Search

BACKGROUND: Myocardial infarction secondary to spontaneous coronary artery dissection (SCAD) can be traumatic and potentially trigger posttraumatic stress disorder (PTSD). In a large, multicenter, registry-based cohort, we documented prevalence of lifetime and past-month SCAD-induced PTSD, as well as related treatment seeking, and examined a range of health-relevant correlates of SCAD-induced PTSD. METHODS AND RESULTS: Patients with SCAD were enrolled in the iSCAD (International SCAD) Registry. At baseline, site investigators completed medical report forms, and patients reported demographics, medical/SCAD history, psychosocial factors (including SCAD-induced PTSD symptoms), health behaviors, and health status via online questionnaires. Of 1156 registry patients, 859 patients (93.9% women; mean age, 52.3 years) completed questionnaires querying SCAD-induced PTSD. Nearly 35% (n=298) of patients met diagnostic criteria for probable SCAD-induced PTSD in their lifetime, and 6.4% (n=55) met criteria for probable past-month PTSD. Of 811 patients ever reporting any SCAD-induced PTSD symptoms, 34.8% indicated seeking treatment for this distress. However, 46.0% of the 298 patients with lifetime probable SCAD-induced PTSD diagnoses reported never receiving trauma-related treatment. Younger age at first SCAD, fewer years since SCAD, being single, unemployed status, more lifetime trauma, and history of anxiety were associated with greater past-month PTSD symptom severity in multivariable regression models. Greater past-month SCAD-induced PTSD symptoms were associated with greater past-week sleep disturbance and worse past-month disease-specific health status when adjusting for various risk factors. CONCLUSIONS: Given the high prevalence of SCAD-induced PTSD symptoms, efforts to support screening for these symptoms and connecting patients experiencing distress with empirically supported treatments are critical next steps. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique

Amphibians are the most threatened vertebrate class globally. Multiple factors have been implicated in their global decline, and it has been hypothesized that interactions between stressors may be a major cause. Increased ultraviolet (UV) radiation, as a result of ozone depletion, has been identified as one such stressor. Exposure to UV radiation has been shown to have detrimental effects on amphibians and can exacerbate the effects of other stressors, such as chemical pollutants. Chemical pollution has likewise been recognized as a major factor contributing to amphibian declines, particularly, endocrine-disrupting chemicals. In this regard, 17 beta-trenbolone is a potent anabolic steroid used in the agricultural industry to increase muscle mass in cattle and has been repeatedly detected in the environment where amphibians live and breed. At high concentrations, 17 beta-trenbolone has been shown to impact amphibian survival and gonadal development. In the present study, we investigated the effects of environmentally realistic UV radiation and 17 beta-trenbolone exposure, both in isolation and in combination, on the morphology and behavior of tadpoles (Limnodynastes tasmaniensis). We found that neither stressor in isolation affected tadpoles, nor did we find any interactive effects. The results from our 17 beta-trenbolone treatment are consistent with recent research suggesting that, at environmentally realistic concentrations, tadpoles may be less vulnerable to this pollutant compared to other vertebrate classes. The absence of UV radiation-induced effects found in the present study could be due to species-specific variation in susceptibility, as well as the dosage utilized. We suggest that future research should incorporate long-term studies with multiple stressors to accurately identify the threats to, and subsequent consequences for, amphibians under natural conditions. Environ Toxicol Chem 2024;00:1-12. (c) 2024 The Authors. Environmental Toxicology and Chemistr

The message of living simply and wanting less may be the most important message outdoor educators can give their students. The nature of outdoor education provides a combination of factors that create an effective learning environment for the practice of living simply. These factors are: (1) going away from the home or school environment to a setting where actions are more related to basic survival; (2) interacting with a group--creating an entire micro-society for the duration of the trip--which can speed up the processes of personal relationships because of close living and interdependence; and (3) living close to nature, which provides the opportunity to learn about basic needs and the essentials of a quality life. To use the potential of this learning environment to the fullest, whatever time is available should contribute to the main message. Expectations can be discussed during planning sessions, the bus trip can be used to teach how to share a small space equitably with comfort for all, setting up camp can be used to teach minimal impact and balance between group versus personal space needs, and structured discussion during the bush experience itself helps participants put into perspective their role as inhabitants of Earth. Outdoor educators should model their own behavior to show participants how to integrate the message into their lives. (TD)

The electroweak interaction in the Standard Model (SM) is described by a pure vector-axial-vector structure, though any Lorentz-invariant component could contribute. In this work, we present the most precise measurement of tensor currents in the low-energy regime by examining the $\beta$-$\bar{\nu}$ correlation of trapped $^{8}$Li ions with the Beta-decay Paul Trap. We find $a_{\beta\nu} = -0.3325 \pm 0.0013_{stat} \pm 0.0019_{syst}$ at $1\sigma$ for the case of coupling to right-handed neutrinos $(C_T=-C_T')$, which is consistent with the SM prediction., Comment: 6 pages, 3 figures, 1 table

PURPOSE: To measure changes in dual x-ray absorptiometry (DXA) derived body composition in Intensive Care Unit (ICU) survivors in the year following discharge and compare to population controls. MATERIALS AND METHODS: Using prospective observational data changes in hip and spine DXA estimated lean and fat mass between ICU discharge and 1-year follow-up were calculated and compared with age-sex-height matched controls from the Geelong Osteoporosis Study via multivariable linear regression. RESULTS: Sixty-four participants were included, with median age 68.8 yr [IQR 60.8, 74.6], ICU length of stay 6.5 d [IQR 4, 9] and duration of mechanical ventilation 87 h [IQR 47, 143]. ICU survivors demonstrated greater annual increases in lean (+0.92 kg; 95%CI 0.67 to 1.18, p < 0.01) and fat mass (+2.50 kg, 95%CI 1.94 to 3.05; p < 0.01) than controls. At 1-yr follow-up, the ICU group had lower lean mass (-0.96 kg, 95%CI -1.91 to -0.01; p = 0.047) and greater fat mass (6.79 kg, 95%CI 4.55 to 9.03; p < 0.001). CONCLUSIONS: Mechanically ventilated adult ICU patients gained lean mass in the year following critical illness but did not reach the level of matched population-based peers. Understanding the factors associated with, and effect of increasing muscle mass and reducing fat mass in the year after critical illness requires further investigation.

Whole-body dual X-ray absorptiometry (DXA) accurately measures lean mass but is not routinely used in clinical practice. Hip and spine DXA are used in the diagnosis of osteoporosis, and with the common co-occurrence of sarcopenia with osteoporosis, regional DXA scans provide an opportunity for assessment of lean mass. The aim of this study is to develop predictive equations for the estimation of whole-body lean mass (WBLM), appendicular lean mass (ALM) and whole-body fat mass (WBFM) from regional DXA scans. A total of 2427 participants (ages 20-96 year; 57.7% men) from the Geelong Osteoporosis Study who underwent both regional and whole-body DXA were included in the analysis. Using forward stepwise multivariable linear regression, percentage fat (spine%fat, hip%fat) values from lumbar spine and femoral neck DXA were used in combination with clinical data to develop and validate equations for the estimation of WBLM, WBFM and ALM. Mean age was 53.5 year (± 19.2), weight 78.2 kg (± 15.4), height 169.6 cm (± 9.4), WBLM 50.4 kg (± 11.1), ALM 22.8 kg (± 5.4) and WBFM 24.3 kg (± 10.4). Spine%fat (r = 0.21) and hip%fat (r = - 0.34) were correlated with whole-body lean mass (p < 0.001). Final predictive equations included age, sex, weight, height, spine%fat, and hip%fat and possessed high predictive value (Adj R2 0.91-0.94, RMSE 1.60-2.84 kg). K-fold cross-validation methods produced median root mean square error (RMSE) ranging from 1.59 to 2.81 kg for the three models. Regional DXA scans of the spine and hip can be used to estimate whole-body and appendicular lean mass, to assist in the identification of low muscle mass.

This research investigated sustainable resource recovery from unsorted urban, industrial and agricultural waste using fry drying and pyrolytic distillation process methods. Thermogravimetric analysis and Fourier Transform Infrared Spectroscopy were used to identify and quantify linkages between feedstock composition, process chemistry and likely end products. Distributed activation energy modelling was used as an initial step towards development of an accurate kinetic process model. It was postulated that sequential pyrolytic distillation technology be developed to create circular economies, reverse environmental pollution, recycle primary resources and produce carbon negative biofuels to replace fossil fuels such as coal, oil and gas.

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes — relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort — provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Abstract Purpose Intensive care unit (ICU) survivors have reduced physical function likely due to skeletal muscle wasting and weakness acquired during critical illness. However, the contribution of pre-morbid muscle mass has not been elucidated. We aimed to examine the association between pre-ICU muscle mass and ICU admission risk. Secondary outcomes include the relationship between muscle mass and ICU outcomes. Methods ICU admissions between June 1, 1998, and February 1, 2019, were identified among participants of Geelong Osteoporosis Study (GOS), a population-based cohort study. Cox proportional hazard regression models estimated hazard ratios (HR) for ICU admission across T-score strata and continuous values of DXA-derived lean mass measures of skeletal mass index (SMI, lean mass/body mass %) and appendicular lean mass corrected for height (ALM/h2, kg/m2). Multivariable regression was used to determine the relationship between lean mass and ICU outcomes. Results One hundred and eighty-six of 3126 participants enrolled in GOS were admitted to the ICU during the follow-up period. In adjusted models, lean mass was not predictive of ICU admission (SMI: HR 0.99 95%CI 0.97–1.01, p = 0.32; ALM/h2: HR 1.11 95%CI 0.94–1.31, p = 0.23), while greater appendicular lean mass was related to reduced 28-day mortality (ALM/h2 adjOR: 0.25, 95%CI 0.10–0.63, p = 0.003, SMI adjOR: 0.91, 95%CI 0.82–1.02, p = 0.09). Conclusion Lean mass was not associated with ICU

Self-harm is one of the most common reasons for admission to an intensive care unit (ICU). While most patients with self-harm survive the ICU admission, little is known about their outcomes after hospital discharge. We conducted a retrospective cohort study of patients in the Barwon region in Victoria admitted to the ICU with self-harm (between 1998 and 2018) who survived to hospital discharge. The primary objective was to determine mortality after hospital discharge, and secondarily estimate relative survival, years of potential life lost, cause of death and factors associated with death. Over the 20-year study period, there were 710 patients in the cohort. The median patient age was 37 years (interquartile range (IQR) 26–48 years). A total of 406 (57%) were female, and 527 (74%) had a prior psychiatric diagnosis. The incidence of ICU admission increased over time (incidence rate ratio 1.05; 95% confidence interval (CI) 1.03–1.06 per annum). There were 105 (15%) patients who died after hospital discharge. Relative survival decreased each year after discharge, with the greatest decrement during the first 12 months. At ten years, relative survival was 0.85 (95% CI 0.81–0.88). The median years of potential life lost was 35 (IQR 22–45). Cause of death was self-harm in 27%, possible self-harm in 32% and medical disease in 41%. The only factors associated with mortality were male sex, older age and re-admission to ICU with self-harm. Further population studies are required to confirm these findings, and to understand what interventions may improve long-term survival in this relatively young group of critically ill patients.

The view of international law as a profession committed to the spread of liberal ideas emerged in Europe and North America in the late nineteenth century.1 One of those ideas was the rule of law. Attempts to realize a global rule of law and attempts to constitute an international community have long been linked. For many international lawyers, this gave international law a sense of forward movement and a clear telos, with the caveat that the reality of unequal power relations meant that international law could never be measured directly against a model borrowed from domestic law and politics.

This article argues that the old international law of empires, greater spaces, and regional orders did not disappear with the creation of the United Nations. While revisionist histories of international law have complicated the claim that a Westphalian order of independent states completely replaced a world of more varied political forms in the mid-seventeenth century, international lawyers nonetheless largely accept that such a transformation did take place at some point. The state is treated as the normative political subject of international law, and any move away from the geography of statehood as the foundation of the international legal system is seen as novel, exceptional, or illegal. The narrative that the state has become the primary political subject and spatial form of international law masks the persistence of regional orders as a core feature of the contemporary legal system. This article shows that international lawyers have been engaged in justifying, making sense of, narrating, and assembling regional orders for at least the past century. It explores the rival regionalisms promoted during the inter-war period, the struggles over regional orders during the early decades of decolonization, the expansive vision of regional orders consolidated in the early post-Cold War decades by the United States and its allies, and the regional ambitions of China in the twenty-first century. It analyses how regional orders are assembled and resisted through international law, what values are proclaimed to justify different forms of regional ordering, whose interests are represented, and the relation between grand narratives and technical transactions in that legal work. The article concludes that bringing the concept of regional orders to the foreground can open up a new and timely set of questions about politics, representation, and the future of international law.

OBJECTIVE: Dravet syndrome (DS) is a severe developmental and epileptic encephalopathy with early childhood onset. Patients with DS do not respond well to antiepileptic drugs and have only a few treatment options available. Here, we evaluated the effect of medium chain triglyceride (MCT) diet therapy in a mouse model of DS. METHODS: Scn1aR1407X/+ DS mice were given diets supplemented with MCTs with varying ratios of decanoic (C10) and octanoic (C8) acid or a control diet for 4 weeks. Video monitoring was performed to evaluate spontaneous convulsive seizure frequency. Susceptibility to hyperthermia-induced seizures was also examined. Medium chain fatty acids, and mitochondrial and antioxidant markers were assessed in brain homogenate. RESULTS: Dietary intervention with MCTs significantly prolonged survival and reduced convulsive seizure frequency during the critical period of highest seizure occurrence in the Scn1aR1407X/+ DS mice. Moreover, MCT diet therapy showed protective effects against hyperthermia-induced seizures. We demonstrated that coadministration of C10/C8 was effective at reducing both seizures and mortality, whereas C10 alone only reduced mortality, suggesting that the ratio of C10 to C8 in the MCT is an important factor for efficacy. When C10 and C8 are supplemented at an 80:20 ratio in the diet, C10 accumulates in the brain in high enough concentrations to enhance brain energy metabolism by both stimulating mitochondrial enrichment and increasing its antioxidant status. SIGNIFICANCE: The results from this study indicate that MCT diet therapy may provide therapeutic benefits in DS. Future clinical studies would elucidate whether these positive effects are mirrored in human patients.

The gambling industry has grown into a global business in the 21st century. This has created the need for a new emphasis on problem prevention. This article highlights the core themes of the book Setting Limits: Gambling, Science and Public Policy, taking a broad view of the consequences of gambling for society as a burden on health, well-being and equality. The book covers the extent of gambling and gambling-related problems in different societies and presents a critical review of research on industry practices, policy objectives and preventive approaches, including services to people suffering from gambling and its consequences. It discusses the developments in game characteristics and gambling environments and provides evidence on how regulation can affect those. Effective measures to minimize gambling harm exist and many are well supported by scientific evidence. They include restrictions on general availability as well as selective measures to prevent gamblers from overspending. The revenue generated from gambling for the industry, governments, and providers of public services funded from gambling returns presents an obstacle to developing policies to implement harm-reduction measures. A public interest approach must weigh these interests against the suffering and losses of the victims of gambling.

Objectives: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. Methods: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. Results: There are clear commonalities across UCIs’ strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. Conclusion: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and cohe, Objectives Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. Methods We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. Results There are clear commonalities across UCIs’ strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. Conclusion UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effecti

The Mexican Revolution is commonly perceived to have been the first social revolution. The revolutionary Mexican Constitution of 1917, at the time perhaps the most radical the world had seen, is well known, as is the subsequent oil nationalisation of the 1930s that it facilitated. Another significant, albeit less immediately striking, consequence of the revolutionary events that took place in Mexico between 1910 and 1920 was that a large number of claims were made against the Mexican state in respect of injuries caused to foreign nationals as a result of the revolution. Such claims found their basis in a (hotly contested) body of international legal rules that had emerged during the second half of the nineteenth century and first decades of the twentieth concerning alien protection: that is, concerning the rights of states to protect their nationals overseas and the duties of states when it came to the treatment of foreign nationals in their territory. The law of alien protection was also known as, or incorporated, state responsibility for injuries to aliens and diplomatic protection. Subsequently, six mixed claims commissions – with the United States, France, Germany, Spain, Britain and Italy – were set up to adjudicate Mexico’s international responsibility for claims that had arisen in respect of loss or damage caused by ‘revolutionary acts’ between 20 November 1910 and 31 May 1920. Loss or damage here encompassed personal injury, property loss or damage and breach of contract. Claims could be brought by ‘corporations, companies, associations, partnerships or individuals’. In addition, there was a second US commission, the ‘general commission’ (in contrast to the ‘special commission’, as the other US commission was known), which also had jurisdiction over certain other ‘revolutionary damage’ claims.

In 1917, the October Revolution and the adoption of the revolutionary Mexican Constitution shook the foundations of the international order and international law in profound, unprecedented and lasting ways. The Mexican and Russian revolutions posed fundamental challenges to the still embryonic profession of international law, its practitioners then largely committed to various forms of liberalism and capitalism. In bringing the ‘social question’ to the forefront of international legal debates, the Mexican and Russian revolutions offered new ways of thinking about foundational concepts of property, statehood and non-intervention – and indeed about the very nature of law itself.

In an experiment performed at Lawrence Berkeley National Laboratory’s 88-inch cyclotron, the isotope 244Md was produced in the 209Bi(40Ar,5n) reaction. Decay properties of 244Md were measured at the focal plane of the Berkeley Gas-filled Separator, and the mass number assignment of A = 244 was confirmed with the apparatus for the identification of nuclide A. The isotope 244Md is reported to have one, possibly two, α-decaying states with α energies of 8.66(2) and 8.31(2) MeV and half-lives of 0.4+0.4-0.1 and ∼6 s, respectively. Additionally, first evidence of the α decay of 236Bk was observed and is reported.

Importance: It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. Objective(s): To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. Design, Setting, and Participant(s): Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. Intervention(s): Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. Main Outcomes and Measures: The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. Result(s): Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was-0.6 hours (95% CI,-8.3 to 7.2 hours; P =.83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI

Retinoid treatment is employed during residual disease treatment in neuroblastoma, where the aim is to induce neural differentiation or death in tumour cells. However, although therapeutically effective, retinoids have only modest benefits and suffer from poor pharmacokinetic properties. In vivo, retinoids induce CYP26 enzyme production in the liver, enhancing their own rapid metabolic clearance, while retinoid resistance in tumour cells themselves is considered to be due in part to increased CYP26 production. Retinoic acid metabolism blocking agents (RAMBAs), which inhibit CYP26 enzymes, can improve retinoic acid (RA) pharmacokinetics in pre-clinical neuroblastoma models. Here, we demonstrate that in cultured neuroblastoma tumour cells, RAMBAs enhance RA action as seen by morphological differentiation, AKT signalling and suppression of MYCN protein. Although active as retinoid enhancers, these RAMBAs are highly hydrophobic and their effective delivery in humans will be very challenging. Here, we demonstrate that such RAMBAs can be loaded efficiently into cationic liposomal particles, where the RAMBAs achieve good bioavailability and activity in cultured tumour cells. This demonstrates the efficacy of RAMBAs in enhancing retinoid signalling in neuroblastoma cells and shows for the first time that liposomal delivery of hydrophobic RAMBAs is a viable approach, providing novel opportunities for their delivery and application in humans.

With food security and soil degradation being a major concern and hurdle in the development goals of sub-Saharan Africa (SSA), there has been and continues to be an attempt to find an alternative cropping system to conventional monocropping that rehabilitates soils whilst increasing productivity and efficiency of the subsistence cropping system. Such a cropping system needs to be realistically adoptable within the SSA social and ecological constraints. An alternative Australian winter rainfall relay cropping system coined pasture cropping (PaCr) was identified as an option that may surmount some of these limitations.This research involved completing a field trial through to model scale introductory assessment of the water dynamics in PaCr and the implications thereof in yield, water use efficiency (WUE) and competition for water; ultimately assessing the potential of PaCr in SSA. PaCr was adapted to an intercropping system for SSA summer rainfall conditions. The three treatments included the representative subsistence crop cowpea (Vigna unguiculate) and a common indigenous pasture (Eragrostis curvula) and an additive PaCr setup of cowpea directly seeded into pasture in water limited (rainfed) field trials in Pretoria, South Africa between 2013-2015. The DM yields of PaCr were 17% and 293% higher in both seasons compared to the conventional cowpea monocrop yield. When comparing PaCr yield to conventional pasture, there was a 12% and 89% higher yield in both seasons compared to the conventional pasture monocrop yield. The greater yield advantage in 2015 with the limited rainfall indicates that PaCr was most advantageous in terms of DM yield in a drier year which is a time of greatest risk and food insecurity. PaCr was also more WUE in both seasons, being significantly higher than the cowpea monocrop in 2015. Competition also showed a higher degree of competitiveness by cowpea in the wetter 2013-14 season and lower competitive ability in the drier 2015, whereas pasture, Da die Ernährungssicherheit und die Bodendegradation ein Hauptanliegen und eine Hürde für die Entwicklungsziele des subsaharischen Afrikas (SSA) darstellen, wurde und wird versucht, ein alternatives Anbausystem zum konventionellen Monokulturanbau zu finden, das die Böden rehabilitiert und gleichzeitig die Produktivität und Effizienz des Subsistenzsystems erhöht. Ein solches Anbausystem muss realistisch an die sozialen und ökologischen Gegebenheiten der SSA angepasst werden können. Für die vorliegende Forschungsarbeit wurde als eine Option, die einige dieser Einschränkungen überwinden könnte, ein alternatives Australisches Winterregenrelais-Erntesystem für das Ernten von Weideflächen (PaCr) identifiziert. Die Forschung beinhaltete den Abschluss eines Feldversuchs bis hin zur modellhaften einleitenden Bewertung der Wasserdynamik bei PaCr und deren Auswirkungen auf Ertrag, Wassernutzungseffizienz (WUE) und Wettbewerb um Wasser. Abschließend wurde das Potenzial von PaCr in SSA bewertet. PaCr wurde an ein Mischkultur für SSA Sommerregenbedingungen angepasst. Die drei Versuche umfassten die repräsentative Subsistenzpflanze Augenbohne (Vigna unguiculate) und eine gemeinsame einheimische Weide (Eragrostis curvula) sowie einen zusätzlichen PaCr-Aufbau von Augenbohne, die in wasserlimitierten Feldversuchen in Pretoria, Südafrika, zwischen 2013-2015 direkt in die Weide gesät wurde. Die Trockenmasse-Erträge von PaCr lagen in beiden Jahreszeiten um 17% bzw. 293% höher als die konventionelle Monokultur-Erträge von Augenbohne. Vergleicht man den PaCr-Ertrag mit dem konventionellen Weidenanbau, so ergibt sich in beiden Jahreszeiten ein um 12% bzw. 89% höherer Ertrag im Vergleich zum konventionellen Monokultur-Ertrag. Der größere Ertragsvorteil im Jahr 2015 mit den begrenzten Niederschlägen zeigt, dass PaCr in einem trockeneren Jahr, welches das größte Risiko unter Gesichtspunkten der Ernährungssicherheit darstellt, in Bezug auf den DM-Ertrag am vorteilhaftesten war. PaCr war in bei

OBJECTIVE: To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED. METHODS: Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital. RESULTS: A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility. CONCLUSION: A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.

While international law has played a central role in creating the conditions for market liberalization on a global scale, many international lawyers have paid less attention to the social question - that is, the question of who is able to participate in political decision-making about economic relations and property rights. The current moment of perceived backlash to international law and institutions offers an opportunity to think again about the ways of relating politics, economics, and the social that have been consolidated through international law and to do so by posing the issue as a question of representation. How might international economic law-making and adjudication be re-embedded within political processes? And how can foundational political questions about property, security, survival, and freedom be returned to democratic control?

IMPORTANCE: It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. OBJECTIVE: To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. INTERVENTIONS: Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. MAIN OUTCOMES AND MEASURES: The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. RESULTS: Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was -0.6 hours (95% CI, -8.3 to 7.2 hours; P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69

PURPOSE: To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock. MATERIAL AND METHODS: Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years). RESULTS: 641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50 years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46-1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81-1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures. CONCLUSIONS: This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.

Percutaneous patent foramen ovale (PFO) closure is recommended for secondary prevention of paradoxical embolism through a PFO. In the United States, two Food and Drug Administration-approved PFO closure devices are currently available, and the choice depends on operator preference and PFO anatomy. Although these devices are easy to implant, there are several potential complications. As opposed to the Amplatzer PFO Occluder, there has been no published case of atrial erosion with Gore closure devices. This report describes two cases of pericardial tamponade due to perforation of the atrial wall induced by a wire frame fracture of the Gore Helex and Cardioform devices.

BACKGROUND: Septic shock is associated with poor outcomes. Vitamin C (ascorbic acid) is a cellular antioxidant and has anti-inflammatory properties. Whether the combination therapy of vitamin C, thiamine and hydrocortisone reduces vasopressor dependency in septic shock is unclear. OBJECTIVES: To describe the protocol and statistical analysis plan of a multicentre, open-label, prospective, phase 2 randomised clinical trial evaluating the effects of vitamin C, thiamine and hydrocortisone when compared with hydrocortisone monotherapy on the duration of vasopressor administration in critically ill patients with septic shock. METHODS: VITAMINS is a multicentre cardiovascular efficacy trial in adult patients with septic shock. Randomisation occurs via a secure website with stratification by site, and allocation concealment is maintained throughout the trial. The primary outcome is the duration of time alive and free of vasopressor administration at Day 7. Secondary outcomes include feasibility endpoints and some patientcentred outcomes. All analyses will be conducted on an intention-to-treat basis. CONCLUSION: The VITAMINS trial will determine whether combination therapy of vitamin C, thiamine and hydrocortisone when compared with hydrocortisone increases vasopressor-free hours in critically ill patients with septic shock. The conduct of this study will provide important information on the feasibility of studying this intervention in a phase 3 trial. TRIAL REGISTRATION: ClinicalTrials.gov, identification No. NCT03333278.