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Study Objective. To assess the effectiveness of using low-dose recombinant activated factor VII (rFVIIa) to reverse the effects of warfarin in critically ill patients with major bleeding events. Design. Prospective observational study. Setting. Intensive care unit of a 500-bed university-affiliated hospital. Patients. Sixteen nonhemophiliac patients who had been receiving warfarin and had an acute major bleeding event. Intervention. Patients received rFVIIa 1.2 mg for reversal of anticoagulation. Measurements and Main Results. Patients were identified from clinical pharmacology consult service electronic tracking records, and their data were cross-checked with the pharmacy information system. Information collected for each patient included extent of bleeding and magnitude of elevation in international normalized ratio (INR). A mean ± SD dose of rFVIIa 16.3 ± 4.1 μg/kg (range 11–25 μg/kg) reduced the mean INR from 2.8 ± 1.6 (range 1.44–6.34) to 1.07 ± 0.27 (range 0.86–1.92, p

As our water reserves diminish, recycled water is increasingly being used for irrigation of turfgrasses. This study was conducted to determine the fate of nutrients contained in Type I recycled water used to irrigate turf and its effect on turf quality. Eighteen plots were randomly assigned to three replications of three irrigation treatments and two grasses. Irrigation treatments included Edwards Aquifer water applied at the evapotranspiration (ET) rate (EA), recycled water applied at the evapotranspiration rate (1XRW), and recycled water applied at 1.1 times the evapotranspiration rate to provide a leaching fraction (LFRW). Grasses included 'Tifway' bermudagrass (Cynodon dactylon (L.) Pers. × C. transvaalensis Burtt Davy) and 'Jamur' zoysiagrass (Zoysia japonica Steud.). Rain, runoff, leachate, and soil samples were collected and analyzed for total salts, Ca, Cu, Fe, Mg, Mn, N, K, Na, and Zn. The use of San Antonio Water System (SAWS) Type I recycled water had no adverse effect on turf quality but did result in a significant increase in soil electrical conductivity (EC) from 0.2518 dS m -1 in the EA treatment to 0.3132 and 0.3171 dS m -1 in the 1XRW and LFRW treatments, respectively. The Ca content increased from 134108 and 135467 mg L -1 in the EA and 1XRW treatments to 142 835 mg L -1 in the LFRW treatment. Na concentrations in the soil were not affected by the use of recycled water. The use of recycled water resulted in increased total salts (EC), Na and nitrate (NO 3 ) concentrations in leachate passing below 76 cm. The EC increased from 0.425 dS m -1 for the EA treatment to 0.626 and 0.614 dS m -1 for the 1XRW and LFRW treatments, respectively. Na concentrations in leachate increased from 18.33 mg L -1 for the EA treatment to 49.10 and 52.91 mg L -1 for the 1XRW and LFRW treatments, respectively. Runoff water from treatments irrigated with recycled water exhibited a trend of increased EC, Ca, Mn, and Na.

Purpose To describe the incidence and outcomes associated with venous thromboembolism (VTE) among patients with colorectal cancer. Methods This was a retrospective analysis of all colorectal cancer patients diagnosed in California between 1993 and 1995 and 1997 to 1999. Principal outcomes were incident symptomatic VTE events and death. Associations between specific risk factors and principal outcomes were analyzed using Cox proportional hazards models. Results Among 68,142 colorectal cancer patients, 50% were women, mean age was 70 ± 15 years, and approximately 70% underwent a major operation. The 2-year cumulative incidence of VTE was 2,100 patients (3.1%), with an incidence rate that decreased significantly over time from 5.0% (events/100 patient-years) in months 0 to 6 to 1.4% during months 7 to 12 to 0.6% during the second year. Significant predictors of VTE included metastatic stage (hazard ratio [HR] = 3.2; 95% CI, 2.8 to 3.8) and three or more comorbid conditions (HR = 2.0; 95% CI, 1.7 to 2.3). The risk of VTE was significantly reduced among Asians/Pacific Islanders (HR = 0.4; 95% CI, 0.3 to 0.5.) and patients who underwent an abdominal operation (HR = 0.4; 95% CI, 0.3 to 0.4). In risk-adjusted models, VTE was a significant predictor of death within 1 year of cancer diagnosis among patients with local- (HR = 1.8; 95% CI, 1.4 to 2.3) or regional-stage disease (HR = 1.5; 95% CI, 1.3 to 1.8) but not among patients with metastatic disease (HR = 1.1; 95% CI, 1.0 to 1.2). Conclusion The incidence of VTE among colorectal cancer patients was highest in the first 6 months after diagnosis and decreased rapidly thereafter. Metastatic disease and the number of medical comorbidities were the strongest predictors of VTE. Incident VTE reduced survival among patients with local or regional disease, suggesting that, in these patients, VTE may reflect the presence of a biologically more aggressive cancer.

SummaryMen have been reported to have a higher incidence of recurrent venous thromboembolism than women. However, it is not known if this gender effect holds among different racial/ethnic groups and for both venous thrombosis and pulmonary embolism. We conducteda retrospective analysis of 18-to 65-year-old Caucasian, African-American and Hispanic cases hospitalized in California with unprovoked venous thromboembolism. The principal outcome was recurrent venous thromboembolism 7–60 months after the index event. Among 11,514 cases that were followed for a mean of 3.0 years, men had a significantly higher rate (events/100 patient-years) of recurrent venous thromboembolism than women for both venous thrombosis [rate ratio (RR)=1.5, 95% confidence interval (CI):1.3–1.8] and pulmonary embolism [RR=1.3, 95%CI:1.0–1.6].Among men the recurrence rate did not vary significantly between the racial/ethnic groups (p>0.05). However, the recurrence rate among Hispanic women with venous thrombosis was significantly higher than in Caucasian women (p

The Upper North Bosque River (UNBR) watershed is under a total maximum daily load (TMDL) mandate to reduce loading of soluble phosphorus (P) in impaired river segments. To address these problems, Texas A&M University researchers have developed a Best Management Practice (BMP) that removes excess nutrients from impaired watersheds through turfgrass sod. Harvest of manure-grown sod removes a thin layer of topsoil along with any residual P in this soil layer. In order to assess the impact of the turfgrass BMP on a watershed scale, the Soil and Water Assessment Tool (SWAT) was used to predict water quality changes among four scenarios in the UNBR watershed. The SWAT model was modified to incorporate turfgrass harvest routines for simulation of manure and soil P export during harvest of turfgrass sod. SWAT simulations of the four BMP scenarios predicted reductions of 20% to 36% for instream P loads in the UNBR depending on manure P rate and areas allotted to sod. In addition, total N load was reduced on average by 31% and sediment load declined on average 16.7% at the watershed outlet. The SWAT model predicted up to 176 kg/ha P was removed per harvest of sod top-dressed with 100 kg manure P/ha. Export increased to 258 kg/ha of P per harvest for the manure P application rate of 200 kg/ha. Depending on the implementation scenario, simulations indicated the turfgrass BMP could export between 262 and 784 metric tons of P out of the UNBR watershed every year.

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.

'Tifdwarf' bermudagrass [C. dactylon (L.) Pers. x C. transvaalensis Burtt-Davy] is one of the most widely used cultivars on golf course putting greens in the southern USA because of its superior putting green quality. This study evaluated the effects of photosynthetic photon flux density (PPFD), temperature, and nitrogen fertilization on growth and development of Tifdwarf bermudagrass. In controlled environment studies, increasing N increased bermudagrass internode length, leaf length, and shoot weights. Increasing N had no significant effect on the chronological appearance rate of successive leaves and axillary buds. The phyllochron was positively correlated with day/night temperature. The internode and leaf length were greatest at the 27/19 degrees C treatment and least at the 35/27 degrees C treatment. Internode length increased from 20 to 40 mm as the PPFD decreased from 975 to 300 micromol m(-2) s(-1) at 27/19 degrees C but only increased from 10 to 22 mm long at 35/27 degrees C. Leaf lengths responded similarly. Leaf and internode length were greater at low than at high day/night temperatures regardless of incident light. The alteration in growth form occurred within 3 to 4 d of treatment initiation. Results indicated that temperature as well as light levels regulated expression of dwarfness in Tifdwarf bermudagrass. In regions that typically have long periods with daytime temperatures of 27 degrees C or less and a PPFD of 600 micromol m(-2) s(-1) or less, the growth form of Tifdwarf bermudagrass may change dramatically, resulting in plants with longer internode spacings and longer leaves. Because of this change in growth form, one may expect faster coverage from newly planted sprigs and faster recovery from disruptive cultural activities when the daytime temperatures are 27 degrees C or less as compared with periods when the daytime temperatures are 30 degrees C or above and the PPFD is >1000 micromol m(-2) s(-1) as is typical of summer in southern climates.

BACKGROUND The low-molecular-weight heparins (LMWHs) have been shown to be effective in the outpatient treatment of deep vein thrombosis (DVT). Data regarding outpatient use of any LMWH in pulmonary embolism (PE) or tinzaparin in DVT while transitioning therapy to a vitamin K antagonist are limited. OBJECTIVE To determine the safety and efficacy of tinzaparin in patients with either DVT or PE being transitioned to warfarin during LMWH therapy in the outpatient setting. METHODS All patients who were treated with at least one outpatient dose of tinzaparin for venous thromboembolism (VTE) were identified. Charts of all patients followed within the University of California Davis healthcare system were reviewed. The incidence of bleeding and recurrent thromboembolism over a minimum of the first 4 weeks to a maximum of 12 weeks after initiating anticoagulation was assessed. RESULTS A total of 178 patients with acute VTE were treated with tinzaparin, and outcomes could be determined in 140 cases. Forty-seven percent of these patients had objectively documented PE. Only one (0.7%) case of recurrent VTE was observed. Major bleeding was documented in 5 (3.6%) and minor bleeding in 8 (5.8%) patients. Two bleeding events, both major, occurred during tinzaparin therapy. CONCLUSIONS Outpatient use of tinzaparin during transition to warfarin therapy in the treatment of VTE, including PE, appears to be feasible in patients who are judged candidates for home therapy.

Application of organic amendments can increase dissolved organic C (DOC) concentrations, which may influence movement of nutrients and heavy metals in soils. The objectives of this study were to investigate the influence of compost sources and application rates on concentrations of soil DOC, NO3-N, and extractable P over 29 months after a one-time application of compost to bermudagrass [Cynodon dactylon (L.) Pers.] turf. Few differences were evident between compost sources for soil total organic C (TOC), DOC, and NO3-N. However, the initial P content of compost sources significantly influenced soil extractable P. Increasing the rate of compost application increased soil TOC initially, but levels remained fairly stable over time. In contrast, DOC continued to increase from 3 to 29 months after application, suggesting that compost mineralization and growth of bermudagrass contributed to DOC dynamics in soil. Dissolved organic C was 98%, 128%, 145%, 175%, and 179% greater 29 months after application of 0, 40, 80, 120, and 160 Mg compost/ha, respectively, than before application. Rate of compost application had less effect on DOC than TOC, as DOC concentrations appeared controlled in part by bermudagrass growth patterns. Soil NO3-N was generally unaffected by compost application rate, as NO3-N decreased similarly for unamended soil and all compost treatments. Soil extractable P initially increased after compost application, but increasing the application rate generally did not increase P from 3 to 29 months. Seasonal or cyclical patterns of TOC, DOC, and extractable P were observed, as significantly lower levels of these parameters were observed in dormant stages of bermudagrass growth during cooler months.

Proper water management is a major responsibility of managers of creeping bentgrass grown on putting greens in the hot and humid southern states. The combination of shallow root systems, sand-based root zones, high temperatures, and high evaporative demands frequently results in severe drought stress on bentgrass (Agrostis palustris Huds.) greens. This study was initiated to determine the effects of irrigation frequency on creeping bentgrass turgor pressure and on the O2 and CO2 concentrations in a sand-based root zone mixture. In total, 81 plots, 1.5 × 1.5 m each, were established on a USGA-type root zone mixture and organized into 9 groups of 9 plots each. Each group could be irrigated individually. One plot in each group was planted to either `A-4', `Crenshaw', `Mariner', `L-93', or `Penncross' creeping bentgrass. Irrigation frequency treatments of 1-, 2-, and 4-day replacement of historical PET were imposed on three groups each. After establishment, measurements of the leaf water potential, osmotic potential, soil oxygen concentration, and soil carbon dioxide concentrations were made over a 1- to 2-year period. Bentgrass irrigated every 1 or 2 days had significantly (P = 0.05) greater turgor pressures at 0600 hr as compared to turf irrigated every 4 days in 1997. No differences were seen in 1998 due to drier environmental conditions. Concentrations of O2 and CO2 in the soil air remained in the optimal range for all treatments, indicating that lack of O2 in the root zone as a result of frequent irrigation may not be the primary cause for reduced rooting depth of bentgrass grown on highly permeable sand-based root zone mixtures.

SummaryAlthough specific criteria for diagnosing the antiphospholipid syndrome (APS) exist (the Sapporo Criteria), most physicians are not aware these include repeat testing and documentation of either a lupus anticoagulant or medium to high levels of anticardiolipin antibody. Incorrect diagnosis of APS may result in unnecessary long-term anticoagulation. The purpose of this study was to determine the clinical and serological characteristics of patients being treated for APS and concordance with published criteria. This cross-sectional study identified APS patients who were being treated with warfarin at one of three universitybased anticoagulation clinics. Levels of anticardiolipin antibody were classified as low-positive if abnormal but

SummaryThere have been very few studies that have describe the epidemiology of first-time venous thromboembolism (VTE) in a large, ethnically diverse population. The California Discharge Data Set was used to identify a cohort of cases with incidentVTE in 1996. Cases associated with traditional provoking risk factors were identified and the remaining cases were labeled as idiopathicVTE. Direct standardization using census information was performed to compare incidence rates across races, gender, and gender within race. There were 21,002 cases with incident VTE in 1996, a crude incidence of 90 events per 100,000 adults. Thirty percent of all VTE events were pulmonary embolism. The directly standardized incidence per 100,000 California adults was 93 ± 1.7 ( ± 95% CI) in women, 85 ± 1.7 in men, 103 ± 2.1 in Caucasians, 138 ± 6.5 in African- Americans, 61 ± 2.8 in Hispanics and 29 ± 2.4 in Asian-Pacific Islanders (p

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.

OBJECTIVE To report a case of probable acute venous thrombosis caused by heparin-induced thrombocytopenia (HIT) in a pediatric patient with a normal platelet count after prolonged enoxaparin therapy. CASE SUMMARY An 11-year-old African American female with Crohn's disease developed extensive vena cava thrombosis. Her deep vein thrombosis (DVT) was treated with intravenous unfractionated heparin followed by extended outpatient warfarin therapy. Four months later, the warfarin was stopped and subcutaneous enoxaparin 1.5 mg/kg once daily was substituted prior to an elective colonoscopy. She was readmitted 6 weeks later with acute DVT with a platelet count of 233 × 10 3 /mm 3 , significantly lower than the count of 550–700 × 10 3 /mm 3 5 months previously and the count of 433 × 10 3 /mm 3 3 months earlier. An enzyme-linked immunosorbent assay for heparin-platelet factor 4 antibodies was strongly positive and a d-dimer was elevated at 2.9 mg/L (normal 300 × 10 3 /mm 3 . Over the next 4 months, there was no further thrombosis. DISCUSSION HIT appears to be rare in the pediatric population, and only a few cases treated with a direct thrombin inhibitor have been reported. This is the first case report to our knowledge of a pediatric patient developing HIT secondary to enoxaparin. An interesting feature of this case is the development of HIT in the face of a normal platelet count, which is rare but has been reported in adults. CONCLUSIONS Pediatric patients receiving low-molecular-weight heparin are still at risk for developing HIT. Treatment of HIT should involve the initial use of a direct thrombin inhibitor to manage thrombosis until the platelet count returns to higher values. Once the platelet count returns, warfarin can be used for long-term thrombosis management.

Nutrient loading on impaired watersheds can be reduced through export of sod grown with manure and export of composted manure for turf production on other watersheds. Effects of the sod and manure exports on receiving watersheds were evaluated through monitoring of total dissolved phosphorus (TDP) and N concentrations and losses in runoff from establishing turf. Three replications of seven treatments were established on an 8.5% slope of a Booneville soil (loamy-skeletal, mixed, superactive Pachic Argicryolls). Three treatments comprised imported 'Tifway' bermudagrass [Cynodon dactylon (L.) Pers. x C. transvaalensis Burtt-Davy) sod grown with composted dairy manure (382 or 191 kg P ha(-1)) or fertilizer (50 kg P ha(-1)). Three treatments were sprigged with Tifway and top-dressed with either composted manure (92 or 184 kg P ha(-1)) or fertilizer (100 kg P ha(-1)). The control was established bermudagrass [Cynodon dactylon (L.) Pers. var. Guymon]. During eight fall rain events, mean TDP concentration in runoff (7.8 mg L(-1)) from sprigged Tifway top-dressed with manure (84 kg P ha(-1)) was 1.6 times greater than sod imported with 129 kg manure P ha(-1). During the first fall event, mass losses of TDP (232 mg m(-2)) and total Kjeldahl nitrogen (TKN) (317 mg m(-2)) from sprigged treatments top-dressed with manure or fertilizer were nearly three times greater than manure-grown sod. Percentages of manure P lost as TDP in runoff from imported sod were 33% of percentages lost from sprigged treatments top-dressed with manure. Sod grown with manure P rates of 190 kg P ha(-1) can be imported without increasing runoff losses of TDP compared with conventional fertilization of establishing turfgrass.

Erath County in the North Bosque River (NBR) watershed of central Texas hosts a large portion of dairy production in the state. In recent years, the Texas Commission on Environmental Quality (TCEQ) has approved a total maximum daily load (TMDL) program for soluble phosphorus (P) for two segments of the NBR. The TMDL program affects dairy producers in the region who contribute to the nonpoint-source (NPS) phosphorus loading in the watershed. Best management practices (BMPs) are now necessary to remedy the issue of excess P. One proposed BMP calls for the production of turfgrass sod using composted dairy manure. The turfgrass sod would be transported out of the watershed, thus exporting nutrients and reducing P loadings to the NBR. The objective of this project was to determine, using geospatial databases, if there was enough land in Erath County suitable for turfgrass sod production to make this proposed BMP economically feasible. Our analysis identified over 5,000 ha of land suitable for turfgrass sod production.

Heparin-induced thrombocytopenia (HIT) is a life-and-limb threatening condition that is associated with the development of antibodies that activate platelets and the coagulation system in the presence of unfractionated heparin or low molecular weight heparin. The binding of antibody to heparin-PF-4 complexes can activate platelets, leading to an acute, often catastrophic, thrombotic diathesis. The most common laboratory finding is the development of thrombocytopenia 5 or more days after beginning heparin treatment, which occur in up to 1 - 5% of patients exposed to heparin, depending on type of heparin and indication for anticoagulation. The onset of thrombocytopenia can be immediate or delayed for several weeks after the exposure to heparin. Approximately 50 - 60% of patients who develop HIT manifest acute venous or arterial thrombosis and a significant percentage of these patients die or develop vascular gangrene of a limb that requires amputation. Given the severe sequelae associated with HIT, recognition and immediate medical management is essential. Treatment of a patient with HIT is complex, as there are several different anticoagulants now available which have been shown to be useful. Optimal management depends on each patient's individual clinical manifestations, as well as the need for ongoing anticoagulation therapy. No single agent or treatment approach can be considered to be 'standard practice' as very few clinical trials have been completed, compare different treatment options. The use of warfarin alone in a patient with HIT, must be avoided in order to avoid the possibility of further activating coagulation, which may hasten the development of venous limb gangrene. There are several different tests available that detect HIT antibodies and each has different sensitivity and specificity for HIT. In this review we discuss the epidemiology and natural history of HIT, risk factors associated with the development of HIT and the clinical and laboratory tests that aid in the diagnosis and treatment. Special emphasis is given to addressing the management of HIT in special populations, particularly patients with renal or liver disease, acute coronary syndromes, pregnancy, paediatrics and patients who require cardiopulmonary bypass surgery.

SummaryThere have been no comprehensive studies that have compared the incidence of symptomatic VTE over a spectrum of different urgent or elective surgical procedures. In this study we determined the incidence of symptomatic venous thromboembolic events (VTE) within a 3 month period after 76 different surgical procedures. Using a large administrative data-base, we analyzed 1,653,275 cases that underwent one of 76 selected surgical procedures between January 1, 1992 and September 30, 1996. The principal outcomes were venous thrombosis or pulmonary embolism, during either the initial hospitalization or a re-hospitalization for VTE within 91 days of the date of surgery. Predictors of VTE were analyzed using logistic regression. Overall, VTE was diagnosed in 13,533 cases (0.8%, 95% CI = 0.7-0.9%) and of these, 5049 (37%, 95% CI = 36-38%) had pulmonary embolism. Predictors of VTE included: advancing age (OR=1.1 per 5 year increment in age, 95% CI =1.1-1.1), Latino ethnicity (OR = 0.9, 95% CI =0.8-0.9), Asian/Pacific Islander ethnicity (OR = 0.5, 95% CI = 0.4-0.6), presence of a malignancy (OR = 1.7, 95% CI = 1.6-1.8) and prior VTE (OR = 6.2, 95% CI = 5.5-7.0). High-risk procedures that had an incidence of symptomatic VTE of approximately 2 to 3% included invasive neurosurgery, total hip arthroplasty, major vascular surgery and radical cystectomy. Fifty-six percent of all VTE events diagnosed within 91 days of surgery occurred after discharge. The findings of this study provide a basis for categorizing different surgical procedures as low, intermediate, high and very high risk for VTE. Because of the high incidence of VTE diagnosed after hospital discharge, further studies of extended thromboprophylaxis appear warranted.

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.

Our understanding of risk factors associated with the development of venous thromboembolism (VTE) has increased steadily over the past 20 years. In the 1980s, the development of VTE was conceptualized in the context of the factors in Virchow's classic triad that he believed led to venous thrombosis. These factors were injury to the endothelium, alteration in blood flow (particularly stasis/immobility for venous thrombosis), and activation of blood coagulation.1 Patients who had a disease or condition that included one of these factors were considered to have a predisposing condition,2 whereas patients without any of these factors were categorized as having an idiopathic venous thrombosis. In the 1980s, the principal terms used to categorize acute venous thrombotic events were idiopathic and secondary venous thromboembolism. Gradually the term unprovoked, first coined by Kearon,3 began to be used instead of idiopathic, and provoked was used in place of secondary. More recently, provoking risk factors have been divided into temporary provoking risk factors and persisting provoking risk factors, although there is no strict definition of what constitutes a temporary or transient risk factor. Practically speaking, clear examples of transient provoking risk factors include a lower-extremity fracture, major surgery, and long-distance travel. However, the notion that a clinician can easily identify a provoking risk factor becomes less certain as the time between the possible provoking event and onset of acute VTE increases. Is surgery a provoking risk factor when an acute VTE develops 90 or 120 days after an operation? The best examples of a persisting provoking VTE risk factor are an active medical diseases such as cancer, inflammatory bowel disease, or nephrotic syndrome, and a chronic medical condition such as immobility or a prior history of VTE. Article see p 2092 Accurate classification of an acute VTE as either provoked or unprovoked …

Elective total hip and total knee arthroplasty surgeries are associated with an extraordinarily high incidence of asymptomatic venous thromboembolism (VTE). Symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) is diagnosed in only 2%-4% of these patients. A number of studies have defined the incidence and time course of symptomatic thromboembolism after these procedures. Knee arthroplasty is associated with a very high incidence of asymptomatic calf vein thrombosis, with almost all symptomatic VTE events diagnosed in the first 21 days after surgery. Hip arthroplasty, however, is associated with a higher incidence of asymptomatic proximal thrombi and a modestly higher incidence of symptomatic VTE events, many diagnosed up to 6 or 8 weeks after hospital discharge. Extended medical thromboprophylaxis has been shown to reduce the incidence of symptomatic and asymptomatic VTE among hip arthroplasty patients but not among knee arthroplasty patients. Risk factors for VTE after knee arthroplasty are not well defined. Important risk factors that have been shown to be associated with the development of VTE after hip surgery include (1) a history of prior VTE, (2) obesity (body mass index > 25), (3) delay in ambulation after surgery, and (4) female sex. Factors associated with lower risk include (1) Asian/Pacific Islander ethnicity, (2) use of pneumatic compression among non-obese patients after surgery, and (3) extended thromboprophylaxis after hospital discharge.

Regulatory mandates have increased demand for best management practices (BMPs) that will reduce nutrient loading on watersheds impaired by excess manure P and N. Export of manure P and N in turfgrass sod harvests is one BMP under consideration. This study quantified amounts and percentages of P and N removed in a sod harvest for different rates of manure and inorganic P and N. Six treatments comprised an unfertilized control, two manure rates with and without supplemental inorganic N, and inorganic P and N only. The treatments were applied to 'Tifway' bermudagrass (Cynodon dactylon L. x C. transvaalensis Burtt-Davey), '609' buffalograss [Buchloe dactyloides (Nutt.) Engelm.], and 'Reveille' bluegrass (Poa arachnifera Torr. x P. pratensis L.) under field conditions. Comparisons among treatments revealed small variations of P and N content in clippings and the plant component of sod, but large variations in the soil component of sod for each turf species. In addition, 2 to 10 times more P and 1.3 to 5 times more N was removed in soil than in plant components of sod for the two manure rates with and without added inorganic N. Percentages of applied P and N in harvested sod were similar for the two manure rates with and without added N for each species, but differed among turf species for each P (46 to 77%) and N (36 to 47%). The large amounts and percentages of manure P and N removed by sod harvest support the feasibility of this BMP in efforts to reduce nutrient loads on watersheds.

Manure applications can benefit turfgrass production and unused nutrients in manure residues can be exported through sod harvests. Yet, nutrients near the soil surface could be transported in surface runoff. Our research objective was to evaluate responses of bermudagrass [Cynodon dactylon (L.) Pers. var. Guymon] turf and volumes and P and N concentrations of surface runoff after fertilizer or composted manure applications. Three replications of five treatments were established on a Boonville fine sandy loam (fine, smectitic, thermic Vertic Albaqualf) that was excavated to create an 8.5% slope. Manure rates of 50 and 100 kg P ha(-1) at the start of two monitoring periods were compared with P fertilizer rates of 25 and 50 kg ha(-1) and an unfertilized control. Compared with initial soil tests, nitrate concentrations decreased and P concentrations increased after two manure or fertilizer applications and eight rain events over the two monitoring periods. The fertilizer sources of P and N produced 19% more dry weight and 21% larger N concentrations in grass clippings than manure sources. Yet, runoff volumes were similar between manure and fertilizer sources of P. Dissolved P concentration (30 mg L(-1)) in runoff during a rain event 3 d after application of 50 kg P ha(-1) was five times greater for fertilizer than for manure P. Observations during both monitoring periods indicated that total P and N losses in runoff were no greater for composted manure than for fertilizer sources of P at relatively large P rates on a steep slope of turfgrass.

Objective: To validate the predictive value of the Canadian clinical probability model for acute venous thrombosis, which, to the best of the authors' knowledge, has not been done in emergency department (ED) settings outside of Canada. Methods: Demographic and clinical information, rapid D-dimer testing, and venous ultrasound imaging were obtained among patients presenting with clinically suspected venous thrombosis at a university-affiliated ED. A diagnosis of deep venous thrombosis (DVT) was made based on venous ultrasound test results or objectively documented venous thromboembolism during a 12-week follow-up period. The probability of venous thrombosis was calculated using the Canadian clinical probability model. Results: Among 102 patients, 17 (17%) were diagnosed as having venous thrombosis initially or during the three-month follow-up period. The frequency of venous thrombosis among patients categorized as having high probability was 10 of 17 [59%, 95% confidence interval (95% CI) = 35% to 82%], 6 of 44 (14%, 95% CI = 4% to 24%) with intermediate probability, and 1 of 41 (2%, 95% CI = 0.1% to 11%) with low probability. This compares with respective values of 49%, 14%, and 3%, reported by Canadian researchers in an ED study. Forty-one of 102 (40%) patients had an alternate diagnosis as likely or more likely than venous thrombosis, but only three (7%, 95% CI = 2% to 18%) of these had venous thrombosis. Conclusions: Use of the Canadian probability model for DVT in this ED resulted in effective risk stratification, comparable to previously published results.

SummaryVenous thrombosis and pulmonary embolism are commonly viewed as different manifestations of a single disease process, venous thromboembolism. Recent evidence suggests that there may be important differences between patients who manifest these two conditions. Using linked hospital discharge records we analyzed 71,250 patients hospitalized with a principal diagnosis of venous thrombosis alone or pulmonary embolism and analyzed predictors of rehospitalization within 6 months for venous thrombosis or pulmonary embolism. There were 51233 patients diagnosed with venous thrombosis alone and 21,625 diagnosed with pulmonary embolism. Comparing patients initially diagnosed with venous thrombosis alone to patients with pulmonary embolism, the relative risk of being rehospitalized with venous thrombosis within 6 months for venous thrombosis was 2.7. Conversely, when patients with pulmonary embolism were compared to patients with venous thrombosis alone, the relative risk of rehospitalization within 6 months with a diagnosis of pulmonary embolism was 4.2. In multivariate models the strongest predictor of recurrent thromboembolism manifest as pulmonary embolism was an initial diagnosis of pulmonary embolism and the strongest predictor of recurrence as venous thrombosis was an initial diagnosis of venous thrombosis. We conclude that the initial clinical manifestation of thromboembolism strongly predicts the manifestation of a recurrence. Venous thrombosis and pulmonary embolism appear to be distinct, albeit overlapping, clinical entities with different natural histories.Presented at the International Society of Thrombosis and Haemostasis Meeting in Paris, France on July 9, 2001

e18181 Background: EGFR mutations and ALK rearrangements are key therapeutic targets in nonsquamous nonsmall cell lung carcinoma (nsNSCLC). Treatment with targeted therapy has been shown to improve progression-free survival and overall survival in many cases. Current guidelines recommend testing all advanced (Stage IIIB and IV) nsNSCLC patients for these genetic aberrations. Our previous work revealed that we were not evaluating a large percentage of eligible patients. In order to improve testing rates, we conducted a series of multidisciplinary meetings aimed at direct physician education and process enhancement. Methods: Utilizing the Association of Community Cancer Centers (ACCC) molecular testing framework in conjunction with support from Pfizer, we launched a lean six sigma initiative aimed at improving our molecular profiling rates. A series of multidisciplinary meetings were conducted addressing action items outlined by the ACCC. A total of 158 advanced nsNSCLC patients were identified from our tumor registry during or shortly after the start of this initiative (2014-2015). Testing rates for EGFR and ALK were determined by individual chart review and compared to our previously published testing rates (2011-2013). Results: We found 77.9% (123/158) and 60.8% (96/158) of patients were tested for EGFR mutations and ALK rearrangements, respectively. We utilized a chi-square test of homogeneity to determine whether there was an increased EGFR and ALK testing rate post-intervention . Our EGFR testing rate increased 80.3%, from 43.2% (2011-2013) to 77.9% (2014-2015), p < 0.00001, and our ALK testing rate increased 155.5%, from 23.8% (2011-2013) to 60.8% (2014-2015), p < 0.00001. Conclusions: Multidisciplinary educational and process enhancement meetings improve molecular testing rates in nsNSCLC.

Source Citation Connolly BJ, Pearce LA, Hart RG. Vitamin K antagonists and risk of subdural hematoma: meta-analysis of randomized clinical trials. Stroke. 2014;45:1672-8. 24876259

As the urban population increases, so does the area of irrigated urban landscape. Summer water use in urban areas can be 2-3x winter base line water use due to increased demand for landscape irrigation. Improper irrigation practices and large rainfall events can result in runoff from urban landscapes which has potential to carry nutrients and sediments into local streams and lakes where they may contribute to eutrophication. A 1,000 m(2) facility was constructed which consists of 24 individual 33.6 m(2) field plots, each equipped for measuring total runoff volumes with time and collection of runoff subsamples at selected intervals for quantification of chemical constituents in the runoff water from simulated urban landscapes. Runoff volumes from the first and second trials had coefficient of variability (CV) values of 38.2 and 28.7%, respectively. CV values for runoff pH, EC, and Na concentration for both trials were all under 10%. Concentrations of DOC, TDN, DON, PO₄₋P, K(+), Mg(2+), and Ca(2+) had CV values less than 50% in both trials. Overall, the results of testing performed after sod installation at the facility indicated good uniformity between plots for runoff volumes and chemical constituents. The large plot size is sufficient to include much of the natural variability and therefore provides better simulation of urban landscape ecosystems.

Background The population-based incidence of acute venous thromboembolism (VTE) in adult patients diagnosed with non-Hodgkin’s lymphoma has not been established, and the effect of VTE on survival is not clear. Aim To determine the incidence of acute VTE in California residents diagnosed with lymphoma, and to determine the effect of acute VTE on survival. Methods We used the California Cancer Registry coupled with the California Patient Discharge database to identify incident cases with lymphoma, 1991-1997, and the incidence of first-time VTE in these patients. Multivariable models were constructed to evaluate risk of developing acute VTE within 2 years, and a proportional hazard model was used to predict death within 2 years, using acute VTE as a time-dependent covariate. Results There were 16,755 patients diagnosed with non-Hodgkin’s lymphoma; 29% had low-grade, 66% intermediate/aggressive grade and 5.6% had high-grade lymphoma. Acute VTE developed in 3.6% of the patients by year 1 and 4.0% by the end of year 2. Significant predictors of acute VTE included advanced stage lymphoma, number of chronic comorbidities and advancing age. Significant predictors of death within 2 years included diagnosis of acute VTE, advanced stage disease, increasing number of co-morbidities, age over 75 years and intermediate or high grade histopathology. The effect of acute VTE on death increased as the time between lymphoma diagnosis and VTE diagnosis increased (HR = 1.7 95%CI:1.5-1.9 for VTEs Conclusions Acute VTE developed frequently in patients with lymphoma, and VTE was a strong predictor of decreased survival. © 2014 Elsevier Ltd. All rights reserved.

We commend the RIETE (Computerized Registry of Patients with Venous Thromboembolism) group for attempting to analyze the benefits of use of an inferior vena cava (IVC) filter after acute pulmonary embolism (PE) using their large prospectively collected registry [(1)][1]. Their propensity-matched

Background Ablation (ABL) is a second-line therapy for the management of atrial fibrillation (AF). Single-center studies have demonstrated the safety and efficacy of ABL; however, the low event rates render it difficult to assess predictors of major adverse events. Objective The purpose of this study was to determine the population-based incidence of data and risk factors for both stroke Methods Patients (n = 6207) identified as having undergone AF ABL between 2005 and 2009 by the California Ambulatory Surgery Database in 97 nonfederal hospitals in California were linked to the California Patient Discharge Database and to a master death registry. Data from these patients were analyzed for primary outcomes of 30-day death and ischemic stroke. Independent risk factors for these end-points were determined. Results Mean patient age was 61.9 years, and the majority of the patients were men. Thirty-day mortality and stroke after ABL were 0.39% and 0.61%, respectively. Independent predictors of death were age ≥80 years (odds ratio [OR] 8.2, 95% confidence interval [CI] 1.5–43) and heart failure (OR 9.2, 95% CI 3.0–28). Prior stroke/transient ischemic attack/stroke was the only independent predictor for stroke (OR 6.3, 95% CI 3–13). Conclusion In our large population-based study, we found higher procedure-related mortality but comparable stroke rate after AF ABL than previously reported. Age ≥80 years and heart failure was each independently associated with >8-fold increase in odds of death. The only significant predictor of stroke was prior stroke/transient ischemic attack. These findings may aid in patient selection for AF ABL.

Oral anticoagulation therapy has demonstrated benefit in the treatment and prevention of a variety of thromboembolic disorders. Most individuals who receive oral anticoagulant therapy are elderly patients with nonvalvular atrial fibrillation and acute or recurrent venous thromboembolism. Anticoagulation in elderly patients poses unique challenges for the practicing clinician because they are simultaneously at higher risk for recurrent thromboembolism and major bleeding, including catastrophic intracranial hemorrhage. The pharmacology of warfarin in the elderly is reviewed, including important drug interactions and current dosing recommendations for elderly patients. Evidence of the benefits and risks of oral anticoagulation therapy are reviewed for patients with atrial fibrillation and venous thromboembolism. This information should enable practitioners to better assess the relative risks and benefit of oral anticoagulation therapy to guide treatment decisions in the elderly.

Disease is a major problem in creeping bentgrass (Agrostis stolonifera L.) on golf course putting greens. Genetic composition and uniformity of host populations can affect disease development. This study was conducted to determine the effects of blending creeping bentgrass cultivars on dollar spot (caused by Sclerotinia homoeocarpa F. T. Bennett) severity. 'Penn A-4', 'Crenshaw', 'L-93', 'Mariner', and 'Penncross' were planted in monostands or as two-way or three-way blends in a completely random design with three replications on a sand-based putting green in the field at College Station, TX. Disease severity was determined by the number of infection centers and by total blighted area. Crenshaw was most susceptible, L-93 most resistant, and all other cultivars were moderately resistant to dollar spot in monostands. Cultivar susceptibility in monostands to S. homoeocarpa was representative of each cultivars contribution to dollar spot severity in blends. In blends, L-93 suppressed, whereas Crenshaw increased dollar spot. Penncross, Penn A-4, and Mariner did not affect dollar spot severity across all blend combinations. Number of infection centers and infected area pooled across all monostands were similar when compared to all two- and three-way blends indicating that dollar spot activity in blends was a compromise between resistance levels of individual cultivars. Two-way blends of Penn A-4, L-93, Mariner, or Penncross with Crenshaw, however, resulted in 46 to 67% fewer infection centers and 71 to 98% less blighted area, when compared to the Crenshaw monostand. These data indicated that blending a resistant cultivar with a susceptible cultivar reduced dollar spot severity in the blended population.

Development of drought resistant, water-conserving cultivars continues to be an objective of turfgrass breeding programs. This study was conducted to determine for 15 zoysiagrasses [Zoysia japonica Steud., Z. matrella (L.) Merr., and Z. japonica Steud. x Z. tenuifolia Willd.] under greenhouse conditions (i) water relations characteristics, (ii) survival and recovery from extreme water stress, and (iii) the relationship of water relations characteristics to supplemental irrigation requirement determined in field studies. Leaf water potential at zero turgor (Ψ L0 ) ranged from -1.76 MPa to -2.52 MPa before, and from -2.18 MPa to -2.59 MPa after water stress. Though Ψ L0 of genotypes such as Cavalier, El Toro, and Emerald decreased after stress, Ψ L0 of genotypes such as Korean Common and DALZ85t5 did not change. Osmotic potential at full turgor (Ψ π100 ) of genotypes such as DALZ8501 and DALZ8506 was similar or increased after water stress but decreased for genotypes such as Crowne and Korean Common. The Ψ L0 and Ψ π100 after stress were negatively correlated with recovery from stress and positively correlated with irrigation requirement. Zoysia genotypes with low relative water content at zero turgor (RWC 0 ), bulk modulus of tissue elasticity (E), and apoplastic water fraction (β) demonstrated poor recovery from stress and required more supplemental irrigation. Cultivars such as Crowne, El Toro, and Palisades had the greatest recovery from stress, the least irrigation requirement, more negative Ψ L0 and Ψ π100 , and positive RWC 0 , e, and β. This study demonstrates that improvements in biophysical as well as morphological traits should contribute to development of water-conserving Zoysiagrass germplasm.

Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined.Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls.A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in kilograms divided by the square of the height in meters) of 25 or greater was associated with rehospitalization for thromboembolism, with an odds ratio of 2.5 (95 percent confidence interval, 1.8 to 3.4). In a multivariate model, the only prophylactic regimens associated with a reduced risk of thromboembolism were pneumatic compression in patients with body-mass indexes of less than 25 (odds ratio, 0.3; 95 percent confidence interval, 0.2 to 0.6) and warfarin treatment after discharge (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 1.0).In patients who underwent total hip arthroplasty, a body-mass index of 25 or greater was associated with subsequent hospitalization for thromboembolism. Pneumatic compression in patients with a body-mass index of less than 25 and prophylaxis with warfarin after discharge were independently protective against thromboembolism.

SummaryOur study compared point-of-care (POC) device monitoring with traditional clinical laboratory methods device of patients on oral anticoagulant therapy. The POC devices used in the study were Coumatrak, CoaguChek, CoaguChek Plus, Thrombolytic Assessment System (TAS) PT-One, TAS PTNC, TAS PT, Hemachron Jr. Signature, Protime Microcoagulation System, and Medtronics ACT II. The clinical laboratory method used thromboplastins with different ISI values: Innovin and Thromboplastin C Plus (TPC). All POC INRs showed strong correlation with both laboratory methods, with correlation coefficients of >0.900. All POC methods demonstrated a significant (p 0.93), but there were still significant (p

Brief reversal of oral anticoagulant therapy is frequently necessary prior to minor surgery or invasive procedures. We sought to determine the effect of an oral dose of 2.0 mg of vitamin K(1) on the international normalized ratio (INR) among patients with a stable therapeutic INR who were maintained on their daily dose of warfarin. We prospectively studied a convenience cohort of patients attending an anticoagulation clinic who had either just completed treatment for venous thromboembolism or were receiving prophylaxis for atrial fibrillation, cardiomyopathy, or peripheral vascular disease. Each patient received an oral dose of 2.0 mg of aqueous vitamin K(1). Serial INR measurements were taken over 1 week. There was wide variation in the INR response between patients, from no change to complete reversal of anticoagulation. The effect also varied widely over time. There was a significant inverse correlation between the fall in logarithm of the INR and the daily warfarin dose required to achieve an INR value of 2.5 (r=-0.52, p=0.011). Use of a 2.0 mg oral dose of vitamin K(1) does not reliably reverse (correct) a therapeutic INR in patients maintained on their daily dose of warfarin.

Background This study aimed to describe the incidence of atrial fibrillation (AF) among older adults during 3 years of follow-up. Methods and Results In this cohort study, 5201 adults ≥65 years old were examined annually on four occasions between June 1989 and May 1993. At baseline, participants answered questionnaires and underwent a detailed examination that included carotid ultrasound, pulmonary function tests, ECG, and echocardiography. Subjects with a pacemaker or AF at baseline (n=357) were excluded. New cases of AF were identified from three sources: (1) annual self-reports, (2) annual ECGs, and (3) hospital discharge diagnoses. Cox proportional-hazards models were used to assess baseline risk factors as predictors of incident AF. Among 4844 participants, 304 developed a first episode of AF during an average follow-up of 3.28 years, for an incidence of 19.2 per 1000 person-years. The onset was strongly associated with age, male sex, and the presence of clinical cardiovascular disease. For men 65 to 74 and 75 to 84 years old, the incidences were 17.6 and 42.7, respectively, and for women, 10.1 and 21.6 events per 1000 person-years. In stepwise models, the use of diuretics, a history of valvular heart disease, coronary disease, advancing age, higher levels of systolic blood pressure, height, glucose, and left atrial size were all associated with an increased risk of AF. The use of β-blockers and high levels of alcohol use, cholesterol, and forced expiratory volume in 1 second were associated with a reduced risk of AF. Conclusions The incidence of AF in older adults may be higher than estimated by previous population studies. Left atrial size appears to be an important risk factor, and the control of blood pressure and glucose may be important in preventing the development of AF.

The compound eye of the tobacco hornworm mothManduca sextacontains green-, blue-, and ultraviolet-sensitive photoreceptors. Electroretinogram spectral-sensitivity measurements were recorded from different regions of the retina in order to broadly map the distribution of the three receptor types. The relative contribution of the three receptors to spectral-sensitivity curves was estimated by fitting theoretical curves based on the absorption spectra of the three rhodopsins. This analysis indicated that the dorsal retina is green and ultraviolet dichromatic, with green-sensitive cells greatly predominating. The ventral retina is trichromatic with a substantial population of blue- and ultraviolet-sensitive receptors. We previously showed that flower visitation for nectar feeding is mediated mainly by blue-sensitive cells. Their localization in the ventral retina seems an appropriate adaptation of the receptor mosaic, since the moths hover above flowers as they feed.

The best management practice of moving manure P and N with turfgrass sod across watershedboundaries was evaluated. The export and import of manure P or N with sod and soil-test Pconcentration in sod were related to P loading and runoff water quality. Up to 274 kg ha-1 of soilP and 72% of applied manure P were removed in a single sod harvest from a dairy wasteapplication site. Total dissolved P (TDP) losses in runoff after import of manure-grown sod on an8.5% slope were directly related to soil-test P of sod. Variation of soil-test P in samples ofimported sod extracted in water, 10 mM CaCl2, and Olsen, Mehlich III, and acidified ammoniumacetate-EDTA solutions accounted for > 77% of variation of TDP concentration in runoff ofsimulated rain. The soil-test P values could be used alone or as a component of a P index toevaluate impacts of manure-grown sod imports on water quality.

Hospital-acquired venous thromboembolism (HA-VTE, VTE occurring during a hospitalization) codes in hospital billing data are often used as a surrogate for hospital-associated VTE events occurring during or up to 30 days after a hospitalization, which are more difficult to measure.Establish the incidence and composition of HA-VTE/superficial venous thrombosis (SVT) coded in a large cohort of medical patients.Retrospective analysis of discharges.Eighty-three academic medical centers in UHC (formerly University HealthSystem Consortium).Patients with medical diagnoses hospitalized2 days between October 1, 2009, and March 31, 2011.Incidence and anatomic location of HA-VTE codes, defined as International Classification of Diseases, Ninth Revision, Clinical Modification codes for VTE coupled to a present-on-admission indicator flag set to "No."Among 2,525,068 medical hospitalizations, 12,847 (0.51%) cases had ≥1 thrombotic code; 2449 (19.1%) with pulmonary embolism (PE), and 3848 (30%) with lower-extremity deep venous thrombosis (LE-DVT) without PE. Upper-extremity DVT (2893; 22.5%) and SVT (3248; 25.3%) comprised the bulk of remaining cases. Among cases with HA-PE/LE-DVT, 34.3% had cancer, 47.8% received care in an intensive care unit, 78% had severe or extreme severity of illness, and 16.5% died in the hospital. Overall, 54.9% of the patients who developed a HA-PE/LE-DVT had been started on VTE pharmacoprophylaxis on hospital day 1 or 2.At academic centers, HA-VTE/SVT is coded in 0.51% of medical inpatients, and HA-PE/LE-DVT is coded in half of those. Most patients with HA-PE/LE-DVT are severely ill and develop VTE despite receiving prophylaxis.