Mucosal Healing and Clinical Efficacy of Adalimumab in Small Intestinal Crohn's Disease (SIMCHA Study): Final Results From a Prospective, Open-Label, Single-Arm Study.

BACKGROUND: Endoscopic healing is a key treatment target in inflammatory bowel disease; few data are available on the clinical and endoscopic efficacy of biological therapy in upper gastrointestinal Crohn's disease. This study aimed to investigate small bowel mucosal healing and clinical efficacy of adalimumab therapy by video capsule endoscopy in patients with endoscopically active upper gastrointestinal Crohn's disease. METHODS: This prospective, open-label, single-arm study included Crohn's disease patients with moderate-severe endoscopic proximal small bowel involvement, defined by a Lewis score >790. Patients were treated with adalimumab monotherapy for 24 weeks. Co-primary outcomes were endoscopic healing, defined as Lewis score <350, and endoscopic response, defined as >50% decrease in Lewis score. Secondary outcomes included clinical (Harvey-Bradshaw index <4) and biomarker remission (fecal calprotectin <250 µg/g, and C-reactive protein <5 mg/L). RESULTS: A total of 59 Crohn's disease patients were screened; 17 patients have met eligibility criteria and were enrolled. Endoscopic healing was observed in 8 patients (47.1%) and endoscopic response in additional 5 patients (29.4%) at 24 weeks. Median Lewis score was significantly decreased compared to baseline (1912 vs. 337, P = .0005). Eleven of 13 patients (84.6%) with clinical activity achieved clinical remission (baseline: 13/17 vs. week 24: 2/17, P < .0001). Nine of 10 patients with elevated C-reactive protein achieved normal C-reactive protein after treatment and the median C-reactive protein significantly decreased from 7.4 to 1.6 mg/L, P = .032. In contrast, no change was observed in fecal calprotectin pre- and posttreatment. CONCLUSIONS: Adalimumab induced endoscopic healing and clinical remission in patients with active small bowel Crohn's disease, with approximately half of the patients achieving endoscopic healing.

Utilization of the Psoriasis Epidemiology Screening Tool (PEST): A Risk Stratification Strategy for Early Referral of Psoriatic Arthritis Patients to Minimize Irreversible Erosive Joint Damage.

Psoriatic arthritis (PsA) can affect a diverse range of anatomical sites and its heterogeneous presentation contributes to misdiagnosis and delayed treatment with conventional and biologic disease-modifying antirheumatic drugs (DMARDs). Up to 15% of psoriasis (PsO) patients affected by PsA remain undiagnosed. Early detection and referral to a rheumatologist are crucial to optimize care and minimize irreversible erosive joint damage. To improve the rheumatology referral process, the authors propose a risk stratification tool to identify and triage patients with possible psoriatic arthritis. With the aim of ultimately assisting in early treatment initiation, this risk stratification algorithm can be used in both dermatology and primary care clinics. It is based on the Psoriasis Epidemiology Screening Tool (PEST) combined with the ClASsification criteria for Psoriatic Arthritis (CASPAR). This article intends to provide a rationale for further prospective studies whose objective would be to validate this screening algorithm.

Use of medical cannabis by patients with fibromyalgia in Canada after cannabis legalisation: a cross-sectional study.

OBJECTIVES: Medications have only small to moderate effects on symptoms in fibromyalgia (FM). Cannabinoids, including medical cannabis (MC) may have potential to fill this gap. Since recreational legalisation of cannabis in Canada, patients have easier access and may be self-medicating with cannabis. We have examined the prevalence and characteristics of MC use in FM patients. METHODS: During a two-month period (June-August 2019), consecutive attending rheumatology patients participated in an onsite survey comprising 2 questionnaires: 1) demographic and disease information completed by the rheumatologist, 2) patient anonymous questionnaire of health status, cannabis use (recreational and/or medicinal) and characteristics of use. RESULTS: In a cohort of 1000 rheumatology attendees, 117 (11.7%) were diagnosed with FM. Ever use of MC was reported by 28 (23.9%; 95%CI: 16.5%-32.7%) FM patients compared to 98 (11.1%; 95%CI: 9.1%-13.4%) non-FM patients. Among FM ever users, 17 (61%) patients continued use of MC. FM ever users vs. FM nonusers tended to be younger, 53 vs. 58 years (p=0.072), were more likely unemployed or disabled 39% vs. 17% (p=0.019) and used more medication types (p=0.013) but did not differ in symptom severity parameters. Cigarette smoking and recreational cannabis were more common in ever users. Global symptom relief on a VAS (1-10) was 7.0±2.3. CONCLUSIONS: FM patients have commonly used MC, with more than half continuing use. Reported symptom relief was substantial. Cigarette smoking and recreational cannabis use may play a facilitatory role in MC use in FM. Adjunctive MC may be a treatment consideration for some FM patients.

Canadian Rheumatologists' Perspectives on Moderate Psoriatic Arthritis and Oligoarticular Psoriatic Arthritis.

OBJECTIVE: Psoriatic arthritis (PsA) substantially impairs quality of life. Clinical trials generally focus on polyarticular PsA, but less is known about the assessment and management of oligoarticular and moderate PsA. An online survey was conducted to determine Canadian rheumatologists' perspectives on the definition and treatment of oligoarticular and moderate PsA. METHODS: Regional and national experts treating patients with PsA were asked to complete an online survey to assess their approach to identifying and managing patients with PsA. Survey questions were developed based on guidance from a committee of Canadian rheumatologists. RESULTS: Sixty-four of 78 rheumatologists responded, representing 6 major Canadian provinces. Nearly half of respondents were in practice > 20 years. The majority of rheumatologists reported using swollen joint count (SJC) to describe moderate PsA (86.4%) and oligoarticular PsA (96.7%), and considered location of inflammation in PsA assessments. SJC cutoff scores for reporting moderate PsA varied among rheumatologists, suggesting lack of an agreed-upon definition for moderate PsA. Sixty-eight percent of rheumatologists identified access to treatment as the greatest challenge with oligoarticular PsA. CONCLUSION: According to the surveyed rheumatologists, SJC remains a key assessment variable when defining oligoarticular and moderate PsA. Although the number of joints is considered when determining the effect of PsA on patients, joint location and functional impairment are also considered when describing the disease as moderate. Access to treatment for patients with < 5 affected joints is challenging.

Long-term effectiveness and safety of infliximab and golimumab in ankylosing spondylitis patients from a Canadian prospective observational registry.

BACKGROUND: The objectives of this study were to describe the profile of ankylosing spondylitis (AS) patients treated with either infliximab (IFX) or subcutaneous golimumab (GLM) treatment in Canadian routine care setting along with assessing long-term effectiveness and safety. METHODS: AS patients who were eligible for treatment with IFX or subcutaneous GLM as per their respective Canadian product monographs were enrolled into the BioTRAC registry from 2005 to 2017. The study visits occurred at baseline and every 6 months thereafter. Effectiveness was assessed by changes in clinical outcomes and acute phase reactants. Safety was evaluated by assessing the incidence of adverse events (AEs) and drug survival rates. RESULTS: A total of 389 IFX- and 421 GLM-treated patients were enrolled. A significant decrease in disease duration at baseline was observed in the IFX cohort, from a median of 8.0 in 2005-2008 to 1.0 years in 2009-2015 (p < 0.001). A reduction in baseline BASFI score (p = 0.011) and proportion of patients in ASDAS very high disease activity (p = 0.004) was also observed over time. Meanwhile, in the GLM cohort, most disease parameters remained similar from 2010 to 2017. Treatment with both agents significantly improved all disease parameters over time with similar efficacy between the two agents. The incidence of AEs and SAEs were 136 and 131 events/100 PYs and 10.5 and 8.45 events/100 PYs for IFX- and GLM-treated patients, respectively. CONCLUSION: Both IFX and GLM treatment in AS significantly reduced disease activity in most outcome measures in a similar fashion and were well tolerated in Canadian routine care. TRIAL REGISTRATION: NCT00741793 .

Medical Cannabis Use by Rheumatology Patients Following Recreational Legalization: A Prospective Observational Study of 1000 Patients in Canada.

OBJECTIVE: Recreational legalization of cannabis may influence the medical use by patients. When only medical access was legally available in Canada, 4.3% of rheumatology patients reported use. With the current recreational legalization, we have reexamined the prevalence and characteristics of medical cannabis use in this same rheumatology setting. METHODS: Consecutively attending rheumatology patients participated in an onsite survey comprising the following two questionnaires: 1) demographic and disease information completed by the rheumatologist and 2) patient anonymous questionnaire of health status, cannabis use (recreational and/or medicinal), and characteristics of cannabis use. RESULTS: Of 1047 attendees from June to August 2019, with 1000 participating, medical cannabis had been used by 12.6% of patients (95% confidence interval 10.7%-14.8%), with half continuing use for mostly pain relief. Discontinuation was due to lack of effect in 57% of patients and side effects in 28% of patients. Ever medical users were younger (61.2 vs. 64.9 years; P = 0.006), more likely unemployed/disabled (16.7% vs. 5.9%; P < 0.001), and had more previous (47.6% vs. 25.5%; P < 0.001) and current recreational cannabis use (17.5% vs. 3.1%; P < 0.001) than nonusers. Most patients used multiple methods of administration, including smoking, vaporizing, and using oral oil preparations, but were poorly knowledgeable of product content, which was bought solely via the legal medical route by only 20%, and only one-third disclosed their use to the rheumatologist. CONCLUSION: Medical cannabis use has tripled for rheumatology patients since recreational legalization, with users being younger, not working, and having recreational cannabis experience. Concerning issues are the poor knowledge of the product being used, access via the nonmedical route, and nondisclosure to the physician.

Detection of Crohn Disease in Patients with Spondyloarthropathy: The SpACE Capsule Study.

OBJECTIVE: Inflammatory bowel disease (IBD) is generally reported to be associated with spondylarthropathies (SpA) in 5%-15% of cases. Systematic colonoscopic assessment by protocol demonstrated mucosal inflammation characteristic of Crohn disease (CD) in up to one-third of patients with SpA. Video capsule endoscopy (CE) is a superior diagnostic tool to detect small bowel mucosal disease. Our study compared the accuracy of CE to standard colonoscopy for detection of inflammatory bowel lesions in patients with SpA, and to describe predictors of small bowel inflammation (SBI) in this cohort. METHODS: Prospective cross-sectional study of adult patients followed for SpA. Patients were evaluated by CE and standard colonoscopy with biopsies. SBI was quantified using the Lewis Score. Additional screening tests included fecal calprotectin (FCP), C-reactive protein (CRP), and a diagnostic panel of serologic, inflammatory and genetic tests (SGI). RESULTS: There were 64 patients recruited (53% female, mean age 42 ± 13 yrs). Chronic gastrointestinal (GI) symptoms were present in 57%. CE revealed significant SBI in 27/64 (42.2%), compared to 7/64 (10.9%) by standard colonoscopy (p = 0.035). Elevated FCP was associated with small bowel CD (OR 4.5, 95% CI 1.01-19.9; p = 0.042). No correlation was observed with presence of GI symptoms, CRP, or SGI results. Finding CD led to a change in management in 65.2% of cases. CONCLUSION: CE uncovered SBI consistent with CD in 42.2% of patients with SpA, with a significant incremental yield over colonoscopy of 31%. FCP levels were significantly correlated with CE results, while GI symptoms and SGI results were poor predictors of SBI.

Survey of herbal cannabis (marijuana) use in rheumatology clinic attenders with a rheumatologist confirmed diagnosis.

Cannabinoids may hold potential for the management of rheumatic pain. Arthritis, often self-reported, is commonly cited as the reason for the use of medicinal herbal cannabis (marijuana). We have examined the prevalence of marijuana use among 1000 consecutive rheumatology patients with a rheumatologist-confirmed diagnosis and compared in an exploratory manner the clinical characteristics of medicinal users and nonusers. Current marijuana use, medicinal or recreational, was reported by 38 patients (3.8%; 95% CI: 2.8-5.2). Ever use of marijuana for medical purposes was reported by 4.3% (95% CI: 3.2-5.7), with 28 (2.8%; 95% CI: 1.9-4.0) reporting current medicinal use. Current medicinal users had a spectrum of rheumatic conditions, with over half diagnosed with osteoarthritis. Medicinal users were younger, more likely unemployed or disabled, and reported poorer global health. Pain report and opioid use was greater for users, but they had similar physician global assessment of disease status compared with nonusers. Medicinal users were more likely previous recreational users, with approximately 40% reporting concurrent recreational use. Therefore, less than 3% of rheumatology patients reported current use of medicinal marijuana. This low rate of use in patients with a rheumatologist-confirmed diagnosis is in stark contrast to the high rates of severe arthritis frequently reported by medicinal marijuana users, especially in Canada. Familiarity with marijuana as a recreational product may explain use for some as disease status was similar for both groups.

Assessing process of care in rheumatoid arthritis at McGill University hospitals.

OBJECTIVE: In rheumatoid arthritis (RA), quality indicators (QIs) are tools used to measure process of care. This study aimed to assess performance of selected QIs from the 2004 Arthritis Foundation's QI Set at 2 major sites of a university network of teaching hospitals. METHODS: The charts and electronic hospital records of 76 RA patients were audited to determine adherence to QIs. Logistic multivariate regression analyses were performed to investigate potential determinants of nonadherence and propose measures to facilitate better QI compliance, as a potential strategy towards RA care improvement. RESULTS: We identified consistent observance of QIs mandating prescription of disease-modifying antirheumatic drug therapy for all patients, drug adjustment with disease activity, prednisone tapering, and bisphosphonate therapy if indicated for patients on glucocorticoids. However, there was either lack of documentation or true inconsistent adherence to QIs dealing with radiograph performance, functional capacity assessment, and screening for hepatitis and tuberculosis before commencement of methotrexate and biologic agents, respectively. For the specific QIs analyzed, we did not find any definite independent associations with the studied variables. CONCLUSIONS: Our findings indicate that while there is frequent evidence for adherence to certain RA quality care standards at our centers, there is less compliance to others. Strategies to optimize the performance or documentation of those found most lacking, namely, functional capacity and screening for specific drug contraindications, could improve patient care. Radiographic disease monitoring, while lacking, may represent a move toward other more sensitive methods of RA progression detection, such as joint ultrasound. The inclusion of patient- and physician-derived information could help elucidate the reasons underlying nonadherence.

Sequencing of seven haloarchaeal genomes reveals patterns of genomic flux.

We report the sequencing of seven genomes from two haloarchaeal genera, Haloferax and Haloarcula. Ease of cultivation and the existence of well-developed genetic and biochemical tools for several diverse haloarchaeal species make haloarchaea a model group for the study of archaeal biology. The unique physiological properties of these organisms also make them good candidates for novel enzyme discovery for biotechnological applications. Seven genomes were sequenced to ∼20×coverage and assembled to an average of 50 contigs (range 5 scaffolds-168 contigs). Comparisons of protein-coding gene compliments revealed large-scale differences in COG functional group enrichment between these genera. Analysis of genes encoding machinery for DNA metabolism reveals genera-specific expansions of the general transcription factor TATA binding protein as well as a history of extensive duplication and horizontal transfer of the proliferating cell nuclear antigen. Insights gained from this study emphasize the importance of haloarchaea for investigation of archaeal biology.

Molecular dissection of cis-regulatory modules at the Drosophila bithorax complex reveals critical transcription factor signature motifs.

At the Drosophila melanogaster bithorax complex (BX-C) over 330kb of intergenic DNA is responsible for directing the transcription of just three homeotic (Hox) genes during embryonic development. A number of distinct enhancer cis-regulatory modules (CRMs) are responsible for controlling the specific expression patterns of the Hox genes in the BX-C. While it has proven possible to identify orthologs of known BX-C CRMs in different Drosophila species using overall sequence conservation, this approach has not proven sufficiently effective for identifying novel CRMs or defining the key functional sequences within enhancer CRMs. Here we demonstrate that the specific spatial clustering of transcription factor (TF) binding sites is important for BX-C enhancer activity. A bioinformatic search for combinations of putative TF binding sites in the BX-C suggests that simple clustering of binding sites is frequently not indicative of enhancer activity. However, through molecular dissection and evolutionary comparison across the Drosophila genus we discovered that specific TF binding site clustering patterns are an important feature of three known BX-C enhancers. Sub-regions of the defined IAB5 and IAB7b enhancers were both found to contain an evolutionarily conserved signature motif of clustered TF binding sites which is critical for the functional activity of the enhancers. Together, these results indicate that the spatial organization of specific activator and repressor binding sites within BX-C enhancers is of greater importance than overall sequence conservation and is indicative of enhancer functional activity.

Evaluation of the clinimetric properties of the Early Inflammatory Arthritis--self-administered comorbidity questionnaire.

OBJECTIVES: To adapt the self-administered comorbidity questionnaire (SCQ) into the Early Inflammatory Arthritis-SCQ (EIA-SCQ) and assess its clinimetric properties in EIA. METHODS: The EIA-SCQ and indices of disease activity, function, pain, health-related quality of life (HRQoL) and health resource utilization were administered to 320 patients with EIA. Twenty patients completed the EIA-SCQ a second time 1 week later. Construct validity was evaluated by testing the hypotheses that a valid comorbidity index would correlate well with age, weakly with HRQoL and recent resource utilization and poorly with indices of disease activity, function and pain. RESULTS: The intra-class correlation coefficient between repeat scores was 0.93 (95% CI 0.83-0.97). Kappa values for individual items ranged from 0.64 to 1.0. EIA-SCQ scores correlated moderately with age (Tau B = 0.29, P < 0.001) and weakly with function (HAQ-DI Tau B = 0.09, P = 0.03), pain (McGill Pain Questionnaire Tau B = 0.09, P = 0.05), some measures of HRQoL [the SF-36 mental component score (MCS) Tau B = - 0.08, P < 0.05; World Health Organization Disease Assessment Schedule II score Tau B = 0.09, P = 0.03] and a measure of resource utilization (number of tests in the last 4 months Tau B = 0.10, P = 0.04). The EIA-SCQ did not correlate with other measures of disease activity, another HRQoL measure [SF-36 physical component score (PCS)] or other measures of resource utilization. CONCLUSIONS: The EIA-SCQ is reliable and valid for use in EIA. It has the potential to become a useful measure of comorbidity in outcome studies of EIA when the resources for a full medical chart review are unavailable.

Symptoms of depression predict the trajectory of pain among patients with early inflammatory arthritis: a path analysis approach to assessing change.

OBJECTIVE: To assess the longitudinal relationships, including directionality, among chronic pain, symptoms of depression, and disease activity in patients with early inflammatory arthritis (EIA). METHODS: One hundred eighty patients with EIA completed an examination, including swollen joint count, and were administered the Center for Epidemiological Studies Depression Scale (CES-D) and the McGill Pain Questionnaire (MPQ) at 2 timepoints 6 months apart. Cross-lagged panel path analysis was used to simultaneously assess concurrent and longitudinal relationships among pain, symptoms of depression, and number of swollen joints. RESULTS: Pain, symptoms of depression, and number of swollen joints decreased over time (p < 0.001) and were prospectively linked to pain, symptoms of depression, and number of swollen joints, respectively, at 6 months. Symptoms of depression and pain were correlated with each other at baseline (0.47) and at 6-month followup assessments (0.28). Baseline symptoms of depression significantly predicted pain symptoms at 6 months (standardized regression coefficient = 0.28, p = 0.001), whereas pain and disease activity did not predict the course of any other variable after controlling for baseline values. CONCLUSION: Symptoms of depression predicted the trajectory of pain from baseline to 6 months. In addition, there were reciprocal/bidirectional associations between pain and symptoms of depression over time. More research is needed to better understand the relationship between pain and depressive symptoms and how to best manage patients with EIA who have high levels of both.

The clinimetric properties of the World Health Organization Disability Assessment Schedule II in early inflammatory arthritis.

OBJECTIVE: To assess the clinimetric properties of a new health-related quality of life (HRQOL) instrument, the World Health Organization Disability Assessment Schedule II (WHODAS II), in patients with early inflammatory arthritis. METHODS: Internal consistency as well as criterion, construct, and discriminative validity of the WHODAS II were assessed in 172 patients with early inflammatory arthritis who completed the WHODAS II, the Medical Outcomes Study Short Form 36 (SF-36), and other measures of disease severity, functioning, pain, depression, and resource use. Test-retest reliability of the WHODAS II was assessed by having a subset of 20 patients complete the WHODAS II a second time, 1 week after the first assessment. RESULTS: The WHODAS II had high internal consistency (Cronbach's alpha = 0.96 for patients working or in school and 0.93 for patients not working or in school). Test-retest intraclass correlation coefficients of the WHODAS II total score and subscales ranged from 0.82-0.96. The WHODAS II total score was strongly correlated with the SF-36 physical component score (Kendall's tau-b 0.51, P < 0.001) and moderately correlated with the SF-36 mental component score (tau-b 0.43, P < 0.001). WHODAS II correlations with disease outcomes ranged from Kendall's tau-b 0.15-0.55. The WHODAS II significantly differentiated between every aspect of disease severity assessed with the exception of measures of health resource use. CONCLUSION: The WHODAS II is a valid and reliable measure of HRQOL in cross-sectional studies of patients with early inflammatory arthritis. Research is still required to investigate potential item redundancy and determine its usefulness in longitudinal studies.

The Canadian Rheumatology Association/ Spondyloarthritis Research Consortium of Canada treatment recommendations for the management of spondyloarthritis: a national multidisciplinary stakeholder project.

OBJECTIVE: Development of treatment recommendations for arthritis has traditionally relied on the compilation of evidence-based data by experts in the field despite recommendations by various bodies for broad stakeholder input. Our objectives were: (1) To develop evidence-based treatment recommendations for the management of spondyloarthritis (SpA) in Canada that also incorporate the perspective of multiple stakeholders. (2) To generate a procedural template for the multidisciplinary development of treatment recommendations. METHODS: The process was directed by a steering committee comprising the SPARCC Executive, rheumatologists from academic and community-based practice, patient consumers, and a representative from the John Dossetor Health Ethics Centre. Guidelines established by EULAR and stipulated in the AGREE instrument were followed. First, a working document was drafted that included a referenced summary of the evidence-based data and the 12 national arthritis care standards developed by the Alliance for the Canadian Arthritis Program. Second, a Web-based survey was conducted among patient consumers to address the relevance to patients of 2 primary outcome instruments that assess the effectiveness of treatment. Third, a list of questions was generated for drafting propositions by the ethics consultant. A Delphi consensus exercise was then conducted. RESULTS: Consensus was generated on a final list of 38 treatment recommendations categorized under the subject headings of general management principles, ethical considerations, target groups, definition of target disease, disease monitoring, and specific management recommendations. CONCLUSION: Using broad stakeholder input, we provide treatment recommendations to guide clinical practice and access to care for patients with SpA in Canada.

A simple intervention to improve hospital antibiotic prescribing.

OBJECTIVE: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 x 6 cm laminated card suitable for clipping to a hospital identification badge. INTERVENTION: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 x 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff. DESIGN: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs. MAIN OUTCOME MEASURES: Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins. RESULTS: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards. CONCLUSION: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

Major nutrients and acidity: budgets and trends at four remote boreal stands in Finland during the 1990s.

Major nutrients and acidity were studied at six plots in four Integrated Monitoring catchments in Finland, located along a south-north deposition gradient. The quality and quantity of bulk precipitation, throughfall, soil water, and litterfall were monitored during the period 1989-1997. The results showed a marked decline in SO4 and H+ concentrations overall. Trends in throughfall ANC values were positive, while those in soil water were mostly negative. The increase in throughfall ANC values indicates recovery from acid deposition. The adsorption of base cations and release of organic acids was implicated in the decrease in soil water ANC trends. For all variables, the changes tended to be the greatest in the most southerly catchment, which received the most deposition loads. Mass balance budgets showed that total deposition inputs were greater than soil leaching outputs (at 40 cm) for NO3, NH4 and SO4, and were attributed to nutrient uptake and cycling processes. In contrast, for Ca, Mg, K and Na, and S (Valkea-Kotinen3 and Vuoskojärvi2 plots only), inputs were less than outputs, indicating net leaching. Throughfall + litterfall inputs to the forest floor showed that the organic layer is particularly important in the retention of Ca, Mg and N. Sulfur was retained in the lower soil layers, and attributed to Al and Fe hydroxide adsorption in the B horizon.

Use of prehospital fluids in hypotensive blunt trauma patients.

OBJECTIVE: To compare the outcomes of blunt trauma victims with systolic blood pressure < or = 90 mm Hg who received prehospital fluids with the outcomes of those who did not receive prehospital fluids. METHODS: This matched-pairs case-control study used records of blunt trauma patients with scene systolic blood pressure < or = 90 mm Hg obtained from the Pennsylvania Trauma Systems Foundation. Patients who received > 500 mL prehospital fluids (n = 75) were matched by Injury Severity Score (ISS) and systolic blood pressure on scene with those who did not receive any prehospital fluids (n = 75). Outcomes compared included change in systolic blood pressure, survival to discharge, and length of hospital stay. RESULTS: Those who received fluids were more likely to have an increase in systolic blood pressure at arrival to the emergency department [odds ratio for fluid use = 2.41; 95% confidence interval (95% CI) = 1.02, 5.73; p = 0.046]. There was no significant difference in survival to discharge (odds ratio for fluid use = 1.02; 95% CI = 0.40, 2.60; p = 0.969). There was no significant difference in length of hospital stay: 5.4 days (SD = 2.8) for those with fluids; 5.2 days (SD = 2.8) for those with no fluids; difference = 0.2 days; 95% CI = -1.6, 1.8; p = 0.870. CONCLUSIONS: This study suggests that prehospital fluid resuscitation of blunt injured trauma patients with systolic blood pressure < or = 90 increases systolic blood pressure but has no effect on survival or length of hospital stay.