Rural Suicide: Demographics, Causes, and Treatment Implications.

Suicide rates in rural areas are higher than urban areas and growing, with current treatment developments only exacerbating this discrepancy. Within individual factors, both age and gender relate to and intersect with personal values related to self-reliance and attitudes toward mental health difficulties and treatment to increase suicide risk. The lethality ubiquitous in rural environments and occupations is a leading factor in rural suicide rates, with other factors such as race alternately noted to be a key factor but with more mixed findings. The cultural values of rural communities as typically negative toward mental health disclosure and treatment contribute to the disengagement of rural communities from treatment that may otherwise prevent suicides, exacerbating the physical lack of treatment access many rural communities experience. Working within the primary care system alongside increased telehealth utilization are suggested to reduce rural suicide rates.

Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

Land-based climate solutions for the United States.

Meeting end-of-century global warming targets requires aggressive action on multiple fronts. Recent reports note the futility of addressing mitigation goals without fully engaging the agricultural sector, yet no available assessments combine both nature-based solutions (reforestation, grassland and wetland protection, and agricultural practice change) and cellulosic bioenergy for a single geographic region. Collectively, these solutions might offer a suite of climate, biodiversity, and other benefits greater than either alone. Nature-based solutions are largely constrained by the duration of carbon accrual in soils and forest biomass; each of these carbon pools will eventually saturate. Bioenergy solutions can last indefinitely but carry significant environmental risk if carelessly deployed. We detail a simplified scenario for the United States that illustrates the benefits of combining approaches. We assign a portion of non-forested former cropland to bioenergy sufficient to meet projected mid-century transportation needs, with the remainder assigned to nature-based solutions such as reforestation. Bottom-up mitigation potentials for the aggregate contributions of crop, grazing, forest, and bioenergy lands are assessed by including in a Monte Carlo model conservative ranges for cost-effective local mitigation capacities, together with ranges for (a) areal extents that avoid double counting and include realistic adoption rates and (b) the projected duration of different carbon sinks. The projected duration illustrates the net effect of eventually saturating soil carbon pools in the case of most strategies, and additionally saturating biomass carbon pools in the case of forest management. Results show a conservative end-of-century mitigation capacity of 110 (57-178) Gt CO2 e for the U.S., ~50% higher than existing estimates that prioritize nature-based or bioenergy solutions separately. Further research is needed to shrink uncertainties, but there is sufficient confidence in the general magnitude and direction of a combined approach to plan for deployment now.

Hospitality Towards People with Mental Illness in the Church: a Cross-cultural Qualitative Study.

Mental illness is a prevalent concern that affects Christian churches in North America in significant ways. Previous studies on the relationship between mental illness and the church have found that beliefs and practices within the church can contribute to stigma towards people with mental illness. Yet, the typical experience of people with mental illness who attend church has been found to be positive, suggesting that there are considerable resources within the church for supporting those who experience mental health problems. One such resource is the concept of hospitality, which promotes a sense of belonging for those with mental illness in the church. This qualitative study advances the construct of hospitality as a helpful paradigm for addressing mental health needs within the church, capturing perspectives and practices that are currently in place or seen as necessary by church attendees. The study methodology also emphasized the need to incorporate cultural considerations that are appropriate for the racial and ethnic make-up of particular churches. Semistructured focus group interviews were conducted with participants from eight churches that were either predominantly African American, Asian American, Latinx, or multi-ethnic. Findings resulting from content analysis of transcripts indicated that hospitality was a broadly helpful construct for addressing mental health concerns in the church, though some cultural differences existed in the understanding and application of hospitality. Both the interface of the findings with the existing scholarly literature and the relevance of findings for church leaders are discussed.

UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma on behalf of the Medicines and Healthcare products Regulatory Agency Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK)-negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimise the need for systemic treatments, reduce morbidity and the risk of poor outcomes.

Empirical Evidence for the Potential Climate Benefits of Decarbonizing Light Vehicle Transport in the U.S. with Bioenergy from Purpose-Grown Biomass with and without BECCS.

Climate mitigation scenarios limiting global temperature increases to 1.5 °C rely on decarbonizing vehicle transport with bioenergy production plus carbon capture and storage (BECCS), but climate impacts for producing different bioenergy feedstocks have not been directly compared experimentally or for ethanol vs electric light-duty vehicles. A field experiment at two Midwest U.S. sites on contrasting soils revealed that feedstock yields of seven potential bioenergy cropping systems varied substantially within sites but little between. Bioenergy produced per hectare reflected yields: miscanthus > poplar > switchgrass > native grasses ≈ maize stover (residue) > restored prairie ≈ early successional. Greenhouse gas emission intensities for ethanol vehicles ranged from 20 to -179 g CO2e MJ-1: maize stover ≫ miscanthus ≈ switchgrass ≈ native grasses ≈ poplar > early successional ≥ restored prairie; direct climate benefits ranged from ∼80% (stover) to 290% (restored prairie) reductions in CO2e compared to petroleum and were similar for electric vehicles. With carbon capture and storage (CCS), reductions in emission intensities ranged from 204% (stover) to 416% (restored prairie) for ethanol vehicles and from 329 to 558% for electric vehicles, declining 27 and 15%, respectively, once soil carbon equilibrates within several decades of establishment. Extrapolation based on expected U.S. transportation energy use suggests that, once CCS potential is maximized with CO2 pipeline infrastructure, negative emissions from bioenergy with CCS for light-duty electric vehicles could capture >900 Tg CO2e year-1 in the U.S. In the future, as other renewable electricity sources become more important, electricity production from biomass would offset less fossil fuel electricity, and the advantage of electric over ethanol vehicles would decrease proportionately.

Measuring Floodplain Inundation Using Diel Amplitude of Temperature.

Assessment of inundation patterns across large and remote floodplains is challenging and costly. Inexpensive loggers that record the damping of the diel amplitude of temperature (DAT) when submerged compared to overlying air can indirectly indicate inundation. We assessed the efficacy of this approach in tropical, subtropical, and temperate floodplains by comparing direct water level measurements using pressure transducers with the indirect indication of inundation ascertained from the DAT at the same location. The approach worked better in tropical than in subtropical and temperate floodplains. However, the relatively small DATs of air in humid and densely vegetated settings made estimation of inundation more challenging compared to the drier and less vegetated settings, where a large diel range of air temperature was markedly damped beneath the water. The indirect temperature approach must be calibrated for a particular ecosystem using direct water-level measurements to define DAT thresholds that are indicative of submergence of the sensors. Temperature provides an inexpensive indicator of duration of inundation that can be particularly useful in studies of large and remote floodplains, although the development of inexpensive sensors that directly measure submergence (e.g., by resistivity) will likely become a better option in the future.

Comparison of Unyvero P55 Pneumonia Cartridge, in-house PCR and culture for the identification of respiratory pathogens and antibiotic resistance in bronchoalveolar lavage fluids in the critical care setting.

Faster respiratory pathogen detection and antibiotic resistance identification are important in critical care due to the severity of illness, significant prior antibiotic exposure and infection control implications. Our objective was to compare the performance of the commercial Unyvero P55 Pneumonia Cartridge (Curetis AG) with routine bacterial culture methods and in-house bacterial multiplex real-time PCR assays. Seventy-four bronchoalveolar lavage specimens from patients admitted to a Scottish intensive care unit (ICU) over a 33-month period were tested prospectively by routine culture and viral PCR and retrospectively by Unyvero P55 and in-house bacterial PCR. Sensitivity/specificity was 56.9%/58.5% and 63.2%/54.8% for the Unyvero P55 and in-house bacterial PCR panels respectively; sensitivity for in-panel targets was 63.5 and 83.7% respectively. Additional organisms were detected by Unyvero P55 and in-house bacterial PCR panels in 16.2% specimens. Antibiotics were changed on the basis of routine test results in 48.3% cases; of these, true-positive or true-negative results would have been obtained earlier by Unyvero P55 or in-house bacterial PCR panel in 15 (53.6%) and 17 (60.7%) cases respectively. However, a false-negative molecular test result may have been acted upon in six (21.4%) cases with either assay. Sensitivity/specificity of Unyvero P55 antibiotic resistance detection was 18.8%/94.9% respectively. Molecular testing identified a number of respiratory pathogens in this patient cohort that were not grown in culture, but resistance detection was not a reliable tool for faster antibiotic modification. In their current set-up, molecular tests may only have benefit as additional tests in the ICU pneumonia setting.

Correction to: 1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study.

In the original article John F. Thompson was inadvertently omitted as an author. The author list is updated as shown in this correction.

1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study.

BACKGROUND: There is a lack of consensus regarding optimal surgical excision margins for primary cutaneous melanoma > 1 mm in Breslow thickness (BT). A narrower surgical margin is expected to be associated with lower morbidity, improved quality of life (QoL), and reduced cost. We report the results of a pilot international study (MelMarT) comparing a 1 versus 2-cm surgical margin for patients with primary melanoma > 1 mm in BT. METHODS: This phase III, multicentre trial [NCT02385214] administered by the Australia & New Zealand Medical Trials Group (ANZMTG 03.12) randomised patients with a primary cutaneous melanoma > 1 mm in BT to a 1 versus 2-cm wide excision margin to be performed with sentinel lymph node biopsy. Surgical closure technique was at the discretion of the treating surgeon. Patients' QoL was measured (FACT-M questionnaire) at baseline, 3, 6, and 12 months after randomisation. RESULTS: Between January 2015 and June 2016, 400 patients were randomised from 17 centres in 5 countries. A total of 377 patients were available for analysis. Primary melanomas were located on the trunk (56.9%), extremities (35.6%), and head and neck (7.4%). More patients in the 2-cm margin group required reconstruction (34.9 vs. 13.6%; p < 0.0001). There was an increased wound necrosis rate in the 2-cm arm (0.5 vs. 3.6%; p = 0.036). After 12 months' follow-up, no differences were noted in QoL between groups. DISCUSSION: This pilot study demonstrates the feasibility of a large international RCT to provide a definitive answer to the optimal excision margin for patients with intermediate- to high-risk primary cutaneous melanoma.

The greenhouse gas cost of agricultural intensification with groundwater irrigation in a Midwest U.S. row cropping system.

Groundwater irrigation of cropland is expanding worldwide with poorly known implications for climate change. This study compares experimental measurements of the net global warming impact of a rainfed versus a groundwater-irrigated corn (maize)-soybean-wheat, no-till cropping system in the Midwest US, the region that produces the majority of U.S. corn and soybean. Irrigation significantly increased soil organic carbon (C) storage in the upper 25 cm, but not by enough to make up for the CO2 -equivalent (CO2 e) costs of fossil fuel power, soil emissions of nitrous oxide (N2 O), and degassing of supersaturated CO2 and N2 O from the groundwater. A rainfed reference system had a net mitigating effect of -13.9 (±31) g CO2 e m-2  year-1 , but with irrigation at an average rate for the region, the irrigated system contributed to global warming with net greenhouse gas (GHG) emissions of 27.1 (±32) g CO2 e m-2  year-1 . Compared to the rainfed system, the irrigated system had 45% more GHG emissions and 7% more C sequestration. The irrigation-associated increase in soil N2 O and fossil fuel emissions contributed 18% and 9%, respectively, to the system's total emissions in an average irrigation year. Groundwater degassing of CO2 and N2 O are missing components of previous assessments of the GHG cost of groundwater irrigation; together they were 4% of the irrigated system's total emissions. The irrigated system's net impact normalized by crop yield (GHG intensity) was +0.04 (±0.006) kg CO2 e kg-1 yield, close to that of the rainfed system, which was -0.03 (±0.002) kg CO2 e kg-1 yield. Thus, the increased crop yield resulting from irrigation can ameliorate overall GHG emissions if intensification by irrigation prevents land conversion emissions elsewhere, although the expansion of irrigation risks depletion of local water resources.

Legacy effects of land use on soil nitrous oxide emissions in annual crop and perennial grassland ecosystems.

Land use conversions into and out of agriculture may influence soil-atmosphere greenhouse gas fluxes for many years. We tested the legacy effects of land use on cumulative soil nitrous oxide (N2 O) fluxes for 5 yr following conversion of 22-yr-old Conservation Reserve Program (CRP) grasslands and conventionally tilled agricultural fields (AGR) to continuous no-till corn, switchgrass, and restored prairie. An unconverted CRP field served as a reference. We assessed the labile soil C pool of the upper 10 cm in 2009 (the conversion year) and in 2014 using short-term soil incubations. We also measured in situ soil N2 O fluxes biweekly from 2009 through 2014 using static chambers except when soils were frozen. The labile C pool was approximately twofold higher in soils previously in CRP than in those formerly in tilled cropland. Five-year cumulative soil N2 O emissions were approximately threefold higher in the corn system on former CRP than on former cropland despite similar fertilization rates (~184 kg N·ha-1 ·yr-1 ). The lower cumulative emissions from corn on former cropland were similar to emissions from switchgrass that was fertilized less (~57 kg N·ha-1 ·yr-1 ), regardless of former land use, and lowest emissions were observed from the unfertilized restored prairie and reference systems. Findings support the hypothesis that soil labile carbon levels modulate the response of soil N2 O emissions to nitrogen inputs, with soils higher in labile carbon but otherwise similar, in this case reflecting land use history, responding more strongly to added nitrogen.

Unexpected population response to increasing temperature in the context of a strong species interaction.

Climate change is driving large changes in the spatial and temporal distributions of species, with significant consequences for individual populations. Community- and ecosystem-level implications of altered species distributions may be complex and challenging to anticipate due to the cascading effects of disrupted interactions among species, which may exhibit threshold responses to extreme climatic events. Toxic, bloom-forming cyanobacteria like Microcystis are expected to increase worldwide with climate change, due in part to their high temperature optima for growth. In addition, invasive zebra mussels (Dreissena polymorpha) have caused an increase in Microcystis aeruginosa, a species typically associated with eutrophication, in low-nutrient lakes. We conducted a 13-yr study of a M. aeruginosa population in a low-nutrient lake invaded by zebra mussels. In 10 of the 13 years, there was a significant positive relationship between M. aeruginosa biomass and accumulated degree days, which are projected to increase with climate change. In contrast, Microcystis biomass was up to an order of magnitude lower than predicted by the above relationship during the other three years, including the warmest in the data set, following repeated heat-induced mass mortality of D. polymorpha. Thus, the positive relationship between Microcystis biomass and temperature was negated when its facilitating species was suppressed during a series of exceptionally warm summers. Predicting the net response of a species to climate change may therefore require, at minimum, quantification of responses of both the focal species and species that strongly interact with it over sufficiently long time periods to encompass the full range of climatic variability. Our results could not have been predicted from existing data on the short-term responses of these two interacting species to increased temperature.

Market Competition and the Health Composition of Manufactured Food.

There has been surprisingly little research to date on the supply-side role of food manufacturers on equilibrium health outcomes for consumers. In this letter we consider an oligopoly model in which food processors choose the health composition of manufactured food. We show that price competition between food processors leads to unhealthy food composition in the market equilibrium, even under circumstances in which consumers know food composition is unhealthy. Taxes on manufactured food decrease the healthiness of manufactured foods whenever improved consumer health increases the price elasticity of food demand. Copyright © 2016 John Wiley & Sons, Ltd.

Word-Decoding Skill Interacts With Working Memory Capacity to Influence Inference Generation During Reading.

The aim of this study was to examine predictions derived from a proposal about the relation between word-decoding skill and working memory capacity, called verbal efficiency theory. The theory states that poor word representations and slow decoding processes consume resources in working memory that would otherwise be used to execute high-level comprehension processes, such as the generation of inferences. Previous research has yielded inconsistent findings about the importance of word decoding in adult readers, and the hypothesis has never been tested experimentally. Verbal efficiency theory was tested in this experiment by manipulating the difficulty of grapheme-phoneme conversion and assessing the extent to which readers made bridging inferences. Participants read two-sentence passages and then responded to lexical decision targets. Some of the passages required a bridging inference to integrate the first and second sentences. Decoding difficulty was manipulated such that the second sentence in some passages was written using pseudohomophones. Participants also received tasks to assess their working memory capacity and decoding ability. Inference priming was found in both the Standard American English and pseudohomophone contexts but was stronger in the former than in the latter. The advantage in priming for the Standard English relative to the pseudohomophone condition was predicted by an interaction between decoding skill and working memory capacity. Poor decoders who scored high on the span tests were less impaired by the pseudohomophone manipulation than were poor decoders who scored low on the tests. The results suggest that working memory capacity compensates for poor decoding skills even among proficient adult readers.

Reflective writing: a user-friendly guide.

Stephen Hamilton, Nurse Education Consultant, Business Services Organisation. In this piece, he outlines the nature of the process of reflection to allay concerns that registered nurses may have about the process, as well as dispel any myths surrounding the purpose of reflection.

Does flood rhythm drive ecosystem responses in tropical riverscapes?

Biotic communities are shaped by adaptations from generations of exposure to selective pressures by recurrent and often infrequent events. In large rivers, floods can act as significant agents of change, causing considerable physical and biotic disturbance while often enhancing productivity and diversity. We show that the relative balance between these seemingly divergent outcomes can be explained by the rhythmicity, or predictability of the timing and magnitude, of flood events. By analyzing biological data for large rivers that span a gradient of rhythmicity in the Neotropics and tropical Australia, we find that systems with rhythmic annual floods have higher-fish species richness, more stable avian populations, and elevated rates of riparian forest production compared with those with arrhythmic flood pulses. Intensification of the hydrological cycle driven by climate change, coupled with reductions in runoff due to water extractions for human use and altered discharge from impoundments, is expected to alter the hydrologic rhythmicity of floodplain rivers with significant consequences for both biodiversity and productivity.

A practical approach for O-linked mannose removal: the use of recombinant lysosomal mannosidase.

The methylotrophic yeast Pichia pastoris is an attractive expression system due to its ability to secrete large amounts of recombinant protein, with the potential for glycosylation. Advances in glycoengineering of P. pastoris have successfully demonstrated the humanization of both the N- and O-linked glycosylation pathways in this organism. However, in certain cases, the presence of O-linked glycans on a therapeutic protein may not be desirable. Recently, we have reported the in vitro utility of jack bean α-1,2/3/6-mannosidase to remove O-linked mannose from intact undenatured glycoproteins produced in glycoengineered P. pastoris. However, one caveat of this strategy is that jack bean mannosidase has yet to be cloned and as such is only available as crude cellular extracts. This raises several concerns for using this reagent to treat large preparations of therapeutic proteins generated in P. pastoris. Therefore, we postulated that lysosomal mannosidases which have been cloned and demonstrated to have similar activities to jack bean mannosidase on N-linked glycans would also process O-linked glycans in a similar fashion. To this end, we screened a panel of recombinant lysosomal mannosidases from different organisms and identified several which cannot only reduce extended O-linked mannose chains but which can also hydrolyze the Man-α-O-Ser/Thr glycosidic bond on intact glycoproteins. As such, not only do we show for the first time the utility of lysosomal mannosidase for O-linked mannose processing, but since this is a recombinant enzyme, it has several benefits over the use of crude jack bean mannosidase extracts.

Assessing the augmented breast: a blinded study comparing round and anatomical form-stable implants.

BACKGROUND: Controversy persists as to whether round or anatomical form-stable breast implants provide the most aesthetically pleasing results, and there is a paucity of evidence comparing cosmetic outcomes of these two implants. A blinded study comparing aesthetic outcomes was conducted in an attempt to address this issue. OBJECTIVES: The authors compare aesthetic outcomes between round and anatomical form-stable breast implants. METHODS: Pre- and postoperative photographs of 60 consecutive patients undergoing breast augmentation (33 round, 27 anatomical) by a single surgeon were reviewed by 22 plastic surgeons. Photographs were graded on a modified Likert scale (1, poor; 4, excellent) for overall aesthetic result, upper pole contour, and natural appearance. The panel was asked to determine implant shape. RESULTS: Anatomical implants scored higher for upper pole contour: anatomical 2.80 (±0.44 - standard deviation) vs round 2.60 (±0.38). With regard to natural appearance and overall aesthetic results, anatomical implants scored higher: 2.89 (±0.42) vs 2.56 (±0.36) and 2.86 (±0.41) vs 2.72 (±0.37), respectively. None of these differences achieved statistical significance, and 62.7% of round and 49% of anatomical implants were correctly identified. There was no significant difference in the body mass index (BMI) between the 2 groups (P = .21). CONCLUSIONS: No significant difference (P > .05) in the general and specific cosmetic points between round and anatomical implants was demonstrated; many on the panel were unable to identify implant shape correctly. Both techniques seem to yield good cosmetic results. Clearly the decision on which implant to use must be made on an individual patient basis because many factors influence overall aesthetic outcome. Anatomical implants should not be assumed to produce a more natural result. LEVEL OF EVIDENCE: 4 Therapeutic.