What interventions add value in lateral compression type 1 fragility pelvis fractures? A retrospective cohort study.

Introduction: Fragility fractures are a large source of morbidity and mortality in the elderly. Orthopaedic surgeons are regularly the main point of contact in patients with lateral compression type 1 pelvis fractures, despite many of these being treated non-operatively. This study aims to identify risk factors for mortality and elucidate which follow-up visits have the potential to improve care for these patients. Methods and materials: In all, 211 patients have been identified with fragility lateral compression type 1 fractures at a level 1 trauma centre over a 5-year period. For all patients, we recorded patient demographics, imaging data, hospital readmissions, medical complications and death dates if applicable. Results: Of the 211 patients identified, 56.4% had at least one orthopaedic follow-up, of which no patient had a clinically meaningful medical intervention initiated. 30-day readmission rate was 19%, and 1-year mortality was 24%. Male sex, need for an assist device, higher Charlson Comorbidity Index and increased age were found to be statistically associated with increased risk of mortality. Patients who followed up with their primary care physician were found to have a statistically lower risk of mortality. Computed tomography scans were obtained in 70% of patients and never limited patient weight-bearing status or found any additional injury not already identified on the radiograph. Discussion/Conclusions: For patients with lateral compression type 1 type fragility fractures, orthopaedic surgeons did not offer additional clinically meaningful intervention after the time of initial diagnosis in this patient cohort. The rate of clinical follow-up with a primary care physician is relatively low despite high rates of medical comorbidity. Computed tomography scans were utilised frequently but did not change recommendations. The high rate of medical complications and lack of orthopaedic intervention suggest that we should re-evaluate the role of the orthopaedic surgeon versus the primary care physician as the primary point of medical contact for patients with these injuries.

Pharmacoequity and Biologics in the Allergy Clinic: Providing the Right Care, at the Right Time, Every Time, to Everyone.

Pharmacoequity refers to equity in access to pharmacotherapy for all patients and is an especially large barrier to biologic agents in patients with allergic diseases. Value-based care models can prompt clinicians to address social determinants of health, promoting pharmacoequity. Pharmacoequity is influenced by numerous factors including socioeconomic status, which may be mediated through insurance status, educational attainment, and access to specialist care. In addition to lower socioeconomic status, race and ethnicity, age, locations isolated from care systems, and off-label indications for biologic agents all constitute barriers to pharmacoequity. Whereas pharmaco-inequity is more apparent for expensive biologics, it also affects many other allergy treatments including epinephrine autoinjectors and SMART for asthma. Current programs aimed at alleviating cost barriers are imperfect. Patient assistance programs, manufacturer-sponsored free drug programs, and rebates often increase the complexity of care, with resultant inequity, particularly for patients with lower health literacy. Ultimately, single silver-bullet solutions are elusive. Long-term improvement instead requires a combination of research, advocacy, and creative problem-solving to design more intelligent and efficient systems that provide timely access to necessary care for every patient, every time.

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy.

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Patient-Centered Practice Guidelines: GRADEing Evidence to Incorporate Certainty, Balance Between Benefits and Harms, Equity, Feasibility, and Cost-Effectiveness.

The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine.

Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions.

Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.

Reducing the Environmental Impact of Health Care Conferences: A Study of Emissions and Practical Solutions.

PURPOSE: We aimed to examine the impact of different conference formats (in-person, virtual, and hybrid) of the ASCO conference on greenhouse gas (GHG) emissions and to recommend sustainable options for future conferences. MATERIALS AND METHODS: This study used data on the number of attendees, their departure locations, and the type of attendance (in-person v virtual) provided by ASCO between 2019 and 2022. The GHG emissions resulting from air and ground travel, remote connectivity, conference space utilization, hotel stays, distributed conference materials, and electricity use were estimated for each year. Emissions were stratified by attendee country of origin, type of attendance, and year. Simulations were conducted to evaluate how changes in conference size, location, and format impact emissions, as well as estimate the resulting mitigations from adopting the proposed changes. RESULTS: The highest estimated GHG emissions, calculated in carbon dioxide equivalents (CO2e), were associated with the 2019 in-person conference (37,251 metric tons of CO2e). Although international attendees had the largest contribution to emissions in all years (>50%), location optimization models, which selected conference locations that most minimized GHG emissions, yielded only minimal reductions (approximately 3%). Simulations examining changes to the conference format, location, and attendance percentage suggested that hub-and-spoke, where multiple conference locations are selected by global region, or hybrid models, with both in-person and virtual components, are likely to cause the largest drops in emissions (up to 86%). CONCLUSION: Using historical conference data, this study identifies key aspects that can be modified to reduce emissions and consequently promote more sustainable and equitable conference attendance. Hybrid conferences may be the best solution to maintain the networking opportunities provided by conferences while balancing out their environmental footprint.

Serologic measurements for peanut allergy: Predicting clinical severity is complex.

Allergist-immunologists use serologic peanut allergy testing to maximize test sensitivity and specificity while minimizing cost and inconvenience. Recent advances toward this goal include a better understanding of specific IgE (sIgE) and component testing, epitope-sIgE assays, and basophil activation testing. Predicting reaction severity with serologic testing is challenged by a range of co-factors that influence reaction severity, such as the amount and form of any allergen consumed and comorbid disease. In 2020, the Allergy Immunology Joint Task Force on Practice Parameters recommended Ara h 2-sIgE as the most cost-effective diagnostic test for peanut allergy because of its superior performance, when compared with skin prick testing and serum IgE. Basophil activation testing, a functional test of allergic response not evaluated in the Joint Task Force on Practice Parameters guideline, is a promising option for both allergy diagnosis and prognosis. Similarly, epitope-sIgE testing may improve prediction of reaction thresholds, but further validation is needed. Despite advances in food allergy testing, many of these tools remain limited by cost, accessibility, and feasibility. In addition, there is a need for further research on how atopic dermatitis may be modifying serologic food allergy severity assessments. Given these limitations, allergy test selection requires a shared decision-making approach so that a patient's values and preferences regarding financial impact, inconvenience, and psychological effects are considered in the context of clinician expertise on the timing and use of optimized testing.

Distance Traveled by Patients Globally to Access Radiation Therapy: A Systematic Review.

PURPOSE: This study aimed to systematically review the literature on the travel patterns of patients seeking radiation therapy globally. It examined the distance patients travel for radiation therapy as well as secondary outcomes, including travel time. METHODS AND MATERIALS: A comprehensive search of 4 databases was conducted from June 2022 to August 2022. Studies were included in the review if they were observational, retrospective, randomized/nonrandomized, published between June 2000 and June 2022, and if they reported on the global distance traveled for radiation therapy in the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English. RESULTS: Of the 168 studies, most were conducted in North America (76.3%), with 90.7% based in the United States. Radiation therapy studies for treating patients with breast cancer were the most common (26.6%), while external beam radiation therapy was the most prevalent treatment modality (16.6%). Forty-six studies reported the mean distance traveled for radiation therapy, with the shortest being 4.8 miles in the United States and the longest being 276.5 miles in Iran. It was observed that patients outside of the United States traveled greater distances than those living within the United States. Geographic location, urban versus rural residence, and patient population characteristics affected the distance patients traveled for radiation therapy. CONCLUSIONS: This systematic review provides the most extensive summary to date of the travel patterns of patients seeking radiation therapy globally. The results suggest that various factors may contribute to the variability in travel distance patterns, including treatment center location, patient residence, and treatment modality. Overall, the study highlights the need for more research to explore these factors and to develop effective strategies for improving radiation therapy access and reducing travel burden.

Growing up with allergies: Transitioning from adolescence to adulthood.

Allergic disease management for adolescents and young adults requires consideration of unique psychosocial challenges and opportunities. Erik Erikson's model for the Stages of Psychosocial Development is a useful lens through which we can understand adolescent and young adult experiences with allergic and immunologic disease, particularly with regard to identity and relationship development. It is important to provide anticipatory guidance for patients who are transitioning environments (eg, home to college), with attention to the anxiety-provoking demands for increased responsibility on top of new stressors such as academic and vocational demands. It is critical that health care professionals use an empathetic, shared decision-making approach regarding the emotional impact of allergy on a patient's social engagement. A patient's ability to develop positive lifelong habits is also shaped by their environment's "culture of wellness," and clinicians can encourage habits to promote healthy choices and effective disease management. Social media provides opportunities and challenges as a conduit for both social connection and possible misinformation. Overall, allergic disease management in adolescents and young adults is a "high-risk, high-reward" period of time-and with awareness, anticipation, and proactive action, health care professionals can better serve patients by leveraging this transitional period to promote positive approaches to management of allergies and asthma, trusting relationships, and personal responsibility.

Agroecosystem edge effects on vegetation, soil properties, and the soil microbial community in the Canadian prairie.

Edge effects resulting from adjacent land uses are poorly understood in agroecosystems yet understanding above and belowground edge effects is crucial for maintaining ecosystem function. The aim of our study was to examine impacts of land management on aboveground and belowground edge effects, measured by changes in plant community, soil properties, and soil microbial communities across agroecosystem edges. We measured plant composition and biomass, soil properties (total carbon, total nitrogen, pH, nitrate, and ammonium), and soil fungal and bacterial community composition across perennial grassland-annual cropland edges. Edge effects due to land management were detected both aboveground and belowground. The plant community at the edge was distinct from the adjacent land uses, where annual, non-native, plant species were abundant. Soil total nitrogen and carbon significantly decreased across the edge (P < 0.001), with the highest values in the perennial grasslands. Both bacterial and fungal communities were different across the edge with clear changes in fungal communities driven directly and indirectly by land management. A higher abundance of pathogens in the more heavily managed land uses (i.e. crop and edge) was detected. Changes in plant community composition, along with soil carbon and nitrogen also influenced the soil fungal community across these agroecosystems edges. Characterizing edge effects in agroecosystem, especially those associated with soil microbial communities, is an important first step in ensuring soil health and resilience in these managed landscapes.

Response to Mindfulness-Based Cognitive Therapy Differs Between Chronic and Episodic Migraine.

OBJECTIVE: Evaluate whether the benefits of Mindfulness-Based Cognitive Therapy for Migraine (MBCT-M) on headache disability differs among people with episodic and chronic migraine (CM). METHODS: This is a planned secondary analysis of a randomized clinical trial. After a 30-day baseline, participants were stratified by episodic (6-14 d/mo) and CM (15-30 d/mo) and randomized to 8 weekly individual sessions of MBCT-M or wait list/treatment as usual (WL/TAU). Primary outcomes (Headache Disability Inventory; Severe Migraine Disability Assessment Scale [scores ≥ 21]) were assessed at months 0, 1, 2, and 4. Mixed models for repeated measures tested moderation with fixed effects of treatment, time, CM, and all interactions. Planned subgroup analyses evaluated treatment*time in episodic and CM. RESULTS: Of 60 participants (MBCT-M N = 31, WL/TAU N = 29), 52% had CM. CM moderated the effect of MBCT-M on Severe Migraine Disability Assessment Scale, F(3, 205) = 3.68, p = 0.013; MBCT-M vs WL/TAU reduced the proportion of people reporting severe disability to a greater extent among people with episodic migraine (-40.0% vs -14.3%) than CM (-16.4% vs +8.7%). Subgroup analysis revealed MBCT-M (vs WL/TAU) significantly reduced Headache Disability Inventory for episodic (p = 0.011) but not CM (p = 0.268). CONCLUSIONS: MBCT-M is a promising treatment for reducing headache-related disability, with greater benefits in episodic than CM. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT02443519. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that MBCT-M reduces headache disability to a greater extent in people with episodic than CM.

Soil Buffering Capacity Can Be Used To Optimize Biostimulation of Psychrotrophic Hydrocarbon Remediation.

Effective bioremediation of hydrocarbons requires innovative approaches to minimize phosphate precipitation in soils of different buffering capacities. Understanding the mechanisms underlying sustained stimulation of bacterial activity remains a key challenge for optimizing bioremediation-particularly in northern regions. Positron emission tomography (PET) can trace microbial activity within the naturally occurring soil structure of intact soils. Here, we use PET to test two hypotheses: (1) optimizing phosphate bioavailability in soil will outperform a generic biostimulatory solution in promoting hydrocarbon remediation and (2) oligotrophic biostimulation will be more effective than eutrophic approaches. In so doing, we highlight the key bacterial taxa that underlie aerobic and anaerobic hydrocarbon degradation in subarctic soils. In particular, we showed that (i) optimized phosphate bioavailability outperformed generic biostimulatory solutions in promoting hydrocarbon degradation, (ii) oligotrophic biostimulation is more effective than eutrophic approaches, and (iii) optimized biostimulatory solutions stimulated specific soil regions and bacterial consortia. The knowledge gleaned from this study will be crucial in developing field-scale biodegradation treatments for sustained stimulation of bacterial activity in northern regions.

Compilation and Analysis of Web-Based Orthopedic Personalized Predictive Tools: A Scoping Review.

Web-based personalized predictive tools in orthopedic surgery are becoming more widely available. Despite rising numbers of these tools, many orthopedic surgeons may not know what tools are available, how these tools were developed, and how they can be utilized. The aim of this scoping review is to compile and synthesize the profile of existing web-based orthopedic tools. We conducted two separate PubMed searches-one a broad search and the second a more targeted one involving high impact journals-with the aim of comprehensively identifying all existing tools. These articles were then screened for functional tool URLs, methods regarding the tool's creation, and general inputs and outputs required for the tool to function. We identified 57 articles, which yielded 31 unique web-based tools. These tools involved various orthopedic conditions (e.g., fractures, osteoarthritis, musculoskeletal neoplasias); interventions (e.g., fracture fixation, total joint arthroplasty); outcomes (e.g., mortality, clinical outcomes). This scoping review highlights the availability and utility of a vast array of web-based personalized predictive tools for orthopedic surgeons. Increased awareness and access to these tools may allow for better decision support, surgical planning, post-operative expectation management, and improved shared decision-making.

Examining a Statewide Educational Consulting Program for Pediatric Brain Injury.

This study describes characteristics of students with acquired brain injury enrolled in a statewide educational consultation program and the program's support activities. Utilizing deidentified data from a statewide brain injury school consultation program, descriptive analyses of demographic and injury characteristics, including medical diagnosis (concussion/mild traumatic brain injury [TBI], moderate-severe TBI, and non-TBI), referral characteristics, educational placement, and the types of program activities were undertaken. 70% of students were referred for concussions/mild TBI and students were infrequently referred by medical professionals. Most students with concussion/mild TBI experienced recreational injuries (59%), while students with moderate/severe TBI commonly experienced road traffic injuries (48%). The greatest proportion of program team members' time was spent in consultation with school personnel (24%), communication with families (20%), and communication with school personnel (16%). Results suggest that the program addresses important communication and coordination needs among families, medical professionals, and educators and identifies opportunities to enhance program utilization.

Economic burden of sarcoidosis in a commercially-insured population in the United States.

BACKGROUND: Sarcoidosis is a multi-system inflammatory disorder characterized by the presence of non-caseating granulomas in involved organs. Patients with sarcoidosis have a reduced quality-of-life and are at an increased risk for several comorbidities. Little is known about the direct and indirect cost of sarcoidosis following the initial diagnosis. AIMS: To provide an estimate of the healthcare resource utilization (HCRU) and costs borne by commercial payers for sarcoidosis patients in the US. METHODS: Patients with a first diagnosis of sarcoidosis between January 1, 1998 and March 31, 2015 ("index date") were selected from a de-identified privately-insured administrative claims database. Sarcoidosis patients were required to have continuous health plan enrollment 12 months prior to and following their index dates. Propensity-score (1:1) matching of sarcoidosis patients with non-sarcoidosis controls was carried out based on a logistic regression of baseline characteristics. Burden of HCRU and work loss (disability days and medically-related absenteeism) were compared between the matched groups over the 12-month period following the index date ("outcome period"). RESULTS: A total of 7,119 sarcoidosis patients who met the selection criteria were matched with a control. Overall, commercial payers incurred $19,714 in mean total annual healthcare costs per sarcoidosis patient. The principle cost drivers were outpatient visits ($9,050 2015 USD, 46%) and inpatient admissions ($6,398, 32%). Relative to controls, sarcoidosis patients had $5,190 (36%) higher total healthcare costs ($19,714 vs $14,524; p < 0.001). Sarcoidosis patients also had significantly more work loss days (15.9 vs 11.3; p < 0.001) and work loss costs ($3,288 vs $2,527; p < 0.001) than matched controls. Sarcoidosis imposes an estimated total direct medical cost of $1.3-$8.7 billion to commercial payers, and an indirect cost of $0.2-$1.5 billion to commercial payers in work loss. CONCLUSIONS: Sarcoidosis imposes a significant economic burden to payers in the first year following diagnosis.

Impacts of fire on non-native plant recruitment in black spruce forests of interior Alaska.

Climate change is expected to increase the extent and severity of wildfires throughout the boreal forest. Historically, black spruce (Picea mariana (Mill.) B.S.P.) forests in interior Alaska have been relatively free of non-native species, but the compounding effects of climate change and an altered fire regime could facilitate the expansion of non-native plants. We tested the effects of wildfire on non-native plant colonization by conducting a seeding experiment of non-native plants on different substrate types in a burned black spruce forest, and surveying for non-native plants in recently burned and mature black spruce forests. We found few non-native plants in burned or mature forests, despite their high roadside presence, although invasion of some burned sites by dandelion (Taraxacum officinale) indicated the potential for non-native plants to move into burned forest. Experimental germination rates were significantly higher on mineral soil compared to organic soil, indicating that severe fires that combust much of the organic layer could increase the potential for non-native plant colonization. We conclude that fire disturbances that remove the organic layer could facilitate the invasion of non-native plants providing there is a viable seed source and dispersal vector.