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Abstract Maintaining optimal fluid balance is crucial for patients with end-stage renal disease on dialysis, as both fluid overload and excess removal can lead to poor outcomes. Traditional approaches such as physical exam and chest X-ray have limitations when assessing volume status. This review carefully examines the tools that provide more precise options, including lung ultrasound, echocardiography, Venous Excess Ultrasound (VEXUS), bioimpedance analysis (BIA), and passive leg raise (PLR). We discuss the principles, supporting evidence, and practical uses of these techniques differentiating between static and dynamic methods to evaluate ultrafiltration tolerance. By integrating these modern techniques with clinical judgment, nephrologists can optimize fluid management in dialysis patients. While these tools show promise, further research is needed to establish standardized protocols and evaluate their impact on patient-centered outcomes.

Abstract Zinc and plant-derived ligands of the aryl hydrocarbon receptor (AHR) are dietary components affecting intestinal epithelial barrier function. Here, we explore whether zinc and the AHR pathway are linked. We show that dietary supplementation with an AHR pre-ligand offers protection against inflammatory bowel disease in a mouse model while protection fails in mice lacking AHR in the intestinal epithelium. AHR agonist treatment is also ineffective in mice fed zinc depleted diet. In human ileum organoids and Caco-2 cells, AHR activation increases total cellular zinc and cytosolic free Zn2+ concentrations through transcription of genes for zinc importers. Tight junction proteins are upregulated through zinc inhibition of nuclear factor kappa-light-chain-enhancer and calpain activity. Our data show that AHR activation by plant-derived dietary ligands improves gut barrier function at least partly via zinc-dependent cellular pathways, suggesting that combined dietary supplementation with AHR ligands and zinc might be effective in preventing inflammatory gut disorders.

ObjectiveTo determine the clinical and financial feasibility of implementing a poc-EEG system in a community hospital.DesignData from a prospective cohort displaying abnormal mentation concerning for NCSE or rhythmic movements due to potential underlying seizure necessitating EEG was collected and compared to a control group containing patient data from 2020.SettingA teaching community hospital with limited EEG support.PatientsThe study group consisted of patients requiring emergent EEG during hours when conventional EEG was unavailable. Control group is made up of patients who were emergently transferred for EEG during the historical period.InterventionsApplication and interpretation of Ceribell®, a poc-EEG system.Measurement and main results88 patients were eligible with indications for poc-EEG including hyperkinetic movements post-cardiac arrest (19%), abnormal mentation after possible seizure (46%), and unresponsive patients with concern for NCSE (35%). 21% had seizure burden on poc-EEG and 4.5% had seizure activity on follow-up EEG. A mean of 1.1 patients per month required transfer to a tertiary care center for continuous EEG. For the control period, a total of 22 patients or a mean of 2 patients per month were transferred for emergent EEG. Annually, we observed a decrease in the number of transferred patients in the post-implementation period by 10.8 (95% CI: −2.17–23.64, p = 0.1). Financial analysis of the control found the hospital system incurred a loss of $3,463.11 per patient transferred for an annual loss of $83,114.64. In the study group, this would compute to an annual loss of $45,713.05 for an overall decrease in amount lost of $37,401.59. We compared amount lost per patient between historical controls and study patients. Implementation of poc-EEG resulted in an overall decrease in annual amount lost of $37,401.59 by avoidance of transfer fees. We calculated the amount gained per patient in the study group to be $13,936.44. To cover the cost of the poc-EEG system, 8.59 patients would need to avoid transfer annually.ConclusionA poc-EEG system can be safely implemented in a community hospital leading to an absolute decrease in transfers to tertiary hospital. This decrease in patient transfers can cover the cost of implementing the poc-EEG system. The additional benefits from transfer avoidance include clinical benefits such as rapid appropriate treatment of seizures and avoidance of unnecessary treatment as well as negating transfer risk and keeping the patient at their local hospital.

OBJECTIVES:. To compare complications and mortality between patients that required extracorporeal membrane oxygenation (ECMO) support for acute respiratory distress syndrome (ARDS) due to COVID-19 and non-COVID-19 viral pathogens. DESIGN:. Retrospective observational cohort study. SETTING:. Adult patients in the Extracorporeal Life Support Organization registry. PATIENTS:. Nine-thousand two-hundred ninety-one patients that required ECMO for viral mediated ARDS between January 2017 and December 2021. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The primary outcomes of interest were mortality during ECMO support and prior to hospital discharge. Time-to-event analysis and logistic regression were used to compare outcomes between the groups. Among 9,291 included patients, 1,155 required ECMO for non-COVID-19 viral ARDS and 8,136 required ECMO for ARDS due to COVID-19. Patients with COVID-19 had longer duration of ECMO (19.6 d [interquartile range (IQR), 10.1–34.0 d] vs 10.7 d [IQR, 6.3–19.7 d]; p < 0.001), higher mortality during ECMO support (44.4% vs 27.5%; p < 0.001), and higher in-hospital mortality (50.2% vs 34.5%; p < 0.001). Further, patients with COVID-19 were more likely to experience mechanical and clinical complications (membrane lung failure, pneumothorax, intracranial hemorrhage, and superimposed infection). After adjusting for pre-ECMO disease severity, patients with COVID-19 were more than two times as likely to die in the hospital compared with patients with non-COVID-19 viral ARDS. CONCLUSIONS:. Patients with COVID-19 that require ECMO have longer duration of ECMO, more complications, and higher in-hospital mortality compared with patients with non-COVID-19–related viral ARDS. Further study in patients with COVID-19 is critical to identify the patient phenotype most likely to benefit from ECMO and to better define the role of ECMO in the management of this disease process.

PurposeTo investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality.Materials and methodsThe data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model.ResultsAmong the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]).ConclusionsIn critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.

Introduction. Sepsis, the leading cause of death in hospitalized patients globally, was investigated in this study, examining the varying effects of positive fluid balance on sepsis subtypes through causal inference. Methods. In this study, data from the eICU database were utilized, extracting 35 features from sepsis patients. Fluid balance during ICU stay was the treatment, and ICU mortality was the primary outcome. Data preprocessing ensured linear assumptions for logistic regression. Binarized positive fluid balance with mortality was examined using DoWhy’s logistic regression, while continuous data were analyzed with random forest T-learner. ATE served as the primary metric. Results. Results revealed that septic patients with higher fluid balance had worse mortality outcomes, with an ATE of 0.042 (95% CI: (0.034, 0.047)) using logistic regression and an ATE of 0.0340 (95% CI: (0.028–0.040)) using T-learner. In the pulmonary sepsis subtype, higher mortality was associated with increased fluid balance, showing an ATE of 0.047 (95% CI: (0.037, 0.055)) using logistic regression and an ATE of 0.28 (95% CI: (0.22, 0.34)) with T-learner. Conversely, urinary sepsis patients had improved mortality with higher fluid balance, presenting an ATE of −0.135 (95% CI: (−0.024, −0.0035)) using logistic regression and an ATE of −0.28 (95% CI: (−0.34, −0.22)) with T-learner. Conclusion. Our research implies that fluid balance impact on ICU mortality differs among sepsis subtypes. Positive fluid balance raises mortality in sepsis and pulmonary sepsis but may protect against urinary sepsis. Further trials are needed to confirm these findings.

Volatile anesthetics have been described as a rescue therapy for patients with refractory status asthmaticus (SA), and the use of isoflurane for this indication has been reported since the 1980s. Much of the literature reports good outcomes when inhaled isoflurane is used as a rescue therapy for patients for refractory SA. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a mode of mechanical circulatory support that is usually employed as a potentially lifesaving intervention in patients who have high risk of mortality, primarily for underlying pulmonary pathology. VV ECMO is usually only considered in cases where patients gas exchange cannot be satisfactorily maintained by conventional therapy and mechanical ventilation strategies. We report the novel use of isoflurane delivered systemically as treatment for severe refractory SA in a patient on VV ECMO. A 51-year-old male with a history of asthma was transferred from another institution for management of severe SA. He was intubated at the referring hospital after failing non-invasive ventilation. Initial arterial blood gas (ABG) showed pH 7.21, partial pressure of carbon dioxide (PCO2) >95 mmHg, and partial pressure of oxygen (PaO2) 60 mmHg. VV ECMO was initiated on hospital day (HD) 1 due to refractory respiratory acidosis. After ECMO initiation, acid-base status improved, however, severe bronchospasm persisted and intrinsic positive end expiratory pressure (PEEP) was measured at 18 cm H2O. Systemic paralysis was employed, respiratory rate (RR) was reduced to 4 breaths per minute. This degree of bronchospasm did not allow for ECMO weaning. On HD 5, the patient received systemic isoflurane via the ECMO circuit for 20 h. The following morning, intrinsic PEEP was 4 cm H2O, and wheezing improved. He was decannulated from VV ECMO on HD 10 and extubated on HD 17. Inhaled isoflurane therapy in patients on VV ECMO for refractory SA has shown good results, but requires delivery of the medication via anesthesia ventilators. Our case highlights an effective alternative, systemic delivery of anesthetic via the ECMO circuit, as it is often difficult and dangerous to transport these patients to the operating room (OR) or have an intensive care unit (ICU) room adjusted to accommodate an anesthesia ventilator.

Mitochondria are cell organelles that play pivotal roles in maintaining cell survival, cellular metabolic homeostasis, and cell death. Mitochondria are highly dynamic entities which undergo fusion and fission, and have been shown to be very motile in vivo in neurons and in vitro in multiple cell lines. Fusion and fission are essential for maintaining mitochondrial homeostasis through control of morphology, content exchange, inheritance of mitochondria, maintenance of mitochondrial DNA, and removal of damaged mitochondria by autophagy. Mitochondrial motility occurs through mechanical and molecular mechanisms which translocate mitochondria to sites of high energy demand. Motility also plays an important role in intracellular signaling. Here, we review key features that mediate mitochondrial dynamics and explore methods to advance the study of mitochondrial motility as well as mitochondrial dynamics-related diseases and mitochondrial-targeted therapeutics.

Pneumomediastinum is a rare complication among non-coronavirus patients but has been published with increased incidence in patients positive for SARS-CoV-2 infection. Most of these studies report patients on mechanical ventilation and an understanding of mechanisms causing this remains limited. We aim to use an increasing occurrence in patients not on mechanical ventilation to further explore mechanisms that predispose patients to pneumomediastinum and to assess characteristics potentially related to poor outcomes. We report a case series of 37 patients diagnosed with COVID-19 and pneumomediastinum at a 2-hospital institution between January 1, 2020 and April 30, 2021. At 28 days after diagnosis of pneumomediastinum, 19 (51.4%) were dead and mortality was significantly higher among those who were older ( t = 2.147, P = .039), female (χ 2 = 10.431, P = .015), body mass index ≥30 (χ 2 = 6.0598, P = .01), intubated (χ 2 = 4.937, P = .026), and had pre-existing lung disease (χ 2 = 4.081, P = .043). Twenty-three patients (62.2%) were identified to have pneumomediastinum without receiving invasive mechanical ventilation, of which 11 (47.8%) were diagnosed without receiving noninvasive ventilation. The increased diagnosis of pneumomediastinum in patients with COVID-19 while not on mechanical ventilation, in this case series and in comparable studies, may attribute to mechanisms aside from positive pressure ventilation such as patient self-induced lung injury and pulmonary frailty.

Purpose: The present study seeks to examine the efficacy of different training modalities on increasing workplace learning, representatives' intent to transfer what they learned into their work, and importantly how training impacts actual work performance. These relationships are tested in the context of a Chinese division of a multinational pharmaceutical company, where pharmaceutical representatives are tasked with relaying relevant efficacy and safety information on pharmaceutical products to health care professionals who prescribe them to patients. Methods: The present study employed a three-group between-subjects experimental design. Representatives received varying forms of training (instruction only, instruction plus reflection, and instruction, reflection, plus direct feedback) based on experimental conditions. After three training sessions over the course of six weeks, representatives were assessed on how much they learned in the training and their actual work performance through observer assessment of meetings with health care professionals, facilitated by the representatives. Findings: In this study, it was found that the process of actively reflecting on what was learned in training led to increased learning, as well as increased performance, compared to simply studying the material. However, receiving direct feedback on training performance, combined with active reflection training, did not provide any further benefits in terms of learning or work performance. Notably, there were no differences in intent to transfer learned material to work, as all conditions reported high levels of transfer intention. Conclusion: The finding provides insightful evidence to support the benefits of fostering trainees' active reflections for work-based learning in the Chinese industry training scenario. In contrast, receiving direct comments on how students performed from a manager or trainer, as well as advise on how do better in the future, had no effect on increasing learning or performance. Although the effect of direct feedback is not statistically significant in this context, further research should be done in understanding individuals' thoughts and behaviors when received direct feedbacks received in workplace training. Relatively little workplace research has assessed both workplace learning and performance in the same study, specifically in the Chinese context. While training efficacy likely varies across cultures to begin with, compensation structures in China do not provide the same monetary incentives for workplace learning (i.e. chance to increase income) as Western culture. This means that any way to increase workplace learning should be of extra value, as employees otherwise may not engage in it at all.

OBJECTIVES:. Older age is a key risk factor for adverse outcomes in critically ill patients with COVID-19. However, few studies have investigated whether preexisting comorbidities and acute physiologic ICU factors modify the association between age and death. DESIGN:. Multicenter cohort study. SETTING:. ICUs at 68 hospitals across the United States. PATIENTS:. A total of 5,037 critically ill adults with COVID-19 admitted to ICUs between March 1, 2020, and July 1, 2020. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The primary exposure was age, modeled as a continuous variable. The primary outcome was 28-day inhospital mortality. Multivariable logistic regression tested the association between age and death. Effect modification by the number of risk factors was assessed through a multiplicative interaction term in the logistic regression model. Among the 5,037 patients included (mean age, 60.9 yr [± 14.7], 3,179 [63.1%] male), 1,786 (35.4%) died within 28 days. Age had a nonlinear association with 28-day mortality (p for nonlinearity

Study region: Athabasca River Watershed, Athabasca Oil Sands Region (AOSR), Alberta, Canada. Study focus: AOSR pre-disturbance landscape consists of a mosaic of upland-peatland complexes, dominated by fens, which have become the focus of recent mandatory reclamation efforts. Quantifiable metrics for evaluating reclamation project trajectories and long-term sustainability are required. Here, the initial performance of a constructed upland-peatland complex (Nikanotee Fen Watershed) is evaluated through a functional-based, ecosystem-scale approach focused on carbon dynamics and water use efficiency (WUE). Initial seven years (2013–2019) post-construction were monitored using eddy covariance and multispectral imagery to capture ecosystem evolution. New hydrological insights for the region: Results indicate the fen quickly evolved from a bare-ground, carbon source (2013) to a sedge-dominated (Carex aquatilis), carbon sink (2015). Slower growth rate of trees (Pinus banksiana, Populus balsamifera) and dry edaphic upland conditions initially resulted in net carbon losses. However, as upland vegetation became established, plant CO2 uptake increased. After 2015, fen WUE remained relatively stable despite fluctuations in seasonal rainfall. Stable WUE reflects a well-connected groundwater network between the two landscape units that supports hydrological self-regulation sufficient to maintain adequate plant function. Because of this groundwater supply, fen plants were no longer dependent solely on precipitation – increasing resilience to intervals of periodic water stress. Overall, carbon and water dynamics during early-development suggests the system is evolving towards a self-sustaining, carbon-accumulating, functional ecosystem.

The number of hospitals with veno-venous extracorporeal membrane oxygenation (VV-ECMO) capabilities is expanding. To support an ECMO program, centers must be equipped to handle associated complications such as pulmonary hemorrhage. We describe a case series of 4 patients with life-threatening pulmonary bleeding and central airway obstruction. A therapeutic approach of anticoagulation cessation coupled with cryoextraction via flexible bronchoscopy led to successful restoration of airway patency without any adverse events. A low threshold to stop anticoagulation with a strong consideration of bronchoscopy with cryotherapy for pulmonary toilet should be done in patients with pulmonary hemorrhage during VV-ECMO.

A doctrine of original sin or of the human condition generally requires an account of how that sin or condition is transmitted. One would think there are two options for thinking about this. Either original sin is innate or it is acquired. Both would seem to be problematic, the former because all the available options involve untoward metaphysical commitments or implicate God in unacceptable ways; the latter because of the uniformity of the human condition the doctrine requires. In this article, I use conceptual advances within the cognitive science of religion and empirical research to advance a plausible model of what the human condition consists in and how it is passed down.

OBJECTIVES:. Critically ill patients with coronavirus disease 2019 have variable mortality. Risk scores could improve care and be used for prognostic enrichment in trials. We aimed to compare machine learning algorithms and develop a simple tool for predicting 28-day mortality in ICU patients with coronavirus disease 2019. DESIGN:. This was an observational study of adult patients with coronavirus disease 2019. The primary outcome was 28-day inhospital mortality. Machine learning models and a simple tool were derived using variables from the first 48 hours of ICU admission and validated externally in independent sites and temporally with more recent admissions. Models were compared with a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 using the area under the receiver operating characteristic curve and calibration. SETTING:. Sixty-eight U.S. ICUs. PATIENTS:. Adults with coronavirus disease 2019 admitted to 68 ICUs in the United States between March 4, 2020, and June 29, 2020. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The study included 5,075 patients, 1,846 (36.4%) of whom died by day 28. eXtreme Gradient Boosting had the highest area under the receiver operating characteristic curve in external validation (0.81) and was well-calibrated, while k-nearest neighbors were the lowest performing machine learning algorithm (area under the receiver operating characteristic curve 0.69). Findings were similar with temporal validation. The simple tool, which was created using the most important features from the eXtreme Gradient Boosting model, had a significantly higher area under the receiver operating characteristic curve in external validation (0.78) than the Sequential Organ Failure Assessment score (0.69), National Early Warning Score (0.60), and CURB-65 (0.65; p < 0.05 for all comparisons). Age, number of ICU beds, creatinine, lactate, arterial pH, and Pao2/Fio2 ratio were the most important predictors in the eXtreme Gradient Boosting model. CONCLUSIONS:. eXtreme Gradient Boosting had the highest discrimination overall, and our simple tool had higher discrimination than a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 on external validation. These models could be used to improve triage decisions and clinical trial enrichment.

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) is initiated in patients with high mortality as a potential lifesaving intervention. Hematologic malignancy (HM) is considered a relative exclusion criterion by the Extracorporeal Life Support Organization (ELSO). This case examines the relative contraindication and presents a successful outcome. A healthy 59-year-old male presented with respiratory distress. On arrival his S pO 2 on room air was 82%, chest x-ray revealed a lobar infiltrate, complete blood count demonstrated severe leukopenia, and a peripheral blood smear demonstrated cytoplasmic inclusions concerning for hairy cells. He was intubated and decision was made to initiate VV-ECMO during hospital day (HD) 1. Cytometry later confirmed a diagnosis of hairy cell leukemia (HCL). A diagnosis of Legionella was confirmed on HD 5. Initial hospitalization was complicated by progression to complete bilateral lung involvement, pulmonary hemorrhage, recurrent tachyarrhythmias, hemodynamic instability, and acute renal failure. Respiratory status stabilized and eventually began to improve. On HD 27, he was decannulated and later discharged to rehabilitation. Four months later he received inpatient chemotherapy and is currently in full remission. This is a successful outcome in a patient with severe ARDS requiring VV-ECMO in the setting of newly diagnosed HCL. The 10-year survival for treated HCL is near 100%. Due to favorable prognosis, HCL should not be considered a relative contraindication to VV-ECMO. While HM remains a relative exclusion criterion by the ELSO, it is important to analyze each patient individually and make decisions based on evolving bodies of evidence.

Polygenic risk scores (PRSs) have been offered since 2019 to screen in vitro fertilization embryos for genetic liability to adult diseases, despite a lack of comprehensive modeling of expected outcomes. Here we predict, based on the liability threshold model, the expected reduction in complex disease risk following polygenic embryo screening for a single disease. A strong determinant of the potential utility of such screening is the selection strategy, a factor that has not been previously studied. When only embryos with a very high PRS are excluded, the achieved risk reduction is minimal. In contrast, selecting the embryo with the lowest PRS can lead to substantial relative risk reductions, given a sufficient number of viable embryos. We systematically examine the impact of several factors on the utility of screening, including: variance explained by the PRS, number of embryos, disease prevalence, parental PRSs, and parental disease status. We consider both relative and absolute risk reductions, as well as population-averaged and per-couple risk reductions, and also examine the risk of pleiotropic effects. Finally, we confirm our theoretical predictions by simulating ‘virtual’ couples and offspring based on real genomes from schizophrenia and Crohn’s disease case-control studies. We discuss the assumptions and limitations of our model, as well as the potential emerging ethical concerns.

Summary: Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

Summary: Diffuse intrinsic pontine glioma (DIPG) is an incurable brain tumor of childhood characterized by histone mutations at lysine 27, which results in epigenomic dysregulation. There has been a failure to develop effective treatment for this tumor. Using a combined RNAi and chemical screen targeting epigenomic regulators, we identify the polycomb repressive complex 1 (PRC1) component BMI1 as a critical factor for DIPG tumor maintenance in vivo. BMI1 chromatin occupancy is enriched at genes associated with differentiation and tumor suppressors in DIPG cells. Inhibition of BMI1 decreases cell self-renewal and attenuates tumor growth due to induction of senescence. Prolonged BMI1 inhibition induces a senescence-associated secretory phenotype, which promotes tumor recurrence. Clearance of senescent cells using BH3 protein mimetics co-operates with BMI1 inhibition to enhance tumor cell killing in vivo.

Surface energy budgets are important to the ecohydrology of complex terrain, where land surfaces cycle in and out of shadows creating distinct microclimates. Shading in such environments can help regulate downstream flow over the course of a growing season, but our knowledge on how shadows impact the energy budget and consequently ecohydrology in montane ecosystems is very limited. We investigated the influence of horizon shade on the surface energy fluxes of a subalpine headwater wetland in the Canadian Rocky Mountains during the growing season. During the study, surface insolation decreased by 60% (32% due to evolving horizon shade and 28% from seasonality). The influence of shade on the energy budget varied between two distinct periods: (1) Stable Shade, when horizon shade was constant and reduced sunlight by 2 h per day; and (2) Dynamic Shade, when shade increased and reduced sunlight by 0.18 h more each day, equivalent to a 13% reduction in incoming shortwave radiation and 16% in net radiation. Latent heat flux, the dominant energy flux at our site, varied temporally because of changes in incoming radiation, atmospheric demand, soil moisture and shade. Horizon shade controlled soil moisture at our site by prolonging snowmelt and reducing evapotranspiration in the late growing season, resulting in increased water storage capacity compared to other mountain wetlands. With the mounting risk of climate-change-driven severe spring flooding and late season droughts downstream of mountain headwaters, shaded subalpine wetlands provide important ecohydrological and mitigation services that are worthy of further study and mapping. This will help us better understand and protect mountain and prairie water resources.

Water use efficiency (WUE) can be calculated using a range of methods differing in carbon uptake and water use variable selection. Consequently, inconsistencies arise between WUE calculations due to complex physical and physiological interactions. The purpose of this study was to quantify and compare WUE estimates (harvest or flux-based) for alfalfa (C3 plant) and maize (C4 plant) and determine effects of input variables, plant physiology and farming practices on estimates. Four WUE calculations were investigated: two “harvest-based” methods, using above ground carbon content and either precipitation or evapotranspiration (ET), and two “flux-based” methods, using gross primary productivity (GPP) and either ET or transpiration. WUE estimates differed based on method used at both half-hourly and seasonal scales. Input variables used in calculations affected WUE estimates, and plant physiology led to different responses in carbon assimilation and water use variables. WUE estimates were also impacted by different plant physiological responses and processing methods, even when the same carbon assimilation and water use variables were considered. This study highlights a need to develop a metric of measuring cropland carbon-water coupling that accounts for all water use components, plant carbon responses, and biomass production.

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

Oxazolidinone antibiotics—linezolid and tedizolid—are often used to treat multidrug-resistant infections. They are highly bioavailable and ideal for transition to enteral therapy when appropriate. However, multiple associated adverse effects are potentially treatment-limiting. The objective of this review is to discuss relevant adverse effects of linezolid and tedizolid, including serotonin syndrome, myelosuppression, neuropathies, and lactic acidosis, and their commonality in real-world experience in the last decade. Mitigation strategies, including the role of therapeutic drug monitoring, are also discussed.

Gram-negative bacteremia and antimicrobial resistance cause significant morbidity and mortality. Strategies are needed to optimize rapid and effective antimicrobial therapy with early de-escalation. In this brief, we describe the utilization of multiplex polymerase chain reaction rapid diagnostic technology for the early de-escalation of broad-spectrum antimicrobials in patients with Enterobacterales bacteremia.