Infection risk and antimicrobial prophylaxis in bendamustine-treated patients with indolent non-Hodgkin lymphoma: An Australasian Lymphoma Alliance study.

Infection and lymphopenia are established bendamustine-related complications. The relationship between lymphopenia severity and infection risk, and the role of antimicrobial prophylaxis, is not well described. This multicentre retrospective study analysed infection characteristics and antimicrobial prophylaxis in 302 bendamustine-treated indolent non-Hodgkin lymphoma patients. Lymphopenia (<1 × 109/L) was near universal and time to lymphocyte recovery correlated with cumulative bendamustine dose. No association between lymphopenia severity and duration with infection was observed. Infections occurred in 44% of patients (50% bacterial) with 27% hospitalised; 32% of infections occurred ≥3 months post bendamustine completion. Infection was associated with obinutuzumab and/or maintenance anti-CD20 therapy, prior therapy and advanced stage. Twenty-four opportunistic infections occurred in 21 patients: ten varicella zoster virus (VZV), seven herpes simplex virus (HSV), one cytomegalovirus, one progressive multifocal leucoencephalopathy, one nocardiosis, one Pneumocystis jiroveci pneumonia (PJP) and three other fungal infections. VZV/HSV and PJP prophylaxis were prescribed to 42% and 54% respectively. Fewer VZV/HSV infections occurred in patients receiving prophylaxis (HR 0.14, p = 0.061) while PJP prophylaxis was associated with reduced risk of bacterial infection (HR 0.48, p = 0.004). Our study demonstrates a significant infection risk regardless of lymphopenia severity and supports prophylaxis to mitigate the risk of early and delayed infections.

The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system.

PURPOSE: Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50. METHODS: An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach. RESULTS: Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach. CONCLUSION: Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

Process and Outcome Measures for Infants Born Moderate and Late Preterm in Tertiary Canadian Neonatal Intensive Care Units.

OBJECTIVE: To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs). STUDY DESIGN: This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. RESULTS: Among 25 669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. CONCLUSIONS: Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.

Variations in Site-Specific Costs for Infants Born Extremely Preterm in Canadian Neonatal Intensive Care Units.

OBJECTIVE: To quantify site-specific costs and their association with survival without major morbidity (SWMM) in Canada for neonates <28 weeks of gestation admitted to large tertiary neonatal intensive care units. METHODS: We conducted a retrospective analysis of infants born at <28 weeks of gestation and admitted to Canadian Neonatal Network sites from 2010 through 2021. Sites that cared for at least 50 eligible infants by gestational age in weeks over the study period were included. Using a validated costing algorithm that assessed physician, nursing, respiratory therapy, diagnostic imaging, transfusions, procedural, medication, and certain indirect costs, we calculated site and resource-specific costs in 2017 Canadian dollars (CAD) and evaluated their relationship with SWMM. RESULTS: Seven sites with 8180 (range 841-1605) eligible neonates with a mean (SD) gestation of 25.4 [1.3] weeks were included. Survival to discharge or transfer was 85.3% with a mean (SD) length of stay of 75 (46) days. The mean (SD) total and daily costs per neonate varied between $94 992 ($60 283) and $174 438 ($130 501) CAD and $1833 ($916) to $2307 ($1281) CAD, respectively. Between sites, there was no relationship between costs and SWMM. CONCLUSIONS: There was marked variation in costs and SWMM between sites in Canada with universal health care. The lack of concordance between both outcomes and costs among sites may provide possibilities for outcomes improvement and cost containment.

Semiautomated electronic medical record based system for monitoring delayed adverse events in pediatric endoscopy and sedation.

OBJECTIVE: To develop a semiautomated electronic medical record (EMR) system to track pediatric endoscopic procedural adverse event (AE) at a tertiary referral children's hospital. METHODS: We developed an automated EMR based query for postprocedure AEs. Main outcome measurements within 30 days of procedure: return to emergency department, return to surgery, unplanned admissions and admissions with longer than intended stays. Events were graded using a recently described classification system for postendoscopy events and tracked for a 36-month period, from January 2017 to December 2019. RESULTS: Development of a semi-automated system was successful in comprehensive identification of endoscopy and sedation related AE. A total of 193 AEs (2%) were identified in all three categories. Seventy cases (0.7%) were noted to be a direct result of an endoscopic procedure. Of these cases, 31 (44%) were noted to be Grade 3, 5 cases (7%) Grade 4, and no Grade 5 AE occured. Higher rates of AE were observed after therapeutic procedures versus diagnostic (2.6% vs. 0.3%, p = <0.00001). AEs related to sedation occurred in 0.5% of procedures with the majority (84%) reported in patients with American Society of Anesthesia classification of 3 or greater. CONCLUSIONS: Diagnostic endoscopy remains a safe procedure and risk of both endoscopy and sedation related AE are low. Therapeutic procedures carry a higher risk but are still overwhelmingly safe. Institutional investment in this EMR based system allowed for sustainability and comprehensive tracking of endoscopy related AE.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study.

OBJECTIVES: To implement an early rehabilitation bundle in two Canadian PICUs. DESIGN AND SETTING: Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2). PATIENTS: All children under 18 years old admitted to the PICU were eligible for the intervention. INTERVENTIONS: A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement. CONCLUSIONS: A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Control of nitrogen and odor emissions during chicken manure composting with a carbon-based microbial inoculant and a biotrickling filter.

Although aerobic composting is usually utilized in livestock manure disposal, the emission of odorous gases from compost not only induces harm to the human body and the environment, but also causes loss of nitrogen, sulfur, and other essential elements, resulting in a decline in product quality. The impact of biotrickling filter (BTF) and insertion of carbon-based microbial agent (CBMA) on compost maturation, odor emissions, and microbial population during the chicken manure composting were assessed in the current experiment. Compared with the CK group, CBMA addition accelerated the increase in pile temperature (EG group reached maximum temperature 10 days earlier than CK group), increased compost maturation (GI showed the highest increase of 41.3% on day 14 in EG group), resulted in 36.59% and 14.60% increase in NO3--N content and the total nitrogen retention preservation rate after composting. The deodorization effect of biotrickling filter was stable, and the removal rates of NH3, H2S, and TVOCs reached more than 90%, 96%, and 56%, respectively. Furthermore, microbial sequencing showed that CBMA effectively changed the microbial community in compost, protected the ammonia-oxidizing microorganisms, and strengthened the nitrification of the compost. In addition, the nitrifying and denitrifying bacteria were more active in the cooling period than they were in the thermophilic period. Moreover, the abundance of denitrification genes containing nirS, nirK, and nosZ in EG group was lower than that in CK group. Thus, a large amount of nitrogen was retained under the combined drive of BTF and CBMA during composting. This study made significant contributions to our understanding of how to compost livestock manure while reducing releases of odors and raising compost quality.

Spatial distribution of PAHs and microbial communities in intertidal sediments of the Pearl River Estuary, South China.

The exploration of sediment pollution caused by PAHs and its impact on microbial communities can provide valuable insights for the remediation of sediments. The spatial distribution of PAHs and their impact on the microbial community within the Pearl River Estuary were investigated in this study. The findings revealed that the total concentration ranges of 16 PAHs were between 24.26 and 3075.93 ng/g, with naphthalene, fluorene, and phenanthrene potentially exerting adverse biological effects. More PAHs were found to accumulate in subsurface sediments, and their average accumulation rates gradually decreased as the number of rings in PAHs increased, ranging from 180 % for 2-ring to 36 % for 6-ring. The phyla Proteobacteria, Bacteroidetes, Actinobacteria, and Chloroflexi were found to dominate both surface and subsurface sediments The correlation between microbial genera and PAHs contents was weak in sediments with low levels of PAHs contamination, while a more significant positive relationship was observed in sediments with high levels of PAHs contamination. The physicochemical properties of sediments, such as pH, soil structure and Cu significantly influence bacterial community composition in highly contaminated sediments. Additionally, the network analysis revealed that certain bacterial genera, including Novosphingobium, Robiginitalea and Synechococcus_CC9902, played a pivotal role in the degradation of PAHs. These findings are significant in comprehending the correlation between bacterial communities and environmental factors in intertidal ecosystems, and establish a scientific foundation for bioremediation of intertidal zones.

Characterization and stabilization of incineration fly ash from a new multi-source hazardous waste co-disposal system: field-scale study on solidification and stabilization.

The multi-source hazardous waste co-disposal system, a recent innovation in the industry, offers an efficient approach for hazardous waste disposal. The incineration fly ash (HFA) produced by this system exhibits characteristics distinct from those of typical incineration fly ash, necessitating the use of adjusted disposal methods. This study examined the physicochemical properties, heavy metal content, heavy metal leaching concentration, and dioxin content of HFA generated by the new co-disposal system and compared them with those of conventional municipal waste incineration fly ash. This study investigated the solidification and stabilization of HFA disposal using the organic agent sodium diethyl dithiocarbamate combined with cement on a field scale. The findings revealed significant differences in the structure, composition, and dioxin content of HFA and FA; HFA contained substantially lower levels of dioxins than FA did. Concerning the heavy metal content and leaching; HFA exhibited an unusually high concentration of zinc, surpassing the permitted emission limits, making zinc content a critical consideration in HFA disposal. After stabilization and disposal, the heavy metal leaching and dioxin content of HFA can meet landfill disposal emission standards when a 1% concentration of 10% sodium diethyldithiocarbamate (DDTC) and 150% silicate cement were employed. These results offer valuable insights into the disposal of fly ash resulting from incineration of mixed hazardous waste.

Corrected Age at Bayley Assessment and Developmental Delay in Extreme Preterms.

BACKGROUND AND OBJECTIVES: Research on outcomes of prematurity frequently examines neurodevelopment in the toddler years as an end point, but the age range at examination varies. We aimed to evaluate whether the corrected age (CA) at Bayley-III assessment is associated with rates of developmental delay in extremely preterm children. METHODS: This retrospective cohort study included children born at <29 weeks' gestation who were admitted in the Canadian Neonatal Network between 2009 and 2017. The primary outcomes were significant developmental delay (Bayley-III score <70 in any domain) and developmental delay (Bayley-III score <85 in any domain). To assess the association between CA at Bayley-III assessment and developmental delay, we compared outcomes between 2 groups of children: those assessed at 18 to 20 months' CA and 21-24 months. RESULTS: Overall, 3944 infants were assessed at 18-20 months' CA and 881 at 21-24 months. Compared with infants assessed at 18-20 months, those assessed at 21-24 months had higher odds of significant development delay (20.0% vs 12.5%; adjusted odds ratio, 1.75; 95% confidence interval [CI], 1.41-2.13) and development delays (48.9% vs 41.7%, adjusted odds ratio 1.33; 95% CI, 1.11-1.52). Bayley-III composite scores were on average 3 to 4 points lower in infants evaluated at 21-24 months' CA (for instance, adjusted mean difference and 95% CI for language: 3.49 [2.33-4.66]). Conversely, rates of cerebral palsy were comparable (4.6% vs 4.7%) between the groups. CONCLUSIONS: Bayley-III assessments performed at 21-24 months' CA were more likely to diagnose a significant developmental delay compared with 18- to 20-month assessments in extremely preterm children.

Silver sulfide nanoparticles eliminate the stimulative effects of earthworms on nutrient uptake by soybeans in high organic matter soils.

A significant knowledge gap exists regarding the impact of soil organic matter on the bioavailability of Ag2S-NPs (environmentally relevant forms of Ag-NPs) in soil-earthworm-plant systems. This study used two soils with varying organic matter content, both with and without earthworms, to investigate the bioavailability of Ag2S-NPs. The findings revealed an 80 % increase in Ag bioaccessibility to soybeans in soils with high organic matter content compared to soils with low organic matter. Additionally, the presence of earthworms significantly increased Cl concentrations from 24.3-62.2 mg L-1 to 80.1-147.2 mg L-1, triggering the elevated bioavailability of Ag. Interestingly, Ag2S-NPs eliminated the stimulative effects of earthworms on plant nutrient uptake. In the presence of earthworms, the high organic matter soil amended with Ag2S-NPs exhibited lower concentrations of essential elements (Ca, Cu, Fe, K, and P) in plant tissues compared to soils without earthworms. Our study presents evidence of the transformation of Ag2S-NPs into Ag-NPs across various soil solutions, resulting in the formation of Ag nanoparticle complexes. Particularly noteworthy is the significant reduction in particle sizes in soils incubated with earthworms and high organic matter content, from 85.0 nm to 40.2 nm. Notably, in the rhizosphere soil, a decrease in the relative abundance of nutrient cycling-related phyla was observed, with reductions of 18.5 % for Proteobacteria and 30.0 % for Actinobacteriota. These findings offer valuable insights into the biological and biochemical consequences of Ag2S-NP exposure on earthworm-mediated plant nutrient acquisition.

Triclocarban transformation and removal in sludge conditioning using chalcopyrite-triggered percarbonate treatment.

Herein, a facile combination approach of chalcopyrite and sodium percarbonate (CuFeS2+ SPC) was established to augment both TCC removal efficiency and sludge dewatering. Results showed that utilizing the CuFeS2 dosage of 600 mg/g total solids (TS) under the optimal condition, along with the SPC dosage of 12.5 mg/g TS, an initial pH of 4.0, and a reaction duration of 40 min, led to a substantial reduction of 53.9% in the TCC content within the sludge, accompanied by a notable decrease of 36.9% in the water content. Compared to well-studied iron-based advanced oxidation processes, CuFeS2 + SPC treatment proved to be more cost-effective and environmentally friendly. Mechanistic findings demonstrated that •OH oxidation played a significant role in TCC removal, with O2•- and 1O2 acting as secondary factors. During the CuFeS2 + SPC process, the received •OH, O2•-, and 1O2 destroyed the main binding sites of extracellular polymeric substances to TCC, including tryptophan-like protein, amide, CO stretch, and -COO- functional groups. As a result, approximately 50% of TCC was partially degraded within the solid sludge phase after the attack of radicals. Meanwhile, the decreased macromolecular organic compounds in solid sludge attenuated the binding efficacy of TCC, giving rise to the transfer of partial TCC to the liquid phase. Ultimately, the TCC in sludge was successfully removed, and five transformation products were identified. This study significantly contributes to our understanding regarding TCC transformation and removal in the sludge conditioning process.

Peer and lay health work for people experiencing homelessness: A scoping review.

Homelessness poses complex health obstacles for individuals and communities. Peer and lay health worker programs aim to increase access to health care and improve health outcomes for PEH by building trust and empowering community-based workers. The scope and breadth of peer and lay health worker programs among PEH has not been synthesized. The primary objective of this scoping review is to understand the context (setting, community, condition or disease) encompassing peer and lay health worker programs within the homelessness sector. The secondary objective is to examine the factors that either facilitate or hinder the effectiveness of peer and lay health worker programs when applied to people experiencing homelessness (PEH). We searched CINHAL, Cochrane, Web of Science Core Collection, PsycINFO, Google Scholar and MEDLINE. We conducted independent and duplicate screening of titles and abstracts, and extracted information from eligible studies including study and intervention characteristics, peer personnel characteristics, outcome measures, and the inhibitors and enablers of effective programs. We discuss how peer and lay health work programs have successfully been implemented in various contexts including substance use, chronic disease management, harm reduction, and mental health among people experiencing homelessness. These programs reported four themes of enablers (shared experiences, trust and rapport, strong knowledge base, and flexibility of role) and five themes of barriers and inhibitors (lack of support and clear scope of role, poor attendance, precarious work and high turnover, safety, and mental well-being and relational boundaries). Organizations seeking to implement these interventions should anticipate and plan around the enablers and barriers to promote program success. Further investigation is needed to understand how peer and lay health work programs are implemented, the mechanisms and processes that drive effective peer and lay health work among PEH, and to establish best practices for these programs.

Changes in microbial dynamics and fermentation characteristics of alfalfa silage: A potent approach to mitigate greenhouse gas emission through high-quality forage silage.

Feeding ruminants with high-quality forage can enhance digestibility and reduce methane production. Development of high-quality silage from leguminous plants with lactic acid bacteria can improve digestibility and it mitigate the greenhouse gas emissions. In this study, we developed a high-quality alfalfa silage with improved fermentation index and microbial dynamics using Levilactobacillus brevis-KCC-44 at low or high moisture (LM/HM) conditions and preserved it for 75 or 150 days. Alfalfa fermentation with L. brevis enhances acidification and fermentation characteristics primarily due to the dominance of lactic acid bacteria (LAB) L. brevis (>95%) compared to alfalfa fermented with epiphytic LAB. The inoculant L. brevis improved the anaerobic fermentation indexes resulting in a higher level of lactic acid in both high (10.0 ± 0.12 & 8.90 ± 0.31%DM) and low moisture (0.55 ± 0.08 & 0.39 ± 0.0 %DM) in 75 and 150 days respectively, compared to control silage. In addition, the marginal amount of acetic acid (range from 0.23 ± 0.07 to 2.04 ± 0.27 %DM) and a reduced level of butyric acid (range between 0.03 ± 0.0 to 0.13 ± 02 %DM) was noted in silage treated with LAB than the control. The LAB count and abundance of Levilactobacillus were higher in alfalfa silage fermented with L. brevis. Microbial richness and diversity were reduced in alfalfa silage treated with L. brevis which prompted lactic acid production at a higher level even for a prolonged period of time. Therefore, this L.brevis is an effective inoculant for producing high-quality alfalfa silage since it improves fermentation indexes and provides reproducible ensiling properties.

Degradation and detoxification of 6PPD-quinone in water by ultraviolet-activated peroxymonosulfate: Mechanisms, byproducts, and impact on sediment microbial community.

N-(1,3-dimethylbutyl)-N'-phenyl-p-phenylenediamine quinone (6PPD-Q) has been identified to induce acute toxicity to multifarious aquatic organisms at exceptionally low concentrations. The ubiquity and harmful effects of 6PPD-Q emphasize the critical need for its degradation from water ecosystems. Herein, we explored the transformation of 6PPD-Q by an ultraviolet-activated peroxymonosulfate (UV/PMS) system, focusing on mechanism, products and toxicity variation. Results showed that complete degradation of 6PPD-Q was achieved when the initial ratio of PMS and 6PPD-Q was 60:1. The quenching experiments and EPR tests indicated that SO4•- and •OH radicals were primarily responsible for 6PPD-Q removal. Twenty-one degradation products were determined through high-resolution orbitrap mass spectrometry, and it was postulated that hydroxylation, oxidative cleavage, quinone decomposition, ring oxidation, as well as rearrangement and deamination were the major transformation pathways of 6PPD-Q. Toxicity prediction revealed that all identified products exhibited lower acute and chronic toxicities to fish, daphnid and green algae compared to 6PPD-Q. Exposure experiments also uncovered that 6PPD-Q considerably reduced the community diversity and altered the community assembly and functional traits of the sediment microbiome. However, we discovered that the toxicity of 6PPD-Q degradation solutions was effectively decreased, suggesting the superior detoxifying capability of the UV/PMS system for 6PPD-Q. These findings highlight the underlying detrimental impacts of 6PPD-Q on aquatic ecosystems and enrich our understanding of the photochemical oxidation behavior of 6PPD-Q.

Integrating advanced techniques and machine learning for landfill leachate treatment: Addressing limitations and environmental concerns.

This review article explores the challenges associated with landfill leachate resulting from the increasing disposal of municipal solid waste in landfills and open areas. The composition of landfill leachate includes antibiotics (0.001-100 µg), heavy metals (0.001-1.4 g/L), dissolved organic and inorganic components, and xenobiotics including polyaromatic hydrocarbons (10-25 µg/L). Conventional treatment methods, such as biological (microbial and phytoremediation) and physicochemical (electrochemical and membrane-based) techniques, are available but face limitations in terms of cost, accuracy, and environmental risks. To surmount these challenges, this study advocates for the integration of artificial intelligence (AI) and machine learning (ML) to strengthen treatment efficacy through predictive analytics and optimized operational parameters. It critically evaluates the risks posed by recalcitrant leachate components and appraises the performance of various treatment modalities, both independently and in tandem with biological and physicochemical processes. Notably, physicochemical treatments have demonstrated pollutant removal rates of up to 90% for various contaminants, while integrated biological approaches have achieved over 95% removal efficiency. However, the heterogeneous nature of solid waste composition further complicates treatment methodologies. Consequently, the integration of advanced ML algorithms such as Support Vector Regression, Artificial Neural Networks, and Genetic Algorithms is proposed to refine leachate treatment processes. This review provides valuable insights for different stakeholders specifically researchers, policymakers and practitioners, seeking to fortify waste disposal infrastructure and foster sustainable landfill leachate management practices. By leveraging AI and ML tools in conjunction with a nuanced understanding of leachate complexities, a promising pathway emerges towards effectively addressing this environmental challenge while mitigating potential adverse impacts.

CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study.

BACKGROUND AND OBJECTIVES: Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV. METHODS: We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference. RESULTS: A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01). CONCLUSIONS: CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.

Implications of transient ischemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium.

PURPOSE: Guidelines recommend stress only (SO) myocardial perfusion imaging (MPI) without follow-up rest imaging if perfusion and left ventricular ejection fraction (LVEF) are normal. However additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) suggestive of 'balanced ischemia'. Concurrent coronary artery calcium (CAC) scoring helps to identify subclinical atherosclerosis. The safety of SO MPI when CAC is elevated is unclear. We aim to assess the incidence and outcomes of TID and iLVEFr amongst stress/rest MPIs with normal SO images and elevated CAC. METHODS: Retrospective analysis of normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC >300. Cases were stratified by presence of TID and/or iLVEFr. Major adverse cardiac events (MACE, defined as cardiac death, non-fatal myocardial infarction and revascularization) within 24 months were compared. RESULTS: There were 230 cases included of which 43 (18.7%) had TID and/or iLVEFr. Presence of TID and/or iLVEFr was associated with higher 24-month MACE (23.3 vs. 8.6%, p = 0.013), driven by more elective revascularizations (18.6 vs. 4.3%, p = 0.001). Cardiac death and non-fatal myocardial infarction rates were similar. TID and/or iLVEFr significantly predicted overall MACE after multivariate analysis (OR 2.933 [1.214 - 7.087], p = 0.017). CONCLUSIONS: TID and/or iLVEFr is seen in the minority of normal stress MPI with elevated CAC, and is associated with higher 24-month MACE, driven by higher elective revascularizations. Overall cardiac death and non-fatal myocardial infarction rates were low and not significantly different between both groups.