Timing of tertiary trauma surveys during a time of increased trauma presentations - The Alice Springs Hospital Finke Desert Race experience.

Purpose: The Finke Desert Race is an offroad motorbike and buggy race held annually in central Australia. Owing to the treacherous conditions, this race sees a significant influx of trauma presentations to Alice Springs Hospital, the closest rural hospital. Completion of a tertiary trauma survey (TTS) within 24 hours of a patient's admission is part of standard trauma management. Method: A retrospective analysis was undertaken of trauma presentations managed by general surgery over a 5-day period of the Finke Desert Race weekend, compared to a 3-month control period from February to April of the same year. To be included, patients met the criteria for completion of a TTS. Results: The total number of trauma presentations over the 5-day period of the race weekend was 18 (an incidence rate of 3.6 cases/day), compared to a total of 31 in the 3-month control period (an incidence rate of 0.36 cases/day). The daily rate of major trauma presentations during the Finke race weekend was 9.9 times greater than during the control period. Completion of TTS was missed in only 5.6 % of patients over the Finke weekend, compared to 14.3 % of patients in the control period. The median time from presentation to the emergency department to completion of TTS during the Finke weekend was 20 h 19 min, compared to 20 h 36 min during the control period. Conclusion: Despite the substantial influx of trauma during the race weekend, fewer patients missed having a TTS completed compared to the control period. The median time taken to completion of TTS was similar between the two time periods. These findings suggest that the general surgery department was able to maintain standard trauma management principles.

Coral restoration can drive rapid reef carbonate budget recovery.

Restoration is increasingly seen as a necessary tool to reverse ecological decline across terrestrial and marine ecosystems.1,2 Considering the unprecedented loss of coral cover and associated reef ecosystem services, active coral restoration is gaining traction in local management strategies and has recently seen major increases in scale. However, the extent to which coral restoration may restore key reef functions is poorly understood.3,4 Carbonate budgets, defined as the balance between calcium carbonate production and erosion, influence a reef's ability to provide important geo-ecological functions including structural complexity, reef framework production, and vertical accretion.5 Here we present the first assessment of reef carbonate budget trajectories at restoration sites. The study was conducted at one of the world's largest coral restoration programs, which transplants healthy coral fragments onto hexagonal metal frames to consolidate degraded rubble fields.6 Within 4 years, fast coral growth supports a rapid recovery of coral cover (from 17% ± 2% to 56% ± 4%), substrate rugosity (from 1.3 ± 0.1 to 1.7 ± 0.1) and carbonate production (from 7.2 ± 1.6 to 20.7 ± 2.2 kg m-2 yr-1). Four years after coral transplantation, net carbonate budgets have tripled and are indistinguishable from healthy control sites (19.1 ± 3.1 and 18.7 ± 2.2 kg m-2 yr-1, respectively). However, taxa-level contributions to carbonate production differ between restored and healthy reefs due to the preferential use of branching corals for transplantation. While longer observation times are necessary to observe any self-organization ability of restored reefs (natural recruitment, resilience to thermal stress), we demonstrate the potential of large-scale, well-managed coral restoration projects to recover important ecosystem functions within only 4 years.

The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status.

Background: Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function. Aims: The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function. Methods: In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction. Results: Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03). Conclusions: After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.

Widespread retreat of coastal habitat is likely at warming levels above 1.5 °C.

Several coastal ecosystems-most notably mangroves and tidal marshes-exhibit biogenic feedbacks that are facilitating adjustment to relative sea-level rise (RSLR), including the sequestration of carbon and the trapping of mineral sediment1. The stability of reef-top habitats under RSLR is similarly linked to reef-derived sediment accumulation and the vertical accretion of protective coral reefs2. The persistence of these ecosystems under high rates of RSLR is contested3. Here we show that the probability of vertical adjustment to RSLR inferred from palaeo-stratigraphic observations aligns with contemporary in situ survey measurements. A deficit between tidal marsh and mangrove adjustment and RSLR is likely at 4 mm yr-1 and highly likely at 7 mm yr-1 of RSLR. As rates of RSLR exceed 7 mm yr-1, the probability that reef islands destabilize through increased shoreline erosion and wave over-topping increases. Increased global warming from 1.5 °C to 2.0 °C would double the area of mapped tidal marsh exposed to 4 mm yr-1 of RSLR by between 2080 and 2100. With 3 °C of warming, nearly all the world's mangrove forests and coral reef islands and almost 40% of mapped tidal marshes are estimated to be exposed to RSLR of at least 7 mm yr-1. Meeting the Paris agreement targets would minimize disruption to coastal ecosystems.

Evaluating the generalizability of deep learning image classification algorithms to detect middle ear disease using otoscopy.

To evaluate the generalizability of artificial intelligence (AI) algorithms that use deep learning methods to identify middle ear disease from otoscopic images, between internal to external performance. 1842 otoscopic images were collected from three independent sources: (a) Van, Turkey, (b) Santiago, Chile, and (c) Ohio, USA. Diagnostic categories consisted of (i) normal or (ii) abnormal. Deep learning methods were used to develop models to evaluate internal and external performance, using area under the curve (AUC) estimates. A pooled assessment was performed by combining all cohorts together with fivefold cross validation. AI-otoscopy algorithms achieved high internal performance (mean AUC: 0.95, 95%CI: 0.80-1.00). However, performance was reduced when tested on external otoscopic images not used for training (mean AUC: 0.76, 95%CI: 0.61-0.91). Overall, external performance was significantly lower than internal performance (mean difference in AUC: -0.19, p ≤ 0.04). Combining cohorts achieved a substantial pooled performance (AUC: 0.96, standard error: 0.01). Internally applied algorithms for otoscopy performed well to identify middle ear disease from otoscopy images. However, external performance was reduced when applied to new test cohorts. Further efforts are required to explore data augmentation and pre-processing techniques that might improve external performance and develop a robust, generalizable algorithm for real-world clinical applications.

Inter-rater agreement between 13 otolaryngologists to diagnose otitis media in Aboriginal and Torres Strait Islander children using a telehealth approach.

INTRODUCTION: Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor. OBJECTIVE: To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach. DESIGN: Blinded, inter-rater reliability study. SETTING: Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia. PARTICIPANTS: Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female). INTERVENTIONS: Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). MAIN OUTCOME MEASURES: Proportion of agreement to the reference standard, prevalence-and-bias adjusted κ coefficients, mean difference in accuracy estimates between each tier of clinical data. RESULTS: Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63-68%), κ = 0.53 (95%CI: 0.48-0.57); Tier B: 77% (95%CI: 74-79%), 0.68 (95%CI: 0.65-0.72); C: 85% (95%CI: 82-87%), 0.79 (95%CI: 0.76-0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data. CONCLUSIONS: There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone.

Coral adaptive capacity insufficient to halt global transition of coral reefs into net erosion under climate change.

Projecting the effects of climate change on net reef calcium carbonate production is critical to understanding the future impacts on ecosystem function, but prior estimates have not included corals' natural adaptive capacity to such change. Here we estimate how the ability of symbionts to evolve tolerance to heat stress, or for coral hosts to shuffle to favourable symbionts, and their combination, may influence responses to the combined impacts of ocean warming and acidification under three representative concentration pathway (RCP) emissions scenarios (RCP2.6, RCP4.5 and RCP8.5). We show that symbiont evolution and shuffling, both individually and when combined, favours persistent positive net reef calcium carbonate production. However, our projections of future net calcium carbonate production (NCCP) under climate change vary both spatially and by RCP. For example, 19%-35% of modelled coral reefs are still projected to have net positive NCCP by 2050 if symbionts can evolve increased thermal tolerance, depending on the RCP. Without symbiont adaptive capacity, the number of coral reefs with positive NCCP drops to 9%-13% by 2050. Accounting for both symbiont evolution and shuffling, we project median positive NCPP of coral reefs will still occur under low greenhouse emissions (RCP2.6) in the Indian Ocean, and even under moderate emissions (RCP4.5) in the Pacific Ocean. However, adaptive capacity will be insufficient to halt the transition of coral reefs globally into erosion by 2050 under severe emissions scenarios (RCP8.5).

Temperature, species identity and morphological traits predict carbonate excretion and mineralogy in tropical reef fishes.

Anthropogenic pressures are restructuring coral reefs globally. Sound predictions of the expected changes in key reef functions require adequate knowledge of their drivers. Here we investigate the determinants of a poorly-studied yet relevant biogeochemical function sustained by marine bony fishes: the excretion of intestinal carbonates. Compiling carbonate excretion rates and mineralogical composition from 382 individual coral reef fishes (85 species and 35 families), we identify the environmental factors and fish traits that predict them. We find that body mass and relative intestinal length (RIL) are the strongest predictors of carbonate excretion. Larger fishes and those with longer intestines excrete disproportionately less carbonate per unit mass than smaller fishes and those with shorter intestines. The mineralogical composition of excreted carbonates is highly conserved within families, but also controlled by RIL and temperature. These results fundamentally advance our understanding of the role of fishes in inorganic carbon cycling and how this contribution will change as community composition shifts under increasing anthropogenic pressures.

Structure-from-motion photogrammetry demonstrates variability in coral growth within colonies and across habitats.

Coral growth is an important metric of coral health and underpins reef-scale functional attributes such as structural complexity and calcium carbonate production. There persists, however, a paucity of growth data for most reef-building regions, especially for coral species whose skeletal architecture prevents the use of traditional methods such as coring and Alizarin staining. We used structure-from-motion photogrammetry to quantify a range of colony-scale growth metrics for six coral species in the Mexican Caribbean and present a newly developed workflow to measure colony volume change over time. Our results provide the first growth metrics for two species that are now major space occupiers on Caribbean reefs, Agaricia agaricites and Agaricia tenuifolia. We also document higher linear extension, volume increase and calcification rates within back reef compared to fore reef environments for four other common species: Orbicella faveolata, Porites astreoides, Siderastrea siderea and Pseudodiploria strigosa. Linear extension rates in our study were lower than those obtained via computed tomography (CT) scans of coral cores from the same sites, as the photogrammetry method averages growth in all dimensions, while the CT method depicts growth only along the main growth axis (upwards). The comparison of direct volume change versus potential volume increase calculated from linear extension emphasizes the importance of assessing whole colony growth to improve calcification estimates. The method presented here provides an approach that can generate accurate calcification estimates alongside a range of other whole-colony growth metrics in a non-invasive way.

Understanding the tumor microenvironment in head and neck squamous cell carcinoma.

Head and neck squamous cell carcinoma (HNSCC) represents a heterogeneous group of tumors. While significant progress has been made using multimodal treatment, the 5-year survival remains at 50%. Developing effective therapies, such as immunotherapy, will likely lead to better treatment of primary and metastatic disease. However, not all HNSCC tumors respond to immune checkpoint blockade therapy. Understanding the complex cellular composition and interactions of the tumor microenvironment is likely to lead to new knowledge for effective therapies and treatment resistance. In this review, we discuss HNSCC characteristics, predictive biomarkers, factors influencing immunotherapy response, with a focus on the tumor microenvironment.

Artificial intelligence to classify ear disease from otoscopy: A systematic review and meta-analysis.

OBJECTIVES: To summarise the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy. DESIGN: Systematic review and meta-analysis. METHODS: Using the PRISMA guidelines, nine online databases were searched for articles that used AI computer vision algorithms developed from various methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees and k-nearest neighbours) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma and canal obstruction. MAIN OUTCOME MEASURES: Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias. RESULTS: Thirty-nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1-91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multiclassification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3-97.9%) accuracy to differentiate between normal, AOM and OME in three studies. AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5-96.4%) versus 73.2% (95%CI: 67.9-78.5%) accuracy in three studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods. CONCLUSION: AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI-supported otoscopy system may assist health care workers, trainees and primary care practitioners with less otology experience identify ear disease.

An Artificial Intelligence Computer-vision Algorithm to Triage Otoscopic Images From Australian Aboriginal and Torres Strait Islander Children.

OBJECTIVE: To develop an artificial intelligence image classification algorithm to triage otoscopic images from rural and remote Australian Aboriginal and Torres Strait Islander children. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary referral center. PATIENTS: Rural and remote Aboriginal and Torres Strait Islander children who underwent tele-otology ear health screening in the Northern Territory, Australia between 2010 and 2018. INTERVENTIONS: Otoscopic images were labeled by otolaryngologists to classify the ground truth. Deep and transfer learning methods were used to develop an image classification algorithm. MAIN OUTCOME MEASURES: Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under the curve (AUC) of the resultant algorithm compared with the ground truth. RESULTS: Six thousand five hundred twenty seven images were used (5927 images for training and 600 for testing). The algorithm achieved an accuracy of 99.3% for acute otitis media, 96.3% for chronic otitis media, 77.8% for otitis media with effusion (OME), and 98.2% to classify wax/obstructed canal. To differentiate between multiple diagnoses, the algorithm achieved 74.4 to 92.8% accuracy and an AUC of 0.963 to 0.997. The most common incorrect classification pattern was OME misclassified as normal tympanic membranes. CONCLUSIONS: The paucity of access to tertiary otolaryngology care for rural and remote Aboriginal and Torres Strait Islander communities may contribute to an under-identification of ear disease. Computer vision image classification algorithms can accurately classify ear disease from otoscopic images of Indigenous Australian children. In the future, a validated algorithm may integrate with existing telemedicine initiatives to support effective triage and facilitate early treatment and referral.

The importance of 1.5°C warming for the Great Barrier Reef.

Tropical coral reefs are among the most sensitive ecosystems to climate change and will benefit from the more ambitious aims of the United Nations Framework Convention on Climate Change's Paris Agreement, which proposed to limit global warming to 1.5° rather than 2°C above pre-industrial levels. Only in the latest Intergovernmental Panel on Climate Change focussed assessment, the Coupled Model Intercomparison Project phase 6 (CMIP6), have climate models been used to investigate the 1.5° warming scenario directly. Here, we combine the most recent model updates from CMIP6 with a semi-dynamic downscaling to evaluate the difference between the 1.5 and 2°C global warming targets on coral thermal stress metrics for the Great Barrier Reef (GBR). By ~2080, severe bleaching events are expected to occur annually under intensifying emissions (shared socioeconomic pathway SSP5-8.5). Adherence to 2° warming (SSP1-2.6) halves this frequency but the main benefit of confining warming to 1.5° (SSP1-1.9) is that bleaching events are reduced further to 3 events per decade. Attaining low emissions of 1.5° is also paramount to prevent the mean magnitude of thermal stress from stabilizing close to a critical thermal threshold (8 Degree Heating Weeks). Thermal stress under the more pessimistic pathways SSP3-7.0 and SSP5-8.5 is three to fourfold higher than the present day, with grave implications for future reef ecosystem health. As global warming continues, our projections also indicate more regional warming in the central and southern GBR than the far north and northern GBR.

Quantifying production rates and size fractions of parrotfish-derived sediment: A key functional role on Maldivian coral reefs.

Coral reef fish perform numerous important functional roles on coral reefs. Of these, carbonate sediment production, as a by-product of parrotfish feeding, is especially important for contributing to reef framework construction and reef-associated landform development. However, only limited data exist on: (i) how production rates vary among reef habitats as a function of parrotfish assemblages, (ii) the relative importance of sediment produced from eroded, reworked, and endogenous sources, or (iii) the size fractions of sediment generated by different parrotfish species and size classes. These parameters influence not only overall reef-derived sediment supply, but also influence the transport potential and depositional fate of this sedimentary material. Here, we show that parrotfish sediment production varies significantly between reef-platform habitats on an atoll-margin Maldivian reef. Highest rates of production (over 0.8 kg m-2 year-1) were calculated in three of the eight platform habitats; a rubble-dominated zone, an Acropora spp. dominated zone, and a patch reef zone. Habitat spatial extent and differences in associated parrotfish assemblages strongly influenced the total quantities of sediment generated within each habitat. Nearly half of total parrotfish sediment production occurred in the rubble habitat, which comprised only 8% of the total platform area. Over 90% of this sedimentary material originated from eroded reef framework as opposed to being reworked existing or endogenously produced sediment, and comprised predominantly coral sands (predominantly 125-1000 µm in diameter). This is comparable to the dominant sand types and size fractions found on Maldivian reef islands. By contrast, nearly half of the sediment egested by parrotfish in the Acropora spp. dominated and patch reef habitats resulted from reworked existing sediments. These differences between habitats are a result of the different parrotfish assemblages supported. Endogenous carbonate production was found to be insignificant compared to the quantity of eroded and reworked material. Our findings have important implications for identifying key habitats and species which act as major sources of sediment for reef-island systems.

Calcium carbonate production in the southernmost subtropical Atlantic coral reef.

Emerging evidence have been supporting the idea that the better known South Atlantic coral reefs (located between 18°S and 24°S) are now essentially senescent structures that have experienced little or no additional vertical reef growth over the past millennia. This has often coincided with a shift to a dominance of non-coral calcifying organisms becoming the main CaCO3 producers in these high latitude and marginal marine settings. Here, we used Calcification Accretion Units (CAUs) and census-based methods to measure non-coral rates of CaCO3 production on the geologically senescent reef and adjacent rhodolith beds within the southernmost subtropical Atlantic reef (i.e., Queimada Grande Reef, QGR). The reef habitat is currently producing CaCO3 at rates of ∼126 g m-2 yr-1. In contrast, fragments of dead corals skeletons deposited adjacent to the reef over the last ∼2000 years are now colonized by crustose coralline red algae. These form a rhodolith bed that produces CaCO3 at rates of 858 g m-2 yr-1. Our results indicate that, whilst not sufficient to promote active net framework accumulation, CaCO3 production by coralline algae and bryozoans on the QGR appears to be sufficient to at least limit net large-scale erosion of the underlying reef structure, allowing the reef structure to persist in a state close to budgetary stasis. Finally, our results are also of relevance for providing insights regarding the balance of CaCO3 production/dissolution/erosion processes in coral reefs, especially in these less understood marginal reefs.

Marine litter pollution on coral reefs of Darvel Bay (East Sabah, Malaysia).

Marine litter is recognized as an increasing component of marine ecosystem pollution. In this baseline study, we document the magnitude, types, sources, and potential impacts of litter on six coral reefs in East Sabah. We applied a simplified classification of litter to extract abundance data from video transects. The average density was 10.7 items per 100 m2. Plastics represent 91% and the remaining 9% were metal, glass, and wood. Most (~70%) plastics are single-use items derived from dumping. Discarded fishing gear accounts for ~25%. Litter pollution increases closer to urban developments, with Sakar reef having higher densities (51 items per 100 m2), and higher Clean Coast Index (CCI = 10.2, dirty) and higher Plastic Abundance Index (PAI = 4.68) scores. This method could and should be readily integrated into ongoing monitoring programs to support assessments of the extent and magnitude of marine litter pollution on reefs worldwide.

Global declines in coral reef calcium carbonate production under ocean acidification and warming.

Ocean warming and acidification threaten the future growth of coral reefs. This is because the calcifying coral reef taxa that construct the calcium carbonate frameworks and cement the reef together are highly sensitive to ocean warming and acidification. However, the global-scale effects of ocean warming and acidification on rates of coral reef net carbonate production remain poorly constrained despite a wealth of studies assessing their effects on the calcification of individual organisms. Here, we present global estimates of projected future changes in coral reef net carbonate production under ocean warming and acidification. We apply a meta-analysis of responses of coral reef taxa calcification and bioerosion rates to predicted changes in coral cover driven by climate change to estimate the net carbonate production rates of 183 reefs worldwide by 2050 and 2100. We forecast mean global reef net carbonate production under representative concentration pathways (RCP) 2.6, 4.5, and 8.5 will decline by 76, 149, and 156%, respectively, by 2100. While 63% of reefs are projected to continue to accrete by 2100 under RCP2.6, 94% will be eroding by 2050 under RCP8.5, and no reefs will continue to accrete at rates matching projected sea level rise under RCP4.5 or 8.5 by 2100. Projected reduced coral cover due to bleaching events predominately drives these declines rather than the direct physiological impacts of ocean warming and acidification on calcification or bioerosion. Presently degraded reefs were also more sensitive in our analysis. These findings highlight the low likelihood that the world's coral reefs will maintain their functional roles without near-term stabilization of atmospheric CO2 emissions.

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations.

INTRODUCTION: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. MAIN RECOMMENDATIONS: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch-up ear health checks for at-risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21-30 dB) and moderate (> 30 dB) hearing impairment have been updated. New "OMapp" enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Structural Disadvantage and Culture, Race, and Ethnicity in Early Psychosis Services: International Provider Survey.

OBJECTIVE: Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns. METHODS: An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded. RESULTS: Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation. CONCLUSIONS: An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

Two decades of carbonate budget change on shifted coral reef assemblages: are these reefs being locked into low net budget states?

The ecology of coral reefs is rapidly shifting from historical baselines. One key-question is whether under these new, less favourable ecological conditions, coral reefs will be able to sustain key geo-ecological processes such as the capacity to accumulate carbonate structure. Here, we use data from 34 Caribbean reef sites to examine how the carbonate production, net erosion and net carbonate budgets, as well as the organisms underlying these processes, have changed over the past 15 years in the absence of further severe acute disturbances. We find that despite fundamental benthic ecological changes, these ecologically shifted coral assemblages have exhibited a modest but significant increase in their net carbonate budgets over the past 15 years. However, contrary to expectations this trend was driven by a decrease in erosion pressure, largely resulting from changes in the abundance and size-frequency distribution of parrotfishes, and not by an increase in rates of coral carbonate production. Although in the short term, the carbonate budgets seem to have benefitted marginally from reduced parrotfish erosion, the absence of these key substrate grazers, particularly of larger individuals, is unlikely to be conducive to reef recovery and will thus probably lock these reefs into low budget states.