Examining service-user perspectives for the development of a good outcome checklist for individuals at clinical high risk for psychosis.

AIMS: Around 15% of patients at clinical high risk for psychosis (CHR-P) experience symptomatic remission and functional recovery at follow-up, yet the definition of a good outcome (GO) in this population requires further development. Outcomes are typically designed and rated by clinicians rather than patients, to measure adverse as opposed to GOs. Here we investigate how CHR-P subjects define a GO, with the aim of developing a checklist that could be used to measure GO in this clinical group. METHODS: A set of GO-focused questions were designed in collaboration with a service-user. CHR-P patients (n = 48) were asked to rate the importance of items that could indicate short-term (1 year) and long-term (5 years) GO. These items were then ranked using the relative importance index (RII). RESULTS: Patients rated improvement in subjective wellbeing (RII = 0.829) and non-specific presenting symptoms (RII = 0.817) amongst the factors most important for indicating GO in the short-term, and improved resilience (RII = 0.879) and negative symptoms (RII = 0.858) as key items for indicating long-term GO. Patients regarded building resilience (RII = 0.842) and having support from mental health services (RII = 0.833) as being protective for their mental health. These measures were included in a preliminary 12-item GO checklist (GO-12) for assessing GO in CHR-P subjects. CONCLUSIONS: Patient-defined measures of GO included items that are not incorporated into conventional measures of outcomes in CHR-P subjects, such as subjective wellbeing and resilience. Integrating patient-defined metrics of GO may improve the assessment of outcomes in the CHR-P population.

Medical student support for vulnerable patients during COVID-19 - a convergent mixed-methods study.

BACKGROUND: The coronavirus pandemic has exerted significant impacts on primary care, causing rapid digital transformation, exacerbating social isolation, and disrupting medical student and General Practice [GP] trainee education. Here we report on a medical student telephone initiative set-up by a final year GP trainee (the equivalent of a family medicine resident), which aimed to support patients at high risk and vulnerable to the Coronavirus Disease of 2019 [Covid-19]. In addition, it was hoped the project would mitigate a digital divide, enable proactive anticipatory planning, and provide an active learning environment to compensate for the pandemic's impact on medical education. METHODS: Thirty-three medical students conducted daily telephone conversations with high risk and vulnerable patients as specified by the initial NHSE published lists. They confirmed public health messages, offered details for voluntary support groups, established need for medication delivery, explored levels of digital connectivity, and prompted discussions around end-of-life choices. Students had access to online reflective resources and daily remote debriefing sessions with the GP trainee. A convergent mixed-methods evaluation was subsequently undertaken, using quantitative process and descriptive data and individual qualitative interviews were conducted according to a maximal variation sampling strategy with students, General Practitioners [GPs], and the GP trainee. Inductive thematic analysis was then applied with cross-validation, respondent validation, and rich evidential illustration aiding integrity. RESULTS: Ninety-seven 'high risk' and 781 'vulnerable' calls were made. Individuals were generally aware of public heath information, but some struggled to interpret and apply it within their own lives. Therefore respondents felt students provided additional practical and psychological benefits, particularly with regard to strengthening the links with the community voluntary groups. The project was widely liked by students who reported high levels of skill development and widened awareness, particularly valuing the active learning environment and reflective feedback sessions. CONCLUSION: This study demonstrates utilization of medical students as wider assets within the primary health care team, with an initiative that enables support for vulnerable patients whilst promoting active medical education. Ongoing integration of students within 'normal' primary health care roles, such as chronic disease or mental health reviews, could provide similar opportunities for supported active and reflective learning.

"Climatic fluctuations in the hyperarid core of the Atacama Desert during the past 215 ka".

Paleoclimate records from the Atacama Desert are rare and mostly discontinuous, mainly recording runoff from the Precordillera to the east, rather than local precipitation. Until now, paleoclimate records have not been reported from the hyperarid core of the Atacama Desert (<2 mm/yr). Here we report the results from multi-disciplinary investigation of a 6.2 m drill core retrieved from an endorheic basin within the Coastal Cordillera. The record spans the last 215 ka and indicates that the long-term hyperarid climate in the Central Atacama witnessed small but significant changes in precipitation since the penultimate interglacial. Somewhat 'wetter' climate with enhanced erosion and transport of material into the investigated basin, commenced during interglacial times (MIS 7, MIS 5), whereas during glacial times (MIS 6, MIS 4-1) sediment transport into the catchment was reduced or even absent. Pelagic diatom assemblages even suggest the existence of ephemeral lakes in the basin. The reconstructed wetter phases are asynchronous with wet phases in the Altiplano but synchronous with increased sea-surface temperatures off the coasts of Chile and Peru, i.e. resembling modern El Niño-like conditions.

Arsenic Speciation in Mekong Delta Sediments Depends on Their Depositional Environment.

Arsenic contamination in groundwater is pervasive throughout deltaic regions of Southeast Asia and threatens the health of millions. The speciation of As in sediments overlying contaminated aquifers is poorly constrained. Here, we investigate the chemical and mineralogical compositions of sediment cores collected from the Mekong Delta in Vietnam, elucidate the speciation of iron and arsenic, and relate them to the sediment depositional environment. Gradual dissolution of ferric (oxyhydr)oxides with depth is observed down to 7 m, corresponding to the establishment of reducing conditions. Within the reduced sediment, layers originating from marine, coastal or alluvial depositional environments are identified and their age is consistent with a late Holocene transgression in the Mekong Delta. In the organic matter- and sulfur-rich layers, arsenic is present in association with organic matter through thiol-bonding and in the form of arsenian pyrite. The highest arsenic concentration (34-69 ppm) is found in the peat layer at 16 m and suggests the accumulation of arsenic due to the formation of thiol-bound trivalent arsenic (40-55%) and arsenian pyrite (15-30%) in a paleo-mangrove depositional environment (∼8079 yr BP). Where sulfur is limited, siderite is identified, and oxygen- and thiol-bound trivalent arsenic are the predominant forms. It is also worth noting that pentavalent arsenic coordinated to oxygen is ubiquitous in the sediment profile, even in reduced sediment layers. But the identity of the oxygen-bound arsenic species remains unknown. This work shows direct evidence of thiol-bound trivalent arsenic in the Mekong Delta sediments and provides insight to refine the current model of the origin, deposition, and release of arsenic in the alluvial aquifers of the Mekong Delta.

Northward migration of the eastern Himalayan syntaxis revealed by OSL thermochronometry.

Erosion influences the dynamical evolution of mountains. However, evidence for the impact of surface processes on tectonics mostly relies on the circumstantial coincidence of rugged topography, high stream power, erosion, and rock uplift. Using the optically stimulated luminescence (OSL) thermochronometry technique, we quantified the spatial and temporal exhumation of the eastern Himalayan syntaxis. We found increasing exhumation rates within the past million years at the northeast end of the Namche Barwa-Gyala Peri dome. These observations imply headward propagation of erosion in the Parlung River, suggesting that the locus of high exhumation has migrated northward. Although surface processes influence exhumation rates, they do not necessarily engage in a feedback that sets the location of tectonic deformation.

Late reactivation of thyroid orbitopathy.

BACKGROUND: Thyroid orbitopathy is characterized by spontaneous remissions and exacerbations. Although data on the natural history are scarce, the active phase is usually self-limited, encompassing an average period of 18-36 months. Late reactivation, defined as active orbitopathy occurring after more than 5 years of quiescent disease, appears to be an uncommon and poorly documented event. The aim of the present study was to assess the incidence and characteristics of late reactivation of thyroid orbitopathy within a tertiary referral orbital clinic. METHODS: A retrospective case review was conducted of patients with thyroid orbitopathy seen at the Royal Adelaide Hospital Orbital Clinic between 1996 and 2001. RESULTS: From 193 cases of thyroid orbitopathy, eight cases (5%) of late reactivation were identified. The mean age of patients was 51 years (range 32-76 years) with a female to male ratio of 3:1. All cases presented with proptosis and seven demonstrated increased diplopia and gaze restriction. Signs of soft tissue inflammation were seen in three cases. All were euthyroid at presentation with a past history of thyroid orbitopathy and hyperthyroidism. One patient had an association of smoking with reactivation but the remainder had no discernible precipitants. The average interval between the initial orbitopathy and reactivation was 12 years (range 6-30 years). Computed tomography revealed enlarged extraocular muscles in seven cases and two showed partial response to treatment with low dose radiotherapy and steroids. The average length of disease activity was 14 months (range 9-18 months). CONCLUSION: Late reactivation of thyroid orbitopathy appears to be an uncommon phenomenon. It may occur under euthyroid conditions with no obvious precipitants and often presents as a reactivation of myopathy.