The purpose of the present paper was to investigate methods for calculating the total blubber burden of organochlorine pollutants (OCs) in phocid seals. Harp seals (Phoca groenlandica) were used as the model species. A sample of fat pre-breeding adult females (N = 9) and a sample of thin moulting adult females (N = 7) were collected. From each animal blubber samples from five different body sites (complete blubber columns and samples from different blubber layers), in addition to a sample from a homogenate derived from the entire blubber mass, were analyzed for selected OCs. Significant differences in the concentrations of major OC contaminants were found between inner and outer blubber layer. Within each seal group, no significant difference in OC concentrations was found between homogenates from whole blubber columns from the five different sites of the animals or when comparing these with the OC concentrations found in the blubber sample deriving from a homogenate of the entire blubber mass. When comparing the two seal groups, the mean OC concentrations were significantly higher in the thin seals. However, blubber burden of OCs measured directly and calculated indirectly were not significantly different, and did not vary between the two groups of seals. Since these seals are of the same age and sex group and from the same population, this is not an unexpected result. The present results suggest that comparison of blubber concentrations of OCs in phocid seals should be avoided, especially when comparing differences between geographical areas or for time-trend analyses. For this type of study, we suggest that the blubber burden of OCs is applied as standard in the future. Furthermore, since blubber depth at a specific sampling site is required when using the estimator for calculation of the percent blubber content in phocid seals (the LMD-index), we suggest that this sampling site (central dorsally) is introduced as a standard when sampling blubber for OC analyses in phocid seals.

Owing to limitations in spatial resolution and sensitivity, it is difficult for conventional angiography to detect minute changes of perfusion in diffuse lung diseases, including pulmonary emphysema (PE). However, a high-gain avalanche rushing amorphous photoconductor (HARP) detector can give high sensitivity to synchrotron radiation (SR) angiography. SR angiography with a HARP detector provides high spatial resolution and sensitivity in addition to time resolution owing to its angiographic nature. The purpose of this study was to investigate whether this SR angiography with a HARP detector could evaluate altered microcirculation in PE. Two groups of rats were used: group PE and group C (control). Transvenous SR angiography with a HARP detector was performed and histopathological findings were compared. Peak density of contrast material in peripheral lung was lower in group PE than group C (p < 0.01). The slope of the linear regression line in scattering diagrams was also lower in group PE than C (p < 0.05). The correlation between the slope and extent of PE in histopathology showed significant negative correlation (p < 0.05, r = 0.61). SR angiography with a HARP detector made it possible to identify impaired microcirculation in PE by means of its high spatial resolution and sensitivity.

Results of study of several blood biochemical parameters of the harp seal Pagophilus groenlandicus Erxleben, 1777, from birth to the adult state are presented. The following age groups of the animals have been studied--newborns, 1.5-2 months, 1 year, 2 years, 3 years, and adults (older than 6 months). The content of total protein and its fractions, free amine nitrogen, urea, creatinine, glucose, total lipids, total calcium, and inorganic phosphorus was determined in the seal blood plasma. Differences of the degree of expression of levels of all studied parameters in the course of early postnatal ontogenesis of the animals have been established. The most significant metabolic changes in the harp seals were revealed at the period of end of weaning and transition to independent ingestion and then after the first year of life.

Certain environmental contaminants found in marine mammals have been shown to cause DNA damage and cancer. The micronuclei (MN), sister chromatid exchange (SCE) and/or chromosome aberration (CA) assays were used to assess baseline (spontaneous) levels of DNA damage in blood lymphocytes of individuals of the relatively healthy and lightly contaminated Arctic beluga whale (Delphinapterus leucas), Sarasota Bay, FL, bottlenose dolphin (Tursiops truncatus) and Northwestern Atlantic grey (Halichoerus grypus) and harp (Phoca groenlandicus) seal populations. MN cell (MNC) frequencies ranged between 2 and 14/1000 binucleated (BN) cells and were statistically similar between species. In bottlenose dolphins, MNC frequency was correlated with age and was significantly higher in females than in males. No intraspecific variation in MNC frequency was found in beluga whales. Intraspecific variation was not tested in seals due to the small sample size. Frequencies of SCEs and total CAs, excluding gaps, ranged, respectively, between 1 and 15 SCE(s)/per cell and 4-6 CAs/100 cells in beluga whales. SCE and CA frequencies did not vary with age or sex in beluga whales. The MN, SCE and CA assays were found to be practical tools for the detection of DNA damage in marine mammals and could be used in the future to compare DNA damage between relatively lightly and highly contaminated populations.

Three novel halogenated organic compounds (HOCs) have been identified in the blubber of marine mammals from coastal New England with the molecular formulae C(9)H(3)N(2)Br(6)Cl, C(9)H(3)N(2)Br(7), and C(9)H(4)N(2)Br(5)Cl. They were identified using high and low resolution gas chromatography mass spectrometry (GCMS) and appear to be highly brominated analogues of Q1, a heptachlorinated HOC suspected to be naturally produced. These compounds were found in Atlantic white sided dolphin (Lagenorhynchus acutus), bottlenose dolphin (Tursiops truncatus), common dolphin (Delphinus delphis), Risso's dolphin (Grampus griseus), harbor porpoise (Phocoena phocoena), beluga whale (Delphinapterus leucas), fin whale (Balaenoptera physalus), grey seal (Halichoerus grypus), harp seal (Phoca groenlandica) and a potential food source (Loligo pealei) with concentrations as high as 2.7 microg/g (lipid weight). The regiospecificity of C(9)H(3)N(2)Br(6)Cl is suggestive of a biogenic origin. Debromination of C(9)H(3)N(2)Br(6)Cl may be significant in the formation of C(9)H(4)N(2)Br(5)Cl.

Capelin (Mallotus villosus) is among the most abundant fish species in the Barents Sea, and represents a critical food source for many predators in the area including Atlantic cod and harp seal. In Norway, the fish is of economic importance since whole capelin and roe are valuable export products. Despite its economic and ecological importance, the parasites of Barents Sea capelin are poorly known. However, the presence of parasites in the edible parts may adversely affect product quality and consumer safety. During the main annual catching seasons of 2009-2012, we investigated the diversity and infection dynamics of ascaridoid nematodes in capelin (n = 620) from the southern Barents Sea. Three anisakid species were identified by genetic or molecular methods; Anisakis simplex (s.s.), Contracaecum osculatum sp. B, and Hysterothylacium aduncum, with C. osculatum sp. B as the most prevalent and abundant species. The present findings suggest that the ascaridoid species composition in capelin reflects its trophic position in the Barents Sea ecosystem. There appears to be a link between infection level of the nematode species and the preferred prey organisms of the different developmental phases of capelin. Thus, the higher abundance of C. osculatum sp. B compared to A. simplex (s.s.) and H. aduncum may be related to more extensive feeding on calanoid copepods over a wider ontogenetic size range including adolescence, while the main intermediate hosts of the latter nematode species, i.e. euphausiids and amphipods, appear to be the preferred prey of larger capelin.

Three adult harp seals (Phoca groenlandica) were fed different daily amounts of capelin (Mallotus villosus), and their body composition determined by use of the tritiated water method at different levels of fattening. Basal metabolic rate (BMR) was measured after 5 days of fasting by indirect calorimetry, and was on average 1.1 W.kg-1 when 45% of body mass (BM) was fat and 2.3 W.kg-1 when body fat was reduced to 13% of BM. This suggests that body fat contributes little to BMR in these animals. It follows, that predictions of BMR on the basis of BM is questionable in seals, in which body fat may change seasonally between 20 and 60% of BM.

OBJECTIVE

To analyse the effect of the expert end-point committee (EPC) review on histological endpoint classification of cervical intraepithelial neoplasia (CIN).

METHODS

A cohort of women living with HIV were recruited in Burkina Faso (BF) and South Africa (SA) and followed over 18 months. Four-quadrant cervical biopsies were obtained in women with abnormalities detected by at least one screening test. A central review by a panel of five pathologists was organised at baseline and at endline.

RESULTS

At baseline the prevalence of high-grade CIN (CIN2+) was 5.1% (28/554) in BF and 23.3% (134/574) in SA by local diagnosis, and 5.8% (32/554) in BF and 22.5% (129/574) in SA by the EPC. At endline the prevalence of CIN2+ was 2.3% (11/483) in BF and 9.4% (47/501) in SA by local diagnosis, and 1.4% (7/483) in BF and 10.2% (51/501) in SA by EPC. The prevalence of borderline CIN1/2 cases was 2.8% (32/1128) and 0.8% (8/984) at baseline and endline. Overall agreement between local diagnosis and final diagnosis for distinguishing CIN2+ from ≤CIN1 was 91.2% (κ=0.82) and 88.9% (κ=0.71) for BF at baseline and endline, and 92.7% (κ=0.79) and 98.7% (κ=0.97) for SA at baseline and endline. Among the CIN1/2 cases, 12 (37.5%) were graded up to CIN2 and 20 (62.5%) were graded down to CIN1 at baseline, and 3 (37.5%) were graded up to CIN2 and 5 (62.5%) were graded down to CIN1 at endline.

CONCLUSIONS

This study highlights the importance of a centralised rigorous re-reading with exchange of experiences among pathologists from different settings.

BACKGROUND

Among the psychological difficulties seen in children of parents with substance use problems, the anxiety disorders are among the most chronic conditions. Although children of alcoholic parents often struggle with the effects of parental substance use problems long into adulthood, empirical investigations of the influence of parental substance use disorders on the course of anxiety disorders in adult offspring are rare. The purpose of this study was to examine prospectively the relationship between parental substance use disorders and the course of anxiety disorders in adulthood over the course of 12 years.

METHODS

Data on 618 subjects were derived from the Harvard/Brown Anxiety Research Project (HARP), a longitudinal naturalistic investigation of the clinical course of multiple anxiety disorders. Kaplan-Meier survival estimates were used to calculate probabilities of time to anxiety disorder remission and relapse. Proportional hazards regressions were conducted to determine whether the likelihood of remission and relapse for specific anxiety disorders was lower for those who had a history of parental substance use disorders than for individuals without this parental history.

RESULTS

Adults with a history of parental substance use disorders were significantly more likely to be divorced and to have a high school level of education. History of parental substance use disorder was a significant predictor of relapse of social phobia and panic disorders.

CONCLUSIONS

These findings provide compelling evidence that adult children of parents with substance use disorders are more likely to have relapses of social phobia and panic disorders. Clinicians who treat adults with anxiety disorders should assess parental substance use disorders and dependence histories. Such information may facilitate treatment planning with regards to their patients' level of vulnerability to perceive scrutiny by others in social situations, and ability to maintain a long-term panic-free state.

Contaminant dynamics in arctic marine food webs may be impacted by current climate-induced food web changes including increases in transient/subarctic species. We quantified food web organochlorine transfer in the Cumberland Sound (Nunavut, Canada) arctic marine food web in the presence of transient species using species-specific biomagnification factors (BMFs), trophic magnification factors (TMFs), and a multifactor model that included δ(15)N-derived trophic position and species habitat range (transient versus resident), and also considered δ(13)C-derived carbon source, thermoregulatory group, and season. Transient/subarctic species relative to residents had higher prey-to-predator BMFs of biomagnifying contaminants (1.4 to 62 for harp seal, Greenland shark, and narwhal versus 1.1 to 20 for ringed seal, arctic skate, and beluga whale, respectively). For contaminants that biomagnified in a transient-and-resident food web and a resident-only food web scenario, TMFs were higher in the former (2.3 to 10.1) versus the latter (1.7 to 4.0). Transient/subarctic species have higher tissue contaminant levels and greater BMFs likely due to higher energetic requirements associated with long-distance movements or consumption of more contaminated prey in regions outside of Cumberland Sound. These results demonstrate that, in addition to climate change-related long-range transport/deposition/revolatilization changes, increasing numbers of transient/subarctic animals may alter food web contaminant dynamics.

Study Design Study protocol for a randomized controlled trial and a prospective cohort. Background The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high-quality evidence of the effect of such interventions is lacking. Objectives The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient-reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long-term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). Methods The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool-33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self-Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient-Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. Conclusion To determine the true effect of surgery, beyond that of placebo, double-blinded placebo-controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence-based treatment of FAIS. Predictors for long-term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined. J Orthop Sports Phys Ther 2018;48(4):325-335. doi:10.2519/jospt.2018.7931.

This study was performed to investigate the effect of live, spontaneous harp music on individual patients in an intensive care unit (ICU), either pre- or postoperatively. The purpose was to determine whether this intervention would serve as a relaxation or healing modality, as evidenced by the effect on patient's pain, heart rate, respiratory rate, blood pressure, oxygen saturation, and heart rate variability. Each consenting patient was randomly assigned to receive either a live 10-minute concert of spontaneous music played by an expert harpist or a 10-minute rest period. Spontaneous harp music significantly decreased patient perception of pain by 27% but did not significantly affect heart rate, respiratory rate, oxygen saturation, blood pressure, or heart rate variability. Trends emerged, although being not statistically significant, that systolic blood pressure increased while heart rate variability decreased. These findings may invoke patient engagement, as opposed to relaxation, as the underlying mechanism of the decrease in the patients' pain and of the healing benefit that arises from the relationship between healer, healing modality, and patient.

Computational Saturation Mutagenesis is an in-silico approach that employs systematic mutagenesis of each amino acid residue in the protein to all other amino acid types, and predicts changes in thermodynamic stability and affinity to the other subunits/protein counterparts, ligands and nucleic acid molecules. The data thus generated are useful in understanding the functional consequences of mutations in antimicrobial resistance phenotypes. In this study, we applied computational saturation mutagenesis to three important drug-targets in Mycobacterium leprae (M. leprae) for the drugs dapsone, rifampin and ofloxacin namely Dihydropteroate Synthase (DHPS), RNA Polymerase (RNAP) and DNA Gyrase (GYR), respectively. M. leprae causes leprosy and is an obligate intracellular bacillus with limited protein structural information associating mutations with phenotypic resistance outcomes in leprosy. Experimentally solved structures of DHPS, RNAP and GYR of M. leprae are not available in the Protein Data Bank, therefore, we modelled the structures of these proteins using template-based comparative modelling and introduced systematic mutations in each model generating 80,902 mutations and mutant structures for all the three proteins. Impacts of mutations on stability and protein-subunit, protein-ligand and protein-nucleic acid affinities were computed using various in-house developed and other published protein stability and affinity prediction software. A consensus impact was estimated for each mutation using qualitative scoring metrics for physicochemical properties and by a categorical grouping of stability and affinity predictions. We developed a web database named HARP (a database of Hansen's Disease Antimicrobial Resistance Profiles), which is accessible at the URL - https://harp-leprosy.org and provides the details to each of these predictions.

Keywords: Computational saturation mutagenesis; Drug resistance; Interatomic interactions; Mutations; Mycobacterium leprae; Protein stability.

Variable retention harvesting (VRH), in which trees are removed at variable intensity and spatial configuration across the landscape, retains greater forest structural heterogeneity than traditional clear-cut harvesting and is being recommended as an alternative for sustainable management of the boreal forest. Little is known about its effects on forest fauna; thus, we studied the influence of one type of VRH (harvesting with advanced regeneration [HARP]) on the Syrphidae (Diptera) community in northern Ontario forests of peatland black spruce (Picea mariana). We examined the effects of varying structural retention (from unharvested through partial retention to clear-cut) on syrphid species richness and abundance, and abundance of functional assemblages. Greater species richness and population abundances were found generally in harvested than in unharvested forests. Overall species richness and the abundance of four species (Platycheirus rosarum, Toxomerus marginatus, Xylota annulifera, and X. tuberculata) and larval predators were all higher in both clear-cut sites and those with structural retention than in unharvested sites. Similarly, overall species richness and the abundance of nine species were higher in clear-cut than in unharvested sites. Species responses are discussed in an ecological context. Differences among the levels of forest retention harvesting were relatively minor compared with those of the clear-cut and unharvested area, suggesting that local habitat characteristics may play a more important role in determining the syrphid community than the landscape configuration. However, a landscape level effect was evident, suggesting that syrphids may be useful in reflecting changes in stand structure at the landscape scale.

Psychiatric and neurological disorders are afflictions of the brain that can affect individuals throughout their lifespan. Many brain magnetic resonance imaging (MRI) studies have been conducted; however, imaging-based biomarkers are not yet well established for diagnostic and therapeutic use. This article describes an outline of the planned study, the Brain/MINDS Beyond human brain MRI project (BMB-HBM, FY2018 ~ FY2023), which aims to establish clinically-relevant imaging biomarkers with multi-site harmonization by collecting data from healthy traveling subjects (TS) at 13 research sites. Collection of data in psychiatric and neurological disorders across the lifespan is also scheduled at 13 sites, whereas designing measurement procedures, developing and analyzing neuroimaging protocols, and databasing are done at three research sites. A high-quality scanning protocol, Harmonization Protocol (HARP), was established for five high-quality 3 T scanners to obtain multimodal brain images including T1 and T2-weighted, resting-state and task functional and diffusion-weighted MRI. Data are preprocessed and analyzed using approaches developed by the Human Connectome Project. Preliminary results in 30 TS demonstrated cortical thickness, myelin, functional connectivity measures are comparable across 5 scanners, suggesting sensitivity to subject-specific connectome. A total of 75 TS and more than two thousand patients with various psychiatric and neurological disorders are scheduled to participate in the project, allowing a mixed model statistical harmonization. The HARP protocols are publicly available online, and all the imaging, demographic and clinical information, harmonizing database will also be made available by 2024. To the best of our knowledge, this is the first project to implement a prospective, multi-level harmonization protocol with multi-site TS data. It explores intractable brain disorders across the lifespan and may help to identify the disease-specific pathophysiology and imaging biomarkers for clinical practice.

Keywords: HCP-style brain imaging; Harmonization protocol; Multi-site study; Neurological disorders; Psychiatric disorders; Traveling subjects.

Polybrominated diphenyl ethers (PBDEs) are highly lipophilic components of brominated flame retardants that are environmentally persistent and bioaccumulate. PBDEs are taken up from the gastrointestinal tract and accumulate mainly in fat depots and liver tissues. Seal species inhabiting Arctic and sub-Arctic regions can have upwards of 30% of their body mass composed of blubber. When those blubber stores are mobilized for energy, stored toxicants are also released into circulation. Most studies reporting accumulation of PBDEs in seals have focused on harbor and grey seals with few examining harp and hooded seals. In this study, PBDEs concentrations were analyzed in seal blubber from 21 stranded harp and 9 stranded hooded seals sampled along the northeast coast of the U.S. (1999-2010). A PBDE congener profile was determined for each individual. The results show that both species of seals are accumulating PBDEs with BDE-47 being the dominant congener. Mean ƩPBDE concentrations in harp seals were 70.55 ± 33.59 ng/g ww and for hooded seals 94.28 ± 42.65 ng/g ww. The results of this study are consistent with previous studies reporting a decrease in bioaccumulation with an increase in bromination. For both species, BDE-47 represented the highest percentage of the ƩPBDEs, composing over 50% of the ƩPBDEs in harp seals. When compared to stranding condition code, animals found alive had overall higher PBDE concentrations than those found in a state of moderate decomposition. This difference could be due to decreased blubber levels in the decomposed animals or potential degradation of the compounds in the blubber. Almost all seals used in this study were yearlings which is the most likely age class to strand. Yearling seals are at a crucial stage of development, especially of their immune system, which can be impacted by high levels of contaminants like PBDEs and increase the susceptibility to disease.

We provide and evaluate an open-source software solution for automatically hippocampal segmentation from T1-weighted (T1w) magnetic resonance imaging (MRI). The method is applied for measuring the hippocampal volume, which allows discriminate between patients with Alzheimer's disease (AD) or mild cognitive impairment (MCI) and elderly controls (NC). The method is based on a fast patch-based label fusion method, whose selected patches and their weights are calculated from a combination of similarity measures between patches using intensity-based distances and labeling-based distances. These combined similarity measures produces better selection of the patches, and their weights are more robust. The algorithm is trained with the Harmonized Hippocampal Protocol (HarP). The proposal is compared with FreeSurfer and other label fusion methods. To evaluate the performance and the robustness of the proposed label fusion method, we employ two databases of T1w MRI of human brains. For AD vs NC, we obtain a high degree of accuracy, approximately 90 %. For MCI vs NC, we obtain accuracies around 75 %. The average time for the hippocampal segmentation from a T1w MRI is less than 17 minutes.

Phagocytic and cytochemical parameters of peripheral blood leukocytes in adult and 1.5-month-old harp seal pups were studied. Phagocytic number, proportion of phagocytic leukocytes, and phagocytic activity, average number of absorbed latex particles per leukocyte, were determined. Differences between groups of seals by average values of these indicators have not been revealed. A correlation analysis revealed a significant relationship between the phagocytic activity of leukocytes and their glycogen content in adult seals (r = 0.89). Content of cationic bactericidal protein (CP) in leukocytes of adult animals was 10-12 times higher than in pups. Correlation of CP and eosinophil count in adults was high (r = 0.88). Adult had significantly more eosinophils than pups. The noted features can provide higher efficiency of phagocytosis and destruction of absorbed bacteria in adult seals as compared to pups, despite the high level of indicators of the first, absorbing, phase of phagocytosis in the latter.

Keywords: harp seal; immunity; marine mammals; phagocytosis.

The ability of marine mammals to cope with environmental challenges is a key determining factor in strandings and successful release of rehabilitated animals. Dive behavior is related to foraging and thus survival. While dive adaptations have been well studied, it is unknown how the immune system responds to diving and whether health status impacts immune function during diving. This study investigated the functional response of ex situ immune cells from stranded phocids to in vitro increased pressure, over the course of rehabilitation. Blood samples were drawn from stranded harbor seals (Phoca vitulina), gray seals (Halichoerus grypus) and harp seals (Phoca groenlandica) at the time of admit to the Mystic Aquarium, Mystic, CT and again after rehabilitation (pre-release). Phagocytosis, lymphocyte proliferation and immune cell activation were measured in vitro, with and without exposure to 2000 psi (simulated dive depth of 1360 m). Plasma epinephrine and norepinephrine, and serum cortisol were measured in vivo. All hormone values decreased between admit and release conditions. Under admit or release conditions, pressure exposures resulted in significant changes in granulocyte and monocyte phagocytosis, granulocyte expression of CD11b and lymphocyte expression of the IL2 receptor (IL2R). Overall, pressure exposures resulted in decreased phagocytosis for admit conditions, but increased phagocytosis in release samples. Expression of leukocyte activation markers, CD11b and IL2R, increased and the response did not differ between admit and release samples. Specific hematological and serum chemistry values also changed significantly between admit and release and were significantly correlated with pressure-induced changes in immune function. Results suggest (1) dive duration affects the response of immune cells, (2) different white blood cell types respond differently to pressure and (3) response varies with animal health. This is the first study describing the relationship between diving, immune function and health status in phocids.

Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health's Hospital Admission Risk Program (HARP).Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model.Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P=0.037) and complex needs (P<0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P<0.001), heart disease (P=0.015) and complex needs (P=0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs.Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0-65, had received more targeted care.What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation.What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia's health system.What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.

Sacred Harp singers the world over gather weekly to sing out of The Sacred Harp, a collection of shape-note songs first published in 1844. Their tradition is highly ritualized, and it plays an important role in the lives of many participants. Following the implementation of lockdown protocols to combat the COVID-19 pandemic, groups of Sacred Harp singers quickly and independently devised a variety of means by which to sing together online using Zoom ("zinging"), Jamulus ("jamzinging"), and Facebook Live ("stringing"). The rapidity and creativity with which Sacred Harp singers developed ways to sustain their activities attests to the strength and significance of this community of practice, and in this article I describe each modality and provide an account of how it came to be developed and widely used. As a participant-observer, I completed extensive fieldwork across these digital sites and conducted semi-structured interviews with 22 other singers. I found that online singing practices have reshaped the Sacred Harp community. Many singers who did not previously have the opportunity to participate now have access, while others have lost access due to technological barriers or lack of interest in online activities. At the same time, geographical barriers have disintegrated, and singing organizers must make an effort to maintain local identity. A stable community of singers has emerged in the digital realm, but it is by no means identical to the community that predated the pandemic. I also identify the ways in which online singing has proven meaningful to participants by providing continuity in their personal and communal practice. Specifically, online singing allows participants to access and celebrate their collective memories of the Sacred Harp community, carry out significant rituals, and continue to grow as singers. While no single modality replicates the complete Sacred Harp singing experience, together they function "like pieces in a puzzle" (as one singer put it), allowing individual participants to access many of the elements of Sacred Harp singing that are most meaningful to them.

Keywords: COVID-19; Sacred Harp singing; community singing; memory; participatory music-making; ritual; virtual community.

The aim of this prospective study was to investigate the ability of five indices of risk stratification to predict functional decline and prolonged length of stay (LOS) in older Mexicans hospitalized in the acute care setting. A total of 254 patients aged ≥60 years were followed up. Risk indices were constructed from baseline data collected during the first 48h of ward admission, and included: Frailty Index (FI), Hospital Admission Risk Profile (HARP), Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie (SHERPA), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Charlson's Co-morbidity Index (CCI). Area Under Receiver Operating Characteristic (auROC) curves was used to compare the ability of risk indices to predict adverse outcome, with outcomes of interest being prolonged LOS, and functional decline, the latter defined as ≥10% drop in Barthel Index score across hospitalization. Mean (SD) FI score was 0.31 (0.14). Effective in predicting long LOS were FI, SHERPA and APACHE II; effective in predicting functional decline were SHERPA and HARP. Indices generally showed high specificity values (most were >80%), although all indices lacked adequate sensitivity values for outcome prediction (<80%). Geriatricians could use information from FI, SHERPA, APACHE II, HARP to guide patient management decisions. However, given that all indices lacked accuracy of prediction, results should be interpreted with caution.