Responses of vascular plant fine roots and associated microbial communities to whole-ecosystem warming and elevated CO2 in northern peatlands.

Warming and elevated CO2 (eCO2) are expected to facilitate vascular plant encroachment in peatlands. The rhizosphere, where microbial activity is fueled by root turnover and exudates, plays a crucial role in biogeochemical cycling, and will likely at least partially dictate the response of the belowground carbon cycle to climate changes. We leveraged the Spruce and Peatland Responses Under Changing Environments (SPRUCE) experiment, to explore the effects of a whole-ecosystem warming gradient (+0°C to 9°C) and eCO2 on vascular plant fine roots and their associated microbes. We combined trait-based approaches with the profiling of fungal and prokaryote communities in plant roots and rhizospheres, through amplicon sequencing. Warming promoted self-reliance for resource uptake in trees and shrubs, while saprophytic fungi and putative chemoorganoheterotrophic bacteria utilizing plant-derived carbon substrates were favored in the root zone. Conversely, eCO2 promoted associations between trees and ectomycorrhizal fungi. Trees mostly associated with short-distance exploration-type fungi that preferentially use labile soil N. Additionally, eCO2 decreased the relative abundance of saprotrophs in tree roots. Our results indicate that plant fine-root trait variation is a crucial mechanism through which vascular plants in peatlands respond to climate change via their influence on microbial communities that regulate biogeochemical cycles.

Peat loss collocates with a threshold in plant-mycorrhizal associations in drained peatlands encroached by trees.

Drainage-induced encroachment by trees may have major effects on the carbon balance of northern peatlands, and responses of microbial communities are likely to play a central mechanistic role. We profiled the soil fungal community and estimated its genetic potential for the decay of lignin and phenolics (class II peroxidase potential) along peatland drainage gradients stretching from interior locations (undrained, open) to ditched locations (drained, forested). Mycorrhizal fungi dominated the community across the gradients. When moving towards ditches, the dominant type of mycorrhizal association abruptly shifted from ericoid mycorrhiza to ectomycorrhiza at c. 120 m from the ditches. This distance corresponded with increased peat loss, from which more than half may be attributed to oxidation. The ectomycorrhizal genus Cortinarius dominated at the drained end of the gradients and its relatively higher genetic potential to produce class II peroxidases (together with Mycena) was positively associated with peat humification and negatively with carbon-to-nitrogen ratio. Our study is consistent with a plant-soil feedback mechanism, driven by a shift in the mycorrhizal type of vegetation, that potentially mediates changes in aerobic decomposition during postdrainage succession. Such feedback may have long-term legacy effects upon postdrainage restoration efforts and implication for tree encroachment onto carbon-rich soils globally.

Ecosystem consequences of introducing plant growth promoting rhizobacteria to managed systems and potential legacy effects.

The rapidly growing industry of crop biostimulants leverages the application of plant growth promoting rhizobacteria (PGPR) to promote plant growth and health. However, introducing nonnative rhizobacteria may impact other aspects of ecosystem functioning and have legacy effects; these potential consequences are largely unexplored. Nontarget consequences of PGPR may include changes in resident microbiomes, nutrient cycling, pollinator services, functioning of other herbivores, disease suppression, and organic matter persistence. Importantly, we lack knowledge of whether these ecosystem effects may manifest in adjacent ecosystems. The introduced PGPR can leave a functional legacy whether they persist in the community or not. Legacy effects include shifts in resident microbiomes and their temporal dynamics, horizontal transfer of genes from the PGPR to resident taxa, and changes in resident functional groups and interaction networks. Ecosystem functions may be affected by legacies PGPR leave following niche construction, such as when PGPR alter soil pH that in turn alters biogeochemical cycling rates. Here, we highlight new research directions to elucidate how introduced PGPR impact resident microbiomes and ecosystem functions and their capacity for legacy effects.

Fungal community structure and function shifts with atmospheric nitrogen deposition.

Fungal decomposition of soil organic matter depends on soil nitrogen (N) availability. This ecosystem process is being jeopardized by changes in N inputs that have resulted from a tripling of atmospheric N deposition in the last century. Soil fungi are impacted by atmospheric N deposition due to higher N availability, as soils are acidified, or as micronutrients become increasingly limiting. Fungal communities that persist with chronic N deposition may be enriched with traits that enable them to tolerate environmental stress, which may trade-off with traits enabling organic matter decomposition. We hypothesized that fungal communities would respond to N deposition by shifting community composition and functional gene abundances toward those that tolerate stress but are weak decomposers. We sampled soils at seven eastern US hardwood forests where ambient N deposition varied from 3.2 to 12.6 kg N ha-1  year-1 , five of which also have experimental plots where atmospheric N deposition was simulated through fertilizer application treatments (25-50 kg N ha-1  year-1 ). Fungal community and functional responses to fertilizer varied across the ambient N deposition gradient. Fungal biomass and richness increased with simulated N deposition at sites with low ambient deposition and decreased at sites with high ambient deposition. Fungal functional genes involved in hydrolysis of organic matter increased with ambient N deposition while genes involved in oxidation of organic matter decreased. One of four genes involved in generalized abiotic stress tolerance increased with ambient N deposition. In summary, we found that the divergent response to simulated N deposition depended on ambient N deposition levels. Fungal biomass, richness, and oxidative enzyme potential were reduced by N deposition where ambient N deposition was high suggesting fungal communities were pushed beyond an environmental stress threshold. Fungal community structure and function responses to N enrichment depended on ambient N deposition at a regional scale.

Pediatric Ethics Consultation: Practical Considerations for the Clinical Ethics Consultant.

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this area.

Plant-mycorrhizal interactions mediate plant community coexistence by altering resource demand.

As the diversity of plants increases in an ecosystem, so does resource competition for soil nutrients, a process that mycorrhizal fungi can mediate. The influence of mycorrhizal fungi on plant biodiversity likely depends on the strength of the symbiosis between the plant and fungi, the differential plant growth responses to mycorrhizal inoculation, and the transfer rate of nutrients from the fungus to plant. However, our current understanding of how nutrient-plant-mycorrhizal interactions influence plant coexistence is conceptual and thus lacks a unified quantitative framework. To quantify the conditions of plant coexistence mediated by mycorrhizal fungi, we developed a mechanistic resource competition model that explicitly included plant-mycorrhizal symbioses. We found that plant-mycorrhizal interactions shape plant coexistence patterns by creating a tradeoff in resource competition. Especially, a tradeoff in resource competition was caused by differential payback in the carbon resources that plants invested in the fungal symbiosis and/or by the stoichiometric constraints on plants that required additional, less-beneficial, resources to sustain growth. Our results suggested that resource availability and the variation in plant-mycorrhizal interactions act in concert to drive plant coexistence patterns. Applying our framework, future empirical studies should investigate plant-mycorrhizal interactions under multiple levels of resource availability.

Automated vs. manual coding of neuroimaging reports via natural language processing, using the international classification of diseases, tenth revision.

Objective: Natural language processing (NLP) can generate diagnoses codes from imaging reports. Meanwhile, the International Classification of Diseases (ICD-10) codes are the United States' standard for billing/coding, which enable tracking disease burden and outcomes. This cross-sectional study aimed to test feasibility of an NLP algorithm's performance and comparison to radiologists' and physicians' manual coding. Methods: Three neuroradiologists and one non-radiologist physician reviewers manually coded a randomly-selected pool of 200 craniospinal CT and MRI reports from a pool of >10,000. The NLP algorithm (Radnosis, VEEV, Inc., Minneapolis, MN) subdivided each report's Impression into "phrases", with multiple ICD-10 matches for each phrase. Only viewing the Impression, the physician reviewers selected the single best ICD-10 code for each phrase. Codes selected by the physicians and algorithm were compared for agreement. Results: The algorithm extracted the reports' Impressions into 645 phrases, each having ranked ICD-10 matches. Regarding the reviewers' selected codes, pairwise agreement was unreliable (Krippendorff α = 0.39-0.63). Using unanimous reviewer agreement as "ground truth", the algorithm's sensitivity/specificity/F2 for top 5 codes was 0.88/0.80/0.83, and for the single best code was 0.67/0.82/0.67. The engine tabulated "pertinent negatives" as negative codes for stated findings (e.g. "no intracranial hemorrhage"). The engine's matching was more specific for shorter than full-length ICD-10 codes (p = 0.00582x10-3). Conclusions: Manual coding by physician reviewers has significant variability and is time-consuming, while the NLP algorithm's top 5 diagnosis codes are relatively accurate. This preliminary work demonstrates the feasibility and potential for generating codes with reliability and consistency. Future works may include correlating diagnosis codes with clinical encounter codes to evaluate imaging's impact on, and relevance to care.

Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement.

Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.

Beyond Developmental Supports for a Child Refugee.

CASE: Zahid is a 10-year-old boy who moved to the United States 18 months ago with his parents and 3 younger siblings. He and his family are refugees from Syria. Zahid was born in Syria after an uncomplicated pregnancy and delivery. Zahid's parents first became concerned about Zahid's development when he was 9 months old because he had not started cooing or babbling and did not respond to his name. At 3 years, a doctor in Syria expressed concern that Zahid may have autism spectrum disorder; however, his parents did not know what symptoms triggered the concern and believed his behavior was because of his ongoing exposure to trauma.Zahid underwent a full evaluation 1 year ago in the United States and was found to meet the criteria for autism spectrum disorder. Coaching was provided to his parents in obtaining appropriate educational support for their son, and a referral was placed for applied behavior analysis (ABA) to be provided by an organization in the community. After several meetings between the parents and school administration, an Individualized Education Program was initiated. Despite acceptance into a community-based ABA program, Zahid has not begun the intervention because of transportation difficulties. In-home ABA was offered but was refused by the family.The family is under significant stress. Zahid is nonverbal and has displayed behaviors affecting safety, including wandering/eloping and turning on kitchen appliances resulting in a kitchen fire. Zahid's mother completed high school, and his father completed sixth grade. Both parents speak limited English, and neither is employed. The family receives financial support through the government, but this will be ending soon. Zahid's father is concerned that employment outside of the home will further limit his ability to transport Zahid to necessary appointments. Zahid's mother does not drive. Zahid's father requests that the physician provide a letter requesting exemption from requirements to participate in work or training programs because of Zahid's needs. How would you respond to this overwhelmed father?

Neighborhood Socioeconomic Status Affects Patient-Reported Outcome 2 Years After ACL Reconstruction.

BACKGROUND: Lower socioeconomic status (SES) is associated with worse patient-reported outcome (PRO) after orthopaedic procedures. In patients with anterior cruciate ligament (ACL) reconstruction, evaluating SES by use of traditional measures such as years of education or occupation is problematic because this group has a large proportion of younger patients. We hypothesized that lower education level and lower values for SES would predict worse PRO at 2 years after ACL reconstruction and that the effect of education level would vary with patient age. PURPOSE: To compare the performance of multivariable models that use traditional measures of SES with models that use an index of neighborhood SES derived from United States (US) Census data. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of 675 patients (45% female; median age, 20 years), were prospectively enrolled and evaluated 2 years after ACL reconstruction with questionnaires including the International Knee Documentation Committee (IKDC) questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Marx activity rating scale (Marx). In addition, a new variable was generated for this study, the SES index, which used geocoding performed retrospectively to identify the census tract of residence for each participant at the time of enrollment and extract neighborhood SES measures from the 2000 US Census Descriptive Statistics. Multivariable models were constructed that included traditional measures of SES as well as the SES index, and the quality of models was compared through use of the likelihood ratio test. RESULTS: Lower SES index was associated with worse PRO for all measures. Models that included the SES index explained more variability than models with traditional SES. In addition, a statistically significant variation was found regarding the impact of education on PRO based on patient age for the IKDC score, the Marx scale, and 4 of the 5 KOOS subscales. CONCLUSION: This study demonstrates that lower neighborhood SES is associated with worse PRO after ACL reconstruction and that age and education have a significant interaction in this patient population. Future studies in patients who have undergone ACL reconstruction should attempt to account for neighborhood SES when adjusting for confounding factors; further, targeting patients from areas with lower neighborhood SES with special interventions may offer an opportunity to improve their outcomes.

Practice procedures in models of primary care collaboration for children with ADHD.

INTRODUCTION: With nationwide movement toward an integrated medical home, evidence to support, compare, and specify effective models for collaboration between primary care and behavioral health professionals is essential. This study compared 2 models of primary care with behavioral health integration on American Academy of Pediatrics guideline adherence for attention-deficit/hyperactivity disorder (ADHD) assessment and treatment. METHOD: We conducted a retrospective chart review of a random sample of children aged 6-13 years, seen for ADHD services in 2 primary care offices, 1 fully integrated model and 1 co-located service only model, comparing ADHD assessment and treatment practices. We used chi-square analyses and logistic regression modeling to determine differences by type of health care model. RESULTS: Among children with ADHD (n = 149), the integrated care model demonstrated higher rates of guideline adherence, more direct contact with schools, and more frequent behavioral observation during clinical encounters. Families in the integrated practice received more caregiver education on ADHD, behavioral management training, and school advocacy, however, these associations did not remain after accounting for variance associated with onsite engagement with a psychologist. Practices were equivalent on use of medication and psychiatric consultation, although, more families in the integrated practice engaged with a psychologist and attended more frequent medication follow-up appointments than those in the co-located practice. DISCUSSION: This study is among the first to compare different levels of collaborative care on practice procedures. Understanding how we can best integrate between behavioral health and primary care services will optimize outcomes for children and families. (PsycINFO Database Record

"We Didn't Consent to This".

Patients and their families have identified the need for ongoing and effective communication as one of the important aspects of medical care, especially when the cessation of disease-modifying therapies is being considered at the end-of-life (EOL). Despite recognizing that this communication is extremely important, clinicians are uneasy and find themselves inadequately trained to "break bad news" and manage emotional responses from the patient/family. The inherent difficulties in accurately predicting prognosis and discussing potential complications make these conversations even more challenging. In most circumstances, patients and their families want to know the truth about their disease and what will be done to make them feel better, and to receive enough information to help them choose a course of action. For many terminally ill patients and their families who have elected to transfer to the palliative care unit (PCU) for EOL care, the assumption is that most of these conversations have already been held, and the ongoing focus becomes managing these patients' physical and psychological sources of distress, validating their and their families' emotional responses and preparing them for what is to come. This case report illustrates the need for cultural understanding and clear communication among physicians, members of the clinical team, and patients and their family members.

From Noise to Signal: The Age and Social Patterning of Intra-Individual Variability in Late-Life Health.

OBJECTIVES: Despite a long tradition of attending to issues of intra-individual variability in the gerontological literature, large-scale panel studies on late-life health disparities have primarily relied on average health trajectories, relegating intra-individual variability over time to random error terms, or "noise." This article reintegrates the systematic study of intra-individual variability back into standard growth curve modeling and investigates the age and social patterning of intra-individual variability in health trajectories. METHOD: Using panel data from the Health and Retirement Study, we estimate multilevel growth curves of functional limitations and cognitive impairment and examine whether intra-individual variability in these two health outcomes varies by age, gender, race/ethnicity, and socioeconomic status, using level-1 residuals extracted from the adjusted growth curve models. RESULTS: For both outcomes, intra-individual variability increases with age. Racial/ethnic minorities and individuals with lower socioeconomic status tend to have greater intra-individual variability in health. Relying exclusively on average health trajectories may have masked important "signals" of life course health inequality. DISCUSSION: The findings contribute to scientific understanding of the source of heterogeneity in late-life health and highlight the need to further investigate specific life course mechanisms that generate the social patterning of intra-individual variability in health status.

The Continued Eclipse of Heterogeneity in Gerontological Research.

OBJECTIVES: After a long history of neglect, diversity among older people and increasing heterogeneity with age are now familiar ideas in gerontological discourse. We take up the question of whether this increased attention is translating into the domain of empirical research. We replicate Nelson and Dannefer's (1992) review of the treatment of age-based variability in gerontological research, the most recent known assessment of the issue. METHOD: A sample of empirical studies was drawn from six gerontological journals to determine (a) whether measures of within-age variability were reported and/or discussed and (b) if reported, the observed age-based pattern of variability in the outcome(s). RESULTS: The majority of studies neither reported nor discussed age-based variability. Among those that did report, the great majority indicated either stability or increasing variability with age. Observed patterns varied by outcome type. Although a majority of analyses of psychological and social outcomes suggested that variability was stable across age, half of the analyses of biological/health outcomes indicated increasing variability. Overall, very few (3%) of studies suggested decreasing variability. DISCUSSION: Consistent with earlier reports of studies, researchers continue to focus on average differences between age groups, yet key issues in social gerontology require attention to intra-age variability.

Assessing racial health inequality in older adulthood: comparisons from mixed-mode panel interviews.

OBJECTIVES: Estimates of the extent of health disparities among Black and White older adults are not consistent across studies. The purpose of this study was to systematically compare responses from Black and White older adults in telephone and face-to-face interviews in order to determine whether estimates of racial health inequality vary by survey interview mode. METHODS: By using data from a mixed-mode panel study, I compared estimates of changing health inequality for Black and White older adults collected from face-to-face and telephone interviews. I calculated trajectories of physical disability by using latent growth models across seven waves of data. RESULTS: Face-to-face interviews yielded consistently higher reports of disability relative to telephone interviews of the same persons. Black adults had significantly greater and increasing disability than did White adults for both interview modes. After adjusting for covariates, I found that Black and White older adults had parallel disability trajectories in face-to-face interviews but a widening gap in disability over time in telephone interviews. DISCUSSION: Researchers should judiciously consider whether estimates of racial health inequality-and change in disability more broadly-may be misleading because of interview-mode effects.

The color of hospitalization over the adult life course: cumulative disadvantage in black and white?

OBJECTIVES: Drawing from cumulative disadvantage theory, this research addresses the following questions: Do hospital admission and discharge rates differ for White and Black adults? If yes, do the differences amplify in later life? METHODS: This study made use of hospital records abstracted from a long-term prospective study of adults in the National Health and Nutrition Examination Survey I: Epidemiologic Follow-up Study (N = 6,833). Semi-Markov models were specified to examine the likelihood of hospital admission and discharge for Black and White adults aged 25 to 74 years old at baseline. RESULTS: Black adults were less likely than White adults to be admitted to the hospital, but they had longer lengths of stay. The risk of death in the hospital was greater for both Black men and women than for White men and women. In addition, the observed racial differences in hospitalization experiences amplified in later life. DISCUSSION: Health inequality in America is manifest in how White and Black adults enter and exit hospitals. The findings demonstrate growing heterogeneity in later life by race.

When do older adults become "disabled"? Social and health antecedents of perceived disability in a panel study of the oldest old.

Disability carries negative social meaning, and little is known about when (or if), in the process of health decline, persons identify themselves as "disabled." We examine the social and health criteria that older adults use to subjectively rate their own disability status. Using a panel study of older adults (ages 72+), we estimate ordered probit and growth curve models of perceived disability over time. Total prevalent morbidity, functional limitations, and cognitive impairment are predictors of perceived disability. Cessation of driving and receipt of home health care also influence older adults 'perceptions of their own disability. A dense social network slowed the rate of labeling oneself disabled, while health anxiety accelerated the process over time, independent of health status. When considering perceived disability, the oldest old use multidimensional criteria capturing function, recent changes in health status and social networks, and anxiety about their health.

Developmental Screening of Refugees: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Refugee children are at high developmental risk due to dislocation and deprivation. Standardized developmental screening in this diverse population is challenging. We used the Health Belief Model to guide key-informant interviews and focus groups with medical interpreters, health care providers, community collaborators, and refugee parents to explore key elements needed for developmental screening. Cultural and community-specific values and practices related to child development and barriers and facilitators to screening were examined. METHODS: We conducted 19 interviews and 2 focus groups involving 16 Bhutanese-Nepali, Burmese, Iraqi, and Somali participants, 7 community collaborators, and 6 providers from the Center for Refugee Health in Rochester, New York. Subjects were identified through purposive sampling until data saturation. Interviews were recorded, coded, and analyzed using a qualitative framework technique. RESULTS: Twenty-one themes in 4 domains were identified: values/beliefs about development/disability, practices around development/disability, the refugee experience, and feedback specific to the Parents' Evaluation of Developmental Status screen. Most participants denied a word for "development" in their primary language and reported limited awareness of developmental milestones. Concern was unlikely unless speech or behavior problems were present. Physical disabilities were recognized but not seen as problematic. Perceived barriers to identification of delays included limited education, poor healthcare knowledge, language, and traditional healing practices. Facilitators included community navigators, trust in health care providers, in-person interpretation, visual supports, and education about child development. CONCLUSIONS: Refugee perspectives on child development may influence a parent's recognition of and response to developmental concerns. Despite challenges, standardized screening was supported.