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We followed the COVID-19 pandemic in Manaus, one of the epicenters of COVID-19 in Brazil, using an epidemiological mathematical model and made five main conclusions. First, in early 2022, the actual cases exceed officially reported data by up to 8 times. Second, despite vaccination campaigns, the collective immunity threshold necessary was insufficient to contain severe cases of COVID-19. Next, the low observed mortality demonstrated the effectiveness of vaccination. Next, the drop in the vaccination rate combined with immune escape by the Omicron sub-variants (BA.2.12.1, BA.4, and BA.5) resulted in new wave after November 2022. Finally, to minimize severe cases of COVID-19, we need to raise vaccination thresholds above 90-95% of the entire population including children aged 6 months and older and require booster doses at least in four-month intervals. This approach would help to prevent severe cases of COVID-19 that cause hospitalizations and deaths., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests. Ethical approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Amazonia contains the most extensive tropical forests on Earth, but Amazon carbon sinks of atmospheric CO 2 are declining, as deforestation and climate-change-associated droughts 1-4 threaten to push these forests past a tipping point towards collapse 5-8 . Forests exhibit complex drought responses, indicating both resilience (photosynthetic greening) and vulnerability (browning and tree mortality), that are difficult to explain by climate variation alone 9-17 . Here we combine remotely sensed photosynthetic indices with ground-measured tree demography to identify mechanisms underlying drought resilience/vulnerability in different intact forest ecotopes 18,19 (defined by water-table depth, soil fertility and texture, and vegetation characteristics). In higher-fertility southern Amazonia, drought response was structured by water-table depth, with resilient greening in shallow-water-table forests (where greater water availability heightened response to excess sunlight), contrasting with vulnerability (browning and excess tree mortality) over deeper water tables. Notably, the resilience of shallow-water-table forest weakened as drought lengthened. By contrast, lower-fertility northern Amazonia, with slower-growing but hardier trees (or, alternatively, tall forests, with deep-rooted water access), supported more-drought-resilient forests independent of water-table depth. This functional biogeography of drought response provides a framework for conservation decisions and improved predictions of heterogeneous forest responses to future climate changes, warning that Amazonia's most productive forests are also at greatest risk, and that longer/more frequent droughts are undermining multiple ecohydrological strategies and capacities for Amazon forest resilience., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

For more than three decades, major efforts in sampling and analyzing tree diversity in South America have focused almost exclusively on trees with stems of at least 10 and 2.5 cm diameter, showing highest species diversity in the wetter western and northern Amazon forests. By contrast, little attention has been paid to patterns and drivers of diversity in the largest canopy and emergent trees, which is surprising given these have dominant ecological functions. Here, we use a machine learning approach to quantify the importance of environmental factors and apply it to generate spatial predictions of the species diversity of all trees (dbh ≥ 10 cm) and for very large trees (dbh ≥ 70 cm) using data from 243 forest plots (108,450 trees and 2832 species) distributed across different forest types and biogeographic regions of the Brazilian Amazon. The diversity of large trees and of all trees was significantly associated with three environmental factors, but in contrasting ways across regions and forest types. Environmental variables associated with disturbances, for example, the lightning flash rate and wind speed, as well as the fraction of photosynthetically active radiation, tend to govern the diversity of large trees. Upland rainforests in the Guiana Shield and Roraima regions had a high diversity of large trees. By contrast, variables associated with resources tend to govern tree diversity in general. Places such as the province of Imeri and the northern portion of the province of Madeira stand out for their high diversity of species in general. Climatic and topographic stability and functional adaptation mechanisms promote ideal conditions for species diversity. Finally, we mapped general patterns of tree species diversity in the Brazilian Amazon, which differ substantially depending on size class., (© 2023 John Wiley & Sons Ltd.)

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Gamma variant of concern has spread rapidly across Brazil since late 2020, causing substantial infection and death waves. Here we used individual-level patient records after hospitalization with suspected or confirmed coronavirus disease 2019 (COVID-19) between 20 January 2020 and 26 July 2021 to document temporary, sweeping shocks in hospital fatality rates that followed the spread of Gamma across 14 state capitals, during which typically more than half of hospitalized patients aged 70 years and older died. We show that such extensive shocks in COVID-19 in-hospital fatality rates also existed before the detection of Gamma. Using a Bayesian fatality rate model, we found that the geographic and temporal fluctuations in Brazil's COVID-19 in-hospital fatality rates were primarily associated with geographic inequities and shortages in healthcare capacity. We estimate that approximately half of the COVID-19 deaths in hospitals in the 14 cities could have been avoided without pre-pandemic geographic inequities and without pandemic healthcare pressure. Our results suggest that investments in healthcare resources, healthcare optimization and pandemic preparedness are critical to minimize population-wide mortality and morbidity caused by highly transmissible and deadly pathogens such as SARS-CoV-2, especially in low- and middle-income countries., (© 2022. The Author(s).)

Predictions of the magnitude and timing of leaf phenology in Amazonian forests remain highly controversial. Here, we use terrestrial LiDAR surveys every two weeks spanning wet and dry seasons in Central Amazonia to show that plant phenology varies strongly across vertical strata in old-growth forests, but is sensitive to disturbances arising from forest fragmentation. In combination with continuous microclimate measurements, we find that when maximum daily temperatures reached 35 °C in the latter part of the dry season, the upper canopy of large trees in undisturbed forests lost plant material. In contrast, the understory greened up with increased light availability driven by the upper canopy loss, alongside increases in solar radiation, even during periods of drier soil and atmospheric conditions. However, persistently high temperatures in forest edges exacerbated the upper canopy losses of large trees throughout the dry season, whereas the understory in these light-rich environments was less dependent on the altered upper canopy structure. Our findings reveal a strong influence of edge effects on phenological controls in wet forests of Central Amazonia., (© 2022. The Author(s).)

High-quality atmospheric CO 2  measurements are sparse in Amazonia, but can provide critical insights into the spatial and temporal variability of sources and sinks of CO 2 . In this study, we present the first 6 years (2014-2019) of continuous, high-precision measurements of atmospheric CO 2 at the Amazon Tall Tower Observatory (ATTO, 2.1°S, 58.9°W). After subtracting the simulated background concentrations from our observational record, we define a CO 2 regional signal ( Δ CO 2 obs ) that has a marked seasonal cycle with an amplitude of about 4 ppm. At both seasonal and inter-annual scales, we find differences in phase between Δ CO 2 obs and the local eddy covariance net ecosystem exchange (EC-NEE), which is interpreted as an indicator of a decoupling between local and non-local drivers of Δ CO 2 obs . In addition, we present how the 2015-2016 El Niño-induced drought was captured by our atmospheric record as a positive 2σ anomaly in both the wet and dry season of 2016. Furthermore, we analyzed the observed seasonal cycle and inter-annual variability of Δ CO 2 obs together with net ecosystem exchange (NEE) using a suite of modeled flux products representing biospheric and aquatic CO 2 exchange. We use both non-optimized and optimized (i.e., resulting from atmospheric inverse modeling) NEE fluxes as input in an atmospheric transport model (STILT). The observed shape and amplitude of the seasonal cycle was captured neither by the simulations using the optimized fluxes nor by those using the diagnostic Vegetation and Photosynthesis Respiration Model (VPRM). We show that including the contribution of CO 2 from river evasion improves the simulated shape (not the magnitude) of the seasonal cycle when using a data-driven non-optimized NEE product (FLUXCOM). The simulated contribution from river evasion was found to be 25% of the seasonal cycle amplitude. Our study demonstrates the importance of the ATTO record to better understand the Amazon carbon cycle at various spatial and temporal scales., (© 2021 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

The SARS-CoV-2 Gamma variant spread rapidly across Brazil, causing substantial infection and death waves. We use individual-level patient records following hospitalisation with suspected or confirmed COVID-19 to document the extensive shocks in hospital fatality rates that followed Gamma's spread across 14 state capitals, and in which more than half of hospitalised patients died over sustained time periods. We show that extensive fluctuations in COVID-19 in-hospital fatality rates also existed prior to Gamma's detection, and were largely transient after Gamma's detection, subsiding with hospital demand. Using a Bayesian fatality rate model, we find that the geographic and temporal fluctuations in Brazil's COVID-19 in-hospital fatality rates are primarily associated with geographic inequities and shortages in healthcare capacity. We project that approximately half of Brazil's COVID-19 deaths in hospitals could have been avoided without pre-pandemic geographic inequities and without pandemic healthcare pressure. Our results suggest that investments in healthcare resources, healthcare optimization, and pandemic preparedness are critical to minimize population wide mortality and morbidity caused by highly transmissible and deadly pathogens such as SARS-CoV-2, especially in low- and middle-income countries., Note: The following manuscript has appeared as 'Report 46 - Factors driving extensive spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals' at https://spiral.imperial.ac.uk:8443/handle/10044/1/91875 ., One Sentence Summary: COVID-19 in-hospital fatality rates fluctuate dramatically in Brazil, and these fluctuations are primarily associated with geographic inequities and shortages in healthcare capacity.

Cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Manaus, Brazil, resurged in late 2020 despite previously high levels of infection. Genome sequencing of viruses sampled in Manaus between November 2020 and January 2021 revealed the emergence and circulation of a novel SARS-CoV-2 variant of concern. Lineage P.1 acquired 17 mutations, including a trio in the spike protein (K417T, E484K, and N501Y) associated with increased binding to the human ACE2 (angiotensin-converting enzyme 2) receptor. Molecular clock analysis shows that P.1 emergence occurred around mid-November 2020 and was preceded by a period of faster molecular evolution. Using a two-category dynamical model that integrates genomic and mortality data, we estimate that P.1 may be 1.7- to 2.4-fold more transmissible and that previous (non-P.1) infection provides 54 to 79% of the protection against infection with P.1 that it provides against non-P.1 lineages. Enhanced global genomic surveillance of variants of concern, which may exhibit increased transmissibility and/or immune evasion, is critical to accelerate pandemic responsiveness., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Cases of SARS-CoV-2 infection in Manaus, Brazil, resurged in late 2020, despite high levels of previous infection there. Through genome sequencing of viruses sampled in Manaus between November 2020 and January 2021, we identified the emergence and circulation of a novel SARS-CoV-2 variant of concern, lineage P.1, that acquired 17 mutations, including a trio in the spike protein (K417T, E484K and N501Y) associated with increased binding to the human ACE2 receptor. Molecular clock analysis shows that P.1 emergence occurred around early November 2020 and was preceded by a period of faster molecular evolution. Using a two-category dynamical model that integrates genomic and mortality data, we estimate that P.1 may be 1.4-2.2 times more transmissible and 25-61% more likely to evade protective immunity elicited by previous infection with non-P.1 lineages. Enhanced global genomic surveillance of variants of concern, which may exhibit increased transmissibility and/or immune evasion, is critical to accelerate pandemic responsiveness., Competing Interests: Competing interests: Authors declare that they have no competing interests.

Major and trace element deposition across western Washington, USA was assessed in 2016 and 2017 by analyzing tissue metal concentrations in the epiphytic mosses Isothecium stoloniferum (Bridel) and Kindbergia praelonga (Hedw.) Ochyra. We used an intensive, vertically stratified sampling approach in Acer macrophyllum canopies in the Hoh Rainforest on the Olympic Peninsula, WA and in Seattle, WA to collect 214 samples of I. stoloniferum. An extensive, ground-based sampling approach was used across an urban-to-wildland gradient to collect 59 K. praelonga samples. Intensive samples were collected four times (April, July, and October of 2016 and in January 2017) and extensive samples three times (April, July, and October 2016) to assess seasonal differences in metal concentrations across sampling locations. A total of 273 moss samples were analyzed for Cd, Cr, Cu, Fe, K, Mg, Mn, Ni, Pb, Sr, Ti, and Zn concentrations. Elevated concentrations of these elements were found in moss samples from both intensive and extensive sampling efforts across all seasons. Sampling location for both intensive and extensive sampling efforts was found to be a significant factor in determining moss metal concentrations. Metal deposition in and around Seattle appears to be derived from the regional transportation sector and other industrial sources. Ten I. stoloniferum samples from Seattle and the Hoh Rainforest were analyzed for Pb and Sr isotope ratios to help differentiate between natural and industrial-based emission sources. Hoh Rainforest Pb isotopes appear to be explained by a mixture of long-range Asian Pb influences and natural Pb sources, whereas Seattle Pb isotopes appear driven by industrial and road dust sources., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Sustained drought and concomitant high temperature may reduce photosynthesis and cause tree mortality. Possible causes of reduced photosynthesis include stomatal closure and biochemical inhibition, but their relative roles are unknown in Amazon trees during strong drought events. We assessed the effects of the recent (2015) strong El Niño drought on leaf-level photosynthesis of Central Amazon trees via these two mechanisms. Through four seasons of 2015, we measured leaf gas exchange, chlorophyll a fluorescence parameters, chlorophyll concentration, and nutrient content in leaves of 57 upper canopy and understory trees of a lowland terra firme forest on well-drained infertile oxisol. Photosynthesis decreased 28% in the upper canopy and 17% in understory trees during the extreme dry season of 2015, relative to other 2015 seasons and was also lower than the climatically normal dry season of the following non-El Niño year. Photosynthesis reduction under extreme drought and high temperature in the 2015 dry season was related only to stomatal closure in both upper canopy and understory trees, and not to chlorophyll a fluorescence parameters, chlorophyll, or leaf nutrient concentration. The distinction is important because stomatal closure is a transient regulatory response that can reverse when water becomes available, whereas the other responses reflect more permanent changes or damage to the photosynthetic apparatus. Photosynthesis decrease due to stomatal closure during the 2015 extreme dry season was followed 2 months later by an increase in photosynthesis as rains returned, indicating a margin of resilience to one-off extreme climatic events in Amazonian forests., (© 2018 John Wiley & Sons Ltd.)

Satellite observations of Amazon forests show seasonal and interannual variations, but the underlying biological processes remain debated. Here we combined radiative transfer models (RTMs) with field observations of Amazon forest leaf and canopy characteristics to test three hypotheses for satellite-observed canopy reflectance seasonality: seasonal changes in leaf area index, in canopy-surface leafless crown fraction and/or in leaf demography. Canopy RTMs (PROSAIL and FLiES), driven by these three factors combined, simulated satellite-observed seasonal patterns well, explaining c. 70% of the variability in a key reflectance-based vegetation index (MAIAC EVI, which removes artifacts that would otherwise arise from clouds/aerosols and sun-sensor geometry). Leaf area index, leafless crown fraction and leaf demography independently accounted for 1, 33 and 66% of FLiES-simulated EVI seasonality, respectively. These factors also strongly influenced modeled near-infrared (NIR) reflectance, explaining why both modeled and observed EVI, which is especially sensitive to NIR, captures canopy seasonal dynamics well. Our improved analysis of canopy-scale biophysics rules out satellite artifacts as significant causes of satellite-observed seasonal patterns at this site, implying that aggregated phenology explains the larger scale remotely observed patterns. This work significantly reconciles current controversies about satellite-detected Amazon phenology, and improves our use of satellite observations to study climate-phenology relationships in the tropics., (No claim to original US Government works New Phytologist © 2017 New Phytologist Trust.)

We compared religiously integrated cognitive behavioral therapy (RCBT) versus conventional CBT (CCBT) on increasing daily spiritual experiences (DSE) in major depressive disorder and chronic medical illness. A total of 132 participants aged 18-85 were randomized to either RCBT (n = 65) or CCBT (n = 67). Participants received ten 50-min sessions (primarily by telephone) over 12 weeks. DSE was assessed using the Daily Spiritual Experiences Scale (DSES). Mixed-effects growth curve models compared the effects of treatment group on trajectory of change in DSE. Baseline DSE and changes in DSE were examined as predictors of change in depressive symptoms. DSE increased significantly in both groups. RCBT tended to be more effective than CCBT with regard to increasing DSE (group by time interaction B = -1.80, SE = 1.32, t = -1.36, p = 0.18), especially in those with low religiosity (B = -4.26, SE = 2.27, t = -1.88, p = 0.07). Higher baseline DSE predicted a decrease in depressive symptoms (B = -0.09, SE = 0.04, t = -2.25, p = 0.025), independent of treatment group, and an increase in DSE with treatment correlated with a decrease in depressive symptoms (r = 0.29, p = 0.004). RCBT tends to be more effective than CCBT in increasing DSE, especially in persons with low religiosity. Higher baseline DSE and increases in DSE over time predict a faster resolution of depressive symptoms. Efforts to increase DSE, assessed by a measure such as the DSES, may help with the treatment of depression in the medically ill.

Objectives: To examine the relationship between religious involvement (RI) and adaptation of women caring for family members with severe physical or neurological disability., Design: Two-site cross-sectional study., Setting: Community., Participants: A convenience sample of 251 caregivers was recruited. RI and caregiver adaptation (assessed by perceived stress, caregiver burden, and depressive symptoms) were measured using standard scales, along with caregiver characteristics, social support, and health behaviors. Bivariate and multivariate analyses were conducted to identify relationships and mediating and moderating factors., Results: Religious involvement (RI) was associated with better caregiver adaptation independent of age, race, education, caregiver health, care recipient's health, social support, and health behaviors (B = -0.09, standard error = 0.04, t = -2.08, P = .04). This association was strongest in caregivers aged 58-75 and spouses and for perceived stress in blacks., Conclusion: Religious involvement (RI) in female caregivers is associated with better caregiver adaptation, especially for those who are older, spouses of the care recipients, and blacks. These results are relevant to the development of future interventions that provide support to family caregivers., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

In evergreen tropical forests, the extent, magnitude, and controls on photosynthetic seasonality are poorly resolved and inadequately represented in Earth system models. Combining camera observations with ecosystem carbon dioxide fluxes at forests across rainfall gradients in Amazônia, we show that aggregate canopy phenology, not seasonality of climate drivers, is the primary cause of photosynthetic seasonality in these forests. Specifically, synchronization of new leaf growth with dry season litterfall shifts canopy composition toward younger, more light-use efficient leaves, explaining large seasonal increases (~27%) in ecosystem photosynthesis. Coordinated leaf development and demography thus reconcile seemingly disparate observations at different scales and indicate that accounting for leaf-level phenology is critical for accurately simulating ecosystem-scale responses to climate change., (Copyright © 2016, American Association for the Advancement of Science.)

Telomere length (TL) is an indicator of cellular aging associated with longevity and psychosocial stress. We examine here the relationship between religious involvement and TL in 251 stressed female family caregivers recruited into a 2-site study. Religious involvement, perceived stress, caregiver burden, depressive symptoms, and social support were measured and correlated with TL in whole blood leukocytes. Results indicated a U-shaped relationship between religiosity and TL. Those scoring in the lowest 10% on religiosity tended to have the longest telomeres (5743 bp ± 367 vs. 5595 ± 383, p = 0.069). However, among the 90% of caregivers who were at least somewhat religious, religiosity was significantly and positively related to TL after controlling for covariates (B = 1.74, SE = 0.82, p = 0.034). Whereas nonreligious caregivers have relatively long telomeres, we found a positive relationship between religiosity and TL among those who are at least somewhat religious.

Background: Treatments that integrate religious clients' beliefs into therapy may enhance the therapeutic alliance (TA) in religious clients., Objective: Compare the effects of religiously integrated cognitive behavioral therapy (RCBT) and standard CBT (SCBT) on TA in adults with major depression and chronic medical illness., Method: Multi-site randomized controlled trial in 132 participants, of whom 108 (SCBT = 53, RCBT = 55) completed the Revised Helping Alliance Questionnaire (HAQ-II) at 4, 8, and 12 weeks. Trajectory of change in scores over time was compared between groups., Results: HAQ-II score at 4 weeks predicted a decline in depressive symptoms over time independent of treatment group (B = -0.06, SE = 0.02, p = 0.002, n = 108). There was a marginally significant difference in HAQ-II scores at 4 weeks that favored RCBT (p = 0.076); however, the mixed effects model indicated a significant group by time interaction that favored the SCBT group (B = 1.84, SE = 0.90, degrees of freedom = 181, t = 2.04, p = 0.043, d = 0.30)., Conclusions: While RCBT produces a marginally greater improvement in TA initially compared with SCBT, SCBT soon catches up.

Background: We compared the effectiveness of religiously integrated cognitive behavioral therapy (RCBT) versus standard CBT (SCBT) on increasing optimism in persons with major depressive disorder (MDD) and chronic medical illness., Methods: Participants aged 18-85 were randomized to either RCBT (n = 65) or SCBT (n = 67) to receive ten 50-min sessions remotely (94% by telephone) over 12 weeks. Optimism was assessed at baseline, 12 and 24 weeks by the Life Orientation Test-Revised. Religiosity was assessed at baseline using a 29-item scale composed of religious importance, individual religious practices, intrinsic religiosity, and daily spiritual experiences. Mixed effects growth curve models were used to compare the effects of treatment group on trajectory of change in optimism., Results: In the intention-to-treat analysis, both RCBT and SCBT increased optimism over time, although there was no significant difference between treatment groups (B = -0.75, SE = 0.57, t = -1.33, P = .185). Analyses in the highly religious and in the per protocol analysis indicated similar results. Higher baseline religiosity predicted an increase in optimism over time (B = 0.07, SE = 0.02, t = 4.12, P < .0001), and higher baseline optimism predicted a faster decline in depressive symptoms over time (B = -0.61, SE = 0.10, t = -6.30, P < .0001), both independent of treatment group., Conclusions: RCBT and SCBT are equally effective in increasing optimism in persons with MDD and chronic medical illness. While baseline religiosity does not moderate this effect, religiosity predicts increases in optimism over time independent of treatment group., (© 2015 Wiley Periodicals, Inc.)

We studied the tree-regeneration patterns in three distinct agricultural settlements in the Eastern Amazon to test the influence of land-use mosaics. The following questions are addressed: are the floristic structure and composition of regenerating trees affected by the various land-use types applied in the agricultural settlements? Do tree-regeneration patterns respond similarly to distinct land-use mosaics? Is there a relationship between tree regeneration and soil characteristics among the land-use types? The regeneration was inventoried at 45 sampling points in each settlement. At each sampling point, fourteen soil variables were analyzed. Nine different land-use types were considered. The floristic structure and composition of the settlements showed differences in the density of individuals and species and high species heterogeneity among the land-use types. The maximum Jaccard similarity coefficient found between land-use types was only 29%. Shade-tolerant species were the most diverse functional group in most land-use types, including pasture and annual crops, ranging from 91% of the number of species in the conserved and exploited forests of Travessão 338-S to 53% in the invaded pastures of Maçaranduba. The land-use types influenced significantly the floristic structure and composition of regenerating trees in two agricultural settlements, but not in third the settlement, which had greater forest cover. This finding demonstrates that the composition of each land-use mosaic, established by different management approaches, affects regeneration patterns. Tree regeneration was related to soil characteristics in all mosaics. Preparation of the area by burning was most likely the determining factor in the differences in soil characteristics between forests and agricultural areas.

We examine the efficacy of conventional cognitive behavioral therapy (CCBT) versus religiously integrated CBT (RCBT) in persons with major depression and chronic medical illness. Participants were randomized to either CCBT (n = 67) or RCBT (n = 65). The intervention in both groups consisted of ten 50-minute sessions delivered remotely during 12 weeks (94% by telephone). Adherence to treatment was similar, except in more religious participants in whom adherence to RCBT was slightly greater (85.7% vs. 65.9%, p = 0.10). The intention-to-treat analysis at 12 weeks indicated no significant difference in outcome between the two groups (B = 0.33; SE, 1.80; p = 0.86). Response rates and remission rates were also similar. Overall religiosity interacted with treatment group (B = -0.10; SE, 0.05; p = 0.048), suggesting that RCBT was slightly more efficacious in the more religious participants. These preliminary findings suggest that CCBT and RCBT are equivalent treatments of major depression in persons with chronic medical illness. Efficacy, as well as adherence, may be affected by client religiosity.

Intervention studies have found that psychotherapeutic interventions that explicitly integrate clients' spiritual and religious beliefs in therapy are as effective, if not more so, in reducing depression than those that do not for religious clients. However, few empirical studies have examined the effectiveness of religiously (vs. spiritually) integrated psychotherapy, and no manualized mental health intervention had been developed for the medically ill with religious beliefs. To address this gap, we developed and implemented a novel religiously integrated adaptation of cognitive-behavioral therapy (CBT) for the treatment of depression in individuals with chronic medical illness. This article describes the development and implementation of the intervention. First, we provide a brief overview of CBT. Next, we describe how religious beliefs and behaviors can be integrated into a CBT framework. Finally, we describe Religiously Integrated Cognitive Behavioral Therapy (RCBT), a manualized therapeutic approach designed to assist depressed individuals to develop depression-reducing thoughts and behaviors informed by their own religious beliefs, practices, and resources. This treatment approach has been developed for 5 major world religions (Christianity, Judaism, Islam, Buddhism, and Hinduism), increasing its potential to aid the depressed medically ill from a variety of religious backgrounds., ((PsycINFO Database Record (c) 2015 APA, all rights reserved).)

Terrestrial carbon stock mapping is important for the successful implementation of climate change mitigation policies. Its accuracy depends on the availability of reliable allometric models to infer oven-dry aboveground biomass of trees from census data. The degree of uncertainty associated with previously published pantropical aboveground biomass allometries is large. We analyzed a global database of directly harvested trees at 58 sites, spanning a wide range of climatic conditions and vegetation types (4004 trees ≥ 5 cm trunk diameter). When trunk diameter, total tree height, and wood specific gravity were included in the aboveground biomass model as covariates, a single model was found to hold across tropical vegetation types, with no detectable effect of region or environmental factors. The mean percent bias and variance of this model was only slightly higher than that of locally fitted models. Wood specific gravity was an important predictor of aboveground biomass, especially when including a much broader range of vegetation types than previous studies. The generic tree diameter-height relationship depended linearly on a bioclimatic stress variable E, which compounds indices of temperature variability, precipitation variability, and drought intensity. For cases in which total tree height is unavailable for aboveground biomass estimation, a pantropical model incorporating wood density, trunk diameter, and the variable E outperformed previously published models without height. However, to minimize bias, the development of locally derived diameter-height relationships is advised whenever possible. Both new allometric models should contribute to improve the accuracy of biomass assessment protocols in tropical vegetation types, and to advancing our understanding of architectural and evolutionary constraints on woody plant development., (© 2014 John Wiley & Sons Ltd.)

Objective: Religious involvement may help individuals with chronic medical illness cope better with physical disability and other life changes. We examine the relationships between religiosity, depressive symptoms, and positive emotions in persons with major depression and chronic illness., Methods: 129 persons who were at least somewhat religious/spiritual were recruited into a clinical trial to evaluate the effectiveness of religious vs. secular cognitive behavioral therapy. Reported here are the relationships at baseline between religious involvement and depressive symptoms, purpose in life, optimism, generosity, and gratefulness using standard measures., Results: Although religiosity was unrelated to depressive symptoms (F=0.96, p=0.43) and did not buffer the disability-depression relationship (B=-1.56, SE 2.90, p=0.59), strong relationships were found between religious indicators and greater purpose, optimism, generosity, and gratefulness (F=7.08, p<0.0001)., Conclusions: Although unrelated to depressive symptoms in the setting of major depression and chronic medical illness, higher religious involvement is associated with positive emotions, a finding which may influence the course of depression over time., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Forest inventory studies in the Amazon indicate a large terrestrial carbon sink. However, field plots may fail to represent forest mortality processes at landscape-scales of tropical forests. Here we characterize the frequency distribution of disturbance events in natural forests from 0.01 ha to 2,651 ha size throughout Amazonia using a novel combination of forest inventory, airborne lidar and satellite remote sensing data. We find that small-scale mortality events are responsible for aboveground biomass losses of ~1.7 Pg C y(-1) over the entire Amazon region. We also find that intermediate-scale disturbances account for losses of ~0.2 Pg C y(-1), and that the largest-scale disturbances as a result of blow-downs only account for losses of ~0.004 Pg C y(-1). Simulation of growth and mortality indicates that even when all carbon losses from intermediate and large-scale disturbances are considered, these are outweighed by the net biomass accumulation by tree growth, supporting the inference of an Amazon carbon sink.

We map the extent, infer the life-cycle length and describe spatial and temporal patterns of flowering of sarmentose bamboos (Guadua spp) in upland forests of the southwest Amazon. We first examine the spectra and the spectral separation of forests with different bamboo life stages. False-color composites from orbital sensors going back to 1975 are capable of distinguishing life stages. These woody bamboos flower produce massive quantities of seeds and then die. Life stage is synchronized, forming a single cohort within each population. Bamboo dominates at least 161,500 km(2) of forest, coincident with an area of recent or ongoing tectonic uplift, rapid mechanical erosion and poorly drained soils rich in exchangeable cations. Each bamboo population is confined to a single spatially continuous patch or to a core patch with small outliers. Using spatial congruence between pairs of mature-stage maps from different years, we estimate an average life cycle of 27-28 y. It is now possible to predict exactly where and approximately when new bamboo mortality events will occur. We also map 74 bamboo populations that flowered between 2001 and 2008 over the entire domain of bamboo-dominated forest. Population size averaged 330 km(2). Flowering events of these populations are temporally and/or spatially separated, restricting or preventing gene exchange. Nonetheless, adjacent populations flower closer in time than expected by chance, forming flowering waves. This may be a consequence of allochronic divergence from fewer ancestral populations and suggests a long history of widespread bamboo in the southwest Amazon.

The integration of behavioral health and primary care has received much attention in the literature. Behavioral health providers (BHPs) in integrated settings are faced with different treatment constraints than those who work in specialty mental health. The existing literature focuses on what BHPs should do in primary care settings; however, little research exists specifying what BHPs are actually doing. This study provides a glimpse into what types of interventions BHPs are using, and what types of patients they are seeing, in primary care. A chart review was conducted of patients (N = 180) seen by BHPs in five Veterans Affairs primary care clinics. Depression was the most common diagnosis, while less common presenting problems included substance abuse/dependence, psychosis, and bipolar disorder. Common interventions used were medical management, psycho-education, elements of cognitive-behavioral therapy (CBT), and supportive psychotherapy. Future research should examine the efficacy of brief interventions in primary care settings.

Two studies were conducted to examine the practical implementation of an integrated health care model in five primary care clinics in the Upstate New York Veterans Affairs (VA) system. The aims of the studies were: (a) to describe the basic clinical elements of the integrated health care service offered by behavioral health providers (BHPs) in the primary care setting, and (b) to evaluate the perceptions of providers and patients regarding integrated health care practices in their primary care clinics. In Study 1, we reviewed 180 electronic medical records of patients who met with a BHP in primary care. In Study 2, we used semistructured interviews and self-report questionnaires to collect information from 46 primary care providers, 12 BHPs, and 140 patients regarding their perceptions of integrated health care in their primary care clinics. Both studies illustrate a useful method for evaluating the practical implementation of integrated health care models., (PsycINFO Database Record (c) 2010 APA, all rights reserved.)

A 52-year-old man with chronic hepatitis C presented with painless, bilateral, simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) and peripheral neuropathy. Symptoms began 19 weeks after starting peginterferon alpha-2a. The peripheral neuropathy and vision of the right eye improved, but the vision of the left eye worsened after stopping interferon. We identified 23 additional cases of NAION during interferon alpha therapy. At least 12 of these patients suffered bilateral NAION. Patients lost vision 1-40 weeks after initiating therapy. Of 21 eyes that had documented initial and follow-up acuities, 8 improved, 1 worsened, and the rest remained stable. One patient had a painful peripheral neuropathy. Treatment with interferon alpha may result in NAION. Discontinuation of therapy deserves consideration after weighing individual risks and benefits.

Objective: The purpose of this study was to validate and calibrate an in vitro test method for screening the performance of peroxide-containing toothpastes against actual clinical whitening performance. An additional objective was to estimate the whitening performance of a new peroxide-additive gel using the in vitro methodology., Methods: A one-month longitudinal clinical study was performed to provide a benchmark for the in vivo intrinsic whitening performance of a peroxide-containing fluoride toothpaste. An in vitro study was then conducted, using freshly prepared slurries of the same peroxide-containing toothpaste in artificial saliva, to repeatedly treat extracted human teeth with natural intrinsic stain. The effect of cumulative treatment time on whiteness was determined using objective chromometer whiteness measurements (L*, a*, and b*), and more subjective Vita Shade guide (Vitapan) comparisons, and the results were correlated. A non-peroxide fluoride toothpaste was used as a negative control. The peroxide gel additive, combined in a 1:1 ratio with each of two non-peroxide toothpastes and diluted in artificial saliva, was evaluated using the same instrumental and subjective measures for in vitro whitening efficacy. The previously evaluated peroxide toothpaste and one of the non-peroxide toothpastes were used as positive and negative controls, respectively., Results: In the clinical study, the peroxide-containing toothpaste produced a linear increase in tooth whiteness with time, achieving an approximately two Vita Shade guide improvement in whiteness at the end of four weeks. The same peroxide toothpaste in vitro produced a curvilinear increase in tooth whiteness versus cumulative treatment time, with a two-shade increase being achieved in 116 minutes. The non-peroxide control toothpaste produced less than half a shade guide increase in whiteness within the first 30 minutes, and none thereafter. Both the clinical and in vitro studies indicated that further whitening can be obtained with longer use of the peroxide-containing toothpaste or peroxide-additive gel., Conclusion: Treatment of naturally stained teeth in vitro with the peroxide toothpaste for 116 cumulative minutes produced the same two-shade increase in whiteness as obtained with twice-daily brushing for four weeks in vivo. The peroxide-additive gel, combined with a non-peroxide toothpaste, is projected to provide a similar two-shade increase in whiteness when used twice daily for four weeks. There are indications that greater intrinsic whiteness increase would be achieved with the peroxide toothpaste or with the peroxide-additive gel plus non-peroxide toothpaste with more extended regular twice-daily use in vivo.

Aim: Toothbrushing effectiveness can be improved with at-home reinforcement of proper technique. This study evaluated the ability of a power brush with a wireless remote display (Oral-B Triumph with SmartGuide) to improve brushing force and thoroughness., Methods and Materials: At baseline, 61 pre-screened subjects were videotaped while brushing. The wireless display was also videotaped. Subjects were then randomized to the power brush alone or the power brush with the wireless display. After 30 days of home use, subjects returned and brushed for two minutes using a two-way mirror. Brushing behavior and the wireless display were videotaped., Results: Fifty-eight subjects were included in the pressure sensor analysis. The reduction in pressure sensor activation time at day 30 versus baseline was 88.5% for the power brush with wireless display and 53.4% for the power brush alone. The difference between groups was statistically significant in favor of the power brush with display (p=0.034). Forty-six subjects were included in the brushing thoroughness assessment. Subjects using the power brush with the wireless display showed statistically significantly more thorough brushing across the dentition and lingual/buccal surfaces relative to baseline. The power brush alone did not show a significant difference relative to baseline., Conclusion: Subjects using the power brush with the wireless display brushed with less force than subjects using the power brush alone after 30 days of home use., Clinical Significance: The power brush with the wireless display can be incorporated in patients' home care routine to improve brushing technique, including brushing pressure and thoroughness.

Childhood onset basal cell carcinoma is uncommon. In addition to occurring in children with albinism, Bazex syndrome, basal cell carcinoma nevus syndrome, nevus sebaceus, radiotherapy-treated cancers, solid organ transplants, and xeroderma pigmentosum, childhood onset basal cell carcinoma has also occurred, albeit less commonly, de novo. We describe a boy with idiopathic childhood onset basal cell carcinoma. Previously published children with de novo basal cell carcinoma were collected from computerized medical literature search (PubMed) and citations from earlier reports. To our knowledge, childhood onset idiopathic basal cell carcinoma has been observed in a total of 107 children, including our patient. Tumors were most commonly located on the head (90%). The tumors are most frequently nodular in appearance (52%) and in histology (at least 17%); however, aggressive histologic variants were observed in 20% of tumors. Basal cell carcinoma in children may be associated with prior sun exposure. The most common treatment is excision, with or without using the Mohs technique. However, 15 of 85 children, nearly 20%, developed recurrent tumors during a follow-up period ranging from 4 months to 20 years.

Background: The purse string suture can be used to provide primary closure for small skin defects or as a partial closure for larger round wounds. The size of the defect is reduced secondary to the tension placed on the suture, which uniformly advances the skin from the entire periphery of the wound., Methods: We reviewed retrospectively the features of 98 consecutive patients for whom a total of 100 cuticular purse string sutures were used to partially close their postoperative surgical defects. The location and types of the tumors removed were also summarized., Results: Postoperative wounds were created following Mohs' micrographic excision of nonmelanoma skin cancer (basal cell carcinoma, 44; squamous cell carcinoma, 25), wide local excision of melanoma (29), or conservative excision of benign cutaneous neoplasms (two). The incidence of purse string suture for partial closure of each tumor was 4.1% for basal cell carcinoma, 7.3% for squamous cell carcinoma, and 46.3% for melanoma. The tumors were equally distributed on the trunk, head and neck, and extremities; however, purse string closures for basal cell carcinomas were more frequent on the trunk, head, and neck, relative to squamous cell carcinomas and melanomas, which were more common on the extremities. Concurrent medical problems and/or the use of an agent with anticoagulant or antiplatelet effects were noted in more than 50% of patients. Absorbable material of thicker diameter was most frequently used for the suture, and the postoperative wound area decreased by 6-90% (mean, 60%) following purse string partial closure. The suture was usually removed after 3-4 weeks. Postoperative complications occurred in six patients: allergic contact dermatitis in two, wound infection in two, exuberant granulation tissue in one, and hypertrophic scar in one. All of the wounds healed completely with either a round or linear scar., Conclusion: The cuticular purse string suture is a rapid and simple procedure that provides complete or partial closure of round skin defects and excellent long-term cosmetic and functional results. This closure provides uniform tension to the wound, enhances hemostasis at the tissue edge, and significantly decreases the size of the defect. Partial wound closure with the purse string suture may be advantageous following the local excision of melanoma, either as definitive surgical wound management or as a temporary partial wound closure prior to subsequent complete repair of the surgical defect. The purse string suture is also useful following nonmelanoma skin cancer removal in patients who insist on maintaining an active lifestyle in the immediate postoperative period, who are receiving one or more systemic anticoagulant and/or antiplatelet agents, and who have large surgical wounds that would require either a skin graft or a local cutaneous flap in order to close the postoperative defect.

Clear cell squamous cell carcinoma in situ, also referred to as pagetoid or clear cell Bowen disease, is a rare pathologic variant of this neoplasm. It is characterized by neoplastic cells with clear or pale cytoplasm. An octogenarian husband and wife concurrently developed new facial skin lesions which demonstrated squamous cell carcinoma in situ consisting of cancer cells with clear cytoplasm. Cutaneous human papillomavirus (HPV) typing detected HPV Type 5 and HPV Type 21 in the tumors of the husband and wife, respectively. HPV is a potential etiologic factor in the oncogenesis of nonmelanoma skin cancer, and HPV DNA has been demonstrated in extragenital squamous cell carcinoma in situ. The detection of DNA from different HPV types in the tumors of our patients suggests that the concurrent occurrence of their skin cancers may have been coincidental. However, the presence of HPV DNA in their tumors introduces the possibility of a viral-associated oncogenesis for clear cell squamous cell carcinoma in situ.

The purse-string suture provides complete or partial closure of round postoperative skin defects. It is a rapid and simple procedure to perform. Tension placed on the suture uniformly advances the skin from the entire periphery of the wound, resulting in a significant reduction of the defect size and enhancement of hemostasis at the wound edge. The history, modifications of the technique, advantages, and potential complications of the purse-string suture are reviewed. It is not only useful following the removal of nonmelanoma skin cancer but also after the local excision of melanoma. In addition, this technique is especially suitable for the repair of round surgical wounds for patients who are unable to modify their active lifestyles during the week following surgery, individuals concurrently being treated with anticoagulants, antiplatelet agents or both, and people with extensive postoperative defects that would otherwise require either a skin graft or a large cutaneous flap. Typically, the site of the surgical wound following partial or complete closure with the purse-string suture demonstrates excellent long-term cosmetic and functional results.

In redesigning its front-end workflow to include demographic verification and evaluation of patient financial need, Parkland Memorial Hospital, Dallas, learned the following lessons: Automation is necessary. Integrated technology provides significant benefits. The automated system should evaluate patient financial need. Front-end technology should ensure nondiscriminatory compliance with hospital policy. Community public relations should be maintained.

The TRPM7 (transient receptor potential melastatin 7) ion channel has been implicated in the uptake of Mg2+ into vertebrate cells, as elimination of TRPM7 expression through gene targeting in DT40 B-lymphocytes renders them unable to grow in the absence of supplemental Mg2+. However, a residual capacity of TRPM7-deficient cells to accumulate Mg2+ and proliferate when provided with supplemental Mg2+ suggests the existence of Mg2+ uptake mechanism(s) other than TRPM7. Evaluation of the expression of several members of the SLC41 (solute carrier family 41) family, which exhibit homology with the MgtE class of prokaryotic putative bivalent-cation transporters, demonstrated that one, SLC41A2 (solute carrier family 41 member 2), is expressed in both wild-type and TRPM7-deficient DT40 cells. Characterization of heterologously expressed SLC41A2 protein indicated that it is a plasma-membrane protein with an N-terminus-outside/C-terminus-inside 11-TM (transmembrane)-span topology, consistent with its functioning as a trans-plasma-membrane transporter. In contrast with a previous report of ion-channel activity associated with SLC41A2 expression in oocytes, investigation of whole cell currents in SLC41A2-expressing DT40 cells revealed no novel currents of any type associated with SLC41A2 expression. However, expression of SLC41A2 in TRPM7-deficient cells under the control of a doxycycline-inducible promoter was able to conditionally enhance their net uptake of 26Mg2+ and conditionally and dose-dependently provide them with the capacity to grow in the absence of supplemental Mg2+, observations strongly supporting a model whereby SLC41A2 directly mediates trans-plasma-membrane Mg2+ transport. Overall, our results suggest that SLC41A2 functions as a plasma-membrane Mg2+ transporter in vertebrate cells.

Ulceration of the nose may be inadvertently induced by the patient. Although trigeminal trophic syndrome is an uncommon cause of chronic ulcers, healthcare providers should consider the possibility of this disorder when encountering a patient with nasal ulcerations. Trigeminal trophic syndrome most commonly occurs in older women following therapy for trigeminal neuralgia. The ulcers usually involve the nasal ala and paranasal areas. The clinical vignette of a man with a self-induced nasal ulcer secondary to trigeminal trophic syndrome, which was initially suspected to be skin cancer, is presented. Since nasal ulcerations can be secondary to other conditions, a lesional biopsy should be performed to exclude other diagnoses when trigeminal trophic syndrome is entertained. In addition to trigeminal trophic syndrome, the differential diagnosis of conditions that can cause nasal ulcers include factitial disorders with self-induced ulcerations (such as dermatitis artifacta and neurotic excoriations), granulomatous conditions, infectious diseases, malignancy, and pyoderma gangrenosum. Treatment of trigeminal trophic syndrome requires prevention of digital manipulation of the lesion-either by occluding contact with the ulcer, initiating psychotropic medication, or both. Psychiatric and/or pharmacologic intervention should be considered to reduce or resolve further habitual self-inflicted injury before surgical intervention.