Posttraumatic stress disorder and posttraumatic stress symptoms among adults with hemophilia A and B.

Background: Persons with hemophilia may encounter various traumatic experiences related to their bleeding disorder throughout their lifetime. Little is known about the clinical impact of disease-related trauma on this population. Objectives: To explore the prevalence of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms in adults with hemophilia A and B and characterize the traumatic experiences they report. Methods: An online survey tool collecting data on participant characteristics and a validated questionnaire containing the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders 5 were distributed via Research Electronic Data Capture to adults with hemophilia A and B during their annual visit to their hemophilia treatment center. Participants were asked about traumatic experiences specific to their hemophilia prior to self-administering the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders 5 questionnaire. Results: Survey responses from 178 individuals across 3 hemophilia treatment centers were included in the analysis, representing a 70% response rate. One hundred one (56.7%) participants identified a hemophilia-related traumatic event, and 21 (11.8%) participants met criteria for a provisional diagnosis of PTSD. Multivariable analysis showed higher odds of a positive PTSD screen in participants with noninfectious (odds ratio [OR], 13.89; 95% CI, 2.23-86.62) and infectious comorbidities (OR, 11.18; 95% CI, 1.34-93.45) and in participants with >1 mental health comorbidity (OR, 10.07; 95% CI, 2.39-42.52). On the contrary, age >46 years (OR, 0.6; 95% CI, 0.01-0.62) and higher education (OR, 0.25; 95% CI, 0.07-0.88) reduced odds of PTSD. Conclusion: Persons with hemophilia are at risk of developing PTSD and posttraumatic stress symptoms. These data support the need for trauma screening, psychosocial services in the bleeding disorders community, and provision of trauma-informed care by providers.

Governing Ecological Connectivity in Cross-Scale Dependent Systems.

Ecosystem management and governance of cross-scale dependent systems require integrating knowledge about ecological connectivity in its multiple forms and scales. Although scientists, managers, and policymakers are increasingly recognizing the importance of connectivity, governmental organizations may not be currently equipped to manage ecosystems with strong cross-boundary dependencies. Managing the different aspects of connectivity requires building social connectivity to increase the flow of information, as well as the capacity to coordinate planning, funding, and actions among both formal and informal governance bodies. We use estuaries in particular the San Francisco Estuary, in California, in the United States, as examples of cross-scale dependent systems affected by many intertwined aspects of connectivity. We describe the different types of estuarine connectivity observed in both natural and human-affected states and discuss the human dimensions of restoring beneficial physical and ecological processes. Finally, we provide recommendations for policy, practice, and research on how to restore functional connectivity to estuaries.

Mapping legal authority for terrestrial conservation corridors along streams.

Wildlife corridors aim to promote species' persistence by connecting habitat patches across fragmented landscapes. Their implementation is limited by patterns of land ownership and complicated by differences in the jurisdictional and regulatory authorities under which lands are managed. Terrestrial corridor conservation requires coordination across jurisdictions and sectors subject to site-specific overlapping sources of legal authority. Mapping spatial patterns of legal authority concurrent with habitat condition can illustrate opportunities to build or leverage capacity for connectivity conservation. Streamside areas provide pragmatic opportunities to leverage existing policy mechanisms for riverine and terrestrial habitat connectivity across boundaries. Conservation planners and practitioners can make use of these opportunities by harmonizing actions for multiple conservation outcomes. We formulated an integrative, data-driven method for mapping multiple sources of legal authority weighted by capacity for coordinating terrestrial habitat conservation along streams. We generated a map of capacity to coordinate streamside corridor protections across a wildlife habitat gap to demonstrate this approach. We combined values representing coordination capacity and naturalness to generate an integrated legal-ecological resistance map for connectivity modeling. We then computed least-cost corridors across the integrated map, masking the terrestrial landscape to focus on streamside areas. Streamside least-cost corridors in the integrated, local-scale model diverged (∼25 km) from national-scale least-cost corridors based on naturalness. Spatial categories comparing legal- and naturalness-based resistance values by stream reach highlighted potential locations for building or leveraging existing capacity through spatial coordination of policy mechanisms or restoration actions. Agencies or nongovernmental organizations intending to restore or maintain habitat connectivity across fragmented landscapes can use this approach to inform spatial prioritization and build coordination capacity. Article impact statement: Combined mapping of legal authority and habitat condition reveals capacity to coordinate actions along streams for clean water and wildlife.

Mapeo de la Autoridad Legal para los Corredores Terrestres de Conservación a lo Largo de Ríos Stahl et al. Resumen Los corredores de fauna buscan promover la persistencia de las especies al conectar los fragmentos de hábitat a lo largo de paisajes fragmentados. Su implementación está limitada por los patrones de propiedad de tierras y se complica con las diferencias entre las autoridades jurisdiccionales y regulatorias que las administran. La conservación por corredores terrestres requiere de coordinación entre las jurisdicciones y los sectores sujetos a fuentes de autoridad legal que se traslapan y que son específicas del sitio. El mapeo de los patrones espaciales de la autoridad legal simultánea a la condición del hábitat puede ilustrar oportunidades para construir o hacer uso de la capacidad para la conservación por conectividad. Las áreas adyacentes a los cauces fluviales proporcionan oportunidades prácticas para hacer uso de los mecanismos políticos existentes para la conectividad de hábitats ribereño y terrestre a través de las fronteras. Los planificadores y practicantes de la conservación pueden usar estas oportunidades al armonizar las acciones para múltiples resultados de conservación. Formulamos un método integrativo orientado por los datos para mapear las múltiples fuentes de autoridad legal ponderadas por la capacidad para coordinar la conservación de hábitats terrestres a lo largo de ríos. Generamos un mapa de la capacidad para coordinar los corredores de protección a lo largo de los vacíos en los hábitats de fauna para demostrar esta estrategia. Combinamos los valores por medio de la representación de la capacidad de coordinación y la naturalidad para generar un mapa de resistencia legal y ecológica para el modelado de la conectividad. Después, computamos los corredores de menor costo en todo el mapa integrado, enmascarando el paisaje terrestre para enfocarnos en las áreas adyacentes al cauce fluvial. Los corredores de menor costo adyacentes a los cauces dentro del modelo integrado de escala local difirieron (∼25 km) de los corredores de menor costo basados en la naturalidad a escala nacional. Las categorías espaciales que compararon los valores de resistencia basada en la legalidad y en la naturalidad por alcance del río resaltaron las localidades potenciales para la construcción o el uso de la capacidad existente por medio de la coordinación espacial de los mecanismos de política o de las acciones de restauración. Las agencias y organizaciones no gubernamentales con la intención de restaurar o mantener la conectividad del hábitat en un paisaje fragmentado pueden utilizar esta estrategia para informar la priorización espacial y construir la capacidad de coordinación.

A Medical Student Perspective on Physician-Assisted Suicide.

Physician-assisted suicide and euthanasia (PAS/E) has been increasingly discussed and debated in the public arena, including in professional medical organizations. However, the medical student perspective on the debate has essentially been absent. We present a medical student perspective on the PAS/E debate as future doctors and those about to enter the profession. We argue that PAS/E is not in line with the core principles of medicine and that the focus should be rather on providing high-quality end-of-life and palliative care.

Limb-Threatening Acute Venous Thromboembolism in a Patient Undergoing Postarrest Therapeutic Hypothermia.

Postcardiac arrest patients are at high risk for developing venous thromboembolism (VTE). Current postarrest guidelines do not provide recommendations for prevention or surveillance of VTE and there is little guidance regarding the optimal prophylaxis or treatment of VTE during therapeutic hypothermia (TH). Many patients develop acute liver dysfunction resulting from severe global hypoperfusion during cardiac arrest, compounding concerns for bleeding with the initiation of TH. However, significant VTE may occur following arrest and can contribute to additional morbidity and mortality. The pharmacokinetics of anticoagulation, the routine treatment for VTE, have not been extensively researched or tested under hypothermic conditions. Standard approaches for prevention and treatment have been utilized, such as unfractionated heparin, but their efficacy remains uncertain. This case illustrates the significant imbalance of coagulation in a postcardiac arrest patient undergoing TH.