The geographic extent of bird populations affected by renewable-energy development.

Bird populations are declining globally. Wind and solar energy can reduce emissions of fossil fuels that drive anthropogenic climate change, yet renewable-energy production represents a potential threat to bird species. Surveys to assess potential effects at renewable-energy facilities are exclusively local, and the geographic extent encompassed by birds killed at these facilities is largely unknown, which creates challenges for minimizing and mitigating the population-level and cumulative effects of these fatalities. We performed geospatial analyses of stable hydrogen isotope data obtained from feathers of 871 individuals of 24 bird species found dead at solar- and wind-energy facilities in California (USA). Most species had individuals with a mix of origins, ranging from 23% to 98% nonlocal. Mean minimum distances to areas of likely origin for nonlocal individuals were as close as 97 to >1250 km, and these minimum distances were larger for species found at solar-energy facilities in deserts than at wind-energy facilities in grasslands (Cohen's d = 6.5). Fatalities were drawn from an estimated 30-100% of species' desingated ranges, and this percentage was significantly smaller for species with large ranges found at wind facilities (Pearson's r = -0.67). Temporal patterns in the geographic origin of fatalities suggested that migratory movements and nonmigratory movements, such as dispersal and nomadism, influence exposure to fatality risk for these birds. Our results illustrate the power of using stable isotope data to assess the geographic extent of renewable-energy fatalities on birds. As the buildout of renewable-energy facilities continues, accurate assessment of the geographic footprint of wildlife fatalities can be used to inform compensatory mitigation for their population-level and cumulative effects.

Extensión geográfica de las poblaciones de aves afectadas por desarrollos de energía renovable Resumen Las poblaciones mundiales de aves están en declive. Las energías solar y eólica pueden reducir las emisiones de combustibles fósiles que causan el cambio climático, aunque la producción de energías renovables representa una amenaza potencial para las aves. Los censos para evaluar los efectos potenciales en los centros de energía renovable son exclusivamente locales y se sabe poco sobre la extensión geográfica representada por las aves que mueren en estas instalaciones, lo que plantea obstáculos para mitigar los efectos acumulativos y de nivel poblacional de estas muertes. Realizamos análisis geoespaciales con datos del isótopo de hidrógeno estable obtenido de las plumas de 871 ejemplares de 24 especies de aves que fueron hallados muertos en los centros de energía solar y eólica en California, EE.UU. La mayoría de las especies contó con ejemplares de orígenes mixtos, con un rango del 23% al 98% no local. La media de la distancia mínima a las áreas de probable origen de los ejemplares no locales varía entre los 97 hasta > 1,250 km. Estas distancias mínimas fueron mayores para las especies encontradas en los centros de energía solar situadas en desiertos que para las especies encontradas en los centros de energía eólica localizadas en pastizales (d de Cohen = 6.5). Las muertes representan un 30­100% de la extensión de las especies. Este porcentaje fue significativamente menor para las especies con extensiones amplias encontradas en instalaciones eólicas (r de Pearson = ­0.67). Los patrones temporales en el origen geográfico de las muertes sugieren que los movimientos migratorios y no migratorios, como la dispersión y el nomadismo, influyen en la exposición de estas aves al riesgo de muerte. Nuestros resultados demuestran la utilidad de los isótopos estables para evaluar el alcance geográfico de las muertes de aves asociadas a energías renovables. Con el progresivo aumento de instalaciones de energía renovable, una evaluación precisa de la huella geográfica de la mortandad de fauna salvaje podrá guiar la mitigación compensatoria de sus efectos acumulativos y de nivel poblacional.

Seasonal patterns of bird and bat collision fatalities at wind turbines.

Information on when birds and bats die from collisions with wind turbines can help refine efforts to minimize fatalities via curtailment of energy productions and can offer insight into the risk factors associated with collision fatalities. Using data pooled from 114 post-construction monitoring studies conducted at wind facilities across the United States, we described seasonal patterns of fatalities among birds and bats. Bat fatalities peaked in the fall. Silver-haired bat (Lasionycteris noctivagans), a long-distance migrant, and Mexican free-tailed bat (Tadarida brasiliensis) both showed maximum fatality counts later in the year-October and November, respectively-than any other bat species. The other common species in our sample-hoary bat (Aeorestes cinereus), Eastern red bat (Lasiurus borealis), and big brown bat (Eptesicus fuscus)-showed broadly overlapping peaks of fatality counts in August. Fatalities of silver-haired bat showed a smaller spring peak in some ecoregions; no other bat species exhibited this pattern. Seasonal patterns of bird fatalities varied among guilds. Woodland birds, many of which were long-distance migrants, showed two peaks in fatalities corresponding to spring and fall migration. Grassland birds and soaring birds, most of which were resident or short-distance migrants, did not exhibit strong seasonal peaks in fatalities. Species in these guilds tend to inhabit regions with extensive wind-energy development year-round, which may explain the more consistent numbers of fatalities that we observed. Our results highlight the value of pooling data to develop science-based solutions to reduce conflicts between wind-energy development and wildlife but also emphasize the need for more extensive data and standardization of post-construction monitoring to support more robust inferences regarding wind-wildlife interactions and collision risk.

Vulnerability of avian populations to renewable energy production.

Renewable energy production can kill individual birds, but little is known about how it affects avian populations. We assessed the vulnerability of populations for 23 priority bird species killed at wind and solar facilities in California, USA. Bayesian hierarchical models suggested that 48% of these species were vulnerable to population-level effects from added fatalities caused by renewables and other sources. Effects of renewables extended far beyond the location of energy production to impact bird populations in distant regions across continental migration networks. Populations of species associated with grasslands where turbines were located were most vulnerable to wind. Populations of nocturnal migrant species were most vulnerable to solar, despite not typically being associated with deserts where the solar facilities we evaluated were located. Our findings indicate that addressing declines of North American bird populations requires consideration of the effects of renewables and other anthropogenic threats on both nearby and distant populations of vulnerable species.

The effect of Share 35 on biliary complications: An interrupted time series analysis.

The purpose of the Share 35 allocation policy was to improve liver transplant waitlist mortality, targeting high MELD waitlisted patients. However, policy changes may also have unintended consequences that must be balanced with the primary desired outcome. We performed an interrupted time series assessing the impact of Share 35 on biliary complications in a select national liver transplant population using the Vizient CDB/RM database. Liver transplants that occurred between October 2012 and September 2015 were included. There was a significant change in the incident-rate of biliary complications between Pre-Share 35 (n = 3018) and Post-Share 35 (n = 9984) cohorts over time (P = .023, r2  = .44). As a control, a subanalysis was performed throughout the same time period in Region 9 transplant centers, where a broad sharing agreement had previously been implemented. In the subanalysis, there was no change in the incident-rate of biliary complications between the two time periods. Length of stay and mean direct cost demonstrated a change after implementation of Share 35, although they did not meet statistical difference. While the target of improved waitlist mortality is of utmost importance for the equitable allocation of organs, unintended consequences of policy changes should be studied for a full assessment of a policy's impact.

Comorbid TBI-depression costs in veterans: a chronic effect of neurotrauma consortium (CENC) study.

BACKGROUND: The U.S. Veterans Health Administration (VHA) provides depression treatment to veterans with Traumatic Brain Injury (TBI). VHA costs of comorbid TBI-depression were estimated by Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) status over 14 years. METHODS: VHA-USING veterans with TBI DIAGNOSED IN 2000-2010 were followed through FY2014. TBI severity was determined using the Department of Defense criteria. Depression was identified by the Elixhauser algorithm. Generalized linear and seemingly unrelated regression models were used to estimate the impact of depression on annual per veteran and total VHA inpatient, outpatient, and pharmaceutical costs, by OEF/OIF status. RESULTS: A total of 66.57% of pre-OEF/OIF and 87.46% of OEF/OIF veterans had depression. Depression was estimated to increase annual total ($1,847), outpatient ($1,558), and pharmaceutical ($287) costs for pre-OEF/OIF, and $1,228, $1,685, and $191 for OEF/OIF veterans. However, depression was estimated to lower annual inpatient costs by $648 per OEF/OIF veteran. The annual VHA cost for all veterans with comorbid TBI-depression was estimated at $1,101,329,953. CONCLUSIONS: The estimated annual cost for Veterans with comorbid TBI-depression was more than $1 billion. TBI and depression screening/treatment may result in reduced inpatient VHA costs in OEF/OIF veterans exposed to TBI. VHA policymakers should consider screening for TBI and depression in pre-OEF/OIF veterans.

Can targeted policies reduce obesity and improve obesity-related behaviours in socioeconomically disadvantaged populations? A systematic review.

This review synthesized evidence from controlled studies pertaining to the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged children and adults. Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity guidelines were followed. Eligible studies were published from 2004 to August 2015 and examined the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged populations. Twenty articles (18 studies) were included. Eight studies examined organizational policies within multi-component interventions in schools. Common elements of successful policy-containing interventions included nutritional standards, enhancements to physical education, additional physical activity opportunities, school self-assessments, and nutrition and physical activity education. Of the 10 studies of government policies, policies providing information/education and fruit and vegetable subsidies had positive impacts amongst children, but no impact amongst adults. Policies involving changes to built environments yielded nearly uniformly null findings in children and adults. Overall, the largest quantity of high-quality evidence of effectiveness was for comprehensive interventions that included school policies, and government policies targeting disadvantaged children in schools. None of the government policies targeting disadvantaged adults proved effective. Interventions during childhood may ameliorate negative obesity-related manifestations of socioeconomic disadvantage. Gaps in knowledge remain surrounding effective policies in adults, adolescents and very young children.

Mobile Health in Solid Organ Transplant: The Time Is Now.

Despite being in existence for >40 years, the application of telemedicine has lagged significantly in comparison to its generated interest. Detractors include the immobile design of most historic telemedicine interventions and the relative lack of smartphones among the general populace. Recently, the exponential increase in smartphone ownership and familiarity have provided the potential for the development of mobile health (mHealth) interventions that can be mirrored realistically in clinical applications. Existing studies have demonstrated some potential clinical benefits of mHealth in the various phases of solid organ transplantation (SOT). Furthermore, studies in nontransplant chronic diseases may be used to guide future studies in SOT. Nevertheless, substantially more must be accomplished before mHealth becomes mainstream. Further evidence of clinical benefits and a critical need for cost-effectiveness analysis must prove its utility to patients, clinicians, hospitals, insurers, and the federal government. The SOT population is an ideal one in which to demonstrate the benefits of mHealth. In this review, the current evidence and status of mHealth in SOT is discussed, and a general path forward is presented that will allow buy-in from the health care community, insurers, and the federal government to move mHealth from research to standard care.

Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Can policy ameliorate socioeconomic inequities in obesity and obesity-related behaviours? A systematic review of the impact of universal policies on adults and children.

This systematic review examined the impact of universal policies on socioeconomic inequities in obesity, dietary and physical activity behaviours among adults and children. PRISMA-Equity guidelines were followed. Database searches spanned from 2004 to August 2015. Eligible studies assessed the impact of universal policies on anthropometric, dietary or physical activity-related outcomes in adults or children according to socioeconomic position. Thirty-six studies were included. Policies were classified as agentic, agento-structural or structural, and their impact on inequities was rated as positive, neutral, negative or mixed according to the dominant associations observed. Most policies had neutral impacts on obesity-related inequities regardless of whether they were agentic (60% neutral), agento-structural (68% neutral) or structural (67% neutral). The proportion of positive impacts was similar across policy types (10% agentic, 18% agento-structural and 11% structural), with some differences for negative impacts (30% agentic, 14% agento-structural and 22% structural). The majority of associations remained neutral when stratified by participant population, implementation level and socioeconomic position measures and by anthropometric and behavioural outcomes. Fiscal measures had consistently neutral or positive impacts on inequities. Findings suggest an important role for policy in addressing obesity in an equitable manner and strengthen the case for implementing a broad complement of policies spanning the agency-structure continuum.

Modeling with uncertain science: estimating mitigation credits from abating lead poisoning in Golden Eagles.

Challenges arise when renewable energy development triggers "no net loss" policies for protected species, such as where wind energy facilities affect Golden Eagles in the western United States. When established mitigation approaches are insufficient to fully avoid or offset losses, conservation goals may still be achievable through experimental implementation of unproven mitigation methods provided they are analyzed within a framework that deals transparently and rigorously with uncertainty. We developed an approach to quantify and analyze compensatory mitigation that (1) relies on expert opinion elicited in a thoughtful and structured process to design the analysis (models) and supplement available data, (2) builds computational models as hypotheses about cause-effect relationships, (3) represents scientific uncertainty in stochastic model simulations, (4) provides probabilistic predictions of "relative" mortality with and without mitigation, (5) presents results in clear formats useful to applying risk management preferences (regulatory standards) and selecting strategies and levels of mitigation for immediate action, and (6) defines predictive parameters in units that could be monitored effectively, to support experimental adaptive management and reduction in uncertainty. We illustrate the approach with a case study characterized by high uncertainty about underlying biological processes and high conservation interest: estimating the quantitative effects of voluntary strategies to abate lead poisoning in Golden Eagles in Wyoming due to ingestion of spent game hunting ammunition.

A National Survey Assessing the Current Workforce of Transplant Pharmacists Across Accredited U.S. Solid Organ Transplant Programs.

Integration of pharmacists into multidisciplinary transplant patient care has advanced in recent years, with limited data available to evaluate the current status of the profession. This was a national survey developed as an AST Pharmacy COP initiative. Responses were solicited from pharmacists practicing at U.S. transplant programs based on UNOS listing; 176 participants from 113 centers (41%) responded, with 79% practicing ≤10 years. There is a median of 1.4 pharmacist full-time equivalents (FTEs) (range 0.1-7.1) for every 100 transplants. The predominant activities performed by pharmacists during the transplant phase include medication review (95%), lab review (92%), allergy review (88%), medication therapy management (92%), bedside rounds (87%), medication education (79%), documentation (71%), and coordinating discharge medications (58%). Similar activities were reported during the other phases, but participation was less common. The involvement of dedicated transplant pharmacists within multidisciplinary care has become standard at a large number of centers, although expansion is still needed to ensure core pharmaceutical care components are provided to all transplant recipients across all centers. These results inform on the typical responsibilities of pharmacists practicing within the field of transplantation and illustrate that the level of pharmacist involvement significantly varies across transplant centers and the phases of transplantation.

Prediction of medication non-adherence and associated outcomes in pediatric kidney transplant recipients.

Studies have continued to evaluate risk factors associated with post-transplant non-adherence in pediatric patients. However, many of these studies fail to evaluate how risk factors can be utilized to predict MNA. The aims of this study were to (i) determine salient risk factors associated with MNA to develop an adequate predictive risk model and (ii) assess transplant outcomes based on the presence of MNA in a large, diverse cohort of pediatric KTX recipients. One hundred and seventy-five solitary pediatric KTX recipients transplanted from 1999 to 2013 were included. AA, males, older patients, those who lived in urban environments, had legal issues, and lived shorter distances from the transplant center were more likely to have MNA. Using logistic regression, a parsimonious model applying nine risk factors together was developed for predicting MNA, demonstrating a PPV of 69% and a NPV of 81%. Patients with MNA had more than twice the risk of biopsy proven acute rejection, 1.6 times the risk of hospitalization, and 1.8 times the risk of graft loss. Utilization of a predictive model to determine risk of MNA after pediatric KTX may offer clinicians the ability to efficiently and effectively monitor MNA following transplant.

Clinical outcomes and costs associated with in-hospital biliary complications after liver transplantation: a cross-sectional analysis.

INTRODUCTION: In-hospital biliary complications (BCs) after liver transplantation (LT) are reported in up to 20 % of patients and contribute to poor outcomes and increased costs. Existing single-center outcome and cost analyses studies are limited in scope. METHODS: This is a cross-sectional analysis of national data involving 7,967 patients transplanted between 2011 and 2012 with the primary aim of determining the association between BCs and clinical outcomes and costs. Age, race, diagnosis, and severity of illness are associated with the development of BCs. RESULTS: BCs develop in 14.6 % of LT recipients and have substantial implications for perioperative outcomes, including length of hospital and ICU stay (27.9 vs 19.6 mean days, p < 0.001 and 12.0 vs 8.3 mean days, p < 0.001, respectively), in-hospital morbidity (39 vs 27 %, p < 0.001), 30-day readmissions (14.8 vs 11.2 %, p < 0.001), and in-hospital mortality (5.8 vs 4.0 %, p < 0.001). BCs contributed to a mean increase in in-hospital costs of $36,212 (p < 0.001), due to increases in accommodations ($9,539, p < 0.001), surgical services ($3,988, p < 0.001), and pharmacy services ($8,445, p < 0.001). DISCUSSION: BCs are a predominant etiology for in-hospital morbidity and mortality, while contributing significantly to the high cost of LT. Efforts should be focused on understanding salient and modifiable risk factors, while developing innovative strategies to reduce BCs.

Critical analysis of valganciclovir dosing and renal function on the development of cytomegalovirus infection in kidney transplantation.

BACKGROUND: Cytomegalovirus (CMV) infection is one of the most common and important opportunistic infections following kidney transplantation. It causes significant morbidity and mortality. Valganciclovir (VGCV) is the drug of choice for prophylaxis to prevent CMV infection. METHODS: We conducted a post-hoc analysis of a randomized controlled trial in 187 kidney transplant recipients to evaluate the impact of VGCV dosing and renal function on the development of CMV infection. RESULTS AND CONCLUSION: The results demonstrate that the following variables were independent risk factors for the development of CMV infection: high-risk CMV serostatus (donor positive/recipient negative; hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.46-5.28, P = 0.002); anti-thymocyte globulin induction therapy (HR 2.1, 95% CI 1.08-4.07, P = 0.028); higher mean tacrolimus trough concentration (HR 1.4, 95% CI 1.09-1.74, P = 0.007); creatinine clearance <60 mL/min (HR 3.4, 95% CI 1.64-6.85, P = 0.001); and body weight >80 kg (HR 2.1, 95% CI 1.05-4.37, P = 0.037). VGCV dosing was appropriate for most patients, in those who did and did not develop CMV infection. These results strongly suggest that the currently recommended dose adjustments of VGCV dosing based on estimated renal function calculated using ideal body weight may underestimate the renal function of overweight patients and indirectly result in underexposure of overweight patients to VGCV. Based on these findings, further VGCV pharmacokinetic analyses are warranted in kidney transplant recipients with moderate-to-severe renal dysfunction.

Improving transplant patient safety through pharmacist discharge medication reconciliation.

Greater than 50% of medication errors are estimated to occur during transitions of care, and solid-organ transplant recipients are at an increased risk for errors due to significant changes in their medication regimen following transplantation. This prospective, observational study with a historical control group was conducted to evaluate the discharge process for transplant recipients and determine if transplant pharmacist involvement would improve safety. During the prospective period, a total of 191 errors were made on discharge medication reconciliations (n = 64, mean rate 3.0 per patient); however, pharmacists prevented 119 of these errors (1.9 errors per patient). In the retrospective period, none of the 430 errors identified were prevented at the time of discharge (n = 128, p < 0.0001). The 72 errors not prevented at the time of discharge in the prospective cohort were identified by the pharmacist at the patient's first clinic visit (1.1 errors per patient). In the historical cohort, all 430 errors made at discharge persisted until at least the time of the first clinic visit (3.4 errors per patient, p < 0.0001). This study demonstrates that transplant recipients are at a high risk for medication errors and that transplant pharmacist involvement leads to improved safety through the significant reduction of medication errors.

Disruptions in the supply of medications used in transplantation: implications and management strategies for the transplant clinician.

Drug shortages are a threat to patient care and public health, and the number of drugs on shortage is growing at an exponential rate. The major therapy areas affected by these shortages are oncology, anti-infective, cardiovascular and central nervous system. However, drugs utilized in the transplant patient population have not been exempt, and can have significant influence on posttransplant outcomes. The purpose of this review is to discuss the current and historical solid organ transplant-related disruptions in the supply of medications and implications on patient care and safety. Transplant centers should be armed with an implementation plan when imperative transplant-related drugs such as tacrolimus, mycophenolate, or antithymocyte globulin go on shortage. This plan should provide steps to manage the shortage, and provide effective therapeutic alternatives.

Early aspirin therapy may reduce hepatic artery thrombosis in liver transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) remains among the leading causes of early graft loss after liver transplantation. Our transplant center began using universal aspirin prophylactic therapy immediately posttransplantation in 2007. The aim of this study was to determine the safety and efficacy of early aspirin therapy on clinical outcomes. METHODS: This large-scale, cross-sectional analysis included all adult liver transplantations performed between 2000 and 2009. Pediatric and multiorgan transplants were excluded. Patients were grouped and compared based on whether they received early initiation of aspirin 325 mg PO daily posttransplantation. RESULTS: A total of 541 adult liver transplantations occurred during the study period; 439 had complete documentation and were analyzed. Clinical outcomes show aspirin patients had similar rates of early and late HAT, but had significantly lower early HAT, defined as HAT occurring within the first 30 days posttransplant, leading to graft loss. Other clinical outcomes were similar between groups including bleeding events and wound complications. CONCLUSIONS: Immediate initiation of aspirin therapy after liver transplantation may reduce the rate of HAT leading to early graft loss, without increasing bleeding or other complication rates.

The impact of early corticosteroid withdrawal on graft survival in liver transplant recipients.

BACKGROUND: There has been increased interest in recent years in reducing or eliminating steroids from the immunosuppression regimen of transplant recipients to reduce adverse effects associated with their use. The purpose of this study was to compare clinical outcomes between early versus late steroid withdrawal after liver transplant to determine the optimal duration of steroid use in this population. METHODS: This large-scale, retrospective analysis of liver transplants occurred at our institution between 2000 and 2009. Patients were excluded if they were <18 years old, received a multiorgan transplant, or remained on steroids for >1 year. The early steroid withdrawal group had steroids eliminated by 3 months posttransplant; late steroid withdrawal patients had steroids withdrawn between 3 and 12 months posttransplant. RESULTS: A total of 586 liver transplants occurred during the study period; 330 patients were included in the analysis. Graft survival was significantly lower in the early steroid withdrawal group. There was no difference in patient survival or overall acute rejection. However, the late steroid withdrawal group had a significantly higher rate of early acute rejection episodes. There was no difference with regard to new-onset diabetes after transplant, hyperlipidemia, or cardiovascular events between groups. CONCLUSION: The results of this study suggest that late corticosteroid withdrawal is associated with better long-term graft survival without increasing the rates of diabetes, hyperlipidemia, or cardiovascular events in liver transplant recipients. A prospective study is warranted to confirm these findings.