Supplementing Environmental Assessments with Cumulative Effects Scenario Modeling for Grizzly Bear Connectivity in the Bow Valley, Alberta, Canada.

Persistence of sensitive wildlife in populated regions requires conservation strategies that address gradual expansion of development footprint and human activity. The project-based environmental assessment regime for municipal development is poorly suited to provide necessary strategic perspective, given its focus on local and short-term impacts. We used the ALCES cumulative effects model to strategically assess impacts to grizzly bears (Ursus arctos) in the Bow Valley of Alberta, Canada. Landscape simulation mapped expansion of past and potential future development footprint in the region over multiple decades. Consequences to movement connectivity for grizzly bears were estimated by applying a least cost path analysis to the landscape simulation. An index of recreational activity was derived from fitness tracking data and integrated with the landscape simulation to model change in recreational activity through time. Maps of grizzly bear connectivity and recreational activity were combined to calculate human-bear conflict risk. The analysis suggests that connectivity has been altered through displacement to upslope areas by settlement expansion, such that surrounding natural areas have become important for grizzly bear connectivity. These areas are also popular for outdoor recreation, resulting in elevated human-bear conflict risk which can be expected to increase if development and human activity continue to expand in high connectivity areas. Conservation of wildlife in populated regions will be supported by broadening the scope of environmental assessment to address cumulative effects of development footprint and human activity over large spatial and temporal scales.

Evaluation of Radiology Reports by the Emergency Department Clinical Providers: A Message to Radiologists [Formula: see text].

OBJECTIVES: This study is an evaluation of the emergency department (ED) satisfaction with the current radiologic reporting system used at a major Northeastern academic medical center. The radiology reports are the main form of communication and usually the final product of any radiological investigation delivered to clinicians. The aim of this study was to improve current radiology reporting practices and to better tailor reports to match the needs and expectations of ED clinicians. METHODS: A 9-question online survey was sent to ED residents, fellows, faculty, and nurse practitioners/advanced practice providers at a major Northeastern academic medical center in the United States. For the open-ended section, coding and emergent theme categorization was conducted for quantification of responses. The survey was designed to evaluate the attitudes toward the structure, style, form, and wording used in reports. RESULTS: The response rate was 48.6% (68/140). The ED respondents were generally satisfied with radiology reports, their language, vocabulary, and clarity. They preferred the impression section to be before the findings in simple examinations and to stratify the reports according to emergency status for complex examinations. They did not like extended differential, hedge terms, and delayed reporting. Additionally, ED respondents recommended focused, fast reporting with considerable changes toward a more standardized report. CONCLUSIONS: This evaluation delivered a list of actionable recommendations. The top recommendation is to standardize reporting structure, style, and lexicon, in addition to being focused, timely, and brief.

Is desiccation tolerance and avoidance reflected in xylem and phloem anatomy of two coexisting arid-zone coniferous trees?

Plants close their stomata during drought to avoid excessive water loss, but species differ in respect to the drought severity at which stomata close. The stomatal closure point is related to xylem anatomy and vulnerability to embolism, but it also has implications for phloem transport and possibly phloem anatomy to allow sugar transport at low water potentials. Desiccation-tolerant plants that close their stomata at severe drought should have smaller xylem conduits and/or fewer and smaller interconduit pits to reduce vulnerability to embolism but more phloem tissue and larger phloem conduits compared with plants that avoid desiccation. These anatomical differences could be expected to increase in response to long-term reduction in precipitation. To test these hypotheses, we used tridimensional synchroton X-ray microtomograph and light microscope imaging of combined xylem and phloem tissues of 2 coniferous species: one-seed juniper (Juniperus monosperma) and piñon pine (Pinus edulis) subjected to precipitation manipulation treatments. These species show different xylem vulnerability to embolism, contrasting desiccation tolerance, and stomatal closure points. Our results support the hypothesis that desiccation tolerant plants require higher phloem transport capacity than desiccation avoiding plants, but this can be gained through various anatomical adaptations in addition to changing conduit or tissue size.

Reductions in tree performance during hotter droughts are mitigated by shifts in nitrogen cycling.

Climate warming should result in hotter droughts of unprecedented severity in this century. Such droughts have been linked with massive tree mortality, and data suggest that warming interacts with drought to aggravate plant performance. Yet how forests will respond to hotter droughts remains unclear, as does the suite of mechanisms trees use to deal with hot droughts. We used an ecosystem-scale manipulation of precipitation and temperature on piñon pine (Pinus edulis) and juniper (Juniperus monosperma) trees to investigate nitrogen (N) cycling-induced mitigation processes related to hotter droughts. We found that while negative impacts on plant carbon and water balance are manifest after prolonged drought, performance reductions were not amplified by warmer temperatures. Rather, increased temperatures for 5 years stimulated soil N cycling under piñon trees and modified tree N allocation for both species, resulting in mitigation of hotter drought impacts on tree water and carbon functions. These findings suggest that adjustments in N cycling are likely after multi-year warming conditions and that such changes may buffer reductions in tree performance during hotter droughts. The results highlight our incomplete understanding of trees' ability to acclimate to climate change, raising fundamental questions about the resistance potential of forests to long-term, compound climatic stresses.

Tree water dynamics in a drying and warming world.

Disentangling the relative impacts of precipitation reduction and vapour pressure deficit (VPD) on plant water dynamics and determining whether acclimation may influence these patterns in the future is an important challenge. Here, we report sap flux density (FD ), stomatal conductance (Gs ), hydraulic conductivity (KL ) and xylem anatomy in piñon pine (Pinus edulis) and juniper (Juniperus monosperma) trees subjected to five years of precipitation reduction, atmospheric warming (elevated VPD) and their combined effects. No acclimation occurred under precipitation reduction: lower Gs and FD were found for both species compared to ambient conditions. Warming reduced the sensibility of stomata to VPD for both species but resulted in the maintenance of Gs and FD to ambient levels only for piñon. For juniper, reduced soil moisture under warming negated benefits of stomatal adjustments and resulted in reduced FD , Gs and KL . Although reduced stomatal sensitivity to VPD also occurred under combined stresses, reductions in Gs , FD and KL took place to similar levels as under single stresses for both species. Our results show that stomatal conductance adjustments to high VPD could minimize but not entirely prevent additive effects of warming and drying on water use and carbon acquisition of trees in semi-arid regions.

Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care.

INTRODUCTION: Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety. METHODS: A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns. RESULTS: 184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted. CONCLUSION: This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.

A prospective feasibility study of sub-millisievert abdominopelvic CT using iterative reconstruction in Crohn's disease.

OBJECTIVE: Iterative reconstruction (IR) allows diagnostic CT imaging with less radiation exposure than filtered back projection (FBP). We studied an IR low-dose CT abdomen/pelvis (LDCTAP) protocol, designed to image at an effective dose (ED) approximating 1 mSv in patients with Crohn's disease (CD). METHODS: Forty patients, mean age 37 ± 13.4 years (range 17-69), with CD underwent two synchronous CT protocols (conventional-dose (CDCTAP) and LDCTAP). CDCTAP and LDCTAP images were compared for diagnostic acceptability, yield, image quality and ED (in millisieverts). The optimal level of IR for LDCTAP was also studied. RESULTS: LDCTAP yielded a mean ED of 1.3 ± 0.8 mSv compared with 4.7 ± 2.9 mSv for CDCTAP, reducing ED by 73.7 ± 3.3 % (mean dose reduction, 3.5 ± 2.1 mSv; P < 0.001) and dose length product by 73.6 ± 2.6 % (P < 0.001). Sub-millisievert (0.84 mSv) imaging was performed for patients with a body mass index (BMI) less than 25 (i.e. 63 % of our cohort). LDCTAP resulted in increased image noise and reduced diagnostic acceptability compared with CDCTAP despite use of IR, but detection of extra-luminal complications was comparable. CONCLUSION: Patients with suspected active CD can be adequately imaged using LDCTAP, yielding comparable information regarding extent, activity and complications of CD compared with CDCTAP, but with 74 % less dose. LDCTAP at doses equivalent to that of two abdominal radiographs represents a feasible alternative to CDCTAP. KEY POINTS: • Radiation dose is a concern when imaging patients with Crohn's disease. • New techniques allow low-dose abdominopelvic CT with acceptable image quality. • Using hybrid iterative reconstruction, its diagnostic yield compares well with that of conventional CT. • Sub-millisievert CT of patients with Crohn's disease appears technically and clinically feasible.

Benefits of symbiotic ectomycorrhizal fungi to plant water relations depend on plant genotype in pinyon pine.

Rhizosphere microbes, such as root-associated fungi, can improve plant access to soil resources, affecting plant health, productivity, and stress tolerance. While mycorrhizal associations are ubiquitous, plant-microbe interactions can be species specific. Here we show that the specificity of the effects of microbial symbionts on plant function can go beyond species level: colonization of roots by ectomycorrhizal fungi (EMF) of the genus Geopora has opposite effects on water uptake, and stomatal control of desiccation in drought tolerant and intolerant genotypes of pinyon pine (Pinus edulis Engelm.). These results demonstrate, for the first time, that microorganisms can have significant and opposite effects on important plant functional traits like stomatal control of desiccation that are associated with differential mortality and growth in nature. They also highlight that appropriate pairing of plant genotypes and microbial associates will be important for mitigating climate change impacts on vegetation.

Diagnostic accuracy of computed tomography using lower doses of radiation for patients with Crohn's disease.

BACKGROUND & AIMS: Magnetic resonance and ultrasonography have increasing roles in the initial diagnosis of Crohn's disease, but computed tomography (CT) with positive oral contrast agents is most frequently used to identify those with acute extramural complications. However, CT involves exposure of patients to radiation. We prospectively compared the diagnostic accuracy of low-dose CT (at a dose comparable to that used to obtain an abdominal radiograph) with conventional-dose CT in patients with active Crohn's disease. METHODS: Low and conventional dose CT of the abdomen and pelvis were acquired from 50 patients with Crohn's disease, referred from an inflammatory bowel disease service (20 male; median age, 34 years). Acute complications of Crohn's disease were suspected. Iterative reconstruction was performed on all CT datasets to facilitate dose reduction. Three radiologists reviewed the low-dose CT images before the conventional-dose CT images. RESULTS: The median effective dose (interquartile range) of radiation for the low-dose CT was reduced by 72% from that of conventional CT: from 3.5 mSv (3-5.08 mSv) to 0.98 mSv (0.77-1.42 mSv) (P < .001). As expected, the quality indexes of the low-dose images were inferior to those of the conventional-dose images, but no clinically significant diagnostic findings were missed with low-dose imaging. Follow-up CT examinations were recommended for 5 patients; 1 had a cervical tumor, 1 had a pancreatic lesion, and 3 had intra-abdominal abscess. In each case, the image obtained by low-dose CT was considered sufficient for diagnosis. CONCLUSIONS: Although low-dose CT images are of lower quality than images obtained with conventional doses of radiation, no clinically significant diagnostic findings were missed from low-dose CT images of patients with Crohn's disease. The low-dose CT was obtained at a median effective dose equivalent to 1.4 abdominal radiographs.

Effects of Soil Microbes on Functional Traits of Loblolly Pine (Pinus taeda) Seedling Families From Contrasting Climates.

Examining factors that influence seedling establishment is essential for predicting the impacts of climate change on tree species' distributions. Seedlings originating from contrasting climates differentially express functional traits related to water and nutrient uptake and drought resistance that reflect their climate of origin and influence their responses to drought. Soil microbes may improve seedling establishment because they can enhance water and nutrient uptake and drought resistance. However, the relative influence of soil microbes on the expression of these functional traits between seedling families or populations from contrasting climates is unknown. To determine if soil microbes may differentially alter functional traits to enhance water and nutrient uptake and drought resistance between dry and wet families, seeds of loblolly pine families from the driest and wettest ends of its geographic range (dry, wet) were planted in sterilized sand (controls) or in sterilized sand inoculated with a soil microbial community (inoculated). Functional traits related to seedling establishment (germination), water and nutrient uptake and C allocation (root:shoot biomass ratio, root exudate concentration, leaf C:N, leaf N isotope composition (δ15N)), and drought resistance (turgor loss point, leaf carbon isotope composition (δ13C)) were measured. Then, plants were exposed to a drought treatment and possible shifts in photosynthetic performance were monitored using chlorophyll fluorescence. Inoculated plants exhibited significantly greater germination than controls regardless of family. The inoculation treatment significantly increased root:shoot biomass ratio in the wet family but not in the dry family, suggesting soil microbes alter functional traits that improve water and nutrient uptake more so in a family originating from a wetter climate than in a family originating from a drier climate. Microbial effects on photosynthetic performance during drought also differed between families, as photosynthetic performance of the dry inoculated group declined fastest. Regardless of treatment, the dry family exhibited a greater root:shoot biomass ratio, root exudate concentration, and leaf δ15N than the wet family. This indicates that the dry family allocated more resources belowground than the wet and the two family may have used different sources of plant available N, which may be related to their contrasting climates of origin and influence their drought resistance. Examination of variation in impacts of soil microbes on seedling physiology improves efforts to enhance seedling establishment and beneficial plant-microbe interactions under climate change.

Prolonged warming and drought modify belowground interactions for water among coexisting plants.

Understanding how climate alters plant-soil water dynamics, and its impact on physiological functions, is critical to improved predictions of vegetation responses to climate change. Here we analyzed how belowground interactions for water shift under warming and drought, and associated impacts on plant functions. In a semi-arid woodland, adult trees (piñon and juniper) and perennial grasses (blue grama) were exposed to warming and precipitation reduction. After 6 years of continuous treatment exposure, soil and plant water isotopic composition was measured to assess plant water uptake depths and community-level water source partitioning. Warming and drought modified plant water uptake depths. Under warming, contrasting changes in water sources between grasses and trees reduced belowground water source partitioning, resulting in higher interspecific competition for water. Under drought, shifts in trees and grass water sources to deeper soil layers resulted in the maintenance of the naturally occurring water source partitioning among species. Trees showed higher water stress, and reduced water use and photosynthesis in response to warming and drought. This case study demonstrates that neighboring plants shift their competitive interactions for water under prolonged warming and drought, but regardless of whether changes in moisture sources will result in increased competition among species or maintained partitioning of water resources, these competitive adaptations may easily be overridden by climate extremes.

Plant-microbe interactions before drought influence plant physiological responses to subsequent severe drought.

We examined the effect of soil microbial communities on plant physiological responses to drought. Bouteloua gracilis seeds were planted in sterilized sand with (inoculated) and without (controls) soil microbial communities. After substantial growth, drought was imposed by completely withholding water. Before soil moisture declined to zero, inoculated plants germinated faster, were significantly taller, and maintained greater soil moisture than controls. The greater soil moisture of the inoculated plants allowed greater photosynthesis but also induced lower tissue drought tolerance (as indicated by turgor loss point) compared to controls. The inoculated plants were more susceptible to severe drought compared to control plants as indicated by significantly lower mean stomatal conductance, as well as marginally significantly greater mean wilting score, for the entire severe drought period after soil moisture declined to zero. Inoculated plants exhibited enhanced growth and photosynthesis and dampened drought stress over short timescales, but also increased susceptibility to drought over long timescales. This work demonstrates (1) an unexpected insight that microbes can have positive initial effects on plant performance, but negative impacts on plant performance during severe drought, and (2) that microbially altered effects on plant function during well-watered and moderate drought conditions can influence plant function under subsequent severe drought.

Lack of acclimation of leaf area:sapwood area ratios in piñon pine and juniper in response to precipitation reduction and warming.

The leaf area to sapwood area ratios of trees (Al:AS) can shift to maintain homeostatic gas exchange per unit leaf area in response to climate variability. We tested the hypothesis that trees alter their Al:AS ratios in response to long-term warming and reduced precipitation in order to maintain leaf-specific gas exchange rates under more stressful conditions. Whole-tree Al:AS was measured on mature piñon pine (Pinus edulis Engelm.) and one-seed juniper (Juniperus monosperma (Engelm.) Sarg.) trees after 5 years (2012-16) of chronic exposure to increased temperature (+4.8 °C), precipitation reduction (-45%), or both simultaneously. No difference was found in Al:As among treatments for either species. Associated with this lack of shift in Al:As were large changes in pre-dawn leaf water potential and stomatal conductance, consistent with theoretical expectations of interactions between leaf and whole-tree hydraulic supply. Our results suggest that a lack of whole-tree acclimation in Al:As results in the reductions in plant gas exchange and water status associated with long-term warming and reduced precipitation in semi-arid woodlands.

Pilot Investigation into the Use of an Anthropomorphic Breast Sonography Phantom as a Training and Assessment Tool.

A device for the training and quantitative assessment of the competency of trainee radiologists in the technically challenging area of breast sonography was developed and evaluated. Currently, suitable commercially available devices are lacking, and there is a growing realization that the reliance on direct exposure to patients for learning may not represent best practice from either the trainees' or patients' perspective. Three devices (PI, PII and PIII) were designed to produce very realistic sonographic images of breast morphology with a range of embedded pathologies. The pilot evaluation used a case study research design to evaluate the role of the anthropomorphic breast sonography training device in training and assessment in a clinical environment. Through the case study, it was possible to evaluate the process and relationships when using this type of training intervention for a small group of radiology resident trainees. The investigation involved a baseline assessment of trainees' (n = 4) ability to detect and characterize all lesions in PI, followed by a 4-wk training period on PII and a post-training assessment using PIII. The evaluation revealed an improvement of 30% ± 8% in the trainee's performance from pre- to post-training. It was expected that the performance of the trainees would improve as the training phantom described in this study aligns with the learning theory of constructivism and fits the ideal specifications of a medical training device in terms of its realism and facilitation of self-directed learning and deliberate practice of the trainees. The device provides a useful platform upon which training and assessment can be facilitated.

Communication of unexpected and significant findings on chest radiographs with an automated PACS alert system.

PURPOSE: An integral part of realizing the enormous potential of imaging in patient care is close communication between radiologists and referring physicians. One key element of this process is the communication of unexpected significant findings. The authors examined the performance of a PACS-based alert system in the appropriate communication of reports containing unexpected significant findings to referring physicians. METHODS: A PACS-integrated key word system was developed such that an e-mail was sent to the referring clinician if a radiologist detected a significant unexpected finding. The number, source, and outcome of chest radiographic unexpected findings over a 14-month period were analyzed. The time for response of the referring physician plus time for follow-up were also examined. RESULTS: Key words were applied to 158 of the 39,665 chest radiographs (0.4%) obtained during the study period. The emergency department was the most frequent referral location (46.2%). Final diagnostic categories included malignancy (13.9%), benign lesion (49.4%), and no abnormality (20.2%). The average time to acknowledgment by clinicians of notification was 3.1 days, although 57.6% were acknowledged within 24 hours. The mean time interval to the next relevant radiologic investigation was 26 days among the 77.8% of findings that underwent radiologic follow-up. CONCLUSIONS: The development of electronic alert systems, which are integrated into PACS, can aid greatly in report communication and eliminate the risk associated with unread reports that contain significant or unexpected findings.

Interventional radiology and the care of the oncology patient.

Interventional Radiology (IR) is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Adequate diagnostic samples can be obtained under image guidance by percutaneous biopsy and needle aspiration in an accurate and minimally invasive manner. IR techniques may be used to place central venous access devices with well-established safety and efficacy. Therapeutic applications of IR in the oncology patient include local tumour treatments such as transarterial chemo-embolisation and radiofrequency ablation, as well as management of complications of malignancy such as pain, organ obstruction, and venous thrombosis.

An assessment of medical students' awareness of radiation exposures associated with diagnostic imaging investigations.

OBJECTIVES: This study assessed students' awareness of radiation exposures and determined the impact a curriculum in clinical radiology (CICR) had on awareness. METHODS: Six hundred seventy medical students at one medical school were studied. CICR was delivered in yearly modules over the 5-year programme. Five hundred twenty-three students (years 1-5), exposed to increasing numbers of CICR modules and 147 students beginning medical school (year 0), represented the study and control groups, respectively. Students completed a multiple choice questionnaire assessing radiation knowledge and radiology teaching. RESULTS: Most students in the study population received CICR but 87% considered they had not received radiation protection instruction. The percentage of correctly answered questions was significantly higher in the study population than the control group (59.7% versus 38%, p < 0.001). Students who received CICR achieved higher scores than those who did not (61.3% compared with 42.8%, p < 0.001). Increasing exposure to CICR with each year of medical education was associated with improved performance. CONCLUSIONS: Assessment of students' awareness of radiation exposures in diagnostic imaging demonstrates improved performance with increasing years in medical school and/or increasing exposure to CICR. Findings support the Euroatom 97 directive position, advocating implementation of radiation protection instruction into the undergraduate medical curriculum.