Interleukin-6, C-Reactive Protein, and Recurrence After Stroke: A Time-Course Analysis of Individual-Participant Data.

BACKGROUND: Inflammation promotes atherogenesis. Randomized controlled trials of anti-inflammatory therapies for prevention after stroke have not yet demonstrated clear benefit. IL-6 (interleukin-6) and hsCRP (high-sensitivity C-reactive protein) are independently associated with major adverse cardiovascular events poststroke and may guide patient selection in future randomized controlled trials. Optimal timing of hsCRP/IL-6 measurement poststroke is unknown, as early blood levels may be confounded by the inflammatory response to brain infarction. METHODS: Using individual-participant data from a systematic review, we performed a time-course analysis to investigate the association between hsCRP/IL-6 and recurrent events stratified by timing of sampling. The prespecified coprimary end points after sample measurement were: (1) recurrent major adverse cardiovascular events (first major coronary event, recurrent stroke, or vascular death) and (2) recurrent stroke (ischemic, hemorrhagic, or unspecified). The poststroke dynamics of IL-6/hsCRP were analyzed by plotting their median (interquartile interval) concentrations within each tenth of the sampling timeframe. Acute/postacute phases were defined for each biomarker according to the shape of this relationship. RESULTS: There were data for 9798 patients from 11 studies (19 891 person-years follow-up, 10 observational cohorts, and 1 randomized trial). Each marker was measured once. IL-6 was markedly elevated <24 hours poststroke compared with postacute levels (≥24 hours; 11.6 versus 3.02 pg/mL; P<0.001). HsCRP was elevated for 10 days. IL-6 was associated with recurrent major adverse cardiovascular events in the postacute phase (≥24 hours; risk ratio, 1.30 [CI, 1.19-1.41], per unit logeIL-6), but not in the acute phase (<24 hours; risk ratio, 1.10 [CI, 0.98-1.25]; Pinteraction=0.03). After adjustment for risk factors/medication, the association remained for postacute IL-6 when analyzed per logeunit (risk ratio, 1.16 [CI, 1.05-1.66]) and per quarter increase (risk ratio, 1.55 [CI, 1.19-2.02]; Q4 versus Q1), but not if measured acutely. Similar findings were observed for recurrent stroke. There was no evidence of time-dependent interaction with hsCRP. CONCLUSIONS: Timing of sample measurement after stroke modifies the association with recurrent major adverse cardiovascular events for IL-6 but not hsCRP. These data inform future randomized controlled trial designs incorporating biomarker-based selection of patients for anti-inflammatory therapies.

C-Reactive Protein, Interleukin-6, and Vascular Recurrence After Stroke: An Individual Participant Data Meta-Analysis.

BACKGROUND: Anti-inflammatory therapies reduce recurrent vascular events in coronary disease. Existing studies have reported highly conflicting findings for the association of blood inflammatory markers with vascular recurrence after stroke leading to uncertainty about the potential of anti-inflammatory therapies after stroke and no consensus about the utility of measurement of inflammatory markers in current guidelines. METHODS: We investigated the association between hsCRP (high-sensitivity C-reactive protein), IL-6 (interluekin-6), and recurrent major adverse cardiovascular events (MACE), and stroke from individual participant data from 8420 patients with ischemic stroke/transient ischemic attack from 10 prospective studies. We did within-study multivariable regression analyses and then combined adjusted risk ratio (RR) by random-effects meta-analysis. RESULTS: During 18 920 person-years of follow-up, 1407 (16.7% [95% CI, 15.9-17.5]) patients had MACE and 1191 (14.1% [95% CI, 13.4-14.9]) patients had recurrent stroke. On bivariate analysis, baseline IL-6 was associated with MACE (RR, 1.26 [95% CI, 1.10-1.43]) and recurrent stroke (RR, 1.18 [95% CI, 1.05-1.32]), per unit increase logeIL-6. Similar associations were observed for hsCRP (MACE RR, 1.19 [95% CI, 1.09-1.29]; recurrent stroke RR, 1.12 [95% CI, 1.04-1.21], per unit increase logehsCRP). After adjustment for vascular risk factors and treatment, independent associations remained with MACE (IL-6, RR, 1.12 [95% CI, 1.04-1.21]; hsCRP, RR, 1.09 [95% CI, 1.04-1.15]) and recurrent stroke (IL-6, RR, 1.09 [95% CI, 1.00-1.19]; hsCRP, RR, 1.05 [95% CI, 1.00-1.11]). Comparing the top with the bottom quarters (Q4 versus Q1), IL-6 (RR, 1.35 [95% CI, 1.09-1.67]) and hsCRP (RR, 1.31 [95% CI, 1.07-1.61]) were associated with MACE after adjustment. Similar results were observed for recurrent stroke for IL-6 (RR, 1.33 [95% CI, 1.08-1.65]) but not hsCRP (RR, 1.16 [95% CI, 0.93-1.43]). CONCLUSIONS: Blood markers of inflammation were independently associated with vascular recurrence after stroke, strengthening the rationale for randomized trials of anti-inflammatory therapies for secondary prevention after ischemic stroke/TIA.

Growing small solid nodules in lung cancer screening: safety and efficacy of a 200 mm3 minimum size threshold for multidisciplinary team referral.

The optimal management of small but growing nodules remains unclear. The SUMMIT study nodule management algorithm uses a specific threshold volume of 200 mm3 before referral of growing solid nodules to the multidisciplinary team for further investigation is advised, with growing nodules below this threshold kept under observation within the screening programme. Malignancy risk of growing solid nodules of size >200 mm3 at initial 3-month interval scan was 58.3% at a per-nodule level, compared with 13.3% in growing nodules of size ≤200 mm3 (relative risk 4.4, 95% CI 2.17 to 8.83). The positive predictive value of a combination of nodule growth (defined as percentage volume change of ≥25%), and size >200 mm3 was 65.9% (29/44) at a cancer-per-nodule basis, or 60.5% (23/38) on a cancer-per-participant basis. False negative rate of the protocol was 1.9% (95% CI 0.33% to 9.94%). These findings support the use of a 200 mm3 minimum volume threshold for referral as effective at reducing unnecessary multidisciplinary team referrals for small growing nodules, while maintaining early-stage lung cancer diagnosis.

Telephone risk-based eligibility assessment for low-dose CT lung cancer screening.

Eligibility for lung cancer screening (LCS) requires assessment of lung cancer risk, based on smoking history alongside demographic and medical factors. Reliance on individual face-to-face eligibility assessment risks inefficiency and costliness. The SUMMIT Study introduced a telephone-based lung cancer risk assessment to guide invitation to face-to-face LCS eligibility assessment, which significantly increased the proportion of face-to-face attendees eligible for LCS. However, levels of agreement between phone screener and in-person responses were lower in younger individuals and minority ethnic groups. Telephone-based risk assessment is an efficient way to optimise selection for LCS appointments but requires further iteration to ensure an equitable approach.

Dose-Dependent Association of Inflammatory Cytokines with Carotid Atherosclerosis in Transient Ischaemic Attack: Implications for Clinical Trials.

INTRODUCTION: The 5-year recurrence risk after ischaemic stroke and transient ischaemic attack (TIA) is 25-30%. Although inflammation may be a target for prevention trials, the contribution of plaque inflammation to acute cerebrovascular events remains unclear. We investigated the association of acute inflammatory cytokines and high-sensitivity C-reactive protein (CRP) with recently symptomatic carotid atherosclerosis in a prospective cohort study. METHODS: Blood and Imaging markers of TIA BIO-TIA) is a multicentre prospective study of imaging and inflammatory markers in patients with TIA. Exclusion criteria were infection and other co-morbid illnesses associated with inflammation. CRP and serum cytokines (interleukin [IL]-6, IL-1ß, IL-8, IL-10, IL-12, interferon-γ [IFN-γ] and tumour necrosis factor-α [TNF-α]) were measured. All patients had carotid imaging. RESULTS: Two hundred and thirty-eight TIA cases and 64 controls (TIA mimics) were included. Forty-nine (20.6%) cases had symptomatic internal carotid artery stenosis. Pro-inflammatory cytokine levels increased in a dose-dependent manner across controls, TIA without carotid stenosis (CS), and TIA with CS (IL-1ß, ptrend = 0.03; IL-6, ptrend < 0.0001; IL-8, ptrend = 0.01; interferon (IFN)-γ, ptrend = 0.005; TNF-α, ptrend = 0.003). Results were unchanged when DWI-positive cases were excluded. On multivariable linear regression, only age (p = 0.01) and CS (p = 0.04) independently predicted log-IL-6. On multivariable Cox regression, CRP was the only independent predictor of 90-day stroke recurrence (adjusted hazard ratio per 1-unit increase 1.03 [95% CI: 1.01-1.05], p = 0.003). CONCLUSION: Symptomatic carotid atherosclerosis was associated with elevated cytokines in TIA patients after controlling for other sources of inflammation. High-sensitivity CRP was associated with recurrent ischaemic stroke at 90 days. These findings implicate acute plaque inflammation in the pathogenesis of cerebral thromboembolism and support a rationale for randomized trials of anti-inflammatory therapy for stroke patients, who were excluded from coronary trials.

Improving Turnaround Time in a Hospital-based CT Division with the Kaizen Method.

The Kaizen method is an approach to lean process improvement that is based on the idea that small ongoing positive changes can lead to major improvements in efficiency and reduction of waste. The hospital-based CT division at Mayo Clinic Arizona had been receiving numerous concerns of delays in the performance of examinations from inpatients, outpatients, and patients presenting to the emergency department. These concerns, along with a planned hospital expansion, provided the impetus to perform a process improvement project with the goal of reducing inpatient, emergency department, and outpatient turnaround times by 20%. Kaizen process improvement was chosen because of the emphasis on reduction of waste, standardization, and empowerment of frontline staff. The project was led by a process improvement coach who was trained in lean process improvement and A3 thinking. At the end of a weeklong Kaizen event, inpatient turnaround time decreased by 54%, emergency department turnaround time decreased by 29%, and outpatient turnaround time decreased by 45%. These results were achieved and sustained by establishing standardized work, developing frontline problem solvers, instituting visual management, aligning with relevant metrics, emphasizing patient and staff satisfaction, and reducing lead time and non-value-added work. When done properly, a Kaizen event can be an effective tool for process improvement in the health care setting. Online supplemental material is available for this article. ©RSNA, 2022.

Potentially inappropriate medication use and mortality in patients with cognitive impairment.

PURPOSE: Potentially inappropriate medications (PIMs) are associated with falls, hospitalization, and cognitive decline. Few studies have investigated the association between PIMs related to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI). METHODS: This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013 to 2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥ 5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs). RESULTS: Four hundred eighteen patients were included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range [IQR] 74-82) and median follow-up was 809 days (IQR 552-1571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson's Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease (HR 1.96, 95% CI 1.24-3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51-7.11) but not with non-vascular death (HR 1.40 95% CI 0.78-2.52). CONCLUSION: PIMCog use in patients with cognitive impairment is high. It is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in this patient cohort. Further research is required to independently validate this finding.

Spinal metastasis: The rise of minimally invasive surgery.

INTRODUCTION: Bone is the third most common site of metastatic cancer, of which the spine is the most frequently involved. As metastatic cancer prevalence rises and surgical techniques advance, operative intervention for spinal metastases is expected to rise. In the first operative cohort of spinal metastasis in Ireland, we describe the move towards less invasive surgery, the causative primary types and post-operative survival. METHODS: This is a retrospective cohort study of all operative interventions for spinal metastasis in a tertiary referral centre over eight years. Primary spinal tumours and local invasion to the spine were excluded. Median follow up was 1895 days. RESULTS: 225 operative procedures in 196 patients with spinal metastasis were performed over eight years. Average cases per year increased form 20 per year to 29 per year. Percutaneous procedures became more common, accounting for the majority (53%) in the final two years. The most common primary types were breast, myeloma, lung, prostate and renal. Overall survival at 1 year was 51%. Primary type was a major determinant of survival, with breast and the haematological cancers demonstrating good survival, while lung had the worst prognosis. CONCLUSION: This is the first descriptive cohort of operative interventions for spinal metastasis in an Irish context. Surgery for spinal metastasis is performed at an increasing rate, especially through minimally-invasive means. The majority of patients survive for at least one year post-operatively. Prudent resource planning is necessary to prepare for this growing need.

Documentation of Do-Not-Attempt-Cardiopulmonary-Resuscitation orders amid the COVID-19 pandemic.

INTRODUCTION: the COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation (CPR) into focus. The aim of this study is to compare rates of Do-Not-Attempt-CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. METHODS: this was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from 1 March to 31 May 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period and were also compared to the documentation rates pre-COVID-19 pandemic (1 March-31 May 2019). RESULTS: of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. Of 131 older (≥65 years) patients with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 older patients without COVID-19 (P < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (P < 0.0001). Almost fifty percent of DNACPR orders were recorded within 24 h of a positive swab result for SARS-CoV-2. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. CONCLUSION: the COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case fatality rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain as part of good clinical practice despite the pandemic.

Osteoporotic Vertebral Fractures are Common in Hip Fracture Patients and are Under-recognized.

INTRODUCTION: The vertebrae are the most common site for osteoporotic fracture. While they can result in disability and increased mortality, only one-third present clinically. People with multiple fractures are at greater risk of future fractures. Most hip fracture patients are neither diagnosed nor treated for their underlying osteoporosis. Computed tomography (CT) studies are often performed on hospitalised patients, can be used to diagnose osteoporosis and are gaining popularity for opportunistic osteoporosis screening by measuring BMD and other bone strength indices. The aim of this study was to assess the prevalence of vertebral fractures on CT pulmonary angiograms (CTPA) in a cohort of hip fracture patients and whether this increased their diagnosis and treatment rates. METHODS: We retrospectively identified all hip fractures admitted to our institution between 2010 and 2017 to identify those who underwent CTPA scans. An independent, blinded consultant musculoskeletal radiologist reviewed the images for vertebral fractures and quantified severity using Genant criteria. Results were compared to the original radiology report, discharge diagnoses and treatment rates for osteoporosis. RESULTS: Eleven percent (225/2122) of patients had CTPA images available. Seventy percent (158) were female with a mean age of 78 years (SD: 11). The median length of stay for all patients was 16 days (1-301). Forty percent (90) of patients had at least one vertebral fracture present and 20% (46) had more than one fracture. Only one in 5 radiology reports noted the fractures. 24% of subjects had osteoporosis treatment recorded at hospital discharge and there was no difference between those with vertebral fractures to those without. CONCLUSION: Many hip fracture patients have undiagnosed spine fractures. A screening strategy which evaluates CT scans for fractures has potential to increase diagnosis and treatment rates of osteoporosis. However, more work is needed to increase awareness.

Does country of origin influence research outcomes in operative interventions for lumbar spinal stenosis?

INTRODUCTION: Bias undermines evidence-based decision making. To counter this, surgeons must be aware of biases that may influence studies' reported outcomes. Lumbar spinal stenosis often requires operative intervention, with multiple available surgical strategies. Our aim was to assess the role that country of origin plays in published surgical outcomes for lumbar spinal stenosis. METHODS: We performed a search strategy of MEDLINE and EMBASE for all English language primary research papers evaluating operative interventions for lumbar spinal stenosis during the years 2010-2019 inclusive. Small case series and meta-analyses were excluded. Papers were assessed for outcome positivity and country of origin. Data analysis was conducted using GraphPad Prism statistical software. RESULTS: A total of 487 papers met the inclusion criteria. Of these, 419 (86%) reported positive outcomes. Asian studies were the most likely to report positive outcomes, at 93% (220 of 236), followed by US studies at 89% (98 of 110). European studies had the lowest positive publication rate at 69% (84 of 121). Region of origin was an independent predictor of positive study outcome on multivariable analysis when controlling for different study designs and healthcare systems. CONCLUSION: There is an association between country of origin and positive reported outcome in studies evaluating interventions for lumbar spinal stenosis. Clinicians should consider this when making management decisions based on published evidence. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

A Risk Score Including Carotid Plaque Inflammation and Stenosis Severity Improves Identification of Recurrent Stroke.

Background and Purpose- In randomized trials of symptomatic carotid endarterectomy, only modest benefit occurred in patients with moderate stenosis and important subgroups experienced no benefit. Carotid plaque 18F-fluorodeoxyglucose uptake on positron emission tomography, reflecting inflammation, independently predicts recurrent stroke. We investigated if a risk score combining stenosis and plaque 18F-fluorodeoxyglucose would improve the identification of early recurrent stroke. Methods- We derived the score in a prospective cohort study of recent (<30 days) non-severe (modified Rankin Scale score ≤3) stroke/transient ischemic attack. We derived the SCAIL (symptomatic carotid atheroma inflammation lumen-stenosis) score (range, 0-5) including 18F-fluorodeoxyglucose standardized uptake values (SUVmax <2 g/mL, 0 points; SUVmax 2-2.99 g/mL, 1 point; SUVmax 3-3.99 g/mL, 2 points; SUVmax ≥4 g/mL, 3 points) and stenosis (<50%, 0 points; 50%-69%, 1 point; ≥70%, 2 points). We validated the score in an independent pooled cohort of 2 studies. In the pooled cohorts, we investigated the SCAIL score to discriminate recurrent stroke after the index stroke/transient ischemic attack, after positron emission tomography-imaging, and in mild or moderate stenosis. Results- In the derivation cohort (109 patients), recurrent stroke risk increased with increasing SCAIL score (P=0.002, C statistic 0.71 [95% CI, 0.56-0.86]). The adjusted (age, sex, smoking, hypertension, diabetes mellitus, antiplatelets, and statins) hazard ratio per 1-point SCAIL increase was 2.4 (95% CI, 1.2-4.5, P=0.01). Findings were confirmed in the validation cohort (87 patients, adjusted hazard ratio, 2.9 [95% CI, 1.9-5], P<0.001; C statistic 0.77 [95% CI, 0.67-0.87]). The SCAIL score independently predicted recurrent stroke after positron emission tomography-imaging (adjusted hazard ratio, 4.52 [95% CI, 1.58-12.93], P=0.005). Compared with stenosis severity (C statistic, 0.63 [95% CI, 0.46-0.80]), prediction of post-positron emission tomography stroke recurrence was improved with the SCAIL score (C statistic, 0.82 [95% CI, 0.66-0.97], P=0.04). Findings were confirmed in mild or moderate stenosis (adjusted hazard ratio, 2.74 [95% CI, 1.39-5.39], P=0.004). Conclusions- The SCAIL score improved the identification of early recurrent stroke. Randomized trials are needed to test if a combined stenosis-inflammation strategy improves selection for carotid revascularization where benefit is currently uncertain.

Anti-inflammatory therapy for preventing stroke and other vascular events after ischaemic stroke or transient ischaemic attack.

BACKGROUND: An increasing body of evidence suggests that inflammation plays a key role in stroke, in particular stroke of atherosclerotic origin. Anti-inflammatory medications are a widely heterogeneous group of drugs that are used to suppress the innate inflammatory pathway and thus prevent persistent or recurrent inflammation. Anti-inflammatory agents have the potential to stabilise atherosclerotic plaques by impeding the inflammatory pathway. By targeting specific cytokines, the inflammatory pathway may be interrupted at various stages. OBJECTIVES: To assess the benefits and harms of anti-inflammatory medications plus standard care versus standard care with or without placebo for prevention of vascular events (stroke, myocardial infarction (MI), non-fatal cardiac arrest, unstable angina requiring revascularisation, vascular death) and all-cause mortality in people with a prior history of ischaemic stroke or transient ischaemic attack (TIA). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; last searched 29 May 2019); MEDLINE (1948 to 29 May 2019); Embase (1980 to 29 May 2019); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 29 May 2019); and Scopus (1995 to 29 May 2019). In an effort to identify additional published, unpublished, and ongoing trials, we searched several grey literature sources (last searched 30 May 2019). We incorporated all identified studies into the results section. We applied no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) and cluster-randomised controlled trials that evaluated anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed for inclusion titles and abstracts of studies identified by the search. Two review authors independently reviewed full-text articles for inclusion in this review. We planned to assess risk of bias and to apply the GRADE method. MAIN RESULTS: We identified no studies that met the inclusion criteria. AUTHORS' CONCLUSIONS: There is currently a paucity of evidence on the use of anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA. RCTs are needed to assess whether use of anti-inflammatory medications in this setting is beneficial.

How are nitrogen availability, fine-root mass, and nitrogen uptake related empirically? Implications for models and theory.

Understanding the effects of global change in terrestrial communities requires an understanding of how limiting resources interact with plant traits to affect productivity. Here, we focus on nitrogen and ask whether plant community nitrogen uptake rate is determined (a) by nitrogen availability alone or (b) by the product of nitrogen availability and fine-root mass. Surprisingly, this is not empirically resolved. We performed controlled microcosm experiments and reanalyzed published pot experiments and field data to determine the relationship between community-level nitrogen uptake rate, nitrogen availability, and fine-root mass for 46 unique combinations of species, nitrogen levels, and growing conditions. We found that plant community nitrogen uptake rate was unaffected by fine-root mass in 63% of cases and saturated with fine-root mass in 29% of cases (92% in total). In contrast, plant community nitrogen uptake rate was clearly affected by nitrogen availability. The results support the idea that although plants may over-proliferate fine roots for individual-level competition, it comes without an increase in community-level nitrogen uptake. The results have implications for the mechanisms included in coupled carbon-nitrogen terrestrial biosphere models (CN-TBMs) and are consistent with CN-TBMs that operate above the individual scale and omit fine-root mass in equations of nitrogen uptake rate but inconsistent with the majority of CN-TBMs, which operate above the individual scale and include fine-root mass in equations of nitrogen uptake rate. For the much smaller number of CN-TBMs that explicitly model individual-based belowground competition for nitrogen, the results suggest that the relative (not absolute) fine-root mass of competing individuals should be included in the equations that determine individual-level nitrogen uptake rates. By providing empirical data to support the assumptions used in CN-TBMs, we put their global climate change predictions on firmer ground.

Do medical students believe the back pain myths? A cross-sectional study.

BACKGROUND: Low back pain (LBP) is common, affecting 58-84% of adults at some point. In benign cases, misinformation can lead to harmful coping strategies and prolonged recovery time. Deyo has identified seven 'Myths of Back Pain' as misconceptions commonly seen in clinical practice of which doctors-in-training should be aware. We sought to determine medical students' baseline knowledge of the prognosis and management of LBP compared to the general public and to dispel the 'Myths of Back Pain'. METHODS: We carried out a cross-sectional study of medical students (pre-clinical and clinical) at the National University of Ireland, Galway where students completed a questionnaire outlining the seven 'Myths of Back Pain'. Final year students completed the survey before and after a seminar on LBP. Students' results were compared with a random sample of the public who attended Galway University Hospital. RESULTS: Two hundred nineteen students completed the questionnaire (59% female, 41% male). The mean age was 21 years (17-32). The mean number of correct answers increased according to medical school year (premedical 3/7, first year 4/7, final year 5/7). A personal history of back pain and female sex were associated with higher scores. On average, medical students answered 4/7 questions correctly overall, compared to the public (n = 131) who averaged at 3/7. Final years dispelled one further myth after their LBP seminar. CONCLUSIONS: Common misconceptions around LBP are prevalent among medical students and the general public. It is important that medical school curricula address these issues as part of their musculoskeletal programme.

Treatment Factors That Influence Mortality in Acromegaly.

Acromegaly is a rare condition characterized by excessive secretion of growth hormone (GH), which is almost always due to a pituitary adenoma. Acromegaly is associated with significant morbidity such as hypertension, type 2 diabetes, cardiomyopathy, obstructive sleep apnoea, malignancy and musculoskeletal abnormalities. Acromegaly has also been associated with increased mortality in several retrospective studies. This review will focus on the epidemiological data relating to mortality rates in acromegaly, the relationship between acromegaly and malignancy, the role of GH and insulin-like growth factor-I in assessing the risk of future mortality, and the impact of radiotherapy and hypopituitarism on mortality.

Greenhouse Gas Emissions from Stored Dairy Slurry from Multiple Farms.

A significant need exists to improve our understanding of the extent of greenhouse gas emissions from the storage of livestock manure to both improve the reliability of inventory assessments and the impact of beneficial management practice adoption. Factors affecting the extent and variability of greenhouse gas emissions from stored dairy manure were investigated. Emissions from six slurries stored in clean concrete tanks under identical "warm-season" conditions were monitored consecutively over 173 d (18°C average air temperature). Methane (CH) emissions varied considerably among the manures from 6.3 to 25.9 g m d and accounted for ∼96% of the total CO equivalent greenhouse gas emissions. The duration of the lag period, when methane emissions were near baseline levels, varied from 30 to 90 d from the beginning of storage. As a result, CH emissions were poorly correlated with air temperature prior to the time of peak emissions (i.e., the initial 48 to 108 d of storage) but improved afterward. The air temperature following the time of the peak CH flux and the length of the active methanogenesis period (i.e., when the daily CH emissions ≥ 7.6 g m d) were highly correlated with CH emissions ( = 0.98, < 0.01). Methane conversion factors (MCFs) ranged from 0.08 to 0.52 for the different manures. The MCFs generated from existing CH emission models were correlated ( = 0.68, = 0.02) to MCFs calculated for the active methanogenesis period for manure containing wood bedding. A temperature component was added that improved the accuracy ( = 0.82, < 0.01). This demonstrated that an improved understanding of lag period dynamics will enhance stored dairy manure greenhouse gas emission inventory calculations.

Do "Myths" of low back pain exist among Irish population? A cross-sectional study.

INTRODUCTION: Low back pain remains major public health problem in the Western industrialized world. The known prevalence of low back pain in Ireland is approximately 13 %. It is one of the leading causes of sickness compensation and disability pension in our justification. We hypothesized that there is a widespread misconception about the perception of low back pain among the Irish population. The aim of this study was to investigate whether the "Myths" of low back pain existed among the Irish population. MATERIALS AND METHODS: We carried out a cross-sectional study in the Republic of Ireland from April 2013 to August 2013. The Irish population who visited Galway University Hospital, Galway, Ireland, was contacted randomly at point of entry to the hospital. During the survey, the authors obtained verbal consent before handing the questionnaire, which contained the Deyo's seven myths. The responders were asked to mark their response in a three-point scale (agree, unsure, disagree) to the seven statements. RESULTS: Out of 500 responders, 59 (11.8 %) people answered none of the questions correctly. Fifty-six (11.2 %) answered one question correctly, 106 (21.2 %) answered two questions correctly, 85 (17 %) people disagreed with three myths, 88 (17.6 %) disagreed with four myths, 55 (11 %) people answered five questions correctly, and 34 (6.8 %) answered six questions correctly. Therefore, only 17 (3.4 %) people disagreed with all the seven myths. CONCLUSION: In conclusion, this cross-sectional study showed that myths of low back pain widely exist among Irish population studied . The level of education played an important role. The findings from this study suggest that public health information regarding low back pain is inadequate and has not affected attitudes to low back pain in an Irish population.