Climate adaptation for rural water and sanitation systems in the Solomon Islands: A community scale systems model for decision support

Delivering water and sanitation services are challenging in data poor rural settings in developing countries. In this paper we develop a Bayesian Belief Network model that supports decision making to increase the availability of safe drinking water in five flood-prone rural communities in the Solomon Islands. We collected quantitative household survey data and qualitative cultural and environmental knowledge through community focus group discussions. We combined these data to develop our model, which simulates the state of eight water sources and ten sanitation types and how they are affected by season and extreme events. We identify how climate and current practices can threaten the availability of drinking water for remote communities. Modelling of climate and intervention scenarios indicate that water security could be best enhanced through increased rainwater harvesting (assuming proper installation and maintenance). These findings highlight how a systems model can identify links between and improve understanding of water and sanitation, community behaviour, and the impacts of extreme events. The resultant BBN provides a tool for decision support to enhance opportunities for climate resilient water and sanitation service provision.

Chronic neutrophilic leukemia: 2020 update on diagnosis, molecular genetics, prognosis, and management

DISEASE OVERVIEW

Chronic neutrophilic leukemia (CNL) is a rare, often aggressive myeloproliferative neoplasm (MPN) defined by persistent mature neutrophilic leukocytosis, bone marrow granulocyte hyperplasia, and frequent hepatosplenomegaly. The seminal discovery of oncogenic driver mutations in colony-stimulating factor 3 receptor (CSF3R) in the majority of patients with CNL in 2013 anchored a new scientific framework, deepening our understanding of its molecular pathogenesis, providing a diagnostic biomarker, and rationalizing the use of pharmacological targeting.

DIAGNOSTIC CRITERIA

In 2016, the World Health Organization (WHO) included the presence of activating CSF3R mutations as a central diagnostic feature of CNL. Other criteria include leukocytosis of ≥25 × 10⁹ /L comprising >80% neutrophils with <10% circulating precursors and rare blasts, and absence of dysplasia or monocytosis, while not fulfilling criteria for other MPN.

DISEASE UPDATES

Increasingly comprehensive genetic profiling of CNL has disclosed a complex genomic landscape and additional prognostically relevant mutational combinations. Though prognostic determination and therapeutic decision-making remain challenging, emerging data on prognostic markers and the use of newer therapeutic agents, such as JAK inhibitors, are helping to define state-of-the-art management in CNL.

Using consensus methods to develop a Social Prescribing Learning Needs Framework for practitioners in Wales

Aims:

Social prescribing is being widely implemented in Wales, but there is no consensus on the necessary learning, training and education needs for people delivering social prescribing. The purpose of the study was to develop an education and training needs conceptual framework for social prescribers in Wales, which could be used by commissioners and providers for the development of social prescribing curricula.

Methods:

This study used two consensus methods. First, Group Concept Mapping using Concept Systems Global MaxTM software which identified the important and available learning needs of 18 ( n = 18) geographically spread social prescribing practitioners. Second, a world café style workshop asked 85 ( n = 85) social prescribers to identify when training and support would be most appropriate and valuable in developing their role and skills.

Results:

A Social Prescribing Learning Needs Framework was developed identifying important learning needs and their availability across a timeline from induction onwards. This was conceptualised from a group concept mapping cluster map and go-zone report. The map comprises five clusters of statements (compassion, interpersonal relationships, socioeconomic disadvantage, networking and monitoring data) from the original 120 statements of learning needs identified by participants. The Go-Zone report displayed how each learning need was rated by participants on scales of importance and availability. A large number of training needs (45%) that were identified as important, are not currently available to social prescribers. All training needs were placed within the first year of the social prescriber working timeline, with 39% placed in an induction period.

Conclusion:

The use of two different consensus methods enabled social prescribers geographically spread across Wales to engage with the study. The Social Prescribing Learning Needs Framework will be used to inform the commissioning and decommissioning of training for people delivering social prescribing in Wales.

Clinical outcome of patients diagnosed with myelodysplastic syndrome-unclassifiable (MDS-U): single center experience

Myelodysplastic syndrome unclassifiable (MDS-U) is a small subtype of myelodysplastic syndromes (MDS). However, rare literature exists in terms of natural progression and clinical outcome of patients with MDS-U. In the present study, we investigated the characteristics and the clinical outcomes of patients categorized as MDS-U based on 2008 World Health Organization criteria (WHO) in a single center comparing to other MDS groups. Out of eight hundred and two patients who met WHO criteria for MDS at our institution, ninety patients (11%) were initially classified as MDS-U. Upon pathological review, only half of the cases were confirmed to be MDS-U. With follow up, half of the MDS-U cases were reclassified to another subtype. We found neither significant difference in median overall survival nor in risk of transformation to acute myeloid leukemia when comparing MDS-U to other MDS groups. Additional larger studies are needed to confirm our results.

Oil and gas infrastructure decommissioning in marine protected areas: System complexity, analysis and challenges

Many offshore oil and gas production facilities are nearing the end of their operational life, with decommissioning now becoming a global challenge. The compatibility of decommissioning operations to marine protected areas (MPAs) creates further challenges. The recently-developed DAPSI(W)R(M) problem structuring framework (covering Drivers, Activities, Pressures, State changes, Impacts (on Welfare) and Responses (as Measures)) was applied here to interrogate the complexity of decommissioning oil and gas infrastructure within MPAs, with outputs feeding into the development of a novel database tool for Screening Potential Impacts of Decommissioning Activities (SPIDA). In meeting the current requirements of the marine regulatory regime, SPIDA provides a more streamlined, evidence-based process which can be applied by industry, statutory nature conservation bodies and regulators for identifying and evaluating evidence that supports the implications of decommissioning alternatives on the condition of MPAs. SPIDA has been developed to be adapted for other activities and sectors, including offshore renewables.

Is less more? Assessing the utility of early clinical and radiographic follow-up for operative supracondylar humerus fractures

PURPOSE

Postoperative protocols following surgical management of supracondylar humerus fractures (SCFs) are often based upon surgeon preference rather than clinical merit. The purpose of this study is to determine the utility of early clinical and radiographic follow-up.

METHODS

A retrospective review of patients who underwent closed reduction and percutaneous pinning (CRPP) for SCF between 2009 and 2015 was performed using a database of prospectively-collected consecutive patient data. Previously undiagnosed neuropathies documented at the first postoperative visit were identified. Unscheduled visits and postoperative complications were compared between patients who were seen at one week and those with delayed first clinic visits.

RESULTS

Of 873 patients, 823 (94.3%) were seen within ten days of surgery (early follow-up) and 50 (5.7%) had a delayed first clinic appointment. Among patients seen for early follow-up, 12 (1.5%) had a previously undocumented neuropathy diagnosed but only eight (1%) had an alteration of management secondary to clinical findings. Greater than 90% of patients seen for early follow-up had radiographs performed, but only one had an alteration in management due to radiographic findings. Patients seen for early follow-up had the same rate of unscheduled visits (2.9% versus 4%, p = 0.66) and postoperative complications (1.6% versus 0%, p > 0.99) as those with delayed first appointments. Radiographic parameters were comparable at final follow-up (Baumann's angle 74.5° versus 73.7°, p = 0.40; lateral humeral condylar angle 40.2° versus 41.2°, p = 0.53).

CONCLUSION

The early follow-up visit after CRPP of SCF rarely leads to alterations in care and does not reduce unscheduled visits or late complications.

LEVEL OF EVIDENCE

Level IV.

Pre-operative neutrophil count and neutrophil-lymphocyte count ratio (NLCR) in predicting the histological grade of paediatric brain tumours: a preliminary study

INTRODUCTION

The neutrophil-lymphocyte count ratio (NLCR) is an established prognostic marker for renal, lung and colorectal carcinomas and has been suggested to be predictive of histological grade and outcome in adult intracranial tumours. The purpose of this study was to determine whether a correlation of the pre-operative neutrophil count (NC) and NLCR with the final histological grade exists in paediatric intracranial tumours.

METHODS

A retrospective analysis was undertaken at a single centre. Patients less than 18 years old at the time of surgery who underwent tumour-related procedures from 2006 to 2015 were included. Patients with recurrent tumours, previous bone marrow transplant and metastases were excluded. Pre-operative full blood counts (FBC), collected before the diagnosis of intracranial pathology and before administration of steroids, were matched with histological diagnosis for each patient. Post-operative FBC was also recorded, together with survival data where applicable.

RESULTS

A total of 116 patients (74 male, 42 female; mean age, 8 ± 0.9 years) with a diagnosis of primary intracranial tumours had pre-operative FBC that could be matched to final histological grade. Pre-operative NC and NLCR were higher with increasing grade of tumour: grade 1 (NC 4.29 10⁹/l, NLCR 2.26), grade 2 (NC 4.59 10⁹/l, NLCR 2.38), grade 3 (NC 5.67 10⁹/l, NLCR 2.72) and grade 4 (NC 6.59 10⁹/l, NLCR 3.31). Patients with WHO grade 1 and 2 tumours pooled together had a lower NC (4.37 95% CI ± 0.67 10⁹/l) compared to WHO grade 3 and 4 patients (6.41 95% CI ± 0.99 10⁹/l, p = 0.0013). The NLCR was lower in grade 1 and 2 tumours (2.29 ± 0.59) (compared to grade 3 and 4 tumours; 3.20 ± 0.76) but this did not reach significance (p = 0.069). The subgroup of patients with pilocytic astrocytoma had a significantly lower NC when compared to patients with high-grade tumours (p = 0.005). Medulloblastoma and supratentorial PNET subgroups had significantly higher NC compared to the low-grade group (p = 0.033, p = 0.002). Post-operative NC was significantly higher in the high-grade tumours (p = 0.034), but no difference was observed for NLCR (p = 0.28).

CONCLUSIONS

No evidence exists to support the correlation of pre-operative NC or NLCR to histological diagnosis in paediatric intracranial tumours. Our results indicate that a higher pre-operative NC/NLCR correlates with a higher histological grade of tumour. This suggests that immunological mechanisms may be involved in the pathogenesis of paediatric brain tumours, and a further prospective study is required to substantiate and expand these findings.

The in vitro detection of botulinum neurotoxin-cleaved endogenous VAMP is epitope-dependent

The in vitro potency of botulinum neurotoxin (BoNT) serotypes is often measured by monitoring cleavage of their soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) protein substrates. A frequently used method is Western blot, whereby the full-length protein and cleaved form migrate at different molecular weights. Until now, it has been extremely difficult to detect the cleaved cellular form of the SNARE protein vesicle associated membrane protein 1, 2 or 3 (VAMP1, 2 or 3) by Western blot. These VAMP isoforms are the substrates of BoNT serotypes BoNT/B, D, F and G as well as tetanus neurotoxin. Using custom made anti-VAMP antibodies against epitopes either side of the cleavage sites for BoNT/B, BoNT/D and BoNT/F, we have successfully detected the cleaved C-terminal VAMP fragment in cortical neurons. These new antibodies enable quantitative assessment of the potency of VAMP-cleaving neurotoxins by a gain of signal Western blot assay.

Development and application of a machine learning algorithm for classification of elasmobranch behaviour from accelerometry data

Discerning behaviours of free-ranging animals allows for quantification of their activity budget, providing important insight into ecology. Over recent years, accelerometers have been used to unveil the cryptic lives of animals. The increased ability of accelerometers to store large quantities of high resolution data has prompted a need for automated behavioural classification. We assessed the performance of several machine learning (ML) classifiers to discern five behaviours performed by accelerometer-equipped juvenile lemon sharks (Negaprion brevirostris) at Bimini, Bahamas (25°44'N, 79°16'W). The sharks were observed to exhibit chafing, burst swimming, headshaking, resting and swimming in a semi-captive environment and these observations were used to ground-truth data for ML training and testing. ML methods included logistic regression, an artificial neural network, two random forest models, a gradient boosting model and a voting ensemble (VE) model, which combined the predictions of all other (base) models to improve classifier performance. The macro-averaged F-measure, an indicator of classifier performance, showed that the VE model improved overall classification (F-measure 0.88) above the strongest base learner model, gradient boosting (0.86). To test whether the VE model provided biologically meaningful results when applied to accelerometer data obtained from wild sharks, we investigated headshaking behaviour, as a proxy for prey capture, in relation to the variables: time of day, tidal phase and season. All variables were significant in predicting prey capture, with predations most likely to occur during early evening and less frequently during the dry season and high tides. These findings support previous hypotheses from sporadic visual observations.

Phylogeny of the order Phyllachorales (Ascomycota, Sordariomycetes): among and within order relationships based on five molecular loci

The order Phyllachorales (Pezizomycotina, Ascomycota) is a group of biotrophic, obligate plant parasitic fungi with a tropical distribution and high host specificity. Traditionally two families are recognised within this order: Phyllachoraceae and Phaeochoraceae, based mostly on morphological and host characteristics. Currently, the position of the order within the class Sordariomycetes is inconclusive, as well as the monophyly of the order, and its internal phylogenetic structure. Here we present a phylogeny of the order Phyllachorales based on sequence data of 29 species with a broad host range resulting from a wide geographical sampling. We inferred Maximum Likelihood and Bayesian phylogenies from data of five DNA regions: nrLSU rDNA, nrSSU rDNA, ITS rDNA, and the protein coding genes RPB2, and TEF1. We found that the order Phyllachorales is monophyletic and related to members of the subclass Sordariomycetidae within Sordariomycetes. Within the order, members of the family Phaeochoraceae form a monophyletic group, and the family Phyllachoraceae is split into two lineages. Maximum Likelihood ancestral state reconstructions indicate that the ancestor of Phyllachorales had a monocotyledonous host plant, immersed perithecia, and a black stroma. Alternative states of these characters evolved multiple times independently within the order. Based on our results we redefine the family Phyllachoraceae and propose the new family Telimenaceae with Telimena erythrinae as type species, resulting in three families in the order. Species of Telimena spp. occur in several monocotyledonous and eudicotyledonous host plants except Poaceae, and generally have enlarged black pseudostroma around the perithecia, a character not present in species of Phyllachoraceae.

Outcome of elderly patients after failure to hypomethylating agents given as frontline therapy for acute myeloid leukemia: Single institution experience

Outcomes of acute myeloid leukemia (AML) in elderly patients unfit for intensive chemotherapy is challenging. Hypomethylating agents (HMAs) can be effective in these patients but responses are usually short-lived. The majority of patients will either have stable disease or progress through therapy. We hereby describe the outcome of these patients at our institution after they fail HMAs. The data on 56 AML patients at Mayo Clinic, Rochester were reviewed. Patients were considered for our study if they received HMA as frontline therapy for their AML. Out of 56 patients, 15 (27%) patients received azacitidine (AZA) and 41 (73%) received decitabine. Complete remission was found in 10 (18%), with overall response of 28% and median response duration of 10 months. Thirteen (81%) out of 16 responders relapsed. Therefore 53 patients were included in the primary or secondary failure analysis with a median overall survival (OS) of 2 months after the date of failure. Out of 53 patients, 12 (23%) received subsequent treatments. None of the 12 patients who got first salvage therapy achieved remission. Five out of the 12 patients received second salvage therapy, 2 (40%) of which achieved CR. Median OS for patients who received subsequent salvage therapies was better than those who did not receive any subsequent therapy after failing HMA (9.5 vs. 2 months, P = .0009). Outcome for patients who have primary or secondary failure is very poor. Our study provides important historical data for future novel therapies, which are sorely needed for these patients.

"And DPSIR begat DAPSI(W)R(M)!" - A unifying framework for marine environmental management

The marine environment is a complex system formed by interactions between ecological structure and functioning, physico-chemical processes and socio-economic systems. An increase in competing marine uses and users requires a holistic approach to marine management which considers the environmental, economic and societal impacts of all activities. If managed sustainably, the marine environment will deliver a range of ecosystem services which lead to benefits for society. In order to understand the complexity of the system, the DPSIR (Driver-Pressure-State-Impact-Response) approach has long been a valuable problem-structuring framework used to assess the causes, consequences and responses to change in a holistic way. Despite DPSIR being used for a long time, there is still confusion over the definition of its terms and so to be appropriate for current marine management, we contend that this confusion needs to be addressed. Our viewpoint advocates that DPSIR should be extended to DAPSI(W)R(M) (pronounced dap-see-worm) in which Drivers of basic human needs require Activities which lead to Pressures. The Pressures are the mechanisms of State change on the natural system which then leads to Impacts (on human Welfare). Those then require Responses (as Measures). Furthermore, because of the complexity of any managed sea area in terms of multiple Activities, there is the need for a linked-DAPSI(W)R(M) framework, and then the connectivity between marine ecosystems and ecosystems in the catchment and further at sea, requires an interlinked, nested-DAPSI(W)R(M) framework to reflect the continuum between adjacent ecosystems. Finally, the unifying framework for integrated marine management is completed by encompassing ecosystem structure and functioning, ecosystem services and societal benefits. Hence, DAPSI(W)R(M) links the socio-ecological system of the effects of changes to the natural system on the human uses and benefits of the marine system. However, to deliver these sustainably in the light of human activities requires a Risk Assessment and Risk Management framework; the ISO-compliant Bow-Tie method is used here as an example. Finally, to secure ecosystem health and economic benefits such as Blue Growth, successful, adaptive and sustainable marine management Responses (as Measures) are delivered using the 10-tenets, a set of facets covering all management disciplines and approaches.

Simultaneous Bistability of a Qubit and Resonator in Circuit Quantum Electrodynamics

We explore the joint activated dynamics exhibited by two quantum degrees of freedom: a cavity mode oscillator which is strongly coupled to a superconducting qubit in the strongly coherently driven dispersive regime. Dynamical simulations and complementary measurements show a range of parameters where both the cavity and the qubit exhibit sudden simultaneous switching between two metastable states. This manifests in ensemble averaged amplitudes of both the cavity and qubit exhibiting a partial coherent cancellation. Transmission measurements of driven microwave cavities coupled to transmon qubits show detailed features which agree with the theory in the regime of simultaneous switching.

Rural Community Health Needs Assessment Findings: Access to Care and Mental Health

This article highlights the qualitative results from focus groups conducted as part of a Community Health Needs Assessments in two rural Georgia communities. Four 1-hr focus groups were facilitated with 32 community stakeholders. Sessions were audio recorded and transcribed verbatim. Thematic analysis identified two primary themes: mental health and barriers to accessing health care. Focus group participants discussed mental health challenges as they related to substance abuse and suicide. Participants acknowledged barriers to access, including no health insurance, cost, eligibility gaps for government-sponsored programs, the low availability of specialty care, and poverty. Addressing mental health and access to care in rural communities may require alternative, tailored programs.