Evaluating agricultural best management practices in tile-drained subwatersheds of the Mackinaw River, Illinois.

Best management practices (BMPs) are widely promoted in agricultural watersheds as a means of improving water quality and ameliorating altered hydrology. We used a paired watershed approach to evaluate whether focused outreach could increase BMP implementation rates and whether BMPs could induce watershed-scale (4000 ha) changes in nutrients, suspended sediment concentrations, or hydrology in an agricultural watershed in central Illinois. Land use was >90% row crop agriculture with extensive subsurface tile drainage. Outreach successfully increased BMP implementation rates for grassed waterways, stream buffers, and strip-tillage within the treatment watershed, which are designed to reduce surface runoff and soil erosion. No significant changes in nitrate-nitrogen (NO-N), total phosphorus (TP), dissolved reactive phosphorus, total suspended sediment (TSS), or hydrology were observed after implementation of these BMPs over 7 yr of monitoring. Annual NO-N export (39-299 Mg) in the two watersheds was equally exported during baseflow and stormflow. Mean annual TP export was similar between the watersheds (3.8 Mg) and was greater for TSS in the treatment (1626 ± 497 Mg) than in the reference (940 ± 327 Mg) watershed. Export of TP and TSS was primarily due to stormflow (>85%). Results suggest that the BMPs established during this study were not adequate to override nutrient export from subsurface drainage tiles. Conservation planning in tile-drained agricultural watersheds will require a combination of surface-water BMPs and conservation practices that intercept and retain subsurface agricultural runoff. Our study emphasizes the need to measure conservation outcomes and not just implementation rates of conservation practices.

The Pancreas Can Take the Cold: Lower Waitlist Times Through Importation.

BACKGROUND: Our center has used a strategy of pancreas importation owing to long regional waitlist times. Here we assess the clinical outcomes and financial considerations of this strategy. METHODS: This was a retrospective observational cohort study of patients who received a pancreas transplant at Montefiore Medical Center (MMC) from 2014 to 2017 (n = 28). Clinical parameters, including hemoglobin A1c and complications, were analyzed. The cohort was compared with United Network for Organ Sharing (UNOS) Region 9 with the use of the UNOS/Organ Procurement and Transplantation Network database. Cost analysis of length of stay (LOS), standard acquisition (SAC) fees, and transportation was performed with the use of internal financial data. RESULTS: Pancreas importation resulted in significantly shorter simultaneous pancreas kidney transplant waitlist times compared with Region 9: 518 days vs 1001 days (P = .038). In addition, postoperative complications and 1-year HbA1c did not differ between groups: local 6.30% vs import 6.17% (P = .87). Patients receiving local pancreata stayed an average of 9.2 days compared with 11 days for the import group (P = .36). As such, pancreas importation was associated with higher mean charges ($445,968) compared with local pancreas recipients ($325,470). CONCLUSIONS: Long waitlist times in Region 9 have encouraged our center's adoption of pancreas importation to address the needs of our patient population. This practice has resulted in a reduction of waitlist times by an average of 483 days. Understandably, centers have long been wary of importation owing to perceived risk in clinical outcomes. In our single-center experience, we have demonstrated equivalent postoperative glucose control and graft survival. Importantly, there does appear to be increased costs associated with importation, which are mainly driven by LOS. Curiously, importation from regions with lower SAC fees has the potential to offset costs related to transportation expenses. Notwithstanding these findings, pancreas importation does have the potential to lessen the financial societal burden through reduction in waitlist times.

Platelet glycoprotein inhibitors in patients with medically managed acute coronary syndrome: does the enthusiasm exceed the science?

Guidelines from the American Heart Association and the American College of Cardiology, as well as numerous review articles, have strongly and enthusiastically recommended that platelet glycoprotein IIb/IIIa inhibitors be used in patients with medically managed unstable angina or non-ST-segment myocardial infarction (UA/NSTEMI). We explore whether there is sufficient experimental evidence to justify these recommendations. We review the 4 large randomized trials of US Food and Drug Administration-approved platelet glycoprotein IIb/IIIa inhibitors that included medically managed UA/NSTEMI patients, first taking each trial's results at face value and then in the context of likely biases. The risk differences, unadjusted for potential biases, are 2.5% (0.6%, 4.4%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) study, 2.3% (-1.9%, 6.5%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study (tirofiban plus heparin), 0.9% (-0.9%, 2.8%) for the Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, -0.2% (-1.7%, 1.3%) for the least harmful treatment arm of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-IV) trial, and -1.9% (-6.8%, 3.0%) for the PRISM-PLUS study (tirofiban alone) (positive numbers indicate benefit). The 95% confidence interval produced by combining the studies using a random effects model is -1.3% to 3.2% (mean 0.9%); this is consistent with drugs providing a small benefit, no benefit, or causing harm. Confounding caused by the nonrandom selection of patients for percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in all trials except GUSTO-IV and problems arising from the fact that enrolled patients were much sicker than typical UA/NSTEMI patients are likely to have biased the studies away from the null and make an assertion of benefit even more tenuous. Given the equivocal results, it would appear that the authors are relying on opinion rather than evidence to formulate their conclusions. Clinicians should understand that opinion and factors other than medical evidence may influence the content of the recommendations.

Adenosine in wide-complex tachycardia.

The use of adenosine as a therapeutic and diagnostic tool in wide-complex tachycardia is suggested in the current Advanced Cardiac Life Support (ACLS) guidelines. The ACLS guidelines are now 4 years old, and new information on the safety and efficiency of adenosine in wide-complex tachycardia is available. We review the ACLS recommendations in light of the current available literature. In general, the ACLS recommendations remain reasonable with some important caveats.

Influence of one-week hindlimb suspension and intermittent high load exercise on rat muscles.

Hindlimb suspension (HS) is a ground-based simulation model for spaceflight commonly used to study the effects of unloading on skeletal muscle. The purpose of the present study was to determine the effects of a daily short-duration, high-load exercise training program in ameliorating the atrophic response and associated adaptations in the mechanical properties of the soleus (SOL) and medial gastrocnemius (MG) muscles to HS. Male Sprague-Dawley rats (mean body weight, approximately 250 g) were assigned randomly to one of three groups: control (CON, n = 7), HS, (n = 7), and HS plus exercise (HS-EX, n = 8). The exercise consisted of rats climbing up a 1-m grid inclined at approximately 85 degrees for eight repetitions with a load equal to 75% body weight attached to their tails repeated four times daily during their active period. Following 7 days, soleus wet weights in the HS and HS-EX rats were 42 and 23% lower than those in the CON rats. The SOL muscle weight to body weight ratio in the HS group was 32% smaller than that in the CON group, whereas it was similar to that of CON in the HS-EX. Maximum tetanic tensions in the HS and HS-EX groups were 44 and 27% less than that in CON, with that in HS-EX being significantly greater than that in HS.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure to agree on the electrocardiographic diagnosis of ventricular tachycardia.

STUDY OBJECTIVE: To determine the extent of interobserver agreement in the ECG diagnosis of ventricular tachycardia (VT) by using a four-step algorithm and three observers. METHODS: Simulated emergency department setting from records of an urban university teaching hospital. All ECGs taken in the ED during a 2-year period that showed a QRS duration of more than 120 msec and a heart rate faster than 110 beats per minute were reviewed. ECGs were categorized as demonstrating sinus rhythm (SR), irregular broad-complex tachycardia (I-BCT), or regular broad-complex tachycardia (BCT). Copies of the BCT ECGs and short clinical histories were given to each of three emergency physicians, who used a published, four-step algorithm (the Brugada algorithm) to categorize the BCT ECGs as indicating VT, indicating supraventricular tachycardia with aberrancy (SVT-A), or indeterminate. Interobserver agreement was assessed with the K-statistic. RESULTS: The records contained 178 ECGs, 88 of which were SR, 63 I-BCT, and 27 BCT. The 27 BCT ECGs were selected for review. The emergency physicians disagreed with each other 22% of the time in differentiating VT from SVT-A (K = .58). CONCLUSION: Application of the algorithm to actual clinical practice in the ED would probably result in the misdiagnosis of a substantial minority of patients having BCT, with potentially serious adverse consequences.

Magnetic resonance imaging of the upper airway. Effects of propofol anesthesia and nasal continuous positive airway pressure in humans.

BACKGROUND: Anesthetic agents inhibit the respiratory activity of upper airway muscles more than the diaphragm, creating a potential for narrowing or complete closure of the pharyngeal airway during anesthesia. Because the underlying mechanisms leading to airway obstruction in sleep apnea and during anesthesia are similar, it was hypothesized that anesthesia-induced pharyngeal narrowing could be counteracted by applying nasal continuous positive airway pressure (CPAP). METHODS: Anesthesia was induced in ten healthy volunteers (aged 25-34 yr) by intravenous administration of propofol in 50-mg increments every 30-s to a maximum of 300 mg. Magnetic resonance images of the upper airway (slice thickness of 5 mm or less) were obtained in the awake state, during propofol anesthesia, and during administration of propofol plus 10 cm nasal CPAP. RESULTS: Minimum anteroposterior diameter of the pharynx at the level of the soft palate decreased from 6.6 +/- 2.2 mm (SD) in the awake state to 2.7 +/- 1.5 mm (P < 0.05) during propofol anesthesia and increased to 8.43 +/- 2.5 mm (P < 0.05) after nasal CPAP application. Anteroposterior diameter of the pharynx at the level of the dorsum of the tongue increased from 7.9 +/- 3.5 mm during propofol anesthesia to 12.9 +/- 3.6 mm (P < 0.05) after nasal CPAP. Pharyngeal volume (from the tip of the epiglottis to the tip of the soft palate, assuming this space to be a truncated cone) significantly increased from 2,437 +/- 1,008 mm3 during propofol anesthesia to 5,847 +/- 2,827 mm3 (P < 0.05) after nasal CPAP application. CONCLUSIONS: In contrast to the traditional view that relaxation of the tongue causes airway obstruction, this study suggests that airway closure occurs at the level of the soft palate. Application of nasal CPAP can counteract an anesthesia-induced pharyngeal narrowing by functioning as a pneumatic splint. This is supported by the observed reduction in anteroposterior diameter at the level of the soft palate during propofol anesthesia and the subsequent increase in this measurement during nasal CPAP application.