A comprehensive assessment of anthropogenic and natural sources and sinks of Australasia\u27s carbon budget

Regional carbon budget assessments attribute and track changes in carbon sources and sinks and support the development and monitoring the efficacy of climate policies. We present a comprehensive assessment of the natural and anthropogenic carbon (C-CO2) fluxes for Australasia as a whole, as well as for Australia and New Zealand individually, for the period from 2010 to 2019, using two approaches: bottom-up methods that integrate flux estimates from land-surface models, data-driven models, and inventory estimates; and top-down atmospheric inversions based on satellite and in situ measurements. Our bottom-up decadal assessment suggests that Australasia\u27s net carbon balance was close to carbon neutral (−0.4 ± 77.0 TgC yr−1). However, substantial uncertainties remain in this estimate, primarily driven by the large spread between our regional terrestrial biosphere simulations and predictions from global ecosystem models. Within Australasia, Australia was a net source of 38.2 ± 75.8 TgC yr−1, and New Zealand was a net CO2 sink of −38.6 ± 13.4 TgC yr−1. The top-down approach using atmospheric CO2 inversions indicates that fluxes derived from the latest satellite retrievals are consistent within the range of uncertainties with Australia\u27s bottom-up budget. For New Zealand, the best agreement was found with a national scale flux inversion estimate based on in situ measurements, which provide better constrained of fluxes than satellite flux inversions. This study marks an important step toward a more comprehensive understanding of the net CO2 balance in both countries, facilitating the improvement of carbon accounting approaches and strategies to reduce emissions

Reduced anticoagulation targets in extracorporeal life support (RATE):study protocol for a randomized controlled trial

BackgroundAlthough life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT).However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome.MethodsWe will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2–2.5 times baseline aPTT, 1.5–2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months.DiscussionWe hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO.Trial registrationClinicalTrials.gov NCT04536272. Registered on 2 September 2020. Netherlands Trial Register NL796

International Survey on Mechanical Ventilation During Extracorporeal Membrane Oxygenation

The optimal ventilation strategy for patients on extracorporeal membrane oxygenation (ECMO) remains uncertain. This survey reports current mechanical ventilation strategies adopted by ECMO centers worldwide. An international, multicenter, cross-sectional survey was conducted anonymously through an internet-based tool. Participants from North America, Europe, Asia, and Oceania were recruited from the extracorporeal life support organization (ELSO) directory. Responses were received from 48 adult ECMO centers (response rate 10.6%). Half of these had dedicated ventilation protocols for ECMO support. Pressure-controlled ventilation was the preferred initial ventilation mode for both venovenous ECMO (VV-ECMO) (60%) and venoarterial ECMO (VA-ECMO) (34%). In VV-ECMO, the primary goal was lung rest (93%), with rescue therapies commonly employed, especially neuromuscular blockade (93%) and prone positioning (74%). Spontaneous ventilation was typically introduced after signs of pulmonary recovery, with few centers using it as the initial mode (7%). A quarter of centers stopped sedation within 3 days after ECMO initiation. Ventilation strategies during VA-ECMO focused less on lung-protective goals and transitioned to spontaneous ventilation earlier. Ventilation strategies during ECMO support differ considerably. Controlled ventilation is predominantly used initially to provide lung rest, often facilitated by sedation and neuromuscular blockade. Few centers apply "awake ECMO" early during ECMO support, some utilizing partial neuromuscular blockade.</p

International Survey on Mechanical Ventilation During Extracorporeal Membrane Oxygenation

The optimal ventilation strategy for patients on extracorporeal membrane oxygenation (ECMO) remains uncertain. This survey reports current mechanical ventilation strategies adopted by ECMO centers worldwide. An international, multicenter, cross-sectional survey was conducted anonymously through an internet-based tool. Participants from North America, Europe, Asia, and Oceania were recruited from the extracorporeal life support organization (ELSO) directory. Responses were received from 48 adult ECMO centers (response rate 10.6%). Half of these had dedicated ventilation protocols for ECMO support. Pressure-controlled ventilation was the preferred initial ventilation mode for both venovenous ECMO (VV-ECMO) (60%) and venoarterial ECMO (VA-ECMO) (34%). In VV-ECMO, the primary goal was lung rest (93%), with rescue therapies commonly employed, especially neuromuscular blockade (93%) and prone positioning (74%). Spontaneous ventilation was typically introduced after signs of pulmonary recovery, with few centers using it as the initial mode (7%). A quarter of centers stopped sedation within 3 days after ECMO initiation. Ventilation strategies during VA-ECMO focused less on lung-protective goals and transitioned to spontaneous ventilation earlier. Ventilation strategies during ECMO support differ considerably. Controlled ventilation is predominantly used initially to provide lung rest, often facilitated by sedation and neuromuscular blockade. Few centers apply "awake ECMO" early during ECMO support, some utilizing partial neuromuscular blockade.</p

Characterizing Long COVID in Children and Adolescents

ImportanceMost research to understand postacute sequelae of SARS-CoV-2 infection (PASC), or long COVID, has focused on adults, with less known about this complex condition in children. Research is needed to characterize pediatric PASC to enable studies of underlying mechanisms that will guide future treatment.ObjectiveTo identify the most common prolonged symptoms experienced by children (aged 6 to 17 years) after SARS-CoV-2 infection, how these symptoms differ by age (school-age [6-11 years] vs adolescents [12-17 years]), how they cluster into distinct phenotypes, and what symptoms in combination could be used as an empirically derived index to assist researchers to study the likely presence of PASC.Design, setting, and participantsMulticenter longitudinal observational cohort study with participants recruited from more than 60 US health care and community settings between March 2022 and December 2023, including school-age children and adolescents with and without SARS-CoV-2 infection history.ExposureSARS-CoV-2 infection.Main outcomes and measuresPASC and 89 prolonged symptoms across 9 symptom domains.ResultsA total of 898 school-age children (751 with previous SARS-CoV-2 infection [referred to as infected] and 147 without [referred to as uninfected]; mean age, 8.6 years; 49% female; 11% were Black or African American, 34% were Hispanic, Latino, or Spanish, and 60% were White) and 4469 adolescents (3109 infected and 1360 uninfected; mean age, 14.8 years; 48% female; 13% were Black or African American, 21% were Hispanic, Latino, or Spanish, and 73% were White) were included. Median time between first infection and symptom survey was 506 days for school-age children and 556 days for adolescents. In models adjusted for sex and race and ethnicity, 14 symptoms in both school-age children and adolescents were more common in those with SARS-CoV-2 infection history compared with those without infection history, with 4 additional symptoms in school-age children only and 3 in adolescents only. These symptoms affected almost every organ system. Combinations of symptoms most associated with infection history were identified to form a PASC research index for each age group; these indices correlated with poorer overall health and quality of life. The index emphasizes neurocognitive, pain, and gastrointestinal symptoms in school-age children but change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents. Clustering analyses identified 4 PASC symptom phenotypes in school-age children and 3 in adolescents.Conclusions and relevanceThis study developed research indices for characterizing PASC in children and adolescents. Symptom patterns were similar but distinguishable between the 2 groups, highlighting the importance of characterizing PASC separately for these age ranges

Genetic Studies of Leptin Concentrations Implicate Leptin in the Regulation of Early Adiposity.

Leptin influences food intake by informing the brain about the status of body fat stores. Rare LEP mutations associated with congenital leptin deficiency cause severe early-onset obesity that can be mitigated by administering leptin. However, the role of genetic regulation of leptin in polygenic obesity remains poorly understood. We performed an exome-based analysis in up to 57,232 individuals of diverse ancestries to identify genetic variants that influence adiposity-adjusted leptin concentrations. We identify five novel variants, including four missense variants, in LEP, ZNF800, KLHL31, and ACTL9, and one intergenic variant near KLF14. The missense variant Val94Met (rs17151919) in LEP was common in individuals of African ancestry only, and its association with lower leptin concentrations was specific to this ancestry (P = 2 × 10-16, n = 3,901). Using in vitro analyses, we show that the Met94 allele decreases leptin secretion. We also show that the Met94 allele is associated with higher BMI in young African-ancestry children but not in adults, suggesting that leptin regulates early adiposity

Samenspel tussen jongerenwerk en specialistische jeugdzorg: Groeikansen voor persoonlijke ontwikkeling en maatschappelijke participatie

Samenvatting Een deel van de jongeren die in het jongerenwerk participeert ontvangt specialistische jeugdzorg, vanuit bijvoorbeeld verslavingszorg, jeugdreclassering, jeugd-ggz of intensieve gezinsbehandeling. Hoewel professioneel jongerenwerk voor een brede groep jongeren in kwetsbare situaties positief bijdraagt aan hun persoonlijke ontwikkeling en maatschappelijke participatie, is er weinig bekend over de betekenis van het jongerenwerk voor jongeren die specialistische jeugdzorg ontvangen. Voor dit verkennende onderzoek zijn interviews afgenomen met: 1) zeven jongeren (16+) die specialistische jeugdzorg ontvangen en in jongerenwerk participeren; 2) zeven jongerenwerkers en 3) zes jeugdhulpverleners werkzaam in specialistische jeugdzorg. Een thematische analyse maakt inzichtelijk dat het jongerenwerk op vijf manieren van betekenis is voor jongeren in specialistische jeugdzorg. Jongerenwerkers zijn ten eerste toegankelijke gesprekspartners die deze jongeren motiveren om problemen serieus te nemen en daarbij professionele hulp te accepteren. Het jongerenwerk biedt deze jongeren daarnaast een omgeving om 2) betekenisvolle relaties op te bouwen, 3) hun zelfbeeld en eigenwaarde te versterken, 4) hun maatschappelijke participatie te vergroten en 5) ondersteuning te vinden om hun zelfstandigheid te vergroten. De resultaten maken inzichtelijk dat het jongerenwerk ook voor deze specifieke groep jongeren groeikansen biedt voor hun persoonlijke ontwikkeling en maatschappelijke participatie. Daarnaast leert dit onderzoek dat participatie van deze doelgroep in het jongerenwerk een positieve invloed kan hebben op de jeugdhulpverleningsprocessen en -resultaten. Hiermee bieden de resultaten gemeenten en de jeugdzorg een beter begrip van hoe het jongerenwerk als preventieve voorziening van betekenis is voor jongeren in specialistische jeugdzorg en een bijdrage kan leveren om de druk op de jeugdzorg te verlichten

Exploring the importance of teachers' institutional structure on the development of teachers' standards of assessment in Belgium

While a large body of research has focused on the effects of teachers' educational standards and/or expectations of different types of pupils related to pupils' ability, race/ethnicity, gender, and/or social class, there has been much less research on how such standards/expectations are formed by teachers' institutional structure. Previous research on the impact of institutional factors on teachers' pedagogy and curriculum has suggested the usefulness of a particular embedded, ecological model in studying the development of teachers' standards/expectations of pupils. This article uses ethnographic data gathered from one Belgian (Flemish) multicultural vocational and technical education school to illustrate the usefulness of this conceptual framework for studying the development of teachers' standards of assessment of pupils. The conclusion discusses implications for future research on the development of teachers' standards and/or expectations of pupils