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© 2013 Wolters Kluwer Health, Inc. All rights reserved. Background: Symptomatic venous thromboembolism is a common postoperative complication. The Agency for Healthcare Research and Quality (AHRQ) has developed a Patient Safety Indicator 12 to assist hospitals, payers, and other stakeholders to identify patients who experienced this complication. Objectives: To determine whether newly created and recently redefined ICD-9-CM codes improved the criterion validity of Patient Safety Indicator 12, based on new samples of records dated after October 2009. Research Design, Subjects, Measures: Two sources of data were used: (1) UHC retrospective case-control study of risk factors for acute symptomatic venous thromboembolism occurring within 90 days after total knee arthroplasty in teaching hospitals; (2) chart abstraction data by volunteer hospitals participating in the Validation Pilot Project of the AHRQ. Results: In the UHC sample, the positive predictive value (PPV) was 99% (125/126) and the negative predictive value was 99.4% (460/463). In the AHRQ sample, the overall PPV was 81% (126/156). Conclusions: The PPV based on both samples shows substantial improvement compared with the previously reported PPVs of 43%-48%, suggesting that changes in ICD-9-CM code architecture and better coding guidance can improve the usefulness of coded data.

BACKGROUND Hospital-acquired venous thromboembolic (HA-VTE) events are an important, preventable cause of morbidity and death, but accurately identifying HA-VTE events requires labor-intensive chart review. Administrative diagnosis codes and their associated "present-on-admission" (POA) indicator might allow automated identification of HA-VTE events, but only if VTE codes are accurately flagged "not present-on-admission" (POA=N). New codes were introduced in 2009 to improve accuracy. METHODS We identified all medical patients with at least 1 VTE "other" discharge diagnosis code from 5 academic medical centers over a 24-month period. We then sampled, within each center, patients with VTE codes flagged POA=N or POA=U (insufficient documentation) and POA=Y or POA=W (timing clinically uncertain) and abstracted each chart to clarify VTE timing. All events that were not clearly POA were classified as HA-VTE. We then calculated predictive values of the POA=N/U flags for HA-VTE and the POA=Y/W flags for non-HA-VTE. RESULTS Among 2070 cases with at least 1 "other" VTE code, we found 339 codes flagged POA=N/U and 1941 flagged POA=Y/W. Among 275 POA=N/U abstracted codes, 75.6% (95% CI, 70.1%-80.6%) were HA-VTE; among 291 POA=Y/W abstracted events, 73.5% (95% CI, 68.0%-78.5%) were non-HA-VTE. Extrapolating from this sample, we estimated that 59% of actual HA-VTE codes were incorrectly flagged POA=Y/W. POA indicator predictive values did not improve after new codes were introduced in 2009. CONCLUSIONS The predictive value of VTE events flagged POA=N/U for HA-VTE was 75%. However, sole reliance on this flag may substantially underestimate the incidence of HA-VTE.

Background The extent to which vena cava filter (VCF) use varies between hospitals in the management of acute venous thromboembolism (VTE) is not clear. Methods We conducted a retrospective observational study that compared the frequency of VCF use among California hospitals from January 1, 2006, through December 31, 2010. Using administrative hospital discharge data, we followed explicit criteria to identify nontrauma patients with acute VTE, and determined the frequency of VCF placement in each of the hospitals that admitted more than 55 VTE patients. Multivariable hierarchical regression models to predict VCF use included important clinical and demographic variables as fixed effects and hospital as a random effect. Results Among the 263 hospitals included, 130 643 acute VTE hospitalizations occurred with the placement of 19 537 VCFs (14.95%). Variation in the percentage of acute VTE hospitalizations that included VCF placement was very high, from 0% to 38.96% (interquartile range, 6.23%-18.14%), with 18.49% of the observed variation due to differences among the hospitals that provided care. Significant clinical predictors of VCF use included acute bleeding at the time of admission (odds ratio, 3.4 [95% CI, 3.2-3.6]), a major operation after admission for VTE (3.4 [3.3-3.5]), presence of metastatic cancer (1.7 [1.6-1.8]), and extreme severity of illness (2.5 [2.3-2.7] vs mild). Insertion of VCFs occurred more frequently than expected in 109 hospitals and less frequently in 59. Hospital characteristics associated with VCF use included a small number of beds (odds ratio, 0.2 [95% CI, 0.2-0.4], 400 beds), a rural location (0.4 [0.2-0.5]), and other private vs Kaiser hospitals (1.5 [1.1-2.0]). Use of VCFs varied widely even in geographically proximate areas. Conclusions The frequency of VCF use in patients with acute VTE varied widely and depended on which hospital provided the care, even after adjusting for clinical and socioeconomic factors. Further research is needed to determine whether this variation is associated with local cultural differences between hospitals or with differences in the availability of interventional radiologists or specialists, or whether it reflects the absence of high-quality evidence that VCFs are effective.

Article-at-a-Glance Background The Joint Commission Venous Thromboembolism (VTE) National Hospital Inpatient Quality Measure VTE-5 outlines four criteria for discharge patient education when starting anticoagulation (usually, warfarin) therapy. The criteria do not specify content regarding patient recognition of potentially dangerous warfarin-related scenarios. A study was conducted to investigate how well patients assess the risks and consequences of potential warfarin-related safety threats. Methods From an adult population on long-term warfarin, 480 patients were randomly selected for a telephone-based survey. Warfarin-knowledge questions were drawn from a previous survey; warfarin-associated risk scenarios were developed via focus interviews. Expert anticoagulation pharmacists categorized each scenario as urgent, moderately urgent, or not urgent, as did survey participants. Results For the 184 patients (38% completion rate), the mean knowledge score was 69% (standard deviation [SD], 0.20). Overall classification accuracy of situational urgency was 59% (95% confidence interval [CI], 57.3%–60.3%). Respondents overestimated non-urgent-severity situations 23% of the time (95% CI, 20.8%–24.7%), while underestimating urgent-severity situations 21% of the time (95% CI, 19.0%–23.9%). A significant percentage of patients failed to recognize the urgency of stroke symptoms (for example, loss of vision), the risk of bleeding after incidental head trauma, or medication mismanagement. Conclusions Despite fair factual warfarin knowledge, participants did not appear to recognize well the clinical severity of warfarin-associated scenarios. Warfarin education programs should incorporate patient-centered strategies to teach recognition of high-risk situations that compromise patient safety.

Phoma macrostoma is a fungus being developed as a natural herbicide (bioherbicide) for selective weed control in turfgrass. Previous research with this product is limited to cool-season turfgrass, and information is limited on appropriate application rates or efficacy at higher temperatures and weeds associated with warmseason turf. Field studies were conducted in College Station, TX to evaluate efficacy of the bioherbicidefor slender aster (Aster subulatusvar. ligulatus Shinners) control in common bermudagrass. In 2011, applications of 128 g m-2, split-applied between days 0 and 28 resulted in good control (88%); however, 64 and 32 g m-2 rates failed to provide adequate control. In 2012, single applications of 128 gave excellent control (94%), while the 32 and 64 g m-2 rates gave poor control (54 and 68%, respectively) relative to untreated plots.No injury to common bermudagrass occurred in either study.

Because of the consequent lack of photopigment chromophore, carotenoid/ retinoid (vitamin A) deprivation during the larval period of Drosophila leads to decreased rhodopsin in adult photoreceptors. Decreased density of P-face particles in photoreceptor membrane (rhabdomeric microvilli) is a prominent ultrastructural feature of this rhodopsin deficiency. When adults are fed carotenoid, the rhabdomeric P-face particle density-which reflects the concentration of rhodopsin-increases halfway to the replete control level during the first 12 hours, and is fully restored by 2 days. Based on freeze-fracture replicas, there is a continuity of membrane between rhabdomeric microvilli and the parent retinula cell. That confluence is relevant to turnover of photoreceptive membrane. Microvillar and retinula cell P-face particle densities covary. The relevance of the demonstration of rapid recovery from chromophore depletion is discussed in relation to hypotheses that the chromophore and/or related retinoids regulate opsin gene transcription, and/or post-translational processing and deployment from the endoplasmic reticulum to the rhabdomere.

Importance Deep vein thrombosis (DVT) isolated to the calf veins (distal to the popliteal vein) is frequently detected with duplex ultrasonography and may result in proximal thrombosis or pulmonary embolism (PE). Objective To evaluate whether therapeutic anticoagulation is associated with a decreased risk for proximal DVT or PE after diagnosis of an isolated calf DVT. Design, Setting, and Participants All adult patients with ultrasonographic detection of an isolated calf DVT from January 1, 2010, to December 31, 2013, at the Vascular Laboratory of the University of California, Davis, Medical Center were included. Patients already receiving therapeutic anticoagulation and those with a chronic calf DVT, a contraindication to anticoagulation, prior venous thromboembolism within 180 days, or diagnosis of a PE suspected at the time of calf DVT diagnosis were excluded. Data were analyzed from August 18, 2015, to February 14, 2016. Exposures Intention to administer therapeutic anticoagulation. Main Outcomes and Measures Proximal DVT or PE within 180 days of the diagnosis of the isolated calf DVT. Results From 14 056 lower-extremity venous duplex studies, we identified 697 patients with an isolated calf DVT and excluded 313 of these. The remaining 384 patients were available for analysis (222 men [57.8%]; 162 women [42.2%]; mean [SD] age, 60 [16] years). The calf DVT involved an axial vein (anterior tibial, posterior tibial, or peroneal) in 243 patients (63.2%) and a muscular branch (soleus or gastrocnemius) in 215 (56.0%). Physicians attempted to administer therapeutic anticoagulation in 243 patients (63.3%), leaving 141 control participants. Proximal DVT occurred in 7 controls (5.0%) and 4 anticoagulation recipients (1.6%); PE, in 6 controls (4.3%) and 4 anticoagulation recipients (1.6%). Therapeutic anticoagulation was associated with a decreased risk for proximal DVT or PE at 180 days (odds ratio [OR], 0.34; 95% CI, 0.14-0.83) but an increased risk for bleeding (OR, 4.35; 95% CI, 1.27-14.9), findings that persisted after adjustment for confounding factors (ORs, 0.33 [95% CI, 0.12-0.87] and 4.87 [95% CI, 1.37-17.3], respectively) and sensitivity analyses. Conclusions and Relevance Rates of proximal DVT or PE are low after isolated calf DVT. Therapeutic anticoagulation is associated with a reduction of these outcomes but an increase in bleeding.

Declining availability of water for landscape irrigation has increased the need for drought-resistant turfgrasses. Though drought-resistance mechanisms are known to include deep rooting in some plants, little is known concerning zoysiagrass rooting characteristics. This study was conducted to determine if differences in rooting parameters exist among zoysiagrasses, and if they are associated with drought resistance. Twenty-five zoysiagrasses cultivars and species [Zoysia japonica Steud., Z. matrella (L.) Merr., and Z. japonica Steud. x Z. tenuifolia Willd. ex Trin.] were studied in polyethylene tubes in a glasshouse. Differences were observed for average maximum root depth (AMRD), total root weight, and root numbers and weights at increasing 100-mm depth increments. Average maximum root depth was positively correlated with total root weight and root number and weight at increasing 100-mm depth increments. Grasses with superior AMRD, total root weight, and root numbers at deeper profile depths (300-500 mm) included QT2047, El Toro, DALZ8512, TC5018, Meyer, DALZ8514, and DALZ8516 In a previously reported field experiment, 11 of the 25 zoysiagrasses were rated for percent of plot area covered by green turfgrass (an indicator of drought resistance) under three levels of irrigation (0, 35, and 100% of turfgrass evapotranspiration [ET]). Average maximum root depth, total root weight, and root numbers at 200-, 300-, and 400-mm depths in polyethylene root tubes were positively correlated with percent green plot cover in the field under deficit irrigation (0 and 35% ET), indicating that rooting depth, weight, and branching at lower depths are important drought-resistance mechanisms in zoysiagrasses.

Source Citation Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315-52. 26867832

International audience; BACKGROUND: Post-thrombotic syndrome (PTS) is the most frequent complication of deep vein thrombosis (DVT). Its diagnosis is based on clinical characteristics. However, symptoms and signs of PTS are non-specific, and could result from concomitant primary venous insufficiency (PVI) rather than DVT. This could bias evaluation of PTS. METHODS: Using data from the REVERSE multicenter study, we assessed risk factors for PTS in patients with a first unprovoked unilateral proximal DVT 5-7 months earlier who were free of clinically significant PVI (defined as absence of moderate or severe venous ectasia in the contralateral leg). RESULTS: Among the 328 patients considered, the prevalence of PTS was 27.1%. Obesity (odds ratio [OR] 2.6 [95% confidence interval (CI) 1.5-4.7]), mild contralateral venous ectasia (OR 2.2 [95% CI 1.1-4.3]), poor International Normalized Ratio (INR) control (OR per additional 1% of time with INR < 2 during anticoagulant treatment of 1.018 [95% CI 1.003-1.034]) and the presence of residual venous obstruction on ultrasound (OR 2.1 [95% CI 1.1-3.7]) significantly increased the risk for PTS in multivariable analyses. When we restricted our analysis to patients without any signs, even mild, of contralateral venous insufficiency (n = 244), the prevalence of PTS decreased slightly to 24.6%. Only obesity remained an independent predictor of PTS (OR 2.6 [95% CI 1.3-5.0]). Poor INR control and residual venous obstruction also increased the risk, but the results were no longer statistically significant (OR 1.017 [95% CI 0.999-1.035] and OR 1.7 [95% CI 0.9-3.3], respectively). CONCLUSIONS: After a first unprovoked proximal DVT, obese patients and patients with even mild PVI constitute a group at increased risk of developing PTS for whom particular attention should be paid with respect to PTS prevention. Careful monitoring of anticoagulant treatment may prevent PTS.

International audience; BACKGROUND: Post-thrombotic syndrome (PTS) is the most frequent complication of a deep vein thrombosis (DVT). International guidelines recommend assessing PTS with the Villalta scale, a clinical measure that incorporates venous symptoms and signs in the leg ipsilateral to a DVT. However, these signs and symptoms are not specific for PTS and their prevalence and relevance in the contralateral leg have not previously been studied. METHODS: Using data from the REVERSE prospective multicentre cohort study, we compared the Villalta total score and prevalence of venous signs and symptoms in the ipsilateral vs. contralateral leg in patients with a first, unilateral DVT 5 to 7 months previously. RESULTS: Among the 367 patients analyzed, the mean Villalta score was higher in the ipsilateral than in the contralateral leg (mean ± standard deviation [SD] 3.7 [3.4] vs. 1.9 [2.5], respectively; P4) was present in 31.6% (n=116) of patients. Among these, 39.7% (n=46) of patients had a Villalta score >4 in the contralateral leg, and the distribution of Villalta symptoms and signs components was similar between the legs. CONCLUSIONS: Villalta scores in the ipsilateral and contralateral legs are strongly correlated. Almost half of cases considered to be PTS might reflect pre-existing symptomatic chronic venous disease. Alternatively, patients with pre-existing chronic venous disease might be more prone to developing PTS after a DVT. Performing a bilateral assessment of Villalta scores at the acute phase of DVT could be of clinical interest from a diagnostic, prognostic and therapeutic point of view.

Background: Over the last decade, the number of endovascular procedures for peripheral arterial disease (PAD) has surpassed the number of open surgical bypass procedures. Yet, the effectiveness of endovascular procedures in comparison to open procedures is not fully understood. The aim of this study was to compare the outcomes of open and endovascular procedures for PAD in a population-based study. Methods: We used the Patient Discharge Data (PDD) from California’s Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. The PDD is linked to the death database. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate between the endovascular and open groups adjusting for age, gender, race/ethnicity, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions. 25,635 (61.7%) underwent endovascular procedures and 15,872 underwent open procedures. There were 17,942 women (43.2%) and 23,565 men. 4,094 (25.8%) of the patients in the open group and 8,593 (33.5%) of patients in the endovascular group underwent reintervention for PAD. The 12-month reintervention rate was significantly associated with endovascular procedures ( p p =0.154); the hazard ratio was 1.07 in the endovascular group (95%CI 0.97-1.15) compared to the open group. Conclusions: Nearly a third of all patients who undergo a lower extremity arterial revascularization procedure require reintervention within the first year. Our results demonstrate that although endovascular procedures are more likely than open procedures to require reintervention, the amputation-free survival is not improved with endovascular procedures. Cost analysis of multiple reinterventions can be beneficial in understanding the cost-effectiveness of endovascular procedures. Further research is also needed to understand patient characteristics that distinguish patients who benefit more from endovascular procedure for PAD.

Background: Endovascular procedures are being increasingly performed for peripheral arterial disease (PAD), exceeding the number of open surgical bypass procedures. Previously, it had been demonstrated that there is a disparity in access to and outcomes of PAD treatment based on race/ethnicity. Blacks have been shown to be more likely to undergo amputation and less likely to undergo revascularization procedures for limb salvage compared to whites. The aim of this study was to determine if there is disparity in the outcomes of endovascular PAD procedures based on race/ethnicity in this contemporary population-based study. Methods: We used the Patient Discharge Data (PDD) from California's Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open bypass procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate among the racial groups adjusting for age, gender, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions; 25,635 (61.7%) underwent endovascular procedures. There were 11,389 women (44.2%) and 14,246 men. This cohort included 17,433 (68%) non-Hispanic (NH) whites, 4,417 (17.3%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others. The Hazard ratio for amputation or death was 1.69 in Hispanics (95%CI 1.50-1.89) and 1.65 in blacks (95%CI 1.42-1.92) compared to NH whites ( p p =0.001). The odds ratio for 12-month reintervention was 1.18 in Hispanics (95% CI 1.06-1.31) and 1.08 in blacks (95%CI 0.95-1.22) compared to NH whites following endovascular procedures. Conclusions: Our study demonstrates that Hispanics and blacks have worse amputation-free survival than NH whites following endovascular PAD procedures in this contemporary state-wide database. However, Hispanics and blacks were more likely than NH whites to undergo reintervention. Further research is needed to understand if the higher reintervention rate is secondary to more severe illness and/or poor access to proper follow-up care and cardiovascular risk factor modifications.

Composted organic materials used to stabilize roadside embankments in Texas promote rapid revegetation of soils disturbed by construction activities. Yet, adding compost to soil may increase total and soluble plant nutrients available for loss in runoff water. Composted municipal biosolids and dairy manure products were applied to soils in Texas according to prescribed Texas Department of Transportation specifications for stabilizing roadside soils. The specifications included a method for incorporating compost into soils prior to seeding or applying a compost and woodchip mix over a disturbed soil and then seeding. Applying compost and woodchips over the soil surface limited sediment losses (14 to 32 fold decrease) compared to incorporating compost into the soil. Yet, the greatest total phosphorus and nitrogen losses in runoff water occurred from soils where the compost and woodchip mix was applied. The greatest losses of soluble phosphorus also occurred when the compost and woodchip mix was applied. In contrast, nitrate-nitrogen losses in runoff were similar when compost was incorporated in the soil or applied in the woodchip mix. Compost source affected the nutrient losses in runoff. While the composted municipal biosolids added greater nutrient loads to the soil, less nutrient loss in runoff occurred.

International audience; Background: Risk factors for the post-thrombotic syndrome (PTS) remain poorly understood. Objectives: In this multinational multicenter study, we evaluated whether subtherapeutic warfarin anticoagulation was associated with development of PTS. Methods: Patients with a first unprovoked deep venous thrombosis (DVT) received standard anticoagulation for 5-7 months and were then assessed for PTS. The time in the therapeutic range was calculated from the international normalized ratio (INR) data. An INR below 2, more than 20% of the time, was considered as subtherapeutic anticoagulation. Results: Of the 349 patients enrolled, 97 (28%) developed PTS. The overall frequency of PTS in patients with subtherapeutic anticoagulation was 33.5%, compared to 21.6% in those with an INR below 2 for ≤20% of the time (p=0.01). During the first 3 months of therapy, the odds ratio (OR) for developing PTS if a patient had subtherapeutic anticoagulation was 1.78 (95% CI 1.10-2.87). After adjusting for confounding variables, the OR was 1.84 (95% CI 1.13-3.01). Corresponding ORs for the full period of anticoagulation were 1.83 (95% CI 1.14-3.00) [crude] and 1.88 (95% CI 1.15-3.07) [adjusted]. Conclusion: Subtherapeutic warfarin anticoagulation after a first unprovoked DVT was significantly associated with the development of PTS. © 2012 International Society on Thrombosis and Haemostasis.

Objective: To evaluate a computerized scheduling model that employs nonlinear optimization to recommend optimal follow-up intervals for patients taking warfarin.

Branching is regulated by environmental signals including phytochrome B (phyB)-mediated responses to the ratio of red to far red light. While the mechanisms associated with phytochrome regulation of branching are beginning to be elucidated, there is little information regarding other light signals, including photosynthetic photon flux density (PPFD) and how it influences phytochrome-mediated responses. This study shows that Arabidopsis (Arabidopsis thaliana) branching is modified by both varying PPFD and phyB status and that significant interactions occur between these variables. While phyB deficiency decreased branching when the PPFD was low, the effect was suppressed by high PPFD and some branching aspects were actually promoted. Photosynthesis measurements showed that PPFD may influence branching in phyB-deficient plants at least partially through a specific signalling pathway rather than directly through energy effects on the shoot. The expression of various genes in unelongated buds of phyB-deficient and phyB-sufficient plants grown under high and low PPFD demonstrated potential roles for several hormones, including auxin, cytokinins and ABA, and also showed imperfect correlation between expression of the branching regulators BRC1 and BRC2 and bud fate. These results may implicate additional undiscovered bud autonomous mechanisms and/or components contributing to bud outgrowth regulation by environmental signals.

We report a new method to diagnose acute pulmonary embolism (PE) by single photon emission computerized tomography (SPECT) after administration of (99m)Tc-labeled anti-D-dimer (DI-80B3) monoclonal antibody Fab' fragments. This novel technique provides an additional approach to diagnosing PE in patients for whom other methods are nondiagnostic or contraindicated.We performed a prospective, multicenter study to investigate the sensitivity and specificity of (99m)Tc-DI-80B3/SPECT in patients with suspected acute PE.Subjects with a moderate to high clinical probability of PE or a positive D-dimer test underwent a PE-protocol contrast-enhanced multidetector thoracic computed tomography (CT) scan as well as (99m)Tc-DI-80B3/SPECT (0.5 mg (99m)Tc-DI-80B3 intravenously followed by a thoracic SPECT 2.5 h later). Separate and independent adjudication committees, blinded to clinical data and other test results, interpreted the (99m)Tc-DI-80B3/SPECT scans (PE detected as foci of abnormally increased (99m)Tc uptake) and the thoracic CT scans using Prospective Investigation of Pulmonary Embolism Diagnosis II criteria.Of the 52 patients who were enrolled and completed both tests, 42 had both evaluable SPECT scans and thoracic CT scans. Using the criterion standard (thoracic CT scan) there were 21 patients with PE and 21 without. (99m)Tc-DI-80B3/SPECT had a sensitivity of 76.2% (95% confidence interval, 52.8-91.8%) and a specificity of 90.5% (95% confidence interval, 69.8-98.8%). Treatment-related serious adverse events did not occur.(99m)Tc-DI-80B3/SPECT was sensitive and specific for acute PE in subjects with moderate to high clinical probability of PE or a positive D-dimer test. (99m)Tc-DI-80B3/SPECT demonstrated an acceptable safety profile and avoids exposure to contrast.

This report documents IDA's examination of the infusion of language, regional and cultural (LRC) content across the Services, from officer and enlisted accession programs through General and Flag Officer Professional Military Education (PME). This task involved a thorough literature review and examination of on-line resources, as well as an extensive series of site visits and interviews. In our examination of PME, we focused on three primary goals: (1) to develop a robust understanding of the PME landscape as it relates to LRC content, (2) to identify best practices, as well as ascertain content gaps and hurdles faced by PME Institutions (PMEI) in terms of the infusion of LRC content, and (3) to determine the extent to which LRC-related educational needs are met by PMEI. Throughout DoD, tremendous effort is being expended in regards to the inclusion of LRC content in PME and accession programs. While each Service is moving down the path of infusing LRC in PME, they are moving at divergent speeds, are at different stages, and have different views on the desired destination. In this report, we highlight best practices, identify trends, and also raise potential areas of concern.

Creeping bentgrass (Agrostis palustris Huds.) often requires daily irrigation and syringing to persist in turf areas in warmer environments with high evapotranspiration rates. Turfgrass performance could be enhanced if turgor maintenance under decreasing soil moisture levels could be incorporated into new bentgrass cultivars. The objectives of this study were to determine: (i) if genetic variation in leaf water potential (LWP) existed among creeping bentgrass clones under declining soil moisture, (ii) if LWP was associated with maintenance of growth under declining soil moisture levels, and (iii) if genotypic variation existed in water-relation characteristics, including components of LWP, as determined by a hydraulic press

beta-emitting 166Ho (t1/2 = 26.78 hours, E(beta)max = 1.8 MeV) complexed with the phosphonic acid chelator, 1,4,7,10 tetraazacyclododecane-1,4,7,10-tetra(methylene phosphonic acid) (DOTMP) at a ligand-to-metal ratio of 1.5:1 binds to bone. This radioactive complex is a marrow-ablating radiopharmaceutical that appears useful for preparation of bone marrow (BM) transplant recipients without the morbidity usually associated with total body irradiation preparatory regimens. We have found with seven splenectomized young adult beagle dogs that a 166Ho radiopharmaceutical dosage of 370 MBq/kg body weight provides an initial skeletal radioactivity burden of at least 1.5 GBq/kg skeleton and results in complete ablation of hematopoietic marrow cell populations within 7 days. The beta particle flux distribution in BM-forming skeletal tissue is not uniform. Red marrow radiation doses varied from 30 to 115 Gy as estimated by direct radioassay and autoradiographic analyses of both bone biopsies and postmortem samples; the median value of 61 Gy agreed with our theoretical expectations. In vivo radioactivity distribution was evaluated with nuclear imaging methods. Apparently, normal hematopoiesis was restored in three dogs with autologous BM transplants performed 5 to 6 days after administration of the marrow ablative radiopharmaceutical, 166Ho-DOTMP. BM biopsies at 7 to 10 months posttransplantation indicate continued normal hematopoietic activity.

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.

International audience; INTRODUCTION: Case-control studies suggest that elevated lipoprotein (a) (Lp(a)) is a risk factor for first venous thromboembolism (VTE). Lp(a) has not been prospectively investigated as a possible risk factor for recurrent VTE in first unprovoked VTE patients. We sought to determine if serum Lp(a) levels in patients with unprovoked VTE who discontinue anticoagulants after 5 to 7 months of therapy predict VTE recurrence in a prospective cohort study. MATERIALS AND METHODS: Serum Lp(a) measurements were obtained from 510 first unprovoked VTE patients treated for 5 -7 months with anticoagulants in a 12 center study. Patients were subsequently followed for a mean of 16.9 months (SD+/-11.2) for symptomatic VTE recurrence which was independently adjudicated with reference to baseline imaging. RESULTS: There was no significant association between Lp(a) as a continuous variable and recurrent VTE nor in gender stratified subgroups. No statistically significant differences were observed in the median Lp(a) concentrations between patients who recurred and those who did not recur (median (interquartile range): 0.09 g/L (0.17) versus 0.06 g/L (0.11) respectively; p=0.15). The Lp(a) cut-off point of 0.3g/L was not significantly associated with recurrent VTE for the overall population nor in gender stratified subgroups. CONCLUSIONS: Elevated serum Lp(a) does not appear to be associated with recurrent VTE in patients with history of first unprovoked VTE and may not play a role in identifying patients with unprovoked VTE at high risk of recurrence. There was no optimal predictive threshold for the overall population or for sex sub-groups and Lp(a)>or=0.3 g/L was not a significant predictor of recurrent VTE.

International audience; BACKGROUND: Previous studies are mixed as to whether patients with unprovoked pulmonary embolism (PE) have a higher rate of venous thromboembolism (VTE) recurrence after anticoagulation is discontinued than patients with unprovoked deep vein thrombosis (DVT). OBJECTIVES: To determine whether patients with unprovoked PE have a higher rate of VTE recurrence than patients with unprovoked DVT in a prospective multicenter cohort study. PATIENTS/METHODS: Six hundred and forty-six patients with a first episode of symptomatic unprovoked VTE were treated with heparin and subsequent oral anticoagulation for 5-7 months, and were followed every 6 months for recurrent VTE after their anticoagulant therapy was discontinued. RESULTS: Of 646 patients, 194 had isolated PE, 339 had isolated DVT, and 113 had both DVT and PE. After a mean of 18 months of follow-up, there were 91 recurrent VTE events (9.5% annualized risk of recurrent VTE in the total population). The crude recurrent VTE rate for the isolated PE, isolated DVT and DVT and PE groups were 7.7%, 16.5% and 17.7%, respectively. The relative risk of recurrent VTE for isolated DVT vs. isolated PE was 2.1 (95% confidence interval 1.2-3.7). CONCLUSIONS: This study has demonstrated that patients with a first episode of unprovoked isolated DVT are 2.1 times more likely to have a recurrent VTE episode than patients with a first episode of unprovoked isolated PE. These findings need to be considered when determining the optimal duration of anticoagulant therapy for patients with unprovoked VTE.

In this paper, we present a new method to diagnose the integrity of concentric neutral wires in underground power distribution cables. This method uses a commercially available 3-axis anisotropic magnetoresistive (AMR) magnetic field sensor chip. The AMR sensor is passed once along the energized cable axially, and the cable's 3-axis magnetic field is plotted as a function of position over the cable. Peaks corresponding to the individual concentric neutral currents are observed, and can be analyzed to diagnose breaks in concentric neutrals due to total corrosion or other means.

The association of malignancies and venous thromboembolism (VTE) is a long held axiom in medicine. A growing number of studies have demonstrated that the risk of VTE associated with the hematological malignancies acute leukemia, lymphoma, and multiple myeloma is considerable. In fact, the incidence associated with these malignancies exceeds that for many solid tumors. Contributing factors include malignancy associated hypercoagulable factors; antineoplastic therapies such as high dose corticosteroids, L-asparaginase, and new immunomodulatory agents; central venous catheters; and hematopoietic growth factors. Primary and secondary pharmacological prophylaxis can be problematic in these patients who are often thrombocytopenic. Strategies to prevent VTE, especially upper extremity catheter-associated thrombosis need to be developed.

BACKGROUND: The incidence, risk factors, time course, and impact on survival of venous thromboembolism (VTE) in a large, population-based study of patients with bladder cancer have not been identified previously. METHODS: The California Cancer Registry was merged with the California Patient Discharge Data Set to determine the incidence of VTE in patients with newly diagnosed bladder cancer within a 6-year period. Cox proportional hazards models were used to determine the risk factors for VTE and the effects of VTE on survival. RESULTS: Among 24,861 patients with bladder cancer, the 2-year incidence of VTE was 1.9%. The highest incidence of VTE occurred in the first 6 months regardless of age, sex, race, tumor stage, or histologic subtype. In a multivariate model, significant risk factors for the development of VTE included major surgery, advancing disease stage, and increasing number of comorbidities. Compared with the general population, the 1-year standardized incidence ratio for VTE in the bladder cancer cohort was 5.3 (95% confidence interval, 4.8-5.9). Among patients with bladder cancer, significant risk factors for death included advancing disease stage, increasing comorbidities, African-American race, nontransitional cell carcinoma histology, and the development of VTE. CONCLUSIONS: Patients with bladder cancer had a 1.9% 2-year incidence of VTE. Metastatic disease was the strongest predictor of both VTE and death. It was noteworthy that cancer-associated surgery was associated with a higher risk of VTE, which differed from the results reported from other studies in solid tumors. VTE was a significant predictor of death in the first 2 years. Cancer 2010. © 2010 American Cancer Society.

Land application of composted municipal biosolids (CMB) enhances soil physical properties and turf establishment. Yet large, volume-based rates of CMB can increase nonpoint source losses of sediment and nutrients from urban soils to surface waters. The objectives were (i) to compare runoff losses of sediment, N, P, and organic C among contrasting establishment treatments for bermudagrass [Cynodon dactylon (L.) Pers. x C. transvaalensis Burtt-Davy, var. Tifway] and (ii) to evaluate relationships between runoff and soil measurements of N, P, and organic C. Three replications of seven establishment treatments were installed on an excavated slope (8.5%) under field conditions. Five treatments comprised sod transplanted from Tifway bermudagrass grown with and without CMB on soil with and without incorporation of CMB. Two other treatments were composed of Tifway sprigged in soil with and without CMB. Runoff from seven natural rain events was channeled into collection tanks for sampling and analysis. Runoff concentrations and mass loss of dissolved P and organic C forms were greater for CMB-amended sod than for sprigs planted in soil with or without CMB or treatments comprising sod established without CMB. In addition, a linear relationship (R 2 = 0.87) was observed between water extractable soil P of sodded and sprigged treatments and concentrations and mass losses of dissolved P in runoff. Transplanted sod reduced sediment loss compared with sprigged treatments and incorporation of CMB reduced sediment loss from sprigged treatments. Incorporation of CMB within soil on which sod grown without CMB was transplanted proved the best option for achieving benefits of CMB while reducing nutrient runoff loss compared to sod transplanted from Tifway grown with CMB.

Background. Coronary artery bypass surgery (CABG) is associated with a significant risk of stroke. Some studies suggest that off-pump CABG (OPCAB) may reduce postoperative stroke rate. We performed this study to evaluate the relationship between postoperative stroke and OPCAB compared with conventional on-pump CABG (CCB) in a recent, large cohort of patients. Methods. Data from the California CABG Outcomes Reporting Program were analyzed in patients who had OPCAB or CCB for isolated CABGs in 2006 to 2007. Two multivariable logistic regression models were developed for the analysis, and the “recycled predictions” method was used to compute risk-adjusted postoperative stroke rates in the two surgical groups. Results. Of 30,426 isolated CABGs, 7,720 (23.7%) were OPCAB. The model developed in the CCB subset indicated that CCB had a lower predicted stroke risk than OPCAB, yet the observed rate of stroke was higher in the CCB subset. The model using both CCB and OPCAB patients revealed that OPCAB was associated with a reduction in postoperative stroke (adjusted odds ratio: 0.76, 95% confidence interval [CI] 0.59 to 0.98). For patients with cardiogenic shock, OPCAB was also associated with a lower risk-adjusted postoperative stroke rate compared with CCB (OPCAB: 3.06%, 95% CI 2.83% to 3.28%; CCB: 4.05%, 95% CI 3.76% to 4.33%, p < 0.001). However, the 793 (11%) OPCAB patients who were converted to CCB intraoperatively had an increased postoperative stroke rate (with conversion: 2.02%, 95% CI 1.04% to 3.00% versus without conversion: 0.96%, 95% CI 0.73% to 1.20%, p < 0.001). Conclusions. The OPCAB was associated with a significantly lower postoperative stroke rate compared with CCB even for older and higher risk patients. However, intraoperative OPCAB to CCB conversion was associated with the highest postoperative stroke rate. (Ann Thorac Surg 2010;90:753‐9) © 2010 by The Society of Thoracic Surgeons

Summary. Background: The incidence of recurrent venous thromboembolism (VTE) varies depending on the nature of the initial provoking risk factor(s). Objectives: To compare the incidence and time course of recurrent VTE after unprovoked VTE vs. VTE provoked by nine different types of surgery. Methods: Retrospective analysis of linked California hospital and emergency department discharge records. Between 1997 and 2007, all surgery-provoked VTE cases had a first-time VTE event diagnosed within 60 days after undergoing a major operation. The incidence of recurrent VTE was compared during specified follow-up periods by matching each surgery-provoked case with three unprovoked cases based on age, race, gender, VTE event, calendar year and co-morbidity. Results: The 4-year Kaplan–Meier cumulative incidence of recurrent VTE was 14.7% (95%CI: 14.2–15.1) in the matched unprovoked VTE group vs. 7.6% (CI: 7.0–8.2) in 11 797 patients with surgery-provoked VTE (P

Tall fescue (Festuca arundinacae Schreb.) is grown as a forage, turfgrass, and conservation grass from the Gulf Coast to Canada in the eastern USA. The presence of endophytes in grasses can confer resistance to insect pests, enhance growth, and improve tall fescue persistence under high temperature and drought stress. Most tall fescue is infected with Acremonium coenophialum Morgan-Jones & Gams, a fungal endophyte (.)

Deficiency of the photopigment chromophore, resulting from carotenoid/retinoid (vitamin A) deprivation, that severely impairs the visual function of Manduca sexta also leads to the hypertrophy of smooth endoplasmic reticulum in the photoreceptors. The excess endomembrane accumulates in the stacked cisternae of myeloid bodies. Although 11-cis retinal promotes substantial recovery of function in the retinas of deprived moths maintained in darkness, the myeloid bodies remain. When such recovering photoreceptors were exposed to light of moderate intensities, the amount of endomembrane diminished to normal levels over a period of several hours, while rhabdomeres grew larger. Since there was no endocytolysis, the myeloid bodies must have provided the membrane for rhabdomere enlargement. Bright light similarly mobilized the myeloid bodies in deprived receptors. Thus the persistence of myeloid bodies in moderately illuminated chromophoredeficient receptors is a consequence of their insensitivity. However, the initial hypertrophy of endomembrane does not appear to result from the lack of adequate stimulation: normal, chromophore-replete photoreceptors maintained in darkness from before the period of retinal development had large rhabdomeres and no myeloid bodies. The development of myeloid bodies during the differentiation of vitamin A-deprived photoreceptors appears to entail an influence of the chromophore at another level of receptor cell function.

Aberrations of photoreceptor ultrastructure resulting from carotenoid/retinoid (vitamin A) deprivation were studied in the retina of Manduca sexta. The syndrome of chromophore deficiency included hypertrophy of smooth endoplasmic reticulum, variable dilation of rhabdomeric microvilli, the insertion of endomembrane fingers into such enlarged microvilli, and the formation of ‘rhabdomeric vacuoles’, intracellular compartments containing microvilli similar to those of the rhabdomere. Retinas were processed either with conventional procedures employing preliminary aldehyde fixation followed by heavy metal postfixation, or by fixation and incubation in unbuffered OsO4. The latter method deposits osmium throughout the endomembrane system, within the rhabdomeric vacuoles, and in the extracellular space of the rhabdom. However, the intravillous fingers were rarely impregnated with osmium, despite their continuity with densely stained cisternae of the smooth endoplasmic reticulum. We suggest that the insertion of endomembrane fingers into dilated microvilli results from a cytoskeleton-mediated link between cisternae of the smooth endoplasmic reticulum and the rhabdomeric membrane, an association that may be important in the turnover of photoreceptor membrane. We interpret endomembrane hypertrophy and development of rhabdomeric vacuoles as symptoms of disturbance in the pathway leading to the assembly of the rhabdomere resulting from reduced synthesis of visual pigment.

Economical, rapid methods are needed to identify drought-tolerant turfgrasses. Objectives of this study were to (i) examine water relations of three tall fescue (Festuca arundinacea Schreb.) selections, (ii) determine the relationship between these characteristics and recovery from water deficit under greenhouse conditions, and (iii) assess the feasibility of using a competitive soil moisture extraction technique to select tall fescue germplasm with superior drought tolerance(.)

Large, volume-based rates of composted biosolids (CB) enhance turfgrass establishment and soil properties, but nonpoint-source runoff losses could occur during production and after transplanting of sod. The objective was to evaluate runoff losses of N, P, sediment, and organic C during establishment of sprigs or transplanted sod of Tifway bermudagrass (Cynodon dactylon L. Pers. X C. transvaalensis Burtt-Davey) with and without CB and aluminum sulfate (Alum). Four treatments comprised Tifway sprigged in a sandy loam soil with and without incorporation of 0.25 m3 CB m−3 soil and Alum. In four additional treatments, sod transplanted from Tifway grown with and without CB was established with and without a surface spray of Alum. During early establishment, CB incorporated in soil before sprigging reduced runoff loss of sediment and total N to amounts comparable to transplanted sod. In contrast, mean runoff losses of total dissolved P and soluble-reactive P (SRP) were more than 50% greater for CB-amended sod than for fertilizer-grown sod or Tifway sprigged in soil with or without CB. Yet, the surface spray of Alum reduced runoff loss from sod more than 88% for SRP and 41% for dissolved organic C. Both surface sprays and incorporation of Alum effectively reduced SRP runoff loss from CB, soil, and turfgrass sources during turfgrass establishment.

Before surgery, most patients receiving oral anticoagulation require temporary cessation of treatment. Physicians sometimes substitute heparin or low-molecular-weight heparin for oral anticoagulation in the perioperative setting ("bridging therapy"). We sought to characterize rates of bridging therapy use at 9 clinical centers to determine the extent to which the use of bridging is explained by clinical characteristics of patients (vs physician style) and to determine the 30-day incidence of thrombotic and bleeding complications.This was a prospective, multicenter, observational study. Periprocedural bridging anticoagulation was classified as none, prophylactic-dose heparin/low-molecular-weight heparin, or full-dose heparin/low-molecular-weight heparin. We collected data on patient and surgery characteristics, anticoagulation management, and thromboembolic and bleeding events.A total of 492 of 497 consecutive patients completed the study; 54%, 14%, and 33% of patients had no, prophylactic, and full (therapeutic) doses, respectively, of heparin/low-molecular-weight heparin postprocedure. Two hospitals treated more than 80% of their patients with full-dose heparin, whereas the remaining 7 hospitals used full-dose heparin in an average of 22% of cases (P.001); this variation persisted after adjustment for patient characteristics. There were 4 thromboembolic events (0.8%) and 16 major bleeding events (3.2%). Full-dose heparin/low-molecular-weight heparin postprocedure was associated with a higher likelihood of major bleeding: adjusted odds ratio 4.4 (95% confidence interval, 1.5-14.7).Management of anticoagulation after an invasive procedure varies widely and is not explained by clinical characteristics of patients alone. The risk of major bleeding is strongly associated with the use of postoperative therapeutic doses of heparin/low-molecular-weight heparin.

Although cancer is recognized as a major risk factor for venous thromboembolism, the exact magnitude of the problem and specific risk factors most strongly associated with the development of VTE is not well defined. Several recent studies have shown that the incidence of VTE is highest in patients who present with metastatic cancer, particularly cancers associated with a high one-year mortality rate, such as pancreatic cancer. The incidence rate of VTE is highest in the first few months after the diagnosis of cancer, and it decreases over time thereafter. For most cancers, it is not clear to what extent undergoing major surgery adds to the already high risk of VTE associated with the presence of the cancer. However, patients with glioma clearly have a very high incidence of VTE soon after they undergo any invasive neurosurgical procedure. Active chemotherapy, the use of erythropoetin agents, and the use of certain anti-cancer therapies such as thalidomide, high-dose steroids, and anti-angiogenic therapy also increase the risk of thrombosis. Similar to patients without cancer, the risk of VTE is higher in patients with coexisting chronic medical illnesses. Development of VTE is clearly associated with decreased survival and this effect is greater among patients initially diagnosed with local or regional stage cancer compared to patients with metastatic cancer.

Recent studies have better defined the epidemiology of venous thromboembolism (VTE) in cancer patients. The incidence is highest in patients who have metastatic disease at the time of presentation and who have fast growing, biologically aggressive cancers associated with a poor prognosis. The incidence is also high in patients with haematological cancers. Other specific risk factors that affect the incidence of VTE include undergoing invasive neurosurgery, the number of underlying chronic co-morbid conditions, and being of Asian/Pacific Islander decent (lower incidence). The incidence is highest in the first few months after diagnosis, which may reflect the biology of the cancer or medical interventions such as major surgery or start of chemotherapy. The development of VTE is clearly associated with decreased survival, and this effect is greater among patients initially diagnosed with local- or regional-stage cancer compared with patients with metastatic cancer, probably because VTE reflects the presence of a biologically aggressive cancer. Finally, a small percentage of patients with idiopathic VTE and no clinical or laboratory evidence of cancer may harbour an aggressive but ‘occult’ malignancy likely causally linked to the development of VTE.

International audience; UNLABELLED: SUMMARY INTRODUCTION: The diagnosis of recurrent venous thromboembolism (VTE) is a challenge in clinical practice. Our objective was to evaluate the safety of a diagnostic strategy utilizing comparison of diagnostic test results with baseline imaging results to rule out suspected recurrent VTE. METHODS: The REVERSE study was a prospective cohort study whose primary aim was to develop a clinical prediction rule for recurrent VTE. We included and followed patients who completed 5-7 months of anticoagulant therapy after a first unprovoked VTE. Suspected cases of recurrent VTE were assessed according to standardized diagnostic criteria based on comparison of diagnostic test results with those obtained at the time of anticoagulant treatment withdrawal. RESULTS: Out of the 398 suspected events, a recurrent VTE was diagnosed in 106 cases (26.6%) and excluded in 292 cases. In 76 cases (19%), the diagnosis of recurrent VTE was excluded on the basis of the fact that no significant change on diagnostic imaging was detected when compared to baseline imaging. During the ensuing 3 months, six patients received anticoagulant therapy after recurrent VTE was excluded, and two were lost to follow-up. Eight of 284 remaining patients in whom recurrent VTE had been excluded, who were not treated and who were not lost to follow-up were diagnosed with subsequent VTE (3-month risk, 2.8%; 95% confidence interval, 1.4-5.5%). Six of these eight patients with subsequent recurrent VTE had a known superficial or distal thrombosis at the time of initial suspected recurrent VTE. CONCLUSION: A diagnostic strategy comparing diagnostic test results obtained at the time of the suspected recurrent event with those obtained at baseline can safely and effectively rule out recurrent VTE in a significant proportion of patients. Registered at http://www.clinicaltrials.gov identifier: NCT00261014.

Larvae of the tobacco hornworm moth Manduca sexta were reared on either a carotenoid-supplemented or a carotenoid-deficient diet. The former yields fortified adults with normal visual function, whereas visual sensitivity and rhodopsin content are reduced by 2−4 log units in the compound eyes of the deprived moths reared on the latter. We characterized the retinoids of fortified retinas and investigated the recovery of visual function in deprived moths that were provided with retinaldehyde as a source of photopigment chromophore. Retinoids were identified and measured by high-performance liquid chromatography (HPLC). Fortified retinas contained mainly 3-hydroxyretinaldehyde (R3); 11-cis R3 predominated in dark-adaptation, all-trans in light-adaptation, indicating that R3 is the photopigment chromophore. No retinoids could be measured in deprived eyes. Retinaldehyde (R1) was delivered to the retinas of deprived moths by “painting” solutions of 11-cis or all-trans R1 in dimethylsulfoxide (DMSO) on the corneal surfaces of the compound eyes or on the head capsule between the eyes. 11-cis R1 induced rapid recovery: during 3 days, sensitivity rose to within a log unit of that measured from fortified animals. By 7 days, sensitivity was close to normal. Although rhodopsin and P-face particle densities of photoreceptor membranes increased, neither rose to the levels found in fortified animals. All-trans R1 induced only a slight increase in sensitivity that could have resulted from some nonspecific isomerization of the all-trans to the 11-cis isomer; we found no evidence for a retinal isomerase that functions in darkness. Small amounts of R3 were measured in recovering retinas, indicating some conversion of R1 to R3. However, the chromophore of most of the rhodopsin that was synthesized must have been R1. It is possible that rhodopsin did not reach normal levels in the retina even after a week of recovery because the normal chromophore R3 was not provided. Although the rhodopsin that initially formed in recovering moths may have resulted from the association of the chromophore with pre-existing opsin, the extent of eventual recovery indicates that opsin synthesis was stimulated by 11-cis R1.

Analyses of the effects of x rays on optical components consisting of a metal reflecting layer, a beryllium heat sink, and a fused silica substrate were done using the computer code xrth. These are compared with calculations for components lacking the beryllium layer. Our analyses show that the addition of the beryllium significantly hardens the system against x rays. The mechanisms for this increased hardness are elucidated by time‐dependent temperature and enthalpy plots. The relative effectiveness of beryllium and diamondlike carbon heat sinks is explored. Complex designs which incorporate reflection‐enhancing dielectric stacks are also discussed. Some comparisons with experiments are given.

In a prospective, randomized clinical trial, we compared the accuracy of warfarin dosage-adjustments predictions using a computer program to the skill of an experienced anticoagulation nurse-specialist. The computer program predicts the steady state warfarin dose by applying Bayesian forecasting techniques to a mathematical model of the dynamic pharmacologic response to warfarin. Fifty patients who were receiving chronic warfarin therapy and who required a dosage adjustment because their prothrombin time was greater than or equal to 2 s away from their target prothrombin time were enrolled. The baseline characteristics of each group were similar, including the mean of the absolute value of the differences between initial prothrombin times and corresponding target prothrombin times. After a new a new warfarin dose was predicted, the prothrombin time was measured at least 7 days after dosage adjustment. Overall, the results in each group were comparable. There was no significant difference between groups and the mean of the absolute value of the differences between final prothrombin times and target prothrombin times, nor was there a difference in the proportion of patients who had a final prothrombin time within 2 s of the target prothrombin time. We conclude that the accuracy of warfarin dosage adjustments made using computer modeling is comparable to the skill of an anticoagulation nurse-specialist.

A population-based cohort was used to determine the incidence and risk factors associated with development of venous thromboembolism (VTE) among Californians diagnosed with acute leukemia between 1993 to 1999. Principal outcomes were deep vein thrombosis in both the lower and upper extremities, pulmonary embolism, and mortality. Among 5394 cases with acute myelogenous leukemia (AML), the 2-year cumulative incidence of VTE was 281 (5.2%). Sixty-four percent of the VTE events occurred within 3 months of AML diagnosis. In AML patients, female sex, older age, number of chronic comorbidities, and presence of a catheter were significant predictors of development of VTE within 1 year. A diagnosis of VTE was not associated with reduced survival in AML patients. Among 2482 cases with acute lymphoblastic leukemia (ALL), the 2-year incidence of VTE in ALL was 4.5%. Risk factors for VTE were presence of a central venous catheter, older age, and number of chronic comorbidities. In the patients with ALL, development of VTE was associated with a 40% increase in the risk of dying within 1 year. The incidence of VTE in acute leukemia is appreciable, and is comparable with the incidence in many solid tumors.

Background: Among patients undergoing isolated coronary artery bypass graft surgery (CABG), the risk of post-operative stroke has not been compared between patients with chronic atrial fibrillation (AF) versus patients with hospital-acquired new-onset AF (new-AF). Methods: Using linked hospital discharge data together with comprehensive clinical data from the California CABG outcomes reporting program, we conducted a retrospective cohort study of all patients undergoing isolated CABG in California between years 2003–2006. Using hospital discharge data, chronic AF was defined as ICD-9-CM =427.31 present at time of admission and during a previous hospitalization. New-AF was defined as a first-ever code for AF that was not present at the time of admission. The risk of stroke < 30 days after surgery, defined using specific ICD-9-CM codes, was analyzed using logistic regression, with adjustment for 15 clinically important stroke risk factors. As a sensitivity analysis, we developed a propensity model for new-AF, and analyzed the risk of stroke after hospital discharge but within 30 days of surgery. Results: Among 61,031 cases, 2081 (3.4%) had chronic AF; 9858 (17%) had new-AF; the 30-day incidence of stroke was 1222 (2.0%). Compared to patients with no-AF, the adjusted risk of stroke in patients with chronic AF was odds ratio (OR) = 1.2 (CI: 0.9 –1.5), whereas for new-AF, it was OR= 1.7 (CI: 1.5–1.9), c-statistic = 0.73. Using the propensity analysis, the risk of stroke after hospital discharge associated with new-AF versus no-AF was similar across quintiles of the risk score (OR range=1.7–1.8). Conclusion: After adjusting for stroke risk factors, patients who developed AF during hospitalization for CABG had an approximately 70% higher risk of stroke within 30 days compared to patients without AF, whereas the risk of stroke in patients with chronic AF was not significantly increased. Interventions that reduce the incidence of new-AF after CABG surgery may reduce the incidence of subsequent stroke.

BACKGROUND: Whether to continue oral anticoagulant therapy beyond 6 months after an "unprovoked" venous thromboembolism is controversial. We sought to determine clinical predictors to identify patients who are at low risk of recurrent venous thromboembolism who could safely discontinue oral anticoagulants. METHODS: In a multicentre prospective cohort study, 646 participants with a first, unprovoked major venous thromboembolism were enrolled over a 4-year period. Of these, 600 participants completed a mean 18-month follow-up in September 2006. We collected data for 69 potential predictors of recurrent venous thromboembolism while patients were taking oral anticoagulation therapy (5-7 months after initiation). During follow-up after discontinuing oral anticoagulation therapy, all episodes of suspected recurrent venous thromboembolism were independently adjudicated. We performed a multivariable analysis of predictor variables (p < 0.10) with high interobserver reliability to derive a clinical decision rule. RESULTS: We identified 91 confirmed episodes of recurrent venous thromboembolism during follow-up after discontinuing oral anticoagulation therapy (annual risk 9.3%, 95% CI 7.7%-11.3%). Men had a 13.7% (95% CI 10.8%-17.0%) annual risk. There was no combination of clinical predictors that satisfied our criteria for identifying a low-risk subgroup of men. Fifty-two percent of women had 0 or 1 of the following characteristics: hyperpigmentation, edema or redness of either leg; D-dimer > or = 250 microg/L while taking warfarin; body mass index > or = 30 kg/m(2); or age > or = 65 years. These women had an annual risk of 1.6% (95% CI 0.3%-4.6%). Women who had 2 or more of these findings had an annual risk of 14.1% (95% CI 10.9%-17.3%). INTERPRETATION: Women with 0 or 1 risk factor may safely discontinue oral anticoagulant therapy after 6 months of therapy following a first unprovoked venous thromboembolism. This criterion does not apply to men. CONTEXTE : La poursuite de l'anticoagulothérapie orale au-delà de six mois suivant une thromboembolie veineuse «spontanée» ne fait pas l'unanimité. Nous avons tenté de d'identifier des facteurs prédictifs cliniques de manière à reconnaître les patients exposés à un risque faible de récurrence de thromboembolie veineuse qui pourraient cesser sans danger leurs anticoagulants oraux. METHODES : Lors d'une étude de cohorte prospective ulticentrique, 646 participants ayant subi une première thromboembolie veineuse majeure spontanée ont été inscrits sur une période de quatre ans. Parmi ces participants, 600 avaient mené à terme 18 mois de suivi en moyenne, en date de septembre 2006. Nous avons recueilli des données sur 69 facteurs prédictifs potentiels de récurrence de thromboembolie veineuse alors que les patients se trouvaient sous anticoagulothérapie orale (5–7 mois après le début). Durant le suivi consécutif à l'arrêt de l'anticoagulothérapie orale, tous les épisodes de récurrence soupçonnée de thromboembolie veineuse ont été évalués de manière indépendante. Nous avons réalisé une analyse multivariée des variables prédictives (p < 0,10) avec une forte concordance inter-observateurs afin d'établir une règle de décision clinique. RESULTATS : Nous avons recensé 91 épisodes confirmés de récurrence de thromboembolie veineuse durant la période de suivi, après l'arrêt de l'anticoagulothérapie orale (risque annuel (9,3 %, IC à 95 %, de 7,7 % à 11,3 %). Les hommes présentaient un risque annuel de 13,7 % (IC à 95 %, de 10,8 % à 17,0 %). Aucune association de facteurs prédictifs cliniques n'a correspondu à nos critères d'identification d'un sous-groupe d'hommes à risque faible. Cinquante-deux pour cent des femmes présentaient 0 ou 1 des caractéristiques suivantes : hyperpigmentation, œdème ou rougeur à l'une ou l'autre de leurs jambes, taux de d-dimère ≥ 250 ug/L pendant le traitement par warfarine, indice de masse corporelle ≥ 30 kg/m2 ou âge ≥ 65 ans. Ces femmes présentaient un risque annuel de 1,6 % (IC à 95 %, de 0,3 % à 4,6 %). Les femmes qui présentaient deux de ces signes ou plus étaient exposées à un risque annuel de 14,1 % (IC à 95 %, de 10,9 % à 17,3 %). INTERPRETATION : Les femmes présentant 0 ou 1 facteur de risque peuvent cesser sans danger leur anticoagulothérapie orale après six mois de traitement à la suite d'une thromboembolie veineuse spontanée. Ce critère ne s'applique pas aux hommes.