Facilitators and barriers to using telemedicine for gender-affirming care in gender-diverse youth: A qualitative study.

INTRODUCTION: Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC among GD youth, we sought to further explore their perspectives on the use of TM in their care. METHODS: We used a semi-structured interview guide, with prompts developed to explore participants' knowledge of TM, identify factors that influenced use, and advantages or disadvantages of use. RESULTS: Thirty GD participants aged 13-21 years old participated in TM. While TM was not the preferred option for medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit. The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects of GAC. DISCUSSION: The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement, being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient preferences and concerns and be flexible with visit types.

Cardiac Sarcoidosis and a Likely Pathogenic TTN Variant in a Patient Presenting With Ventricular Tachycardia.

Rare variants in TTN are the most common monogenic cause of early-onset atrial fibrillation and dilated cardiomyopathy. Whereas cardiac sarcoidosis is very underdiagnosed, a common presentation can be ventricular arrhythmias. This report presents a patient with a likely pathogenic TTN variant and cardiac sarcoidosis. (Level of Difficulty: Intermediate.).

Antithrombotic therapy for atrial fibrillation in hereditary hemorrhagic telangiectasia.

Antithrombotic therapy reduces stroke risk in patients with atrial fibrillation but at the cost of increased bleeding risk. Patients with hereditary hemorrhagic telangiectasia (HHT) are at increased bleeding risk due to fragile mucocutaneous telangiectasias and visceral arteriovenous malformations. These patients are simultaneously at elevated thrombotic risk due to the vascular abnormalities of HHT. Managing atrial fibrillation in patients with HHT represents an understudied and challenging clinical scenario. We present a retrospective cohort study investigating antithrombotic therapy in patients with HHT and atrial fibrillation. We found that antithrombotic therapy was poorly tolerated, leading to premature dose-reduction or discontinuation of therapy in a majority of patients and in a majority of treatment episodes. Five patients undergoing left atrial appendage procedures did well despite difficulties completing the prescribed course of post-procedure antithrombotic therapy. Left atrial appendage occlusion or simultaneous administration of systemic anti-angiogenic therapy may represent alternatives but require additional study in patients with HHT.

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa.

Background: Despite South Africa's substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives: Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods: Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results: For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks' gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion: Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants.

Aerial strategies advance volcanic gas measurements at inaccessible, strongly degassing volcanoes.

Volcanic emissions are a critical pathway in Earth's carbon cycle. Here, we show that aerial measurements of volcanic gases using unoccupied aerial systems (UAS) transform our ability to measure and monitor plumes remotely and to constrain global volatile fluxes from volcanoes. Combining multi-scale measurements from ground-based remote sensing, long-range aerial sampling, and satellites, we present comprehensive gas fluxes-3760 ± [600, 310] tons day-1 CO2 and 5150 ± [730, 340] tons day-1 SO2-for a strong yet previously uncharacterized volcanic emitter: Manam, Papua New Guinea. The CO2/ST ratio of 1.07 ± 0.06 suggests a modest slab sediment contribution to the sub-arc mantle. We find that aerial strategies reduce uncertainties associated with ground-based remote sensing of SO2 flux and enable near-real-time measurements of plume chemistry and carbon isotope composition. Our data emphasize the need to account for time averaging of temporal variability in volcanic gas emissions in global flux estimates.

"Always Events® " just another quality improvement tool or is it?

INTRODUCTION: Always Events® are defined as "those aspects of the care experience that should always occur when patients, their family members or other care partners, and service users interact with health care professionals and the health care system". It is a quality improvement methodology that starts by asking our patients the simple question "what matters to you?" and then through coproduction, works out a way to achieve this. METHODS AND RESULTS: This article tells our story and highlights the value of undertaking an Always Event® within the Radiology department at Warrington and Halton Hospitals. It will demonstrate how this approach combines research, an evaluation of findings and implementation of those findings within a very short timeframe. Embedded within the article are comments from our staff, volunteers and patients which reflect upon their experiences, our limitations, the outcomes we achieved and the impact it has had upon our patients and staff. CONCLUSION AND IMPLICATIONS FOR PRACTICE: It was important to our patients that they would be informed of how long they would wait for their examination once they booked in at x-ray reception. By undertaking an Always Event® this process is now embedded in our departments everyday activities with over 90% of our patients now being informed of their waiting time. This continued collaboration has really emphasised the value of listening to our patients, and the benefits this can lead to. It has also encouraged a positive research culture within our department (optimisation studies, working with industry, quality projects), helping to progress our profession and resulting in a quality service for our patients.

Author Correction: Combined ground and aerial measurements resolve vent-specific gas fluxes from a multi-vent volcanic system.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Combined ground and aerial measurements resolve vent-specific gas fluxes from a multi-vent volcano.

Volcanoes with multiple summit vents present a methodological challenge for determining vent-specific gas emissions. Here, using a novel approach combining multiple ultraviolet cameras with synchronous aerial measurements, we calculate vent-specific gas compositions and fluxes for Stromboli volcano. Emissions from vent areas are spatially heterogeneous in composition and emission rate, with the central vent area dominating passive emissions, despite exhibiting the least explosive behaviour. Vents exhibiting Strombolian explosions emit low to negligible passive fluxes and are CO2-dominated, even during passive degassing. We propose a model for the conduit system based on contrasting rheological properties between vent areas. Our methodology has advantages for resolving contrasting outgassing dynamics given that measured bulk plume compositions are often intermediate between those of the distinct vent areas. We therefore emphasise the need for a vent-specific approach at multi-vent volcanoes and suggest that our approach could provide a transformative advance in volcano monitoring applications.

Correction: A chemical inhibitor of PPM1D that selectively kills cells overexpressing PPM1D.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Migration tracking reveals geographic variation in the vulnerability of a Nearctic-Neotropical migrant bird.

We compared the vulnerability of a Nearctic-Neotropical migrant (Swainson's Thrush, Catharus ustulatus) for three geographically-defined breeding populations in California by linking breeding and wintering regions, estimating migration distances, and quantifying relative forest loss. Using data from light-level geolocator and GPS tags, we found that breeding birds from the relatively robust coastal population in the San Francisco Bay area wintered predominantly in western Mexico (n = 18), whereas the far rarer breeding birds from two inland populations that occur near one another in the Sierra Nevada and southern Cascades mountain ranges migrated to farther wintering destinations, with birds from the Lassen region (n = 5) predominantly going to Central America and birds from the Tahoe region (n = 7) predominantly to South America. Landscape-level relative forest loss was greater in the breeding and wintering regions of the two Cascade-Sierra populations than those of coastal birds. Longer migration distances and greater exposure to recent forest loss suggest greater current vulnerability of Cascade-Sierra birds. Our results demonstrate that for some species, quantifying migration distances and destinations across relatively small distances among breeding populations (in this case, 140-250 km apart) can identify dramatically different vulnerabilities that need to be considered in conservation planning.

Efficacy of Climate Forcings in PDRMIP Models.

Quantifying the efficacy of different climate forcings is important for understanding the real-world climate sensitivity. This study presents a systematic multimodel analysis of different climate driver efficacies using simulations from the Precipitation Driver and Response Model Intercomparison Project (PDRMIP). Efficacies calculated from instantaneous radiative forcing deviate considerably from unity across forcing agents and models. Effective radiative forcing (ERF) is a better predictor of global mean near-surface air temperature (GSAT) change. Efficacies are closest to one when ERF is computed using fixed sea surface temperature experiments and adjusted for land surface temperature changes using radiative kernels. Multimodel mean efficacies based on ERF are close to one for global perturbations of methane, sulfate, black carbon, and insolation, but there is notable intermodel spread. We do not find robust evidence that the geographic location of sulfate aerosol affects its efficacy. GSAT is found to respond more slowly to aerosol forcing than CO2 in the early stages of simulations. Despite these differences, we find that there is no evidence for an efficacy effect on historical GSAT trend estimates based on simulations with an impulse response model, nor on the resulting estimates of climate sensitivity derived from the historical period. However, the considerable intermodel spread in the computed efficacies means that we cannot rule out an efficacy-induced bias of ±0.4 K in equilibrium climate sensitivity to CO2 doubling when estimated using the historical GSAT trend.

Sensible heat has significantly affected the global hydrological cycle over the historical period.

Globally, latent heating associated with a change in precipitation is balanced by changes to atmospheric radiative cooling and sensible heat fluxes. Both components can be altered by climate forcing mechanisms and through climate feedbacks, but the impacts of climate forcing and feedbacks on sensible heat fluxes have received much less attention. Here we show, using a range of climate modelling results, that changes in sensible heat are the dominant contributor to the present global-mean precipitation change since preindustrial time, because the radiative impact of forcings and feedbacks approximately compensate. The model results show a dissimilar influence on sensible heat and precipitation from various drivers of climate change. Due to its strong atmospheric absorption, black carbon is found to influence the sensible heat very differently compared to other aerosols and greenhouse gases. Our results indicate that this is likely caused by differences in the impact on the lower tropospheric stability.

A PDRMIP multi-model study on the impacts of regional aerosol forcings on global and regional precipitation.

Atmospheric aerosols such as sulfate and black carbon (BC) generate inhomogeneous radiative forcing and can affect precipitation in distinct ways compared to greenhouse gases (GHGs). Their regional effects on the atmospheric energy budget and circulation can be important for understanding and predicting global and regional precipitation changes, which act on top of the background GHG-induced hydrological changes. Under the framework of the Precipitation Driver Response Model Inter-comparison Project (PDRMIP), multiple models were used for the first time to simulate the influence of regional (Asian and European) sulfate and BC forcing on global and regional precipitation. The results show that, as in the case of global aerosol forcing, the global fast precipitation response to regional aerosol forcing scales with global atmospheric absorption, and the slow precipitation response scales with global surface temperature response. Asian sulphate aerosols appear to be a stronger driver of global temperature and precipitation change compared to European aerosols, but when the responses are normalised by unit radiative forcing or by aerosol burden change, the picture reverses, with European aerosols being more efficient in driving global change. The global apparent hydrological sensitivities of these regional forcing experiments are again consistent with those for corresponding global aerosol forcings found in the literature. However, the regional responses and regional apparent hydrological sensitivities do not align with the corresponding global values. Through a holistic approach involving analysis of the energy budget combined with exploring changes in atmospheric dynamics, we provide a framework for explaining the global and regional precipitation responses to regional aerosol forcing.

Carbon dioxide physiological forcing dominates projected Eastern Amazonian drying.

Future projections of east Amazonian precipitation indicate drying, but they are uncertain and poorly understood. In this study we analyse the Amazonian precipitation response to individual atmospheric forcings using a number of global climate models. Black carbon is found to drive reduced precipitation over the Amazon due to temperature-driven circulation changes, but the magnitude is uncertain. CO2 drives reductions in precipitation concentrated in the east, mainly due to a robustly negative, but highly variable in magnitude, fast response. We find that the physiological effect of CO2 on plant stomata is the dominant driver of the fast response due to reduced latent heating, and also contributes to the large model spread. Using a simple model we show that CO2 physiological effects dominate future multi-model mean precipitation projections over the Amazon. However, in individual models temperature-driven changes can be large, but due to little agreement, they largely cancel out in the model-mean.

Understanding Rapid Adjustments to Diverse Forcing Agents.

Rapid adjustments are responses to forcing agents that cause a perturbation to the top of atmosphere energy budget but are uncoupled to changes in surface warming. Different mechanisms are responsible for these adjustments for a variety of climate drivers. These remain to be quantified in detail. It is shown that rapid adjustments reduce the effective radiative forcing (ERF) of black carbon by half of the instantaneous forcing, but for CO2 forcing, rapid adjustments increase ERF. Competing tropospheric adjustments for CO2 forcing are individually significant but sum to zero, such that the ERF equals the stratospherically adjusted radiative forcing, but this is not true for other forcing agents. Additional experiments of increase in the solar constant and increase in CH4 are used to show that a key factor of the rapid adjustment for an individual climate driver is changes in temperature in the upper troposphere and lower stratosphere.

Quantifying the Importance of Rapid Adjustments for Global Precipitation Changes.

Different climate drivers influence precipitation in different ways. Here we use radiative kernels to understand the influence of rapid adjustment processes on precipitation in climate models. Rapid adjustments are generally triggered by the initial heating or cooling of the atmosphere from an external climate driver. For precipitation changes, rapid adjustments due to changes in temperature, water vapor, and clouds are most important. In this study we have investigated five climate drivers (CO2, CH4, solar irradiance, black carbon, and sulfate aerosols). The fast precipitation responses to a doubling of CO2 and a 10-fold increase in black carbon are found to be similar, despite very different instantaneous changes in the radiative cooling, individual rapid adjustments, and sensible heating. The model diversity in rapid adjustments is smaller for the experiment involving an increase in the solar irradiance compared to the other climate driver perturbations, and this is also seen in the precipitation changes.

An unexpected diagnosis of breast malignancy.

Inflammatory breast cancer constitutes 5% of all breast cancer diagnoses. Diagnosis is based on clinical signs including skin changes, erythema and oedema, together with rapid progression and involvement of more than one-third of the affected breast. It is an aggressive tumour with great metastatic potential, metastases being present in 30% of patients at first presentation. Primary non-Hodgkin's lymphoma of the breast is rare but is well reported. It accounts for 0.5% of all breast malignancies and 1% of all non-Hodgkin's diagnoses. Prognosis of primary breast lymphoma varies depending on the stage of disease with stage IE having a 5-year survival rate of 78-83% and stage IIE having a 5-year survival rate of 20-57%. We present a rare case of non-Hodgkin's lymphoma mimicking an inflammatory breast cancer. The aim of this case report is to highlight an unusual presentation of non-Hodgkin's lymphoma and the diagnostic difficulties that arise.

PDRMIP: A Precipitation Driver and Response Model Intercomparison Project, Protocol and preliminary results.

As the global temperature increases with changing climate, precipitation rates and patterns are affected through a wide range of physical mechanisms. The globally averaged intensity of extreme precipitation also changes more rapidly than the globally averaged precipitation rate. While some aspects of the regional variation in precipitation predicted by climate models appear robust, there is still a large degree of inter-model differences unaccounted for. Individual drivers of climate change initially alter the energy budget of the atmosphere leading to distinct rapid adjustments involving changes in precipitation. Differences in how these rapid adjustment processes manifest themselves within models are likely to explain a large fraction of the present model spread and needs better quantifications to improve precipitation predictions. Here, we introduce the Precipitation Driver and Response Model Intercomparison Project (PDRMIP), where a set of idealized experiments designed to understand the role of different climate forcing mechanisms were performed by a large set of climate models. PDRMIP focuses on understanding how precipitation changes relating to rapid adjustments and slower responses to climate forcings are represented across models. Initial results show that rapid adjustments account for large regional differences in hydrological sensitivity across multiple drivers. The PDRMIP results are expected to dramatically improve our understanding of the causes of the present diversity in future climate projections.

Verification Testing to Confirm VO2max in Altitude-Residing, Endurance-Trained Runners.

We sought to explore the utility of the verification trial to confirm individual attainment of 'true' VO2max in altitude-residing, endurance-trained runners during treadmill exercise. 24 elite endurance-trained men and women runners (age=21.5±3.3 yr, ht=174.8±9.3 cm, body mass=60.5±6.7 kg, PR 800 m 127.5±13.1 s) completed a graded exercise test (GXT) trial (VO2max=60.0±5.8 mL·kg(-1)·min(-1)), and returned 20 min after incremental exercise to complete a verification trial (VO2max=59.6±5.7 mL·kg(-1)·min(-1)) of constant load, supramaximal exercise. The incidence of 'true' VO2max confirmation using the verification trial was 24/24 (100%) with all participants revealing differences in VO2max≤3% (the technical error of our equipment) between the GXT and verification trials. These findings support use of the verification trial to confirm VO2max attainment in altitude-residing, endurance-trained runners.