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Margaret P. Adam, M.D.

• University of Washington School of Medicine
• Seattle, Washington

The issue was raised frequently in these consultations and generally in negative terms and in the context of needing to reduce the practice blood pressure reducers cheap 0.25 mg digoxin amex. In their 2010 expert panel report arteria labialis superior order digoxin without prescription, Bancroft and Crosland recommended phasing out clearcutting and promote uneven-aged management and discussed the negative impacts from clearcutting in the Acadian forest at-length arrhythmia young age digoxin 0.25 mg on-line. In his expert panel report blood pressure chart kpa buy digoxin american express, Porter recommended the inclusion of clearcutting among a range of management practices that should be used heart attack high dead end counterpart digoxin 0.25 mg low price. His rationale was that if good forest management practices are encouraged and used blood pressure low symptoms safe digoxin 0.25mg, that clearcutting will naturally be reduced in favour of other practices, and therefore prohibition should not be required even though this practice may currently be overused (Porter 2010). The steering panel for the Natural Resources Strategy recommended clearcutting only be allowed by permit, which is generally not a feasible approach when so much of the harvesting is occurring on private land where the province exerts little control over harvest methods. Ultimately, the government put this target of 50% in 5 years in the 2010 policy framework and then in the 2011 policy and action plans. In the 2-year progress report, it was noted that this definition was produced, and that the department was undertaking testing to see about using the Code of Forest Practice as a means to reduce clearcutting. In light of that, they are no longer pursuing the direct objective of reducing clearcutting to 50%, but instead using ecosystem-based management and the Code of Forest Practice to encourage appropriate harvest methods where needed, and clearcutting remains a part of that harvesting method toolbox. On the surface it would appear that the objective to reduce clearcutting down to 50% was a somewhat arbitrary policy decision made largely to address strong public concern. Now that they have backed off this objective, public opposition is growing again, and it is unclear whether this was a strategic move by the department, or an attempt to appease the public and ultimately a policy mistake. Our government has initiated a significant shift in policy in forest sector development. Instead of large corporate handouts to specific companies, our focus is on innovation and solutions for the entire sector. Going forward, it is essential that the provincial government undertake planning and consultations on how to navigate this shift in the industry. Will provincial policy ultimately encourage the use of wood fibre, either primary forest products or wastes and co-products, to support the production of biofuels and biomaterialsfi Will the cautious approach to biomass electricity generation be maintained, and under what conditions might the approach become more supportivefi What are the implications for the forest in terms of the amounts and forms of wood fibre that must be harvested to support these types of emerging sectors in the industryfi How does the management of the forest for these emerging sectors relate to other forest policy objectives within the ecosystem-based management approachfi These are questions that must be addressed in the next iteration of forest policy development in Nova Scotia. The Foundation for Environmental, Social, and Economic Prosperity in Nova Scotia: A Panel of Expertise Report on Biodiversity to the Steering Panel. Summary of Nova Scotia Natural Resources Strategy Process & Publications: From 2007 to 2016. The Effects of Hurricane Juan on Management Stands Commercially Thinned in Central Nova Scotia. Nova Scotia Department of Natural Resources Forest Management Planning Forest Research Report. Nova Scotia Forest Inventory Based on Forest Inventory Permanent Sample Plots Measured Between 1994 and 1998. Nova Scotia Forest Inventory Based on Permanent Sample Plots Measured Between 1999 and 2003. The Roots of Sustainable Prosperity in Nova Scotia: An Expert Panel Report on Forests to the Steering Panel. Gaps were identified when comparing the Nova Scotia State of Forest report to the national report and those from Ontario and British Columbia; these included consistent reporting of trends, data confidence, data sources, targets, and thresholds. An adaptive, globally respected, and science-based framework of Criteria and Indicators for sustainable forest management in Canada has been available since 2003. Missing ecological indicators include landscape connectivity indicators, compliance rates with Wildlife Habitat and Watercourses Protection regulations, and non-compliances reported by third party certification auditors. There are numerous technical considerations in the choice of reference points for data presented for each indicator. Efforts should be made, however, to provide data with the longest time series available for each indicator, and clear explanations must be provided to justify the choice of years provided. Recommended research priorities include the following: collaborative development of locally relevant criteria and indicators from the national framework; data collection for social indicators; forest ecosystem carbon storage by forest type and age class. Other jurisdictions outside of Canada were also considered and exemplary criteria and indicators from the United States and Australia are provided. This was undertaken by reviewing the key documents and websites listed in Appendix 1. There was not sufficient time for direct personal communications with experts to verify currency of online documents for interprovincial comparisons of State of Forest reports. Data from other sources including the National Forestry Database, Statistics Canada, Nova Scotia Registry of Buyers, and Global Forest Watch were downloaded and analyzed. In those four reports as well as State of Forest reports from British Columbia, Saskatchewan, and New Brunswick, methodology and data sources were provided. As reports from other jurisdictions have demonstrated, it is not necessary for full details to be provided about statistical analysis but it is in the public interest that indicators are presented clearly and that their analysis is scientifically defensible and referenced. Throughout the report explanations about why a trend is increasing or decreasing. Despite the considerable resources spent to develop frameworks, the full potential of criteria and indicators remains untapped for sustainable forest management and has yet to be integrated in prospective analyses in the development of forest policy (Duinker 2011). Other indicators, which may be difficult but not impossible to quantify, and are of great public interest, include: 2. Other jurisdictions, including Prince Edward Island, Northwest Territories, and Saskatchewan include criteria for which no data are currently available. A 2006 study on carbon storage in Red spruce forests in Central Nova Scotia indicated that total site carbon storage increases throughout stand development. Carbon peaked in the 81 to 100 year age class indicating that rotations in this time frame maximize carbon storage (Taylor et al. There have also been recent studies in Nova Scotia and the northeastern United States that indicate that harvesting frequency and structural retention significantly affect mean carbon storage within the soil, particularly within soil depths greater than 20 cm (Prest et al. Simply reporting on annual net change in forest ecosystem carbon based on harvesting levels is not a true reflection of carbon storage and release. Non-compliances are noted and made publicly available so data limitation is not a problem. Crown land management also requires both pre-and post treatment assessments for which data should be available. Key physical and biological attributes of streams and adjacent riparian areas were assessed after logging and compared to reference conditions found in mature, undisturbed forest stands. We recommend that future State of Forest reports should describe current soil nutrient modelling, and provide available data even if they are just from pilot study sites. Nova Scotia exported an average of $247,944 per year worth of Maple Products between 2008 and 2012 (Figure 1; Agriculture and Agri-Food Canada January 2014). Nature-related expenditures by residents of Nova Scotia on these and other nature related activities, including recreation, education, fishing and photography, totaled an estimated $973m in 2012 (Federal, Provincial, and Territorial Governments of Canada, 2012 p. Nova Scotia Maple Products Export Revenue from Agriculture and Agri-Food Canada January 2014. Many private landowners consider price to be an important factor driving participation in the forestry sector. Data on forest product prices may be available from the Registry of Buyers but they are not presented in annual reports. With the time and resources we had available, we were able to present data from Digby County from 1998-2017 showing that prices have remained fairly constant (Figure 2). It would be informative to compare prices to costs associated with forest harvesting. Anecdotally, it is well understood that operational costs increased between 1998 and 2017. Roadside logs/pulps (Canadian dollars not adjusted for inflation) paid by Bowater Mersey Paper Company (1998-2012) and Harry Freeman & Son Limited (2012-2017) to woodlot owners in Digby County. According to the Gardner-Pinfold report (2016), there were 6100 direct and 5400 spinoff jobs in the forestry sector suggesting that indirect jobs are may be as important as direct jobs and should be presented. More research is needed to understand why the trends for support activities differ from the other direct forestry sector jobs. Ontario identifies Communities of Concern based on three measures of resiliency and forest dependency (socioeconomic, lifestyle, and economic) and then calculates trends in their number through time. The number of active sawmills, which has declined dramatically, is another relevant social indicator about the distribution of benefits for which data are available in Nova Scotia (Registry of Buyers). The most recent data suggest that there were 85 active sawmills and 2 active pulp and paper mills in Nova Scotia in 2016 compared to 267 active sawmills and 3 active pulp and paper mills in 2000 (Registry of Buyers 2016). Sawmill production increased quickly during the 1990s and stayed high until 2005 but then decreased quickly for ten years until 2015 (Figure 3). Sawmill production Nova Scotia 1965-2015 from Registry of Buyers of Primary Forest Products 2015 Calendar Year (June 2016). In addition to the silviculture programs reported in the State of the Forest 2016 report, some consideration could be given to reporting other programs. Road programs have been administered by Forests Nova Scotia for the last fifty years to private landowners. All these programs, as well as those that could benefit sawmills, pulp mills, and other industry players could be reported as an indicator. There are likely statistical tools available to accommodate changes in sample size that occurred after 1998. Provincial forest area by age classes over 61 years as percentage of total forest area from 1958- 2003. It is more difficult for the public to understand harvest volume than harvest area. Data on area harvested since 1994 are readily available in the National Forestry Database (Figure 6), and show an overall declining trend when all land tenures are summed. Historical Harvest Levels for Nova Scotia 1935-2015 from Registry of Buyers of Primary Forest Products 2015 Calendar Year (June 2016).

The total number of child behaviour problems was significantly correlated with parenting stress (Reber et al 1987) hypertension 95th percentile order digoxin 0.25mg online. This discrepancy could reflect the different times that two studies were carried out blood pressure norms discount digoxin 0.25 mg line, as a number of refinements have made to the low-Phe diet over the past 60 years (Singh et al 2014) hypertension pamphlet purchase 0.25 mg digoxin free shipping. It bears consideration that these two studies emanated from the same research group pulse pressure 57 cheap 0.25 mg digoxin mastercard, which used the same research methods and outcome measures arrhythmia signs discount 0.25 mg digoxin mastercard. This could account for the similar findings reported (Kazak 1987; Kazak et al 1988b) blood pressure negative feedback loop buy digoxin mastercard. Families who experienced financial difficulties providing low-protein products for their child had significantly higher depression and anxiety scores compared to families who experienced little or no difficulties (Gunduz et al 2015). However, as these findings emanate from the same research group, it is possible that they represent the specific expectations of the authors or funding body, leading to circular lines of investigation. This too, could lead to repetitive findings being reported in the research literature. Personal stress and marital satisfaction were highly significantly negatively correlated for both mothers and fathers (Kazak 1987). One study found main effects for distress with smaller social networks and greater network density (Kazak et al 1988a). A possible reason for this trend is due to differences in the way mothers and fathers perceive and utilise social support (Kazak et al 1988a). As previously stated, it is possible that these findings are influenced by changes to the low-Phe dietary guidelines over the past 60 years (Singh et al 2014). In addition, escape-avoidance coping was significantly correlated with reported distress (Lord et al 2008). Other findings show anxiety and depression were highly significantly correlated with each other (Gunduz et al 2015). Therefore, the findings are not directly comparable with those reported in the other studies. Fifteen studies measuring quality of life, parenting stress and psychological distress were examined. Four studies revealed demographic variables significantly predicted parental well-being and three reported statistically significant correlations. There was also a trend for 25 increasing child age to be associated with improved parental well-being. These findings are supported by studies with parents of children with developmental delay and type 1 diabetes, which highlight the role of the demographic variables in parenting stress and coping (Barak-Levy and Atzaba-Poria 2013; Streisand et al 2005). However, it should be noted that three of the reviewed studies reported non-significant correlations between demographic factors and parental well-being. Social support was the next most reproducible factor related to parental well-being, identified in six of the reviewed studies. Larger, more dispersed social networks were associated with reduced psychological distress in parents, particularly mothers, and perceived social support mediated the impact of family stress on quality of life. Similar findings are reported in the literature on children with long-term conditions (Horton and Wallander 2001), including cancer and congenital heart disease (Speechley and Noh 1992; Tak and McCubbin 2002). A recent study by Thomas et al (2017) also found fewer people in the social network and poor satisfaction with social support were related to worse health related quality of life in parents of children with a range of inherited metabolic conditions. Three studies found psychological variables significantly predicted well-being and one study reported a significant correlation. Two studies found a significant correlation between child behaviour and parental well-being and one study reported child developmental level (as measured by adaptive behaviour) was a significant predictor of well-being. Due to the low numbers of studies represented here, further research is needed to clarify the implications of these findings in relation to parental well-being. Limitations Firm conclusions cannot be drawn from the research findings due to heterogeneity in the study methodologies, outcome measures and statistical analyses used. Overall, sample sizes were small and few studies provided detailed information on the sample characteristics. This meant it was difficult to discern the representativeness of the samples included. Recommendations for clinical practice There are a number of recommendations for professionals working in clinical settings based on the findings reviewed. For example, it may be beneficial for professionals to routinely assess parental well-being to identify individuals who require additional support. Families may benefit from support programmes that focus on empowering parents to actively seek out a range of social relationships and broaden their social networks (Fidika et al 2013). A small number of studies identified a link between 28 psychological variables, child behaviour, the demands of managing treatment and parental well-being. In summary, demographic variables and social support were the two most widely reported factors associated with parental well-being. Barak-Levy Y, Atzaba-Poria N (2013) Parental versus maternal coping styles with child diagnosis of developmental delay. Sirriyeh R, Lawton R, Gardner P, Armitage G (2012) Reviewing studies with diverse designs: the development and evaluation of a new tool. Smith I, Knowles J (2000) Behaviour in early treated Phenylketonuria: A systematic review. Study Design Comparison group Country Primary aim Cohort characteristics Total score/ quality range 10 Mahmoudi- Cross- None Iran To investigate quality N=49 parents, mean age 35. Moderate al disease dependence on health services in mothers of N= 29 mothers of children with mitochondrial disease. High Fahrbach K al genetic disorders, stress in parents of et al (2004) including: children with Median family size= 2 children, 54% of children boys, galactosemia; biochemical genetic 46% girls, age range= 6 months-18 years old. Statement of aims/objectives in main body of the 3 3 3 2 3 3 3 3 3 2 3 3 2 3 3 report 3. Evidence of sample size considered in terms of 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 analysis 5. Representative sample of target group of a 3 2 2 1 1 1 1 2 2 1 1 2 3 3 1 reasonable size 6. Statistical assessment of reliability and validity of 1 0 1 0 1 3 2 3 3 1 3 3 1 2 3 measurement tools 10. Fit between stated research question and method 3 3 3 2 3 3 3 3 3 3 3 2 3 2 3 of data collection 11. Fit between research question and method of 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 analysis 12. Good justification for analytical method selected 3 3 2 1 0 1 1 3 3 1 2 3 3 1 0 13. Strengths and limitations critically discussed 3 3 3 2 1 2 2 3 3 2 2 3 2 3 3 Total score 32 31 28 20 22 29 28 34 33 23 25 34 30 30 30 40 Table 3. Simple mediation analysis to examine the relationship between Perceived social support mediated the impact of family social support, perceived stress and quality of stress on quality of life. Multiple -Parents with a lower academic attainment level Inventory regression analysis was used to examine the -Difficulty providing low protein products predictors of anxiety and depression. Cohort Age Measure of Measurement tool Analysis Overview of the factors associated with psychological size of range of psychological functioning parents children functioning 4 37 4-14 Coping Coping Strategies the Student t-test and Mann-Whitney U-test Parents who reported feeling anger and guilt also years old Questionnaire were used to compare mean scores on the reported significantly more child behavior problems on questionnaire domains between the samples. Child anxiety, depression, somatic complaints and internalising behaviour were significantly correlated with emotional coping in parents. Statistical -Lower impact of the disease on aspects of personal life significance was interpreted at the p<. Paired samples t-tests were also used to compare subscale scores with the change in this relationship was not significantly correlated with trauma levels over time. Statistical age of the parent, number of years since the diagnosis or significance was interpreted at the p<. Stress Index adaptability; marital satisfaction; child No significant correlations between Phe control and behaviour; demographic variables and child distress, parenting stress, marital adjustment, family cognitive development scales. University of Manchester, School of Psychological Sciences this paper has been written for submission to the Journal of Inherited Metabolic Disease. The word count in this version has been extended to provide additional information. Word count abstract: 246 Word count excluding abstract, tables and references: 5,494 Number of tables and figures: 4 *Corresponding author: Dr Dougal Julian Hare, HareD@cardiff. By comparison, psychological resilience and generic child behaviour only accounted for 19% of the variance in distress for parents in the general population. Future research should include larger, more diverse samples and use longitudinal study designs. The condition is caused by a deficiency or absence of phenylalanine hydroxylase, an enzyme needed to convert amino acid phenylalanine (Phe) into tyrosine (Moyle et al 2007). In the absence of this enzyme, toxic levels of Phe accumulate in the central nervous system, leading to irreversible damage to brain structures and cognitive function (Blau et al 2010). This concept is widely used as an indicator of mental health status in clinical, population and intervention studies (Drapeau et al 2012). Research into psychological distress 48 has encompassed a range of outcome measures, such as measures of stress, quality of life, well-being and depression (Masse et al 1998; Ridner 2004). The findings revealed that mean scores on generic quality of life domains were comparable to the general population. Findings from research into long-term conditions, such as asthma, indicate that a sense of coherence and family hardiness predicts parental well-being (Svavarsdottir et al 2000). High levels of parenting stress have also been reported in parents of young children with type 1 diabetes (Streisand et al 2005). Satisfaction with social support 49 was associated with parental quality of life in research on a range of inherited metabolic conditions (Thomas et al 2017). However, these findings are not consistent across studies, as some report non-significant relationships between demographic variables, the demands of managing treatment and parental distress (Gunduz et al 2015; Reber et al 1987). A recent systematic review also identified a number of limitations in the current literature, including heterogeneity in study methodologies, small sample sizes and an overall lack of studies (Ambler and Hare in press). Another factor that could affect distress in parents of children who have long-term conditions is the presence of child emotional and behavioural problems (Craig et al 2016).

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A full understanding of the costs primary cell walls plus middle lamella of the adjacent conduits arteria obturatriz discount digoxin 0.25 mg fast delivery. Hydrolysis during xylem cell death is thought to remove all hemicelluloses and a debatable portion of pectins from the pit membrane blood pressure medication in the morning or at night purchase digoxin canada, leaving a porous cellulosic mesh of microfibrils Confining embolism with inter-conduit pitting (Butterfield 1995) pulse pressure change during exercise buy digoxin 0.25mg otc. Pit membrane chemistry pulse pressure 19 buy digoxin uk, structure prehypertension hypertension stage 1 order generic digoxin from india, and development of themselves arteria vertebral best order for digoxin, much of a tension, i. Pits consist of openings in the secondary wall (apertures) leading to pit chambers that are spanned by a pit membrane which is the modified primary cell wall and middle lamella of the adjacent vessel elements. Structure and function of inter-conduit pits in efficiently as an ideal cylindrical capillary tube of the same conifer tracheids (left) and angiosperm vessels (right). The most extensive survey indicates that adding inter-conduit (A) Pit membranes, face view. The lower number for vessels (C) Schematic of pit location within conduit network. What is surprising is that the greater length of vessels does not have more of often with no pores detectable, whereas inter-tracheid pits an effect: if inter-vessel pits have the same area-specific pit of conifers have a highly porous margo (pores 500 nm) resistance as inter-tracheid pits, placing the end-walls 10 times (Petty and Preston 1969) peripheral to a central thickened torus further apart should increase lumen resistivity by less than a (Figure 16A, left). In this way, the torus can seal off the pit with a sufficiently to infiuence xylem fiow resistance in a very complex and poorly negative Pmin to minimize air passage (Figure 16D). Skepticism about the the vapor pressure of water, and also below pure vacuum for importance of the phenomenon in planta (Van Iepeeren 2007) a gas (Canny 1998; Zimmermann et al. Finally, we need to add the typical P of by xylem-phloem exchange (Zwieniecki et al. However, recent observations with mechanism to operate, transition from the liquid phase to the atomic force microscopy do not support a pore-widening effect. The extent of strong atomic and intermolecular bonds allow it to be placed pectins or similar gel materials in pit membranes appears to be under tension; i. Uncertainty scopic world of normal human experience, hence the cohesion- about the extent of hydrogel components of pit membranes has tension skeptics. Water boils at 100fiC, and vacuum pumps be- led to an alternative (and perhaps complementary) hypothesis come gas-locked at or above fi0. But in these familiar that ions increase permeability by reducing the diffuse-double cases, the phase change to vapor (cavitation) is nucleated by layer of cations lining negatively charged nano-scale pores contact with foreign agents that destabilize the inter-molecular in the membrane (Van Doorn et al. Experiments with a variety of systems ranging from the meniscus with a Pmin negative enough to hold against a centrifuged capillary tubes to water-filled quartz crystals have substantial range of negative P values (Figure 16D). Species can differ considerably in their maximum hydraulic conductivity (x axis intercept) and how readily they lose it to cavitation (from Hacke et al. Stems or roots are spun in a custom Considerable attention has been given to how the structure centrifuge rotor that places their xylem under a known tension of inter-conduit pitting relates to its function in cavitation re- at the center of rotation. In conifer tracheids, where torus aspiration seals the during or between spinning, and the experiment is continued pits, it has been proposed that air-seeding occurs when the pit until the conductivity has dropped to negligible values, thus membrane is stretched sufficiently to displace the torus from indicating complete blockage of fiow by cavitation. Typical the aperture, exposing part of the margo through which air can species-specific variation is shown in Figure17A, and Figure17B readily pass (Figure 16D). Displacement has been observed mi- compares the P value causing complete loss of xylem con- croscopically, and conifers that are more resistant to cavitation ductivity with the minimum P values measured in nature for generally have less fiexible pit membranes, and can have a 102 species (Sperry 2000). Clearly, the xylem of some species torus that covers the aperture with greater overlap (Sperry and cavitates much more readily than others, but these vulnerable Tyree 1990; Domec et al. In some conifers, air-seeding could also occur through cohesion-tension mechanism. In support of these mechanisms is a depen- Although the centrifuge method is widely accepted for dence of Pmin on the sap surface tension (Cochard et al. However, it is not clear controversy about its ability to measure the vulnerability of long- whether sap solutions that lower the surface tension also alter vesseled taxa where many conduits can exceed the length of pit membrane fiexibility and, hence, the ease of torus displace- the spinning conductivity segment. It is also unclear whether the torus-margo membrane can taxa indicate that a significant number of these large vessels de-aspirate to function a second time if the embolized tracheids cavitate at very modest negative P values. In angiosperm inter-vessel pits, air seeding probably occurs Comparisons with other methods have verified this type of by displacement of the air-water meniscus from pores in curve in many (Christman et al. The Pmin of membrane, or perhaps created or enlarged by the partial inter-conduit connections is easily measured from the positively or complete aspiration of the membrane that likely precedes applied gas pressure that just breaches their seal (Christman the air-seeding (Thomas 1972). From a variety of techniques employed across a strength is indicated by the effects of removing Ca2+ from wide range of species, the Pmin range of inter-conduit pitting the membrane using various chelators such as oxalic acid. In consequence, vulnerability curves can conductivity, but they can dramatically increase membrane usually be reproduced using positive gas pressures rather than fiexibility and vulnerability to cavitation (Sperry and Tyree 1988; placing the xylem sap under tension (Cochard et al. The sap P in the cavitated conduit immediately deformed the membrane to make it more porous. Cavitation rises to 0, and the sap is very quickly drained out of the conduit fatigue is potentially reversible in vivo and with artificial xylem by the surrounding transpiration stream until the entire conduit saps, suggesting the stressed and air-seeded pit membrane becomes filled with water vapor and air, the exact composition can be restored back to its normal form (Hacke et al. According to this the possibility that pores are created by mechanical stress model, cavitation and embolism can propagate from conduit- on the pit membrane is also consistent with the typical rarity of to-conduit via pit failure. Thus, the mean there are few to no pores in the non-stressed water con- same cavitation resistance is likely to be achieved by multiple ducting pit membrane, with water penetrating the hydrated gel structural combinations. Freezing of the xylem sap in nature chamber wall, a factor that must lie behind the elusive adaptive usually occurs under conditions where transpiration is minimal. Instead, P would likely An additional complexity in linking cavitation resistance to become less negative, or even become positive because of pit structure is a seemingly inescapable role for probability. However, dissolved gases in the sap are single inter-conduit seal consists of hundreds if not thousands insoluble in ice, and under typical freezing conditions will form of individual pits. Not all of these pits will be created equal, and bubbles in the middle of the conduit. Hence, cavitation seal, the weaker the seal will be, because by chance the would occur during the thawing rather than the freezing phase, leakier will be the leakiest pit (Wheeler et al. This will a prediction supported by experimental observation (Mayr and be true whether the air-seeding pores are pre-existing, or are Sperry 2010). This hypothesis is supported Just as for cavitation by water stress, there is considerable by the general trend for larger vessels to be more vulnerable variation between species in their vulnerability to freeze-thaw to cavitation (because they would have more pits), and by a cavitation. It is scarcely detectible in some species regard- correlation between the extent of inter-conduit pit area and less of the negative sap P values, and others are blocked increasing vulnerability (Hacke et al. However, unlike the both pit quantity and pit quality interact to set the P value at water stress situation, there appears to be a single structural which air-seeding occurs and, hence, the cavitation resistance variable of over-riding importance for determining vulnerability (Lens et al. That variable is the xylem conduit Because cavitation appears to spread from conduit to con- lumen diameter: wider conduits are uniformly more susceptible duit, the three dimensional connectivity of the conduit network to cavitation than narrower ones, regardless of whether the should have an additional impact on cavitation resistance. Woody species differ considerably in the extent of overlap the simplest explanation is that wider vessels form larger or connectivity between individual conduits (Carlquist 1984). A greater vessel grouping index (higher connectiv- a given conduit diameter (Langan et al. Similarly, the amount of embolism should rather than enhanced vulnerability (Lens et al. This decrease with a greater rate of freezing, which reduces gas trend supports the earlier notion that the greater redundancy bubble size (Sevanto et al. However, experiments indicate no loss of conductivity when stems frozen under negative P conditions are thawed at atmospheric pressure; the conductivity only drops when the thaw occurs under negative P values (Mayr and Sperry 2010). It is possible that other phenomena besides conduit cavitation are causing freezing-associated acoustic emissions. Importantly, not all embolism events during winter are necessarily caused by freeze-thaw cycles. Sublimation and cavitation by water stress in thawed and transpiring crowns with frozen boles or soil represent other potential causes (Peguero-Pina et al. Negative xylem sap P and conduit collapse the cohesion-tension mechanism requires conduit walls that are sufficiently rigid to withstand collapse by the required negative P values. Hence, the evolution of secondary walls and lignification necessarily paralleled the evolution of xylem tissues. While many factors contribute to the strength of conduit walls to prevent implosion, a dominant variable is the ratio of wall thickness to conduit lumen radius. This ratio tends to increase with cavitation resistance, as expected from concomi- tantly more negative sap P values. A higher thickness-to-span ratio also increases wood density, consistent with the tendency for greater wood density in more cavitation-resistant trees that generally experience more negative P values (Hacke et al. The lower value for vessels presumably refiects their minimal role in mechanical support of the tree, a function performed by wood fibers. Vulnerability of xylem to cavitation by freeze-thaw However, conifer tracheids must be additionally reinforced events. Freezing of a sap-filled functional vessel creates tracheids of pine needles (Cochard et al. If bubbles persist long tracheids of podocarps (Brodribb and Holbrook 2005), and enough after thawing, and negative pressures are low enough, they metaxylem vessels in maize (Kaufman et al. In each will trigger cavitation and result in an embolized conduit (from Sperry case, the collapse was apparently reversible. Data are species averages for angiosperm vessels (black) and conifer tracheids (blue) (from Pittermann and Sperry 2003). It is the cohesion-tension mechanism, and its limitation by cav- possible that the lower ice temperature and consequent tissue itation and conduit collapse, suggest potential trade-offs in dehydration creates, locally, a more negative sap P, post- the xylem conduit structure for minimizing fiow resistance on thaw (Ball et al. Acoustic emissions are often without cavitation or conduit collapse on the other hand (safety). Tradeoffs arise cost them in terms of greater fiow resistance and vascular because narrower lumens would have exponentially greater construction costs. Conversely, xeric-adapted species that fiow resistance, and higher thickness-to-span increases con- periodically endure more negative P values must be more struction costs. Greater resistance to cavitation by freeze-thaw resistant to cavitation, and their consequently greater fiow cycles also comes at the expense of narrower lumens, and resistance and construction costs competitively exclude them consequently, higher fiow resistance per conduit (Davis et al. Resistance to freeze-thaw embolism can, in turn, trade- is that species tend to be only as resistant to cavitation as they off with photosynthetic capacity in evergreen species (Choat have to be for the native P range they experience over their et al. Enhanced resistance to cavitation by water stress also tends the limiting process of cavitation naturally constrains the to be associated with higher fiow resistances, as seen in the xylem P over which productivity can be sustained. The an important adaptive advantage of stomatal regulation of P more vulnerable species tend to have higher initial hydraulic is to keep it from reaching such negative values that would conductivities than the more cavitation-resistant ones. While intuitively one might expect that pits which are and it is a dramatic and quick cause of mortality (Holtta et al. Estimates of pit fiow resistances across directly prevent the gradual accumulation of cavitation as the several angiosperm and conifer species showed no relationship xylem P becomes more negative due to limited soil water with cavitation resistance (Pittermann et al. Furthermore, the drop in fiow resistance via the ionic shifts push plants towards excessive cavitation, resulting in effect on pit membranes had no effect on cavitation resistance partial or complete dieback from chronic reductions (70% or (Cochard et al. Instead, the efficiency-safety trade-off greater) in hydraulic conductivity from cavitation (Anderegg may arise at the whole-conduit and conduit-network scale. Soil-plant-atmosphere models rare pit hypothesis were correct, greater cavitation resistance that incorporate cavitation resistance can be successful in would require fewer pits per conduit, which would generally predicting responses of vegetation to drought (Sperry et al. The refilling of embolized xylem conduits has been documented the fiow resistance penalty of narrower and shorter conduits in numerous studies. Embolisms accumulating over the winter can be compensated by increasing their number per wood from freeze-thaw cycles and other causes can be reversed in area (Hacke et al. Diurnal embolism and refilling cycles have also been to tracheids and, thus, achieve similar whole stem hydraulic documented (Stiller et al. For of structure can be compensated for at another scale, vastly this to happen, at a minimum, transpiration must be negligible complicating the adaptive interpretation of wood structure and and the soil w must be close to zero. Less observed correlation between cavitation resistance and the negative P values, even positive values, could develop from range of native sap P values (Figure 17B). Accordingly, mesic- foliar uptake of rain or dew, and especially from osmotically 338 Journal of Integrative Plant Biology Vol. Water entered empty vessels from the also develop positive stem P values in response to freeze- direction of the rays, a pattern consistent with phloem-directed thaw cycles in early spring (Tyree and Zimmermann 2002). There was no obvious ated with bulk refilling in a variety of woody and herbaceous mechanism to prevent drainage of the accumulating water back plants (Sperry 1993; Stiller et al. The natural failure stayed partially embolized depended on the difference between of root pressure and spring refilling, owing to freezing-related the rate of water infiux from the rays, versus drainage to mortality of shallow roots, has been linked to birch dieback the surrounding transpiration stream. Diminishing root pressure variation in the onset, rate, and eventual success or failure, in with plant height has also been invoked as a limit to the stature the plants imaged. Nevertheless, the results too negative to allow sap to move back into the embolized con- lend strong support to a phloem-coupled refilling mechanism duits (Salleo et al. There must be a pumping mechanism that refills by pumping water into the embolized vessels faster that brings sap into the embolized conduit and keeps it there than it is withdrawn. The pumping mechanism is unknown, but several hypotheses have been proposed (see Engineering xylem properties: A path to increased Nardini et al.

Risk assessment the designated person should assess and document the risk as soon as possible after every incident of occupational exposure blood pressure zetia buy discount digoxin online, referring to the expert information network as required (see attachment 1) arrhythmia and palpitation generic 0.25 mg digoxin otc. In an occupational setting a risk assessment should be conducted on the basis of the type of exposure and the amount and type of infectious material involved hypertension guidelines aha buy generic digoxin on line. A risk assessment should be undertaken based on the degree of exposure blood pressure chart age 50 order discount digoxin on line, guided by the information in Table 1 and Table 2 blood pressure below 60 purchase digoxin with a mastercard. If these baseline tests are positive heart attack gun buy digoxin 0.25mg on line, more specific testing of viral load may be indicated. Confidentiality should be maintained, not only of the source individual, but also regarding the current exposure. Testing of needles or other sharp instruments implicated in an exposure, regardless of whether 1 the source is known or unknown, is not recommended. Confidentiality should be maintained, not only of the exposed person, but also regarding the current exposure or injury. Serum should be stored for at least 12 months to enable parallel testing if necessary. During the follow up period, the exposed person is not required to take any special precautions while at work to prevent secondary transmission other than following standard precautions as recommended for all healthcare workers. The exposed person should be advised of the following measures to prevent secondary transmission: not to donate plasma, blood, organs, body tissue, breast milk or sperm4 exercise sexual abstinence or use condoms to prevent sexual transmission and avoid pregnancy4 Management of occupational exposure to blood and body fluids 2017 -8- 4 seek expert medical advice regarding breastfeeding and/or pregnancy. The designated medical officer should seek the advice of an appropriate medical specialist prior to commencement of antiretroviral therapy. Attachment 4 contains an information sheet on the medication contained in the starter pack. Exposures from a source taking antiretroviral therapy should be discussed with an expert from the Expert Information Network (Attachment 1), as the exposed person may need to be treated with a different combination of drugs. The designated medical officer should document the decision of the exposed person to accept or decline treatment. Hepatitis B vaccination or proof that an individual is not susceptible to hepatitis B is a condition of employment for all Queensland Health staff who have direct contact with patients or who in the course of their work may be exposed to blood/body fluids or contaminated sharps. The decision to accept or decline treatment is that of the exposed person, and should be documented. For further information refer to the current edition of the Australian Immunisation Handbook, available at. The exposed person should be advised that during the follow up period they should refrain from donating plasma, blood, organs, body tissue, breast milk or sperm. The exposed person should also be advised to attend for evaluation if they become unwell with symptoms consistent with acute hepatitis such as nausea, vomiting, abdominal discomfort or jaundice. Care when the exposed person is a patient When the exposed person is a patient, the same requirements as for occupational exposures should be applied. For Queensland Health facilities, staff should follow the processes outlined in the Queensland Health Clinical Incident Management Policy including Root Cause Analysis and Open Disclosure. Commonwealth of Australia Management of occupational exposure to blood and body fluids 2017 -16- 6. Kuhar D, Henderson D, Struble K, Heneine W, Thomas V, Cheever L, Gomaa A, Panlilio A. Schillie S, Murphy T, Sawyer M, Ly K, Hughes E, Jiles R, de Perio M, Reilly M, Byrd K, Ward J. Attachment 1: Expert information network Expert Information Network Advice is available 24 hours, seven days a week by the Infectious Diseases Physician on call. Attachment 2: Management of blood and body fluid exposures Management of occupational exposure to blood and body fluids 2017 -19- 7. Informed Consent for Testing Informed consent for testing means that the person being tested agrees to be tested on the basis of understanding the testing procedures, the reasons for testing and is able to assess the personal implications of the potential test results. On these rare occasions where informed consent cannot be attained, pre-test provision of all appropriate information to the person should still take place. The person performing the test should use their clinical judgment in securing informed consent. The discussion should be appropriate to the gender, culture, behaviour and literacy level of the person being tested and to their intellectual capacity. The person being tested needs to be made aware of confidentiality considerations and protections. Management of occupational exposure to blood and body fluids 2017 -20- the person who requests the test is responsible for ensuring that appropriate mechanisms are in place for delivering the test result. If the result is negative, reinforcing positive education and messages about safe behaviours, and examining any difficulties or issues that the client may have in practicing safe behaviours It is imperative that the clinician makes all attempts to ensure that the result is being provided to the person who was tested. Conveying a hepatitis B test result: susceptible (non-immune) It is imperative that the meaning of a negative (susceptible) result is fully understood and that the person being tested receives appropriate information about and opportunity for hepatitis B vaccination, and is made aware of other harm reduction strategies in relation to the spread of blood borne viruses and sexually transmissible infections. The person should be informed of the reasons why repeat testing after an interval may be necessary. In this situation the clinician should enter the person into a system for automatic recall, rather than relying on the person to follow up on their own initiative. When a person is identified as being immune, either through natural infection or vaccination, this should be clearly entered in their medical record and conveyed to the person, to avoid unnecessary repeat serologic testing or vaccination in the future. Patients immune through natural infection should be advised that they may be at risk in settings of immunosuppression. You will need to make an appointment to get further supplies as the medication must be continued for a total of four weeks. It is important that your doctor is aware of all the medications you currently take. At the pharmacy, you will be required to register as a patient of the hospital so that your medication can be dispensed. Body fluids In addition to blood and body fluids containing visible blood, the following fluids are considered potentially infectious: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic 1 fluid. Many of the reporting, follow-up, and treatment functions may be designated to a non-medical professional; however, some functions may not. Designated person Person employed within the position that has been designated by the Hospital and Health Service or facility to perform the functions of reporting and providing treatment and follow-up for exposed persons. This person may be in (but not limited to) an infection control position, occupational health and safety position, emergency department physician position or other medical or nursing position. For example, a needlestick injury or cut with a sharp object such as a scalpel blade8. Sharp An object or device having sharp points, protuberances or cutting edges capable of causing a penetrating injury to humans. This includes hypodermic, intravenous or other medical needles, Pasteur pipettes, disposable dental picks and drill bits, scalpel blades, lancets, scissors, glass slides and broken laboratory glass. Serological Testing Laboratory tests done on blood serum to measure antibodies against antigens of the micro-organism thought to be causing the infection. Window Period the time from exposure to seroconversion when the source may be asymptomatic or experiencing seroconversion illness. Document approval details Document custodian Dr Heidi Carroll, Medical Director, Communicable Diseases Branch Approval officer Dr Sonya Bennett, Executive Director, Communicable Diseases Branch Approval date: 25/11/2016 10. Adverse Effects of Vaccines: Evidence and Causality Adverse Effects of Vaccines Evidence and Causality Committee to Review Adverse Effects of Vaccines Board on Population Health and Public Health Practice Kathleen Stratton, Andrew Ford, Erin Rusch, and Ellen Wright Clayton, Editors Copyright National Academy of Sciences. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Centers for Disease Control and Preven- tion and the National Vaccine Program Offce also provided support through that contract. Any opinions, fndings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily refect the view of the organizations or agencies that provided support for this project. Adverse effects of vaccines: evidence and causality / Committee to Review Adverse Effects of Vaccines, Board on Population Health and Public Health Practice; Kathleen Stratton. Printed in the United States of America the serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Adverse Effects of Vaccines: Evidence and Causality the National Academy of Sciences is a private, nonproft, self-perpetuating society of distinguished scholars engaged in scientifc and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientifc and technical matters. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientifc and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Aban, Associate Professor, Department of Biostatistics, University of Alabama, Birmingham Douglas J. Barrett, Professor, Departments of Pediatrics, Molecular Genetics & Microbiology, Pathology, Immunology, & Laboratory Medicine, University of Florida College of Medicine Martina Bebin, Associate Professor of Neurology and Pediatrics, University of Alabama at Birmingham Kirsten Bibbins-Domingo, Associate Professor and Attending Physician, University of California, San Francisco Graham A. Siteman Cancer Center, and Niess-Gain Professor in the School of Medicine, Department of Surgery, Washington University School of Medicine Martha Constantine-Paton, Investigator, McGovern Institute for Brain Research; Professor of Biology, Department of Biology, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology Deborah J. Claiborne Johnston, Associate Vice Chancellor of Research; Director, Clinical and Translational Science, Institute Professor of Neurology and Epidemiology; Director, Neurovascular Disease and Stroke Center; University of California, San Francisco Anthony L. Paige Lawrence, Associate Professor of Environmental Medicine; Associate Professor of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry M. Louise Markert, Associate Professor of Pediatrics and Immunology, Division of Pediatric Allergy and Immunology, Department of Pediatrics, Duke University Medical Center 1Committee member resigned August 2010. Nguyen,2 Assistant Professor, Division of Epidemiology and Community Health, University of Minnesota School of Public Health Marc C. Patterson, Chair, Division of Child and Adolescent Neurology; Professor of Neurology, Pediatrics, and Medical Genetics; Director, Child Neurology Training Program, Mayo Clinic Hugh A. Sampson, Professor of Pediatrics and Immunology; Dean for Translational Biomedical Sciences; Director of the Jaffe Food Allergy Institute, Mount Sinai School of Medicine Pauline A. Thomas, Associate Professor, Department of Preventive Medicine and Community Health, New Jersey Medical School; and Associate Professor, School of Public Health, University of Medicine and Dentistry of New Jersey Leslie P. Chair in Neurology; Professor of Neurology and Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California Study Staff Kathleen Stratton, Study Director Andrew Ford, Program Offcer Erin Rusch, Research Associate Trevonne Walford, Research Assistant (from August 2009) William McLeod, Senior Research Librarian Hope Hare, Administrative Assistant Amy Pryzbocki, Financial Associate Rose Marie Martinez, Director, Board on Population Health and Public Health Practice 2Committee member resigned March 2010. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the deliberative process. Griffn, Vanderbilt University Medical Center Neal Halsey, Johns Hopkins Bloomberg School of Public Health Diane Harper, University of Missouri-Kansas City School of Medicine Sean Hennessy, University of Pennsylvania School of Medicine Gerald T.