A patient-centred and multi-stakeholder co-designed observational prospective study protocol: Example of the adolescent experience of treatment for X-linked hypophosphataemia (XLH).

The importance of patient centricity and keeping the patient at the heart of research design is now well recognised within the healthcare community. The involvement of patient, caregiver and clinician representatives in the study design process may help researchers to achieve this goal and to ensure robust and meaningful data generation. Real-world data collection allows for a more flexible and patient-centred research approach for gaining important insights into the experience of disease and treatments, which is acutely relevant for rare diseases where knowledge about the disease is more likely to be limited. Here, we describe a practical example of a patient-centric, multi-stakeholder approach that led to the co-design of a prospective observational study investigating the lived experience of adolescents with the rare disease, X-linked hypophosphataemia. Specifically, we describe how the knowledge and expertise of a diverse research team, which included expert physicians, research and technology specialists, patients and caregivers, were applied in order to identify the relevant research questions and to ensure the robustness of the study design and its appropriateness to the population of interest within the context of the current clinical landscape. We also demonstrate how a structured patient engagement exercise was key to informing the selection of appropriate outcome measures, data sources, timing of data collection, and to assessing the feasibility and acceptability of the proposed data collection approach.

The lived experience of major and treatment-resistant depression in England: a mixed-methods study.

INTRODUCTION: Major depressive disorder (MDD) is a common, frequently recurrent condition associated with decreased well-being and increased healthcare-related costs. Mixed-methods research provides multiple ways of illustrating the phenomenon to better understand patient experience, including where treatment is not working, referred to here as treatment-resistant depression (TRD). METHODS: A mixed-methods study investigated the experiences of people with symptomatic MDD, symptomatic TRD or TRD in remission, surveying 148 adults recruited from English clinical sites to measure symptom severity (Patient Health Questionnaire-9 [PHQ-9]), HRQoL (EQ-5D-5L/World Health Organisation Brief Assessment of QoL [WHOQOL-BREF]) and work productivity/activity impairment (WPAI:D). Interviews with 26 survey respondents were analysed thematically. Integrated datasets explored areas of convergence and divergence, with concepts mapped against the EQ-5D-5L. RESULTS: Qualitative data explained low WHOQOL-BREF domain scores and the interrelation of psychological, emotional, cognitive and physical difficulties. Tiredness, lack of energy and motivation impacted daily activities, socialising and career goals. Low work performance scores were explained by poor concentration, decision-making and motivation. Participants also described the influence of social support and housing insecurity. Only 19 % of HRQoL qualitative codes mapped to the EQ-5D-5L. Themes dominant in patients with TRD were inability to cope, self-care challenges, dissatisfaction with mental health services and treatment pessimism. LIMITATIONS: Limited data collected on people with TRD in remission. CONCLUSIONS: The EQ-5D-5L and WPAI:D likely underestimate how depression impacts the HRQoL and work of people with MDD or TRD. Qualitative data suggest increased distress for people with TRD compared to those with MDD. Clinical management and treatment access decisions should consider the broader impacts of depression and environmental factors affecting the patient's experience.

"Because it is a rare disease it needs to be brought to attention that there are things out of the norm": a qualitative study of patient and physician experiences of Wilson disease diagnosis and management in the US.

BACKGROUND: Wilson disease (WD) is a genetic disorder of copper metabolism that leads to copper accumulation in various organs, primarily the liver and brain, resulting in heterogenous hepatic, neurologic, and psychiatric symptoms. Diagnosis can occur at any age, requiring lifelong treatment, which can involve liver transplantation. This qualitative study aims to understand the wider patient and physician experience of the diagnosis and management of WD in the US. METHODS: Primary data were collected from 1:1 semi structured interviews with US-based patients and physicians and thematically analyzed with NVivo. RESULTS: Twelve WD patients and 7 specialist WD physicians (hepatologists and neurologists) were interviewed. Analysis of the interviews revealed 18 themes, which were organized into 5 overarching categories: (1) Diagnosis journey, (2) Multidisciplinary approach, (3) Medication, (4) The role of insurance, and (5) Education, awareness, and support. Patients who presented with psychiatric or neurological symptoms reported longer diagnostic journeys (range 1 to 16 years) than those presenting with hepatic symptoms or through genetic screening (range 2 weeks to 3 years). All were also affected by geographical proximity to WD specialists and access to comprehensive insurance. Exploratory testing was often burdensome for patients, but receipt of a definitive diagnosis led to relief for some. Physicians emphasized the importance of multidisciplinary teams beyond hepatology, neurology, and psychiatry and recommended a combination of chelation, zinc, and a low-copper diet; however, only half the patients in this sample were on a chelator, and some struggled to access prescription zinc due to insurance issues. Caregivers often advocated for and supported adolescents with their medication and dietary regimen. Patients and physicians recommended more education and awareness for the healthcare community. CONCLUSIONS: WD requires the coordination of care and medication among several specialists due to its complex nature, but many patients do not have access to multiple specialties due to geographical or insurance barriers. Because some patients cannot be treated in Centers of Excellence, easy access to reliable and up-to-date information is important to empower physicians, patients, and their caregivers in managing the condition, along with general community outreach programs.

Redefining American conservation for equitable and inclusive social-environmental management.

Efforts to recruit, retain, and include Blacks, Indigenous, and People of Color (BIPOC) in environmental fields often fall short, in part due to limited conceptualizations of conservation and environment. At the core of this is the North American Model for Wildlife Conservation, an important approach to conservation and wildlife management that has influenced conservation globally. This model, however, is based upon a specific subset of worldviews, driven by Western and Eurocentric constructions of wilderness and nature. This model creates a narrow view of human-environment relationships and erases cultures and communities that explicitly view themselves as part of nature. We review the seven tenets of the North American Model for Wildlife Conservation, highlighting their limitations and exclusion of other models of environmental and natural resource management and alternative relationships with nature. In order to support long-term environmental engagement and culturally responsive research, 21st century environmental practitioners should shift our thinking around conservation to center counter narratives of BIPOC communities, scientists, and professionals as part of and meaningfully connected to nature. We argue that relying solely on the historically dominant language and ideologies at the core of the North American Model perpetuates disparities in environmental engagement and limits retention of BIPOC in environmental fields. We further highlight how shifts in understanding conservation and relationships to nature enables us to re-frame our work to support equitable, inclusive, and just conservation science and practice.

Elevated international normalized ratio is correlated with large volume transfusion in pediatric trauma patients.

BACKGROUND: Pediatric trauma patients may benefit from a balanced transfusion strategy, however, determining when to activate massive transfusion protocols remains uncertain. The purpose of this study was to explore whether certain scoring systems can predict the need for large volume transfusion. METHODS: We conducted a retrospective review of pediatric trauma patients who presented to our center and required a transfusion of packed red blood cells. Baseline laboratory and clinical data were used to calculate Trauma Associated Severe Hemorrhage (TASH) score and a previously reported composite of acidosis and coagulopathy. RESULTS: We identified 518 pediatric trauma patients who presented to our center between January 1, 2013 and December 31, 2018. These patients were less than 18 years of age (mean 9.6 years) and had an injury severity score ranging from 1 to 50 (mean 11.3). Forty-three patients (8.3%) received a transfusion within 24 hours of presentation, ranging from 4 to 139 mL/kg of packed red blood cells (mean 23.1 mL/kg). Transfusion volume was associated with acidosis and coagulopathy scores (r = 0.37, p = 0.033) and international normalized ratio (INR) (r = 0.34, p = 0.03) but not TASH (p = 0.72). Patients with INR≥1.3 received a higher mean volume of packed red cells compared to those with normal values (34 versus 18 mL/kg, p = 0.046). CONCLUSION: Pediatric trauma patients who undergo transfusion of packed red blood cells are likely to require large volume transfusion if their baseline INR is ≥1.3. These patients may benefit from a balanced transfusion strategy, such as utilization of massive transfusion protocols or whole blood.

Wildlife impacts and changing climate pose compounding threats to human food security.

High-level policy debates surrounding elephant management often dominate global conservation headlines, yet realities for people living with wildlife are not adequately incorporated into policymaking or evident in related discourse.1,2 Human health and livelihoods can be severely impacted by wildlife and indirectly by policy outcomes.3 In landscapes where growing human and elephant (Loxodonta spp. and Elephas maximus) populations compete over limited resources, human-elephant conflict causes crop loss, human injury and death, and retaliatory killing of wildlife.4-6 Across Africa, these problems may be increasingly compounded by climate change, which intensifies resource competition and food insecurity.6-9 Here, we examine how human-wildlife impacts interact with climate change and household food insecurity across the Kavango-Zambezi Transfrontier Conservation Area, the world's largest terrestrial transboundary conservation area, spanning five African nations. We use hierarchical Bayesian statistical models to analyze multi-country household data together with longitudinal satellite-based climate measures relevant to rainfed agriculture. We find that crop depredation by wildlife, primarily elephants, impacts 58% of sampled households annually and is associated with significant increases in food insecurity. These wildlife impacts compound effects of changing climate on food insecurity, most notably observed as a 5-day shortening of the rainy season per 10 years across the data record (1981-2018). To advance sustainability goals, global conservation policy must better integrate empirical evidence on the challenges of human-wildlife coexistence into longer term strategies at transboundary scales, specifically in the context of climate change.3,9-11.

Survival after acute episodes of immune-mediated thrombotic thrombocytopenic purpura (iTTP) - cognitive functioning and health-related quality of life impact: a descriptive cross-sectional survey of adults living with iTTP in the United Kingdom.

OBJECTIVES: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare life-threatening thrombotic microangiopathy affecting adults with unpredictable disease onset and acute presentation. This study aimed to describe the health-related quality of life (HRQoL), cognitive functioning and work productivity of survivors following acute episode(s) of iTTP in the United Kingdom (UK). METHODS: An online survey was developed in collaboration with the TTP Network. Descriptive statistics were calculated for the health questionnaire Short Form Survey-36 Version 2 (SF-36v2), the Hospital Anxiety and Depression Score (HADS), the PROMIS Cognitive Function Abilities Subset - Short Form 6a (PROMIS CFAS - SF6a), and the Work Productivity and Activity Index: Specific Health Problem (WPAI-SHP), along with several iTTP-specific bespoke questions. RESULTS: Fifty participants were recruited between July-November 2019. The mean (standard deviation [SD]) standardized SF-36v2 physical and mental component scores were 42.16 (9.59) and 33.61 (12.34), lower than population norms. The mean (SD) standardized PROMIS CFAS - SF6a score was 39.69 (7.86), lower than population norms. HADS mean (SD) scores of 12.18 (3.14) and 11.78 (2.36) indicated moderate levels of anxiety and depression, respectively. Of those employed (58%), approximately 42.73% of participants reported work productivity loss due to their iTTP. Participants also reported experiencing flashbacks, fatigue interference in family, social and intimate life, and fears of relapse. DISCUSSION AND CONCLUSION: Regardless of recency of the last acute episode, participant scores signified impairments in all domains. Remission from an acute episode of disease does not signify the conclusion of care, but rather the requirement for long-term healthcare particularly focused on psychological support.

Patient-Reported Complications, Symptoms, and Experiences of Living With X-Linked Hypophosphatemia Across the Life-Course.

CONTEXT: X-linked hypophosphatemia (XLH) is a rare, genetic phosphate-wasting disease resulting in bone, muscular, and dental problems, beginning in childhood and increasing in adulthood. OBJECTIVE: This qualitative analysis aimed to explore patient-reported symptoms, complications, and experiences of XLH over the life-course, using data from a large multinational online survey. METHODS: Responses to 2 open-ended questions from 209 adults and 86 children/adolescents (proxy report) with self-reported XLH were analyzed in 8 age groups. Two researchers independently coded and analyzed the responses, using thematic analysis, with differences settled among a multidisciplinary group. Six themes were identified, with age subgroup analysis conducted on the 3 most common, according to coding frequency. RESULTS: Within theme 1, "Clinical Signs and Symptoms of XLH," "Pain" was a dominant subtheme across the life-course, but "Skeletal Pathology" dominated the responses of children/adolescents. Within theme 2, "Impacts of Clinical Signs and Symptoms," interference with "Physical Exertion" and "Emotional Wellbeing" (comprising depression/anxiety in adults and lack of self-esteem in children/adolescents) was reported across all ages. For theme 3, "Negative Treatment Experiences," "Medication" was problematic for children, with adults reporting lack of "Access to Appropriate Treatment." Three further themes were identified: "Resilience," "Positive Treatment Experiences," and "Information Needs." CONCLUSION: The multiple burdens imposed on people with XLH throughout their lifetime encompassed the physical, emotional, and social, although the most challenging symptoms or complications differed between ages. Burden was further exacerbated by adults' lack of access to appropriate treatment, illustrating the need for age-appropriate multidisciplinary care.

Woodlot management and livelihoods in a tropical conservation landscape.

In biodiversity hotspots, there is often tension between human needs and conservation, exacerbated when protected areas prevent access to natural resources. Forest-dependent people may compensate for exclusion by managing unprotected forests or cultivating planted woodlots. Outside Bwindi Impenetrable National Park in Uganda, household wood product needs are high and population growth puts pressure on the environment. We investigated the role of privately and collectively managed woodlots in provisioning wood products and supporting local livelihoods. We found that households relied heavily on woodlots for daily needs and as resources during time of need. We also found that locally relevant social institutions, called stretcher groups, played a role in the management of woodlots, providing shared community resources. Privately and collectively owned woodlots support local livelihoods and wood product needs in the region. Long-term management of forests in Uganda should consider the value of woodlots and the mechanisms required to support them.

Wildlife impacts and vulnerable livelihoods in a transfrontier conservation landscape.

Interactions between humans and wildlife resulting in negative impacts are among the most pressing conservation challenges globally. In regions of smallholder livestock and crop production, interactions with wildlife can compromise human well-being and motivate negative sentiment and retaliation toward wildlife, undermining conservation goals. Although impacts may be unavoidable when human and wildlife land use overlap, scant large-scale human data exist quantifying the direct costs of wildlife to livelihoods. In a landscape of global importance for wildlife conservation in southern Africa, we quantified costs for people living with wildlife through a fundamental measure of human well-being, food security, and we tested whether existing livelihood strategies buffer certain households against crop depredation by wildlife, predominantly elephants. To do this, we estimated Bayesian multilevel statistical models based on multicounty household data (n = 711) and interpreted model results in the context of spatial data from participatory land-use mapping. Reported crop depredation by wildlife was widespread. Over half of the sample households were affected and household food security was reduced significantly (odds ratio 0.37 [0.22, 0.63]). The most food insecure households relied on gathered food sources and welfare programs. In the event of crop depredation by wildlife, these 2 livelihood sources buffered or reduced harmful effects of depredation. The presence of buffering strategies suggests a targeted compensation strategy could benefit the region's most vulnerable people. Such strategies should be combined with dynamic and spatially explicit land-use planning that may reduce the frequency of negative human-wildlife impacts. Quantifying and mitigating the human costs from wildlife are necessary steps in working toward human-wildlife coexistence.

Impactos de la Fauna y Medios de Subsistencia Vulnerables en unkl Paisaje de Conservación Transfronteriza Resumen Las interacciones entre los humanos y la fauna que resultan en impactos negativos se encuentran entre los desafíos más apremiantes para la conservación a nivel mundial. En las regiones de ganaderos y agricultores minifundistas, las interacciones con la fauna pueden poner en peligro el bienestar humano y motivar sentimientos negativos y represalias hacia la fauna, lo que debilita los objetivos de conservación. Aunque los impactos pueden evitarse cuando el uso de suelo por humanos y fauna se traslapa, existen pocos datos humanos a gran escala que cuantifiquen el costo directo de la fauna para los medios de subsistencia. Cuantificamos el costo para las personas que conviven con animales silvestres en un paisaje de importancia global para la conservación de fauna en el sur de África. La cuantificación fue realizada por medio de una medida fundamental de bienestar humano y seguridad alimentaria, y probamos si las estrategias existentes de subsistencia amortiguan a ciertos hogares ante la depredación de cultivos realizada por animales silvestres, predominantemente los elefantes. Para realizar esto, estimamos algunos modelos estadísticos bayesianos de niveles múltiples basados en los datos de hogares ubicados en múltiples condados (n = 711) e interpretamos los resultados de los modelos en el contexto de los datos espaciales a partir de un mapeo participativo de uso de suelo. La depredación de cultivos por animales silvestres fue reportada de manera generalizada. Más de la mitad de los hogares en la muestra estuvieron afectados y la seguridad alimenticia de los hogares se redujo significativamente (proporción de probabilidades 0.37 [0.22, 0.63]). Los hogares con la menor seguridad alimentaria dependían de fuentes de recolección de alimentos y programas de bienestar. En el evento de la depredación por fauna de los cultivos, estas dos fuentes de subsistencia amortiguaron o redujeron los efectos dañinos de la depredación. La presencia de las estrategias de amortiguamiento sugiere que una estrategia de compensación enfocada podría beneficiar a las personas más vulnerables de la región. Dichas estrategias deberían estar combinadas con la planeación del uso de suelo dinámica y espacialmente explícita, la cual podría reducir la frecuencia de los impactos negativos entre los humanos y la fauna. La cuantificación y mitificación del costo humano a partir de la fauna son pasos necesarios en el camino hacia la coexistencia entre los humanos y la fauna.

Screening for alcohol and substance use in pediatric trauma patients: A retrospective review.

PURPOSE: Alcohol and drug use in adolescence is associated with traumatic injuries. This study aimed to assess the rates of screening for substance use in pediatric trauma patients presenting at a single Canadian center. METHODS: A retrospective chart review of pediatric trauma patients (aged 12-17) was performed. Injury specifics, rates of patients screened for alcohol and/or substance use, and screening outcomes were determined. Patients screened were compared to those not screened. Continuous variables were analyzed using independent samples t-tests and categorical using chi-square. Significance was set at p < 0.05. RESULTS: Three hundred twenty-seven patients were included, with 217(66%) being male. The average age was 14.6 years (±1.5). Traffic collisions accounted for 50% of injuries. A blood alcohol test was conducted for significantly more patients (199, 61%) than a urine drug screen (55, 17%; p < 0.001). Of those screened, 27/199(14%) tested positive for alcohol and 29/55(53%) for drugs. Older age and increased injury severity were associated with being screened for drugs (p = 0.000, p = 0.050). Only 39% of patients with positive screening tests were referred on to secondary services such as inpatient psychiatry or social work. CONCLUSION: Screening rates remain low. Institutional guidelines for alcohol and drug screening in trauma patients should be instituted to avoid random screening and underestimations of substance involvement. TYPE OF STUDY: Retrospective Chart Review. LEVEL OF EVIDENCE: III.

A Jail-Based Competency Restoration Unit as a Component of a Continuum of Restoration Services.

This study reports on restoration outcomes of a sample of pretrial defendants (n = 877, 69% male) who were found incompetent to stand trial and underwent restoration services in a large urban county. Each male defendant was initially assigned to restoration in one of four settings on a continuum of services of varying intensity (ie, outpatient, jail general population, dedicated jail-based restoration unit, or forensic hospital inpatient unit) based on the defendant's assessed clinical need. Of those who received services on the jail-based restoration unit (n = 398), 40 percent were restored to competency, 31 percent were diverted out of the criminal justice system, and 29 percent were referred for more intensive inpatient services, primarily because of refusal of medication (i.e., the jail would not allow involuntary medication, even if court-ordered). Advantages of restoration on the jail unit compared with inpatient hospitalization included more rapid institution of restoration services and higher rates of diversion out of the criminal justice system at one-third of the cost of inpatient restoration services. A continuum of restoration services that allows the type of restoration service to be matched to the needs of the individual incompetent defendant has significant advantages over routine transfer to a forensic hospital for restoration.

Climate-Driven Adaptation, Household Capital, and Nutritional Outcomes among Farmers in Eswatini.

Globally, communities are increasingly impacted by the stressors of climate change. In response, people may adapt to maintain their livelihoods and overall health and nutrition. However, the relationship between climate adaptation and human nutrition is poorly understood and results of adaptation are often unclear. We investigated the relationship between adaptation and child nutrition, in Eswatini (formerly Swaziland) during an extreme drought. Households varied in both adaptation behavior and household resources and we found that, overall, households that adapted had better child nutrition than those that didn't adapt. When controlling for the influence of household capital, we found that more vulnerable households, those with greater dependence on natural resources and lower income, had a stronger positive relationship between adaptation and nutrition than less vulnerable households. We also found that some adaptations had stronger positive relationships with nutrition than others. In our system, the adaptation that most strongly correlated with improved nutrition, selling chickens, most likely benefits from local social networksand consistent demand, and performed better than other adaptations. Our results emphasize the need to measure adaptation outcomes and identify and support the types of adaptations are most likely to improve nutrition in the future.

Combining MALDI-TOF and genomics in the study of methicillin resistant and multidrug resistant Staphylococcus pseudintermedius in New Zealand.

Staphylococcus pseudintermedius is an opportunistic and emerging zoonotic pathogen that primarily colonises the skin of dogs. Many common variants are methicillin resistant (MRSP) or multidrug resistant (MDR), and drug resistance is increasingly reported across the globe. In New Zealand, MRSP isolation remains rare in clinics. To pre-emptively inform diagnostic and antimicrobial stewardship practices, we examine isolates of S. pseudintermedius, MRSP and MDR-MRSP from New Zealand dogs using a combination of methodologies. Genetic and genomic data combined with antimicrobial susceptibility screening identify common drug-resistance profiles and their genetic determinants. We demonstrate that sensitive and specific species-level identification of S. pseudintermedius can be achieved using Bruker MALDI-TOF MS and, further, that this technique can be used to identify some common subtype variants, providing a level of categorical precision that falls somewhere between single-locus and multi-locus sequence typing. Comparative genomics analysis of global S. pseudintermedius data shows that MRSP moves frequently across the globe, but that horizontal gene transfer events resulting in the acquisition of the SCCmec cassette (responsible for beta-lactam antibiotic resistance) are infrequent. This suggests that biosecurity and surveillance in addition to antibiotic stewardship should play important roles in mitigating the risk of MRSP, especially in countries such as New Zealand where MRSP is still rare.

Understanding paediatric patients' attitudes toward obesity and expectations prior to entering a weight management program.

OBJECTIVE: This qualitative study explored attitudes toward weight management and knowledge of healthy, active living among paediatric patients referred to a weight management program. The objective of this study was to determine the emotional state and attitudes of patients entering into a paediatric weight management program. METHODS: Study participants (aged 7 to 17 years old) were recruited during clinic orientation. Semistructured interviews were conducted, audiotaped and transcribed verbatim. Qualitative content analysis generated a thematic coding scheme, identifying concepts and linkages in the data. Study rigour was achieved collaboratively through an audit trail, and data triangulation. RESULTS: Fifteen patients (median age 11 years) consented to interviews. Three recurring themes emerged: emotions, motivation and learning. A total of nine subthemes were identified. Four key spheres of influence (family, peers, school and health care providers) affected the patient's outlook on obesity positively by providing support or negatively by adversely influencing their emotions and motivation. The level of individual motivation to engage in the weight management program varied. A positive outlook toward learning about obesity from school officials and health care providers emerged. CONCLUSIONS: This study provided insight regarding paediatric attitudes related to entering a weight management program. The negative emotional state and sometimes fear of the program expressed should be considered by the referring physician and by clinicians in weight management programs engaging in their care.

What works for whom and why: A narrative systematic review of interventions for reducing post-traumatic stress disorder and problematic substance use among women with experiences of interpersonal violence.

BACKGROUND AND AIMS: Women with histories of interpersonal violence (IPV) experience high levels of post-traumatic stress disorder (PTSD), problematic substance use, and repeat victimization. Previous systematic reviews considering the effectiveness of integrated trauma-specific treatments to address PTSD and substance use have lacked sub-group analysis by gender or trauma type. Furthermore, mindfulness-based interventions for treating both issues together are under-researched. It is unclear what treatment components and contextual factors impacting implementation work best for women with IPV experiences. This narrative review examines a range of quantitative and qualitative data to explore: for which groups of women do integrated interventions work (subgroups)? How (mechanisms of action), and/or under what contexts (factors external to the intervention)? METHODOLOGY: A two-staged search strategy identified eligible studies. This process identified 20 controlled trials reporting on the effectiveness of psychological or mindfulness-based interventions for PTSD and substance use and 39 relevant supplementary information related to the trials. Narrative synthesis using thematic analysis was conducted on manuscripts identified in both stages. FINDINGS: Safe social support and ongoing risks of violence were identified as contextual factors which may affect treatment outcomes, requiring attention by researchers and treatment providers. Whilst there was some evidence that reduced PTSD correlates with substance use decrease, there may be more than one pathway to substance use reduction among women with PTSD, requiring a focus on emotional regulation. Other 'active mechanisms' included different modalities of coping skills and support to rebuild connection with self and others. Lack of supplementary studies for trials involving past-focused treatment precluded detailed discussion of these models. CONCLUSIONS: Integrated PTSD and substance use treatment which teaches extensive coping skills to promote external safety, symptom stabilisation, and emotional regulation, combined with access to safe social support and external advocacy, may be particularly useful for women with more severe PTSD, or for those experiencing ongoing victimization for whom past-focused treatments are contraindicated. Long-term support and organisational trauma-informed practice in substance use treatment services should also be promoted.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

PURPOSE: The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. METHODS: We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. RESULTS: We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). CONCLUSION: This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. LEVELS OF EVIDENCE: Level III-Treatment study, Retrospective comparative study.

An Overview of Canadian Research Activities on Diseases Caused by Phytophthora ramorum: Results, Progress, and Challenges.

International trade and travel are the driving forces behind the spread of invasive plant pathogens around the world, and human-mediated movement of plants and plant products is now generally accepted as the primary mode of their introduction, resulting in huge disturbance to ecosystems and severe socio-economic impact. These problems are exacerbated under the present conditions of rapid climatic change. We report an overview of the Canadian research activities on Phytophthora ramorum. Since the first discovery and subsequent eradication of P. ramorum on infected ornamentals in nurseries in Vancouver, British Columbia, in 2003, a research team of Canadian government scientists representing the Canadian Forest Service, Canadian Food Inspection Agency, and Agriculture and Agri-Food Canada worked together over a 10-year period and have significantly contributed to many aspects of research and risk assessment on this pathogen. The overall objectives of the Canadian research efforts were to gain a better understanding of the molecular diagnostics of P. ramorum, its biology, host-pathogen interactions, and management options. With this information, it was possible to develop pest risk assessments and evaluate the environmental and economic impact and future research needs and challenges relevant to P. ramorum and other emerging forest Phytophthora spp.