Increased dominance of heat-tolerant symbionts creates resilient coral reefs in near-term ocean warming.

Climate change is radically altering coral reef ecosystems, mainly through increasingly frequent and severe bleaching events. Yet, some reefs have exhibited higher thermal tolerance after bleaching severely the first time. To understand changes in thermal tolerance in the eastern tropical Pacific (ETP), we compiled four decades of temperature, coral cover, coral bleaching, and mortality data, including three mass bleaching events during the 1982 to 1983, 1997 to 1998 and 2015 to 2016 El Niño heatwaves. Higher heat resistance in later bleaching events was detected in the dominant framework-building genus, Pocillopora, while other coral taxa exhibited similar susceptibility across events. Genetic analyses of Pocillopora spp. colonies and their algal symbionts (2014 to 2016) revealed that one of two Pocillopora lineages present in the region (Pocillopora "type 1") increased its association with thermotolerant algal symbionts (Durusdinium glynnii) during the 2015 to 2016 heat stress event. This lineage experienced lower bleaching and mortality compared with Pocillopora "type 3", which did not acquire D. glynnii. Under projected thermal stress, ETP reefs may be able to preserve high coral cover through the 2060s or later, mainly composed of Pocillopora colonies that associate with D. glynnii. However, although the low-diversity, high-cover reefs of the ETP could illustrate a potential functional state for some future reefs, this state may only be temporary unless global greenhouse gas emissions and resultant global warming are curtailed.

Surgical scheduling via optimization and machine learning with long-tailed data : Health care management science, in press.

Using data from cardiovascular surgery patients with long and highly variable post-surgical lengths of stay (LOS), we develop a modeling framework to reduce recovery unit congestion. We estimate the LOS and its probability distribution using machine learning models, schedule procedures on a rolling basis using a variety of optimization models, and estimate performance with simulation. The machine learning models achieved only modest LOS prediction accuracy, despite access to a very rich set of patient characteristics. Compared to the current paper-based system used in the hospital, most optimization models failed to reduce congestion without increasing wait times for surgery. A conservative stochastic optimization with sufficient sampling to capture the long tail of the LOS distribution outperformed the current manual process and other stochastic and robust optimization approaches. These results highlight the perils of using oversimplified distributional models of LOS for scheduling procedures and the importance of using optimization methods well-suited to dealing with long-tailed behavior.

On incorporating forecasts into linear state space model Markov decision processes.

Weather forecast information will very likely find increasing application in the control of future energy systems. In this paper, we introduce an augmented state space model formulation with linear dynamics, within which one can incorporate forecast information that is dynamically revealed alongside the evolution of the underlying state variable. We use the martingale model for forecast evolution (MMFE) to enforce the necessary consistency properties that must govern the joint evolution of forecasts with the underlying state. The formulation also generates jointly Markovian dynamics that give rise to Markov decision processes (MDPs) that remain computationally tractable. This paper is the first to enforce MMFE consistency requirements within an MDP formulation that preserves tractability. This article is part of the theme issue 'The mathematics of energy systems'.

The development and deployment of a model for hospital-level COVID-19 associated patient demand intervals from consistent estimators (DICE).

Hospitals commonly project demand for their services by combining their historical share of regional demand with forecasts of total regional demand. Hospital-specific forecasts of demand that provide prediction intervals, rather than point estimates, may facilitate better managerial decisions, especially when demand overage and underage are associated with high, asymmetric costs. Regional point forecasts of patient demand are commonly available, e.g., for the number of people requiring hospitalization due to an epidemic such as COVID-19. However, even in this common setting, no probabilistic, consistent, computationally tractable forecast is available for the fraction of patients in a region that a particular institution should expect. We introduce such a forecast, DICE (Demand Intervals from Consistent Estimators). We describe its development and deployment at an academic medical center in California during the 'second wave' of COVID-19 in the Unite States. We show that DICE is consistent under mild assumptions and suitable for use with perfect, biased and unbiased regional forecasts. We evaluate its performance on empirical data from a large academic medical center as well as on synthetic data.

Contributions of the UK biobank high impact papers in the era of precision medicine.

To review the highest impact studies published from the UK Biobank and assess their contributions to "precision medicine." We reviewed 140 of 689 studies published between 2008 and May 2019 from the UK Biobank deemed to be high impact by citations, alternative metric data, or publication in a high impact journal. We classified studies according to whether they (1) were largely methods papers, (2) largely replicated prior findings or associations, (3) generated novel findings or associations, (4) developed risk prediction models that did not yield clinically significant improvements in risk estimation over prior models or (5) developed models that produced significant improvements in individualized risk assessment, targeted screening, or targeted treatment. This final category represents "precision medicine." We classified 15 articles as category 1, 33 as category 2, 85 as category 3, six as category 4, and one as category 5. In this assessment of the first 7 years of the UK Biobank and first 4 years of genetic data availability, the majority of high impact UK Biobank studies either replicated known associations or generated novel associations without clinically relevant improvements in risk prediction, screening, or treatment. This information may be useful for designers of other cohort studies in terms of input to design and follow-up to facilitate precision medicine research.

Measuring the impact of epilepsy on families.

OBJECTIVE: Caring for a child with illness or a child with disability impacts family in various ways. The ability to assess the impact of this care on families is one way to proactively provide the necessary support and resources for impacted families. Accordingly, the goal of the current study was to assess the impact of pediatric epilepsy on individual families in a comprehensive epilepsy clinic using a slightly modified version of the Impact on Families Scale (IFS). METHODS: Families of patients with epilepsy completed the IFS up to three times. The IFS score and the six categories (i.e., total impact, financial impact, general impact, family/social impact, coping, and sibling impact) were assessed using Student's two sample t-test to determine the differences between binary groups and Pearson's correlation to assess the associations with continuous variables. Linear regression modeling was used to develop a model to predict IFS score. RESULTS: Three hundred and forty-one patients completed the scale at one time point, 314 at two time points, and 61 at three time points. The overall impact of epilepsy on families was 109 (95% confidence interval (CI): 106-112) at time point 1, 111 (95% CI: 108-114) at time point 2, and 112 (95% CI: 105-119) at time point 3. There was no statistical difference in IFS score among the three time points. There were no associations with age or gender. Multivariable modeling using stepwise regression indicated that treatment resistance and seizure-free status were associated with IFS score. No interaction effects were identified. CONCLUSIONS: Findings from the current study suggest that the impact of epilepsy is highest for families that have children with active seizures at the time of their clinical visit and for those with children having treatment-resistant epilepsy. Although intuitive, this is the first study, to our knowledge, that has empirically verified these findings.

Impact of a Make-A-Wish experience on healthcare utilization.

OBJECTIVES: To evaluate the impact of receiving a wish from the Make-A-WishR Foundation on (1) patient healthcare utilization and (2) savings benefit measures. STUDY DESIGN: Make-A-WishR arranges experiences, or "wishes," to children with progressive, life-threatening, or life-limiting illness. A retrospective, case-control analysis was performed comparing patients who received or did not receive a wish and associated impact on healthcare utilization and costs across 2 years. Healthcare utilization was defined as visits to primary, urgent, emergent care, and planned/unplanned inpatient hospitalizations. We defined wish savings benefit as a decline in the cost of care from years 1 to 2, which exceeded the average cost of a wish in 2016, $10,130. RESULTS: From 2011 to 2016, 496 Nationwide Children's Hospital patients received a wish. We matched these patients to 496 controls based on age, gender, disease category, and disease complexity. Patients who received a wish were 2.5 and 1.9 times more likely to have fewer unplanned hospital admissions and emergency department visits, respectively. These decreases were associated with a higher likelihood (2.3-fold and 2.2-fold greater odds) of the wish achieving a savings benefit compared to hospital charges. CONCLUSIONS: Participation in the Make-A-WishR program may provide children quality of life relief while reducing hospital visits and healthcare expenditures.

A hospital-based study on caregiver preferences on acute seizure rescue medications in pediatric patients with epilepsy: Intranasal midazolam versus rectal diazepam.

RATIONALE: About 20 per 100,000 children have convulsive status epilepticus every year, a life-threatening condition. Benzodiazepines are the first-line treatment for prolonged and recurrent seizures. Our study was designed to gain understanding of caregiver perception of acute seizure treatments. METHODS: Our project uses a cross-sectional survey study design using the electronic medical record and a survey at a large academic tertiary children's medical center. Subjects were patients with epilepsy prescribed intranasal (IN) midazolam and/or per rectum (PR) diazepam. The survey was administered to caregivers of children with epilepsy regarding information on the comfort, efficacy, ease of use, and time of administration for patients receiving both abortive seizure medications. Exact binomial tests were employed to determine whether or not differences in caregiver preference exist. RESULTS: One hundred and sixty responses were obtained. Incomplete and duplicate surveys were excluded, leaving 153 responses. Of those responses, 59 respondents reported administering both medications. Among parents who expressed a preference for one medication over the other, more parents felt overall greater comfort with IN midazolam compared with rectal diazepam (p = 0.0004 and p = 0.001), IN midazolam was perceived as easier to use (68%, p = 0.0038 and 74%, p = 0.0004) and more effective (87%, p < 0.0001) than rectal diazepam. Intranasal midazolam was found to be superior to rectal diazepam in several other categories as well. CONCLUSIONS: These parents of children with epilepsy report increased ease of use, comfort, and efficacy with IN midazolam as compared with rectal diazepam suggesting that a readily available form of IN midazolam would be well received in the pediatric population.

A depth refugium from catastrophic coral bleaching prevents regional extinction.

Species intolerant of changing climate might avoid extinction within refugia buffered from extreme conditions. Refugia have been observed in the fossil record but are not well documented or understood on ecological time scales. Using a 37-year record from the eastern Pacific across the two most severe El Niño events on record (1982-1983 and 1997 1998) we show how an exceptionally thermally sensitive reef-building hydrocoral, Millepora intricata, twice survived catastrophic bleaching in a deeper-water refuge (> 11 m depth). During both events, M. intricata was extirpated across its range in shallow water, but showed recovery within several years, while two other hydrocorals without deep-water populations were driven to regional extinction. Evidence from the subfossil record in the same area showed shallow-water persistence of abundant M. intricata populations from 5000 years ago, through severe El Niño-Southern Oscillation cycles, suggesting a potential depth refugium on a millennial timescale. Our data confirm the deep refuge hypothesis for corals under thermal stress.

Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management.

Systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations. SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis. While cardiac involvement is the second leading SSc-related cause of death, it is frequently clinically silent in early disease and often missed with routine screening. To facilitate identification of cardiac disease in this susceptible population, we present here a review of cardiac imaging modalities and potential uses in the SSc patient population. We describe well-characterized techniques including electrocardiography and 2D echocardiography with Doppler, but also discuss more advanced imaging approaches, such as speckle-tracking echocardiography, cardiovascular magnetic resonance imaging (CMR), and stress imaging, among others. We also suggest an algorithm for the appropriate application of these modalities in the workup and management of patients with SSc. Finally, we discuss future opportunities for cardiac imaging in SSc research to achieve early detection and to optimize treatment.

Poorly cemented coral reefs of the eastern tropical Pacific: possible insights into reef development in a high-CO2 world.

Ocean acidification describes the progressive, global reduction in seawater pH that is currently underway because of the accelerating oceanic uptake of atmospheric CO(2). Acidification is expected to reduce coral reef calcification and increase reef dissolution. Inorganic cementation in reefs describes the precipitation of CaCO(3) that acts to bind framework components and occlude porosity. Little is known about the effects of ocean acidification on reef cementation and whether changes in cementation rates will affect reef resistance to erosion. Coral reefs of the eastern tropical Pacific (ETP) are poorly developed and subject to rapid bioerosion. Upwelling processes mix cool, subthermocline waters with elevated pCO(2) (the partial pressure of CO(2)) and nutrients into the surface layers throughout the ETP. Concerns about ocean acidification have led to the suggestion that this region of naturally low pH waters may serve as a model of coral reef development in a high-CO(2) world. We analyzed seawater chemistry and reef framework samples from multiple reef sites in the ETP and found that a low carbonate saturation state (Omega) and trace abundances of cement are characteristic of these reefs. These low cement abundances may be a factor in the high bioerosion rates previously reported for ETP reefs, although elevated nutrients in upwelled waters may also be limiting cementation and/or stimulating bioerosion. ETP reefs represent a real-world example of coral reef growth in low-Omega waters that provide insights into how the biological-geological interface of coral reef ecosystems will change in a high-CO(2) world.

Validating Coding for the Identification of Pediatric Treatment Resistant Epilepsy Patients.

The International Classification of Diseases (ICD) system includes sub codes to indicate that an individual with epilepsy is treatment resistant. These codes would be a valuable tool to identify individuals for quality improvement and population health, as well as for recruitment into clinical trials. However, the accuracy of these codes is unclear. We performed a single center cross sectional study to understand the accuracy of ICD codes for treatment resistant epilepsy. We identified 344 individuals, roughly half with treatment resistant epilepsy The ICD code had a sensitivity of 90% (147 of 164) and specificity of 86% (155 of 180). The miscoding of children with refractory epilepsy was attributed to the following reasons: 5 patients had epilepsy surgery, 4 had absence epilepsy, 4 patients were seen by different providers, and 1 patient was most recently seen in movement disorders clinic. ICD codes accurately identify children with treatment resistant epilepsy.

Evaluation of a Care Management Program for Pediatric Epilepsy Patients.

OBJECTIVE: To evaluate the impact of a pediatric epilepsy care management intervention on emergency department visits, hospitalizations, and seizure freedom. METHODS: We conducted a prospective observational study at a single academic medical center. Children with epilepsy with high risk of frequent emergency department use were enrolled in the intervention from January through May 2015, which included a baseline visit and follow-up support from a care management team. Controls selected from the same institution received standard of care. Baseline and follow-up information were collected from electronic health records and surveys (Family Impact Scale, Pediatric Epilepsy Medication Self-Management Questionnaire). Propensity score-weighted logistic regression compared emergency department visits, unplanned hospitalizations, and 3-month seizure freedom after 1 year in the intervention vs control groups. RESULTS: A total of 56 children were enrolled in the intervention and 359 received standard of care. The intervention group was younger and had greater use of health services at baseline. When comparing the intervention to standard of care after 1 year, we found no significant difference in the risk of any emergency department visit (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 0.6-8.5) or seizure freedom (adjusted OR 2.5, 95% CI 0.3-21.5). However, the risk of unplanned hospital admissions remained higher in the intervention group (adjusted OR 23.1, 95% CI 5.1-104). CONCLUSION: We did not find that children with epilepsy who received a care management intervention had less use of health services or better clinical outcomes after a year compared with controls. The study is limited by small sample size and nonrandomized study design.

Heart Failure Risk Distribution and Trends in the United States Population, NHANES 1999-2016.

BACKGROUND: Implementation of effective preventive interventions requires identification of high-risk individuals. We sought to define the distribution and trends of heart failure risk in the US population. METHODS: We calculated 10-year predicted heart failure risk among a representative sample of US adults aged 30-79 years, without baseline cardiovascular disease, from the National Health and Nutrition Examination Surveys (NHANES) 1999-2016. We used the published Pooled Cohort Equations to Prevent Heart Failure (PCP-HF) model, which integrates demographic and risk factor data, to estimate 10-year heart failure risk. Participants were stratified by NHANES cycle, sex, age, and race/ethnicity and by 10-year heart failure risk, defined as low (<1%), intermediate (1% to <5%), and high (≥5%). RESULTS: From 1999-2000 to 2015-2016, mean predicted 10-year heart failure risk increased significantly from 2.0% to 3.0% (P < .05) in the population, most notably among non-Hispanic black (2.1% to 3.7%) and non-Hispanic white (2.4% to 3.6%) men. In 2013-2016, 17.6% of the studied population was at high predicted 10-year heart failure risk. The prevalence of high predicted heart failure risk was highest among non-Hispanic black men (23.1%), followed by non-Hispanic white men (19.2%) and non-Hispanic white women (17.9%). DISCUSSION: Mean population risk of heart failure increased significantly from 1999-2016. A substantial proportion of US adults are at high 10-year heart failure risk (≥5%), particularly non-Hispanic black men. These data underscore the importance of identifiying individuals at increased heart failure risk for targeted prevention measures to reduce the future burden of heart failure.

Geographic Variation in Trends and Disparities in Heart Failure Mortality in the United States, 1999 to 2017.

Background Cardiovascular disease mortality related to heart failure (HF) is rising in the United States. It is unknown whether trends in HF mortality are consistent across geographic areas and are associated with state-level variation in cardiovascular health (CVH). The goal of the present study was to assess regional and state-level trends in cardiovascular disease mortality related to HF and their association with variation in state-level CVH. Methods and Results Age-adjusted mortality rates (AAMR) per 100 000 attributable to HF were ascertained using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research from 1999 to 2017. CVH at the state-level was quantified using the Behavioral Risk Factor Surveillance System. Linear regression was used to assess temporal trends in HF AAMR were examined by census region and state and to examine the association between state-level CVH and HF AAMR. AAMR attributable to HF declined from 1999 to 2011 and increased between 2011 and 2017 across all census regions. Annual increases after 2011 were greatest in the Midwest (ß=1.14 [95% CI, 0.75, 1.53]) and South (ß=0.96 [0.66, 1.26]). States in the South and Midwest consistently had the highest HF AAMR in all time periods, with Mississippi having the highest AAMR (109.6 [104.5, 114.6] in 2017). Within race‒sex groups, consistent geographic patterns were observed. The variability in HF AAMR was associated with state-level CVH (P<0.001). Conclusions Wide geographic variation exists in HF mortality, with the highest rates and greatest recent increases observed in the South and Midwest. Higher levels of poor CVH in these states suggest the potential for interventions to promote CVH and reduce the burden of HF.

Coral reefs: corals' adaptive response to climate change.

The long-term response of coral reefs to climate change depends on the ability of reef-building coral symbioses to adapt or acclimatize to warmer temperatures, but there has been no direct evidence that such a response can occur. Here we show that corals containing unusual algal symbionts that are thermally tolerant and commonly associated with high-temperature environments are much more abundant on reefs that have been severely affected by recent climate change. This adaptive shift in symbiont communities indicates that these devastated reefs could be more resistant to future thermal stress, resulting in significantly longer extinction times for surviving corals than had been previously assumed.

Population dynamics of the reef crisis: Consequences of the growing human population.

An unequivocal link exists between human population density and environmental degradation, both in the near field (local impacts) and far field (impacts due to teleconnections). Human population is most widely predicted to reach 9-11 billion by 2100, when the demographic transition is expected in all but a handful of countries. Strongest population growth is in the tropics, where coral reefs face dense human population and concomitant heavy usage. In most countries, >50% will be urbanized but growth of rural population and need for food in urban centres will not alleviate pressure on reef resources. Aquaculture will alleviate some fishing pressure, but still utilizes reef surface and is also destructive. Denser coastal populations and greater wealth will lead to reef degradation by coastal construction. Denser populations inland will lead to more runoff and siltation. Effects of human perturbations can be explored with metapopulation theory since they translate to increases in patch-mortality and decreases in patch-colonization (=regeneration). All such changes will result in a habitat with overall fewer settled patches, so fewer live reefs. If rescue effects are included, bifurcations in system dynamics will allow for many empty patches and, depending on system state relative to stable and unstable equilibria, a part-empty system may either trend towards stability at higher patch occupancy or extinction. Thus, unless the disturbance history is known, it may be difficult to assess the direction of system trajectory-making management difficult. If habitat is decreased by destruction, rescue effects become even more important as extinction-debt, accumulated by efficient competitors with weaker dispersal ability, is realized. Easily visible trends in human population dynamics combined with well-established and tested ecological theory give a clear, intuitive, yet quantifiable guide to the severity of survival challenges faced by coral reefs. Management challenges and required actions can be clearly shown and, contrary to frequent claims, no scientific ambiguity exists with regards to the serious threat posed to coral reefs by humankind's continued numerical increase.

A tropical eastern Pacific invasive brittle star species (Echinodermata: Ophiuroidea) reaches southeastern Florida.

The invasive brittle star Ophiothela mirabilis (family Ophiotrichidae), a tropical Indo-Pacific endemic species, first reported in Atlantic waters off southern Brazil in 2000, has extended its range northward to the Caribbean Sea, to the Lesser Antilles in 2011, and was first reported in south Florida in January 2019. Its occurrence in southeast Florida extends along nearly 70km of coastline, from near the Port of Miami, Miami-Dade County, northward to Deerfield Beach, Broward County. It occurs abundantly as an epizoite on octocorals, attaining population densities of 25 individuals and more per 10-cm long octocoral stem. The surface texture of octocoral hosts (rough, smooth) did not affect the densities of the ophiuroid epizoites, and there were significantly greater abundances on octocorals during two winter sampling periods than in the summer. Beige and orange-coloured morphs are sometimes present on the same octocoral stem. Gut content analysis supported a suspension feeding mode, revealing essentially identical ingested items in both colour morphs with a preponderance of amorphous detritus and filamentous algae. Molecular genetic evidence (COI & 16s) has established the identity of O. mirabilis and its relationship to invasive Brazilian populations. The orange and beige morphs form two distinct, but closely related lineages that may represent two separate introductions. The orange morph shares haplotypes with Brazilian and Caribbean specimens suggesting a further range expansion of the 'original' invasion. The beige morph, however, shares haplotypes with specimens from the Mexican Pacific and Peru and potentially represents a secondary introduction. Traits promoting dispersal and establishment of this species in new habitats are manifold: vagility and ability to cling tightly to diverse host taxa (e.g. sponges, cnidarians, bryozoans, and echinoderms), frequent asexual reproduction (fissiparity), suspension feeding, including a wide range of dietary items, possession of integument-covered ossicles and arm spines offering protection from predators, and an effective competitive edge over associated microbiota for substrate space.

Evaluation of an Activity Tracker to Detect Seizures Using Machine Learning.

Currently, the tracking of seizures is highly subjective, dependent on qualitative information provided by the patient and family instead of quantifiable seizure data. Usage of a seizure detection device to potentially detect seizure events in a population of epilepsy patients has been previously done. Therefore, we chose the Fitbit Charge 2 smart watch to determine if it could detect seizure events in patients when compared to continuous electroencephalographic (EEG) monitoring for those admitted to an epilepsy monitoring unit. A total of 40 patients were enrolled in the study that met the criteria between 2015 and 2016. All seizure types were recorded. Twelve patients had a total of 53 epileptic seizures. The patient-aggregated receiver operating characteristic curve had an area under the curve of 0.58 [0.56, 0.60], indicating that the neural network models were generally able to detect seizure events at an above-chance level. However, the overall low specificity implied a false alarm rate that would likely make the model unsuitable in practice. Overall, the use of the Fitbit Charge 2 activity tracker does not appear well suited in its current form to detect epileptic seizures in patients with seizure activity when compared to data recorded from the continuous EEG.