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Background Obesity is associated with a higher incidence of atrial fibrillation (AF). Weight reduction improves outcomes in patients known to have AF. Objective The purpose of this study was to compare the incidence of heart failure (HF) or first-time AF hospitalization in obese patients undergoing bariatric surgery (BAS) vs other abdominal surgeries. Methods A retrospective cohort study was conducted using linked hospital discharge records from 1994–2014. Obese patients without known AF or atrial flutter (AFL) who had undergone abdominal hernia or laparoscopic cholecystectomy surgery were identified for each case that underwent BAS (2:1). Clinical outcomes were HF, first-time hospitalization for AF, AFL, gastrointestinal bleeding (GIB), and ischemic or hemorrhagic stroke. Outcomes were analyzed using conditional proportional hazard modeling accounting for the competing risk of death, adjusting for demographics and comorbidities. Results There were 1581 BAS cases and 3162 controls (48% age, Graphical abstract

© 2016 Elsevier Ltd. All rights reserved. Background Few studies have evaluated the use and outcomes of inferior vena cava filters (IVCF) insertion in cancer patients with deep venous thrombosis (DVT) or pulmonary embolism (PE). Methods Hospital records of patients with a principal diagnosis of lower extremity DVT and/or PE and cancer in California between January 1, 2005 and December 31, 2009 were analyzed. Multivariable logistic regression analysis was used to identify variables associated with IVCF use and propensity matched methodology was used to determine the effect of IVCF insertion on clinical outcomes. Results An IVCF was placed in 19.6% of 14,000 cancer patients and VTE. This varied widely across hospitals, from 0% to 52%, and by cancer type. The strongest predictors of IVCF use were a diagnosis of brain cancer (OR = 4.6, CI: 3.7-5.6), undergoing major surgery (OR = 4.9, CI: 3.9-6.1), and bleeding (OR = 2.7, CI: 2.0-3.5). Only 21% of patients with IVCF had a strong contraindication to anticoagulation (bleeding or major surgery). There was no benefit for 30-day mortality and no reduction in subsequent PE (+/- DVT). Additionally, there was 60% increased risk of recurrent DVT and 20% increased risk of subsequent bleeding when an IVCF was placed. Conclusions An IVCF was placed in approximately 20% of acute VTE patients with cancer and use varied widely between hospitals and cancer types. Most patients did not have a contraindication for anticoagulation. There was no benefit in short-term mortality or risk of PE; there was increased risk of DVT and subsequent bleeding.

Background Information regarding dosing of low-molecular-weight heparins (LMWH) for therapeutic anticoagulation in hemodialysis (HD) patients is limited. The aim of this study was to retrospectively compare the safety and efficacy of enoxaparin versus unfractionated heparin (UFH) for therapeutic anticoagulation in HD patients. Materials and Methods This retrospective chart review evaluated HD patients treated with subcutaneous enoxaparin that were matched based on the indication for anticoagulation with patients treated with intravenous UFH to achieve therapeutic anticoagulation. Primary outcome measures included 30-day incidence of thromboembolic events and major bleeding. Secondary outcomes included rehospitalization within 30 days, length of stay, and mortality. Results One hundred sixty-four patients were evaluated, 82 in each group. The average daily dose of enoxaparin used to target therapeutic levels was 0.7 ± 0.2 mg/kg/day (range = 0.4-1). Comparing enoxaparin to UFH, there was no significant difference in major bleeding (6.1% vs 11%, p = 0.4) or thromboembolism (0% vs 2.4%, p = 0.5). Hospital length of stay was shorter in the enoxaparin group (20 ± 53.8 vs 28.9 ± 44.5 days, p = 0.02); there was no significant difference between groups in mortality or readmission. Adjusting for risk factors for bleeding there was a slight but statistically non-significant difference between enoxaparin versus UFH (OR = 0.77, 95%CI: 0.2-3.5, p = 0.73). Conclusions These findings suggest that therapeutic dosing of enoxaparin, in doses that ranged from 0.4-1 mg/kg/day, was as safe as intravenous UFH in providing therapeutic anticoagulation in stable patients requiring chronic hemodialysis.

Mechanical ventilation (MV) is one of the most common, but difficult, costly and variably delivered therapies in intensive care. Model-based estimated patient-specific respiratory elastance can be used to guide clinical staff in selecting positive end-expiratory pressure (PEEP) for MV patients. The Clinical Utilisation of Respiratory Elastance (CURE) trial investigates the potential to optimise PEEP in MV patients. A software system, CURE Soft, capable of providing real-time patient-specific respiratory elastance was developed for the purpose of CURE clinical trial. CURE Soft uses airway pressure and flow data from the ventilator to calculate respiratory elastance using a time-varying elastance model. The CURE Soft graphical user interface (GUI) was developed to provide patient-specific respiratory elastance in real time, history and response during a recruitment manoeuvre both of which offer significant clinical insight. CURE Soft was extensively tested on a mechanical test lung to verify the model-based elastance estimation and its robustness. Model fitting errors are low across a range of ventilation modes, showing it can successfully identify respiratory elastance. Real-time monitoring of respiratory elastance enables new insights into patient-specific lung condition, with no added patient burden. The additional insight available to clinicians will provide the information necessary for improved decision-making and patient outcomes.

Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism) is associated with a poor prognosis in most malignancies and is a major cause of death among cancer patients. Universal anticoagulation for primary thromboprophylaxis in the outpatient setting is precluded by potential bleeding complications, especially without sufficient evidence that all patients would benefit from such prophylaxis. Therefore, appropriately targeting cancer patients for thromboprophylaxis is key to reducing morbidity and perhaps mortality. Predictive biomarkers could aid in identifying patients at high risk for VTE. Possible biomarkers for VTE include C-reactive protein, platelet and leukocyte counts, D-dimer and prothrombin fragment 1 + 2, procoagulant factor VIII, tissue factor, and soluble P-selectin. Evidence is emerging to support the use of risk assessment models in selecting appropriate candidates for primary thromboprophylaxis in the cancer setting. Further studies are needed to optimize these models and determine utility in reducing morbidity and mortality from cancer-associated thromboembolism.

Background The assessment of patients with suspected deep vein thrombosis (DVT) remains challenging despite current diagnostic algorithms. 99m Tc-labelled DI-DD3B6/22-80B3 Fab´ fragments ( 99m Tc-DI-80B3, ThromboView®) is a novel diagnostic test that uses a radiolabelled humanized monoclonal antibody fragment specific for the D-dimer region of cross-linked fibrin to detect DVT. This test has an anatomic component to locate DVT and a functional component to differentiate acute (newly formed) thrombus from inactive (old) thrombus. Methods In a multi-centre prospective cohort trial we investigated the diagnostic accuracy and safety of 99m Tc-DI-80B3 in consecutive patients with suspected DVT who had the diagnosis confirmed or excluded by venography. Results We enrolled 94 patients with suspected DVT of whom 12 did not have 99m Tc-DI-80B3 imaging, leaving 82 patients for the safety analysis. Of these patients, there were 16 with non-evaluable imaging (11 venography, 7 99m Tc-DI-80B3, both in two patients) leaving 66 patients for the accuracy analysis. 99m Tc-DI-80B3 imaging was well-tolerated: 2 patients developed urticaria; none developed serious adverse events. For proximal DVT, the sensitivity (84.2%; 95% confidence interval [CI]: 62.4–94.5) and specificity (97.6%; CI: 83.3–99.4) were highest when the combined 0.25-hour and 3-hour 99m Tc-DI-80B3 images were used. The accuracy was lower for distal DVT, irrespective of the images used. There were insufficient patients to comment on the accuracy of 99m Tc-DI-80B3 imaging for suspected recurrent DVT. Conclusions 99m Tc-DI-80B3 (ThromboView®) is a novel diagnostic modality for patients with suspected DVT with a promising accuracy and safety profile that justifies additional clinical development in diagnostic accuracy and clinical management studies.

To find a safer surgical option, a number of studies have compared postoperative complications after bilateral total knee arthroplasty vs staged total knee arthroplasty (STKA) by contrasting postoperative complications collected retrospectively. However, we believe that a comparison based on retrospective studies could be biased. The purpose of this study was to demonstrate the misclassification bias associated with a retrospective study in comparing operative outcomes. Our analysis indicates that any conclusions based simply on retrospective analysis of subjects who successfully completed STKA is biased because it includes only cases that recovered after the first operation, rather than all of the patients who had planned STKA. In the absence of a prospective study to date, published studies should be interpreted with caution.

See also Watson HG. RVO – Real value obscure. This issue, pp 1116–8; Carrier M, Rodger MA, Wells PS, Righini M, Le Gal G. Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis. This issue, pp 1119–25. Summary. Objectives: There is growing interest in using residual vein obstruction (RVO) to guide the duration of oral anticoagulant therapy (OAT) for unprovoked deep vein thrombosis (DVT). We sought to determine if RVO as determined by compression ultrasonography (CUS) after completion of 5–7 months of anticoagulation for unprovoked DVT is associated with an increased risk of recurrent venous thromboembolism (VTE). Materials and Methods: This was a multicentre multinational prospective cohort study undertaken in tertiary care centers. Patients with a first ‘unprovoked’ major VTE were enrolled over a 4-year period and completed a mean 18-month follow-up in September 2006. All 452 patients with DVT had baseline CUS at inclusion to assess any RVO before stopping OAT at 5–7 months. During follow-up off OAT, all episodes of suspected recurrent VTE were independently adjudicated with reference to baseline imaging. Results: Forty-five out of 231 patients with abnormal CUS (19.5%) had recurrent VTE during follow-up, as compared with 32 out of 220 patients with normal CUS (14.6%), and one patient had inadequate CUS. There was no significant association between an abnormal CUS at inclusion and the risk of recurrent VTE: hazard ratio 1.4 (95% confidence interval, 0.9–2.1), P = 0.19. None of the different degrees of clot resolution on baseline CUS was statistically significantly associated with the risk of recurrent VTE. Conclusion: In our study, the presence of RVO at the time of OAT withdrawal was not associated with a statistically significant higher risk of recurrent VTE. RVO assessment may not be useful to guide duration of anticoagulation.

Plasma renin activity (PRA) is a measure of renin-angiotensin system activity and is associated with cardiovascular outcomes in patients with heart failure (HF). We conducted a prospective analysis to assess whether elevated baseline PRA is associated with cardiovascular outcomes in 1,165 patients with coronary artery disease (or =70% stenosis on the coronary angiogram) enrolled in the Intermountain Heart Collaborative Study. The exclusion criteria included previous myocardial infarction (MI) or HF, ejection fractionor =45%, and a discharge diagnosis of MI/beta-blocker treatment. Baseline PRA measurements were evaluated as risk categories (or =0.50, 0.51 to 2.30, and2.30 ng/ml/h) and as tertiles (or =0.40, 0.41 to 1.90, andor =1.90 ng/ml/h). Predefined cardiovascular outcomes were assessed for a minimum follow-up of 3 years (mean 6.4 +/- 3.2, maximum 14.6) using Cox regression analysis to adjust for the baseline characteristics. The mean patient age was 64.4 years; most patients were men (73.1%) and hypertensive (63.2%). Elevated baseline PRA (high vs low category;2.30 vsor =0.50 ng/ml/h) was associated with a significantly increased risk of 3-year cardiac morbidity/mortality (hazard ratio 1.96; p = 0.004), MI (hazard ratio 2.41; p = 0.02), HF hospitalization (hazard ratio 4.39; p = 0.03), and all-cause death (hazard ratio 1.80; p = 0.01). Elevated baseline PRA was also associated with longer-term HF hospitalization (hazard ratio 2.12; p = 0.004) and all-cause death (hazard ratio 1.56; p = 0.002). Similar results were observed for the PRA tertiles. The association of PRA with outcomes was observed after correction for hypertension, hyperlipidemia, diabetes, a family history of cardiovascular events, smoking, renal failure, and the use of statins. In conclusion, elevated baseline PRA is associated with cardiac morbidity and mortality in patients with coronary artery disease but normal left ventricular function and no previous MI or HF.

To determine the positive predictive value of International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) discharge codes for acute deep vein thrombosis or pulmonary embolism.Retrospective review of 3456 cases hospitalized between 2005 and 2007 that had a discharge code for venous thromboembolism, using 3 sample populations: a single academic hospital, 33 University HealthSystem Consortium hospitals, and 35 community hospitals in a national Joint Commission study. Analysis was stratified by position of the code in the principal versus a secondary position.Among 1096 cases that had a thromboembolism code in the principal position the positive predictive value for any acute venous thrombosis was 95% (95%CI:93-97), whereas among 2360 cases that had a thromboembolism code in a secondary position the predictive value was lower, 75% (95%CI:71-80). The corresponding positive predictive values for lower extremity deep-vein thrombosis or pulmonary embolism were 91% (95%CI:86-95) and 50% (95%CI:41-58), respectively. More highly defined codes had higher predictive value. Among codes in a secondary position that were false positive, 22% (95%CI:16-27) had chronic/prior venous thrombosis, 15% (95%CI:10-19) had an upper extremity thrombosis, 6% (95%CI:4-8) had a superficial vein thrombosis, and 7% (95%CI:4-13) had no mention of any thrombosis.ICD-9-CM codes for venous thromboembolism had high predictive value when present in the principal position, and lower predictive value when in a secondary position. New thromboembolism codes that were added in 2009 that specify chronic thrombosis, upper extremity thrombosis and superficial venous thrombosis should reduce the frequency of false-positive thromboembolism codes.

Summary. Background: The extent to which chronic atrial fibrillation affects the risk of postoperative stroke is largely unknown. Objectives: We sought to determine the 30-day rate of stroke among patients with and without chronic AF who underwent 10 different types of surgery. Patients/methods: The crude incidence of stroke was retrospectively determined using a population-based linked administrative database of hospitalized patients who underwent specified operations between 1 January 1996 and 30 November 2005. The risk of stroke in patients with AF was adjusted for age, race, sex, presence of diabetes, heart failure, hypertension and prior stroke. Results: The overall 30-day rate of stroke in 69 202 patients with chronic AF was 1.8% (95% CI, 1.7–1.9%) vs. 0.6% (CI, 0.58–0.62%) in 2 470 649 patients without AF. The risk-adjusted odds of a postoperative stroke in patients with chronic AF were 2.1 (CI, 2.0–2.3). The highest incremental difference in the crude rate of stroke was observed in patients undergoing neurologic or vascular surgery, with a difference of approximately 2%. Conclusion: Patients with chronic AF had twice the risk of postoperative stroke. Randomized trials are needed to determine if aggressive perioperative anticoagulation can reduce the incidence of postoperative stroke in patients with AF.

Deep vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), affect an estimated 900,000 people in the U.S. each year, resulting in several hundred thousand hospitalizations and about 300,000 deaths. Despite this substantial public health burden, no systematic collection of VTE-related morbidity and mortality data exists in the U.S. The available information about disease prevalence and incidence consists of estimates based mainly on population-based epidemiologic studies and analysis of hospital discharge or health insurance claims databases. The limited scope of the available data has raised the question of whether a systematic surveillance system for VTE should be established. To help answer this question and to make recommendations for the next steps toward better surveillance of VTE, the CDC asked the American Society of Hematology (ASH) to convene a national workshop of stakeholders representing relevant federal agencies, experts in VTE epidemiology and treatment, public health experts in VTE, and patient representatives. These groups were assembled by ASH for a 1-day meeting in Washington DC. The subspecialty experts included representatives from internal medicine, cardiovascular diseases, adult and pediatric hematology, surgery, obstetrics and gynecology, radiology, emergency medicine and trauma care, hospital practice and critical care, and geriatrics. Experts in epidemiology, healthcare quality, and health policy also participated. During the workshop, experts discussed their perspectives on the burden of disease from VTE and its diagnosis, treatment, and prevention. The workshop also focused on the advisability and feasibility of establishing systematic surveillance for VTE and included preliminary discussion of the advantages and disadvantages of various approaches. The workshop concluded that (1) improved utilization in clinical practice of existing, proven-effective preventive measures is critical to reducing the disease burden from VTE; (2) systematic surveillance of DVT and PE is needed to provide nationally representative data on the prevalence and annual incidence of DVT and PE in the U.S.; (3) tracking and documenting changes in the incidence of DVT and PE through systematic surveillance will be important to enhance prevention efforts; and (4) the CDC should convene a second group of experts to advise the agency in detail on the strengths, weaknesses, and feasibility of possible approaches to systematic surveillance for DVT and PE.

Although there is strong evidence that the prevalence of venous thrombo-embolism (VTE) varies significantly among different ethnic/racial groups, the genetic, physiologic and/or clinical basis for these differences remain largely undefined. African-American patients have a significantly higher rate of incident VTE, particularly following exposure to a provoking risk factor such as surgery, medical illness, trauma, etc. In addition, African-Americans are more likely to be diagnosed with pulmonary embolism (PE) than deep-vein thrombosis (DVT) compared to Caucasian and other racial groups. On the other extreme, Asians/Pacific Islanders have a 70% lower prevalence of VTE and this is true for both idiopathic VTE and provoked, or 'secondary', VTE. Hispanics have a significantly lower prevalence of VTE compared to Caucasians, but higher than Asians/Pacific Islanders. The incidence of recurrent VTE varies depending on gender, type of thromboembolic event and race. Further research is needed in order to determine the fundamental differences between racial/ethnic groups that explain the observed differences in the prevalence of VTE. Race/ethnicity should be considered an important factor in the risk-stratification of patients with suspected VTE or patients at some risk for developing VTE.

Duplex ultrasound (US) is used to "rule out" deep venous thrombosis (DVT), but can also diagnose other causes of leg pain or swelling in Emergency Department (ED) patients. Recent literature suggests that US imaging is unnecessary among patients with low or moderate clinical probability of DVT with a normal D-dimer. We attempted to determine the incidence of clinically important incidental findings detected using venous US imaging in patients with suspected lower extremity DVT. We conducted a retrospective chart review of all ultrasounds performed by the non-invasive vascular laboratory on ED patients > 18 years old. Results were classified: normal, DVT, or incidental finding. The latter were classified as clinically significant major findings if the diagnosis led to immediate and specific treatment to prevent morbidity, or clinically significant minor findings. A total of 484 US studies were reviewed; 179 were excluded (arterial studies, penetrating trauma, upper extremity US). Findings among 305 studies were: 238 (78%) normal, 28 (9%) DVT, and 39 (12%) incidental findings. Among 39 incidental findings, 10 were clinically significant major findings and 29 clinically significant minor findings. Clinically significant major findings included: pseudoaneurysm, arterial occlusive disease, vascular graft complication, compartment syndrome, and tumor. Among 38 abnormal US studies that required immediate treatment, DVT comprised 74% (95% confidence interval 59%-85%) and important major incidental findings 26% (95% confidence interval 14%-41%). Among ED patients who underwent US to evaluate leg pain and swelling, 26% of positive studies showed clinically important findings other than DVT. Further research is needed to determine if D-dimer plus a clinical probability tool will include or exclude the patients with clinically significant major findings.

Summary. Background: The incidence of venous thromboembolism (VTE) by lung cancer histology and stage is unknown. Objectives: To determine the incidence of VTE and the risk factors associated with development of VTE in a large population-based study of patients with non-small cell and small cell lung cancer. Methods: The California Cancer Registry was merged with the Patient Discharge Data Set to determine the incidence of VTE among lung cancer cases diagnosed between 1993 and 1999. Results: Among 91 933 patients with newly diagnosed lung cancer, the 1-year and 2-year cumulative VTE incidences were 3.0% and 3.4%, respectively, with a person-time rate of 7.2 events/100 patient-years during the first 6 months. The 1-year incidence of VTE was significantly increased in comparison to the general population [standardized incidence ratio = 21.2, 95% confidence interval (CI) = 20.4–22.0]. In a multivariate model, significant predictors of developing VTE within 1 year of non-small cell lung cancer (NSCLC) diagnosis were: younger age, the number of chronic medical comorbidities [hazard ratio (HR) = 2.8 if 3 vs. 0, 95% CI = 2.5–3.1], advancing cancer stage (HR = 4.0 for metastatic vs. local disease, 95% CI = 3.4–4.6) and adenocarcinoma histology (HR = 1.9 vs. squamous cell, 95% CI = 1.7–2.1). In multivariate models, VTE was a significant predictor of death within 2 years for both NSCLC and small cell lung cancer (SCLC), HR = 2.3, 95% CI = 2.2–2.4, and HR = 1.5, 95% CI = 1.3–1.7, respectively. Conclusions: Approximately 3% of lung cancer patients developed VTE within 2 years. The diagnosis of VTE was associated with a higher risk of death within 2 years for NSCLC and SCLC.

Compost application to turfgrass soils may increase dissolved organic C (DOC) levels which affects nutrient dynamics in soil. The objectives of this study were to investigate the influence of compost source and application rate on soil organic C (SOC), DOC, NO(3), and available P during 29 months after a one-time application to St. Augustinegrass [Stenotaphrum secundatum (Walt.) Kuntze] turf. Compost sources had variable composition, yet resulted in few differences in SOC, DOC, and NO(3) after applied to soil. Available NO(3) rapidly decreased after compost application and was unaffected by compost source and application rate. Available P increased after compost application and exhibited cyclical seasonal patterns related to DOC. Compost application decreased soil pH relative to unamended soil, but pH increased during the course of the study due to irrigation with sodic water. Increasing the compost application rate increased SOC by 3 months, and levels remained fairly stable to 29 months. In contrast, DOC continued to increase from 3 to 29 months after application, suggesting that compost mineralization and growth of St. Augustinegrass contributed to seasonal dynamics. Dissolved organic C was 75%, 78%, and 101% greater 29 months after application of 0, 80, and 160 Mg compostha(-1), respectively, than before application. Impacts of composts on soil properties indicated that most significant effects occurred within a few months of application. Seasonal variability of SOC, DOC, and available P was likely related to St. Augustinegrass growth stages as well as precipitation, as declines occurred after precipitation events.

The disposal of manure on agricultural land has caused water quality concerns in many rural watersheds, sometimes requiring state environmental agencies to conduct total maximum daily load (TMDL) assessments of stream nutrients, such as nitrogen (N) and phosphorus (P). A best management practice (BMP) has been developed in response to a TMDL that mandates a 50% reduction of annual P load to the North Bosque River (NBR) in central Texas. This BMP exports composted dairy manure P through turfgrass sod from the NBR watershed to urban watersheds. The manure-grown sod releases P slowly and would not require additional P fertilizer for up to 20 years in the receiving watershed. This would eliminate P application to the sod and improve the water quality of urban streams. The soil and water assessment tool (SWAT) was used to model a typical suburban watershed that would receive the sod grown with composted dairy manure to assess water quality changes due to this BMP. The SWAT model was calibrated to simulate historical flow and estimated sediment and nutrient loading to Mary's Creek near Fort Worth, Texas. The total P stream loading to Mary's Creek was lower when manure-grown sod was transplanted instead of sod grown with inorganic fertilizers. Flow, sediment and total N yield were the same for both cases at the watershed outlet. The SWAT simulations indicated that the turfgrass BMP can be used effectively to import manure P into an urban watershed and reduce in-stream P levels when compared to sod grown with inorganic fertilizers.

Objective. To determine the incidence, time-course, and risk factors associated with the development of thromboembolism (VTE) in a population-based study of women with ovarian cancer. Methods. Using the California Cancer Registry, cases diagnosed with ovarian cancer for a 6-year period were identified. These cases were linked with the California Patient Discharge Data Set to determine the incidence of VTE. Proportional hazards modeling was performed to analyze the strength of specified risk factors to predict development of VTE or death within 2 years. Results. Among 13,031 cases with ovarian cancer, 5.2% were diagnosed with a VTE event within 24 months after diagnosis. The cumulative incidence varied from 1.4% among women with local stage disease to 6.7% among women with advanced disease. The person-time incidence rate of VTE decreased over time, with the highest rate noted during the first 3 months. In a multivariate model, significant risk factors for VTE included advancing age, increasing number of chronic comorbid conditions, more advanced cancer stage, invasive histology, and absence of any major surgery. For all stages of cancer, development of VTE within 2 years was a significant risk factor for decreased survival, and the magnitude of the risk was greatest among the cases diagnosed with localized disease (HR 4.7, 95% CI: 2.3–9.5). Conclusions. VTE occurred in a significant proportion of ovarian cancer patients and adversely impacted survival, particularly among cases with local or regional stage cancer.

Jones T, Ugalde V, Franks P, Zhou H, White RH. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Objective To analyze the incidence of venous thromboembolism (VTE) after spinal cord injury (SCI). Design Retrospective cohort analysis of all SCI cases (16,240) in California from 1991 through 2001. Setting All public hospitals in California. Participants Subjects (cases) coded as having complete or incomplete SCI. Interventions Not applicable. Main Outcome Measure Diagnosis of VTE or death within 91 days of the day of hospital admission. Results For all cases, the 91-day cumulative incidence of VTE was 5.4%. In a multivariate model, significant predictors of VTE included male sex (odds ratio [OR]=1.4; 95% confidence interval [CI], 1.2–1.7), African-American race (OR=1.6; 95% CI, 1.3–1.9), complete paraplegia versus tetraplegia (OR=1.8; 95% CI, 1.4–2.3), and presence of 3 or more comorbid conditions versus none (OR=1.6; 95% CI, 1.3–2.1). Age less than 14 years was predictive of not developing VTE (OR=0.2; 95% CI, 0.1–0.7). The incidence of VTE did not change significantly over the 11-year time period ( P =.07), and VTE was not a significant predictor of death in the first 91 days after hospitalization. Conclusions The incidence of VTE in SCI patients in California did not change between 1991 and 2001. We identified specific risk factors for VTE. Further studies are needed to determine if prompt initiation of medical prophylaxis in high risk subjects reduces the incidence of symptomatic VTE.

A best management practice (BMP) for exporting manure phosphorus (P) in turfgrass sod from the North Bosque River (NBR) watershed in central Texas was assessed using a geographic information system (GIS). The NBR watershed has a mandate to reduce the total annual P load to the NBR by 50% as a result of total maximum daily load regulation. Since dairy waste applications to fields are identified as the major nonpoint source of P to the river, innovative BMPs, such as export of manure P in turfgrass, will be needed to achieve the 50% reduction. However, methods are needed to evaluate the feasibility of these innovative management practices prior to their implementation. A geospatial database of suitable turfgrass production sites was developed for Erath County using GIS. Erath County largely encompasses the upper portion of the NBR watershed. Information from field experiments, production practices, and ground-truthing was used to search, analyze, and verify a geospatial database developed from national and regional sources. The integration and analyses of large databases supports the search by turf producers for sites suitable for turfgrass sod production in Erath County. In addition, GIS enables researchers and regulators to estimate manure P exports and reduced P loading due to implementation of the manure export BMP on a county scale. Under optimal conditions 198,000 kg manure P yr −1 could be used and 114,840 kg manure P yr −1 exported from the NBR watershed through implementation of a system using dairy manure to produce turfgrass sod. This is the equivalent of the manure P applied from 10,032 dairy cows yr −1 and exported from 5808 dairy cows yr −1 . Application of GIS to large-scale planning and decision-making transcends traditional field-scale applications in precision agriculture.

Objective There is little data regarding the accuracy of pregnancy-specific ICD-9-CM codes used to identify patients with venous thromboembolism (VTE). Study design and setting We identified a large cohort of pregnant patients in whom there were one or more pregnancy-specific (600 codes) or standard ICD-9-CM codes (400 codes) for VTE. Charts of these cases were abstracted to determine the presence of objectively documented VTE. Results A total of 214 cases had a code for VTE either during pregnancy or the 6-week postpartum period; 82% had a pregnancy-specific code and 18% a standard code. Overall, 84 (39%, 95% CI = 33–46%) had objectively documented VTE. A pregnancy-specific ICD-9-CM for VTE had a positive predictive value (PPV) of 54/174 = 31% (95% CI = 24–38%), whereas standard VTE codes had a PPV of 30 of 38 = 80% (95% CI = 63–99%). A PPV in the range of 95–100% could be attained using other criteria, at the expense of detecting only 28 to 45% of all VTE cases. Conclusions Pregnancy-specific ICD-9-CM codes for VTE have low PPV. Other criteria must be applied to select cases with a high probability of having objectively documented VTE.

Purpose To determine the incidence of deep vein thrombosis and pulmonary embolism in two cohorts representing regions of the United States. Methods The sample comprised 21,680 participants of the Atherosclerosis Risk in Communities study and the Cardiovascular Health Study. Subjects were aged ≥45 years, resided in six communities, and were followed for 7.6 years. All hospitalizations were identified and thromboses were validated by chart review. Results The age-standardized incidence of first-time venous thromboembolism was 1.92 per 1000 person-years. Rates were higher in men than women, and increased with age in both sexes. There was no antecedent trauma, surgery, immobilization, or diagnosis of cancer for 48% (175/366) of events. The 28-day case-fatality rate was 11% (29/265) after a first venous thromboembolism and 25% (17/67) for cancer-associated thrombosis. The recurrence rate 2 years after a first venous thromboembolism was 7.7% per year (95% confidence interval [CI]: 4.5% to 10.9% per year). Cancer was the only factor independently associated with 28-day fatality (relative risk [RR] = 5.2; 95% CI: 1.4 to 19.9) or recurrent thrombosis (RR = 9.2; 95% CI: 2.0 to 41.7). Conclusion The incidence of venous thromboembolism in this cohort of middle- and older-aged subjects was similar to that observed in more geographically homogenous samples. Half of cases were idiopathic. Short-term mortality and 2-year recurrence rates were appreciable, especially among subjects with cancer. Based on this study we estimate that 187,000 cases of first-time venous thromboembolism are diagnosed yearly in the United States among those aged 45 years or older.

One of the most common postoperative complications is venous thromboembolism, a term encompassing deep vein thrombosis and pulmonary embolism. This article reviews the epidemiology, natural history, difficulties in diagnosis, and strategies for the prevention of postoperative venous thromboembolism. We thoroughly review the currently available methods for thromboprophylaxis including: early ambulation, elastic compression stockings, pneumatic compression devices, inferior vena cava filters, and a variety of pharmacologic agents such as unfractionated heparin, warfarin, aspirin, low molecular weight heparin, and pentasaccharides. Finally, we review the perioperative management of patients on long-term oral anticoagulation.

The development and use of genetically improved turf-grasses containing useful endophytes is of great value in efforts to enhance the environment, reduce maintenance cost, and conserve and improve precious soil and water resources. Acremonium endophyte-infected (E+) turg-grasses have frequently shown dramatic enhancement of resistance to many foliage-feeding insect pests. Modest improvements in resistance to root-feeding white grubs and some nematodes have been reported. Improvements in stress tolerance and modifications in water relations have been observed under certain conditions. Acremonium endophytes cause modifications to physiological mechanisms of adaptation of the host that result in superior performance of some turf-grass genotypes during moisture deficits. An understanding of the role of endophytes in modifying host plant performance makes turf-grass breeding and evaluation much more efficient. During 1990, an estimated 6000 tonnes of seed of elite, E+ containing perennial ryegrasses, Lolium perenne L., was produced and utilized throughout the world. Endophyte-enhanced ryegrass cultivars include ‘Advent’, ‘Assure’, ‘Dandy’, ‘Dasher II’, ‘Gettysburg’, ‘Pinnacle’, ‘Repell’, ‘SR 4200’, ‘Seville’, and ‘Sherwood’. Acremonium endophytes have been incorporated into ‘Reliant’ and ‘SR 3000’ hard fescue, Festuca longifolia Thuill, ‘SR 5000’ and ‘Jamestown II’ Chewings fescue, Festuca rubra L. subsp. commutata Gaud., as well as elite germplasm of these species. Lower-growing, turf-type tall fescues, Festuca arundinacea Schreb., are being developed with high infection levels of useful Acremonium endophytes. Efforts are being made to find or develop and use desirable endophytes in Kentucky bluegrass, Poa pratensis L., strong creeping red fescue, F. rubra L. subsp. rubra, blue fescue, Festuca glauca Lam., and various bentgrasses, Agrostis spp. The discovery and/or development of superior genetic strains of Acremonium endophytes will make endophyte-enhanced turf-grass performance of even greater significance. There is also the potential to discover, genetically modify, and use other species of fungal and bacterial endophytes with the ability to improve turf-grass performance.

Methods: The California Cancer Registry was used to identify diagnosed cases of 19 common malignancies during a 6-year period. Cases were linked to a hospital discharge database to identify incident VTE events in the year before the cancer diagnosis date. The standardized incidence ratio (SIR) of unprovoked VTE was determined by using the age-, race-, and sex-specific incidence rates in California.

1. 1. Energy dispersive X-ray spectra were obtained from thin sections of larval mosquito ocelli using a scanning electron microscope equipped with a probe. 2. 2. Prominent sulfur and calcium peaks were characteristic of spectra from ommochrome pigment granules. EGTA dissolved granules from thin sections, and the contents of the granules were extracted when EGTA was included in aldehyde fixatives, indicating that calcium is a structural component of the granules. 3. 3. Similar results were obtained with the compound eyes of a moth and a dragonfly. However. granules in the eyes of a fly and crayfish did not contain calcium.