Quantifying stream phosphorus dynamics and total suspended sediment export in forested watersheds in Vermont

Globally the quantity of reactive phosphorus (P) in soils, streams and groundwater has greatly increased throughout the 20th and early 21st centuries. This phenomenon is problematic in Vermont, evidenced by the repeated cyanobacteria blooms in shallow bays in Lake Champlain. While many studies have focused on P dynamics in agricultural watersheds, there is limited information on P dynamics in forested watersheds. Current remediation plans under the Lake Champlain total maximum daily loads (TMDL) call for substantial reductions in P loadings from forested areas of the basin. However, the lack of information and knowledge regarding forest P dynamics limits management and remediation plans. This study was conducted in three small forested watersheds, ranging in size from 2.5 to 8.3 square kilometers that have been managed under varying practices, including logging and maple sugaring. All three watersheds drain into Missisquoi Bay, a shallow bay in Lake Champlain that consistently has seasonal algal blooms. Streams in the forested watersheds were instrumented with turbidity sensors and pressure transducers to measure stage. A rating curve was developed during field visits to relate stage to discharge. Water samples were collected from May through November 2017 using ISCO Automated Samplers. A total of twenty storm events were captured, along with periodic baseflow sampling, and these data were used to characterize P concentrations and calculate seasonal P loadings. Results indicate that there is a strong positive relationship between turbidity, total suspended sediment and total phosphorus concentrations (R2 ranging from 0.64 to 0.83). The results of this project provide insight into transport of P and total suspended sediment within forested catchments of Lake Champlain tributaries. In particular, the research shows that fluxes in total phosphorus are linked to fluxes in total suspended sediment and that the overall monthly totals of P being exported from forested catchments are low, relative to urban, suburban and agricultural areas

The clinical effectiveness and cost-effectiveness of inhaler devices used in the routine management of chronic asthma in older children: a systematic review and economic evaluation

Background: This review examines the clinical effectiveness and cost-effectiveness of hand-held inhalers to deliver medication for the routine management of chronic asthma in children aged between 5 and 15 years. Asthma is a common disease of the airways, with a prevalence of treated asthma in 5–15-year-olds of around 12% and an actual prevalence in the community as high as 23%. Treatment for the condition is predominantly by inhalation of medication. There are three main types of inhaler device, pressurised metered dose, breath actuated, and dry powder, with the option of the attachment of a spacer to the first two devices under some prescribed circumstances. Two recent reviews have examined the clinical and cost-effectiveness evidence on inhaler devices, but one was for children aged under 5 years and the comparison in the second was made between pressurised metered dose inhalers and other types only. Objectives: This review examines the clinical effectiveness and cost-effectiveness of manual pressurised metered dose inhalers, breath-actuated metered dose inhalers, and breath-actuated dry powder inhalers, with and without spacers as appropriate, to deliver medication for the routine management of chronic asthma in children aged between 5 and 15 years. Methods: Two previous HTA reviews have compared the effectiveness of inhaler devices, one focusing on asthma in children aged under 5 years and the other on asthma and chronic obstructive airways disease in all age groups. For the current review, a literature search was carried out to identify all evidence relating to the use of inhalers in older children with chronic asthma. A search of in-vitro studies undertaken for one of the previous reviews was also updated. The data sources used were: 15 electronic bibliographic databases; the reference lists of one of the previous HTA reports and other relevant articles; health services research-related internet resources; and all sponsor submissions. Studies were selected according to strict inclusion and exclusion criteria, and relevant information concerning effectiveness and patient compliance and preference was extracted directly on to an extraction/evidence table. Quality assurance was monitored. Economic evaluation was undertaken by reviewing existing cost-effective evidence. Further economic modelling was carried out, and tables constructed to determine device cost-minimisation and incremental quality-adjusted life-year (QALY) thresholds between devices. Results: Number and quality of studies, and direction of evidence: Fourteen randomised controlled studies were identified relating to the clinical effectiveness of inhaler devices for delivering β2-agonists. A further five were on devices delivering corticosteroids and one concerned the delivery of cromoglicate. Overall, there were no differences in clinical efficacy between inhaler devices, but a pressurised metered dose inhaler with a spacer would appear to be more effective than one without. These findings endorse those of a previous HTA review but extend them to other inhaler devices. Seven randomised controlled trials examined the impact on clinical effectiveness of using a nonchlorofluorocarbon (CFC) propellant in place of a CFC propellant in metered dose inhalers, both pressurised and breath activated, although only one study considered the latter type. No differences were found between inhalers containing either propellant. A further 30 studies of varying quality, from 12 randomised controlled trials to non-controlled studies, were identified that concerned the impact of use by, and preference for, inhaler type, and treatment adherence in children. Differences between the studies, and limitations in comparative data between various inhaler device types, make it difficult to draw any firm conclusions from this evidence. Summary of benefits: No obvious benefits for one inhaler device type over another for use in children aged 5–15 years were identified. Costs and cost per quality-adjusted life-year: Two approaches have been taken: cost-minimisation and QALY threshold. In the QALY threshold approach, additional QALYs that each device must produce compared with a cheaper device to achieve an acceptable cost per QALY were calculated. Using the cheapest and most expensive devices for delivering 200 μg of beclometasone per day, assuming no cost offset for any device, and a threshold of £5000, the largest QALY needed was 0.00807. With such a small QALY increase, no intervention can be categorically rejected as not cost-effective. Conclusions: Generalisability of findings: On the available evidence there are no obvious benefits for one inhaler device over another when used by children aged 5–15 years with chronic asthma. However, the evidence, in the majority of cases, was compiled on children with mild to moderate asthma and restricted to a limited number of drugs. Therefore the findings may not be generalisable to those at the more severe end of the spectrum of the disease or to inhaler devices delivering some of the drugs used in the management of asthma. Need for further research: Many of the previous studies are likely to have been underpowered. Further clinical trials with a robust methodology, sufficient power and qualitative components are needed to demonstrate any differences in clinical resource use and patients’ asthma symptoms. Further studies should also include the behavioural aspects of patients towards their medication and its delivery mechanisms. It is acknowledged that sufficient power may prove impractical owing to the large numbers of patients required

Economics of tandem mass spectrometry screening of neonatal inherited disorders

Objectives: The aim of this study was to evaluate the cost-effectiveness of neonatal screening for phenylketonuria (PKU) and medium-chain acyl-coA dehydrogenase (MCAD) deficiency using tandem mass spectrometry (tandem MS). Methods: A systematic review of clinical efficacy evidence and cost-effectiveness modeling of screening in newborn infants within a UK National Health Service perspective was performed. Marginal costs, life-years gained, and cost-effectiveness acceptability curves are presented. Results: Substituting the use of tandem MS for existing technologies for the screening of PKU increases costs with no increase in health outcomes. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS, with an operational range of 50,000 to 60,000 specimens per system per year, would result in a mean incremental cost of −£17,298 (−£129,174, £66,434) for each cohort of 100,000 neonates screened. This cost saving is associated with a mean incremental gain of 57.3 (28.0, 91.4) life-years. Conclusions: Cost-effectiveness analysis using economic modeling indicates that substituting the use of tandem MS for existing technologies for the screening of PKU alone is not economically justified. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS would be economically attractive

Newborn screening using tandem mass spectrometry: A systematic review

Objectives: To evaluate the evidence for the clinical effectiveness of neonatal screening for phenylketonuria (PKU) and medium-chain acyl-coA dehydrogenase (MCAD) deficiency using tandem mass spectrometry (tandem MS). Study design: Systematic review of published research. Data sources: Studies were identified by searching 12 electronic bibliographic databases; conference proceedings and experts consulted. Results: Six studies were selected for inclusion in the review. The evidence of neonatal screening for PKU and MCAD deficiency using tandem MS was primarily from observational data of large-scale prospective newborn screening programmes and systematic screening studies from Australia, Germany and the USA. Tandem MS based newborn screening of dried blood spots for PKU and/or MCAD deficiency was shown to be highly sensitive (>93.220%) and highly specific (>99.971%). The false positive rate for PKU screening was less than 0.046% and for MCAD deficiency the false positive rate was less than 0.023%. The positive predictive values ranged from 20 to 32% and 19 to 100%, respectively. Conclusions: This review suggests that neonatal screening of dried blood spots using a single analytical technique (tandem MS) is highly sensitive and specific for detecting cases of PKU and MCAD deficiency, and provides a basis for modelling of the clinical benefits and potential costeffectiveness

A streamwise-constant model of turbulent pipe flow

A streamwise-constant model is presented to investigate the basic mechanisms responsible for the change in mean flow occuring during pipe flow transition. Using a single forced momentum balance equation, we show that the shape of the velocity profile is robust to changes in the forcing profile and that both linear non-normal and nonlinear effects are required to capture the change in mean flow associated with transition to turbulence. The particularly simple form of the model allows for the study of the momentum transfer directly by inspection of the equations. The distribution of the high- and low-speed streaks over the cross-section of the pipe produced by our model is remarkably similar to one observed in the velocity field near the trailing edge of the puff structures present in pipe flow transition. Under stochastic forcing, the model exhibits a quasi-periodic self-sustaining cycle characterized by the creation and subsequent decay of "streamwise-constant puffs", so-called due to the good agreement between the temporal evolution of their velocity field and the projection of the velocity field associated with three-dimensional puffs in a frame of reference moving at the bulk velocity. We establish that the flow dynamics are relatively insensitive to the regeneration mechanisms invoked to produce near-wall streamwise vortices and that using small, unstructured background disturbances to regenerate the streamwise vortices is sufficient to capture the formation of the high- and low-speed streaks and their segregation leading to the blunting of the velocity profile characteristic of turbulent pipe flow

Amplification and nonlinear mechanisms in plane Couette flow

We study the input-output response of a streamwise constant projection of the Navier-Stokes equations for plane Couette flow, the so-called 2D/3C model. Study of a streamwise constant model is motivated by numerical and experimental observations that suggest the prevalence and importance of streamwise and quasi-streamwise elongated structures. Periodic spanwise/wall-normal (z–y) plane stream functions are used as input to develop a forced 2D/3C streamwise velocity field that is qualitatively similar to a fully turbulent spatial field of direct numerical simulation data. The input-output response associated with the 2D/3C nonlinear coupling is used to estimate the energy optimal spanwise wavelength over a range of Reynolds numbers. The results of the input-output analysis agree with previous studies of the linearized Navier-Stokes equations. The optimal energy corresponds to minimal nonlinear coupling. On the other hand, the nature of the forced 2D/3C streamwise velocity field provides evidence that the nonlinear coupling in the 2D/3C model is responsible for creating the well known characteristic “S” shaped turbulent velocity profile. This indicates that there is an important tradeoff between energy amplification, which is primarily linear, and the seemingly nonlinear momentum transfer mechanism that produces a turbulent-like mean profile