Traumatic Brain Injury in Older Adults: A Descriptive & Etiologic Analysis

A two-part study was undertaken to determine the characteristics and incidence of older adults who sustained a traumatic brain injury (TBI) while in Ontario home care from 2003 to 2013, and to determine the association between depression and sustaining a TBI. Both parts used data from the Ontario Association of Community Care Access Center’s database. Data were retrieved for all service users 65 years or older who had home care between 2003 and 2013; these data are based on the Resident Assessment Instrument-Home Care. The variables used in the analyses included: TBI, depression, demographics, neurological conditions and history of falling. For the descriptive component, comparisons of characteristics were made between service users who did and did not sustain a TBI using odds ratios (OR). The ten-year trend of annual cumulative incidence and standardized incidence rates were assessed using regression. For the etiologic component, incident TBI cases were matched to four controls by age, sex and date of assessment. Crude OR’s were determined for the association between depression and TBI. Multivariable conditional logistic regression was used to adjust for potential confounders and identify effect modifiers. Multivariable estimates were stratified by history of falling. A total of 554,313 service users were included, of which 5215 (0.9%) had a TBI and 39,048 (7.0%) had depression. Characteristics associated with TBI were: male sex (OR: 1.54, 95% CI: 1.45, 1.62), aboriginal origin (OR: 1.98; 95% CI: 1.57, 2.50), increasing age (OR: 1.22, 95% CI: 1.09, 1.35 for 70-74; up to OR: 2.31, 95% CI: 2.05, 2.59 for >90; referent group 65-69), being widowed (OR: 1.59, 95% CI: 1.41, 1.80), having a history of one or more falls (OR: 2.31, 95% CI: 2.19, 2.44), the use of antidepressants (OR: 1.49, 95% CI: 1.40, 1.59) and the presence of depression (OR: 1.57, 95% CI: 1.43, 1.71), dementia (OR: 1.65, 95% CI: 1.54, 1.76), hemiplegia (OR: 4.34, 95% CI: 3.88, 4.85), multiple sclerosis (OR: 3.19, 95% CI: 2.49, 4.08) and parkinsonism (OR: 1.22, 95% CI: 1.07, 1.38). Incidence was significantly higher than previously reported figures in the general population. There was a decrease in the annual cumulative incidence over the ten-year period. Female standardized rates decreased significantly (p<0.05) in a linear fashion while male and overall decreased in a non-linear fashion. The crude OR for the association between depression and TBI was 1.54 (95% CI: 1.43, 1.64). Stratified analyses indicated that the association was significantly different for those with a history of falling (OR: 1.45, 95% CI: 1.22, 1.73) and those without a history of falling (OR: 1.19, 95% CI: 0.99, 1.42). Multivariable analysis suggested that there were three significant effect modifiers for the exposure: history of falling, level of education and Alzheimer’s. As the level of education increased, the association between depression and TBI became smaller (OR: 1.88, 95% CI: 1.30, 2.70 for 8th grade or less compared to OR: 1.11, 95% CI: 0.78, 1.65 for graduate degree). Service users with a TBI had greater odds of having a history of falling (OR: 1.45, 95% CI: 1.22, 1.73) and being diagnosed with Alzheimer’s Disease (OR: 1.18, 95% CI: 1.05, 1.32). Longitudinal studies are needed to confirm this finding, as our study was cross-sectional in nature, and to investigate the association between other chronic conditions and TBI

Application rates to surgical residency programs in Canada

Purpose:&nbsp;The purpose of this study is to identify if the&nbsp;previously reported declining interest in surgery amongst medical students persists,&nbsp;and also&nbsp;to&nbsp;provide more descriptive analysis of trends by surgical specialty and medical school. Our hypothesis is that the previously reported decreasing interest in surgery remains constant for some surgical disciplines. Methods:&nbsp;The&nbsp;Canadian Resident Matching Service and the Association of Faculties of Medicine of Canada provided&nbsp;data for this study.&nbsp;Several metrics of interest in surgery,&nbsp;including overall application trends, applications by discipline, and rankings by school of graduation were evaluated.&nbsp;Descriptive statistics and linear regression modeling&nbsp;were used.&nbsp; Results:&nbsp;Between 2007 and 2017 the number of non-surgical residency positions and Canadian medical graduates increased significantly. However, the number&nbsp;of surgical residency positions and&nbsp;applications to surgical programs did&nbsp;not change significantly. The number of rankings to orthopedic and vascular surgery decreased significantly.&nbsp;&nbsp;Likewise,&nbsp;applicants to general, orthopedic, plastic, otolaryngology, and vascular surgery decreased significantly.&nbsp;Vascular surgery saw a significant decrease in first choice rankings.&nbsp;&nbsp;Total rankings to surgical programs increased significantly at McGill, with no significant change at other Canadian institutions.&nbsp; Conclusions:&nbsp;The findings of this study suggest that while the number of applicants to surgical residency positions has been consistent, it is not keeping pace with the growing number of both CMGs and non-surgical residency positions. Furthermore, by using other measures of medical student interest in surgical specialties, such as the total number of rankings to a specialty through the residency matching process, the total number of applicants applying to a surgical discipline and the total number of first choice ranks that each surgical discipline received, we have demonstrated that there is a possible declining interest in some surgical disciplines.&nbsp

Texture Segregation By Visual Cortex: Perceptual Grouping, Attention, and Learning

A neural model is proposed of how laminar interactions in the visual cortex may learn and recognize object texture and form boundaries. The model brings together five interacting processes: region-based texture classification, contour-based boundary grouping, surface filling-in, spatial attention, and object attention. The model shows how form boundaries can determine regions in which surface filling-in occurs; how surface filling-in interacts with spatial attention to generate a form-fitting distribution of spatial attention, or attentional shroud; how the strongest shroud can inhibit weaker shrouds; and how the winning shroud regulates learning of texture categories, and thus the allocation of object attention. The model can discriminate abutted textures with blurred boundaries and is sensitive to texture boundary attributes like discontinuities in orientation and texture flow curvature as well as to relative orientations of texture elements. The model quantitatively fits a large set of human psychophysical data on orientation-based textures. Object boundar output of the model is compared to computer vision algorithms using a set of human segmented photographic images. The model classifies textures and suppresses noise using a multiple scale oriented filterbank and a distributed Adaptive Resonance Theory (dART) classifier. The matched signal between the bottom-up texture inputs and top-down learned texture categories is utilized by oriented competitive and cooperative grouping processes to generate texture boundaries that control surface filling-in and spatial attention. Topdown modulatory attentional feedback from boundary and surface representations to early filtering stages results in enhanced texture boundaries and more efficient learning of texture within attended surface regions. Surface-based attention also provides a self-supervising training signal for learning new textures. Importance of the surface-based attentional feedback in texture learning and classification is tested using a set of textured images from the Brodatz micro-texture album. Benchmark studies vary from 95.1% to 98.6% with attention, and from 90.6% to 93.2% without attention.Air Force Office of Scientific Research (F49620-01-1-0397, F49620-01-1-0423); National Science Foundation (SBE-0354378); Office of Naval Research (N00014-01-1-0624

A process-based model of conifer forest structure and function with special emphasis on leaf lifespan

We describe the University of Sheffield Conifer Model (USCM), a process-based approach for simulating conifer forest carbon, nitrogen, and water fluxes by up-scaling widely applicable relationships between leaf lifespan and function. The USCM is designed to predict and analyze the biogeochemistry and biophysics of conifer forests that dominated the ice-free high-latitude regions under the high pCO2 “greenhouse” world 290–50 Myr ago. It will be of use in future research investigating controls on the contrasting distribution of ancient evergreen and deciduous forests between hemispheres, and their differential feedbacks on polar climate through the exchange of energy and materials with the atmosphere. Emphasis is placed on leaf lifespan because this trait can be determined from the anatomical characteristics of fossil conifer woods and influences a range of ecosystem processes. Extensive testing of simulated net primary production and partitioning, leaf area index, evapotranspiration, nitrogen uptake, and land surface energy partitioning showed close agreement with observations from sites across a wide climatic gradient. This indicates the generic utility of our model, and adequate representation of the key processes involved in forest function using only information on leaf lifespan, climate, and soils

Phase II trial of tamoxifen and goserelin in recurrent epithelial ovarian cancer

Endocrine therapy is a recognised option in the treatment of chemo-resistant ovarian cancer. We conducted a nonrandomised phase II evaluation of combination endocrine therapy with tamoxifen and goserelin in patients with advanced ovarian cancer that had recurred following chemotherapy. In total, 26 patients entered the study, of which 17 had platinum-resistant disease. The median age was 63 years and enrolled patients had received a median of three chemotherapy regimens prior to trial entry. Patients were given oral tamoxifen 20 mg twice daily on a continuous basis and subcutaneous goserelin 3.6 mg once a month until disease progression. Using the definition of endocrine response that included patients with stable disease (SD) of 6 months or greater, the overall response rate (clinical benefit rate) was 50%. This included one complete response (CR) (3.8%), two partial responses (PR) (7.7%) and 10 patients with SD (38.5%). The median progression-free interval (PFI) was 4 months (95% CI 2.4–9.6) while the median overall survival (OS) was 13.6 months (95% CI 5.5–30.6). Four patients received treatment for more than 2 years (range 1–31) and one of them is still on treatment. In none of the four patients was there any evidence of recurrent or cumulative treatment related toxicity. Treatment-limiting toxicity was not seen in any of the study population. Endocrine data demonstrated a marked suppression of luteinising hormone (LH) and follicle-stimulating hormone (FSH) to less than 4% of baseline values. No consistent correlation could be established between LH/FSH suppression and tumour response. Likewise no relationship was observed between Inhibin A/B and pro-alpha C levels and tumour response. Inhibin is unlikely to be a useful surrogate marker for response in locally advanced or metastatic ovarian cancer. Combination endocrine therapy with tamoxifen and goserelin is an active regimen in platinum-resistant ovarian cancer patients. Hormonal therapy is advantageous in its relative lack of toxicity, ease of administration and tolerability, thus making it suitable for patients with heavily pretreated disease, compromised bone marrow function and other comorbid conditions that contraindicate cytotoxic therapy as well as in patients with indolent disease

Comparative analysis of the impact of geological activity on astronomical sites of the Canary Islands, Hawaii and Chile

An analysis of the impact of seismic and volcanic activity was carried out at selected astronomical sites, namely the observatories of El Teide (Tenerife, Canary Islands), Roque de los Muchachos (La Palma, Canary Islands), Mauna Kea (Hawaii) and Paranal (Chile) and the candidate site of Cerro Ventarrones (Chile). Hazard associated to volcanic activity is low or negligible at all sites, whereas seismic hazard is very high in Chile and Hawaii. The lowest geological hazard in both seismic and volcanic activity was found at Roque de los Muchachos observatory, in the island of La Palma.Comment: 12 pages and 11 figure

Digital IAPT: the effectiveness & cost-effectiveness of internet-delivered interventions for depression and anxiety disorders in the Improving Access to Psychological Therapies programme: study protocol for a randomised control trial

BACKGROUND: Depression and anxiety are common mental health disorders worldwide. The UK's Improving Access to Psychological Therapies (IAPT) programme is part of the National Health Service (NHS) designed to provide a stepped care approach to treating people with anxiety and depressive disorders. Cognitive Behavioural Therapy (CBT) is widely used, with computerised and internet-delivered cognitive behavioural therapy (cCBT and iCBT, respectively) being a suitable IAPT approved treatment alternative for step 2, low- intensity treatment. iCBT has accumulated a large empirical base for treating depression and anxiety disorders. However, the cost-effectiveness and impact of these interventions in the longer-term is not routinely assessed by IAPT services. The current study aims to evaluate the clinical and cost-effectiveness of internet-delivered interventions for symptoms of depression and anxiety disorders in IAPT. METHODS: The study is a parallel-groups, randomised controlled trial examining the effectiveness and cost-effectiveness of iCBT interventions for depression and anxiety disorders, against a waitlist control group. The iCBT treatments are of 8 weeks duration and will be supported by regular post-session feedback by Psychological Wellbeing Practitioners. Assessments will be conducted at baseline, during, and at the end of the 8-week treatment and at 3, 6, 9, and 12-month follow-up. A diagnostic interview will be employed at baseline and 3-month follow-up. Participants in the waitlist control group will complete measures at baseline and week 8, at which point they will receive access to the treatment. All adult users of the Berkshire NHS Trust IAPT Talking Therapies Step 2 services will be approached to participate and measured against set eligibility criteria. Primary outcome measures will assess anxiety and depressive symptoms using the GAD-7 and PHQ-9, respectively. Secondary outcome measures will allow for the evaluation of long-term outcomes, mediators and moderators of outcome, and cost-effectiveness of treatment. Analysis will be conducted on a per protocol and intention-to-treat basis. DISCUSSION: This study seeks to evaluate the immediate and longer-term impact, as well as the cost effectiveness of internet-delivered interventions for depression and anxiety. This study will contribute to the already established literature on internet-delivered interventions worldwide. The study has the potential to show how iCBT can enhance service provision, and the findings will likely be generalisable to other health services. TRIAL REGISTRATION: Current Controlled Trials ISRCTN ISRCTN91967124. DOI: https://doi.org/10.1186/ISRCTN91967124 . Web: http://www.isrctn.com/ISRCTN91967124 . Clinicaltrials.gov : NCT03188575. Trial registration date: June 8, 2017 (prospectively registered)

Active Hydrothermal Features as Tourist Attractions

Tourists are looking increasingly for adventurous experiences by exploring unusual and interesting landscapes. Active volcanic and hydrothermal landscapes and their remarkable manifestations of geysers, fumaroles and boiling mud ponds are some of the surface features that fascinate visitors of National Parks, Geoparks and World Heritage areas worldwide. The uniqueness of hydrothermal activity based on volcanism has provided popular tourist attractions in many countries for several thousand years. The Romans for example have used hydrothermal springs on the Italian island Ischia and visited the Campi Flegrei for recreational purposes. In Iceland the original Geysir already attracted international visitors over 150 years ago, who came to observe this spectacular hydrothermal phenomenon. In Greece and Turkey volcanic hot springs have historically provided attractive destinations, as well as in New Zealand, Japan and the Americas. The fact that locations with hydrothermal activity based on active volcanism have acquired various forms of protected site status, adds a further dimension to their attraction and demonstrates a significant contribution to sustainable and nature based tourism. Countries such as Iceland, New Zealand and Japan have a long tradition of using hydrothermal activity in its various forms to offer tourists a unique natural experience. These environments however are also known for their unpredictable and potentially hostile nature, as the use of hydrothermal features as a natural resource for tourism does harbour certain risks with the potential to affect human health and safety. Hydrothermal systems have erupted in the past, thereby causing the destruction of their immediate environment. Depending on the level of magnitude explosions of super heated water and steam mixed with fractured rocks and hot mud can be violent enough to create craters varying in size from a few metres to several hundred metres in diameter. Apart from unexpected eruptions of hydrothermal vents with the potential to cause thermal burns, further risk factors include seismic activity such as earthquakes, lethal gas emissions of hydrogen sulphide (H2S) as well as ground instability through hydrothermal alteration. While it is essential to prevent injuries to tourists the management of hydrothermal hazards remains problematic. Precursory signs are not well understood by the general public and the communication of imminent danger is frequently unachievable. As a consequence serious thought needs to be given to the risk factors and the potential danger of areas in the proximity of active hydrothermal manifestations such as extreme hot springs and geysers. To improve the safety standards in hydrothermal landscapes that are used as main features in tourism, strategic guidelines for best practice management must cover ALL active volcanic and hydrothermal areas. This chapter looks at management issues at hydrothermal destinations with special consideration of areas where these unique features are integrated as tourist attractions. Examples from destinations traditionally based on active volcanic and hydrothermal phenomena are presented as case studies to highlight the risk management processes in individual countries. Potential hazards in volcanic and hydrothermal areas are assessed with a focus on the prevention of accidents and injuries to tourists

Natriuretic peptides and integrated risk assessment for cardiovascular disease: an individual-participant-data meta-analysis

BACKGROUND: Guidelines for primary prevention of cardiovascular diseases focus on prediction of coronary heart disease and stroke. We assessed whether or not measurement of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) concentration could enable a more integrated approach than at present by predicting heart failure and enhancing coronary heart disease and stroke risk assessment. METHODS: In this individual-participant-data meta-analysis, we generated and harmonised individual-participant data from relevant prospective studies via both de-novo NT-proBNP concentration measurement of stored samples and collection of data from studies identified through a systematic search of the literature (PubMed, Scientific Citation Index Expanded, and Embase) for articles published up to Sept 4, 2014, using search terms related to natriuretic peptide family members and the primary outcomes, with no language restrictions. We calculated risk ratios and measures of risk discrimination and reclassification across predicted 10 year risk categories (ie, <5%, 5% to <7·5%, and ≥7·5%), adding assessment of NT-proBNP concentration to that of conventional risk factors (ie, age, sex, smoking status, systolic blood pressure, history of diabetes, and total and HDL cholesterol concentrations). Primary outcomes were the combination of coronary heart disease and stroke, and the combination of coronary heart disease, stroke, and heart failure. FINDINGS: We recorded 5500 coronary heart disease, 4002 stroke, and 2212 heart failure outcomes among 95 617 participants without a history of cardiovascular disease in 40 prospective studies. Risk ratios (for a comparison of the top third vs bottom third of NT-proBNP concentrations, adjusted for conventional risk factors) were 1·76 (95% CI 1·56-1·98) for the combination of coronary heart disease and stroke and 2·00 (1·77-2·26) for the combination of coronary heart disease, stroke, and heart failure. Addition of information about NT-proBNP concentration to a model containing conventional risk factors was associated with a C-index increase of 0·012 (0·010-0·014) and a net reclassification improvement of 0·027 (0·019-0·036) for the combination of coronary heart disease and stroke and a C-index increase of 0·019 (0·016-0·022) and a net reclassification improvement of 0·028 (0·019-0·038) for the combination of coronary heart disease, stroke, and heart failure. INTERPRETATION: In people without baseline cardiovascular disease, NT-proBNP concentration assessment strongly predicted first-onset heart failure and augmented coronary heart disease and stroke prediction, suggesting that NT-proBNP concentration assessment could be used to integrate heart failure into cardiovascular disease primary prevention. FUNDING: British Heart Foundation, Austrian Science Fund, UK Medical Research Council, National Institute for Health Research, European Research Council, and European Commission Framework Programme 7