Stakeholder involvement in the systematic optimisation of two school-based relationships and sex education interventions,Project Respect and Positive Choices

Background

There is increasing emphasis on involving intended beneficiaries and other stakeholders in the development of public health interventions to maximise acceptability and remove barriers to adoption, implementation, and maintenance before costly implementation. Yet the processes whereby key actors are engaged in intervention development are rarely reported, and frameworks for carrying out such work remain limited. We outline our approach to involving stakeholders in the optimisation of two school-based relationships and sex education programmes (Project Respect and Positive Choices) and reflect on the challenges of co-producing with teachers, students, and other partners.

North American tree migration paced by climate in the West,lagging in the East

Tree fecundity and recruitment have not yet been quantified at scales needed to anticipate biogeographic shifts in response to climate change. By separating their responses, this study shows coherence across species and communities, offering the strongest support to date that migration is in progress with regional limitations on rates. The southeastern continent emerges as a fecundity hotspot, but it is situated south of population centers where high seed production could contribute to poleward population spread. By contrast, seedling success is highest in the West and North, serving to partially offset limited seed production near poleward frontiers. The evidence of fecundity and recruitment control on tree migration can inform conservation planning for the expected long-term disequilibrium between climate and forest distribution.

Effective planning for the redistribution of habitats from climate change will depend on understanding demographic rates that control population spread at continental scales. Mobile species are moving, some migrating poleward (1, 2) and/or upward in elevation (3, 4). Species redistribution is also predicted for sessile, long-lived trees that provide the resource and structural foundation for global forest biodiversity (5–7), but their movement is harder to study. Contemporary range shifts are recognized primarily where contractions have followed extensive die-backs (8) or where local changes occur along compact climate gradients in steep terrain (9, 10). Whether migration capacity can pace habitat shifts of hundreds of kilometers on decade time scales depends on seed production and juvenile recruitment (Fig. 1A), which have not been fitted to data in ways that can be incorporated in models to anticipate biogeographic change (11–13). For example, do the regions of rapid warming coincide with locations where species can produce abundant seed (Fig. 1B)? If so, does seed production translate to juvenile recruitment? Here, we combine continent-wide fecundity estimates from the Masting Inference and Forecasting (MASTIF) network (13) with tree inventories to identify North American hotspots for recruitment and find that species are well-positioned to track warming in the West and North, but not in parts of the East.Open in a separate windowFig. 1.Transitions, hypothesized effects on spread, and sites. (A) Population spread from trees (BA) to new recruits is controlled by fecundity (seed mass per BA) followed by recruitment (recruits per seed mass). (B) The CTH that warming has stimulated fecundity ahead of the center of adult distributions, which reflect climate changes of recent decades. Arrows indicate how centroids from trees to fecundity to recruitment could be displaced poleward with warming climate. (C) The RSH that cold-sensitive fecundity is optimal where minimum temperatures are warmer than for adult trees and, thus, may slow northward migration. The two hypotheses are not mutually exclusive. B and C refer to the probability densities of the different life stages. (D) MASTIF sites are summarized in SI Appendix, Table S2.2 by eco-regions: mixed forest (greens), montane (blues), grass/shrub/desert (browns), and taiga (blue-green).Suitable habitats for many species are projected to shift hundreds of kilometers in a matter of decades (14, 15). While climate effects on tree mortality are increasingly apparent (16–19), advances into new habitats are not (20–23). For example, natural populations of Pinus taeda may be sustained only if the Northeast can be occupied as habitats are lost in the South (Fig. 2). Current estimates of tree migration inferred from geographic comparisons of juvenile and adult trees have been inconclusive (2, 7, 21, 24, 25). Ambiguous results are to be expected if fecundity and juvenile success do not respond to change in the same ways (20, 26–29). Moreover, seedling abundances (7, 30) do not provide estimates of recruitment rates because seedlings may reside in seedling banks for decades, or they may turn over annually (31–33). Another method based on geographic shifts in population centers calculated from tree inventories (3, 34) does not separate the effects of mortality from recruitment, i.e., the balance of losses in some regions against gains in others. The example in Fig. 2 is consistent with an emerging consensus that suitable habitats are moving fast (2, 14, 15), even if population frontiers are not, highlighting the need for methods that can identify recruitment limitation on population spread. Management for forest products and conservation goals under transient conditions can benefit from an understanding of recruitment limitation that comes from seed supply, as opposed to seedling survival (35).Open in a separate windowFig. 2.Suitable habitats redistribute with decade-scale climate change for P. taeda (BA units m² /ha). (Suitability is not a prediction of abundance, but rather, it is defined for climate and habitat variables included in a model, to be modified by management and disturbance [e.g., fire]. By providing habitat suitability in units of BA, it can be related it to the observation scale for the data.) Predictive distributions for suitability under current (A) and change expected from mid-21^st-century climate scenario Representative Concentration Pathway 4.5 (B) showing habitat declines in the Southwest and East. Specific climate changes important for this example include net increases in aridity in the southeast (especially summer) and western frontier and warming to the North. Occupation of improving habitats depends on fecundity in northern parts of the range and how it is responding. Obtained with Generalized Joint Attribute Modeling (see Materials and Methods for more information).We hypothesized two ways in which fecundity and recruitment could slow or accelerate population spread. Contemporary forests were established under climates that prevailed decades to centuries ago. These climate changes combine with habitat variables to affect seeds, seedlings, and adults in different ways (36, 37). The “climate-tracking hypothesis” (CTH) proposes that, after decades of warming and changing moisture availability (Fig. 3 A and B), seed production for many species has shifted toward the northern frontiers of the range, thus primed for poleward spread. “Fecundity,” the transition from tree basal area (BA) to seed density on the landscape (Fig. 1A), is taken on a mass basis (kg/m² BA) as a more accurate index of reproductive effort than seed number (38, 39). “Recruitment,” the transition from seed density to recruit density (recruits per kg seed), may have also shifted poleward, amplifying the impact of poleward shifts in fecundity on the capacity for poleward spread (Fig. 1B). Under CTH, the centers for adult abundance, fecundity, and recruitment are ordered from south to north in Fig. 1B as might be expected if each life-history stage leads the previous stage in a poleward migration.Open in a separate windowFig. 3.Climate change and tracking. (A) Mean annual temperatures since 1990 have increased rapidly in the Southwest and much of the North. (Zero-change contour line is in red.) (B) Moisture deficit index (monthly potential evapotranspiration minus P summed over 12 mo) has increased in much of the West. (Climate sources are listed in SI Appendix.) (C) Fecundity (kg seed per BA summed over species) is high in the Southeast. (D) Recruits per kg seed (square-root transformed) is highest in the Northeast. (E and F) Geographic displacement of 81 species show transitions in Fig. 1A, as arrows from centroids for adult BA to fecundity (E) and from fecundity to recruitment (F). Blue arrows point north; red arrows point south. Consistent with the RSH (Fig. 1B), most species centered in the East and Northwest have fecundity centroids south of adult distributions (red arrows in E). Consistent with the CTH, species of the interior West have fecundity centroids northwest of adults (blue arrows). Recruitment is shifted north of fecundity for most species (blue arrows in F). SI Appendix, Fig. S2 shows that uncertainty in vectors is low.The “reproductive-sensitivity hypothesis” (RSH) proposes that recruitment may limit population growth in cold parts of the range (Fig. 1C), where fecundity and/or seedling survival is already low. Cold-sensitive reproduction in plants includes late frost that can disrupt flowering, pollination, and/or seed development, suggesting that poleward population frontiers tend to be seed-limited (40–44). While climate warming could reduce the negative impacts of low temperatures, especially at northern frontiers, these regions still experience the lowest temperatures. The view of cold-sensitive fecundity as a continuing rate-limiting step, i.e., that has not responded to warming in Fig. 1C, is intended to contrast with the case where warming has alleviated temperature limitation in Fig. 1B. Lags can result if cold-sensitive recruitment naturally limits growth at high-latitude/high-altitude population frontiers (Fig. 1C). In this case, reproductive sensitivity may delay the pace of migration to an extent that depends on fecundity, recruitment, or both at poleward frontiers. The arrows in Fig. 1C depict a case where optimal fecundity is equator-ward of optimal growth and recruitment. The precise location of recruitment relative to fecundity in Fig. 1C will depend on all of the direct and indirect effects of climate, including through seed and seedling predators and disturbances like fire. Fig. 1C depicts one of many hypothetical examples to show that climate variables might have opposing effects on fecundity and recruitment.Both CTH and RSH can apply to both temperature and moisture; the latter is here quantified as cumulative moisture deficit between potential evapotranspiration and precipitation, D=∑m=112(PETm−Pm) for month m, derived from the widely used Standardized Precipitation Evapotranspiration Index (45). Whereas latitude dominates temperature gradients and longitude is important for moisture in the East, gradients are complicated by steep terrain in the West, with temperature tending to decline and moisture increase with elevation.We quantified the transitions that control population spread, from adult trees (BA) to fecundity (seeds per BA) to recruitment (recruits per kg seed) (Fig. 1A–C). Fecundity observations are needed to establish the link between trees and recruits in the migration process. They must be available at the tree scale across the continent because seed production depends on tree species and size, local habitat, and climate for all of the dominant species and size classes (13, 46). These estimates are not sufficient in themselves, because migration depends on seed production per area, not per tree. The per-area estimates come from individual seed production and dispersal from trees on inventory plots that monitor all trees that occupy a fixed sample area. Fecundity estimates were obtained in the MASTIF project (13) from 211,000 (211K) individual trees and 2.5 million (2.5M) tree-years from 81 species. We used a model that accommodates individual tree size, species, and environment and the codependence between trees and over time (Fig. 1C). In other words, it allows valid inference on fecundity, the quasisynchronous, quasiperiodic seed production typical of many species (47). The fitted model was then used to generate a predictive distribution of fecundity for each of 7.6M trees on 170K forest inventory plots across the United States and Canada. Because trees are modeled together, we obtain fecundity estimates per plot and, thus, per area. BA (m² /ha) of adult trees and new recruits into the smallest diameter class allowed us to determine fecundity as kg seed per m² BA and recruitment per kg seed, i.e., each of the transitions in Fig. 1A.Recruitment rates, rather than juvenile abundances, come from the transitions from seedlings to sapling stages. The lag between seed production and recruitment does not allow for comparisons on an annual basis; again, residence times in a seedling bank can span decades. Instead, we focus on geographic variation in mean rates of fecundity and recruitment.We summarized the geographic distributions for each transition as 1) the mean transition rates across all species and 2) the geographic centroids (central tendency) for each species as weighted-average locations, where weights are the demographic transitions (BA to fecundity, fecundity to recruitment, and BA to recruitment). We analyzed central tendency, or centroids (e.g., refs. 3 and 34) because range limits cannot be accurately identified on the basis of small inventory plots (21). If fecundity is not limiting poleward spread (CTH of Fig. 1B), then fecundity centroids are expected to be displaced poleward from the adult population. If reproductive sensitivity dominates population spread (RSH of Fig. 1C), then fecundity and/or recruitment centroids will be displaced equator-ward from adult BA. The same comparisons between fecundity and recruitment determine the contribution of recruitment to spread.     

Geographic, seasonal, and precipitation chemistry influence on the abundance and activity of biological ice nucleators in rain and snow

Biological ice nucleators (IN) function as catalysts for freezing at relatively warm temperatures (warmer than −10 °C). We examined the concentration (per volume of liquid) and nature of IN in precipitation collected from Montana and Louisiana, the Alps and Pyrenees (France), Ross Island (Antarctica), and Yukon (Canada). The temperature of detectable ice-nucleating activity for more than half of the samples was ≥ −5 °C based on immersion freezing testing. Digestion of the samples with lysozyme (i.e., to hydrolyze bacterial cell walls) led to reductions in the frequency of freezing (0–100%); heat treatment greatly reduced (95% average) or completely eliminated ice nucleation at the measured conditions in every sample. These behaviors were consistent with the activity being bacterial and/or proteinaceous in origin. Statistical analysis revealed seasonal similarities between warm-temperature ice-nucleating activities in snow samples collected over 7 months in Montana. Multiple regression was used to construct models with biogeochemical data [major ions, total organic carbon (TOC), particle, and cell concentration] that were accurate in predicting the concentration of microbial cells and biological IN in precipitation based on the concentration of TOC, Ca²⁺, and NH₄⁺, or TOC, cells, Ca²⁺, NH₄⁺, K⁺, PO₄³⁻, SO₄²⁻, Cl⁻, and HCO₃⁻. Our results indicate that biological IN are ubiquitous in precipitation and that for some geographic locations the activity and concentration of these particles is related to the season and precipitation chemistry. Thus, our research suggests that biological IN are widespread in the atmosphere and may affect meteorological processes that lead to precipitation.     

The role of nutricline depth in regulating the ocean carbon cycle

Carbon uptake by marine phytoplankton, and its export as organic matter to the ocean interior (i.e., the “biological pump”), lowers the partial pressure of carbon dioxide (pCO₂) in the upper ocean and facilitates the diffusive drawdown of atmospheric CO₂. Conversely, precipitation of calcium carbonate by marine planktonic calcifiers such as coccolithophorids increases pCO₂ and promotes its outgassing (i.e., the “alkalinity pump”). Over the past ≈100 million years, these two carbon fluxes have been modulated by the relative abundance of diatoms and coccolithophores, resulting in biological feedback on atmospheric CO₂ and Earth's climate; yet, the processes determining the relative distribution of these two phytoplankton taxa remain poorly understood. We analyzed phytoplankton community composition in the Atlantic Ocean and show that the distribution of diatoms and coccolithophorids is correlated with the nutricline depth, a proxy of nutrient supply to the upper mixed layer of the ocean. Using this analysis in conjunction with a coupled atmosphere–ocean intermediate complexity model, we predict a dramatic reduction in the nutrient supply to the euphotic layer in the coming century as a result of increased thermal stratification. Our findings indicate that, by altering phytoplankton community composition, this causal relationship may lead to a decreased efficiency of the biological pump in sequestering atmospheric CO₂, implying a positive feedback in the climate system. These results provide a mechanistic basis for understanding the connection between upper ocean dynamics, the calcium carbonate-to-organic C production ratio and atmospheric pCO₂ variations on time scales ranging from seasonal cycles to geological transitions.     

Climate regulation of fire emissions and deforestation in equatorial Asia

Drainage of peatlands and deforestation have led to large-scale fires in equatorial Asia, affecting regional air quality and global concentrations of greenhouse gases. Here we used several sources of satellite data with biogeochemical and atmospheric modeling to better understand and constrain fire emissions from Indonesia, Malaysia, and Papua New Guinea during 2000–2006. We found that average fire emissions from this region [128 ± 51 (1σ) Tg carbon (C) year⁻¹, T = 10¹²] were comparable to fossil fuel emissions. In Borneo, carbon emissions from fires were highly variable, fluxes during the moderate 2006 El Niño more than 30 times greater than those during the 2000 La Niña (and with a 2000–2006 mean of 74 ± 33 Tg C yr⁻¹). Higher rates of forest loss and larger areas of peatland becoming vulnerable to fire in drought years caused a strong nonlinear relation between drought and fire emissions in southern Borneo. Fire emissions from Sumatra showed a positive linear trend, increasing at a rate of 8 Tg C year⁻² (approximately doubling during 2000–2006). These results highlight the importance of including deforestation in future climate agreements. They also imply that land manager responses to expected shifts in tropical precipitation may critically determine the strength of climate–carbon cycle feedbacks during the 21st century.     

The early rise and late demise of New Zealand’s last glacial maximum

Recent debate on records of southern midlatitude glaciation has focused on reconstructing glacier dynamics during the last glacial termination, with different results supporting both in-phase and out-of-phase correlations with Northern Hemisphere glacial signals. A continuing major weakness in this debate is the lack of robust data, particularly from the early and maximum phase of southern midlatitude glaciation (∼30–20 ka), to verify the competing models. Here we present a suite of 58 cosmogenic exposure ages from 17 last-glacial ice limits in the Rangitata Valley of New Zealand, capturing an extensive record of glacial oscillations between 28–16 ka. The sequence shows that the local last glacial maximum in this region occurred shortly before 28 ka, followed by several successively less extensive ice readvances between 26–19 ka. The onset of Termination 1 and the ensuing glacial retreat is preserved in exceptional detail through numerous recessional moraines, indicating that ice retreat between 19–16 ka was very gradual. Extensive valley glaciers survived in the Rangitata catchment until at least 15.8 ka. These findings preclude the previously inferred rapid climate-driven ice retreat in the Southern Alps after the onset of Termination 1. Our record documents an early last glacial maximum, an overall trend of diminishing ice volume in New Zealand between 28–20 ka, and gradual deglaciation until at least 15 ka.According to the Milankovitch orbital theory of glaciation, variations in northern high-latitude summer insolation are responsible for glacial–interglacial cycles (1, 2). On this basis, it is commonly assumed that climatic changes in the Northern Hemisphere (NH) constitute the principle forcing mechanism for glaciation in the Southern Hemisphere (SH) (3). However, in recent times, this view has been challenged by studies showing that at least some glacial signals in the SH have no NH correlative or precede events in the NH by up to 1.5 ka (4–7). Although some of these patterns can be explained by an extended bipolar seesaw model, other features, including the decreasing expression of hemispheric antiphasing away from the polar regions, indicate that additional forcing mechanisms must be involved (8).A compilation of glacial records from the NH indicates that midlatitude ice sheets in North America and northern Eurasia began a major expansion phase between 33–29 ka (9). From this time onward, relative sea level reconstructions indicate a steady increase in global ice volume, until most ice sheets had reached a near-maximum extent by 26.5 ka, followed by 6–7 ky of equilibrium conditions until the onset of final retreat around 20–19 ka (9). For the midlatitude SH, specifically New Zealand (NZ), paleoecologic data (10), supported by dated glaciofluvial aggradation sequences (11), have also suggested an onset of mountain glacier growth around 30–28 ka (12). Contrary to NH ice volume trends, however, recent records from NZ may indicate that maximum glaciation in the Southern Alps occurred before 28 ka, several thousand years before the NH ice maximum (13–15). A second aspect in the debate centers on determining the precise onset of last glacial maximum (LGM) retreat (a period referred to as Termination 1 and dated to ∼19–10 ka) and the mode of this deglaciation (i.e., models of collapse versus slow recession) in NZ. Together, these issues are responsible for ongoing controversy about the evolution of the last glacial-to-interglacial transition in the SH midlatitudes and the relative importance of interhemispheric climate forcing versus regional insolation and/or synoptic forcing of SH glaciation.     

Developing a risk prediction model for 30-day unplanned hospitalization in patients receiving outpatient parenteral antimicrobial therapy

ObjectivesOutpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat a wide range of infections. However, there is risk of hospital readmissions. The study aim was to develop a prediction model for the risk of 30-day unplanned hospitalization in patients receiving OPAT.MethodsUsing a retrospective cohort design, we retrieved data on 1073 patients who received OPAT over 2 years (January 2015 to January 2017) at a large teaching hospital in Sheffield, UK. We developed a multivariable logistic regression model for 30-day unplanned hospitalization, assessed its discrimination and calibration abilities, and internally them validated using bootstrap resampling.ResultsThe 30-day unplanned hospitalization rate was 11% (123/1073). The main indication for hospitalization was worsening or nonresponse of infection (52/123, 42%). The final regression model consisted of age (adjusted odds ratio (aOR), 1.18 per decade; 95% confidence interval (CI), 1.04–1.34), Charlson comorbidity score (aOR, 1.11 per unit increase; 95% CI, 1.00–1.23), prior hospitalizations in past 12 months (aOR, 1.30 per admission; 95% CI, 1.17–1.45), concurrent intravenous antimicrobial therapy (aOR, 1.89; 95% CI, 1.03–3.47) and endovascular infection (aOR, 3.51; 95% CI, 1.49–8.28). Mode of OPAT treatment was retained in the model as a confounder. The model had adequate concordance (c-statistic 0.72; 95% CI 0.67–0.77) and calibration (Hosmer-Lemeshow p 0.546; calibration slope 0.99; 95% CI 0.78–1.21), and low degree of optimism (bootstrap optimism corrected c-statistic, 0.70).ConclusionsWe identified a set of six important predictors of unplanned hospitalization based on readily available data. The prediction model may help improve OPAT outcomes through better identification of high-risk patients and provision of tailored care.     

组织创新氛围研究对我国护理发展的启示

本文以“climate for innovation”“creative climate”“creative work environment”“创新（造）氛围”“创新（造）气氛”等为关键词,分别在EBSCO、JSTOR、Springer、Pubmed、GoogleScholar、万方与CNKI等数据库中进行文献检索,回顾了国内外组织创新氛围的概念、维度和主要测量工具的发展,重点阐述了组织创新氛围的应用效果及其对我国护理发展的启示,提示护理管理者应注重培育良好的组织创新氛围,为提升护理创新管理提供科学依据。     

基于信息熵的中医证候与季节气候关联性评价方法

介绍并采用一种基于信息熵的不确定条件下的多属性评价方法,探讨中医证候与季节关联的复杂性问题,为中医干预慢性病毒性乙型肝炎(乙肝)及其临床诊断提供参考。方法:将871例乙肝患者的中医临床资料按发病季节进行分类,然后统计各个季节不同证候的发生次数,建立评价表,利用信息熵评价方法进行计算和分析。结果:经过实例计算,对中医乙肝肝肾阴虚证在不同季节气候发生的可能性进行排序,发现乙肝肝肾阴虚证在夏季发生的可能性最大,在春季3、4月发生的可能性最小。结论:不同季节对中医证候的演化具有一定影响,能为中医临床诊断和评价提供一定的借鉴。