Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions.

BACKGROUND: Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions. METHODS: We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m(2)) of their recommended referrals based on their use of creatinine versus eGFR. RESULTS: Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m(2), p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01). CONCLUSIONS: Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.

The impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults.

The present study examined the impact of the developmental timing of trauma exposure on posttraumatic stress disorder (PTSD) symptoms and psychosocial functioning in a large sample of community-dwelling older adults (N = 1,995). Specifically, we investigated whether the negative consequences of exposure to traumatic events were greater for traumas experienced during childhood, adolescence, young adulthood, midlife, or older adulthood. Each of these developmental periods is characterized by age-related changes in cognitive and social processes that may influence psychological adjustment following trauma exposure. Results revealed that older adults who experienced their currently most distressing traumatic event during childhood exhibited more severe symptoms of PTSD and lower subjective happiness compared with older adults who experienced their most distressing trauma after the transition to adulthood. Similar findings emerged for measures of social support and coping ability. The differential effects of childhood compared with later life traumas were not fully explained by differences in cumulative trauma exposure or by differences in the objective and subjective characteristics of the events. Our findings demonstrate the enduring nature of traumatic events encountered early in the life course and underscore the importance of examining the developmental context of trauma exposure in investigations of the long-term consequences of traumatic experiences.

Análise praxeológica e articulação de conhecimentos Matemáticos: noção de função afim no ensino médio no Brasil

El objetivo de este trabajo de investigación es identificar las organizaciones praxeológicas que permiten la articulación de la noción de función afín con otras nociones tanto en el contexto matemático como extramatemático en la Educación Media en Brasil. Los análisis se apoyan en la Teoría Antropológica de lo didáctico de Chevallard (2001) y los enfoques teóricos en términos de marcos definidos por Douady (1992) y niveles de conocimiento que se esperan de los estudiantes según la definición de Robert (1997). Tres libros de texto que fueron analizados darán una visión general de las relaciones institucionales que sobreviven actualmente en Brasil. Observamos la existencia de diferentes formas de articulación que dependen de las técnicas desarrolladas, necesitando la atención de profesores que deben proponer el mayor número posible de situaciones para que sus estudiantes puedan aplicar la noción de función afín en diferentes tareas, sean ellas escolares o no.

Changes in development timing and cohort width of Neocalanus plumchrus degree ' flemingeri copepods in the eastern North Pacific

Neocalanus plumchrus/flemingeri copepods make up a large proportion of spring mesozooplankton biomass and are a valuable nutritional source for many higher trophic levels. Copepodites through to sub-adult stage are present in surface waters for a relatively short period of time each spring, and the date of maximum biomass has been calculated as the date when 50% of the population were at the sub-adult, CV stage. This index allows quite a precise date to be calculated from relatively infrequent sampling and interannual comparisons between 1957 and 2004 have demonstrated that the timing of peak abundance is significantly advanced in warmer years. However, recent data from the Continuous Plankton Recorder survey, which samples the surface NE Pacific more frequently during spring, has found that maximum numbers of CV copepodites occur after the 50% point is reached so that maximum biomass occurs some weeks later than predicted by this index (although comparisons between years show that the magnitude of the timing shift is similar). Comparisons with depth-stratified profiles from the BIONESS show that this is not just due to single-depth near-surface sampling by the CPR. We speculate on the cause of this change which could be related to the width of the cohort (which appears to now be narrower, at least in warm years) or the length of time that the CV stage needs to spend in the surface accumulating lipid before beginning diapause. A narrower cohort has implications for predators who will have less time to take advantage of this food source.

Temperature affects the timing of spawning and migration of North Sea mackerel

Climate change accentuates the need for knowing how temperature impacts the life history and productivity of economically and ecologically important species of fish. We examine the influence of temperature on the timing of the spawning and migrations of North Sea Mackerel using data from larvae CPR surveys, egg surveys and commercial landings from Danish coastal fisheries in the North Sea, Skagerrak, Kattegat and inner Danish waters. The three independent sources of data all show that there is a significant relationship between the timing of spawning and sea surface temperature. Large mackerel are shown to arrive at the feeding areas before and leave later than small mackerel and the sequential appearance of mackerel in each of the feeding areas studied supports the anecdotal evidence for an eastward post-spawning migration. Occasional commercial catches taken in winter in the Sound N, Kattegat and Skagerrak together with catches in the first quarter IBTS survey furthermore indicate some overwintering here. Significant relationships between temperature and North Sea mackerel spawning and migration have not been documented before. The results have implications for mackerel resource management and monitoring. An increase in temperature is likely to affect the timing and magnitude of the growth, recruitment and migration of North Sea mackerel with subsequent impacts on its sustainable exploitation.

Basin-scale phenology and effects of climate variability on global timing of initial seaward migration of Atlantic salmon (Salmo salar)

Migrations between different habitats are key events in the lives of many organisms. Such movements involve annually recurring travel over long distances usually triggered by seasonal changes in the environment. Often, the migration is associated with travel to or from reproduction areas to regions of growth. Young anadromous Atlantic salmon (Salmo salar) emigrate from freshwater nursery areas during spring and early summer to feed and grow in the North Atlantic Ocean. The transition from the freshwater (parr') stage to the migratory stage where they descend streams and enter salt water (smolt') is characterized by morphological, physiological and behavioural changes where the timing of this parr-smolt transition is cued by photoperiod and water temperature. Environmental conditions in the freshwater habitat control the downstream migration and contribute to within- and among-river variation in migratory timing. Moreover, the timing of the freshwater emigration has likely evolved to meet environmental conditions in the ocean as these affect growth and survival of the post-smolts. Using generalized additive mixed-effects modelling, we analysed spatio-temporal variations in the dates of downstream smolt migration in 67 rivers throughout the North Atlantic during the last five decades and found that migrations were earlier in populations in the east than the west. After accounting for this spatial effect, the initiation of the downstream migration among rivers was positively associated with freshwater temperatures, up to about 10 degrees C and levelling off at higher values, and with sea-surface temperatures. Earlier migration occurred when river discharge levels were low but increasing. On average, the initiation of the smolt seaward migration has occurred 2.5days earlier per decade throughout the basin of the North Atlantic. This shift in phenology matches changes in air, river, and ocean temperatures, suggesting that Atlantic salmon emigration is responding to the current global climate changes.

Disentangling the impacts of heat wave magnitude, duration and timing on the structure and diversity of sessile marine assemblages

Extreme climatic events, including heat waves (HWs) and severe storms, influence the structure of marine and terrestrial ecosystems. Despite growing consensus that anthropogenic climate change will increase the frequency, duration and magnitude of extreme events, current understanding of their impact on communities and ecosystems is limited. Here, we used sessile invertebrates on settlement panels as model assemblages to examine the influence of HW magnitude, duration and timing on marine biodiversity patterns. Settlement panels were deployed in a marina in southwest UK for ≥5 weeks, to allow sufficient time for colonisation and development of sessile fauna, before being subjected to simulated HWs in a mesocosm facility. Replicate panel assemblages were held at ambient sea temperature (∼17 °C), or +3 °C or +5 °C for a period of 1 or 2 weeks, before being returned to the marina for a recovery phase of 2–3 weeks. The 10-week experiment was repeated 3 times, staggered throughout summer, to examine the influence of HW timing on community impacts. Contrary to our expectations, the warming events had no clear, consistent impacts on the abundance of species or the structure of sessile assemblages. With the exception of 1 high-magnitude long-duration HW event, warming did not alter not assemblage structure, favour non-native species, nor lead to changes in richness, abundance or biomass of sessile faunal assemblages. The observed lack of effect may have been caused by a combination of (1) the use of relatively low magnitude, realistic heat wave treatments compared to previous studies (2), the greater resilience of mature adult sessile fauna compared to recruits and juveniles, and (3) the high thermal tolerance of the model organisms (i.e., temperate fouling species, principally bryozoans and ascidians). Our study demonstrates the importance of using realistic treatments when manipulating climate change variables, and also suggests that biogeographical context may influence community-level responses to short-term warming events, which are predicted to increase in severity in the future.

Identification of tone duration, line length and letter position: An experimental approach to timing and working memory deficits in schizophrenia.

Patients with schizophrenia display numerous cognitive deficits, including problems in working memory, time estimation, and absolute identification of stimuli. Research in these fields has traditionally been conducted independently. We examined these cognitive processes using tasks that are structurally similar and that yield rich error data. Relative to healthy control participants (n = 20), patients with schizophrenia (n = 20) were impaired on a duration identification task and a probed-recall memory task but not on a line-length identification task. These findings do not support the notion of a global impairment in absolute identification in schizophrenia. However, the authors suggest that some aspect of temporal information processing is indeed disturbed in schizophrenia.