Evaluating use of IOTA two-step strategy to classify adnexal masses identified in pregnancy: pilot study.

OBJECTIVES: The primary aim was the validation of benign descriptors (BDs), followed by Assessment of Different NEoplasia's of the adneXa (ADNEX) (when BDs cannot be applied), in a two-step strategy to classify adnexal masses in pregnancy. The secondary aim was to describe the natural history of adnexal masses in pregnancy. METHODS: Retrospective analysis of prospectively collected data of women with an adnexal mass on ultrasonography identified during pregnancy between 2017 and 2022. The study was conducted at Queen Charlotte's and Chelsea Hospital, UK. Relevant clinical and ultrasound data were extracted from the medical records and ultrasound software astraia. Adnexal masses were classified and managed according to expert subjective assessment (SA). Ultrasound features were recorded prospectively at the time of ultrasound examination. Borderline ovarian tumours (BOT) were classified as malignant. Benign Descriptors (BDs) were applied to classify adnexal masses, in cases where BDs were not applicable, the ADNEX model (using a risk of malignancy of >10%) was used, in a two-step strategy. The two-step strategy was applied retrospectively. The reference standard used was histology (where available) or expert SA at the postnatal ultrasound scan. RESULTS: 291 women with a median age of 33 (IQR 29-36) years presented with an adnexal mass in pregnancy, at a median gestation of 12 (IQR 8-17) weeks. 267 (267/291, 91.8%) women were followed up to the postnatal period, as 24 women (24/291, 8.2%) were lost to follow up. Based on the reference standard, 4.1% of adnexal masses (11/267) were classified as malignant (all BOTs) and 95.9% (256/267) as benign (41 on histology and 215 based on expert SA at postnatal ultrasound). BDs could be applied to 68.9% of adnexal masses (184/267); of these only one mass (BOT) was misclassified as benign (1/184, 0.5%). ADNEX was used to classify the residual masses (83/267) and misclassified three BOTs as benign (3/10, 30.0%) and 25 benign masses (based on reference standard) as malignant (25/73, 34.2%), 13 (13/25, 52.0%) of these were classified as decidualised endometriomas on expert SA, with confirmed resolution of decidualisation in the postnatal period. The two-step strategy had a specificity of 90.2%, sensitivity of 63.6%, negative predictive value of 98.3% and positive predictive value of 21.9%. 56 (56/267, 21.0%) women had surgical intervention, four as an emergency during pregnancy (4/267, 1.5%,) and four (4/267, 1.5%) electively during caesarean section. 48 (48/267, 18.0%) women had surgical intervention in the post-natal period, 11 (11/267, 4.1%) in the first 12 weeks postnatal and 37 >12 weeks (37/267, 13.9%) postnatal. 64 (64/267, 24.0%) adnexal masses resolved spontaneously during follow up. Cyst-related complications occurred in four women (4/267, 1.5%) during pregnancy (ovarian torsion n=2, cyst rupture n=2) and six (6/267, 2.2%) in the postnatal period (all ovarian torsion). 196 (196/267, 73.4%) had a persistent adnexal mass, including one of the women who had an ovarian torsion and underwent de-torsion and had a persistent adnexal mass at postnatal ultrasound. Presumed decidualisation occurred in 31.1% (19/61) of endometriomas and had resolved in 89.5% (17/19) by the first postnatal ultrasound scan. CONCLUSION: We found Benign Descriptors apply to most masses in pregnancy, however the small number of malignant tumours in the cohort (4.1%) restricted the evaluation of the ADNEX model, so expert subjective assessment should be used to classify adnexal masses in pregnancy, when BDs do not apply. A larger multicentre prospective study is required to evaluate the use of the ADNEX model to classify adnexal masses in pregnancy. Our data suggests that most adnexal masses can be managed expectantly during pregnancy given a large proportion of masses spontaneously resolved and the low risk of complications. This article is protected by copyright. All rights reserved.

Successful return to work in anaesthesia after maternity leave: a qualitative study.

Returning to work after maternity leave poses significant challenges, with potential long-term implications including decreased engagement or attrition of clinicians. Many quantitative studies have identified challenges and supports for women during pregnancy, maternity leave and re-entry to clinical practice. This qualitative study explored the experiences of anaesthetists returning to clinical work after maternity leave, to identify influential factors with the aim of providing a framework to assist planning re-entry. We conducted semi-structured interviews with 15 anaesthetists. Attendees of a re-entry programme were invited to participate, with purposive sampling and snowball recruitment to provide diversity of location and training stage, until data saturation was reached at 13 interviews. Five themes were identified: leave duration; planning re-entry; workplace culture; career impact and emotional impact. Leave duration was influenced by concerns about deskilling, but shorter periods of leave had logistical challenges, including fatigue. Most participants started planning to return to work with few or no formal processes in the workplace. Workplace culture, including support for breastfeeding, was identified as valuable, but variable. Participants also experienced negative attitudes on re-entry, including difficulty accessing permanent work, with potential career impacts. Many participants identified changes to professional and personal identity influencing the experience with emotional sequelae. This research describes factors which may be considered to assist clinicians returning to work after maternity leave and identifies challenges, including negative attitudes, which may pose significant barriers to women practising in anaesthesia and may contribute to lack of female leadership in some workplaces.

Simulating nitrogen balance in Canadian agricultural soils from 1981 to 2016.

Agriculture produces food, fiber and biofuels for the world's growing population, however, agriculture can be a major contributor of nitrogen (N) losses including emissions of ammonia (NH3), nitrous oxide (N2O) and nitrate (NO3-) leaching and runoff. A Canadian Agricultural Nitrogen Budget for Reactive N (CANBNr) model was developed to estimate the soil N balance in 3487 soil landscape of Canada polygons from 1981 to 2016. The CANBNr model integrates NH3 emission from fertilizers, manure from housing, storage and field, as well as direct/indirect N2O emissions from fertilizers, manures, crop residues and soil organic matter. The NO3- leaching is estimated based on the residual soil N (RSN) at harvest and drainage derived with the DeNitrification-DeComposition (DNDC) model. From 1981 to 2016, the N input from fertilizer and N fixation increased at a greater rate than N removal in harvested crops in all provinces of Canada, resulting in an increase in the RSN and N losses. In 2016, the Prairie provinces had lower N losses (11.7 kg N ha-1) from N2O, NH3 and NO3- compared with 43.2 kg N ha-1 in central Canada, and 76.5 kg N ha-1 in Atlantic Canada. However, the Prairie provinces had 84.3% of the total Canadian farmland (74.3% of the total Canadian N input), while central Canada had 12.9% of Canadian farmland (21.7% of the total Canadian N input). In the Prairie provinces, the total N2O loss from fertilizer N ranged 4.4-8.6 Gg N whereas NH3 loss ranged from 17.1 to 44.6 Gg N and these values were influenced by both emission intensity and total land area. Total N2O losses from manure were highest in Alberta, Ontario and Quebec resulting in 4.8, 4.4, and 3.4 Gg N and NH3 losses from manure were also highest in these 3 provinces at 61.1, 45.2 and 40.4 Gg N, respectively. Nitrate leaching was impacted by drainage volumes, soil type and N inputs. In the non-growing season, NO3- leaching losses (36-yr average) were 63.3 Gg in Ontario and 57.5 Gg N in Quebec compared with 20.8 Gg N for Ontario and 35.5 Gg N for Quebec in the growing season. In contrast, the Prairie provinces showed higher NO3- leaching in the growing season (23.1-37.4 Gg N) than in the non-growing season (10.4-13.7 Gg N). In summary, total fertilizer N increased the most over the 36 years in the Prairies which resulted in increased RSN and N leaching losses that will require further intervention.

Development of a multi-task learning V-Net for pulmonary lobar segmentation on CT and application to diseased lungs.

AIM: To develop a multi-task learning (MTL) V-Net for pulmonary lobar segmentation on computed tomography (CT) and application to diseased lungs. MATERIALS AND METHODS: The described methodology utilises tracheobronchial tree information to enhance segmentation accuracy through the algorithm's spatial familiarity to define lobar extent more accurately. The method undertakes parallel segmentation of lobes and auxiliary tissues simultaneously by employing MTL in conjunction with V-Net-attention, a popular convolutional neural network in the imaging realm. Its performance was validated by an external dataset of patients with four distinct lung conditions: severe lung cancer, COVID-19 pneumonitis, collapsed lungs, and chronic obstructive pulmonary disease (COPD), even though the training data included none of these cases. RESULTS: The following Dice scores were achieved on a per-segment basis: normal lungs 0.97, COPD 0.94, lung cancer 0.94, COVID-19 pneumonitis 0.94, and collapsed lung 0.92, all at p<0.05. CONCLUSION: Despite severe abnormalities, the model provided good performance at segmenting lobes, demonstrating the benefit of tissue learning. The proposed model is poised for adoption in the clinical setting as a robust tool for radiologists and researchers to define the lobar distribution of lung diseases and aid in disease treatment planning.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial.

BACKGROUND: A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI. METHODS: This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety. DISCUSSION: We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI. TRIAL REGISTRATION: ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

Presence, resilience, and compassion training in clinical education (PRACTICE): Evaluation of a mindfulness-based intervention for residents.

Background: Residents' well-being tends to decline in the course of training, yet research on preventive and restorative interventions for residents is limited. Mindfulness-based interventions have been successfully employed to support well-being in practicing physicians, but their impacts on residents are not well established. Objective: This paper describes the structure, content, and evaluation of a pilot mindfulness-based intervention program designated PRACTICE (presence, resilience and compassion training in clinical education) that was designed specifically to support resident well-being. Methods: A combined sample of 14 postgraduate year one residents from two residency training programs participated in a four-session (8 h) mindfulness-based intervention in the Fall/Winter of 2018. Participants were surveyed before, after, and at 3 months postintervention, on measures of wellness (Professional Fulfillment Index) and mental health (Patient Health Questionnaire-4), along with measures of program engagement. Results: Participants demonstrated a significant reduction in burnout at the conclusion of the program. Depression and anxiety screening scores also trended toward improvement. However, participants were not able to sustain these gains. Three months after the conclusion of the program wellness measures had returned to preintervention levels. Conclusions: The results of this study support the use of mindfulness-based interventions in resident wellness programs. The lack of an enduring effect indicates the need for a maintenance phase intervention.

Circadian timing and alignment in healthy adults: associations with BMI, body fat, caloric intake and physical activity.

INTRODUCTION: Disruption of circadian rhythms is one of the proposed mechanisms linking late sleep timing to obesity risk but few studies have evaluated biological markers outside of the laboratory. The goal of this study was to determine the relationship between the timing and alignment of melatonin and sleep onset (phase angle) with body mass index (BMI), body fat and obesity-related behaviors. We hypothesized that circadian alignment (relationship of melatonin to sleep timing) rather than circadian (melatonin) timing would be associated with higher BMI, body fat, dietary intake and lower physical activity. SUBJECTS/METHODS: Adults with sleep duration ⩾6.5 h completed 7 days of wrist actigraphy, food diaries and SenseWear arm band monitoring. Circadian timing, measured by dim light melatonin onset was measured in the clinical research unit. Circadian alignment was calculated as the duration between dim light melatonin onset and average sleep onset time in the prior week (phase angle). Body fat was evaluated using dual-energy X-ray absorptiometry. Data were analyzed using bivariate correlations and multivariable regression analyses controlling for age, sex, sleep duration and evening light exposure. RESULTS: Participants included 97 adults (61 F, age 26.8±7.3 years) with average sleep duration 443.7 (s.d.=50.4) minutes. Average phase angle was 2.2 h (s.d.=1.5). Circadian alignment was associated with circadian timing (P<0.001) and sleep duration (P=0.005). In multivariable analyses, later circadian timing was associated with lower BMI (P=0.04). Among males only, circadian alignment was associated with percent body fat (P=0.02) and higher android/gynoid fat ratio (P=0.04). Circadian alignment was associated with caloric intake (P=0.049) carbohydrate intake (P=0.04) and meal frequency (P=0.03) among both males and females. CONCLUSION: Circadian timing and alignment were not associated with increased BMI or body fat, among healthy adults with ⩾6.5 h of sleep, but circadian alignment was associated with dietary intake. There may be sex differences in the relationship between circadian alignment and body fat.

Circular dichroism in photoelectron images from aligned nitric oxide molecules.

We have used velocity map photoelectron imaging to study circular dichroism of the photoelectron angular distributions (PADs) of nitric oxide following two-color resonance-enhanced two-photon ionization via selected rotational levels of the A 2Σ+, v'=0 state. By using a circularly polarized pump beam and a counter-propagating, circularly polarized probe beam, cylindrical symmetry is preserved in the ionization process, and the images can be reconstructed using standard algorithms. The velocity map imaging set up enables individual ion rotational states to be resolved with excellent collection efficiency, rendering the measurements considerably simpler to perform than previous measurements conducted with a conventional photoelectron spectrometer. The results demonstrate that circular dichroism is observed even when cylindrical symmetry is maintained, and serve as a reminder that dichroism is a general feature of the multiphoton ionization of atoms and molecules. The observed PADs are in good agreement with calculations based on parameters extracted from previous experimental results obtained by using a time-of-flight electron spectrometer.

A Q methodology study to investigate the experiences of head and neck cancer patients from diagnosis to 1 year.

The experiences of disease and treatment for patients diagnosed with head and neck cancer (H&NC) are known to be important indicators of the quality of care but are represented poorly in the literature. Survival is a major outcome measure to which health-related quality of life (HRQoL) adds detail but outcomes are not fully representative of the patients' experiences because quality of care and reality of treatment are overlooked. This study explored the HRQoL, quality of care and reality of treatment themes using a mixed-methods approach, Q Methodology. In total, 18 participants who were at least 12 months post-diagnosis rank-ordered 45 prepared statements to reflect their own experiences of H&NC. After the statements had been sorted, the participants reviewed the order in an interview to clarify experiences. The statements become a way of facilitating the discussion because the participant can explain the position of specific statements that are notable for them. The ranking was factor-analysed case-wise and five factors provided the best conceptual fit: meaning and attachment to illness; overwhelmed by the cancer; surviving or not; change and recovery; and keep control for the greater good of others. The findings suggest there are distinct ways that H&NC patients experience the disease and its treatment. The concept of the experience being different and defined for individuals has practical implications at a clinical level and is a way of ensuring care is truly patient-centred.

Age-associated declines in muscle mass, strength, power, and physical performance: impact on fear of falling and quality of life.

UNLABELLED: This 3-year longitudinal study among older adults showed that declining muscle mass, strength, power, and physical performance are independent contributing factors to increased fear of falling, while declines of muscle mass and physical performance contribute to deterioration of quality of life. Our findings reinforce the importance of preserving muscle health with advancing age. INTRODUCTION: The age-associated loss of skeletal muscle quantity and function are critical determinants of independent physical functioning in later life. Longitudinal studies investigating how decrements in muscle components of sarcopenia impact fear of falling (FoF) and quality of life (QoL) in older adults are lacking. METHODS: Twenty-six healthy older subjects (age, 74.1 ± 3.7; Short Physical Performance Battery (SPPB) score ≥10) and 22 mobility-limited older subjects (age, 77.2 ± 4.4; SPPB score ≤9) underwent evaluations of lower extremity muscle size and composition by computed tomography, strength and power, and physical performance at baseline and after 3-year follow-up. The Falls Efficacy Scale (FES) and Short Form-36 questionnaire (SF-36) were also administered at both timepoints to assess FoF and QoL, respectively. RESULTS: At 3-year follow-up, muscle cross-sectional area (CSA) (p < 0.013) and power decreased (p < 0.001), while intermuscular fat infiltration increased (p < 0.001). These decrements were accompanied with a longer time to complete 400 m by 22 ± 46 s (p < 0.002). Using linear mixed-effects regression models, declines of muscle CSA, strength and power, and SPPB score were associated with increased FES score (p < 0.05 for each model). Reduced physical component summary score of SF-36 over follow-up was independently associated with decreased SPPB score (p < 0.020), muscle CSA (p < 0.046), and increased 400 m walk time (p < 0.003). CONCLUSIONS: In older adults with and without mobility limitations, declining muscle mass, strength, power, and physical performance contribute independently to increase FoF, while declines of muscle mass and physical performance contribute to deterioration of QoL. These findings provide further rationale for developing interventions to improve aging muscle health.

Secondary contact and asymmetrical gene flow in a cosmopolitan marine fish across the Benguela upwelling zone.

The combination of oceanographic barriers and habitat heterogeneity are known to reduce connectivity and leave specific genetic signatures in the demographic history of marine species. However, barriers to gene flow in the marine environment are almost never impermeable which inevitably allows secondary contact to occur. In this study, eight sampling sites (five along the South African coastline, one each in Angola, Senegal and Portugal) were chosen to examine the population genetic structure and phylogeographic history of the cosmopolitan bluefish (Pomatomus saltatrix), distributed across a large South-east Atlantic upwelling zone. Molecular analyses were applied to mtDNA cytochrome b, intron AM2B1 and 15 microsatellite loci. We detected uncharacteristically high genetic differentiation (FST 0.15-0.20; P<0.001) between the fish sampled from South Africa and the other sites, strongly influenced by five outlier microsatellite loci located in conserved intergenic regions. In addition, differentiation among the remaining East Atlantic sites was detected, although mtDNA indicated past isolation with subsequent secondary contact between these East Atlantic populations. We further identified secondary contact, with unidirectional gene flow from South Africa to Angola. The directional contact is likely explained by a combination of the northward flowing offshore current and endogenous incompatibilities restricting integration of certain regions of the genome and limiting gene flow to the south. The results confirm that the dynamic system associated with the Benguela current upwelling zone influences species distributions and population processes in the South-east Atlantic.

Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 2: Six-Month Outcomes of a Randomized Controlled Trial and Qualitative Feedback From Participants.

BACKGROUND: Despite empirical evidence supporting the use of Web-based interventions for problem drinking, much remains unknown about factors that influence their effectiveness. OBJECTIVE: We evaluated the performance of 2 resources for people who want to achieve and maintain abstinence: SMART Recovery (SR) and Overcoming Addictions (OA). OA is a Web application based on SR. We also examined participant and intervention-related factors hypothesized to impact clinical outcomes of Web-based interventions. METHODS: We recruited 189 heavy drinkers through SR's website and in-person meetings throughout the United States. We began by randomly assigning participants to (1) SR meetings alone, (2) OA alone, and (3) OA and SR (OA+SR). Recruitment challenges compelled us to assign participants only to SR (n=86) or OA+SR (n=102). The experimental hypotheses were as follows: (1) Both groups will reduce their drinking and alcohol-related consequences at follow-up compared with their baseline levels, and (2) The OA+SR condition will reduce their drinking and alcohol or drug-related consequences more than the SR only condition. Additionally, we derived 3 groups empirically (SR, OA, and OA+SR) based on the participants' actual use of each intervention and conducted analyses by comparing them. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol or drug-related consequences. Postbaseline assessments were conducted by phone at 3 and 6 months. Secondary analyses explored whether clinical issues (eg, severity of alcohol problems, level of distress, readiness to change) or intervention-related factors (eg, Internet fluency, satisfaction with site) affected outcomes. RESULTS: Both intent-to-treat analyses and the actual-use analyses showed highly significant improvement from baseline to follow-ups for all 3 groups. Mean within-subject effect sizes were large (d>0.8) overall. There was no significant difference between groups in the amount of improvement from baseline to the average of the follow-ups. We found that participants who stopped drinking before joining the clinical trial had significantly better outcomes than participants who were still drinking when they joined the study. Neither Internet fluency nor participants' reported ease of navigating the site had an impact on outcomes. CONCLUSIONS: These results support our first experimental hypothesis but not the second. On average, participants improved on all dependent measures. Both SR and OA helped participants recover from their problem drinking. Web-based interventions can help even those individuals with lengthy histories of heavy drinking to make clinically significant reductions in their consumption and related problems. These interventions work well for individuals in the action stage of change. TRIAL REGISTRATION: Clinicaltrials.gov NCT01389297; https://clinicaltrials.gov/ct2/show/NCT01389297 (Archived by WebCite at http://www.webcitation.org/6kLNUNDcc).

A founder mutation in the TCIRG1 gene causes osteopetrosis in the Ashkenazi Jewish population.

Osteopetrosis is a rare and heterogeneous genetic disorder characterized by dense bone mass that is a consequence of defective osteoclast function and/or development. Autosomal recessive osteopetrosis (ARO) is the most severe form and is often fatal within the first years of life; early hematopoietic stem cell transplant (HSCT) remains the only curative treatment for ARO. The majority of the ARO-causing mutations are located in the TCIRG1 gene. We report here the identification and characterization of an A to T transversion in the fourth base of the intron 2 donor splice site (c.117+4A→T) in TCIRG1, a mutation not previously seen in the Ashkenazi Jewish (AJ) population. Analysis of a random sample of individuals of AJ descent revealed a carrier frequency of approximately 1 in 350. Genotyping of five loci adjacent to the c.117+4A→T-containing TCIRG1 allele revealed that the presence of this mutation in the AJ population is due to a single founder. The identification of this mutation will enable population carrier testing and will facilitate the identification and treatment of individuals homozygous for this mutation.

Vertebral heart size and vertebral left atrial size reference ranges in healthy Miniature Schnauzers.

OBJECTIVE: The inclusion of vertebral heart score (VHS) and, more recently, the inclusion of the vertebral left atrial size (VLAS) in radiographic evaluation have become important screening tools for identifying dogs with occult cardiac disease. Several recent papers have shown there are interbreed variations in the VHS reference range. Our hypothesis is that the Miniature Schnauzer would also have a higher reference range for its VHS. ANIMALS: The electronic medical records of IDEXX Telemedicine Consultants were searched for Miniature Schnauzers undergoing thoracic radiographs between March 1, 2022, and February 28, 2023. METHODS: Dogs were included if they had 3 view thoracic radiographs performed and no evidence of cardiopulmonary disease was detected. Dogs with incomplete radiographic studies or cardiac or extracardiac disease were excluded. The VHS and VLAS measurements were performed by 2 board-certified cardiologists independent of one another. RESULTS: A total of 1,000 radiographs were obtained of which 272 were included for the study. The overall range for the VHS in this cohort was 9.68 to 12.07 with a median of 10.9. For VLAS measurements, a range of 1.71 to 2.4 was documented with a median of 2.0. CLINICAL RELEVANCE: The VHS for Miniature Schnauzers without cardiac disease was confirmed to be higher than the canine reference range.

Tools in the assessment of sarcopenia.

This review provides a framework for the development of an operational definition of sarcopenia and of the potential end points that might be adopted in clinical trials among older adults. While the clinical relevance of sarcopenia is widely recognized, there is currently no universally accepted definition of the disorder. The development of interventions to alter the natural history of sarcopenia also requires consensus on the most appropriate end points for determining outcomes of clinical importance which might be utilized in intervention studies. We review current approaches to the definition of sarcopenia and the methods used for the assessment of various aspects of physical function in older people. The potential end points of muscle mass, muscle strength, muscle power, and muscle fatigue, as well as the relationships between them, are explored with reference to the availability and practicality of the available methods for measuring these end points in clinical trials. Based on current evidence, none of the four potential outcomes in question is sufficiently comprehensive to recommend as a uniform single outcome in randomized clinical trials. We propose that sarcopenia may be optimally defined (for the purposes of clinical trial inclusion criteria as well as epidemiological studies) using a combination of measures of muscle mass and physical performance. The choice of outcome measures for clinical trials in sarcopenia is more difficult; co-primary outcomes, tailored to the specific intervention in question, may be the best way forward in this difficult but clinically important area.

Decision-making for ecosystem-based management: evaluating options for a krill fishery with an ecosystem dynamics model.

Decision-makers charged with implementing ecosystem-based management (EBM) rely on scientists to predict the consequences of decisions relating to multiple, potentially conflicting, objectives. Such predictions are inherently uncertain, and this can be a barrier to decision-making. The Convention on the Conservation of Antarctic Marine Living Resources requires managers of Southern Ocean fisheries to sustain the productivity of target stocks, the health and resilience of the ecosystem, and the performance of the fisheries themselves. The managers of the Antarctic krill fishery in the Scotia Sea and southern Drake Passage have requested advice on candidate management measures consisting of a regional catch limit and options for subdividing this among smaller areas. We developed a spatially resolved model that simulates krill-predator-fishery interactions and reproduces a plausible representation of past dynamics. We worked with experts and stakeholders to identify (1) key uncertainties affecting our ability to predict ecosystem state; (2) illustrative reference points that represent the management objectives; and (3) a clear and simple way of conveying our results to decision-makers. We developed four scenarios that bracket the key uncertainties and evaluated candidate management measures in each of these scenarios using multiple stochastic simulations. The model emphasizes uncertainty and simulates multiple ecosystem components relating to diverse objectives. We summarize the potentially complex results as estimates of the risk that each illustrative objective will not be achieved (i.e., of the state being outside the range specified by the reference point). This approach allows direct comparisons between objectives. It also demonstrates that a candid appraisal of uncertainty, in the form of risk estimates, can be an aid, rather than a barrier, to understanding and using ecosystem model predictions. Management measures that reduce coastal fishing, relative to oceanic fishing, apparently reduce risks to both the fishery and the ecosystem. However, alternative reference points could alter the perceived risks, so further stakeholder involvement is needed to identify risk metrics that appropriately represent their objectives.

Overcoming Addictions, a Web-based application, and SMART Recovery, an online and in-person mutual help group for problem drinkers, part 1: three-month outcomes of a randomized controlled trial.

BACKGROUND: Overcoming Addictions (OA) is an abstinence-oriented, cognitive behavioral, Web application based on the program of SMART Recovery. SMART Recovery is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum, and other resources. OBJECTIVE: To evaluate the effectiveness of OA and SMART Recovery (SR) with problem drinkers who were new to SMART Recovery. Our experimental hypotheses were: (1) all groups will reduce their drinking and alcohol/drug-related consequences at follow-up compared to their baseline levels, (2) the OA condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR), and (3) the OA+SR condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR only). METHODS: We recruited 189 heavy problem drinkers primarily through SMART Recovery's website and in-person meetings throughout the United States. We randomly assigned participants to (1) OA alone, (2) OA+attend SMART Recovery (SR) meetings (OA+SR), or (3) attend SR only. Baseline and follow-ups were conducted via GoToMeeting sessions with a Research Assistant (RA) and the study participant. We interviewed significant others to corroborate the participant's self-report. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol/drug-related consequences. RESULTS: The intent-to-treat analysis of the 3-month outcomes supported the first hypothesis but not the others. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001). Actual use relationships were found for the OA groups, between SR online meetings and improvement in PDA (r=.261, P=.033). In addition in the OA groups, the number of total sessions of support (including SR & other meetings, counselor visits) was significantly related to PDA (r=.306, P=012) and amount of improvement in alcohol-related problems (r=.305, P=.012). In the SR only group, the number of face-to-face meetings was significantly related to all three dependent variables, and predicted increased PDA (r=.358, P=.003), fewer mean DDD (r=-.250, P=.039), and fewer alcohol-related problems (r=-.244, P=.045), as well as to the amount of improvement in all three of these variables. Six-month follow-ups have been completed, and the results are currently being analyzed. CONCLUSIONS: These results support our first experimental hypothesis but not the second or third. All groups significantly increased their PDA and decreased both their mean DDD and their alcohol-related problems, which indicates that both interventions being investigated were equally effective in helping people recover from their problem drinking.

Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices.

The defining characteristic of a profession - and especially a health-care profession - is that the behaviour of its members is proscribed by a formal code of ethics. The main purpose of such codes is to guide practitioners' interactions with patients, assuring that patient interests are protected. In other words, the ethical code requires practitioners to place their patients' needs for proper diagnosis and appropriate treatment ahead of their own needs for income and advancement. The dental profession has a code of ethics that was developed by the American Dental Association many years ago; in most clinical situations, determination of proper behaviour is self-evident. However, the field of temporoman-dibular disorders (TMDs) has been the subject of considerable controversy for over half a century, and many people have argued that this makes it impossible to evaluate various approaches to treatment of TMDs within an ethical framework. In this article, the authors argue that the large volume of scientific evidence in the contemporary TMD literature provides an ethical framework for the diagnosis and treatment of patients with TMDs within a biopsychosocial medical model. They present a summary of the research with contemporary scientific integrity, which has produced that information over a period of many years. Based on that research, they conclude that dentists may provide conservative and reversible treatments that will be successful for most TMDs and in doing so will comply with the profession's code of ethics. Conversely, the authors claim that those dentists who continue to follow the older mechanistic models of TMD aetiology and treatment are not only out of step scientifically, but are placing their patients' welfare at risk by providing unnecessary irreversible bite-changing and jaw-repositioning interventions. Therefore, debate of these issues should not be solely focused on scientific merit, but also upon the compelling ethical obligations that dentists have as a result of the contemporary scientific literature regarding TMDs.

Management of an Unexploded Intracorporeal Firework in a Low Resource Setting: Case Report and Tips.

Surgical removal of unexploded ordnance has been described in literature, usually in the context of the military. We describe a case of a 31-year-old gentleman who presented with a traumatic fireworks injury resulting in an unexploded three-inch aerial shell lodged in his left upper thigh. The sole regional Explosive Ordinance Disposal (EOD) expert was not available, so a local pyrotechnic engineer was contacted and he helped in identification of the firework. The firework was removed without the use of electrocautery, irrigation, or metal instrument contact after skin incision. The patient recovered well after prolonged wound healing. Creativity needs to be employed in low resource settings to identify all available resources that can impart knowledge when medical training is not enough. People with knowledge of explosives can be, as in our case, local pyrotechnics engineer or can be local cannon enthusiasts, veterans, or active military personnel at a nearby military base.