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Mediterranean mussel farming in Greece developed considerably during the last 40 years reaching a gross commodity product up to the limits of the country's production capacity (35–40,000 tonnes/year). Despite the achievements in the sector's growth, little or no effort has been attributed yet to risk assessment and moreover to risk management of the activity. The present effort aims at developing a working framework for the shellfish aquaculture of Greece to be used as a tool by the sector's decision makers to advance strategies for risk elimination or avoidance. The work was based on a generic risk management standard tool, the Joint Australian and New Zealand Risk Management Standard AS/NZS ISO 31000:2009 that has been adapted to the specific national characteristics of all levels of the mussel farming business -activities and the industry function. The framework supported by data sets regarding development, production, profits and losses, retrieved by surveys through distributed questionnaires or interviews during site-visits, as well as by collecting data from national and international authorities. Data input covered technology, farm size, farmer risk-attitude, risk-management strategies, risk-perceptions and socioeconomic profiles. Major risks and risk management options were identified providing aid for remediation risk policies to the stakeholders.

As a system reliability analysis technology, failure mode and effect analysis (FMEA) has been widely used in various industries to reduce the failure risk of products, systems, and services. In recent years, many researchers have found that this technology has limitations in failure mode assessment and failure mode prioritization in complex uncertain environment. In order to solve this problem, this article proposes a new FMEA model, which combines hesitant Pythagorean fuzzy sets (HPFSs) and ORESTE method. Specifically, HPFSs are used to describe the risk assessment information of experts. The ORESTE method is extended to determine the risk priority of the failure modes in FMEA. Moreover, the PIR structure of ORESTE is improved to reduce the subjective influence of experts. Finally, an example of risk assessment of intelligent aquaculture system is given to verify the applicability and effectiveness of the proposed FMEA model. The results show that the proposed FMEA model can not only accurately describe the hesitation and uncertainty of experts’ risk assessment information, but also obtain more suitable risk ranking of failure modes, based on which managers can further take corresponding preventive measures.

We implemented the HIV preexposure prophylaxis (PrEP) care continuum among individuals receiving medication for opioid use disorder (MOUD). We screened HIV-negative MOUD participants for PrEP eligibility by assessing injection drug use risk factors and sexual behaviors. Implementation of the PrEP care continuum was challenging; less than a third of MOUD participants were aware of PrEP, and very few initiated PrEP. Findings should promote the development of effective interventions to increase engagement in PrEP during MOUD treatment. (Am J Public Health. 2022;112(1):34–37. https://doi.org/10.2105/AJPH.2021.306566 )

Pheasants are declining everywhere in the world and therefore updated information about their population and habitats are important for conservation and management. The present study was conducted in the Palas Valley, District Kohistan, Pakistan in late spring (May and June) 2020 and early spring (March and April) 2021 to assess the population and anthropogenic stress. The major focus was on three sympatric pheasant species, including Western Horned Tragopan (Tragopan melanocephalus), Himalayan Monal (Lophophorus impejanus), and Koklass Pheasant (Pucrasia macrolopha). We used the “Call Count Method” for the population assessment in the field, and a questionnaire survey was conducted to document the risk assessment of local residents of the valley. The population assessments revealed that the Koklass Pheasant is more adapted to increasing anthropogenic activities and its population appeared more or less similar as 22 years ago. In the past 22 years, Western Tragopan and Himalayan Monal have lost about 40–50% of their populations. Human interference in the form of illegal hunting, deforestation, and overgrazing was found to be common in the valley. The study concludes that the Palas Valley habitat is ideal for pheasant species; however, human interference in the form of urbanization, habitat fragmentation, illegal hunting, and deforestation is occurring at a rapid pace, causing havoc in the pheasant population.

We reported two infantile cases of mediastinal neuroblastoma with life-threatening tracheal obstructions presenting as oncologic emergencies that were successfully treated per tentative risk classification using serum-based

Second opinion consultation is a well-established practice in different clinical settings of diagnostic medicine. However, little is known about second opinion consultation activity in transplantation, and even less is known about it concerning donor assessment. The consultations provided by the second opinion service led to the safer and homogeneous management of donors with a history of malignancy or ongoing neoplasm by transplant centers. Indeed, two of the most important aspects are the reduction of semantic differences in cancer reporting and the standardization of procedures, which are mainly due to the different settings and logistics of different pathology services. This article aims to discuss the role and the future of the second opinion in Italy during organ procurement, highlighting the critical issues and areas for improvement.

PURPOSE Patients with malignant pleural mesothelioma, a rapidly progressing malignancy with a median survival time of 6 to 9 months, have previously responded poorly to chemotherapy. We conducted a phase III trial to determine whether treatment with pemetrexed and cisplatin results in survival time superior to that achieved with cisplatin alone. PATIENTS AND METHODS Chemotherapy-naive patients who were not eligible for curative surgery were randomly assigned to receive pemetrexed 500 mg/m2 and cisplatin 75 mg/m2 on day 1, or cisplatin 75 mg/m2 on day 1. Both regimens were given intravenously every 21 days. RESULTS A total of 456 patients were assigned: 226 received pemetrexed and cisplatin, 222 received cisplatin alone, and eight never received therapy. Median survival time in the pemetrexed/cisplatin arm was 12.1 months versus 9.3 months in the control arm ( P = .020, two-sided log-rank test). The hazard ratio for death of patients in the pemetrexed/cisplatin arm versus those in the control arm was 0.77. Median time to progression was significantly longer in the pemetrexed/cisplatin arm: 5.7 months versus 3.9 months ( P = .001). Response rates were 41.3% in the pemetrexed/cisplatin arm versus 16.7% in the control arm ( P < .0001). After 117 patients had enrolled, folic acid and vitamin B12 were added to reduce toxicity, resulting in a significant reduction in toxicities in the pemetrexed/cisplatin arm. CONCLUSION Treatment with pemetrexed plus cisplatin and vitamin supplementation resulted in superior survival time, time to progression, and response rates compared with treatment with cisplatin alone in patients with malignant pleural mesothelioma. Addition of folic acid and vitamin B12 significantly reduced toxicity without adversely affecting survival time.

Предшестващата анемия е известен предиктор за смърт при пациенти със остър инфаркт на миокарда със SТ-елевация. Данните за влиянието на анемичния синдром са доста по-оскъдни при остър миокарден инфаркт без SТ-елевация (NSTEMI). Цел: Поставихме си за цел да оценим честотата на анемията и влиянието ѝ върху ранните и късните резултати при български пациенти с NSTEMI. Материал и методи: Проведохме амбиспективен анализ на 138 последователни пациенти с NSTEMI, като наличие на анемия се прие при изходен хемоглобин < 120 g/L за жени, < 130 g/L за мъже. Резултати: Няма значима разлика в честота на основните рискови фактори при пациентите със и без анемия. Анемичните пациенти са по възрастни, с по-ниско тегло спрямо ръста и по-лоша изходна бъбречна функция. Изходната анемия е свързана с по-високи стойности на рисковия сбор GRACE и по голям предполагаем размер на реализирания инфаркт според достигнат максимален тропонин І. Няма разлика в приложението на интервенционално лечение. Болничният престой е значително по-дълъг в групата с анемия и е свързан с повече усложнения. Няма разлика в честотата на вътреболничните хеморагични събития и в проведената антиагрегантна терапия, но пациентите с изходна анемия значимо по-често са получили кръвопреливане. Общата смъртност е по-висока при анемичните пациенти както по време на първичния болничен престой, така и по време на проследяването. Заключение: Анемията при постъпването е свързана с повишен риск за усложнен болничен престой и вътреболнична смъртност, както и за влошена отдалечена преживяемост при пациентите с NSTEMI и следва да се включва в общата оценка на риска. Anaemia at admission is a known predictor of death in patients with myocardial infarction with ST-elevation (STEMI). Data on the effect of anaemia on the prognosis in patients with non-ST-elevation myocardial infarction (NSTEMI) is less readily available. Purpose: We aimed to evaluate the frequency of anaemia in a Bulgarian tertiary centre NSTEMI patient population, and its effect on the immediate and extended prognosis of the patients. Methods: We performed ambispective analysis of 138 consecutive patients with NSTEMI, and anaemia was defi ned as haemoglobin at admission below 120 g/L for females and below 130 g/L for males. Results: There was no signifi cant difference in the frequencies of standard risk factors between patients with and without anaemia. Anaemic patients tended to be older, with lower body mass index and worse kidney function. Patients with baseline anaemia tended to have higher GRACE risk scores and a larger size of the realised myocardial infarction as judged by maximal reached troponin I. There was no signifi cant difference in interventional treatment in both groups. Median hospital stay was signifi cantly longer in anaemic patients and was marked by more complications. Despite a lack of increase in inhospital bleeding and no difference in treatment with oral antiaggregants, patients with anaemia received haemotransfusion treatment more often. Mortality rate was higher in anaemic patients both during the index hospitalization and during the follow up. Conclusion: Anaemia at admission is associated with an increased risk of both in hospital cardiovascular complications and after dehospitalisation all-cause mortality in patients with NSTEMI and should be considered as an additional risk factor in the global risk assessment of patients.

Fugitive emission has been becoming an important source of volatile organic compounds (VOCs) in pharmaceutical industry, but the exact contribution of fugitive emission remains incompletely understood. In present study, pollution characteristics, odorous activity and health risk of stack and fugitive emissions of VOCs from four functional units (e.g., workshop, sewage treatment station, raw material storage and hazardous waste storage) of three representative pharmaceutical factories were investigated. Workshop was the dominant contributor to VOCs of fugitive emission in comparison with other functional units. Extreme high concentration of VOCs from fugitive emission in unsealed workshop (94.87 mg/m

Key Points Question Are results of universal and selective screening for suicide risk implemented in a pediatric emergency department associated with future suicidal behaviors? Findings In this cohort study of 15 003 youths aged 8 to 18 years, positive screens were significantly associated with subsequent suicide-related hospital visits compared with standard emergency department procedures. Screening also more than doubled the detection of suicide risk compared with treatment as usual. Meaning These findings suggest that screening for suicide risk in pediatric emergency departments is an effective approach to identify risk for subsequent suicide-related emergency department visits., This cohort study examines the association between results of universal and selective screening for suicide risk in a pediatric emergency department using the Ask Suicide-Screening Questions (ASQ) instrument and subsequent suicide-related outcomes., Importance According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. Objective To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. Design, Setting, and Participants In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Exposure Positive ASQ screen at baseline ED visit. Main Outcomes and Measures The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. Results The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Conclusions and Relevance Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

The pollution of antibiotics commonly existed throughout the entire aquaculture process, but the residues of antibiotics at different aquaculture stages have rarely been studied. This study investigated the occurrence, distribution and risk assessment of antibiotics at different aquaculture stages (the non-aquaculture stage, the early aquaculture stage, the middle aquaculture stage, and the late aquaculture stage) in two typical marine aquaculture areas (Mahegang River and Dingzi Bay) surrounding the Yellow Sea. Fluoroquinolones and tetracyclines were commonly used antibiotics in the aquaculture of these areas with high detection frequencies (17% to 83%). Compared among four aquaculture stages, the highest concentration of antibiotics (9032.08 ng/L) in aquaculture ponds was detected at the late aquaculture stage. And the antibiotic pollution level of natural water was directly related to the aquaculture stages. Similarly, at the aquaculture stages, the detection frequency of antibiotics in sediments was higher than that at the non-aquaculture stage. Based on the correlation analysis, the concentration of main antibiotics in water showed a positive correlation with total nitrogen (p0.05) and chlorophyll a (p0.01), while it showed a negative correlation with salinity (p0.01) in coastal water of the Dingzi Bay. According to the risk assessment, with the development of aquaculture stages, the selection pressure of fluoroquinolones and tetracyclines on resistant bacteria had increased. And the ecological risks caused by sulfonamides and tetracyclines to aquatic organisms had also increased markedly. Overall, this study may provide a reference for formulating regulatory policies regarding antibiotic use at different aquaculture stages.

Objective: To evaluate the conservative management of newborns born at ≥35 weeks of gestational age, at risk for early-onset neonatal sepsis (EOS). Methods: Retrospective, analytic cohort study (2016 to 2019), including newborns ≥35 weeks of gestational at risk of EOS, asymptomatic at birth, managed conservatively in full rooming-in: serial physical examination and clinical observation for at least 48 h. They were classified into three groups, according to the clinical course: asymptomatic (group A), symptomatic for other reasons (group B), and with sepsis (group C). Risk factors, clinical signs and differential diagnoses of sepsis, length of stay, and discharge conditions were evaluated. Results: The authors evaluated 769 asymptomatic newborns at risk of EOS. (mean birth weight 2999 ± 485 g and gestational age 37.6 ± 1.7 weeks, respectively) corresponding to 12.2% of rooming-in admissions. The most prevalent risk factors were colonization by Group B Streptococcus (29%), prolonged rupture membrane duration (21.9%) and preterm labor (21.4%). Most of all of them (53.9%) remained asymptomatic (group A). Group B corresponded for 45.3%, and the most common clinical signs were hypothermia (24.5%), tremors (8.7%) and vomiting (8%). Environmental dysthermia (50.7%), prematurity (20.0%), and feeding intolerance (15.7%) were common in Group B. Laboratory tests were performed in 3.5%. Five patients (one confirmed) comprised group C (0.8/1,000 live births). There were no deaths. The median length of stay was 64 h (IQR 50-93). Conclusion: The rate of clinical/confirmed EOS was low. Most of the symptomatic patients only needed clinical evaluation to rule out sepsis. Management was shown to be safe.

Our aim was to understand to what extent the characteristics of psychopathy are correlated with personality traits and human values in a sample of imprisoned inmates. To this end, a total of 56 prisoners were evaluated, predominantly female (80.4%) with a mean age of 33.44 (SD=7.15). The following instruments were employed: (1) Hare scale, (2) Human Values Questionnaire (BVQ), (3) Big Five Personality Traits Inventory (BFI-S) and (4) Demographic Questionnaire. Descriptive statistics and Spearman’s rank correlation coefficient were applied. The results indicated a positive correlation between a socially deviant/antisocial lifestyle (Factor 2) and the dimensions of neuroticism (r s =0.44; p

Organizations and laboratories tend to integrate systems based on risk management. Risk management helps to optimize laboratory processes and information flow, increase valid and reliable results, and make better decisions. This paper describes the development and present trends in risk management related to standard ISO/IEC 17025. This paper focuses on risk assessment in the accredited testing laboratories using the FMEA tool. In the basic eight defined laboratory areas, risks were identified and evaluated, and methods were proposed to minimize them.

NTRK -rearranged uterine sarcomas are rare spindle cell neoplasms that typically arise in the uterine cervix of young women. Some tumors recur or metastasize, but features which predict behavior have not been identified to date. Distinguishing these tumors from morphologic mimics is significant because patients with advanced stage disease may be treated with TRK inhibitors. Herein, we present 15 cases of NTRK- rearranged uterine sarcomas, the largest series to date. Median patient age was 35 years (range: 16 to 61). The majority arose in the uterine cervix (n=14) and all but 2 were organ-confined at diagnosis. Tumors were composed of an infiltrative, fascicular proliferation of spindle cells and most showed mild-to-moderate cytologic atypia. All were pan-TRK positive by immunohistochemistry (13/13); S100 (11/13) and CD34 (6/10) were usually positive. RNA or DNA sequencing found NTRK1 (10/13) and NTRK3 (3/13) fusions with partners TPR , TPM3 , EML4 , TFG , SPECC1L , C16orf72 , and IRF2BP2 . Unusual morphology was seen in 2 tumors which were originally diagnosed as unclassifiable uterine sarcomas, 1 of which also harbored TP53 mutations. Follow up was available for 9 patients, of whom 3 died of disease. By incorporating outcome data of previously reported tumors, adverse prognostic features were identified, including a mitotic index ≥8 per 10 high-power fields, lymphovascular invasion, necrosis, and NTRK3 fusion. Patients with tumors which lacked any of these 4 features had an excellent prognosis. This study expands the morphologic spectrum of NTRK -rearranged uterine sarcomas and identifies features which can be used for risk stratification.

Although commercial polychlorinated biphenyl (PCB) production was banned in 1979 under the Toxics Substance Control Act, inadvertent generation of PCBs through a variety of chemical production processes continues to contaminate products and waste streams. In this research, a total of 39 consumer products purchased from local and online retailer stores were analyzed for 209 PCB congeners. Inadvertent PCBs (iPCBs) were detected from seven products, and PCB-11 was the only congener detected in most of the samples, with a maximum concentration exceeding 800 ng/g. Emission of PCB-11 to air was studied from one craft foam sheet product using dynamic microchambers at 40 °C for about 120 days. PCB-11 migration from the product to house dust was also investigated. The IAQX program was then employed to estimate the emissions of PCB-11 from 10 craft foam sheets to indoor air in a 30 m

8 Pág., Cultivated bread wheat (Triticum aestivum L.) spontaneously hybridizes with wild/weedy related Aegilops populations, but little is known about the actual rates at which this hybridization occurs under field conditions. It is very important to provide reliable empirical data on this phenomenon in order to assess the potential crop-wild introgression, especially in the context of conducting risk assessments for the commercialization of genetically modified (GM) wheat, as gene flow from wheat to Aegilops species could transfer into the wild species genes coding for traits such as resistance to herbicides, insects, diseases or environmental stresses., This work was supported by the Comisión Interministerial de Ciencia y Tecnología (CICYT) from Spain under the project AGL2004-07101-C02-01/AGR

Through a systematic review and a series of meta-analyses, we evaluated the general responsiveness of putative transcriptional biomarkers of general toxicity and chemical stress. We targeted metal exposures performed on bivalves under controlled laboratory conditions, and selected six transcripts associated with general toxicity for evaluation: catalase (cat), glutathione-S-transferase (gst), heat shock proteins 70 and 90 (hsp70, hsp90), metallothionein (mt) and superoxide dismutase (sod). Transcriptional responses (n = 396) were extracted from published scientific articles (k = 22) and converted to log response ratios (lnRRs). By estimating toxic units (TUs), we normalized different metal exposures to a common scale, as a proxy of concentration. Using Bayesian hierarchical random effect models, we then tested the effects of metal exposure on lnRR, both for metal exposure in general and in meta-regressions using TU and exposure time as independent variables. Corresponding analyses were also repeated with transcript and tissue as additional moderators. Observed patterns were similar for general as for transcript- and tissue-specific responses. The expected overall response to arbitrary metal exposure was a lnRR of 0.50, corresponding to a 65 % increase relative a non-exposed control. However, when accounting for publication bias, the estimated ‘true’ response showed no such effect. Furthermore, expected response magnitude increased slightly with exposure time, but there was little support for general monotonic concentration-dependence with regards to TU. Altogether, this work reveals potential limitations that need consideration prior to applying the selected transcripts as biomarkers in environmental risk assessment. This article is protected by copyright. All rights reserved. Environ Toxicol Chem 2022;00:0–0. CC BY 4.0© 2022 SETAC. This article is protected by copyright. All rights reserved.First published: 06 October 2022Correspondence gustaf.ekelund_ugge@biol.lu.se

High-dimensional dependence modeling remains a crucial challenge in quantitative project cost and time risk analysis. Building a complete and mathematically consistent correlation matrix becomes unrealistically restrictive as the number of uncertain performance units in a project (i.e., activity times and costs) increases, regardless of using empirical data or with subjective judgment. This article presents a pair of additive factor dependence models that provide analytic solutions to the generation of a complete and mathematically consistent correlation matrix. The additive risk factor (ARF) models account for multiple risk factors in two classes (i.e., extra-marginal and intramarginal) while providing additional flexibility for a strategic tradeoff between the accuracy and the scalability to high-dimensional project risks. We extend the ARF models to present an analytic solution to the program evaluation and review technique (PERT) problem with correlated activity times. Numerical examples demonstrate the accuracy and computational efficiency of the ARF approaches. The ARF approaches and the ARF-PERT would serve as a quick and sensible alternative to large-scale Monte Carlo simulation, in particular during the early stage of the project life-cycle.

Nitrated polycyclic aromatic hydrocarbons (NPAHs) are widespread organic pollutants that possess carcinogenic and mutagenic properties, so they may pose a risk to the environment and human health. In this study, the concentrations of 15 NPAHs and 16 polycyclic aromatic hydrocarbons (PAHs) in 30 surface water samples and 26 sediment samples were measured in 2018 from the Taige Canal, one of the main rivers flowing into Taihu Lake, China. The total NPAH concentrations in water and sediment ranged from 14.7 to 235 ng/L and 22.9 to 96.5 ng/g dw, respectively. 9-nitrophenanthrene (nd-76.3 ng/L) was the dominant compound in surface water, while 2+3-nitrofluoranthene (1.73-18.1 ng/g dw) dominated in sediment. Among PAHs, concentration ranging from 1,097 to 2,981 ng/L and 1,089 to 4,489 ng/g dw in surface water and sediment, respectively. There was a strong positive correlation between the log octanol-water partition coefficient (K

Suicide risk stratification and individual-level prediction among major depressive disorder (MDD) is important but unrecognized. Here, we construct models to detect suicidality in MDD using machine learning (ML) and whole-brain functional connectivity (FC).A cross-sectional assessment was conducted on 200 subjects, including 126 MDD with high suicide risk (HSR; 73 patients with suicidal ideation [SI], 53 patients with suicidal attempts [SA]), 36 patients with low suicide risk (LSR) and 38 healthy controls (HCs). Whole-brain FC features were calculated, the least absolute shrinkage and selection operator (LASSO) method was used for feature selection. A support vector machine (SVM) was performed to build models to distinguish MDD from HCs, and for suicide risk stratification among MDD. Leave-one-out cross-validation (LOOCV) was performed for validation.The models constructed using SVM on whole-brain FC had powerful classification efficiency in screening MDD from HCs (accuracy = 88.50 %), and in suicide risk stratification among MDD patients (with accuracy = 84.56 % and 74.60 % in classifying patients with HSR or LSR, and SA or SI, respectively). Subsequent analysis demonstrated that intra-network dysconnectivity in the sensorimotor network and inter-network dysconnectivity between the default and dorsal attention network could characterize HSR and SA in MDD, separately.This study was a single center cohort study without external validation.These findings indicate ML approaches are useful in suicide risk stratification among MDD based on whole-brain FC, which may help to identify individuals with different suicide risks in MDD and provide an individual-level prediction.

Urban Drainage Systems can cause ecological and public health issues by releasing untreated contaminated water into the environment. Real-time control (RTC), augmented with rainfall nowcast, can effectively reduce these pollution loads. This research aims to identify key dynamics in the nowcast accuracies and relate those to the performance of nowcast-informed rule-based (RB)-RTC procedures. The developed procedures are tested in the case study of Rotterdam, the Netherlands. Using perfect nowcast data, all developed procedures showed a reduction in combined sewer overflow volumes of up to 14.6%. Considering real nowcast data, it showed a strong ability to predict if no more rain was expected, whilst performing poorly in quantifying rainfall depths. No relation was found in the nowcast accuracy and the consistency of the predicted rainfall using a moving horizon. Using the real nowcast data, all procedures, with the exception of the one predicting the end of the rainfall event, showed a significant risk of operative deterioration (performing worse than the baseline RB-RTC), linked to the relative performance of the nowcast algorithm. Understanding the strengths of a nowcast algorithm can ensure the reliability of the RB-RTC procedure and can negate the need for detailed modelling studies by inferring risks from nowcast data.

Chemicals have improved the functionality and convenience of industrial and consumer products, but sometimes at the expense of human or ecological health. Existing regulatory systems have proven to be inadequate for assessing and managing the tens of thousands of chemicals in commerce. A different approach is urgently needed to minimize ongoing production, use, and exposures to hazardous chemicals. The premise of the essential-use approach is that chemicals of concern should be used only in cases in which their function in specific products is necessary for health, safety, or the functioning of society and when feasible alternatives are unavailable. To optimize the essential-use approach for broader implementation in the United States and Canada, we recommend that governments and businesses (1) identify chemicals of concern for essentiality assessments based on a broad range of hazard traits, going beyond toxicity; (2) expedite decision-making by avoiding unnecessary assessments and strategically asking up to three questions to determine whether the use of the chemical in the product is essential; (3) apply the essential-use approach as early as possible in the process of developing and assessing chemicals; and (4) engage diverse experts in identifying chemical uses and functions, assessing alternatives, and making essentiality determinations and share such information broadly. If optimized and expanded into regulatory systems in the United States and Canada, other policymaking bodies, and businesses, the essential-use approach can improve chemicals management and shift the market toward safer chemistries that benefit human and ecological health., Environmental Science & Technology, 57 (4), ISSN:0013-936X, ISSN:1520-5851

Objective: We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease.Methods: Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy.Results: A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA2DS2-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%.Conclusion: Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI. Objective: We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease.Methods: Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy.Results: A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA2DS2-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%.Conclusion: Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.

Pouchitis is the most common complication following restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Fecal calprotectin (FC) is a noninvasive indicator of the intestinal inflammatory status. This study was conducted to evaluate the clinical value of the FC concentration for the diagnosis and risk assessment of pouchitis.This retrospective study involved patients who underwent IPAA for UC at Tianjin Medical University General Hospital from January 2015 to January 2019. The patients were categorized into pouchitis and non-pouchitis groups based on their Pouchitis Disease Activity Index (PDAI) score. Laboratory indicators, including the FC concentration, were collected from both groups.Sixty-six patients with UC after IPAA were included in the study and divided into the non-pouchitis group (FC is a useful biomarker in patients with pouchitis. Patients are advised to regularly undergo FC measurement to monitor for pouchitis. An FC concentration in the range of 143.25-579.60 μg/g is predictive of a high risk for pouchitis, and further examination and preventive treatment are necessary in such patients.KEY MESSAGESFecal calprotectin can be used to quantify pouch inflammation.Fecal calprotectin can be used to predict a high risk of pouchitis.

The underlying mechanisms of atrial remodeling in cardiac implanted electronic device(CIED)-detected atrial high-rate episodes(AHRE) remains to be elucidated.A cardiac computed tomography and a strain echocardiography were performed to delineate the structural and functional characteristics of both atria. Biatrial volumes, emptying fraction(EF) and peak atrial longitudinal/contractile strain(PALS/PACS) were evaluated. All AHRE were analyzed.A total of 80 CIED patients with AHRE were categorized by AHRE duration into 3 groups: Group 1:6 min(n = 42), Group 2: 6 min ∼ 6 h(n = 23), and Group 3:6 h(n = 15). Left atrial(LA) maximal volume(VFunctional remodeling of the atria manifested after AHRE6 min. Increased biatrial volumes and decreased LA reservoir and pump function occurred when AHRE were 6 h. These LA structural and functional may be considered surrogate imaging markers for stroke risk assessment in patients with CHA

Public Significance Statement This meta-analysis shows that the Structured Assessment of Protective Factors for violence risk (SAPROF), a risk assessment tool that focuses exclusively on protective factors, can significantly predict the absence of violent behavior in an institution and after discharge into the community. It highlights the importance of adding dynamic protective factors to structured risk assessment to lower the risk of future violence.Although the inclusion of protective factors in risk assessment is believed to improve prediction, most risk assessment tools emphasize risk factors. In response, the Structured Assessment of Protective Factors for violence risk (SAPROF) has been developed, which focuses exclusively on protective factors and is used in conjunction with a structured risk assessment tool. It has received increasing attention from both researchers and forensic mental health practitioners, and additional versions have been developed for use with adolescents (SAPROF-YV) and sex offenders (SAPROF-SO). To assess their psychometric performance, we conducted a meta-analysis of validation studies. Our final sample included 39 articles with 5,434 subjects from 16 countries. Overall, the SAPROF(-YV/-SO) showed good interrater reliability and moderate-to-good predictive performance for the absence of recidivism and institutional misconduct. All three instruments exhibited incremental validity when used in conjunction with a risk-focused assessment tool. Our meta-analysis additionally showed that changes on the SAPROF are associated with decreased violent and general recidivism after controlling for baseline risk. We also uncovered several shortcomings in current research with the SAPROF(-YV/-SO). Studies did not report calibration indices and most studies were retrospective and limited to male offenders. The present findings provide support for the relevance of protective factors in risk assessment, but future research should focus on their hypothesized role in treatment and risk management.

Adverse cardiac events after laparoscopic bariatric surgery are rare, yet preoperative cardiology evaluation and testing remain common, resulting in the overuse of cardiac testing in low-risk patients. Our objective was to assess the frequency of, and factors associated with, overuse of preoperative cardiac testing in patients at low cardiac risk before laparoscopic bariatric surgery. We retrospectively reviewed data from 1,094 adult patients who underwent laparoscopic bariatric surgery at our institution from January 1, 2015, through December 31, 2019. The cardiac risk was determined using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk model. Multivariate logistic regression was used to evaluate risk factors associated with the overuse of cardiac testing in low-risk patients. Overall, 1,059 patients (96.8%) were estimated to be at low cardiac risk by the RCRI, and 1,094 (100%) were at low cardiac risk by NSQIP MICA. A total of 587 patients (51.8%) were referred to cardiology for preoperative evaluation, and 643 patients (56.7%) underwent one or more preoperative cardiac tests. Factors associated with overuse of preoperative cardiac testing in low-risk patients included preoperative cardiology referral (adjusted odds ratio 37.2, 95% confidence interval 25.3 to 54.7) and patient age (adjusted odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Overuse of preoperative cardiac testing was common in patients at low cardiac risk before laparoscopic bariatric surgery. Preoperative referral to cardiology was the most significant risk factor associated with the overuse of preoperative cardiac testing. Application of risk models such as the RCRI or NSQIP MICA at the time of bariatric program enrollment may reduce unnecessary preoperative cardiac testing in low-risk patients.

Patients undergoing open or endovascular infrainguinal revascularization are at an elevated risk for postoperative cardiovascular complications due to high rates of comorbidities and the physiologic stress of surgery. Transfusions are known to be associated with adverse events but knowledge of specific risks associated with transfusion timing, product type, and long-term outcomes while accounting for preoperative cardiovascular risk factors is not well understood in this population. This study aimed to characterize the association of intraoperative and perioperative transfusion, anemia, and cardiovascular risk factors with cardiovascular events and mortality in patients undergoing infrainguinal revascularization.A single-center retrospective study was performed on 564 infrainguinal revascularization procedures, including both open (n = 250) and endovascular (n = 314) approaches (2016-2020). Comprehensive clinical data were collected including patient demographics, cardiovascular risk factors, preoperative hemoglobin, and detailed transfusion data. Multivariable logistic regression tested the association of transfusions with composite 30-day outcomes of cardiac complications (postoperative myocardial infarction [postop-MI], congestive heart failure, or dysrhythmia) and with major adverse cardiovascular events (MACE-postop-MI or death). Kaplan-Meier analysis and Cox proportional hazard modeling examined the association of transfusions, anemia, and cardiovascular risk factors with mortality up to 1 year.Intraoperative transfusion was performed in 15% of cases and 13% underwent transfusion in the early postoperative period. Intraoperative transfusion was associated with higher Revised Cardiac Risk Index (RCRI), lower preoperative hemoglobin, increased blood loss, and open procedures (all P 0.05). Within each RCRI score, intraoperative transfusion was associated with 2-4-fold increased MACE at 30 days. Intraoperative packed red blood cells transfusion and early postoperative packed red blood cells transfusion was associated with more than 2-fold adjusted odds of any cardiovascular complication and intraoperative transfusion was also associated with MACE (all P 0.05). Intraoperative transfusion was associated with mortality at 1 year on unadjusted analysis, but after adjustment for RCRI, age, and preoperative hemoglobin, only RCRI scores of 2 and 3+ and preoperatively hemoglobin remained significant risk factors for mortality.Intraoperative and early perioperative transfusions are strongly associated with worse cardiovascular outcomes after infrainguinal revascularization. These findings may have a prognostic value for further risk stratifying patients perioperatively at a high risk for complications. However, prospective studies are needed to elucidate whether optimizing transfusion strategies mitigates these risks.

Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US).To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs).A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed.No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups.ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes.

Syncopal events in patients with hypertrophic cardiomyopathy (HCM) are of concern as they are a vital consideration in algorithms for risk stratification for sudden cardiac death (SCD) and ICD implantation. However, the cause of syncope is often under-investigated and/or unexplained. Current syncope guidelines do not provide a detailed definition of unexplained syncope. To address this important gap, an international panel of experts in the field of both syncope and HCM wrote a consensus document with the aim of providing practical guidance for the diagnosis and management of syncope in patients with HCM.

Prediction tools focused on cardiovascular and cerebrovascular events after noncardiac surgery are lacking, particularly for Chinese patients. We developed and validated what we believe is a new predictive tool for postoperative major cardiovascular and cerebrovascular events (MACCEs) in Chinese patients in this study. Overall, 401 variables derived from 598 patients who received noncardiac surgery at our center were retrospectively analyzed to develop and validate the new predictive model for MACCEs during hospitalization. The 7 strongest predictors for MACCEs in the development cohort were chronic heart failure, age, atrial fibrillation, general anesthesia, history of coronary heart disease, high-risk procedures, and lymphocyte count. The area under the receiver operating characteristic curve was 0.698 (95% confidence interval 0.616 to 0.780) for the new predictive tool with the validation cohort. Receiver operating characteristic curve analysis showed the new predictive tool had better performance than the Revised Cardiac Risk Index and the American College of Surgeons National Surgical Quality Improvement Program scores. This new predictive tool is effective for the prediction of postoperative MACCEs in patients who undergo noncardiac surgery.

Pulmonary embolism (PE) is a disease caused by blood clots, tumor embolism, and other emboli within the pulmonary arteries. Various scoring scales are used for PE. One such same is the PESI, but it has 12 variables, making it inconvenient for clinical application.The aim of this study was to develop a new simple nomogram model to assess 30-day survival in PE patients. The new nomogram makes it easier and faster for clinicians to assess the prognosis of patients with PE.We collected data about the patients with PE from the Medical Information Mart for Intensive Care-III (MIMIC-III) database and used the receiver operating characteristic (ROC) curve, area under the ROC curve (AUROC), calibration plot, integrated discrimination improvement (IDI), and decision curve analysis (DCA) to evaluate the predictive power of the new model, and compared these with the PESI.According to the multivariable Cox regression model results, alongside the actual clinical conditions, we included the following seven variables: race, bicarbonate, age, tumor, systolic blood pressure (SBP), body temperature, and oxygen saturation (Spo2). The AUROC of the new model was greater than 0.70. Its IDI exceeded 0, but with P-value0.05.The predictive performance of the new model was not worse than the PESI, but the new model only has seven variables, and is therefore more convenient for clinicians to use.

Janus kinase inhibitor therapy and venous thromboembolism risk factors Key words: Janus kinase (JAK) inhibitor, tofacitinib, inflammatory bowel disease (IBD), ulcerative colitis, extended-duration prophylaxis. Identifying validated venous thromboembolism risk assessment tools Key words: venous thromboembolism (VTE) protocol, Caprini risk assessment model (RAM), risk identification, clinical workflow, bleeding risk. Timing of the preoperative venous thromboembolism risk assessment Key words: Caprini risk assessment model (RAM), venous thromboembolism (VTE) risk, patient assessment, presurgical testing visit, family history. Communicating venous thromboembolism and bleeding risk after surgery Key words: venous thromboembolism (VTE) risk, bleeding risk, hand over, postanesthesia care unit RN, intraoperative events.

Introduction: Frailty indices are highly predictive of major medical and mechanical complications, lengths of hospital stay, and mortality rates after spine procedures. However, several barriers limit the extent to which spine surgeons employ these indices. The main purposes of the current study were to assess the use of frailty indices by Latin-American spine surgeons and identify the main barriers perceived to restrict their clinical application. Methods: For this cross-sectional survey, a questionnaire evaluating the demographic characteristics of participating surgeons and their utilization of frailty indices were created in Google form and sent by e-mail to every registered member of AO Spine Latin America between October and November 2020. Results: Of the 1047 surgeons sent the survey, 293 responded (response rate=28%). Half of the surgeons (51.7%) said they were unfamiliar with the terms ¨frailty´ and ¨frailty index”, while 70.3% claimed not to use any frailty scale during their pre-operative assessments. The most frequently utilized index was the modified Frailty Index (mFI) (18%). The most important perceived barrier was the excessive amount of time required to calculate each patient’s frailty score. Ninety-two percent of the spine surgeons felt sure that these scores could influence their therapeutic decisions, while 91% desired an easier-to-use risk-prevention scale. Conclusion: The main perceived barriers restricting the use of frailty indices were the time required to complete them, lack of index validation, and need for specific instruments to calculate the index score.

Purpose To identify independent risk factors, including the Risk Assessment and Prediction Tool (RAPT) score, associated with extended length of stay (eLOS) and non-home discharge following elective multi-level instrumented spine fusion operations for diagnosis of adult spinal deformity (ASD) and lumbar degenerative pathology. Methods Adults who underwent multi-level ($$\ge 3$$ ≥ 3 segments) instrumented spine fusions for ASD and lumbar degenerative pathology at a single institution (2016–2021) were reviewed. Presence of a pre-operative RAPT score was used as an inclusion criterion. Excluded were patients who underwent non-elective operations, revisions, operations for trauma, malignancy, and/or infections. Outcomes were eLOS (> 7 days) and discharge location (home vs. non-home). Predictor variables included demographics, comorbidities, operative information, Surgical Invasiveness Index (SII), and RAPT score. Fisher’s exact test was used for univariate analysis, and significant variables were implemented in multivariate binary logistic regression, with generation of 95% percent confidence intervals (CI), odds ratios (OR), and p-values. Results Included for analysis were 355 patients. Post-operatively, 36.6% (n = 130) had eLOS and 53.2% (n = 189) had a non-home discharge. Risk factors significant for a non-home discharge were older age (> 70 years), SII > 36, pre-op RAPT 20, RAPT Conclusion The RAPT score and SII were most important significant predictors of eLOS and non-home discharges following multi-level instrumented fusions for lumbar spinal pathology and deformity. Preoperative optimization of the RAPT’s individual components may provide a useful strategy for decreasing LOS and modifying discharge disposition.

Deriving water quality benchmarks based on the species sensitivity distribution (SSD) is crucial for assessing the ecological risks of antibiotics. The application of extrapolation methods such as interspecies correlation estimation (ICE) and acute-to-chronic ratios (ACRs) can effectively supplement insufficient toxicity data for these emerging contaminants. Acute-to-chronic ratios can predict chronic toxicity from acute toxicity, and ICE can extrapolate an acute toxicity value from one species to another species. The present study explored the impact of two extrapolation methods on the reliability of SSDs by analyzing different scenarios. The results show that, compared with the normal and Weibull distributions, the logistic model was the best-fitting model. For most antibiotics, SSDs derived by extrapolation have high reliability, with 82.9% of R

Background: Pulse pressure (PP), a marker of arterial stiffening, is closely related to adverse outcomes in hypertensive patients. Correspondingly, less attention has been paid to the value of PP in the population with normal blood pressure. Methods: The study included normotensive elders aged over 60 years from the 1999–2014 National Health and Nutrition Examination Survey (NHANES). All included participants were followed up until the date of death or 31 December 2015. Restricted cubic spline analyses were used to explore the associations of PP with cardiovascular mortality and all-cause mortality. The population was categorized into two groups according to the optimal cut-off of PP for all-cause mortality by X-tile software. Propensity matching score analysis was further performed to reduce confounding bias. The Kaplan–Meier curves and Cox proportional hazard models were applied to estimate the associations of widening PP cardiovascular mortality and all-cause mortality. Subgroup analyses were also conducted. Results: A total of 6309 participants were included (52.9% men and median age 69 (63, 75) years). The median follow-up duration was 74 (42, 114) months. The restricted cubic spline analyses revealed that continuous PP was linearly related to cardiovascular mortality (p for linearity < 0.001; p for nonlinearity = 0.284) and nonlinearly related to all-cause mortality (p for nonlinearity = 0.001). After propensity score matching, 1855 subjects with widening PP and 1855 matched counterparts were included (50.2% men and average age 72 (66, 78) years, 50.9% men and average age 72 (66, 78) years, respectively), of which 966 (26.0%) died during a median follow-up duration of 71 (39, 105) months. In the Cox proportional hazards model, widening PP was associated with increased cardiovascular mortality Hazard Ratio (HR) 1.47; 95% Confidence Interval (CI) 1.07–2.00, p < 0.05] and all-cause mortality (HR 1.15; 95% CI 1.01–1.31, p < 0.05). After adjusting for other traditional risk factors, the association of widening PP with cardiovascular mortality (HR 1.44; 95%CI 1.05–1.98, p < 0.05) remained, and the association of widening PP with all-cause mortality was not statistically significant (p > 0.05). Conclusion: In the normotensive elder population, a low-risk population without traditional coronary risk factors, PP is an independent risk factor for cardiovascular mortality.

Comprehensive two-dimensional gas chromatography (GCxGC) offers unrivaled separation of petroleum substances, which can contain thousands of constituents or more. However, interpreting substance compositions from GCxGC data is costly and requires expertise. To facilitate environmental risk assessments, industries provide aggregated compositional information known as "hydrocarbon blocks" (HCBs), but these proprietary methods do not transparently associate the HCBs with GCxGC chromatogram data. These obstacles frustrate efforts to study the environmental risks of petroleum substances and associated environmental samples. To address this problem, we developed a GCxGC elution model for user-defined petroleum substance compositions. We calibrated the elution model to experimental GCxGC retention times of 56 known hydrocarbons by fitting three tunable model parameters to two candidate instrument methods. With the calibrated model, we simulated retention times for a library of 15,447-15,455 hydrocarbon structures (plus 40-48 predicted as chromatographically unretained) spanning 11 classes of petroleum substance constituents in the C

BACKGROUND: In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood. OBJECTIVE: This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals. METHOD: The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that these risk assessments were regularly updated. RESULTS: The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions. CONCLUSION: Including the ‘risk formulation’ and ‘scenarios’ from the HCR-20 in clients’ crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone’s business.