Over the last century, intakes of omega-6 (ω-6) fatty acids in Western diets have dramatically increased, while omega-3 (ω-3) intakes have fallen. Resulting ω-6/ω-3 intake ratios have risen to ...nutritionally undesirable levels, generally 10 to 15, compared to a possible optimal ratio near 2.3. We report results of the first large-scale, nationwide study of fatty acids in U.S. organic and conventional milk. Averaged over 12 months, organic milk contained 25% less ω-6 fatty acids and 62% more ω-3 fatty acids than conventional milk, yielding a 2.5-fold higher ω-6/ω-3 ratio in conventional compared to organic milk (5.77 vs. 2.28). All individual ω-3 fatty acid concentrations were higher in organic milk--α-linolenic acid (by 60%), eicosapentaenoic acid (32%), and docosapentaenoic acid (19%)--as was the concentration of conjugated linoleic acid (18%). We report mostly moderate regional and seasonal variability in milk fatty acid profiles. Hypothetical diets of adult women were modeled to assess milk fatty-acid-driven differences in overall dietary ω-6/ω-3 ratios. Diets varied according to three choices: high instead of moderate dairy consumption; organic vs. conventional dairy products; and reduced vs. typical consumption of ω-6 fatty acids. The three choices together would decrease the ω-6/ω-3 ratio among adult women by ∼80% of the total decrease needed to reach a target ratio of 2.3, with relative impact "switch to low ω-6 foods" > "switch to organic dairy products" ≈ "increase consumption of conventional dairy products." Based on recommended servings of dairy products and seafoods, dairy products supply far more α-linolenic acid than seafoods, about one-third as much eicosapentaenoic acid, and slightly more docosapentaenoic acid, but negligible docosahexaenoic acid. We conclude that consumers have viable options to reduce average ω-6/ω-3 intake ratios, thereby reducing or eliminating probable risk factors for a wide range of developmental and chronic health problems.
In January 2018, the Center for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list. This impacted hospital reimbursement, Comprehensive Joint ...Replacement (CJR) bundle volumes, and bundle performance. We describe these impacts at an academic teaching hospital.
We reviewed CJR bundle data provided by CMS and internal databases to identify the shift in CJR TKA episode volume since January 2018, the impact on postacute care (PAC) utilization rates and readmissions, financial impact to the bundle, and impact on hospital reimbursement. We used data provided to CJR participants, internal hospital sources, and the Medicare Limited Data Set.
Between 2017 and 2018, CJR TKA episodes decreased from 91 to 51 (44% reduction). Inpatient PAC utilization was significantly higher in 2018 (20% vs 8%). The 90-day readmission rates increased from 5.5% to 12.7%. Average variance to target dropped from 15% to 5%. Average CMS reimbursement for TKA at our institution in 2019 was $14,823 for inpatients and $9299 for outpatients. We experienced $930,463 in decreased reimbursement from January 2018 to September 2019 as a result of the shift from inpatient to outpatient. In addition, we expect $625,143 in decreased incentive payments as higher functioning and lower cost outpatient TKAs are excluded from CJR.
Although CMS projected a minimal impact on CJR bundle participants, this has not been the case at our institution. We experienced reduced volumes, increased PAC utilization, and a substantial financial impact. We expect a similar outcome when CMS removes total hip arthroplasty from the inpatient-only list.
Centers for Medicare and Medicaid Services removed total knee arthroplasties (TKAs) from the Inpatient-Only list on January 1, 2018, which meant TKAs could be performed on a hospital outpatient ...basis. We sought to understand (1) what the financial implications have been for hospitals, (2) to what extent financial incentives have influenced the adoption of outpatient TKAs across hospitals, (3) whether adoption of outpatient TKAs has impacted the success of hospitals with managing post-acute care (PAC) spend, and (4) the financial implications to Medicare of the adoption of outpatient TKAs.
We used national patient-level Medicare fee-for-service Part A claims data (100% sample) from January 2018 through June 2019 to calculate the inpatient and outpatient TKA payment rate for each hospital, and the distribution in these payments across the country. We then ran case-level regressions to understand the factors associated with adoption of outpatient TKAs, and the drivers of PAC spend. Finally, we quantified the savings to Medicare.
Hospitals on average received $3682 (30%) lower payment from Medicare for outpatient TKA cases, but this varied widely across hospitals. The difference in payment rates across hospitals was not statistically significantly related to their adoption rate of outpatient TKAs. PAC spend was higher for same-day discharges, but lower for cases that stayed at least 1 night. Based on the adoption rate of outpatient TKAs in Q2 2019, Medicare saved $355M on a run rate basis.
Hospitals have adopted outpatient TKAs independent of the financial impact. Medicare has benefited from lower PAC spend and lower payments to hospitals.
Abstract
Background
For years the United States Department of Agriculture’s Pesticide Data Program and the United Kingdom’s Food Standards Agency have published annual or quarterly data on pesticide ...residues in foods. Both programs report residues in conventionally grown, organic, and imported foods. The US program has tested about 288,000 food samples since 1992, primarily fruits and vegetables consumed by children. Since 1999 the UK has tested about 72,000 samples of a wider range of foods. These data are vital inputs in tracking trends in pesticide dietary risks.
Methods
The Dietary Risk Index (DRI) system facilitates detailed analyses of US and UK pesticide residue data, trends, and chronic risk distributions. The DRI value for a pesticide is the dietary intake of that pesticide from a single serving of food divided by the pesticide’s acceptable daily intake as set by the US Environmental Protection Agency. It can be calculated based on average annual residue concentrations, and on residue levels in individual samples of food. DRI values can be aggregated over multiple pesticides in single foods, and over individual pesticides in multiple foods.
Results
The DRI system provides insights into the levels, trends, and distribution of pesticide dietary risk across most widely consumed foods. By drawing on both US Pesticide Data Program and UK-Food Standards Agency residue data, the DRI is capable of assessing pesticide risks in a significant portion of the global food supply. Substantial reductions in pesticide dietary risks occurred in the early 2000s, primarily from replacement of organophosphate insecticides with seemingly lower-risk neonicotinoids. However, there remain several areas of concern and opportunities to reduce risks. Both herbicide and fungicide dietary risks are rising. Organically grown produce poses risks far lower than corresponding, conventionally grown produce. Risk differences are inconsistent between domestic and imported foods.
Conclusions
The surest ways to markedly reduce pesticide dietary risks are to shift relatively high-risk fruits and vegetables to organic production. For other foods, reducing reliance on pesticides overall, and especially high-risk pesticides, will incrementally lower risks. The DRI system can help focus such efforts and track progress in reducing pesticide dietary risk.
Higher body mass index (BMI) has been associated with postoperative complications in total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, the association of incremental increases ...of BMI and its effects on postoperative complications has not been well studied. We hypothesize that there is a BMI cutoff at which there is a significant increase of the risk of postoperative complications.
We studied the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2013. The final cohort included 77,785 primary TKA and 49,475 primary THA subjects, respectively. Patients were separated into 7 groups based on BMI (18.5-24.9 kg/m(2), 25.0-29.9 kg/m(2), 30.0-34.9 kg/m(2), 35.0-39.9 kg/m(2), 40.0-44.9 kg/m(2), 45.0-49.9 kg/m(2), and >50.0 kg/m(2)). We analyzed data on five 30-day composite complication variables, including any complication, major complication, wound infection, systemic infection, and cardiac and/or pulmonary complication.
The odds ratio for 4 (any complication, major complication, wound infection, and systemic infection) of 5 composite complications started to increase exponentially once BMI reached 45.0 kg/m(2) or higher in TKA. Similarly, the odds ratio in 3 (any complication, systemic infection, and wound infection) of 5 composite complications showed similar trends in THA patients. These findings were further confirmed with propensity score matching and entropy balancing.
Our study suggested that there was a positive correlation between BMI and incidences of 30-day postoperative complications in both TKA and THA. The odds of complications increased dramatically once BMI reached 45.0 kg/m(2).
Background
The continued presence of biofilm may be one cause of the high risk of failure observed with irrigation and débridement with component retention in acute periprosthetic joint infection ...(PJI). There is a poor understanding of the role of biofilm antibiotic tolerance in PJI.
Questions/purposes
(1) Do increasing doses of cefazolin result in decreased viable biofilm mass on arthroplasty materials? (2) Is cefazolin resistance phenotypic or genotypic? (3) Is biofilm viability a function of biofilm depth after treatment with cefazolin? (4) Is the toxin-antitoxin system,
yoeB
expression, associated with antibiotic stress?
Methods
Methicillin-sensitive
Staphylococcus aureus
biofilm was cultured on total knee arthroplasty (TKA) materials and exposed to increasing doses of cefazolin (control, 0.5, 1.0, 10.0, 100.0 μg/mL). Quantitative confocal microscopy and quantitative culture were used to measure viable biofilm cell density. To determine if cefazolin resistance was phenotypic or genotypic, we measured minimum inhibitory concentration (MIC) after exposure to different cefazolin concentrations; changes in MIC would suggest genotypic features, whereas unchanged MIC would suggest phenotypic behavior. Finally, quantitative reverse transcription-polymerase chain reaction was used to quantify expression of
yoeB
levels between biofilm and planktonic bacteria after exposure to 1 μg/mL cefazolin for 3 hours.
Results
Although live biofilm mass was reduced by exposure to cefazolin when compared with biofilm mass in controls (39.2 × 10
3
± 26.4 × 10
3
pixels), where the level after 0.5 µg/mL exposure also showed reduced mass (20.3 × 10
3
± 11.9 × 10
3
pixels), no further reduction was seen after higher doses (mass at 1.0 µg/mL: 5.0 × 10
3
pixels ± 1.1 × 10
3
pixels; at 10.0 µg/mL: 6.4 × 10
3
± 9.6 × 10
3
pixels; at 100.0 µg/mL: 6.4 × 10
3
± 3.9 × 10
3
). At the highest concentration tested (100 µg/mL), residual viable biofilm was present on all three materials, and there were no differences in percent biofilm survival among cobalt-chromium (18.5% ± 15.1%), polymethylmethacrylate (22.8% ± 20.2%), and polyethylene (14.7% ± 10.4%). We found that tolerance was a phenotypic phenomenon, because increasing cefazolin exposure did not result in changes in MIC as compared with controls (MIC in controls: 0.13 ± 0.02; at 0.5 µg/mL: 0.13 ± 0.001, p = 0.96; at 1.0 µg/m: 0.14 ± 0.04, p = 0.95; at 10.0 µg/m: 0.11 ± 0.016, p = 0.47; at 100.0 µg/m: 0.94 ± 0.047, p = 0.47). Expression of
yoeB
after 1 µg/mL cefazolin for 3 hours in biofilm cells was greater in biofilm but not in planktonic cells (biofilm: 62.3-fold change, planktonic cells: −78.8-fold change, p < 0.001).
Conclusions
Antibiotics are inadequate at complete removal of the biofilm from the surface of TKA materials. Results suggest that bacterial persisters are responsible for this phenotypic behavior allowing biofilm high tolerance to antibiotics.
Clinical Relevance
Antibiotic-tolerant biofilm suggests a mechanism behind the poor results in irrigation and débridement for acute TKA PJI.
Power system substations have intelligent electronic devices (IEDs) that collect data and control other devices. As the bridge between the physical and cyber parts of the power system, IEDs capture ...some key system behaviors. Since adversaries can modify the system's behavior, physical and cyber data can be used to infer characteristics about the adversary. In this article, we present alert and control logic for hardware-based power system defense using the physical data and communication status in substation IEDs for cyber threat detection , cyber-physical contingency detection and response , and physical contingency identification and response . The proposed alert and control logic routines are implemented in an industrial real-time automation controller using IEC 61131-3 in the resilient energy systems lab testbed. The goal is to help operators identify adversaries and protect the power grid in a cyber-physical environment. The effectiveness and accuracy of logic schemes are validated under different adversarial scenarios. Comparing the proposed schemes with an intrusion detection system, Snort, our results also suggest the benefits of using cyber and physical data to identify threats. The results also suggest the use of such hardware-based schemes with software algorithms in a next-generation cyber-physical energy management system, which can implement automatic control actions to protect power grids and its physical equipment against cyber threats.
Proliferation of herbicide‐resistant weeds demands re‐evaluation of fundamental weed control objectives. Yield loss mitigation remains a priority, but limiting weed seed return (WSR) to the soil ...seedbank is key to preventing herbicide‐resistant annual weeds from multiplying. The critical period for weed seed control (CPWSC) is the period of the growing season during which weed control can minimise weed seed production. The CPWSC provides a framework to limit WSR by targeting weeds during phenological stages critical for seed development. We aim to (a) introduce the CPWSC concept, (b) provide an example using Bassia scoparia as a model species and (c) offer a framework for future research.
Abstract In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at ...removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty.
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