Early mobilization after transcatheter aortic valve implantation: observational cohort study.

AIMS: Early mobilization is associated with improved outcomes in hospitalized older patients. We sought to determine the effect of a nurse-led protocol on mobilization 4 h after transfemoral transcatheter aortic valve implantation (TAVI) across different units of care. METHODS AND RESULTS: We conducted a prospective observational cohort single-centre study of consecutive patients. We implemented a standardized protocol for safe early recovery and progressive mobilization in the critical care and cardiac telemetry units. We measured the time to first mobilization and conducted descriptive statistics to identify patient and system barriers to timely ambulation. We recruited 139 patients (82.5 years, SD = 6.7; 46% women). At baseline, patients who were mobilized early (≤4 h) and late (>4 h) did not differ, except for higher rates of diabetes (25.5% vs. 43.9%, P = 0.032) and peripheral arterial disease (8.2% vs. 26.8%, P = 0.003) in the late mobilization group. The median time to mobilization was 4 h [inter-quartile range (IQR) 3.25, 4]; 98 patients (70.5%) were mobilized successfully after 4 h of bedrest; 118 (84.9%) were walking by the evening of the procedure (<8 h bedrest); and 21 (15.1%) were on bedrest overnight and mobilized the following day. Primary reasons for overnight bedrest were arrhythmia monitoring (n = 10, 7.2%) and haemodynamic and/or neurological instability (n = 6, 4.3%); six patients (4.3%) experienced delayed ambulation due to system issues. Procedure location in the hybrid operating room and transfer to critical care were associated with longer bedrest times. CONCLUSION: Standardized nurse-led mobilization 4 h after TF TAVI is feasible in the absence of clinical complications and system barriers.

Bacterial denitrification drives elevated N2O emissions in arid southern California drylands.

Soils are the largest source of atmospheric nitrous oxide (N2O), a powerful greenhouse gas. Dry soils rarely harbor anoxic conditions to favor denitrification, the predominant N2O-producing process, yet, among the largest N2O emissions have been measured after wetting summer-dry desert soils, raising the question: Can denitrifiers endure extreme drought and produce N2O immediately after rainfall? Using isotopic and molecular approaches in a California desert, we found that denitrifiers produced N2O within 15 minutes of wetting dry soils (site preference = 12.8 ± 3.92 per mil, δ15Nbulk = 18.6 ± 11.1 per mil). Consistent with this finding, we detected nitrate-reducing transcripts in dry soils and found that inhibiting microbial activity decreased N2O emissions by 59%. Our results suggest that despite extreme environmental conditions-months without precipitation, soil temperatures of ≥40°C, and gravimetric soil water content of <1%-bacterial denitrifiers can account for most of the N2O emitted when dry soils are wetted.

Wetting-induced soil CO2 emission pulses are driven by interactions among soil temperature, carbon, and nitrogen limitation in the Colorado Desert.

Warming-induced changes in precipitation regimes, coupled with anthropogenically enhanced nitrogen (N) deposition, are likely to increase the prevalence, duration, and magnitude of soil respiration pulses following wetting via interactions among temperature and carbon (C) and N availability. Quantifying the importance of these interactive controls on soil respiration is a key challenge as pulses can be large terrestrial sources of atmospheric carbon dioxide (CO2 ) over comparatively short timescales. Using an automated sensor system, we measured soil CO2 flux dynamics in the Colorado Desert-a system characterized by pronounced transitions from dry-to-wet soil conditions-through a multi-year series of experimental wetting campaigns. Experimental manipulations included combinations of C and N additions across a range of ambient temperatures and across five sites varying in atmospheric N deposition. We found soil CO2 pulses following wetting were highly predictable from peak instantaneous CO2 flux measurements. CO2 pulses consistently increased with temperature, and temperature at time of wetting positively correlated to CO2 pulse magnitude. Experimentally adding N along the N deposition gradient generated contrasting pulse responses: adding N increased CO2 pulses in low N deposition sites, whereas adding N decreased CO2 pulses in high N deposition sites. At a low N deposition site, simultaneous additions of C and N during wetting led to the highest observed soil CO2 fluxes reported globally at 299.5 µmol CO2  m-2  s-1 . Our results suggest that soils have the capacity to emit high amounts of CO2 within small timeframes following infrequent wetting, and pulse sizes reflect a non-linear combination of soil resource and temperature interactions. Importantly, the largest soil CO2 emissions occurred when multiple resources were amended simultaneously in historically resource-limited desert soils, pointing to regions experiencing simultaneous effects of desertification and urbanization as key locations in future global C balance.

Using a paired tower approach and remote sensing to assess carbon sequestration and energy distribution in a heterogeneous sclerophyll forest.

The critically endangered Cumberland Plain woodland within the greater Sydney metropolitan area hosts a dwindling refuge for melaleuca trees, an integral part of Australia's native vegetation. Despite their high carbon stocks, melaleucas have not explicitly been targeted for studies assessing their carbon sequestration potential, and especially little is known about their energy cycling or their response to increasing climate stress, precluding a holistic assessment of the resilience of Australia's forests to climate change. To improve our understanding of the role of melaleuca forest responses to climate stress, we combined forest inventory and airborne LiDAR data to identify species distribution and associated variations in forest structure, and deployed flux towers in a melaleuca-dominated (AU-Mel) and in a eucalypt-dominated (AU-Cum) stand to simultaneously monitor carbon and energy fluxes under typical growing conditions, as well as during periods with high atmospheric demand and low soil water content. We discovered that the species distribution at our study site affected the vertical vegetation structure, leading to differences in canopy coverage (75% at AU-Cum vs. 84% at AU-Mel) and plant area index (2.1 m2 m-2 at AU-Cum vs. 2.6 m2 m-2 at AU-Mel) that resulted in a heterogeneous forest landscape. Furthermore, we identified that both stands had comparable net daytime carbon exchange and sensible heat flux, whereas daytime latent heat flux (115.8 W m-2 at AU-Cum vs 119.4 W m-2 at AU-Mel, respectively) was higher at the melaleuca stand, contributing to a 0.3 °C decrease in air temperature and reduced vapor pressure deficit above the melaleuca canopy. However, increased canopy conductance and higher latent heat flux during moderate VPD or when soil moisture was low indicated a lack of water preservation at the melaleuca stand, highlighting the potential for increased vulnerability of melaleucas to projected hotter and drier future climates.

Patient perspectives of an individualized diabetes care management plan.

PURPOSE: This cross sectional study examines patients' knowledge, attitudes and beliefs about a diabetic care management plan (DCMP) that was developed to provide patient education on diabetes guidelines and display individual diabetic core measures. Secondary objectives included a comparison of diabetic core measures [hemoglobin A1C (HbA1C), systolic and diastolic blood pressure (SBP, DBP), low-density lipoprotein (LDL) and urine microalbumin (Um)] before and after DCMP implementation. We hypothesize this tool will contribute to patients' awareness of current disease status, diabetes knowledge and diabetic core value improvement over time. METHODS: A consecutive sample of 102 adult patients with diabetes mellitus type 2 in a primary care setting participated. Patients' perspectives on the care plan and knowledge about diabetes was collected via survey after care plan implementation. A comparison of selected diabetic core measures was conducted at baseline and post-DCMP. Descriptive statistics summarized survey response and diabetic core measures. A repeated measures ANOVA was used to assess change in diabetic core measures over time. RESULTS: Participants understood the DCMP (96%), found it important because it explained their laboratory results and medications (89%) and believed it would help them to have better diabetic control (99%). There was a significant interaction between time and being at goal pre-DCMP for HbA1c, SBP and LDL. Patients not at goal pre-DCMP for the above measures decreased significantly over time (P = <0.01 for HbA1c, SBP and LDL). Participants at goal for all diabetic core measures increased pre- to post-DCMP from 13% to 20% (P = 0.28). CONCLUSION: Patients perceived the diabetic care management plan favorably and their diabetic core measurements improved over time. This simple and reproducible self-management intervention can enhance self-management in a patient population with diabetes mellitus type 2.

Wetland loss patterns and inundation-productivity relationships prognosticate widespread salt for southern New England.

Tidal salt marsh is a key defense against, yet is especially vulnerable to, the effects of accelerated sea level rise. To determine whether salt marshes in southern New England will be stable given increasing inundation over the coming decades, we examined current loss patterns, inundation-productivity feedbacks, and sustaining processes. A multi-decadal analysis of salt marsh aerial extent using historic imagery and maps revealed that salt marsh vegetation loss is both widespread, and accelerating, with vegetation loss rates over the past four decades summing to 17.3%. Seaward retreat of the marsh edge, widening and headward expansion of tidal channel networks, loss of marsh islands, and the development and enlargement of interior depressions found on the marsh platform contributed to vegetation loss. Inundation due to sea level rise is strongly suggested as a primary driver: vegetation loss rates were significantly negatively correlated with marsh elevation (r2=0.96; p=0.0038), with marshes situated below mean high water (MHW) experiencing greater declines than marshes sitting well above MHW. Growth experiments with Spartina alterniflora, the Atlantic salt marsh ecosystem dominant, across a range of elevations and inundation regimes further established that greater inundation decreases belowground biomass production of Spartina alterniflora and thus negatively impacts organic matter accumulation. These results suggest that southern New England salt marshes are already experiencing deterioration and fragmentation in response to sea level rise, and may not be stable as tidal flooding increases in the future.

The psychological impact of exposure to floods.

A number of studies have shown a range of symptoms resulting from exposure to natural disasters such as flooding. Among these consequences, individuals may experience symptoms of post-traumatic stress disorder (PTSD), depression and anxiety. The aim of this study was to examine the psychological impact of flooding in the UK. A cross-sectional survey was used to investigate the psychological symptoms associated with the aftermath of the flood amongst adults living in the affected communities. A questionnaire battery including the Harvard Trauma Questionnaire (trauma and symptoms associated with PTSD), Hopkins Symptom Checklist (anxiety and depression), Coping Strategies Questionnaire and a range of questions addressing sociodemographic characteristics and factors relating to the flood was administered to households in flood-affected areas. Four hundred and forty four completed questionnaires were returned. 27.9% of participants met criteria for symptoms associated with PTSD, 24.5% for anxiety and 35.1% for depression. Females had higher mean scores on PTSD, anxiety and depression than males. Most frequently reported coping strategies were rational, detached and avoidant, with the least frequent being emotional coping. Having to vacate home following flood, previous experience of flooding and poor health were associated with greater psychological distress. Detached coping appeared to be related to less distress. Although it is not possible to determine whether the symptoms were a direct consequence of the flood, symptoms of distress are a significant issue amongst communities affected by environmental events warranting further attention to prevent chronic distress.