Effect of a machine learning-based severe sepsis prediction algorithm on patient survival and hospital length of stay: a randomised clinical trial.

IntroductionSeveral methods have been developed to electronically monitor patients for severe sepsis, but few provide predictive capabilities to enable early intervention; furthermore, no severe sepsis prediction systems have been previously validated in a randomised study. We tested the use of a machine learning-based severe sepsis prediction system for reductions in average length of stay and in-hospital mortality rate.MethodsWe conducted a randomised controlled clinical trial at two medical-surgical intensive care units at the University of California, San Francisco Medical Center, evaluating the primary outcome of average length of stay, and secondary outcome of in-hospital mortality rate from December 2016 to February 2017. Adult patients (18+) admitted to participating units were eligible for this factorial, open-label study. Enrolled patients were assigned to a trial arm by a random allocation sequence. In the control group, only the current severe sepsis detector was used; in the experimental group, the machine learning algorithm (MLA) was also used. On receiving an alert, the care team evaluated the patient and initiated the severe sepsis bundle, if appropriate. Although participants were randomly assigned to a trial arm, group assignments were automatically revealed for any patients who received MLA alerts.ResultsOutcomes from 75 patients in the control and 67 patients in the experimental group were analysed. Average length of stay decreased from 13.0 days in the control to 10.3 days in the experimental group (p=0.042). In-hospital mortality decreased by 12.4 percentage points when using the MLA (p=0.018), a relative reduction of 58.0%. No adverse events were reported during this trial.ConclusionThe MLA was associated with improved patient outcomes. This is the first randomised controlled trial of a sepsis surveillance system to demonstrate statistically significant differences in length of stay and in-hospital mortality.Trial registrationNCT03015454

Influence of Timber Harvesting Operations and Streamside Management Zone Effectiveness on Sediment Delivery to Headwater Streams in Appalachia

Disturbances created by timber harvesting equipment and associated haul roads and skid trails can create overland sediment flows (sediment paths), especially in steeply sloping terrain, leading to stream sedimentation. This study investigated the effect of variables associated with GPS tracked harvest equipment movement, skid trail development and retirement, topography, and streamside management zone (SMZ) width and tree retention on sediment delivery to streams. While the intensity of harvest equipment traffic was not correlated with sediment path development, the presence and location of skid trails were. All of the sediment paths were found to originate at water control structures, influenced by microtopographic features, on the skid trails directly adjacent to SMZs. Mesic slopes were associated with increased sediment path development across all SMZ configurations. Two factors, the accumulation of coarse logging debris in the SMZ and the increased distance of skid trails to streams, were both correlated with decreased sediment path development. The study provides insight into how these variables interact and can be used to develop site-specific guidelines for SMZs in steeply sloping terrain that could improve their efficiency and effectiveness

Establishing Pine Monocultures and Mixed Pine-Hardwood Stands on Reclaimed Surface Mined Land in Eastern Kentucky: Implications for Forest Resilience in a Changing Climate

Surface mining and mine reclamation practices have caused significant forest loss and forest fragmentation in Appalachia. Shortleaf pine (Pinus echinata) is threatened by a variety of stresses, including diseases, pests, poor management, altered fire regimes, and climate change, and the species is the subject of a widescale restoration effort. Surface mines may present opportunity for shortleaf pine restoration; however, the survival and growth of shortleaf pine on these harsh sites has not been critically evaluated. This paper presents first-year survival and growth of native shortleaf pine planted on a reclaimed surface mine, compared to non-native loblolly pine (Pinus taeda), which has been highly successful in previous mined land reclamation plantings. Pine monoculture plots are also compared to pine-hardwood polyculture plots to evaluate effects of planting mix on tree growth and survival, as well as soil health. Initial survival of shortleaf pine is low (42%), but height growth is similar to that of loblolly pine. No differences in survival or growth were observed between monoculture and polyculture treatments. Additional surveys in coming years will address longer-term growth and survival patterns of these species, as well as changes to relevant soil health endpoints, such as soil carbon

Spoil Type Influences Soil Genesis and Forest Development on an Appalachian Surface Coal Mine Ten Years After Placement

Surface mining for coal (or other mineral resources) is a major driver of land-use change around the world and especially in the Appalachian region of the United States. Intentional and well-informed reclamation of surface-mined land is critical for the restoration of healthy ecosystems on these disturbed sites. In Appalachia, the pre-mining land cover is predominately mixed hardwood forest, with rich species diversity. In recent years, Appalachian mine reforestation has become an issue of concern, prompting the development of the Forestry Reclamation Approach, a series of mine reforestation recommendations. One of these recommendations is to use the best available soil substitute; however, the characteristics of the “best” soil substitute have been an issue. This study was initiated to compare the suitability of several types of mine spoil common in the Appalachian region: brown sandstone (Brown), gray sandstone (Gray), mixed spoils (Mixed), and shale (Shale). Experimental plots were established in 2007 with each spoil type replicated three times. These plots were planted with a mix of native hardwood species. Ten years after plot construction and planting, tree growth and canopy cover were highest in Brown, followed by Shale, Mixed, and Gray. Soil conditions (particularly pH) in Brown and Shale were more favorable for native tree growth than Mixed or Gray, largely explaining these differences in tree growth and canopy cover. However, soil chemistry did not clearly explain differences in tree growth between Brown and Shale. These differences were more likely related to differences in near-surface soil temperature, which is related to soil color and available shade

Diet Composition: A Proximate Mechanism Explaining Stream Salamander Declines in Surface Waters with Elevated Specific Conductivity

Changes in land use, such as mountaintop removal mining with valley fills (MTR-VF), often results in headwater streams with elevated specific conductivity (SC). Stream salamanders appear to be particularly sensitive to elevated SC, as previous studies have shown occupancy and abundance decline consistently among all species and life stages as SC increases. Yet, the proximate mechanism responsible for the population declines in streams with elevated SC have eluded researchers. We sampled salamander assemblages across a continuous SC gradient (30–1966 μS/cm) in southeastern Kentucky and examined the diet of larval and adult salamanders to determine if the ratio of aquatic to terrestrial prey (autochthony), total prey volume, aquatic prey importance (Ix), and body condition are influenced by SC. Further, we asked if threshold points for each diet component were present along a gradient of SC. Larval salamanders experienced a 12–fold decline in autochthony at 153 μS/cm, a 4.2–fold decline in total prey volume at 100 μS/cm, a 2.2-fold decline in aquatic Ix at 135 μS/cm, and a rapid decline in body condition as SC increased. Adult salamanders experienced a 3–fold decline in autochthony at 382 μS/cm, no change in prey volumes, a 2-fold decline in aquatic Ix at 163 μS/cm, and a decline in body condition as SC increased. Our results indicate that SC indirectly affects stream salamander populations by changing the composition of diet, which suggests that food availability is a proximate mechanism that leads to reduced population occupancy, abundance, and persistence in streams with elevated SC

\u3cem\u3ePhytophthora cinnamomi\u3c/em\u3e Colonized Reclaimed Surface Mined Sites in Eastern Kentucky: Implications for the Restoration of Susceptible Species

Appalachian forests are threatened by a number of factors, especially introduced pests and pathogens. Among these is Phytophthora cinnamomi, a soil-borne oomycete pathogen known to cause root rot in American chestnut, shortleaf pine, and other native tree species. This study was initiated to characterize the incidence of P. cinnamomi on surface mined lands in eastern Kentucky, USA, representing a range of time since reclamation (10, 12, 15, and 20 years since reclamation). Incidence of P. cinnamomi was correlated to soil properties including overall soil development, as indicated by a variety of measured soil physical and chemical parameters, especially the accumulation of soil organic carbon. P. cinnamomi was detected in only two of the four sites studied, aged 15 and 20 years since reclamation. These sites were generally characterized by higher organic matter accumulation than the younger sites in which P. cinnamomi was not detected. These results demonstrate that P. cinnamomi is capable of colonizing reclaimed mine sites in Appalachia; additional research is necessary to determine the impact of P. cinnamomi on susceptible tree species at these sites

Assessment of Streamside Management Zones for Conserving Benthic Macroinvertebrate Communities Following Timber Harvest in Eastern Kentucky Headwater Catchments

Headwater streams generally comprise the majority of stream area in a watershed and can have a strong influence on downstream food webs. Our objective was to determine the effect of altering streamside management zone (SMZ) configurations on headwater aquatic insect communities. Timber harvests were implemented within six watersheds in eastern Kentucky. The SMZ configurations varied in width, canopy retention and best management practice (BMP) utilization at the watershed scale. Benthic macroinvertebrate samples collected one year before and four years after harvest indicated few differences among treatments, although post-treatment abundance was elevated in some of the treatment streams relative to the unharvested controls. Jaccard index values were similar across SMZ treatments after logging, indicating strong community overlap. These findings suggest that stream invertebrate communities did respond to the timber harvest, though not negatively. Results also suggest that SMZ criteria for aquatic habitats in steeply sloping topography, including at least 50 percent canopy retention and widths of at least 16.8 m, appear to be adequate for protecting benthic macroinvertebrate communities from logging impacts

Development and Deployment of a Bioreactor for the Removal of Sulfate and Manganese from Circumneutral Coal Mine Drainage

Surface mining, in the form of contour mining and mountain-top removal, is a common means for retrieving coal in the Appalachian Coal Belt region of Kentucky. Overburden or excess spoil generated by these two methods is placed in valley fills. Traditionally Constructed fills have been shown to adversely impact headwater ecosystems via stream burial and through alterations to the hydrology, sediment supply, water quality and biological composition of downstream reaches. Mine drainages emanating from the toe of valley fills often contain elevated levels of total dissolved solids and heavy metals. Drainage chemistry from Guy Cove, a valley fill located in eastern Kentucky, exhibited a mean pH of 6.5 and Fe, Mn and SO4 concentrations of 1.5, 14, and 1264 mg L-1, respectively. The objective of this research was to develop an anaerobic bioreactor for the purpose of reducing Mn and SO4 concentrations in the mine drainage. Development began with batch experiments that tested five different organic carbon sources and five different inorganic substrates. A synthetic mine drainage with a pH of 6.2 and Mn and SO4 concentrations of 90 and 1,500 mg/L, respectively, was used in the experiment. Manganese and SO4 removal varied widely between treatment matrices, with removal rates \u3c 10 to 100% for Mn and \u3c 10 to \u3e 80% for SO4. The substrate sources which provided the most treatment were hardwood mulch and biosolids combined with creek sediment. Subsequent experiments were performed using the synthetic mine drainage in small bioreactors (55 liter plastic tanks) filled with creek sediment with either hardwood mulch or biosolids, each replicated three times. Over a 65 day treatment period \u3e 90% of the Mn and 70% of the SO4 was removed. There were no statistical differences between the two organic substrates. Using this information, in-situ bioreactors consisting of two 5,500 liter plastic septic tanks filled with creek sediment, hardwood mulch and manure compost were installed at Guy Cove. Mine drainage was collected in a sump and conveyed through the inline bioreactors by gravity. Gate valves were used to control flow through the bioreactors. After a 10-month monitoring period, the in-situ bioreactors removed 12, 11, and 64% of Mn, SO4 and Fe from the drainage, respectively. Results from the field differed greatly from those observed under controlled laboratory conditions. Efforts to improve the efficiency of the in-situ bioreactors are underway

Occupancy and Abundance of Stream Salamanders along a Specific Conductance Gradient

In the Central Appalachians (USA), mountaintop-removal mining accompanied by valley fills often leads to streams with elevated specific conductivity (SC). Thus, the ionic composition of freshwaters in this region is hypothesized to be a driver of the distribution and abundance of freshwater taxa, including stream salamanders. We examined the association between SC and stream salamander populations by conducting salamander counts in 30 southeastern Kentucky streams across a continuous gradient of SC that ranged from 30 to 1966 μS/cm. We counted 2319 salamanders across 5 species and, using a hierarchical Bayesian version of the N-mixture model, found a negative association between SC and salamander occupancy rates. This finding was consistent across adults and larvae of the 5 species we examined. Furthermore, we found that most salamander species and life stages showed reduced abundances given occupancy at greater SC levels. For example, estimated mean abundance given occupancy of larval Southern Two-lined Salamanders (Eurycea cirrigera) was 67.69 (95% credible interval 48.31–98.25) ind/10 m at 250 μS/cm and 2.30 (95% credible interval 1.46–3.93) ind/10 m at 2000 μS/cm. The consistent negative association across all species and life stages supports the hypothesis that salamander distributions and abundances are negatively associated with elevated SC of streams in southeastern Kentucky, even though physical and chemical environmental attributes, such as forest cover within stream catchments, were correlated with SC. Restoration of streams affected by mountaintop-removal mining should focus on restoring the ionic compositions that naturally occur in this region