Trajectory of cardiac troponin T following moderate-to-severe COVID-19 and the association with cardiac abnormalities.

BACKGROUND: COVID-19 has been associated with cardiac troponin T (cTnT) elevations and changes in cardiac structure and function, but the link between cardiac dysfunction and high-sensitive cardiac troponin T (hs-cTnT) in the acute and convalescent phase is unclear. OBJECTIVE: To assess whether hs-cTnT concentrations are associated with cardiac dysfunction and structural abnormalities after hospitalization for COVID-19, and to evaluate the performance of hs-cTnT to rule out cardiac pathology. METHODS: Patients hospitalized with COVID-19 had hs-cTnT measured during the index hospitalization and after 3-and 12 months, when they also underwent an echocardiographic study. A subset also underwent cardiovascular magnetic resonance imaging (CMR) after 6 months. Cardiac abnormalities were defined as left ventricular hypertrophy or dysfunction, right ventricular dysfunction, or CMR late gadolinium. RESULTS: We included 189 patients with hs-cTnT concentrations measured during hospitalization for COVID-19, and after 3-and 12 months: Geometric mean (95%CI) 13 (11-15) ng/L, 7 (6-8) ng/L and 7 (6-8) ng/L, respectively. Cardiac abnormalities after 3 months were present in 45 (30%) and 3 (8%) of patients with hs-cTnT ≥ and < 5 ng/L at 3 months, respectively (negative predictive value 92.3% [95%CI 88.5-96.1%]). The performance was similar in patients with and without dyspnea. Hs-cTnT decreased from hospitalization to 3 months (more pronounced in intensive care unit-treated patients) and remained unchanged from 3 to 12 months, regardless of the presence of cardiac abnormalities. CONCLUSION: Higher hs-cTnT concentrations in the convalescent phase of COVID-19 are associated with the presence of cardiac pathology and low concentrations (< 5 ng/L) may support in ruling out cardiac pathology following the infection.

Accelerated increase in plant species richness on mountain summits is linked to warming.

Globally accelerating trends in societal development and human environmental impacts since the mid-twentieth century 1-7 are known as the Great Acceleration and have been discussed as a key indicator of the onset of the Anthropocene epoch 6 . While reports on ecological responses (for example, changes in species range or local extinctions) to the Great Acceleration are multiplying 8, 9 , it is unknown whether such biotic responses are undergoing a similar acceleration over time. This knowledge gap stems from the limited availability of time series data on biodiversity changes across large temporal and geographical extents. Here we use a dataset of repeated plant surveys from 302 mountain summits across Europe, spanning 145 years of observation, to assess the temporal trajectory of mountain biodiversity changes as a globally coherent imprint of the Anthropocene. We find a continent-wide acceleration in the rate of increase in plant species richness, with five times as much species enrichment between 2007 and 2016 as fifty years ago, between 1957 and 1966. This acceleration is strikingly synchronized with accelerated global warming and is not linked to alternative global change drivers. The accelerating increases in species richness on mountain summits across this broad spatial extent demonstrate that acceleration in climate-induced biotic change is occurring even in remote places on Earth, with potentially far-ranging consequences not only for biodiversity, but also for ecosystem functioning and services.

Iatrogenic botulism. / Iatrogen botulisme.

This case study describes severe iatrogenic botulism following treatment with a botulinum toxin injection at a private clinic abroad.

Nurse managers' support of fundamental care in the hospital setting. An interpretive description of nurse managers' experiences across Australia, Denmark, and New Zealand.

AIMS: To explore the role of ward-based nurse managers in supporting nurses to undertake high-quality fundamental care. DESIGN: A qualitative study guided by the principles of interpretive description. Reported in accordance with Consolidated Criteria for Reporting Qualitative Research (COREQ). METHODS: Nurse managers in three urban, publicly funded hospitals in Australia, Denmark and New Zealand, were invited to participate in group interviews to discuss how they support fundamental care in their clinical areas. Six group interviews were conducted between February 2017 and March 2020 involving 31 participants. RESULTS: Six interrelated themes were identified: Difficulty expressing how to support the nurse-patient relationship; Establishing expectations for care delivery without clear strategies for how this can be achieved; Role modelling desired behaviours; Significance of being present to support care quality; The importance of engaging and supporting staff in their work; and Recognizing the challenges of prioritizing care needs. CONCLUSION: This study indicates that nurse managers are not universally clear in explaining how they support their staff to provide fundamental care. If fundamental care is not clearly understood and communicated in the nursing team, then there are risks that fundamental care will not be prioritized, with potential negative consequences for patient care. Nurse managers may benefit from additional resources and guidance to help them to support fundamental care delivery in their clinical areas. IMPACT: Previous research exploring fundamental care and missed care highlights the importance of the role of the nurse manager in influencing nursing care. This study demonstrates that though nurse managers have a passion for supporting their staff to deliver fundamental care, clear strategies to achieve this are not always evident. This study suggests that scholarship around leadership to promote and facilitate fundamental care is crucial to improving nursing practice and patient outcomes.

Ambivalence in nurses' use of the early warning score: A focussed ethnography in a hospital setting.

AIM: This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting. DESIGN: A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'. METHODS: Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis. FINDINGS: The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores. CONCLUSION: Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool. IMPACT: The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies.

[Brucellosis with acute arthritis and positive blood culture] / Brucellose med akutt artritt og positiv blodkultur.

BACKGROUND: Brucellosis is transmitted from infected animals to humans mainly by unpasteurised dairy products. Typical symptoms include undulant fever and arthralgia, but the disease can affect all organ systems and cause chronic debilitating and disabling illness. The condition is likely severely underdiagnosed, especially in impoverished populations. CASE PRESENTATION: A young girl presented with a one-day history of ankle pain and low-grade fever. She was born in a refugee camp in the Middle East, but lived with a Norwegian foster family and was considered to be healthy before the symptoms emerged. Blood culture surprisingly revealed growth of Brucella melitensis. She was successfully treated with a combination of trimethoprim-sulfamethoxazole and rifampicin. INTERPRETATION: This girl was likely infected with Brucella through ingestion of goat's milk, which she was given in the refugee camp. The disease presented with arthritis nearly two years after exposure.

Cardiac pathology 6 months after hospitalization for COVID-19 and association with the acute disease severity.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may cause myocardial injury and myocarditis, and reports of persistent cardiac pathology after COVID-19 have raised concerns of long-term cardiac consequences. We aimed to assess the presence of abnormal cardiovascular resonance imaging (CMR) findings in patients recovered from moderate-to-severe COVID-19, and its association with markers of disease severity in the acute phase. METHODS: Fifty-eight (49%) survivors from the prospective COVID MECH study, underwent CMR median 175 [IQR 105-217] days after COVID-19 hospitalization. Abnormal CMR was defined as left ventricular ejection fraction (LVEF) <50% or myocardial scar by late gadolinium enhancement. CMR indices were compared to healthy controls (n = 32), and to circulating biomarkers measured during the index hospitalization. RESULTS: Abnormal CMR was present in 12 (21%) patients, of whom 3 were classified with major pathology (scar and LVEF <50% or LVEF <40%). There was no difference in the need of mechanical ventilation, length of hospital stay, and vital signs between patients with vs without abnormal CMR after 6 months. Severe acute respiratory syndrome coronavirus 2 viremia and concentrations of inflammatory biomarkers during the index hospitalization were not associated with persistent CMR pathology. Cardiac troponin T and N-terminal pro-B-type natriuretic peptide concentrations on admission, were higher in patients with CMR pathology, but these associations were not significant after adjusting for demographics and established cardiovascular disease. CONCLUSIONS: CMR pathology 6 months after moderate-to-severe COVID-19 was present in 21% of patients and did not correlate with severity of the disease. Cardiovascular biomarkers during COVID-19 were higher in patients with CMR pathology, but with no significant association after adjusting for confounders. TRIAL REGISTRATION: COVID MECH Study ClinicalTrials.gov Identifier: NCT04314232.

High heart rates in hunting harbour porpoises.

The impressive breath-hold capabilities of marine mammals are facilitated by both enhanced O2 stores and reductions in the rate of O2 consumption via peripheral vasoconstriction and bradycardia, called the dive response. Many studies have focused on the extreme role of the dive response in maximizing dive duration in marine mammals, but few have addressed how these adjustments may compromise the capability to hunt, digest and thermoregulate during routine dives. Here, we use DTAGs, which record heart rate together with foraging and movement behaviour, to investigate how O2 management is balanced between the need to dive and forage in five wild harbour porpoises that hunt thousands of small prey daily during continuous shallow diving. Dive heart rates were moderate (median minimum 47-69 bpm) and relatively stable across dive types, dive duration (0.5-3.3 min) and activity. A moderate dive response, allowing for some perfusion of peripheral tissues, may be essential for fuelling the high field metabolic rates required to maintain body temperature and support digestion during diving in these small, continuously feeding cetaceans. Thus, despite having the capacity to prolong dives via a strong dive response, for these shallow-diving cetaceans, it appears to be more efficient to maintain circulation while diving: extreme heart rate gymnastics are for deep dives and emergencies, not everyday use.

Novel UCHL1 mutations reveal new insights into ubiquitin processing.

Recessive loss of function of the neuronal ubiquitin hydrolase UCHL1 has been implicated in early-onset progressive neurodegeneration (MIM no. 615491), so far only in one family. In this study a second family is characterized, and the functional consequences of the identified mutations in UCHL1 are explored. Three siblings developed childhood-onset optic atrophy, followed by spasticity and ataxia. Whole exome sequencing identified compound heterozygous variants in UCHL1, c.533G > A (p.Arg178Gln) and c.647C > A (p.Ala216Asp), cosegregating with the phenotype. Enzymatic activity of purified recombinant proteins analysed by ubiquitin hydrolase assays showed a 4-fold increased hydrolytic activity of the recombinant UCHL1 mutant Arg178Gln compared to wild type, whereas the Ala216Asp protein was insoluble. Structural 3D analysis of UCHL1 by computer modelling suggests that Arg178 is a rate-controlling residue in catalysis which is partly abolished in the Arg178Gln mutant and, consequently, the Arg178Gln mutant increases the enzymatic turnover. UCHL1 protein levels in fibroblasts measured by targeted mass spectrometry showed a total amount of UCHL1 in control fibroblasts about 4-fold higher than in the patients. Hence, studies of the identified missense variants reveal surprisingly different functional consequences as the insoluble Ala216Asp variant leads to loss of function, whereas the Arg178Gln leads to increased enzyme activity. The reported patients have remarkably preserved cognition, and we propose that the increased enzyme activity of the Arg178Gln variant offers a protective effect on cognitive function. This study establishes the importance of UCHL1 in neurodegeneration, provides new mechanistic insight about ubiquitin processing, and underlines the complexity of the different roles of UCHL1.

Drivers of the dive response in trained harbour porpoises (Phocoena phocoena).

Pronounced dive responses through peripheral vasoconstriction and bradycardia enable prolonged apnoea in marine mammals. For most vertebrates, the dive response is initiated upon face immersion, but little is known about the physical drivers of diving and surfacing heart rate in cetaceans whose faces are always mostly submerged. Using two trained harbour porpoises instrumented with an ECG-measuring sound-and-movement tag (DTAG-3), we investigated the initiation and progression of bradycardia and tachycardia during apnoea and eupnoea for varying levels of immersion. We show that paranasal wetting drives bradycardia initiation and progression, whereas apnoea leads to dive-level bradycardia eventually, but not instantly. At the end of dives, heart rate accelerates independently of lung expansion, perhaps in anticipation of surfacing; however, full tachycardia is only engaged upon inhalation. We conclude that breathing drives surface tachycardia, whereas blowhole wetting is an important driver of bradycardia; however, anticipatory/volitional modulation can overrule such responses to sensory inputs.

The devil is in the detail: Nonadditive and context-dependent plant population responses to increasing temperature and precipitation.

In climate change ecology, simplistic research approaches may yield unrealistically simplistic answers to often more complicated problems. In particular, the complexity of vegetation responses to global climate change begs a better understanding of the impacts of concomitant changes in several climatic drivers, how these impacts vary across different climatic contexts, and of the demographic processes underlying population changes. Using a replicated, factorial, whole-community transplant experiment, we investigated regional variation in demographic responses of plant populations to increased temperature and/or precipitation. Across four perennial forb species and 12 sites, we found strong responses to both temperature and precipitation change. Changes in population growth rates were mainly due to changes in survival and clonality. In three of the four study species, the combined increase in temperature and precipitation reflected nonadditive, antagonistic interactions of the single climatic changes for population growth rate and survival, while the interactions were additive and synergistic for clonality. This disparity affects the persistence of genotypes, but also suggests that the mechanisms behind the responses of the vital rates differ. In addition, survival effects varied systematically with climatic context, with wetter and warmer + wetter transplants showing less positive or more negative responses at warmer sites. The detailed demographic approach yields important mechanistic insights into how concomitant changes in temperature and precipitation affect plants, which makes our results generalizable beyond the four study species. Our comprehensive study design illustrates the power of replicated field experiments in disentangling the complex relationships and patterns that govern climate change impacts across real-world species and landscapes.

From facilitation to competition: temperature-driven shift in dominant plant interactions affects population dynamics in seminatural grasslands.

Biotic interactions are often ignored in assessments of climate change impacts. However, climate-related changes in species interactions, often mediated through increased dominance of certain species or functional groups, may have important implications for how species respond to climate warming and altered precipitation patterns. We examined how a dominant plant functional group affected the population dynamics of four co-occurring forb species by experimentally removing graminoids in seminatural grasslands. Specifically, we explored how the interaction between dominants and subordinates varied with climate by replicating the removal experiment across a climate grid consisting of 12 field sites spanning broad-scale temperature and precipitation gradients in southern Norway. Biotic interactions affected population growth rates of all study species, and the net outcome of interactions between dominants and subordinates switched from facilitation to competition with increasing temperature along the temperature gradient. The impacts of competitive interactions on subordinates in the warmer sites could primarily be attributed to reduced plant survival. Whereas the response to dominant removal varied with temperature, there was no overall effect of precipitation on the balance between competition and facilitation. Our findings suggest that global warming may increase the relative importance of competitive interactions in seminatural grasslands across a wide range of precipitation levels, thereby favouring highly competitive dominant species over subordinate species. As a result, seminatural grasslands may become increasingly dependent on disturbance (i.e. traditional management such as grazing and mowing) to maintain viable populations of subordinate species and thereby biodiversity under future climates. Our study highlights the importance of population-level studies replicated under different climatic conditions for understanding the underlying mechanisms of climate change impacts on plants.

Plant movements and climate warming: intraspecific variation in growth responses to nonlocal soils.

Most range shift predictions focus on the dispersal phase of the colonization process. Because moving populations experience increasingly dissimilar nonclimatic environmental conditions as they track climate warming, it is also critical to test how individuals originating from contrasting thermal environments can establish in nonlocal sites. We assess the intraspecific variation in growth responses to nonlocal soils by planting a widespread grass of deciduous forests (Milium effusum) into an experimental common garden using combinations of seeds and soil sampled in 22 sites across its distributional range, and reflecting movement scenarios of up to 1600 km. Furthermore, to determine temperature and forest-structural effects, the plants and soils were experimentally warmed and shaded. We found significantly positive effects of the difference between the temperature of the sites of seed and soil collection on growth and seedling emergence rates. Migrant plants might thus encounter increasingly favourable soil conditions while tracking the isotherms towards currently 'colder' soils. These effects persisted under experimental warming. Rising temperatures and light availability generally enhanced plant performance. Our results suggest that abiotic and biotic soil characteristics can shape climate change-driven plant movements by affecting growth of nonlocal migrants, a mechanism which should be integrated into predictions of future range shifts.

Low hunting costs in an expensive marine mammal predator.

Many large terrestrial mammalian predators use energy-intensive, high-risk, high-gain strategies to pursue large, high-quality prey. However, similar-sized marine mammal predators with even higher field metabolic rates (FMRs) consistently target prey three to six orders of magnitude smaller than themselves. Here, we address the question of how these active and expensive marine mammal predators can gain sufficient energy from consistently targeting small prey during breath-hold dives. Using harbor porpoises as model organisms, we show that hunting small aquatic prey is energetically cheap (<20% increase in FMR) for these marine predators, but it requires them to spend a large proportion (>60%) of time foraging. We conclude that this grazing foraging strategy on small prey is viable for marine mammal predators despite their high FMR because they can hunt near continuously at low marginal expense. Consequently, cessation of foraging due to human disturbance comes at a high cost, as porpoises must maintain their high thermoregulation costs with a reduced energy intake.

Intensive Care Unit Physicians' Perspectives on Artificial Intelligence-Based Clinical Decision Support Tools: Preimplementation Survey Study.

BACKGROUND: Artificial intelligence-based clinical decision support (AI-CDS) tools have great potential to benefit intensive care unit (ICU) patients and physicians. There is a gap between the development and implementation of these tools. OBJECTIVE: We aimed to investigate physicians' perspectives and their current decision-making behavior before implementing a discharge AI-CDS tool for predicting readmission and mortality risk after ICU discharge. METHODS: We conducted a survey of physicians involved in decision-making on discharge of patients at two Dutch academic ICUs between July and November 2021. Questions were divided into four domains: (1) physicians' current decision-making behavior with respect to discharging ICU patients, (2) perspectives on the use of AI-CDS tools in general, (3) willingness to incorporate a discharge AI-CDS tool into daily clinical practice, and (4) preferences for using a discharge AI-CDS tool in daily workflows. RESULTS: Most of the 64 respondents (of 93 contacted, 69%) were familiar with AI (62/64, 97%) and had positive expectations of AI, with 55 of 64 (86%) believing that AI could support them in their work as a physician. The respondents disagreed on whether the decision to discharge a patient was complex (23/64, 36% agreed and 22/64, 34% disagreed); nonetheless, most (59/64, 92%) agreed that a discharge AI-CDS tool could be of value. Significant differences were observed between physicians from the 2 academic sites, which may be related to different levels of involvement in the development of the discharge AI-CDS tool. CONCLUSIONS: ICU physicians showed a favorable attitude toward the integration of AI-CDS tools into the ICU setting in general, and in particular toward a tool to predict a patient's risk of readmission and mortality within 7 days after discharge. The findings of this questionnaire will be used to improve the implementation process and training of end users.

Wild harbour porpoises startle and flee at low received levels from acoustic harassment device.

Acoustic Harassment Devices (AHD) are widely used to deter marine mammals from aquaculture depredation, and from pile driving operations that may otherwise cause hearing damage. However, little is known about the behavioural and physiological effects of these devices. Here, we investigate the physiological and behavioural responses of harbour porpoises (Phocoena phocoena) to a commercial AHD in Danish waters. Six porpoises were tagged with suction-cup-attached DTAGs recording sound, 3D-movement, and GPS (n = 3) or electrocardiogram (n = 2). They were then exposed to AHDs for 15 min, with initial received levels (RL) ranging from 98 to 132 dB re 1 µPa (rms-fast, 125 ms) and initial exposure ranges of 0.9-7 km. All animals reacted by displaying a mixture of acoustic startle responses, fleeing, altered echolocation behaviour, and by demonstrating unusual tachycardia while diving. Moreover, during the 15-min exposures, half of the animals received cumulative sound doses close to published thresholds for temporary auditory threshold shifts. We conclude that AHD exposure at many km can evoke both startle, flight and cardiac responses which may impact blood-gas management, breath-hold capability, energy balance, stress level and risk of by-catch. We posit that current AHDs are too powerful for mitigation use to prevent hearing damage of porpoises from offshore construction.

Climate influence on plant-pollinator interactions in the keystone species Vaccinium myrtillus.

Climate change is altering the world's ecosystems through direct effects of climate warming and precipitation changes but also indirectly through changes in biotic interactions. For instance, climate-driven changes in plant and/or insect communities may alter plant-pollinator interactions, thereby influencing plant reproductive success and ultimately population dynamics of insect-pollinated plants. To better understand how the importance of insect pollination for plant fruit set varies with climate, we experimentally excluded pollinators from the partly selfing keystone species Vaccinium myrtillus along elevational gradients in the forest-tundra ecotone in central Norway. The study comprised three mountain areas, seven elevational gradients spanning from the climatically relatively benign birch forest to the colder alpine areas above the tree line, and 180 plots of 1 × 1 m, with experimental treatments allocated randomly to plots within sites. Within the experimental plots, we counted the number of flowers of V. myrtillus and counted and weighed all fruits, as well as seeds for a selection of fruits. Excluding pollinators resulted in lower fruit production, as well as reduced fruit and seed mass of V. myrtillus. In the alpine sites pollinator exclusion resulted in 84% fewer fruits, 50% lower fruit weight, and 50% lower seed weight compared to control conditions. Contrary to our expectations, the negative effect of pollinator exclusion was less pronounced in the forest compared to alpine sites, suggesting that the importance of insect pollination for seed production is lower at low elevations. Our findings indicate that the keystone species V. myrtillus is relatively robust to changes in the pollinator community in a warmer climate, thereby making it less vulnerable to climate-driven changes in plant-pollinator interactions.

Increased household transmission and immune escape of the SARS-CoV-2 Omicron compared to Delta variants.

Understanding the epidemic growth of the novel SARS-CoV-2 Omicron variant is critical for public health. We compared the ten-day secondary attack rate (SAR) of the Omicron and Delta variants in households using Norwegian contact tracing data, December 2021 - January 2022. Omicron SAR was higher than Delta, with a relative risk (RR) of 1.41 (95% CI 1.27-1.56). We observed increased susceptibility to Omicron infection in household contacts compared to Delta, independent of contacts' vaccination status. Among three-dose vaccinated contacts, the mean SAR was lower for both variants. We found increased Omicron transmissibility from primary cases to contacts in all vaccination groups, except 1-dose vaccinated, compared to Delta. Omicron SAR of three-dose vaccinated primary cases was high, 46% vs 11 % for Delta. In conclusion, three-dose vaccinated primary cases with Omicron infection can efficiently spread in households, while three-dose vaccinated contacts have a lower risk of being infected by Delta and Omicron.