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Central sensitization, a pathophysiologic process in which the central nervous system undergoes changes that alter its processing of pain and other sensory stimuli, may be the mechanism underlying various conditions in which patients have unexplained pain and fatigue. Patients frequently misunderstand the cause of their symptoms and pursue unnecessary evaluations and treatments. Clinicians have a pivotal role in decreasing this misunderstanding by providing patient education, which can affect perception, management, functional status, and quality of life.

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Hypervigilance, attentional bias, and negative views of the world play a significant role in post trauma symptomatology and can be associated with both clinical depression and posttraumatic stress. However, both theory and research suggest there may be discernible differences in attentional patterns between these two outcomes. While depression may be associated with a general negativity bias, posttraumatic stress may be specifically associated with visual scanning, hypervigilance, and threat detection. In this study, seventy-seven community trauma survivors completed self-assessments for hypervigilance, depression, and posttraumatic cognitions and then had their eyes tracked while looking at a series of thirty neutral but ambiguous and complex pictures on a computer screen. Mean age of the sample was 36.3 with 52 % of the sample identifying as female. We found that hypervigilance scores and negative views of the world predicted both the number of fixations and area of the picture covered. These factors did not predict pupil size. These findings suggest that there are discernable gaze patterns after trauma associated with posttraumatic stress but not depression. Specifically, ambiguous pictures generate more fixations and scanning that is associated with vigilance but not depression.

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Cardiac surgeries account for approximately 20% of blood use in the United States. Allogeneic transfusion has been associated with increased risk of morbidity and mortality, further justifying the need to reduce blood use. This study aimed at determining whether a point-of-care coagulation test, thromboelastography (TEG), impacted blood product administration and outcomes. Patients undergoing isolated coronary artery bypass grafting (CABG) were retrospectively reviewed before the use of TEG (2008-2009) (n = 640) and after implementation (2011-2012) (n = 458). Blood product use was compared between time frames. Logistic regression and generalized linear models were created to estimate the impact on outcomes including the reoperation rate, mortality, and cost. The mean use of each blood product was significantly reduced in the perioperative period. Overall blood product use was decreased by over 40%. Mediastinal re-exploration of bleeding was significantly reduced with TEG (4.8 vs. 1.5%). Six-month mortality was not impacted in this cohort nor was the readmission rate or hospital length of stay. However, blood cost and patient charges were significantly lower after TEG was introduced. The use of TEG to guide the administration of blood products during isolated CABG significantly affected the amounts and types of products given intra- and perioperatively. This resulted in less chest tube drainage, fewer returns to the operating room, and more accurate diagnosis of coagulopathic status. Cost savings to the patient and institution were appreciated as a consequence of these improved clinical outcomes.

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AIMS: High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. METHODS: A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI. RESULTS: Mean operating time increased with BMI and for BMI > 50 kg/m2 was approximately twice that of BMI 10 kg/m2 to 15 kg/m2. Mean inpatient cost did not vary significantly with BMI. Mean total reimbursement was lowest for the lowest BMI cohort and increased with BMI. Mean LOS was greatest at the extremes of BMI (4.0 days for BMI 10 kg/m2 to 15 kg/m2; 3.75 days for BMI > 50 kg/m2) and twice that of normal BMI. Mean complication rates were greatest in the lowest BMI cohort (16% for BMI 10 kg/m2 to 15 kg/m2) and five times the mean rate of complications in the normal BMI cohorts. Furthermore, 30-day readmissions were greatest in the highest BMI cohort (10% for BMI > 50 kg/m2) and five times the rate for normal BMI patients. CONCLUSION: LOS, complications, and 30-day readmissions all increase at the extremes of BMI and appear to be greater than those of patients with normal BMI. The lowest BMI patients had the lowest payment for inpatient stay yet were at considerable risk for complications and readmission. Patients with extreme BMI should be counselled about their increased risk of complications for THA and nutritional status/obesity optimized preoperatively if possible. Cite this article: Bone Joint J 2020;102-B(7 Supple B):62-70.

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Natural hazards and climate-related disasters disregard political borders, where additional barriers can complicate mitigation, response and recovery efforts within and between the sectors of Climate Change Adaptation (CCA) and Disaster Risk Reduction (DRR). The ESPREssO Project (Enhancing Synergies for Disaster Prevention in the European Union) aims to improve management of transboundary disasters by encouraging closer synergies between the CCA and DRR communities. Using targeted stakeholder interviews, questionnaires, Think Tank discussions and purpose-built serious games, ESPREssO draws on both CCA and DRR stakeholder experiences and informed perspectives in order to identify current gaps. Set within a fictitious border zone, ESPREssO's RAMSETE II serious game challenges CCA and DRR stakeholders in making coordinated decisions before, during and after a simulated disaster, in protection of population and critical infrastructure. Results highlight the essential role of local governance mechanisms as the sharp end of the policy wedge, with current examples of proactivity that require to be championed and supported at national level in order to thrive. These good practice examples reflect the fact that transboundary settings, despite their challenges, act as fertile ground for mutual growth, offering opportunities for CCA and DRR communities to find innovative ways to cooperate and unite in developing synergies and strengthening their mutual efforts towards resilience. Stakeholders emphasise a need to invest more resources in informal cooperation and call on policy makers to recognise that each border zone raises its own unique set of complex challenges that requires flexibility and special consideration by transboundary authorities in management of disasters.

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BACKGROUND: Transfusion of allogenic blood products is associated with substantial morbidity and increased risk of mortality. Thrombelastography (TEG) to direct transfusion management during and immediately after cardiothoracic surgery reduced blood product usage in our institution. The goal of this study was to quantify the impact of TEG on postoperative outcomes. METHODS: All patients who underwent cardiac surgical procedures before and after implementation of TEG were retrospectively analyzed. Baseline patient characteristics, blood product administration, and length of stay (LOS) were compared. A logistic regression model was used to evaluate the impact of TEG on the odds of reoperation, LOS, and 6-month mortality. RESULTS: Included in analysis were 367 patients in the pre-TEG period and 310 patients in the post-TEG period. Baseline characteristics did not vary between periods. Exposure to blood products was significantly reduced after implementation of TEG (p < 0.001). The incidence of reoperation was lower in the post-TEG period (7.1% versus 3.5%, p = 0.04). Controlling for related factors on multivariate analysis, TEG was associated with reduction in postoperative LOS (11.3 versus 9.9 days, p = 0.04) and 6-month mortality (odds ratio 2.98, 95% confidence limits: 1.13 and 7.85). CONCLUSIONS: The use of TEG to guide blood product administration substantially affected patient outcomes, including LOS, odds of reoperation, and short-term mortality. The impacts appreciated may be due to the reduced use of allogenic blood products and the ability to distinguish between postoperative coagulopathy and surgical bleeding with the use of this point-of-care test.

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BACKGROUND: Limited data are available regarding observers' visual attention to faces with congenital difference. We implemented eye tracking technology to examine this issue, as it pertains particularly to faces with cleft deformity. METHOD: Four hundred three observers assessed 273 clinical images, while their eye movements were unobtrusively tracked using an infrared sensor. Forty-one facial images of the repaired cleft lip, 137 images of other facial conditions, and 95 images of matched controls were assessed. Twenty facial regions of interest ("lookzones") were considered for all images observed. A separate cohort of 720 raters evaluated the images for attractiveness. Observer and image demographic information was collected. Visual fixation counts and durations were computed across all 20 lookzones for all images. The effect of a variety of variables on lookzone fixation was analyzed using factorial ANOVA testing. RESULTS: Cleft-repaired faces were rated as less attractive and drew observers' attention preferentially to the affected upper lip lookzone (p<.001). Images rated as less attractive garnered greater visual attention in the cleft-affected lookzones (p<.001). The eye tracking methodology demonstrated exquisite sensitivity to laterality of cleft deformity (p<.001). Individuals reporting a personal or a family history of facial deformity fixated more on the perioral region of cleft-repaired faces than did naïve observers (p<.001). CONCLUSION: These findings highlight the utility of eye tracking measures for understanding critical variables that influence the visual processing of faces with cleft deformity. The data may provide analytical tools for assessing surgical outcome and direct priority setting during surgeons' conversations with patients.

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OBJECTIVE: Negative views of both the self and the world are commonly seen in individuals who have suffered psychological trauma. These negative cognitions are thought to be significant as they are likely to play a critical role in furthering, if not promoting, other symptoms and exacerbating the dysfunction sometimes seen after a traumatic event. This has led to the inclusion of "persistent negative beliefs and expectations about oneself or the world" in the DSM-5 (American Psychiatric Association, 2013). Although there is considerable self-report and behavioral evidence for negative biases after trauma, there is less concurrent neurophysiological data. This study used the N400, an event-related potential sensitive to semantic expectancies, to assess negative expectations in a trauma sample. METHOD: In this study, 39 participants completed an N400 task in which they read ambiguous sentence stems that ended either with a positive final word (Things will turn out . . . fine) or a negative final word (Things will turn out . . . badly). The authors predicted that those trauma survivors with negative cognitions (as measured by the Posttraumatic Cognitions Inventory [PTCI]: Foa et al., 1999) would show N400 amplitudes indicating expectancies for negative endings. Augmenting the previous self-report data, this would provide evidence for negative expectancies that are fairly early and relatively automatic. RESULTS: N400 amplitudes to negative sentence endings were significantly related to negative views of the world as measured by the PTCI. CONCLUSIONS: This suggests that negative world views in trauma survivors have demonstrable neurophysiological correlates and impact on expectations in ambiguous situations. (PsycINFO Database Record

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The Multi-Parameter Wireless Sensing (MPwise) system is an innovative instrumental design that allows different sensor types to be combined with relatively high-performance computing and communications components. These units, which incorporate off-the-shelf components, can undertake complex information integration and processing tasks at the individual unit or node level (when used in a network), allowing the establishment of networks that are linked by advanced, robust and rapid communications routing and network topologies. The system (and its predecessors) was originally designed for earthquake risk mitigation, including earthquake early warning (EEW), rapid response actions, structural health monitoring, and site-effect characterization. For EEW, MPwise units are capable of on-site, decentralized, independent analysis of the recorded ground motion and based on this, may issue an appropriate warning, either by the unit itself or transmitted throughout a network by dedicated alarming procedures. The multi-sensor capabilities of the system allow it to be instrumented with standard strong- and weak-motion sensors, broadband sensors, MEMS (namely accelerometers), cameras, temperature and humidity sensors, and GNSS receivers. In this work, the MPwise hardware, software and communications schema are described, as well as an overview of its possible applications. While focusing on earthquake risk mitigation actions, the aim in the future is to expand its capabilities towards a more multi-hazard and risk mitigation role. Overall, MPwise offers considerable flexibility and has great potential in contributing to natural hazard risk mitigation.

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For Brazil, a country frequented by droughts and whose rural inhabitants largely depend on groundwater, reliance on isotope for its monitoring, though accurate, is expensive and limited in spatial coverage. We exploit total water storage (TWS) derived from Gravity Recovery and Climate Experiment (GRACE) satellites to analyse spatial-temporal groundwater changes in relation to geological characteristics. Large-scale groundwater changes are estimated using GRACE-derived TWS and altimetry observations in addition to GLDAS and WGHM model outputs. Additionally, TRMM precipitation data are used to infer impacts of climate variability on groundwater fluctuations. The results indicate that climate variability mainly controls groundwater change trends while geological properties control change rates, spatial distribution, and storage capacity. Granular rocks in the Amazon and Guarani aquifers are found to influence larger storage capability, higher permeability (>10-4 m/s) and faster response to rainfall (1 to 3months' lag) compared to fractured rocks (permeability <10-7 m/s and lags > 3months) found only in Bambui aquifer. Groundwater in the Amazon region is found to rely not only on precipitation but also on inflow from other regions. Areas beyond the northern and southern Amazon basin depict a 'dam-like' pattern, with high inflow and slow outflow rates (recharge slope > 0.75, discharge slope < 0.45). This is due to two impermeable rock layer-like 'walls' (permeability <10-8 m/s) along the northern and southern Alter do Chão aquifer that help retain groundwater. The largest groundwater storage capacity in Brazil is the Amazon aquifer (with annual amplitudes of > 30cm). Amazon's groundwater declined between 2002 and 2008 due to below normal precipitation (wet seasons lasted for about 36 to 47% of the time). The Guarani aquifer and adjacent coastline areas rank second in terms of storage capacity, while the northeast and southeast coastal regions indicate the smallest storage capacity due to lack of rainfall (annual average is rainfall <10cm).

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Complex cardiac procedures often require blood transfusion because of surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates peri- and postoperatively. All patients who underwent complex cardiac surgery, defined as open multiple valve repair/replacement, coronary artery bypass grafting with open valve repair/replacement, or aortic root/arch repair before and after implementation of TEG were identified and retrospectively analyzed. Minimally invasive cases were excluded. Patient characteristics and blood use were compared with t test and chi-square test. A generalized linear model including patient characteristics, preoperative and postoperative lab values, and autotransfusion volume was used to determine the impact of TEG on perioperative, postoperative, and total blood use. In total, 681 patients were identified, 370 in the pre-TEG period and 311 patients post-TEG. Patient demographics were not significantly different between periods. Mean units of red blood cells, plasma, and cryoprecipitate were significantly reduced after TEG was implemented (all, p < .0001); use of platelets was reduced but did not reach significance. Mean units of all blood products in the perioperative period and over the entire stay were reduced by approximately 40% (both, p < .0001). Total proportion of patients exposed to transfusion was significantly lower after introduction of TEG (p < .01). Controlling for related factors on multivariate analysis, such as preoperative laboratory values and autotransfusion volume, use of TEG was associated with significant reduction in perioperative and overall blood product transfusion. TEG-directed management of blood product administration during complex cardiac surgeries significantly reduced the units of blood products received perioperatively but not blood usage more than 24 hours after surgery. Overall, fewer patients were exposed to allogenic blood. The use of TEG to guide blood product administration significantly impacted transfusion therapy and associated costs.

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Accurate quantification of the millennial-scale mass balance of the Greenland ice sheet (GrIS) and its contribution to global sea-level rise remain challenging because of sparse in situ observations in key regions. Glacial isostatic adjustment (GIA) is the ongoing response of the solid Earth to ice and ocean load changes occurring since the Last Glacial Maximum (LGM; ~21 thousand years ago) and may be used to constrain the GrIS deglaciation history. We use data from the Greenland Global Positioning System network to directly measure GIA and estimate basin-wide mass changes since the LGM. Unpredicted, large GIA uplift rates of +12 mm/year are found in southeast Greenland. These rates are due to low upper mantle viscosity in the region, from when Greenland passed over the Iceland hot spot about 40 million years ago. This region of concentrated soft rheology has a profound influence on reconstructing the deglaciation history of Greenland. We reevaluate the evolution of the GrIS since LGM and obtain a loss of 1.5-m sea-level equivalent from the northwest and southeast. These same sectors are dominating modern mass loss. We suggest that the present destabilization of these marine-based sectors may increase sea level for centuries to come. Our new deglaciation history and GIA uplift estimates suggest that studies that use the Gravity Recovery and Climate Experiment satellite mission to infer present-day changes in the GrIS may have erroneously corrected for GIA and underestimated the mass loss by about 20 gigatons/year.

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Strongyloides stercoralis is well known to cause hyperinfection syndrome during the period of immunosuppression; but dissemination, worsening hyperinfection, and development of multiorgan dysfunction syndrome after initiation of ivermectin has not been reported in the past. Herein, we describe the case of a 62-year-old man with chronic strongyloidiasis and human T-cell lymphotropic virus-1 coinfection, who developed significant clinical worsening after 24-48 hours of initiation of treatment with ivermectin (200 µg/kg daily). Oral albendazole (600 mg every 12 hours) was added to the regimen due to clinical deterioration. Notably, after a protracted clinical course with multiple complications, which included respiratory failure from gram-negative pneumonia and pulmonary alveolar hemorrhage, Klebsiella meningitis, Clostridium difficile colitis, and herpes labialis, the patient eventually recovered. Health-care providers should be aware that during the early days of antihelminthic treatment initiation, significant dissemination of S. stercoralis and worsening of the clinical scenario can occur.

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In both primary care and consultative practices, patients presenting with fibromyalgia (FM) often have other medically unexplained somatic symptoms and are ultimately diagnosed as having central sensitization (CS). Central sensitization encompasses many disorders where the central nervous system amplifies sensory input across many organ systems and results in myriad symptoms. A pragmatic approach to evaluate FM and related symptoms, including a focused review of medical records, interviewing techniques, and observations, is offered here, giving valuable tools for identifying and addressing the most relevant symptoms. At the time of the clinical evaluation, early consideration of CS may improve the efficiency of the visit, reduce excessive testing, and help in discerning between typical and atypical cases so as to avoid an inaccurate diagnosis. Discussion of pain and neurophysiology and sensitization often proves helpful.

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A number of prominent theories suggest that hypervigilance and attentional bias play a central role in anxiety disorders and PTSD. It is argued that hypervigilance may focus attention on potential threats and precipitate or maintain a forward feedback loop in which anxiety is increased. While there is considerable data to suggest that attentional bias exists, there is little evidence to suggest that it plays this proposed but critical role. This study investigated how manipulating hypervigilance would impact the forward feedback loop via self-reported anxiety, visual scanning, and pupil size. Seventy-one participants were assigned to either a hypervigilant, pleasant, or control condition while looking at a series of neutral pictures. Those in the hypervigilant condition had significantly more fixations than those in the other two groups. These fixations were more spread out and covered a greater percentage of the ambiguous scene. Pupil size was also significantly larger in the hypervigilant condition relative to the control condition. Thus the study provided support for the role of hypervigilance in increasing visual scanning and arousal even to neutral stimuli and even when there is no change in self-reported anxiety. Implications for the role this may play in perpetuating a forward feedback loop are discussed.

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BACKGROUND: The InBox messaging system is an internal, electronic program used at Mayo Clinic, Rochester, MN, to facilitate the sending, receiving, and answering of patient-specific messages and alerts. A standardized InBox was implemented in the Division of General Internal Medicine to decrease the time physicians, physician assistants, and nurse practitioners (clinicians) spend on administrative tasks and to increase efficiency. METHODS: Clinicians completed surveys and a preintervention InBox pilot test to determine inefficiencies related to administrative burdens and defects (message entry errors). Results were analyzed using Pareto diagrams, value stream mapping, and root cause analysis to prioritize administrative-burden inefficiencies to develop a new, standardized InBox. Clinicians and allied health staff were the target of this intervention and received standardized InBox training followed by a postintervention pilot test for clinicians. RESULTS: Sixteen of 28 individuals (57%) completed the preintervention survey. Twenty-eight clinicians participated in 2 separate 8-day pilot tests (before and after intervention) for the standardized InBox. The number of InBox defects was substantially reduced from 37 (Pilot 1) to 7 (Pilot 2). Frequent InBox defects decreased from 25% to 10%. More than half of clinicians believed the standardized InBox positively affected their work, and 100% of clinicians reported no negative affect on their work. CONCLUSIONS: This project demonstrated the successful implementation of the standardized InBox messaging system. Initial assessments show substantial reduction of InBox entry defects and administrative tasks completed by clinicians. The findings of this project suggest increased clinician and allied health staff efficiency, satisfaction, improved clinician work-life balance, and decreased clinician burden caused by administrative tasks.

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Hypervigilance toward ambiguous or threatening stimuli is a prominent feature in many trauma survivors including active and returning soldiers. This study set out to investigate the factors that contribute to hypervigilance in a mixed sample. One hundred forty-five individuals, 50 of whom were war zone veterans, filled out a series of questionnaires including the Hypervigilance Questionnaire (HVQ; Kimble, Fleming, & Bennion, 2009). Other participants included military cadets, college undergraduates, and a traumatized community sample. In this sample, a history of military deployment and posttraumatic stress disorder symptoms independently predicted hypervigilance. The findings suggest that deployment to a war zone, in and of itself, can lead to hypervigilant behavior. Therefore, characterizing hypervigilance as pathological in a veteran sample must be done so with caution.

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BACKGROUND: Posttraumatic stress disorder (PTSD) is a disorder that theoretically and clinically is thought to be associated with persistent and exaggerated negative expectancies. This study used the N400 event-related potential (ERP) to investigate expectancies for threatening endings to ambiguous sentence stems. The N400 ERP is thought to reflect the amount of effort required to integrate a stimulus into a given context. In sentence reading tasks, the N400 is reliably larger when a word is unexpected. METHOD: In this study, fifty-seven trauma survivors of various types (22 with PTSD and 35 without) read ambiguous sentence stems on a computer screen. These sentence stems were completed with either an expected ("The unfortunate man lost his…wallet"), unexpected ("The unfortunate man lost his…artist"), or threatening word endings ("The unfortunate man lost his…leg"). RESULTS: Participants with PTSD, as compared to those without, showed significantly smaller N400s to threatening sentence endings suggesting enhanced expectancies for threat. Behavioral responses supported this conclusion. CONCLUSIONS: These findings are consistent with the clinical presentation of hypervigilance and proposed revisions to the DSM-V that emphasize persistent and exaggerated negative expectations about one's self, others, or the world. Relative to earlier behavioral studies, this work further suggests that this expectancy bias occurs automatically and at the early stages of information processing. The discussion focuses on the potential impact of a negative expectancy bias in PTSD and the value of the ambiguous sentence paradigm for studying PTSD as well as other disorders.

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In environmental monitoring, environmental impact assessments and environmental audits, topographical maps play an essential role in providing a means by which the locations of sampling sites may be selected, in assisting with the interpretation of physical features, and in indicating the impact or potential impact on an area due to changes in the system being monitored (e.g., spatially changing features such as wetlands). Global Navigation Satellite Systems (GNSS) are hereby presented as a rapid method for monitoring spatial changes to support environmental monitoring decisions and policies. To validate the GNSS-based method, a comparison is made of results from a small-scale topographic survey using radio-based real-time kinematic GNSS (GNSS-RTK) and total station survey methods at Jack Finnery Lake, Perth, Australia. The accuracies achieved by the total station in this study were 2 cm horizontally and 6 cm vertically, while the GNSS-RTK also achieved an accuracy of 2 cm horizontally, but only 28 cm vertically. While the GNSS-RTK measurements were less accurate in the height component compared to those from the total station method, it is still capable of achieving accuracies sufficient for a topographic map at a scale of 1:1,750 that could support environmental monitoring tasks such as identifying spatial changes in small water bodies or wetlands. The time taken to perform the survey using GNSS-RTK, however, was much shorter compared to the total station method, thereby making it quite suitable for monitoring spatial changes within an environmental context, e.g., dynamic mining activities that require rapid surveys and the updating of the monitored data at regular intervals.

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Trauma and its consequences can have lasting biological and cognitive effects on those who experience them. This study investigated the extent to which trauma, posttraumatic stress disorder (PTSD), and dissociation influenced attention to basic auditory stimuli in a sample of military cadets. After filling out a series of psychometric questionnaires, 27 male military cadets varying in their trauma history participated in the "novelty" oddball task in which participants were asked to count high-pitched tones while ignoring other auditory stimuli. Electroencephalogram (EEG) was continually recorded in order to assess P300 responses, an event-related potential (ERP) associated with attention and memory processes. Trauma history only, and not dissociation or PTSD scores, predicted smaller P300 amplitudes to target tones. To distracting novel sounds, only trauma history and dissociation predicted unique variance in P300 amplitudes. The findings suggest that PTSD may not be central to the attentional disturbances found in traumatized samples, while trauma history and dissociation may play a more important role. Future studies investigating attentional processes post trauma should utilize dissociation scales and a non-trauma sample.

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