A Tale of Two Sylamores: Understanding Relationships Among Land Use, Nutrients, and Aquatic Communities Across a Subsidy-Stress Gradient

Agricultural land use is known to degrade aquatic systems with high inputs of nutrients, sediments, and pesticides. Increased nutrients can lead to increased algal growth and thus possible hypoxic conditions in slow moving water, while increased sediment loads have been shown to obstruct light and reduce substrate stability. These conditions negatively impact primary producers, macroinvertebrates, and fish. However, small-scale changes in land use can subsidize an aquatic ecosystem instead, where an increase in nutrients allows nutrient-limited biota to flourish, and minor increases in sedimentation may help support populations of collector-filterers. The stimulation in performance caused by small disturbances is part of the subsidy-stress gradient, where increasing perturbation subsidizes an ecosystem until a certain threshold is reached, at which a decline in performance and increased variability starts to occur. The North and South Sylamore watersheds in north Arkansas provide a useful template to investigate the subsidy-stress gradient in relation to land use. North Sylamore flows through the Ozark National Forest and has a heavily forested catchment, while South Sylamore flows through mostly private land, some of which is pasture (23%). Physicochemical, macroinvertebrate, and fish data were collected from multiple sites within each watershed to determine if South Sylamore is exhibiting a response to pasture/agriculture characteristic of a subsidy-stress gradient. Sites within South Sylamore had significantly higher nitrate levels, larger macroinvertebrate populations dominated by collector-filterers, and greater abundance of algivorous fish, suggesting South Sylamore may be subsidized by the surrounding pastoral lands. However, South Sylamore also had a significantly lower proportional abundance of sensitive macroinvertebrate taxa and more unique tolerant fish taxa, suggesting South Sylamore is experiencing stress as well. Habitat quality of South Sylamore could be improved by restoration of trees within the riparian zone. Monitoring aquatic systems for subsidy-stress responses can inform restoration/management decisions and guide intervention prior to watersheds and aquatic communities becoming overly stressed

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used