Determining critical periods for thermal acclimatisation using a distributed lag non-linear modelling approach.

Rapid changes in thermal environments are threatening many species worldwide. Thermal acclimatisation may partially buffer species from the impacts of these changes, but currently, the knowledge about the temporal dynamics of acclimatisation remains limited. Moreover, acclimatisation phenotypes are typically determined in laboratory conditions that lack the variability and stochasticity that characterise the natural environment. Through a distributed lag non-linear model (DLNM), we use field data to assess how the timing and magnitude of past thermal exposures influence thermal tolerance. We apply the model to two Scottish freshwater Ephemeroptera species living in natural thermal conditions. Model results provide evidence that rapid heat hardening effects are dramatic and reflect high rates of change in temperatures experienced over recent hours to days. In contrast, temperature change magnitude impacted acclimatisation over the course of weeks but had no impact on short-term responses. Our results also indicate that individuals may de-acclimatise their heat tolerance in response to cooler environments. Based on the novel insights provided by this powerful modelling approach, we recommend its wider uptake among thermal physiologists to facilitate more nuanced insights in natural contexts, with the additional benefit of providing evidence needed to improve the design of laboratory experiments.

Smallholder oil palm plantation sustainability assessment using multi-criteria analysis and unmanned aerial vehicles.

Oil palm agriculture has caused extensive land cover and land use changes that have adversely affected tropical landscapes and ecosystems. However, monitoring and assessment of oil palm plantation areas to support sustainable management is costly and labour-intensive. This study used an unmanned aerial vehicles (UAV) to map smallholder farms and applied multi-criteria analysis to data generated from orthomosaics, to provide a set of sustainability indicators for the farms. Images were acquired from a UAV, with structure from motion (SfM) photogrammetry then used to produce orthomosaics and digital elevation models of the farm areas. Some of the inherent problems using high spatial resolution imagery for land cover classification were overcome by using texture analysis and geographic object-based image analysis (OBIA). Six spatially explicit environmental metrics were developed using multi-criteria analysis and used to generate sustainability indicator layers from the UAV data. The SfM and OBIA approach provided an accurate, high-resolution (~5 cm) image-based reconstruction of smallholder farm landscapes, with an overall classification accuracy of 89%. The multi-criteria analysis highlighted areas with lower sustainability values, which should be considered targets for adoption of sustainable management practices. The results of this work suggest that UAVs are a cost-effective tool for sustainability assessments of oil palm plantations, but there remains the need to plan surveys and image processing workflows carefully. Future work can build on our proposed approach, including the use of additional and/or alternative indicators developed through consultation with the oil palm industry stakeholders, to support certification schemes such as the Roundtable on Sustainable Palm Oil (RSPO).

Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England.

OBJECTIVE: Around one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care. DESIGN: Mixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods. SETTING AND PARTICIPANTS: Three secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101). ANALYSIS: Qualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation. RESULTS: Participants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation). CONCLUSIONS: Clinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

Patient experience and reflective learning (PEARL): a mixed methods protocol for staff insight development in acute and intensive care medicine in the UK.

INTRODUCTION: Patient and staff experiences are strongly influenced by attitudes and behaviours, and provide important insights into care quality. Patient and staff feedback could be used more effectively to enhance behaviours and improve care through systematic integration with techniques for reflective learning. We aim to develop a reflective learning framework and toolkit for healthcare staff to improve patient, family and staff experience. METHODS & ANALYSIS: Local project teams including staff and patients from the acute medical units (AMUs) and intensive care units (ICUs) of three National Health Service trusts will implement two experience surveys derived from existing instruments: a continuous patient and relative survey and an annual staff survey. Survey data will be supplemented by ethnographic interviews and observations in the workplace to evaluate barriers to and facilitators of reflective learning. Using facilitated iterative co-design, local project teams will supplement survey data with their experiences of healthcare to identify events, actions, activities and interventions which promote personal insight and empathy through reflective learning. Outputs will be collated by the central project team to develop a reflective learning framework and toolkit which will be fed back to the local groups for review, refinement and piloting. The development process will be mapped to a conceptual theory of reflective learning which combines psychological and pedagogical theories of learning, alongside theories of behaviour change based on capability, opportunity and motivation influencing behaviour. The output will be a locally-adaptable workplace-based toolkit providing guidance on using reflective learning to incorporate patient and staff experience in routine clinical activities. ETHICS & DISSEMINATION: The PEARL project has received ethics approval from the London Brent Research Ethics Committee (REC Ref 16/LO/224). We propose a national cluster randomised step-wedge trial of the toolkit developed for large-scale evaluation of impact on patient outcomes.

Clinical correlates of oppositional defiant disorder and attention-deficit/hyperactivity disorder in adults.

OBJECTIVE: Oppositional defiant disorder (ODD) is a common comorbidity of attention-deficit/hyperactivity disorder (ADHD) in both children and adolescents. Although there is research demonstrating that ADHD persists into adulthood, less is known about the frequency of its persistence, clinical characteristics, and impairment when associated with comorbid ODD in adults with ADHD. METHOD: Data from a randomized clinical trial of adults with ADHD were analyzed to determine the prevalence and clinical correlates of comorbid ODD. As per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, patients who reported having ≥ 4 symptoms "often" or "very often" were classified as meeting the symptom criteria for the disorder. RESULTS: Forty percent of this sample met symptom criteria for ODD. Subjects with ODD were more likely to have other comorbid disorders, lower investigator ratings of overall functioning, and lower patient life satisfaction (P < 0.05). A regression analysis using these variables predicted 40% of the variance of ODD as a comorbid condition in addition to ADHD. Although the presence or absence of ODD at baseline does not moderate response of ADHD symptoms with treatment, improvement in ODD symptoms was mediated by improvement in ADHD symptoms (P < 0.0001). Oppositional defiant disorder treatment was more responsive to dextroamphetamine than paroxetine, despite the contribution of irritability and reactive tantrums, as symptoms of the disorder. CONCLUSION: Oppositional defiant disorder is a valid and impairing disorder requiring evaluation and treatment in adults.

The validity of the Gammarus:Asellus ratio as an index of organic pollution: abiotic and biotic influences.

In freshwaters. Gammarus spp. are more sensitive to organic pollution than Asellus spp. and the relative abundance of the two taxa has been proposed as a pollution index. We tested the validity of this by examining the relationship between the Gammarus: Asellus (G : A) ratio and (1) a suite of physico-chemical variables. (2) established biotic (average score per taxon, ASPT) and richness (species richness (S) and Ephemeroptera, Plecoptera and Trichoptera families richness (EPT family richness)) indices generated from the macroinvertebrate community. In addition, we investigated a suspected biotic interaction, predation, between Gammarus and Asellus. Both univariate and multivariate analyses showed that the G: A ratio was sometimes responsive to changes in parameters linked to organic pollution, such as BOD5 and nitrate levels. However, the G : A ratio also appeared responsive to variables not directly linked to organic pollution, such as conductivity and distance from source. There were significant positive correlations among the G : A ratio and the ASPT, S and EPT, indicating that changes in the relative abundances of Gammarus and Asellus were reflected in changes in the pollution sensitivity and richness of the wider macroinvertebrate community. A laboratory experiment revealed significant predation of Asellus aquaticus juveniles by Gammarus duebeni celticus adults, but no reciprocal predation. We propose that the G: A ratio may be useful as a crude measure of organic pollution that could supplement more complex indices in a multimetric approach to pollution monitoring or be used for monitoring individual sites, where a simple technique is required for monitoring purposes over a period of time. Also, we urge recognition of the possible role of biotic interactions among taxa used in the generation of pollution indices.