Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught

Background and aims: Medical students receive training in the management of chronic pain, but the training is often suboptimal. Considering that the basis for physician’s knowledge is their medical education, it is important to explore the attitudes and beliefs of medical students with respect both to chronic pain management and to their views on current pain education. Therefore, the aim of this study was to compare Swedish and Australian medical student’s attitudes and beliefs about patients with chronic pain, and their perceptions regarding their chronic pain management education. Methods: An online survey was conducted with final year Australian and Swedish medical students from two different universities between December 2016 and February 2017. Attitudes and beliefs towards chronic pain patients were measured using the Health Care Providers’ Pain and Impairment Scale (HC-PAIRS). A thematic analysis was conducted on open end questions regarding their views on their education and important skills for chronic pain management. Results: A total of 57 Swedish and 26 Australian medical students completed the HC-PAIRS scale. The Swedish medical students showed statistically significantly lower total mean HC-PAIRS scores compared to Australian medical students (46 and 51, respectively). Australian students had statistically significantly higher scores than the Swedish students for two of four factors: functional expectations and need for cure, whereas no significant differences were seen for the factors social expectations or for projected cognition. From the open end questions it was evident that final year medical students are knowledgeable about key chronic pain items described in clinical guidelines. However, both cohorts described their chronic pain training as poor and in need of improvement in several areas such as more focus on the biopsychosocial model, working in multidisciplinary teams, seeing chronic pain patients and pharmacological training. Conclusions: Attitudes and beliefs are formed during medical education, and our study exploring attitudes of medical students towards chronic pain and how it is taught have provided valuable information. Our survey provided detailed and cohesive suggestions for education improvement that also are in line with current clinical guidelines. This study indicates that the Swedish final year students have a more positive attitude towards chronic pain patients compared to their Australian counterparts. The majority of students in both cohorts perceived chronic pain management education in need of improvement. Implications: This study highlights several areas of interest that warrant further investigation, for example, the impact of a changed medical curriculum in alignment with these clinical guidelines requested by students in this survey, and correspondingly if their attitudes towards chronic pain patients can be improved through education. Further, we conclude that it would be valuable to align the implementation of the HC-PAIRS instrument in order to achieve comparable results between future studies

HYDROLOGICAL NORMALIZATION OF NUTRIENT DELIVERIES FROM AGRICULTURAL CATCHMENTS

Nutrient deliveries from agricultural catchments are strongly influenced by natural fluctuations in water discharge. Hydrological normalization of such data may therefore facilitate estimation of human impact on the environment. In the present study, we compared conventional statistical normalization techniques with a recently proposed, semi-parametric regression technique, which can accommodate time-dependent relationships between nutrient deliveries and water discharge. Case studies of agricultural catchments in Sweden and Norway demonstrated that all of the tested normalization techniques were able to remove a substantial fraction of the interannual variation in nitrogen deliveries, whereas normalization of phosphorus loads was problematic. Semi-parametric regression models were found to be useful when temporal trends were present in the analyzed time series

Face-to-Face Versus Telephonic Extended Glasgow Outcome Score Testing After Traumatic Brain Injury

OBJECTIVE: The Extended Glasgow Outcome Scale (GOS-E) is used for objective assessment of functional outcome in traumatic brain injury (TBI). In situations where face-to-face contact is not feasible, telephonic assessment of the GOS-E might be desirable. The aim of this study is to assess the level of agreement between face-to-face and telephonic assessment of the GOS-E. SETTING: Multicenter study in 2 Dutch University Medical Centers. Inclusion was performed in the outpatient clinic (face-to-face assessment, by experienced neurologist), followed by assessment via telephone of the GOS-E after ±2 weeks (by trained researcher). PARTICIPANTS: Patients ±6 months after TBI. DESIGN: Prospective validation study. MAIN MEASURES: Interrater agreement of the GOS-E was assessed with Cohen's weighted κ. RESULTS: From May 2014 until March 2018, 50 patients were enrolled; 54% were male (mean age 49.1 years). Median time between trauma and in-person GOS-E examination was 158 days and median time between face-to-face and telephonic GOS-E was 15 days. The quadratic weighted κ was 0.79. Sensitivity analysis revealed a quadratic weighted κ of 0.77, 0.78, and 0.70 for moderate-severe, complicated mild, and uncomplicated mild TBI, respectively. CONCLUSION: No disagreements of more than 1 point on the GOS-E were observed, with the κ value representing good or substantial agreement. Assessment of the GOS-E via telephone is a valid alternative to the face-to-face interview when in-person contact is not feasible

Links between traumatic brain injury and ballistic pressure waves originating in the thoracic cavity and extremities

Identifying patients at risk of traumatic brain injury (TBI) is important because research suggests prophylactic treatments to reduce risk of long-term sequelae. Blast pressure waves can cause TBI without penetrating wounds or blunt force trauma. Similarly, bullet impacts distant from the brain can produce pressure waves sufficient to cause mild to moderate TBI. The fluid percussion model of TBI shows that pressure impulses of 15-30 psi cause mild to moderate TBI in laboratory animals. In pigs and dogs, bullet impacts to the thigh produce pressure waves in the brain of 18-45 psi and measurable injury to neurons and neuroglia. Analyses of research in goats and epidemiological data from shooting events involving humans show high correlations (r > 0.9) between rapid incapacitation and pressure wave magnitude in the thoracic cavity. A case study has documented epilepsy resulting from a pressure wave without the bullet directly hitting the brain. Taken together, these results support the hypothesis that bullet impacts distant from the brain produce pressure waves that travel to the brain and can retain sufficient magnitude to induce brain injury. The link to long-term sequelae could be investigated via epidemiological studies of patients who were gunshot in the chest to determine whether they experience elevated rates of epilepsy and other neurological sequelae

An integrated Pan-European perspective on coastal Lagoons management through a mosaic-DPSIR approach

© The Author(s), 2016. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Scientific Reports 6 (2016): 19400, doi:10.1038/srep19400.A decision support framework for the management of lagoon ecosystems was tested using four European Lagoons: Ria de Aveiro (Portugal), Mar Menor (Spain), Tyligulskyi Liman (Ukraine) and Vistula Lagoon (Poland/Russia). Our aim was to formulate integrated management recommendations for European lagoons. To achieve this we followed a DPSIR (Drivers-Pressures-State Change-Impacts-Responses) approach, with focus on integrating aspects of human wellbeing, welfare and ecosystem sustainability. The most important drivers in each lagoon were identified, based on information gathered from the lagoons’ stakeholders, complemented by scientific knowledge on each lagoon as seen from a land-sea perspective. The DPSIR cycles for each driver were combined into a mosaic-DPSIR conceptual model to examine the interdependency between the multiple and interacting uses of the lagoon. This framework emphasizes the common links, but also the specificities of responses to drivers and the ecosystem services provided. The information collected was used to formulate recommendations for the sustainable management of lagoons within a Pan-European context. Several common management recommendations were proposed, but specificities were also identified. The study synthesizes the present conditions for the management of lagoons, thus analysing and examining the activities that might be developed in different scenarios, scenarios which facilitate ecosystem protection without compromising future generations.This study was supported by the European Commission, under the 7th Framework Programme, through the collaborative research project LAGOONS (contract n° 283157); by European funds through COMPETE and by Portuguese funds through the national Foundation for Science and Technology – FCT (PEst-C/MAR/LA0017/2013). The post-Doc grant SFRH/BPD/41117/2007 (M Dolbeth) and the PhD grant SFRH/BD/79170/2011 (LP Sousa) supported by FCT are also acknowledged

Land and Water Use Interactions Emerging Trends and Impact on Land-use Changes in the Tungabhadra and Tagus River Basins

The paper provides a comprehensive analysis of the issues, current status and complex interlinkages in land and water management, emerging trends and its impact in two river basins1 - the Tungabhadra sub-basin in India and the Tagus basin in Spain and Portugal. The paper covers a wide range of issues including changing water demands affected by erratic hydrological cycles, frequent fires affecting forests, biodiversity and soil thus influencing the livelihoods of marginal communities. The paper also brings to the forefront the need for integrated water management in view of poor integration across and within sectors. Therefore, an attempt is made to understand the dynamics of rain fed and irrigated farming highlighting the technological and institutional options required for improving water-use efficiency. There is still a long way to go in both the basins before suitable integration can be achieved leading to an effective Integrated Water Resource Management strategy

Spatially explicit integrated modeling and economic valuation of climate driven land use change and its indirect effects

We present an integrated model of the direct consequences of climate change on land use, and the indirect effects of induced land use change upon the natural environment. The model predicts climate-driven shifts in the profitability of alternative uses of agricultural land. Both the direct impact of climate change and the induced shift in land use patterns will cause secondary effects on the water environment, for which agriculture is the major source of diffuse pollution. We model the impact of changes in such pollution on riverine ecosystems showing that these will be spatially heterogeneous. Moreover, we consider further knock-on effects upon the recreational benefits derived from water environments, which we assess using revealed preference methods. This analysis permits a multi-layered examination of the economic consequences of climate change, assessing the sequence of impacts from climate change through farm gross margins, land use, water quality and recreation, both at the individual and catchment scale

The Temporal Development of Fatty Infiltrates in the Neck Muscles Following Whiplash Injury: An Association with Pain and Posttraumatic Stress

Radiological findings associated with poor recovery following whiplash injury remain elusive. Muscle fatty infiltrates (MFI) in the cervical extensors on magnetic resonance imaging (MRI) in patients with chronic pain have been observed. Their association with specific aspects of pain and psychological factors have yet to be explored longitudinally.44 subjects with whiplash injury were enrolled at 4 weeks post-injury and classified at 6 months using scores on the Neck Disability Index as recovered, mild and moderate/severe. A measure for MFI and patient self-report of pain, loss of cervical range of movement and posttraumatic stress disorder (PTSD) were collected at 4 weeks, 3 months and 6 months post-injury. The effects of time and group and the interaction of time by group on MFI were determined. We assessed the mediating effect of posttraumatic stress and cervical range of movement on the longitudinal relationship between initial pain intensity and MFI. There was no difference in MFI across all groups at enrollment. MFI values increased in the moderate/severe group and were significantly higher in comparison to the recovered and mild groups at 3 and 6 months. No differences in MFI values were found between the mild and recovered groups. Initial severity of PTSD symptoms mediated the relationship between pain intensity and MFI at 6 months. Initial ROM loss did not.MFI in the cervical extensors occur soon following whiplash injury and suggest the possibility for the occurrence of a more severe injury with subsequent PTSD in patients with persistent symptoms

The Role of Headwater Streams in Downstream Water Quality1

Knowledge of headwater influences on the water-quality and flow conditions of downstream waters is essential to water-resource management at all governmental levels; this includes recent court decisions on the jurisdiction of the Federal Clean Water Act (CWA) over upland areas that contribute to larger downstream water bodies. We review current watershed research and use a water-quality model to investigate headwater influences on downstream receiving waters. Our evaluations demonstrate the intrinsic connections of headwaters to landscape processes and downstream waters through their influence on the supply, transport, and fate of water and solutes in watersheds. Hydrological processes in headwater catchments control the recharge of subsurface water stores, flow paths, and residence times of water throughout landscapes. The dynamic coupling of hydrological and biogeochemical processes in upland streams further controls the chemical form, timing, and longitudinal distances of solute transport to downstream waters. We apply the spatially explicit, mass-balance watershed model SPARROW to consider transport and transformations of water and nutrients throughout stream networks in the northeastern United States. We simulate fluxes of nitrogen, a primary nutrient that is a water-quality concern for acidification of streams and lakes and eutrophication of coastal waters, and refine the model structure to include literature observations of nitrogen removal in streams and lakes. We quantify nitrogen transport from headwaters to downstream navigable waters, where headwaters are defined within the model as first-order, perennial streams that include flow and nitrogen contributions from smaller, intermittent and ephemeral streams. We find that first-order headwaters contribute approximately 70% of the mean-annual water volume and 65% of the nitrogen flux in second-order streams. Their contributions to mean water volume and nitrogen flux decline only marginally to about 55% and 40% in fourth- and higher-order rivers that include navigable waters and their tributaries. These results underscore the profound influence that headwater areas have on shaping downstream water quantity and water quality. The results have relevance to water-resource management and regulatory decisions and potentially broaden understanding of the spatial extent of Federal CWA jurisdiction in U.S. waters