Optimising gout treatment: insights from a nurse-led cohort study.

OBJECTIVES: Currently, gout management, particularly urate-lowering therapy (ULT), is often suboptimal. Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative. This real-life prospective cohort study evaluated the effectiveness of nurse-led care employing a treat-to-target strategy for gout management over a 2-year period. METHODS: All consecutively confirmed gout patients were included. The nurse-led clinic provided a structured treatment plan with consultations, patient leaflets, telephone contacts and laboratory monitoring. After a year of nurse-led care, patients transitioned to continued care in general practice. Follow-up data were complete through registries. The primary outcome was achieving target p-urate levels (<0.36 mmol/L) at 2 years after diagnosis. Secondary outcomes included treatment continuation and achievement of target p-urate levels in specific subgroups. The results were compared with patients diagnosed in the same clinic but followed up in 'usual care'. RESULTS: In the nurse-led group (n=114), 83% achieved target p-urate levels and ULT was continued by 98%. This trend persisted across various patient subgroups. Only 44% of patients in usual care achieved target p-urate and with insufficient doses of allopurinol . Nurse-led care involved an average of two visits and three telephone contacts over 336 days. The 2-year mortality rate was 15%. CONCLUSIONS: Nurse-led gout care, employing a targeted approach, was associated with a very high uptake of and adherence to ULT. The encouraging results were not achieved in usual care although a direct comparison might be influenced by selection bias.

The taxonomic identity of Trigona lacteipennis Friese, 1900 and description of a new bee species of the Trigona cilipes (Fabricius, 1804) group (Hymenoptera: Apidae: Meliponini).

A critical study of type material for Trigona lacteipennis Friese, 1900 and allied species is presented along with a discussion of literature data. This work reveals that T. lacteipennis is a junior subjective synonym of Melipona paupera Provancher, 1889 (new synonymy), a species currently classified placed in the genus Frieseomelitta. Similarly, T. lehmanni Friese, 1901 and T. parastigma Cockerell, 1918 are also junior subjective synonyms of Melipona paupera (new synonymies). Morphological characters, photographic illustrations of type specimens, and data on distribution are provided for Frieseomelitta paupera. Also, we describe a new species of Trigona cilipes species group, Trigona (Aphaneuropsis) silveirai sp. nov., which is very similar to the former and had been misidentified with it.

Nutrients or resin? - The relationship between resin and food foraging in stingless bees.

Stingless bees are important pollinators in tropical forests. Yet, we know little about their foraging behavior (e.g., their nutritional requirements or their floral sources visited for resource collection). Many stingless bees not only depend vitally on pollen and nectar for food but also on resin for nest building and/or defense. However, it is unclear whether the large effort devoted to collecting resin as a non-food resource by certain stingless bees affects their foraging behavior. Therefore, in this study, we analyzed differences in foraging patterns (i.e., foraging activity, proportion of collected resources, and specialization in plants visited) and resource nutritional composition (i.e., sucrose amount in nectar and amino acids in pollen) of seven different stingless bee species (eleven wild colonies) in north-western Ecuador with a particular focus on the role of resin collection. We found that species with a high resin intake tended to be more active than species with a low resin intake. The foragers per minute invested for pollen collection were similar across all species. Sucrose intake per minute differed between some species but was not affected by increased resin intake. Interestingly, high and low resin collectors partly differed in the plants visited for pollen collection. Pollen amino acid profiles largely, but not completely, overlapped between the two resin collection groups. Our findings show that the foraging patterns and plant choices of stingless bees may vary depending on their resin intake, highlighting the need for more research focusing on resin collection and use by stingless bees.

Las abejas sin aguijón son polinizadores importantes en los bosques tropicales. Sin embargo, sabemos poco acerca de su comportamiento de forrajeo (e.g., sus requisitos nutricionales o las fuentes florales visitadas para la recolección de recursos). Muchas abejas sin aguijón dependen vitalmente no solo de polen y de néctar como alimento, sino también de resinas para la construcción de su nido y/o defensa. Sin embargo, no está claro si el gran esfuerzo dedicado a la recolección de resina como recurso no alimentario de ciertas abejas sin aguijón afecta su comportamiento de forrajeo. Por lo tanto, en este estudio, analizamos las diferencias en los patrones de forrajeo (i.e., actividad de forrajeo, proporción de recursos recolectados y especialización en las plantas visitadas) y la composición nutricional de los recursos recolectados (i.e., cantidad de sacarosa en el néctar y de aminoácidos en el polen) de siete especies diferentes de abejas sin aguijón (once colonias silvestres) en el noroeste de Ecuador, con un enfoque particular en el rol de la recolección de resina. Encontramos que las especies con una recolección alta de resina tienden a ser más activas que las especies con una recolección baja de resina. La cantidad de forrajeadores por minuto dedicada a la recolección de polen fue similar en todas las especies. La ingesta de sacarosa por minuto difirió entre algunas especies, pero no se vio afectada por un aumento en la recolección de resina. Interesantemente, las abejas con una recolección alta y baja de resina difirieron parcialmente en las plantas que visitaron para la recolección de polen. Entre los dos grupos de recolección de resina también hubo diferencias con respecto al perfil de aminoácidos en el polen que recolectaron. El perfil de aminoácidos se sobrelapaba, pero no completamente, entre los dos grupos. Nuestros resultados muestran que los patrones de forrajeo y las elecciones de plantas de las abejas sin aguijón pueden variar según su consumo de resina, destacando la necesidad de hacer más investigaciones centradas en la recolección y el uso de resina por parte de las abejas sin aguijón.

Influenza Vaccine Type-Dependent Antibody Response in Patients with Autoimmune Inflammatory Rheumatic Diseases.

BACKGROUND: The study aimed to explore influenza antibody response in patients with autoimmune inflammatory rheumatoid diseases (AIIRDs) stratified by the different vaccine types applied in Denmark during the 2018-2019 influenza season. METHODS: Included patients were diagnosed with rheumatoid arthritis, psoriatic arthritis, or spondyloarthritis receiving biological disease-modifying antirheumatic drugs (bDMARDs) with or without conventional synthetic disease-modifying antirheumatic drugs. Influenza vaccination status in the 2018-2019 season and vaccine type received were reviewed in the Denmark. Blood samples were drawn ≥ 14 days post vaccination, and antibody titers were determined by the hemagglutinin inhibition (HAI) assay for the serotypes A/Michigan/H1N1, A/Singapore/H3N2, and B/Colorado included in the influenza vaccines in the 2018-2019 season. An overall serotype HAI geometric mean titer (GMT) was calculated from the 3 serotype-specific HAI titers. An overall serotype HAI GMT ≥ 40 was considered protective. RESULTS: Of the 205 included patients, 105 (51%) had received influenza vaccination. One-quarter of vaccinated patients achieved post-vaccination overall serotype HAI GMT ≥40. For patients vaccinated with Influvac, a significantly higher proportion had HAI titers ≥ 40 for 2 serotypes, namely, A/Michigan/H1N1 and A/Singapore/H3N2, than patients vaccinated with Vaxigrip or VaxigripTetra. The same applied to all serotypes HAI GMT, where significantly more patients who received Influvac achieved postvaccination HAI GMT≥40 versus patients who received Vaxigrip (p=0.02) or VaxigripTetra (p=0.002). The latter outcome was explored in a multivariable logistic regression analysis and remained significant when including the following variables: age, sex, treatment with methotrexate and/or prednisolone, type of influenza vaccine, time interval from vaccination to antibody measurement, and previous vaccination status. CONCLUSION: Influenza antibody levels following vaccination with Influvac in bDMARD-treated patients with AIIRDs were superior to Vaxigrip and VaxigripTetra. Treatment with methotrexate (MTX) did not reduce the antibody response.

Stingless bee classification and biology (Hymenoptera, Apidae): a review, with an updated key to genera and subgenera.

Stingless bees (Meliponini) are a ubiquitous and diverse element of the pantropical melittofauna, and have significant cultural and economic importance. This review outlines their diversity, and provides identification keys based on external morphology, brief accounts for each of the recognized genera, and an updated checklist of all living and fossil species. In total there are currently 605 described extant species in 45 extant genera, and a further 18 extinct species in nine genera, seven of which are extinct. A new fossil genus, Adactylurina Engel, gen. nov., is also described for a species in Miocene amber from Ethiopia. In addition to the systematic review, the biology of stingless bees is summarized with an emphasis on aspects related to their nesting biology and architecture.

Stable pollination service in a generalist high Arctic community despite the warming climate.

Insects provide key pollination services in most terrestrial biomes, but this service depends on a multistep interaction between insect and plant. An insect needs to visit a flower, receive pollen from the anthers, move to another conspecific flower, and finally deposit the pollen on a receptive stigma. Each of these steps may be affected by climate change, and focusing on only one of them (e.g., flower visitation) may miss important signals of change in service provision. In this study, we combine data on visitation, pollen transport, and single-visit pollen deposition to estimate functional outcomes in the high Arctic plant-pollinator network of Zackenberg, Northeast Greenland, a model system for global warming-associated impacts in pollination services. Over two decades of rapid climate warming, we sampled the network repeatedly: in 1996, 1997, 2010, 2011, and 2016. Although the flowering plant and insect communities and their interactions varied substantially between years, as expected based on highly variable Arctic weather, there was no detectable directional change in either the structure of flower-visitor networks or estimated pollen deposition. For flower-visitor networks compiled over a single week, species phenologies caused major within-year variation in network structure despite consistency across years. Weekly networks for the middle of the flowering season emerged as especially important because most pollination service can be expected to be provided by these large, highly nested networks. Our findings suggest that pollination ecosystem service in the high Arctic is remarkably resilient. This resilience may reflect the plasticity of Arctic biota as an adaptation to extreme and unpredictable weather. However, most pollination service was contributed by relatively few fly taxa (Diptera: Spilogona sanctipauli and Drymeia segnis [Muscidae] and species of Rhamphomyia [Empididae]). If these key pollinators are negatively affected by climate change, network structure and the pollination service that depends on it would be seriously compromised.

Mobile emergency department care to nursing home residents: a novel outreach service.

BACKGROUND: Every month, 6% of Danish nursing home residents are admitted to hospital. However, these admissions might have limited benefits and are associated with an increased risk of complications. We initiated a new mobile service comprising consultants performing emergency care in nursing homes. OBJECTIVE: Describe the new service, the recipients of this service, hospital admission patterns and 90-day mortality. DESIGN: A descriptive observational study. MODEL: When an ambulance is requested to a nursing home, the emergency medical dispatch centre simultaneously dispatches a consultant from the emergency department who will provide an emergency evaluation and decisions regarding treatment at the scene in collaboration with municipal acute care nurses. METHOD: We describe the characteristics of all nursing home contacts from 1st November 2020 to 31st December 2021. The outcome measures were hospital admissions and 90-day mortality. Data were extracted from the patients' electronic hospital records and prospectively registered data. RESULTS: We identified 638 contacts (495 individuals). The new service had a median of two (interquartile range: 2-3) new contacts per day. The most frequent diagnoses were related to infections, unspecific symptoms, falls, trauma and neurologic disease. Seven out of eight residents remained at home following treatment, 20% had an unplanned hospital admission within 30 days and 90-day mortality was 36.4%. CONCLUSION: Transitioning emergency care from hospitals to nursing homes could present an opportunity for providing optimised care to a vulnerable population and limiting unnecessary transfers and admissions to hospitals.

Ultra-low dose computed tomography of the chest in an emergency setting: A prospective agreement study.

Ultra-low dose computed tomography (ULD-CT) assessed by non-radiologists in a medical Emergency Department (ED) has not been examined in previous studies. To (i) investigate intragroup agreement among attending physicians caring for ED patients (i.e., radiologists, senior- and junior clinicians) and medical students for the detection of acute lung conditions on ULD-CT and supine chest X-ray (sCXR), and (ii) evaluate the accuracy of interpretation compared to the reference standard. In this prospective study, non-traumatic patients presenting to the ED, who received an sCXR were included. Between February and July 2019, 91 patients who underwent 93 consecutive examinations were enrolled. Subsequently, a ULD-CT and non-contrast CT were performed. The ULD-CT and sCXR were assessed by 3 radiologists, 3 senior clinicians, 3 junior clinicians, and 3 medical students for pneumonia, pneumothorax, pleural effusion, and pulmonary edema. The non-contrast CT, assessed by a chest radiologist, was used as the reference standard. The results of the assessments were compared within each group (intragroup agreement) and with the reference standard (accuracy) using kappa statistics. Accuracy and intragroup agreement improved for pneumothorax on ULD-CT compared with the sCXR for all groups. Accuracy and intragroup agreement improved for pneumonia on ULD-CT when assessed by radiologists and for pleural effusion when assessed by medical students. In patients with acute lung conditions ULD-CT offers improvement in the detection of pneumonia by radiologists and the detection of pneumothorax by radiologists as well as non-radiologists compared to sCXR. Therefore, ULD-CT may be considered as an alternative first-line imaging modality to sCXR for non-traumatic patients who present to EDs.

Healthcare professionals' experience with emergency department-based acute care performed within nursing homes.

BACKGROUND: hospital admissions of residents from nursing homes often lead to delirium, infections, mortality and reduced functional capacity. We initiated a new service, 'emergency department-based acute care service', maintained by consultants from an emergency department (ED) moving emergency care from the hospitals into nursing homes. OBJECTIVE: this study explored healthcare professionals' experiences with this service. DESIGN: qualitative semi-structured focus group discussions. INTERVENTION/SETTING: the new service provides acute on-site evaluation and treatment to nursing home residents following calls to the emergency dispatch centre. METHODS: we conducted focus groups with general practitioners, prehospital personnel, municipal acute care nurses, ED staff and nursing home staff. The analysis was performed using the iterative and explorative approach, 'systematic text condensation'. RESULTS: the participants considered the service as a meaningful and appropriate alternative to hospital admission, as the treatment can be tailored to meet the residents' wishes and daily capabilities. This was experienced to promote dignity for the residents by reducing unnecessary transfers to the ED and the residents could remain in familiar surroundings with staff who knew their habitual behaviour and history. The nursing home staff contributed valuable information to the ED consultants' decision-making. The service made it possible to base the decision-making on complete patient pictures, as the ED consultants had the time to get to understand the residents. CONCLUSION: acute care at nursing homes provides an alternative to routine admissions to hospitals and enables healthcare professionals to provide more dignity in the care of nursing home residents.

The Native Bees of Lolland (Denmark) Revisited after 100 Years: The Demise of the Specialists.

There is a global concern over insect declines, including both species loss and population declines. In particular, declines of species, such as bees that anchor trophic interactions and shoulder many of the essential ecosystem services, have been the focus of broad public concern. However, our understanding of what characterizes those species that are lost because of declines over long periods is limited by a scarcity of comparative studies. We here compare the species composition from a collection of bees sampled over two decades (2000-2019) from the island of Lolland in Denmark, with a collection also sampled over two decades (1900-1919), but a century ago by Jørgensen and his contemporaries. We further test if (1) the probability that bee species that were sampled a century ago are also found today depends on their degree of floral specialization; (2) and use information from pollen samples from bees from the historical records to assess if certain floral resources have been lost. In total, 203 species were recorded in the two periods, but less than half, 92 species, occurred in both sampling periods. A total of 174 species of bees were recorded from 1900-1919, and 121 species were recorded from 2000-2019, including 29 species not reported in 1900-1919. Notably, we report a reduction in the species composition among forage specialist bees from 26.4% to 15.7% of the bee fauna, a consistent and highly significant decline both when correcting for parasitic and social species. Pollen swabs from bees collected in the first period, 1900-1919, did not identify any plants that are not available today but documented a series of plants that were important to bees back then. These plants are still common today, such as Taraxacum and Salix. Our findings highlight the importance of local and historical faunistic studies, such as that of Jørgensen, who was a resident schoolteacher on the island of Lolland in southern Denmark, for documenting how changes over time affect the species composition in bee communities.

[Severe tophaceous gouty arthritis can be treated but is still overlooked in healthcare].

This is a case report of a 68-year-old male with severe tophaceous gouty arthritis, diabetes, kidney impairment and ischaemic heart disease. The patient had repeated attacks of acute gout during a 20-year period and excessive tophaceous depositions. Walking was severely hampered by feet deformity and pain. No urate-lowering therapy was initiated despite contacts to several medical specialties. After the diagnosis was established, the patient was finally treated with allopurinol with an obvious beneficial effect on his symptoms and the size of the tophaceous depositions.

Evaluating competition for forage plants between honey bees and wild bees in Denmark.

A recurrent concern in nature conservation is the potential competition for forage plants between wild bees and managed honey bees. Specifically, that the highly sophisticated system of recruitment and large perennial colonies of honey bees quickly exhaust forage resources leading to the local extirpation of wild bees. However, different species of bees show different preferences for forage plants. We here summarize known forage plants for honey bees and wild bee species at national scale in Denmark. Our focus is on floral resources shared by honey bees and wild bees, with an emphasis on both threatened wild bee species and foraging specialist species. Across all 292 known bee species from Denmark, a total of 410 plant genera were recorded as forage plants. These included 294 plant genera visited by honey bees and 292 plant genera visited by different species of wild bees. Honey bees and wild bees share 176 plant genera in Denmark. Comparing the pairwise niche overlap for individual bee species, no significant relationship was found between their overlap and forage specialization or conservation status. Network analysis of the bee-plant interactions placed honey bees aside from most other bee species, specifically the module containing the honey bee had fewer links to any other modules, while the remaining modules were more highly inter-connected. Despite the lack of predictive relationship from the pairwise niche overlap, data for individual species could be summarized. Consequently, we have identified a set of operational parameters that, based on a high foraging overlap (>70%) and unfavorable conservation status (Vulnerable+Endangered+Critically Endangered), can guide both conservation actions and land management decisions in proximity to known or suspected populations of these species.

Prehospital emergency medical technicians can perform ultrasonography and blood analysis in prehospital evaluation of patients with chronic obstructive pulmonary disease: a feasibility study.

INTRODUCTION: Crowding of the emergency departments is an increasing problem. Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are often treated in the emergency departments for a very short period before discharged to their homes. It is possible that this treatment could take place in the patients' homes with sufficient diagnostics supporting the treatment. In an effort to keep the diagnostics and treatment of some of these patients in their homes and thus to reduce the patient load at the emergency departments, we implemented a prehospital treat-and-release strategy based on ultrasonography and blood testing performed by emergency medical technicians (EMT) or paramedics (PM) in patients with acute exacerbation of COPD. METHOD: EMTs and PMs were enrolled in a six-hour educational program covering ultrasonography of the lungs and point of care blood tests. During the seasonal peak of COPD exacerbations (October 2018 - May 2019) all patients who were treated by the ambulance crews for respiratory insufficiency were screened in the ambulances. If the patient had uncomplicated COPD not requiring immediate transport to the hospital, ultrasonographic examination of the lungs, measurements of C-reactive protein and venous blood gases analyses were performed. The response to the initial treatment and the results obtained were discussed via telemedical consultation with a prehospital anaesthesiologist who then decided to either release the patient at the scene or to have the patient transported to the hospital. The primary outcome was strategy feasibility. RESULTS: We included 100 EMTs and PMs in the study. During the study period, 771 patients with respiratory insufficiency were screened. Uncomplicated COPD was rare as only 41patients were treated according to the treat-and-release strategy. Twenty of these patients (49%) were released at the scene. In further ten patients, technical problems were encountered hindering release at the scene. CONCLUSION: In a few selected patients with suspected acute exacerbations of COPD, it was technically and organisationally feasible for EMTs and PMs to perform prehospital POCT-ultrasound and laboratory testing and release the patients following treatment. None of the patients released at the scene requested a secondary ambulance within the first 48 h following the intervention.

Patients with severe gout treated in mixed settings.

INTRODUCTION We aimed to investigate whether patients with a definite gout diagnosis who were treated in mixed real-life settings (various hospital departments or general practice) followed treatment recommendations. METHODS We included all patients in the hospital's uptake area in 2015-2017 who had been diagnosed with gout after microscopy findings of urate crystals. Data regarding comorbidities and indications for urate-lowering therapy (ULT) were collected. The criteria for treatment success were a p-urate level less-than 6 mg/dl (less-than 0.36 mmol/l) or less-than 5 mg/dl (less-than 0.30 mmol/l) if tophi were present. All patients were followed up for 24 months. RESULTS The study included 100 patients with a median age of 70 years, and 82% of patients were males. An indication for ULT was present in 99 patients and initiated in 79 patients. Fourteen of these 99 patients died within one year. For the remaining 85 patients, p-urate was measured, and the target was reached by 22 (26%) patients, not reached by 33 (39%) patients and not measured in 30 (35%) patients. Treatment success was positively associated with a written treatment plan in the rheumatology record after microscopy, initiation of ULT in the clinic, provision of a gout leaflet, a higher number of outpatient visits and non-smoking status. CONCLUSIONS Many patients with crystal-proven gout did not receive ULT as recommended. Even if ULT was initiated, the p-urate level was monitored infrequently and the dose of ULT was not escalated when necessary. The best outcomes were associated with continued care in a rheumatology clinic. FUNDING none. TRIAL REGISTRATION The study was assessed by the Ethics Committee, which decided it was a quality assurance project and the study was subsequently approved by the Regions data protection office service with ID 2018-62.

Evaluation of Oral Health Status and Oral Care of Patients with Rheumatoid Arthritis.

OBJECTIVE: Rheumatoid arthritis (RA) and periodontal disease (PD) are common chronic, immunoinflammatory, destructive, and progressive diseases; however, the correlations between those two are not yet widely discussed. The purpose of this study was to evaluate the relationship between the selected demographic and clinical parameters of RA patients and oral health status parameters, on the basis of self-assessment. MATERIALS AND METHODS: Three hundred patients under treatment were included in the study. Questionnaires were completed by 164 out of 300 patients. RESULTS: A total of 100 females and 64 males took part in the study, with a mean age of 65 ± 11.1 years. In younger patients, the disease activity score (DAS28) was higher, and it was associated with pain or discomfort in the oral cavity and with difficulties in toothbrushing. Discomfort or pain in the oral cavity was to a significant extent associated with the poor gingival state, gingival bleeding, and difficulties in biting or chewing. CONCLUSIONS: In RA patients, difficulties in biting or chewing, discomfort or pain in oral cavity, feeling of the presence of movable teeth, and gingival bleeding are indications of periodontal infection. Maintaining awareness of oral health and RA is a key issue in the simultaneous management of proper oral care and RA due to the mutual influence of those two factors.

Biological therapy and international travel: A questionnaire survey among Danish patients with rheumatic disease.

OBJECTIVE: To describe travel activities, preparations, and health problems encountered by patients with arthritis receiving biological therapy. METHODS: A travel survey was conducted in a Danish rheumatology outpatient clinic by distribution of a semistructured questionnaire to 300 consecutive patients with arthritis. RESULTS: Among the 273 (91%) patients returning the questionnaire, a history of traveling outside Denmark was reported by 203 (74%) respondents and outside Europe by 92 (34%). In 81% of the patients, travel activities had not decreased after the initiation of biological treatment. However, 24% reported that they had become more cautious regarding the choice of travel destination. Pre-travel advice was sought by less than one-third of the patients, whereas travel insurance was taken out by 86%, but only half of them had disclosed information about the biological treatment. Treatment was discontinued temporarily while traveling in 26% of patients on subcutaneous biologics. The main reason for discontinuation was concern about transport and storage of medicine. Only 6% of the travelers had experienced health problems, which were of only minor importance. CONCLUSION: Treatment with biologics seems not to have any major influence on international travel activity among Danish patients with arthritis. Health problems when traveling were of minor importance. However, pre-travel advice issues, including treatment compliance, transport of medicine, and insurance coverage, need to be addressed proactively by the outpatient clinic staff as part of patient consultation.

[Findings in post-mortem CT and autopsy in a 53-year-old-man with COVID-19].

In this case report, a 53-year old man died after ten days with fever and coughing and was tested positive for coronavirus disease 2019 (COVID-19). A post-mortem CT disclosed ground-glass opacities with focal consolidation in both lungs. At autopsy, the lungs were dark and heavy with increased consistency and without pleural fibrin. Microscopy of lung tissue showed diffuse alveolar damage with hyaline membranes, sparse chronic interstitial inflammation and foci of bronchopneumonia. The deceased was a non-smoker, who did not suffer from a serious illness. He was overweight (BMI = 34 kg/m2), an emerging predictor for poor outcome of COVID-19.

Insufficiency fractures of the knee, ankle, and foot in rheumatoid arthritis: A case series and case-control study.

OBJECTIVE: To evaluate cases of insufficiency fractures verified by magnetic resonance imaging (MRI) of the knee, ankle, and foot in patients with rheumatoid arthritis (RA) cared for in our clinic over an 8-year period, to identify possible risk factors, and to test these in a case-control study. METHODS: All patients in the rheumatology clinic with RA were registered prospectively in the database, DANBIO. All MRIs ordered from the clinic were registered and coded according to the anatomical region. We were thus able to retrieve all patients with RA and performed an MRI of the knee or ankle/foot. The patients with fractures constituted the case series, and the patients without fractures constituted the control group. RESULTS: The RA clinic population comprised 1,624 patients who underwent a total of 70 MRIs. CASE SERIES: 39 insufficiency fractures were identified in 32 patients; 93% were women, and the median age was 68 years (range 33-89 years). Half of the patients had a T score >-2.5. The case control group without fractures comprised 38 patients; 74% were women, and the median age was 62 years (range 32-84 years). In the case series, 20 patients experienced later additional episodes of insufficiency fractures in the knee, ankle, or foot. CONCLUSION: Insufficiency fractures of the knee, ankle, and foot are a significant cause of pain and long-lasting disability in RA. Recurrent fractures are common. Diagnosis is often delayed and confused with arthritic activity. Conventional radiography and DEXA scan are often normal. Older age, female gender, radiological erosions in hand/wrist, and treatment with methotrexate were all significantly associated with fractures.

A primer of host-plant specialization in bees.

The bee-flower biological association is one of the most famous examples of insect-plant interactions, and it is axiomatic that these are of critical importance for sustaining thriving terrestrial ecosystems. Yet, the most familiar associations are often artificially managed agricultural ecosystems, reflecting an exceptionally narrow range of bee species (often only one) and a concomitantly restricted range of associated behaviors, morphologies, and mechanisms tied to pollination. Here we provide a brief account of the range of bee-floral associations encompassing floral specialization in terms of diet, behavior, and morphology. These natural associations not only promote healthy ecosystems, but also can be integrated in sustainable ways for more efficient pollination of crops by targeting bee species whose diets, behaviors, and pollen-gathering structures evolved precisely to visit such floral species rather than less efficient, and often non-native, generalists that are otherwise exploited for such purposes.