Assessment of Nitrate Export in Agricultural Sub-Catchments of the Grand River Watershed: An Isotope Approach

Nitrate (NO3-) is one of the most widespread contaminants in freshwater systems globally. This is largely due to high fertilizer application rates that are required to maximize crop yield. Elevated NO3- concentrations can cause detrimental health effects to both humans and aquatic ecosystems. While the drinking water standard for NO3- in Canada is 10 mg N/L, this level is often surpassed in small headwater agricultural streams and tile drainage. Inorganic (synthetic) and organic (manure) fertilizers are the greatest non-point sources of NO3- to freshwater and groundwater systems in Canada. Inherent isotope fractionation during production of inorganic and organic fertilizers allows these N sources to be differentiated using the isotopic ratios of nitrogen and oxygen. Small agricultural catchments play an important role in nutrient export to larger freshwater systems, however the source and timing of export is often unknown. The main objective of this thesis is to better understand the sources and processes governing NO3- concentration and export in four small agricultural catchments where large changes in nutrient concentration can occur over the course of a year. Land-use within these catchments is predominantly agriculture (>77%). Geochemical and isotopic analysis of the four creeks, the Conestogo River, the Grand River as well as tile drain and shallow groundwater piezometers located along one creek (Boomer Creek) was undertaken. NO3- concentration varied seasonally, concomitantly with stream discharge, with increased concentrations and export occurring during the non-growing season at scales from small watershed to the Grand River. Peak concentrations (>10 mg N/L) occurred in late fall and early winter and lowest concentrations (<5mg N/L) occurred during the summer months. Median NO3- concentrations from tile drains (5.9 mg N/L) were much higher than that of groundwater samples (0.1 mg N/L). Further, groundwater NO3- concentrations remained consistently low even at times of high discharge and high NO3- concentrations in both the tiles and the creek, indicating that the creek is more influenced by water discharging from tile drains and not that of groundwater. The studied creeks NO3- export varied seasonally with the greatest export occurring in all creeks during spring melt on both a per day basis and over the duration of the melt compared to other seasons. Summer low flow NO3- concentrations in the Conestogo River is a function of the NO3- concentration within the Conestogo Reservoir. Annual precipitation amounts as well as reservoir residence time are believed to be the largest factors governing reservoir NO3- concentrations and thus summer Conestogo River NO3- concentrations. δ15N and δ18O analysis of NO3- was used to examine NO3- sources as well as seasonal changes in N-cycling processes. Both δ15N and δ18O were lower (+ 6 to + 8‰ and - 2 to + 1‰) in the fall and winter months with higher values (> + 10‰ and > + 4‰) during the summer for all creeks with the exception of the δ18O of Swan Creek. Increased isotopic values occurred at lower NO3- concentrations and concomitant increases in both 18O and 15N in an expected ratio (approx. 1:2) providing strong evidence of the occurrence of denitrification. Annual fluctuations in concentrations of N2O and CH4 are also consistent with active denitrification. δ15N-NO3- values corrected for the isotopic effects caused by denitrification were consistent with that of values reported for manure (+ 8‰). Despite the δ15N being within that of manure, the source of NO3- to these watersheds is inconclusive as a result several NO3- sources also falling within the same range. Isotopic analysis suggests that Boomer Creek stream water is similar to water discharging from tile drains along Boomer Creek. NO3- concentration and isotope data from tile drains and Boomer Creek indicate a strong influence from tile drains on annual stream NO3- concentration and export. The influence of tile drains will only become greater as 30 million meters of new tiles are installed annually in Ontario. Understanding nutrient dynamics in small watersheds is vital to understanding and predicting water quality in larger surface water systems. This study re-emphasises the fact that understanding the seasonality in annual NO3- export requires knowledge of the N sources and processes that govern N transformation. Only with this knowledge can effective best management practices be implemented to successfully maintain surface and ground water quality

Best practices for virtual participation in meetings : experiences from synthesis centers

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Enhancing treatment success in inflammatory bowel disease: Optimising the use of anti-TNF agents and utilising their biosimilars in clinical practice.

Abstract Anti-tumour necrosis factor (TNF) agents such as infliximab and adalimumab have greatly altered the treatment landscape in inflammatory bowel disease (IBD). However, there are remaining unmet needs and opportunities to optimise their use. Recent data suggest that proactive therapeutic drug monitoring may lead to more efficient usage of these agents, with potential for higher rates of corticosteroid-free clinical remission than with reactive monitoring. Expanded application of faecal calprotectin measurements may also be valuable, given the ease of use of the assay and its proven effectiveness as a diagnostic tool and predictor of relapse risk. From a practical viewpoint, improved multidisciplinary working may be essential to optimise patient care, with IBD nurse specialists playing an increasingly central role within this model. Finally, the availability of biosimilars of the anti-TNF agents allow drug costs to be reduced without compromising safety or efficacy – thereby providing opportunities to improve accessibility. Alongside extensive data on originator to biosimilar infliximab switch, new studies are beginning to demonstrate the safety of biosimilar to biosimilar switch, as well as adalimumab biosimilar transitions. The risk of a nocebo effect when switching to a biosimilar can be reduced through improved patient education and preparation

anti tnf biosimilars in crohn s disease a patient centric interdisciplinary approach

ABSTRACTIntroduction: The purpose of this review is to highlight the role of biosimilars in early treatment in IBD and introduce ways to facilitate a patient-centric switching process through multi..

Development and Deployment of the OpenMRS-Ebola Electronic Health Record System for an Ebola Treatment Center in Sierra Leone.

BACKGROUND: Stringent infection control requirements at Ebola treatment centers (ETCs), which are specialized facilities for isolating and treating Ebola patients, create substantial challenges for recording and reviewing patient information. During the 2014-2016 West African Ebola epidemic, paper-based data collection systems at ETCs compromised the quality, quantity, and confidentiality of patient data. Electronic health record (EHR) systems have the potential to address such problems, with benefits for patient care, surveillance, and research. However, no suitable software was available for deployment when large-scale ETCs opened as the epidemic escalated in 2014. OBJECTIVE: We present our work on rapidly developing and deploying OpenMRS-Ebola, an EHR system for the Kerry Town ETC in Sierra Leone. We describe our experience, lessons learned, and recommendations for future health emergencies. METHODS: We used the OpenMRS platform and Agile software development approaches to build OpenMRS-Ebola. Key features of our work included daily communications between the development team and ground-based operations team, iterative processes, and phased development and implementation. We made design decisions based on the restrictions of the ETC environment and regular user feedback. To evaluate the system, we conducted predeployment user questionnaires and compared the EHR records with duplicate paper records. RESULTS: We successfully built OpenMRS-Ebola, a modular stand-alone EHR system with a tablet-based application for infectious patient wards and a desktop-based application for noninfectious areas. OpenMRS-Ebola supports patient tracking (registration, bed allocation, and discharge); recording of vital signs and symptoms; medication and intravenous fluid ordering and monitoring; laboratory results; clinician notes; and data export. It displays relevant patient information to clinicians in infectious and noninfectious zones. We implemented phase 1 (patient tracking; drug ordering and monitoring) after 2.5 months of full-time development. OpenMRS-Ebola was used for 112 patient registrations, 569 prescription orders, and 971 medication administration recordings. We were unable to fully implement phases 2 and 3 as the ETC closed because of a decrease in new Ebola cases. The phase 1 evaluation suggested that OpenMRS-Ebola worked well in the context of the rollout, and the user feedback was positive. CONCLUSIONS: To our knowledge, OpenMRS-Ebola is the most comprehensive adaptable clinical EHR built for a low-resource setting health emergency. It is designed to address the main challenges of data collection in highly infectious environments that require robust infection prevention and control measures and it is interoperable with other electronic health systems. Although we built and deployed OpenMRS-Ebola more rapidly than typical software, our work highlights the challenges of having to develop an appropriate system during an emergency rather than being able to rapidly adapt an existing one. Lessons learned from this and previous emergencies should be used to ensure that a set of well-designed, easy-to-use, pretested health software is ready for quick deployment in future

Establishing Key Performance Indicators for Inflammatory Bowel Disease in the United Kingdom

Background and aimsHealthcare quality improvement (QI) is the systematic process to continuously improve the quality of care and outcomes for patients. The landmark Inflammatory Bowel Disease (IBD) UK National Audits provided a means to measure the variation in care, highlighting the need to define the standards of excellence in IBD care. Through a consensus approach, we aimed to establish key performance indicators (KPIs), providing reliable benchmarks for IBD care delivery in UK.MethodsKPIs that measure critical aspects of a patient journey within an IBD service were identified though stakeholder meetings. A two-stage Delphi consensus was then conducted. The first involved a multidisciplinary team of IBD clinicians and patients to refine definitions and methodology. The second stage assessed feasibility and utility of the proposed QI process by surveying gastroenterology services across UK.ResultsFirst, the four proposed KPIs were refined and included time from primary care referral to diagnosis in secondary care, time to treatment recommendation following a diagnosis, appropriate use of steroids and advanced therapies prescreening and assessment. Second, the Delphi consensus reported >85% agreement on the feasibility of local adoption of the QI process and >75% agreement on the utility of benchmarking of the KPIs.ConclusionsThrough a structured approach, we propose quantifiable KPIs for benchmarking to improve and reduce the individual variation in IBD care across the UK

Timber Monuments, Landscape and the Environment in the Nith Valley, Dumfries and Galloway

This paper considers the impact of landscape and environment upon monuments built during the Neolithic period. Taking a group of timber monuments of Neolithic date in the Nith Valley region, Dumfries and Galloway, it examines their relationship to the topography and environment and seeks to explain their uniquely linear nature, a feature of timber monuments built in this region. It discusses the importance of incorporating plough-levelled sites into landscape approaches to monuments, the potential impact of vegetation upon visibility patterns and the value of considering the immediate locations of monuments, arguing that monuments built upon a heightened awareness of landscape topography, arising out of a long-term relationship with place