Explore the vast range of titles available.

Escaping flames and barbed wire, a mother, a baby, a boy, and a dog flee into a sailboat and set off to sea.

Horseshoe crabs have persisted for more than 200 million years, and fossil forms date to 450 million years ago. The American horseshoe crab ( Limulus polyphemus ), one of four extant horseshoe crab species, is found along the Atlantic coastline of North America ranging from Alabama to Maine, USA with another distinct population on the coasts of Campeche, Yucatán and Quintana Roo in the Yucatán Peninsula, México. Although the American horseshoe crab tolerates broad environmental conditions, exploitation and habitat loss threaten the species. We assessed the conservation status of the American horseshoe crab by comprehensively reviewing available scientific information on its range, life history, genetic structure, population trends and analyses, major threats, and conservation. We structured the status assessment by six genetically-informed regions and accounted for sub-regional differences in environmental conditions, threats, and management. The transnational regions are Gulf of Maine (USA), Mid-Atlantic (USA), Southeast (USA), Florida Atlantic (USA), Northeast Gulf of México (USA), and Yucatán Peninsula (México). Our conclusion is that the American horseshoe crab species is vulnerable to local extirpation and that the degree and extent of risk vary among and within the regions. The risk is elevated in the Gulf of Maine region due to limited and fragmented habitat. The populations of horseshoe crabs in the Mid-Atlantic region are stable in the Delaware Bay area, and regulatory controls are in place, but the risk is elevated in the New England area as evidenced by continuing declines understood to be caused by over-harvest. The populations of horseshoe crabs in the Southeast region are stable or increasing. The populations of horseshoe crabs in the Florida Atlantic region show mixed trends among areas, and continuing population reductions at the embayment level have poorly understood causes. Within the Northeast Gulf of Mexico, causes of population trends are poorly understood and currently there is no active management of horseshoe crabs. Horseshoe crabs within México have conservation protection based on limited and fragmented habitat and geographic isolation from other regions, but elevated risk applies to the horseshoe crabs in the Yucatán Peninsula region until sufficient data can confirm population stability. Future species status throughout its range will depend on the effectiveness of conservation to mitigate habitat loss and manage for sustainable harvest among and within regions.

Internet-based treatment programs present a solution for providing access to pain management for those unable to access clinic-based multidisciplinary pain programs. Attrition from internet interventions is a common issue. Clinician-supported guidance can be an important feature in web-based interventions; however, the optimal level of therapist guidance and expertise required to improve adherence remains unclear. The aim of this study is to evaluate whether augmenting the existing Reboot Online program with telephone support by a clinician improves program adherence and effectiveness compared with the web-based program alone. A 2-armed, CONSORT (Consolidated Standards of Reporting Trials)-compliant, registered randomized controlled trial with one-to-one group allocation was conducted. It compared a web-based multidisciplinary pain management program, Reboot Online, combined with telephone support (n=44) with Reboot Online alone (n=45) as the control group. Participants were recruited through web-based social media and the This Way Up service provider network. The primary outcome for this study was adherence to the Reboot Online program. Adherence was quantified through three metrics: completion of the program, the number of participants who enrolled into the program, and the number of participants who commenced the program. Data on adherence were collected automatically through the This Way Up platform. Secondary measures of clinical effectiveness were also collected. Reboot Online combined with telephone support had a positive effect on enrollment and commencement of the program compared with Reboot Online without telephone support. Significantly more participants from the Reboot Online plus telephone support group enrolled (41/44, 93%) into the course than those from the control group (35/45, 78%; χ =4.2; P=.04). Furthermore, more participants from the intervention group commenced the course than those from the control group (40/44, 91% vs 27/45, 60%, respectively; χ =11.4; P=.001). Of the participants enrolled in the intervention group, 43% (19/44) completed the course, and of those in the control group, 31% (14/45) completed the course. When considering the subgroup of those who commenced the program, there was no significant difference between the proportions of people who completed all 8 lessons in the intervention (19/40, 48%) and control groups (14/27, 52%; χ =1.3; P=.24). The treatment efficacy on clinical outcome measures did not differ between the intervention and control groups. Telephone support improves participants' registration, program commencement, and engagement in the early phase of the internet intervention; however, it did not seem to have an impact on overall course completion or efficacy. Australian New Zealand Clinical Trials Registry ACTRN12619001076167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001076167.

Background Social anxiety disorder (SAD) is a serious mental health disorder that when left untreated can lead to significant social, occupational, educational, and functional impairment. Cognitive behaviour therapy (CBT) is the recommended first-line psychological treatment for SAD and has been shown to be efficacious in face-to-face and online formats. However, treatment is lengthy, and many people drop out prematurely. Pilot research suggests that brief intensive internet CBT (iCBT) for SAD is feasible and acceptable, but further evaluation using randomised controlled trials (RCT) is needed. Methods A RCT to evaluate the acceptability, feasibility, and efficacy of an intensive 7-day iCBT program for adults diagnosed with SAD (with or without comorbid major depressive disorder) in comparison to a waitlist control (WLC) is currently in progress. Eligible participants will be randomised to an intervention or WLC group. Participants allocated to the intervention will complete 6 iCBT modules over 7 days, with CBT skills practice each day, and clinician guidance provided remotely by telephone and email. Participants allocated to the WLC will be given access to the program after a 6-week waiting period. All participants will complete assessments at baseline, 2 weeks and 6 weeks post-baseline. Outcome measures will assess for social anxiety (SIAS, SPS), depression (PHQ-9), personality (LPFS, PID-5-BF), and functioning (WSAS). Intention-to-treat linear mixed model analyses will be used to evaluate primary and secondary outcomes. Discussion Previous findings from a pilot trial showed that 7-day iCBT is feasible and acceptable to clients with SAD. Based on these findings, we expect the treatment group will improve significantly on measures of symptoms of social anxiety, depression, and functional impairment compared to the WLC, and these improvements will be sustained at 1-month follow-up. If demonstrated to be effective in this RCT, intensive 7-day iCBT for SAD is a novel way to deliver CBT more quickly, with potential to reach more clients and reduce drop-out rates. It has great potential to provide rapid symptom improvement to individuals with SAD. Trial registration This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry on March 1, 2022 (ACTRN12622000361707).

IntroductionMethamphetamine use disorder is a significant public health concern. No pharmacological treatment options currently exist for methamphetamine use disorder, and psychotherapy is only moderately effective. Preliminary evidence suggests that ketamine-assisted psychotherapy produces sustained improvements in substance use and mental health symptomatology. In addition to direct antidepressant properties, ketamine is hypothesised to increase synaptogenesis and facilitate neuroplasticity, in turn prolonging and enhancing the effects of psychotherapy. Given the withdrawal-associated dysphoria and neurocognitive impairments characterising methamphetamine use disorder, ketamine-assisted psychotherapy may improve the efficacy of psychotherapy alone by addressing these features and facilitating therapeutic engagement. This pilot study aims to investigate the safety and feasibility (time taken to recruit sample, proportion of ineligible participants at pre-screening and screening, number of participants who complete four sessions of psychotherapy, retention rate over full duration of study, acceptability of the intervention) of subanaesthetic ketamine in combination with psychotherapy (cognitive behavioural therapy) for adults with methamphetamine use disorder. Changes in methamphetamine use, cravings and withdrawal, quality of life, and treatment satisfaction will also be explored.Methods and analysisThis is an open-label, single-arm clinical trial. 20 adults meeting DSM-5-TR criteria for methamphetamine use disorder who are seeking to reduce or cease methamphetamine use will be enrolled in the study through a single-site specialist outpatient stimulant treatment service in inner Sydney (St Vincent’s Hospital, Sydney). A 4-week course with three subcutaneous ketamine doses (0.75 mg/kg to 0.9 mg/kg, titrated according to tolerability) at weekly intervals and four sessions of cognitive behavioural therapy (one at treatment initiation and three within 24–48 hours following each ketamine administration session) will be delivered. Safety and feasibility will be assessed over an 8-week period. Secondary outcomes (changes in methamphetamine use, cravings, withdrawal, quality of life and treatment satisfaction) will be assessed over a 24-week period.Ethics and disseminationThis study has been approved by the St Vincent’s Hospital Human Research Ethics Committee, reference 2023/ETH00530. Study findings will be disseminated through articles in scientific, peer-reviewed journals, and at national and international conferences.Trial registration numberANZCTR: ACTRN12624000895583.Protocol versionThe trial protocol (Version 4.0) was approved on 24 June 2024.

To assess if a change in our cardiology fellowship program impacted our ST elevation myocardial infarction (STEMI) program. Fellows covering the cardiac care unit were spending excessive hours in the hospital while on call, resulting in increased duty hours violations. A night float fellow system was started on July 1, 2012, allowing the cardiac care unit fellow to sign out to a night float fellow at 5:30 pm. The night float fellow remained in-house until the morning. We performed a retrospective study assessing symptom onset to arrival, arterial access to first device, and door-to-balloon (D2B) times, in consecutive STEMI patients presenting to our emergency department before and after initiation of the night float fellow system. From 2009 to 2013, 208 STEMI patients presented to our emergency department and underwent primary percutaneous coronary intervention. There was no difference in symptom onset to arrival (150±102 minutes vs 154±122 minutes, =0.758), arterial access to first device (12±8 minutes vs 11±7 minutes, =0.230), or D2B times (50±32 minutes vs 52±34 minutes, =0.681) during regular working hours. However, there was a significant decrease in D2B times seen during off-hours (72±33 minutes vs 49±15 minutes, =0.007). There was no difference in in-hospital mortality (11% vs 8%, =0.484) or need for intra-aortic balloon pump placement (7% vs 8%, =0.793). In academic medical centers, in-house cardiology fellow coverage during off-hours may expedite care of STEMI patients.

Interventions are required that address delays in treatment-seeking and low treatment coverage among people consuming methamphetamine. We aim to determine whether a self-administered smartphone-based intervention, the \"S-Check app\" can increase help-seeking and motivation to change methamphetamine use, and determine factors associated with app engagement. This study is a randomized, 28-day waitlist-controlled trial. Consenting adults residing in Australia who reported using methamphetamine at least once in the last month were eligible to download the app for free from Android or iOS app stores. Those randomized to the intervention group had immediate access to the S-Check app, the control group was wait-listed for 28 days before gaining access, and then all had access until day 56. Actual help-seeking and intention to seek help were assessed by the modified Actual Help Seeking Questionnaire (mAHSQ), modified General Help Seeking Questionnaire, and motivation to change methamphetamine use by the modified readiness ruler. χ comparisons of the proportion of positive responses to the mAHSQ, modified General Help Seeking Questionnaire, and modified readiness ruler were conducted between the 2 groups. Logistic regression models compared the odds of actual help-seeking, intention to seek help, and motivation to change at day 28 between the 2 groups. Secondary outcomes were the most commonly accessed features of the app, methamphetamine use, feasibility and acceptability of the app, and associations between S-Check app engagement and participant demographic and methamphetamine use characteristics. In total, 560 participants downloaded the app; 259 (46.3%) completed eConsent and baseline; and 84 (32.4%) provided data on day 28. Participants in the immediate access group were more likely to seek professional help (mAHSQ) at day 28 than those in the control group (n=15, 45.5% vs n=12, 23.5%; χ =4.42, P=.04). There was no significant difference in the odds of actual help-seeking, intention to seek help, or motivation to change methamphetamine use between the 2 groups on the primary logistic regression analyses, while in the ancillary analyses, the imputed data set showed a significant difference in the odds of seeking professional help between participants in the immediate access group compared to the waitlist control group (adjusted odds ratio 2.64, 95% CI 1.19-5.83, P=.02). For participants not seeking help at baseline, each minute in the app increased the likelihood of seeking professional help by day 28 by 8% (ratio 1.08, 95% CI 1.02-1.22, P=.04). Among the intervention group, a 10-minute increase in app engagement time was associated with a decrease in days of methamphetamine use by 0.4 days (regression coefficient [β] -0.04, P=.02). The S-Check app is a feasible low-resource self-administered intervention for adults in Australia who consume methamphetamine. Study attrition was high and, while common in mobile health interventions, warrants larger studies of the S-Check app. Australian New Zealand Clinical Trials Registry ACTRN12619000534189; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377288&isReview=true.

Opportunities exist to improve patient experience in the emergency department for low-risk (ie, non-cardiac) chest pain patients with anxiety and panic as the underlying cause of symptoms. Referral to internet-based cognitive behavioral therapy (iCBT) with guided support is a scalable, evidence-based option that is underused, particularly among non-white patients. In collaboration with a diverse group of patient and community partners, we co-developed and tested an existing iCBT course for generalized anxiety disorder with delivery of guided support by a peer recovery specialist with concordant lived experience. We analyzed patient partner feedback from debriefing sessions during the testing phase using conventional content analysis. Results revealed overall positive experiences with both iCBT lessons and peer support calls. Key points derived from qualitative findings include: (1) iCBT lesson content resonated reasonably well with the diverse group of patient partners, (2) the peer relationship was key to individualizing application of content to various lived experiences, and (3) the guided discussion should be participant-driven and based on content that resonates most with the participant. In conclusion, iCBT with guided peer support was acceptable to patient partners involved in co-development and testing who were representative of a diverse patient population.

Clostridium perfringens bacteremia is an uncommon yet serious clinical syndrome that typically arises from a gastrointestinal source. However, clinicians should consider nongastrointestinal sources as well. We present a rare case of C. perfringens bacteremia of urinary origin that required surgical intervention for definitive treatment. A 61-year-old male presented with acute nausea and vomiting, altered mental status, and chronic diarrhea. His physical exam revealed right costovertebral tenderness and his laboratory work-up revealed acute renal failure. Percutaneous blood cultures grew C. perfringens. Cross-sectional imaging revealed a right-sided ureteral stone with hydronephrosis, which required nephrostomy placement. On placement of the nephrostomy tube, purulent drainage was identified and Gram stain of the drainage revealed Gram-variable rods. A urinary source of C. perfringens was clinically supported. Although it is not a common presentation, nongastrointestinal sources such as a urinary source should be considered in C. perfringens bacteremia because failure to recognize a nongastrointestinal source can delay appropriate treatment, which may include surgical intervention.