The hydroecology of groundwater-fed streams in a glacierised catchment

Groundwater flow typically provides stable stream habitat within glacierised floodplains. However, spatio-temporal differences within and between groundwater flow pathways can create marked variability in the physicochemical characteristics of groundwater-fed streams. Research conducted on a floodplain terrace of the Toklat River, Denali National Park, Alaska, predominantly from May to September 2008, determined the influence of groundwater flow dynamics upon benthic and hyporheic macroinvertebrate assemblages. During periods of resource depletion benthic macroinvertebrate abundance was dependent upon contributions from specific flow pathways (DFSdeep), which supplied fine particulate organic matter. Dynamics of groundwater flow pathways influenced macroinvertebrates throughout the summer, however, with higher diversity observed in perennial streams which received groundwater flow from DFSdeep. Ephemeral flow pathways of glacial seepage supported lower diversity. Within the hyporheic zone, environmental stability of surface waters was influential, as this reflected the sub-surface residence time of percolating waters; nested routes of flow within each flow pathway, of varying length or permeability, created differences in the environmental stability of each stream. Macroinvertebrate diversity in the hyporheic zone was higher at sites of lower surface environmental stability, suggesting possible migration into the hyporheic zone. Digital remote sensing used to estimate the spatial extent of groundwater upwellings within two national parks in Alaska indicated that these groundwater-fed habitats are widespread

Modelling phosphorus in Lake Simcoe and its subcatchments: scenario analysis to assess alternative management strategies

In Lake Simcoe (Ontario, Canada), anthropogenic phosphorus (P) loads have contributed to increased algal growth, low hypolimnetic dissolved oxygen concentrations, and impaired fish reproduction. Management targets to control eutrophication require an ambitious programme to reduce P loads to the lake. Remediation strategies rely upon an improved understanding of P sources and assessment of the effectiveness of different control options. Here we present an application of the integrated catchment model for phosphorus (INCA-P) to examine P sources across the Lake Simcoe watershed and simulate in-lake P concentrations. This is the first application of INCA-P to a complex watershed of this nature and the first to include a lake component. We evaluated a set of management actions to simulate anticipated effects of P reduction strategies on in-lake total phosphorus (TP) concentrations. The INCA-P scenarios show the difficulty of achieving large-scale reductions from the watershed, given the low rates of P export; however, the study shows that a multifaceted strategy, including fertilizer reduction, addition of buffer strips, more stringent controls on sewage treatment plant effluent, and reduced deposition of P to the lake surface, could achieve a 25% reduction in lake-water TP concentrations and produce TP close to the target of 0.01 mg L−1

Phosphorus dynamics across intensively monitored subcatchments in the Beaver River

We report results from a spatially intensive monitoring and modelling study to assess phosphorus (P) dynamics in the Beaver River, a tributary of Lake Simcoe, Ontario. We established multiple monitoring stations (9 flow and 24 water quality stations) from headwaters to near the outflow that were operated for 2 field seasons, complementing longer term data from a flow monitoring site and water chemistry monitoring site. We applied the Branched-INCA-P model, which allows fully distributed simulations supported by highly distributed monitoring data. Using spatially distributed data helped better understand variable P and sediment dynamics across the catchment and identify key model uncertainties and uncertainties related to catchment P management. Measured and modelled total P concentrations often exceeded provisional water quality thresholds in many areas of the catchment and highlight the value of studying water quality across multiple subcatchments rather than at a single site. Total P export coefficients differed widely among subcatchments, ranging from 2.1–21.4 kg km-2 y-1 over a single year. Export coefficients were most strongly (negatively) related to the proportion of wetland cover in subcatchments. The INCA-P model captured spatial variation in P concentrations relatively well, but short-term temporal variability in the observed data was not well simulated across sites, in part due to unmodelled hydrological phenomena including beaver activity and unknown drivers of P peaks that were not associated with hydrological events

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

Effect of transcatheter aortic valve implantation vs surgical aortic valve replacement on all-cause mortality in patients with aortic stenosis

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. Design, Setting, and Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of −2.0% (1-sided 97.5% CI, −∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). Conclusions and Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. Trial Registration: isrctn.com Identifier: ISRCTN57819173