Similar QALY gain in primary and revision knee arthroplasty: A cost analysis and Markov model.

PURPOSE: The aim of this study is to investigate the cost-effectiveness of revision total knee arthroplasty compared to primary total knee arthroplasty in terms of cost-per-quality-adjusted life year (QALY). METHODS: Data were retrieved for all primary and revision total knee replacement (TKA) procedures performed at a tertiary Swiss hospital between 2006 and 2019. A Markov model was created to evaluate revision risk and we calculated lifetime QALY gain and lifetime procedure costs through individual EuroQol 5 dimension (EQ-5D) scores, hospital costs, national life expectancy tables and standard discounting processes. Cost-per-QALY gain was calculated for primary and revision procedures. RESULTS: EQ-5D data were available for 1343 primary and 103 revision procedures. Significant QALY gains were seen following surgery in all cases. Similar, but significantly more QALYs were gained following primary TKA (PTKA) (5.67 ± 3.98) than following revision TKA (RTKA) (4.67 ± 4.20). Cost-per-QALY was €4686 for PTKA and €10,364 for RTKA. The highest average cost-per-QALY was seen in two-stage RTKA (€12,292), followed by one-stage RTKA (€8982). CONCLUSION: RTKA results in a similar QALY gain as PTKA. The costs of achieving health gain are two to three times higher in RTKA, but both procedures are highly cost-effective. LEVEL OF EVIDENCE: Economic level II.

Digital economy exhibits varying degrees of mitigation of air pollution in China: Total cities-economic subdivisions-urban agglomerations.

Air pollution is a challenge for many cities. The digital economy enhances support for environmental pollution management, while the mechanisms and scaling heterogeneity remain unclear. This study explored the contribution of digital economy development to PM2.5 concentrations control in China and driving mechanisms in different economic subregions and urban agglomerations. Results show that the spillover transfer effect on air pollution mitigation far exceeded the direct effect at different scales. At the national scale, the air pollution mitigation effect of digital economy was mainly through empowering industrial structure optimization and green technology innovation, while it also affected economic subregions and urban agglomerations through varying scenario combinations of pathways with structural optimization, green production, resource allocation, and technology innovation. Research findings provide support for cross-regional joint management strategies of digital economy and air quality and designing regionally differentiated pollution control pathways in the digital economy dimension.

Factors influencing the reimbursement of cancer drugs in Europe: A scoping review.

RATIONALE: Reimbursement process of oncology drugs in Europe occurs within a complex decision-making process that varies between Member States. Distinctions between the States trigger societal debates since it is necessary to balance access to medicines and health systems sustainability. AIMS AND OBJECTIVES: We aimed to review the evidence concerning factors associated with the reimbursement decision or Health Technology Agency recommendation of oncology drugs in Europe. METHODS: A systematic literature search was performed in two databases from inception to august 2023. Screening and data extraction were performed by pairs. RESULTS: Thirteen articles were included and encompassed data from 11 nations. Seven articles showed that cost-effective (C-E) drugs and lower Incremental Cost-Effectiveness Ratios (ICERs) had higher likelihood of reimbursement. Disease severity might influence the reimbursement decision with financial agreements. Improvement in clinical outcomes, substantial clinical benefit (p < 0.01) or overall survival gains (p < 0.05) were positively associated. Orphan drug designation impact varies between countries but positive decisions are usually achieved under specific conditions. Clinical and C-E uncertainty frequently led to reimbursement with financial agreements or outcomes-based conditions. Sociodemographic factors as: social health insurance system, higher Gross Domestic Product and larger elderly population were positively associated with reimbursement (p < 0.01). CONCLUSION: There is a need for further research into key determinants of reimbursement decisions in Europe and the development of drug access models that can effectively address and overcome costs and effectiveness uncertainties.

Effect of gamification with a support partner to increase physical activity in older adults at risk for Alzheimer's disease: The STEP 4Life randomized clinical trial.

INTRODUCTION: Physical activity is associated with reduced risk of cognitive and functional decline but scalable, sustainable interventions for populations at risk for Alzheimer's disease (AD) and AD and related dementias (ADRD) are lacking. METHODS: A 12-week randomized-controlled trial was conducted with a 3-week follow-up using a national AD prevention registry (GeneMatch). The control group (n = 50) set step goals and received daily feedback. The intervention group (n = 44) also received a behaviorally designed game based on achieving step goals and reinforced by a support partner. RESULTS: Intervention participants (94 participants, mean age 70, 78% female) had greater change in mean daily step count than control of 1699 steps/day (95% confidence interval [CI], 1149-2249), P < 0.0001, which was sustained in the follow-up period at 1219 steps/day (95% CI, 455-1983), P = 0.0018. Carriers of the apolipoprotein E ε4 gene (high risk) did not perform differently than non-carriers; however, high self-reported risk perception was associated with higher activity. DISCUSSION: A gamified intervention was effective in promoting and sustaining higher physical activity in older adults at genetic risk for AD/ADRD. HIGHLIGHTS: A simple game played with a support partner increased walking in older adults at risk for Alzheimer's disease (AD). The game also increased minutes of moderate-to-vigorous physical activity per day. Perception of lifelong AD risk was associated with increased activity but genetic risk (apolipoprotein E ε4+) was not. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05069155.

Cost-effectiveness of preoperative pharmaceutical care consultations: a 5-year analysis.

OBJECTIVES: Preoperative medication errors can be prevented by screening patients through a preoperative pharmaceutical care consultation. The aim of this study was to analyse the cost-effectiveness of implementing such a consultation and to determine which patients would benefit most. METHODS: A retrospective study was conducted that included all patients who underwent a preoperative pharmacy consultation between 2016 and 2020. During this consultation, two part-time pharmacists reviewed patients' appropriate preoperative chronic medication management. All prevented errors were collected and classified by therapeutic group and type of error. A team of pharmacists and anaesthetists assigned to each prevented medication error a probability of causing an adverse event 'p', following the methodology of Nesbit et al by establishing five different 'p' values: 0, 0.01, 0.1, 0.4, and 0.6. 'p' = 1 was not considered. The cost of an adverse event was determined to be between €4124 and €6946 according to current literature, and a sensitivity analysis was performed by increasing the interval by 20% above and below. The cost of employing two part-time specialist pharmacists was estimated to be €59 142. Savings per medication error prevented were calculated as (€4124 OR €6946) × 'p'. Total savings were the sum of all costs associated with prevented medication errors. Patients on chronic medications who were in therapeutic groups with a 0.6 probability of an adverse event or who were in therapeutic groups responsible for 50% of the prevented adverse events were considered prioritisable. RESULTS: 3105 patients attended the consultation and 1179 medication errors were prevented, corresponding to 300 adverse events. 42.2% of the errors had a 'p' of 0.4. The costs avoided by this consultation ranged from €1 237 200 to €2 083 800, while the cost of its implementation was €295 710. The cost-effectiveness ratio was between €4.2 and €7.0 saved per euro invested. In the sensitivity analysis, the ratios ranged from €3.3 to €8.5 per euro invested. Fifteen different therapeutic groups accounted for 90% of the medication errors prevented. The therapeutic groups 'Agents acting on the renin-angiotensin system', 'Antidiabetics, non-insulin (excluding SGLT2)' and 'Antithrombotics: low molecular weight heparins' were responsible for 56% of the prevented adverse events. The therapeutic groups 'Antidiabetics: rapid-acting insulin' and 'Antithrombotic agents: vitamin K antagonists, low-molecular-weight heparins, or direct oral anticoagulants' had a 'p' of 0.6. Therefore, patients in six therapeutic groups should be prioritised for preoperative pharmacy counselling. CONCLUSIONS: The implementation of preoperative pharmaceutical care consultations in Spain has proven to be cost-effective. Incorporating the probability of a medication error causing an adverse event allowed the prioritisation of patients for these consultations. Patients taking anticoagulants, oral antidiabetics, rapid-acting insulins, and agents acting on the renin-angiotensin system benefited the most. This study could serve as a basis for implementing such consultations in other hospitals, as they are effective in reducing the cost of medication errors in surgical patients.

Antithrombin testing and treatment in pregnancy: Their real-world relationship to clinical outcomes.

BACKGROUND: Antithrombin (AT) deficiency is a severe thrombophilia associated with increased rates of maternal morbidity, mortality, and greater healthcare resource utilization during pregnancy and postpartum. METHODS: Two large U.S. healthcare databases were queried for women aged 15-44 with delivery-related encounters: Cerner Real-World Data (CRWD, 01/01/2000-12/31/2021) and Premier Healthcare Database (PHD, 01/01/2016-01/01/2019). Individuals receiving cardiopulmonary bypass were excluded. Three cohorts were created: 1) Individuals who had AT levels tested any time between 9-months pre- through 3-months post-delivery (CRWD Test Cohort); 2) individuals prescribed AT concentrate (ATc) within 1-year pre- or 1-year post-delivery in CRWD (CRWD Medication Cohort); and 3) the same criteria as 2) applied to PHD (PHD Medication Cohort). RESULTS: There were 5411 individuals in the CRWD Test Cohort, 13 in the CRWD Medication Cohort and 38 in the PHD Medication Cohort. Demographic and baseline clinical characteristics were similar across cohorts. AT level testing occurred pre-delivery in 47.9 % of the CRWD Test Cohort and 23.1 % of the CRWD Medication Cohort. ATc was administered during the delivery hospitalization to 0.1 %, 23.1 % and 50.0 % of the CRWD Test, CRWD Medication, and PHD Medication Cohorts, respectively. Across cohorts, 5.4-7.9 % of individuals experienced thrombosis during the delivery-related encounter. Mean (SD) total costs for delivery through 1-year post-delivery were $190,894 ($276,893) with $123,763 ($177,122) of total costs related to abnormal coagulation. CONCLUSION: Opportunities exist to enhance the care of pregnant individuals with low AT levels throughout pregnancy, aiming for optimal maternal outcomes.

Balancing long-term and short-term strategies in a sustainability game.

Our society is marked by a tension between short-term objectives, such as economic growth, and long-term sustainability goals, including mitigating resource depletion. In such a competitive setting, it is crucial to ascertain whether a system can maintain long-term viability and, if so, how. This article aims to enhance the understanding of this issue by analyzing how sustainability concerns change over time by means of a game, and the effect of this variation on the final status of a system. Leveraging insights from the game, we implement an agent-based model to elicit the tension between short-term objectives and sustainability, emphasizing the influence of individual actions on the overall system. The simulation results suggest that the likelihood of a collapse is contingent upon the availability of resources and the manner in which information regarding these resources is gathered and utilized. Finally, the paper proposes practical suggestions for managing this kind of system.

Adverse event costs of systemic therapies for metastatic colorectal cancer previously treated with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy and biologics in the US.

Aim: The objective of this study was to compare adverse event (AE) management costs for fruquintinib, regorafenib, trifluridine/tipiracil (T/T) and trifluridine/tipiracil+bevacizumab (T/T+bev) for patients with metastatic colorectal cancer (mCRC) previously treated with at least two prior lines of therapy from the US commercial and Medicare payer perspectives. Materials & methods: A cost-consequence model was developed to calculate the per-patient and per-patient-per-month (PPPM) AE costs using rates of grade 3/4 AEs with incidence ≥5% in clinical trials, event-specific management costs and duration treatment. Anchored comparisons of AE costs were calculated using a difference-in-differences approach with best supportive care (BSC) as a common reference. AE rates and treatment duration were obtained from clinical trials: FRESCO and FRESCO-2 (fruquintinib), RECOURSE (T/T), CORRECT (regorafenib) and SUNLIGHT (T/T, T/T+bev). AE management costs for the commercial and Medicare perspectives were obtained from publicly available sources. Results: From the commercial perspective, the AE costs (presented as per-patient, PPPM) were: $4015, $1091 for fruquintinib (FRESCO); $4253, $1390 for fruquintinib (FRESCO-2); $17,110, $11,104 for T/T (RECOURSE); $9851, $4691 for T/T (SUNLIGHT); $8199, $4823 for regorafenib; and $11,620, $2324 for T/T+bev. These results were consistent in anchored comparisons: the difference-in-difference for fruquintinib based on FRESCO was -$1929 versus regorafenib and -$11,427 versus T/T; for fruquintinib based on FRESCO-2 was -$2257 versus regorafenib and -$11,756 versus T/T. Across all analyses, results were consistent from the Medicare perspective. Conclusion: Fruquintinib was associated with lower AE management costs compared with regorafenib, T/T and T/T+bev for patients with previously treated mCRC. This evidence has direct implications for treatment, formulary and pathways decision-making in this patient population.

Unraveling elements of value-based pricing from a pharmaceutical industry's perspective: a scoping review.

Health authorities use value-based pricing models to determine the value of innovative drugs and to establish a price. Pharmaceutical companies prefer value-based pricing over cost-based pricing. It is ambiguous whether value-based pricing has the same meaning to these stakeholders. We aimed to identify the elements that attribute to value-based pricing of innovative drugs from a pharmaceutical industry's perspective and as possible starting point for (value-based) contracting of drugs. We performed a scoping review of publications available in scientific databases with terms such as 'value-based pricing', 'pharmacoeconomics', 'drug cost', 'innovative drug' and 'drug therapy'. We included 31 publications, covering value elements of innovative drugs from a pharmaceutical industry's perspective. Overall, all found elements of value-based pricing were congruent with the elements of value-based pricing from a health authority's perspective. However, the emphasis placed on the elements differed. The most frequently mentioned elements in our review were economic considerations and cost aspects. Least mentioned were elements regarding cost-effectiveness, disease characteristics and patient characteristics. Although all elements in the drug value framework were present which indicate congruity, there seems controversy on the importance of cost-effectiveness as an element of value. Consequently, establishing a coherent and to all stakeholders' acceptable framework to value and price innovative drugs seems complicated. Mutual understanding can be found in the value elements societal considerations and healthcare process benefits. Our results supported the importance of economic and cost aspects regarding determination of prices of innovative drugs. Further research is required to quantify the weights of all relevant elements in the drug value framework, observe their possible interlinkages, and to weigh them over time.

Enhancing agricultural output: Investigating the impact of advanced organic formulations on crop productivity, nutrient use efficiency, and profitability in a multi-crop system.

The significance of integrating agricultural by-products such as paddy husk ash (PHA) and potato peels with organic fertilizers lies in enhancing soil fertility, increasing crop yields, and reducing reliance on traditional organic fertilizers like farmyard manure (FYM) or compost alone. Grounded in sustainable agriculture and nutrient management frameworks, this study examines the impact of diverse formulations derived from agricultural waste on productivity, nutrient efficiency, and profitability in a pigeon pea-vegetable mustard-okra cropping system. A two-year field experiment (2020-2022) at ICAR-IARI, New Delhi tested seven nutrient sources viz., (T1) control, (T2) 100% RDN through FYM, (T3) 100% RDN through improved RRC, (T4) 100% RDN through PHA based formulation, (T5) 75% RDN through PHA based formulation, (T6) 100% RDN through PPC based formulation and (T7) 75% RDN through PPC based formulation that were tested in RBD and replicated thrice. Treatment T4 had significant effect on seed yield of pigeon pea (1.89 ± 0.09 and 1.97 ± 0.12 t ha-1), leaf yield of vegetable mustard (81.57 ± 4.59 and 82.97 ± 4.17 t ha-1), and fruit yield of okra (13.54 ± 0.82 and 13.78 ± 0.81 t ha-1) grown in rotation, followed by treatment T6 and T2 during both the years respectively over control. Enhanced system uptake of N, P and K along with system gross and net returns in T4, showed increases of 78.9%, 83.8%, 72.4%, 54.4% and 56.8% in the first year and 77.5%, 80.8%, 77.7%, 54.8% and 57.4% in the second year, respectively, over control. Treatment T4 significantly improved apparent recovery by 66.3% and 69.2% in pigeon pea, 64.7% and 47.9% in vegetable mustard, and 72.7% and 79.4% in okra over T3, averaged across two years. Based on the above findings, (T4) 100% RDN through PHA-based formulation, and (T6) 100% RDN through PPC-based formulation can be recommended for areas with a shortage of FYM but availability of rice husk ash/potato peels for sustainable agricultural wastes and improved sustainability.

Dataset on global trade networks of COVID-19 medical products.

This paper presents a comprehensive dataset on the global trade dynamics of COVID-19-related medical products for the years 2019 and 2020. The dataset, derived from the BACI database, focuses on eight distinct product categories identified by six-digit codes. The trade flow data for 224 countries is structured as a multilevel network, with countries as nodes and product categories as layers. Directed edges represent trading activities, and edge weights are determined by the difference in exported values between 2019 and 2020. The dataset is provided in an edges-and-nodes format. Additionally, the associated R script transforms the data into the MuxViz R package format, facilitating further analysis and visualization of the dataset. The dataset is valuable for researchers in the field of foreign trade or medical products, and for decision-makers in these fields, whether at company or national level.

Measuring Cannabis Reinforcement among Young Adults: A Mixed Methods Examination.

Introduction: Increasing reinforcement received from cannabis-free activities, relative to reinforcement from cannabis-related activities, is one way to reduce harmful cannabis use. Thus, accurate measurement of cannabis reinforcement is important. Using convergent mixed methods, we developed the Adolescent Reinforcement Survey Schedule-Cannabis Use Version (ARSS-CUV). ARSS-CUV, adapted from the alcohol use version, measures cannabis reinforcement by asking individuals how frequently they engaged in, and how much they enjoyed, different activities when using and not using cannabis. Method: Young adults (N = 65; M age = 20.4 years [SD = 1.8]) completed measures of cannabis use, the ARSS-CUV, and provided feedback on included activities, via focus groups. Following Standards for Educational and Psychological Testing framework, this study examined evidence of measurement validity based on item content. Results: Quantitative findings revealed that peer interactions were the most reinforcing activities, whereas activities related to family were least reinforcing. Qualitative findings indicated some confusion with question wording. Participants also indicated the importance of environmental context when using cannabis and noted who they use cannabis with may be more important than the activity they are doing. Changes were made to survey flow and response choices after participant feedback. Conclusions: ARSS-CUV includes revisions in activities solicited and response format. The revised ARSS-CUV provides opportunities to advance measurement of an important construct (i.e., reinforcement) in the study of cannabis use. Psychometric properties of the ARSS-CUV across different populations and contexts of use (e.g., polysubstance use) should be examined.

Do Behavioral Characteristics Influence the Breast Cancer Diagnosis Delay? Evidence from French Retrospective Data.

OBJECTIVES: To analyze the behavioral determinants of breast cancer diagnosis delays in France. To do so, we investigated whether time discounting, risk tolerance, and personality traits influenced the breast cancer diagnosis delay of patients. METHODS: We used original retrospective data collected on two large online patient networks from 402 women diagnosed with breast cancer. The breast cancer diagnosis delay was measured by the difference between the date of diagnosis and the date of first symptoms. Time discounting and risk tolerance are measured with both self-reported questions and hypothetical lotteries. Personality traits are measured with the 10-items Big-Five indicator. Ordinary Least Square and Probit models were used to analyze whether these behavioral characteristics influenced the breast cancer diagnosis delay. RESULTS: Results showed that risk tolerance and time discounting were not significantly associated with the breast cancer diagnosis delay. We found, however, a longer diagnosis delay for women with a Neuroticism personality trait (standardized coefficients ranged from 0.104 (p-value = 0.036) to 0.090 (p-value = 0.065)). CONCLUSIONS: Overall, our findings underline the need for an increased consideration of cancer screening public health policy for women with mental vulnerabilities since such vulnerabilities were found to be highly correlated with a Neuroticism personality trait.

Socioeconomic disparity in the natural history of cutaneous melanoma: evidence from two large prospective cohorts.

BACKGROUND: Previous studies on the associations between socioeconomic status (SES) and cutaneous malignant melanoma (CMM) failed to distinguish the effects of different SES factors under an individual-data-based prospective study design. METHODS: Based on UK Biobank (UKB) and China Kadoorie Biobank (CKB), we estimated the effects of four SES factors on transitions from baseline to CMM in situ, subsequently to invasive CMM and further CMM mortality by applying multistate models. We further explored to which extent the associations between SES and CMM incidence could be explained by potential mediators including sun exposure, lifestyle and ageing in UKB. RESULTS: In multistate analyses, good household income was independently associated with an increased risk of CMM in situ (HR=1.38, 95% CI: 1.21 to 1.58) and invasive CMM (HR=1.34, 95% CI: 1.22 to 1.48) in UKB. These findings were partly validated in CKB. Especially in UKB, we observed an increased risk of CMM in situ and invasive CMM among participants with good type of house; only good education was independently associated with lower risk of evolving to invasive CMM among patients with CMM in situ (HR=0.69, 95% CI: 0.52 to 0.92); only good household income was independently associated with lower risk of CMM mortality among patients with CMM (HR=0.65, 95% CI: 0.45 to 0.95). In mediation analysis, the proportions attributable to the mediating effect were <6% for all selected variables, including self-reported sun exposure-related factors. CONCLUSION: SES factors have different effects on the incidence and progression of CMM. The association between SES and incident CMM is neither causal nor well explained by selected mediators.

Impact of changes in anaesthesia staff assignments on billing compliance, financial margins, and costs of anaesthesia services: development and application of a margin-cost estimation tool.

BACKGROUND: The US Centers for Medicare and Medicaid Services provide guidelines for the coverage of anaesthesia residents and certified registered nurse anaesthetists (CRNAs) by anaesthesiologists. We tested the hypothesis that changes in the anaesthesia staffing model increase billing compliance. METHODS: We analysed 13 926 anaesthesia cases performed between September 2019 and November 2019 (baseline), and between September 2020 and November 2020 (after change in staff model) at a US academic medical centre using an estimation tool. The intervention was assignment of additional 12-h weekday CRNAs plus an additional anaesthesiologist who covered weekdays after 17:00, weekends, and holidays. The proportion of cases with billing compliant coverage (covered either by solo anaesthesiologist or anaesthesiologist covering two or fewer residents or four or fewer CRNAs) was analysed using logistic and segmented regression analyses. RESULTS: The change in staff model was associated with a decrease in non-optimal anaesthesia staff assignments from 4.2% to 1.2% of anaesthesia cases (adjusted odds ratio 0.25; 95% confidence interval [CI] 0.20-0.32; P<0.001) and an increase in billable anaesthesia units of 0.6 per anaesthesia case (95% CI 0.4-0.8; P<0.001). An increased revenue margin associated with optimal staffing levels would only be achieved with salary levels at the 25th percentile of relevant benchmark compensation levels. Total staff overtime for all anaesthesia providers decreased (adjusted absolute difference -4.1 total overtime hours per day; 95% CI -7.0 to -1.3; P=0.004). CONCLUSIONS: Implementation of a change in anaesthesia staffing model was associated with improved billing compliance, higher billable anaesthesia units, and reduced overtime. The effects of the anaesthesia staff model on revenue and financial margin can be determined using our web-based margin-cost estimation tool.

Overcoming the central planner approach - Bilevel optimization of the European energy transition.

The energy transition is a multinational challenge to mitigate climate change, with a joint reduction target for greenhouse gas emissions. Simultaneously, each country is interested in minimizing its own energy supply cost. Still, most energy system models neglect national interests when identifying cost-optimal transition pathways. We design the European energy system transition until 2050, considering competition between countries in a shared electricity and carbon market using bilevel optimization. We find that national objectives substantially impact the transition pathway: Compared to the model solved using the common centralized optimization, the overall installed capacity increases by just 3% when including national interests. However, the distribution of the installed capacity changes dramatically by more than 40% in most countries. Our results underline the risk of miscalculating the need for national capacity expansion when neglecting stakeholder representation in energy system models and demonstrate the need for cooperation for an efficient energy transition.

Catalytic methane decomposition on CNT-supported Fe-catalysts.

Methane, either as natural gas or as a resource obtained from various bioprocesses (e.g., digestion, landfill) can be converted to carbon and hydrogen according to. CH4(g)→C(s)+2H2(g)ΔH298K=74.8kJ/mol. Previous research has stressed the growing importance of substituting the high-temperature Steam Methane Reforming (SMR) by a moderate temperature Catalytic Methane Decomposition (CMD). The carbon formed is moreover of nanotube nature, in high industrial demand. To avoid the use of an inert support for the active catalyst species, e.g., Al2O3 for Fe, leading to a progressive contamination of the catalyst by support debris and coking of the catalyst, the present research investigates the use of carbon nanotubes (CNTs) as Fe-support. Average CH4 conversions of 75-85% are obtained at 700 °C for a continuous operation of 40 h. The produced CNT from the methane conversion can be continuously removed from the catalyst bed by carry-over due to its bulk density difference (∼120 kg/m3) with the catalyst itself (∼1500 kg/m3). CNT properties are fully specified. No thermal regeneration of the catalyst is required. A tentative process layout and economic analysis demonstrate the scalability of the process and the very competitive production costs of H2 and CNT.

Evolutionary history and root trait coordination predict nutrient strategy in tropical legume trees.

Plants express diverse nutrient use and acquisition traits, but it is unclear how trait combinations at the species level are constrained by phylogeny, trait coordination, or trade-offs in resource investment. One trait - nitrogen (N) fixation - is assumed to correlate with other traits and used to define plant functional groups, despite potential confounding effects of phylogeny. We quantified growth, carbon metabolism, fixation rate, root phosphatase activity (RPA), mycorrhizal colonization, and leaf and root morphology/chemistry across 22 species of fixing and nonfixing tropical Fabaceae trees under common conditions. Belowground trait variation was high even among closely related species, and most traits displayed a phylogenetic signal, including N-fixation rate and nodule biomass. Across species, we observed strong positive correlations between physiological traits such as RPA and root respiration. RPA increased ~ fourfold per unit increase in fixation, supporting the debated hypothesis that N-fixers 'trade' N for phosphatases to enhance phosphorus acquisition. Specific root length and root N differed between functional groups, though for other traits, apparent differences became nonsignificant after accounting for phylogenetic nonindependence. We conclude that evolutionary history, trait coordination, and fixation ability contribute to nutrient trait expression at the species level, and recommend explicitly considering phylogeny in analyses of functional groupings.