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A preliminary investigation was carried out by the US Environmental Protection Agency (EPA) on the impact of regional ozone concentrations on climate change in the country. The main objective of the investigation was to enhance the ability of air quality managers to consider global change in their decisions through improved characterization of the potential effects of global change on air quality, including O3, PM, and Hg. An integrated assessment framework was designed that supported the research and development efforts within the EPA and the academic research professionals. This design recognized the challenges of bridging spatial scales, temporal scales, and disciplines that characterize the global change and regional air quality problem. A major component of the assessment approach involved the development and application of global to regional climate and air quality modeling systems.

An overview of the LADCO (Lake Michigan Air Directors Consortium) Winter Nitrate Study (WNS) is presented. Sampling was conducted at ground level at an urbanrural pair of sites during January-March 2009 in eastern Wisconsin, toward the western edge of the US Great Lakes region. Areas surrounding these sites experience multiday episodes of wintertime PM2.5 pollution characterized by high fractions of ammonium nitrate in PM, low wind speeds, and air mass stagnation. Hourly surface monitoring of inorganic gases and aerosols supplemented long-term 24-h aerosol chemistry monitoring at these locations. The urban site (Milwaukee, WI) experienced 13 PM2.5 episodes, defined as periods where the seven-hour moving average PM2.5 concentration exceeded 27 µgm-3 for at least four consecutive hours. The rural site experienced seven episodes by the same metric, and all rural episodes coincided with urban episodes. Episodes were characterized by low pressure systems, shallow/stable boundary layer, light winds, and increased temperature and relative humidity relative to climatological mean conditions. They often occurred in the presence of regional snow cover at temperatures near freezing, when snow melt and sublimation could generate fog and strengthen the boundary layer inversion. Substantial contribution to nitrate production from nighttime chemistry of ozone and NO2 to N2O5 and nitric acid is likely and requires further investigation. Pollutant-specific urban excess during episode and non-episode conditions is presented. The largest remaining uncertainties in the conceptual model of the wintertime episodes are the variability from episode-to-episode in ammonia emissions, the balance of daytime and nighttime nitrate production, the relationship between ammonia controls, NOx controls and ammonium nitrate reductions, and the extent to which snow and fog are causal (either through meteorological or chemical processes) rather than just correlated with episodes because of similar synoptic meteorology. [ABSTRACT FROM AUTHOR]

The article offers information on several programs carried out under the Clean Air Act by the U.S. Environmental Protection Agency (EPA) to lower the circulating concentrations of air pollutants. It states that these programs will help EPA to study global climate change effects on U.S. regional air quality. It informs that air pollutant ozone does emit in atmosphere directly and is formed due to the chemical reaction of nitrogen oxides and volatile organic compound in sunlight.

This paper provides a synthesis of results that have emerged from recent modeling studies of the potential sensitivity of U.S. regional ozone (O3) concentrations to global climate change (ca. 2050). This research has been carried out under the auspices of an ongoing U.S. Environmental Protection Agency (EPA) assessment effort to increase scientific understanding of the multiple complex interactions among climate, emissions, atmospheric chemistry, and air quality. The ultimate goal is to enhance the ability of air quality managers to consider global change in their decisions through improved characterization of the potential effects of global change on air quality, including O3. The results discussed here are interim, representing the first phase of the EPA assessment. The aim in this first phase was to consider the effects of climate change alone on air quality, without accompanying changes in anthropogenic emissions of precursor pollutants. Across all of the modeling experiments carried out by the different groups, simulated global climate change causes increases of a few to several parts per billion (ppb) in summertime mean maximum daily 8-h average O3 concentrations over substantial regions of the country. The different modeling experiments in general do not, however, simulate the same regional patterns of change. These differences seem to result largely from variations in the simulated patterns of changes in key meteorological drivers, such as temperature and surface insolation. How isoprene nitrate chemistry is represented in the different modeling systems is an additional critical factor in the simulated O3 response to climate change., Engineering and Applied Sciences, Version of Record

Abstract Background Hawthorn extract has been used for cardiovascular diseases for centuries. Recent trials have demonstrated its efficacy for the treatment of heart failure, and the results of several small trials suggest it may lower blood pressure. However, there is little published evidence to guide its dosing. The blood pressure lowering effect of hawthorn has been linked to nitric oxide-mediated vasodilation. The aim of this study was to investigate the relationship between hawthorn extract dose and brachial artery flow mediated dilation (FMD), an indirect measure of nitric oxide release. Methods We used a four-period cross-over design to evaluate brachial artery FMD in response to placebo or hawthorn extract (standardized to 50 mg oligomeric procyanidin per 250 mg extract). Randomly sequenced doses of hawthorn extract (1000 mg, 1500 mg, and 2500 mg) and placebo were assigned to each participant. Doses were taken twice daily for 3 1/2 days followed by FMD and a 4-day washout before proceeding to the next dosing period. Results Twenty-one prehypertensive or mildly hypertensive adults completed the study. There was no evidence of a dose-response effect for our main outcome (FMD percent) or any of our secondary outcomes (absolute change in brachial artery diameter and blood pressure). Most participants indicated that if given evidence that hawthorn could lower their blood pressure, they would be likely to use it either in conjunction with or instead of lifestyle modification or anti-hypertensive medications. Conclusion We found no evidence of a dose-response effect of hawthorn extract on FMD. If hawthorn has a blood pressure lowering effect, it is likely to be mediated via an NO-independent mechanism. Trial Registration This trial has been registered with ClinicalTrials.gov, a service of the U.S. National Institutes of Health: NCT01331486.

Background: Air pollutants, including particulates from wood smoke, are a significant cause of exacerbation of lung disease. γ-Tocopherol is an anti-inflammatory isoform of vitamin E that has been shown to reduce allergen-, ozone-, and endotoxin-induced inflammation., Objective: The objective of this study was to determine whether γ-tocopherol would prevent experimental wood smoke-induced airway inflammation in humans., Methods: This was a randomized, placebo-controlled clinical trial testing the effect of a short course of γ-tocopherol-enriched supplementation on airway inflammation following a controlled exposure to wood smoke particulates., Results: Short-course γ-tocopherol intervention did not reduce wood smoke-induced neutrophilic airway inflammation, but it did prevent wood smoke-induced eosinophilic airway inflammation., Conclusion: γ-Tocopherol is a potential intervention for exacerbation of allergic airway inflammation, but further study examining longer dosing periods is required., (© 2023 The Author(s).)

Background: Anorexia nervosa (AN) is associated with maladaptive cardiovascular changes. This study investigated whether individuals who recovered from AN during adolescence experience long-term cardiovascular risk in early adulthood., Methods: Former AN patients discharged from the Royal Children's and Monash Children's Hospital Eating Disorder Services in Melbourne, Australia underwent cardiovascular testing. Measurements were performed using an oscillometric device for blood pressure and pulse wave velocity, ultrasound for carotid wall structure/function, resting electrocardiogram for heart-rate variability, and the EndoPat 2000 (Itamar) system for endothelial function. Patient measures were compared to healthy controls and/or normal thresholds., Results: Ninety-one percent of the former AN patients (N = 22) and controls (N = 66) were female, aged approximately 25 years, with a healthy body mass index. The mean time interval from AN recovery to participation was 7.4 years. Pulse wave velocity was lower in the former AN patients than controls. Carotid intima-media thickness was not different; however, carotid distensibility and compliance were lower, and the elastic modulus higher in the former AN patients. Greater vagal tone was observed and endothelial dysfunction was evident in 46% of the former patients., Conclusions: Young adults who recovered from adolescent AN exhibit persistent cardiovascular adaptations. Routine cardiovascular monitoring could manage potential disease risk., Impact: Cardiovascular complications are common in patients with anorexia nervosa (AN) and population studies have revealed that developmental adaptations in response to undernutrition have long-term consequences for cardiovascular health. In this study of young adults treated for AN during adolescence, there was evidence of increased carotid artery stiffness, reduced aortic stiffness, vagal hyperactivity, and endothelial dysfunction in early adulthood when compared to healthy controls. It is important to consider the cardiovascular health of patients with AN beyond achieving medical stability. Interventions that monitor cardiovascular health could minimise the burden of future cardiovascular disease., (© 2023. The Author(s).)

Aim: Family-based treatment (FBT) has the greatest evidence base for the treatment of adolescents with anorexia nervosa (AN). However, little is known about the long-term outcomes for patients who receive FBT. The current study aimed to investigate the long-term psychological health of former patients who received FBT for AN during adolescence., Methods: Former patients diagnosed and treated for AN at the Royal Children's Hospital and Monash Children's Hospital (N = 36) in Melbourne, Australia completed self-report questionnaires to assess eating, exercising, mood and the impact of the coronavirus (COVID-19) pandemic. Patient scores were compared to healthy controls (N = 29) and normative data., Results: The eating and exercising behaviours of the patients who formerly had AN were comparable to controls. However, the former patients experience significantly greater levels of depression, anxiety, and stress than the controls (P < 0.05). The COVID-19 pandemic appeared to impact the former patients and controls to a similar extent across quantifiable criteria., Conclusions: This study extends previous research highlighting FBT as an effective intervention for adolescents with AN. Positive short- and long-term patient outcomes can be achieved with this form of treatment., (© 2022 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: The New Zealand Rotator Cuff Registry represents the largest prospective cohort of rotator cuff repairs. Despite this, there are limited medium- to long-term data of rotator cuff repair outcomes., Purpose: To (1) analyze the pain and functional outcomes of a large cohort of primary rotator cuff repairs and (2) evaluate the effect of patient factors and tear characteristics on medium-term outcomes., Study Design: Cohort study; Level of evidence, 2., Methods: This was a multicenter, multisurgeon prospective cohort study of rotator cuff repairs from March 2009 until December 2010. Surgical data were collected by the operating surgeon. Primary outcome measures were the Flexilevel Scale of Shoulder Function (FLEX-SF) and a pain score, collected at baseline, 6, 12, and 24 months, and 5 years. Univariate and multivariate analyses were carried out., Results: Overall, 2533 primary rotator cuff repairs were analyzed with 81% follow-up at 5 years. The mean age of the cohort was 56 years. In the 2052 patients with final follow-up data, improvement on the FLEX-SF continued until 24 months postoperatively and remained high at 5 years. Mean improvement in FLEX-SF from baseline to 5 years was 15 points. Patients aged >70 years had lower FLEX-SF scores but no significant difference in improvement compared with patients ≤70 years. The mean anteroposterior tear size was 2.2 cm, and on multivariate analysis, tears >4 cm had worse 5-year FLEX-SF scores. If the affected tendon was easily reducible, there was no difference in FLEX-SF score for retracted or larger tears compared with smaller tears. The reoperation rate was 6.2%., Conclusion: Results indicated that rotator cuff repairs provide a sustained clinical improvement out past 5 years. Most functional improvement and pain relief occurred within the first 6 months, but improvement continued out to 24 months. Most population groups did well after rotator cuff repairs, including those >70 years. Tear size >4 cm and tendon reducibility correlated with outcome. Even patients with large tear sizes had clinically significant improvement in FLEX-SF scores after repair., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The New Zealand Rotator Cuff Registry is a charitable trust that has received funding from a number of sources: a majority grant from the New Zealand Accident Compensation Commission (government-funded agency) as well as funding from the New Zealand Shoulder and Elbow Society, The New Zealand Orthopaedic Association Trust and The Wishbone Trust, Device Technologies, Johnson & Johnson, and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Objectives: Temporally quantify and localize paravalvular aortic leak (PVL) after transcatheter aortic valve replacement (TAVR) in the Medtronic CoreValve (MCV) versus the Edwards Sapien Valve (ESV)., Background: In order to increase the precision of THV selection and PVL intervention, an understanding of PVL characteristics is essential., Methods: The frequency, severity, and location of post-TAVR PVL were evaluated with transthoracic echocardiography pre-discharge, one month, and one-year post-procedure in 202 patients receiving a MCV (N = 120) or ESV (N = 81). This was done through application of a clock face to the short axis of the aortic valve in order to divide the area into three tertiles., Results: Pre-discharge differences between PVL frequency and severity in the MCV and ESV lost significance over time. Localizing these trends, MCV PVL frequency and severity significantly decreased in the first and third tertiles during most time periods while PVL in the second tertile of the MCV or in any of the tertiles of the ESV failed to improve. Presence of pre-discharge PVL was predictive of 30-day HF readmission and/or death (OR = 3.16, 95% CI: 0.99-10.12). Presence of pre-discharge and 30-day PVL was predictive of 1-year HF readmissions and/or death (OR = 2.12, 95% CI: 1.09-4.13 and OR = 1.99, 95% CI: 0.96-4.12)., Conclusions: When comparing the MCV and ESV, not all locations of PVL improve equally over time, which has implications for heart failure readmissions. This could be used to influence valve selection and to identify cases in which earlier intervention on PVL may be appropriate., (© 2018 Wiley Periodicals, Inc.)

Since 2013, Kaiser Permanente Northern California has engaged in a systematic effort to elicit, document, and honor the care preferences of patients as they near the end of life. This is done through its Advanced Steps program, in which selected patients discuss their preferences for future medical care with their healthcare agent during a structured conversation with a trained advance care planning facilitator. The facilitator then translates the patient's wishes into an actionable medical order set using a Physician's Order for Life-Sustaining Treatment (POLST) form. We wanted to know whether these patients' recorded wishes were concordant with care received at the end of life. To evaluate, we conducted an in-depth chart review of 300 patients who died in 2015 and had participated in the program. We determined that 290 patients received concordant care, whereas three patients received care discordant with their wishes before death. Seven patients did not have sufficient information in their record to determine concordance. Interestingly, we found care preferences often changed over time; ∼20% of patients revised their end-of-life preferences after having the facilitated conversation, with most of those patients opting for less intensive care. Most changes to preferences were made verbally in the final setting of care. While advance care planning and the POLST form provide invaluable tools for recording patients' wishes, our study highlights a need to track patients' wishes as they evolve over time and a need for ongoing, real-time conversations about goals of care, even after a POLST is completed.

Patients hospitalized for noncardiac conditions often experience increased levels of stress and hemodynamic challenges, making them susceptible to acute coronary events. The clinical features, management strategy, and outcomes of inpatient non-ST segment elevation myocardial infarction (NSTEMI) have not been described. This single-center retrospective study identified patients with inpatient NSTEMI from the University of North Carolina Hospitals discharge database in February 2008 to April 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes. This process generated an initial list of 485 cases that were subsequently manually reviewed. The associations of cardiac catheterization with in-hospital mortality and length of stay were analyzed using multivariable logistic regression and multiple linear regression. A total of 302 patients were confirmed to have inpatient NSTEMI, with 154 patients admitted to surgical and 148 admitted to nonsurgical services. The in-hospital mortality rate of patients with inpatient NSTEMI was high (19%). Patients with inpatient NSTEMI who underwent cardiac catheterization had lower in-hospital mortality rates than those who did not undergo cardiac catheterization (6% vs 25%; adjusted odds ratio 0.19, 95% confidence interval 0.07 to 0.50) and were discharged 6.8 days earlier (95% confidence interval 2.3 to 11.2 days). Inpatient NSTEMIs on surgical services compared with nonsurgical services were more likely to generate cardiology consultation (96% vs 62%, p <0.0001) and left heart catheterization (41% vs 24%, p = 0.002), with similar rates of revascularization (56% vs 56%, p = 1.0). In conclusion, both nonsurgical and surgical patients with inpatient NSTEMI who underwent invasive management had lower in-hospital mortality rates and shorter lengths of stay., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine the ability of simple hemodynamic parameters obtained at the time of cardiac catheterization to predict in-hospital mortality following ST-elevation myocardial infarction (STEMI)., Background: Hemodynamic parameters measured at the time of primary percutaneous coronary intervention (PPCI) could potentially identify high-risk patients who would benefit from aggressive hemodynamic support in the Cardiac Catheterization laboratory., Methods: This is a retrospective single-center study of 219 consecutive patients with STEMI. Left ventricular end-diastolic pressure (LVEDP), systolic blood pressure (SBP), and aortic diastolic blood pressure were obtained after successful revascularization. The prognostic ability of LVEDP, pulse pressure, and SBP/LVEDP ratio were compared to major mortality risk scores., Results: Patients had a mean age of 60 ±14 years, were predominantly white (73%), male (64%), with anterior wall infarcts in 39%. Comorbidities included diabetes mellitus (27%), heart failure (9%), and chronic kidney disease (7%). In-hospital mortality was 9%. Patients with SBP/LVEDP ≤ 4 had increased risk of in-hospital death (32% vs. 5.3%, P < 0.0001), intra-aortic balloon pump (IABP) usage (51.6% vs. 9.6%, P < 0.0001) and combined endpoint of death or IABP usage (58.1% vs. 13.3%, P < 0.0001) compared to patients with SBP/LVEDP > 4. The area under curve (AUC) for SBP/LVEDP ratio for in-hospital mortality (0.69) was more predictive than LVEDP (0.61, P = 0.04) or pulse pressure (0.55, P = 0.02) but similar to Shock Index (ratio of heart rate to SBP) and Modified Shock Index (ratio of HR to mean arterial pressure)., Conclusion: An SBP/LVEDP ratio ≤ 4 identified a group of STEMI patients at high risk of in-hospital death. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: This study is a collation of baseline demographic characteristics of those presenting for rotator cuff repair in New Zealand, and exploration of associations with preoperative function and pain. Data were obtained from the New Zealand Rotator Cuff Registry; a multicentre, nationwide prospective cohort of rotator cuff repairs undertaken from 1 March 2009 until 31 December 2010., Methods: A total of 1383 patients were included in the study. This required complete demographic information, preoperative Flex-SF (functional score) and pain scores. Following univariate analysis, a multivariate model was used., Results: The average age was 58 years (69% males and 11% smokers). New Zealand Europeans made up 90% and Maori 5%. The average preoperative Flex-SF was significantly lower (poorer function) in those over 65 years, females, smokers and Maori, in the non-dominant patients, using a multivariate model. Average preoperative pain scores were significantly worse (higher scores) in females, Maori, Polynesians, smokers, using a multivariate model., Conclusion: This is the largest reported prospective cohort of patients presenting for rotator cuff surgery. Results can be used to understand the effect of rotator cuff tears on the different patients, for example Maori patients who are under-represented, present younger, with more pain and poorer function., (© 2017 Royal Australasian College of Surgeons.)

Aim: The role of acromioplasty with rotator cuff repair remains unclear. This study aims to test the null hypothesis-that acromioplasty in conjunction with rotator cuff repair has no effect on improvement in pain or shoulder function at two years follow up., Methods: Data was obtained from a collaborative nationwide project between March 2009 and December 2010, and consisted of a total of 2,441 patients undergoing primary repair of superior rotator cuff tears. Multivariate analysis was performed to assess the effect of the inclusion of acromioplasty at the time of rotator cuff repair on visual analogue scale (VAS) pain scores and Flex Shoulder Function (Flex SF) scores at 24-month follow up., Results: On univariate analysis there was a significantly higher Flex SF score in the acromioplasty group (40.5) compared to the no acromioplasty group (38.7) and a lower mean pain score at 24 months in the acromioplasty group (1.44 vs 1.74). There was a significant difference in tear area and surgical repair technique between the two groups. On multivariate analysis there was no statistically significant difference in Flex SF or VAS pain scores between the two groups., Conclusion: There was no difference in pain or function scores at two years following rotator cuff repair regardless of whether or not acromioplasty was performed. This paper represents the largest study to date comparing acromioplasty to no acromioplasty in the setting of cuff repair. It supports previous literature in showing no significant difference in pain or shoulder function between the two groups., Competing Interests: Nil.

Background: The New Zealand Rotator Cuff Registry is a multicentre, nationwide prospective study of rotator cuff repairs established in March 2009., Methods: A total of 1383 rotator cuff repairs were included in this study, all with completed baseline Flex-SF scores, pain scores and standardized operative forms., Results: Increasing tear size and tear retraction, over 4 cm, were associated with decreasing Flex-SF scores but not pain. Tear area (a composite of tear size and retraction) is increased with advancing age, male gender and a traumatic history but not with smoking. Increased pain scores were associated with supraspinatus (SS) single tears, compared to subscapularis tears, and with labral tears. SS/infraspinatus tears had lower Flex-SF scores compared to subscapularis/SS., Conclusion: This study presents the relationship between baseline function, pain and tear characteristics in symptomatic rotator cuff tears. Increasing tear size and retraction are related to a loss of function but have minimal effect upon pain. Pain generators included labral pathology, and the involvement of SS. The intraoperative appearance of the long head of biceps pathology did not predict baseline pain and function., (© 2017 Royal Australasian College of Surgeons.)

Although recent studies show an improved survival of children with sickle cell disease in the US and Europe, for adult patients mortality remains high. This study was conducted to evaluate the factors associated with mortality in adult patients following the approval of hydroxyurea. We first evaluated the association between selected variables and mortality at an academic center (University of North Carolina). Data sources were then searched for publications from 1998 to June 2016, with meta-analysis of eligible studies conducted in North America and Europe to evaluate the associations of selected variables with mortality in adult patients. Nine studies, combined with the UNC cohort (total n=3257 patients) met the eligibility criteria. Mortality was significantly associated with age (per 10-year increase in age) [7 studies, 2306 participants; hazard ratio (HR): 1.28; 95% confidence interval (CI): 1.10-1.50], tricuspid regurgitant jet velocity 2.5 m/s or more (5 studies, 1577 participants; HR: 3.03; 95%CI: 2.0-4.60), reticulocyte count (3 studies, 1050 participants; HR: 1.05; 95%CI: 1.01-1.10), log(N-terminal-pro-brain natriuretic peptide) (3 studies, 800 participants; HR: 1.68; 95%CI: 1.48-1.90), and fetal hemoglobin (7 studies, 2477 participants; HR: 0.97; 95%CI: 0.94-1.0). This study identifies variables associated with mortality in adult patients with sickle cell disease in the hydroxyurea era., (Copyright© Ferrata Storti Foundation.)

Complications are common after surgery, highlighting the need for innovations that reduce postsurgical morbidity and mortality. In this report, we describe the design, development, and implementation of an Enhanced Recovery After Surgery program in the Kaiser Permanente Northern California integrated health care delivery system. This program was implemented and disseminated in 2014, targeting patients who underwent elective colorectal resection and those who underwent emergent hip fracture repair across 20 Medical Centers. The program leveraged multidisciplinary and broad-based leadership, high-quality data and analytic infrastructure, patient-centered education, and regional-local mentorship alignment. This program has already had an impact on more than 17,000 patients in Northern California. It is now in its fourth phase of planning and implementation, expanding Enhanced Recovery pathways to all surgical patients across Kaiser Permanente Northern California.