Determinants and Practice Variability of Oxygen Administration during Surgery in the United States: A Retrospective Cohort Study.

BACKGROUND: The best approaches to supplemental oxygen administration during surgery remain unclear, which may contribute to variation in practice. This study aimed to assess determinants of oxygen administration and its variability during surgery. METHODS: Using multivariable linear mixed-effects regression, the study measured the associations between intraoperative fraction of inspired oxygen and patient, procedure, medical center, anesthesiologist, and in-room anesthesia provider factors in surgical cases of 120 min or longer in adult patients who received general anesthesia with tracheal intubation and were admitted to the hospital after surgery between January 2016 and January 2019 at 42 medical centers across the United States participating in the Multicenter Perioperative Outcomes Group data registry. RESULTS: The sample included 367,841 cases (median [25th, 75th] age, 59 [47, 69] yr; 51.1% women; 26.1% treated with nitrous oxide) managed by 3,836 anesthesiologists and 15,381 in-room anesthesia providers. Median (25th, 75th) fraction of inspired oxygen was 0.55 (0.48, 0.61), with 6.9% of cases less than 0.40 and 8.7% greater than 0.90. Numerous patient and procedure factors were statistically associated with increased inspired oxygen, notably advanced American Society of Anesthesiologists classification, heart disease, emergency surgery, and cardiac surgery, but most factors had little clinical significance (less than 1% inspired oxygen change). Overall, patient factors only explained 3.5% (95% CI, 3.5 to 3.5%) of the variability in oxygen administration, and procedure factors 4.4% (95% CI, 4.2 to 4.6%). Anesthesiologist explained 7.7% (95% CI, 7.2 to 8.2%) of the variability in oxygen administration, in-room anesthesia provider 8.1% (95% CI, 7.8 to 8.4%), medical center 23.3% (95% CI, 22.4 to 24.2%), and 53.0% (95% CI, 52.4 to 53.6%) was unexplained. CONCLUSIONS: Among adults undergoing surgery with anesthesia and tracheal intubation, supplemental oxygen administration was variable and appeared arbitrary. Most patient and procedure factors had statistical but minor clinical associations with oxygen administration. Medical center and anesthesia provider explained significantly more variability in oxygen administration than patient or procedure factors.

Data-Driven Blood Transfusion Thresholds for Severely Injured Patients During Blood Shortages.

INTRODUCTION: Crises like the COVID-19 pandemic create blood product shortages. Patients requiring transfusions are placed at risk and institutions may need to judiciously administer blood during massive blood transfusions protocols (MTP). The purpose of this study is to provide data-driven guidance for the modification of MTP when the blood supply is severely limited. METHODS: This is a retrospective cohort study of 47 Level I and II trauma centers (TC) within a single healthcare system whose patients received MTP from 2017 to 2019. All TC used a unifying MTP protocol for balanced blood product transfusions. The primary outcome was mortality as a function of volume of blood transfused and age. Hemoglobin thresholds and measures of futility were also estimated. Risk-adjusted analyses were performed using multivariable and hierarchical regression to account for confounders and hospital variation. RESULTS: Proposed MTP maximum volume thresholds for three age groupings are as follows: 60 units for ages 16-30 y, 48 units for ages 31-55 y, and 24 units for >55 y. The range of mortality under the transfusion threshold was 30%-36% but doubled to 67-77% when the threshold was exceeded. Hemoglobin concentration differences relative to survival were clinically nonsignificant. Prehospital measures of futility were prehospital cardiac arrest and nonreactive pupils. In hospital risk factors of futility were mid-line shift on brain CT and cardiopulmonary arrest. CONCLUSIONS: Establishing MTP threshold practices under blood shortage conditions, such as the COVID pandemic, could sustain blood availability by following relative thresholds for MTP use according to age groups and key risk factors.

Trauma Prevalence and Resource Utilization During 4 COVID-19 "Surges": A National Analysis of Trauma Patients From 92 Trauma Centers.

INTRODUCTION: We aim to assess the trends in trauma patient volume, injury characteristics, and facility resource utilization that occurred during four surges in COVID-19 cases. METHODS: A retrospective cohort study of 92 American College of Surgeons (ACS)-verified trauma centers (TCs) in a national hospital system during 4 COVID-19 case surges was performed. Patients who were directly transported to the TC and were an activation or consultation from the emergency department (ED) were included. Trends in injury characteristics, patient demographics & outcomes, and hospital resource utilization were assessed during four COVID-19 case surges and compared to the same dates in 2019. RESULTS: The majority of TCs were within a metropolitan or micropolitan division. During the pandemic, trauma admissions decreased overall, but displayed variable trends during Surges 1-4 and across U.S. regions and TC levels. Patients requiring surgery or blood transfusion increased significantly during Surges 1-3, whereas the proportion of patients requiring plasma and/or platelets increased significantly during Surges 1-2. Patients admitted to the hospital had significantly higher Injury Severity Score (ISS) and mortality as compared to pre-pandemic during Surge 1 and 2. Patients with Medicaid or uninsured increased significantly during the pandemic. Hospital length of stay (LOS) decreased significantly during the pandemic and more trauma patients were discharged home. CONCLUSIONS: Trauma admissions decreased during Surge 1, but increased during Surge 2, 3 and 4. Penetrating injuries and firearm-related injuries increased significantly during the pandemic, patients requiring surgery or packed red blood cells (PRBCs) transfusion increased significantly during Surges 1-3. The number of patients discharged home increased during the pandemic and was accompanied by a decreased hospital length of stay (LOS).

What Makes a Trauma Patient "Pediatric"? Survey of Providers' Admission Decision Making for Pediatric Trauma Patients.

BACKGROUND: Only a fraction of pediatric trauma patients are treated in pediatric-specific facilities, leaving the remaining to be seen in centers that must decide to admit the patient to a pediatric or adult unit. Thus, there may be inconsistencies in pediatric trauma admission practices among trauma centers. OBJECTIVE: Describe current practices in admission decision making for pediatric patients. METHODS: An email survey was distributed to members of three professional organizations: The American Association for the Surgery of Trauma, Society of Trauma Nurses, and Pediatric Trauma Society. The survey contained questions regarding pediatric age cutoffs, institutional placement decisions, and scenario-based assessments to determine mitigating placement factors. RESULTS: There were 313 survey responses representing freestanding children's hospitals (114, 36.4%); children's hospitals within general hospitals (107, 34.2%), and adult centers (not a children's hospital; 90, 28.8%). The mean age cutoff for pediatric admission was 16.6 years. The most reported cutoff ages were 18 years (77, 25.6%) and 15 years (76, 25.2%). The most common rationales for the age cutoffs were "institutional experience/tradition" (139, 44.4%) and "physician preference" (89, 28.4%). CONCLUSION: There was no single widely accepted age cutoff that distinguished pediatric from adult trauma patients for admission placement. There was significant variability between and within the types of facilities, with noted ambiguity in the definition of a "pediatric" patient. Thresholds appear to be based primarily on subjective criteria such as traditions or preferences rather than scientific data. Institutions should strive for objective, evidence-based policies for determining the appropriate placement of pediatric patients.

Climate and lawn management interact to control C4 plant distribution in residential lawns across seven U.S. cities.

In natural grasslands, C4 plant dominance increases with growing season temperatures and reflects distinct differences in plant growth rates and water use efficiencies of C3 vs. C4 photosynthetic pathways. However, in lawns, management decisions influence interactions between planted turfgrass and weed species, leading to some uncertainty about the degree of human vs. climatic controls on lawn species distributions. We measured herbaceous plant carbon isotope ratios (δ13 C, index of C3 /C4 relative abundance) and C4 cover in residential lawns across seven U.S. cities to determine how climate, lawn plant management, or interactions between climate and plant management influenced C4 lawn cover. We also calculated theoretical C4 carbon gain predicted by a plant physiological model as an index of expected C4 cover due to growing season climatic conditions in each city. Contrary to theoretical predictions, plant δ13 C and C4 cover in urban lawns were more strongly related to mean annual temperature than to growing season temperature. Wintertime temperatures influenced the distribution of C4 lawn turf plants, contrary to natural ecosystems where growing season temperatures primarily drive C4 distributions. C4 cover in lawns was greatest in the three warmest cities, due to an interaction between climate and homeowner plant management (e.g., planting C4 turf species) in these cities. The proportion of C4 lawn species was similar to the proportion of C4 species in the regional grass flora. However, the majority of C4 species were nonnative turf grasses, and not of regional origin. While temperature was a strong control on lawn species composition across the United States, cities differed as to whether these patterns were driven by cultivated lawn grasses vs. weedy species. In some cities, biotic interactions with weedy plants appeared to dominate, while in other cities, C4 plants were predominantly imported and cultivated. Elevated CO2 and temperature in cities can influence C3 /C4 competitive outcomes; however, this study provides evidence that climate and plant management dynamics influence biogeography and ecology of C3 /C4 plants in lawns. Their differing water and nutrient use efficiency may have substantial impacts on carbon, water, energy, and nutrient budgets across cities.

A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists.

BACKGROUND: Burnout affects all medical specialists, and concern about it has become common in today's health care environment. The gold standard of burnout measurement in health care professionals is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures emotional exhaustion, depersonalization (DP), and personal accomplishment. Besides affecting work quality, burnout is thought to affect health problems, mental health issues, and substance use negatively, although confirmatory data are lacking. This study evaluates some of these effects. METHODS: In 2011, the American Society of Anesthesiologists and the journal Anesthesiology cosponsored a webinar on burnout. As part of the webinar experience, we included access to a survey using MBI-HSS, 12-item Short Form Health Survey (SF-12), Social Support and Personal Coping (SSPC-14) survey, and substance use questions. Results were summarized using sample statistics, including mean, standard deviation, count, proportion, and 95% confidence intervals. Adjusted linear regression methods examined associations between burnout and substance use, SF-12, SSPC-14, and respondent demographics. RESULTS: Two hundred twenty-one respondents began the survey, and 170 (76.9%) completed all questions. There were 266 registrants total (31 registrants for the live webinar and 235 for the archive event), yielding an 83% response rate. Among respondents providing job titles, 206 (98.6%) were physicians and 2 (0.96%) were registered nurses. The frequency of high-risk responses ranged from 26% to 59% across the 3 MBI-HSS categories, but only about 15% had unfavorable scores in all 3. Mean mental composite score of the SF-12 was 1 standard deviation below normative values and was significantly associated with all MBI-HSS components. With SSPC-14, respondents scored better in work satisfaction and professional support than in personal support and workload. Males scored worse on DP and personal accomplishment and, relative to attending physicians, residents scored worse on DP. There was no significant association between MBI-HSS and substance use. CONCLUSIONS: Many anesthesiologists exhibit some high-risk burnout characteristics, and these are associated with lower mental health scores. Personal and professional support were associated with less emotional exhaustion, but overall burnout scores were associated with work satisfaction and professional support. Respondents were generally economically satisfied but also felt less in control at work and that their job kept them from friends and family. The association between burnout and substance use may not be as strong as previously believed. Additional work, perhaps with other survey instruments, is needed to confirm our results.

Assessing the homogenization of urban land management with an application to US residential lawn care.

Changes in land use, land cover, and land management present some of the greatest potential global environmental challenges of the 21st century. Urbanization, one of the principal drivers of these transformations, is commonly thought to be generating land changes that are increasingly similar. An implication of this multiscale homogenization hypothesis is that the ecosystem structure and function and human behaviors associated with urbanization should be more similar in certain kinds of urbanized locations across biogeophysical gradients than across urbanization gradients in places with similar biogeophysical characteristics. This paper introduces an analytical framework for testing this hypothesis, and applies the framework to the case of residential lawn care. This set of land management behaviors are often assumed--not demonstrated--to exhibit homogeneity. Multivariate analyses are conducted on telephone survey responses from a geographically stratified random sample of homeowners (n = 9,480), equally distributed across six US metropolitan areas. Two behaviors are examined: lawn fertilizing and irrigating. Limited support for strong homogenization is found at two scales (i.e., multi- and single-city; 2 of 36 cases), but significant support is found for homogenization at only one scale (22 cases) or at neither scale (12 cases). These results suggest that US lawn care behaviors are more differentiated in practice than in theory. Thus, even if the biophysical outcomes of urbanization are homogenizing, managing the associated sustainability implications may require a multiscale, differentiated approach because the underlying social practices appear relatively varied. The analytical approach introduced here should also be productive for other facets of urban-ecological homogenization.

Reduced snow cover alters root-microbe interactions and decreases nitrification rates in a northern hardwood forest.

Snow cover is projected to decline during the next century in many ecosystems that currently experience a seasonal snowpack. Because snow insulates soils from frigid winter air temperatures, soils are expected to become colder and experience more winter soil freeze-thaw cycles as snow cover continues to decline. Tree roots are adversely affected by snowpack reduction, but whether loss of snow will affect root-microbe interactions remains largely unknown. The objective of this study was to distinguish and attribute direct (e.g., winter snow- and/or soil frost-mediated) vs. indirect (e.g., root-mediated) effects of winter climate change on microbial biomass, the potential activity of microbial exoenzymes, and net N mineralization and nitrification rates. Soil cores were incubated in situ in nylon mesh that either allowed roots to grow into the soil core (2 mm pore size) or excluded root ingrowth (50 µm pore size) for up to 29 months along a natural winter climate gradient at Hubbard Brook Experimental Forest, NH (USA). Microbial biomass did not differ among ingrowth or exclusion cores. Across sampling dates, the potential activities of cellobiohydrolase, phenol oxidase, and peroxidase, and net N mineralization rates were more strongly related to soil volumetric water content (P < 0.05; R2  = 0.25-0.46) than to root biomass, snow or soil frost, or winter soil temperature (R2  < 0.10). Root ingrowth was positively related to soil frost (P < 0.01; R2  = 0.28), suggesting that trees compensate for overwinter root mortality caused by soil freezing by re-allocating resources towards root production. At the sites with the deepest snow cover, root ingrowth reduced nitrification rates by 30% (P < 0.01), showing that tree roots exert significant influence over nitrification, which declines with reduced snow cover. If soil freezing intensifies over time, then greater compensatory root growth may reduce nitrification rates directly via plant-microbe N competition and indirectly through a negative feedback on soil moisture, resulting in lower N availability to trees in northern hardwood forests.

Assessment of regional variation in streamflow responses to urbanization and the persistence of physiography.

Aquatic ecosystems are sensitive to the modification of hydrologic regimes, experiencing declines in stream health as the streamflow regime is altered during urbanization. This study uses streamflow records to quantify the type and magnitude of hydrologic changes across urbanization gradients in nine U.S. cities (Atlanta, GA, Baltimore, MD, Boston, MA, Detroit, MI, Raleigh, NC, St. Paul, MN, Pittsburgh, PA, Phoenix, AZ, and Portland, OR) in two physiographic settings. Results indicate similar development trajectories among urbanization gradients, but heterogeneity in the type and magnitude of hydrologic responses to this apparently uniform urban pattern. Similar urban patterns did not confer similar hydrologic function. Study watersheds in landscapes with level slopes and high soil permeability had less frequent high-flow events, longer high-flow durations, lower flashiness response, and lower flow maxima compared to similarly developed watersheds in landscape with steep slopes and low soil permeability. Our results suggest that physical characteristics associated with level topography and high water-storage capacity buffer the severity of hydrologic changes associated with urbanization. Urbanization overlain upon a diverse set of physical templates creates multiple pathways toward hydrologic impairment; therefore, we caution against the use of the urban homogenization framework in examining geophysically dominated processes.

Soil denitrification fluxes from three northeastern North American forests across a range of nitrogen deposition.

In northern forests, large amounts of missing N that dominate N balances at scales ranging from small watersheds to large regional drainage basins may be related to N-gas production by soil microbes. We measured denitrification rates in forest soils in northeastern North America along a N deposition gradient to determine whether N-gas fluxes were a significant fate for atmospheric N inputs and whether denitrification rates were correlated with N availability, soil O2 status, or forest type. We quantified N2 and N2O fluxes in the laboratory with an intact-core method and monitored soil O2, temperature and moisture in three forests differing in natural and anthropogenic N enrichment: Turkey Lakes Watershed, Ontario; Hubbard Brook Experimental Forest, New Hampshire; and Bear Brook Watershed, Maine (fertilized and reference plots in hardwood and softwood stands). Total N-gas flux estimates ranged from <1 in fertilized hardwood uplands at Bear Brook to >100 kg N ha(-1) year(-1) in hardwood wetlands at Turkey Lakes. N-gas flux increased systematically with natural N enrichment from soils with high nitrification rates (Bear Brook < Hubbard Brook < Turkey Lakes) but did not increase in the site where N fertilizer has been added since 1989 (Bear Brook). Our results show that denitrification is an important and underestimated term (1-24% of atmospheric N inputs) in N budgets of upland forests in northeastern North America, but it does not appear to be an important sink for elevated anthropogenic atmospheric N deposition in this region.

Winter climate change affects growing-season soil microbial biomass and activity in northern hardwood forests.

Understanding the responses of terrestrial ecosystems to global change remains a major challenge of ecological research. We exploited a natural elevation gradient in a northern hardwood forest to determine how reductions in snow accumulation, expected with climate change, directly affect dynamics of soil winter frost, and indirectly soil microbial biomass and activity during the growing season. Soils from lower elevation plots, which accumulated less snow and experienced more soil temperature variability during the winter (and likely more freeze/thaw events), had less extractable inorganic nitrogen (N), lower rates of microbial N production via potential net N mineralization and nitrification, and higher potential microbial respiration during the growing season. Potential nitrate production rates during the growing season were particularly sensitive to changes in winter snow pack accumulation and winter soil temperature variability, especially in spring. Effects of elevation and winter conditions on N transformation rates differed from those on potential microbial respiration, suggesting that N-related processes might respond differently to winter climate change in northern hardwood forests than C-related processes.

Differential Carbon and Nitrogen Controls of Denitrification in Riparian Zones and Streams along an Urban to Exurban Gradient.

Denitrification is an anaerobic microbial process that transforms nitrate (NO) to nitrogen (N) gas, preventing the movement of NO into coastal waters where it can lead to eutrophication. Urbanization can reduce the potential for denitrification in riparian zones and streams by altering the environmental conditions that foster denitrification (i.e., low oxygen and available C). Here we evaluated the factors limiting denitrification potential in forested and herbaceous riparian and stream pool and organic debris dam habitats in urban, suburban, exurban, and forested reference watersheds in the Baltimore, Maryland metropolitan area. Denitrification potential (with and without C and NO additions) and microbial biomass C and N content, potential net N mineralization and nitrification, microbial respiration, and inorganic N pools were measured in summer (June) and fall (November). Denitrification potentials were highest in the herbaceous riparian soils and lowest in pool sediments. Forested riparian soil denitrification potential was highest in the exurban watershed but in other habitats did not vary with watershed type. Nearly all variables were higher in June than in November. Overall, C was a more important driver of denitrification potential than N; potentials in unamended and N-amended treatments were very similar (<200 ng N g h) and were much lower than in the C-amended and C+N-amended treatments (>800 ng N g h). Our results suggest that efforts to enhance denitrification in urban watersheds need to focus on the differential controls of denitrification across habitats, urban land use types, and seasons.

Drought-induced saltwater incursion leads to increased wetland nitrogen export.

Coastal wetlands have the capacity to retain and denitrify large quantities of reactive nitrogen (N), making them important in attenuating increased anthropogenic N flux to coastal ecosystems. The ability of coastal wetlands to retain and transform N is being reduced by wetland losses resulting from land development. Nitrogen retention in coastal wetlands is further threatened by the increasing frequency and spatial extent of saltwater inundation in historically freshwater ecosystems, due to the combined effects of dredging, declining river discharge to coastal areas due to human water use, increased drought frequency, and accelerating sea-level rise. Because saltwater incursion may affect N cycling through multiple mechanisms, the impacts of salinization on coastal freshwater wetland N retention and transformation are not well understood. Here, we show that repeated annual saltwater incursion during late summer droughts in the coastal plain of North Carolina changed N export from organic to inorganic forms and led to a doubling of annual NH(4)(+) export from a 440 hectare former agricultural field undergoing wetland restoration. Soil solution NH(4)(+) concentrations in two mature wetlands also increased with salinization, but the magnitude of increase was smaller than that in the former agricultural field. Long-term saltwater exposure experiments with intact soil columns demonstrated that much of the increase in reactive N released could be explained by exchange of salt cations with sediment NH(4)(+). Using these findings together with the predicted flooding of 1661 km(2) of wetlands along the NC coast by 2100, we estimate that saltwater incursion into these coastal areas could release up to 18 077 Mg N, or approximately half the annual NH(4)(+) flux of the Mississippi River. Our results suggest that saltwater incursion into coastal freshwater wetlands globally could lead to increased N loading to sensitive coastal waters.

The burden of geriatric traumatic brain injury on trauma systems: Analysis of 348,800 Medicare inpatient claims.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high-risk group. METHODS: Using 2016-2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD-10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy-string matching. Patient variables were compared across trauma center levels. RESULTS: Three hundred forty-eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non-trauma centers treated 21.5%. Overall inter-facility transfer rate was 19.2%; in Level I/II trauma centers transfers-in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in-hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers. CONCLUSIONS: This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted.

Low Prevalence but High Impact of COVID-19 Positive Status in Adult Trauma Patients: A Multi-institutional Analysis of 28 904 Patients.

BACKGROUND: Few large investigations have addressed the prevalence of COVID-19 infection among trauma patients and impact on providers. The purpose of this study was to quantify the prevalence of COVID-19 infection among trauma patients by timing of diagnosis, assess nosocomial exposure risk, and evaluate the impact of COVID-19 positive status on morbidity and mortality. METHODS: Registry data from adults admitted 4/1/2020-10/31/2020 from 46 level I/II trauma centers were grouped by: timing of first positive status (Day 1, Day 2-6, or Day ≥ 7); overall Positive/Negative status; or Unknown if test results were unavailable. Groups were compared on outcomes (Trauma Quality Improvement Program complications) and mortality using univariate analysis and adjusted logistic regression. RESULTS: There were 28 904 patients (60.7% male, mean age: 56.4, mean injury severity score: 10.5). Of 13 274 (46%) patients with known COVID-19 status, 266 (2%) were Positive Day 1, 119 (1%) Days 2-6, 33 (.2%) Day ≥ 7, and 12 856 (97%) tested Negative. COVID-19 Positive patients had significantly worse outcomes compared to Negative; unadjusted comparisons showed longer hospital length of stay (10.98 vs 7.47;P < .05), higher rates of intensive care unit (57.7% vs 45.7%; P < .05) and ventilation use (22.5% vs 16.9%; P < .05). Adjusted comparisons showed higher rates of acute respiratory distress syndrome (1.7% vs .4%; P < .05) and death (8.1% vs 3.4%; P < .05). CONCLUSIONS: This multicenter study conducted during the early pandemic period revealed few trauma patients tested COVID-19 positive, suggesting relatively low exposure risk to care providers. COVID-19 positive status was associated with significantly higher mortality and specific morbidity. Further analysis is needed with consideration for care guidelines specific to COVID-19 positive trauma patients as the pandemic continues.

Greenhouse gas fluxes in southeastern U.S. coastal plain wetlands under contrasting land uses.

Whether through sea level rise or wetland restoration, agricultural soils in coastal areas will be inundated at increasing rates, renewing connections to sensitive surface waters and raising critical questions about environmental trade-offs. Wetland restoration is often implemented in agricultural catchments to improve water quality through nutrient removal. Yet flooding of soils can also increase production of the greenhouse gases nitrous oxide and methane, representing a potential environmental trade-off. Our study aimed to quantify and compare greenhouse gas emissions from unmanaged and restored forested wetlands, as well as actively managed agricultural fields within the North Carolina coastal plain, USA. In sampling conducted once every two months over a two-year comparative study, we found that soil carbon dioxide flux (range: 8000-64 800 kg CO2 x ha(-1) x yr(-1)) comprised 66-100% of total greenhouse gas emissions from all sites and that methane emissions (range: -6.87 to 197 kg CH4 x ha(-1) x yr(-1)) were highest from permanently inundated sites, while nitrous oxide fluxes (range: -1.07 to 139 kg N2O x ha(-1) x yr(-1)) were highest in sites with lower water tables. Contrary to predictions, greenhouse gas fluxes (as CO2 equivalents) from the restored wetland were lower than from either agricultural fields or unmanaged forested wetlands. In these acidic coastal freshwater ecosystems, the conversion of agricultural fields to flooded young forested wetlands did not result in increases in greenhouse gas emissions.

Bacteremia in Trauma: A Contemporary Analysis of Blood Culture Results and Outcomes in 158,884 Patients.

Background: Bacteremia is a potentially lethal complication. Limited research exists describing its incidence and associated outcomes in trauma patients. This descriptive study characterized the incidence, risk factors, and outcomes of bacteremia in trauma patients. Methods: This study used 2017-2020 system-wide Trauma Registry/Electronic Data Warehouse to select trauma activations aged ≥18 years. Blood culture information, including pathogen genera and species, was obtained from electronic laboratory records. Bacteremia positive was defined as two blood cultures within two hours of each other, growing the same organism; bacteremia negative as no growth, only one blood culture with growth, or growth of two different organisms. Bacteremia-positive and bacteremia-negative patients were compared with patients without blood cultures. Logistic regression compared blood culture results with outcomes, adjusting for age, gender, Injury Severity Score (ISS), and comorbidities. Results: Of 158,884 patients at 89 centers, 17,166 (10.8%) had blood cultures. Of those with blood cultures, 1214 were bacteremia positive (7.1%). Compared with no blood cultures, bacteremia-positive patients were more likely male, with higher ISS, and more comorbidities and intensive care unit use. Bacteremia-positive patients were more likely to die (adjusted odds ratio [aOR], 3.78; 95% confidence interval [CI], 3.17-4.51; p < 0.001) and have severe sepsis/septic shock (aOR, 114.91; 95% CI, 95.09-138.85; p < 0.001). Most common isolates were Staphylococcus epidermidis (14%), non-methicillin resistant Staphylococcus aureus (12%), and Escherichia coli (6%), with highest mortality associated with Pseudomonas aeruginosa (45%), Enterococcus faecalis (30%), and Escherichia coli (28%). Conclusions: Bacteremia in trauma is uncommon (<1%) but associated with increased resource use and poorer outcomes. Bacteremia, or suspicion thereof, identifies a high-risk population and justifies aggressive empiric intervention to maximize survival.

Hyperglycemia in nondiabetic adult trauma patients is associated with worse outcomes than diabetic patients: An analysis of 95,764 patients.

BACKGROUND: The adverse impact of acute hyperglycemia is well documented but its specific effects on nondiabetic trauma patients are unclear. The purpose of this study was to analyze the differential impact of hyperglycemia on outcomes between diabetic and nondiabetic trauma inpatients. METHODS: Adults admitted 2018 to 2019 to 46 Level I/II trauma centers with two or more blood glucose tests were analyzed. Diabetes status was determined from International Classification of Diseases-10th Rev.-Clinical Modification, trauma registry, and/or hemoglobin A1c greater than 6.5. Patients with and without one or more hyperglycemic result >180 mg/dL were compared. Logistic regression examined the effects of hyperglycemia and diabetes on outcomes, adjusting for age, sex, Injury Severity Score, and body mass index. RESULTS: There were 95,764 patients: 54% male; mean age, 61 years; mean Injury Severity Score, 10; diabetic, 21%. Patients with hyperglycemia had higher mortality and worse outcomes compared with those without hyperglycemia. Nondiabetic hyperglycemic patients had the highest odds of mortality (diabetic: adjusted odds ratio, 3.11; 95% confidence interval, 2.8-3.5; nondiabetics: adjusted odds ratio, 7.5; 95% confidence interval, 6.8-8.4). Hyperglycemic nondiabetics experienced worse outcomes on every measure when compared with nonhyperglycemic nondiabetics, with higher rates of sepsis (1.1 vs. 0.1%, p < 0.001), more SSIs (1.0 vs. 0.1%, p < 0.001), longer mean hospital length of stay (11.4 vs. 5.0, p < 0.001), longer mean intensive care unit length of stay (8.5 vs. 4.0, p < 0.001), higher rates of intensive care unit use (68.6% vs. 35.1), and more ventilator use (42.4% vs. 7.3%). CONCLUSION: Hyperglycemia is associated with increased odds of mortality in both diabetic and nondiabetic patients. Hyperglycemia during hospitalization in nondiabetics was associated with the worst outcomes and represents a potential opportunity for intervention in this high-risk group. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

Poised for Change: University Students Are Positively Disposed toward Food Waste Diversion and Decrease Individual Food Waste after Programming.

Eaters (consumers of food) are responsible for 60% of waste along the food cycle in developed countries. Programs that target individual and household food waste behavior change are essential to addressing such waste. School cafeterias worldwide offer an opportune microcosm in which to educate on food and nutrition skills and change related behavior. No Scrap Left Behind, a cafeteria food waste diversion program, was developed, piloted, and assessed based on measures of both direct and indirect food waste behavior, and attitudes, knowledge, and emotions related to food waste. Participants had positive attitudes towards food waste reduction, engaged in food waste diversion actions, had some knowledge of the impacts of wasted food, and considered their actions important to waste reduction generally. Food waste per student was decreased by 28% over the course of the first year of programming (p = 0.000967), and by 26% in the following year when measured a week before and a week after programming occurred (p = 0.0218). Results indicate that students were poised for food behavior change and that related programming did impact behavior in the short term. Programming may, therefore, help improve student attitudes and skills to develop long-term change as well, although future research should explore this specifically. In comparison with other research on cafeteria programming, results suggest that food waste diversion programming can positively impact students' dispositions and behaviors, and may be more effective when tailored to the specific population.

Redefining geriatric trauma: 55 is the new 65.

INTRODUCTION: As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines. METHODS: Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities. RESULTS: A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001). CONCLUSION: This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations. LEVEL OF EVIDENCE: Epidemiological study, level III; Care management, level IV.