Methodology for Evaluation of WIAMan Injury Assessment Reference Curves Using Whole Body Match-Paired Data.

Development of the Warrior Injury Assessment Manikin (WIAMan) capability has included the creation of injury assessment reference curves (IARCs) specific to under-body blast (UBB) loading mechanisms and injuries. The WIAMan IARCs were created from high-rate vertical loading tests of component post-mortem human surrogates (PMHS) and analogous components of the WIAMan anthropomorphic test device (ATD). Validation of the WIAMan IARCs is required prior to the WIAMan ATD being utilized for injury assessment in live-fire vehicle test events. A portion of the validation process involves evaluating the ability of the IARCs to predict injury at the system level (whole body). This study evaluates a methodology to assess the performance of the WIAMan IARCs using match-paired tests of whole body PMHS and the WIAMan ATD. The methodology includes a qualitative analysis designed to identify false-positive and false-negative ATD predictions, as well as a quantitative analysis that utilizes area under the receiver-operating characteristic curve (AROC) and Brier score indices to grade IARC performance. Three WIAMan IARCs were used to exemplify the proposed methodology and results are provided. Attributes of the false-prediction, AROC, and Brier score portions of the methodology are presented, with results indicating the new methodology is thorough and robust in evaluation of IARCs.

The predictive validity of the Functional Assessment for Burns - Critical Care (FAB-CC) score for discharge outcomes in major burns.

INTRODUCTION: Physical function scoring of burn ICU patients is recommended but currently validated scores are lacking. OBJECTIVE: To evaluate the predictive validity of the FAB -CC for burn ICU patients' discharge outcome. METHODS: All patients underwent daily exercise and FAB -CC screen if they were stable. Two FAB-CC scores were performed; FAB-CC1 on the first day the patient passed the FAB-CC screen, FAB-CC2 within 48 h before ICU discharge. Hospital discharge outcome was defined as transfer for further inpatient rehabilitation or home with social care versus home with no social care. 76 patients' data were entered into the analyses. We used multiple logistic regression analysis to identify variables that predict discharge outcome. RESULTS: Increasing patient age (p = 0.001), duration of ventilation (p = 0.0003), ICU Length of stay (LOS) (p = 0.0001), total hospital LOS (p < 0.0001), presence of cardiopulmonary disease (p = 0.008), neurological disorder (p = 0.0003) and psychiatric illness (p = 0.003) are positively associated with transfer for inpatient rehabilitation or home with social care. Increasing FAB-CC1 (p < 0.0001) and FAB -CC2 (p = 0.0001) are negatively associated with transfer for inpatient rehabilitation or home with social care. The most predictive model for discharge outcome combined the variables patient age, FAB-CC1, FAB-CC2 and psychiatric illness. Patient age (p = 0.01), FAB-CC1 (p = 0.02) and psychiatric illness (p = 0.009) independently predict discharge outcome. CONCLUSIONS: FAB-CC2 is associated with, and FAB-CC1 has predictive validity for, patient hospital discharge outcome. These findings, in conjunction with our earlier work, confirm clinical utility of the FAB-CC for burns ICU patients.

Perspective: Increasing blue carbon around Antarctica is an ecosystem service of considerable societal and economic value worth protecting.

Precautionary conservation and cooperative global governance are needed to protect Antarctic blue carbon: the world's largest increasing natural form of carbon storage with high sequestration potential. As patterns of ice loss around Antarctica become more uniform, there is an underlying increase in carbon capture-to-storage-to-sequestration on the seafloor. The amount of carbon captured per unit area is increasing and the area available to blue carbon is also increasing. Carbon sequestration could further increase under moderate (+1°C) ocean warming, contrary to decreasing global blue carbon stocks elsewhere. For example, in warmer waters, mangroves and seagrasses are in decline and benthic organisms are close to their physiological limits, so a 1°C increase in water temperature could push them above their thermal tolerance (e.g. bleaching of coral reefs). In contrast, on the basis of past change and current research, we expect that Antarctic blue carbon could increase by orders of magnitude. The Antarctic seafloor is biophysically unique and the site of carbon sequestration, the benthos, faces less anthropogenic disturbance than any other ocean continental shelf environment. This isolation imparts both vulnerability to change, and an avenue to conserve one of the world's last biodiversity refuges. In economic terms, the value of Antarctic blue carbon is estimated at between £0.65 and £1.76 billion (~2.27 billion USD) for sequestered carbon in the benthos around the continental shelf. To balance biodiversity protection against society's economic objectives, this paper builds on a proposal incentivising protection by building a 'non-market framework' via the 2015 Paris Agreement to the United Nations Framework Convention on Climate Change. This could be connected and coordinated through the Antarctic Treaty System to promote and motivate member states to value Antarctic blue carbon and maintain scientific integrity and conservation for the positive societal values ingrained in the Antarctic Treaty System.

A prospective study comparing the FLIR ONE with laser Doppler imaging in the assessment of burn depth by a tertiary burns unit in the United Kingdom.

INTRODUCTION: Laser Doppler imaging (LDI) is the 'gold standard' tool for the assessment of burn depth. However, it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera used to assess burn wound temperature. This study compares the FLIR ONE and LDI in assessing burn depth and predicting healing times. METHODS: Forty-five adult patients with burn wounds, presenting at 1-5 days, were imaged with the FLIR ONE and LDI. Infected, chemical and electrical burns were excluded. Healing potential was determined by comparing wound and normal skin temperature for the FLIR ONE and blood flow changes with the LDI. Healing potential was categorised into wounds healing in less than and over 21 days. Pearson's test was used to determine the correlation between changes in wound temperature and healing potential. RESULTS: Percent total body surface area (%TBSA) was in the range of 0.5-45. FLIR demonstrated a sensitivity of 66.67% and specificity of 76.67% in predicting healing within 21 days, while LDI demonstrated a sensitivity of 93.33% and specificity of 40%. The FLIR ONE showed a significant difference in the mean temperature changes between burns that healed in less than (0.1933 ± 0.3554) and over 21 days (-1 ± 0.4329) (P = 0.04904). Pearson's test showed a significant correlation between the difference in wound and normal skin temperature with healing times (P = 0.04517). CONCLUSION: The inexpensive FLIR ONE shows a significant correlation between changes in wound temperature and healing times. It is useful in predicting healing within 21 days. However, evaporative cooling at the wound surface can lead to overprediction of healing times and overtreatment. LAY SUMMARY: Background Laser Doppler imaging is currently the main tool for burn depth assessment. It works by analysing the blood flow in a burn wound. Based on these findings, it can predict the depth of the burn injury and predict if it will heal in less than or over 21 days. The main problem is that it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera. It can be used to assess burn depth by comparing the temperature of the burn wound to the surrounding normal skin. This information can then be used to predict healing times into less than and over 21 days. The issue being explored The usefulness of the FLIR ONE in assessing burn depth and predicting healing time when compared to the LDI. How was the work conducted? Forty-five adult patients who sustained a burn injury within the last five days were imaged with both the FLIR ONE and LDI. Those with infected, electrical or chemical burns were excluded. Healing potential was determined by comparing the temperature of the burn wound with normal skin for the FLIR ONE and by changes in wound blood flow with the LDI. Healing potential was categorised into wounds healing in less than and over 21 days. The correlation between the temperature changes of the burn wound and healing time was evaluated for the FLIR ONE. What we learned from the study This study was able to demonstrate that the FLIR ONE showed a significant correlation between the temperature difference between the burn wound and normal skin with healing times. When compared with the LDI, the FLIR ONE was useful in predicting if a burn wound will heal in less than 21 days. The FLIR ONE has advantages over the LDI, it is low cost, portable and produces instantaneous images. Ultimately, this developing technology may increase access to higher standard burn care in centres where LDI is not affordable.

Do racial patterns in psychological distress shed light on the Black-White depression paradox? A systematic review.

PURPOSE: Major epidemiologic studies in the US reveal a consistent "paradox" by which psychiatric outcomes such as major depressive disorder (MDD) are less prevalent among Blacks relative to Whites, despite greater exposure to social and economic stressors and worse physical health outcomes. A second paradox, which has received less attention and has never been systematically documented, is the discrepancy between these patterns and Black-White comparisons in psychological distress, which reveal consistently higher levels among Blacks. By systematically documenting the latter paradox, this paper seeks to inform efforts to explain the first paradox. METHODS: We conduct a systematic review of the literature estimating the prevalence of MDD and levels of psychological distress in Blacks and Whites in the US. RESULTS: The literature review yielded 34 articles reporting 54 relevant outcomes overall. Blacks have a lower prevalence of MDD in 8 of the 9 comparisons observed. In contrast, Blacks have higher levels of psychological distress (in terms of "high distress" and mean scores) than Whites in 42 of the 45 comparisons observed. Tests of statistical significance, where available, confirm this discrepant pattern. CONCLUSIONS: A systematic review of the epidemiologic evidence supports the existence of a "double paradox" by which Blacks' lower prevalence of MDD relative to Whites' is inconsistent with both the expectations of social stress theory and with the empirical evidence regarding psychological distress. Efforts to resolve the Black-White depression paradox should account for the discordant distress results, which seem to favor artifactual explanations.

Sexual orientation disparities in mental health: the moderating role of educational attainment.

PURPOSE: Mental health disparities between sexual minorities and heterosexuals remain inadequately understood, especially across levels of educational attainment. The purpose of the present study was to test whether education modifies the association between sexual orientation and mental disorder. METHODS: We compared the odds of past 12-month and lifetime psychiatric disorder prevalence (any Axis-I, any mood, any anxiety, any substance use, and comorbidity) between lesbian, gay, and bisexual (LGB) and heterosexual individuals by educational attainment (those with and without a bachelor's degree), adjusting for covariates, and tested for interaction between sexual orientation and educational attainment. Data are drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative survey of non-institutionalized US adults (N = 34,653; 577 LGB). RESULTS: Sexual orientation disparities in mental health are smaller among those with a college education. Specifically, the disparity in those with versus those without a bachelor's degree was attenuated by 100 % for any current mood disorder, 82 % for any current Axis-I disorder, 76 % for any current anxiety disorder, and 67 % for both any current substance use disorder and any current comorbidity. Further, the interaction between sexual orientation and education was statistically significant for any current Axis-I disorder, any current mood disorder, and any current anxiety disorder. Our findings for lifetime outcomes were similar. CONCLUSIONS: The attenuated mental health disparity at higher education levels underscores the particular risk for disorder among LGBs with less education. Future studies should consider selection versus causal factors to explain the attenuated disparity we found at higher education levels.

Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought.

PURPOSE: Although decades of research have yielded considerable insight into physicians' clinical reasoning processes, assessing these processes remains challenging; thus, the authors sought to compare diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. METHOD: This 2011-2012 multicenter randomized study of 393 clinicians (medical students, postgraduate trainees, and faculty) measured diagnostic accuracy on clinical vignettes under two conditions: one encouraged participants to give their first impression (FI), and the other led participants through a directed search (DS) for the correct diagnosis. The authors compared accuracy, feasibility, reliability, and relation to United States Medical Licensing Exam (USMLE) scores under each condition. RESULTS: A 2 (instructional condition) × 2 (vignette complexity) × 3 (experience level) analysis of variance revealed no difference in accuracy as a function of instructional condition (F[1,379] = 2.44, P = .12), but demonstrated the expected main effects of vignette complexity (F[1,379] = 965.2, P < .001) and experience (F[2,379] = 39.6, P < .001). Pearson correlations revealed greater associations between assessment scores and USMLE performance in the FI condition than in the DS condition (P < .001). Spearman-Brown calculations consistently indicated that alpha ≥ 0.75 could be achieved more efficiently under the FI condition relative to the DS condition. CONCLUSIONS: Instructions to trust one's first impres-sions result in similar performance when compared with instructions to consider clinical information in a systematic fashion, but have greater utility when used for the purposes of assessment.

Highly diverse, poorly studied and uniquely threatened by climate change: an assessment of marine biodiversity on South Georgia's continental shelf.

We attempt to quantify how significant the polar archipelago of South Georgia is as a source of regional and global marine biodiversity. We evaluate numbers of rare, endemic and range-edge species and how the faunal structure of South Georgia may respond to some of the fastest warming waters on the planet. Biodiversity data was collated from a comprehensive review of reports, papers and databases, collectively representing over 125 years of polar exploration. Classification of each specimen was recorded to species level and fully geo-referenced by depth, latitude and longitude. This information was integrated with physical data layers (e.g. temperature, salinity and flow) providing a visualisation of South Georgia's biogeography across spatial, temporal and taxonomic scales, placing it in the wider context of the Southern Hemisphere. This study marks the first attempt to map the biogeography of an archipelago south of the Polar Front. Through it we identify the South Georgian shelf as the most speciose region of the Southern Ocean recorded to date. Marine biodiversity was recorded as rich across taxonomic levels with 17,732 records yielding 1,445 species from 436 families, 51 classes and 22 phyla. Most species recorded were rare, with 35% recorded only once and 86% recorded <10 times. Its marine fauna is marked by the cumulative dominance of endemic and range-edge species, potentially at their thermal tolerance limits. Consequently, our data suggests the ecological implications of environmental change to the South Georgian marine ecosystem could be severe. If sea temperatures continue to rise, we suggest that changes will include depth profile shifts of some fauna towards cooler Antarctic Winter Water (90-150 m), the loss of some range-edge species from regional waters, and the wholesale extinction at a global scale of some of South Georgia's endemic species.

Prostaglandin analogues for ophthalmic use: a cost-effectiveness analysis.

BACKGROUND: The objective of this study was to perform an economic analysis of the cost-effectiveness of prostaglandin analogues for the treatment of increased intraocular pressure (IOP). Prostaglandin analogues for ophthalmic use are more costly than alternative agents for the lowering of IOP. An important policy decision is whether to support continued open listing of these agents or to restrict them to limited use status. METHODS: The cost-effectiveness of prostaglandin analogues was assessed using a decision analytic model. Latanoprost was compared with timolol, dorzolamide, and brimonidine, and travoprost was compared with timolol separately. The effectiveness data used for this economic analysis were the number of millilitres of mercury of IOP reduction compared with baseline and the incidence of adverse events resulting in a withdrawal of the patient from the study. Sensitivity analyses were conducted to assess the robustness of the study results. RESULTS: Compared with latanoprost, dorzolamide was not a cost-effective strategy. Compared with brimonidine, latanoprost provided a higher IOP reduction with an incremental cost-effectiveness ratio of $16.17 (base case), but the additional IOP reduction with latanoprost was obtained at a cost higher than the average cost per millimetre of mercury reduction obtained with brimonidine. Compared with timolol, latanoprost and travoprost had a positive incremental cost-effectiveness ratio of $34.48 and $39.06, respectively. INTERPRETATION: For the first-line treatment of glaucoma and elevated IOP, latanoprost is a more cost-effective strategy than dorzolamide and brimonidine. Latanoprost and travoprost are more effective than timolol but also more expensive. For those for whom timolol is not contraindicated, it would be preferable, from a cost-effectiveness standpoint, to initiate treatment with timolol and reserve the prostaglandin analogues as an alternative treatment or as add-on therapy for patients not achieving a clinical response with timolol. Better treatment compliance associated with these analogues improves their cost-effectiveness.

Scientific research, stakeholders, and policy: continuing dialogue during research on radionuclides on Amchitka Island, Alaska.

It is increasingly clear that a wide range of stakeholders should be included in the problem formulation phase of research aimed at solving environmental problems; indeed the inclusion of stakeholders at this stage has been formalized as an integral part of ecological risk assessment. In this paper, we advocate the additional inclusion of stakeholders in the refinement of research methods and protocols and in the execution of the research, rather than just at the final communication and reporting phase. We use a large study of potential radionuclide levels in marine biota around Amchitka Island as a case study. Amchitka Island, in the Aleutian Island Chain of Alaska, was the site of three underground nuclear tests (1965-1971). The overall objective of the biological component of the study was to collect a range of marine biota for radionuclide analysis that could provide data for assessing current food safety and provide a baseline for developing a plan to monitor human and ecosystem health in perpetuity. Stakeholders, including regulators (State of Alaska), resource trustees (US Fish and Wildlife Service, State of Alaska), representatives of the Aleut and Pribilof Island communities, the Department of Energy (DOE), and others, were essential for plan development. While these stakeholders were included in the initial problem formulation and approved science plan, we also included them in the refinement of protocols, selection of bioindicators, selection of a reference site, choice of methods of collection, and in the execution of the study itself. Meetings with stakeholders resulted in adding (or deleting) bioindicator species and tissues, prioritizing target species, refining sampling methods, and recruiting collection personnel. Some species were added because they were important subsistence foods for the Aleuts, and others were added because they were ecological equivalents to replace species deleted because of low population numbers. Two major refinements that changed the research thrust were (1) the inclusion of Aleut hunters and fishers on the biological expedition itself to ensure that subsistence foods and methods were represented, and (2) the addition of a fisheries biologist on a NOAA research trawler to allow sampling of commercial fishes. Although the original research design called for the collection of biota by Aleut subsistence fishermen, and by a commercial fishing boat, the research was modified with continued stakeholder input to actually include Aleuts and a fisheries biologist on the expeditions to ensure their representation. The inclusion of stakeholders during the development of protocols and the research itself improved the overall quality of the investigation, while making it more relevant to the interested and affected parties. Final responsibility for the design and execution of the research and radionuclide analysis rested with the researchers, but the process of stakeholder inclusion made the research more valuable as a source of credible information and for public policy decisions.

Science, policy, and stakeholders: developing a consensus science plan for Amchitka Island, Aleutians, Alaska.

With the ending of the Cold War, the US Department of Energy is responsible for the remediation of radioactive waste and disposal of land no longer needed for nuclear material production or related national security missions. The task of characterizing the hazards and risks from radionuclides is necessary for assuring the protection of health of humans and the environment. This is a particularly daunting task for those sites that had underground testing of nuclear weapons, where the radioactive contamination is currently inaccessible. Herein we report on the development of a Science Plan to characterize the physical and biological marine environment around Amchitka Island in the Aleutian chain of Alaska, where three underground nuclear tests were conducted (1965-1971). Information on the ecology, geology, and current radionuclide levels in biota, water, and sediment is necessary for evaluating possible current contamination and to serve as a baseline for developing a plan to ensure human and ecosystem health in perpetuity. Other information required includes identifying the location of the salt water/fresh water interface where migration to the ocean might occur in the future and determining groundwater recharge balances, as well as assessing other physical/geological features of Amchitka near the test sites. The Science Plan is needed to address the confusing and conflicting information available to the public about radionuclide risks from underground nuclear blasts in the late 1960s and early 1970s, as well as the potential for volcanic or seismic activity to disrupt shot cavities or accelerate migration of radionuclides into the sea. Developing a Science Plan involved agreement among regulators and other stakeholders, assignment of the task to the Consortium for Risk Evaluation with Stakeholder Participation, and development of a consensus Science Plan that dealt with contentious scientific issues. Involvement of the regulators (State of Alaska), resource trustees (U S Fish and Wildlife Service), representatives of the Aleut and Pribilof Island communities, and other stakeholders was essential for plan development and approval, although this created tensions because of the different objectives of each group. The complicated process of developing a Science Plan involved iterations and interactions with multiple agencies and organizations, scientists in several disciplines, regulators, and the participation of Aleut people in their home communities, as well as the general public. The importance of including all parties in all phases of the development of the Science Plan was critical to its acceptance by a broad range of regulators, agencies, resource trustees, Aleutian/Pribilof communities, and other stakeholders.