Nutritional constraints have been proposed as a contributor to population declines in the endangered Steller sea lion Eumetopias jubatus in some regions of the North Pacific. Isotopic analysis of ...vibrissae (whiskers) is a potentially useful approach to resolving the nutritional ecology of this species because long-term (up to 8 yr) dietary information is sequentially recorded and metabolically inert once formed. Additionally, vibrissae are grown in utero, potentially offering indirect inference on maternal diet. However, diet reconstruction using isotopic techniques requires a priori knowledge of trophic enrichment factors (TEFs), which can vary relative to diet quality and among animal species. In this study, we provide new TEF estimates for (1) maternal relative to pup vibrissae during both gestation and nursing and (2) adult vibrissae relative to a complex diet. Further, we refine vibrissa–milk TEFs based on an additional 76 animals with an age distribution ranging from 1 to 20 mo. Mother–pup vibrissae TEF values during gestation and nursing were near zero for δ13C and averaged 0.8 and 1.6‰, respectively, for δ15N. In contrast, vibrissa–fish/invertebrate TEFs averaged 3.3 (± 0.3 SD) and 3.7‰ (±0.3) for lipid-free δ13C and δ15N, respectively. Average lipid-free δ13C and δ15N vibrissa–milk TEFs were 2.5 (±0.9) and 1.8‰ (±0.8), respectively, and did not differ among metapopulations. Empirically determined TEFs are critical for accurate retrospective diet modeling, particularly for evaluating the hypothesis of nutritional deficiency contributing to the lack of Steller sea lion population recovery in some regions of Alaska.
Background Guidelines recommend cardiac rehabilitation after acute myocardial infarction, yet little is known about the impact of cardiac rehabilitation on medication adherence and clinical outcomes ...among contemporary older adults. The optimal number of cardiac rehabilitation sessions is not clear. Methods We linked patients 65 years or older enrolled in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from January 2007 to December 2010 to Medicare longitudinal claims data to obtain 1 year follow-up. Results A total of 11,862 patients participated in cardiac rehabilitation after acute myocardial infarction, attending a median number of 26 sessions. Patients attending ≥26 sessions were more likely to be male, had lesser prevalence of comorbid conditions and prior revascularization, and were more likely to present with ST-segment elevation myocardial infarction, compared with patients attending 1 to 25 sessions. Among patients with Medicare Part D prescription coverage, increasing number of cardiac rehabilitation sessions was associated with improvement in adherence to secondary prevention medications such as P2Y12 inhibitors and β-blockers. Each 5-session increase in participation was associated with lower mortality (adjusted hazard ratio HR 0.87, 95% CI 0.83-0.92) and lower overall risk of major adverse cardiac event (adjusted HR 0.69, 95% CI 0.65-0.73) and death/readmission (adjusted HR 0.79, 95% CI 0.76-0.83). Conclusions In this older patient population, number of cardiac rehabilitation sessions attended was associated with improved medication adherence and lower downstream cardiovascular risk in a dose-response relationship. This provides support for the continued use of cardiac rehabilitation for older adults and encourages efforts to maximize attendance.
Alcohol consumption has both adverse and beneficial effects on survival. We examined the balance of these in a large prospective study of mortality among U.S. adults.
Of 490,000 men and women (mean ...age, 56 years; range, 30 to 104) who reported their alcohol and tobacco use in 1982, 46,000 died during nine years of follow-up. We compared cause-specific and rates of death from all causes across categories of base-line alcohol consumption, adjusting for other risk factors, and related drinking and smoking habits to the cumulative probability of dying between the ages of 35 and 69 years.
Causes of death associated with drinking were cirrhosis and alcoholism; cancers of the mouth, esophagus, pharynx, larynx, and liver combined; breast cancer in women; and injuries and other external causes in men. The mortality from breast cancer was 30 percent higher among women reporting at least one drink daily than among nondrinkers (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.6). The rates of death from all cardiovascular diseases were 30 to 40 percent lower among men (relative risk, 0.7; 95 percent confidence interval, 0.7 to 0.8) and women (relative risk, 0.6; 95 percent confidence interval, 0.6 to 0.7) reporting at least one drink daily than among nondrinkers, with little relation to the level of consumption. The overall death rates were lowest among men and women reporting about one drink daily. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease. Alcohol consumption was associated with a small reduction in the overall risk of death in middle age (ages 35 to 69), whereas smoking approximately doubled this risk.
In this middle-aged and elderly population, moderate alcohol consumption slightly reduced overall mortality. The benefit depended in part on age and background cardiovascular risk and was far smaller than the large increase in risk produced by tobacco.
Abstract Background Certain alleles of the CYP2C19 gene are associated with higher platelet reactivity and increased ischemic events among patients treated with clopidogrel. However, the relationship ...of CYP2C19 genotype and outcomes in medically managed patients with acute coronary syndromes (ACS) is not known. Objectives This study sought to assess the effect of CYP2C19 genotype on ischemic outcomes in patients with ACS initially managed medically without revascularization who were randomized to either clopidogrel or prasugrel. Methods We classified patients as extensive metabolizers (EM) or reduced metabolizers (RM) based on CYP2C19 genotype and evaluated ischemic outcomes and platelet reactivity. Among 9,326 patients enrolled from 2008 to 2011, 5,736 participated in the genetics cohort; of these, 2,236 had platelet function testing data. Results There was no association between CYP2C19 metabolizer status (EM vs. RM) and the primary composite endpoint of cardiovascular death, myocardial infarction (MI), or stroke (hazard ratio HR: 0.86). EM and RM patients had similar rates of the primary endpoint whether treated with prasugrel (HR: 0.82) or clopidogrel (HR: 0.91; p for interaction = 0.495). After adjusting for clinical and treatment variables, EM patients had a lower risk of MI versus RM patients (HR: 0.80), but risks of other outcomes were similar. RM patients had significantly higher mean P2Y12 reaction units versus EM patients when treated with clopidogrel (39.93), but not with prasugrel (3.87). Conclusions CYP2C19 metabolizer status is not associated with the composite outcome of cardiovascular death, MI, or stroke in medically managed ACS patients treated with clopidogrel or prasugrel. Our findings do not support routine CYP2C19 genetic testing in this population. (A Comparison of Prasugrel and Clopidogrel in Acute Coronary Syndrome Subjects TRILOGY ACS; NCT00699998 )
Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise ...require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.
We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.
We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients 87%). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio HR 0.77, 95% confidence interval CI 0.54-1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45-0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96-2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.
For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.
Abstract Background Heart transplantation is the gold-standard treatment for end-stage heart failure. Short- and long-term outcomes have been excellent, but the shortage of organs persists. The ...number of potential recipients who die while awaiting orthotopic heart transplantation increases yearly. In 2004, the label “high-risk donor” (HRD) was applied, by the United Network for Organ Sharing (UNOS), to any organ donor who met the Centers for Disease Control (CDC) criteria for behavior that put them at high risk of infection. Despite organ shortages, grafts from HRD CDCs are often declined, because of concerns regarding infection. We undertook this study to analyze our extensive experience with orthotopic heart transplantation of grafts from HRD CDCs, and to determine the short- and long-term outcomes associated with recipients of hearts from HRD CDCs, particularly transmission of infection. Methods We performed 367 heart transplantations at our center from September 2008 to September 2014, a timeframe during which the HRD CDC labeling had been implemented. Of the total number of orthotopic heart transplantations performed, 55 patients (15%) received organs from HRD CDCs that had known negative serology for human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. We reviewed demographic, perioperative, and short- and long-term outcomes. The recipients of grafts from HRD CDCs were followed closely, with 3- and 12-month surveillance laboratory testing of viral load for HIV, for hepatitis B, and for hepatitis C core- and surface-antigen serology. Results All 55 patients (72.7% were men) underwent a successful transplantation procedure. One patient was excluded from follow-up analysis because he was re-transplanted within 4 days owing to the posttransplant finding of metastatic lung adenocarcinoma within the donor. Primary etiology of heart failure was ischemic in 18 of the patients. The most common blood type was O positive, in 20 patients (37.1%), followed by A positive, in 19 patients (35.2%). A total of 19 (35.2%) patients were supported with a mechanical assist device before the transplantation. The average allograft ischemic time was 173 ± 96 minutes. The median length of hospital stay was 19.5 days. A low incidence was observed of the postoperative complications of stroke (1.9%), dialysis (3.9%), and complete heart block (3.9%). Kaplan-Meier analysis demonstrated excellent survival, both short-term (1 year; 94%) and long-term (3 years; 80%). Allograft function was excellent at time of discharge with a left ejection fraction of 67.8% ± 7.3%. Only one patient (1.9%) was noted to have hepatitis C seroconversion at 105 days after receiving the transplant. After antiviral treatment, the patient has had undetectable viral loads to date. All other patients had undetectable plasma viral loads of HIV, hepatitis C, and hepatitis B, determined using rigorous testing. Conclusions We present the only single-center series on recipients of heart transplants from HRD CDCs. This potential source of suitable donor organs is shown to lead to excellent survival, without an increased incidence of perioperative or postoperative complications. Furthermore, the risk of transmission of infection from donors in this subgroup seems to be minimal.
Background The use of oral P2Y12 receptor inhibitors following acute myocardial infarction (MI) can reduce risks of subsequent major adverse cardiovascular events (MACE; composite of all-cause death, ...recurrent MI, and stroke), yet medication persistence is suboptimal. While copayment cost has been implicated as a factor influencing medication persistence, it remains unclear whether reducing or eliminating these costs can improve medication persistence and/or downstream clinical outcomes. Design The Affordability and Real-world Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS) is a multicenter, cluster-randomized clinical trial designed to examine whether eliminating patient copayment for P2Y12 receptor inhibitor therapy affects medication persistence and clinical outcomes. We will enroll approximately 11,000 patients hospitalized for acute ST-elevation and non–ST-elevation MI at 300 hospitals. Choice and duration of treatment P2Y12 receptor inhibitor will be determined by the treating physician. Hospitals randomized to the copayment intervention will provide vouchers to cover patients’ copayments for their P2Y12 receptor inhibitor for up to 1 year post-discharge. The co-primary end points are 1-year P2Y12 receptor inhibitor persistence and MACE. Secondary end points include choice of P2Y12 receptor inhibitor, patient-reported outcomes, and post-discharge cost of care. Conclusion ARTEMIS will be the largest randomized assessment of a medication copayment reduction intervention on medication persistence, clinical outcomes, treatment selection, and cost of care after acute MI.
City governments are fundamental to implement international environmental agreements, such as the convention on biological diversity (CBD). Even though many of them are not directly involved in the ...negotiation of international agreements, which are signed by national governments, most of those agreements are in fact implemented at the city level. The importance of city governance to tackle the challenges of biodiversity loss has increased as urban population has grown enormously in the last decades, particularly in developing countries. The way cities are designed, planned and governed influences the magnitude of their direct and indirect impacts on biodiversity.
This paper analyzes the relationship between cities, local governance and biodiversity. Initially, we examine the relationships between cities and biodiversity by looking at the major influences cities have on biodiversity loss or conservation within and outside the city boundaries, as well as the benefits of biodiversity conservation to cities, such as the provision of ecosystem services. The paper then moves to understand what are the main urban processes and governance mechanisms that can be improved to make cities effective to implement the directives of the CBD.
Urbanization creates new challenges for biodiversity conservation. As a large part of the world’s population moves from rural to urban areas, there are changes in the link between human activities and biodiversity, and consequently to the way we should think biodiversity conservation policies. However, scarce attention has been given to understand how to make cities more biodiversity friendly, both within the urban fabric, but particularly in faraway places.
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