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Present concentrations of mercury in large portions of San Francisco Bay (Bay), the Sacramento-San Joaquin Delta (Delta), and the Sacramento and San Joaquin rivers are high enough to warrant concern for the health of humans and wildlife. Large scale tidal wetland restoration is currently under consideration as a means of increasing populations of fish species of concern. Tidal wetland restoration activities may lead to increased concentrations of mercury in the estuarine food web and exacerbate the existing mercury problem. This paper evaluates our present ability to predict the local and regional effects of restoration actions on mercury accumulation in aquatic food webs. A sport fish consumption advisory is in place for the Bay, and an advisory is under consideration for the Delta and lower Sacramento and San Joaquin rivers. Mercury concentrations in eggs of several water bird species from the Bay have exceeded the lowest observed effect level. A variety of mercury sources, largely related to historic mercury and gold mining, is present in the watershed and has created a spatially heterogeneous distribution of mercury in the Bay-Delta Estuary. Mercury exists in the environment in a variety of forms and has a complex biogeochemical cycle. The most hazardous form, methylmercury, is produced at a relatively high rate in wetlands and newly flooded aquatic habitats. It is likely that distinct spatial variation on multiple spatial scales exists in net methylmercury production in Bay-Delta tidal wetlands, including variation within each tidal wetland, among tidal wetlands in the same region, and among tidal wetlands in different regions. Understanding this spatial variation and its underlying causes will allow environmental managers to minimize the negative effects of mercury bioaccumulation as a result of restoration activities. Actions needed to reduce the uncertainty associated with this issue include a long term, multifaceted research effort, long term monitoring on local and regional scales, and careful evaluation of individual restoration projects with regard to potential increase of food web mercury.

OBJECTIVES The purposes of this study are to perform a large-scale evaluation of the standardized dosage adjustment nomogram recommended by the American College of Chest Physicians (CHEST) for the management of enoxaparin in hospitalized pediatric patients and to determine the necessity of routine and repeated anti--factor Xa (anti-Xa) levels. METHODS A retrospective cohort study was designed, and charts were reviewed in a single tertiary care institution for all patients who received enoxaparin between October 1, 2010, through September 30, 2016. Patients were included if they were receiving treatment doses of enoxaparin according to the pediatric CHEST guidelines, had a subtherapeutic or supratherapeutic anti-Xa level drawn at 3.5 to 6 hours after a dose, had a dose changed in an attempt to attain a therapeutic anti-Xa level, and had a second anti-Xa level drawn 3.5 to 6 hours after the dose change. Descriptive statistical methods were used to characterize the ability of dose adjustment via a nomogram to attain an anti-Xa of 0.5 to 1 unit/mL. RESULTS A total of 467 patients were identified who received the appropriate initial dose and dosage adjustment and whose levels were drawn according to the CHEST guidelines. In patients who had an initial anti-Xa level of <0.35 units/mL and received the nomogram recommended dose increase of 25% ± 5%, 28 out of 96 patients (29.2%) reached therapeutic levels. Of 197 patients who had an initial anti-Xa level between 0.35 and 0.49 units/mL and who received the nomogram recommended dose increase of 10% ± 5%, 116 (58.9%) reached therapeutic levels. Of 50 patients with an initial anti-Xa level between 1.1 and 1.5 units/mL and who received the nomogram dose decrease of 20% ± 5%, 31 (62%) reached therapeutic levels. CONCLUSIONS The current dosage adjustment nomogram recommended by the CHEST guidelines does not reliably lead to therapeutic anti-Xa levels when used to adjust enoxaparin doses in pediatric patients. [ABSTRACT FROM AUTHOR]