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Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia.Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value0.05 was considered significant.Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p0.001) and 12 h (p0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p0.001) and switched to oral opioids sooner than the epidural group (p0.001). Fewer patients in the IVPCA group required urinary catheterization (p0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p0.001). Readmission was comparable at 3.48% in the total sample.Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.

Traditional breeding techniques, applied incrementally over thousands of years, have yielded huge benefits in the characteristics of agricultural animals. This is a result of significant, measurable changes to the genomes of those animal species and breeds. Genome editing techniques may now be applied to achieve targeted DNA sequence alterations, with the potential to affect traits of interest to production of agricultural animals in just one generation. New opportunities arise to improve characteristics difficult to achieve or not amenable to traditional breeding, including disease resistance, and traits that can improve animal welfare, reduce environmental impact, or mitigate impacts of climate change. Countries and supranational institutions are in the process of defining regulatory approaches for genome edited animals and can benefit from sharing approaches and experiences to institute progressive policies in which regulatory oversight is scaled to the particular level of risk involved. To facilitate information sharing and discussion on animal biotechnology, an international community of researchers, developers, breeders, regulators, and communicators recently held a series of seven virtual workshop sessions on applications of biotechnology for animal agriculture, food and environmental safety assessment, regulatory approaches, and market and consumer acceptance. In this report, we summarize the topics presented in the workshop sessions, as well as discussions coming out of the breakout sessions. This is framed within the context of past and recent scientific and regulatory developments. This is a pivotal moment for determination of regulatory approaches and establishment of trust across the innovation through-chain, from researchers, developers, regulators, breeders, farmers through to consumers.

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Foreign Agricultural Service of the U.S. Department of Agriculture; U.S. Department of Agriculture Published version The work of author Eric M. Hallerman in this area is supported by a grant from the Foreign Agricultural Service of the U.S. Department of Agriculture. The work of author Diane Wray-Cahe is supported by the U.S. Department of Agriculture. Public domain – authored by a U.S. government employee

Few studies have investigated the effectiveness of the psychological consultation process specifically for offender managers. This study involves a total of 23 offender managers’ views and perceptions of the consultation process within four areas of the North West of England. Within each location, a focus group was conducted involving between four and eight participants and interpretative phenomenological analysis was used to analyse the responses. The analysis revealed four main themes: validation of thoughts, feelings and practice; professional support; a personal touch; and room for improvement. These findings are discussed along with implications for further research.

Marine sediments are a sink for microplastics, making seabed organisms particularly exposed. We used meta-analysis to reveal general patterns in a surge in experimental studies and to test for microplastic impact on biological processes including invertebrate feeding, survival and energetics. Using Hedge's effect size (g), which assesses the mean response of organisms exposed to microplastics compared to control groups, we found negative impacts (significant negative g values) across all life stages (overall effect size (g) = -0.57 95 % CI [-0.76, -0.38]), with embryos most strongly affected (g = -1.47 [-2.21, -0.74]). Six of seven biological process rates were negatively impacted by microplastic exposure, including development, reproduction, growth and feeding. Survival strongly decreased (g = -0.69 [-1.21, -0.17]), likely due to cumulative effects on other processes such as feeding and growth. Among feeding habits, omnivores and deposit feeders were most negatively impacted (g = -0.93 [-1.69, -0.16] and -0.92 [-1.53, -0.31], respectively). The study incorporated the first meta-analysis to contrast the effects of leachates, virgin, aged and contaminated particles. Exposure to leachates had by far the strongest negative effects (g = -0.93 [-1.35, -0.51]), showing studies of contaminants and leachates are critical to future research. Overall, our meta-analysis reveals stronger and more consistent negative impacts of microplastics on seabed invertebrates than recorded for other marine biota. Seabed invertebrates are numerous and diverse, and crucial to bottom-up processes, including nutrient remineralisation, bentho-pelagic coupling and energy transfer through the ocean food web. Marine sediments will store microplastics over long timescales. The reveal that microplastics impinge on multiple fundamental biological processes of seabed fauna implies plastic pollution could have significant and enduring effects on the functioning of the ocean.

An influential theory posits that dopaminergic neurons in the mid-brain implement a model-free reinforcement learning algorithm based on temporal difference (TD) learning. A fundamental assumption of this model is that the reward function being optimized is fixed. However, for biological creatures the ‘reward function’ can fluctuate substantially over time depending on the internal physiological state of the animal. For instance, food is rewarding when you are hungry, but not when you are satiated. While a variety of experiments have demonstrated that animals can instantly adapt their behaviour when their internal physiological state changes, under current thinking this requires model-based planning since the standard model of TD learning requires retraining from scratch if the reward function changes. Here, we propose a novel and simple extension to TD learning that allows for the zero-shot (instantaneous) generalization to changing reward functions. Mathematically, we show that if we assume the reward function is a linear combination ofreward basis vectors, and if we learn a value function for each reward basis using TD learning, then we can recover the true value function by a linear combination of these value function bases. This representational scheme allows instant and perfect generalization to any reward function in the span of the reward basis vectors as well as possesses a straightforward implementation in neural circuitry by parallelizing the standard circuitry required for TD learning. We demonstrate that our algorithm can also reproduce behavioural data on reward revaluation tasks, predict dopamine responses in the nucleus accumbens, as well as learn equally fast as successor representations while requiring much less memory.

BACKGROUND AND OBJECTIVES Premature infants are often given glycerin suppositories or enemas to facilitate meconium evacuation and the transition to enteral feeds. We reviewed the best-available evidence for the use of glycerin suppositories and enemas in premature infants. METHODS We searched MEDLINE, Embase, and Cochrane Central for randomized controlled trials (RCTs) of premature infants treated with glycerin suppositories or enemas through January 2022. Studies were screened and data extracted independently and in duplicate. We included RCTs of premature infants RESULTS We identified 6 single-center, RCTs of 389 premature infants treated with glycerin suppositories (n = 207) or enemas (n = 182). Mortality rates ranged from 0% to 17%, and the meta-analysis revealed no differences between treatment groups (P = .86). Active treatment was associated with earlier meconium evacuation (mean, 1.5 days; 95% confidence interval, 3.0 to 0.01; P = .05) but not a faster time to enteral feeds (mean, 0.5 days; P = .48). We identified 1 ongoing trial with a target recruitment of 220 premature infants. The quality of evidence was very low to moderate because of inadequate statistical power and other methodologic issues. CONCLUSIONS The use of glycerin suppositories and enemas in premature infants is associated with earlier meconium evacuation, but the clinical significance of this finding is uncertain. Treatment has no definitive effects on mortality, necrotizing enterocolitis, or enteral feeds.

Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy.We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality.We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age32 weeks, birth weight1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037).Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.

Background Sharing information about learners during training is seen as an important component supporting learner progression and relevant to patient safety. Shared information may cover topics from accommodation requirements to unprofessional behavior. The purpose of this study was to determine the views of key stakeholders on a proposed national information sharing process during the transition from undergraduate to postgraduate medical education in Canada, termed the Learner Education Handover (LEH). Method Key stakeholder groups including medical students, resident physicians, residency program directors, medical regulatory authority representatives, undergraduate medical education deans, student affairs leaders, postgraduate medical education deans participated in focus groups conducted via teleconference. Data were transcribed and coded independently by two coders, then analyzed for themes informed by principles of constructivist grounded theory. Results Sixty participants (33 males and 27 females) from 16 focus groups representing key stakeholder groups participated. Most recognized value in a national LEH that would facilitate a smooth learner transition from medical school to residency. Potential risks and benefits of the LEH were identified. Themes significant to the content, process and format of the LEH also emerged. Guiding principles of the LEH process were determined to include that it be learner-centered while supporting patient safety, resident wellness and professional behavior. The learner and representatives from their undergraduate medical education environment would each contribute to the LEH. Conclusions The LEH must advocate for the learner with respect for learner privacy, while promoting professionalism, patient safety and learner wellness.

Purpose Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). Methods A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. Results After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (± 3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. Conclusion Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. Level of evidence 2A [ 1 ].

Purpose Children with intractable constipation are often treated with antegrade continence enemas. This requires the creation of a Malone appendicostomy in the operating room or insertion of a cecostomy tube using endoscopic, radiologic, or surgical techniques. The purpose of this study was to assess the evidence regarding these procedures. Methods We conducted a search of Embase, Medline, CINAHL, and Web of Science up to October 2016. We included comparative studies of children treated with Malone appendicostomy or cecostomy tube insertion. Two reviewers screened abstracts, reviewed studies, and extracted data. Results We identified 166 children from three retrospective studies who underwent Malone appendicostomy (n=82) or cecostomy tube insertion (n=84). There were no differences in the number of patients who achieved continence (80% versus 70%, p=0.76), but the need for additional surgery was higher in children treated with Malone appendicostomy (30% versus 12%, p=0.01). Studies reported a variety of tube and stoma-related complications, but quality of life was not assessed using validated measures. Conclusion Malone appendicostomy and cecostomy tube insertion are comparable in terms of achieving continence. Children treated with Malone appendicostomy appear to be more likely to require additional surgery due to early or late complications. Level of Evidence Therapeutic, 1c.

In 2010, the Association of Faculties of Medicine of Canada, Collège des médecins du Québec, College of Family Physicians of Canada, and Royal College of Physicians and Surgeons of Canada launched the Future of Medical Education in Canada Postgraduate (FMEC PG) Project to examine postgraduate medical education (PGME) in Canada and make recommendations for improvement. One recommendation that emerged concerns the transitions learners experience across the undergraduate medical education-PGME-practice continuum. The FMEC PG, using a thorough process, developed projects to address these often-tumultuous transitions for the learner, aiming to provide support, tools, and standards for the learner's educational journey.With leadership by two senior academics and the Transitions Implementation Committee, three working groups helped implement these transitions projects, which addressed (1) the medical-school-to-residency transition, (2) career planning and the residency matching process, and (3) the residency-to-practice transition. Work products include the development of a learner education handover protocol and the establishment of pan-Canadian entrustable professional activities to be used nationally to help define expectations for new graduates entering residencies. A postmatch boot camp tool and a simulated night on-call tool were developed and are available to all medical schools. National standards are being promoted for career services counseling and best practices in residency selection. A practice management curriculum framework, mentorship resources, resiliency training for graduating residents, and the entry-level disciplines of residency are also being explored.Ultimately, with system-wide change and better integration of all players, transitions for Canada's learners will greatly improve.

Purpose Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. Methods A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. Results 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. Conclusion Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. Level of Evidence Level II, retrospective prognosis study.

In order to implement spatial fisheries management in the Arabian Gulf, a better understanding of the distribution of fish in relation to benthic habitats is required. To facilitate this, hydroacoustic fish surveys were conducted over oyster bed/reef (“shallow”) and surrounding soft sediment (“deep”) habitats in the offshore central Gulf, within Qatari waters. Transects at ‘shallow’ sites had significantly higher mean fish density and biomass. Mean target strength of individual fish was also significantly higher at ‘shallow’ sites. Fish positions in the water column were examined and overall there was a closer association with the seabed at the ‘shallow’ sites. Larger fish were found significantly closer to the seabed than smaller fish across all sites, but more so at ‘shallow’ sites than at ‘deep’ sites. Acoustic return from the seabed was extracted to provide information on the habitat type both using ‘Sonar5′ and ‘Visual Habitat’ software. The different site categories (‘shallow’ vs ‘deep’) were significantly different for all the measures of acoustic habitat. Fish density was significantly related to ‘Visual Habitat’ data, more so than depth alone. Our results show that fish distribution in the offshore Gulf is associated with complex, shallow oyster bed/reef habitats, and this is particularly the case for larger demersal fish that are commercially exploited. The ability to characterise benthic habitats from acoustic fish survey data shows promise, with important time saving implications for the monitoring of marine environments and developing a spatial approach to fisheries management. This may include the identification of habitats with a relatively high density of larger fish for inclusion in candidate marine protected areas. This document details the acoustic survey component of the collaborative project between Qatar University, Bangor University and Department of Fisheries, Ministry of Municipality and Environment, State of Qatar entitled: �Identification of Essential Fish Habitat to Achieve An Ecosystem-Based approach to Fisheries Management�. It was funded by the Qatar National Research Foundation (QNRF) NPRP 6-1680-4-027 . We would particularly like to thank Dr Bruno Giraldes for assistance in the dive surveys and also Fish Unite, Environmental Lab., Environmental Monitoring Department, Ministry of Municipality and Environment, State of Qatar. Thanks to goes to the comments provided by two anonymous reviewers whose constructive advice strengthened the manuscript considerably. Acoustic equipment was kindly provided by Echology Ltd. Appendix A Scopus

Background The failure rate on certification examinations of The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) is significantly higher for international medical graduates than for Canadian medical school graduates. The purpose of the current study was to generate evidence that supports or refutes the validity of hypotheses proposed to explain the lower success rates. Methods We conducted retrospective analyses of admissions and certification data to determine the factors associated with success of international medical graduate residents on the certification examinations. International medical graduates who entered an Ontario residency program between 2005 and 2012 and had written a certification examination by the time of the analysis (2015) were included in the study. Data available at the time of admission for each resident, including demographic characteristics, previous experiences and previous professional experiences, were collected from each of the 6 Ontario medical schools and matched with certification examination results provided by The CFPC and the RCPSC. We developed logistic regression models to determine the association of each factor with success on the examinations. Results Data for 900 residents were analyzed. The models revealed resident age to be strongly associated with performance across all examinations. Fluency in English, female sex and the Human Development Index value associated with the country of medical school training had differential associations across the examinations. Interpretation The findings should contribute to an improved understanding of certification success by international medical graduates, help residency programs identify at-risk residents and underpin the development of specific educational and remedial interventions. In considering the results, it should be kept in mind that some variables are not amenable to changes in selection criteria.

As with many other regions in the world, more complete information on the distribution of marine habitats in the Gulf is required to inform environmental policy, and spatial management of fisheries resources will require better understanding of the relationships between habitat and fish communities. Towed cameras and sediment grabs were used to investigate benthic habitats and associated epifauna, infauna and fish communities in the central Gulf, offshore from the east coast of Qatar, in water depths of between 12 and 52 m. Six different habitats were identified: (i) soft sediment habitats of mud and (ii) sand, and structured habitats of (iii) macro-algal reef, (iv) coral reef, (v) mixed reef, and (vi) oyster bed. The epibenthic community assemblage of the mud habitat was significantly different to that of sand, which in turn differed from the structured habitats of coral reef, mixed reef and oyster bed, with the macroalgal assemblage having similarities to both sand and the other structured habitats. Fish assemblages derived from video data did not differ between habitats, although certain species were only associated with particular habitats. Epibenthic diversity indices were significantly lower in mud, sand and macro-algal habitats, with no differences recorded for fish diversity. Soft sediment grab samples indicated that mud habitats had the highest benthic diversity, with Shannon-Weiner values of >4, and were more diverse than sand with values of 3.3. The study demonstrates high biodiversity in benthic habitats in the central and southwestern Gulf, which may in part be due to the absence of trawling activity in Qatari waters. There is a strong influence of depth on benthic habitat type, so that depth can be used to predict habitat distribution with a high level of accuracy. The presence of outcrops of hard substrata creates a mosaic of patchy shallow structured benthic habitat across extensive areas of the offshore seabed. Such heterogeneity, and the association of commercially exploited fish species with specific habitats, indicates that this region is well suited to a spatial approach to fisheries management.

Background Residents are being asked to perform educator roles such as curriculum design and learner assessment with minimal professional development in leadership or medical education. The Multidisciplinary Academic Day (MAD) planning committee is a resident-led initiative responsible for delivering combined educational half-day sessions and workshops for all residents at McMaster University. Objective We sought to determine the impact participation in MAD planning committee had on residents' professional development and career goals. Methods We conducted a program evaluation survey of 19 of 30 (63.3%) current and former committee members to determine how the MAD planning committee’s alumni perceived its usefulness, and how participation affected their professional development. Results Residents cited a desire to gain medical education experience, learn about event planning and management, and improve resident education as reasons for joining the committee; 89.5% of respondents felt they had met these goals. Experience on the committee included skills related to curriculum design, developing needs assessments and programmatic evaluation. Many residents felt it helped them acquire leadership skills such as decision-making, idea generation, delegation, and public speaking. Several noted that it had sparked an interest in medical education as part of an academic career, and one former member subsequently pursued a Master’s of Education. The majority of the respondents (78.9%) felt it was helpful for their careers and 94.7% would recommend this experience to others interested in leadership and medical education. Conclusion Involvement in the MAD planning committee is a highly useful way for residents to acquire leadership skills, develop an interest in medical education and work in a multidisciplinary team.

Purpose Mucous fistula (MF) refeeding of proximal stoma effluent in neonates after small bowel resection can promote nutrient absorption and prevent atrophy of the unused distal bowel. This study aimed to assess the safety of this practice in neonates. Methods A retrospective chart review of all patients admitted to the neonatal intensive care unit (NICU) between 2009 and 2015 who underwent a laparotomy with creation of an enterostomy and mucous fistula was performed. Patients were included if they were refed proximal stoma effluent into the MF. Results Thirty-one patients were identified that were refed. There were no major complications (perforation, stricture, death) related to refeeding. Patients were refed for an average of 41 days (± 22), with patients gaining an average of 25.7 g/day (± 10.1) while being refed. Total parental nutrition (TPN) was administered for an average of 55 days (± 31.4) between resection and reanastomosis, with only 7 (23%) developing cholestasis and 15 (48%) reaching full feeds in this time. Mean time to full feeds after reanastomosis was 36 days (± 58.6) with two patients having anastomotic leaks. Conclusion MF refeeding is a safe technique that has the potential to contribute to significant weight gain and a decreased dependence on total parenteral nutrition. Level of evidence II

Background Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. Methods Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. Results We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000–2013, n =195), Children's Hospital, London Health Sciences Centre (2009–2013, n =39), and McMaster Children's Hospital (2007–2014, n =80). Median length of stay was 11days (range 5–69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. Conclusions Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

Central venous access device (CVAD) insertion is one of the most common procedures performed on paediatric haemophilia patients. There are no clear guidelines outlining the optimal dosing schedule of factor VIII (FVIII) and duration of treatment required to achieve adequate haemostasis during and after surgery. In this article, we describe the experience at McMaster Children's Hospital using FVIII replacement therapy in 15 children with severe haemophilia A during the course of 7 years. This is a retrospective institutional chart review. Patients between 0 and 18 years of age with severe haemophilia A that underwent CVAD insertion at McMaster Children's Hospital in Hamilton, Ontario, from 2004 to 2010, were identified and charts were reviewed. A total of 15 CVAD insertion surgeries were reviewed. The total average preoperative dose of FVIII was 93.5 IU/kg (range: 53.7-145.4 IU/kg). The total average postoperative dose was 818.7 IU/kg (range: 441-1258 IU/kg). The total perioperative dose was 912.2 IU/kg (range: 495.2-1349 IU/kg). The current study attempts to describe the experience at McMaster Children's Hospital for CVAD insertion surgeries, the average factor dose administered has decreased during the years. These results may be of help in the development of optimal treatment schedules.

Trichocorixa verticalis verticalis, a North American water boatman, is the only alien corixid in European fresh waters. It has rapidly spread, becoming the dominant corixid in and around the Doñana protected area in SW Spain. Its high abundance and similar morphology to native corixids suggest that T. verticalis may impact them through competition for food. Here we used stable isotopes of nitrogen (N) and carbon (C) and Bayesian analytical tools to investigate niche partitioning between T. verticalis and the native water boatman Sigara lateralis and Sigara scripta through a combination of experimental and field data. Species sampled from permanent ponds and laboratory aquaria could be separated based on their isotopic values (δ15N and δ13C). S. lateralis consistently showed higher δ15N values than T. verticalis, suggesting that the invasive species may be feeding at a lower trophic position and relying more on herbivory than its native competitors. This was particularly true for the T. verticalis nymph stage, which showed lower δ15N values compared to adults, indicating ontogenetic dietary shifts. In contrast, native corixids and the invasive species showed similar isotopic compositions in temporary habitats at different stages in the flooding-desiccation cycle, suggesting some degree of niche overlap and a slight reduction in trophic level for S. lateralis when inhabiting ephemeral systems. The combination of experimental and field data can help elucidate trophic interactions during a biological invasion. Stable isotopes provided insights into the trophic ecology of this invasive species and into the mechanisms facilitating co-existence with native species

We report the case of a 4-year-old girl who presented to the emergency department after ingestion of a nickel-plated coin. Abdominal radiographs confirmed the presence of a coin in her stomach but she was otherwise asymptomatic. She was discharged with assurances that the foreign body would pass spontaneously. The patient developed significant generalised urticaria the next day, which became progressively more severe. Her symptoms prompted endoscopic removal of the nickel-plated coin and a postoperative course of corticosteroids and antihistamine therapy. This is the first reported case of generalised urticaria secondary to ingestion of a coin with nickel plating only (2% nickel content overall). A review of similar cases is provided.

For most people, the report of the birth of Dolly the sheep in 1996 was their first inclination that cloning animals was not science fiction. Dolly’s arrival was both a seminal moment in the science of reproduction and another step in the evolution of Advanced Reproduction Technologies (ART) in livestock. Somatic cell nuclear transfer (SCNT, aka “cloning”), the process that led to Dolly, is a form of ART that results in exact genetic copies of the donor animal. Livestock produced through cloning are no different than any other animal, and livestock products, e.g., meat and milk, from cloned animals, were found by regulators from Europe, Japan, and the United States to be identical to products from conventional animals. Companies in China, Australia, South America, and the United States provide cloning services to livestock producers and breeders. Cost, burdensome regulatory processes, and public antipathy, especially in Europe, have limited the impact of cloning.

Introduction: Transitions are traditionally viewed as challenging for clinicians. Throughout medical career pathways, clinicians need to successfully navigate successive transitions as they become progressively more independent practitioners. In these guidelines, we aim to synthesize the evidence from the literature to provide guidance for supporting clinicians in their development of independence, and highlight areas for further research. Methods: Drawing upon D3 method guidance, four key themes universal to medical career transitions and progressive independence were identified by all authors through discussion and consensus from our own experience and expertise: workplace learning, independence and responsibility, mentoring and coaching, and patient perspectives. A scoping review of the literature was conducted using Medline database searches in addition to the authors’ personal archives and reference snowballing searches. Results: 387 articles were identified and screened. 210 were excluded as not relevant to medical transitions (50 at title screen; 160 at abstract screen). 177 full-text articles were assessed for eligibility; a further 107 were rejected (97 did not include career transitions in their study design; 10 were review articles; the primary references of these were screened for inclusion). 70 articles were included of which 60 provided extractable data for the final qualitative synthesis. Across the four key themes, seven do’s, two don’ts and seven don’t knows were identified, and the strength of evidence was graded for each of these recommendations. Conclusion: The two strongest messages arising from current literature are first, transitions should not be viewed as one moment in time: career trajectories are a continuum with valuable opportunities for personal and professional development throughout. Second, learning needs to be embedded in practice and learners provided with authentic and meaningful learning opportunities. In this paper, we propose evidence-based guidelines aimed at facilitating such transitions through the fostering of progressive independence.

© 2015 Elsevier B.V. The lack of space and opportunity for development has been identified as key reasons behind the stagnation of the European aquaculture industry. With the historical loss and degradation of current European wetlands there is an opportunity for harnessing the commercial investment of the aquaculture industry in construction of dual purpose wetlands that incorporate both conservation and extensive aquaculture activities. These wetlands can be used to expand the area available to suitable aquaculture into ecologically sensitive areas, such as Natura 2000 sites. Veta la Palma (VLP) situated in the Doñana Natural Park (and a Natura 2000 site) is an example of such an aquaculture development and a possible model for future opportunities. In the current study some of the important ecosystem services that are provided by VLP are assessed. The provisioning services of VLP were the economic rationale for the investment and more than 820tonnesyr-1 of fish and shrimp is produced, through a mixture of semi-extensive and extensive aquaculture. The regulating services include nutrient absorption, and the flow of river water through VLP and high primary production results in the absorption of 377tonnes of dissolved inorganic nitrogen yr-1, and 516tonnes of Cyr-1. Supporting services include the provision of habitat for more than 94 bird and 21 fish species. The primary production that supports the birds, extensive and semi-extensive aquaculture production was also estimated to be 167,000tonnes, 50,000tonnes and 133,000tonnesyr-1, respectively. The losses to birds are substantial and these estimates indicate that almost half of the primary production supports the wetland birds which directly consume 249tonnes of fish and 2578tonnes of invertebrates per annum. However it is the ecological credentials of the farm that enable premium prices and hence ensure the economic viability of the farm. The study demonstrates the possibility of using aquaculture to mitigate the historical loss of wetlands, provide significant ecosystem services and contribute to achievement of the European environmental legislative goals, and furthers the opportunity for the expansion of aquaculture into sensitive but impacted habitats.

Offspring size variation in relation to maternal size and season is characteristic of a range of species living in seasonal environments. Little is known about the proximate mechanisms explaining the links between maternally driven variation in offspring phenotypes, for instance when mothers have different diets depending on their size or the season. Here, we use stable isotopes techniques to quantify size dependent and seasonal variations in diet in mothers of shrimp Palaemon serratus and explore possible links between maternal diet and phenotype of embryos and freshly hatched larvae. We found that larger females, which occur more frequently in winter, produce larvae with higher carbon and nitrogen content as well as higher percent carbon, than smaller mothers collected in winter. In addition, isotopic composition suggest that larger mothers collected in winter, were feeding at a higher trophic level, or on an enriched prey pool compared with smaller mothers collected in summer. Overall, there seems to be a strong association between offspring size and maternal diet, mediated by maternal size and/or season.

Dieulafoy’s lesion is a rare cause of severe upper gastrointestinal hemorrhage in children. This lesion most often occurs in the proximal part of the stomach. We report a case of massive upper gastrointestinal (GI) bleeding in a 16-year-old male originating from Dieulafoy’s lesion in the third part of the duodenum. Esophageal gastric duodenal endoscopy and angiography failed, and surgical intervention was required.

Mangrove forest productivity is normally sustained by nutrients from terrestrial runoff, with freshwater inputs driving the resulting outwelling of production, but arid mangroves lack this input. The movement of material between seagrass beds and mangroves was examined using the stable C and N isotopic composition of organisms, sediments and suspended matter in 3 seagrass-mangrove transects in the Arabian Gulf. The isotopic signal of suspended particulate material indicated a mixed origin that did not differ over a spring tide. Filter feeders showed significant 13C enrichment along transects from mangrove forests into seagrass beds, indicating that location within a habitat had a significant effect on isotopic composition. Similarly, 13C of both sediments and grazers increased sharply outside the mangrove forest, suggesting retention of mangrove carbon, although some outwelling was detected, the strength of which was site specific. The lack of freshwater-mediated nutrient inputs suggests any outwelling of mangrove ecosystem productivity must be balanced by inwelling, and isotopic signatures of both sediment grazers and filter feeders found within the mangrove forest confirmed the inwelling of seagrass production. Significant mangrove isotope signals in the tissue of juveniles of fishes commercially harvested offshore indicate ontogenetic movement of carbon. Additional biological movement of mangrove carbon through ontogenetic migration and 'trophic relay' is evidenced by the isotopic signature of juvenile and mature fish captured in waters exiting the mangrove forest, which indicated they fed on mangrove-sustained food webs. This study demonstrates tight coupling between arid mangroves and subtidal seagrass areas and implies that arid mangroves cannot be managed or replanted without consideration of connectivity to downstream systems such as seagrasses. Scopus

The Arabian Gulf represents one of the more northerly extremes of mangrove distribution in the Indo-Pacific, and is populated only by Avicennia marina , due to its tolerance of high salinity and wide temperature extremes. Recent studies suggest that in the arid coastal environment of the western Arabian Gulf, export of carbon and nitrogen from mangroves to adjacent habitats may be limited, though it is not clear if this is due to low productivity or physical factors such as the lack of freshwater flow and the tidal regime. Although seagrass and macroalgal habitats are relatively much more dominant by area, with only small pockets of mangrove around the edges of embayments, it is not evident if inwelling from these habitats support mangrove fauna. Year-round sampling in mangroves at Al-Khor, Qatar, indicates that Palaemon khori , an endemic shrimp species, is strongly associated with mangroves throughout its post-settlement life cycle, from recruitment as small 9–10 mm juveniles through to mating and egg production. Rapid post-recruitment growth ( k = 1.8, L ∞ = 42 mm for females, k = 1.5, L ∞ = 35 mm for male) means that most individuals reached adult size in the first few months after settlement, with reproduction occurring in the following spring. As might be expected from year-round residence in the mangrove, dual 13 C and 15 N isotope analysis indicated a strong contribution of mangroves to shrimp tissue growth (Mean and 95% confidence range, 37% and 27–48%), but with a weaker significant contribution from particulate organic matter (20% and 1–37%), mangrove epiphytes (16% and 2–33%) and seagrasses (9% and 0.2–18%). Other primary producers contribute the remaining 18% to shrimp nutrition but the 95% confidence ranges include zero, suggesting possibly non-significant roles in supporting the shrimp population. This dietary information supports the view that fauna resident within arid mangrove systems are mainly dependent on localised retention and cycling of nutrients with a smaller contribution from inwelling.

Introduction While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. Methods A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2weeks, 3, 6, 9, and 12months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). Results A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57–3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12months. Conclusion Gastrostomy not only improves the child's physical health, but also improves the mental health of the child's caregivers, especially at (or after) one year.

Central venous catheter (CVC) placement is associated with increased risk of thrombosis in the paediatric population, particularly in relation to the type of catheter and the manner of its insertion. Here, we investigate risk factors associated with CVC-related thrombosis in children, with particular emphasis on positioning of the catheter tip. Patients aged 0-18 who underwent at least one CVC placement from 2008 to 2013 at a single centre with a subsequent follow-up echocardiogram were included for a total of 104 patients and 147 lines. Data on clinical and catheter-related risk factors were collected from patient charts. Statistical analysis using Pearson's χ tests, independent samples t-test, and odds ratios were used to assess potential risk factors for thrombosis. Neither insertion site (subclavian vein or otherwise), left- vs. right-sided insertion, nor catheter type were significant risk factors for thrombosis. There were no thrombotic events reported at the superior vena cava (SVC)-right atrium junction and no significant differences in thrombotic risk with initial tip placement in the SVC-right atrium junction vs. the SVC, right atrium, or inferior vena cava. Acute lymphoblastic leukaemia was a major clinical risk factor for thrombosis. Tip movement was common and may have been an important factor in the development of CVC-related thrombi. Prospective studies can yield insight into the role of follow-up imaging in the prevention of catheter-related thrombosis in children.

Seagrass beds form an important part of the coastal ecosystem in many parts of the world but are very sensitive to anthropogenic nutrient increases. In the last decades, stable isotopes have been used as tracers of anthropogenic nutrient sources and to distinguish these impacts from natural environmental change, as well as in the identification of food sources in isotopic food web reconstruction. Thus, it is important to establish the extent of natural variations on the stable isotope composition of seagrass, validating their ability to act as both tracers�of nutrients and food sources. Around the world, depending on the seagrass species and ecosystem, values of seagrass N normally vary from 0 to 8 ? ?15N. In this study, highly unusual seagrass N isotope values were observed on the east coast of Qatar, with significant spatial variation over a scale of a few metres, and with ?15N values ranging from +2.95 to ?12.39 ? within a single bay during March 2012. This pattern of variation was consistent over a period of a year although there was a seasonal effect on the seagrass ?15N values. Seagrass, water column and sediment nutrient profiles were not correlated with seagrass ?15N values and neither were longer-term indicators of nutrient limitation such as seagrass biomass and height. Sediment ?15N values were correlated with Halodule uninervis ?15N values and this, together with the small spatial scale of variation, suggest that localised sediment processes may be responsible for the extreme isotopic values. Consistent differences in sediment to plant 15N discrimination between seagrass species also suggest that species-specific nutrient uptake mechanisms contribute to the observed ?15N values. This study reports some of the most extreme, negative ?15N values ever noted for seagrass (as low as ?12.4 ?) and some of the most highly spatially variable (values varied over 15.4 ? in a relatively small area of only 655�ha). These results are widely relevant, as they demonstrate the need for adequate spatial and temporal sampling when working with N stable isotopes to identify food sources in food web studies or as tracers of anthropogenic nutrients. Scopus

Penaeid shrimp can be useful ecological indicators of linkages between shallow tropical coastal habitats, acting as integrators of carbon and nitrogen sources due to their generalist feeding habits and their mobility between habitats and with tidal cycles. In the current study, the contribution of mangrove, seagrass and microbial mat to the nutrition of two penaeid shrimp species, Penaeus semisulcatus and Metapeneus ensis, in a shallow arid embayment in the Arabian Gulf was assessed through a combination of analysis of stomach contents and dual carbon and nitrogen stable isotope signatures. Shrimp tissue stable isotope signatures identified seagrass as a major source of carbon and nitrogen for both species, contributing 21–38 % (1–99 ‰). Microbial mat was also detected as a significant nutritional source for early-stage Metapenaeus affinis postlarvae (1–27 %). However, mangroves were not identified as a significant source, with the range of results including the possibility of a zero contribution. Moreover, the greatest possible contribution of mangroves as source of carbon was less than for the other primary producers. This may be due the high salinity and wide temperature range limiting mangrove productivity as well as the low export of dissolved and particulate organic material out of the mangroves due to low rainfall.

Small-scale fisheries are an important element of the ecosystem goods and services that mangrove habitats provide, especially to poorer coastal communities that rely most on natural resources, and have similar values to payments for ecosystem services (PES) under carbon-trading schemes. In advance of fishery-enhancement trials for the mud crab Scylla olivacea, a mark–recapture study was conducted to estimate population size and turnover in 50 ha of isolated mangrove on Panay Island, Philippines. A total of 811 crabs were released in six sessions with an overall recapture rate of 41.5 ± 3.6%. Population size ranged from 607–1637 individuals. There was a high degree of site-fidelity, with 45.5% of recaptures in the same sampling areas as releases. Total mortality was 0.79 month-1, with fishing mortality accounting for 95% of overall mortality. Von Bertalanffy and Gompertz growth models yielded estimates for L∞ (carapace width) of 117.3 ± 14.7 and 110.6 ± 2.1 mm and for k of 2.16 ± 0.74 and 3.25 ± 0.81, respectively. Crab densities of 12–33 individuals ha-1 in the study area were lower than in other mangrove systems owing to intermittent recruitment, while growth rates indicated no limitation in terms of food supply. The study demonstrates that in specific mangrove habitats that are below carrying capacity, there is potential for fisheries enhancement to sustain or increase direct economic benefits from mangrove ecosystems and hence promote community engagement in broader conservation and PES initiatives. Copyright © 2012 John Wiley & Sons, Ltd.

This study, employing contingent behavior approach, examines the benefits of improving water quality in the largest remaining tidal flat in South Korea. The southern tidal flat of Ganghwa Island, a major stopping point for significant numbers of migratory birds on the Austral-Asian flyway, draws thousands of visitors every month. However, the current water quality, degraded due to pollution, negatively affects ecosystem services that the tidal flat provides for many creatures, including the last remaining populations of endangered black-faced spoonbill. Questionnaire surveys targeting visitors to the tidal flat have been conducted in 2009. Application of the negative binomial model has indicated that the total recreational value of the tidal flat is approximately 11.2 billion Korean won (KRW) per year. The annual benefits of improving the water quality by introducing sewage-treatment plants are estimated as KRW 13.4 billion, while the costs of constructing and operating the plants account for less than 3% of the benefits. There is a strong economic justification for investing in the plants to improve the water quality. These findings are useful for policymakers to positively consider public spending in the tidal flat conservation.

A thematic analysis was conducted to explore the Complex Case Consultation Forums within Lancashire Care NHS Trust. The main themes were the nature of difficulties staff experience working with complex clients, staff anxiety and frustration and recommendations of care made by the forum.

This paper describes the various stages of the design and completion of the 45-storey Strata SE1 tower housing a wind generator in the Elephant and Castle district in south London, UK. At nearly 150 m above street level, the roofline incorporates three 9 m diameter wind turbines, estimated to generate 8% of the building's energy consumption. The landmark tower is the first building in the world to have integrated wind turbines, setting a benchmark for innovation and sustainable design.

This case study outlines key considerations for healthcare organizations experiencing significant transformational change, based on the experience of Ontario Shores Centre for Mental Health Sciences (Ontario Shores), formerly Whitby Mental Health Centre. Significant systemic change requires specific and intentional efforts from the leaders tasked with carrying out transformational activities. This article presents the perspectives of leaders involved in the transformation of Ontario Shores as it moved from a government-based agency to a stand-alone specialty psychiatric hospital in 2006. During this time, several conventional strategies were employed to manage the transition, but various critical approaches also emerged that assisted the organization to effect significant change and achieve marked improvements over key evaluation metrics. These critical strategies included maximizing the distinct and collective roles of governance and leadership; balancing strategy and action through a culture of accountability; leveraging strategic communication opportunities; and shifting the organizational mindset.

Background: Many patients who experience bulimia nervosa (BN) and binge eating disorder (BED) find it hard to access evidence-based treatments. Rates of failure to enter outpatient services following initial assessment are high, as are dropout rates from specialist outpatient eating disorders services. Aims: To offer CD-Rom CBT, a cognitive-behavioural multi-media supported self-help treatment, in a locality-based outpatient NHS Eating Disorders Service to patients who have binge eating disorder and bulimia nervosa. Method: Patients referred to a catchment-based NHS outpatient eating disorders service who were assessed and had an eating disorder with a binge-eating component were offered CD-Rom based CBT (Overcoming Bulimia) whilst on the waiting list for individual CBT. Results: Forty patients completed the 8 sessions and attended the evaluation appointment (13 had BN, 27 had BED). For both groups, there were significant improvements in well-being and functioning, as well as significant reductions in problems and risk. There was also a significant reduction on the “Bulimic Subscale” of the EDI. These results were comparable with the original study findings (Schmidt, Treasure and Williams, 2001). Dropouts from the CD-Rom reflected rates common to other EDS treatments suggesting that CD-Rom did not directly impact upon service dropout rates. Conclusions: Computer assisted CBT for Eating Disorders offers a promising, feasible and acceptable first step for patients who have bulimia nervosa or binge eating disorder and access treatment from specialist eating disorders services.

Yellow Sea tidal flats are internationally recognised for their contribution to biological diversity and yet are under enormous pressure from reclamation, pollution and overexploitation. The benthic macroinfauna community is the dominant community on these tidal flats and a reliable indicator of benthic environmental changes. We surveyed the current benthic macroinfauna community of the Ganghwa Southern Tidal Flat, the largest remaining Korean mud flat in the Yellow Sea, in order to examine changes in the environmental situation of this benthic ecosystem. The results show a significant decline in species diversity from the last survey made in 2003, and a shift in species composition with appearances of polychaetes indicative of pollution and physical disturbances and other opportunistic species becoming dominant in both density and biomass. The benthic community shift observed during the two study periods may be associated with increased nutrient pollution as well as increased physical disturbances in this area. However, we recognise the limitations of the data both in frequency and scope but believe the significant changes to the composition of the benthic fauna are sufficient to warrant concern. Observations are required to examine the extent to which these human activities induce benthic community shift in this tidal flat.