The Whole is Greater than the Sum of Its Parts: Engaging Communities for Flood Risk Reduction, Species Recovery and Other Community Priorities

A picture of a floodplain can invoke different meanings for the people of Puget Sound: home, working lands, livelihood, culture, floods, altered ecosystem, disappearing salmon and identify. Each of these meanings is valid and each is powerful. In many of Puget Sound’s large rivers over 70% of floodplain habitat have been altered or lost. Puget Sound Chinook salmon, steelhead and bull trout, which rely on healthy rivers and floodplains are listed as threatened under the Endangered Species Act with habitat restoration playing a critical role in their recovery. Salmon are central to the culture and identity of the Native American Tribes in the region. Puget Sound’s rich floodplain soils are also home to vibrant agricultural communities, which were founded upon some of the most productive soils in the world. Floodplains are also increasingly encroached upon by residential communities and the businesses and amenities that accompany them. These communities are at an ever increasing risk of flooding as climate change is predicted to produce wetter winters with more frequent, large flood events. People working in floodplains understand that floodplains and the management of these important systems are viewed very differently by the sometimes conflicting interests of Puget Sound residents. One of the most pressing management issues facing our region is integrating multiple community, stakeholder, and trustee interests to maximize ecological and social outcomes for the region. By working with local communities and designing to address multiple objectives, several projects have been completed in which the whole is greater than the sum of their parts: functional habitat, flood risk reduction, and preservation of working lands. This presentation will focus on the regional context related to the need for floodplain restoration, and the potential for multiple-benefits project to meet this need. Through the use of case studies from Puget Sound, this presentation will highlight the specific ways local sponsors, NOAA’s Restoration Center and The Nature Conservancy are successfully working across interests to gain a broad base of support, and achieve greater gains than separate, single objective actions

Skagit Delta alternatives analysis: using output from the Salish Sea hydrodynamic model to quantify benefits and impacts of restoration project concepts

The Skagit Hydrodynamic Model Project was initiated by the Farms, Fish, and Flood Initiative (3FI) to conduct a landscape-scale alternative analysis in the Skagit River delta region. Twenty-three proposed restoration projects were assessed based on a number of quantitative indicators identified by representatives from each interest (Farm, Fish, and Flood). The study area focused on the Skagit River delta downstream of Mount Vernon, Washington. This reach of the Skagit River is tidally influenced and includes both the North Fork and South Fork distributaries, Skagit Bay, Padilla Bay, and the Swinomish Channel. The study area indirectly included approximately 55,000 acres of highly productive sub-tidal farmland. Several indicators were developed for the alternatives analysis to evaluate restoration concepts under a variety of flow and tidal conditions and under a climate change scenario. These indicators were directly informed using output from the Salish sea hydrodynamic model (HDM) using a normalized scoring methodology. This presentation will provide detail about how our team used output from the HDM to quantify indicators. It will also present how our team evaluated potential system- wide changes to water surface elevation, the balance of flow between the major distributaries, and salinity due to implementation of large restoration concepts, groups of projects and how we accounted for these system wide changes in our indicators. Finally, results from the climate change analysis and how we evaluated potential future impacts to habitat and agricultural practices will be presented

Adolescents’ lived experience of panic disorder: an interpretative phenomenological analysis

Background: Panic disorder is a debilitating anxiety disorder that has a serious impact on adolescents’ social and academic functioning and general wellbeing. Panic disorder is experienced by around 1 to 3% of the adolescent population. The aim of this study was to examine adolescents’ experiences of having panic disorder. Methods: Semi-structured interviews were conducted with eight adolescents with a primary diagnosis of panic disorder. Interpretative Phenomenological Analysis (IPA) was used to gain an understanding of adolescents’ lived experience of panic disorder. Results: Two superordinate themes were identified: 1) Drowning in sensations, and 2) An unacceptable self. The findings show that adolescents experience panic disorder as extremely overwhelming and unpleasant, with debilitating feelings of drowning in sensations. Adolescents’ experiences largely fit with the cognitive model of panic, in which catastrophic misinterpretation of bodily sensations is associated with anxiety, avoidance, and safety behaviours, creating a vicious cycle. Attempts to avoid or prevent the attacks appear to inadvertently make them worse. Social worries, feeling broadly misunderstood, and unhelpful responses from others, contributed to feelings of being different or abnormal and were connected to a negative self-concept. Negative social interactions with teachers and peers in the school environment were particularly damaging. Conclusions: These findings offer new insight into these adolescents’ lived experience of panic disorder and highlight the need for adolescents to access timely, evidence-based treatment, as well as the need for increased awareness and understanding of panic disorder in schools

Exercise Induced cardiac troponin elevation:An update on the evidence, mechanism and implications

Post-exercise cardiac troponin (cTn) elevation is a recognised phenomenon which historically has been detected using standard sensitivity assays. More recently high-sensitivity assays have been developed and are now the gold standard for detection of cTn in the clinical setting. Although the assay's enhanced sensitivity confers benefits it has created new challenges for clinicians. By evaluating the change in cTn values over time, taking into account biological and analytical variation, the clinician is able to differentiate between a pathological and normal cTn value. As a result, serial cTn testing has become a fundamental component of the clinical assessment of chest pain patients and is included in the most recent definition for myocardial infarction and the latest guidelines for the management of acute coronary syndromes without persistent ST-segment elevation. A review of the cTn kinetics literature demonstrates a pattern of elevation and peak within the first 4 h after exercise dropping within 24 h. In contrast myocardial necrosis demonstrates a later cTn peak with a slower downslope occurring over several days. Understanding cTn kinetics facilitates clinician's decision making when presented with a chest pain patient post-exercise. Furthermore, it helps elucidate the underlying mechanism and establish the clinical significance of post-exercise cTn elevation, which in all other situations confers negative prognostic value. We recommend serial cTn testing in this scenario with a suggested algorithm included in this review. Keywords: Troponin, Kinetics, Heart, Exercis

The effectiveness of psychological therapies for anxiety disorders in adolescents: a meta-analysis

Objective: Anxiety disorders are common in adolescence but outcomes for adolescents are unclear and we do not know what factors moderate treatment outcome for this age group. We conducted meta-analyses to establish the effectiveness of psychological therapies for adolescent anxiety disorders in (i) reducing anxiety disorder symptoms, and (ii) remission from the primary anxiety disorder, compared with controls, and examine potential moderators of treatment effects. Method: The protocol was registered with PROSPERO (CRD42018091744). Electronic databases (Web of Science, MEDLINE, Psychinfo, EMBASE) were searched from January 1990 to December 2019. 2511 articles were reviewed, those meeting strict criteria were included. Random effects meta-analyses were conducted. Results: Analyses of symptom severity outcomes comprised sixteen studies (CBT k = 15, non-CBT k = 1; n = 766 adolescents), and analyses of diagnostic remission outcomes comprised nine (CBT k = 9; n = 563 adolescents). Post-treatment, those receiving treatment were significantly more likely to experience reduced symptom severity (SMD = .454, 95% CI = 0.22-0.69) and remission from the primary anxiety disorder than controls (RR = 7.94, 95% CI = 3.19-12.7) (36% treatment vs. 9% controls in remission). None of the moderators analysed were statistically significant. Conclusion: Psychological therapies targeting anxiety disorders in adolescents are more effective than controls. However, with only just over a third in remission post-treatment, there is a clear need to develop more effective treatments for adolescents, evaluated through high quality randomised controlled trials incorporating active controls and follow-up data

Kinematic and kinetic differences between military patients with patellar tendinopathy and asymptomatic controls during single leg squats

© 2019 Background: Knee valgus alignment has been associated with lower-limb musculoskeletal injury. This case-control study aims to: assess biomechanical differences between patients with patellar tendinopathy and healthy controls. Methods: 43 military participants (21 cases, 22 controls) were recorded using 3D-motion capture performing progressively demanding, small knee bend, single leg and single leg decline squats. Planned a priori analysis of peak: hip adduction, knee flexion, pelvic tilt, pelvic obliquity and trunk flexion was conducted using MANOVA. Kinematic and kinetic data were graphed with bootstrapped t-tests and 95% CI's normalised to the squat cycle. ANOVA and correlations in SPSS were used for exploratory analysis. Findings: On their symptomatic side cases squatted to less depth (−6.62° p 0.05). Cases experienced more pain on testing on decline board (ES = 0.69, p 0.05), correlated with extensor knee moment. Interpretation: Knee valgus alignment is a plausible risk factor for patellar tendinopathy. Conclusions relating to causation are limited by the cross-sectional study design. Increasing squat depth, use of a declined surface and isolating the eccentric phase enable progression of loading prescription guided by pain

Validity and Reliability of the Perceived Readiness for Discharge After Birth Scale

Objective: To assess the psychometric properties of a scale measuring mothers’ perceptions of readiness for discharge after birth. Design: Psychometric analyses including construct validity using factor analysis and known groups comparisons, predictive validity, and reliability. Data were collected at discharge and 6 weeks postdischarge. Setting: Tertiary-level perinatal center in the Midwestern United States. Participants: 1,462 postpartum mothers. Intervention: None. Main Outcome Measures: Perceived Readiness for Discharge After Birth Scale scores; subscale scores for personal status and knowledge factors.\u27 Results: Exploratory and confirmatory factor analyses indicated that the scale contained two factors. Perceived Readiness for Discharge After Birth Scale scores were lower for mothers who were breast-feeding, married, primiparous, and had a short hospital stay (less than 30 hours) than for their comparison groups. The Perceived Readiness for Discharge After Birth Scale personal status factor was predictive of self-reported physical and psychosocial problems and unscheduled utilization of health services in the first 6 weeks postpartum. The knowledge factor was predictive of postdischarge telephone calls to the pediatric provider. Reliability estimates ranged from 0.83 to 0.89 for the total scale and subscales. Conclusions: The Perceived Readiness for Discharge After Birth Scale performed well in psychometric testing. Assessing mothers’perceptions of readiness for discharge is important for measuring outcomes of hospitalization and for identifying mothers at risk for postdischarge problems

Study protocol: a double blind randomised control trial of high volume image guided injections in achilles and patellar tendinopathy in a young active population

Background: Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). Methods: RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. Discussion: Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment