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This work surveys stakeholders of America’s Marine Highway to identify their perceived influence on each other’s resource allocation decision making. The value/criticality of the resource held by the stakeholder group can be indirectly measured by the influence exerted by the group on its peers and its external stakeholders. The stakeholder map visualizes how the various stakeholder groups influence each other. Survey of the US Marine Highway stakeholders reveals peers as the most dominant influence among shippers, environmental advocates, and regulators. Results suggest that only suppliers and transportation providers exhibit distinct dominance of customer-supplier influence over that of their peers. This snapshot of stakeholder relationships is a powerful tool for both businesses as well as regulators in their pursuit of shared objectives in a network-centric environment. Stakeholder relationship influence results, and their graphical illustration, contribute to understanding the underlying dynamics of a changing value advantage in the current and coming decades of shipping.

Global shipping pattern is widely used to assess vessel-borne pollution risk and inform environmental policymaking. Due to ice retreat under climate change, new trans-Arctic navigation routes may b...

Spread of nonindigenous organisms by shipping is one of the largest threats to coastal ecosystems. Limited monitoring and understanding of this phenomenon currently hinder development of effective prevention policies. Surveying ports in North America, South America, Europe, Southeast Asia, and Australia we explored environmental DNA community profiles evident of ship-born species spread. We found that community similarities between ports increased with the number of ship voyages, particularly if the ports had similar environments, and when indirect stepping-stone connections were considered. We also found 57 known non-indigenous taxa, some in hitherto unreported locations. We demonstrate the usefulness of eDNA-based tools for global biodiversity surveys, and highlight that shipping homogenizes biodiversity in predictable that could inform policy and management.

The Ballast Water Management Convention can decrease the introduction risk of harmful aquatic organisms and pathogens, yet the Convention increases shipping costs and causes subsequent economic impacts. This paper examines whether the Convention generates disproportionate invasion risk reduction results and economic impacts on Small Island Developing States (SIDS) and Least Developed Countries (LDCs). Risk reduction is estimated with an invasion risk assessment model based on a higher-order network, and the effects of the regulation on national economies and trade are estimated with an integrated shipping cost and computable general equilibrium modeling framework. Then we use the Lorenz curve to examine if the regulation generates risk or economic inequality among regions. Risk reduction ratios of all regions (except Singapore) are above 99%, which proves the effectiveness of the Convention. The Gini coefficient of 0.66 shows the inequality in risk changes relative to income levels among regions, but risk reductions across all nations vary without particularly high risks for SIDS and LDCs than for large economies. Similarly, we reveal inequality in economic impacts relative to income levels (the Gini coefficient is 0.58), but there is no evidence that SIDS and LDCs are disproportionately impacted compared to more developed regions. Most changes in GDP, real exports, and real imports of studied regions are minor (smaller than 0.1%). However, there are more noteworthy changes for select sectors and trade partners including Togo, Bangladesh, and Dominican Republic, whose exports may decrease for textiles and metal and chemicals. We conclude the Convention decreases biological invasion risk and does not generate disproportionate negative impacts on SIDS and LDCs.

Global ballast water management regulations aiming to decrease aquatic species invasion require actions that can increase shipping costs. We employ an integrated shipping cost and global economic modeling approach to investigate the impacts of ballast water regulations on bilateral trade, national economies, and shipping patterns. Given the potential need for more stringent regulation at regional hotspots of species invasions, this work considers two ballast water treatment policy scenarios: implementation of current international regulations, and a possible stricter regional regulation that targets ships traveling to and from the United States while other vessels continue to face current standards. We find that ballast water management compliance costs under both scenarios lead to modest negative impacts on international trade and national economies overall. However, stricter regulations applied to U.S. ports are expected to have large negative impacts on bilateral trade of several specific commodities for a few countries. Trade diversion causes decreased U.S. imports of some products, leading to minor economic welfare losses.

Ship traffic emissions degrade air quality in coastal areas and contribute to climate impacts globally. The estimated health burden of exposure to shipping emissions in coastal areas may inform policy makers as they seek to reduce exposure and associated potential health impacts. This work estimates the PM2.5-attributable impacts in the form of premature mortality and cardiovascular and respiratory hospital admissions, from long-term exposure to shipping emissions. Health impact assessment (HIA) was performed in 8 Mediterranean coastal cities, using a baseline conditions from the literature and a policy case accounting for the MARPOL Annex VI rules requiring cleaner fuels in 2020. Input data were (a) shipping contributions to ambient PM2.5 concentrations based on receptor modelling studies found in the literature, (b) population and health incidence data from national statistical registries, and (c) geographically-relevant concentration-response functions from the literature. Long-term exposure to ship-sourced PM2.5 accounted for 430 (95% CI: 220–650) premature deaths per year, in the 8 cities, distributed between groups of cities: Barcelona and Athens, with >100 premature deaths/year, and Nicosia, Brindisi, Genoa, Venice, Msida and Melilla, with tens of premature deaths/year. The more stringent standards in 2020 would reduce the number of PM2.5-attributable premature deaths by 15% on average. HIA provided a comparative assessment of the health burden of shipping emissions across Mediterranean coastal cities, which may provide decision support for urban planning with a special focus on harbour areas, and in view of the reduction in sulphur content of marine fuels due to MARPOL Annex VI in 2020. © 2020 The Authors, The authors gratefully acknowledge the providers of health data and statistics: Nicosia (M. Athanasiadou, Health Monitoring Unit, Ministry of Health), Brindisi (M. Stafoggia, L. Bauleo, UOC Epidemiologia eziologica ed occupazionale, Dipartimento Epidemiologia del S.S.R. - ASL RME, Regione Lazio, Genoa-Venice (Istituto Superiore di sanità/Health Institute, http://old.iss.it/publ/ ), Misda (S. Distefano, Department for Policy in Health, Health Information and Research), Melilla ( https://pestadistico.inteligenciadegestion.mscbs.es/publicoSNS/Comun/ ), Athens (Hellenic Statistical Authority, http://www.statistics.gr/en/statistics/-/publication/SPO09/2014 ), and Barcelona (Servei Català de la Salut and the Registre de Mortalitat de Catalunya). The data provided by the Servei Català de la Salut and the Registre de Mortalitat de Catalunya, Servei de Gestió I Anàlisi de la Informació per a la Planificació Estratègica, Direcció General de Planificació en Salut, Departament de Salut were processed internally by CSIC. The authors also acknowledge fruitful technical discussions with Dr. A. Patton (Health Effects Institute, HEI). This work was partially funded by AGAUR (project 2017 SGR41 ) and by the Spanish Ministry of Science and Innovation (Project CEX2018-000794-S ). A. Karanasiou acknowledges support received through the Ramón y Cajal program (grant RYC-2014-16885 ) of the Spanish Ministry of Science, Innovation and Universities .

This study helps understand the ballast water-mediated species spread risk dynamics in the Mediterranean and examine potential policy options for ballast water management to further reduce species spread risk in the region. Results show that Gibraltar, Suez, and Istanbul remained high-risk ports from 2012 to 2018, and they are hub ports connecting several clusters. We reveal ballast water management implications for both the Mediterranean region and individual hub ports respectively. To further reduce the risks of individual Mediterranean hub ports beyond the IMO standards, the most effective (cost-effective) regulatory method is to set more stringent regulation towards such hub ports besides the IMO regulation. To further reduce the risks of the Mediterranean as a whole, the most effective (cost-effective) regulatory scenario is to set more stringent regulation towards all Mediterranean ports besides the IMO regulation. The barge-based method is the most cost-effective technology to achieve stricter regulations.

Global and multinational trade across all transportation modes impacts the environment. This chapter explores the environmental issues related to the international transport of goods in trade. International movement of goods continues to have significant environmental consequences, including increase of short-lived and long-lived greenhouse gas (GHG) emissions globally, introduction of invasive species into waterways regionally, and harm to human health through particulate pollution locally. The international community is responding to these problems (arguably more slowly than national regulatory action) and is working to address environmental concerns through a variety of policy instruments, including regulated performance limits or requirements, mandatory reporting and documentation, and/or incentivized performance targets responding to economic signals. This chapter introduces several key environmental issues surrounding international shipping, and discusses policy developments and innovations that may lead to a more sustainable supply chain.

The introduction and establishment of nonindigenous species (NIS) through global ship movements poses a significant threat to marine ecosystems and economies. While ballast-vectored invasions have been partly addressed by some national policies and an international agreement regulating the concentrations of organisms in ballast water, biofouling-vectored invasions remain largely unaddressed. Development of additional efficient and cost-effective ship-borne NIS policies requires an accurate estimation of NIS spread risk from both ballast water and biofouling. We demonstrate that the first-order Markovian assumption limits accurate modeling of NIS spread risks through the global shipping network. In contrast, we show that higher-order patterns provide more accurate NIS spread risk estimates by revealing indirect pathways of NIS transfer using Species Flow Higher-Order Networks (SF-HON). Using the largest available datasets of non-indigenous species for Europe and the United States, we then compare SF-HON model predictions against those from networks that consider only first-order connections and those that consider all possible indirect connections without consideration of their significance. We show that not only SF-HONs yield more accurate NIS spread risk predictions, but there are important differences in NIS spread via the ballast and biofouling vectors. Our work provides information that policymakers can use to develop more efficient and targeted prevention strategies for ship-borne NIS spread management, especially as management of biofouling is of increasing concern.

This paper presents a life-cycle emissions analysis of conventional and natural gas-based marine transportation in the United States. We apply a total fuel cycle&mdash, or &ldquo, well-to-propeller&rdquo, &mdash, analysis that evaluates emissions along the fuel production and delivery pathway, including feedstock extraction, processing, distribution, and use. We compare emissions profiles for methanol, liquefied natural gas, and low sulfur marine fuel in our analysis, with a focus on exploring tradeoffs across the following pollutants: greenhouse gases, particulate matter, sulfur oxides, and nitrogen oxides. For our greenhouse gas analysis, we apply global warming potentials that consider both near-term (20-year) and long-term (100-year) climate forcing impacts. We also conduct uncertainty analysis to evaluate the impacts of methane leakage within the natural gas recovery, processing, and distribution stages of its fuel cycle. Our results indicate that natural-gas based marine fuels can provide significant local environmental benefits compared to distillate fuel, however, these benefits come with a near-term&mdash, and possibly long-term&mdash, global warming penalty, unless such natural gas-based fuels are derived from renewable feedstock, such as biomass. These results point to the importance of controlling for methane leaks along the natural gas production process and the important role that renewable natural gas can play in the shipping sector. Decision-makers can use these results to inform decisions related to increasing the use of alternative fuels in short sea and coast-wise marine transportation systems.

The article “America’s Marine Highway stakeholders: a system-scale analysis of influence in decision-making” written by Amit J. Mokashi, Austin Becker, and James J. Corbett, was originally published electronically on the publisher’s internet portal on July 24, 2020, without open access.

Objective Spinocerebellar ataxia (SCA) leads to abnormal ocular motility and alignment. The objective of this study was to quantitatively assess vision, ocular motility and alignment and its impact on vision related quality of life (VRQOL) in SCA. Methods Nineteen genetically diagnosed SCA subjects (11 SCA type 3, 3 SCA type 1 and 5 SCA type 6) participated at two university centers. All subjects completed the National Eye Institute Visual Function Questionnaire (NEI-VFQ), 10-Item Neuro-Ophthalmic Supplement (NOS), scale for assessment and rating of ataxia (SARA) and ophthalmic examination. Twelve subjects seen at one of the 2 sites underwent quantitative ocular motility and alignment assessment. Results Composite scores for NEI-VFQ (mean 76.3 ± 13) and NOS (mean 65.2 ± 16.8) were significantly decreased in SCA subjects. NEI-VFQ subscale scores were decreased for general, near, distance and peripheral vision and driving. SCA patients had decreased low contrast sensitivity, stereoacuity and multiple ocular motility defects which included gaze limitation (9/12), nystagmus (5/12), distance esophoria (11/12), near exophoria (12/12) and receded near point of convergence. A significant negative correlation was noted between composite scores and distance convergence fusional amplitude. Conclusion VRQOL is significantly decreased in SCA compared to normal population. All SCA patients should be screened for visual disability and referred for neuro-ophthalmic assessment promptly.

This paper explores whether a Panama Canal Authority pollution tax could be an effective economic instrument to achieve Emission Control Area (ECA)-like reductions in emissions from ships transiting the Panama Canal. This tariff-based policy action, whereby vessels in compliance with International Maritime Organisation (IMO) ECA standards pay a lower transit tariff than noncompliant vessels, could be a feasible alternative to petitioning for a Panamanian ECA through the IMO. A $4.06/container fuel tax could incentivize ECA-compliant emissions reductions for nearly two-thirds of Panama Canal container vessels, mainly through fuel switching; if the vessel(s) also operate in IMO-defined ECAs, exhaust-gas treatment technologies may be cost-effective. The RATES model presented here compares current abatement technologies based on hours of operation within an ECA, computing costs for a container vessel to comply with ECA standards in addition to computing the Canal tax that would reduce emissions in Panama. Retrofitted open-loop scrubbers are cost-effective only for vessels operating within an ECA for more than 4500 h annually. Fuel switching is the least-cost option to industry for vessels that operate mostly outside of ECA regions, whereas vessels operating entirely within an ECA region could reduce compliance cost with exhaust-gas treatment technology (scrubbers).

A 53-year-old woman with history of mitral valve prolapse and astroesophageal reflux, presented to the Emergency Department ith right eye pain and blurry vision for 2 days. She had acute onset f retro-orbital pain and headache, eye pain with eye movement ut no nausea or vomiting. She also reported seeing gray spots and ad ‘blurry vision’ in the right eye. She reported that the temporal isual field was entirely gray in the right eye. She had no prior visual ymptoms and no family history of eye disease. She had no other eurological complaints. Her neurological examination showed extra ocular movements o be intact. She had a relative afferent pupillary defect in the right ye. On Humphrey 24-2 visual field, she had an enlarged blind spot nd constriction peripherally. On ophthalmoscopic examination he patient had disk swelling in the right eye (Fig. 1). There were no emorrhages or exudates. There was pain on eye movement. The emainder of her neurological and general physical examination as normal. Patient was admitted for evaluation of what was thought to be ptic neuritis. MRI brain with and without contrast did not reveal ny lesions suggestive of multiple sclerosis or other demyelinating isease. Lumbar puncture was normal. She was started on high dose

The study explores the environmental input–output (EIO) model as a decision-support tool for marine spatial planning at the regional level. Using empirical data, an EIO model is developed to examine the economic and environmental impacts associated with two leading ocean industries in Xiamen. Results of the study show that, under select economic and environmental scenarios, waterfront tourism is generally preferable to marine transportation in terms of unit environmental and resource effects. Thus, it is more beneficial for the region to promote the growth of the waterfront tourism sector.

The objectives of this study were to present the rationale for the main aspects of the study design and describe the trial methodology for the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT).Eligible candidates with mild visual field loss (automated perimetric mean deviation [PMD] -2 to -7 dB) were randomized to receive either acetazolamide or matching placebo tablets. Randomized participants were offered participation in a supervised dietary program. The primary outcome variable, PMD, was measured at 6 months. Additionally, cerebrospinal fluid from subjects and serum from study participants and matched controls were collected for genetic analysis and vitamin A studies. An ancillary optical coherence substudy was added to investigate the changes of papilledema in the optic nerve head and retina that correlate with Frisén grading, visual field deficits, and low-contrast visual acuity.The randomized trial entered 165 participants from March 17, 2010, through November 27, 2012, from the United States and Canada. The primary outcome (month 6) visits were successfully completed by June 15, 2013. Blood specimens were obtained from 165 controls without IIH to investigate vitamin A metabolism and genetic markers of potential risk factors for IIH.The IIHTT is the first randomized, double-masked placebo-controlled trial to study the effectiveness of medical treatment for patients with IIH.

Graves orbitopathy (GO) is an autoimmune disorder representing the most frequent extrathyroidal manifestation of Graves disease. It is rare, with an age-adjusted incidence of approximately 16.0 cases per 100,000 population per year in women and 2.9 cases per 100,000 population per year in men. GO is an inflammatory process characterized by edema and inflammation of the extraocular muscles and an increase in orbital connective tissue and fat. Despite recent progress in the understanding of its pathogenesis, GO often remains a major diagnostic and therapeutic challenge. It has become increasingly important to classify patients into categories based on disease activity at initial presentation. A Hertel exophthalmometer measurement of >2 mm above normal for race usually categorizes a patient as having moderate-to-severe GO. Encouraging smoking cessation and achieving euthyroidism in the individual patient are important. Simple treatment measures such as lubricants for lid retraction, nocturnal ointments for incomplete eye closure, prisms in diplopia, or botulinum toxin injections for upper-lid retraction can be effective in mild cases of GO. Glucocorticoids, orbital radiotherapy, and decompression/rehabilitative surgery are generally indicated for moderate-to-severe GO and for sight-threatening optic neuropathy. Future therapies, including rituximab aimed at treating the molecular and immunological basis of GO, are under investigation and hold promise for the future.

[1] The retreat of Arctic sea ice has led to renewed calls to exploit Arctic shipping routes. The diversion of ship traffic through the Arctic will shorten shipping routes and possibly reduce global shipping emissions. However, deposition of black carbon (BC) aerosol emitted by additional Arctic ships could cause a reduction in the albedo of snow and ice, accelerating snowmelt and sea ice loss. Here we use recently compiled Arctic shipping emission inventories for 2004 and 2050 together with a global aerosol model to quantify the contribution of future Arctic shipping to high-latitude BC deposition. Our results show that Arctic shipping in 2050 will contribute less than 1% to the total BC deposition north of 60°N due to the much greater relative contribution of BC transported from non-shipping sources at lower latitudes. We suggest that regulation of the Arctic shipping industry will be an insufficient control on high-latitude BC deposition.

We quantify the concentrations changes and Radiative Forcing (RF) of short-lived atmospheric pollutants due to shipping emissions of NOx, SOx, CO, NMVOCs, BC and OC. We use high resolution ship emission inventories for the Arctic that are more suitable for regional scale evaluation than those used in former studies. A chemical transport model and a RF model are used to evaluate the time period 2004–2030, when we expect increasing traffic in the Arctic region. Two datasets for ship emissions are used that characterize the potential impact from shipping and the degree to which shipping controls may mitigate impacts: a high (HIGH) scenario and a low scenario with Maximum Feasible Reduction (MFR) of black carbon in the Arctic. In MFR, BC emissions in the Arctic are reduced with 70% representing a combination technology performance and/or reasonable advances in single-technology performance. Both scenarios result in moderate to substantial increases in concentrations of pollutants both globally and in the Arctic. Exceptions are black carbon in the MFR scenario, and sulfur species and organic carbon in both scenarios due to the future phase-in of current regulation that reduces fuel sulfur content. In the season with potential transit traffic through the Arctic in 2030 we find increased concentrations of all pollutants in large parts of the Arctic. Net global RFs from 2004–2030 of 53 mW m−2 (HIGH) and 73 mW m−2 (MFR) are similar to those found for preindustrial to present net global aircraft RF. The found warming contrasts with the cooling from historical ship emissions. The reason for this difference and the higher global forcing for the MFR scenario is mainly the reduced future fuel sulfur content resulting in less cooling from sulfate aerosols. The Arctic RF is largest in the HIGH scenario. In the HIGH scenario ozone dominates the RF during the transit season (August–October). RF due to BC in air, and snow and ice becomes significant during Arctic spring. For the HIGH scenario the net Arctic RF during spring is 5 times higher than in winter.

Background The risk of optic disc haemorrhages on visual outcome in idiopathic intracranial hypertension (IIH) is unknown. We report the type and frequency of optic disc haemorrhages and other funduscopic abnormalities at baseline in the study eye of the 133 subjects enrolled in the Idiopathic Intracranial Hypertension Treatment Trial completing 6 months of follow-up. Methods We reviewed optic disc photographs to tabulate the frequency and type of optic disc haemorrhages, other funduscopic abnormalities and papilloedema grades of the study eye at baseline and analyse if their presence is associated with a poor visual outcome. Results 27.2% of subjects had nerve fibre layer haemorrhages in at least one eye. Five of seven, 71% of subjects that met criteria for treatment failure, had nerve fibre layer haemorrhages in at least one eye (Fisher9s exact test: p=0.02). There was a good correlation between presence of nerve fibre layer haemorrhages and Frisen grade (Spearman9s correlation, p=0.002; r=0.271). Subjects with nerve fibre layer haemorrhages had a higher cerebrospinal fluid pressure (40.0 mm water, p=0.04). There was poor correlation between nerve fibre layer haemorrhages at baseline and the perimetric mean deviation change at 6 months. Cotton wool spots were present in 4% of subjects, exudates in 3% and pseudodrusen in 4%. Conclusions Nerve fibre layer haemorrhages are common in patients with IIH with mild visual loss and correlate with the severity of the papilloedema. They occur more frequently in treatment failure subjects and therefore may be associated with poor visual outcomes. Trial registration number NCT01003639, Post-results.

Vitamin A and its metabolites (called retinoids) have been thought to play a role in the development of idiopathic intracranial hypertension (IIH). The IIH Treatment Trial (IIHTT) showed the efficacy of acetazolamide (ACZ) in improving visual field function, papilledema grade, quality of life and cerebrospinal fluid (CSF) pressure. We postulated that IIH patients would demonstrate elevated measures of vitamin A metabolites in the serum and CSF.Comprehensive measures of serum vitamin A and its metabolites were obtained from 96 IIHTT subjects, randomly assigned to treatment with ACZ or placebo, and 25 controls with similar gender, age and body mass index (BMI). These included retinol, retinol binding protein, all-trans retinoic acid (ATRA), alpha- and beta-carotenes, and beta-cryptoxanthin. The IIHTT subjects also had CSF and serum vitamin A and metabolite measurements obtained at study entry and at six months.At study entry, of the vitamin A metabolites only serum ATRA was significantly different in IIHTT subjects (median 4.33nM) and controls (median 5.04nM, p=0.02). The BMI of IIHTT subjects showed mild significant negative correlations with serum ATRA, alpha- and beta-carotene, and beta-cryptoxanthin. In contrast, the control subject BMI correlated only with serum ATRA. At six months, the serum retinol, alpha-carotene, beta-carotene, and CSF retinol were increased from baseline in the ACZ treated group, but only increases in alpha-carotene (p=0.02) and CSF ATRA (p=0.04) were significantly greater in the ACZ group compared with the placebo group. No other vitamin A measures were significantly altered over the six months in either treatment group. Weight loss correlated with only with the change in serum beta-carotene (r=-0.44, p=0.006) and the change in CSF retinol (r=-0.61, p=0.02).Vitamin A toxicity is unlikely a contributory factor in the causation of IIH. Our findings differ from those of prior reports in part because of our use of more accurate quantitative methods and measuring vitamin A metabolites in both serum and CSF. ACZ may alter retinoid metabolism in IIH patients.

This paper examines the relationship between environmental policy and “green” innovation in shipbuilding. The primary motivating question of this work is whether there is evidence of: i) technology push from innovation that enables environmental policy initiatives; and/or, ii) policy pull that induces innovation leading to “green” ships. This paper focuses on four environmental categories of technological innovation in the shipbuilding industry, encompassing oil spill recovery, emissions control, climate change mitigation and ballast water treatment. The analysis draws upon documents filed at the International Maritime Organization (IMO) to proxy for policy measures, and uses patent data of the Worldwide Statistical Patent Database, maintained by the European Patent Office (EPO), to account for innovation. Our results show a similar trend between patent activity and IMO document submissions over the years 1998 to 2012 for the two environmental categories, climate change mitigation and emissions control. The key contribution of this work are to provide more insights into environmental policy in shipbuilding and its role in innovation activity, as well as to develop a rich dataset focused on IMO policies aimed at encouraging improved environmental performance by ships.

Background It is difficult to predict the neurologic outcome and ambulatory status in children with perinatal neurologic insult until 2–5 years age. This study aims to correlate clinical optic nerve head (ONH) findings-cupping, pallor and hypoplasia, with gestational period and neurologic (motor) outcomes in patients with cerebral palsy (CP) from perinatal insults. Methods 54 consecutive patients with CP from perinatal insults were enrolled. Patients with intraocular disease, retinopathy of prematurity and hydrocephalus were excluded. ONH was labeled as pale, hypoplastic or large cup (cup/disc ratio ≥ 0.5) if 2 ophthalmologists independently agreed after an ophthalmoscopic examination. Inter-rater reliability was excellent. Results Mean age at examination was 10.98 ± 6.49 years; mean gestational period was 33.26 ± 4.78 weeks. Abnormal ONH (pallor, cupping or hypoplasia) was seen in 38/54 (70%) patients. Of patients with pallor (n = 17), 88% were quadriplegic and 82% non-ambulatory. Mean cup/disc ratio was 0.45 ± 0.22; 50% patients had large cup. Multivariate logistic regression models showed that disc pallor was associated with non-ambulatory status (OR: 21.7; p = 0.003) and quadriplegia (OR: 12.8; p = 0.03). Large cup was associated with age at examination (OR 1.15; p = 0.03). Cup/disc ratio showed positive correlation with age at examination (Pearson's r = 0.39; p = 0.003). There was no significant association of ONH parameters with gestational age. Conclusion Clinically observed ONH changes (pallor, cupping and hypoplasia) are common in CP. Presence of ONH pallor serves as an indicator for poor motor outcome in patients who develop CP from perinatal causes and should prompt early referral for rehabilitation.

Background: We analyzed the potential for the Panama Canal expansion to change CO2 and criteria pollutant emissions (oxides of nitrogen, oxides of sulfur and particulate matter) from Asia–US container flows by estimating the modal shift from landside truck/rail network to larger ships enabled by canal expansion. We develop an intermodal case study comparison within the Geospatial Intermodal Freight Transportation framework, assuming potential diversion of 1.2 million 20-foot equivalent units (TEUs) to 5000 origin–destination pairs. Results: Potential TEU diversions of land-bridge transport through an expanded canal reduced mode-specific emissions substantially, but land-bridge emission reductions due to cargo diversion to post-Panamax vessels, with lower emissions per TEU, cannot offset higher waterborne emissions from longer routes. Conclusion: Green-freight policy measures must consider multimodal network solutions to maximize emission benefits.

Energy and environmental concerns have spawned new policies aimed at reducing emissions and fuel consumption of heavy-duty vehicles (HDVs) worldwide. While such policies intend to reduce HDV energy consumption and emissions, energy savings that reduce transportation costs may lead to increased demand for HDV transportation services. Increased HDV transportation, in turn, can result in increased energy use and emissions—i.e., a direct “rebound effect.” This paper provides a critical review of the literature related to the HDV rebound effect. Results of this review demonstrate that the lack of focused studies in this area combined with the variability and heterogeneity of the trucking sector limit general understanding of the HDV rebound effect. Currently, the studies that do exist often create biased or erroneous rebound effect estimates by inappropriately relying on freight elasticities or applying metrics that omit important elements of fuel consumption. Research following a more transparent and coherent approach can improve estimates of the rebound effect from policy measures to improve HDV energy efficiency.

The International Maritime Organization (IMO) has moved to address the health and climate impact of the emissions from the combustion of low-quality residual fuels within the commercial shipping industry. Fuel sulfur content (FS) limits and an efficiency design index for future ships are examples of such IMO actions. The impacts of black carbon (BC) emissions from shipping are now under review by the IMO, with a particular focus on the potential impacts of future Arctic shipping. Recognizing that associating impacts with BC emissions requires both ambient and onboard observations, we provide recommendations for the measurement of BC. We also evaluate current insights regarding the effect of ship speed (engine load), fuel quality and exhaust gas scrubbing on BC emissions from ships. Observations demonstrate that BC emission factors (EFBC) increases 3 to 6 times at very low engine loads (BC at 85–100% load); absolute BC emissions (per nautical mile of travel) also increase up to 100% depending on engine load, even with reduced load fuel savings. If fleets were required to operate at lower maximum engine loads, presumably associated with reduced speeds, then engines could be re-tuned, which would reduce BC emissions. Ships operating in the Arctic are likely running at highly variable engine loads (25–100%) depending on ice conditions and ice breaking requirements. The ships operating at low load may be emitting up to 50% more BC than they would at their rated load. Such variable load conditions make it difficult to assess the likely emissions rate of BC. Current fuel sulfur regulations have the effect of reducing EFBC by an average of 30% and potentially up to 80% regardless of engine load; a removal rate similar to that of scrubbers. Uncertainties among current observations demonstrate there is a need for more information on a) the impact of fuel quality on EFBC using robust measurement methods and b) the efficacy of scrubbers for the removal of particulate matter by size and composition.

Visual field assessment is important in the evaluation of lesions involving the visual pathways and should be performed at baseline and periodically in the follow-up. Standard automated perimetry has been shown to be adequate in neuro-ophthalmic practise and is now the technique of choice for a majority of practitioners. Goldman kinetic visual fields are useful for patients with severe visual and neurologic deficits and patients with peripheral visual field defects. Visual fields are useful in monitoring progression or recurrence of disease and guide treatment for conditions such as idiopathic intracranial hypertension (IIH), optic neuropathy from multiple sclerosis, pituitary adenomas, and other sellar lesions. They are used as screening tools for toxic optic neuropathy from medications such as ethambutol and vigabatrin. Visual field defects can adversely affect activities of daily living such as personal hygiene, reading, and driving and should be taken into consideration when planning rehabilitation strategies. Visual field testing must be performed in all patients with lesions of the visual pathway.

We read with interest the suggestion for new criteria for the diagnosis of pseudotumor cerebri syndrome and idiopathic intracranial hypertension written by our esteemed colleagues.1 We disagree with the need for this exercise since the nomenclature we have used over the years and for the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT), we believe, is simpler, is accurate, describes the condition, and is easily modified as new information surfaces. Diseases or syndromes should be named for what they are—“idiopathic intracranial hypertension”—rather than what they are not—“pseudotumor cerebri,” “primary pseudotumor cerebri” or “pseudotumor cerebri syndrome (PTCS).” This was impressed on us during a visit to the National Eye Institute many years ago when we were told “we are not going to fund a pseudo anything.” We do not believe there is need for the term PTCS. Secondary causes of intracranial hypertension should also be called what they are: e.g., vitamin A-induced intracranial hypertension, tetracycline-induced intracranial hypertension, steroid withdrawal-related intracranial hypertension, rather than subsuming them with the PTCS acronym. When criteria for IIH are not met and no secondary cause is found, “intracranial hypertension of unknown cause” should …

Evaluating potential cost–effectiveness of abatement technologies in parallel with emerging scientific evidence is important for better management decisions related to integrated environmental problems. This article evaluates six black carbon (BC) emissions reduction technologies for marine engines, including the net effect on a set of short-lived climate forcers from marine diesel combustion. Technologies evaluated include slide valves, water-in-fuel emulsion, diesel particulate filters, low-sulfur fuel, emulsified fuel and sea water scrubbing. Cost–effectiveness values for these technologies implemented alone or in combination are reported in terms of US$/metric ton (mt) for BC, particulate matter and CO2 equivalents (CO2eq), with the latter including CO2 emitted directly due to parasitic fuel use and both warming and cooling short-lived climate forcers affected by control technology performance. The article finds that the most cost-effective strategy evaluated (i.e., the least US$/mt CO2eq) occurs thro...

The Arctic is a sensitive region in terms of climate change and a rich natural resource for global economic activity. Arctic shipping is an important contributor to the region's anthropogenic air emissions, including black carbon – a short-lived climate forcing pollutant especially effective in accelerating the melting of ice and snow. These emissions are projected to increase as declining sea ice coverage due to climate change allows for increased shipping activity in the Arctic. To understand the impacts of these increased emissions, scientists and modelers require high-resolution, geospatial emissions inventories that can be used for regional assessment modeling. This paper presents 5 km×5 km Arctic emissions inventories of important greenhouse gases, black carbon and other pollutants under existing and future (2050) scenarios that account for growth of shipping in the region, potential diversion traffic through emerging routes, and possible emissions control measures. Short-lived forcing of ~4.5 gigagrams of black carbon from Arctic shipping may increase climate forcing; a first-order calculation of global warming potential due to 2030 emissions in the high-growth scenario suggests that short-lived forcing of ~4.5 gigagrams of black carbon from Arctic shipping may increase climate forcing due to Arctic ships by at least 17% compared to warming from these vessels' CO2 emissions (~42 000 gigagrams). The paper also presents maximum feasible reduction scenarios for black carbon in particular. These emissions reduction scenarios will enable scientists and policymakers to evaluate the efficacy and benefits of technological controls for black carbon, and other pollutants from ships.

This paper applies a geospatial network optimization model to explore environmental, economic, and time-of-delivery tradeoffs associated with the application of marine vessels as substitutes for heavy-duty trucks operating in the Great Lakes region. The geospatial model integrates U.S. and Canadian highway, rail, and waterway networks to create an intermodal network and characterizes this network using temporal, economic, and environmental attributes (including emissions of carbon dioxide, particulate matter, carbon monoxide, sulfur oxides, volatile organic compounds, and nitrogen oxides). A case study evaluates tradeoffs associated with containerized traffic flow in the Great Lakes region, demonstrating how choice of freight mode affects the environmental performance of movement of goods. These results suggest opportunities to improve the environmental performance of freight transport through infrastructure development, technology implementation, and economic incentives.

This study investigates the effectiveness of a video team-based activity as a learning experience in a sales management course. Students perceived this learning activity approach as a beneficial and effective instructional technique. The benefits of making a video in a marketing course reinforce the understanding and the use of the sales process in a creative way. In addition, we found this learning activity helped develop critical thinking by engaging students in creating and developing innovative products and services. This unique procedure in involving them with hand-on learning activities through a video presentation is professed by students to greatly improve their performance in a sales management course.

Background: Idiopathic intracranial hypertension (IIH) typically affects young, obese women. We examined 2 groups of atypical patients with IIH: those with a normal body mass index (BMI) and those at least 50 years of age. Methods: A retrospective cohort study of 407 consecutive adult patients with IIH with known BMI from 3 centers was undertaken. Demographics, associated factors, visual acuity, and visual fields were collected at presentation and follow-up. Results: We identified 18 IIH patients (4%) with normal BMI and 19 (5%) aged 50 years or older at the time of diagnosis who were compared with the remainder of the cohort. Medication-induced IIH was more frequent in patients with IIH with normal BMI (28 vs 7%, p = 0.008). No patient with IIH with a normal BMI had severe visual loss in either eye (0 vs 17%, p = 0.09). Older patients with IIH had a lower BMI, but were still generally obese (33 vs 38, p = 0.04). Older patients were less likely to report headache as initial symptom (37 vs 76%, p p = 0.03). Treatment of any type was less likely in older patients (significant for medications: 74 vs 91%, p = 0.004), and they were more likely to have persistent disc edema at last follow-up (median Frisen grade: 1 vs 0, p = 0.002), but had similar, if not better, visual outcomes compared with younger patients. A case-control study did not identify any new medication or risk factor associations. Conclusions: Patients with normal body mass index and those 50 years or older make up a small proportion of patients with idiopathic intracranial hypertension (IIH), but appear to have better visual outcomes than more typical patients with IIH.

Greenhouse gas emissions from international shipping are an increasing concern. The paper evaluates whether vessel speed reduction can be a potentially cost-effective CO2 mitigation option for ships calling on US ports. By applying a profit-maximizing equation to estimate route-specific, economically-efficient speeds, we explore policy impacts of a fuel tax and a speed reduction mandate on CO2 emissions. The profit-maximizing function incorporates opportunity costs associated with speed reduction that go unobserved in more traditional marginal abatement cost analyses. We find that a fuel tax of about $150/ton fuel will lead to average speed-related CO2 reductions of about 20–30%. Moreover, a speed reduction mandate targeted to achieve 20% CO2 reduction in the container fleet costs between $30 and $200 per ton CO2 abated, depending on how the fleet responds to a speed reduction mandate.

Successful mitigation of vessel-whale encounters requires quantitative estimates of vessel strikes, how strike rates change over time, where strikes are most likely to occur, and options for minimizing strikes. In addressing these issues, we first demonstrate a 3- to 4-fold increase in the number of reported large whale-vessel strikes worldwide from the early 1970s to the early 2000s, corresponding to a 3-fold increase in the number of vessels in the world fleet that is paralleled by an increase in vessel tonnage and speed. Second, we estimate a 50% chance of 14 or more annual ves- sel-strike reports worldwide between 1999 and 2002. For North Atlantic right whales Eubalaena glacialis, we estimate a 60% chance of observing at least 1 right whale death from vessel strike. Adjusting for undetermined causes of death and unobserved deaths, we estimate a 10-fold increase (from 1 to 10) in the expected annual number of fatal ship strikes. Third, we evaluate the eastern United States geographic distribution of right whales and vessels to calculate relative probabilities of vessel-whale encounters among 3 major right whale habitats. We determine that the Southern Calv- ing Ground poses the greatest threat of a vessel strike: 1.6- and 7-fold greater than in Cape Cod Bay and the Great South Channel, respectively. Finally, for the Great South Channel region we present a quantitatively determined vessel-traffic routing option that would achieve a 39% reduction in ves- sel-whale encounter probabilities. The methods employed in assessing encounter probabilities and vessel-routing options can be applied elsewhere to enhance the conservation of endangered and threatened species that suffer vessel-strike mortality.

Background:Case reports of familial idiopathic intracranial hypertension (IIH) have appeared sporadically and infrequently.Methods:We reviewed the medical records of all patients with IIH seen at our institution to identify the number of familial cases.Results:Out of a cohort of 237 patients with II

North Atlantic right whale feeding and calving behaviors provide predictable spatial and temporal windows in which to conduct surveys and facilitate collection of opportunistic sightings data. Migration behavior makes it more difficult to locate and sample marine animals systematically or to observe them opportunistically. The lack of data creates a critical gap in understanding social behavior; it also hampers the development of mitigation strategies to anthropogenic disturbances such as vessel strikes, acoustic pollution and entanglements. We employ regression analysis to fill this gap to model northerly movements of North Atlantic right whales in the coastal mid-Atlantic migratory corridor of the United States. The modeling suggests an early to mid-March departure from Jacksonville, Florida, with a 30 day departure range; an average travel time of 21–24 days to the tip of Long Island, corresponding to a mean migration/displacement rate of 1.5–1.7 knots (2.8–3.1 km/h). Right whales migrating with calves begin their northern migration several days after right whales migrating without calves. These statistical models can supplement the absence of migratory survey data and help direct and stratify survey efforts in migratory corridors. The combination of rigorous statistical prediction with direct observation also should facilitate the creation of more effective mitigation measures. The methods employed here can be applied to other megafauna elsewhere around the world in many situations where migratory data are sparse.

Potential costs and benefits of policy options for reducing offshore ship pollution are examined using a meta-analysis of studies synthesized regionally for the US West Coast. Net benefits of reducing SO2 emissions from cargo ships in the US West Coast waters are found to range between $98 million and $284 million, annually; the benefit–cost ratio varies between 1.8 and 3.36, depending on the size of the control area and the sulfur content limit. The results show that about 21,000 tons of on-land equivalent SO2 emissions or about 33% of SO2 emissions from all mobile sources in California in 2005 can be reduced annually if the US West Coast exclusive economic zone is designated as an International Maritime Organization-compliant SOx emission control area (SECA) with fuel-sulfur content not exceeding 1.5%. The analysis demonstrates that designating this area reduces more emissions than establishing a smaller zone at a lower but favorable benefit-cost ratio. Control measures that require 0.5% low-sulfur fuels reduce more SO2 emissions, and also may have higher net benefits. Technological alternatives may achieve benefits of emissions reductions on the US West Coast across higher ranges of potential fuel prices. Combinations of fuel switching and control technology strategies provide the most cost-effective benefits from SECAs on the US West Coast and other world regions.

To identify cutpoints for visual measures at baseline and 1 month predictive of abnormal 6-month vision that could be used as eligibility criteria in a clinical trial to test potential neuroprotection or myelin repair agents in patients with optic neuritis. To determine whether moderate-to-severe dysfunction in one or more visual measures at baseline or 1 month correlates with having major vision loss at 6 months.We used the Optic Neuritis Treatment Trial database to evaluate various cutpoints for baseline and 1-month vision levels that predicted abnormal 6-month vision. For selected cutpoints, we computed a 95% CI for positive predictive value and the required sample size if the cutpoint was to be used for clinical trial eligibility. We evaluated whether the degree of visual loss at baseline, 1 month, or change in visual function from baseline to 1 month correlated with 6-month visual acuity, contrast sensitivity, or threshold visual field.The best cutpoints for baseline and 1 month were visual acuityor= 20/50, contrast sensitivity1.0 log units, and visual field mean deviationor= -15 dB. The same levels of visual dysfunction at 1 month, but not at baseline, correlated with having 6-month moderate-to-severe loss for each of these measures (p = 0.01). A trial could require as few as 100 subjects for an outcome variable of one or more abnormal measures. Cutpoints at 1 month were highly predictive of abnormal 6-month vision, but the proportion of patients who would be eligible for a trial would be small.Provided data can be used either for the clinician to counsel patients on expected visual outcome or for designing studies to test therapies that might reduce the amount of permanent optic nerve damage due to optic neuritis in high-risk patients.

The waterway network ship traffic, energy, and environment model (STEEM) is applied to geographically characterize energy use and emissions for interport ship movement for North America, including the United States, Canada, and Mexico. STEEM advances existing approaches by (i) estimating emissions for large regions on the basis of nearly complete data describing historical ship movements, attributes, and operating profiles of individual ships, (ii) solving distances on an empirical waterway network for each pair of ports considering ship draft and width constraints, and (iii) allocating emissions on the basis of the most probable routes. We estimate that the 172 000 ship voyages to and from North American ports in 2002 consumed about 47 million metric tonnes of heavy fuel oil and emitted about 2.4 million metric tonnes of SO2. Comparison with port and regional studies shows good agreement in total estimates and better spatial precision than current top-down methods. In quantifying limitations of top-down approaches that assume existing proxies for ship traffic density are spatially representative across larger domains, we find that International Comprehensive Ocean-Atmosphere Data Set (ICOADS) proxy data are spatially biased, especially at small scales. Emissions estimated by STEEM for ships within 200 nautical miles of the coastal areas of the United States are about 5 times the emissions estimated in previous studies using cargo as a proxy.

When in port, ships burn marine diesel in on-board generators to produce electricity and are significant contributors to poor local and regional air quality. Supplying ships with grid electricity can reduce these emissions. We use two integrated assessment models to quantify the benefits of reducing the emissions of NOX, SO2, PM2.5, and CO2 that would occur if shore power were used. Using historical vessel call data, we identify combinations of vessels and berths at U.S. ports that could be switched to shore power to yield the largest gains for society. Our results indicate that, depending on the social costs of pollution assumed, an air quality benefit of $70-150 million per year could be achieved by retrofitting a quarter to two-thirds of all vessels that call at U.S. ports. Such a benefit could be produced at no net cost to society (health and environmental benefits would be balanced by the cost of ship and port retrofit) but would require many ships to be equipped to receive shore power, even if doing so would result in a private loss for the operator. Policy makers could produce a net societal gain by implementing incentives and mandates to encourage a shift toward shore power.