Successful mitigation of stormwater-driven nutrient, fecal bacteria and suspended solids loading in a recreational beach community.

Marine and estuarine waterways adjacent to urban areas are often the final recipient of polluted stormwater runoff. Microbial degradation of coastal water quality is a direct threat to human health through fecal contamination of bathing waters and shellfish, as well as distressing local economies through the loss of waterways to commercial (shellfishing) and recreational use. In coastal waters reduction of nitrogen loading is a key strategy for prevention of noxious and toxic algal blooms. Best management practices (BMPs) can be successful tools for mitigating such pollutants in runoff, but BMPs must be tailored to individual situations for maximum effectiveness. This study examines the efficacy of a set of BMPs installed in the coastal resort Town of Wrightsville Beach, North Carolina, USA. The BMPs targeted the highly-impervious (90%+) drainage area of two stormwater outfall pipes emptying into recreationally used Banks Channel. Mitigation measures included replacement of impervious pavement with pervious concrete and construction of an infiltration chamber in the parking lot of a local recreational seaside club. Significant reductions were achieved in total stormwater discharge (62%), as well as loading of the fecal indicator bacteria Enterococcus (76%) and total nitrogen (TN - 87% decrease). Additionally, there were reductions in loading of total phosphorous (TP) and total suspended solids (TSS) to estuarine waters following BMP installment. The set of BMPs applied here have wide management applicability to coastal ecosystems, as well as freshwater riparian areas characterized by sandy, porous soils.

Waste nutrients from U.S. animal feeding operations: Regulations are inconsistent across states and inadequately assess nutrient export risk.

Livestock production in the United States has been transformed over the past several decades, largely as a result of widespread development of industrial-scale mass production facilities, termed Animal Feeding Operations (AFOs). These facilities generate massive amounts of animal waste that can concentrate in small areas. Animal wastes from AFOs have led to high levels of nutrients and other pollutants in nearby surface waters, as well as groundwater. The environmental problems associated with these disposal practices have led to federal and state modifications to the rules and regulations governing waste practices. We summarize the federal guidelines for AFO nutrient management, focusing on swine, and compare the regulations of four AFO-rich states in different regions of the USA. Furthermore, we discuss inconsistencies among regulations and regulatory gaps, and identify issues with waste nutrient management practices that lead to environmental degradation in watersheds hosting AFOs. Finally, we address these shortcomings and the need to implement policy updates that would alleviate some of these environmental and human concerns.

Tracing nutrient pollution from industrialized animal production in a large coastal watershed.

One of the highest concentrations of swine and poultry concentrated animal feeding operations (CAFOs) in North America is located on the Coastal Plain of North Carolina, in which the Cape Fear River basin is located. The CAFOs produce vast amounts of manure causing loading of nutrients and other pollutants to receiving waters. With the Cape Fear River basin vulnerable to nutrient pollution, as are many other watersheds with CAFOs, δ13C and δ15N stable isotopic signatures were identified from water samples collected within the Northeast Cape Fear, Black, and lower Cape Fear River watersheds to trace nutrient sources and their distribution downstream. The spatial and temporal variability of nutrients and isotopic signatures were also identified to understand water quality impacts of animal waste spraying season and proximity to CAFOs. Our results showed that significantly enriched δ15N signatures characterized sites in close proximity to CAFOs as well as point-source wastewater discharge areas, while the opposite was true for an unimpacted control stream and two estuarine sites. Additionally, the impacted sites yielded significantly (p < 0.05) higher nitrate concentrations than control and estuarine sites. Statistical analyses demonstrated that nitrate concentrations were positively correlated with heavier δ15N signatures, suggesting that animal waste, as well as human wastewater, are relatively more important sources of N to this large watershed than fertilizers from traditional row crop agriculture. Our results also suggested that during appropriate hydrological conditions CAFO-derived N can be detected many kilometers downstream from freshwater sources areas to the estuary.

Transesophageal Echocardiography During Cardiopulmonary Resuscitation Is Associated With Shorter Compression Pauses Compared With Transthoracic Echocardiography.

STUDY OBJECTIVE: Point-of-care ultrasonography provides diagnostic information in addition to visual pulse checks during cardiopulmonary resuscitation (CPR). The most commonly used modality, transthoracic echocardiography, has unfortunately been repeatedly associated with prolonged pauses in chest compressions, which correlate with worsened neurologic outcomes. Unlike transthoracic echocardiography, transesophageal echocardiography does not require cessation of compressions for adequate imaging and provides the diagnostic benefit of point-of-care ultrasonography. To assess a benefit of transesophageal echocardiography, we compare the duration of chest compression pauses between transesophageal echocardiography, transthoracic echocardiography, and manual pulse checks on video recordings of cardiac arrest resuscitations. METHODS: We analyzed 139 pulse check CPR pauses among 25 patients during cardiac arrest. RESULTS: Transesophageal echocardiography provided the shortest mean pulse check duration (9 seconds [95% confidence interval {CI} 5 to 12 seconds]). Mean pulse check duration with transthoracic echocardiography was 19 seconds (95% CI 16 to 22 seconds), and it was 11 seconds (95% CI 8 to 14 seconds) with manual checks. Intraclass correlation coefficient between abstractors for a portion of individual and average times was 0.99 and 0.99, respectively (P<.001 for both). CONCLUSION: Our study suggests that pulse check times with transesophageal echocardiography are shorter versus with transthoracic echocardiography for ED point-of-care ultrasonography during cardiac arrest resuscitations, and further emphasizes the need for careful attention to compression pause duration when using transthoracic echocardiography for point-of-care ultrasonography during ED cardiac arrest resuscitations.

Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation.

Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

Season matters when sampling streams for swine CAFO waste pollution impacts.

Concentrated (or confined) animal feed operations (CAFOs) are the principal means of livestock production in the United States, and such facilities pollute nearby waterways because of their waste management practices; CAFO waste is pumped from the confinement structure into a cesspit and sprayed on a field. Stocking Head Creek is located in eastern North Carolina, a state with >9,000,000 head of swine confined in CAFOs. This watershed contains 40 swine CAFOs; stream water quality was investigated at seven sites during 2016, with five sampling dates in early spring and five in summer. Geometric mean fecal coliform counts were in the thousands/100 mL at five sites in spring and all seven sites in summer. Excessive nitrate pollution was widespread with concentrations up to >11.0 mg N/L. Seasonality played an important role in pollutant concentrations. In North Carolina, spraying animal waste on adjoining fields is permissible from March 1 through September 30. Seasonal data showed significantly higher (p < 0.01) concentrations of conductivity, nitrate, total nitrogen, total organic carbon, and fecal bacteria in summer as opposed to early spring. Thus, sampling performed only in winter-early spring would significantly underestimate impacts from swine CAFO spray fields on nearby waterways.

Does the Addition of M-Mode to B-Mode Ultrasound Increase the Accuracy of Identification of Lung Sliding in Traumatic Pneumothoraces?

OBJECTIVES: It is unknown whether the addition of M-mode to B-mode ultrasound (US) has any effect on the overall accuracy of interpretation of lung sliding in the evaluation of a pneumothorax by emergency physicians. This study aimed to determine what effect, if any, this addition has on US interpretation by emergency physicians of varying training levels. METHODS: One hundred forty emergency physicians were randomized via online software to receive a quiz with B-mode clips alone or B-mode with corresponding M-mode images and asked to identify the presence or absence of lung sliding. RESULTS: The sensitivity, specificity, and accuracy of the diagnosis of lung sliding with and without M-mode US were compared. Overall, the sensitivities, specificities, and accuracies of B-mode + M-mode US versus B-mode US alone were 93.1% and 93.2% (P = .8), 96.0% and 89.8% (P < .0001), and 91.5% and 94.5% (P = .0091), respectively. A subgroup analysis showed that in those providers with fewer than 250 total US scans done previously, M-mode US increased accuracy from 88.2% (95% confidence interval, 86.2%-90.2%) to 94.4% (92.8%-96.0%; P = .001) and increased the specificity from 87.0% (84.5%-89.5%) to 97.2% (95.4%-99.0%; P < .0001) compared with B-mode US alone. There was no statistically significant difference observed in the sensitivity, specificity, and accuracy of B-mode + M-mode US compared with B-mode US alone in those with more than 250 scans. CONCLUSIONS: The addition of M-mode images to B-mode clips aids in the accurate diagnosis of lung sliding by emergency physicians. The subgroup analysis showed that the benefit of M-mode US disappears after emergency physicians have performed more than 250 US examinations.

Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program.

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.

Medical expulsive therapy use in emergency department patients diagnosed with ureteral stones.

OBJECTIVE: Recent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones <10mm not requiring an urgent intervention. Prior studies have reported low rates of use of MET by emergency physicians. We sought to describe patterns of alpha-blocker use and to determine factors associated with utilization in patients diagnosed with ureterolithiasis in the ED. METHODS: We used data from a randomized trial of CT scan vs. ultrasound in participants with suspected urolithiasis enrolled at 15 EDs between October 2011 and February 2013. The use of medical expulsive therapy was identified by the prescription of an alpha-blocker, calcium channel blocker, or steroid at the ED visit. The prevalence of alpha-blocker use in participants with ureteral stones on imaging was calculated, and multivariable models were used to examine risk factors for utilization. RESULTS: Of the 524 participants who were identified with a ureteral stone on CT scan and discharged from the ED, 375 (71.4%) received an alpha-blocker, and 2 (<1%) received a steroid. There was no significant difference in alpha-blocker use for participants based on stone size or location. However, there was a 3.6-fold difference in alpha-blocker use between the lowest and highest use ED sites. In the multivariable analysis, ED site was independently associated with utilization of alpha-blockers. CONCLUSIONS: Alpha-blockers were prescribed in more than two-thirds of patients with a distal ureteral stone on imaging, a much higher prevalence than previously reported. There was substantial variability in alpha-blocker use based on ED site.

Micro-zooplankton grazing as a means of fecal bacteria removal in stormwater BMPs.

A priority for environmental managers is control of stormwater runoff pollution, especially fecal microbial pollution. This research was designed to determine if fecal bacterial grazing by micro-zooplankton is a significant control on fecal bacteria in aquatic best management practices (BMPs); if grazing differs between a wet detention pond and a constructed wetland; and if environmental factors enhance grazing. Both 3-day grazing tests and 24-h dilution assays were used to determine grazing differences between the two types of BMP. Micro-zooplankton grazing was a stronger bacteria removal mechanism in stormwater wetlands rich in aquatic vegetation compared to a standard wet detention pond, although grazing was important in detention ponds as well. Our experiments indicated that the majority of grazers that fed on fecal bacteria were <20 µm in size. Grazing rates were positively correlated with fecal coliform abundance and increased water temperatures. Enumeration of grazers demonstrated that protozoans were significantly more abundant among wetland vegetation than in open water, and open wetland waters contained more flagellates and dinoflagellates than open wet detention pond waters. Grazing on fecal bacteria in BMPs is enhanced by aquatic vegetation, and grazing in aquatic BMPs in warmer climates should be greater than in cooler climates.

Emergency physician-performed transesophageal echocardiography for extracorporeal life support vascular cannula placement.

INTRODUCTION: There is growing interest and application of extracorporeal membrane oxygenation (ECMO) as a life-saving procedure for out-of-hospital cardiac arrest (OHCA), also called extracorporeal life support (ECLS). Extracorporeal membrane oxygenation cannulation with ongoing chest compressions is challenging, and transesophageal echocardiography (TEE) is an invaluable tool with which to guide ECMO wire guidance and cannula positioning. METHODS: We describe our protocol for TEE guidance by emergency physicians in our hospital. RESULTS: Of our first 12 cases of ECLS, 10 have had TEE guidance by an emergency physician with successful placement and without complication or need for repositioning. Emergency physician-performed TEE for ECLS vascular cannula placement has been both feasible and useful in our experience and warrants further study.

Assessing hog lagoon waste contamination in the Cape Fear Watershed using Bacteroidetes 16S rRNA gene pyrosequencing.

Hog lagoons can be major sources of waste and nutrient contamination to watersheds adjacent to pig farms. Fecal source tracking methods targeting Bacteroidetes 16S rRNA genes in pig fecal matter may underestimate or fail to detect hog lagoon contamination in riverine environments. In order to detect hog lagoon wastewater contamination in the Cape Fear Watershed, where a large number of hog farms are present, we conducted pyrosequencing analyses of Bacteroidetes 16S rRNA genes in hog lagoon waste and identified new hog lagoon-specific marker sequences. Additional pyrosequencing analyses of Bacteroidetes 16S rRNA genes were conducted with surface water samples collected at 4 sites during 5 months in the Cape Fear Watershed. Using an operational taxonomic unit (OTU) identity cutoff value of 97 %, these newly identified hog lagoon markers were found in 3 of the river samples, while only 1 sample contained the pig fecal marker. In the sample containing the pig fecal marker, there was a relatively high percentage (14.1 %) of the hog lagoon markers and a low pig fecal marker relative abundance of 0.4 % in the Bacteroidetes 16S rRNA gene sequences. This suggests that hog lagoon contamination must be somewhat significant in order for pig fecal markers to be detected, and low levels of hog lagoon contamination cannot be detected targeting only pig-specific fecal markers. Thus, new hog lagoon markers have a better detection capacity for lagoon waste contamination, and in conjunction with a pig fecal marker, provide a more comprehensive and accurate detection of hog lagoon waste contamination in susceptible watersheds.

Diagnosis of appendicitis by bedside ultrasound in the ED.

BACKGROUND: Computed tomography (CT) has largely become standard of care for diagnosing appendicitis at the expense of increased patient radiation exposure, cost, and time to surgical intervention. To date, there are very limited data on the accuracy of bedside ultrasound (BUS) for the diagnosis of appendicitis in adults. OBJECTIVE: The objective of this study is to evaluate test characteristics of BUS for diagnosis of acute appendicitis in the emergency department. METHODS: Data were prospectively collected on 97 cases of suspected appendicitis, which had BUS performed by trained residents with attending supervision between August 2011 and November 2013. All BUS interpretation and additional diagnostic imaging were left to the discretion of the physician or surgical consultants. A blinded ultrasound fellowship-trained physician reviewed all images after clinical treatment. Bedside ultrasound findings and patient outcomes were reported. RESULTS: A total of 97 adult cases underwent diagnostic ultrasound scans for suspected appendicitis. Of 97 cases, 34 had acute appendicitis by surgery/pathology report. Twenty-four BUS were positive for acute appendicitis and 11 were nondiagnostic. Of 24 positive ultrasounds, 23 had appendicitis on pathology report. There was 1 false-positive result, yielding a sensitivity of 67.65% (95% confidence limits, 49.5%-82.6%) and a specificity of 98.41% (95% confidence limits, 91.4%-99.7%). Of 23 positive BUS, 12 cases went to the Operating Room without an abdominal CT yielding a 12% reduction in CT utilization. If all positive BUS went to the OR without a CT scan, this would yield a 24% reduction in CT utilization. CONCLUSIONS: Bedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department.

The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip.

Children presenting with hip pain or a limp are a diagnostic challenge for the clinician. The differential diagnosis is extensive, and the workup can be broad. This review focuses on differentiating between transient synovitis and septic arthritis of the hip. The role of bedside ultrasound in the clinical evaluation of these patients is addressed, including the technique and appropriate indications for bedside ultrasound of the hip in the emergency department.

Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation.

BACKGROUND: Interest in the use of dynamic ultrasound (US) for cricothyrotomy has sparked a debate regarding its applicability in a crash airway situation. Ultrasound-guided marking of the cricothyroid membrane (CTM) as a preintubation procedure may be better than the dynamic method. No prior study has evaluated the accuracy of using US to premark the CTM before attempted intubation. OBJECTIVES: To determine the feasibility of US-guided marking of the CTM before attempted simulated intubation so that this marking may be used as the location for the initial incision after failed intubation. METHODS: Resident and attending physicians participated. Ultrasound was used to identify and mark the CTM with an invisible pen. Failed intubation was simulated, and the same operator then identified the CTM with US and marked the location with a black pen. The difference in the preintervention and postintervention markings was measured in millimeters. The length of the CTM was also measured as a reference. RESULTS: Twenty-three models and operators were used for data collection. The average CTM sagittal length was 13.9 mm (95% confidence interval [CI], 13.4-14.4). The average sagittal and axial differences before and after simulated intubation were found to be 0.91 mm (95% CI, 0.35-1.47) and 1.04 mm (95% CI, 0.38-1.7), respectively. The sagittal variability is 1/15 the total length of the CTM. CONCLUSIONS: Ultrasound marking of the CTM of healthy volunteers before simulated intubation accurately identifies the CTM after neck manipulation expected during a failed intubation. Further research is indicated to determine the clinical applicability of this model.

Web-based emergency department patient satisfaction surveys may introduce potential for bias.

BACKGROUND: Emergency departments (ED) have proposed utilizing a Web-based format to distribute patient satisfaction surveys, but the potential for bias in this distribution method has not been assessed. OBJECTIVE: The aim of this study was to evaluate the characteristics of ED patients who have access to the Internet to better understand potential bias in Web-based patient satisfaction surveys. METHODS: We distributed a 20-question survey to consenting, English-speaking adult patients presenting to the ED from December 2010 to March 2012. Patients reported demographic information and answered questions related to their access and use of the Internet. RESULTS: Seven hundred four patients participated in the study; 90% of Whites reported Internet access, vs. 82% of Hispanics (p = 0.034). Ninety-two percent of patients with at least some college education had Internet access, compared to 79% of those with a high school education level or lower (p ≤ 0.001). Of households reporting an income of > $22,000/year, 95% had Internet access, compared to 77% of those reporting a household income < $22,000/year (p ≤ 0.001). Ninety-four percent of participants < 40 years of age had Internet access, compared to 83% between the ages of 40 and 56 years, and 77% for those over 56 years of age (p < 0.001). CONCLUSION: A Web-based distribution of ED patient satisfaction surveys may underrepresent minorities, patients without college education, those with lower income, and patients older than 40 years. This information may provide guidance in interpreting results of Web-based patient satisfaction surveys and may suggest the need for multiple sampling methods.

Prospective evaluation of the use of the thrombolysis in myocardial infarction score as a risk stratification tool for chest pain patients admitted to an ED observation unit.

BACKGROUND: The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30-day and 1-year outcomes in emergency department (ED) patients with potential acute coronary syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and compare outcomes among differing scores. METHODS: A prospective observational study with 30-day telephone follow-up for a 12 month period. Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to place patients in observation. RESULTS: N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients), myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require admission (15.4% vs 9.8%, P = .048). CONCLUSION: The TIMI risk score may serve as an effective risk stratification tool among chest pain patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered for inpatient admission and/or more aggressive evaluation and therapy.

A pilot retrospective study of a physician-directed and genomics-based model for precision lifestyle medicine.

Precision lifestyle medicine is a relatively new field in primary care, based on the hypothesis that genetic predispositions influence an individual's response to specific interventions such as diet, exercise, and prescription medications. Despite the increase in commercially available genomic testing, few studies have investigated effects of a physician-directed program to optimize chronic disease using genomics-based precision medicine. We performed an pilot, observational cohort study to evaluate effects of the Wild Health program, a physician and health coach service offering genomics-based lifestyle and medical interventions, on biomarkers indicative of chronic disease. 871 patients underwent genomic testing, biomarker testing, and ongoing health coaching after initial medical consultation by a physician. Improvements in several clinically relevant out-of-range biomarkers at baseline were identified in a large proportion of patients treated through lifestyle intervention without the use of prescription medication. Notably, normalization of several biomarkers associated with chronic disease occurred in 47.5% (hemoglobin A1c [HbA1c]), 33.3% (low density lipoprotein particle number [LDL-P]), and 33.2% (C-reactive protein [CRP]). However, due to the inherent limitations of our observational study design and use of retrospective data, ongoing work will be crucial for continuing to shed light on the effectiveness of physician-led, genomics-based lifestyle coaching programs. Future studies would benefit from implementing a randomized controlled study design, tracking specific interventions, and evaluating physiological data, such as BMI.

GlideScope versus flexible fiber optic for awake upright laryngoscopy.

STUDY OBJECTIVES: We compare laryngoscopic quality and time to highest-grade view between a face-to-face approach with the GlideScope and traditional flexible fiber-optic laryngoscopy in awake, upright volunteers. METHODS: This was a prospective, randomized, crossover study in which we performed awake laryngoscopy under local anesthesia on 23 healthy volunteers, using both a GlideScope video laryngoscopy face-to-face technique with the blade held upside down and flexible fiber-optic laryngoscopy. Operator reports of Cormack-Lehane laryngoscopic views and video-reviewed time to highest-grade view, as well as number of attempts, were recorded. RESULTS: Ten women and 13 men participated. A grade II or better view was obtained with GlideScope video laryngoscopy in 22 of 23 (95.6%) participants and in 23 of 23 (100%) participants with flexible fiber-optic laryngoscopy (relative risk GlideScope video laryngoscopy versus flexible fiber-optic laryngoscopy 0.96; 95% confidence interval 0.88 to 1.04). Median time to highest-grade view for GlideScope video laryngoscopy was 16 seconds (interquartile range 9 to 34) versus 51 seconds (interquartile range 35 to 96) for flexible fiber-optic laryngoscopy. A distribution of interindividual differences demonstrated that GlideScope video laryngoscopy was, on average, 39 seconds faster than flexible fiber-optic laryngoscopy (95% confidence interval 0.2 to 76.9 seconds). CONCLUSION: GlideScope video laryngoscopy can be used to obtain a Cormack-Lehane grade II or better view in the majority of awake, healthy volunteers when an upright face-to-face approach is used and was slightly faster than traditional flexible fiber-optic laryngoscopy. However, flexible fiber-optic laryngoscopy may be more reliable at obtaining high-grade views of the larynx. Awake, face-to-face GlideScope use may offer an alternative approach to the difficulty airway, particularly among providers uncomfortable with flexible fiber-optic laryngoscopy.