A human cadaveric model for venous air embolism tool development.

Purpose: A human cadaveric model combining standard lung protective mechanical ventilation and modified cardiac bypass techniques was developed to allow investigation into automated modes of detection of venous air emboli (VAE) prior to in vivo human or animal investigations. Methods: In this study, in order to create an artificial cardiopulmonary circuit in a cadaver that could mimic VAE physiology, the direction of flow was reversed from conventional cardiac bypass. Saline was circulated in isolation through the heart and lungs as opposed to the peripheral organs by placing the venous cannula into the aorta and the arterial cannula into the inferior vena cava with selective ligation of other vessels. Results: Mechanical ventilation and this reversed cardiac bypass scheme allowed preliminary detection of VAE independently but not in concert in our current simulation scheme due to pulmonary edema in the cadaver. A limited dissection approach was used initially followed by a radical exposure of the great vessels, and both proved feasible in terms of air signal detection. We used electrical impendence as a preliminary tool to validate detection in this cadaveric model however we theorize that it would work for echocardiographic, intravenous ultrasound or other novel modalities as well. Conclusion: A cadaveric model allows monitoring technology development with reduced use of animal and conventional human testing.

Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding.

BACKGROUND & AIMS: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification. METHODS: We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk. RESULTS: There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%). CONCLUSIONS: A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.

Leverage points for improving global food security and the environment.

Achieving sustainable global food security is one of humanity's contemporary challenges. Here we present an analysis identifying key "global leverage points" that offer the best opportunities to improve both global food security and environmental sustainability. We find that a relatively small set of places and actions could provide enough new calories to meet the basic needs for more than 3 billion people, address many environmental impacts with global consequences, and focus food waste reduction on the commodities with the greatest impact on food security. These leverage points in the global food system can help guide how nongovernmental organizations, foundations, governments, citizens' groups, and businesses prioritize actions.

Emissions and air quality impacts of truck-to-rail freight modal shifts in the Midwestern United States.

We present an examination of the potential emissions and air quality benefits of shifting freight from truck to rail in the upper Midwestern United States. Using a novel, freight-specific emissions inventory (the Wisconsin Inventory of Freight Emissions, WIFE) and a three-dimensional Eulerian photochemical transport model (the Community Multiscale Air Quality Model, CMAQ), we quantify how specific freight mode choices impact ambient air pollution concentrations. Using WIFE, we developed two modal shift scenarios: one focusing on intraregional freight movements within the Midwest and a second on through-freight movements through the region. Freight truck and rail emissions inventories for each scenario were gridded to a 12 km × 12 km horizontal resolution as input to CMAQ, along with emissions from all other major sectors, and three-dimensional time-varying meteorology from the Weather Research and Forecasting model (WRF). The through-freight scenario reduced monthly mean (January and July) localized concentrations of nitrogen dioxide (NO2) by 28% (-2.33 ppbV) in highway grid cells, and reduced elemental carbon (EC) by 16% (-0.05 µg/m(3)) in highway grid cells. There were corresponding localized increases in railway grid cells of 25% (+0.83 ppbV) for NO2, and 22% (+0.05 µg/m(3)) for EC. The through-freight scenario reduced CO2 emissions 31% compared to baseline trucking. The through-freight scenario yields a July mean change in ground-level ambient PM2.5 and O3 over the central and eastern part of the domain (up to -3%).

Closing yield gaps through nutrient and water management.

In the coming decades, a crucial challenge for humanity will be meeting future food demands without undermining further the integrity of the Earth's environmental systems. Agricultural systems are already major forces of global environmental degradation, but population growth and increasing consumption of calorie- and meat-intensive diets are expected to roughly double human food demand by 2050 (ref. 3). Responding to these pressures, there is increasing focus on 'sustainable intensification' as a means to increase yields on underperforming landscapes while simultaneously decreasing the environmental impacts of agricultural systems. However, it is unclear what such efforts might entail for the future of global agricultural landscapes. Here we present a global-scale assessment of intensification prospects from closing 'yield gaps' (differences between observed yields and those attainable in a given region), the spatial patterns of agricultural management practices and yield limitation, and the management changes that may be necessary to achieve increased yields. We find that global yield variability is heavily controlled by fertilizer use, irrigation and climate. Large production increases (45% to 70% for most crops) are possible from closing yield gaps to 100% of attainable yields, and the changes to management practices that are needed to close yield gaps vary considerably by region and current intensity. Furthermore, we find that there are large opportunities to reduce the environmental impact of agriculture by eliminating nutrient overuse, while still allowing an approximately 30% increase in production of major cereals (maize, wheat and rice). Meeting the food security and sustainability challenges of the coming decades is possible, but will require considerable changes in nutrient and water management.

Resorption and remodeling of hydroxyapatite-poly-L-lactic acid composite anterior cruciate ligament interference screws.

PURPOSE: The purpose of this study was to evaluate the progression of hydroxyapatite-poly-L-lactic acid (HA-PLLA) interference screw resorption and remodeling in patients after anterior cruciate ligament (ACL) reconstruction. METHODS: Sixty-five patients undergoing ACL reconstruction with patellar tendon autograft or allograft fixed at both the femur and tibia with HA-PLLA screws were evaluated. We evaluated 10 patients each at 2, 3, and 4 years postoperatively, whereas 35 patients were evaluated at 5 years postoperatively. In all patients a physical examination was performed and functional outcome scores and computed tomography (CT) analysis were obtained at follow-up. RESULTS: Screw tract densities determined by CT at 5 years postoperatively were higher than muscle and were similar to the surrounding bone. At 4 years, 80% to 90% of screws were completely resorbed. At 5-year follow-up, 29% of patients showed complete ossification of the screw tract in the femur versus 34% in the tibia. There was no tunnel widening or sclerosis noted. Subjective and objective clinical results remained high throughout the study period. CONCLUSIONS: The HA-PLLA interference screws are slowly resorbed over time, and the majority are completely resorbed between 3 and 4 years after ACL reconstruction with patellar tendon autograft or allograft. Osteoconductivity and remodeling were confirmed by CT scans, and no tunnel widening, sclerosis, cysts, or inflammatory changes were noted. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Solutions for a cultivated planet.

Increasing population and consumption are placing unprecedented demands on agriculture and natural resources. Today, approximately a billion people are chronically malnourished while our agricultural systems are concurrently degrading land, water, biodiversity and climate on a global scale. To meet the world's future food security and sustainability needs, food production must grow substantially while, at the same time, agriculture's environmental footprint must shrink dramatically. Here we analyse solutions to this dilemma, showing that tremendous progress could be made by halting agricultural expansion, closing 'yield gaps' on underperforming lands, increasing cropping efficiency, shifting diets and reducing waste. Together, these strategies could double food production while greatly reducing the environmental impacts of agriculture.

A global comparison of national biodiesel production potentials.

This study presents a consistent, national-level evaluation of potential biodiesel volumes and prices, replicated across 226 countries, territories, and protectorates. Utilizing all commercially exported lipid feedstocks from existing agricultural lands, we compare the upper-limit potential for expanded biodiesel production in terms of absolute biodiesel volumes, profitable potential from biodiesel exports, and potential from expanded vegetable oil production through agricultural yield increases. Country findings are compared across a variety of economic, energy, and environmental metrics. Our results show an upper-limit worldwide volume potential of 51 billion liters from 119 countries; 47 billion of which could be produced profitably at today's import prices. Also significant production gains are possible through increasing agricultural yields: a 12-fold increase over existing potential, primarily hinging on better management of tropical oilseed varietals.