New phosphorus losses via tile drainage depend on fertilizer form, placement, and timing.

Agricultural phosphorus (P) losses are harmful to water quality, but knowledge gaps about the importance of fertilizer management practices on new (recently applied) sources of P may limit P loss mitigation efforts. Weighted regression models applied to subsurface tile drainage water quality data enabled estimating the new P losses associated with 155 P applications in Ohio and Indiana, USA. Daily discharge and dissolved reactive P (DRP) and total P (TP) loads were used to detect increases in P loss following each application which was considered new P. The magnitude of new P losses was small relative to fertilizer application rates, averaging 79.3 g DRP ha-1 and 96.1 g TP ha-1 , or <3% of P applied. The eight largest new P losses surpassed 330 g DRP ha-1 or 575 g TP ha-1 . New P loss mitigation strategies should focus on broadcast liquid manure applications; on average, manure applications caused greater new P losses than inorganic fertilizers, and surface broadcast applications were associated with greater new P losses than injected or incorporated applications. Late fall applications risked having large new P losses applications. On an annual basis, new P contributed an average of 14% of DRP and 5% of TP losses from tile drains, which is much less than previous studies that included surface runoff, suggesting that tile drainage is relatively buffered with regard to new P losses. Therefore old (preexisting soil P) P sources dominated tile drain P losses, and P loss reduction efforts will need to address this source.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Efficacy of Doxycycline and Ciprofloxacin for Treatment of Pneumonic Tularemia in Cynomolgus Macaques.

BACKGROUND: The incidence of pneumonic tularemia is very low; therefore, it is not feasible to conduct clinical efficacy testing of tularemia medical countermeasures (MCMs) in humans. The US Food and Drug Administration's Animal Model Qualification Program under the Drug Development Tools Program is a regulatory pathway for animal models used in MCM efficacy testing and approval under the Animal Rule. The National Institute of Allergy and Infectious Diseases and Biomedical Advanced Research and Development Authority worked together to qualify the cynomolgus macaque model of pneumonic tularemia. METHODS: Using the model parameters and end points defined in the qualified model, efficacy of the antibiotics doxycycline and ciprofloxacin was evaluated in separate studies. Antibiotic administration, aimed to model approved human dosing, was initiated at time points of 24 hours or 48 hours after onset of fever as an indicator of disease. RESULTS: Upon aerosol exposure (target dose of 1000 colony-forming units) to Francisella tularensis SchuS4, 80% of vehicle-treated macaques succumbed or were euthanized. Ciprofloxacin treatment led to 10 of 10 animals surviving irrespective of treatment time. Doxycycline administered at 48 hours post-fever led to 10 of 10 animals surviving, while 9/10 animals survived in the group treated with doxycycline 24 hours after fever. Selected surviving animals in both the placebo and doxycycline 48-hour group showed residual live bacteria in peripheral tissues, while there were no bacteria in tissues from ciprofloxacin-treated macaques. CONCLUSIONS: Both doxycycline and ciprofloxacin were efficacious in treatment of pneumonic tularemia, although clearance of bacteria may be different between the 2 drugs.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Uncertainty in phosphorus fluxes and budgets across the US long-term agroecosystem research network.

Phosphorus (P) budgets can be useful tools for understanding nutrient cycling and quantifying the effectiveness of nutrient management planning and policies; however, uncertainties in agricultural nutrient budgets are not often quantitatively assessed. The objective of this study was to evaluate uncertainty in P fluxes (fertilizer/manure application, atmospheric deposition, irrigation, crop removal, surface runoff, and leachate) and the propagation of these uncertainties to annual P budgets. Data from 56 cropping systems in the P-FLUX database, which spans diverse rotations and landscapes across the United States and Canada, were evaluated. Results showed that across cropping systems, average annual P budget was 22.4 kg P ha-1 (range = -32.7 to 340.6 kg P ha-1 ), with an average uncertainty of 13.1 kg P ha-1 (range = 1.0-87.1 kg P ha-1 ). Fertilizer/manure application and crop removal were the largest P fluxes across cropping systems and, as a result, accounted for the largest fraction of uncertainty in annual budgets (61% and 37%, respectively). Remaining fluxes individually accounted for <2% of the budget uncertainty. Uncertainties were large enough that determining whether P was increasing, decreasing, or not changing was inconclusive in 39% of the budgets evaluated. Findings indicate that more careful and/or direct measurements of inputs, outputs, and stocks are needed. Recommendations for minimizing uncertainty in P budgets based on the results of the study were developed. Quantifying, communicating, and constraining uncertainty in budgets among production systems and multiple geographies is critical for engaging stakeholders, developing local and national strategies for P reduction, and informing policy.

The effects of inspiratory muscle training on inspiratory muscle strength, lung function and quality of life in adults with spinal cord injuries: a systematic review and Meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to evaluate the effectiveness of inspiratory muscle training (IMT) on respiratory muscle strength, lung function and quality of life (QOL) in adults with spinal cord injuries (SCI). METHODS: Databases were searched up to June 2022; CENTRAL, CINAHL, MEDLINE, PEDRo, and PubMed. Following PRISMA reporting guidelines, two independent reviewers selected studies and extracted data. Study quality and levels of evidence were assessed. RESULTS: Following selection from 624 initial search results, six randomised controlled trials were identified, comprising 124 participants. Quality of Evidence was very low to moderate. Meta-analysis showed that post intervention, IMT significantly improved maximal inspiratory pressure (MD 15.72 cmH2O, 95% CI 5.02, 26.41, p = 0.004) when compared with a control intervention. There was no significant benefit for physical QOL (SMD 0.12, 95% CI -1.01, 1.25, p = 0.84), mental QOL (SMD -0.2, 95% CI -1.72, 1.33, p = 0.80), maximal expiratory pressure (MD 5.19 cmH2O, 95% CI -4.16, 14.55, p = 0.80), or FEV1 (MD 0.26 L, 95% CI -0.19, 0.7, p = 0.26). Sensitivity analyses found larger effects for studies with 8 week interventions (MD 17.5 cmH2O (95% CI 3.36 to 31.66)) and spring loaded devices alone (MD 21.18 cmH2O, 95% CI 9.65 to 32.72). CONCLUSION: Moderate quality evidence suggests IMT improves respiratory strength in adults with an SCI. The mental and physical QOL outcomes provided very low quality of evidence, with considerable heterogeneity between study results, leading to inconsistency. Further research is warranted to investigate medium and long-term impact of robust IMT protocols, accounting for patient motivation and adherence to IMT.IMPLICATIONS FOR REHABILITATIONInspiratory muscle training (IMT) significantly improves respiratory muscle strength in adults with spinal cord injuries-irrespective of time since injury, or degree of injury completeness.IMT is a feasible, safe, and worthwhile intervention to implement with adults with spinal cord injuries and can be utilized in a variety of settings.IMT interventions that are 8 weeks long and utilize a spring-loaded inspiratory threshold device may generate the largest improvements in respiratory strength.

Long-term effect of poultry litter application on phosphorus balances and runoff losses.

Assessment of annual and cumulative impacts of phosphorus (P) management strategies at field and watershed scales is needed to improve crop use efficiency and minimize environmental impacts. The objectives of this study were (a) to assess relationships among P balance, soil test P (STP) concentration, and runoff dissolved reactive P (DRP) concentration from fields receiving different poultry litter application rates (0.0-13.4 Mg ha-1 ) and (b) to determine the effect of long-term poultry litter application to fields on watershed DRP loss. Nutrient management practices, crop yield, STP, and runoff losses were assessed from nine fields and two watersheds located near Riesel, TX, from 2000 to 2015. Field-scale P balances were largely controlled by P application rate and exhibited a positive relationship with STP and runoff DRP flow-weighted mean concentration. Using a before-after control-impact experimental design that included monitoring at both field and watershed scales showed the influence of field P management on watershed DRP loss varied according to both source (i.e., P application rate, impacted area) and transport (i.e., hydrological connectivity) factors. Increased risk of watershed DRP loss was observed during wet years and years with two poultry litter applications to fields within the watershed. The percentage of the total watershed area receiving high rates of poultry litter also played a critical role in determining the risk of DRP loss. Findings highlight the impact of long-term P management strategies on DRP loss at both field and watershed scales and show the importance of incorporating hydrologic connectivity when assessing conservation effects on water quality.

One size does not fit all: Toward regional conservation practice guidance to reduce phosphorus loss risk in the Lake Erie watershed.

Agricultural phosphorus (P) losses to surface water bodies remain a global eutrophication concern, despite the application of conservation practices on farm fields. Although it is generally agreed upon that the use of multiple conservation practices ("stacking") will lead to greater improvements to water quality, this may not be cost effective to farmers, reducing the likelihood of adoption. At present, wholesale recommendations of conservation practices are given; however, the application of specific conservation practices in certain environments (e.g., no-till with surface application, cover crops) may not be effective and can even lead to unintended consequences. In this paper, we present the Lake Erie watershed as a case study. The Lake Erie watershed contains regions with unique physical geographies that include differences in climate, soil, topography, and land use, which have implications for both P transport from agricultural fields and the efficacy of conservation practices in mitigating P losses. We define major regions within the Lake Erie watershed where common strategies for conservation practice implementation are appropriate, and we propose a five-step plan for bringing regionally tailored, adaptive, and cost-conscious conservation practice into watershed planning. Although this paper is specific to the Lake Erie watershed, our framework can be transferred across broader geographic regions to provide guidance for watershed planning.

Cognitive and sensorimotor function in participants being treated for trigeminal neuralgia pain.

BACKGROUND: Trigeminal neuralgia (TN) is an orofacial condition defined by reoccurring, spontaneous, short-lived but excruciating stabbing pain. Pharmacological interventions constitute the first-line treatment for TN, with antiepileptic drugs commonly prescribed. People treated for TN pain with antiepileptic drugs describe cognitive and motor difficulties affecting activities of daily living, and report poorer quality of life. We undertook the first comprehensive objective evaluation of sensorimotor and cognitive performance in participants being treated for TN pain with antiepileptic drugs relative to age-matched controls. METHODS: Participants (43 TN, 41 control) completed a battery of sensorimotor (steering, aiming and tracking) and cognitive (working memory, processing speed, inhibition) tasks. RESULTS: The TN group performed significantly worse than controls on the sensorimotor tracking and aiming tasks and across all cognitive measures. CONCLUSIONS: The data explain why patients treated with antiepileptic drugs report impairment when conducting activities of daily living (given the need for cognitive and motor capability within most of these). The study is an important first step in: (i) ensuring there is adequate information on the impact of pharmacological treatment; (ii) identifying measures to determine optimal medication dosage and track change over time; (iii) creating an evidence base that could allow scientific justification of alternative pain treatment options for TN (e.g. the costs/benefits of surgery).

Discovery and Development of S6821 and S7958 as Potent TAS2R8 Antagonists.

In humans, bitter taste is mediated by 25 TAS2Rs. Many compounds, including certain active pharmaceutical ingredients, excipients, and nutraceuticals, impart their bitter taste (or in part) through TAS2R8 activation. However, effective TAS2R8 blockers that can either suppress or reduce the bitterness of these compounds have not been described. We are hereby reporting a series of novel 3-(pyrazol-4-yl) imidazolidine-2,4-diones as potent and selective TAS2R8 antagonists. In human sensory tests, S6821 and S7958, two of the most potent analogues from the series, demonstrated efficacy in blocking TAS2R8-mediated bitterness and were selected for development. Following data evaluation by expert panels of a number of national and multinational regulatory bodies, including the US, the EU, and Japan, S6821 and S7958 were approved as safe under conditions of intended use as bitter taste blockers.

A Holistic Multi-Scale Approach to Using 3D Scanning Technology in Accident Reconstruction.

Three-dimensional scanning and documentation methods are becoming increasingly employed by law enforcement personnel for crime scene and accident scene recording. Three-dimensional documentation of the victim's body in such cases is also increasingly used as the field of forensic radiology and imaging is expanding rapidly. These scanning technologies enable a more complete and detailed documentation than standard autopsy. This was used to examine a fatal pedestrian-vehicle collision where the pedestrian was killed by a van while crossing the road. Two competing scenarios were considered for the vehicle speed calculation: the pedestrian being projected forward by the impact or the pedestrian being carried on the vehicle's bonnet. In order to assist with this, the impact area of the accident vehicle was scanned using laser surface scanning, the victim was scanned using postmortem CT and micro-CT and the data sets were combined to virtually match features of the vehicle to injuries on the victim. Micro-CT revealed additional injuries not previously detected, lending support to the pedestrian-carry theory.

Phase-dependent modulation of cortical and thalamic sensory responses during spike-and-wave discharges.

OBJECTIVE: The neuronal underpinnings of impaired consciousness during absence seizures remain largely unknown. Spike-and-wave (SW) activity associated with absences imposes two extremely different states in cortical neurons, which transition from suprathreshold synaptic depolarizations during spike phases to membrane hyperpolarization and electrical silence during wave phases. To investigate whether this rhythmic alternation of neuronal states affects the processing of sensory information during seizures, we examined cortical and thalamic responsiveness to brief sensory stimuli in the different phases of the epileptic cycle. METHODS: Electrocorticographic (ECoG) monitoring from the primary somatosensory cortex combined with intracellular recordings of subjacent pyramidal neurons, or extracellular recordings of somatosensory thalamic neurons, were performed in the Genetic Absence Epilepsy Rat From Strasbourg. Sensory stimuli consisted of pulses of compressed air applied to the contralateral whiskers. RESULTS: Whisker stimuli delivered during spike phases evoked smaller depolarizing synaptic potentials and fewer action potentials in cortical neurons compared to stimuli occurring during wave phases. This spike-related attenuation of cortical responsiveness was accompanied by a reduced neuronal membrane resistance, likely due to the large increase in synaptic conductance. Sensory-evoked firing in thalamocortical neurons was also decreased during ECoG spikes as compared to wave phases, indicating that time-to-time changes in the thalamocortical volley may also contribute to the variability of cortical responses during seizures. SIGNIFICANCE: These findings demonstrate that thalamocortical sensory processing during absence seizures is nonstationary and strongly suggest that the cortical impact of a given environmental stimulus is conditioned by its exact timing relative to the SW cycle. The lack of stability of thalamic and cortical responses along seizures may contribute to impaired conscious sensory perception during absences.

Role of Yoga in Cardiac Disease and Rehabilitation.

PURPOSE: Cardiovascular disease continues to be the leading cause of morbidity and mortality around the world. Yoga, a combination of physical postures (asana), breathing exercises (pranayama), and meditation (dhyana), has gained increasing recognition as a form of mind-body exercise. In this narrative review, we intended to review the emerging evidence assessing the physiologic and clinical effects of yoga on the cardiovascular system and the potential role of yoga as a component of comprehensive cardiac rehabilitation. METHODS: We searched PubMed, Google Scholar, Embase, and Cochrane databases for literature related to cardiovascular effects of yoga from inception up until 2017. RESULTS: Yoga has been shown to have favorable effects on systemic inflammation, stress, the cardiac autonomic nervous system, and traditional and emerging cardiovascular risk factors. CONCLUSIONS: Yoga has shown promise as a useful lifestyle intervention that can be incorporated into cardiovascular disease management algorithms. Although many investigators have reported the clinical benefits of yoga in reducing cardiovascular events, morbidity, and mortality, evidence supporting these conclusions is somewhat limited, thereby emphasizing the need for large, well-designed randomized trials that minimize bias and methodological drawbacks.

Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives.

BACKGROUND: Care coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model. Research exists on opinions of providers of care coordination but there is limited information on perspectives of those in the insurance industry about key elements. We sought to gather opinions from primary care providers and administrators in Minnesota who were involved in a CMS (Center for Medicare and Medicaid Services) transformational grant implementing COMPASS (Care Of Mental, Physical And Substance-use Syndromes), an evidence-based model of care coordination for depressed patients comorbid with diabetes and/or cardiovascular disease. We then sought to compare these views with those of private insurance representatives in Minnesota. METHODS: We used qualitative methods to conducted forty-two key informant interviews with primary care providers (n = 15); administrators (n = 15); and insurers (n = 12). We analyzed the recorded and transcribed data, once de-identified, using a frameworks analysis approach. RESULTS: We identified six primary themes: 1) a defined scope, rationale, and key partnerships for building comprehensive care coordination programs, 2) effective information exchange, 3) a trained and available workforce, 4) the need for a business model and a financially justifiable program, 5) a need for evaluation and ongoing improvement of care coordination, and 6) the importance of patient and family engagement. Overall consensus across stakeholder groups was high including a call for payment reform to support a valued service. Despite their role in paying for care, insurance representatives did not stress reduced utilization as more important than other outcomes. CONCLUSIONS: Primary care providers and administrators from different organizations and backgrounds, all with experience in COMPASS, in large part agreed with insurance representatives on the main elements of a sustainable model and the need for health reform to sustain this service.

Current practice in the rehabilitation of complex regional pain syndrome: a survey of practitioners.

INTRODUCTION: International clinical guidelines for Complex Regional Pain Syndrome recommend a wide range and variation of rehabilitation therapies as the core treatment. It is likely that most therapists employ a range of approaches when managing people with Complex Regional Pain Syndrome but a recent Cochrane review identified little evidence relating to the effectiveness of multi-modal rehabilitation. There is need for up to date trials of rehabilitation for Complex Regional Pain Syndrome, but in order to develop a clear model of best practice that can be rigorously evaluated we need to understand current practice. METHOD: An electronic survey was disseminated internationally to clinicians involved in the rehabilitation of individuals with Complex Regional Pain Syndrome. The survey aimed to establish which criteria are used for diagnosis and which modalities clinicians use to treat Complex Regional Pain Syndrome and which they consider ineffective or harmful. RESULTS: 132 valid responses were received. A third of participants did not use any established criteria to diagnose Complex Regional Pain Syndrome. Current practice commonly included patient education, encouragement of self-management, and physical exercises. Cortically directed treatments such as graded motor imagery and psychological approaches were often incorporated into treatment whereas pain provocative therapies, splinting, contrast bathing, and cold and heat therapy were rarely used in the acute or chronic phase of Complex Regional Pain Syndrome. CONCLUSION: A broad range of modalities are currently used in Complex Regional Pain Syndrome rehabilitation. Practice appears to be characterized by educational and exercise based interventions delivered in a pain-contingent manner which largely echoes recommendations in international clinical guidelines. Implications for Rehabilitation: Patients with Complex Regional Pain Syndrome suffer from a painful and disabling condition for which we still do not know the best treatment options. From our survey sample most clinicians use treatments recommended in the international guidelines. A large proportion of clinicians from our survey sample are not using internationally recognized diagnostic criteria and we therefore recommend that clinicians become familiar with these criteria and use them for all suspected Complex Regional Pain Syndrome cases.

Effectiveness in Regular Practice of Collaborative Care for Depression Among Adolescents: A Retrospective Cohort Study.

OBJECTIVE: Depression is common among adolescents, but many lack ready access to mental health services. Integrated models of care for depression are needed, along with evidence to support their use in regular practice. The authors examined the effectiveness of an ongoing collaborative care program for depressed adolescents embedded in a busy primary care practice. METHODS: This retrospective cohort study assessed EMERALD (Early Management and Evidence-based Recognition of Adolescents Living with Depression), a collaborative care program. All patients ages 12-17 and age 18 and still in high school with a score of ≥10 on the nine-item Patient Health Questionnaire for Adolescents (PHQ-9A) and without a diagnosis of bipolar disorder were eligible. The sample included 162 EMERALD participants and 499 similarly eligible non-EMERALD patients. Outcomes were six-month remission of depression (score <5) and six-month treatment response (>50% reduction from baseline) as measured by the PHQ-9A. Analyses included logistic regression and propensity score matching to adjust for differences in demographic factors and number of contacts-observations. RESULTS: After propensity score matching, EMERALD patients had better adjusted rates of depression remission (11 percentage points higher, p=.035) and treatment response (14 percentage points higher, p<.001) than comparison patients. Results from primary analyses were as conservative as or more conservative than results from all sensitivity analyses tested. CONCLUSIONS: Collaborative care for adolescents in regular practice led to better remission and treatment response than usual care. Future studies could examine which groups might benefit most and flexible payment models to support these services.

Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits.

BACKGROUND: Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models. METHODS: From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers. RESULTS: Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. CONCLUSION: True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.

Phosphorus Availability in Western Lake Erie Basin Drainage Waters: Legacy Evidence across Spatial Scales.

The Western Lake Erie Basin (WLEB) was inundated with precipitation during June and July 2015 (two to three times greater than historical averages), which led to significant nutrient loading and the largest in-lake algal bloom on record. Using discharge and concentration data from three spatial scales (0.18-16,000 km), we contrast the patterns in nitrate (NO-N) and dissolved reactive phosphorus (DRP) concentration dynamics and discuss potential management implications. Across all scales, NO-N concentration steadily declined with each subsequent rainfall event as it was flushed from the system. In contrast, DRP concentration persisted, even on soils at or below agronomic P levels, suggesting that legacy P significantly contributes to nutrient loads in the WLEB. These findings highlight the need to revisit current P fertility recommendations and soil testing procedures to increase P fertilizer use efficiency and to more holistically account for legacy P.

Healthy Lifestyle Medicine in the Traditional Healthcare Environment-Primary Care and Cardiac Rehabilitation.

There is unquestioned value of the need to incorporate Healthy Lifestyle Medicine (HLM) within the traditional models of healthcare. Primary care providers are well positioned to implement HLM as a routine aspect of their healthcare practice. Unfortunately, barriers for this to occur, including poor professional training in the components of HLM and limitations in the time they have available to spend with patients, result in inadequate delivery of HLM from primary care providers. Thus, new approaches for the delivery of HLM need to be developed that would allow primary care providers better, and more, opportunities to make patient referrals. Ideally, this would start with creating a culture change within communities that embraces the importance on living a healthy lifestyle. One opportunity which should be considered is expanding access to currently available options, such as cardiac rehabilitation programs and worksite wellness programs. Both types of programs already provide key elements of HLM within their existing structure. However, new models also need to be developed. Community-based HL centers comprising HL specialists including counselors, exercise physiologists, dietitians, and physical therapists, could be developed and become core locations for the promotion of HLM.

The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease.

OBJECTIVE: To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. METHODS: Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. RESULTS: The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work. CONCLUSIONS: The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.