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To identify and classify methods for assessing professionalism across health profession degree programs and identify gaps in the literature regarding types of assessments. The authors conducted a scoping review of articles published from database inception through 24 January 2020. Included articles described an assessment approach for professionalism in health profession degree programs available in full-text in the English language. Articles were classified based on profession, timing of assessment, feedback type, assessment type, professionalism dimension, and Barr's modified Kirkpatrick hierarchy. Authors classified 277 articles meeting inclusion criteria. Most articles were from medical education (62.5%) conducted during didactic (62.1%) or experiential/clinical curriculum (49.8%). Few articles (15.5%) described longitudinal assessment. Feedback type was formative (32.2%) or summative (35%), with only 8.3% using both. Assessment types frequently reported included self-administered rating scales (30%), reflections (18.8%), observed clinical encounters (17.3%), and knowledge-based tests (13.4%). Ethical practice principles (65%) and effective interactions with patients (48.4%) were the most frequently assessed dimensions of professionalism. Authors observed balanced distribution among Barr's modified Kirkpatrick model at levels of reaction (38.3%), modification of perceptions and attitudes (33.6%), acquisition of knowledge and skills (39%), and behavioral change (36.1%). The classification scheme identified in current literature on professionalism assessment does not align with International Ottawa Conference Working Group on the Assessment of Professionalism recommendations. Gaps identified were limited description of professionalism assessment during admissions, infrequent longitudinal assessment, limited use of methods for both formative and summative assessment, and limited reports of assessments applicable to interprofessional education settings. [ABSTRACT FROM AUTHOR]

Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described. The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status. Of 84,554 children, 873 (1.03%) had PCSI. Patients < 4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001). Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging. IV. [ABSTRACT FROM AUTHOR]

Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries. We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 0–2) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited). Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others. CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity. Level III retrospective comparative study [ABSTRACT FROM AUTHOR]

Congenital diaphragmatic hernias (CDH) affect variable portions of diaphragm, resulting in herniation of abdominal contents into the chest. CDH typically is diagnosed prenatally or presents soon after birth with respiratory distress and abnormal chest X-ray (CXR) findings. Presentation after infancy is rare but well described. We present a case of delayed presentation of a right CDH following left CDH repair. An 18-month-old boy with a history of a left CDH repaired in the newborn period presented with a newly elevated right hemidiaphragm presumed to be an eventration. He re-presented 9 months later with abdominal pain and respiratory distress. Xray was concerning for gastric volvulus within the right chest. Surgical exploration revealed a small right sided diaphragmatic hernia with an incarcerated liver and stomach. This was repaired without event. Normal appearing CXR following L CDH repair led to delayed recognition of this right CDH. Delayed presentation was likely due to the liver covering the small diaphragmatic defect, preventing early migration of the intra-abdominal viscera into the chest. Recurrence of the CDH is the most common cause of respiratory and gastrointestinal symptoms following prior repair, but an unrecognized contralateral defect is a rare possibility. In a patient with a prior history of a left CDH who presents with respiratory and gastrointestinal symptoms, along with a recurrence of the left sided CDH, the presence of a right sided defect should be considered if the right hemidiaphragm is newly elevated. • One percent of patients with congenital diaphragmatic hernia have bilateral disease and may have a delayed presentation. • Small, right sided bochdalek hernias may be radiographically occult on newborn chest Xray • In patients with history of a Left CDH repair, new elevation of the right diaphgram on Xray may indicate a missed right CDH. [ABSTRACT FROM AUTHOR]

Continental-scale estimates of vegetation cover, including land-surface properties and biogeographic trends, reflect the response of plant species to climate change over the past millennia. These estimates can help assess the effectiveness of simulations of climate change using forward and inverse modelling approaches. With the advent of transient and contiguous time-slice palaeoclimate simulations, vegetation datasets with similar temporal qualities are desirable. We collated fossil pollen records for the period 21,000–0 cal yr BP (kyr cal BP; calibrated ages) for Europe and Asia north of 40°N, using extant databases and new data; we filtered records for adequate dating and sorted the nomenclature to conform to a consistent yet extensive taxon list. From this database we extracted pollen spectra representing 1000-year time-slices from 21 kyr cal BP to present and used the biomization approach to define the most likely vegetation biome represented. Biomes were mapped for the 22 time slices, and key plant functional types (PFTs, the constituents of the biomes) were tracked though time. An error matrix and index of topographic complexity clearly showed that the accuracy of pollen-based biome assignments (when compared with modern vegetation) was negatively correlated with topographic complexity, but modern vegetation was nevertheless effectively mapped by the pollen, despite moderate levels of misclassification for most biomes. The pattern at 21 ka is of herb-dominated biomes across the whole region. From the onset of deglaciation (17–18 kyr cal BP), some sites in Europe record forest biomes, particularly the south, and the proportion of forest biomes gradually increases with time through 14 kyr cal BP. During the same period, forest biomes and steppe or tundra biomes are intermixed across the central Asian mountains, and forest biomes occur in coastal Pacific areas. These forest biome occurrences, plus a record of dated plant macrofossils, indicate that some tree populations existed in southern and Eastern Europe and central and far-eastern Eurasia. PFT composition of the herbaceous biomes emphasises the significant contribution of diverse forbs to treeless vegetation, a feature often obscured in pollen records. An increase in moisture ca. 14 kyr cal BP is suggested by a shift to woody biomes and an increase in sites recording initialization and development of lakes and peat deposits, particularly in the European portion of the region. Deforestation of Western Europe, presumably related to agricultural expansion, is clearly visible in the most recent two millennia. [ABSTRACT FROM AUTHOR]

This review investigated the relative performance of digital breast tomosynthesis (DBT) (alone or with full field digital mammography (FFDM) or synthetic digital mammography) compared with FFDM alone for detecting breast cancer lesions in asymptomatic women. A systematic review was carried out according to systematic reviewing principles provided in the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. A protocol was developed a priori . The review was registered with PROSPERO (number CRD42014013949). Searches were undertaken in October 2014. Following selection, five studies were eligible. Higher cancer detection rates were observed when comparing DBT + FFDM with FFDM in two European studies: the summary difference per 1000 screens was 2.43 (95% CI: 1.8 to 3.1). Both European studies found lower false positive rates for individual readers. One found a lower recall rate based on conditional recall. The second study was not designed to compare post-arbitration recall rates between FFDM and DBT + FFDM. One European study presented data on interval cancer rates; sensitivity and specificity for DBT + FFDM were both higher compared to FFDM. One large multicentre US study showed a higher cancer detection rate for DBT + FFDM, while two smaller US studies did not find statistically significant differences. Reductions in recall and false positive rates were observed in the US studies in favour of DBT + FFDM. In comparison to FFDM, DBT, as an adjunct to FFDM, has a higher cancer detection rate, increasing the effectiveness of breast cancer screening. Additional benefits of DBT may also include reduced recalls and, consequently, reduced costs and distress caused to women who would have been recalled. [ABSTRACT FROM AUTHOR]

Case 1 is an 18 year-old woman with a third recurrence of a left congenital diaphragmatic hernia (CDH). She had previously undergone a primary repair of a recurrence via laparotomy and an additional repair of a second recurrence with PTFE mesh via a thoracotomy. Following her third recurrence she underwent successful laparoscopic repair utilizing composite polyester/collagen (Parietex™ Composite, Covidien, Sofradim, France) mesh. Six years following surgery, she has carried a pregnancy to term and has not recurred. Case 2 is a 5 month-old infant who presented with a recurrent right-sided CDH. She initially underwent primary repair via thoracotomy along with a right pneumonectomy at an outside institution. She presented with incarceration of her liver, hepatic venous thrombosis, mediastinal shift, and respiratory distress. She underwent successful repair with composite mesh through a right thoracoabdominal incision. At 8 months post-operatively, she has no evidence of recurrence in spite of the expected mediastinal deviation to the right and right thoracic volume loss as a result of being status post right pneumonectomy. Recurrences occur in a significant number of patients following repair of congenital diaphragmatic hernia, particularly cases in which a mesh implant are utilized. Historically, PTFE has been the product of choice for a diaphragmatic implant by pediatric surgeons. However, this product does not incorporate into surrounding tissues which theoretically places patients at risk for recurrence. Polyester/collagen composite mesh has been used for decades in adults undergoing complex groin and ventral hernia repairs with excellent results. However, its use for congenital diaphragmatic hernias has not been previously described. We present the successful utilization of this product in two cases which were at extremely high risk for future recurrence. Additional investigations should be done and long term follow up regarding application of this product for this challenging clinical condition. [ABSTRACT FROM AUTHOR]

Background/Purpose The use of caudal anesthesia with sedation (CAS) has theoretical benefits over general anesthesia (GA) in high risk neonates undergoing inguinal hernia repair. This benefit has not been established in clinical studies. We compare outcomes of these two approaches at a single institution. Methods A retrospective review was performed of all neonates and preterm infants undergoing inguinal hernia over an 8 year period. Results Of 71 infants meeting inclusion criteria, 50 underwent repair with caudal block and systemic sedation, and 21 with general anesthesia. Minor incidents of respiratory depression requiring non invasive interventions were common in the first 24 h post operatively (24% for CAS, 14% with GA), 4% of patients receiving CAS had a respiratory complication which prolonged their hospital stay beyond 24 h post operation. Both required conversion to general anesthesia. Statistically significant differences between the two groups were lacking in terms of preoperative risk and post operative outcome. Conclusions CAS is a safe, effective anesthetic option for high risk neonates undergoing inguinal hernia repair. Patients requiring conversion to GA from CAS may be at increased risk for complications. Large, randomized trials are needed to determine any benefit over GA. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by the United States (US) Military in Iraq and Afghanistan. Study Design: A review of the Patient Administration Systems and Biostatistics Activity (PASBA) database for all admissions from 2002 to 2012 by US military hospitals in Afghanistan and Iraq for children 14 years of age and younger provided data to analyze the use of medical care. North Atlantic Treaty Organization Standardization Agreement (STANAG) injury codes provided injury cause and the ICD-codes provided diagnosis. In-hospital mortality, blood usage, number of invasive procedures, and hospital stay were analyzed by country and injury category. Results: There were 6,273 admissions that met inclusion criteria. In Afghanistan, there were more than twice as many pediatric noncombat-related admissions (2,197) as pediatric combat-related admissions (1,095). In Iraq, the difference was minimal (1,391 noncombat vs 1,590 combat). The most common cause of noncombat-related admission in both countries was injury: primarily motor vehicle related and burns, which varied significantly by age. Older patients (older than 8 years in Afghanistan and older than 4 years in Iraq) were more likely combat victims. Mortality was highest for combat trauma in Iraq (11%) and noncombat trauma in Afghanistan (8%). The in-hospital mortality in both countries was 5% for admissions unrelated to trauma. Resource use was highest for combat trauma in both countries. Conclusions: Noncombat-related medical care was the primary reason for pediatric humanitarian admissions to United States military combat hospitals in Iraq and Afghanistan from 2002 to 2012. Combat-related injuries have a higher mortality than noncombat injuries or other admissions. [Copyright &y& Elsevier]

Abstract: Non-steroidal anti-inflammatory drugs (NSAIDs) are a known cause of peptic ulcer disease, resulting in gastrointestinal bleeding or perforation. We present a case of a sixteen year old male athlete who presented with abdominal pain and was found to have a pyogenic liver abscess secondary to a gastrohepatic fistula due to a deeply penetrating ulcer from NSAID use. This patient was successfully managed with antibiotics, a proton pump inhibitor (PPI), percutaneous drainage, and bowel rest. Perforating peptic ulcer disease (PPU) is rare in children, and this is a novel report of a resulting gastrohepatic fistula and subcapsular hepatic abscess. In otherwise healthy adolescents with abdominal complaints, a careful history of NSAID use should be obtained. [Copyright &y& Elsevier]

This study investigated the bullying experience in the workplace of newly licensed registered nurses (RNs). Preventing newly licensed nurses from leaving the profession is important, especially because there is a nursing shortage. Education of staff and administrators provides recognition of negative behaviors in the workplace. Participants in this research study included 135 newly licensed RN's from 5 nursing schools in Northwestern Ohio licensed in years 2007-2010. Quantitative methods and a descriptive design process included chi-square tests and descriptive statistical methods. Bullying workplace behaviors were identified by participants utilizing the survey tool, the Negative Acts Questionnaire-Revised, and a questionnaire on work relationships and bullies recognized in the workplace. Nursing peers, physicians, or a patient's family were the main sources of bullying, and 29.5% had considered leaving the nursing profession. Education of staff is imperative for providing recognition of negative behaviors in the workplace. Bullying occurs in the workplace and is affecting the new graduates' work performance. Retaining newly graduated nurses is the ultimate goal for maintaining RN's in the workforce. [ABSTRACT FROM AUTHOR]

Abstract: Following pancreatic trauma, loss of uninjured parenchyma as a result of surgical management is expected, and atrophy of parenchyma following nonoperative management has been described. While endocrine insufficiency as a sequela of pancreatic trauma has been reported in adults, it is not a described entity in children. We report a case of pancreatic atrophy following blunt injury in an 8year old boy who presented 3years later with diabetes mellitus. Further analysis revealed significant genetic predisposition to diabetes. [Copyright &y& Elsevier]

Abstract: Purpose: Congenital lung malformations (CLM) predispose patients to recurrent respiratory tract infections and pose a rare risk of malignant transformation. Although pulmonary lobectomy is the most common treatment of a CLM, some advocate segmental resection as a lung preservation strategy. Our study evaluated lung-preserving thoracoscopic segmentectomy as an alternative to lobectomy for CLM resection. Methods: We conducted a retrospective review of patients who underwent thoracoscopic segmentectomy for CLM from 2007 to 2010. Results: Fifteen patients underwent thoracoscopic segmentectomy for CLM. There were five postoperative complications: three asymptomatic pneumothoraces and a small air leak that resolved without intervention. One patient developed a bronchopulmonary fistula requiring thoracoscopic repair. At follow-up, all patients are asymptomatic. One patient has a small amount of residual disease on postoperative computed tomography (CT), and re-resection has been recommended. Conclusions: Thoracoscopic segmentectomy for CLM is a safe and effective means of lung parenchymal preservation. The approach spares larger airway anatomy and has a complication rate that is comparable with that of thoracoscopic lobectomy. Residual disease can often only be appreciated on postoperative CT scan and may require long-term follow-up or reoperation in rare cases. This lung preservation technique is best suited to smaller lesions. [Copyright &y& Elsevier]

Abstract: Annexation, the process of bringing land from one jurisdiction to another is the means by which municipalities physically expand in the United States. The process of annexation is implemented through procedures at the local level and authorized by general state enabling legislation. State annexation policy varies widely across the United States, but it has the potential to play a significant role in facilitating or constraining local annexation activity. This paper details the effects of specific provisions of state annexation law on municipal annexation activity. A sample of over 900 cities containing at least 10,000 people that annexed during the 1990–1999 decade was used to explore the effects. Eleven different provisions of state law were included in the analysis, including whether the state has a boundary agency overseeing annexation and whether an election is required to complete the annexation process. Results show that nearly all state provisions affect the frequency of municipal annexation, although some had unexpected results. State provisions also affect rates of annexation and acre growth through annexation, but not as consistently as they affect frequencies. The paper concludes with a discussion of the efficacy of state policy to influence local annexation activity. [ABSTRACT FROM AUTHOR]

Here we report successful thoracoscopic-assisted sclerotherapy of a large, prenatally diagnosed microcystic thoracoabdominal lymphatic malformation in a 3-month-old infant born at 38 weeks gestational age. Compression of the inferior vena cava and aortic displacement was demonstrated on imaging. Treatment options include medical management, percutaneous sclerotherapy, or surgical resection. The latter options were complicated by the location of this lesion. Therefore, sclerotherapy under direct visualization via thoracoscopy was performed with near resolution of the lesion after one treatment. This is the first description of treatment of a lymphatic malformation via this approach reported in the literature. [ABSTRACT FROM AUTHOR]

Abstract: Background/Purpose: The aim of this study was to determine the presentation, treatment, and outcome of children requiring surgery for peptic ulcer disease (PUD) in the post–histamine2-blocker era. Methods: The charts of all children undergoing surgery for PUD in our institution since 1980 were retrospectively reviewed. Data were collected regarding clinical presentation, operative details, postoperative course, and outcome. Results: Twenty-nine children (7.2 ± 7.5 years) required surgery for complications of PUD. Indications for operation were bleeding (n = 11), pneumoperitoneum (n = 13), peritonitis (n = 3), and gastric outlet obstruction refractory to medical therapy (n = 2). For those children with bleeding, 8 had simple oversew of the bleeding ulcer(s), 2 had oversew with vagotomy and pyloroplasty, and 1 required vagotomy and antrectomy. All patients with perforation (n = 16) were treated with simple closure with or without omental patch. One child with gastric outlet obstruction underwent vagotomy and antrectomy and 1 had vagotomy and pyloroplasty. Preoperative risk factors or comorbidities were present in 27 of 29 patients and included steroid or nonsteroidal antiinflammatory drug medications in 13 children (only 3 of whom were receiving antiulcer prophylaxis). Postoperative complications occurred in 11 of 29 patients. Three (10%) children required reoperation for persistent or recurrent ulcer disease and 4 children died. Conclusions: PUD remains a highly morbid and mortal condition in children despite the availability of effective acid-reducing medications. Effective prophylaxis of children receiving steroids and nonsteroidal antiinflammatory drugs may play a role in decreasing the risk of PUD. [ABSTRACT FROM AUTHOR]

Abstract: Intralobar pulmonary sequestrations are congenital lung malformations sometimes known to cause symptoms of heart failure in the neonate because of shunting of blood flow from an anomalous systemic feeding artery into the pulmonary venous system. These are cured by pulmonary lobectomy. We report the case of a 37-weeks'' gestational age infant who presented with bilateral pleural effusions perinatally, followed by hypertensive heart failure and hyperreninemia 2 weeks postnatally. Computed tomography revealed a large artery from the infradiaphragmatic aorta proximal to the celiac axis supplying a right lower lobe intralobar pulmonary sequestration and 4 small nonstenosed renal arteries. Subsequent to a right lower lobectomy, the patient recovered with a precipitous drop in plasma renin assay level and was discharged from the neonatal intensive care unit in good condition 12 days postoperatively. This is the first reported case of hyperreninemia treated by lobectomy. We hypothesize that the aberrant feeding vessel resulted in a relative deficiency in renal perfusion via a “steal” effect that was relieved by surgical ligation of the artery. [Copyright &y& Elsevier]

Vascular malformations involving the gastrointestinal tract are uncommon and have a variety of clinical presentations. In this paper, we present a case of a jejunal vascular malformation presenting as a small bowel obstruction in a 2-year-old boy. After clinical and radiologic evaluation, the patient underwent an exploratory laparotomy during which a jejunal mass was identified as the cause of the obstruction and was removed. Pathologic diagnosis confirmed the mass as a benign cavernous hemangioma within the jejunum. The patient recovered well post-operatively. [ABSTRACT FROM AUTHOR]

Abstract: Chilaiditi syndrome is a rare disorder characterized by abdominal pain, respiratory distress, constipation, and vomiting in association with Chilaiditi''s sign. Chilaiditi''s sign is the finding on plain roentgenogram of colonic interposition between the liver and diaphragm and is usually asymptomatic. Surgery is typically reserved for cases of catastrophic colonic volvulus or perforation because of the syndrome. We present a case of a 6-year-old boy who presented with Chilaiditi syndrome and resulting failure to thrive because of severe abdominal pain and vomiting, which did not improve with laxatives and dietary changes. He underwent a laparoscopic gastrostomy tube placement and laparoscopic colopexy of the transverse colon to the falciform ligament and anterior abdominal wall. Postoperatively, his symptoms resolved completely, as did his failure to thrive. His gastrostomy tube was removed 3 months after surgery and never required use. This is the first case of Chilaiditi syndrome in the pediatric literature we are aware of that was treated with an elective, minimally invasive colopexy. In cases of severe Chilaiditi syndrome refractory to medical treatment, a minimally invasive colopexy should be considered as a possible treatment option and potentially offered before development of life-threatening complications such as volvulus or perforation. [Copyright &y& Elsevier]

Abstract: Retroperitoneal teratomas are rare, representing only 1% to 11% of primary retroperitoneal neoplasms. They typically present as an asymptomatic abdominal mass but can grow to enormous size. This case describes a patient who initially presented in childhood with an acute abdomen because of an abdominal abscess that was treated with surgical drainage and antibiotics. Fifteen years later, the patient had a recurrence of symptoms and the abscess was ultimately recognized to be an infected retroperitoneal teratoma. There have been reports of intraabdominal and pelvic teratomas presenting as abscesses in adults. However, to our knowledge, there has been no prior description of this phenomenon in children. In an otherwise healthy child who presents with an unexplained abscess in the sacrococcygeal area, gonads, mediastinum, or retroperitoneum, one should entertain the diagnosis of teratoma. [Copyright &y& Elsevier]

When tracing vegetation dynamics over long timescales, obtaining enough floristic information to gain a detailed understanding of past communities and their transitions can be challenging. The first high-resolution sedimentary DNA (sed aDNA) metabarcoding record from lake sediments in Alaska—reported here—covers nearly 15,000 years of change. It shows in unprecedented detail the composition of late-Pleistocene "steppe-tundra" vegetation of ice-free Alaska, part of an intriguing late-Quaternary "no-analogue" biome, and it covers the subsequent changes that led to the development of modern spruce-dominated boreal forest. The site (Chisholm Lake) lies close to key archaeological sites, and the record throws new light on the landscape and resources available to early humans. Initially, vegetation was dominated by forbs found in modern tundra and/or subarctic steppe vegetation (e.g., Potentilla , Draba , Eritrichium , Anemone patens), and graminoids (e.g., Bromus pumpellianus, Festuca, Calamagrostis, Puccinellia), with Salix the only prominent woody taxon. Predominantly xeric, warm-to-cold habitats are indicated, and we explain the mixed ecological preferences of the fossil assemblages as a topo-mosaic strongly affected by insolation load. At ca. 14,500 cal yr BP (calendar years before C.E. 1950), about the same time as well documented human arrivals and coincident with an increase in effective moisture, Betula expanded. Graminoids became less abundant, but many open-ground forb taxa persisted. This woody-herbaceous mosaic is compatible with the observed persistence of Pleistocene megafaunal species (animals weighing ≥44 kg)—important resources for early humans. The greatest taxonomic turnover, marking a transition to regional woodland and a further moisture increase, began ca. 11,000 cal yr BP when Populus expanded, along with new shrub taxa (e.g., Shepherdia , Eleagnus, Rubus, Viburnum). Picea then expanded ca. 9500 cal yr BP, along with shrub and forb taxa typical of evergreen boreal woodland (e.g., Spiraea, Cornus, Linnaea). We found no evidence for Picea in the late Pleistocene, however. Most taxa present today were established by ca. 5000 cal yr BP after almost complete taxonomic turnover since the start of the record (though Larix appeared only at ca. 1500 cal yr BP). Prominent fluctuations in aquatic communities ca. 14,000–9,500 cal yr BP are probably related to lake-level fluctuations prior to the lake reaching its high, near-modern depth ca. 8,000 cal yr BP. • Detailed sed a DNA record of 15,000 yr of late-Quaternary floristic change in Alaska. • Late-glacial steppe and tundra mosaic likely reflects local topoclimatic control. • Major turnover during early-Holocene transitions to deciduous, then spruce forest. • Open-ground-woodland mosaic until 9500 cal yr BP was a resource for diverse mammals. • Forest expansion and higher aquatic diversity with moisture rise ca. 9500 cal yr BP. [ABSTRACT FROM AUTHOR]

COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in December 2020. Advanced Clinical Practitioners (ACPs) in England working with older people with frailty, experienced their clinical role changing in response to the emergency health needs of this complex population group. In contrast to other countries, in England Advanced Clinical Practitioners are drawn from both nursing and allied health professions. Whilst much of the literature emphasises the importance of ensuring the sustainability of the Advanced Clinical Practitioners' role, the pandemic threw further light on its potential and challenges. However, an initial review of the literature highlighted a lack of research of Advanced Clinical Practitioners' capabilities working with uncertainty in disaster response situations. To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020–January 2021). A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners' professional and social media networks on Twitter using a snowballing technique. Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n = 9) or as part of 3 focus groups (n = 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision. Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians. The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty. [ABSTRACT FROM AUTHOR]

Abstract: Physical and geochemical proxy analyses of sediment cores from Harding Lake in central Alaska are used to reconstruct paleoenvironmental change and millennial scale fluctuations in lake level for the last ∼31,000 years. We analyzed a composite 422 cm core from the lake depocenter (42.1 m water depth) and identified 4 distinct lithologic units based on variability in dry bulk density, organic matter, biogenic silica, carbon to nitrogen mass ratios (C/N), organic matter carbon isotopes (δ13C), pollen, and elemental abundances via scanning X-ray fluorescence, with age control provided by 16 Accelerator Mass Spectrometry radiocarbon dates and 210Pb dating. In addition, we analyzed a transect of cores from 7.1 m, 10.75 m, 15.91 m, and 38.05 m water depths to identify lake level fluctuations and to characterize sediment compositional changes as a function of water depth. Organic matter content and magnetic susceptibility values in surface sediments from all transect cores show a strong correlation with water depth. Interpretation of four lithologic units with well-dated contacts produced a record of water-depth variations that is consistent with independent climate records from eastern Beringia. Basal coarse-grained sediments (quartz pebble diamicton) were deposited prior to 30,700 calendar years before present (yr BP), possibly from fluvial reworking or deflation during a period of severe aridity. Unit 1 sediments were deposited between 30,700 and 15,700 yr BP and are characterized by a low organic matter content, a high magnetic susceptibility, and low biogenic silica concentrations resulting from very low lake levels, low terrestrial and in-lake productivity and a high flux of clastic sediment. An abrupt increase in organic matter and biogenic silica concentration marks the transition into Unit 2 sediments, which were deposited between 15,700 and 9,400 yr BP when lake levels were higher and variable (relative to Unit 1). The transition to full interglacial conditions at 9,400 yr BP marks the beginning of Unit 3. Here an abrupt increase in the sedimentation rate, organic matter and biogenic silica concentration occurs (along with a corresponding decrease to low magnetic susceptibility). These high values persist until 8,700 yr BP, signifying a rapid rise to higher lake levels (in comparison to Units 1 and 2). Unit 4 sediments were deposited between 8,700 yr BP to 2010 AD and generally contain high concentrations of organic matter and biogenic silica with low magnetic susceptibility, suggesting that lake levels were relatively high and stable during the middle to late Holocene. [Copyright &y& Elsevier]

Abstract: Chukotka is a key region for understanding both Quaternary environmental history and transcontinental migrations of flora and fauna during the Pleistocene as it lies at the far eastern edge of Asia bordering the Bering Sea. The now submerged land bridge is the least understood region of Beringia yet the most critical to understanding migrations between the Old and New Worlds. The insect fauna of the Main River Ledovy Obryv (Ice Bluff) section, which is late Pleistocene in age (MIS 3-2), is markedly different from coeval faunas of areas further to the west, as it is characterized by very few thermophilous steppe elements. From the fauna we reconstruct a steppe-tundra environment and relatively cold conditions; the reconstructed environment was moister than that of typical steppe-tundra described from further west. The data from this locality, if typical of the Chukotka Peninsula as a whole, may indicate that a barrier associated with the environments of the land bridge restricted trans-Beringian migrations, particularly the more thermophilous and xeric-adapted elements of the Beringian biota, supporting the hypothesis of a cool but moist land-bridge filter inferred from evidence from several other studies. [Copyright &y& Elsevier]

Abstract: Andrei Sher (1939–2008) was a key individual in Beringian studies who made substantial and original contributions, but also, importantly, built bridges between western and eastern Beringian scientists spanning some five decades of research. He is perhaps best known as a Quaternary palaeontologist, specializing in large mammals, and mammoths in particular, but his field of his scientific research was much broader, encompassing Quaternary geology, stratigraphy, geocryology, and paleoenvironmental reconstructions. He worked mainly in Siberia, in the Kolyma and Indigirka lowlands, and Chukotka, but also completed fieldwork in Alaska and Yukon through joint projects with American and Canadian scientists. Andrei was an active scientist until the last days of his life. He was involved in many different research projects ranging from mammoth evolution, fossil insects and environmental changes and ancient DNA. Without Andrei’s connections between researchers, many unique discoveries would likely be unknown. [Copyright &y& Elsevier]

Abstract: We present a database of late-Quaternary plant macrofossil records for northern Eurasia (from 23° to 180°E and 46° to 76°N) comprising 281 localities, over 2300 samples and over 13,000 individual records. Samples are individually radiocarbon dated or are assigned ages via age models fitted to sequences of calibrated radiocarbon dates within a section. Tree species characteristic of modern northern forests (e.g. Picea, Larix, tree-Betula) are recorded at least intermittently from prior to the last glacial maximum (LGM), through the LGM and Lateglacial, to the Holocene, and some records locate trees close to the limits of the Scandinavian ice sheet, supporting the hypothesis that some taxa persisted in northern refugia during the last glacial cycle. Northern trees show differing spatio-temporal patterns across Siberia: deciduous trees were widespread in the Lateglacial, with individuals occurring across much of their contemporary ranges, while evergreen conifers expanded northwards to their range limits in the Holocene. [Copyright &y& Elsevier]

A 24,000-year record of plant community dynamics, based on pollen and ancient DNA from the sediments (sed aDNA) of Lake Bolshoye Shchuchye in the Polar Ural Mountains, provides detailed information on the flora of the Last Glacial Maximum (LGM) and also changes in plant community composition and dominance. It greatly improves on incomplete records from short and fragmented stratigraphic sequences found in exposed sedimentary sections in the western Russian Arctic. In total, 162 plant taxa were detected by sed aDNA and 115 by pollen analysis. Several shifts in dominance between and within plant functional groups occurred over the studied period, but most taxa appear to have survived in situ. A diverse arctic-alpine herb flora characterised the interval ca. 24,000–17,000 cal years BP and persisted into the Holocene. Around 17,000 cal years BP, sedges (e.g. Carex) and bryophytes (e.g. Bryum , Aulacomnium) increased. The establishment of shrub-tundra communities of Dryas and Vaccinium sp., with potentially some Betula pubescens trees (influx ∼290 grains cm2 year−1), followed at ca. 15,000 cal years BP. Forest taxa such as Picea and ferns (e.g. Dryopteris fragrans, Gymnocarpium dryopteris) established near the lake from ca. 10,000 cal years BP, followed by the establishment of Larix trees from ca. 9000 cal years BP. Picea began to decline from ca. 7000 cal years BP. A complete withdrawal of forest tree taxa occurred by ca. 4000 cal years BP, presumably due to decreasing growing-season temperatures, allowing the expansion of dwarf-shrub tundra and a diverse herb community similar to the present-day vegetation mosaic. Contrary to some earlier comparative studies, sed aDNA and pollen from Lake Bolshoye Shchuchye showed high similarity in the timing of compositional changes and the occurrence of key plant taxa. The sed aDNA record revealed several features that the pollen stratigraphy and earlier palaeorecords in the region failed to detect; a sustained, long-term increase in floristic richness since the LGM until the early Holocene, turnover in grass and forb genera over the Pleistocene-Holocene transition, persistence of a diverse arctic-alpine flora over the late Quaternary, and a variable bryophyte flora through time. As pollen records are often limited by taxonomic resolution, differential productivity and dispersal, sed aDNA can provide improved estimates of floristic richness and is better able to distinguish between different plant assemblages. However, pollen remains superior at providing quantitative estimates of plant abundance changes and detecting several diverse groups (e.g. Poaceae, Cyperaceae, Asteraceae) which may be underreported in the sed aDNA. Joint use of the two proxies provided unprecedented floristic detail of past plant communities and helped to distinguish between long-distance transport of pollen and local presence, particularly for woody plant taxa. • The proxies show high overlap in the pattern of occurrence of key plant taxa. • In contrast to pollen, sed aDNA shows increasing richness from LGM until early Holocene. • Sed aDNA is superior at identifying floristic richness changes and distinguishing between plant assemblages. • Pollen remains superior at quantitative estimates of plant abundance changes. • Joint use of the proxies provides unprecedented floristic detail of past plant communities. [ABSTRACT FROM AUTHOR]

Abstract: A terrestrial sediment sequence exposed in an eroding pingo provides insights into the late-Quaternary environmental history of the northern Seward Peninsula, Alaska. We have obtained the first radiocarbon-dated evidence for a mid-Wisconsin thermokarst lake, demonstrating that complex landscape dynamics involving cyclic permafrost aggradation and thermokarst lake formation occurred over stadial–interstadial as well as glacial–interglacial time periods. High values of Picea pollen and the presence of Larix pollen in sediments dated to 50–40 ka BP strongly suggest the presence of forest or woodland early in MIS 3; the trees grew within a vegetation matrix dominated by grass and sedge, and there is indirect evidence of grazing animals. Thus the interstadial ecosystem was different in structure and composition from the Holocene or from the preceding Last Interglacial period. An early Holocene warm period is indicated by renewed thermokarst lake formation and a range of fossil taxa. Multiple extralimital plant taxa suggest mean July temperatures above modern values. The local presence of spruce during the early Holocene warm interval is evident from a radiocarbon-dated spruce macrofossil remain and indicates significant range extension far beyond the modern tree line. The first direct evidence of spruce in Northwest Alaska during the early Holocene has implications for the presence of forest refugia in Central Beringia and previously assumed routes and timing of post-glacial forest expansion in Alaska. [Copyright &y& Elsevier]

Understanding how species and ecosystems respond to climate change has become a major focus of ecology and conservation biology. Modelling approaches provide important tools for making future projections, but current models of the climate-biosphere interface remain overly simplistic, undermining the credibility of projections. We identify five ways in which substantial advances could be made in the next few years: (i) improving the accessibility and efficiency of biodiversity monitoring data, (ii) quantifying the main determinants of the sensitivity of species to climate change, (iii) incorporating community dynamics into projections of biodiversity responses, (iv) accounting for the influence of evolutionary processes on the response of species to climate change, and (v) improving the biophysical rule sets that define functional groupings of species in global models. [Copyright &y& Elsevier]

Abstract: Fossil Chironomidae assemblages (with a few Chaoboridae and Ceratopogonidae) from Zagoskin and Burial Lakes in western Alaska provide quantitative reconstructions of mean July air temperatures for periods of the late-middle Wisconsin (∼39,000–34,000 cal yr B.P.) to the present. Inferred temperatures are compared with previously analyzed pollen data from each site summarized here by indirect ordination. Paleotemperature trends reveal substantial differences in the timing of climatic warming following the late Wisconsin at each site, although chronological uncertainty exists. Zagoskin Lake shows early warming beginning at about 21,000 cal yr B.P., whereas warming at Burial Lake begins ∼4000 years later. Summer climates during the last glacial maximum (LGM) were on average ∼3.5 °C below the modern temperatures at each site. Major shifts in vegetation occurred from ∼19,000 to 10,000 cal yr B.P. at Zagoskin Lake and from ∼17,000 to 10,000 cal yr B.P. at Burial Lake. Vegetation shifts followed climatic warming, when temperatures neared modern values. Both sites provide evidence of an early postglacial thermal maximum at ∼12,300 cal yr B.P. These chironomid records, combined with other insect-based climatic reconstructions from Beringia, indicate that during the LGM: (1) greater continentality likely influenced regions adjacent to the Bering Land Bridge and (2) summer climates were, at times, not dominated by severe cold. [Copyright &y& Elsevier]

: PurposeThe Ocular Hypertension Treatment Study (OHTS) seeks to evaluate the safety and efficacy of topical ocular hypotensive medication in preventing or delaying the onset of visual field loss and/or optic nerve damage in ocular hypertensive subjects at risk for developing primary open-angle glaucoma. This study evaluates the baseline visual field test characteristics (visual field status, reliability properties, etc.) of patients who underwent eligibility visual field testing for entry to the OHTS.: DesignCross-sectional study of baseline data as part of a longitudinal randomized clinical trial.: ParticipantsTwo thousand eight hundred nineteen ocular hypertensive individuals, aged 40 to 80 (mean age, 55).: MethodsSubjects underwent at least two Humphrey Field Analyzer Program 30-2 Full Threshold visual field examinations in both eyes for study eligibility. A third examination was performed if a prior test was abnormal, questionable, or unreliable. For final eligibility, two sets of visual field examinations had to meet OHTS criteria for reliability and had to be classified as “normal.” All OHTS visual field tests of potential subjects were submitted for eligibility assessment to the OHTS Visual Field Reading Center.: Main Outcome MeasuresThe percentage of visual fields that were normal and reliable according to OHTS criteria.: ResultsOf the subset of 2304 subjects who completed the eligibility assessments, 1828 (79%) were OHTS-eligible based on visual field test requirements. A third eligibility test was required for 11% of all eyes because of unreliable, questionable, or abnormal test results. With the 33% fixation loss cutoff in the OHTS, 97% of all eligibility visual field examinations were reliable and 3% were unreliable. The most frequent cause (69.5%) of unreliability was excessive fixation losses.: ConclusionsPermitting one repeat test after an abnormal or unreliable test allowed an extra 560 patients to be “eligible” for the study based on visual field tests. A clinical screening review of otherwise normal and reliable tests was not restrictive. The adoption of a 33% fixation loss cutoff significantly reduced the number of required retests and prevented study rejection of 89 patients. [Copyright &y& Elsevier]

Andøya on the NW coast of Norway is a key site for understanding the Last Glacial Maximum (LGM) in northern Europe. Controversy has arisen concerning the local conditions, especially about the timing and extent of local glacial cover, maximum July temperatures and whether pine and/or spruce could have grown there. We reviewed all existing data and add newly analysed ancient sedimentary DNA (seda DNA), pollen, macrofossils, geochemistry and stable isotopes from three lake sediment cores from Øvre Æråsvatnet. A total of 23 new dates and age-depth modelling suggests the lake has been ice-free since GI2 (<23.4 cal ka BP) and possibly GS3 (<26.7 cal ka BP). Pinus and Picea seda DNA was found in all three cores but at such low frequencies that it could not be distinguished from background contamination. LGM samples have an exceptionally high organic matter content, with isotopic values indicating that carbon and nitrogen derive from a marine source. Along with finds of bones of the little auk (Alle alle), this indicates that the lake received guano from an adjacent bird colony. Seda DNA, pollen and macrofossil assemblages were dominated by Poaceae, Brassicaceae and Papaver , but scattered occurrence of species currently restricted to the Low Arctic Tundra Zone (July temperature of 8–9 °C) such as Apiaceae (seda DNA, 8–9 °C), and Alchemilla alpina (macrofossil, 8–9 °C) were also recorded. The review of >14.7 cal ka BP data recorded 94 vascular plant taxa, of which 38% have a northern limit in Shrub Tundra or more southern vegetation zones. This unusual assemblage likely stems from a combination of proximity to ice-free water in summer, geographical isolation linked with stochastic long-distance dispersal events, and the presence of bird-fertilized habitats. The environmental reconstruction based on all records from the area does not preclude local growth of tree species, as the local climate combined with high nutrient input may have led to periodically suitable environmental 'hotspot' conditions. • High organic content of Last Glacial Maximum sediments from a northern refugium. • Isotopes and bones indicate birds roosted near the ice edge. • Conifer DNA found in sediments, but frequency not significantly above background contamination. • Review of all Andøya LGM studies reveals presence of boreal and arctic taxa. • Environmental reconstruction does not preclude intermittent growth conditions for trees. [ABSTRACT FROM AUTHOR]