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Abstract Background Hypoadrenocorticism is an important differential for hypercalcemia. The etiology of hypercalcemia in hypoadrenocorticism in dogs is unclear. Objective To review the prevalence of hypercalcemia and use statistical models to identify clinical, demographic, and biochemical variables associated with hypercalcemia in dogs with primary hypoadrenocorticism. Animals One hundred ten dogs with primary hypoadrenocorticism; 107 with recorded total calcium (TCa), 43 recorded ionized calcium (iCa). Methods Multicenter retrospective observational study at 4 UK referral hospitals. Univariable logistic regression analyses were performed to assess the association between independent variables of signalment, hypoadrenocorticism type (glucocorticoid only deficient hypoadrenocorticism [GHoC] vs glucocorticoid and mineralocorticoid deficient hypoadrenocorticism [GMHoC]), clinicopathological variables and hypercalcemia. Hypercalcemia was defined as elevated TCa, an elevated iCa, or both elevated TCa and iCa (Model 1) or as elevated iCa (Model 2). Results Overall prevalence of hypercalcemia was 34.5% (38/110). The odds of hypercalcemia (Model 1) were increased (P

Abstract Disruptions to key lifelines, especially electrical power, can cause outsized impacts on human functioning. The state of the art on developed countries has focused on enhancing resilience to electrical grid infrastructure but has neglected to track changes regarding how the private market has developed electricity continuity measures over time. Backup generators are among the most accessible tools to maintain electricity continuity in case of power failure, but their role as a buffer remains understudied outside the technical domain, along with the humanitarian and emergency response sectors. This paper analyzes generator sales across the U.S. to understand some underlying trends that may have influenced changes in consumer preference for electricity resilience. Reports from major backup generator sellers and import data of backup generators reveal an increase in backup generators across the U.S. and find that private demand for energy resilience is likely increasing due to consumers’ perceived risk and rising levels of intolerance to power disruptions. The discussion finds that an increase in private demand and use of backup generators may be impacting electricity resilience at a communal and societal level, which seems to be underexamined by studies focusing on private generator usage in the U.S..

Summary: Background: Living in greener areas, or close to green and blue spaces (GBS; eg, parks, lakes, or beaches), is associated with better mental health, but longitudinal evidence when GBS exposures precede outcomes is less available. We aimed to analyse the effect of living in or moving to areas with more green space or better access to GBS on subsequent adult mental health over time, while explicitly considering health inequalities. Methods: A cohort of the people in Wales, UK (≥16 years; n=2 341 591) was constructed from electronic health record data sources from Jan 1, 2008 to Oct 31, 2019, comprising 19 141 896 person-years of follow-up. Household ambient greenness (Enhanced Vegetation Index [EVI]), access to GBS (counts, distance to nearest), and common mental health disorders (CMD, based on a validated algorithm combining current diagnoses or symptoms of anxiety or depression [treated or untreated in the preceding 1-year period], or treatment of historical diagnoses from before the current cohort [up to 8 years previously, to 2000], where diagnosis preceded treatment) were record-linked. Cumulative exposure values were created for each adult, censoring for CMD, migration out of Wales, death, or end of cohort. Exposure and CMD associations were evaluated using multivariate logistic regression, stratified by area-level deprivation. Findings: After adjustment, exposure to greater ambient greenness over time (+0·1 increased EVI on a 0–1 scale) was associated with lower odds of subsequent CMD (adjusted odds ratio 0·80, 95% CI 0·80–0·81), where CMD was based on a combination of current diagnoses or symptoms (treated or untreated in the preceding 1-year period), or treatments. Ten percentile points more access to GBS was associated with lower odds of a later CMD (0·93, 0·93–0·93). Every additional 360 m to the nearest GBS was associated with higher odds of CMD (1·05, 1·04–1·05). We found that positive effects of GBS on mental health appeared to be greater in more deprived quintiles. Interpretation: Ambient exposure is associated with the greatest reduced risk of CMD, particularly for those who live in deprived communities. These findings support authorities responsible for GBS, who are attempting to engage planners and policy makers, to ensure GBS meets residents' needs. Funding: National Institute for Health and Care Research Public Health Research programme.

BackgroundBrain aneurysms represent a significant cause of hemorrhagic stroke. Prior research has demonstrated links between stress and stroke, including brain aneurysms. We aimed to determine relationships between select psychiatric disorders and aneurysms and aneurysmal SAH.MethodsWe performed retrospective, case-control study of a National Veterans Affairs population with two experimental groups (aneurysm-only and aneurysmal SAH) and 10-fold controls per group matched by age, date, and clinical data source. The studied the presence of 4 psychiatric disorders: Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and other mood disorders. Our main outcomes Unadjusted and multivariable adjusted ORs of PTSD, MDD, GAD, and mood disorders within aneurysm-only and aSAH groups.ResultsIn 6,320,789 US Veterans who were enrolled for at least 5 years in Medicare and/or the Veterans Health Administration, we identified 35,094 cases of aneurysm without SAH and 5,749 cases of aneurysm with SAH between 1/2005 and 12/2019. In analyses adjusted for sex, hypertension, and tobacco use, patients with aneurysm were more likely than matched controls to have a history of PTSD (OR 1.48), MDD (OR 1.33), GAD (OR 1.26), and other mood disorders (OR 1.34) (all p-values < 0.0001). Similarly, patients with aSAH were more likely than controls to have a history of PTSD (OR 1.35), MDD (OR 1.38), GAD (OR 1.18), and other mood disorders (OR 1.30) (all p-values < 0.0001).ConclusionThe study, the largest of its kind, further suggests links between psychiatric disorders and stroke. This is important as patients with aneurysms are not routinely screened for such psychiatric risk factors. Additional research on this topic could lead to novel strategies to improve stroke prevention.

Objectives To examine the characteristics and circumstances of infants who died while sleeping or in a sleep environment and compare deaths classified as either unintentional asphyxia or an unexplained cause.Design A retrospective cohort study.Setting Data were extracted from the National Fatality Review Case Reporting System and Florida Vital Statistics databases.Participants Data on 778 sleep-related infant deaths occurring from 2014 to 2018 in Florida were analysed.Primary outcome measure Cause of death classification as unintentional asphyxia or unexplained.Results Overall, 36% (n=276) of sleep-related infant deaths in this study sample were classified as resulting from an unexplained cause compared with unintentional asphyxia. Most infants were reported to be in an adult bed (60%; n=464) and sharing a sleep surface with a person or animal (60%; n=468); less than half (44%; n=343) were reportedly placed to sleep on their back. After controlling for the influence of other independent variables, female sex (adjusted risk ratio: 1.36; 95% CI 1.06 to 1.74) and fully obstructed airway condition (adjusted risk ratio: 0.30; 95% CI 0.18 to 0.50) were associated with an unexplained cause of death.Conclusions The results of this analysis indicate that sleep environment hazards remain prevalent among infants who die suddenly and unexpectedly, regardless of the cause of death determination. While significant differences were observed for some factors, in many others the distributions of both demographic and incident characteristics were similar between unexplained deaths and those resulting from asphyxia. The results of this study support growing evidence that unsafe sleep environments contribute to all forms of sudden unexpected infant death, underscoring the need for standardising cause of death determination practices and promoting consistent, high-quality forensic investigations to accurately explain, monitor and prevent these deaths.

BACKGROUND/OBJECTIVE: Given the poor overall survival (OR) and progression-free survival (PFS) rates for lung cancers managed with surgical resection, there is a need to identify the prognostic markers that would improve the risk stratification of patients with operable lung cancer to inform treatment decisions. We investigate the prognostic utility of two established inflammation-based scores, the neutrophil–lymphocyte ratio (NLR) and the change in neutrophil–lymphocyte ratio (ΔNLR), throughout the operative period in a prospective cohort of patients with lung cancer who underwent surgical resection. METHODS: Demographic, clinical, and treatment details for 345 patients with lung cancer who underwent surgical resection between 2000 and 2019 at multiple centers across Melbourne, Victoria (Australia), were prospectively collected. Preoperative NLR and ΔNLR were calculated after which Cox univariate and multivariate analyses were conducted for OS and PFS against the known prognostic factors. RESULTS: Both univariate and multivariate analyses showed that preoperative NLR >4.54, as well as day 1 and day 2 postoperative NLR (P < 0.01), was associated with increased risk for postoperative mortality (hazard ratio 1.8; P < 0.01) and PFS (P < 0.05), whereas ΔNLR was not a significant predictor of OS or PFS. CONCLUSION: Elevated NLR among patients with lung cancer who underwent surgical resection was prognostic for poor OS and PFS, whereas ΔNLR was not found to be prognostic for either OS or PFS. Further research may yet reveal a prognostic value for ΔNLR when compared across a greater time period.

Abstract Objective The objective of this project is to create a three‐dimensional (3D) printed smartphone adaptor for flexible nasolaryngoscopy (FNL) to provide an affordable alternative to commercial options and a better fit than generic telescope phone adaptors. Method We designed an adaptor using computer aided software to connect an iPhone XS to an Olympus Rhino‐Laryngo Fibre Scope. We experimented with various 3D printing materials and iterative designs to create a case that allowed for quality recording of a nasolaryngoscope exam using the iPhone's built in ×2 telescopic zoom lens. Results Our 3D printed adaptor provides a cost‐effective alternative to commercially available FNL smartphone adaptors and is capable of capturing high‐quality images and videos of the nasopharynx and larynx. These images are useful for senior clinician review, decrease the need for repeat examination, can be utilized for education, avail telehealth review, and provides a way to digitally record examinations to electronic medical records for future comparison without the need for an endoscopy tower. Conclusion Smartphone adaptors for FNL have been established to be of clinical value. Despite being simple devices, they continue to be expensive. This potentially limits access to junior clinicians, who stand to gain most from the ability to review images of examinations with senior colleagues. Our 3D printed smartphone case provides a cost‐effective alternative, with a better fit than generic adaptors, at a print cost of $29 AUD. This is $131 AUD less than the next cheapest commercial alternative. The files are freely available for use and modification. Level of Evidence 4

Abstract Background In Australia, the number of medical graduates per year has increased at a greater rate than the increase in the number of specialist training places. Consequently, competition for training positions is intensifying. There is anecdotal evidence to suggest that medical graduates are acquiring additional qualifications to compete with their peers Stevenson 2017 (https://insightplus.mja.com.au/2017/36/specialty-training-places-the-other-looming-crisis/). Our study investigates this phenomenon of additional credentialing and demonstrates the number and type of postgraduate and research qualifications obtained by specialists in training in Australia. This is the first study to assess the number and type of credentials acquired by registrars in each specialty and to provide insight into differences between specialities. Methods Information on specialists in training was obtained through the Medicine in Australia: Balancing Employment and Life (MABEL) survey conducted between 2008 and 2014. The number of any additional qualifications and specific PhD, Master’s degree, postgraduate diploma/certificate and research degrees from medical school were assessed for each specialist training scheme in the database. Results Overall, 995 registrars representing 13 specialties were included. Just under a third (30.4%) completed a research-based degree during their medical degree and almost half (46.7%) of specialist registrars obtained further qualifications after completing medicine. A significantly higher proportion of ophthalmology (78.6%) and paediatric (67.5%) registrars, and a lower percentage of emergency medicine (36.7%) registrars, held postgraduate qualifications. Overall, 2.4% of registrars held a PhD and 10.1% held a Master’s degree. A higher percentage of either PhD or Master’s was held by ophthalmology (64.3%) and surgical (30.6%) trainees and a lower percentage by anaesthetics (6.3%) and physician trainees (7.9%). Postgraduate diplomas or certificates were most common among paediatric (41.2%) and obstetrics and gynaecology (25.6%) registrars. Conclusion This is the first study to investigate the additional qualifications of specialists in training in Australia. Almost half of specialists in training surveyed (46.7%) have completed some form of additional study, whether it is a PhD, Master’s, postgraduate diploma/certificate or research degree from medical school. Trainees of specialist training schemes are more qualified than specialists who trained in the past Aust Fam Physician 32:92-4, 2003.

Abstract Forage availability and predation risk interact to affect habitat use of ungulates across many biomes. Within sky‐island habitats of the Mojave Desert, increased availability of diverse forage and cover may provide ungulates with unique opportunities to extend nutrient uptake and/or to mitigate predation risk. We addressed whether habitat use and foraging patterns of female mule deer (Odocoileus hemionus) responded to normalized difference vegetation index (NDVI), NDVI rate of change (green‐up), or the occurrence of cougars (Puma concolor). Female mule deer used available green‐up primarily in spring, although growing vegetation was available during other seasons. Mule deer and cougar shared similar habitat all year, and our models indicated cougars had a consistent, negative effect on mule deer access to growing vegetation, particularly in summer when cougar occurrence became concentrated at higher elevations. A seemingly late parturition date coincided with diminishing NDVI during the lactation period. Sky‐island populations, rarely studied, provide the opportunity to determine how mule deer respond to growing foliage along steep elevation and vegetation gradients when trapped with their predators and seasonally limited by aridity. Our findings indicate that fear of predation may restrict access to the forage resources found in sky islands.

Introduction Chiari 1 malformation (CM1) is a structural abnormality of the hindbrain characterised by the descent of the cerebellar tonsils through the foramen magnum. The management of patients with CM1 remains contentious since there are currently no UK or international guidelines for clinicians. We therefore propose a collaborative, prospective, multicentre study on the investigation, management and outcome of CM1 in the UK: the UK Chiari 1 Study (UKC1S). Our primary objective is to determine the health-related quality of life (HRQoL) in patients with a new diagnosis of CM1 managed either conservatively or surgically at 12 months of follow-up. We also aim to: (A) determine HRQoL 12 months following surgery; (B) measure complications 12 months following surgery; (C) determine the natural history of patients with CM1 treated conservatively without surgery; (D) determine the radiological correlates of presenting symptoms, signs and outcomes; and (E) determine the scope and variation within UK practice in referral patterns, patient pathways, investigations and surgical decisions.Methods and analysis The UKC1S will be a prospective, multicentre and observational study that will follow the British Neurosurgical Trainee Research Collaborative model of collaborative research. Patients will be recruited after attending their first neurosurgical outpatient clinic appointment. Follow-up data will be collected from all patients at 12 months from baseline regardless of whether they are treated surgically or not. A further 12-month postoperative follow-up timepoint will be added for patients treated with decompressive surgery. The study is expected to last three years.Ethics and dissemination The UKC1S received a favourable ethical opinion from the East Midlands Leicester South Research Ethics Committee (REC reference: 20/EM/0053; IRAS 269739) and the Health Research Authority. The results of the study will be published in peer-reviewed medical journals, presented at scientific conferences, shared with collaborating sites and shared with participant patients if they so wish.

Arterioenteric or arteriotracheal fistula is a known complication of an aberrant right subclavian artery (ARSA) and is often associated with prolonged nasogastric or endotracheal intubation or oesophageal stenting. Fistula formation from the ARSA can present unexpectedly with rapid exsanguination with massive haemoptysis or haematemesis, and unless promptly recognised and treated is rapidly fatal. We present a novel endovascular method for treating a fistula between the oesophagus, trachea and an ARSA in an unstable patient following oesophageal stent removal, utilising a covered iliac limb stent, eliminating the need for an open surgical approach.

Introduction Green and blue spaces (GBS), such as parks, woodlands, rivers, and beaches, are thought to be important for mental health and wellbeing. Our longitudinal cohort contains objective household-level environment data linked at the invidual level to routinely recorded mental health data, augmented with cross sectional self-reported health behaviours, including leisure visits to the outdoors. Objectives and Approach Our overall approach will evaluate if residential proximity to GBS is associated with mental health and wellbeing, and if any associations are modified by visits to outdoors spaces following individual-level data linkage. Here, we examined cross-sectional survey data on time spent visiting nature outdoors. Wellbeing outcomes were assessed using self-reported scores. Data were analysed using generalised additive models in the SAIL Databank. Results Using a sample of National Survey for Wales respondents (2016/17, n=3,481), over 40% of adults in Wales reported spending less than 30 minutes outdoors each week. Weekly time outdoors was positively associated with wellbeing (p=0.007) and life satisfaction (p=0.03) having adjusted for potential confounders including, age, rurality, loneliness, employment status. Confidence intervals varied along the fitted GAM model. Models using a second wave of survey data (n≈7,000), anonymously record-linked to residential environment and health data will explore these associations further. Conclusion A previous study based in England (White et al. 2019) found an upper wellbeing benefit threshold of 2 hours per week for time spent in nature. This was not apparent in our preliminary models, but may be revealed in further analyses. We will next incorporate longitudinal mental health and environmental data for 2 million adults living in Wales, UK. Linking to ambient and accessible residential GBS, while taking into account changes due to migration and actual visits, will allow us to provide valuable guidance to local government, who are often responsible for provisioning and maintaining outdoor facilities.

Introduction Common mental health disorders (CMD) are significant contributors to impaired health and well-being, and drive greater health resource utilisation. Electronic health records (EHR) are increasingly used for case identification of CMD when ascertaining social determinants of mental health. We seek to compare self-reported well-being indicators in groups identified using EHR-based CMD methods. Objectives and Approach The National Survey for Wales (NSW) contains self-reported well-being indicators (Warwick Edinburgh Mental Well-being Scale, WEMWBS) recorded annually on ~7,000 individuals. We combined data from two NSWs and linked well-being indicators with Welsh Longitudinal General Practice (WLGP) data within the Secure Anonymised Information Linkage (SAIL) Databank, using individual response dates. We then used WGLP data to algorithmically derive identifiers of CMD cases within survey respondents. This individual-level linkage enables a comparison of NSW responses in CMD and non-CMD cases, and to assess sensitivity and specificity of the current CMD algorithm. Results Survey participants comprised 18,450 adults aged 16+ and living in Wales during 16/17 or 18/19. WEMWBS responses indicate 2,338 (12.6%) participants could be considered possibly depressed, and 2,268 (12.3%) probably depressed with low mental well-being (LMW). For participants with LMW, a 42/58 percentage split is observed between male/female respondents, compared to a 45/55 respective split of those not identified with LMW. Participants with LMW recorded low measures for overall satisfaction with life, 998 (44%) reported a value of 5 or less (/10) compared to 1123 (7%) participants not identified with LMW. Similarly, 828 (37%) participants identified with LMW reported 5 or less (/10) on the life worthwhile index, compared to 800 (5%) of non-LMW participants. Conclusion / Implications Linkage to the NSW provides a rich data source to compare objective well-being to algorithmically derived CMD cases from routinely collected primary care data. The individual-level linkage involved will allow for the wider determinants of mental health disorders to be examined.

Introduction The emergence of the novel respiratory SARS-CoV-2 and subsequent COVID-19 pandemic have required rapid assimilation of population-level data to understand and control the spread of infection in the general and vulnerable populations. Rapid analyses are needed to inform policy development and target interventions to at-risk groups to prevent serious health outcomes. We aim to provide an accessible research platform to determine demographic, socioeconomic and clinical risk factors for infection, morbidity and mortality of COVID-19, to measure the impact of COVID-19 on healthcare utilisation and long-term health, and to enable the evaluation of natural experiments of policy interventions.Methods and analysis Two privacy-protecting population-level cohorts have been created and derived from multisourced demographic and healthcare data. The C20 cohort consists of 3.2 million people in Wales on the 1 January 2020 with follow-up until 31 May 2020. The complete cohort dataset will be updated monthly with some individual datasets available daily. The C16 cohort consists of 3 million people in Wales on the 1 January 2016 with follow-up to 31 December 2019. C16 is designed as a counterfactual cohort to provide contextual comparative population data on disease, health service utilisation and mortality. Study outcomes will: (a) characterise the epidemiology of COVID-19, (b) assess socioeconomic and demographic influences on infection and outcomes, (c) measure the impact of COVID-19 on short -term and longer-term population outcomes and (d) undertake studies on the transmission and spatial spread of infection.Ethics and dissemination The Secure Anonymised Information Linkage-independent Information Governance Review Panel has approved this study. The study findings will be presented to policy groups, public meetings, national and international conferences, and published in peer-reviewed journals.

The deregulatory perspective on labor market institutions argues that such institutions push up wage and employment costs while discouraging hiring and job seeking. In contrast, an institutionalist perspective argues that labor market institutions support deeper skill formation and better job searches. Building on this literature, the authors focus on temporal variation, emphasizing that some labor market institutions are likely countercyclical: they can potentially limit job losses in economic downturns. For 21 countries from 1985 to 2012, the authors examine the association of labor market institutions with overall employment outcomes as well as how these associations vary during financial crises. They find limited first-order associations of institutions with employment outcomes, procyclical associations for union density, and countercyclical associations for unemployment insurance and employment protection legislation. These findings suggest that labor market institutions could be a useful countercyclical tool in an era of recurrent financial crises.

Foram colhidos fragmentos de músculos da carcaça de 74 suínos de abate e de 150 porcas descartadas de granjas de ciclo completo, abatidos em frigorífico no Rio Grande do Sul. Os materiais foram inoculados em meio EMJH (Ellinghausen, MacCullough, Johnson & Harris), incubados a 30ºC e o cultivo foi passado a placas de agar sangue através de membrana de 0,45µm. Foram obtidas 69 amostras de Arcobacter sp, classificadas por PCR como A. butzleri, respectivamente de suínos de abate (21 isolamentos, 29,3%) e matrizes descartadas (48 isolamentos, 32%).Portions of muscle from carcasses of 74 fattening pigs and 150 culled sows were collected from abattoir in the State of Rio Grande do Sul, Brazil. The samples were inoculated into EMJH (Ellinghausen, MacCullough, Johnson & Harris) medium and the culture filtered through 0.45µm membrane on blood agar. Arcobacter sp were isolated, 69 isolates, typed by PCR as Arcobater butzleri, respectively from fattening pigs (21 isolates, 29.3%) and culled sows (48 isolates, 32%).

Se presenta un caso de leiomioma facial. Hasta el 2002 se habían reportado aproximadamente 70 casos en la región bucal y maxilofacial. Teniendo en cuenta la escasa frecuencia de esta entidad, se consideró de interés aportar un nuevo caso, comentando los aspectos clínicos e histopatológicos. Se realizó una revisión del tema. Se presenta una paciente femenina con diagnóstico de leiomioma facial diagnosticada clínica e histológicamente en el Hospital Provincial Clinicoquirúrgico Docente "Manuel Ascunce Domenech" de Camagüey y que fue tratada quirúrgicamente en dicha institución.A case of facial leiomyoma is reported in this paper. Approximately 70 cases had been reported in the oral and maxillofacial regions until the year 200e. Taking into account the causistry of leiomyoma, we decided to present a new case making comments on clinical and histopathological aspects and to make a literature review in this regard. Here is the case of a female patient diagnosed with facial leiomyoma by clinical and histological means at "Manuel Ascunce" teaching clinical-surgical hospital in Camaguey province where she was also surgically treated.