Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review.

BACKGROUND: Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence. METHODS: A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II. RESULTS: In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C. CONCLUSIONS: Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology.

Immuno-PET Imaging of the Programmed Cell Death-1 Ligand (PD-L1) Using a Zirconium-89 Labeled Therapeutic Antibody, Avelumab.

OBJECTIVE: The goal is to evaluate avelumab, an anti-PD-L1 monoclonal immunoglobulin G antibody labeled with zirconium-89 in human PD-L1-expressing cancer cells and mouse xenografts for clinical translation. METHODS: [89Zr]Zr-DFO-PD-L1 monoclonal antibody (mAb) was synthesized using avelumab conjugated to desferrioxamine. In vitro binding studies and biodistribution studies were performed with PD-L1+MDA-MB231 cells and MDA-MB231 xenograft mouse models, respectively. Biodistributions were determined at 1, 2, 3, 5, and 7 days post coinjection of [89Zr]Zr-DFO-PD-L1 mAb without or with unlabeled avelumab (10, 20, 40, and 400 µg). RESULTS: [89Zr]Zr-DFO-PD-L1 mAb exhibited high affinity (Kd ∼ 0.3 nM) and detected moderate PD-L1 expression levels in MDA-MB231 cells. The spleen and lymph nodes exhibited the highest [89Zr]Zr-DFO-PD-L1 mAb uptakes in all time points, while MDA-MB231 tumor uptakes were lower but highly retained. In the unlabeled avelumab dose escalation studies, spleen tissue-muscle ratios decreased in a dose-dependent manner indicating specific [89Zr]Zr-DFO-PD-L1 mAb binding to PD-L1. In contrast, lymph node and tumor tissue-muscle ratios increased 4- to 5-fold at 20 and 40 µg avelumab doses. CONCLUSIONS: [89Zr]Zr-DFO-PD-L1 mAb exhibited specific and high affinity for PD-L1 in vitro and had target tissue uptakes correlating with PD-L1 expression levels in vivo. [89Zr]Zr-DFO-PD-L1 mAb uptake in PD-L1+tumors increased with escalating doses of avelumab.

Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials: An ACTTION Systematic Review.

Objective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment. This study reviewed those existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of our study suggest that a wide range of measures has been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design, as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures can be developed on the basis of our findings. We believe that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Modified APEX model for Simulating Macropore Phosphorus Contributions to Tile Drains.

The contribution of macropore flow to phosphorus (P) loadings in tile-drained agricultural landscapes remains poorly understood at the field scale, despite the recognized deleterious impacts of contaminant transport via macropore pathways. A new subroutine that couples existing matrix-excess and matrix-desiccation macropore flow theory and a modified P routine is implemented in the Agricultural Policy Environmental eXtender (APEX) model. The original and modified formulation were applied and evaluated for a case study in a poorly drained field in Western Ohio with 31 months of surface and subsurface monitoring data. Results highlighted that a macropore subroutine in APEX improved edge-of-field discharge calibration and validation for both tile and total discharge from satisfactory and good, respectively, to very good and improved dissolved reactive P load calibration and validation statistics for tile P loads from unsatisfactory to very good. Output from the calibrated macropore simulations suggested median annual matrix-desiccation macropore flow contributions of 48% and P load contributions of 43%, with the majority of loading occurring in winter and spring. While somewhat counterintuitive, the prominence of matrix-desiccation macropore flow during seasons with less cracking reflects the importance of coupled development of macropore pathways and adequate supply of the macropore flow source. The innovative features of the model allow for assessments of annual macropore P contributions to tile drainage and has the potential to inform P site assessment tools.

Edge-Of-Field Evaluation of the Ohio Phosphorus Risk Index.

The Phosphorus Index (PI) has been the cornerstone for phosphorus (P)-based management and planning over the past twenty years, yet field-scale evaluation of many state PIs has been limited. In this study, P loads measured in surface runoff and tile discharge from 40 agricultural fields in Ohio with prevailing management practices were used to evaluate the Ohio PI. Annual P loads were highly variable among fields (dissolved reactive P: 0.03-4.51 kg ha, total P: 0.03-6.88 kg ha). Both measured annual dissolved reactive P ( = 0.36, < 0.001) and total P ( = 0.25, < 0.001) loads were significantly related to Ohio PI score. The relationship between measured load and PI score substantially improved when averaged annual field values were used (dissolved reactive P: = 0.71, total P: = 0.73), indicating that the Ohio PI should be utilized to evaluate average annual risk of P loss, rather than as an annual risk tool. Comparison between the Ohio PI and other established local and national metrics resulted in large differences in potential P management recommendations for the monitored fields. In the near term, revision of Ohio PI risk categories and management recommendations using local P loading thresholds is needed. To meet the minimum criteria for state PI tools, future research efforts should focus on using measured field data (i) to incorporate new input factors (i.e., P application timing and leaching potential) into the Ohio PI, and (ii) to calibrate and validate the Ohio PI to provide better P risk assessments and management recommendations.

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.

Luminal microbes promote monocyte-stem cell interactions across a healthy colonic epithelium.

The intestinal epithelium forms a vital barrier between luminal microbes and the underlying mucosal immune system. Epithelial barrier function is maintained by continuous renewal of the epithelium and is pivotal for gut homeostasis. Breaching of the barrier causes mobilization of immune cells to promote epithelial restitution. However, it is not known whether microbes at the luminal surface of a healthy epithelial barrier influence immune cell mobilization to modulate tissue homeostasis. Using a mouse colonic mucosal explant model, we demonstrate that close proximity of luminal microbes to a healthy, intact epithelium results in rapid mucus secretion and movement of Ly6C(+)7/4(+) monocytes closer to epithelial stem cells. These early events are driven by the epithelial MyD88-signaling pathway and result in increased crypt cell proliferation and intestinal stem cell number. Over time, stem cell number and monocyte-crypt stem cell juxtapositioning return to homeostatic levels observed in vivo. We also demonstrate that reduced numbers of tissue Ly6C+ monocytes can suppress Lgr5EGFP+ stem cell expression in vivo and abrogate the response to luminal microbes ex vivo. The functional link between monocyte recruitment and increased crypt cell proliferation was further confirmed using a crypt-monocyte coculture model. This work demonstrates that the healthy gut epithelium mediates communication between luminal bacteria and monocytes, and monocytes can modulate crypt stem cell number and promote crypt cell proliferation to help maintain gut homeostasis.

Efficacy Outcome Measures for Procedural Sedation Clinical Trials in Adults: An ACTTION Systematic Review.

Successful procedural sedation represents a spectrum of patient- and clinician-related goals. The absence of a gold-standard measure of the efficacy of procedural sedation has led to a variety of outcomes being used in clinical trials, with the consequent lack of consistency among measures, making comparisons among trials and meta-analyses challenging. We evaluated which existing measures have undergone psychometric analysis in a procedural sedation setting and whether the validity of any of these measures support their use across the range of procedures for which sedation is indicated. Numerous measures were found to have been used in clinical research on procedural sedation across a wide range of procedures. However, reliability and validity have been evaluated for only a limited number of sedation scales, observer-rated pain/discomfort scales, and satisfaction measures in only a few categories of procedures. Typically, studies only examined 1 or 2 aspects of scale validity. The results are likely unique to the specific clinical settings they were tested in. Certain scales, for example, those requiring motor stimulation, are unsuitable to evaluate sedation for procedures where movement is prohibited (e.g., magnetic resonance imaging scans). Further work is required to evaluate existing measures for procedures for which they were not developed. Depending on the outcomes of these efforts, it might ultimately be necessary to consider measures of sedation efficacy to be procedure specific.

Contributions of systematic tile drainage to watershed-scale phosphorus transport.

Phosphorus (P) transport from agricultural fields continues to be a focal point for addressing harmful algal blooms and nuisance algae in freshwater systems throughout the world. In humid, poorly drained regions, attention has turned to P delivery through subsurface tile drainage. However, research on the contributions of tile drainage to watershed-scale P losses is limited. The objective of this study was to evaluate long-term P movement through tile drainage and its manifestation at the watershed outlet. Discharge data and associated P concentrations were collected for 8 yr (2005-2012) from six tile drains and from the watershed outlet of a headwater watershed within the Upper Big Walnut Creek watershed in central Ohio. Results showed that tile drainage accounted for 47% of the discharge, 48% of the dissolved P, and 40% of the total P exported from the watershed. Average annual total P loss from the watershed was 0.98 kg ha, and annual total P loss from the six tile drains was 0.48 kg ha. Phosphorus loads in tile and watershed discharge tended to be greater in the winter, spring, and fall, whereas P concentrations were greatest in the summer. Over the 8-yr study, P transported in tile drains represented <2% of typical application rates in this watershed, but >90% of all measured concentrations exceeded recommended levels (0.03 mg L) for minimizing harmful algal blooms and nuisance algae. Thus, the results of this study show that in systematically tile-drained headwater watersheds, the amount of P delivered to surface waters via tile drains cannot be dismissed. Given the amount of P loss relative to typical application rates, development and implementation of best management practices (BMPs) must jointly consider economic and environmental benefits. Specifically, implementation of BMPs should focus on late fall, winter, and early spring seasons when most P loading occurs.

Linking nitrogen management, seep chemistry, and stream water quality in two agricultural headwater watersheds.

Riparian seepage zones in headwater agricultural watersheds represent important sources of nitrate-nitrogen (NO-N) to surface waters, often connecting N-rich groundwater systems to streams. In this study, we examined how NO-N concentrations in seep and stream water were affected by NO-N processing along seep surface flow paths and by upslope applications of N from fertilizers and manures. The research was conducted in two headwater agricultural watersheds, FD36 (40 ha) and RS (45 ha), which are fed, in part, by a shallow fractured aquifer system possessing high (3-16 mg L) NO-N concentrations. Data from in-seep monitoring showed that NO-N concentrations generally decreased downseep (top to bottom), indicating that most seeps retained or removed a fraction of delivered NO-N (16% in FD36 and 1% in RS). Annual mean N applications in upslope fields (as determined by yearly farmer surveys) were highly correlated with seep NO-N concentrations in both watersheds (slope: 0.06; = 0.79; < 0.001). Strong positive relationships also existed between seep and stream NO-N concentrations in FD36 (slope: 1.01; = 0.79; < 0.001) and in RS (slope: 0.64; = 0.80; < 0.001), further indicating that N applications control NO-N concentrations at the watershed scale. Our findings clearly point to NO-N leaching from upslope agricultural fields as the primary driver of NO-N losses from seeps to streams in these watersheds and therefore suggest that appropriate management strategies (cover crops, limiting fall/winter nutrient applications, decision support tools) be targeted in these zones.

Phosphorus transport in agricultural subsurface drainage: a review.

Phosphorus (P) loss from agricultural fields and watersheds has been an important water quality issue for decades because of the critical role P plays in eutrophication. Historically, most research has focused on P losses by surface runoff and erosion because subsurface P losses were often deemed to be negligible. Perceptions of subsurface P transport, however, have evolved, and considerable work has been conducted to better understand the magnitude and importance of subsurface P transport and to identify practices and treatments that decrease subsurface P loads to surface waters. The objectives of this paper were (i) to critically review research on P transport in subsurface drainage, (ii) to determine factors that control P losses, and (iii) to identify gaps in the current scientific understanding of the role of subsurface drainage in P transport. Factors that affect subsurface P transport are discussed within the framework of intensively drained agricultural settings. These factors include soil characteristics (e.g., preferential flow, P sorption capacity, and redox conditions), drainage design (e.g., tile spacing, tile depth, and the installation of surface inlets), prevailing conditions and management (e.g., soil-test P levels, tillage, cropping system, and the source, rate, placement, and timing of P application), and hydrologic and climatic variables (e.g., baseflow, event flow, and seasonal differences). Structural, treatment, and management approaches to mitigate subsurface P transport-such as practices that disconnect flow pathways between surface soils and tile drains, drainage water management, in-stream or end-of-tile treatments, and ditch design and management-are also discussed. The review concludes by identifying gaps in the current understanding of P transport in subsurface drains and suggesting areas where future research is needed.

Canonical Wnt signals combined with suppressed TGFß/BMP pathways promote renewal of the native human colonic epithelium.

BACKGROUND: A defining characteristic of the human intestinal epithelium is that it is the most rapidly renewing tissue in the body. However, the processes underlying tissue renewal and the mechanisms that govern their coordination have proved difficult to study in the human gut. OBJECTIVE: To investigate the regulation of stem cell-driven tissue renewal by canonical Wnt and TGFß/bone morphogenetic protein (BMP) pathways in the native human colonic epithelium. DESIGN: Intact human colonic crypts were isolated from mucosal tissue samples and placed into 3D culture conditions optimised for steady-state tissue renewal. High affinity mRNA in situ hybridisation and immunohistochemistry were complemented by functional genomic and bioimaging techniques. The effects of signalling pathway modulators on the status of intestinal stem cell biology, crypt cell proliferation, migration, differentiation and shedding were determined. RESULTS: Native human colonic crypts exhibited distinct activation profiles for canonical Wnt, TGFß and BMP pathways. A population of intestinal LGR5/OLFM4-positive stem/progenitor cells were interspersed between goblet-like cells within the crypt-base. Exogenous and crypt cell-autonomous canonical Wnt signals supported homeostatic intestinal stem/progenitor cell proliferation and were antagonised by TGFß or BMP pathway activation. Reduced Wnt stimulation impeded crypt cell proliferation, but crypt cell migration and shedding from the crypt surface were unaffected and resulted in diminished crypts. CONCLUSIONS: Steady-state tissue renewal in the native human colonic epithelium is dependent on canonical Wnt signals combined with suppressed TGFß/BMP pathways. Stem/progenitor cell proliferation is uncoupled from crypt cell migration and shedding, and is required to constantly replenish the crypt cell population.

Immuno-PET imaging of tumor endothelial marker 8 (TEM8).

Tumor endothelial marker 8 (TEM8) is a cell surface receptor that is highly expressed in a variety of human tumors and promotes tumor angiogenesis and cell growth. Antibodies targeting TEM8 block tumor angiogenesis in a manner distinct from the VEGF receptor pathway. Development of a TEM8 imaging agent could aid in patient selection for specific antiangiogenic therapies and for response monitoring. In these studies, L2, a therapeutic anti-TEM8 monoclonal IgG antibody (L2mAb), was labeled with (89)Zr and evaluated in vitro and in vivo in TEM8 expressing cells and mouse xenografts (NCI-H460, DLD-1) as a potential TEM8 immuno-PET imaging agent. (89)Zr-df-L2mAb was synthesized using a desferioxamine-L2mAb conjugate (df-L2mAb); (125)I-L2mAb was labeled directly. In vitro binding studies were performed using human derived cell lines with high, moderate, and low/undetectable TEM8 expression. (89)Zr-df-L2mAb in vitro autoradiography studies and CD31 IHC staining were performed with cryosections from human tumor xenografts (NCI-H460, DLD-1, MKN-45, U87-MG, T-47D, and A-431). Confirmatory TEM8 Western blots were performed with the same tumor types and cells. (89)Zr-df-L2mAb biodistribution and PET imaging studies were performed in NCI-H460 and DLD-1 xenografts in nude mice. (125)I-L2mAb and (89)Zr-df-L2mAb exhibited specific and high affinity binding to TEM8 that was consistent with TEM8 expression levels. In NCI-H460 and DLD-1 mouse xenografts nontarget tissue uptake of (89)Zr-df-L2mAb was similar; the liver and spleen exhibited the highest uptake at all time points. (89)Zr-L2mAb was highly retained in NCI-H460 tumors with <10% losses from day 1 to day 3 with the highest tumor to muscle ratios (T:M) occurring at day 3. DLD-1 tumors exhibited similar pharmacokinetics, but tumor uptake and T:M ratios were reduced ∼2-fold in comparison to NCI-H460 at all time points. NCI-H460 and DLD-1 tumors were easily visualized in PET imaging studies despite low in vitro TEM8 expression in DLD-1 cells indicating that in vivo expression might be higher in DLD-1 tumors. From in vitro autoradiography studies (89)Zr-df-L2mAb specific binding was found in 6 tumor types (U87-MG, NCI-H460, T-47D MKN-45, A-431, and DLD-1) which highly correlated to vessel density (CD31 IHC). Westerns blots confirmed the presence of TEM8 in the 6 tumor types but found undetectable TEM8 levels in DLD-1 and MKN-45 cells. This data would indicate that TEM8 is associated with the tumor vasculature rather than the tumor tissue, thus explaining the increased TEM8 expression in DLD-1 tumors compared to DLD-1 cell cultures. (89)Zr-df-L2mAb specifically targeted TEM8 in vitro and in vivo although the in vitro expression was not necessarily predictive of in vivo expression which seemed to be associated with the tumor vasculature. In mouse models, (89)Zr-df-L2mAb tumor uptakes and T:M ratios were sufficient for visualization during PET imaging. These results would suggest that a TEM8 targeted PET imaging agent, such as (89)Zr-df-L2mAb, may have potential clinical, diagnostic, and prognostic applications by providing a quantitative measure of tumor angiogenesis and patient selection for future TEM8 directed therapies.

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.

Controls on subsurface nitrate and dissolved reactive phosphorus losses from agricultural fields during precipitation-driven events.

The magnitude of nitrogen (N) and phosphorus (P) exported from agricultural fields via subsurface tile drainage systems is determined by site-specific interactions between weather, soil, field, and management characteristics. Here, we used multiple regression analyses to evaluate the influence of 29 controls of precipitation event-driven discharge, nitrate (NO3--N) load, and dissolved reactive P (DRP) load from subsurface tile drains, leveraging a unique dataset of ~7000 precipitation events observed across 40 agricultural fields (n = 190 site years) instrumented to collect continuous water quality samples. We calculated marginal effects of significant controls and assessed the modifying influence of event rainfall, duration, and intensity, and antecedent precipitation. Tile discharge was strongly and positively influenced by previous 7-day precipitation and total rainfall and negatively influenced by daily temperature and tile spacing. Both tile NO3--N and DRP loads were positively influenced by transport and source variables, including event discharge and total fertilizer applied as well as soil test P (STP) in the case of tile DRP load; factors with the strongest negative influence on tile NO3--N and DRP loads were related to time of year. The strength and direction of both positive and negative controls also varied with precipitation characteristics. For example, the positive influence of event discharge on nutrient loads lessened as event duration, event intensity, and previous 7-day precipitation increased, while the positive influence of N and P sources strengthened, particularly in response to extreme (or maximum) events. Results here demonstrate the predominant role of transport and source controls while accounting for interactive effects among site-specific characteristics and underscore the importance of storm dynamics when managing N and P loss from agricultural fields.

Patterns of DNA methylation in individual colonic crypts reveal aging and cancer-related field defects in the morphologically normal mucosa.

Methylation of CpG islands (CGIs) in the promoter regions of tumour suppressor genes is common in colorectal cancer and occurs also in an age-dependent manner in the morphologically normal colorectal mucosa. In this study, we quantified the level of methylation of six genes associated with the Wnt signalling pathway (adenomatous polyposis coli, DKK1, WIF1, SFRP1, SFRP2 and SFRP5) together with long-interspersed nuclear element-1 as a surrogate for global methylation. DNA methylation was analysed in 260 individual colorectal crypts obtained from eight female patients with no evidence of colorectal disease and five with colorectal cancer. Significant variation in methylation levels for each of the six genes existed between crypts from the same biopsy. The variation in both global and gene-specific CGI methylation between crypts from the same individual was significantly less than that between individuals. Bisulphite sequencing provided insight into the mechanism of aberrant methylation showing that CGI methylation occurs in an 'all-or-none' manner by the directional spreading of methylation from further upstream. Univariate statistical analyses revealed that there were significant differences in crypt-specific methylation associated with both aging and disease status. A multivariate statistical modelling approach was able to distinguish both subject age and health status based on crypt-specific methylation profiles. Our results indicate that the differential methylation of genes associated with the Wnt signalling pathway affecting individual morphologically normal crypts may contribute to the age-dependent generation of the colonic field defect and, in combination with mutations, to the stepwise development of colorectal neoplasia.

Perineural involvement of squamous cell carcinoma presenting with formication.

Perineural involvement of a cutaneous neoplasm marks an aggressive feature. Tumors with perineural involvement share an increased propensity for local invasion via perineural spread. Formication may be an indicator of perineural involvement by cutaneous neoplasms. We present a case of an 82-year-old man with perineural involvement of a squamous cell carcinoma (SCC) identified by clinical symptoms of formication. Successful resolution of these symptoms was achieved with radiation therapy.