Field assessment of metal and base cation accumulation in green stormwater infrastructure soils.

Green stormwater infrastructure (GSI) is adopted to reduce the impact of stormwater on urban flooding and water quality issues. This study assessed the performance of GSI, like bioretention basins, in accumulating metals. Twenty one GSI basins were considered for this study, which were located in New York and Pennsylvania, USA. Shallow (0-5 cm) soil samples were collected from each site at inlet, pool, and adjacent reference locations. The study analyzed 3 base cations (Ca, Mg, Na) and 6 metals (Cd, Cr, Cu, Ni, Pb, and Zn), some of which are toxic to ecosystem and human health. The accumulation of cations/metals at the inlet and pool differed between the selected basins. However, accumulation was consistently higher at the inlet or the pool of the basin as compared to the reference location. Contrary to prior research, this study did not find significant accumulation with age, suggesting that other factors such as site characteristics (e.g., loading rate) might be confounding. GSI basins that receive water only from parking lots or parking lots and building roofs combined showed higher metals and Na accumulation as compared to the basins that received stormwater only from building roofs. Cu, Mg and Zn accumulation showed a positive relationship with the organic matter content in soil, indicating likely sorption of metals on organic matter. Ca and Cu accumulation was greater in GSI basins with larger drainage areas. A negative relationship between Cu and Na implies that Na loading from de-icers may reduce Cu retention. Overall, the study found that the GSI basins are successfully accumulating metals and some base cations, with highest accumulation at the inlet. Additionally, this study provided evidence of GSI effectiveness in accumulating metals using a more cost efficient and time averaged approach compared to traditional means of stormwater inflow and outflow monitoring.

Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion.

As the worst global pandemic of the past century, coronavirus disease 2019 (COVID-19) has had a disproportionate effect on maintenance dialysis patients and their health care providers. At a virtual roundtable on June 12, 2020, Dialysis Outcomes and Practice Patterns Study (DOPPS) investigators from 15 countries in Asia, Europe, and the Americas described and compared the effects of COVID-19 on dialysis care, with recent updates added. Most striking is the huge difference in risk to dialysis patients and staff across the world. Per-population cases and deaths among dialysis patients vary more than 100-fold across participating countries, mirroring burden in the general population. International data indicate that the case-fatality ratio remains at 10% to 30% among dialysis patients, confirming the gravity of infection, and that cases are much more common among in-center than home dialysis patients. This latter finding merits urgent study because in-center patients often have greater community exposure, and in-center transmission may be uncommon under optimal protocols. Greater telemedicine use is a welcome change here to stay, and our community needs to improve emergency planning and protect dialysis staff from the next pandemic. Finally, the pandemic's challenges have prompted widespread partnering and innovation in kidney care and research that must be sustained after this global health crisis.

Seasonal shifts in the gut microbiome indicate plastic responses to diet in wild geladas.

BACKGROUND: Adaptive shifts in gut microbiome composition are one route by which animals adapt to seasonal changes in food availability and diet. However, outside of dietary shifts, other potential environmental drivers of gut microbial composition have rarely been investigated, particularly in organisms living in their natural environments. RESULTS: Here, we generated the largest wild nonhuman primate gut microbiome dataset to date to identify the environmental drivers of gut microbial diversity and function in 758 samples collected from wild Ethiopian geladas (Theropithecus gelada). Because geladas live in a cold, high-altitude environment and have a low-quality grass-based diet, they face extreme thermoregulatory and energetic constraints. We tested how proxies of food availability (rainfall) and thermoregulatory stress (temperature) predicted gut microbiome composition of geladas. The gelada gut microbiome composition covaried with rainfall and temperature in a pattern that suggests distinct responses to dietary and thermoregulatory challenges. Microbial changes were driven by differences in the main components of the diet across seasons: in rainier periods, the gut was dominated by cellulolytic/fermentative bacteria that specialized in digesting grass, while during dry periods the gut was dominated by bacteria that break down starches found in underground plant parts. Temperature had a comparatively smaller, but detectable, effect on the gut microbiome. During cold and dry periods, bacterial genes involved in energy, amino acid, and lipid metabolism increased, suggesting a stimulation of fermentation activity in the gut when thermoregulatory and nutritional stress co-occurred, and potentially helping geladas to maintain energy balance during challenging periods. CONCLUSION: Together, these results shed light on the extent to which gut microbiota plasticity provides dietary and metabolic flexibility to the host, and might be a key factor to thriving in changing environments. On a longer evolutionary timescale, such metabolic flexibility provided by the gut microbiome may have also allowed members of Theropithecus to adopt a specialized diet, and colonize new high-altitude grassland habitats in East Africa. Video abstract.

Anemia and iron deficiency among chronic kidney disease Stages 3-5ND patients in the Chronic Kidney Disease Outcomes and Practice Patterns Study: often unmeasured, variably treated.

BACKGROUND: International variation in anemia assessment and management practices in chronic kidney disease (CKD) is poorly understood. METHODS: We performed a cross-sectional analysis of anemia laboratory monitoring, prevalence and management in the prospective Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps). A total of 6766 participants with CKD Stages 3a-5ND from nephrology clinics in Brazil, France, Germany and the USA were included. RESULTS: Among patients with anemia (hemoglobin <12 g/dL), 36-58% in Brazil, the USA and Germany had repeat hemoglobin measured and 40-61% had iron indices measured within 3 months of the index hemoglobin measurement. Anemia was more common in the USA and Brazil than in France and Germany across CKD stages. Higher ferritin and lower iron saturation (TSAT) levels were observed with lower hemoglobin levels, and higher ferritin with more advanced CKD. The proportion of anemic patients with ferritin <100 ng/mL or TSAT <20% ranged from 42% in Brazil to 53% in France and Germany, and of these patients, over 40% in Brazil, Germany and the USA, compared with 27% in France, were treated with oral or intravenous iron within 3 months after hemoglobin measurement. The proportion of patients with hemoglobin <10 g/dL treated with erythropoiesis-stimulating agents ranged from 28% in the USA to 57% in Germany. CONCLUSIONS: Hemoglobin and iron stores are measured less frequently than per guidelines. Among all regions, there was a substantial proportion of anemic patients with iron deficiency who were not treated with iron, highlighting an area for practice improvement in CKD care.

International variation in dialysis discontinuation in patients with advanced kidney disease.

BACKGROUND: Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. METHODS: We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. RESULTS: A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. INTERPRETATION: We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.

International Anemia Prevalence and Management in Peritoneal Dialysis Patients.

Background:The optimal treatment for managing anemia in peritoneal dialysis (PD) patients and best clinical practices are not completely understood. We sought to characterize international variations in anemia measures and management among PD patients.Methods:The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) enrolled adult PD patients from 6 countries from 2014 to 2017. Hemoglobin (Hb), ferritin levels, and transferrin saturation (TSAT), as well as erythropoiesis stimulating agents (ESAs) and iron use were compared cross-sectionally at study enrollment in Australia and New Zealand (A/NZ), Canada, Japan, the United Kingdom (UK), and the United States (US).Results:Among 3,603 PD patients from 193 facilities, mean Hb ranged from 11.0 - 11.3 g/dL across countries. The majority of patients (range 53% - 59%) had Hb 10 - 11.9 g/dL, with 4% - 12% patients ≥ 13 g/dL and 16% - 23% < 10 g/dL. Use of ESAs was higher in Japan (94% of patients) than elsewhere (66% - 79% of patients). In the US, 63% of patients had a ferritin level > 500 ng/mL, compared with 5% - 38% in other countries. In the US and Japan, 87% - 89% of PD patients had TSAT ≥ 20%, compared with 73% - 76% in other countries. Intravenous (IV) iron use within 4 months of enrollment was higher in the US (55% of patients) than elsewhere (6% - 17% patients).Conclusions:In this largest international observational study of anemia and anemia management in patients receiving PD, comparable Hb levels across countries were observed but with notable differences in ESA and iron use. Peritoneal dialysis patients in the US have higher ferritin levels and higher IV iron use than other countries.

Remote Management for Peritoneal Dialysis: A Qualitative Study of Patient, Care Partner, and Clinician Perceptions and Priorities in the United States and the United Kingdom.

RATIONALE & OBJECTIVE: Peritoneal dialysis (PD) is a home-based kidney replacement therapy used by a growing number of patients with kidney failure. This qualitative study explores the impact of remote management technologies on PD treatment priorities of patients, their care partners, and clinicians. STUDY DESIGN: Qualitative study, designed and conducted in collaboration with a stakeholder panel that included patients, patient advocates, care partners, and health care professionals. SETTING & PARTICIPANTS: 13 health care providers, 13 patients, and 4 care partners with at least 3 months experience with PD were recruited from the United States and United Kingdom through postings in PD clinics, websites, and social media. METHODOLOGY: Semi-structured telephone interviews with a purposive sample of participants. ANALYTICAL APPROACH: Inductive thematic development adapted from a grounded theory approach through analysis of interview transcripts by 3 independent coders. RESULTS: 4 main themes about PD treatments emerged that enabled evaluation of remote management: (1) impact of PD on everyday life, (2) simplifying treatment processes, (3) awareness and visibility of at-home treatments, and (4) support for managing treatments. The relative importance of these themes differed between patients/care partners and health care providers and by use of remote management cyclers. LIMITATIONS: Remote management is new to PD, mirrored in the limited penetration of use in the study sample, suggestive of findings reflecting early adoption. CONCLUSIONS: Participants welcomed technological advances such as remote management for PD, although priorities differed by stakeholder group. Remote management could potentially influence health care provider decisions about patient suitability for PD, while patients/care partners prioritized pre-emptive and early treatment adjustments. Currently, decisions about access to remote management are outside the control of patients and families, but this may change with more widespread use.

Education and screening for chronic kidney disease in Indian youth: pilot program results.

BACKGROUND: There is a paucity of information on kidney education and screening programs in Indian youth. METHODS: Participants (n=2,158) from Chennai colleges were educated about the kidneys and chronic kidney disease (CKD) and screened in a pilot program from April to May 2013. This entailed: 1) a presentation and educational video and 2) an on-site assessment of weight, blood pressure, and demographic information. Urinalysis (UA) kits were distributed and returned in ≤48 hours. We examined participant characteristics and their association with dipstick proteinuria using logistic regression. RESULTS: The mean (standard deviation [SD]) age was 18.9 (1.6) years, and 1,451 (68%) were men. Mean (SD) body mass index (BMI) was 21.9 (4.3) kg/m2; 745 (36%) had a BMI consistent with being overweight or obese. Mean (SD) systolic blood pressure (SBP) was 118.7 (13.1) mm Hg, and 94 (5%) of the participants had SBP ≥140. Mean (SD) diastolic blood pressure (DBP) was 70.9 (11.4) mm Hg, with 119 participants (6%) having ≥90 mm Hg. A total of 136 participants had glycosuria (UA≥1+) and 120 (6%) had proteinuria (UA≥1+). In unadjusted analyses, sex (odds ratio [OR]=1.64 [confidence interval, CI 1.06-2.55]; p=0.026 men vs. women) and age (OR=1.13 per year [CI 1.01-1.26]; p=0.032) were significantly associated with proteinuria. In the analysis adjusted for age, sex, SBP, DBP, glycosuria, and BMI, age remained independently associated with higher odds for proteinuria (OR=1.14 per year [1.02-1.29]; p=0.026). Males showed a trend of higher risk compared with women (OR=1.57 [CI 1.00-2.50]; p=0.051). CONCLUSION: This education and screening pilot program in a population of college students offers unique opportunities for identification, education, and early intervention for CKD.

Characteristics of alpha males in Nepal gray langurs.

In species with strong male-male competition, access to females in multimale-multifemale groups is usually regulated via a dominance hierarchy. The highest ranking (alpha) male often has priority of access and sires most offspring. The alpha male can change in three basic ways: (i) a recent immigrant or a resident challenges and becomes the new alpha; (ii) formation of a new group; (iii) succession-becoming alpha after higher ranking males have left. When, in a given primate population, the alpha male changes in different ways, two questions arise: (a) which is the most successful tactic and (b) do male attributes, such as age, aggressiveness or propensity to commit infanticide, affect the outcome? We examined these questions in the seasonally breeding Nepal gray langurs (Semnopithecus schistaceus) at Ramnagar, where new alpha males were either recent immigrants or residents. Success was measured as alpha tenure, residency duration, and the number of offspring sired (paternity exclusion based on DNA analysis, 28 infants). We documented 12 alpha-male tenures across two multimale-multifemale groups between 1991 and 1997. The predominant mode of change was the immigrant tactic. Age had no effect perhaps because alpha males were among the youngest adult males in their group. As expected, infanticidal males performed similarly to non-infanticidal ones. Alpha tenure was highly variable and longer for immigrant alphas and hyper-aggressive ones. However, none of the tactics or attributes examined resulted in significantly longer residencies or more offspring, likely because of the timing of immigrations and stochastic effects (i.e., the number of conceptions occurring per alpha tenure). The influence of female mate choice on male reproductive success requires further investigation. Furthermore, it remains to be examined why resident alpha males-with their presumed better knowledge of their opponents -performed so poorly. Am. J. Primatol. 79:e22437, 2017. © 2015 Wiley Periodicals, Inc.

Dominance relationships in male Nepal gray langurs (Semnopithecus schistaceus).

OBJECTIVES: Reproductive skew is proposed to link to despotism in dominance hierarchies. While studies illustrating male skew are plentiful, demonstrating the link to despotism is rare. Likewise, it is often unknown which factors (e.g., resource holding potential, age, physical condition) affect a male's dominance rank. Here we investigated correlates of male rank and hierarchy characteristics in Nepal gray langurs (Semnopithecus schistaceus), a population with high male reproductive skew, and compared the results to other multi-male groups of nonhuman primates. METHODS: We collected dyadic displacement interactions from two groups (mean 3.0 and 4.1 adult males) for five years each. We assessed dominance ranks for demographically stable phases (n = 11, n = 28) and analyzed the effects of age and physical condition through linear mixed models (LMM). We analyzed hierarchy characteristics via the program MatMan. We used data from 27 primate groups (cercopithecines, colobines, hominoids) as a comparative sample. RESULTS: The highest ranks were attained by adults in one group (LMM, P < 0.091) and by young adults in the other group (LMM, P < 0.001). With some exceptions, rank was highest for males with higher physical condition scores (LMM, P < 0.05). Hierarchies had high directional consistency (mean > 0.93) and linearity (mean >0.81) and were relatively steep (mean >0.66) when compared with other species. DISCUSSION: Dominance rank followed a pattern predicted by resource holding potential, but other individual attributes and group composition also seemed important. As predicted, hierarchy characteristics indicated a despotic system in line with the strong reproductive skew. Across primates, however, the degree of despotism did not appear to match the degree of reproductive skew. Am J Phys Anthropol 160:208-219, 2016. © 2016 Wiley Periodicals, Inc.

Understanding the medical marriage: physicians and their partners share strategies for success.

PURPOSE: Physicians and their spouses experience challenges to their relationships, some of which are shared with the general population and others of which are unique to the field of medicine. Trainees and junior faculty members remain curious about how they will balance their careers alongside marriage and family obligations. This study explores the challenges and strengths of dual- and single-physician relationships. METHOD: In 2009, using appreciative inquiry as a theoretical framework, the authors conducted in-depth qualitative interviews with 25 individuals: 12 women and 13 men; 10 from dual-physician and 15 from single-physician relationships. A phenomenological analytic approach was used to arrive at the final themes. RESULTS: Four themes emerged during the interviews: "We rely on mutual support in our relationships," "We recognize the important roles of each family member," "We have shared values," and "We acknowledge the benefit of being a physician to our relationships." CONCLUSIONS: These findings illustrate that physicians identify strategies to navigate the difficult aspects of their lives. Learn ing from others' best practices can assist in managing personal relationships and work-life balance. These data can also be useful when counseling physicians on successful relationship strategies. As systems are developed that improve wellness and focus on role models for work-life balance, it will be important for this topic to be integrated into formal curricula across the continuum of medical education.

Quality of life of older patients undergoing renal transplantation: finding the right immunosuppressive treatment.

Kidney transplantation is currently the best treatment for end-stage renal disease, both in terms of mortality benefit and quality of life (QOL). Elderly patients are a rapidly growing subset of the kidney transplant waiting list. While it is clear that elderly individuals have a mortality benefit from kidney transplant, it is less clear how to make sure these individuals benefit from optimal QOL following transplant. Several studies demonstrate superiority of some immunosuppressive regimens over others in the QOL domain. Tacrolimus has been shown to be associated with better QOL than cyclosporine (ciclosporin), as has corticosteroid-free immunosuppressive regimens. Similarly, patients on drug regimens, which tend to lessen the side effects, report better QOL. However, these studies are observational or cross-sectional and not focused exclusively on the elderly patient. More studies are needed to determine optimal immunosuppression regimens for elderly individuals. Additionally, further studies on determinants of QOL in elderly kidney transplant recipients are also needed.

A successful faculty development program for implementing a sociocultural ePortfolio assessment tool.

Portfolios are emerging as a tool for documenting learning progression and assessing competency. ePortfolios are appealing as a portable and fluid means of documenting both learning and relevant experiences in a large number of students. Competence and learning can be especially difficult to document in important aspects of education and training, such as patient-centeredness, the cultural context of disease, and social determinants of health that do not lend themselves to fact-based assessment methods. Successful implementation of a method such as an ePortfolio requires explicit faculty development, as many faculty members have limited expertise with modern educational assessment technology. As part of the authors' introduction of a Sociocultural ePortfolio Assessment Tool in the undergraduate medical curriculum, three faculty development workshops were held to expand faculty skills in using this technology. In addition to gaining comfort using a new Web-based technology, faculty members also needed to develop skills with providing mentored feedback and stimulating student reflection. Workshops were modeled after other successful programs reported in the literature and allowed faculty to develop a structured format for evaluating student content. Faculty members were given multiple opportunities to practice their newly developed skills providing mentored reflections using an ePortfolio. The workshop evaluations were positive, suggesting that faculty participation in the workshops were a necessary component for them to develop sufficient assessment skills for providing mentored reflection. Faculty members who participated in this program-whether or not they had content expertise in sociocultural medicine-valued the hands-on faculty development program.