Differing climate and landscape effects on regional dryland vegetation responses during wet periods allude to future patterns.

Dryland vegetation is influenced by biotic and abiotic land surface template (LST) conditions and precipitation (PPT), such that enhanced vegetation responses to periods of high PPT may be shaped by multiple factors. High PPT stochasticity in the Chihuahuan Desert suggests that enhanced responses across broad geographic areas are improbable. Yet, multiyear wet periods may homogenize PPT patterns, interact with favorable LST conditions, and in this way produce enhanced responses. In contrast, periods containing multiple extreme high PPT pulse events could overwhelm LST influences, suggesting a divergence in how climate change could influence vegetation by altering PPT periods. Using a suite of stacked remote sensing and LST datasets from the 1980s to the present, we evaluated PPT-LST-Vegetation relationships across this region and tested the hypothesis that enhanced vegetation responses would be initiated by high PPT, but that LST favorability would underlie response magnitude, producing geographic differences between wet periods. We focused on two multiyear wet periods; one of above average, regionally distributed PPT (1990-1993) and a second with locally distributed PPT that contained two extreme wet pulses (2006-2008). 1990-1993 had regional vegetation responses that were correlated with soil properties. 2006-2008 had higher vegetation responses over a smaller area that were correlated primarily with PPT and secondarily to soil properties. Within the overlapping PPT area of both periods, enhanced vegetation responses occurred in similar locations. Thus, LST favorability underlied the geographic pattern of vegetation responses, whereas PPT initiated the response and controlled response area and maximum response magnitude. Multiyear periods provide foresight on the differing impacts that directional changes in mean climate and changes in extreme PPT pulses could have in drylands. Our study shows that future vegetation responses during wet periods will be tied to LST favorability, yet will be shaped by the pattern and magnitude of multiyear PPT events.

Regional grassland productivity responses to precipitation during multiyear above- and below-average rainfall periods.

There is considerable uncertainty in the magnitude and direction of changes in precipitation associated with climate change, and ecosystem responses are also uncertain. Multiyear periods of above- and below-average rainfall may foretell consequences of changes in rainfall regime. We compiled long-term aboveground net primary productivity (ANPP) and precipitation (PPT) data for eight North American grasslands, and quantified relationships between ANPP and PPT at each site, and in 1-3 year periods of above- and below-average rainfall for mesic, semiarid cool, and semiarid warm grassland types. Our objective was to improve understanding of ANPP dynamics associated with changing climatic conditions by contrasting PPT-ANPP relationships in above- and below-average PPT years to those that occurred during sequences of multiple above- and below-average years. We found differences in PPT-ANPP relationships in above- and below-average years compared to long-term site averages, and variation in ANPP not explained by PPT totals that likely are attributed to legacy effects. The correlation between ANPP and current- and prior-year conditions changed from year to year throughout multiyear periods, with some legacy effects declining, and new responses emerging. Thus, ANPP in a given year was influenced by sequences of conditions that varied across grassland types and climates. Most importantly, the influence of prior-year ANPP often increased with the length of multiyear periods, whereas the influence of the amount of current-year PPT declined. Although the mechanisms by which a directional change in the frequency of above- and below-average years imposes a persistent change in grassland ANPP require further investigation, our results emphasize the importance of legacy effects on productivity for sequences of above- vs. below-average years, and illustrate the utility of long-term data to examine these patterns.

Reference Intervals Generated by Electronic Medical Record Data Mining with Clinical Exclusions: Age-Specific Intervals for Thyroid-Stimulating Hormone from 33038 Euthyroid Patients.

BACKGROUND: Serum thyroid-stimulating hormone (TSH) reference intervals are dependent on population characteristics, including prevalent thyroid disease and iodine status. Studies in the US have demonstrated increasing TSH levels with age, and the American Thyroid Association recommends higher TSH goals for older patients taking thyroid supplementation, but few laboratories offer age-specific reference intervals for TSH. Our objective was to establish TSH reference ranges in our racially diverse population in northern California. METHODS: Data mining of electronic medical records was used with the a posteriori approach to select a euthyroid reference population for TSH reference intervals. A report gathered all TSH results from 2 weeks from >1 year in the past, excluding results from patients with thyroid-related disease or medication use at any time before or after the TSH test. RESULTS: The reference population numbered 33038 and consisted of approximately 44% of the total TSH results reported in the selected time periods. The population identified as 46.5% white, 18.3% Asian, 17.0% Hispanic/Latino, 8.0% black/African American, and 10.3% other or unknown. These data demonstrate an increase in the median and 97.5 percentile of TSH levels with increasing age in adults. No clinically significant difference was seen between female and male individuals or between the self-identified races, except for lower TSH levels in the black/African American population. CONCLUSIONS: The a posteriori approach using data mining for disease-specific criteria proved to be an efficient method for obtaining a large healthy reference population. Age-specific TSH reference ranges could prevent inappropriate diagnoses of subclinical hypothyroidism in older patients.

Serum Fibrosis Marker Panels FIB-4 Index and Aspartate Aminotransferase (AST)-to-Platelet Ratio Index (APRI) Are Equivalent to AST Alone at Predicting Liver Fibrosis in a Cohort of 1731 Patients Infected with Hepatitis C Virus.

BACKGROUND: Efficient tools are needed to stage liver disease before treatment of patients infected with hepatitis C virus (HCV). Compared to biopsy, several studies demonstrated favorable performance of noninvasive multianalyte serum fibrosis marker panels [fibrosis-4 (FIB-4) index] and aspartate aminotransferase (AST)-to-platelet ratio index (APRI), but suggested cutoffs vary widely. Our objective was to evaluate FIB-4 index and APRI and their component tests for staging fibrosis in our HCV-infected population and to determine practical cutoffs to help triage an influx of patients requiring treatment. METHODS: Transient elastography (TE) results from 1731 HCV-infected patients were mapped to an F0-F4 equivalent scale. Each patient's APRI and FIB-4 index were calculated. Areas under the receiver operator curve (AUROCs) and false-positive and false-negative rates were calculated to retrospectively compare the performance of the indices and their component tests. RESULTS: The highest AUROCs for distinguishing severe (F3-F4) from mild-to-moderate (F0-F2) fibrosis had overlapping 95% CIs: APRI (0.77; 0.74-0.79), FIB-4 index (0.76; 0.73-0.78), and AST (0.74; 0.72-0.77). Cutoffs had false-negative rates of 2.7%-2.8% and false-positive rates of 6.4%-7.4% for all 3 markers. CONCLUSIONS: AST was as effective as FIB-4 index and APRI at predicting fibrosis. Published cutoffs for APRI and FIB-4 index would have been inappropriate in our population, with false-negative rates as high as 11%. For our purposes, no serum fibrosis marker was sufficiently sensitive to rule-out significant fibrosis, but cutoffs developed for AST, FIB-4 index, and APRI all had specificities of 79.2%-80.3% for ruling-in severe fibrosis and could be used to triage 1/3 of our population for treatment without waiting for TE or liver biopsy.

Press-pulse interactions: effects of warming, N deposition, altered winter precipitation, and fire on desert grassland community structure and dynamics.

Global environmental change is altering temperature, precipitation patterns, resource availability, and disturbance regimes. Theory predicts that ecological presses will interact with pulse events to alter ecosystem structure and function. In 2006, we established a long-term, multifactor global change experiment to determine the interactive effects of nighttime warming, increased atmospheric nitrogen (N) deposition, and increased winter precipitation on plant community structure and aboveground net primary production (ANPP) in a northern Chihuahuan Desert grassland. In 2009, a lightning-caused wildfire burned through the experiment. Here, we report on the interactive effects of these global change drivers on pre- and postfire grassland community structure and ANPP. Our nighttime warming treatment increased winter nighttime air temperatures by an average of 1.1 °C and summer nighttime air temperature by 1.5 °C. Soil N availability was 2.5 times higher in fertilized compared with control plots. Average soil volumetric water content (VWC) in winter was slightly but significantly higher (13.0% vs. 11.0%) in plots receiving added winter rain relative to controls, and VWC was slightly higher in warmed (14.5%) compared with control (13.5%) plots during the growing season even though surface soil temperatures were significantly higher in warmed plots. Despite these significant treatment effects, ANPP and plant community structure were highly resistant to these global change drivers prior to the fire. Burning reduced the cover of the dominant grasses by more than 75%. Following the fire, forb species richness and biomass increased significantly, particularly in warmed, fertilized plots that received additional winter precipitation. Thus, although unburned grassland showed little initial response to multiple ecological presses, our results demonstrate how a single pulse disturbance can interact with chronic alterations in resource availability to increase ecosystem sensitivity to multiple drivers of global environmental change.

Beyond arctic and alpine: the influence of winter climate on temperate ecosystems.

Winter climate is expected to change under future climate scenarios, yet the majority of winter ecology research is focused in cold-climate ecosystems. In many temperate systems, it is unclear how winter climate relates to biotic responses during the growing season. The objective of this study was to examine how winter weather relates to plant and animal communities in a variety of terrestrial ecosystems ranging from warm deserts to alpine tundra. Specifically, we examined the association between winter weather and plant phenology, plant species richness, consumer abundance, and consumer richness in 11 terrestrial ecosystems associated with the U.S. Long-Term Ecological Research (LTER) Network. To varying degrees, winter precipitation and temperature were correlated with all biotic response variables. Bud break was tightly aligned with end of winter temperatures. For half the sites, winter weather was a better predictor of plant species richness than growing season weather. Warmer winters were correlated with lower consumer abundances in both temperate and alpine systems. Our findings suggest winter weather may have a strong influence on biotic activity during the growing season and should be considered in future studies investigating the effects of climate change on both alpine and temperate systems.

Carbamazepine and carbamazepine-10,11-epoxide clearance measurements during continuous venovenous hemofiltration in a massive overdose.

INTRODUCTION: Carbamazepine (CBZ) overdose can result in significant neurologic and cardiovascular toxicity, and is compounded by the presence of an active metabolite, carbamazepine-10,11-epoxide (CBZE). Existing publications describing continuous venovenous hemofiltration (CVVH) in CBZ overdose are limited in their ability to calculate accurate clearances. We report a case of CBZ overdose treated with CVVH with detailed measurement of CBZ, CBZE and their respective clearances calculated utilizing serial effluent measurements. This was coupled with serum level determinations comparing two analytical methodologies, time-of-flight mass spectroscopy and an immunoassay. CASE DETAILS: A 41-year-old woman presented unresponsive after an overdose of CBZ. Initial CBZ serum levels were markedly elevated (57.8 µg/mL) and continued to rise. Due to continued hemodynamic instability, extracorporeal removal was initiated using CVVH. MATERIALS AND METHODS: During the first 30 h of CVVH, interval serum samples and all ultrafiltrate bags were collected and analyzed. Serum and effluent levels of CBZ and CBZE were measured using an Agilent 6230 time-of-flight high-resolution mass spectrometer (TOF-MS). CBZ levels were also obtained utilizing the Microgenics CEDIA Carbamazepine Immunoassay (Thermo Fisher, Waltham, MA) for serum and effluent samples. Immunoassay analysis was performed using Siemens ADVIA 1800 instrument. RESULTS: The clearances achieved for CBZE (mean = 25.2, range 17.7-42.6 mL/min) exceeded that for CBZ (mean = 18.1, range 12.7-28.7 mL/min). CVVH removed a total of 1293 and 1261 mg of CBZ and CBZE, respectively. Serum levels of CBZ measured by immunoassay when compared with TOF-MS indicated cross reactivity of CBZE with the immunoassay. CONCLUSIONS: CVVH removed CBZE with higher clearances than CBZ. However, CVVH clearance rates for both CBZ and CBZE were lower than published clearances of CBZ and CBZE by intermittent hemodialysis. Our methodology allowed for a precise pharmacokinetic assessment of clearance based on total quantity of parent drug and active metabolite removed. Use of an immunoassay to determine CBZ serum levels reflects both parent compound and active metabolite due to cross-reactivity with CBZE.

Performance characteristics of the Beckman Coulter total ßhCG (5th IS) assay.

BACKGROUND: Beckman Coulter recently released the first commercially available hCG reagent calibrated against the 5th International Standard (IS) for hCG (total ßhCG (5th IS)). We performed a comprehensive analytical validation of this reagent. METHODS: Precision experiments were completed using 3 concentrations of commercial quality control material. Linearity, sample stability, and analytical sensitivity were evaluated using pools of human serum. Reportable range was assessed by comparing manual dilutions to those performed by the instrument. Male and female reference intervals were established using residual serum specimens submitted for routine testing. Inter-lot variability of hCG assay reagent was assessed by analyzing serum specimens with detectable hCG using 2 different reagent lots. Inter-assay variability was established using 203 serum specimens analyzed for hCG on 6 different reagent platforms. RESULTS: Inter-day precision showed a CV of <6.0% for all concentrations of QC material. LOB, LOD, and LOQ were determined to be 0.3, 0.4, and 0.6 U/l, respectively. The Access (5th IS) reagent has an average positive bias of approximately 20% when compared to most platforms and the previous generation Beckman hCG assay. Results were consistent between lots. Female reference intervals varied by age: <1.0 U/l (<41 y), <6.0 U/l (41-50 y), and <8.0 U/l (>50 y). Male reference intervals were <2.0 U/l. CONCLUSIONS: The analytical performance of the total ßhCG (5th IS) was established. Care should be taken to re-baseline patients needing serial monitoring and/or notify physicians when transitioning to the total ßhCG (5th IS) reagent.

Challenges in harmonizing integrated healthcare network laboratories: Multi-center evaluation of the AccuTnI+3 troponin assay.

BACKGROUND: Beckman Coulter has recently introduced a new troponin assay manufactured for the Access2 and DxI platforms, releasing it under the name AccuTnI+3. Clinical laboratories are required to validate method performance before testing and reporting patient results. METHODS: Beckman Coulter Access 2 instruments (n=42) across Kaiser Permanente Northern California were evaluated for their performance characteristics using the AccuTnI+3 reagent. Precision, linearity, and patient sample comparisons were performed on each instrument. Limit of the blank (LOB), limit of detection (LOD), limit of quantitation (LOQ), serum plasma comparisons, and specimen stability were evaluated using a single instrument. RESULTS: The assay was linear from 0-100,000ng/L. The LOB, LOD and LOQ were determined to be 5, 8 and 20ng/L, respectively. Interday precision on the low QC (mean concentration 41ng/L) ranged from 3.0% to 14.2%. The bias observed between the former assay (AccuTnI) and the AccuTnI+3 was comparable to the inter-instrument bias for either assay. Non-uniform distribution was observed in the precision and inter-instrument/inter-assay comparisons among the instruments evaluated. CONCLUSIONS: The AccuTnI and AccuTnI+3 troponin assays are equivalent across the analytical measuring range. There was no significant difference at the medical decision point. No changes in patient results are anticipated. However, the assay-independent inter-instrument bias observed is an important consideration for harmonization efforts.

Falsely undetectable TSH in a cohort of South Asian euthyroid patients.

CONTEXT: An index case of a clinically euthyroid woman of South Asian descent was identified with discordant TSH results: undetectable TSH on our routine assay and normal TSH on an alternate assay. Low TSH concentrations due to functionally compromising TSH mutations have been reported. Here we describe a new phenomenon of functional TSH that is undetectable by 4 widely used US Food and Drug Administration (FDA)-approved TSH immunoassays marketed by a single vendor. OBJECTIVE: The purpose of this study was to identify additional cases and investigate the cause of the falsely undetectable TSH. DESIGN: All samples with TSH results of <0.01 µIU/mL were retested with a second TSH assay. Discordant samples were evaluated on up to 8 FDA-approved TSH immunoassays and the TSHß gene was sequenced. Retrospectively, thyroid function tests, diagnoses, and medications from 1.6 million individuals were analyzed. RESULTS: Out of approximately 2 million individuals, we have identified a cohort of 20 hypothyroid and euthyroid patients of shared ethnicity with falsely undetectable TSH (<0.01 µIU/mL) in 4 of 8 commercially available TSH assays. Half of these individuals were initially treated based on repeated falsely undetectable TSH values (7 euthyroid patients were treated with methimazole and 2 hypothyroid patients had doses of levothyroxine decreased). In all cases, a retrospective chart review revealed that clinical assessments and free T4 and total T3 results were inconsistent with the undetectable TSH results. Specific antibodies failing to detect TSH in these cases were identified in the 4 affected assays. A novel TSHß point mutation was identified. CONCLUSIONS: Our data suggest that these individuals have a previously unrecognized, functionally normal, TSH variant to which some monoclonal antibodies fail to bind. To assure appropriate patient management, clinicians and laboratorians need to be aware that certain TSH variants may be undetectable in some hyperselective TSH assays.

Role of liquid chromatography-high-resolution mass spectrometry (LC-HR/MS) in clinical toxicology.

BACKGROUND: Gas chromatography (GC) and liquid chromatography (LC) coupled with mass spectrometry (MS) are widely used to confirm drug screening results and for urine screening in presumed intoxicated patients. These techniques are better suited to targeted analysis than to general unknown screening and, due to the complexity of testing, results are seldom available rapidly enough to contribute to the immediate care of the patient. High resolution (HR)/MS with time-of-flight (TOF) or orbitrap instruments offer potential advantages in clinical toxicology. COMPARISON OF GC-MS, LC-MS/MS AND LC-HR/MS: For unknown analyses, GC-MS and LC-MS/MS require comparison of full-scan spectra against preestablished libraries. Operation in full-scan mode greatly reduces sensitivity and some drugs present in low but significant concentrations may be missed. Selected ion monitoring (SIM) in GC/MS and selected reaction monitoring (SRM) in LC-MS/MS, where only targeted ions are monitored, increase sensitivity but require prior knowledge of what compound is to be measured. LC-HR/MS offers mass assignment with an accuracy of 0.001 atomic mass units (amu) compared with 1 amu in conventional MS. Tentative identification is thus directed to a very limited set of compounds (or even one unique compound) based on the exact molecular formula rather than a fragmentation pattern, since HR/MS can discriminate between compounds with the same nominal molecular mass. LC-MS/MS has clear advantages over GC/MS in ease and speed of sample preparation and the opportunities for its automation. LC-HR/MS is more suitable to clinical toxicology because the drugs present in a sample are rarely known a priori, and tentative identifications of unknowns can be made without the availability of a reference standard or a library spectrum. Blood can be used in preference to urine which is more relevant to the patient's current clinical situation. METHODS: A literature search was conducted using PUBMED for clinical toxicology, adulterants in illicit drugs and herbal supplements, and case reports using LC-TOF/MS and LC-HR/MS. Only 42 papers in English were identified in these searches. LC-HR/MS IN CLINICAL TOXICOLOGY: LC-HR/MS has been used to detect designer drugs, doping agents, (neurosteroids) and adulterants such as levamisole, a veterinary antihelmitic found in street cocaine, and pharmaceuticals in herbal medications marketed to contain only natural ingredients. LC-HR/MS has proved useful for cases where existing tests were unable to identify the cause of the intoxication. One patient suffered a drug-induced seizure which was originally thought to be caused by an herbal medication, but diphenhydramine was determined to be the culprit. In another, 5-oxoproline was identified as the cause of metabolic acidosis seen in chronic acetaminophen (paracetamol) use. LC-HR/MS has successfully identified medications that were mislabeled or misrepresented street drugs. In one case, medications sold as diazepam were determined to be glyburide instead. The identification of novel designer amines, stimulants found in "bath salts", and synthetic cannabinoids are well suited to LC-HR/MS. Dozens or even hundreds of possible compounds cannot realistically be tested on an individual basis by targeted LC-MS/MS or GC/MS analysis. CONCLUSIONS: LC-HR/MS offers unique opportunities for time-sensitive clinical analysis of blood samples from intoxicated patients and for comprehensive screening in a wide range of situations and materials. While the identification is not as definitive as that obtained by conventional fragmentation MS, the presumptive identification can be confirmed later with standards and spectral library matches. Optimum utilization of the presumptive diagnosis requires close collaboration between the laboratory analysts and their clinical counterparts.

Rheumatologists' recommendations on what to do in the dermatology office to evaluate and manage psoriasis patients' joint symptoms.

BACKGROUND: Psoriasis patients presenting to the dermatologist for skin disease management may have joint symptoms related to psoriatic arthritis. Dermatologists should ask psoriasis patients about these, yet may not be sure about how to best collaborate with rheumatologists in the management of these patients. OBJECTIVE: To describe how rheumatologists view the role of dermatologists in addressing and identifying signs and symptoms of psoriatic arthritis in psoriasis patients. METHODS: A questionnaire was developed concerning the evaluation and management of joint complaints in a dermatology setting. The survey was sent to rheumatologists interested in psoriatic arthritis. RESULTS: Rheumatologists recommended dermatologists ask psoriasis patients about joint pain, stiffness, swelling, and fatigue to evaluate for psoriatic arthritis. Rheumatology referral was recommended if patients had signs of inflammatory joint disease that were unrelieved by non-prescription non-steroidal anti-inflammatory drugs (NSAIDs). Patients with disabling joint symptoms, no improvement on (disease-modifying antirheumatic drug; DMARD) therapy, or with other causes of joint pain should be referred to rheumatology. Rheumatologists recommended that dermatologists only provide DMARD therapy for joint symptoms if concomitant skin disease warrants such treatment. CONCLUSIONS: Dermatologists play a pivotal role in preventing joint destruction in psoriasis patients by screening for signs of psoriatic arthritis, initiating treatment, and referring patients to a rheumatologist when appropriate.

The sterol response element binding protein regulates cyclooxygenase-2 gene expression in endothelial cells.

We previously demonstrated that cholesterol deprivation increases endothelial cyclooxygenase-2 (COX-2)-dependent prostacyclin [prostaglandin I2 (PGI2)] production in vitro. Cholesterol directly regulates gene transcription through the sterol response element binding protein (SREBP). In this work, we demonstrate that SREBP directly regulates COX-2 expression. Cholesterol reduces human COX-2 promoter-luciferase reporter construct activity in transiently transfected endothelial cells. Conversely, cotransfection with a constitutively active mutant SREBP increases COX-2 promoter activity. SREBP-1a and -2 specifically bind a putative sterol response element (SRE) sequence in the COX-2 promoter. This sequence competes for SREBP binding to a low density lipoprotein receptor consensus sequence in an electromobility-shift assay. These data indicate that endothelial COX-2 is regulated by cholesterol via the SREBP pathway. The present study identifies COX-2 as the first vascular gene without a clear role in lipid metabolism transactivated by SREBP, and suggests that enhanced production of PGI2 through this pathway may be an additional benefit of cholesterol-lowering therapies.

Differential and opposing regulation of PAI-1 promoter activity by estrogen receptor alpha and estrogen receptor beta in endothelial cells.

To investigate the molecular mechanisms involved in the estrogen-dependent control of plasminogen activator inhibitor-1 (PAI-1) gene expression in vascular cells, we compared the transactivation properties of estrogen receptors (ERalpha and ERbeta) in regulating the activity of a human PAI-1 promoter reporter construct in transfected bovine aortic endothelial cells (BAECs). ERalpha increased PAI-1 promoter activity in BAECs by an estrogen-dependent mechanism, whereas ERbeta suppressed PAI-1 promoter activity by an estrogen-independent mechanism. The suppressive activity of ERbeta was dominant over the inductive activity of ERalpha. Mutation of a putative estrogen response element (ERE) located at position -427 in the proximal promoter abolished the ERalpha action without influencing the suppressive effects of ERbeta. Mutation of either AP1-like site did not eliminate the ERalpha or ERbeta actions at the PAI-1 promoter, suggesting that other promoter elements are involved in these responses. These mutations significantly reduced the -3.4kbp PAI-1 promoter response to serum. We concluded that ERalpha and ERbeta exert differential effects on the PAI-1 promoter activity in transfected BAECs. ERalpha activated the PAI-1 promoter through a proximal ERE (-427) and possibly additional EREs located within the PAI-1 promoter, whereas ERbeta suppressed the promoter construct via an unidentified mechanism. This is the first demonstration of the differential regulation of a vascular gene promoter by ERalpha and ERbeta.