Managing a cyanobacteria harmful algae bloom "hotspot" in the Sacramento - San Joaquin Delta, California.

Cyanobacterial harmful algal blooms (CHABs) have become a persistent seasonal problem in the upper San Francisco Estuary, California also known as the Sacramento-San Joaquin Delta (Delta). The Delta is comprised of a complex network of open water bodies, channels, and sloughs. The terminus of the Stockton Channel is an area identified as a CHAB "hotspot." As CHABs increase in severity, there is an urgent need to better understand CHAB drivers to identify and implement mitigation measures that can be used in an estuarine complex like the Delta. We investigated water quality conditions and nutrient dynamics in the Stockton Channel by measuring nutrients in the water column, sediments, and pore waters. In situ nutrient addition bioassay experiments were used to assess the effects of nutrient enrichment on total algal/cyanobacterial growth and pigment concentrations. In both June and September, relative to unamended controls, total chlorophyll and cyanobacterial pigment concentrations were unaffected by nutrient additions; hence, the study area showed signs of classical hypereutrophication, with ambient nitrogen and phosphorus present in excess of algal growth requirements. A cyanobacterial bloom, dominated by Microcystis spp. was present throughout the study area but was most severe and persistent at the shallowest site at the channel terminus. At this site, Microcystis spp. created water quality conditions that allowed for a prolonged bloom from June through September. While targeted nutrient reductions are recommended for long term mitigation, on a shorter timescale, our findings suggest that physical/mechanical controls are the more promising alternative approaches to reduce the severity of CHABs in the terminus of the Stockton Channel.

Prevention of Substance Use Disorders.

Methods to prevent substance use disorders (SUDs) act on the individual risk factors for addiction. Most adults with SUD initiated substance use during their teenage years, so preventive interventions during adolescence are critical. Antisubstance use messaging, routine screening, and pathways for referral to treatment can be extended into all settings whereby trusted adults interact with adolescents such as sports, mentoring programs, child protective services, and juvenile justice settings. Pediatric primary care is an ideal place to incorporate preventive counseling and screening for substance use. Evidence-based technologic interventions for primary, secondary, and tertiary prevention are needed.

Cognitive Outcomes of Young Children After Prenatal Exposure to Medications for Opioid Use Disorder: A Systematic Review and Meta-analysis.

Importance: The number of children with prenatal opioid exposure to medication for addiction treatment (MAT) with methadone and buprenorphine for maternal opioid use disorder is increasing, but the associations of this exposure with cognitive outcomes are not well understood. Objective: To examine the strength and consistency of findings in the medical literature regarding the association of prenatal exposure to MAT with early childhood cognitive development, particularly when accounting for variables outside MAT exposure. Data Sources: A search strategy obtained publications from PubMed, CINAHL, PsycINFO, Web of Science, and Embase from January 1972 to June 2019. Reference lists from identified articles were searched. Study Selection: Inclusion criteria were cohort studies, studies including children aged 1 to 60 months with at least 2 months of prenatal MAT exposure, studies using standardized direct-observation testing scales, and studies reporting means and SDs. Case reports, case series, historical controls, and reviews were excluded. Data Extraction and Synthesis: Two authors independently selected studies for inclusion, extracted data, and assessed study quality. Data extracted included demographic characteristics, covariates, sources of bias, and effect estimates. Meta-analysis was performed using random-effects models. This study was conducted according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data extraction and synthesis were conducted between January 2018 and August 2019. Main Outcomes and Measures: Cognitive test scores and demographic variability between exposed and unexposed groups. Results: A total of 16 unique cohorts, described in 27 articles and including 1086 children (485 [44.7%] with MAT exposure), were included in a quantitative synthesis. On meta-analysis, MAT exposure was associated with lower cognitive development scores (pooled standardized mean difference, -0.57; 95% CI, -0.93 to -0.21; I2 = 81%). Multiple subanalyses on demographic characteristics (ie, maternal education, race/ethnicity, socioeconomic status, prenatal tobacco exposure, infant sex) were conducted. In the subanalysis of studies with comparable prenatal exposure to tobacco smoke, the association of MAT exposure with cognitive scores was no longer statistically significant and became homogeneous (standardized mean difference, -0.11; 95% CI, -0.42 to 0.20; I2 = 0%). Conclusions and Relevance: In this study, predefined subanalyses demonstrated how poor recruitment, particularly imbalances in maternal tobacco use, could contribute to a negative overall association of cognitive development test scores with prenatal MAT exposure. Promoting tobacco cessation for pregnant women with opioid use disorder should be prioritized in this high-risk population.

Including Lifestyle Medicine in Medical Education: Rationale for American College of Preventive Medicine/American Medical Association Resolution 959.

Introduced by the American College of Preventive Medicine and released by the American Medical Association House of Delegates in 2017, Resolution 959 (I-17) supports policies and mechanisms that incentivize and/or provide funding for the inclusion of lifestyle medicine education and social determinants of health in undergraduate, graduate and continuing medical education. Resolution 959 was passed to help address the current healthcare costs of lifestyle-related, noncommunicable chronic diseases that exert a devastating economic burden on the U.S. healthcare system. Approximately 86% of $2.9 trillion is spent annually on obesity, cardiovascular disease, type 2 diabetes, and some cancers, with very poor return on investment for health outcomes. Lifestyle medicine provides an evidence-based solution to the noncommunicable chronic disease epidemic; however, medical education in lifestyle medicine is minimal to nonexistent. This paper provides the case for healthcare innovation to include lifestyle medicine in the prevention and treatment of noncommunicable chronic diseases. Our medical education system recommendation is to provide lifestyle medicine training for prevention and treatment of noncommunicable chronic diseases. Exemplar lifestyle medicine schools are showcased and guidance for reform is highlighted that can be used to aid lifestyle medicine integration across the medical school education continuum. With a transformation of curriculum and development of new policies to support a focus on lifestyle medicine education in medical education across the continuum, a new healthcare model could be successful against noncommunicable chronic diseases and U.S. citizen wellness could become a reality.

Influence of Crohn's disease related polymorphisms in innate immune function on ileal microbiome.

We have previously identified NOD2 genotype and inflammatory bowel diseases (IBD) phenotype, as associated with shifts in the ileal microbiome ("dysbiosis") in a patient cohort. Here we report an integrative analysis of an expanded number of Crohn's disease (CD) related genetic defects in innate immune function (NOD2, ATG16L1, IRGM, CARD9, XBP1, ORMDL3) and composition of the ileal microbiome by combining the initial patient cohort (Batch 1, 2005-2010, n = 165) with a second consecutive patient cohort (Batch 2, 2010-2012, n = 118). These combined patient cohorts were composed of three non-overlapping phenotypes: 1.) 106 ileal CD subjects undergoing initial ileocolic resection for diseased ileum, 2.) 88 IBD colitis subjects without ileal disease (predominantly ulcerative colitis but also Crohn's colitis and indeterminate colitis, and 3.) 89 non-IBD subjects. Significant differences (FDR < 0.05) in microbiota were observed between macroscopically disease unaffected and affected regions of resected ileum in ileal CD patients. Accordingly, analysis of the effects of genetic and clinical factors were restricted to disease unaffected regions of the ileum. Beta-diversity differed across the three disease categories by PERMANOVA (p < 0.001), whereas no significant differences in alpha diversity were noted. Using negative binomial models, we confirmed significant effects of IBD phenotype, C. difficile infection, and NOD2 genotype on ileal dysbiosis in the expanded analysis. The relative abundance of the Proteobacteria phylum was positively associated with ileal CD and colitis phenotypes, but negatively associated with NOD2R genotype. Additional associations with ORMDL3 and XBP1 were detected at the phylum/subphylum level. IBD medications, such as immunomodulators and anti-TNFα agents, may have a beneficial effect on reversing dysbiosis associated with the IBD phenotype. Exploratory analysis comparing microbial composition of the disease unaffected region of the resected ileum between 27 ileal CD patients who subsequently developed endoscopic recurrence within 6-12 months versus 34 patients who did not, suggested that microbial biomarkers in the resected specimen helped stratify patients with respect to risk of post-surgical recurrence.

Determinants of the Nasal Microbiome: Pilot Study of Effects of Intranasal Medication Use.

INTRODUCTION: A role for bacteria and other microbes has long been suspected in the chronic inflammatory sinonasal diseases. Recent studies utilizing culture-independent, sequence-based identification have demonstrated aberrant shifts in the sinus microbiota of chronic rhinosinusitis subjects, compared with ostensibly healthy controls. Examining how such microbiota shifts occur and the potential for physician-prescribed interventions to influence microbiota dynamics are the topics of the current article. METHODS: The nasal cavity microbiota of 5 subjects was serially examined over an 8-week period using pan-bacterial 16S rRNA gene sequencing. Four of the subjects were administered topical mometasone furoate spray, while 1 subject underwent a mupirocin decolonization procedure in anticipation of orthopedic surgery. RESULTS: Measures of microbial diversity were unaffected by intranasal treatment in 2 patients and were markedly increased in the remaining 3. The increase in microbial diversity was related to clearance of Moraxella spp. and a simultaneous increase in members of the phylum Actinobacteria. Both effects persisted at least 2 weeks beyond cessation of treatment. Transient changes in the relative abundance of several bacterial genera, including Staphylococcus and Priopionibacteria, were also observed during treatment. CONCLUSIONS: The effects of intranasal steroids on the sinonasal microbiome are poorly understood, despite their widespread use in treating chronic sinonasal inflammatory disorders. In this longitudinal study, administration of intranasal mometasone furoate or mupirocin resulted in shifts in microbial diversity that persisted to some degree following treatment cessation. Further characterization of these effects as well as elucidation of the mechanism(s) underlying these changes is needed.

Safety of Back-Transfer to Local Hospitals During an Acute Care Hospitalization.

PURPOSE: This paper investigates patient outcomes including length of stay (LOS), cost of hospitalization, bounce-back rates, transition to hospice care, and mortality, following back-transfer. METHODS: This study was an observational case-control study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Back-transfer was defined as the transfer of rural patients near the end of their acute hospitalization in a comprehensive medical center back to a local community hospital for the completion of their medical care. Demographic, geographic, rurality, procedural, and disease information was compared between case and control groups, then propensity score (PS) matching was performed to create comparable groups to perform analyses. FINDINGS: Over the 9-year period, 1,056,773 patients meeting inclusion criteria were admitted, of which 430 (0.04%) were back-transferred. After PS matching, LOS was 60% (95% CI: 0.50-0.71) higher and costs were 42% (95% CI: 0.33-0.50) higher in the back-transferred group. Back-transferred cases had 8.34 (95% CI: 3.66-19.0) times the odds of hospice transition and 2.17 (95% CI: 1.37-3.46) the odds of mortality compared to controls. Four percent of back-transfers "failed" with the patient being returned to the larger hospital before discharge. CONCLUSIONS: Back-transfer is a rare occurrence, and it is associated with longer LOS, higher hospitalization cost, higher mortality, more hospice transfers, and occasional bounce-backs to comprehensive medical centers. Future work should focus more on prospective indications for transfer, the role of end-of-life care, financial impact, and identifying patient populations for whom back-transfer is safest.

Against the current: back-transfer as a mechanism for rural regionalization.

OBJECTIVES: This paper investigates back-transfer: the transfer of patients near the end of their acute hospitalization to a local community hospital for the completion of their medical care. We seek to describe factors contributing to back-transfer, with the goal of elucidating the current use of back-transfer and barriers to its more widespread adoption for rural healthcare regionalization. STUDY DESIGN: Observational unmatched case-control. METHODS: This was a retrospective study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Demographic, geographic, rurality, procedural, and disease information was compared among cases and control groups using univariate analysis and multivariable logistic regression. RESULTS: Over the 9-year period, 172,544 back-transfer eligible patients were admitted to 1 of 5 large Iowa hospitals, of which 287 (0.2%) were back-transferred. Back-transferred patients were more likely than their non-back-transferred counterparts to be older, male, and white; to live in large rural areas; and to have public insurance. As inpatients, they had longer median lengths of stay (15 vs 5 days; P <.001), more medical comorbidities, and were more likely to have a cardiac catheterization procedure than the control group. CONCLUSIONS: Back-transfer is a very rare event. While demographic and medical differences between back-transferred patients and controls may partially explain the infrequency, other systematic barriers must exist to limit back-transfer. These barriers likely include legal, financial, logistical, and patient care concerns. Despite the rarity with which it is employed, back-transfer is a promising strategy that could better utilize health resources, especially in rural America.

Pilot study of patient perception of pharmacists as care providers based on health screening encounters with student pharmacists.

OBJECTIVES: To assess how patient perceptions of the clinical role of pharmacists may be affected by use of the AIDET communication tool during student-led health fairs, as well as how such events can help promote pharmacy practice. SETTING: 12 community health fair screenings throughout northeastern Minnesota and northwestern Wisconsin, from February to November 2012. PRACTICE DESCRIPTION: University of Minnesota-College of Pharmacy students trained in the use of AIDET employed the tool's techniques in their communication with health fair patient attendees. Project participants were those patients aged 18 years and older who successfully completed a health fair survey. PRACTICE INNOVATION: The AIDET communication tool is designed to provide consistency in patient encounters through the use of key words at key times. AIDET is a mnemonic acronym that stands for acknowledge, introduce, duration, explanation, and thank you. University of Minnesota-College of Pharmacy students are taught how to use the AIDET framework in classroom and laboratory settings prior to their interactions with patients at area health fairs. INTERVENTION: Health fair attendees were asked to complete a survey to determine their satisfaction level with student pharmacist-delivered pharmacy services. EVALUATION: 87 patients were surveyed, with a response rate of 22.5% and a completion rate of 91.6%. The average age of the patient population for the study cohort was 52 years, with greater than 50% being 65 years or older. Patient ages ranged from 24 to 89 years. RESULTS: When AIDET techniques were employed in a health fair setting, patients reported high levels of satisfaction with pharmacy services and said they felt "happy, comfortable, and trusting." CONCLUSION: The AIDET framework provides a consistent process for patient-centered care delivery because it places emphasis on patient needs and expectations. Use of the technique is capable of enhancing student and pharmacist engagement with patients.

Treating venomous snakebites in the United States: a guide for nurse practitioners.

This article discusses the current, evidence-based guidelines for managing venomous snakebites indigenous to the United States. A review of common varieties of venomous snakes, venom effects, risk factors for snakebites, and management strategies are presented to assist nurse practitioners in caring for snakebite victims.

Extraction of bioavailable contaminants from marine sediments: an approach to reducing toxicity using adsorbent parcels.

This paper demonstrates an approach to reducing acute toxicity in marine sediments using adsorbent parcels. Acute toxicity tests were carried using the marine amphipod Corophium volutator. Marine sediments were spiked with two know contaminants tributyltin and naphthalene and then treated with adsorbent parcels containing either amberlite XAD4 or activated carbon. Results showed that both types of adsorbent parcels were effective in reducing acute toxicity, not only within spiked sediments containing naphthalene and/or tributyltin, but also in an environmental field samples form an expected contaminated site. Adsorbent parcels such as these could provide a practical approach to remediate areas of contaminated sediment within marine environments. Furthermore adsorbents can be used as an identification tool for problematic contaminants using a toxicity identification evaluation approach.

Feasibility of a navigated registration technique in FAI surgery.

INTRODUCTION: Arthroscopic femoral osteoplasties might be technically demanding, might cause prolonged operative times and restrict the intraoperative overview. An automated navigated matching process of preoperative CT-data and intraoperative fluoroscopy should allow for noninvasive registration for FAI-surgery. METHOD: Six hip joints were used with a conventional navigation system. Defined osseous lesion (2 × 2 mm) in the femoral neck, head neck junction, and head region were created followed by automated segmentation including CT-fluoro image fusion by the navigation system. Precision of registration process was tested trough a lateral arthroscopic portal. In vivo distances between pointer tip to bone were measured. Secondary in vivo distances between an inserted navigated shaver and the osseous lesions were measured. RESULTS: Our results allow a CT-fluoroscopy matching procedure for noninvasive registration process for navigated FAI-surgery in multiplanar planes. Precision is more accurate at the femoral neck and head-neck junction than at the femoral head area. CONCLUSION: Future navigated applications might simplify and increase precision of FAI-surgery.

Revisiting a hazardous waste site 25 years later.

The starting point for this research was a case study of illegal hazardous waste disposal published 25 years ago in the Journal of Environmental Health. The site, located in rural upstate New York, would eventually be managed under county, state, and national remediation programs. For this paper, the authors conducted a historical analysis of reports published about the site. They also interviewed federal, state, and local officials, as well as nearby residents. Drawing on the data obtained in these ways, the paper reviews remedial efforts and community involvement. Despite considerable time and resources invested by stakeholders, groundwater pollution persists at the site. As responsibility for remediation moved through higher levels of government, the character of community involvement shifted from proactive to reactive to quiescent. Today, neighboring residents perceive health problems and demonstrate feelings of powerlessness. Remedial activity has required greater investigation over time, resulting in more documents detailing a larger number of parameters with increasing scientific sophistication. This approach has boosted understanding of groundwater pollution. At the same time, recent remediation has been deprived of useful knowledge that could have been provided by greater local participation in decision making.