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Background: Culturally relevant patient-centered outcomes tools are needed to identify the needs of patients and to assess their palliative care concerns. Aim: To translate and culturally adapt the Integrated Palliative Care Outcome Scale (IPOS) into Hindi. Design: The study applied a standardized methodology entailing six phases for translation and content validation: equivalence setting through a three-step process; forward translation; blind backward translation; expert review by a panel of the POS team; cognitive de-briefing with patients; and proof-reading of the final tool. All interviews and focus groups were audio-recorded, transcribed and analyzed using content analysis. Setting/participants: (1) Healthcare professionals including doctors, nurses, psychologists, counselors, and volunteers working in Indian palliative care settings with expertise in both English and Hindi languages; (2) Hindi speaking patients diagnosed with cancer who were receiving palliative care in community settings. Caregivers, palliative care experts, and language translators contributed to the translation procedure. Results: Phrases like nausea, poor appetite, drowsiness, and depression were difficult to translate into Hindi. Response categories “occasional” and “sometimes” were overlapping. All items, instructions and response categories were simple to understand. A visual thermometer is a unique feature of Hindi IPOS to facilitate responses from less educated patients. Conclusion: Hindi IPOS has face and content validity for use in clinical practice and research. The Hindi IPOS has implications beyond Indian palliative care settings. Millions of Hindi speakers can now respond to IPOS, and have a tool for communicating their palliative care needs in their mother tongue to inform patient-centered care.

Evidence of symptom control outcomes in severe COVID is scant.To determine changes in symptoms among people severely ill or dying with COVID supported by palliative care, and associations with treatments and survival.Multicentre cohort study of people with COVID across England and Wales supported by palliative care services, during the pandemic in 2020 and 2021. We analysed clinical, demographic and survival data, symptom severity at baseline (referral to palliative care, first COVID assessment) and at three follow-up assessments using the Integrated Palliative care Outcome Scale - COVID version.We included 572 patients from 25 services, mostly hospital support teams; 496 (87%) were newly referred to palliative care with COVID, 75 (13%) were already supported by palliative care when they contracted COVID. At baseline, patients had a mean of 2.4 co-morbidities, mean age 77 years, a mean of five symptoms, and were often bedfast or semiconscious. The most prevalent symptoms were: breathlessness, weakness/lack of energy, drowsiness, anxiety, agitation, confusion/delirium, and pain. Median time in palliative care was 46 hours; 77% of patients died. During palliative care, breathlessness, agitation, anxiety, delirium, cough, fever, pain, sore/dry mouth and nausea improved; drowsiness became worse. Common treatments were low dose morphine and midazolam. Having moderate to severe breathlessness, agitation and multimorbidity were associated with shorter survival.Symptoms of COVID quickly improved during palliative care. Breathlessness, agitation and multimorbidity could be used as triggers for timelier referral, and symptom guidance for wider specialities should build on treatments identified in this study.

The recently described fossil angiosperm genus Eophylica (Rhamnaceae) was based on 18 amber-embedded specimens derived from two sites in northern Myanmar. A vegetatively similar fossil, which came from the same amber mines but which lacked flowers, had been previously described as a putative green alga and given the name Electrophycus. The dimensions and vegetative aspect of that taxon’s holotype specimen are identical with those of the Eophylica fossils. Four additional specimens were acquired by the senior author after the publication of Electrophycus, all of which have a single terminal flower that is either immature or essentially fully formed. Using techniques of floral dissection, high magnification microscopy, and microphotography of the better-developed flowers, we present a more detailed picture of the floral organs, especially the stamens and style, of Eophylica. These flowers differ from the holotype specimen of Eophylica and 3 of its paratypes in that they possess involucral bracts of a so-called ‘pseudanthial head,’ a structure that the authors of Eophylica had only ascribed to certain other paratype specimens of the genus.

SUMMARY Understanding the dynamics and evolution of continental rifting is broadly important for our understanding of plate tectonics. The northern East African Rift offers an excellent opportunity to study these processes at an active rift that was initiated by a large magmatic event. Multiple seismic models have been produced to understand the evolution of magmatism which image punctuated slow velocity zones in the asthenosphere. However, the depth extent of the slow velocity bodies has been less well constrained leading to much debate regarding the primary controls on melt generation. Variations between methods, resolution and scale of the seismic models make direct quantitative comparisons challenging. The lack of instrumentation off-rift further limits our understanding of the spatial extent of tectonic and magmatic processes, which is crucial to understanding magmatic continental rifting. In this paper, we jointly invert Rayleigh wave dispersion curves from ambient noise and teleseisms to obtain absolute shear velocity maps at 10–150 km depth. This includes data from a new seismic network located on the Ethiopian Plateau and enhanced resolution at Moho and upper-mantle depths from the joint inversion. At crustal depths, velocities are slowest beneath the Main Ethiopian Rift and the off-rift Ethiopian Plateau (0.1 km s−1 faster than surroundings), in agreement with previous estimates of lithospheric thickness from receiver functions. The fast lid is not observed within the Main Ethiopian Rift or central Afar which instead are underlain by asthenospheric slow velocity anomalies (

1. Bergmann's rule—which posits that larger animals live in colder areas—is thought to influence variation in body size within species across space and time, but evidence for this claim is mixed. 2. We used Bayesian hierarchical models to test four competing hypotheses for spatiotemporal variation in body size within 20 bat species across North America: (1) the heat conservation hypothesis, which posits that increased body size facilitates body heat conservation (and which is the traditional explanation for the mechanism underlying Bergmann's rule); (2) the heat mortality hypothesis, which posits that increased body size increases susceptibility to acute heat stress; (3) the resource availability hypothesis, which posits that increased body size is enabled in areas with more abundant food; and (4) the starvation resistance hypothesis, which posits that increased body size reduces susceptibility to starvation during acute food shortages. 3. Spatial variation in body mass was most consistently (and negatively) correlated with mean annual temperature, supporting the heat conservation hypothesis. Across time, variation in body mass was most consistently (and positively) correlated with net primary productivity, supporting the resource availability hypothesis. 4. Climate change could influence body size in animals through both changes in mean annual temperature and resource availability. Rapid reductions in body size associated with increasing temperatures have occurred in short-lived, fecund species, but such reductions will be obscured by changes in resource availability in longer-lived, less fecund species.

Salpinganthium hispaniolanum gen. et sp. nov. is described as a new fossil legume from mid-Tertiary forests of Hispaniola. Arborescent legumes of tribe Detarieae previously described from these forests include Hymenaea protera and Prioria dominicana. Flowers of the new genus and species have a bilaterally symmetrical corol-la of five petals, 10 free stamens, an elongate, cylindrical hypanthium, and one or two persistent sepals, the others perhaps being deciduous. The petals are of three markedly different shapes. The pistil is exserted from the hypanthium and is densely hirsute. The bracteoles, sepals, and petals are gland-dotted, as is appropriate for members of the resin-producing Detarieae of subfamily Detarioideae.

We examined the potential for urban water sources to act as centers for rabies transmission from bats to mesocarnivores in the arid southwestern United States where free water is often limited. Because residential housing can act as den and roost sites for both mesocarnivores and bats, we also examined the effect of housing density on abundance. Using ultrasonic acoustic recorders to assess bat activity and camera traps to estimate mesocarnivore abundance, we compared 14 pairs of wet and dry locations over two years by surveying twice during the summer, once prior to summer monsoons and once during the monsoon season, when surface waters were more available. Number of calls for all bat species combined were greater at wet sites compared to dry sites and calls of two bat species often associated with rabies, big brown bat (Eptesicus fuscus) and silver-haired bat (Lasionycteris noctivagans), were recorded more at wet sites than dry sites in the monsoon season. In both years, raccoons (Procyon lotor) were photographed more often at wet sites while striped skunks (Mephitis mephitis) and gray foxes (Urocyon cinereoargenteus) were less likely to be detected at wet sites. Bat, fox and raccoon abundance was not associated with housing density while striped skunks showed a positive correlation with housing density. Higher abundance of bats at urban waters could increase potential for cross-species transmission of rabies from bats to mesocarnivores primarily for raccoons.

Holocene-era range expansions are relevant to understanding how a species might respond to the warming and drying climates of today. The harsh conditions of North American deserts have phylogenetically structured desert bat communities but differences in flight capabilities are expected to affect their ability to compete, locate, and use habitat in the face of modern climate change. A highly vagile but data-deficient bat species, the spotted bat (Euderma maculatum) is thought to have expanded its range from central Mexico to western Canada during the Holocene. With specimens spanning this latitudinal extent, we coupled phylogeography (mtDNA) with ecological niche modeling (ENM) to investigate the Holocene biogeography from the rear to leading edges. The ENM and phylogeny supported a Holocene range expansion from Mexico with increased expansion throughout the intermountain west within the last 6 kya. Long-term isolation at the southern-most margin of the range suggests one or more populations were left behind as climate space contracted and are currently of unknown status. The species appears historically suited to track shifts in climate space but differences in flight behaviors between leading edge and core-range lineages suggest that range expansions could be influenced by differences in habitat quality or climate (e.g., drought). Although its vagility could facilitate the tracking of environmental change and thereby extinction avoidance, anthropogenic pressures at the core range could still threaten the ability for beneficial alleles to expand into the leading edge.

Introduction The use of all-terrain vehicles (ATVs) has become increasingly popular as an outdoor recreational activity among people living in the United States, particularly in areas such as the southeast. There are significant risks involved with riding ATVs, especially in the pediatric population, due to lack of training and experience. The purpose of this study was to evaluate the outcomes of pediatric patients involved in ATV-associated accidents. Methods This study is a retrospective review of 98 pediatric patients ages 15 years and younger involved in ATV accidents who were admitted to a pediatric hospital between January 2015 and December 2020. Outcomes, including types of injuries sustained, length of hospital stay, length of ICU stay, and injury severity score (ISS) were analyzed between age groups (0-5, 6-10, and 11-15). Results The mean hospital stay across all age groups was 1.7 ± 1.9 days, mean ICU stay was 3.8 ± 4.0 days, and mean injury severity score (ISS) was 5.9 ±4.8. The 11-15-year-old age group had a significantly longer hospital stay and higher ISS scores compared to both of the younger age groups (0-5 and 6-10 years old). There was no difference in ICU days between the age groups. Orthopedic injuries were the most common type of injury, occurring in 55% of all patients, followed by head injuries in 29% of patients, and spinal fractures in 2% of patients. The most common orthopedic fracture in the 11-15-year-old group was tibia/fibula, while humerus fractures were the most common type of fracture in the 0-5 and 6-10 year age groups. Orthopedic procedures were required in 35% of all included patients. There was no statistically significant difference in types of injuries and types of fractures sustained between each group. Chest injuries, including pneumothorax, lung contusions, and rib fractures, occurred most often in the older age group 11-15 years (n=65). Those who experienced chest injuries had a higher ISS, although it was not statistically significant (p=0.06) compared to those who did not have chest injuries. There was no difference in hospital or ICU length of stay in patients with chest injuries. Conclusions The results of this study demonstrate the outcomes of pediatric patients admitted for ATV accidents at a rural Appalachian pediatric hospital and provide an overview of the most common injuries involved in this trauma mechanism. Pediatric patients aged 11-15 years of age involved in ATV accidents are at risk for longer hospital length of stay and higher ISS compared to younger age groups. Additionally, patients ages 11-15 were more susceptible to chest injuries following ATV accidents. The results of this study will be used to develop a standardized trauma protocol for the management of this specific trauma mechanism in the pediatric population based on common injury patterns among each age group.

We used teleseismic receiver function analysis to image the crustal structure beneath 24 broadband seismic stations densely deployed along two profiles traversing different structural units across the western Afar margin. Our high-resolution receiver function results image pronounced spatial variations in the crustal structure along the profiles and provide improved insights to understand how strain is partitioned in the crust during rifting. Beneath the western plateau next to northern Afar, the crust is likely felsic-to-intermediate in composition (average Vp/Vs 1.74), with a step like thinning of the crust from an average of 38 km beneath the western plateau to an average of 22 km beneath the marginal graben. Consistently thicker crust is observed beneath the southern profile (central Afar), showing four distinct regions of uniform crustal thickness: 1) an average crustal thickness of 42 km beneath the western plateau; 2) 34 km beneath the foothills area; 3) 28 km beneath the marginal graben and the wide extensional basin and 4) 21 km beneath the central rift axis. We use crustal thickness results to estimate a stretching factor β of 2.2 and 2.7 for central Afar and northern Afar respectively. Our estimated values are lower than β > 3.0 predicted from plate reconstructions, and we interpret that the variations are best explained by 2–5 km magmatic addition into the crust. The crustal composition beneath the southern profile is more complex with elevated Vp/Vs ratios ranging between 1.79 and 1.85 beneath the western plateau and marginal graben. This is consistent with a greater mafic component and best explained by crust altered by intrusions due to significant pre and syn-rift magmatic activity. Abnormally high Vp/Vs ratios of more than 1.90 are observed beneath the axial rift zone of central Afar, which most likely suggests the localization of partial melt within the crust.

Background Demand for mental health services in New Zealand and internationally is growing. Little is known about how psychiatrists are faring in this environment. This study aimed to investigate wellbeing of psychiatrists working in the public health system in New Zealand, identify the main risk factors for work-related stress, gauge perceptions of how workload has changed over time, assess job satisfaction and whether individuals intend or desire to leave their work. Methods Psychiatrists working in New Zealand who were also members of the Association of Salaried Medical Specialists were invited to participate in an online survey. Main outcome measures were degree of burnout and stress experienced at work. Supplementary measures included perceived workplace demands and levels of support. Predictor variables included perceptions of changes to workloads over time, degree of job satisfaction and intentions to leave work. Logistic regression assessed characteristics associated with burnout and job satisfaction as well as intentions to leave work. Free text comments were analysed thematically alongside quantitative trends. Results 368/526 responded (70% response rate). 34.6% met the criteria for burnout and 35.3% scored with high work stress. There were no significant patterns of association with demographic variables but significant correlation with all but one predictor variable; having experienced a change to the demands of the on-call workload. 45% agreed they would leave their current job if able and 87% disagreed that they are working in a well-resourced mental health service. Respondents emphasised the impact of growing workloads and expressed concerns about their ability to provide optimal care in these circumstances. Conclusions High burnout appears to affect one in three psychiatrists in New Zealand. Many attribute their feelings of burnout to demand for their services. These findings may assist with better workforce planning for psychiatry and emphasises potential consequences of demand for and poor resourcing of mental health services for the retention and wellbeing of doctors in psychiatry worldwide.

Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes.The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail.Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity.Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

ObjectiveOur objective was to assess the level of COVID-19 preparedness of emergency departments (EDs) in Aotearoa New Zealand (NZ) through the views of emergency medicine specialists working in district health boards around the country. Given the limited experience NZ hospitals have had with SARS-CoV-2, a comparison of current local practice with recent literature from other countries identifying known weaknesses may help prevent future healthcare worker infections in NZ.MethodsWe conducted a cross-sectional survey of NZ emergency specialists in November 2020 to evaluate preparedness of engineering, administrative policy and personal protective equipment (PPE) use.ResultsA total of 137 surveys were completed (32% response rate). More than 12% of emergency specialists surveyed reported no access to negative pressure rooms. N95 fit testing had not been performed in 15 (12%) of respondents. Most specialists (77%) work in EDs that cohort patients with COVID-19, about one-third (34%) do not use spotters during PPE doffing, and most (87%) do not have required space for physical distancing in non-patient areas. Initial PPE training, simulations and segregating patients were widespread but appear to be waning with persistent low SARS-CoV-2 prevalence. PPE shortages were not identified in NZ EDs, yet 13% of consultants do not plan to use respirators during aerosol-generating procedures on patients with COVID-19.ConclusionsNZ emergency specialists identified significant gaps in COVID-19 preparedness, and they have a unique opportunity to translate lessons from other locations into local action. These data provide insight into weaknesses in hospital engineering, policy and PPE practice in advance of future SARS-CoV-2 endemic transmission.

Atherosclerotic plaques form in artery walls due to a chronic inflammatory response driven by lipid accumulation. A key component of the inflammatory response is the interaction between monocyte-derived macrophages and extracellular lipid. Although concentrations of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particles in the blood are known to affect plaque progression, their impact on the lipid load of plaque macrophages remains unexplored. In this paper, we develop a lipid-structured mathematical model to investigate the impact of blood LDL/HDL levels on plaque composition, and lipid distribution in plaque macrophages. A reduced subsystem, derived by summing the equations of the full model, describes the dynamics of biophysical quantities relating to plaque composition (e.g. total number of macrophages, total amount of intracellular lipid). We also derive a continuum approximation of the model to facilitate analysis of the macrophage lipid distribution. The results, which include time-dependent numerical solutions and asymptotic analysis of the unique steady state solution, indicate that plaque lipid content is sensitive to the influx of LDL relative to HDL capacity. The macrophage lipid distribution evolves in a wave-like manner towards an equilibrium profile which may be monotone decreasing, quasi-uniform or unimodal, attaining its maximum value at a non-zero lipid level. Our model also reveals that macrophage uptake may be severely impaired by lipid accumulation. We conclude that lipid accumulation in plaque macrophages may serve as a partial explanation for the defective uptake of apoptotic cells (efferocytosis) often reported in atherosclerotic plaques., Comment: 44 pages, 13 figures