Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker\u27s 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia—Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence—PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic

Conceptualizing Ecological Responses to Dam Removal: If You Remove It, What’s to Come?

One of the desired outcomes of dam decommissioning and removal is the recovery of aquatic and riparian ecosystems. To investigate this common objective, we synthesized information from empirical studies and ecological theory into conceptual models that depict key physical and biological links driving ecological responses to removing dams. We define models for three distinct spatial domains: upstream of the former reservoir, within the reservoir, and downstream of the removed dam. Emerging from these models are response trajectories that clarify potential pathways of ecological transitions in each domain. We illustrate that the responses are controlled by multiple causal pathways and feedback loops among physical and biological components of the ecosystem, creating recovery trajectories that are dynamic and nonlinear. In most cases, short-term effects are typically followed by longer-term responses that bring ecosystems to new and frequently predictable ecological condition, which may or may not be similar to what existed prior to impoundment

A new African titanosaurian sauropod dinosaur from the middle cretaceous galula formation (Mtuka Member), Rukwa Rift Basin, Southwestern Tanzania

Copyright: © 2019 Gorscak, O\u27Connor. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The African terrestrial fossil record has been limited in its contribution to our understanding of both regional and global Cretaceous paleobiogeography, an interval of significant geologic and macroevolutionary change. A common component in Cretaceous African faunas, titanosaurian sauropods diversified into one of the most specious groups of dinosaurs worldwide. Here we describe the new titanosaurian Mnyamawamtuka moyowamkia gen. et sp. nov. from the Mtuka Member of the Galula Formation in southwest Tanzania. The new specimen preserves teeth, elements from all regions of the postcranial axial skeleton, parts of both appendicular girdles, and portions of both limbs including a complete metatarsus. Unique traits of M. moyowamkia include the lack of an interpostzygapophyseal lamina in posterior dorsal vertebrae, pronounced posterolateral expansion of middle caudal centra, and an unusually small sternal plate. Phylogenetic analyses consistently place M. moyowamkia as either a close relative to lithostrotian titanosaurians (e.g., parsimony, uncalibrated Bayesian analyses) or as a lithostrotian and sister taxon to Malawisaurus dixeyi from the nearby Aptian? Dinosaur Beds of Malawi (e.g., tip-dating Bayesian analyses). M. moyowamkia shares a few features with M. dixeyi, including semi-spatulate teeth and a median lamina between the neural canal and interpostzygapophyseal lamina in anterior dorsal vertebrae. Both comparative morphology and phylogenetic analyses support Mnyamawamtuka as a distinct and distant relative to Rukwatitan bisepultus and Shingopana songwensis from the younger Namba Member of the Galula Formation with these results largely congruent with newly constrained ages for the Mtuka Member (Aptian-Cenomanian) and Namba Member (Campanian). Coupled with recent discoveries from the Dahkla Oasis, Egypt (e.g., Mansourasaurus shahinae) and other parts of continental Afro-Arabia, the Tanzania titanosaurians refine perspectives on the development of African terrestrial faunas throughout the Cretaceous-a critical step in understanding non-marine paleobiogeographic patterns of Africa that have remained elusive until the past few years

The role of imaging in the investigation of painless hematuria in adults

The radiologic investigation of asymptomatic hematuria has changed significantly due to the introduction of new imaging modalities and innovative techniques, such as computed tomography urogaphy, which allows a comprehensive evaluation of the entire urinary tract in a single study. There is still a role for “older” imaging modalities, such as intravenous urography and ultrasound, and their use is still advocated in younger patients with a lower risk of malignancy to minimize radiation dose. Combined modality imaging can also be useful for characterization of lesions. Guidelines have recently been published for the radiologic investigation of hematuria; these are discussed in this article

A Revision of the Upper Cretaceous Lepidosirenid Lungfishes from the Quseir Formation, Western Desert, Central Egypt

We evaluate new lungfish remains from the Upper Cretaceous Quseir Formation in the Western Dessert of southern Egypt. Taxa include Lavocatodus protopteroides, L. humei, L. giganteus, and Protopterus nigeriensis. We treat Lavocatodus as members of Lepidosirenidae based on the presence of a well-defined medial articular surface, in the absence of a symphyseal surface of corresponding prearticular bones. Material of L. protopteroides represents the first example of an adult specimen, supporting the retention of the species as valid, and not a junior synonym of L. humei. Specimens of L. humei are the most abundant in the assemblage, and all exhibit the medial articular surface, a feature that is absent from specimens of Ceratodus; therefore, we reassign additional specimens of C. humei to Lavocatodus. New specimens of L. giganteus extend the temporal and spatial ranges of the species (the type material of L. giganteus is from Paleocene deposits of In Farghas, Mali). Finally, a new specimen of Protopterus represents the oldest record of the genus in Egypt. The prearticular is confidently assigned to Protopterus based on the presence of only three ridges on the tooth plate, a medial symphyseal suture, a coronoid process, and a shallow tooth crown plus prearticular depth. We further assign it to P. nigeriensis based the length and merger of tooth ridges. Furthermore, the oldest Cenomanian specimens reported from the Sudan Wadi Milk Formation are assigned to P. nigeriensis, which would extend the temporal range of P. nigeriensis by roughly 14 Ma. © 2014 by the Society of Vertebrate Paleontology

A new assemblage of Cenozoic lungfishes (Dipnoi: Lepidosirenidae) from the late Oligocene Nsungwe Formation, Rukwa Rift Basin, southwestern Tanzania

Lungfish (Dipnoi) date back to the Devonian, and some fossil taxa as well as extant African lungfishes are known for their ability to aestivate, tolerating low-oxygen environments associated with seasonal drying. Extant lungfishes are separated into two families: Lepidosirenidae (Protopterus in Africa and Lepidosiren in South America) and Neoceratodontidae (Neocerotadus in Australia). African lungfishes were more geographically and phylogenetically diverse on the continent in the past than they are today, with only 5% of extinct taxa recorded from the sub-Saharan fossil record. Given the sparse record of Lepidosirenidae fossils from continental Africa, any new materials are important for understanding diversification of the clade. Here we describe new lungfish fossils cautiously referable to Protopterus annectens and Protopterus aethiopicus, which are strongly supported sister taxa based on the molecular phylogeny. Specimens were collected from the late Oligocene Nsungwe Formation in the Rukwa Rift Basin (RRB) of southwestern Tanzania. The late Oligocene Nsungwe Formation represents a sequence of continental rift-fill deposits of the Songwe sub-basin of the RRB and is subdivided into the lower Utengule and upper Songwe members. Recovery of such material from the Paleogene of Africa below the equator addresses a sizable gap in the lungfish fossil record. It also expands the Nsungwe Formation fauna that includes invertebrates, alestid fishes, ptychadenid anurans, snakes, and several clades of mammals, deepening paleoecological insights into the late Oligocene record of the continental African interior. At present, P. aethiopicus and P. dolloi have an extensive modern eastern African distribution associated with the rift lakes and a region where extant members of P. annectens are not presently known. Fossil specimens described herein document presence of the clade during Paleogene volcanic activity in the western branch of the Eastern African Rift System

A Clinical Decision Support System Promotes Shared Decision-Making and Cardiovascular Risk Factor Management

Background/Aims: Cardiovascular (CV) Wizard is a web-based electronic health record-integrated point-of-care clinical decision support (CDS) system that presents personalized CV risk information to providers and patients in both a low-numeracy visual format and a high-numeracy quantitative format. We report primary care provider perspectives on how this CDS system affected shared decision-making and CV risk factor management. Methods: Twenty clinics were randomized to either usual care or use of the CDS system with diabetes, heart disease or high-reversible CV risk adults. The CDS system targeted 20% of office visits and was used at 70–80% of targeted visits over a 2-year period. Consented providers (N = 102) were surveyed at baseline and 18 months after implementation. Corrected survey response rates were 90% at baseline and 82% at follow-up. Generalized linear mixed models were used to compare usual care and CDS responses to common questions at baseline and follow-up, and CDS users were queried on their perceptions of the CDS system at follow-up only. Results: Compared to usual care providers, those in the CDS group reported increased follow-up rates of CV risk calculations while seeing patients (73% vs. 28%, P = 0.006), being better prepared to discuss CV risk reduction priorities with patients (98% vs. 78%, P = 0.03), providing accurate advice on aspirin for primary prevention (75% vs. 48%, P = 0.02) and more often discussing CV risk reduction (60% vs. 30%, P = 0.06). CDS users reported that the CDS system improved CV risk factor control (98%), saved time when talking to patients about CV risk reduction (93%), efficiently elicited patient treatment preferences (90%), was useful for shared decision-making (95%), influenced treatment recommendations (89%) and helped initiate CV risk discussions (94%); 85% of providers reported that their patients liked CV Wizard. Conclusion: The CV Wizard CDS system was successfully integrated into the workflow of primary care visits with high sustained use rates, high primary care provider satisfaction, high patient satisfaction and positive impacts on provider-reported clinical processes related to CV risk factor management

Overuse and Underuse of Aspirin for Primary Prevention of Cardiovascular Events in Primary Care

Background/Aims: The U.S. Preventive Services Task Force (USPSTF) currently recommends aspirin for primary prevention of coronary heart disease in men 45–79 years old and strokes in women 55–79 years old when the potential cardiovascular disease benefit outweighs the potential harm of gastrointestinal hemorrhage. The complexity and time required to assess risks and benefits for primary prevention can be a barrier for providers to giving patients USPSTF-consistent recommendations, resulting in potential overuse and underuse. Methods: As part of a National Institutes of Health-funded randomized trial to lower cardiovascular risk, we developed a sophisticated web-based electronic health record (EHR)-integrated tool to guide aspirin recommendations as determined by algorithms assessing USPSTF criteria and major bleeding risks. Baseline data was collected for whether aspirin was algorithmically indicated (or not) for all patients at their first eligible primary care encounter in 20 clinics over 18 months. The analysis included patients age 18–75 (mean 58.4) with elevated cardiovascular disease risk (mean 10-year ASCVD risk 24.7%) and excluded patients with congenital heart defects or diabetes. Aspirin overuse and underuse was determined by comparing concordance with: a) the algorithm’s aspirin recommendation, and b) EHR-medication documentation of aspirin. Results: Of the 11,682 patients meeting eligibility criteria at baseline, aspirin was indicated in 8,722 (74.7%) and not indicated in 2,960 (25.3%). Among patients with an aspirin indication, 6,493/8,722 (74.4%) did not have aspirin documented (underuse). Among patients without an aspirin indication, 1,021/2,960 (34.4%) had aspirin documented (overuse). Conclusion: Overall, 7,514/11,682 (64.3%) of patients who met study inclusion criteria for age and cardiovascular risk exhibited either potential overuse or underuse of aspirin for primary cardiovascular disease prevention. Despite expected missing documentation of aspirin due to its over-the-counter availability, which would result in measures of greater underuse and lower overuse than actuality, it is clear that patient aspirin use is very commonly inconsistent with USPSTF guidelines. The recommendation to consider colorectal benefits in the latest USPSTF draft could make decisions about aspirin appropriateness even more complex. EHR-based tools to help providers assess individualized risks and benefits of aspirin could greatly improve the quality of aspirin recommendations and potentially reduce costly cardiovascular disease events while simultaneously reducing rates of aspirin-related hazards