Using dynamic modelling to enhance the assessment of the beef water footprint

Current water footprint assessment methods make a meaningful assessment of livestock water consumption difficult as they are mainly static, thus poorly adaptable to understanding future water consumption and requirements. They lack the integration of fundamental ruminant nutrition and growth equations within a dynamic context that accounts for short- and long-term behaviour and time delays associated with economically significant beef-producing areas. The current study utilised the System Dynamics methodology to conceptualise a water footprint for beef cattle within a dynamic and mechanistic modelling framework. The problem of assessing the water footprint of beef cattle was articulated, and a dynamic hypothesis was formed to represent the Texas livestock water use system as the initial step in developing the Dynamic Beef Water Footprint model (DWFB). The dynamic hypothesis development resulted in three causal loop diagrams (CLD): cattle population, growth and nutrition, and the livestock water footprint, that captured the daily water footprint of beef (WFB). Simulations and sensitivity analysis from the hypothesised CLD structures indicated that the framework was able to capture the dynamic behaviour of the WFB system. These behaviours included key reinforcing and balancing feedback processes that drive the WFB. It is extremely difficult to identify policy interventions (i.e., management strategies) for complex systems, like the U.S. beef cattle system, because there are many actors (i.e., cow-calf, stocker, feedlot) and interrelated variables that have delayed effects within and across the supply chain. Identification and understanding of feedback processes driving water use over time will help to overcome policy resistance for more sustainable beef production. Thus, the causal loops identified in the current study provide a system-level insight for the drivers of the WFB within and across each major segment of the beef supply chain to address freshwater concerns more adequately. Further, the nutrient scenarios and sensitivity analysis revealed that the high versus low nutrient composition of pasture, hay, and concentrates resulted in a significant difference in the WFB (2 669 L/kg boneless beef, P < 0.05). The WFB was sensitive to changes in nutrient composition and specific water demand (m3/t) for each production phase, not only phases with high levels of concentrate feed use. As models evolve, there is potential for the DWFB to integrate precision livestock data, further improving quantification of the WFB, precision water-efficient strategies, and selection of water-efficient livestock.

Analytical Unreliability of 25 Hydroxy Vitamin D Measurements in Pre-Term Neonates

BACKGROUND

Vitamin D supplementation is common practice for neonates and infants due to limited stores of vitamin D at birth. Although not commonly encountered, vitamin D toxicity can occur due to over-supplementation. However, toxic concentrations are often not included in method validation experiments, and assays often are not validated in the neonatal population.

METHODS

We compared serial 25 hydroxy vitamin D [25(OH)D] measurements in pre-term neonates receiving 25(OH)D supplementation and identified 12 patients wherein concentrations of 25(OH)D were above 50 ng/mL (125 nM) that required additional investigations as the 25(OH)D results did not match the clinical picture. Available samples were compared across 4 immunoassay platforms (LIAISON XL, Roche Cobas e602, Abbott Alinity i, and Siemens Centaur XP) and LC-MS/MS.

RESULTS

Concentrations of 25(OH)D observed on one individual immunoassay platform (LIAISON XL) fluctuated substantially between subsequent blood draws in select neonates with elevated concentrations. Serum samples from these patients showed variable agreement between LC-MS/MS and other immunoassay platforms. These fluctuations were not explained by the presence of 3-epimer-25(OH)D or 24,25(OH)2D.

CONCLUSIONS

Although we were unable to identify a cause for the variable elevated results, our findings suggest that neonatal 25(OH)D measurements alone should not be used for assessment of nutritional monitoring, and that clinical correlation and other laboratory parameters including ionized calcium should be considered.

A Systematic Review of Clinical Practice Guidelines for Identification and Management of Frailty

OBJECTIVE

This study aims to appraise and summarize consistent recommendations from clinical practice guidelines (CPGs) for identification and management of frailty to maintain and improve functional independence of elderly population.

METHODS

A systematic search of Ovid MEDLINE, Embase, PubMed, PsycINFO, and CINAHL electronic databases using database-specific search terms in two broad areas "guidelines" and "frailty", and a manual search of websites with the key phrase "frailty guideline" was performed. The inclusion criteria included CPGs focusing on identifying and managing frailty in population >65 years old, published in English since January 2010. Three reviewers independently assessed guideline quality using the AGREE II instrument. Data extraction was performed, followed by compilation and comparison of all recommendations to identify the key consistent recommendations.

RESULTS

Six CPGs met the inclusion criteria; however, only three CPGs had high methodological quality in accordance with AGREE II appraisal. The average AGREE II scores of all six CPGs were: 84.5%, 68%, 46.5%, 81.5%, 56.3%, and 60.2% for domains 1-6 (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence) respectively. A total of 54 recommendations were identified, with 12 key recommendations suggested frequently by the CPGs.

CONCLUSION

The AGREE II instrument identified strengths and weaknesses of the CPGs, but failed to assess clinical implications and feasibility of the guidelines. Further research is needed to improve clinical relevance of CPGs in the identification and management of frailty. The feasibility in implementing these guidelines with regards to cost-effectiveness of frailty screening warrants further investigation.

Predictors and Prevalence of Nodal Disease in Salvage Oropharyngectomy

BACKGROUND

Patients with recurrent oropharyngeal cancer often require extensive salvage surgery. For patients with clinically N0 necks, the indication for concurrent neck dissection remains unclear. This study aimed to determine predictors, prevalence, and distribution of nodal disease in patients treated with salvage oropharyngectomy.

METHODS

In a case series with data collection at a single tertiary academic National Cancer Institute (NCI)-designated comprehensive cancer center, this study analyzed patients treated with prior radiation or chemoradiation who had persistent, recurrent, or second primary squamous cell carcinoma of the oropharynx requiring oropharyngeal resection between 1998 and 2017 (n = 95). Clinical and oncologic characteristics and treatment outcomes were collected, and statistical analyses were performed.

RESULTS

The overall rate of nodal positivity was 21% (24/95), and the rate of occult nodal disease was 6% (4/65). Ipsilateral and contralateral level 2 were the most common areas harboring positive nodes. Bivariate analysis showed female sex (p = 0.01), initial overall stage (p = 0.02), and N status (p = 0.03), as well as recurrent overall and T stage (p = 0.05) to be predictors of nodal disease. In the multivariate analysis, recurrent T stage continued to be significantly predictive of pathologic nodal disease. Both computed tomography (CT) and positron emission tomography-CT were moderately accurate in predicting nodal disease in the salvage setting (area under the curve, 0.79 and 0.80, respectively).

CONCLUSION

Occult nodal disease is observed in few patients undergoing salvage oropharyngeal resection. This study identified factors predictive of nodal disease in patients undergoing salvage oropharyngectomy and appropriate diagnostic tests in this setting.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

What Really Matters to You? A Study of Public Perspectives on General Practice in Ireland

Aims In recent years it has been recognised that person-centred care can lead to better outcomes for patients and a reduced burden on healthcare systems. The aim of this study was to explore what really matters to members of the public when they visit a GP in Ireland. Methods This qualitative study used a structured interview methodology with one question; “What really matters to you when you go to see a GP?” Results were analysed using an integrated approach, involving both inductive and deductive methods. Results Responses from the 10 study participants were subdivided into two overarching themes: the General Practitioner as a person and the General Practice as a service. Personality (open, approachable, personable, trusted, interested) and service (time, cost, convenience, personal relationship) traits matter to patients. Conclusion Patients must be facilitated and encouraged to voice what really matters to them in order to inform truly person-centred healthcare improvement.

Guidelines To Validate Control of Cross-Contamination during Washing of Fresh-Cut Leafy Vegetables

The U.S. Food and Drug Administration requires food processors to implement and validate processes that will result in significantly minimizing or preventing the occurrence of hazards that are reasonably foreseeable in food production. During production of fresh-cut leafy vegetables, microbial contamination that may be present on the product can spread throughout the production batch when the product is washed, thus increasing the risk of illnesses. The use of antimicrobials in the wash water is a critical step in preventing such water-mediated cross-contamination; however, many factors can affect antimicrobial efficacy in the production of fresh-cut leafy vegetables, and the procedures for validating this key preventive control have not been articulated. Producers may consider three options for validating antimicrobial washing as a preventive control for cross-contamination. Option 1 involves the use of a surrogate for the microbial hazard and the demonstration that cross-contamination is prevented by the antimicrobial wash. Option 2 involves the use of antimicrobial sensors and the demonstration that a critical antimicrobial level is maintained during worst-case operating conditions. Option 3 validates the placement of the sensors in the processing equipment with the demonstration that a critical antimicrobial level is maintained at all locations, regardless of operating conditions. These validation options developed for fresh-cut leafy vegetables may serve as examples for validating processes that prevent cross-contamination during washing of other fresh produce commodities.

Endotension after Endovascular Aneurysm Repair: Definition, Classification, and Strategies for Surveillance and Intervention

In the ongoing evolution of a categorization system for endoleak, the authors propose the term endotension to define persistent or recurrent pressurization of the aortic aneurysm sac after endovascular repair. Endotension is evidence that the aneurysm remains at risk of rupture and should, therefore, be considered an indication for secondary intervention. Management strategies and a grading system for endotension are offered.

Longitudinal Aneurysm Shrinkage following Endovascular Aortic Aneurysm Repair: A Source of Intermediate and Late Complications

Purpose:

To report the incidence of delayed complications following endovascular abdominal aortic aneurysm (AAA) repair and the relationship of these sequelae to morphological changes in the sac and endograft.

Methods:

Twenty-six AAA patients treated with Vanguard endografts had completed ≥1-year follow-up. Postoperative angiograms and spiral computed tomographic (CT) scans with 3-dimensional reconstruction were compared to the 1-year images to determine morphological changes in the aneurysm sac and the endograft. These changes were then related to complications occurring between 1 and 12 months postoperatively in the study group.

Results:

Comparison of angiograms uncovered endograft buckling in 18 (69%) patients and acutely angled or kinked endografts in 10 (38%). Measurements from the CT scans found that undistorted endografts had a mean change in sac length of +6.6 mm. Mean sac length change in buckled endografts was −3.1 mm, while kinked endografts displayed a mean change of −6.2 mm (p < 0.002, Student's t-test). Five (19%) patients, all with distorted endografts, demonstrated late (1 to 12 months) complications (4 endoleaks and 1 graft limb thrombosis) owing to component separation, distal stent migration, and acute angulation. No movement in the proximal stent was observed. Elongation of the endograft (flow line measurement) was observed in one tube graft only.

Conclusions:

In this study, longitudinal shrinkage of the sac following endovascular aortic aneurysm repair led to buckling or kinking of the endograft within 1 year in 69% of patients. This appears to be an important source of delayed complications.

The use of immunosuppressive agents in the management of recalcitrant lower limb ulcers

OBJECTIVE

Lower limb ulcers that are resistant to standard forms of treatment place a significant burden on both patients and health services. There is no widely agreed definition of a recalcitrant ulcer but failure to heal following 6-12 months of focused treatment would identify a small group of patients with highly resistant ulceration. We describe a series of patients with recalcitrant ulceration for which immunosuppressive agents have been used.

METHODS

This is a case series of 13 patients who underwent immunomodulation therapy for lower limb ulcers at a tertiary referral university hospital. Regimens of immunomodulation used mainly ciclosporin and/or cyclophosphamide, with concurrent antibiotic therapy. Case notes and computer systems were analysed by two reviewers. A patient was deemed to have a success if their ulcer fully healed while on immunomodulation therapy.

RESULTS

Over a period of eight years, from 2004-2012, 13 patients underwent immunomodulation therapy. Among these patients there were 18 ulcerated limbs. Ulcer healing occurred in 10 limbs out of 18 (55.6%) and full healing occurred in six patients (46.2%). Ulcers were present for a median of five years (range 2-40 years), with a median diameter of 7.5 cm (range 4-18 cm) before treatment.

CONCLUSION

Treatment of truly recalcitrant ulceration can be very frustrating for both the patient and physician, with poor success from more standard forms of treatment. We report experience with immunomodulation therapy that suggests there may be benefit from using this treatment in a subset of patients with this debilitating disease.

A novel case of laparoscopic ureterolithotomy in a partial duplex ureteric collecting system: can open procedures still be justified in the minimally invasive era?

BACKGROUND

Impacted ureteric stones can pose a treatment challenge due to the high level of failure of ESWL and endourological approaches. Laparoscopic ureterolithotomy can provide a safe and successful alternative to these and open, invasive procedures.

METHODS

Interval laparoscopic ureterolithtomy was carried out following placement of a percutaneous nephrostomy. This was performed through an trans-peritoneal approach with the ureterotomy closed by intracorporeal suturing and placement of a JJ stent without the need for an abdominal wound drain.

CONCLUSION

Laparoscopic ureterolithotomy is a safe, minimally invasive method of managing large, impacted ureteric stones with minimal associated patient morbidity.

A comprehensive systematic review of evidence on determining the impact of Magnet designation on nursing and patient outcomes: is the investment worth it?

OBJECTIVE

The overall objective is to examine the current evidence of the impact of Magnet designation on patient and nurse outcomes.

INCLUSION CRITERIA

This review considered any quantitative or qualitative study comparing organizational, nurse, patient or economic outcomes in Magnet designated hospitals with a comparison to a non-Magnet facility. Studies which used case-controlled, descriptive comparative, descriptive correlational and qualitative designs were considered due to the nature of the question. Participants included nurses in four hospital types: ANCC Magnet, Reputational Magnet, Magnet-Aspiring, and non-Magnet. Interventions included: Magnet hospitals (ANCC), Reputational Magnet; Magnet-Aspiring hospitals and non-Magnet hospitals.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies and papers, limited to the English language. An initial search of the Joanna Briggs Institute for Evidence Based Nursing and Midwifery and Cochrane Library databases was conducted. A three-step search strategy was then used. A first-stage, limited search of MEDLINE and CINAHL using preliminary key words was done. In consultation with an information scientist experienced in database searching, a comprehensive search strategy incorporating the key words from the preliminary search was undertaken. The third approach was to review the reference lists from all retrieved papers meeting the inclusion criteria to identify any further research not identified in the first two stages.

METHODOLOGICAL QUALITY

Each paper was assessed by two independent reviewers for methodological quality prior to inclusion using the appropriate critical appraisal instrument from the Joanna Briggs Institute.

RESULTS

A total of 17 papers were included in the review. All were descriptive comparative studies with the majority using a cross sectional survey approach comparing outcomes across either two or three categories of Magnet designation. Comparison across studies using the same instrument was limited as survey instruments were not used in the same manner and studies had different Magnet designation comparison groups. Majority of studies investigated professional nurse practice environment, nurse burnout, nurse satisfaction, perception of quality care, and intent to leave. Limited studies found related to patient outcomes, and no studies met criteria for inclusion for economic review.

CONCLUSION

The investment is worth it. There is evidence to support the positive effect of Magnet designation on the professional nurse practice environment (PNPE). Stronger PNPE and Magnet status are associated with lower levels of nurse burnout, higher levels of nursing satisfaction, higher perceptions of quality of care, and decreased intent to leave. There is a need to further investigate the linkage between PNPE and/or Magnet designation with patient outcomes. Understanding the economic implications of a PNPE requires further study.

Relationship between the fungal complex causing Fusarium head blight of wheat and environmental conditions

ABSTRACT Over 4 years, the environmental conditions and the causal agents of Fusarium head blight (FHB) disease of wheat were determined in field sites in four European countries: Hungary, Ireland, Italy, and the United Kingdom. Polymerase chain reaction-based methods were used to detect each species causing FHB and quantify its DNA (as a measurement of fungal abundance) in the samples. Canonical correspondence analysis (CCA) was used to determine the relationship of the incidence and abundance of each species with weather variables. CCA indicated that little variability in the species prevalence data was explained by the weather variables. In contrast, a greater proportion of variability in abundance data was accounted for by the weather variables. Most samples contained two or more species and statistical analysis suggested that these species tended to coexist at field sites. CCA also indicated that there were differences in the relationships of the prevalence and abundance of the six FHB species with environmental variables. Fusarium poae was associated with relatively drier and warmer conditions, whereas F. graminearum was associated with warmer/humid conditions. F. avenaceum and F. culmorum were both associated with niches of cooler/wet/humid conditions. Two Microdochium species were associated with regions of relatively cool/moderate temperatures and frequent rainfalls of short duration. The results also suggested that environmental conditions differentially affect the infection and colonization processes, and the comparative abundance of the six species.