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The American College of Cardiology and the American Heart Association guidelines recommend treatment of patients with severe hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/100 ml) with a high-intensity statin. However, atherosclerotic cardiovascular disease (ASCVD) risk, even among those with severe hypercholesterolemia, is heterogeneous, and coronary artery calcium (CAC) scoring may be used to clarify risk. We sought to evaluate CAC in patients with severe hypercholesterolemia and measure its impact on real-world statin prescriptions. We identified patients with at least 1 LDL-C ≥190 mg100 ml who had a CAC scoring in the Community Benefit of No-Charge Calcium Score Screening Program (CLARIFY) study (NCT04075162) between 2014 and 2020. We explored the CAC distribution, factors associated with CAC0, and ASCVD risk (myocardial infarction, stroke, revascularization, death). A total of 1,904 patients (1.257 women, aged 57.8 ± 9.3 years) with severe hypercholesterolemia were included. LDL-C ranged from 190 to 524 mg100 ml (mean 215.5 ± 27 mg100 ml). A total of 864 patients (45.4%) had CAC = 0 and 1,561 (82%) had CAC100. In patients with LDL-C ≥250 mg100 ml, 67 (36.6%) had CAC = 0. Age, male gender, smoking, diabetes, systolic blood pressure, and obesity (ps ≤0.001) were associated with CAC0. In patients with LDL-C ≥190 mg100 ml, CAC was associated with a higher risk for ASCVD events (CAC ≥100 vs CAC100, hazard ratio 3.57 [1.81 to 7.04], p0.001). A higher CAC category was associated with increased statin use after CAC scoring (p0.001). In patients with severe hypercholesterolemia, 45% had CAC = 0, which was associated with a significantly lower ASCVD risk. CAC was associated with statin prescription and cholesterol lowering. In conclusion, CAC scoring may be used to clarify ASCVD risk in this heterogeneous population with severe hypercholesterolemia.

Peatlands are essential to environmental imperatives with respect to achieving net zero and nature recovery. Sustainable Peatland Management (SPM) can help to restore, maintain and enhance peatlands to ensure they meet their potential in delivering multiple ecosystem benefits. SPM has attracted a great deal of attention in policy and practice but there has been no attempt to carry out a comprehensive review of the law and governance issues in this context. This article does so with reference to an exemplar of an area of deep peat in the southeast corner of the Brecon Beacons National Park, in Wales. Mapping the boundaries of law and governance here reveals a pressing need to amend these systems to facilitate effective SPM. It also unearths broader challenges regarding the legal frameworks for sustainable land management that will require a more fundamental response.

The operational characteristics of Hall effect thrusters are altered by conductive surfaces in vacuum facilities. Conductive surfaces alter charge distribution in the plume by providing pathways for electron-ion recombination that do not exist in the spaceflight environment. Charge recombination pathways impact thruster performance and plume behavior through mechanisms that are not entirely understood. The incomplete understanding of the relationship between charge recombination pathways and thruster behavior limits the ability to characterize thruster performance through ground testing. This paper quantifies the effect of polarity and magnitude of body-to-cathode voltage on coupling between the thruster body and the local plasma environment. The effort operates the T-140 Hall thruster at a single, fixed operating condition of 300 V, 3.5 kW, with anode and cathode xenon flow rates of 11.6 ± 0.03 mg/s and 1.61 ± 0.12 mg/s, respectively. During data collection, the chamber was maintained at a pressure of 8.7 × 10–6 Torr-Xe. The thruster body-to-ground voltage is manipulated by varying body-to-ground resistance. Results show the thruster pole face and body circumference couple to the local plasma environment through distinct sheaths. The polarity of the body-to-cathode voltage determines the characteristics of these sheaths. Therefore, the body-to-cathode voltage controls the interaction between the thruster body recombination pathway and the local plasma environment.

Developed by Breakthrough RESEARCH, this guide will provide social and behavior change (SBC) program implementers, as well as monitoring, evaluation, and research practitioners with information needed to apply social media monitoring and social listening techniques to inform and evaluate campaigns that make use of social media platforms and other internet-based channels, and highlights where additional or external resources, partnerships, or tools may be needed.

Peatland carbon stores are under widespread anthropogenic pressure, resulting in degradation and carbon loss. This paper presents DO14C (Dissolved Organic Carbon) dates from waters draining two eroded blanket peatland catchments in the UK. Both catchments are characterized by severe gully erosion but one additionally has extensive surface erosion on unvegetated surfaces. DO14C values ranged from 104.3 to 88.6 percent modern (present to 976 Before Present). The oldest DOC dates came from the catchment characterized by both gully and surface erosion and are among the oldest reported from waters draining temperate peatlands. Together with peat age-depth data from across the peatland landscape, the DO14C ages identify where in the peat profile carbon loss is occurring. Source depths were compared with modeled water table data indicating that in the catchment where gully erosion alone dominated, mean water table was a key control on depth of DOC production. In the system exhibiting both gully erosion and surface erosion, DOC ages were younger than expected from the age of surficial peats and measured water tables. This may indicate either that the old organic matter exposed at the surface by erosion is less labile or that there are modifications of hydrological flow pathways. Our data indicate that eroded peatlands are losing carbon from depth, and that erosion form may be a control on carbon loss. Our approach uses point measurements of DO14C to indicate DOC source depths and has the potential to act as an indicator of peatland function in degraded and restored systems.

Early accurate diagnosis of infection ± organ dysfunction (sepsis) remains a major challenge in clinical practice. Utilizing effective biomarkers to identify infection and impending organ dysfunction before the onset of clinical signs and symptoms would enable earlier investigation and intervention. To our knowledge, no prior study has specifically examined the possibility of pre-symptomatic detection of sepsis.Blood samples and clinical/laboratory data were collected daily from 4385 patients undergoing elective surgery. An adjudication panel identified 154 patients with definite postoperative infection, of whom 98 developed sepsis. Transcriptomic profiling and subsequent RT-qPCR were undertaken on sequential blood samples taken postoperatively from these patients in the three days prior to the onset of symptoms. Comparison was made against postoperative day-, age-, sex- and procedure- matched patients who had an uncomplicated recovery (n =151) or postoperative inflammation without infection (n =148).Specific gene signatures optimized to predict infection or sepsis in the three days prior to clinical presentation were identified in initial discovery cohorts. Subsequent classification using machine learning with cross-validation with separate patient cohorts and their matched controls gave high Area Under the Receiver Operator Curve (AUC) values. These allowed discrimination of infection from uncomplicated recovery (AUC 0.871), infectious from non-infectious systemic inflammation (0.897), sepsis from other postoperative presentations (0.843), and sepsis from uncomplicated infection (0.703).Host biomarker signatures may be able to identify postoperative infection or sepsis up to three days in advance of clinical recognition. If validated in future studies, these signatures offer potential diagnostic utility for postoperative management of deteriorating or high-risk surgical patients and, potentially, other patient populations.

BACKGROUND Between 2014 and 2018, the penetration of smartphones in sub-Saharan Africa increased from 10% to 30%, enabling increased access to the internet, Facebook, Twitter, Pinterest, and YouTube. These platforms engage users in multidirectional communication and provide public health programs with the tools to inform and engage diverse audiences on a range of public health issues, as well as monitor opinions and behaviors on health topics. OBJECTIVE This paper details the process used by the U.S. Agency for International Development–funded Breakthrough RESEARCH to apply social media monitoring and social listening techniques in Burkina Faso, Côte d’Ivoire, Niger, and Togo for the adaptive management of the Merci Mon Héros campaign. We documented how these approaches were applied and how the lessons learned can be used to support future public health communication campaigns. METHODS The process involved 6 steps: (1) ensure there is a sufficient volume of topic-specific web-based conversation in the target countries; (2) develop measures to monitor the campaign’s social media strategy; (3) identify search terms to assess campaign and related conversations; (4) quantitatively assess campaign audience demographics, campaign reach, and engagement through social media monitoring; (5) qualitatively assess audience attitudes, opinions, and behaviors and understand conversation context through social media listening; and (6) adapt campaign content and approach based on the analysis of social media data. RESULTS We analyzed posts across social media platforms from November 2019 to October 2020 based on identified key search terms related to family planning, reproductive health, menstruation, sexual activity, and gender. Based on the quantitative and qualitative assessments in steps 4 and 5, there were several adaptive shifts in the campaign’s content and approach, of which the following 3 shifts are highlighted. (1) Social media monitoring identified that the Facebook campaign fans were primarily male, which prompted the campaign to target calls to action to the male audience already following the campaign and shift marketing approaches to increase the proportion of female followers. (2) Shorter videos had a higher chance of being viewed in their entirety. In response to this, the campaign shortened video lengths and created screenshot teasers to promote videos. (3) The most negative sentiment related to the campaign videos was associated with beliefs against premarital sex. In response to this finding, the campaign included videos and Facebook Live sessions with religious leaders who promoted talking openly with young people to support intergenerational discussion about reproductive health. CONCLUSIONS Prior to launching health campaigns, programs should test the most relevant social media platforms and their limitations. Inherent biases to internet and social media access are important challenges, and ethical considerations around data privacy must continue to guide the advances in this technology’s use for research. However, social listening and social media monitoring can be powerful monitoring and evaluation tools that can be used to aid the adaptive management of health campaigns that engage populations who have a digital presence.

"I don't know if I could do that eight times a week." That's what I was thinking while watching a play on Broadway, just before coming to UCSD. The emotional availability, and vocal demands, seemed daunting. I was a working actor in New York, but I what I was doing, wasn't really working for me. So I came here in pursuit of a very specific skill set...musical theater.Getting to work on Mr. Burns was a thrilling, frustrating, and surprisingly perfect way to end my time here. I had never been in a "musical" before, nor had the desire, but was excited to tackle a new challenge. Very excited. Cut to, our first two days. Music rehearsal. Dance rehearsal. The room was filled with gorgeous singing voices and fluid dancing... shit... this is not in my wheelhouse. What the hell did I get myself into?Luckily, I already had so much technique from the training here to draw from. Movement and mask work with Charlie. Being gently reminded in Kyle's class, that it's not about you, it's about the other person. Picking out operative words, and chewing on consonants, with Eva. Dancing with Maria. Hearing Greg's voice in my head, "How do you want the other person to feel?" Years of tutorials with Linda, that not only gave me the confidence to call myself a singer, but actually sing on pitch. And most importantly, the countless hours of vocal work with Ursula. I had to be heard in the challenging space that is The Forum. (Still don't know how I ended up in there six times.) I had a vocal warm-up that not only gave strength to release my voice, openly and freely, but allowed me to keep my voice. And the confidence that I could do it again and again, eight times a week.

Peatlands provide a range of ecosystem services but are sensitive to changes in climate and land-use, and many peatlands globally are degraded. We analyse a large-scale, unique and diverse dataset, collected over 15 years, as part of major landscape scale blanket peat restoration projects in the south Pennines, UK. Trajectories of ecosystem change after restoration were assessed by measuring key ecosystem responses including: vegetation cover and indicator species; water table, runoff, and water quality.The reactions of these metrics vary in their behaviour, both in the timing of first response and the rate of change towards a new stable state. Re-establishment of vegetation is a key driver in rapidly reducing particulate carbon loss and attenuating stormflow, while over time biodiversity is improved by the return of native species, and water tables gradually rise. The phasing of these ecosystem service responses indicates that there are different characteristic timescales for the improvement of peatland functions, driven by both surface and subsurface processes. The rapid establishment of vegetation cover over two years, and its importance in improving a broad range of functions, signify it as a key milestone for reporting project success within typical funding timeframes.This study supports the adoption of Lime-Fertiliser-Seed-Mulch restoration on eroding blanket peatlands globally. The trajectories developed are important to help guide practitioners of ecological restoration. Better understanding of the dynamics underpinning the slower response times of subsurface hydrological and biogeochemical function is identified as a key knowledge gap. An understanding of the limits of ecosystems recovery is important when target setting for restoration projects, especially where attaining pristine conditions is unachievable.

Restoration of eroded blanket peatlands through revegetation and gully blocking is observed to also deliver significant natural flood management (NFM) benefits (reduce and delay floodpeaks). But there is a lack of clear understanding regarding how different catchment processes interact/counteract under each intervention scenario. We seek to provide more insight by rigorously calibrating TOPMODEL rainfall-runoff model to different experimental catchments each representing an intervention scenario. Through numerical experimentation with the calibrated parameters, we estimate the impact-magnitude of different processes. Our findings confirm the NFM benefits of these restoration-focused interventions. In both interventions and in our largest storms, both the delay and reduced floodpeaks are primarily due to surface roughness reducing the floodwave speed thus thickening the overland flow; we conceptualize this as an increase in a “kinematic storage.” Impact of gully blocking in increasing kinematic storage is very significant and comparable to that of revegetation alone. Interventions' impact on “static storage” (interception + ponding + evapotranspiration) becomes important for smaller storms. Although interventions always increase lag times, they can be less effective in reducing peak magnitude when maximum rainfall intensity is sustained for durations longer than mean catchment delay. We propose two approaches to further increase catchment's static and kinematic storage. Finally, while our field-scale numerical study contributes to the evidence-base for NFM's effectiveness, it also provides a basis for modeling these interventions in the future. Such catchment-scale numerical studies are necessary to extend our findings to spatial scales where flooding can cause socioeconomic damage, and to provide a tool for optimizing the distributed configuration of these interventions.

Peatlands are wetland ecosystems with great significance as natural habitats and as major global carbon stores. They have been subject to widespread exploitation and degradation with resulting losses in characteristic biota and ecosystem functions such as climate regulation. More recently, large-scale programmes have been established to restore peatland ecosystems and the various services they provide to society. Despite significant progress in peatland science and restoration practice, we lack a process-based understanding of how soil microbiota influence peatland functioning and mediate the resilience and recovery of ecosystem services, to perturbations associated with land use and climate change.\ud \ud We argue that there is a need to: in the short-term, characterise peatland microbial communities across a range of spatial and temporal scales and develop an improved understanding of the links between peatland habitat, ecological functions and microbial processes; in the medium term, define what a successfully restored ’target’ peatland microbiome looks like for key carbon cycle related ecosystem services and develop microbial-based monitoring tools for assessing restoration needs; and in the longer term, to use this knowledge to influence restoration practices and assess progress on the trajectory towards ‘intact’ peatland status.\ud \ud Rapid advances in genetic characterisation of the structure and functions of microbial communities offer the potential for transformative progress in these areas, but the scale and speed of methodological and conceptual advances in studying ecosystem functions is a challenge for peatland scientists. Advances in this area require multidisciplinary collaborations between peatland scientists, data scientists and microbiologists and ultimately, collaboration with the modelling community.\ud \ud Developing a process-based understanding of the resilience and recovery of peatlands to perturbations, such as climate extremes, fires, and drainage, will be key to meeting climate targets and delivering ecosystem services cost effectively.

Objective To describe 5 cases with complete urinary bladder duplication, their associated conditions, and their respective treatment. Urinary bladder duplication is an extremely rare congenital anomaly of the urinary system. So far about 70 cases have been published in the English literature, most of them as case reports and a few case series. Methods and Results All consecutive patients with bladder duplication treated at our institution between 2000 and 2015 were included. Patient records were retrospectively analyzed, and 5 patients with urinary bladder duplication were identified (see Summary Figure). Two patients were male. All duplications were recognized by health care providers. In 1 case recognition was prenatal (MRI in utero at 22 weeks of gestation), the latest recognition was at 12 months of age. A voiding cystourethrography was performed in 4 patients to confirm the diagnosis. In 4 patients the bladder duplication could be classified according to Abrahamson with 3 complete reduplications and one complete sagittal septum. All patients suffered from associated congenital diseases, but only one patient had urinary tract infections. Surgical treatment was only performed in one patient. Median follow-up was 34 months. Discussion Urinary bladder duplications reflect extremely seldom disorders that are almost always associated with other congenital anomalies. Treatment depends on patients’ symptoms and associated conditions and hence needs to be individualized to each patient.

Background Continuous positive airway pressure (CPAP) ventilation may be used as a potential bridge to invasive mechanical ventilation (IMV), or as a ceiling-of-care for persistent hypoxaemia despite standard oxygen therapy, according to UK guidelines. We examined the association of mode of respiratory support and ceiling-of-care on mortality. Methods We conducted a retrospective cohort analysis of routinely collected de-identified data of adults with nasal/throat SARs-CoV-2 swab-positive results, at the Calderdale and Huddersfield NHS Foundation Trust between 10th March-19th April 2020 (outcomes determined on 22nd May). Findings Of 347 patients with SARs-CoV-2 swab-positive results, 294 (84.7%) patients admitted for Covid-19 were included in the study. Sixty-nine patients were trialled on CPAP, mostly delivered by face mask, either as an early ceiling of care instituted within 24 hours of admission (N = 19), or as a potential bridge to IMV (N = 44). Patients receiving a ceiling of care more than 24 hours after admission (N = 6) were excluded from the analysis. Two hundred and fifteen patients (73.1%) maximally received air/standard oxygen therapy, and 45 (15.3%) patients maximally received CPAP. Thirty-four patients (11.6%) required IMV, of which 24 had received prior CPAP. There were 138 patients with an early ceiling-of-care plan (pre-admission/within 24h). Overall, 103(35.0%) patients died and 191(65.0%) were alive at study end. Among all patients trialled on CPAP either as a potential bridge to IMV (N = 44) or as a ceiling-of-care (N = 19) mortality was 25% and 84%, respectively. Overall, there was strong evidence for higher mortality among patients who required CPAP or IMV, compared to those who required only air/oxygen (aOR 5.24 95%CI: 1.38, 19.81 and aOR 46.47 95%CI: 7.52, 287.08, respectively; p Conclusion Our data suggest that among patients with no ceiling-of-care, an initial trial of CPAP as a potential bridge to IMV offers a favourable therapeutic alternative to early intubation. In contrast, among patients with a ceiling-of care, CPAP seems to offer little additional survival benefit beyond oxygen therapy alone. Information on ceilings of respiratory support is vital to interpreting mortality from Covid-19. Strengths and limitations of this study Sample size relatively small. Study sample representative of hospitalised Covid-19 patients in UK. Previously unreported data on role of ceilings-of-care in hospitalised Covid-19 patients. Novel data on use of CPAP separated by indication.

To identify comorbid conditions that may increase the likelihood of revision surgery after primary penile prosthesis implantation. To evaluate trends in utilization of prostheses and selection of device within the Veterans Affairs (VA) system.A retrospective review of the VA Informatics and Computing Infrastructure database was performed using Current Procedural Technology codes to identify any Veteran who underwent penile prosthesis surgery between January 2000 and December 2013. Age, race, procedure type, and relevant comorbidities were identified and compared between groups.A total of 6586 patients underwent primary penile prosthesis placement with at least 1 year of follow-up. Peripheral vascular disease (P .001), smoking (P .001), hypertension (P = .012), and history of prostate cancer (P = .043) were each associated with a significant increased risk of revision or removal surgery. There was an increase in overall number of implants placed during the study and increased durability with malleable penile prosthesis (MPP), but there was a downward trend in the number of MPP placed relative to inflatable penile prosthesis (P .001). MPP were more likely to be placed with increasing age (P .05) and there was a trend toward increased MPP placement in African Americans compared with Caucasians (P = .06).Peripheral vascular disease, hypertension, smoking, and history of prostate cancer are associated with increased risk for secondary surgery. This raises a provocative question of how vascular insufficiency may play a role in the likelihood of secondary surgery after penile prosthesis placement. Utilization of penile prosthesis placement in the VA system is steadily increasing, most notably with increased numbers of inflatable penile prosthesis placement.

The literature about ectopic ureters in anorectal malformations is limited. Repair of an anorectal malformation may require dissection near the normal or abnormal insertion of the ureters. Knowledge of the presence and location of ectopic ureters may prevent intraoperative injury. We aim to describe the incidence and location of ectopic ureters in patients with anorectal malformations and to characterize associated renal anomalies. This is an IRB-approved retrospective study of patients with anorectal malformations and ectopic ureters identified in our colorectal database. Of 2283 patients with anorectal malformation, 79 (3.5%) had ectopic ureter(s). Of those, 29% had bilateral ectopic ureters. Nearly all (87%) of bilateral ectopic ureters occurred in females. Ectopic ureters most commonly inserted into the bladder neck (33%), vagina (15%), or urethra (13%). Renal dysfunction was noted in a high proportion of patients. The majority (59%) of ectopic ureters were associated with dysfunction of the ipsilateral kidney. Interestingly, 29% of patients with unilateral ureteral ectopia had an abnormal contralateral kidney. Only 22 patients (28%) had two normal kidneys, and 5 (6%) had documented renal failure with 2 (2.5%) requiring renal transplant. This compares to a transplant rate of 0.6% among anorectal malformation patients without ectopic ureter. The incidence of ectopic ureter is 3.5% among anorectal malformation patients. Cloaca and recto-bladder neck fistula are the types of anorectal malformation with higher incidence. Ureteral ectopia seems to confer an increased risk of renal failure. Identifying ectopic ureters is important for surgical planning and monitoring renal function vigilantly.

Over the past 15 years there has been a proliferation of projects aiming to restore the structure and function of UK upland blanket mires, primarily by revegetation of bare peat and the blocking of erosion gullies. These restoration measures have potential to alter stormflow responses and contribute to Natural Flood Management, but their impacts on storm hydrographs are poorly quantified. This paper reports a before-after-control-intervention (BACI) study from three experimental headwater micro-catchments in the South Pennines (UK) representing the first rigorous experimental assessment of the impact of blanket peat restoration on catchment runoff. We evaluate the hydrological impacts of two standard restoration interventions; revegetation of bare peat, and revegetation of bare peat with additional gully blocking. Following revegetation there was a significant decrease in depth to water table and an increase in the prevalence of hillslope overland flow production. There were no significant changes in storm runoff coefficient following either restoration treatment. Storm hydrographs following revegetation had significantly longer lag times (106% increase relative to the control), reduced peak flows (27% decrease relative to the control), and attenuated hydrograph shapes. With the addition of gully blocking the effect is almost doubled. Lag times increased by a further 94% and peak flows reduced by an additional 24% relative to the control. We argue that the primary process controlling the observed changes in storm hydrograph behaviour is retardation of overland stormflow due to increased surface roughness. The significant changes to lag times and peak flow provide evidence that the restoration of degraded headwater peatlands can contribute to Natural Flood Management and the reduction of downstream flood risk, subject to wider catchment scale effects and sub-catchment storm hydrograph synchronicity. Keywords: Flood risk management, Natural flood management, Re-vegetation, Gully blocking, Water tables, Peatland hydrology

Abstarct A 59-year-old male developed a proximal stricture of his transplant ureter ten years after a living donor renal transplant. Endoscopic management was unsuccessful, and the patient was temporized with percutaneous nephrostomy tubes for months. Eventually, it became clear he would require surgical revision. Intraoperatively, complete fibrosis of the renal hilum, and intrarenal location of the pelvis precluded the planned pyelovesicostomy. A successful open vesicocalicostomy was performed, anastomosing a bladder flap to a lower pole calix. The patient remains recurrence free after 6 months of follow-up.

Summary Background Urethral duplications are rare congenital anomalies of the urinary tract. Because of their rare occurrence, evidence about epidemiology, diagnosis and treatment is limited. Objective The aim of this study was to describe the characteristics, presentation, and treatment of a single large cohort of patients. Study design The authors describe a cohort of 19 consecutive patients with urethral duplications treated at a single referral institution over a 15-year period. Type of duplication, comorbidities, diagnosis, and treatments are described. Results 68% of the patients were male, and the age at diagnosis ranged from 0 days to 120 months. The most common type of urethral duplication in this cohort of patients was IIA-2 according to Effmann (26%). Diagnosis was made by healthcare providers in 90% and by the children's mothers in 10% of the patients. Furthermore, 10% of patients presented with urinary tract infections. Only 26% of the patients did not have associated diseases or disorders. Fifteen (79%) patients were treated surgically, with a mean number of 2 (standard deviation 1.6) surgeries per patient. Surgeries were performed ranging between 2 days and 10 years of age. Discussion The authors report one of the largest cohorts of patients with urethral duplication. There was a male preponderance, urinary tract infections were rare, and most patients had associated disorders, which is in line with previous reports. In this cohort, most duplications were discovered by healthcare providers, and a small number of patients did not undergo surgical treatment. The broad spectrum of duplications could be confirmed with type IIA-2 being the most common type. The mean number of two procedures per patient was low compared with previous reports. Download : Download high-res image (323KB) Download : Download full-size image