Bimodal spore release heights in the water column enhance local retention and population connectivity of bull kelp, Nereocystis luetkeana.

Dispersal of reproductive propagules determines recruitment patterns and connectivity among populations and can influence how populations respond to major disturbance events. Dispersal distributions can depend on propagule release strategies. For instance, the bull kelp, Nereocystis luetkeana, can release propagules (spores) from two heights in the water column ("bimodal release"): at the water surface, directly from the reproductive tissues (sori) on the kelp's blades, and near the seafloor after the sori abscise and sink through the water column. N. luetkeana is a foundation species that occurs from central California to Alaska and is experiencing unprecedented levels of population declines near its southern range limit. We know little of the kelp's dispersal distributions, which could influence population recovery and restoration. Here, we quantify how bimodal spore release heights affect dispersal outcomes based on a numerical model specifically designed for N. luetkeana. The model incorporates oceanographic conditions typical of the species' coastal range and kelp biological traits. With bimodal release heights, 34% of spores are predicted to settle within 10 m of the parental alga and 60% are predicted to disperse beyond 100 m. As an annual species, bimodal release heights can facilitate the local regeneration of adults within a source kelp forest while also supporting connectivity among multiple forests within broader bull kelp metapopulations. To leverage this pattern of bimodal spore dispersal in bull kelp restoration management, directing resources toward strategically located focal populations that can seed other ones could amplify the scale of recovery.

Season-specific impacts of climate change on canopy-forming seaweed communities.

Understory assemblages associated with canopy-forming species such as trees, kelps, and rockweeds should respond strongly to climate stressors due to strong canopy-understory interactions. Climate change can directly and indirectly modify these assemblages, particularly during more stressful seasons and climate scenarios. However, fully understanding the seasonal impacts of different climate conditions on canopy-reliant assemblages is difficult due to a continued emphasis on studying single-species responses to a single future climate scenario during a single season. To examine these emergent effects, we used mesocosm experiments to expose seaweed assemblages associated with the canopy-forming golden rockweed, Silvetia compressa, to elevated temperature and pCO2 conditions reflecting two projected greenhouse emission scenarios (RCP 2.6 [low] & RCP 4.5 [moderate]). Assemblages were grown in the presence and absence of Silvetia, and in two seasons. Relative to ambient conditions, predicted climate scenarios generally suppressed Silvetia biomass and photosynthetic efficiency. However, these effects varied seasonally-both future scenarios reduced Silvetia biomass in summer, but only the moderate scenario did so in winter. These reductions shifted the assemblage, with more extreme shifts occurring in summer. Contrarily, future scenarios did not shift assemblages within Silvetia Absent treatments, suggesting that climate primarily affected assemblages indirectly through changes in Silvetia. Mesocosm experiments were coupled with a field Silvetia removal experiment to simulate the effects of climate-mediated Silvetia loss on natural assemblages. Consistent with the mesocosm experiment, Silvetia loss resulted in season-specific assemblage shifts, with weaker effects observed in winter. Together, our study supports the hypotheses that climate-mediated changes to canopy-forming species can indirectly affect the associated assemblage, and that these effects vary seasonally. Such seasonality is important to consider as it may provide periods of recovery when conditions are less stressful, especially if we can reduce the severity of future climate scenarios.

Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits.

OBJECTIVE: Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated. METHODS: This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates. RESULTS: Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications. CONCLUSIONS: Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

Automated Electronic Frailty Index is Associated with Non-home Discharge in Patients Undergoing Open Revascularization for Peripheral Vascular Disease.

BACKGROUND: Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization. METHODS: A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.100.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge. RESULTS: We included 295 patients (mean age 65.9 years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48). DISCUSSION: Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home.

Prevalence of chronic opioid use in patients with peripheral arterial disease undergoing revascularization.

OBJECTIVE: Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. METHODS: Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3 months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). RESULTS: A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6 years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. CONCLUSIONS: Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.

Effects of salinity and nutrients on metabolism and growth of Ulva lactuca: Implications for bioremediation of coastal watersheds.

We studied Ulva lactuca to determine its potential for bioremediation of coastal watersheds. We cultured Ulva in orthogonal combinations of two salinities and three nutrient concentrations for six weeks, and then measured its growth, photosynthesis, chlorophyll fluorescence, nitrogen, carbon and phosphorus tissue concentrations, and carbon and nitrogen uptake pathways. Our findings show that Ulva was negatively affected by decreased salinity but these effects were ameliorated by the addition of nutrients to the water, such as would be expected from freshwater runoff during heavy rain events. Also, increased nutrients resulted in altered nitrogen (NH4+ vs. NO3-) and carbon (HCO3- vs. CO2) uptake pathways, which can allow Ulva to retain its bloom potential even under reduced salinities. Together, our study suggests that Ulva is an ideal species to grow for the purpose of bioremediation of coastal bays and estuaries, even during storms that freshen the surface waters and increase nutrients.

Thermal Tolerance May Slow, But Not Prevent, the Spread of Sargassum horneri (Phaeophyceae) along the California, USA and Baja California, MEX Coastline.

Biological invasions have become increasingly prevalent in marine ecosystems, modifying biodiversity and altering the way ecosystems function. Understanding how variation in environmental factors influences the success of non-native species, especially their early life stages, can be a crucial step in identifying habitats that are under threat of invasion, and in predicting how rapidly and far these species may spread once they arrive in novel habitats. The invasive marine macroalga Sargassum horneri was first observed in Long Beach Harbor, CA, USA in 2003, and has since spread throughout the Southern California Bight and along the Baja California Peninsula, MEX where it now forms dense stands on subtidal rocky reefs and displaces native habitat-forming macroalgae. We examined how variation in temperature, nutrients, and irradiance affect survival, growth, and development in S. horneri early life stages over a three-week period. Our experimental treatments consisted of orthogonally crossed temperatures (10, 15, 20, and 25°C), nutrient concentrations (ambient and nutrient-enriched seawater), and irradiances (50 and 500 µmol photons · m-2 · s-1 ). Overall, temperature exerted the greatest influence on S. horneri's germling and juvenile life stages, with moderate temperatures facilitating their greatest survival, growth, and development. In contrast, fewer germlings developed fully under the lowest or highest temperatures, and juvenile survival and growth were reduced, especially when combined with low irradiances. Together, our data suggest that ocean temperatures of or below 10˚C and of or above 25°C may slow, but likely not stop, S. horneri's northward and southward expansion along the California and Baja California coasts.

Evaluating bloom potential of the green-tide forming alga Ulva ohnoi under ocean acidification and warming.

The occurrence of green-tides, whose bloom potential may be increased by various human activities and biogeochemical process, results in enormous economic losses and ecosystem collapse. In this study, we investigated the ecophysiology of the subtropical green-tide forming alga, Ulva ohnoi complex (hereafter: U. ohnoi), under simulated future ocean conditions in order to predict its bloom potential using photosynthesis and growth measurements, and stable isotope analyses. Our mesocosm system included four experimental conditions that simulated the individual and combined effects of elevated CO2 and temperature, namely control (450 µatm CO2 & 20 °C), acidification (900 µatm CO2 & 20 °C), warming (450 µatm CO2 & 25 °C), and greenhouse (900 µatm CO2 & 25 °C). Photosynthetic electron transport rates (rETR) increased significantly under acidification conditions, but net photosynthesis and growth were not affected. In contrast, rETR, net photosynthesis, and growth all decreased significantly under elevated temperature conditions (i.e. both warming and greenhouse). These results represent the imbalance of energy metabolism between electron transport and O2 production that may be expected under ocean acidification conditions. This imbalance appears to be related to carbon and nitrogen assimilation by U. ohnoi. In particular, 13C and 15N discrimination data suggest U. ohnoi prefers CO2 and NH4+ over HCO3- and NO3- as sources of carbon and nitrogen, respectively, and this results in increased N content in the thallus under ocean acidification conditions. Together, our results suggest a trade-off in which the bloom potential of U. ohnoi could increase under ocean acidification due to greater N accumulation and through the saving of energy during carbon and nitrogen metabolism, but that elevated temperatures could decrease U. ohnoi's bloom potential through a decrease in photosynthesis and growth.

Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease.

OBJECTIVES: Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. METHODS: Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. RESULTS: We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). CONCLUSIONS: Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.

Variation in Photosynthetic Performance Relative to Thallus Microhabitat Heterogeneity in Lithothamnion australe (Rhodophyta, Corallinales) Rhodoliths.

Rhodoliths are free-living, coralline algae that create heterogeneous structure over sedimentary habitats. These fragile ecosystems are threatened by anthropogenic disturbances that reduce their size and three-dimensional structural complexity. We investigated how physical disturbance from boat moorings affects photosynthetic performance in the rhodolith Lithothamnion australe. Photosynthetic parameters were measured for intact rhodoliths and crushed rhodolith fragments of two sizes (ca. 1 and 2 cm diameter), while chlorophyll fluorescence was measured at the surface of rhodoliths of these two sizes, between the interior branches of the larger rhodoliths, and at the surface of 52 various sized (0.4-3.5 cm diameter) rhodoliths. Gross productivity and net productivity were 15% and 36% higher, respectively, in the smaller L. australe, while respiration was 10% higher in the larger individuals. Thallus crushing reduced gross productivity by 20% and 41%, and net productivity by 9% and 14% in the smaller and larger rhodoliths, respectively. It also reduced respiration by 33% and 60% in the smaller and larger rhodoliths, respectively. Fluorescence parameters were all greater at the surface of the larger L. australe than the smaller individuals, and greater at the surface than in the interior parts of the larger individuals. Across a range of rhodolith sizes, surface fluorescence parameters were at their maxima in 1.54 to 2.32 cm diameter individuals. These results show that L. australe's complex structure creates heterogeneity in photosynthesis and respiration between their surface and interior parts and among rhodolith sizes. This information can help predict how rhodoliths may respond to disturbance and environmental stressors.

Evaluation of Neuropathy, Glycemic Control, and Revascularization as Risk Factors for Future Lower Extremity Amputation among Diabetic Patients.

BACKGROUND: Diabetes mellitus is a major risk factor for progression to lower extremity amputation (LEA) due to progressive neuropathy and glycemia-induced vasculopathy. In this study, we evaluated risk factors for incident LEA type 2 diabetics during a randomized controlled trial and extended post-trial follow-up. METHODS: The Action to Control Cardiovascular Risk in Diabetes trial randomized 10,251 type 2 diabetics to intensive glycemic control (Hemoglobin A1c (HbA1c) target <6.0%) versus standard glycemic control (HbA1c target 7.0-7.9%). Using backward elimination logistic regression models, we examined relationships between neuropathy using the Michigan Neuropathy Screening Instrument (MNSI) and glycemic control and incident LEA during the clinical trial and subsequent follow-up. RESULTS: 9,746 patients were followed for a mean of 7.9 +/-3.1 (median 8.9) years after randomization. Ninety-eight (1%) participants underwent an incident LEA during the trial or post-trial follow-up period. Baseline demographics and traditional risk factors were examined by incident amputation status. Multivariable models revealed that abnormal 10 gm filament test (HR 4.50, 95% CI 2.92-6.95, P < 0.0001), presence of ulceration (HR 4.22, 95% CI 1.65-10.8, P = 0.0004), abnormal appearance on foot examination (HR 4.75, 95% CI 2.30-9.83, P < 0.0001), and mean postrandomization HbA1c (HR 1.65, 95% CI 1.35-2.00, P < 0.0001) were strongly predictive of LEA when accounting for other common risk factors for amputation. CONCLUSIONS: In this post hoc analysis of a large randomized controlled population of diabetic patients, we found that components of the MNSI score including presence of ulceration, abnormal appearance of the foot, and 10 gm filament monofilament scoring were strongly predictive of LEA. This adds a valuable clinical tool in the risk stratification of diabetic patients for LEA.

Trophic downgrading reduces spatial variability on rocky reefs.

Trophic downgrading in coastal waters has occurred globally during recent decades. On temperate rocky reefs, this has resulted in widespread kelp deforestation and the formation of sea urchin barrens. We hypothesize that the intact kelp forest communities are more spatially variable than the downgraded urchin barren communities, and that these differences are greatest at small spatial scales where the influence of competitive and trophic interactions is strongest. To address this, benthic community surveys were done in kelp forests and urchin barrens at nine islands spanning 1230 km of the Aleutian Archipelago where the loss of predatory sea otters has resulted in the trophic downgrading of the region's kelp forests. We found more species and greater total spatial variation in community composition within the kelp forests than in the urchin barrens. Further, the kelp forest communities were most variable at small spatial scales (within each forest) and least variable at large spatial scales (among forests on different islands), while the urchin barren communities followed the opposite pattern. This trend was consistent for different trophic guilds (primary producers, grazers, filter feeders, predators). Together, this suggests that Aleutian kelp forests create variable habitats within their boundaries, but that the communities within these forests are generally similar across the archipelago. In contrast, urchin barrens exhibit relatively low variability within their boundaries, but these communities vary substantially among different barrens across the archipelago. We propose this represents a shift from small-scale biological control to large-scale oceanographic control of these communities.

Global warming offsets the ecophysiological stress of ocean acidification on temperate crustose coralline algae.

Dramatic increases in the release of anthropogenic CO2 and global temperatures have resulted in alterations to seawater carbonate chemistry and metabolisms of marine organisms. There has been recent interest in the effects of these stressors on crustose coralline algae (CCA) because photosynthesis and calcification are influenced by all components of carbonate chemistry. To examine this, a mesocosm experiment was conducted to evaluate photosynthesis, calcification and growth in the temperate CCA Chamberlainium sp. under acidification (doubled CO2), warming (+5 °C), and greenhouse (doubled CO2 and +5 °C) conditions compared to present-day conditions. After 47 days of acclimation to these conditions, productivity was lowest under acidification, although photochemical properties were improved, while respiration was highest under warming. Likewise, growth was lowest under acidification, but this negative response was offset by elevated temperature under greenhouse. Together, these results suggest that warming offsets the negative effects of acidification by creating more suitable conditions for photosynthesis and growth.

A randomized pilot study to evaluate graft versus fistula vascular access strategy in older patients with advanced kidney disease: results of a feasibility study.

BACKGROUND: Although older adults encompass almost half of patients with advanced chronic kidney disease, it remains unclear which long-term hemodialysis vascular access type, arteriovenous fistula or arteriovenous graft, is optimal with respect to effectiveness and patient satisfaction. Clinical outcomes based on the initial AV access type have not been evaluated in randomized controlled trials. This pilot study tested the feasibility of randomizing older adults with advanced kidney disease to initial arteriovenous fistula versus graft vascular access surgery. METHODS: Patients 65 years or older with pre-dialysis chronic kidney disease or incident end-stage kidney disease and no prior arteriovenous vascular access intervention were randomized in a 1:1 ratio to undergo surgical placement of a fistula or a graft after providing informed consent. Trial feasibility was evaluated as (i) recruitment of ≥ 70% of eligible participants, (ii) ≥ 50 to 70% of participants undergo placement of index arteriovenous access within 90 to 180 days of enrollment, respectively, (iii) ≥ 80% adherence to study-related assessments, and (iv) ≥ 70% of participants who underwent index arteriovenous access placement will have a follow-up duration of ≥ 12 months after index surgery date. RESULTS: Between September 2018 and October 2019, 81% (44/54) of eligible participants consented and were enrolled in the study; 11 had pre-dialysis chronic kidney disease, and 33 had incident or prevalent end-stage kidney disease. After randomization, 100% (21/21) assigned to arteriovenous fistula surgery and 78% (18/23) assigned to arteriovenous graft surgery underwent index arteriovenous access placement within a median (1st, 3rd quartile) of 5.0 (1.0, 14.0) days and 13.0 (5.0, 44.3) days, respectively, after referral to vascular surgery. The completion rates for study-specific assessments ranged between 40.0 and 88.6%. At median follow-up of 215.0 days, 5 participants expired, 7 completed 12 months of follow-up, and 29 are actively being followed. Assessments of grip strength, functional independence, and vascular access satisfaction were completed by > 85% of patients who reached pre-specified post-operative assessment time point. CONCLUSIONS: Results from this study reveal it is feasible to enroll and randomize older adults with advanced kidney disease to one of two different arteriovenous vascular access placement surgeries. The study can progress with minor protocol adjustments to a multisite clinical trial. TRIAL REGISTRATION: Clinical Trials ID, NCT03545113.

The Effects of Case Timing and Care Team Composition on Hospital Operating Room Costs for Endovascular Procedures.

BACKGROUND: The contemporary healthcare environment is complex with mounting pressures to perform greater procedural volumes with less support staff to minimize costs and maximize efficiency. This report details an analysis of routine endovascular procedures performed with dedicated vascular support staff during daytime hours compared to similar cases performed after hours with general operating room staff. METHODS: All lower extremity endovascular cases over a 37-month period were identified using Current Procedural Terminology codes from a query of our institutional database. Emergent/urgent cases and cases with associated open surgical procedures were excluded. Cases were divided according to the time of day and available clinical support structure according to procedure start time: specialty-specific daytime (SS) and general staff after hours for all others (AH). The resulting case list was examined by case type according to SS or AH designation and case types occurring disproportionately during either time frame were excluded to create a homogenous group of cases. Demographics, case specifics, and cost data were then obtained from the electronic health record and our enterprise cost data warehouse. Multivariable mixed linear modeling was used to examine component costs (i.e., anesthesia, supplies, etc.) and total costs controlling for a number of factors that could affect cost. RESULTS: Two hundred fifty-two routine endovascular-only procedures were examined in 232 patients (190 SS, 42 AH). No significant differences in procedure specifics were observed between the groups [number and location of access site(s), indication for procedure, type and number of interventions, etc.]. Multivariable analyses controlled for factors affecting costs. Costs associated with anesthesia (cost ratio 1.90, P = 0.001), operating room time costs (cost ratio 1.29, P = 0.03), and post anesthesia recovery (cost ratio 1.23, P = 0.004) were all significantly increased in AH cases compared to SS cases. The average total hospital cost for routine endovascular cases that performed AH was $8,095 compared to $5,636 for SS cases (cost ratio 1.44, P = 0.008). CONCLUSIONS: Performance of routine endovascular cases was associated with significantly less cost to the hospital system when performed by SS teams during regular hospital hours with a ∼30% increase in total cost associated with AH cases. In the current healthcare environment, investments in SS teams and process improvements are likely to be cost effective.

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design.

Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.

Black abalone (Haliotis cracherodii) population structure shifts through deep time: Management implications for southern California's northern Channel Islands.

For over 10,000 years, black abalone (Haliotis cracherodii) were an important resource in southern California, first for coastal Native Americans, then beginning in the nineteenth century, as one of the state's first commercial shellfisheries. By 1993, after years of heavy fishing, rising sea surface temperatures (SST), and the spread of withering syndrome (WS), black abalone populations declined dramatically, resulting in the closure of the Alta California fishery. After nearly 25 years of management and recovery efforts, black abalone are showing signs of ecological rebound along some Channel Island shorelines. These include the presence of juvenile abalone and increasing densities, largely from data collected by Channel Islands National Park (CINP) monitoring efforts that began in 1985.In an effort to apply deeper historical perspectives to modern fisheries management and restoration, we analyzed black abalone size data from San Miguel Island at prehistoric and historical archeological sites spanning the last 10,000 years and compared these populations to those described by CINP biologists between 1985 and 2013.We found a statistically significant relationship between SST and black abalone size distributions during the ancient record, along with dramatic shifts in population size structure toward larger individuals between the nineteenth century and modern periods. A pattern of larger mean black abalone sizes was identified during warm SSTs, when compared against intervals of cooler SSTs.Synthesis and applications. Our study provides a deep historical perspective of abalone population size distributions, patterns within these distributions through time, and parallels to modern abalone populations. Our results may help managers determine whether the current (and future) size and age structure of intertidal black abalone populations around the northern Channel Islands are "natural" and healthy, measured against the 10,000 year history of black abalone fishing in southern California.

Effect of Intensive Glycemic Control on Risk of Lower Extremity Amputation.

BACKGROUND: Diabetes mellitus is a major risk factor for peripheral arterial disease and lower extremity amputation (LEA). We evaluated the effects of intensive glucose control (IGC) on risk of LEA in patients with type 2 diabetes during a randomized-controlled multicenter trial. STUDY DESIGN: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial randomized patients with type 2 diabetes to IGC (HbA1c target < 6.0%) or standard glycemic control (SGC; HbA1c target 7.0% to 7.9%). Using analysis of mean HbA1c, we examined relationships between glycemic control and incident/recurrent LEA during the clinical trial/follow-up. RESULTS: Mean post-randomization HbA1c over the course of the trial and post-trial follow-up was 7.3% ± 0.9% (6.8% ± 0.8% in the IGC arm, 7.7% ± 0.7% in the SGC arm). There were 124 participants who had at least 1 LEA during the study period; 73 were randomized to the SGC arm and 51 to the IGC arm (p = 0.049). Randomization to IGC was associated with decreased LEA rate (HR 0.69, 95% CI 0.483 to 0.987, p = 0.042). In multivariable models, mean HbA1c was a powerful predictor of LEA (HR 2.07 per 1% increase in HbA1c, 95% CI 1.67 to 2.57, p < 0.0001). Post-randomization mean HbA1c remained a strong predictor of LEA after controlling for other important covariates and competing risk of death (HR 1.94 per 1% increase in HbA1c, 95% CI 1.52 to 2.46, p < 0.0001). CONCLUSIONS: In patients with type 2 diabetes, IGC was associated with a reduction in the risk for LEA. After 3.7 years of IGC, there was an enduring protective effect against LEA. Improved glycemic control was a strong predictor of decreased risk for subsequent LEA. This study suggests that tight glycemic control, even over a short time period, has potential to reduce risk of limb loss.