Estimates of Current Capacity for Diagnosing Alzheimer's Disease in Sweden and the Need to Expand Specialist Numbers.

BACKGROUND: The emergence of disease-modifying Alzheimer's (AD) treatments provides new hope to patients and families but concerns have been raised about the preparedness of healthcare systems to provide timely access to such treatments because of a combination of a complex diagnostic process and a large prevalent pool. OBJECTIVES: We assess the preparedness of Sweden, a high-income country known for its dementia-friendly policies, to diagnose AD patients eligible for treatment within a six-month window, given current capacity for specialist evaluations and biomarker testing. We calculate the investment requirements for Sweden to achieve this target over a timeframe of 20 years. DESIGN: Desk research to identify data for population, mortality, disease burden, cost of services and current capacity, expert consultation to inform assumptions about patient journey, and use of a Markov model to predict waiting times. The model simulates the patients' journey through different evaluation stages: initial evaluation by a primary care specialist, neurocognitive testing by an AD specialist, and confirmatory biomarker testing with PET scanning or cerebrospinal fluid (CSF) testing. The model assumes specialist appointments and PET scans are capacity constrained, and patients progress from cognitively normal to MCI and from MCI to dementia in the resulting waiting times. MEASUREMENTS: Projected waiting times for diagnosis of eligibility for disease-modifying Alzheimer's treatment from 2023 to 2042 assuming current capacity, assuming 20% of Swedish residents aged 60 years and above would seek an evaluation for cognitive decline. Investments required to scale capacity up to reach target of providing diagnosis within six months on average. RESULTS: Initial average waiting times for AD specialist appointments would be around 21 months in 2023 and remain around 55 months through 2042, as demand would continue to outstrip supply throughout the 20-year model horizon. Waiting times for biomarker testing would be stable at less than four weeks, as patients would be held up in the queue for their first specialist consultations, and use of CSF testing is widely accepted in Sweden. An additional 25% of AD specialists would have to be added above the current growth trend to reduce waiting times to less than 6 months at an average annual cost of approximately 805 million SEK. The increased cost of volume of biomarker testing would amount to about 106 million SEK per year. CONCLUSIONS: At current capacity, the Swedish healthcare system is unable to provide timely diagnosis of patients eligible for disease-modifying AD treatment. Although future diagnostic technologies, such as digital cognitive assessments and blood tests for the AD pathology, might decrease demand for capacity-constrained services, substantial investments will be required to meet a target of less than six months of waiting time for a diagnosis.

Social-pair judgment bias testing in slow-growing broiler chickens raised in low- or high-complexity environments.

Impacts of environmental complexity on affective states in slow-growing broiler chickens (Gallus gallus domesticus) are unknown. Chickens' performance in judgment bias tests (JBT) can be limited as they are tested individually, causing fear and anxiety. The objectives were to apply a social-pair JBT to assess the effect of environmental complexity on slow-growing broiler chickens` affective states, and assess the impact of fearfulness, anxiety, and chronic stress on JBT performance. Six-hundred Hubbard Redbro broilers were housed in six low-complexity (similar to commercial) or six high-complexity (permanent and temporary enrichments) pens. Twelve chicken pairs were trained (1 pair/pen, n = 24 chickens) using a multimodal approach (visual and spatial cues), with reward and neutral cues of opposing color and location. Three ambiguous cues were tested: near-positive, middle, and near-neutral cues. Approach and pecking behavior were recorded. Eighty-three percent of chickens (20/24) were successfully trained in 13 days. Fearfulness, anxiety, and chronic stress did not impact chickens' performance. Chickens successfully discriminated between cues. Low-complexity chickens approached the middle cue faster than high-complexity chickens, indicating that they were in a more positive affective state. The environmental complexity provided in this study did not improve affective states in slow-growing broiler chickens compared to a control. A social-pair JBT resulted in excellent learning and testing outcomes in slow-growing broilers.

Setup of a Contamination Control Strategy Using the Hazard Analysis Critical Control Point (HACCP) Methodology.

A Contamination Control Strategy (CCS) is a document that focuses on how to prevent contaminations with microorganisms, particles, and pyrogens within sterile and/or aseptic and preferably also in nonsterile manufacturing facilities. This document determines to what extent measures and controls in place are efficient in preventing contamination. In order to efficiently evaluate and control all potential hazards associated with sources of contamination within a CCS, the Hazard Analysis Critical Control Point (HACCP) methodology could be a useful tool to monitor all Critical Control Points (CCPs) related to various sources of contamination. This article describes a way to set up the CCS within a pharmaceutical sterile and aseptic manufacturing facility (GE HealthCare Pharmaceutical Diagnostics) by applying the HACCP methodology. In 2021, a global CCS procedure and a general HACCP template became effective for the GE HealthCare Pharmaceutical Diagnostics sites having sterile and/or aseptic manufacturing processes. This procedure guides the sites through the setup of the CCS by applying the HACCP methodology and helps each site to evaluate whether the CCS is still effective taking all (proactive and retrospective) data following the CCS into account. A summary of setting up a CCS using the HACCP methodology, specifically for the pharmaceutical company GE HealthCare Pharmaceutical Diagnostics Eindhoven site, is provided in this article. Use of the HACCP methodology enables a company to include proactive data within the CCS, making use of all identified sources of contamination, associated hazards, and/or control measures and CCPs. The constructed CCS allows the manufacturer to identify whether all included sources of contamination are under control and, if not, which mitigatory actions need to be performed. All current states are reflected by a traffic light color to reflect the level of residual risk, thereby providing a simple and clear visual representation of the current contamination control and microbial state of the manufacturing site.

Enhancing their quality of life: environmental enrichment for poultry.

Providing environmental enrichments that increase environmental complexity can benefit poultry welfare. This Poultry Science Association symposium paper is structured around four themes on 1) poultry preferences and affective states 2) species-specific behavior, including play behavior and the relationship between behavior, activity level and walking ability, 3) environmental enrichment and its relationship with indicators of welfare, and 4) a case study focusing on the application of enrichments in commercial broiler chicken production. For effective enrichment strategies, the birds' perspective matters most, and we need to consider individual variation, social dynamics, and previous experience when assessing these strategies. Play behavior can be a valuable indicator of positive affect, and while we do not yet know how much play would be optimal, absence of play suggests a welfare deficit. Activity levels and behavior can be improved by environmental modifications and prior research has shown that the activity level of broilers can be increased, at least temporarily, by increasing the environmental complexity. However, more research on impacts of enrichments on birds' resilience, on birds in commercial conditions, and on slow(er)-growing strains is needed. Finally, incorporating farmers' expertise can greatly benefit enrichment design and implementation on commercial farms.

Public and industry knowledge and perceptions of US swine industry castration practices.

In the United States (US), surgical castration of male piglets is typically performed without any form of analgesia. This may raise concerns with the public; however, there is no information regarding current public knowledge on swine industry practices in the US. In this study we gained insight into public knowledge and perception on castration with and without analgesia in comparison to knowledge of industry stakeholders on these same topics. Through an online survey, 119 respondents were asked four questions about castration in the US swine industry. Industry respondents were contacted via social media and networking. The general public sample was accessed through Mechanical Turk. Survey responses were categorised by experience (industry vs public). Industry respondents were more aware of practices compared to the general public. Most public respondents were unaware of castration practices and the lack of analgesia use. Respondents from rural communities were more aware of castration practices than (sub)urban communities and more aware of analgesia use than those from urban communities. Those with more education had greater awareness of castration practices (occurrence not frequency). Based on the results from this first US sample, knowledge on industry practices was especially lacking for public respondents, but also for a minority of industry respondents, indicating opportunities for education and further research on the topic.

Recovering an endangered frog species through integrative reproductive technologies.

The establishment and management of ex situ breeding and assurance populations around the globe are meant to provide short-term solutions to the formidable loss of amphibian diversity presently occurring. Large multi-scaled facilities, such as zoos and aquariums, can provide the infrastructure to safeguard species and populations. However, often even large, economically viable facilities lack the knowledge to efficiently cater to the plethora of environmentally controlled physiological strategies that amphibians possess. Anurans present a class of amphibians that have often been viewed as easy to maintain ex situ. However, while adult survival may be relatively successful it is rarely accompanied by good reproductive output, health, and fitness. Even more conspicuous is the low survivorship of offspring produced ex situ once they are translocated back into the wild. The mountain yellow-legged frog (R. muscosa) ex situ breeding program EBP is a prime example of the challenges that amphibians EBPs face. Although more research is needed, the R. muscosa program has increased reproductive output and health of its colony by incorporating reproductive technologies and strategic genetic management in conjunction with a greater understanding of the species' natural history, to produce and translocate viable animals each year. This paper highlights the EBPs past decade of research featuring the program's contribution to building empirical, multidisciplinary approaches that boost the robustness of an endangered species, by safeguarding existing genetic diversity and maximizing fitness and survival outcomes.

Evaluation of mechanical cervical dislocation, captive bolt, carbon dioxide, and electrical methods for individual on-farm euthanasia of broiler breeders.

Efficacious euthanasia by applying manual cervical dislocation can be difficult on large and mature poultry. The challenge with using manual cervical dislocation is that the strength required to hold heavy poultry and swiftly apply cervical dislocation can be physically impossible for most people. Therefore, alternative methods of euthanasia are needed for mature and large poultry. Mechanical cervical dislocation using the Koechner Euthanizing Device (KED), captive bolt using the Turkey Euthanasia Device (TED), carbon dioxide (CO2), and electrical euthanasia were evaluated for use on 65-wk-old broiler breeders at flock termination. Following application of each method, physiological reflexes including the eye nictitating membrane reflex, mouth gaping, and body movement, broken skin, blood loss, kill success, time to cessation of heartbeat, and blood plasma corticosterone levels were assessed. Birds euthanized using the KED had longer response durations for eye nictitating membrane (91 s) and reflexive mouth gaping (161 s) compared to TED, CO2, and electrical euthanasia (0-7 s). Body movement durations were also longer for KED (214 s) and TED (209 s) than for CO2 and electrical euthanasia (0-8 s). The highest percentages of broken skin (93%) and blood loss (96%) were observed for TED, followed by KED (71%, 68%), then CO2 (0%, 6%) and electrical euthanasia (0%, 3%). No significant differences (P = 0.1781) were observed for kill success rates with 98% for KED, 100% for TED, 97% for CO2, and 100% for electrical euthanasia at 4-min. Time to heartbeat cessation did not differ between KED (659 s), TED (427 s), or CO2 (583 s) euthanasia methods. No heartbeat was detected following electrical euthanasia. Blood plasma corticosterone levels did not differ between preeuthanasia or posteuthanasia from any of the methods applied. Based on these results each euthanasia method is acceptable for use with broiler breeders.

Impact of environmental complexity and stocking density on affective states of rainbow trout (Oncorhynchus mykiss).

Environmental condition, such as environmental complexity or stocking density, can directly or indirectly influence animal emotion and ultimately, affective state. Affective states of animals can be assessed through judgement bias tests, evaluating responses to ambiguous situations. In this study, we aimed to determine whether environmental complexity and stocking density impacted rainbow trout affective state. Rainbow trout (n = 108) were housed in recirculating aquaculture systems under commercial conditions while trained at tank-level to discriminate between a positively reinforced chamber (feed) in one location and a negative chamber (positive punishment; chase by net for 1 s) in the opposing location. Fish from successful tanks (two out of five tanks) were then housed in treatment tanks of either high- or low- environmental complexity at either high (165 fish/m3) or low (69 fish/m3) stocking density. Trained fish were tested for latencies to approach three intermediate, ambiguous chambers. Fish housed in high-density tanks were faster to enter all chambers than those housed in low-density tanks (8.5 s vs. 15.2 s; P = 0.001), with faster entries into the positive (7.4 s vs. 15.2 s; P = 0.02) and near-negative chambers (10.2 s vs. 17.4 s; P = 0.006), suggesting that these fish were more optimistic to receive a feed reward. Tank complexity did not affect test outcomes. No differences between treatments were observed between body weight, length, and plasma cortisol. Overall, rainbow trout are capable of discriminating between cues during a judgement bias test and fish housed in high-density environments respond more optimistically in ambiguous situations compared to fish in low-density environments.

Environmental complexity positively impacts affective states of broiler chickens.

Affective state can bias an animal's judgement. Animals in positive affective states can interpret ambiguous cues more positively ("optimistically") than animals in negative affective states. Thus, judgement bias tests can determine an animal's affective state through their responses to ambiguous cues. We tested the effects of environmental complexity and stocking density on affective states of broiler chickens through a multimodal judgement bias test. Broilers were trained to approach reinforced locations signaled by one color and not to approach unreinforced locations signaled by a different color. Trained birds were tested for latencies to approach three ambiguous cues of intermediate color and location. Broilers discriminated between cues, with shorter latencies to approach ambiguous cues closest to the reinforced cue than cues closest to the unreinforced cue, validating the use of the test in this context. Broilers housed in high-complexity pens approached ambiguous cues faster than birds in low-complexity pens-an optimistic judgement bias, suggesting the former were in a more positive affective state. Broilers from high-density pens tended to approach all cues faster than birds from low-density pens, possibly because resource competition in their home pen increased food motivation. Overall, our study suggests that environmental complexity improves broilers' affective states, implying animal welfare benefits of environmental enrichment.

[Outpatient clinic for users of anabolic androgenic; experiences and practical tools]. / De Anabolenpoli.

In the Netherlands, an estimated 20,000 men abuse illegal androgens. The confrontation with a patient who uses illegal substances can evoke questions and emotions. We advise not to moralize users of anabolic steroids, but to strive for harm reduction by starting a discussion about the pros and cons of androgen abuse, taking into account your assumptions and judgments about this subject. Underlying psychopathology should be recognized and treated if the user is open to it. We recommend against prescribing anabolic steroids without medical indication and not to perform health checks routinely while the patient continues using anabolic steroids as long as it is not established that this can prevent health damage. If the user reports with health problems, this should be used as a starting point to (re) open the conversation about the advantages and disadvantages of use. Harmful effects of use must be handled according to appropriate guidelines.

Genetics of facial telangiectasia in the Rotterdam Study: a genome-wide association study and candidate gene approach.

BACKGROUND: The severity of facial telangiectasia or red veins is associated with many lifestyle factors. However, the genetic predisposition remains unclear. OBJECTIVES: We performed a genome-wide association study (GWAS) on facial telangiectasia in the Rotterdam Study (RS) and tested for replication in two independent cohorts. Additionally, a candidate gene approach with known pigmentation genes was performed. METHODS: Facial telangiectasia were extracted from standardized facial photographs (collected from 2010-2013) of 2842 northwestern European participants (median age 66.9, 56.8% female) from the RS. Our GWAS top hits (P-value <10-6 ) were tested for replication in 460 elderly women of the SALIA cohort and in 576 additional men and women of the RS. Associations of top single nucleotide polymorphisms (SNPs) with expression quantitative trait loci (eQTL) in various tissues were reviewed (GTEx database) alongside phenotype associations in the UK biobank database. SNP-based associations between known pigmentation genes and facial telangiectasia were tested. Conditional analysis on skin colour was additionally performed. RESULTS: Our most significant GWAS signal was rs4417318 (P-value 5.38*10-7 ), an intergenic SNP on chromosome 12 mapping to the SLC16A7 gene. Other suggestive SNPs tagged genes ZNF211, ZSCAN4, ICOS and KCNN3; SNP eQTLs and phenotype associations tagged links to the vascular system. However, the top signals did not pass significance in the two replication cohorts. The pigmentation genes KIAA0930, SLCA45A2 and MC1R, were significantly associated with telangiectasia in a candidate gene approach but not independently of skin colour. CONCLUSION: In this GWAS on telangiectasia in a northwestern European population, no genome-wide significant SNPs were found, although suggestive signals indicate genes involved in the vascular system might be involved in telangiectasia. Significantly associated pigmentation genes underline the link between skin colour and telangiectasia.

Device and method for nonlinear ultrasonic measurements on highly irradiated 304 stainless steel specimens in a hot cell environment.

This paper reports on the first successful nonlinear ultrasonic measurement on highly irradiated specimens in a hot cell environment. The specimens are ANSI 304 stainless steel specimens for which the microstructure characterization and ultrasonic velocity measurement have been previously conducted. The critical part of this research is the development of an automatic fixture device that can facilitate repeatable loading and unloading to place the contact ultrasonic transducers on and off of the specimen. The key step to achieve high measurement repeatability is a careful adjustment of the support-spring constants such that the contact force at the interface between the transducer face and specimen surface is as uniform and constant as possible. The longitudinal ultrasonic velocities, which are obtained as a by-product of the nonlinear ultrasonic measurements, show a level of random variation in terms of (max-min)/average (%) below 0.2%, and the velocity distributions and magnitudes are in good agreement with those from the previous work. The ultrasonic nonlinearity parameters show the level of random variation below 4.7%, which is extremely low, considering that the measurements are conducted in a hot cell environment. The nonlinearity parameters also show a strong dependence on the measurement location in a particular specimen with respect to the radiation source, demonstrating a possible inhomogeneous microstructure evolution in these 12.7 mm thick specimens. This research demonstrates the feasibility of making nonlinear ultrasonic measurement on highly radioactive materials and/or in a highly radioactive environment using the device and procedure developed.

Epidemiology and determinants of facial telangiectasia: a cross-sectional study.

BACKGROUND: Telangiectasia or red veins are one of the prominent features of facial skin ageing. To date, there are few studies investigating the determinants of telangiectasia. OBJECTIVES: We investigated lifestyle and physiological factors associated with facial telangiectasia in a large prospective Dutch cohort study. METHODS: Telangiectasia was quantified digitally from standardized facial photographs of 2842 North European participants (56.8% female, median age 66.9) from the Rotterdam Study, collected in 2010-2013. Effect estimates from multivariable linear regressions are presented as the percentage difference in the mean value of telangiectasia area per unit increase of a determinant (%Δ) with corresponding 95% CI. RESULTS: Significant determinants were older age [1.7%Δ per year (95% CI 1.4, 2.0)], female sex [18.3%Δ (95% CI 13.2, 23.6)], smoking [current versus never 38.4%Δ (95% CI 30.3, 47.0); former versus never 11.6%Δ (95% CI 6.6, 16.9)], a high susceptibility to sunburn [10.2%Δ (95% CI 5.4, 15.3)] and light skin colour [pale versus white-to-olive 31.4%Δ (95% CI 19.7, 44.1]; white vs. white-to-olive 9.2%Δ (95% CI 2.8, 16.0)]. CONCLUSIONS: In this large cohort study, we confirmed known and described new determinants of facial telangiectasia.

The Pediatric Sepsis Biomarker Risk Model (PERSEVERE) Biomarkers Predict Clinical Deterioration and Mortality in Immunocompromised Children Evaluated for Infection.

Pediatric sepsis and bacterial infection cause significant morbidity and mortality worldwide, with immunocompromised patients being at particularly high risk of rapid deterioration and death. This study evaluated if PERSEVERE, PERSEVERE-II, or the PERSEVERE biomarkers, can reliably estimate the risk of clinical deterioration and 28-day mortality among immunocompromised pediatric patients. This is a single-center prospective cohort study conducted from July 2016 through September 2017 incorporating 400 episodes of suspected bacterial infection from the inpatient units at Cincinnati Children's Hospital Medical Center, a large, tertiary care children's hospital. The primary analysis assessed clinical deterioration within 72 hours of evaluation for infection. Secondarily, we assessed 28-day mortality. Clinical deterioration was seen in 15% of subjects. Twenty-eight day mortality was 5%, but significantly higher among critically ill patients. Neither PERSEVERE nor PERSEVERE-II performed well to predict clinical deterioration or 28-day mortality, thus we derived new stratification models using the PERSEVERE biomarkers with both high sensitivity and negative predictive value. In conclusion, we evaluated previously validated biomarker risk models in a novel population of largely non-critically ill immunocompromised pediatric patients, and attempted to stratify patients based on a new outcome metric, clinical deterioration. The new highly predictive models indicate common physiologic pathways to clinical deterioration or death from bacterial infection.

Tracking progress on the health status and service delivery outcomes for neonates and children in the Metro West geographic service area of the Cape Metropole, 2010 - 2015

Background. Monitoring the health status of populations of children is one of the building blocks of the health system. The provision of an indicator dashboard with disaggregated data that are collected over time can be used to gauge the performance of the health system, guide the allocation of resources and prioritise health interventions within districts.Objectives. To determine neonatal and child mortality, morbidity and health service outcomes over a 6-year period in the Metro West geographic service area (GSA) of the Cape Town metropole.Methods. A dashboard with key indicators was developed using existing data.Results. From 2010 to 2015, there was a decrease in the perinatal mortality rate from 31.7 to 24.8 per 1 000 deliveries, and the early neonatal and neonatal mortality rates from 7.8 and 8.6 to 7.0 and 8.2 per 1 000 live births, respectively. The main obstetric causes of early neonatal deaths were antepartum haemorrhage (22 - 24%) and unexplained intrauterine death (13 - 16%); the main neonatal causes were immaturity (17 - 34%), congenital abnormalities (23 - 29%) and hypoxia (23 - 26%). Under-five mortality decreased in 2013 from 25 to 22 per 1 000 live births, with the main causes being neonatal conditions (32%), pneumonia (25%), congenital abnormalities (9%), injuries (8%) and diarrhoea (8%). Fifty percent of child deaths were out of hospital, with pneumonia and diarrhoea accounting for more than half of these. There was an improvement in health service coverage rates in 2015: immunisation <1 year old (99%); measles second dose (85%), pneumococcal third dose (100%) and rotavirus second dose (100%); maternal antiretroviral coverage (90%); HIV testing in mothers (93%); HIV DNA polymerase chain reaction testing in babies (97%); and a decrease in HIV transmission (2%). Exclusive breastfeeding coverage rates at 14 weeks, and vitamin A supplementation at 12 - 59 months, were only 30% and 44%,respectively, across the GSA.Conclusion. There was a decrease in perinatal, early neonatal, infant and under-five mortality in Metro West over the 6 years. Further reductions in under-five mortality will require focusing on interventions to reduce neonatal and out-of-hospital deaths across the service delivery platform. Home visits to at-risk mothers and infants by community health workers could prevent out-of-hospital deaths and improve exclusive breastfeeding and vitamin A coverage. This will require increasing the number of community health workers and broadening their scope of practice

Development of a 3-D printing-based cardiac surgical simulation curriculum to teach septal myectomy.

OBJECTIVE: We sought to develop a 3-D printing-based simulator for teaching extended septal myectomy to trainees in cardiothoracic surgery (clinical postgraduate year 4-7). This procedure is difficult to teach because of generally unfamiliar and highly variable anatomy, limited visibility for the assistant, and significant potential complications. METHODS: A curriculum using multimedia didactics and 3-D print-based patient-specific surgical simulation was implemented. Six identical 3-D prints were constructed for each of 5 consecutive patients. Preoperative septal myectomy was performed on each printed heart by an attending surgeon and 5 residents. Model myectomy specimen volumes were measured according to liquid displacement. All print resections were videotaped and blindly evaluated by 3 attending surgeons. Pre- and post-test evaluations, and a survey tool were also used to evaluate the curriculum. RESULTS: Baseline myectomy resection volumes differed significantly (attending 15 cm3 vs resident 3.1 cm3; P < .05). Residents resected increasingly larger volumes of tissue over the course of the study. Initial resection volume (compared with faculty) increased by 0.82 cm3 per resection (95% confidence interval, 0.37-1.3 cm3; P < .0001). Total resection volume (compared with faculty) increased by 3.6 cm3 per resection (95% confidence interval, 2.4-4.9 cm3; P < .0001). The residents' survey assessment of the simulator was favorable. CONCLUSIONS: A patient-specific 3-D printing-based simulation module shows promise as a tool to augment and improve cardiothoracic resident training in septal myectomy. The residents were quickly able to perform resections on par with the attending. Residents rated the simulator favorably. Each resident benefited by experiencing the variable anatomy of 5 separate patient-specific models.

Flipping the classroom: Case-based learning, accountability, assessment, and feedback leads to a favorable change in culture.

OBJECTIVE: The 88-week Thoracic Surgery Curriculum is challenging to implement because of the large content in a traditional lecture format. This study investigates flipping the classroom by using a case-based format designed to stimulate resident preparation and engagement. METHODS: The didactic conference format was altered. Curricular reading assignments, case review, and conference participation prepared residents for novel formative assessment quizzes. Ten residents participated, and faculty served as controls. Scores were compared with the use of linear regression adjusted for clustering of responses for each person. A survey was administered to determine impressions of this educational technique. RESULTS: A majority of residents completed curricular readings (82%) and reviewed case presentations (79%). Resident performance initially lagged behind faculty but exceeded faculty performance by the conclusion (interaction P = .047). Junior resident overall performance was superior to senior residents over the entire analysis (P = .026); however, both groups improved over time similarly (P = .34) Increased reading from the curriculum (5% increase per level, P = .001) and case presentation review (6% increase per level, P < .0001) were associated with improved quiz performance. Residents presenting cases at their session performed no better than other quiz-takers for the same session (P = .38). The majority of residents viewed this method favorably. CONCLUSIONS: This method stimulated increased resident participation and engagement in this pilot study. Assessment scores increased at both resident levels, and resident performance exceeded faculty performance with time. By using experiential learning principles, flipping the classroom in this manner may improve educational culture by enhancing accountability, assessment, and feedback.

Long-term depressive symptoms and anxiety after transient ischaemic attack or ischaemic stroke in young adults.

BACKGROUND AND PURPOSE: Few studies exist on long-term post-stroke depressive symptoms and anxiety in young adults, although these young patients have a particular interest in their long-term prognosis, given their usually long life expectancy and being in the midst of an active social, working and family life. The aims of this study were to investigate the prevalence of depressive symptoms and anxiety and their association with clinical and demographic variables and with functional outcome after stroke in young adults. METHODS AND RESULTS: Long-term prevalence of depressive symptoms and anxiety was calculated in 511 patients with a transient ischaemic attack or ischaemic stroke, aged 18-50 years, using the Hospital Anxiety and Depression scale, compared with 147 controls. Functional outcome was assessed with the modified Rankin Score (mRS) and the Instrumental Activities of Daily Living scale (IADL). 16.8% of patients had depressive symptoms and 23.0% had anxiety, versus 6.1% (P = 0.001) and 12.2% (P < 0.001) in controls. In ischaemic stroke patients, depressive symptoms and anxiety were associated with poor functional outcome (mRS > 2 or IADL < 8). CONCLUSION: Even a decade after stroke at young age, depressive symptoms and anxiety were prevalent and associated with poor functional outcome. Therefore, even in the long term, treating physicians should be aware of the long-term presence of these symptoms as their recognition may be the first step in improving long-term functional independence.

The direct impact of landslides on household income in tropical regions: A case study from the Rwenzori Mountains in Uganda.

Landslides affect millions of people worldwide, but theoretical and empirical studies on the impact of landslides remain scarce, especially in Sub-Saharan Africa. This study proposes and applies a method to estimate the direct impact of landslides on household income and to investigate the presence of specific risk sharing and mitigation strategies towards landslides in a tropical and rural environment. An original cross-sectional household survey is used in combination with geographical data to acquire detailed information on livelihoods and on hazards in the Rwenzori mountains, Uganda. Ordinary least square regressions and probit estimations with village fixed effects are used to estimate the impact of landslides and the presence of mitigation strategies. Geographical information at household level allows to disentangle the direct impact from the indirect effects of landslides. We show that the income of affected households is substantially reduced during the first years after a landslide has occurred. We find that members of recently affected households participate more in wage-employment or in self-employed activities, presumably to address income losses following a landslide. Yet, we see that these jobs do not provide sufficient revenue to compensate for the loss of income from agriculture. Given that landslides cause localized shocks, finding a significant direct impact in our study indicates that no adequate risk sharing mechanisms are in place in the Rwenzori sub-region. These insights are used to derive policy recommendations for alleviating the impact of landslides in the region. By quantifying the direct impact of landslides on household income in an agricultural context in Africa this study draws the attention towards a problem that has been broadly underestimated so far and provides a sound scientific base for disaster risk reduction in the region. Both the methodology and the findings of this research are applicable to other tropical regions with high landslide densities.