Nitrous oxide and methane emissions from a Ferralsol as affected by loblolly pine cultivation time in subtropical Brazil.

We hypothesized that the age of loblolly pine stands influences soil methane (CH4) and nitrous oxide (N2O) emissions. This is a relevant topic to be studied in subtropical Brazil, where the pine plantation area is increasing considerably. We evaluated N2O and CH4 emissions for two years in a Ferralsol under loblolly pine (Pinus taeda L.) stands of 1, 9 and 18 year-olds and a native forest (NF). We calculated the net CO2eq emission by considering the N2O and CH4 emissions from soil and the carbon (C) accumulation as litter in the forest floor. The soil N2O emission reduced gradually over the loblolly pine cultivation years, whereas CH4 uptake rates showed no clear pattern. Soil N2O emission showed a positive relationship with soil temperature in NF, and with soil ammonium and nitrate intensities in the pine stands. Soil CH4 uptake was inversely related to water-filled pore space in the pine stands, but this relationship was not observed in NF. The soil CH4 uptake rate was 4.6 times higher (p < 0.10) in NF than the average uptake in loblolly pine stands. On the other hand, soil N2O emissions in 9 and 18-year-old stands were similar (p > 0.10) to those in NF (1.3 kg N ha-1 yr-1). Our results suggest that cultivation with loblolly pine for 18 years can reduce soil N2O emission, and the uptake of CH4 in this system offsets 17 % of N2O emissions. Furthermore, the C accumulation as litter in the forest floor of the mature pine stands (9- and 18-year-old) generated a net emission of -1.6 Mg CO2eq ha-1 yr-1, showing to be an expressive offsetting mechanism. Therefore, we conclude that aged loblolly forests can reach N2O emissions levels comparable to those of NF, and the C sequestration in these forests floor can significantly contribute to offset N2O emissions and act as sink for net atmospheric CO2eq.

Preventing metastatic recurrence in low-risk ER/PR + breast cancer patients-a retrospective clinical study exploring the evolving challenge of persistence with adjuvant endocrine therapy.

PURPOSE: In the genomic era, more women with low-risk breast cancer will forego chemotherapy and rely on adjuvant endocrine therapy (AET) to prevent metastatic recurrence. However, some of these patients will unfortunately relapse. We sought to understand this outcome. Preliminary work suggested that early discontinuation of AET, also known as non-persistence, may play an important role. A retrospective analysis exploring factors related to our breast cancer patients' non-persistence with AET was performed. METHODS: Women who underwent Oncotype-DX® testing between 2011 and 2014 with minimum 5 years follow-up were included. 'Low risk' was defined as Oncotype score < 26. Outcomes of recurrence and persistence were determined by chart review. Patient, tumor and treatment factors were collected, and persistent versus non-persistent groups compared using multivariable ANOVA and Fisher Chi square exact test. RESULTS: We identified six cases of distant recurrence among low-risk patients with a median follow-up of 7.7 years. Among them, five of six patients (83%) were non-persistent with AET. The non-persistence rate in our cohort regardless of recurrence was 57/228 (25%). Non-persistent patients reported more severe side effects compared with persistent patients (p = 0.002) and were more likely to be offered a switch in endocrine therapy, rather than symptom-relief (p = 0.006). In contrast, persistent patients were 10.3 times more likely to have been offered symptom-alleviating medications compared with non-persistent patients (p < 0.001). A subset analysis revealed that patients who persisted with therapy had a higher Oncotype-DX® score than patients who discontinued early (p = 0.028). CONCLUSION: Metastatic recurrence in low-risk breast cancer patients may be primarily due to non-persistence with endocrine therapy. Further work is needed to optimize care for patients who struggle with side effects. To our knowledge, these are the first published data suggesting that Oncotype-DX® score may influence persistence with AET.

Applying the Peter Parker Principle to Healthcare.

The role of power in healthcare can raise many ethical challenges. Power is ownership, whether given, ceded, or taken of another person's autonomy. When a person has power over someone else, they can control or strongly influence the decision-making freedom of that person. From the principalist perspective1,2 of healthcare ethics, denying a person their freedom to choose should only occur when justifying conditions related to beneficence and nonmaleficence are sufficiently satisfied. In healthcare, it is rare to be able to identify situations where paternalism is justified. However, experience suggests that abusive power in healthcare is used too frequently without justifying criteria.

SMART-ly Managing Type 1 Diabetes - Modifying Glucose Metabolism With an Online Mind-Body Intervention: A Feasibility and Pilot Study.

Objective: Managing type 1 diabetes is stressful. Stress physiology influences glucose metabolism. Continuous glucose monitors allow us to track glucose variability in the real-world environment. Managing stress and cultivating resiliency should improve diabetes management and reduce glucose variability. Research Design and Methods: The study was designed as a randomized prospective cohort pre-post study with wait time control. Participants were adult type 1 diabetes patients who used a continuous glucose monitor and recruited from an academic endocrinology practice. The intervention was the Stress Management and Resiliency Training (SMART) program conducted over 8 sessions over web-based video conference software. The main outcome measures were Glucose variability, the Diabetes Self-Management questionnaire (DSMQ),Short-Form Six-Dimension (SF-6D), and the Connor-Davidson Resiliency (CD-RSIC) instrument. Results: There was statistically significant improvement in participants DSMQ and CD RISC scores though the SF-6D did not change. Participants under age 50 years-old showed a statistically significant reduction in average glucose (p = .03) and Glucose Management Index (GMI) (p = .02). Participants also had reduced percentage of time high and increased time in range though this did not reach statistical significance. The participants found doing the intervention online acceptable if not always ideal. Conclusions: An 8-session stress management and resiliency training program reduced diabetes related stress and improved resiliency and reduced average blood glucose and GMI in those under 50 years-old. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04944264.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study.

BACKGROUND: Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts. METHODS: We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality. FINDINGS: On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02). INTERPRETATION: Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide. FUNDING: Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

Informing the Management of Asymptomatic Nephrolithiasis: Markov Decision Analysis for the 1 cm Renal Stone.

INTRODUCTION: The management of an incidentally discovered, asymptomatic renal stone includes watchful waiting, shock wave lithotripsy, ureteroscopy with basket extraction of fragmented stones (URS-B) or ureteroscopy with laser "dusting" (URS-D). Each intervention has varying stone-free rates, requirements for ureteral stenting, and variable impact on a patient's quality of life. Decision analysis was used to assess the optimal quality adjusted life-years associated with each treatment option. METHODS: A Markov model was constructed to represent potential outcomes for a single 1 cm renal stone after treatment. The cohort was followed for 1-month cycles over 3 years and toll penalties for receiving a stent and undergoing surgery were standardized and incorporated into each subtree. Probabilities, utilities and toll penalties were derived from existing literature or clinical extrapolation when no published data were available. One-way sensitivity analyses were performed to determine threshold probabilities/utilities that may alter preferred options. RESULTS: Watchful waiting was the preferred intervention, preserving 2.82 quality adjusted life-years over 3 years. The remaining options had similar but decreasing quality adjusted life-years: URS-B provided 2.78 quality adjusted life-years; shock wave lithotripsy provided 2.72 quality adjusted life-years, and URS-D provided 2.67 quality adjusted life-years. One-way sensitivity analysis showed that URS-D was preferred when stone-free rates from URS-B dropped below 37%. Shock wave lithotripsy was preferred over URS-B when stone-free rates from URS-B dropped below 62%. As stents became progressively less bothersome, watchful waiting is preferred, followed by URS-B, shock wave lithotripsy and URS-D. CONCLUSIONS: Watchful waiting is the preferred management decision for asymptomatic renal stones. However, these results are sensitive to both actual stone-free rate and individual stent tolerance.

Medical Qigong for Mobility and Balance Self-Confidence in Older Adults.

Background/Objectives: Physical inactivity, sedentary lifestyle, and impaired neuromuscular function increases fall risk and fractures in our aging population. Mind-body modalities, improve strength, balance and coordination, mitigating these risks. This study examined whether a manualized Medical Qigong protocol measurably improves balance, gait, and health self-confidence among older adults. Design: Randomized prospective cohort pre-post study with wait time control. Setting: Two martial arts centers in Massachusetts and Arizona. Participants: Ninety-five adults age ≥ 50 (mean age 68.6 y.o., range 51-96) were randomly assigned to an immediate start group (N = 53) or 4-week delayed start group (N = 43). Intervention: A 10 form qigong protocol taught over 12 weekly classes. Measurments: Primary outcome measures were the Community Balance and Mobility Scale (CBMS) and Activities-Specific Balance Confidence (ABC) Scale. Data was collected at baseline, 1-month and 4-months. Results: Both groups at both sites demonstrated improved balance and gait (CBMS + 11.9 points, p < 0.001). This effect was strongest in patients in their 60 s (CBMS +12.9 p < 0.01) and 70 s (CBMS + 14.3, p < 0.001), was equal across genders and socioeconomic status. Balance self-confidence did not significantly change (ABC + 0.9, p = 0.48), though several elements within ABC trended toward improvement [e.g., walk up/down ramp (p = 0.07), bend over/pick up (p = 0.09)]. Falls in the past year was inversely correlated with balance self-confidence (p = 0.01). Conclusion: A 12-week manualized Medical Qigong protocol significantly improved balance and gait and modestly improved balance self-confidence among older adults. Medical Qigong may be a useful clinical intervention for older adults at heightened risk for falls and related injuries. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04430751.

Application of a mind-body tool in a rural population to improve post-operative outcomes in women with breast cancer: A pilot study.

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in women in the United States. While improvements in treatment have improved mortality, they can negatively impact quality of life (QOL). Mindfulness-based programs are low-cost interventions shown to improve QOL. The study aim was to evaluate a well-validated mind-body program - determining its feasibility, acceptability, and improvement in symptomatology in post-operative breast cancer patients in a rural setting. METHODS: We recruited patients during post-operative appointments following mastectomy or lumpectomy for breast cancer. Each participant completed 3 surveys before and after the intervention: (8 PROMIS-29, PROMIS -Global QOL, and MAAS (Mindfulness Attention Awareness Scale). The intervention was an 8-week course: "The Stress Management and Resiliency Training (SMART) - Relaxation Response and Resiliency Program (3RP)", which has been well-validated for the treatment of various clinical problems. Feasibility, acceptability, quantitative survey data, and demographics were analyzed. RESULTS: SMART-3RP was highly acceptable with greater than >80% completion rate. 23% of the invited participants enrolled, although over 70% of patients approached (34/48) expressed interest. The principal recruitment deterrent was scheduling. Sleep and anxiety/depression were improved in participants although not significantly due to small sample size. We also demonstrated improving trends in other QOL measures. CONCLUSIONS: This small pilot study proved feasibility, showed excellent acceptability, and demonstrated a benefit in post-operative breast cancer patients. Even with our small sample size, we found trends in improvement in certain QOL measures which emphasizes SMART-3RP's potential effectiveness. A large-scale randomized controlled trial is warranted.

Simulation Analysis and Comparison of Point of Care Testing and Central Laboratory Testing.

Background. In response to demand for fast and efficient clinical testing, the use of point-of-care testing (POCT) has become increasingly common in the United States. However, studies of POCT implementation have found that adopting POCT may not always be advantageous relative to centralized laboratory testing. Methods. We construct a simulation model of patient flow in an outpatient care setting to evaluate tradeoffs involved in POCT implementation across multiple dimensions, comparing measures of patient outcomes in varying clinical scenarios, testing regimes, and patient conditions. Results. We find that POCT can significantly reduce clinical time for patients, as compared to traditional testing regimes, in settings where clinic and central testing areas are far apart. However, as distance from clinic to central testing area decreased, POCT advantage over central laboratory testing also decreased, in terms of time in the clinical system and estimated subsequent productivity loss. For example, testing for pneumonia resulted in an estimated average of 27.80 (central lab) versus 15.50 (POCT) total lost productive hours in a rural scenario, and an average of 14.92 (central lab) versus 15.50 (POCT) hours in a hospital-based scenario. Conclusions. Our results show that POCT can effectively reduce the average time a patient spends in the system for varying condition profiles and clinical scenarios. However, the number of total lost productive hours, a more holistic measure, is greatly affected by testing quality, where POCT often is at a disadvantage. Thus, it is important to consider factors such as clinical setting, target condition, testing costs, and test quality when selecting appropriate testing regime.

Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities.

BACKGROUND: Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization. OBJECTIVE: Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017. DESIGN: Prospective cohort, pre/post study. SETTING: Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center. PARTICIPANTS: Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs. INTERVENTION: RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers. MEASURES: ED and hospital utilization. RESULTS: RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents. CONCLUSIONS/IMPLICATIONS: The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

Concerted application of LC-MS and ligand binding assays to better understand exposure of a large molecule drug.

AIM: A ligand-binding assay (LBA) was used to measure exposure of PRM-151, the recombinant form of human pentraxin-2 (PTX-2), a complex pentamer with multiple binding partners. However, the assay showed a lack of dose-dependent exposure in select preclinical species and it could not differentiate the infused PRM-151 from the endogenous PTX-2 in nonhuman primates. MATERIALS & METHODS: Instead of assessing interference from its multiple binding partners, which could be time consuming and laborious, a LC-MS assay avoid of these interference was implemented to measure 'total' drug without the use of immunoaffinity capture reagents. RESULTS & CONCLUSION: The resultant LC-MS data confirmed the original data and the lack of dose-dependent exposure is now understood to be due to the multiple and diverse targets and functions and resultant complex biodistribution rather than an assay artifact.

Analysis of the effects of EHR implementation on timeliness of care in a dermatology clinic: a simulation study.

Objective: Quantify the downstream impact on patient wait times and overall length of stay due to small increases in encounter times caused by the implementation of a new electronic health record (EHR) system. Methods: A discrete-event simulation model was created to examine the effects of increasing the provider-patient encounter time by 1, 2, 5, or 10 min, due to an increase in in-room documentation as part of an EHR implementation. Simulation parameters were constructed from an analysis of 52 000 visits from a scheduling database and direct observation of 93 randomly selected patients to collect all the steps involved in an outpatient dermatology patient care visit. Results: Analysis of the simulation results demonstrates that for a clinic session with an average booking appointment length of 15 min, the addition of 1, 2, 5, and 10 min for in-room physician documentation with an EHR system would result in a 5.2 (22%), 9.8 (41%), 31.8 (136%), and 87.2 (373%) minute increase in average patient wait time, and a 6.2 (12%), 11.7 (23%), 36.7 (73%), and 96.9 (193%) minute increase in length of stay, respectively. To offset the additional 1, 2, 5, or 10 min, patient volume would need to decrease by 10%, 20%, 40%, and >50%, respectively. Conclusions: Small changes to processes, such as the addition of a few minutes of extra documentation time in the exam room, can cause significant delays in the timeliness of patient care. Simulation models can assist in quantifying the downstream effects and help analyze the impact of these operational changes.

Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics.

To address prolonged lengths of stay (LOS) in ambulatory care clinics, we analyze the impact of implementing flexible and dynamic policies for assigning exam rooms to providers. In contrast to the traditional approaches of assigning specific rooms to each provider or pooling rooms among all practitioners, we characterize the impact of alternate compromise policies that have not been explored in previous studies. Since ambulatory care patients may encounter multiple different providers in a single visit, room allocation can be determined separately for each encounter accordingly. For the first phase of the visit, conducted by the medical assistant, we define a dynamic room allocation policy that adjusts room assignments based on the current state of the clinic. For the second phase of the visit, conducted by physicians, we define a series of room sharing policies which vary based on two dimensions, the number of shared rooms and the number of physicians sharing each room. Using a discrete event simulation model of an outpatient cardiovascular clinic, we analyze the benefits and costs associated with the proposed room allocation policies. Our findings show that it is not necessary to fully share rooms among providers in order to reduce patient LOS and physician idle time. Instead, most of the benefit of pooling can be achieved by implementation of a compromise room allocation approach, limiting the need for significant organizational changes within the clinic. Also, in order to achieve most of the benefits of room allocation policies, it is necessary to increase flexibility in the two dimensions simultaneously. These findings are shown to be consistent in settings with alternate patient scheduling and distinctions between physicians.

Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.

We implemented a transitional care management service led by a nurse care manager. An interdisciplinary team developed a workflow using a Plan-Do-Study-Act cycle for contacting patients. Of the 146 (97.9%) eligible patients, 143 (97.9%) had a phone call within 48 hours. There were 84 of 120 (70.0%) and 117 of 120 (97.5%) attendance rates of those attending visits within 7 and 14 days. A care manager-led workflow was successfully and easily implemented within a primary care practice.

Correction: Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.

[This corrects the article DOI: 10.1371/journal.pone.0140212.].

Telemedicine and primary care obesity management in rural areas - innovative approach for older adults?

BACKGROUND: The growing prevalence of obesity is paralleling a rise in the older adult population creating an increased risk of functional impairment, nursing home placement and early mortality. The Centers for Medicare and Medicaid recognized the importance of treating obesity and instituted a benefit in primary care settings to encourage intensive behavioral therapy in beneficiaries by primary care clinicians. This benefit covers frequent, brief, clinic visits designed to address older adult obesity. DISCUSSION: We describe the challenges in the implementation and delivery into real-world settings. The challenges in rural settings that have the fastest growing elderly population, high obesity rates, but also workforce shortages and lack of specialized services are emphasized. The use of Telemedicine has successfully been implemented in other specialties and could be a useful modality in delivering much needed intensive behavioral therapy, particularly in distant, under-resourced environments. This review outlines some of the challenges with the current benefit and proposed solutions in overcoming rural primary care barriers to implementation, including changes in staffing models. CONCLUSIONS: Recommendations to extend the benefit's coverage to be more inclusive of non-physician team members is needed but also for improvement in reimbursement for telemedicine services for older adults with obesity.

Simulation as an ethical imperative and epistemic responsibility for the implementation of medical guidelines in health care.

Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize (avoidable) harm in health care, before guideline implementation.

Phosphorus fractions in soil after successive crops of Pinus taeda L. without fertilization / Frações de fósforo após cultivos sucessivos de Pinus taeda L. sem fertilização

ABSTRACT: Pinus cultivation without fertilization is a common practice in southern Brazil, which can induce a decline in the availability of phosphorus (P) in the soil. The purpose of this study was to evaluate the changes in phosphorus fractions in a Humic Cambisol subjected to continuous Pinus taeda L. cultivation without fertilization. Two forest stands were evaluated, after 16 years of Pinus cultivation (1st crop) and 49 years (3rd crop), when soil samples were collected (layers 0-10, 10-20, 20-40, 40-60, and 60-80cm) from six trenches per forest. In soil samples, the P contained in organic (Po) and inorganic (Pi) forms was determined by sequential chemical fractionation. Labile inorganic P fractions remained unchanged after the different cultivation periods. However, the labile organic fractions declined from the first to the third cycle (from 70.6 to 39.8mg dm-3 in the 0-10cm layer), indicating that these forms influence the buffering capacity of labile Pi. The moderately labile organic P acted as a P drain, increasing its percentage of the total, from 34.7 to 56.3%, from the first to the third crop. Soil cultivation for 49 years with Pinus taeda resulted in a reduction of the organic P content, indicating that for this soil use, this P form should be used to diagnose P availability and fertilization requirements.

RESUMO: O cultivo de Pinus sem uso de fertilização é uma prática comum no sul do Brasil e pode levar ao declínio da disponibilidade de fósforo (P) no solo. O objetivo deste estudo foi avaliar as modificações nas frações de fósforo em Cambissolo submetido a sucessivos cultivos de Pinus taeda L. sem fertilização. Foram avaliadas duas florestas, com 16 anos de cultivo de Pinus (1o cultivo) e 49 anos (3o cultivo), onde amostras de solo foram coletadas nas camadas de 0-10, 10-20, 20-40, 40-60 e 60-80cm, em seis trincheiras por floresta. Nas amostras de solo foram determinados os teores de P em formas orgânicas (Po) e inorgânicas (Pi) usando esquema de fracionamento químico sequencial. As frações inorgânicas lábeis de P não sofreram alterações com os diferentes tempos de cultivo, no entanto houve declínio das frações orgânicas lábeis do primeiro para o terceiro cultivo, passando de 70,6 para 39,8mg dm-3 na camada de 0-10cm, indicando que essas formas atuam no tamponamento do Pi lábil. O P orgânico moderadamente lábil atuou como um dreno de P, aumentando seu percentual em relação ao total, de 34,7 para 56,3%, do primeiro para o terceiro cultivo. O cultivo do solo por 49 anos com Pinus taeda provoca a diminuição do teor de fósforo orgânico lábil, indicando que para este tipo de uso do solo essa forma de fósforo deveria ser considerada para diagnóstico da disponibilidade de fósforo e necessidade de fertilização.

National Institute of Biomedical Imaging and Bioengineering Point-of-Care Technology Research Network: Advancing Precision Medicine.

To advance the development of point-of-care technology (POCT), the National Institute of Biomedical Imaging and Bioengineering established the POCT Research Network (POCTRN), comprised of Centers that emphasize multidisciplinary partnerships and close facilitation to move technologies from an early stage of development into clinical testing and patient use. This paper describes the POCTRN and the three currently funded Centers as examples of academic-based organizations that support collaborations across disciplines, institutions, and geographic regions to successfully drive innovative solutions from concept to patient care.