar presentation are commonly found. The relative importance of predictive factors presented here may provide clinicians with some useful guidance in distinguishing rickettsioses from other acute febrile illnesses. Timely administration of empiric treatment in highly suspicious cases can deter potential morbidity from these arthropod-borne infections.

Can metaphors and analogies improve communication with seriously ill patients?

OBJECTIVE: It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills. DESIGN: Cross-sectional observational study of audio-recorded conversations between patients and physicians. SETTING: Three outpatient oncology practices. PATIENTS: Ninety-four patients with advanced cancer and 52 physicians. INTERVENTION: None. MAIN OUTCOME MEASURES: Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate. RESULTS: In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65/101, 64% versus 31/101, 31%; sign test p < 0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0-11 versus mean 0.6, range 0-5; sign rank test p < 0.001). Physicians who used more metaphors elicited better patient ratings of communication (rho = 0.27; p = 0.006), as did physicians who used more analogies (Spearman rho = 0.34; p < 0.001). CONCLUSIONS: The use of metaphors and analogies may enhance physicians' ability to communicate.

Do palliative consultations improve patient outcomes?

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support. CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

Epidemiology and prognosis of coma in daytime television dramas.

OBJECTIVE: To determine how soap operas portray, and possibly misrepresent, the likelihood of recovery for patients in coma. DESIGN: Retrospective cohort study. SETTING: Nine soap operas in the United States reviewed between 1 January 1995 and 15 May 2005. SUBJECTS: 64 characters who experienced a period of unconsciousness lasting at least 24 hours. Their final status at the end of the follow-up period was compared with pooled data from a meta-analysis. RESULTS: Comas lasted a median of 13 days (interquartile range 7-25 days). Fifty seven (89%) patients recovered fully, five (8%) died, and two (3%) remained in a vegetative state. Mortality for non-traumatic and traumatic coma was significantly lower than would be predicted from the meta-analysis data (non-traumatic 4% v 53%; traumatic 6% v 67%; Fisher's exact test both P < 0.001). On the day that patients regained consciousness, most (49/57; 86%) had no evidence of limited function, cognitive deficit, or residual disability needing rehabilitation. Compared with meta-analysis data, patients in this sample had a much better than expected chance of returning to normal function (non-traumatic 91% v 1%; traumatic 89% v 7%; both P < 0.001). CONCLUSIONS: The portrayal of coma in soap operas is overly optimistic. Although these programmes are presented as fiction, they may contribute to unrealistic expectations of recovery.

Hyperparathyroidism and subsequent cancer risk in Denmark.

BACKGROUND: There is increasing evidence that hyperparathyroidism (HPT), a condition that leads to elevated serum calcium levels, is associated with endocrine and other malignancies, suggesting a possible causal link between HPT and carcinoma. METHODS: To investigate the relation of HPT to subsequent cancer risk, the authors conducted a record-linkage study among 2425 patients who were diagnosed with HPT in Danish hospitals. Patients were identified in hospital discharge records, and records were then linked with the Danish National Cancer Registry for the years 1977-1993 to identify cancer incidence. To estimate cancer risk, standardized incidence ratios (SIRs) were computed. RESULTS: After excluding patients who were diagnosed in the first year of follow-up, a total of 219 malignancies were observed, resulting in an SIR of 1.25 (95% confidence interval [95%CI], 1.1-1.4). Cancer risk among women was higher than among men. Among those with primary (idiopathic) HPT, hematopoetic malignancies were elevated significantly (SIR, 1.88; 95%CI, 1.0-3.2; based on 13 patients), with the excess derived primarily from 4 observed patients with multiple myeloma. Patients with secondary HPT had an insignificantly increased risk of overall cancers. Patients who were diagnosed with other or unspecified types of HPT had significant increases in carcinoma of the urinary tract (SIR, 2.71; 95%CI, 1.2-5.3; based on 8 patients) and carcinoma of the thyroid gland (SIR, 21.19; 95%CI, 4.3-61.9; based on 3 patients). CONCLUSIONS: Future studies should monitor whether specific endocrine alterations associated with HPT may affect the long-term risk of hematopoetic, thyroid, and urinary tract carcinomas.

Resistance to antimalarials in Southeast Asia and genetic polymorphisms in pfmdr1.

Resistance to antimalarial drugs is a public health problem worldwide. Molecular markers for drug-resistant malaria, such as pfcrt and pfmdr1 polymorphisms, could serve as useful surveillance tools. To evaluate this possibility, sequence polymorphisms in pfcrt (position 76) and pfmdr1 (positions 86, 184, 1034, 1042, and 1246) and in vitro drug sensitivities were measured for 65 Plasmodium falciparum isolates from Thailand, Myanmar, Vietnam, and Bangladesh. The pfcrt Thr76 polymorphism was present in 97% of samples, consistent with observations that chloroquine resistance is well established in this region. Polymorphisms in pfmdr1 clustered into four specific patterns: the wild type (category I), a Tyr86 polymorphism only (category II), a Phe184 polymorphism only (category III), and Phe184 in combination with Cys1034 and/or Asp1042 (category IV). Isolates in categories I and III were more sensitive to chloroquine and more resistant to mefloquine, artesunate, and artemisinin than isolates in categories II and IV (P /=3. The isolates in all 8 samples fell into categories I and III and were significantly more resistant to mefloquine, quinine, artemisinin, and artesunate and more sensitive to chloroquine than the isolates in the 57 samples with <3 copies of the gene (P

Epstein-Barr virus seroreactivity among unaffected individuals within high-risk nasopharyngeal carcinoma families in Taiwan.

Most adults have been infected with EBV. Many studies have indicated that antibodies against specific EBV antigens, particularly IgA antibodies, can be predictive or prognostic of EBV-associated malignancies, such as NPC. We hypothesized that healthy individuals from families with a history of multiple members affected with NPC (who therefore might be genetically susceptible to NPC themselves) might have an EBV antibody profile that is distinct from that seen in healthy individuals from the community at large. To explore this possibility and examine determinants of anti-EBV antibody levels in healthy, high-risk individuals, we evaluated data from 2 parallel studies of NPC in Taiwan, which included 1,229 healthy members of families in which 2 or more individuals were affected with NPC and 320 controls from the community at large. Blood collected from participants was tested for IgA antibodies against EBV VCA and EBNA-1 and for neutralizing antibodies against EBV DNase using standard assays. We observed evidence of familial aggregation of EBV seroreactivity among individuals from high-risk, multiplex NPC families. Anti-VCA IgA and anti-EBNA-1 IgA antibody seroprevalence in unaffected family members of NPC cases was 5-6 times higher than in members of the community (p < 0.01). This elevated seroprevalence among unaffected individuals from high-risk families was observed regardless of the relationship of the unaffected individual to the closest affected relative (siblings, parents, children or spouses). No sociodemographic or environmental factors examined were found to strongly and consistently correlate with elevated seroprevalence, but patterns emerged of increasing seroprevalence among older individuals and among females. Unaffected individuals from high-risk NPC families have elevated anti-EBV IgA antibody titers. The etiologic and clinical implications of this finding remain to be established.