Increased renal elimination of endogenous and synthetic pyrimidine nucleosides in concentrative nucleoside transporter 1 deficient mice.

Concentrative nucleoside transporters (CNTs) are active nucleoside influx systems, but their in vivo roles are poorly defined. By generating CNT1 knockout (KO) mice, here we identify a role of CNT1 in the renal reabsorption of nucleosides. Deletion of CNT1 in mice increases the urinary excretion of endogenous pyrimidine nucleosides with compensatory alterations in purine nucleoside metabolism. In addition, CNT1 KO mice exhibits high urinary excretion of the nucleoside analog gemcitabine (dFdC), which results in poor tumor growth control in CNT1 KO mice harboring syngeneic pancreatic tumors. Interestingly, increasing the dFdC dose to attain an area under the concentration-time curve level equivalent to that achieved by wild-type (WT) mice rescues antitumor efficacy. The findings provide new insights into how CNT1 regulates reabsorption of endogenous and synthetic nucleosides in murine kidneys and suggest that the functional status of CNTs may account for the optimal action of pyrimidine nucleoside analog therapeutics in humans.

The Role of Inflammation in CKD.

Chronic kidney disease (CKD) affects many adults worldwide. Persistent low-grade inflammation is a substantial factor in its development and progression and has correlated with increased mortality and cardiovascular problems. This low-grade inflammation is a product of dysregulation of the normal balance between pro- and anti-inflammatory markers. Various factors such as increased innate immune system activation, reactive oxygen species production, periodontal disease, dysregulation of anti-inflammatory systems and intestinal dysbiosis result in the dysregulation of this balance. Furthermore, this low-grade inflammation has down-effects such as hypertension, renal fibrosis and acceleration of renal function decline. Moreover, low-grade inflammation over time has been linked to malignancy in CKD. As CKD progresses, many patients require dialysis, which has a negative bidirectional relationship with persistent inflammation. Treatment options for inflammation in CKD are vast, including cytokine inhibitors, statins and diets. However, more research is needed to create a standardized management plan. In this review, we will examine the normal physiology of the kidney and its relationship with the immune system. We will then delve into the pathology behind persistent inflammation, the various causes of inflammation, the downstream effects of inflammation, dialysis and potential treatments for inflammation in CKD.

Evaluating a unique enhanced recovery protocol in laparoscopic donor nephrectomy: A single center experience.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols have been associated with a reduction in opioid consumption and a hastening in recovery in abdominal surgery. However, their impact on laparoscopic donor nephrectomy (LDN) has not been fully elucidated. The aim of this study is to evaluate opioid consumption and other relevant outcome measures before and after implementation of a unique LDN ERAS protocol. METHODS: 244 LDN patients were included in this retrospective cohort study. Forty-six underwent LDN prior to implementation of ERAS, whereas 198 patients received ERAS perioperative care. The primary outcome was daily oral morphine equivalent (OME) consumption averaged over the entire postoperative stay. Due to removal of preoperative oral morphine from the protocol partway through the study period, the ERAS group was further subdivided into morphine recipients and non-recipients for subgroup analysis. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), length of stay, pain scores, and other relevant measures. RESULTS: ERAS donors consumed significantly fewer average daily OMEs than Pre-ERAS donors (21.5 vs. 37.6, respectively; p < .0001). There were no statistically significant differences in OME consumption between morphine recipients and non-recipients. The ERAS group experienced less PONV (44.4% requiring one or more rescue antiemetic postoperatively, vs. 60.9% of Pre-ERAS donors; p = .008). CONCLUSIONS: A protocol pairing lidocaine and ketamine with a comprehensive approach to preoperative PO intake, premedication, intraoperative fluid management and postoperative pain control is associated with reduced opioid consumption in LDN.

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition.

There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.

The Bitter and the Sweet: Relationship of Lactate, Glucose, and Mortality After Severe Blunt Trauma.

BACKGROUND: Hyperglycemia is associated with mortality after trauma; however, few studies have simultaneously investigated the association of depth of shock and acute hyperglycemia. We evaluated lactate, as a surrogate measure for depth of shock, and glucose levels on mortality following severe blunt trauma. We hypothesize that measurements of both lactate and glucose are associated with mortality when considered simultaneously. METHODS: This is a retrospective cohort study at a single academic trauma center. Inclusion criteria are age 18-89 years, blunt trauma, injury severity score (ISS) ≥15, and transferred from the scene of injury. All serum blood glucose and lactate values were analyzed within the first 24 hours of admission. Multiple metrics of glucose and lactate were calculated: first glucose (Glucadm) and lactate (Lacadm) at hospital admission, mean 24-hour after hospital admission glucose (Gluc24-hMean) and lactate (Lac24-hMean), maximum 24-hour after hospital admission glucose (Gluc24-hMax) and lactate (Lac24-hMax), and time-weighted 24-hour after hospital admission glucose (Gluc24-hTW) and lactate (Lac24-hTW). Primary outcome was in-hospital mortality. Multivariable logistic regression modeling assessed the odds ratio (OR) of mortality, after adjusting for confounding variables. RESULTS: A total of 1439 trauma patients were included. When metrics of both glucose and lactate were analyzed, after adjusting for age, ISS, and admission shock index, only lactate remained significantly associated with mortality: Lacadm (OR, 1.28; 95% confidence interval [CI], 1.13-1.44); Lac24-hMean (OR, 1.86; 95% CI, 1.52-2.28); Lac24-hMax (OR, 1.39; 95% CI, 1.23-1.56); and Lac24-hTW (OR, 1.86; 95% CI, 1.53-2.26). CONCLUSIONS: Lactate is associated with mortality in severely injured blunt trauma patients, after adjusting for injury severity, age, and shock index. However, we did not find evidence for an association of glucose with mortality after adjusting for lactate.

Assessing modified aluminum-based water treatment residuals as a plant-available phosphorus source.

Inorganic phosphorus (P) fertilizers are a finite resource; alternative means of creating P fertilizers from current municipal and agricultural waste sources may reduce our reliance on phosphate rock mining, and improve waste disposal and nutrient cycling. Previous research demonstrated that organic aluminum water treatment residual composites (Al/O-WTR), created by mixing aluminum water treatment residuals (Al-WTR) with swine wastewater, have the potential to be a source of plant-available P. A greenhouse study was conducted to compare spring wheat (Triticum aestivum L.) growth with increasing application rates of swine wastewater-derived Al/O-WTR and commercial P fertilizer (both applied at 34, 67, and 135 kg P2O5 ha-1) in either sandy loam or sandy clay loam soil. Spring wheat straw and grain P uptake were comparable across all treatments in the sandy loam, while straw and grain P uptake were lower with Al/O-WTR in the sandy clay loam. The Al/O-WTR did not affect soil organic P concentrations, but did increase phosphatase activity in both soils. Increased phosphatase activity suggests that Al/O-WTR application stimulated microorganisms and enhanced the extent to which microbial communities mineralized Al/O-WTR-bound organic P. Overall, these results suggest that Al-WTR can be used to make P fertilizer, combining two "waste" products to create a useful product. Phosphorus harvesting via Al/O-WTR may be a feasible future alternative to mining phosphate rock, while avoiding unnecessary waste disposal and improving agricultural nutrient cycling.

Leukocyte-Endothelium Interaction in the Sublingual Microcirculation of Coronary Artery Bypass Grafting Patients.

OBJECTIVE: The aim of this study was to apply an innovative methodology to incident dark-field (IDF) imaging in coronary artery bypass grafting (CABG) patients for the identification and quantification of rolling leukocytes along the sublingual microcirculatory endothelium. METHODS: This study was a post hoc analysis of a prospective study that evaluated the perioperative course of the sublingual microcirculation in CABG patients. Video images were captured using IDF imaging following the induction of anesthesia (T0) and cardiopulmonary bypass (CPB) (T1) in 10 patients. Rolling leukocytes were identified and quantified using frame averaging, which is a technique that was developed for correctly identifying leukocytes. RESULTS: The number of rolling leukocytes increased significantly from T0 (7.5 [6.4-9.1] leukocytes/capillary-postcapillary venule/4 s) to T1 (14.8 [13.2-15.5] leukocytes/capillary-postcapillary venule/4 s) (p < 0.0001). A significant increase in systemic leukocyte count was also detected from 7.4 ± 0.9 × 109/L (preoperative) to 12.4 ± 4.4 × 109/L (postoperative) (p < 0.01). CONCLUSION: The ability to directly visualize leukocyte-endothelium interaction using IDF imaging facilitates the diagnosis of a systemic inflammatory response after CPB via the identification of rolling leukocytes. Integration of the frame averaging algorithm into the software of handheld vital microscopes may enable the use of microcirculatory leukocyte count as a real-time parameter at the bedside.

Use of Dimensional Analysis in the X-, Y-, and Z-Axis to Predict Occurrence of Injury in Human Stampede.

BACKGROUND: Human stampedes (HS) may result in mass casualty incidents (MCI) that arise due to complex interactions between individuals, collective crowd, and space, which have yet to be described from a physics perspective. HS events were analyzed using basic physics principles to better understand the dynamic kinetic variables that give rise to HS. METHODS: A literature review was performed of medical and nonmedical sourced databases, Library of Congress databases, and online sources for the term human stampedes resulting in 25,123 references. Filters were applied to exclude nonhuman events. Retrieved references were reviewed for a predefined list of physics terms. Data collection involved recording frequency of each phrase and physics principle to give the final proportions of each predefined principle used a single-entry method for each of the 105 event reports analyzed. Data analysis was performed using the R statistics packages "tidyverse", "psych", "lubridate", and "Hmisc" with descriptive statistics used to describe the frequency of each observed variable. RESULTS: Of the 105 reports of HS resulting in injury or death reviewed, the following frequency of terms were found: density change in a limited capacity, 45%; XY-axis motion failure, 100%; loss of proxemics, 100%; deceleration with average velocity of zero, 90%; Z-axis displacement pathology (falls), 92%; associated structure with nozzle effect, 93%; and matched fluid dynamic of high pressure stagnation of mass gathering, 100%. CONCLUSIONS: Description or reference to principles of physics was seen in differing frequency in 105 reports. These include XY-axis motion failure of deceleration that leads to loss of human to human proxemics, and high stagnation pressure resulting in the Z-axis displacement effect (falls) causing injury and death. Real-time video-analysis monitoring of high capacity events or those with known nozzle effects for loss of proxemics and Z-axis displacement pathology offers the opportunity to prevent mortality from human stampedes.

Mechanisms Responsible for Soil Phosphorus Availability Differences between Sprinkler and Furrow Irrigation.

From a historical perspective, human-induced soil erosion and resulting soil phosphorus (P) losses have likely occurred for thousands of years. In modern times, erosion risk and off-site P transport can be decreased if producers convert from furrow to sprinkler irrigation, but conversion may alter nutrient dynamics. Our study goal was to determine soil P dynamics in furrow- (in place since the early 1900s) versus sprinkler-irrigated (installed within the last decade) soils from four paired producer fields in Idaho. Furrow- and sprinkler-irrigated soils (0-5 cm; Aridisols) contained on average 38 and 20 mg kg of Olsen-extractable P (i.e., plant-available P), respectively; extractable P values over 40 mg kg limit Idaho producers to P application based on crop uptake only. Soil samples were also analyzed using a modified Hedley extraction. Furrow-irrigated soils contained greater inorganic P concentrations in the soluble+aluminum (Al)-bound+iron (Fe)-bound, occluded, and amorphous Fe-bound pools. Phosphorus -edge X-ray absorption near-edge structure (XANES) spectroscopy was unable to detect Fe-associated P but indicated greater amounts of apatite-like or octacalcium phosphate-like P in furrow-irrigated producer soils, while sprinkler-irrigated fields had lower amounts of apatite-like P and greater proportions of P bound to calcite. Findings from a controlled USDA-ARS sprinkler- versus furrow-irrigation study suggested that changes in P dynamics occur slowly over time, as few differences were observed. Overall findings suggest that Fe redox chemistry or changes in calcium (Ca)-associated P in flooded conditions altered P availability under furrow irrigation, even in aridic, calcareous soils, contributing to greater Olsen-extractable P concentrations in long-term furrow-irrigated fields.

X-Ray Spectroscopic Quantification of Struvite and Dittmarite Recovered from Wastewater.

Phosphorus recovery from wastewater as struvite (MgNHPO⋅6HO) or dittmarite (MgNHPO⋅HO) can decrease water pollution risk, as well as produce a P-rich material suitable as fertilizer. However, most studies to date have focused on the removal of P from wastewater, rather than on characterization of the recovered P materials. The objective of this work was to apply microfocused X-ray fluorescence (XRF) spectroscopy, and both bulk and microfused X-ray absorption near edge structure (XANES) spectroscopy, to provide insight into the speciation of recovered P in various struvite-containing and struvite-like materials. Three materials were investigated: homogeneous crystalline struvite on apatite seed, homogeneous dittmarite, and heterogeneous struvite with sand contamination (referred to as the "sandy" material). The struvite materials were recovered from dairy wastewater, whereas the dittmarite was from a cheese processing plant. Phosphorus speciation in the crystalline struvite on apatite seed material was ∼17% apatite and 83% struvite; in the "sandy" material, P was ∼24% apatite and ∼76% struvite, with an uncertainty of approximately ±15%. The P -edge XANES spectra of recovered dittmarite appeared pure. These findings highlight the heterogeneity of recovered P materials and underscore the importance of P speciation to understand P release behavior and bioavailability from recovered phosphates.

Correlation Between the Revised Trauma Score and Injury Severity Score: Implications for Prehospital Trauma Triage.

OBJECTIVE: Prehospital triage of the seriously injured patient is fraught with challenges, and trauma scoring systems in current triage guidelines warrant further investigation. The primary objective of this study was to assess the correlation of the physiologically based Revised Trauma Score (RTS) and MGAP score (mechanism of injury, Glasgow Coma Scale, age, blood pressure) with the anatomically based Injury Severity Score (ISS). The secondary objectives for this study were to compare the accuracy of the MGAP score and the RTS for the prediction of in-hospital mortality for trauma patients. METHODS: This study was a retrospective cohort including 10 years of patient data in a large single-center trauma registry at a primary adult resource center (Level I) for trauma patients. Participants included adults (age ≥18 years). The primary outcome measure was injury severity (measured by ISS) and a secondary analysis compared the RTS and MGAP for the prediction of patient mortality. Descriptive statistics were used to describe the cohort and correlation methods were employed. Each score's accuracy for the prediction of mortality was calculated using the area under receiver operating characteristic (AUROC) curves. RESULTS: In total, 43,082 trauma patient records were reviewed; 32,798 patients had complete RTS data available and 32,371 patients had complete data available for MGAP analyses. The correlation between scene RTS and ISS was poor (-.29), as was the correlation between MGAP and ISS (-.28). For the prediction of mortality, admission MGAP demonstrated the highest sensitivity and specificity for mortality (AUROC 0.96; 95% CI, 0.95-0.96). CONCLUSIONS: While elements of the RTS remain the first criterion recommended to quantify the totality of physiological injury severity, the composite RTS score derived from this system correlates poorly with actual anatomical injury severity. The MGAP scoring system demonstrated higher sensitivity and specificity for mortality but was not superior to the RTS for predicting anatomical injury severity. In the future development of national and international field triage guidelines for trauma patients, the findings from this study may be considered in order to improve the accuracy of prehospital triage. The findings in this analysis complement a growing body of evidence that suggests that MGAP may be a superior and more easily calculable prehospital scoring system for the prediction of mortality in trauma patients.

Microcirculatory perfusion disturbances in septic shock: results from the ProCESS trial.

BACKGROUND: We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis. METHODS: This was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h. RESULTS: We enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p < 0.003), perfused vascular density (beta = 0.005, p < 0.04), and De Backer score (beta = 0.009, p < 0.01) were higher overall in survivors in a generalized estimating equation model, and this association was significant at the 72-h time point (p < 0.05 for each parameter). CONCLUSIONS: Microcirculatory perfusion did not differ between three early septic shock treatment arms. We found an association between microcirculatory perfusion parameters of vascular density at 72 h and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00510835 . Registered on August 2, 2007.

In vivo quantification of rolling and adhered leukocytes in human sepsis.

BACKGROUND: The use of in vivo videomicroscopy at the bedside has demonstrated microcirculatory flow disturbances in sepsis. The ability of in vivo videomicroscopy to detect changes in the prevalence of rolling and adhered leukocytes that occur in sepsis is not well-described in humans. We sought to (1) develop methodology for accessing and quantifying sublingual leukocyte rolling and adherence with sidestream dark field (SDF) imaging; (2) compare the number of rolling and adhered leukocytes between patients with septic shock and non-infected controls; and (3) compare the number of rolling and adhered leukocytes between survivors and non-survivors of septic shock. METHODS: We included adult (age > 18 years) patients in the emergency department presenting with septic shock prospectively enrolled in the ProCESS trial. We recruited comparison non-infected patients as emergency department controls. Using a SDF videomicroscope, we obtained image sequences from the sublingual mucosa, quantifying rolling and adhered leukocytes per 1 mm × 1 mm visual field in a standardized 3-s clip. We report data as median and interquartile range and depicted as box plots. We compared groups using the Mann-Whitney U test, considering a p value < 0.05 significant. RESULTS: We included a total of 64 patients with septic shock and 32 non-infected controls. The median number of adhered leukocytes per field in the sepsis group was 1.0 (IQR 0-3.5) compared to 0 (0-0) in the non-infected group (p < 0.001). The median number of rolling leukocytes was 26 (10.3-42) in the sepsis group and 9.8 (4.8-17.3) in the non-infected group (p < 0.001) per field. Among the patients with sepsis (n = 64), there was an increased number of adhered leukocytes in non-survivors compared to survivors (3.0 (1-5.5) vs. 1.0 (0-3.0)) (p < 0.05); however, there was no difference in rolling leukocytes (35 (20-48) vs. 26 (10-41)) (p = 0.31). CONCLUSIONS: Our results demonstrated a higher number of rolling and adhered leukocytes in patients with septic shock when compared to non-infected controls, and an increased number of adhered leukocytes in non-survivors. TRIAL REGISTRATION: ClinicalTrials.gov , NCT00793442 ; Registered on 19 November 2008 PG0GM076659 (US NIH Grant/Contract). First submitted 18 July 2007. First posted 2 August 2007.

Combining spectroscopic and isotopic techniques gives a dynamic view of phosphorus cycling in soil.

Current understanding of phosphorus (P) cycling in soils can be enhanced by integrating previously discrete findings concerning P speciation, exchange kinetics, and the underlying biological and geochemical processes. Here, we combine sequential extraction with P K-edge X-ray absorption spectroscopy and isotopic methods (33P and 18O in phosphate) to characterize P cycling on a climatic gradient in Hawaii. We link P pools to P species and estimate the turnover times for commonly considered P pools. Dissolved P turned over in seconds, resin-extractable P in minutes, NaOH-extractable inorganic P in weeks to months, and HCl-extractable P in years to millennia. Furthermore, we show that in arid-zone soils, some primary mineral P remains even after 150 ky of soil development, whereas in humid-zone soils of the same age, all P in all pools has been biologically cycled. The integrative information we provide makes possible a more dynamic, process-oriented conceptual model of P cycling in soils.

Phosphorus Sorption Characteristics in Aluminum-based Water Treatment Residuals Reacted with Dairy Wastewater: 1. Isotherms, XRD, and SEM-EDS Analysis.

We examined P sorption characteristics in Al-based water treatment residuals (Al-WTR) generated from slightly alkaline surface water and in an organic residual composite (WW-Al/O-WTR), produced by using the Al-WTR to treat organic-rich and high P concentration dairy wastewater. Solids from both residuals were examined using scanning electron microscopy-energy dispersive spectroscopy (SEM-EDS) and X-ray diffraction (XRD), and exposed to P additions of 0 to 4000 mg L in a sorption experiment. The Al-WTR removed ∼97% of the added P, whereas WW-Al/O-WTR removed only 78% of the added P in the addition range of 0 to 100 mg P L. With P additions of ≥100 mg L, the removal rate declined to <38% by Al-WTR and to 16% by WW-Al/O-WTR, possibly implying a change in sorption mechanisms. Analysis by XRD indicated that the major mineral was calcite, with some silica and poorly crystalline Al hydroxides. Analysis by SEM-EDS, which used three-element overlay maps of the residual surfaces, indicated that P was sparsely sorbed on both calcic and Al (hydr)oxide surfaces, along with a few clusters, even at low P concentrations of the treated waters. Ternary clusters of P, Al, and Ca were more abundant on the WW-Al/O-WTR. Carbon distribution suggested that organic substances covered Al surfaces. Sorption of P onto WW-Al/O-WTR may be reversible due to relatively weak Ca-P and Al-P bonds induced by the slight alkaline nature and in the presence of organic moieties, enhancing the WW-Al/O-WTR potential to act as a P source, rather than a P sink, in agricultural applications.

Phosphorus Sorption to Aluminum-based Water Treatment Residuals Reacted with Dairy Wastewater: 2. X-Ray Absorption Spectroscopy.

Phosphorus capture from wastewater can decrease water pollution and provide a P-rich fertilizer alternative for use in agricultural production. This study was conducted to elucidate P retention mechanisms in Al-based water treatment residuals (Al-WTR) to gain insight regarding P sorption and the potential for P release from Al-WTR after reaction with dairy wastewater. Synchrotron-based microfocused X-ray fluorescence (micro-XRF) spectrometry, bulk P -edge X-ray absorption near edge structure spectroscopy (XANES), and P -edge micro-XANES spectroscopy were used to determine P distribution and speciation within the Al-WTR materials. Bulk XANES analyses indicated a shift from ∼56 P atom % Ca-associated P in the initial Al-WTR to ∼32% P atom % Ca-associated P after reaction with wastewater; Al-associated P made up the remainder of the P species. According to XANES analyses, adsorption appeared to be the primary P retention mechanism in the Al-WTR materials. However, micro-XANES analyses depicted a more complicated picture of P retention mechanisms, with regions of primarily Al-associated P, regions of primarily Ca-associated P, regions of mixed Al- and Ca-associated P, and distinct apatite- or octocalcium phosphate-like P grains. Synchrotron micro-XRF mapping further suggested that exposure of the aggregate exteriors to wastewater caused P to diffuse into the porous Al-WTR aggregates. Organic P species were not explicitly identified via P -edge XANES despite high organic matter content, suggesting that organic P may have been predominantly associated with mineral surfaces. Although diffusion and sorption to Al may decrease P bioavailability, Ca-associated P may increase P bioavailability from Al-WTR that is reused as a soil amendment.

A prospective, multisite, international validation of the Complex Regional Pain Syndrome Severity Score.

Clinical diagnosis of complex regional pain syndrome (CRPS) is a dichotomous (yes/no) categorization, a format necessary for clinical decision making. Such dichotomous diagnostic categories do not convey an individual's subtle gradations in the severity of the condition over time and have poor statistical power when used as an outcome measure in research. This prospective, international, multicenter study slightly modified and further evaluated the validity of the CRPS Severity Score (CSS), a continuous index of CRPS severity. Using a prospective design, medical evaluations were conducted in 156 patients with CRPS to compare changes over time in CSS scores between patients initiating a new treatment program and patients on stable treatment regimens. New vs stable categorizations were supported by greater changes in pain and function in the former. Results indicated that CSS values in the stable CRPS treatment group exhibited much less change over time relative to the new treatment group, with intraclass correlations nearly twice as large in the former. A calculated smallest real difference value revealed that a change in the CSS of ≥4.9 scale points would indicate real differences in CRPS symptomatology (with 95% confidence). Across groups, larger changes in CRPS features on the CSS over time were associated in the expected direction with greater changes in pain intensity, fatigue, social functioning, ability to engage in physical roles, and general well-being. The overall pattern of findings further supports the validity of the CSS as a measure of CRPS severity and suggests it may prove useful in clinical monitoring and outcomes research.

Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes (PCMHs).

BACKGROUND: The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs. METHODS: We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition-44.6%, renewal-35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures. RESULTS: We estimated HealthTexas' corporate costs for initial NCQA recognition (2010-2012) at $1,508,503; for renewal (2014-2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition. CONCLUSION: Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care.

The impact of red blood cell storage duration on tissue oxygenation in cardiac surgery.

OBJECTIVE: Although storage alters red blood cells, several recent, randomized trials found no differences in clinical outcomes between patients transfused with red blood cells stored for shorter versus longer periods of time. The objective of this study was to see whether storage impairs the in vivo ability of erythrocytes to traverse the microcirculation and deliver oxygen at the tissue level. METHODS: A subset of subjects from a clinical trial of cardiac surgery patients randomized to receive transfusions of red blood cells stored ≤10 days or ≥21 days were assessed for thenar eminence and cerebral tissue hemoglobin oxygen saturation (StO2) via the use of near-infrared spectroscopy and sublingual microvascular blood flow via side-stream darkfield videomicroscopy. RESULTS: Among 55 subjects, there was little change in the primary endpoint (thenar eminence StO2 from before to after transfusion of one unit) and the change was similar in the 2 groups: +1.7% (95% confidence interval, -0.3, 3.8) for shorter-storage and +0.8% (95% confidence interval, -1.1, 2.9) for longer-storage; P = .61). Similarly, no significant differences were observed for cerebral StO2 or sublingual microvascular blood flow. These parameters also were not different from preoperatively to 1 day postoperatively, reflecting the absence of a cumulative effect of all red blood cell units transfused during this period. CONCLUSIONS: There were no differences in thenar eminence or cerebral StO2, or sublingual microcirculatory blood flow, in cardiac surgery patients transfused with red blood cells stored ≤10 days or ≥21 days. These results are consistent with the clinical outcomes in the parent study, which also did not differ, indicating that storage may not impair oxygen delivery by red blood cells in this setting.