The role of grassland sward islets in the distribution of arthropods in cattle pastures

1. It is well documented that cattle reduce their grazing activity in the vicinity of cattle dung, which gives rise to distinct patches, or islets as they have been termed, of longer sward. The influence of such islets on pasture utilisation and agronomic performance has been widely studied, but very little information is available concerning their influence on grassland biodiversity. 2. In this study the abundance and distribution of arthropods in relation to islets was assessed, using suction sampling, at 26 commercial farms and in a replicated pasture management experiment in the south and east of Ireland. 3. Islets were found to cover approximately 24% of pastures and to contain between 40% and 50% of arthropod individuals. 4. Islets consistently contained a higher density of arthropods, even when the difference in mean sward height between islets and more strongly grazed sward was accounted for. The relative concentration of arthropods in islets declined with increasing mean sward height, which may be related to the recovery of well-grazed non-islet sward. Islets appear to act as refugia from sward removal. 5. The potential importance of islets in maintaining arthropod biodiversity within intensively grazed pastures and the wider grass-based farming landscape is discussed, particularly with reference to standard agronomic practices such as sward topping and chain harrowing, which aim to remove the sward heterogeneity created by grazing livestock

Peer support for CKD patients and carers : overcoming barriers and facilitating access

Peer support is valued by its users. Nevertheless, there is initial low take-up of formal peer support programmes among patients with chronic kidney disease (CKD), with fewer patients participating than expressing an interest. There is little evidence on reasons for low participation levels. Few studies have examined the perspectives of carers. Objective: To explore with CKD patients and carers their needs, wants and expectations from formal peer support and examine how barriers to participation may be overcome. Methods: Qualitative interviews with a sample of 26 CKD stage five patients and carers. Principles of Grounded Theory were applied to data coding and analysis. Setting: Six NHS Hospital Trusts. Results: Whilst informal peer support might occur naturally and is welcomed, a range of emotional and practical barriers inhibit take‐up of more formalized support. Receptivity varies across time and the disease trajectory and is associated with emotional readiness; patients and carers needing to overcome complex psychological hurdles such as acknowledging support needs. Practical barriers include limited understanding of peer support. An attractive peer relationship is felt to involve reciprocity based on sharing experiences and both giving and receiving support. Establishing rapport is linked with development of reciprocity. Conclusions: There is potential to facilitate active uptake of formal peer support by addressing the identified barriers. Our study suggests several facilitation methods, brought together in a conceptual model, including clinician promotion of peer support as an intervention suitable for anyone with CKD and their carers, and opportunity for choice of peer supporter

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Redo Cardiac Surgery in a Patient with Severe Peripheral Vascular Disease and Pericardia/ Adhesions Using Subclavian Arterial Cannulation and Port-Access Technology

Patients viewed as conventionally inoperative candidates are now given alternative surgical choices. The ability to provide new technology such as the port-access minimally invasive approach, kinetic venous assist, and specialized cannulae have made this possible. This case report discusses the ability to apply and modify this new technology to provide a successful surgical outcome in a patient with severe peripheral vascular disease and dense mediastinal adhesions