Impacts of fire and prospects for recovery in a tropical peat forest ecosystem.

Uncontrolled fires place considerable burdens on forest ecosystems, compromising our ability to meet conservation and restoration goals. A poor understanding of the impacts of fire on ecosystems and their biodiversity exacerbates this challenge, particularly in tropical regions where few studies have applied consistent analytical techniques to examine a broad range of ecological impacts over multiyear time frames. We compiled 16 y of data on ecosystem properties (17 variables) and biodiversity (21 variables) from a tropical peatland in Indonesia to assess fire impacts and infer the potential for recovery. Burned forest experienced altered structural and microclimatic conditions, resulting in a proliferation of nonforest vegetation and erosion of forest ecosystem properties and biodiversity. Compared to unburned forest, habitat structure, tree density, and canopy cover deteriorated by 58 to 98%, while declines in species diversity and abundance were most pronounced for trees, damselflies, and butterflies, particularly for forest specialist species. Tracking ecosystem property and biodiversity datasets over time revealed most to be sensitive to recurrent high-intensity fires within the wider landscape. These megafires immediately compromised water quality and tree reproductive phenology, crashing commercially valuable fish populations within 3 mo and driving a gradual decline in threatened vertebrates over 9 mo. Burned forest remained structurally compromised long after a burn event, but vegetation showed some signs of recovery over a 12-y period. Our findings demonstrate that, if left uncontrolled, fire may be a pervasive threat to the ecological functioning of tropical forests, underscoring the importance of fire prevention and long-term restoration efforts, as exemplified in Indonesia.

Central Sleep Apnea in Patients With Coronary Heart Disease Taking P2Y12 Inhibitors.

ABSTRACT: Central sleep apnea (CSA) is common in patients with heart failure. Recent studies link ticagrelor use with CSA. We aimed to evaluate CSA prevalence in patients with coronary heart disease (CHD) and whether ticagrelor use is associated with CSA. We reviewed consecutive patients with CHD who underwent a polysomnography (PSG) test over a 5-year period from 3 sleep centers. We sampled patients who were on ticagrelor or clopidogrel during a PSG test at a 1:4 ticagrelor:clopidogrel ratio. Patients with an active opioid prescription during PSG test were excluded. Age, left ventricle (LV) dysfunction, and P2Y12 inhibitor use were included in a multivariate logistic regression. A total of 135 patients were included with 26 on ticagrelor and 109 on clopidogrel (age 64.1 ± 11.4, 32% male). High CSA burden (12%) and strict CSA (4.4%) were more common in patients on ticagrelor than in those on clopidogrel (27% vs. 8.3% and 10.0% vs. 1.8%). Ticagrelor use (vs. clopidogrel) was associated with high CSA burden (OR 3.53, 95% CI 1.04-12.9, P = 0.039) and trended toward significance for strict CSA (OR 6.32, 95% CI 1.03-51.4, P = 0.052) when adjusting for age and LV dysfunction. In an additional analysis also adjusting for history of atrial fibrillation, ticagrelor use and strict CSA became significantly associated (OR 10.0, 95% CI 1.32-117, P = 0.035). CSA was uncommon in patients with CHD undergoing sleep studies. Ticagrelor use (vs. clopidogrel) was associated with high CSA burden and trended toward significance for strict CSA.

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences.

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.

Clinical and financial impact of sleep disordered breathing on heart failure admissions.

BACKGROUND: The impact of sleep disordered breathing (SDB) on heart failure (HF) is increasingly recognized. However, limited data exist in support of quantification of the clinical and financial impact of SDB on HF hospitalizations. METHODS: A sleep-heart registry included all patients who underwent inpatient sleep testing during hospitalization for HF at a single cardiac center. Readmission data and actual costs of readmissions were obtained from the institutional honest broker. Patients were classified based on the inpatient sleep study as having no SDB, obstructive sleep apnea (OSA), or central sleep apnea (CSA). Cumulative cardiac readmission rates and costs through 3 and 6 months post-discharge were calculated. Unadjusted and adjusted (age, sex, body mass index, and left ventricular ejection fraction) modeling of cost was performed. RESULTS: The cohort consisted of 1547 patients, 393 (25%) had no SDB, 438 (28%) had CSA, and 716 (46%) had OSA. Within 6 months of discharge, 195 CSA patients (45%), 264 OSA patients (37%), and 109 no SDB patients (28%) required cardiovascular readmissions. Similarly, 3- and 6-month mortality rates were higher in both SDB groups than those with no SDB. Both unadjusted and adjusted readmission costs were higher in the OSA and CSA groups compared to no SDB group at 3 and 6 months post-discharge with the CSA and OSA group costs nearly double (~ $16,000) the no SDB group (~ $9000) through 6 months. INTERPRETATION: Previously undiagnosed OSA and CSA are common in patients hospitalized with HF and are associated with increased readmissions rate and mortality.

Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.

BACKGROUND: The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced. METHODS: As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19-adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically. RESULTS: The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world. CONCLUSION: Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year.

Staged vs Concurrent Hardware Removal During Conversion Total Knee Arthroplasty.

BACKGROUND: Conversion total knee arthroplasty (TKA) in the presence of periarticular hardware can be associated with increased resource utilization, complications, and revisions. However, little guidance exists on the optimal approach to hardware removal. The purpose of this study is to compare outcomes of conversion TKA with hardware removal performed in either a staged or concurrent manner. METHODS: This is a retrospective study of 155 TKA operations performed with staged (45) or concurrent (110) removal of hardware at the time of TKA. Differences in patient data, case data, complications, reoperations, and revisions were evaluated. Subgroup comparisons of cases involving major hardware (plates, nails, rods), minor hardware (screws, buttons, wires), and tibial plates were performed. RESULTS: There were no differences in age, sex, body mass index, or comorbidities between patients who underwent staged or concurrent hardware removal. Rates of complications, reoperations, and revisions did not differ at multiple time points (90 days, 1 year, 2 years, 4 years). Patients who underwent staged hardware removal were more likely to have had prior surgery for fracture reconstruction (68% vs 33%, P < .001), to have had major hardware removed (84% vs 59%, P = .03), and were less likely to have had hardware removal performed through a single incision with TKA (50% vs 92%, P < .001). Subgroup analysis of major and minor hardware cases demonstrated comparable outcomes. CONCLUSION: There remains no established benefit to either a staged or concurrent approach to hardware removal at the time of TKA. This is true regardless of hardware burden. At this time, a case-by-case approach should be taken to conversion TKA in the presence of periarticular hardware.

Characterization of Post-Operative Opioid Use Following Total Joint Arthroplasty.

BACKGROUND: The purpose of our study is to examine post-operative opioid use in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and describe factors associated with the need for refill prescriptions. METHODS: Using online prescription information, we calculated the number of filled prescriptions, total morphine equivalent dose (MED) and quantity of pills, and date of last opioid prescription (days) for 197 TKA and 186 THA patients. Patients were classified based on refill status. Opioid data were compared between TKA and THA patients. Relationships between comorbidities and refill status were examined. RESULTS: Number of prescriptions (P < .001), total quantity (P < .001) and MED (P < .001), and days on opioids (P < .001) were greater for TKA patients. TKA patients required more refills (P < .001) for a greater quantity of pills (P = .007). The presence of a comorbidity (P = .003) or anxiety/depression (P = .004) were correlated with refills for TKA patients only. A comorbidity increased the risk of refills by 3.1 times, while anxiety/depression had a 2.5 times greater risk of refills. CONCLUSION: Compared to THA patients, TKA patients were twice as likely to require refill opioid prescriptions and were prescribed a greater total MED for a longer period of time post-operatively. Patients undergoing TKA who present with a comorbidity or are currently being treated for anxiety or depression are more likely to require a refill.

Small Changes Yield Large Results at NIST's Net-Zero Energy Residential Test Facility.

The Net-Zero Energy Residential Test Facility (NZERTF) was designed to be approximately 60 % more energy efficient than homes meeting the 2012 International Energy Conservation Code (IECC) requirements. The thermal envelope minimizes heat loss/gain through the use of advanced framing and enhanced insulation. A continuous air/moisture barrier resulted in an air exchange rate of 0.6 air changes per hour at 50 Pa. The home incorporates a vast array of extensively monitored renewable and energy efficient technologies including an air-to-air heat pump system with a dedicated dehumidification cycle; a ducted heat-recovery ventilation system; a whole house dehumidifier; a photovoltaic system; and a solar domestic hot water system. During its first year of operation the NZERTF produced an energy surplus of 1023 kWh. Based on observations during the first year, changes were made to determine if further improvements in energy performance could be obtained. The changes consisted of installing a thermostat that incorporated control logic to minimize the use of auxiliary heat, using a whole house dehumidifier in lieu of the heat pump's dedicated dehumidification cycle, and reducing the ventilation rate to a value that met but did not exceed code requirements. During the second year of operation the NZERTF produced an energy surplus of 2241 kWh. This paper describes the facility, compares the performance data for the two years, and quantifies the energy impact of the weather conditions and operational changes.

Complications of Total Hip Arthroplasty: Standardized List, Definitions, and Stratification Developed by The Hip Society.

BACKGROUND: Reporting of complications after total hip arthroplasty (THA) is not standardized, and it is done inconsistently across various studies on the topic. Advantages of standardizing complications include improved patient safety and outcomes and better reporting in comparative studies. QUESTIONS/PURPOSES: The purpose of this project was to develop a standardized list of complications and adverse events associated with THA, develop standardized definitions for each complication, and stratify the complications. A further purpose was to validate these standardized THA complications. METHODS: The Hip Society THA Complications Workgroup proposed a list of THA complications, definitions for each complication, and a stratification scheme for the complications. The stratification system was developed from a previously validated grading system for complications of hip preservation surgery. The proposed complications, definitions, and stratification were validated with an expert opinion survey of members of The Hip Society, a case study evaluation, and analysis of a large administrative hospital system database with a focus on readmissions. RESULTS: One hundred five clinical members (100%) of The Hip Society responded to the THA complications survey. Initially, 21 THA complications were proposed. The validation process reduced the 21 proposed complications to 19 THA complications with definitions and stratification that were endorsed by The Hip Society (bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, dislocation/instability, periprosthetic fracture, abductor muscle disruption, deep periprosthetic joint infection, heterotopic ossification, bearing surface wear, osteolysis, implant loosening, cup-liner dissociation, implant fracture, reoperation, revision, readmission, death). CONCLUSIONS: Acceptance and use of these standardized, stratified, and validated THA complications and adverse events could advance reporting of outcomes of THA and improve assessment of THA by clinical investigators. LEVEL OF EVIDENCE: Level V, therapeutic study.

Preventing Hospital Readmissions and Limiting the Complications Associated With Total Joint Arthroplasty.

Total joint arthroplasty is a highly successful surgical procedure for patients who have painful arthritic joints. The increasing prevalence of total joint arthroplasty is generating substantial expenditures in the American healthcare system. Healthcare payers, specifically the Centers for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, which has resulted in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and to decrease the number of readmissions after total joint arthroplasty. In addition, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may decrease the number of unnecessary hospital readmissions. Identified modifiable risk factors that substantially contribute to poor clinical outcomes after total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if defined total joint arthroplasty complications are standardized and stratification schemes are used to identify high-risk patients. Subsequently, clinical intervention will be warranted to address modifiable risk factors before proceeding with total joint arthroplasty.

An assessment of efficient water heating options for an all-electric single family residence in a mixed-humid climate.

An evaluation of a variety of efficient water heating strategies for an all-electric single family home located in a mixed-humid climate is conducted using numerical modeling. The strategies considered include various combinations of solar thermal, heat pump, and electric resistance water heaters. The numerical model used in the study is first validated against a year of field data obtained on a dual-tank system with a solar thermal preheat tank feeding a heat pump water heater that serves as a backup. Modeling results show that this configuration is the most efficient of the systems studied over the course of a year, with a system coefficient of performance (COPsys) of 2.87. The heat pump water heater alone results in a COPsys of 1.9, while the baseline resistance water heater has a COPsys of 0.95. Impacts on space conditioning are also investigated by considering the extra energy consumption required of the air source heat pump to remove or add heat from the conditioned space by the water heating system. A modified COPsys that incorporates the heat pump energy consumption shows a significant drop in efficiency for the dual tank configuration since the heat pump water heater draws the most heat from the space in the heating season while the high temperatures in the solar storage tank during the cooling season result in an added heat load to the space. Despite this degradation in the COPsys, the combination of the solar thermal preheat tank and the heat pump water heater is the most efficient option even when considering the impacts on space conditioning.

Can Administrative Data Be Used to Analyze Complications Following Total Joint Arthroplasty?

We hypothesized that the Centers for Medicare and Medicaid Services Limited Dataset (CMS-LDS) could be used to validate the complications associated with total hip and knee arthroplasty (THA and TKA) endorsed by the Hip and Knee Societies. Using ICD-9 procedure and diagnosis codes, cases were extracted from the first three quarters of the 2009 CMS-LDS to allow all complications within 90-days be captured in the same calendar year. We were unable to validate the Hip and Knee Societies' complications as we could not connect readmissions or outpatient visits to index admissions. In addition, well-known complications were not detected, raising concerns about coding accuracy and stratification. Furthermore, the assignment of outpatient and inpatient codes allows for duplication of complications which may falsely elevate the true incidence.

Stratification of standardized TKA complications and adverse events: a brief communication.

BACKGROUND: The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. QUESTIONS/PURPOSES: The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. METHODS: A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. RESULTS: The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. CONCLUSIONS: Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.

High-dose insulin and intravenous lipid emulsion therapy for cardiogenic shock induced by intentional calcium-channel blocker and Beta-blocker overdose: a case series.

BACKGROUND: Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe toxicity from calcium-channel blocker (CCB) and beta blocker (BB). OBJECTIVE: Our aim was to describe the use and effectiveness of HDI and ILE for the treatment of CCB and BB overdose. CASE REPORTS: We describe 2 patients presenting to the emergency department after intentional ingestions of CCBs and BBs. A 35-year-old man presented in pulseless electrical activity after ingesting amlodopine, verapamil, and metoprolol. A 59-year-old man presented with cardiogenic shock (CS) after ingesting amlodopine, simvastatin, lisinopril, and metformin. Both patients were initially treated with glucagon, calcium, and vasopressors. Shortly after arrival, HDI (1 unit/kg × 1; 1 unit/kg/h infusion) and ILE 20% (1.5 mL/kg × 1; 0.25 mL/kg/min × 60 min) were initiated. This led to hemodynamic improvement and resolution of shock. At the time of hospital discharge, both patients had achieved full neurologic recovery. CONCLUSIONS: HDI effectively reverses CS induced by CCBs and BBs due to its inotropic effects, uptake of glucose into cardiac muscle, and peripheral vasodilatation. ILE is theorized to sequester agents dependent on lipid solubility from the plasma, preventing further toxicity. To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing CS induced by intentional ingestions of CCBs and BBs.

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance.

Obstructive sleep apnea (OSA) is the most common respiratory sleep disorder in the United States in preschool and school-aged children. In an effort to continue addressing gaps and variations in care in this patient population, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force performed quality measure maintenance on the Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea (originally developed in 2015). The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing pediatric OSA quality measures, and performance data highlighting remaining gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. These revised quality measures have been implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous quality improvement, specifically in outcomes associated with diagnosing and managing OSA in the pediatric population. CITATION: Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

Complications of total knee arthroplasty: standardized list and definitions of the Knee Society.

BACKGROUND: Despite the importance of complications in evaluating patient outcomes after TKA, definitions of TKA complications are not standardized. Different investigators report different complications with different definitions when reporting outcomes of TKA. QUESTIONS/PURPOSES: We developed a standardized list and definitions of complications and adverse events associated with TKA. METHODS: In 2009, The Knee Society appointed a TKA Complications Workgroup that surveyed the orthopaedic literature and proposed a list of TKA complications and adverse events with definitions. An expert opinion survey of members of The Knee Society was used to test the applicability and reasonableness of the proposed TKA complications. For each complication, members of The Knee Society were asked "Do you agree with the inclusion of this complication as among the minimum necessary for reporting outcomes of knee arthroplasty?" and "Do you agree with this definition?" RESULTS: One hundred two clinical members (100%) of The Knee Society responded to the survey. All proposed complications and definitions were endorsed by the members, and 678 suggestions were incorporated into the final work product. The 22 TKA complications and adverse events include bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, medial collateral ligament injury, instability, malalignment, stiffness, deep joint infection, fracture, extensor mechanism disruption, patellofemoral dislocation, tibiofemoral dislocation, bearing surface wear, osteolysis, implant loosening, implant fracture/tibial insert dissociation, reoperation, revision, readmission, and death. CONCLUSIONS: We identified 22 complications and adverse events that we believe are important for reporting outcomes of TKA. Acceptance and utilization of these standardized TKA complications may improve evaluation and reporting of TKA outcomes.

Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force.

The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. Total hip and knee arthroplasties are viewed as ideal treatments to test the effectiveness of this payment model. Providers must learn the nuances of these modified care delivery concepts and evaluate whether their environment is conducive to success in this arena. This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.