Quantifying the effects of sea level rise driven marsh migration on wave attenuation.

Sea level rise (SLR) is the most significant climate change-related threat to coastal wetlands, driving major transformations in coastal regions through marsh migration. Landscape transformations due to marsh migration are manifested in terms of horizontal and vertical changes in land cover and elevation, respectively. These processes will have an impact on saltmarsh wave attenuation that is yet to be explored. This study stands as a comprehensive analysis of spatially distributed wave attenuation by vegetation in the context of a changing climate. Our results show that: i) changes in saltmarsh cover have little to no effect on the attenuation of floods, while ii) changes in elevation can significantly reduce flood extents and water depths; iii) overland wave heights are directly influenced by marsh migration, although iv) being indirectly attenuated by the water depth limiting effects of water depth attenuation driven by changes in elevation; v) the influence of saltmarsh accretion on wave attenuation is largely evident near the marsh edge, where the increasing elevations can drive major wave energy losses via wave breaking. Lastly, vi) considering the synergy between SLR, marsh migration, and changes in elevation results in significantly more wave attenuation than considering the eustatic effects of SLR and/or horizontal marsh migration alone, and therefore should be adopted in future studies.

Projecting the effects of land subsidence and sea level rise on storm surge flooding in Coastal North Carolina.

Much of the United States Atlantic coastline continues to undergo subsidence due to post glacial settlement and ground water depletion. Combined with eustatic sea level rise (SLR), this contributes to an increased rate of relative SLR. In this work, we utilize the ADvanced CIRCulation model to project storm surges across coastal North Carolina. Recent hurricanes Irene and Matthew are simulated considering SLR and subsidence estimates for 2100. Relative to present day conditions, storm surge susceptible regions increase by 27% (Irene) to 40% (Matthew) due to subsidence. Combined with SLR (+ 74 cm), results suggest more than a doubling of areal flood extent for Irene and more than a three-fold increase for Hurricane Matthew. Considering current regional population distributions, this translates to an increase in at-risk populations of 18% to 61% due to subsidence. Even further, exposed populations are projected to swell relative to Matthew and Irene baseline simulations (8200 and 28,500) by more than 70,000 in all SLR scenarios (79,400 to 133,600). While increases in surge inundation are driven primarily by SLR in the region, there remains a substantial contribution due to vertical land movement. This outlines the importance of exploring spatially variable land movement in surge prediction, independent of SLR.

Application of large format tissue processing in the histology laboratory.

In clinical, research and veterinary laboratories of North America, large format histology has more recently been improved with newer equipment and better methodology. Large tissue specimens are frequently sliced in the grossing room and processed in multiple smaller, standard size tissue cassettes. Justifiably, submitting more blocks inherently lends itself to a greater confidence in the accuracy of the diagnosis, yet guidelines for tissue sampling often suggest taking fewer samples. For example, large tumor specimen protocols recommend taking one standard-sized tissue block for each cm diameter of tumor. However, cancers are the culmination of many complex changes in cell metabolism and often appear dissimilar at different tissue locations. As these changes have an uncertain behavior, many other tissue samples are often taken from areas that appear to have either a variable texture or color. Consequently, at microscopy, the complete tissue sample may need to be reassembled like a jigsaw puzzle as the stained sections are frequently presented over many slides. This problem has easily been overcome by using large format cassettes since the entire cross-section of the tissue sample can often be viewed on a single slide. Because these cassettes can effectively hold up to 10 times the volume of conventional standard size cassettes, they are a more efficient way of assessing large areas of tissue samples. This system is easily adapted for all tissue types and has become the established method for assessing large tissue samples in many laboratory settings.

Association Between Postpartum Breast Cancer Diagnosis and Metastasis and the Clinical Features Underlying Risk.

Importance: In women 45 years or younger, breast cancer diagnosis after childbirth increases the risk for metastasis and death, yet limited data exist to define this window of risk and associated prognostic factors. Objective: To assess the window of elevated risk for metastasis following a postpartum breast cancer (PPBC) diagnosis and whether clinical prognostic factors are associated with the increased risk. Design, Setting, and Participants: This multicenter cohort study conducted using cases from the Colorado Young Women's Breast Cancer Cohort diagnosed between January 1, 1981, and December 31, 2014, included 701 women 45 years or younger with stage I to III invasive breast cancer for whom parity data, including time of last childbirth, were available. Data analysis was conducted from July 1 to September 30, 2017. This study involved a tertiary care academic hospital-based breast center and its regional affiliates with cases from the greater Rocky Mountain region. Exposures: Primary exposures were prior childbirth or no childbirth, time between most recent childbirth and breast cancer diagnosis, and time between breast cancer diagnosis and metastasis. Main Outcomes and Measures: The primary outcome was distant metastasis-free survival. Results: A total of 701 women 45 years or younger from the greater Rocky Mountain states region were included in the analysis; mean (SD) age at diagnosis was 37.9 (5.1) years. Breast cancer diagnosis within 10 years after parturition was associated with elevated risk for metastasis, particularly in women with stage I or II disease. In addition, women with PPBC diagnosed within 10 years of a completed pregnancy that was estrogen receptor-positive showed distant metastasis-free survival similar to that of nulliparous patients with estrogen receptor-negative cancer, and women with estrogen receptor-negative PPBC had further reduced metastasis-free survival. Moreover, women with PPBC had increased lymphovascular invasion and lymph node involvement. In addition, tumor-associated Ki67 positivity identified 129 patients with luminal B cancer in the cohort that, independent of parity status, had poorer prognosis compared with patients with luminal A cancer, although it did not reach statistical significance. Conclusions and Relevance: Diagnosis of PPBC within 10 years post partum appears to be associated with an increased risk for metastasis. This increased risk was highest in stages I and II cancer at diagnosis and present in both patients with estrogen receptor-positive and estrogen receptor-negative cancer, persisting in estrogen receptor-positive cases for up to 15 years after diagnosis. Postpartum breast cancer diagnoses were not associated with increased Ki67 index but were associated with increased lymphovascular invasion and lymph node involvement compared with breast cancer in nulliparous patients.

The Galasko report implemented: the role of emergency medicine in the management of head injuries.

INTRODUCTION: The objectives were to demonstrate the extra workload for emergency medicine of inpatient management of mild/moderate head injuries and to determine the effectiveness of current computed tomography guidelines. METHOD: A retrospective study of head injuries presenting to St James's Hospital Dublin, where the Galasko report has been implemented since 2001. We studied injuries presented from January 2001 to January 2002. Length of stay, mechanism of injury, follow-up, indication for admission and computed tomography scan were identified. RESULTS: A total of 2281 patients presented with head injury as their first or second triage complaint. One hundred and twenty-three patients were admitted to the emergency ward, of which 34 had computed tomography investigation. Ten computed tomography scans demonstrated intracranial injury. Intracranial injury was associated with vomiting, Glasgow coma score 14 (confusion), deterioration of Glasgow coma score, clinical basilar skull fracture and alcohol-related falls. The average length of stay for patients admitted to observation ward was 2.3 days and 5 days for those who had a brain injury on computed tomography scan. CONCLUSIONS: Implementation of the Galasko report has resource, manpower and training implications for emergency medicine. The current computed tomography guidelines should be modified to include Glasgow coma score<15 and neurological symptoms for example, vomiting and alcohol-related falls.

Needlestick injuries, management and education: a role for emergency medicine?

INTRODUCTION: The objectives of the study were to study the pattern of needlestick injuries presenting to an inner city emergency department, and to highlight areas where greater training is required. The emergency department is involved in the management of injuries both in the hospital setting and in the community. The setting was an inner city area with a high incidence of intravenous drug abuse, HIV, hepatitis B and C. METHODS: A retrospective review of all emergency notes triaged as needlestick injury for a 12-month period from July 2001 to July 2002. Information studied included times from incident, arrival at department, to be seen by doctor and to get post-exposure prophylaxis (PEP) if indicated; also the number of tetanus toxoid, hepatitis B immunoglobulin/vaccine, HIV PEP given as well the number indicated. The risk of injury and exposure were assessed and follow-up was checked. RESULTS: There were 73 needlestick injuries, 35 (48%) presented during normal working hours (09.00-17.00 h) and 38 (52%) presented outside these hours. Twenty-six (34%) were in healthcare workers, 51 (66%) were in non-healthcare workers. The average time from the incident to arrival was 1.4 h for healthcare workers and 22.6 h for non-healthcare workers. The median time from arrival in the department to be seen by a doctor was 90 min. Ten injuries (13.7%) were high risk. Antiretroviral agents were given to 15 patients (20.1%) and the median time from door to HIV PEP was 90 min (average 141 min). CONCLUSIONS: There is a delay and lack of urgency in the presentation of needlestick injuries for assessment and treatment. Education of emergency staff, other healthcare workers and the general public is needed to reduce the needle-to-door and needle-to-PEP time for the effective management of needlestick injuries and prevention of hepatitis and HIV seroconversion.

Predicting the result of our X-rays, a way to identify overuse? the Ulster Hospital Dundonald.

OBJECTIVE: The objectives of the study were to identify areas of the unnecessary use of diagnostic plain X-rays in the emergency department. Requests for inappropriate plain X-ray investigations have resource, radiation and overcrowding implications for the emergency department. METHODS: The junior doctor or nurse practitioner treating patients attending the emergency department requiring X-ray completed a proforma prospectively. Questions included the type of X-ray, predicted result of the X-ray and observed result of X-ray. RESULTS: A total of 226 out of 280 X-rays (81%) were accurately predicted, 94 X-rays (34%) were abnormal. Facial bones (100%) and skull (79%) were most commonly X-rayed when the result was predicted accurately to be normal. The threshold for X-raying abdomen, kidney, ureter and bladder and lumbar spine was low with normal accurate predictions of 67, 75 and 75%, respectively. Normal knee and foot X-rays were predicted accurately in 61 and 60% of cases, respectively, with a yield of 28 and 13%, respectively. CONCLUSION: The training of emergency medicine staff should include education about clinical indications from guidelines and recommendations about X-ray use, information on the dose of radiation exposure, implications of resources and overcrowding of departments.