High-Efficiency Particulate Air Filters for Preventing Wildfire-related Asthma Complications: A Cost-Effectiveness Study.

Rationale: Air pollution caused by wildfire smoke is linked to adverse health outcomes, especially for people living with asthma. Objectives: To evaluate whether government rebates for high-efficiency particulate air (HEPA) filters, which reduce concentrations of smoke particles indoors, are cost effective in managing asthma and preventing exacerbations in British Columbia (BC), Canada. Methods: We used a Markov model to analyze health states for asthma control, exacerbation severity, and death over a retrospective time horizon of 5 years (2018-2022). Concentrations of wildfire smoke-derived particulate matter with an aerodynamic diameter ⩽2.5 µm (PM2.5) from the Canadian Optimized Statistical Smoke Exposure Model and relevant literature informed the model. The base-case analysis assumed continuous use of a HEPA filter. Costs and quality-adjusted life-years (QALYs) resulting from varying rebates were computed for each Health Service Delivery Area (HSDA). Measurements and Main Results: In the base-case analysis, HEPA filter use resulted in increased costs of $83.34 (SE, $1.03) and increased QALYs of 0.0011 (SE, 0.0001) per person. The average incremental cost-effectiveness ratio among BC HSDAs was $74,652/QALY (SE, $3,517), with incremental cost-effectiveness ratios ranging from $40,509 to $89,206 per QALY in HSDAs. Across the province, the intervention was projected to prevent 4,418 exacerbations requiring systemic corticosteroids, 643 emergency department visits, and 425 hospitalizations during the 5-year time horizon. A full rebate was cost effective in 1 of the 16 HSDAs across BC. The probability of cost-effectiveness ranged from 0.1% to 74.8% across HSDAs. A $100 rebate was cost effective in most HSDAs. Conclusions: The cost-effectiveness of HEPA filters in managing wildfire smoke-related asthma issues in BC varies by region. Government rebates up to two-thirds of the filter cost are generally cost effective, with a full rebate being cost effective only in Kootenay Boundary.

Gene Therapy Versus Common Care for Eligible Individuals With Sickle Cell Disease in the United States : A Cost-Effectiveness Analysis.

BACKGROUND: Sickle cell disease (SCD) and its complications contribute to high rates of morbidity and early mortality and high cost in the United States and African heritage community. OBJECTIVE: To evaluate the cost-effectiveness of gene therapy for SCD and its value-based prices (VBPs). DESIGN: Comparative modeling analysis across 2 independently developed simulation models (University of Washington Model for Economic Analysis of Sickle Cell Cure [UW-MEASURE] and Fred Hutchinson Institute Sickle Cell Disease Outcomes Research and Economics Model [FH-HISCORE]) using the same databases. DATA SOURCES: Centers for Medicare & Medicaid Services claims data, 2008 to 2016; published literature. TARGET POPULATION: Persons eligible for gene therapy. TIME HORIZON: Lifetime. PERSPECTIVE: U.S. health care sector and societal. INTERVENTION: Gene therapy versus common care. OUTCOME MEASURES: Incremental cost-effectiveness ratios (ICERs), equity-informed VBPs, and price acceptability curves. RESULTS OF BASE-CASE ANALYSIS: At an assumed $2 million price for gene therapy, UW-MEASURE and FH-HISCORE estimated ICERs of $193 000 per QALY and $427 000 per QALY, respectively, under the health care sector perspective. Corresponding estimates from the societal perspective were $126 000 per QALY and $281 000 per QALY. The difference in results between models stemmed primarily from considering a slightly different target population and incorporating the quality-of-life (QOL) effects of splenic sequestration, priapism, and acute chest syndrome in the UW model. From a societal perspective, acceptable (>90% confidence) VBPs ranged from $1 million to $2.5 million depending on the use of alternative effective metrics or equity-informed threshold values. RESULTS OF SENSITIVITY ANALYSIS: Results were sensitive to the costs of myeloablative conditioning before gene therapy, effect on caregiver QOL, and effect of gene therapy on long-term survival. LIMITATION: The short-term effects of gene therapy on vaso-occlusive events were extrapolated from 1 study. CONCLUSION: Gene therapy for SCD below a $2 million price tag is likely to be cost-effective when applying a societal perspective at an equity-informed threshold for cost-effectiveness analysis. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

Impact of income-based public drug coverage deductibles on adherence to asthma medications.

BACKGROUND: Cost-related nonadherence to medications can be a barrier to asthma management. OBJECTIVE: To quantify the impact of public drug plan deductibles on adherence to asthma medications. METHODS: We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting ß-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars. RESULTS: Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting ß-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds. CONCLUSION: Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

Cost-effectiveness of budesonide-formoterol vs inhaled epinephrine in US adults with mild asthma.

BACKGROUND: The management of mild asthma has lacked an over-the-counter (OTC) option aside from inhaled epinephrine, which is available in the United States. However, inhaled epinephrine use without an inhaled corticosteroid may increase the risk of asthma death. OBJECTIVE: To compare the cost-effectiveness of OTC as-needed budesonide-formoterol as a plausible alternative to inhaled epinephrine. METHODS: We developed a probabilistic Markov model to compare OTC as-needed budesonide-formoterol inhaler use vs inhaled epinephrine use in adults with mild asthma from a US societal perspective over a lifetime horizon, with a 3% annual discount rate (2022 US dollars). Inputs were derived from the SYmbicort Given as-needed in Mild Asthma (SYGMA) trials, published literature, and commercial costs. Outcomes were quality-adjusted life-years (QALY), costs, incremental net monetary benefit (INMB), severe asthma exacerbations, well-controlled asthma days, and asthma-related deaths. Microsimulation was used to evaluate underinsured Americans living with mild asthma (n = 5,250,000). RESULTS: Inhaled epinephrine was dominated (with lower QALYs gains at a higher cost) by both as-needed budesonide-formoterol (INMB, $15,541 at a willingness-to-pay of $100,000 per QALY) and the no-OTC inhaler option (INMB, $1023). Adults using as-needed budesonide-formoterol had 145 more well-controlled asthma days, 2.79 fewer severe exacerbations, and an absolute risk reduction of 0.23% for asthma-related death compared with inhaled epinephrine over a patient lifetime. As-needed budesonide-formoterol remained dominant in all sensitivity and scenario analyses, with a 100% probability of being cost-effective compared with inhaled epinephrine in probabilistic sensitivity analysis. CONCLUSION: If made available, OTC as-needed budesonide-formoterol for treating mild asthma in underinsured adults without HCP management improves asthma outcomes, prevents fatalities, and is cost-saving.

The root of the problem: diverse vulnerability to xylem cavitation found within the root system of wheat plants.

The propagation of xylem embolism throughout the root systems of drought-affected plants remains largely unknown, despite this process being comparatively well characterized in aboveground tissues. We used optical and X-ray imaging to capture xylem embolism propagation across the intact root systems of bread wheat (Triticum aestivum L. 'Krichauff') plants subjected to drying. Patterns in vulnerability to xylem cavitation were examined to investigate whether vulnerability may vary based on root size and placement across the entire root system. Individual plants exhibited similar mean whole root system vulnerabilities to xylem cavitation but showed enormous 6 MPa variation within their component roots (c. 50 roots per plant). Xylem cavitation typically initiated in the smallest, peripheral parts of the root system and moved inwards and upwards towards the root collar last, although this trend was highly variable. This pattern of xylem embolism spread likely results in the sacrifice of replaceable small roots while preserving function in larger, more costly central roots. A distinct pattern of embolism-spread belowground has implications for how we understand the impact of drought in the root system as a critical interface between plant and soil.

Trends in hospital admissions for chronic obstructive pulmonary disease over 16 years in Canada.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition, and the rate of hospital admissions for COPD is an indicator of the quality of outpatient care. We sought to determine long-term trends in hospital admissions for COPD in Canada. METHODS: Using a comprehensive national database of hospital admissions in Canada, we identified those with a main discharge diagnosis of COPD for patients aged 40 years and older between 2002 and 2017. We calculated sex-specific, age-standardized trends in annual rates of hospital admissions for COPD separately for younger (40-64 yr) and older adults (≥ 65 yr). We used spline regression to examine changes in the admissions trends for each sex and age group. RESULTS: Over 16 years, 1 134 359 hospital admissions were for COPD. Between 2002 and 2017, the total number of admissions increased by 68.8%, from 52 937 to 89 384. The overall crude admission rate increased by 30.0%, from 368 to 479 per 100 000 population, and the sex-and age-standardized admission rate increased by 9.6%, from 437 to 479 per 100 000 population. Age-standardized rates increased by 12.2% among younger females, by 24.4% among younger males and by 29.8% among older females, but decreased by 9.0% among older males. Over the same period, the all-cause sex-and age-standardized admission rate declined by 23.0%. INTERPRETATION: Hospital admissions for COPD have increased since 2010, even after adjusting for population growth and aging, and despite declining rates of all-cause hospital admissions. The secular increase in COPD admissions indicates that the burden of COPD on Canadian health care systems is increasing.

In vivo monitoring of drought-induced embolism in Callitris rhomboidea trees reveals wide variation in branchlet vulnerability and high resistance to tissue death.

Damage to the plant water transport system through xylem cavitation is known to be a driver of plant death in drought conditions. However, a lack of techniques to continuously monitor xylem embolism in whole plants in vivo has hampered our ability to investigate both how this damage propagates and the possible mechanistic link between xylem damage and tissue death. Using optical and fluorescence sensors, we monitored drought-induced xylem embolism accumulation and photosynthetic damage in vivo throughout the canopy of a drought-resistant conifer, Callitris rhomboidea, during drought treatments of c. 1 month duration. We show that drought-induced damage to the xylem can be monitored in vivo in whole trees during extended periods of water stress. Under these conditions, vulnerability of the xylem to cavitation varied widely among branchlets, with photosynthetic damage only recorded once > 90% of the xylem was cavitated. The variation in branchlet vulnerability has important implications for understanding how trees like C. rhomboidea survive drought, and the high resistance of branchlets to tissue damage points to runaway cavitation as a likely driver of tissue death in C. rhomboidea branch tips.

Xylem Embolism Spreads by Single-Conduit Events in Three Dry Forest Angiosperm Stems.

Xylem cavitation resulting in air embolism is a major cause of plant death during drought, yet the spread of embolism throughout the plant water transport system is poorly understood. Our study used optical visualization and x-ray microcomputed tomography imaging to capture the spread of emboli in stems of three drought-resistant angiosperm trees: drooping she-oak (Allocasuarina verticillata), black wattle (Acacia mearnsii), and blue gum (Eucalyptus globulus). These species have similar degrees of xylem network connectivity (vessel grouping) with largely solitary vessels. The high temporal resolution of the optical vulnerability technique revealed that in current year branches, >80% of the cavitation events were discrete, temporally separated events in single vessels. This suggests that in xylem networks with low connectivity, embolism spread between conduits leading to multiple conduit cavitation events is uncommon. A. mearnsii showed both the highest number of multivessel cavitation events and the highest degree of vessel connectivity, suggesting a link between vessel arrangement and embolism spread. Knowledge of embolism spread will help us to uncover the links between xylem anatomy, arrangement, and the path of water flow in the xylem in diverse species to ultimately understand the drivers of cavitation and plant vulnerability to drought.

Cost-effectiveness of implementing objective diagnostic verification of asthma in the United States.

BACKGROUND: Asthma diagnosis in the community is often made without objective testing. OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of implementing a stepwise objective diagnostic verification algorithm among patients with community-diagnosed asthma in the United States. METHODS: We developed a probabilistic time-in-state cohort model that compared a stepwise asthma verification algorithm on the basis of spirometry testing and a methacholine challenge test against the current standard of care over 20 years. Model input parameters were informed from the literature and with original data analyses when required. The target population was US adults (≥15 years old) with physician-diagnosed asthma. The final outcomes were costs (in 2018 dollars) and quality-adjusted life years (QALYs), discounted at 3% annually. Deterministic and probabilistic analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results. RESULTS: In a simulated cohort of 10,000 adults with diagnosed asthma, the stepwise algorithm resulted in removal of the diagnosis of 3,366. This was projected to be associated with savings of $36.26 million in direct costs and a gain of 4,049.28 QALYs over 20 years. Extrapolating these results to the US population indicated an undiscounted potential savings of $56.48 billion over 20 years. The results were robust against alternative assumptions and plausible changes in values of input parameters. CONCLUSION: Implementation of a simple diagnostic testing algorithm to verify asthma diagnosis might result in substantial savings and improvement in patients' quality of life.

Healthcare system encounters before COPD diagnosis: a registry-based longitudinal cohort study.

BACKGROUND: There is high interest in strategies for improving early detection of chronic obstructive pulmonary disease (COPD). These strategies often rely on opportunistic encounters between patients with undiagnosed COPD and the healthcare system; however, the frequency of these encounters is currently unknown. METHODS: We used administrative health data for the province of British Columbia, Canada, from 1996 to 2015. We identified patients with COPD using a validated case definition, and assessed their visits to pharmacists, primary care and specialist physicians in the 5 years prior to the initial diagnosis of COPD. We used generalised linear models to compare the rate of outpatient visits between COPD and non-COPD comparator subjects matched on age, sex and socioeconomic status. RESULTS: We assessed 112 635 COPD and non-COPD pairs (mean 68.6 years, 51.0% male). Patients with COPD interacted with pharmacists most frequently in the 5 years before diagnosis (mean 14.09, IQR 4-17 visits/year), followed by primary care (10.29, IQR 4-13 visits/year) and specialist (8.11, IQR 2-11 visits/year) physicians. In the 2 years prior to diagnosis, 72.1% of patients with COPD had a respiratory-related primary care visit that did not result in a COPD diagnosis. Compared with non-COPD subjects, patients with COPD had higher rates of primary care (rate ratio (RR) 1.40, 95% CI 1.39 to 1.41), specialist (RR 1.35, 95% CI 1.34 to 1.37) and pharmacist (RR 1.62, 95% CI 1.60 to 1.63) encounters. CONCLUSIONS: Patients with COPD used higher rates of outpatient services before diagnosis than non-COPD subjects. Case detection technologies implemented in pharmacy or primary care settings have opportunities to diagnose COPD earlier.

A systematic review of the adverse events and economic impact associated with oral corticosteroids in asthma.

Background: Oral corticosteroids (OCSs) are often used to achieve asthma control. OCS-related comorbidities increase the burden of disease for patients and healthcare providers. Most studies characterizing OCS use and risk of adverse events (AEs) are in non-asthma patients. We sought to systematically review the literature on the burden of OCS use among adults with asthma. Methods: We systematically reviewed the literature including MEDLINE (1946-May 2017), EMBASE (1974-May 2017), and the Cochrane Library (2005-May 2017) to identify studies that considered AEs due to OCS treatment of adults with asthma, their burden on healthcare utilization, and costs. Results: We retrieved 9,589 citations; and 15 studies were included. AEs were significantly higher among OCS-users compared with non-OCS users with pooled adjusted odds ratio (OR) 1.68 (95% CI 1.15-2.46) for diabetes mellitus and 1.34 (95% CI 1.23-1.46) for hypertension. Among high dose OCS-users (>10 mg) compared with non-OCS users, the pooled adjusted ORs for development of any complication was 3.35 (95% CI 2.94-3.82), and bone and muscle complications 2.30 (95% CI 2.18-2.42). The risk of any complication increased with higher doses of OCS, with pooled adjusted OR from 2 studies of 2.26 (95% CI 1.37-3.72), 2.94 (95% CI 2.62-3.29) and 3.35 (95% CI 2.94-3.82) for low dose (<6 mg), medium dose (5-12 mg) and high dose (>10 mg) respectively compared with no OCS use. Conclusions: The use of OCS in the management of asthma is associated with a higher risk of complications. This risk is higher as the OCS dose increases.

Wheat leaves embolized by water stress do not recover function upon rewatering.

New techniques now make it possible to precisely and accurately determine the failure threshold of the plant vascular system during water stress. This creates an opportunity to understand the vulnerability of species to drought, but first, it must be determined whether damage to leaf function associated with xylem cavitation is reparable or permanent. This question is particularly relevant in crop plants such as wheat, which may have the capacity to repair xylem embolism with positive root pressure. Using wheat (Triticum aestivum, Heron), we employed non-invasive imaging to find the water potential causing 50% xylem embolism (-2.87 ± 0.52 MPa) in leaves. Replicate plants were water-stressed to varying degrees to induce embolism ranging from minimal to substantial. Plants were then rewatered to determine the reversibility of xylem damage and photosynthetic inhibition in glasshouse conditions. Rewatering after drought-induced xylem cavitation did not induce visible refilling of embolized xylem, and embolized leaves showed photosynthetic impairment upon rewatering. This impairment was significant even after only 10-20% of leaf veins were embolized, and leaves accumulating >20% embolism died upon rewatering in 7/10 individuals. Photosynthetic damage and hydraulic decline occurred concurrently as wheat leaves dehydrated, and leaf shrinkage during drying was the best predictor of photosynthetic recovery.

The diagnostic performance of patient symptoms in screening for COPD.

It is recommended that screening for COPD be restricted to symptomatic individuals, but supporting evidence is lacking. We determined the performance of wheeze, cough, phlegm, and dyspnea in discriminating COPD versus non-COPD in a population-based sample of 1332 adults. Area Under the Receiver Operating Curves (AUC) indicated that symptoms had modest performance whether assessed individually (AUCs 0.55-0.62), or in combination (AUC for number of symptoms as the predictor 0.64). AUC improved with the inclusion of multiple other factors (AUC 0.71). Restricting screening to symptomatic individuals is unlikely to substantially improve the yield of general population screening for undiagnosed COPD.

Characterizing undiagnosed chronic obstructive pulmonary disease: a systematic review and meta-analysis.

BACKGROUND: A significant proportion of patients with chronic obstructive pulmonary disease (COPD) remain undiagnosed. Characterizing these patients can increase our understanding of the 'hidden' burden of COPD and the effectiveness of case detection interventions. METHODS: We conducted a systematic review and meta-analysis to compare patient and disease factors between patients with undiagnosed persistent airflow limitation and those with diagnosed COPD. We searched MEDLINE and EMBASE for observational studies of adult patients meeting accepted spirometric definitions of COPD. We extracted and pooled summary data on the proportion or mean of each risk factor among diagnosed and undiagnosed patients (unadjusted analysis), and coefficients for the adjusted association between risk factors and diagnosis status (adjusted analysis). RESULTS: Two thousand eighty-three records were identified through database searching and 16 articles were used in the meta-analyses. Diagnosed patients were less likely to have mild (v. moderate to very severe) COPD (odds ratio [OR] 0.30, 95%CI 0.24-0.37, 6 studies) in unadjusted analysis. This association remained significant but its strength was attenuated in the adjusted analysis (OR 0.72, 95%CI 0.58-0.89, 2 studies). Diagnosed patients were more likely to report respiratory symptoms such as wheezing (OR 3.51, 95%CI 2.19-5.63, 3 studies) and phlegm (OR 2.16, 95% CI 1.38-3.38, 3 studies), had more severe dyspnea (mean difference in modified Medical Research Council scale 0.52, 95%CI 0.40-0.64, 3 studies), and slightly greater smoking history than undiagnosed patients. Patient age, sex, current smoking status, and the presence of coughing were not associated with a previous diagnosis. CONCLUSIONS: Undiagnosed patients had less severe airflow obstruction and fewer respiratory symptoms than diagnosed patients. The lower disease burden in undiagnosed patients may significantly delay the diagnosis of COPD.

Conversation level syntax similarity metric.

The syntax and semantics of human language can illuminate many individual psychological differences and important dimensions of social interaction. Accordingly, psychological and psycholinguistic research has begun incorporating sophisticated representations of semantic content to better understand the connection between word choice and psychological processes. In this work we introduce ConversAtion level Syntax SImilarity Metric (CASSIM), a novel method for calculating conversation-level syntax similarity. CASSIM estimates the syntax similarity between conversations by automatically generating syntactical representations of the sentences in conversation, estimating the structural differences between them, and calculating an optimized estimate of the conversation-level syntax similarity. After introducing and explaining this method, we report results from two method validation experiments (Study 1) and conduct a series of analyses with CASSIM to investigate syntax accommodation in social media discourse (Study 2). We run the same experiments using two well-known existing syntactic metrics, LSM and Coh-Metrix, and compare their results to CASSIM. Overall, our results indicate that CASSIM is able to reliably measure syntax similarity and to provide robust evidence of syntax accommodation within social media discourse.

Dictionaries and distributions: Combining expert knowledge and large scale textual data content analysis : Distributed dictionary representation.

Theory-driven text analysis has made extensive use of psychological concept dictionaries, leading to a wide range of important results. These dictionaries have generally been applied through word count methods which have proven to be both simple and effective. In this paper, we introduce Distributed Dictionary Representations (DDR), a method that applies psychological dictionaries using semantic similarity rather than word counts. This allows for the measurement of the similarity between dictionaries and spans of text ranging from complete documents to individual words. We show how DDR enables dictionary authors to place greater emphasis on construct validity without sacrificing linguistic coverage. We further demonstrate the benefits of DDR on two real-world tasks and finally conduct an extensive study of the interaction between dictionary size and task performance. These studies allow us to examine how DDR and word count methods complement one another as tools for applying concept dictionaries and where each is best applied. Finally, we provide references to tools and resources to make this method both available and accessible to a broad psychological audience.

TACIT: An open-source text analysis, crawling, and interpretation tool.

As human activity and interaction increasingly take place online, the digital residues of these activities provide a valuable window into a range of psychological and social processes. A great deal of progress has been made toward utilizing these opportunities; however, the complexity of managing and analyzing the quantities of data currently available has limited both the types of analysis used and the number of researchers able to make use of these data. Although fields such as computer science have developed a range of techniques and methods for handling these difficulties, making use of those tools has often required specialized knowledge and programming experience. The Text Analysis, Crawling, and Interpretation Tool (TACIT) is designed to bridge this gap by providing an intuitive tool and interface for making use of state-of-the-art methods in text analysis and large-scale data management. Furthermore, TACIT is implemented as an open, extensible, plugin-driven architecture, which will allow other researchers to extend and expand these capabilities as new methods become available.

Evidence for a trade-off between growth rate and xylem cavitation resistance in Callitris rhomboidea.

The ideal plant water transport system is one that features high efficiency and resistance to drought-induced damage (xylem cavitation), however, species rarely possess both. This may be explained by trade-offs between traits, yet thus far, no proposed trade-off has offered a universal explanation for the lack of water transport systems that are both highly drought-resistant and highly efficient. Here, we find evidence for a new trade-off, between growth rate and resistance to xylem cavitation, in the canopies of a drought-resistant tree species (Callitris rhomboidea). Wide variation in cavitation resistance (P50) was found in distal branch tips (<2 mm in diameter), converging to low variation in P50 in larger diameter stems (>2 mm). We found a significant correlation between cavitation resistance and distal branchlet internode length across branch tips in C. rhomboidea canopies. Branchlets with long internodes (8 mm or longer) were significantly more vulnerable to drought-induced xylem cavitation than shorter internodes (4 mm or shorter). This suggests that varying growth rates, leading to differences in internode length, drive differences in cavitation resistance in C. rhomboidea trees. The only distinct anatomical difference found between internodes was the pith size, with the average pith to xylem area in long internodes being five times greater than in short internodes. Understanding whether this trade-off exists within and between species will help us to uncover what drives and limits drought resistance across the world's flora.