Waiting in Pain II: An Updated Analysis of the Multidisciplinary Staffing Levels and Clinical Activity in Australian Specialist Persistent Pain Services.

This study provides an update on multidisciplinary staffing and clinical activity in Australian specialist persistent pain services. Of the 109 services identified, 57 responded, met inclusion criteria and completed a study-specific questionnaire detailing service characteristics, staff resources, and clinical activities. Where possible, data were compared between the 'Waiting in Pain' (WIP) investigations (WIP-I: Dec'08-Jan'10, WIP-II: Jul'16-Feb'18). WIP-II found more pain services (Level 1 centres, rural services) and more full-time equivalent (FTE) staffing (overall, psychiatry, psychology, occupational therapy) than WIP-I. Although Level 1 centres employed more FTE staff (overall, medical) than Level 2 clinics, staffing was comparable when considered relative to clinical activity and this was stable over time for most disciplines. Clinical activity in metropolitan and rural services also remained stable, as did rural service staffing (type, FTE), suggesting that newer clinics replicated existing models. WIP-II highlighted greater diversity in group structures than WIP-I and an associated mean .02FTE allied health staff/patient seen (WIP-I = .03 FTE). Staffing (amounts, types) did not change significantly over time when considered relative to clinical activity, supporting the conclusion that these are workable clinical structures. However, changes in group format (duration, staffing) suggest a shift towards lower-intensity programmes that require less allied health staffing to deliver. PERSPECTIVE: This article presents updated data regarding multidisciplinary staffing profiles, clinical activity, and group programme structures within Australian specialist persistent pain services and examines changes since the original investigation. As the only published staffing profile for multidisciplinary pain services, this project provides critical information to inform service (re)design and care delivery.

Emerging challenges of the impacts of pharmaceuticals on aquatic ecosystems: A diatom perspective.

Pharmaceuticals are a ubiquitous group of emerging pollutants of considerable importance due to their biological potency and potential to elicit effects in wildlife and humans. Pharmaceuticals have been quantified in terrestrial, marine, fresh, and transitional waters, as well as the fauna and macro-flora that inhabit them. Pharmaceuticals can enter water ways through different human and veterinary pathways with traditional wastewater treatment, unable to completely remove pharmaceuticals, discharging often unknown quantities to aquatic ecosystems. However, there is a paucity of available information regarding the effects of pharmaceuticals on species at the base of aquatic food webs, especially on phytoplankton, with research typically focussing on fish and aquatic invertebrates. Diatoms are one of the main classes of phytoplankton and are some of the most abundant and important organisms in aquatic systems. As primary producers, diatoms generate ∼40 % of the world's oxygen and are a vital food source for primary consumers. Diatoms can also be used for bioremediation of polluted water bodies but perhaps are best known as bio-indicators for water quality studies. However, this keystone, non-target group is often ignored during ecotoxicological studies to assess the effects of pollutants of concern. Observed effects of pharmaceuticals on diatoms have the potential to be used as an indicator of pharmaceutical-induced impacts on higher trophic level organisms and wider ecosystem effects. The aim of this review is to present a synthesis of research on pharmaceutical exposure to diatoms, considering ecotoxicity, bioremediation and the role of diatoms as bio-indicators. We highlight significant omissions and knowledge gaps which need addressing to realise the potential role of diatoms in future risk assessment approaches and help evaluate the impacts of pharmaceuticals in the aquatic environment at local and global scales.

Osteoarthritis consumers as co-researchers: identifying consumer insights to improve osteoarthritis management by co-designing translational research solutions.

INTRODUCTION: Co-design is a consumer-driven approach that facilitates consumer participation in creating meaningful solutions to complex problems. Poor uptake of core management strategies for osteoarthritis suggests there is a missing link in translation between research and practice. We partnered with osteoarthritis consumers as 'co-researchers' to identify translational research solutions to improve uptake of core management strategies that are grounded in lived experiences. OBJECTIVE: To transparently describe a theory-driven, generative co-design approach using an integrated conceptual framework to collaborate with consumers at the equal partnership level. DESIGN: We used co-design workshops with a non-hierarchical participatory framework. Three workshops with six co-researchers [2 female, mean age 68.7 (9.8) years, 3-30 years symptom duration] were conducted using activities to encourage creative thinking, promote deep reflection on personal/societal beliefs and minimise sensitivities around sharing personal beliefs (e.g., establishing a safe space, prompting questions, perspective-taking, counter-stereotypical exemplars). RESULTS: All six co-researchers actively participated in the workshops. Achievement of an equal collaborative partnership was evidenced by co-researchers challenging a project proposed by the research team and making alternative recommendations that have been implemented in prospective decision-making - representing a complete change in research focus driven by consumer input. A key suggested solution was to develop a scalable knowledge translation intervention that targets misconceptions about osteoarthritis and its management at the societal-level. CONCLUSIONS: Through an innovative co-design approach in partnership with co-researchers, we identified meaningful areas on which to focus translational research for osteoarthritis. Discordance between existing research priorities and novel solutions proposed by co-researchers highlights the value of co-design.

The extent of windfarm infrastructures on recognised European blanket bogs.

Peatland environments are the Earth's largest terrestrial carbon store and have the potential to act as carbon sinks. However, the development of windfarms on peatlands is affecting their morphology, hydrology, ground-level climate conditions, carbon functions and vegetation, and long-term consequences still need to be assessed. Blanket bogs are a rare type of ombrotrophic peatland that are typical of oceanic areas with high precipitation and low temperatures. Their distribution has been mapped across Europe, where they are mainly located on hill summits where wind energy potential is higher, making them attractive sites for windfarm developments. The promotion of renewable energy is currently a priority given the environmental and economic drive to increase low-carbon energy production. Establishing windfarms on peatland in pursuit of greener energy, therefore, risks compromising and undermining the green-energy transition. Despite this, the extent of windfarm infrastructures on blanket bogs have not yet been reported at the European scale. This research reports the extent of windfarm infrastructures on recognised blanket bogs, with a geographical focus on Europe, where blanket bogs have been mapped systematically. Under the EU Habitats Directive (92/43/EEC), there are 36 European regions NUTS level 2 with recognised blanket bogs. Of these, 12 have windfarm developments, including 644 wind turbines, 253.4 km of vehicular access tracks and an affected area of 207.6 ha, mainly in Ireland and Scotland where the extent of blanket bogs is also higher. However, despite Spain having under 0.2% of Europe's recognised blanket bogs area, this was the most affected country. In Scotland, a comparison of the recognised blanket bogs under the Habitats Directive (92/43/EEC) with blanket bogs recorded in national inventories indicates that the extent of windfarm developments was higher, with 1,063 wind turbines and 634.5 km of vehicular access tracks. Our results highlight the extent of windfarm developments on blanket bog habitat, both in areas where peatlands are broadly distributed across the landscape, and also in areas where this recognised habitat is particularly rare. There is a pressing need to assess the long-term impacts of windfarms on peatlands to ensure that efforts to meet energy targets result only in carbon sequestration, and do not jeopardise ecosystem services. Blanket bogs represent a particularly vulnerable habitat, the study of which should be prioritised updating national and international inventories to protect and restore this habitat.

The effect of handedness on mental rotation of hands: a systematic review and meta-analysis.

Body-specific mental rotation is thought to rely upon internal representations of motor actions. Handedness is a source of distinctly different motor experience that shapes the development of such internal representations. Yet, the influence of handedness upon hand mental rotation has never been systematically evaluated. Five databases were searched for studies evaluating hand left/right judgement tasks in adults. Two independent reviewers performed screening, data extraction, and critical appraisal. Eighty-seven datasets were included, with 72 datasets pooled; all had unclear/high risk of bias. Meta-analyses showed that right-handers were faster, but not more accurate, than left-handers at hand mental rotation. A unique effect of handedness was found on performance facilitation for images corresponding to the dominant hand. Meta-analyses showed that right-handers were quicker at identifying images of right hands than left hands-a dominance advantage not evident in left-handers. Differing hand representations (more lateralised hand dominance in right-handers) likely underpin these findings. Given potential differences between hand preference and motor performance, future research exploring their distinct contributions to mental rotation is warranted.

Corrigendum: Sub-ice-shelf sediments record history of twentieth-century retreat of Pine Island Glacier.

This corrects the article DOI: 10.1038/nature20136.

Fermentation products as feed additives mitigate some ill-effects of heat stress in pigs.

Heat stress (HS) may result in economic losses to pig producers across the USA and worldwide. Despite significant advancements in management practices, HS continues to be a challenge. In this study, an in-feed antibiotic (carbadox, CBX) and antibiotic alternatives ( [XPC], and [SGX] fermentation products) were evaluated in a standard pig starter diet as mitigations against the negative effects of HS in pigs. A total of 100 gilts were obtained at weaning (6.87 ± 0.82 kg BW, 19.36 ± 0.72 d of age) and randomly assigned to dietary treatments (2 rooms/treatment, 2 pens/room, 6 to 7 pigs/pen). After 4 wk of dietary acclimation, half of the pigs in each dietary group (1 room/dietary treatment) were exposed to repeated heat stress conditions (RHS; daily cycles of 19 h at 25°C and 5 h at 40°C, repeated for 9 d), and the remaining pigs were housed at constant thermal neutral temperature (25°C, [NHS]). Pigs subjected to RHS had elevated skin surface temperature ( < 0.05; average 41.7°C) and respiration rate ( < 0.05; 199 breaths per minute (bpm) during HS, and overall reduced ( < 0.05) BW, ADG, ADFI, and G:F regardless of dietary treatment. Independent of diet, RHS pigs had significantly shorter ( < 0.05) jejunum villi on d 3 and d 9 compared to NHS pigs. Heat stress resulted in decreased villus height to crypt depth ratio (V:C) in pigs fed with control diet with no added feed additive (NON) and CBX diets at d 3, whereas the pigs fed diets containing XPC or SGX showed no decrease. Transcriptional expression of genes involved in cellular stress (, , , ), tight junction integrity (, , ), and immune response (, , and ) were measured in the ileum mucosa. Pigs in all dietary treatments subjected to RHS had significantly higher ( < 0.05) transcript levels of and , and an upward trend ( < 0.07) of mRNA expression. RHS pigs had higher ( < 0.05) transcript levels of and in NON diet, in XPC and CBX diets, and in SGX diet compared to the respective diet-matched pigs in the NHS conditions. Neither RHS nor diet affected peripheral natural killer () cell numbers or NK cell lytic activity. In conclusion, pigs subjected to RHS had decreased performance, and supplementation with fermentation products in the feed (XPC and SGX) protected pigs from injury to the jejunum mucosa.

Sub-ice-shelf sediments record history of twentieth-century retreat of Pine Island Glacier.

The West Antarctic Ice Sheet is one of the largest potential sources of rising sea levels. Over the past 40 years, glaciers flowing into the Amundsen Sea sector of the ice sheet have thinned at an accelerating rate, and several numerical models suggest that unstable and irreversible retreat of the grounding line-which marks the boundary between grounded ice and floating ice shelf-is underway. Understanding this recent retreat requires a detailed knowledge of grounding-line history, but the locations of the grounding line before the advent of satellite monitoring in the 1990s are poorly dated. In particular, a history of grounding-line retreat is required to understand the relative roles of contemporaneous ocean-forced change and of ongoing glacier response to an earlier perturbation in driving ice-sheet loss. Here we show that the present thinning and retreat of Pine Island Glacier in West Antarctica is part of a climatically forced trend that was triggered in the 1940s. Our conclusions arise from analysis of sediment cores recovered beneath the floating Pine Island Glacier ice shelf, and constrain the date at which the grounding line retreated from a prominent seafloor ridge. We find that incursion of marine water beyond the crest of this ridge, forming an ocean cavity beneath the ice shelf, occurred in 1945 (±12 years); final ungrounding of the ice shelf from the ridge occurred in 1970 (±4 years). The initial opening of this ocean cavity followed a period of strong warming of West Antarctica, associated with El Niño activity. Thus our results suggest that, even when climate forcing weakened, ice-sheet retreat continued.

Modulation of pain via expectation of its location.

BACKGROUND: The spatial precision of expectancy effects on pain is unclear. We hypothesized that expecting nociceptive stimuli at particular skin sites would have an analgesic effect on nociceptive stimuli presented between them (middle zone). METHODS: Laser stimuli (evoking pin-prick pain) were delivered to three discrete skin zones on the forearm, under two conditions. During 'Localization', participants' expectation of stimuli was spatially divided between two locations (expected stimuli in only the outer two skin zones): pain intensity and stimulus location were judged. During 'No-localization' (control condition), participants had no expectation concerning stimulus location; only pain intensity was rated. Additional experiments assessed the importance of the actual location on the forearm by: shifting all skin zones proximally towards the elbow (control for joint proximity, Experiment 2); adding a fourth zone distally (control for interaction between joint proximity and enhanced distal inhibition, Experiment 3). RESULTS: All experiments demonstrated spatially specific pain modulation, but only Experiment 2 (near elbow) supported our hypothesis: middle zone pain intensity was significantly lower (p = 0.02) during Localization than No-localization. Experiment 1 (near wrist) found reduced pain intensity during Localization only for the distal zone (p = 0.04). Experiment 3 confirmed this effect: reduced pain during Localization occurred only for the most distal zone (p = 0.046). CONCLUSION: Expecting a painful stimulus in non-adjacent skin sites has spatially specific effects on pain modulation, but this reflects an interaction between the expected location of stimulation and the actual location. This suggests a more complex connection between somatotopic maps and nociceptive modulation than previously thought; several distinct mechanisms likely contribute.

Complete Genome Sequence of Coriobacteriaceae Strain 68-1-3, a Novel Mucus-Degrading Isolate from the Swine Intestinal Tract.

A novel Coriobacteriaceae bacterium (strain 68-1-3) was isolated from the ileum of the swine intestinal tract using a selective mucus-based medium. Here we present the finished genome sequence for the swine commensal, totaling 1.97 Mb in size.

Uraemic toxins and cardiovascular disease across the chronic kidney disease spectrum: an observational study.

BACKGROUND AND AIMS: There is a growing body of evidence supporting the nephrovascular toxicity of indoxyl sulphate (IS) and p-cresyl sulphate (PCS). Nonetheless, a comprehensive description of how these toxins accumulate over the course of chronic kidney disease (CKD) is lacking. METHODS AND RESULTS: This cross-sectional observational study included a convenience sample of 327 participants with kidney function categorised as normal, non-dialysis CKD and end-stage kidney disease (ESKD). Participants underwent measurements of serum total and free IS and PCS and assessment of cardiovascular history and structure (carotid intima-media thickness [cIMT, a measure of arterial stiffness]), and endothelial function (brachial artery reactivity [flow-mediated dilation (BAR-FMD); glyceryl trinitrate (BAR-GTN)]). Across the CKD spectrum there was a significant increase in both total and free IS and PCS and their free fractions, with the highest levels observed in the ESKD population. Within each CKD stage, concentrations of PCS, total and free, were significantly greater than IS (all p < 0.01). Both IS and PCS, free and total, were correlated with BAR-GTN (ranging from r = -0.33 to -0.44) and cIMT (r = 0.19 to 0.21), even after adjusting for traditional risk factors (all p < 0.01). Further, all toxins were independently associated with the presence of cardiovascular disease (all p < 0.02). CONCLUSION: More advanced stages of CKD are associated with progressive increases in total and free serum IS and PCS, as well as increases in their free fractions. Total and free serum IS and PCS were independently associated with structural and functional markers of cardiovascular disease. Studies of therapeutic interventions targeting these uraemic toxins are warranted.

Channelized ice melting in the ocean boundary layer beneath Pine Island Glacier, Antarctica.

Ice shelves play a key role in the mass balance of the Antarctic ice sheets by buttressing their seaward-flowing outlet glaciers; however, they are exposed to the underlying ocean and may weaken if ocean thermal forcing increases. An expedition to the ice shelf of the remote Pine Island Glacier, a major outlet of the West Antarctic Ice Sheet that has rapidly thinned and accelerated in recent decades, has been completed. Observations from geophysical surveys and long-term oceanographic instruments deployed down bore holes into the ocean cavity reveal a buoyancy-driven boundary layer within a basal channel that melts the channel apex by 0.06 meter per day, with near-zero melt rates along the flanks of the channel. A complex pattern of such channels is visible throughout the Pine Island Glacier shelf.

Stroke prevention in atrial fibrillation: an update on current management strategies.

Stroke attributed to atrial fibrillation (AF) confers significant morbidity and mortality. In the past, warfarin has been the only successful stroke prevention agent available. However, it is often underutilized due to its well-known limitations, leaving many patients without adequate stroke protection. The last decade has seen significant strides forward in the field of anticoagulation for AF. The development of several novel oral anticoagulants that have superior efficacy, improved safety profile and fixed doses without the need for regular monitoring make them favorable as viable alternatives to warfarin. Improved risk scoring systems for both thromboembolism and bleeding have also allowed clinicians to better target patients most likely to benefit from these new therapies. In addition, non-pharmacological approaches to stroke prevention such as left atrial appendage exclusion devices may be useful in patients whom anticoagulation therapy is contraindicated. These new pharmacological and non-pharmacological options for stroke prevention in AF permit clinicians to tailor their management of patients according to individual needs and characteristics. The present review aims to outline the latest up-to-date management of AF in stroke prevention.

Cloacibacillus porcorum sp. nov., a mucin-degrading bacterium from the swine intestinal tract and emended description of the genus Cloacibacillus.

A novel anaerobic, mesophilic, amino-acid-fermenting bacterium, designated strain CL-84(T), was isolated from the swine intestinal tract on mucin-based media. Cells were curved rods (0.8-1.2 × 3.5-5.0 µm), stained Gram-negative and were non-motile with no evidence of spores. Strain CL-84(T) produced acetate, propionate, formate and butyrate as the end products of metabolism when grown on serine. Optimum growth occurred at 39 °C and pH 6.5. The major cellular fatty acids were iso-C15:0, iso-C15:0 3-OH, iso-C17:0 and C16:0, distinguishing strain CL-84(T) from closely related species. The DNA G+C content of strain CL-84(T) was 55.1 mol%. 16S rRNA gene sequence analysis showed that strain CL-84(T) shared 90-95% similarity with characterized genera within the phylum Synergistetes, family Synergistaceae. Phylogenetic analysis showed that strain CL-84(T) was related to, but distinct from, Cloacibacillus evryensis. Based on these findings, we propose that strain CL-84(T) represents a novel species of the genus Cloacibacillus. We further propose the name Cloacibacillus porcorum sp. nov. be designated for this species. The type strain is CL-84(T) (=DSM 25858(T)=CCUG 62631(T)). An emended description of the genus Cloacibacillus is provided.

Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center?

BACKGROUND: The recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown. STUDY OBJECTIVES: The purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center. METHODS: We retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics. RESULTS: Our sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21-39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1-13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home. CONCLUSIONS: In hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.

Alcohol and lung airways function.

BACKGROUND: Limited data suggest that moderate alcohol drinkers may have better lung airways function than abstainers. Because few studies have fully accounted for confounders (including smoking and coronary disease), and some might have been biased by the inclusion with nondrinkers of alcohol drinkers who quit because of illness, we performed a cross-sectional analysis in a large free-living population. METHODS: We studied the relation between alcohol and airways function in 177,721 members of a comprehensive health plan. An item on a questionnaire administered as part of a health examination asked for "usual number of drinks in the past year." Respondents were asked to lump "wine, beer, whiskey, and cocktails" together. Health history queries included 47 items indicative of possible cardiorespiratory (CR) illness; participants with one or more positive response (61.0%) were classified as "CR yes." Lung function measurements were part of the health examination; we studied one-second forced expiratory volume (FEV(1)), forced vital capacity (FVC), and FEV(1)/FVC by analysis of covariance and FEV(1)/FVC <0.7 by logistic regression. Nondrinkers were the referent for alcohol categories; covariates were age, sex, ethnicity, smoking, education, body mass index, and CR composite yes/no. RESULTS: For each measure studied, persons reporting two or fewer drinks per day or three to five drinks per day had better airways function than nondrinkers (p < 0.001), but heavier drinkers had worse function. This J-shaped relation was consistent across multiple strata, including CR "yes" or "no." CONCLUSION: Independent of smoking and evident lung or heart disease, light to moderate drinkers of alcohol had better FEV(1), FVC, and FEV(1)/FVC than abstainers did. Although this association does not prove causality, drinking moderate amounts of alcoholic beverages may have some benefit for lung function.

Urgent in-patient coronary angiography: a comparison of centres with and without cardiac catheter facilities.

OBJECTIVES: To review the referral of patients to a tertiary centre for urgent angiography and to determine if there are differences in invasive treatment strategies for patients with acute coronary syndrome (ACS). METHODS: There were 2 parts to the study, a retrospective part over 3.5 years from a computerised cardiac laboratory booking data base and a prospective part over 3 months. RESULTS: There were 1190 urgent in-patient angiograms performed with 499 (42%) admitted initially to the tertiary centre while the remaining 691 (58%) were admitted to district general hospitals (DGH), with no on-site access to a cardiac laboratory, and subsequently transferred to the tertiary centre. Once referred, DGH patients waited longer for their angiogram (2.7 +/- 3.2 vs 2.0 +/- 2.8 days, p < 0.0001). Interestingly, DGH patients appear to spend an average of 4 days in hospital prior to referral for angiography. DGH patients were more likely to have a higher Thrombosis in Myocardial Infarction (TIMI) risk score at presentation and following angiography were more likely to have coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) and less likely to have angiographically normal arteries. CONCLUSIONS: Our findings are consistent with previous studies demonstrating that access to coronary angiography varies considerably between hospitals. However, we have demonstrated that patients in DGHs wait on average 4 days before referral for coronary angiography suggesting that there may be triage based on initial responses to medical therapy. Further research is needed to determine whether this has a direct effect on outcomes.