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Background The recommended readability of online health education materials is at or below the sixth- to eighth-grade level. Nevertheless, more than a decade of research has demonstrated that most online education materials pertaining to orthopaedic surgery do not meet these recommendations. The repeated evidence of this limited progress underscores that unaddressed barriers exist to improving readability, such as the added time and cost associated with writing easily readable materials that cover complex topics. Freely available artificial intelligence (AI) platforms might facilitate the conversion of patient-education materials at scale, but to our knowledge, this has not been evaluated in orthopaedic surgery. Questions/purposes (1) Can a freely available AI dialogue platform rewrite orthopaedic patient education materials to reduce the required reading skill level from the high-school level to the sixth-grade level (which is approximately the median reading level in the United States)? (2) Were the converted materials accurate, and did they retain sufficient content detail to be informative as education materials for patients? Methods Descriptions of lumbar disc herniation, scoliosis, and spinal stenosis, as well as TKA and THA, were identified from educational materials published online by orthopaedic surgery specialty organizations and leading orthopaedic institutions. The descriptions were entered into an AI dialogue platform with the prompt "translate to fifthgrade reading level" to convert each group of text at or below the sixth-grade reading level. The fifth-grade reading level was selected to account for potential variation in how readability is defined by the AI platform, given that there are several widely used preexisting methods for de- fining readability levels. The Flesch Reading Ease score and Flesch-Kincaid grade level were determined for each description before and after AI conversion. The time to convert was also recorded. Each education material and its respective conversion was reviewed for factual inaccuracies, and each conversion was reviewed for its retention of sufficient detail for intended use as a patient education document. Results As presented to the public, the current descriptions of herniated lumbar disc, scoliosis, and stenosis had median (range) Flesch-Kincaid grade levels of 9.5 (9.1 to 10.5), 12.6 (10.8 to 15), and 10.9 (8 to 13.6), respectively. After conversion by the AI dialogue platform, the median Flesch-Kincaid grade level scores for herniated lumbar disc, scoliosis, and stenosis were 5.0 (3.3 to 8.2), 5.6 (4.1 to 7.3), and 6.9 (5 to 7.8), respectively. Similarly, descriptions of TKA and THA improved from 12.0 (11.2 to 13.5) to 6.3 (5.8 to 7.6) and from 11.6 (9.5 to 12.6) to 6.1 (5.4 to 7.1), respectively. The Flesch Reading Ease scores followed a similar trend. Seconds per sentence conversion was median 4.5 (3.3 to 4.9) and 4.5 (3.5 to 4.8) for spine conditions and arthroplasty, respectively. Evaluation of the materials that were converted for ease of reading still provided a suffi- cient level of nuance for patient education, and no factual errors or inaccuracies were identified. Conclusion We found that a freely available AI dialogue platform can improve the reading accessibility of orthopaedic surgery online patient education materials to recommended levels quickly and effectively. Professional organizations and practices should determine whether their patient education materials exceed current recommended reading levels by using widely available measurement tools, and then apply an AI dialogue platform to facilitate converting their materials to more accessible levels if needed. Additional research is needed to determine whether this technology can be applied to additional materials meant to inform patients, such as surgical consent documents or postoperative instructions, and whether the methods presented here are applicable to non--English language materials. [ABSTRACT FROM AUTHOR]

Because use of high-resolution hydrologic models is becoming more widespread and estimates are made over large domains, there is a pressing need for systematic evaluation of their performance. Most evaluation efforts to date have focused on smaller basins that have been relatively undisturbed by human activity, but there is also a need to benchmark model performance more comprehensively, including basins impacted by human activities. This study benchmarks the long-term performance of two process-oriented, high-resolution, continental-scale hydrologic models that have been developed to assess water availability and risks in the United States (US): the National Water Model v2.1 application of WRF-Hydro (NWMv2.1) and the National Hydrologic Model v1.0 application of the Precipitation–Runoff Modeling System (NHMv1.0). The evaluation is performed on 5390 streamflow gages from 1983 to 2016 (∼ 33 years) at a daily time step, including both natural and human-impacted catchments, representing one of the most comprehensive evaluations over the contiguous US. Using the Kling–Gupta efficiency as the main evaluation metric, the models are compared against a climatological benchmark that accounts for seasonality. Overall, the model applications show similar performance, with better performance in minimally disturbed basins than in those impacted by human activities. Relative regional differences are also similar: the best performance is found in the Northeast, followed by the Southeast, and generally worse performance is found in the Central and West areas. For both models, about 80 % of the sites exceed the seasonal climatological benchmark. Basins that do not exceed the climatological benchmark are further scrutinized to provide model diagnostics for each application. Using the underperforming subset, both models tend to overestimate streamflow volumes in the West, which could be attributed to not accounting for human activities, such as active management. Both models underestimate flow variability, especially the highest flows; this was more pronounced for NHMv1.0. Low flows tended to be overestimated by NWMv2.1, whereas there were both over and underestimations for NHMv1.0, but they were less severe. Although this study focused on model diagnostics for underperforming sites based on the seasonal climatological benchmark, metrics for all sites for both model applications are openly available online. [ABSTRACT FROM AUTHOR]

This study was conducted to evaluate the prevalence and risk factors for work-related respiratory conditions (asthma, farmer's lung, sinusitis, rhinitis, and environmental allergies, diagnosed by a physician) among farm and ranch operators in the central US. A survey was conducted by the Central States Center for Agricultural Safety and Health (CS-CASH) in 2018, focusing on work-related injuries, illnesses, exposures, and preventive measures in a seven-state region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota). Farms and ranches (n = 16,818) with an email address and annual sales exceeding $5,000 were randomly selected for the survey. Agricultural production and weather data were merged with survey responses. The relationship between exposures and respiratory conditions was analyzed using generalized estimating equations. We received responses from 3,268 agricultural operations (19% response rate) containing information on 4,064 individual operators. The life-time prevalence of (any) respiratory conditions among farm/ranch operators was 18%. Risk factors for respiratory conditions included exposures to grain/hay/feed dust (OR 2.41), animal confinement dust (OR 1.57), field/road dust (OR 2.11), manure/silage gasses (OR 1.66), anhydrous ammonia (OR 1.51), fuels/solvents/paints (OR 1.92), older age group >70 vs. <43 (OR 1.40), female gender (OR 1.82), and being primary vs. third operator (OR 1.61). Farmers and ranchers have a high prevalence of respiratory conditions associated with dust and gas exposures at work. More effective protective measures are needed using the hierarchy of controls, including improved use of respiratory protection. [ABSTRACT FROM AUTHOR]

Over the last century, droughts have caused more deaths internationally than any other weather- or climate-related disaster. Like other natural disasters, droughts cause significant changes in the environment that can lead to negative health outcomes. As droughts are becoming more frequent and intense with climate change, public health systems need to address impacts associated with these events. Partnering with federal and local entities, we evaluated the state of knowledge of drought and health in the United States through a National Drought and Public Health Summit and a series of subsequent regional workshops. The intended outcome was to develop public health strategies for implementing activities to better support and prepare public health systems for future droughts. The information gathered from this work identified multiple policy and law options to address the public health issues associated with drought. These policy recommendations include the use of public health emergency declarations for drought events, increased usage of preparedness evaluations for drought emergencies, and engagement of drought and climate experts in state and local risk assessments. As drought events are projected to increase in frequency and magnitude with climate change, taking policy action now will help decrease the health impacts of drought and save lives. [ABSTRACT FROM AUTHOR]

Background: Little is known about the effect of drought on all-cause mortality, especially in higher income countries such as the United States. As the frequency and severity of droughts are likely to increase, understanding the connections between drought and mortality becomes increasingly important.Methods: Our exposure variable was an annual cumulative drought severity score based on the 1-month, county-level Standardized Precipitation Evapotranspiration Index. The outcome variables of demographic subgroup-specific all-cause mortality count data per year were obtained from the National Vital Statistics System. Any counts below 10 deaths were censored in that demographic group per county. We modeled county-stratum-year mortality using interval-censored negative binomial regression with county-level random intercepts, for each combined age-race-sex stratum either with or without further stratification by climate regions. Fixed effects meta-regression was used to test the associations between age, race, sex, and region with the drought-mortality regression coefficients. Predictive margins were then calculated from the meta-regression model to estimate larger subgroup (e.g., 'race' or 'sex') associations of drought with mortality.Results: Most of the results were null for associations between drought severity and mortality, across joint strata of race, age, sex and region, but incidence rate ratios (IRRs) for 17 subgroups were significant after accounting for the multiple testing; ten were < 1 indicating a possible protective effect of drought on mortality for that particular subpopulation. The meta-regression indicated heterogeneity in the association of drought with mortality according to race, climate region, and age, but not by sex. Marginal means of the estimated log-incidence rate ratios differed significantly from zero for age groups 25-34, 35-44, 45-54 and 55-64; for the white race group; and for the South, West and Southwest regions, in the analysis that included wet county-years. The margin of the meta-regression model suggested a slightly negative, but not statistically significant, association of drought with same-year mortality in the overall population.Conclusions: There were significant, heterogeneous-direction associations in subpopulation-stratified models, after controlling for multiple comparisons, suggesting that the impacts of drought on mortality may not be monolithic across the United States. Meta-regression identified systematic differences in the associations of drought severity with all-cause mortality according to climate region, race, and age. These findings suggest there may be important contextual differences in the effects of drought severity on mortality, motivating further work focused on local mechanisms. We speculate that some of the estimated negative associations of drought severity with same-year mortality could be consistent with either a protective effect of drought on total mortality in the same year, or with a delayed health effect of drought beyond the same year. Further research is needed to clarify associations of drought with more specific causes of death and with sublethal health outcomes, for specific subpopulations, and considering lagged effects occurring beyond the same year as the drought. [ABSTRACT FROM AUTHOR]

Land surface air temperature products have been essential for monitoring the evolution of the climate system. Before a temperature dataset is included in such analyses, it is important that nonclimatic influences be removed or changed so that the dataset is considered to be homogenous. These inhomogeneities include changes in station location, instrumentation, and observing practices. Many homogenized products exist on the monthly time scale, but few daily and weekly products exist. Recently, a submonthly homogenized dataset has been developed using data and software from NOAA's National Centers for Environmental Information. Homogeneous daily data are useful for identification and attribution of extreme heat events. Projections of increasing temperatures are expected to result in corresponding increases in the frequency, duration, and intensity of such events. It is also established that heat events can have significant public health impacts, including increases in mortality and morbidity. The method to identify extreme heat events using daily homogeneous temperature data is described and used to develop a climatology of heat event onset, length, and severity. This climatology encompasses nearly 3000 extreme maximum and minimum temperature events across the United States since 1901. A sizeable number of events occurred during the Dust Bowl period of the 1930s; however, trend analysis shows an increase in heat event number and length since 1951. Overnight extreme minimum temperature events are increasing more than daytime maximum temperatures, and regional analysis shows that events are becoming much more prevalent in the western and southeastern parts of the United States. [ABSTRACT FROM AUTHOR]

Motor vehicle crashes remain a leading cause of accidental death in the United States, and weather is frequently cited as a contributing factor in fatal crashes. Previous studies have investigated the link between these crashes and precipitation typically using station-based observations that, while providing a good estimate of the prevailing conditions on a given day or hour, often fail to capture the conditions present at the actual time and location of a crash. Using a multiyear, high-resolution radar reanalysis and information on 125,012 fatal crashes spanning the entire continental United States over a 6-yr period, we find that the overall risk of a fatal crash increases by approximately 34% during active precipitation. The risk is significant in all regions of the continental United States, and it is highest during the morning rush hour and during the winter months. [ABSTRACT FROM AUTHOR]

Antismoking forces hailed the ban on cigarette advertising in the broadcast media as a major victory in their campaign against the tobacco industry. Expectations were that this legislation would reduce the percentage of smokers in the population and the number of young adults adopting the smoking habit. But the percentage of adult smokers actually rose slightly following the ban. In light of this fact, a natural question is, "What exactly has been the effect of the ban?" This paper attempts to provide information relevant to this question by examining trends in cigarette advertising expenditures and cigarette consumption. [ABSTRACT FROM AUTHOR]

Additional advertising regulation is being proposed for both tobacco and alcoholic beverage products. The possible outcome of these proposed regulations is examined based on the effect that advertising regulation has had on tobacco consumption in the past. [ABSTRACT FROM AUTHOR]

Herein, we discuss a case of a 39-year-old male with hemophilia B, who developed end-stage liver disease secondary to nonalcoholic steatohepatitis, that underwent orthotopic liver transplantation (OLT) as a curative means for his liver disease and coagulation disorder. Existing case reports have demonstrated favorable outcomes in patients outside of the United States who received continuous infusions of recombinant factor IX replacement in the perioperative setting after liver transplant. Given limitations in the stability of the recombinant factor IX products in the United States, a dosing strategy was comprised of once daily bolus dosing to achieve satisfactory factor IX levels. Within 48 hours of initial surgery, the patient had sustained factor IX levels above 70% of normal and the patient required no further dosing of factor IX products to date. This strategy helped facilitate less frequent dosing as well as achieved targeted factor levels while synthetic function of the transplanted liver recovered. [ABSTRACT FROM AUTHOR]

Background: Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways.Questions/purposes: (1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed?Methods: Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC). NSQIP is a clinical registry that captures both inpatient and outpatient events up to 30 days after surgery using clinical reviewers and strict definitions for each variable. The other databases are administrative claims databases with their comorbidity and adverse event data defined by diagnosis and procedure codes used for reimbursement. NIS is limited to inpatient data only, whereas HAC and MED also have outpatient data. The number of patients undergoing primary TKA from each database was 48,248 in HAC, 783,546 in MED, 393,050 in NIS, and 43,220 in NSQIP. NSQIP definitions for comorbidities and surgical complications were matched to corresponding International Classification of Diseases, 9 Revision/Current Procedural Terminology codes and these coding algorithms were used to query NIS, MED, and HAC. Age, sex, comorbidities, and inpatient versus 30-day postoperative complications were compared across the four databases. Given the large sample sizes, statistical significance was often detected for small, clinically unimportant differences; thus, the focus of comparisons was whether the difference reached an absolute difference of twofold to signify an important clinical difference.Results: Although there was a higher proportion of males in NIS and NSQIP and patients in NIS were younger, the difference was slight and well below our predefined threshold for a clinically important difference. There was variation in the prevalence of comorbidities and rates of postoperative complications among databases. The prevalence of chronic obstructive pulmonary disease (COPD) and coagulopathy in HAC and MED was more than twice that in NIS and NSQIP (relative risk [RR] for COPD: MED versus NIS 3.1, MED versus NSQIP 4.5, HAC versus NIS 3.6, HAC versus NSQIP 5.3; RR for coagulopathy: MED versus NIS 3.9, MED versus NSQIP 3.1, HAC versus NIS 3.3, HAC versus NSQIP 2.7; p < 0.001 for all comparisons). NSQIP had more than twice the obesity as NIS (RR 0.35). Rates of stroke within 30 days of TKA had more than a twofold difference among all databases (p < 0.001). HAC had more than twice the rates of 30-day complications at all endpoints compared with NSQIP and more than twice the 30-day infections as MED. A comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of wound infections and deep vein thromboses is captured when data are analyzed out to 30 days after TKA (p < 0.001 for all comparisons).Conclusions: When evaluating research utilizing large databases, one must pay particular attention to the type of database used (administrative claims, clinical registry, or other kinds of databases), time period included, definitions utilized for specific variables, and the population captured to ensure it is best suited for the specific research question. Furthermore, with the advent of bundled payments, policymakers must meticulously consider the data sources used to ensure the data analytics match historical sources.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

American chestnuts (Castanea dentata), effectively eliminated from eastern North America by chestnut blight in the twentieth century, are the subject of multiple restoration efforts. Screening individual trees (or tree types) for blight resistance is a critical step in all of these programs. Traditional screening involves inoculating stems of >3-year-old trees with the blight fungus (Cryphonectria parasitica), then measuring resulting cankers a few months later. A quicker, nondestructive, quantitative assay, usable on younger plants, would enhance restoration efforts by speeding the screening process. The assay presented here meets these requirements by inoculating excised leaves with the blight fungus and measuring resulting necrotic lesions. Leaves can be collected from few-month-old seedlings or fully mature trees, and results are measured after less than a week. Leaves from several lines of both American and Chinese chestnuts were inoculated, as well as the congener Allegheny chinquapin, and experimental leaf assay results correlate well with stem assay results from these species. Inoculations with virulent and hypovirulent blight fungi strains also showed relative patterns similar to traditional inoculations. Given the correlations to established stem assay results, this procedure could be a valuable tool to quickly evaluate blight resistance in American chestnut trees used for restoration. [ABSTRACT FROM AUTHOR]

All groundwater pumped is balanced by removal of water somewhere, initially from storage in the aquifer and later from capture in the form of increase in recharge and decrease in discharge. Capture that results in a loss of water in streams, rivers, and wetlands now is a concern in many parts of the United States. Hydrologists commonly use analytical and numerical approaches to study temporal variations in sources of water to wells for select points of interest. Much can be learned about coupled surface/groundwater systems, however, by looking at the spatial distribution of theoretical capture for select times of interest. Development of maps of capture requires (1) a reasonably well-constructed transient or steady state model of an aquifer with head-dependent flow boundaries representing surface water features or evapotranspiration and (2) an automated procedure to run the model repeatedly and extract results, each time with a well in a different location. This paper presents new methods for simulating and mapping capture using three-dimensional groundwater flow models and presents examples from Arizona, Oregon, and Michigan. [ABSTRACT FROM AUTHOR]

The article discusses the growing demand for health-care access in the United States. The article describes how private- and public-spending in the health-care system is increasing relative to the gross domestic product (GDP) of the U.S. Health care coverage in the U.S. is discussed relative to nations in the Organization for Economic Cooperation and Development (OECD), along with the potential solutions for health care problems.

Abstract: This work describes a newly-discovered spatial correlation between paleo-channels and nearshore morphology along the barrier islands of northeastern North Carolina and southeastern Virginia, U.S. mid-Atlantic coast. These nearshore morphological features include regions of shore-oblique sandbars and coincident gravel outcrops that previously have been linked to erosional hotspots at the shoreline. These new findings have direct bearing on both nearshore morphodynamics and shoreline management. Paleo-channels were identified in the chirp seismic record and compared to shore-oblique sandbar locations discerned from bathymetric data and corroborated by gravel outcrops depicted in the side scan record. Both graphical correlation and statistical cross-correlation analyses revealed a significant spatial relationship between these features, with higher statistical correlation for channels >500 m wide. Seismic records also indicate that the gravel outcrops seen on the updrift flanks of the shore-oblique bars are surface expressions of the underlying geology. We hypothesize that these outcrops are composed of relict channel fill sediments that interact with the hydrodynamic regime to produce sorted bedforms. The bathymetric anomalies then serve to alter incident wave energy and affect shoreline behavior. The spatial and temporal stability of these features over several years and through a variety of wave conditions suggests some degree of underlying geologic control. While the mechanisms responsible for this relationship remain speculative, these results may bridge the gap between studies focusing on framework geology and its influence on shoreline change and those that investigate bar morphodynamics and the initiation of sorted bedforms. [Copyright &y& Elsevier]

Beach and nearshore morphology, defined primarily by slope and sandbar development, is very dynamic and is largely controlled by waves, currents and regional sediment characteristics. Results presented here challenge this long-established concept and suggest that underlying, framework geology may also exert a first-order control on nearshore morphology by influencing the stability and/or persistent re-establishment of large-scale sandbar morphology and position as well as surface sediment characteristics. Repeated sub-bottom chirp and swath bathymetry surveys of the nearshore (2–10 m depths) covering over 56 km of the North Carolina Outer Banks and Southeastern Virginia indicate the following: (1) development of shore-oblique sandbars adjacent to large gravel outcrops that are surface exposures of the underlying geologic strata, (2) identical re-development or sustained maintenance of large-scale sandbar morphology and position before and after very energetic conditions, (3) vertical and horizontal heterogeneity of lithology and grain-size and a minimum volume of sand, ranging from 0 to 1.5 m thick, and (4) close spatial alignment between the location of outcrops/shore-oblique bars and shoreline erosional hotspots. A hypothesis is proposed from these findings that links framework geology to bar morphodynamics and sorted bedforms and, ultimately, erosional hotspots. Sediment transport and shoreline evolution models based solely on waves and currents and an assumption of unlimited and uniform sediment may be inadequate in similar heterogeneous, sand-limited regions. [Copyright &y& Elsevier]

In 2001 approximately 40,000 deaths from breast cancer will occur in the United States. Although some estimates suggest possible state-to-state variations in breast cancer mortality rates the reasons for such differences remain unknown. Our objective was to confirm whether breast cancer mortality rates are significantly different by state and to identify predictors for such variation. Administrative data from the National Center for Health Statistics (NCHS) report were used to determine statewide death rates. Analyses were similarly performed with the Surveillance, Epidemiology, and End Results (SEER) cancer database to determine predictors of high versus low mortality rates. State-level variation in breast cancer mortality rates was demonstrated in the NCHS database. A subsequent analysis of high versus low mortality states in the SEER cancer registry demonstrates that stage at presentation was a significant predictor of mortality, as "high" mortality states had more patients presenting with later-stage disease. We conclude that variations in the breast cancer mortality rates exist between states. A nearly 50 per cent increase is observed between the states with the highest and lowest mortality rates. Adjusted analyses demonstrate that stage at presentation is a more important predictor of mortality variation than treatment differences. As such breast cancer mortality rates may be best improved by targeting screening and access-to-care issues rather than treatment. [ABSTRACT FROM AUTHOR]

Investigates the influence of family income and the amount of television viewing time on children's ability to evaluate the nutritional value of heavily advertised cereals in the U.S. Differences in the ability of children from two income groups to identify healthy foods; Tendency of low income children to watch more television than moderate-to-high income children; Awareness of the children from both income groups on the attempt of television commercials to sell products rather than to entertain or educate.

The article presents a research to develop demographic, psychographic, political and media use profiles of consumers that were satisfied and dissatisfied with three dimensions of electric utility company performance. These three dimensions desire to provide quality service to community, efforts to minimize costs to consumers and ability to provide sufficient electricity to satisfy future consumer demand. Data has been collected by personal interviews with 754 randomly selected respondents from large population center in the Southwestern United States. A total of 29 activities, interests and opinions statements have been used to obtain information about the psychographic characteristics of the respondents. Information have been obtained about consumer's perceptions of energy problems and related cost issues in addition to their political beliefs and media consumption habits. In order to examine the relationships between respondent's satisfaction with utility companies, their demographic, political and psychographic profiles, their media usage characteristics and perceptions of the energy crisis, the analysis was conducted for each of the three belief dimensions about utility company performance.

The article focuses on issues related to agricultural credit in the U.S. It investigates the conditions of agricultural indebtedness, indicates the credit facilities of the American farmer and considers the plans suggested for their improvement. A farmer may need credit in several conditions. Different types of credit include ownership credit, working credit and equipment credit. Burden of mortgage indebtedness is also felt by the farmers. Mortgage indebtedness of the American farmer is in excess. Sources of mortgage credit are also given in the article. It was found that the farmer made heavy expenditures to raise his standard of living and has spent large sums on improvements and equipment and in working capital. There are two classes of mortgage companies. The first class are really mortgage brokers. The second class of mortgage companies occupy the position of underwriters. The role of local middleman is also significant in mortgage loaning in the U.S. It is concluded that the solution of the problem of rural credit is in the hands of the farmers themselves.

Estimates the extent of the variation of the ratio of assessed to actual value of residential housing in Tulsa, Oklahoma. Isolation of any socio-economic factors which were associated with high or low ratios; Values for the coefficients of skewness and kurtosis; Estimation of sales price by the value of the revenue stamps on the deed.

Presents letter to the editor on management of personnel administration in Chicago, Illinois.

The article discusses various available cemented femoral components and how orthopedic surgeons choose which one to use. It presents an overview of the history and development over the years of cemented femoral components in the U.S. It describes the femoral revision prevalence of the various femoral components. It describes the factors affecting the long term durability of the cemented stem construct.

Neurosurgery remains a specialty with one of the largest gender gaps in the United States. Neurosurgery residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for neurosurgery residency selection. The purpose of this study was to determine factors that female neurosurgery residents used when selecting their residency. A 2-part survey was sent to female neurosurgical residents by e-mails collected from the American Association of Neurological Surgeons directory and residency program websites. The survey asked participants to score 17 characteristics of residency programs in terms of importance and then asked them to rank their top 5 most influential factors when selecting a neurosurgery residency. The most important factors included variety/number of cases, camaraderie and happiness of current residents, early surgical/clinical experience, and academic reputation. The least important factors included gender diversity of faculty and residents, number of female residents, number of female faculty, and attitudes toward maternity leave. Efforts to increase female applicants in neurosurgery residency programs should focus on highlighting some more universal, non–gender-related factors, such as happiness and camaraderie among residents and anticipated clinical experiences, as opposed to showcasing features that would seemingly appeal to female applicants, such as maternity leave and number of current female faculty or residents. [ABSTRACT FROM AUTHOR]

Abstract: The thermochemical research platform at the National Bioenergy Center, National Renewable Energy Laboratory (NREL) is primarily focused on conversion of biomass to transportation fuels using non-biological techniques. Research is conducted in three general areas relating to fuels synthesis via thermochemical conversion by gasification: [(1)] Biomass gasification fundamentals; chemistry and mechanisms of tar formation [(2)] Catalytic tar reforming and syngas cleaning [(3)] Syngas conversion to mixed alcohols In addition, the platform supports activities in both technoeconomic analysis (TEA) and life cycle assessment (LCA) of thermochemical conversion processes. Results from the TEA and LCA are used to inform and guide laboratory research for alternative biomass-to-fuels strategies. Detailed process models are developed using the best available material and energy balance information and unit operations models created at NREL and elsewhere. These models are used to identify cost drivers which then form the basis for research programs aimed at reducing costs and improving process efficiency while maintaining sustainability and an overall net reduction in greenhouse gases. [Copyright &y& Elsevier]

• We provide the first comprehensive and dated phylogeny of Myrmecocystus ants, using UCE markers. • We identify cryptic diversity and inconsistencies in the current taxonomic classification. • The genus diversified during aridification of the American Southwest, starting about 14 Ma ago. • The ancestral foraging behavior of Myrmecocystus ants was most likely nocturnal. • UCE data from ant museum specimens can be used to resolve clades with poor sample coverage. The New World ant genus Myrmecocystus Wesmael, 1838 (Formicidae: Formicinae: Lasiini) is endemic to arid and semi-arid habitats of the western United States and Mexico. Several intriguing life history traits have been described for the genus, the best-known of which are replete workers, that store liquified food in their largely expanded crops and are colloquially referred to as "honeypots". Despite their interesting biology and ecological importance for arid ecosystems, the evolutionary history of Myrmecocystus ants is largely unknown and the current taxonomy presents an unsatisfactory systematic framework. We use ultraconserved elements to infer the evolutionary history of Myrmecocystus ants and provide a comprehensive, dated phylogenetic framework that clarifies the molecular systematics within the genus with high statistical support, reveals cryptic diversity, and reconstructs ancestral foraging activity. Using maximum likelihood, Bayesian and species tree approaches on a data set of 134 ingroup specimens (including samples from natural history collections and type material), we recover largely identical topologies that leave the position of only few clades uncertain and cover the intra- and interspecific variation of 28 of the 29 described and six undescribed species. In addition to traditional support values, such as bootstrap and posterior probability, we quantify genealogical concordance to estimate the effects of conflicting evolutionary histories on phylogenetic inference. Our analyses reveal that the current taxonomic classification of the genus is inconsistent with the molecular phylogenetic inference, and we identify cryptic diversity in seven species. Divergence dating suggests that the split between Myrmecocystus and its sister taxon Lasius occurred in the early Miocene. Crown group Myrmecocystus started diversifying about 14.08 Ma ago when the gradual aridification of the southwestern United States and northern Mexico led to formation of the American deserts and to adaptive radiations of many desert taxa. [ABSTRACT FROM AUTHOR]

Purpose: Extramural funding is critical to career success and advancement in academic surgery, and surgical residents can apply for both societal and federal funding. Many federal funding mechanisms require proposals to be submitted before residents' formal research years., Methods: To better understand the resident experience with grantsmanship, we distributed a validated grantsmanship self-efficacy assessment inventory for voluntary completion at our academic general surgery training program with 2 years of dedicated research. The survey covers 3 domains: conceptualizing, designing and analyzing, and funding a study. All questions are scored 0 to 10 with 0 indicating no confidence and 10 indicating complete confidence. Median scores for the 3 domains were calculated for all respondents and compared between training years using Kruskal-Wallis with post-hoc Dunn testing., Results: Forty-four surveys were completed with a response rate of 84%. Resident self-efficacy in grantsmanship improved throughout the training years with the greatest changes being in their comfort with conceptualizing and funding a study. Dunn testing identified specific differences between PGY2 and PGY7 comfort with conceptualizing studies (median 5 vs. 7.5, p = 0.003) and understanding of funding mechanisms (median 2.0 vs. 7, p = 0.003)., Conclusions: While comfort with conceptualizing and funding studies does increase throughout the training years, this often develops after critical funding deadlines have already passed and can disadvantage surgical residents interested in academic careers. A curriculum that emphasizes familiarity with the grant writing and funding processes may better facilitate long term career success., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC)., Methods: Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity., Results: Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 ​cm were more likely in men (vs. women: OR 2.47, p ​< ​0.001) and Hispanic patients (vs. White patients: OR 1.52, p ​= ​0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p ​= ​0.002; Hispanic: OR 1.44, p ​= ​0.038) and experienced longer time to surgery (Black: HR 0.66, p ​< ​0.001; Hispanic: HR 0.71, p ​< ​0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p ​= ​0.022)., Conclusions: Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery., Competing Interests: Declaration of competing interest Saiesh Kalva, Sara P. Ginzberg, Jesse E. Passman, Jacqueline M. Soegaard Ballester, Caitlin B. Finn, Douglas L. Fraker, Rachel R. Kelz, and Heather Wachtel have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Large tumor size is associated with poorer outcomes in well-differentiated thyroid cancer, yet it remains unclear whether size >4 cm alone confers increased risk, independent of other markers of aggressive disease. The goal of this study was to assess the relationship between tumor size, other high-risk histopathological features, and survival in well-differentiated thyroid cancer and to evaluate the significance of 4 cm as a cutoff for management decisions. Methods: Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2015) and categorized by tumor size (i.e., small [≤4 cm] or large [>4 cm]) and presence of high-risk histopathological features (e.g., extrathyroidal extension). First, propensity score matching was used to identify patients who were similar across all other observed characteristics except for small versus large tumor size, and a multivariable Cox proportional hazards model was used to estimate the relationship between tumor size and survival. Second, we assessed whether the presence of high-risk features demonstrates conditional effects on survival based on the presence of tumor size >4 cm using an interaction term. Finally, additional models assessed the relationship between incremental 1 cm increases in tumor size and survival. Analyses were repeated using a validation cohort from the Surveillance, Epidemiology, and End Results Program (2008-2013). Results: Of 193,133 patients in the primary cohort, 7.9% had tumors >4 cm, and 30% had at least one high-risk feature. After matching, tumor size >4 cm was independently associated with worse survival (HR 1.63, p < 0.001). However, tumor size >4 cm and one or more other high-risk features together yielded worse survival than either size >4 cm alone (MMD: 0.70, p < 0.001) or other high-risk features alone (MMD: 0.49, p < 0.001). When assessed in 1 cm increments, the largest increases in hazard of death occurred at 2 cm and 5 cm, not 4 cm. Results from the validation cohort were largely consistent with our primary findings. Conclusions: Concomitant high-risk features confer worse survival than large tumor size alone, and a 4 cm cutoff is not associated with the greatest increase in risk. These findings support a more nuanced approach to tumor size in the management of well-differentiated thyroid cancer.

Drought is a distinct and complicated climate hazard that regularly leads to severe economic impacts. Changes in the frequency and occurrence of drought due to anthropogenic climate change can lead to new and unanticipated outcomes. To better prepare for health outcomes, more research is needed to develop methodologies to understand potential consequences. This study suggests a new methodology for assessing the impact of monthly severe drought exposure on mortality in the Northern Rockies and Plains of the United States from 2000 to 2018. A two-stage model with the power prior approach was applied to integrate heterogeneous severe drought pattern and estimate overall risk ratios of all-cause and cardiovascular mortality related to multiple drought indices (the US Drought Monitor, 6- and 12-month Standardized Precipitation-Evapotranspiration Index, 6- and 12 month Evaporative Demand Drought Index). Under severe drought, the risk ratios of all-cause mortality are 1.050 (95 % Cr: 1.031 to 1.071, USDM), 1.041 (95 % Cr: 1.022 to 1.060, 6-SPEI), 1.009 (95 % Cr: 0.989 to 1.031, 12SPEI), 1.045 (95 % Cr: 1.022 to 1.067, 6-EDDI), and 1.035 (95 % Cr: 1.009 to 1.062, 12-EDDI); cardiovascular mortality are 1.057 (95 % Cr: 1.023 to 1.091, USDM), 1.028 (95 % Cr: 0.998 to 1.059, 6-SPEI), 1.005 (95 % Cr: 0.973 to 1.040, 12-SPEI), 1.042 (95 % Cr: 1.005 to 1.080, 6-EDDI), and 1.004 (95 % Cr: 0.959 to 1.049, 12-EDDI). Our results showed that (i) a model with properly accounted for heterogeneous exposure pattern had greater risk ratios if statistically significant; (ii) a mid-term (6-month) severe drought had higher risk ratios compared to longer-term (12-month) drought; and (iii) different severe droughts affect populations in a different way. These results expand the existing knowledge of drought relationship to increasing mortality in the United States. The findings from this study highlight the need for communities and policymakers to establish effective drought-prevention initiatives in this region., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Background: Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC)., Methods: We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes., Results: Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups., Conclusions: There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities., (© 2023. Society of Surgical Oncology.)

Objective: To project the number and proportion of women in the urology workforce using recent demographic trends and develop an app to explore updated projections using future data., Methods: Demographic data were obtained from AUA Censuses and ACGME Data Resource Books. The proportion of female graduating urology residents was characterized with a logistic growth model. "Stock and Flow" models were used to project future population numbers and proportions of female practicing urologists, accounting for trainee demographics, retirement trends, and growth in the field., Results: Assuming growth in urology graduate numbers and continued logistic growth in the proportion of women, 10,957 practicing urologists (38%) will be female by 2062. If the rate of women entering urology residency stagnates, 7038 urologists (24%) will be female. If the retirement rates for women in urology change to mirror those of men and the proportion of female residents continues to experience logistic growth, 11,178 urologists (38%) will be female. An interactive app was designed to allow for a range of assumptions and future data: https://stephenrho.shinyapps.io/uro-workforce/., Conclusion: Workforce projections should incorporate recent growth in numbers of female residents. If current growth continues, 38% of urologists will be female by 2062. The app allows for exploration of different scenarios and can be updated with new data. The projections demonstrate the need for targeted efforts to recruit women into urology, address disparities within the field, and work toward retaining female urologists. We must continue working toward an equitable future workforce that can address the impending shortage of urologists., Competing Interests: DECLARATION OF COMPETING INTEREST None Declared., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Climate change has brought increasing attention to the assessment of health risks associated with climate and extreme events. Drought is a complex climate phenomenon that has been increasing in frequency and severity both locally and globally due to climate change. However, the health risks of drought are often overlooked, especially in places such as the United States, as the pathways to health impacts are complex and indirect. This study aims to conduct a comprehensive assessment of the effects of monthly drought exposure on respiratory mortality for NOAA climate regions in the United States from 2000 to 2018. A two-stage model was applied to estimate the location-specific and overall effects of respiratory risk associated with two different drought indices over two timescales (the US Drought Monitor and the 6-month and 12-month Evaporative Demand Drought Index). During moderate and severe drought exposure, respiratory mortality risk ratio in the general population increased up to 6.0% (95% Cr: 4.8 to 7.2) in the Northeast, 9.0% (95% Cr: 4.9 to 13.3) in the Northern Rockies and Plains, 5.2% (95% Cr: 3.9 to 6.5) in the Ohio Valley, 3.5% (95% Cr: 1.9 to 5.0) in the Southeast, and 15.9% (95% Cr: 10.8 to 20.4) in the Upper Midwest. Our results showed that age, ethnicity, sex (both male and female), and urbanicity (both metro and non-metro) resulted in more affected population subgroups in certain climate regions. The magnitude and direction of respiratory risk ratio differed across NOAA climate regions. These results demonstrate a need for policymakers and communities to develop more effective strategies to mitigate the effects of drought across regions.

Introduction: The importance of sociodemographic factors such as race, education, and income on spine surgery outcomes has been well established, yet the representation of sociodemographic data within randomized controlled trials (RCTs) in spine literature remains undefined in the United States (U.S)., Methods: Medical literature was reviewed within PubMed for RCTs with "spine" in the title or abstract published within the last 8 years (2014 to 2021) in seven major spine journals. This yielded 128 results, and after application of inclusion criteria (RCTs concerning adult spine pathologies conducted in the U.S), 54 RCTs remained for analysis. Each article's journal of publication, year of publication, and spinal pathology was recorded. Pathologies included cervical degeneration, thoracolumbar degeneration, adult deformity, cervical trauma, and thoracolumbar trauma. Sociodemographic variables collected were race, ethnicity, insurance status, income, work status, and education. The Fisher's exact test was used to compare inclusion of sociodemographic data by journal, year, and spinal pathology., Results: Sociodemographic data were included in the results and in any section of 57.4% (31/54) of RCTs. RCTs reported work status in 25.9% (14/54) of results and 38.9% (21/54) of RCTs included work status in any section. Income was included in the results and mentioned in any section in 13.0% (7/54) of RCTs. Insurance status was in the results or any section of 9.3% (5/54) and 18.5% (10/54) of RCTs, respectively. There was no association with inclusion of sociodemographic data within the results of RCTs as a factor of journal ( P = 0.337), year of publication ( P = 0.286), or spinal pathology ( P = 0.199)., Discussion: Despite evidence of the importance of sociodemographic factors on the natural history and treatment outcomes of myriad spine pathologies, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery. Failure to include sociodemographic factors in RCTs potentially bias the generalizability of outcome data., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Direct-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency., Aim: We aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center., Methods: Google was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare., Outcomes: Evaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center., Results: Three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms., Clinical Implications: Patients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage., Strengths & Limitations: Practice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability., Conclusion: This observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment. Jesse E, Sellke N, Rivero M-J, et al. Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy. J Sex Med 2022;19:1608-1615., (Copyright © 2022 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Studies of thunderstorm asthma to understand risk factors using high-resolution climate data and asthma outcomes on a large scale are scarce. Moreover, thunderstorm asthma is not well studied in the United States., Objectives: We examined whether climate parameters involved in thunderstorms are associated with emergency department (ED) visits for acute asthma attacks in the United States., Methods: We analyzed 63,789 asthma-related, daily ED visits for all age groups, and thunderstorm-associated climate data in Louisiana during 2010 through 2012. We performed time-series analyses using quasi-Poisson regression models with natural cubic splines of date, parish, holiday, day of week, season, daily maximum concentrations of ozone ( O 3 ) and fine particulate matter [PM ≤ 2.5 μ m in aerodynamic diameter ( PM 2.5 )], and daily mean pressure, precipitation, and temperature. Because of a significant interaction effect between temperature and lightning days on asthma-related visits, we performed stratified analyses by days with/without lightning or thunderstorm (defined by any lightning and precipitation)., Results: On thunderstorm days, higher asthma-related ED visits were associated with higher daily mean precipitation [ relative risk  ( RR ) = 1.145  per  1   g / m 2 / s (95% CI: 1.009, 1.300)] and lower daily mean temperature [ RR = 1.011 per 1°C change (1.000-1.021)] without carry-over effect to the next non-thunderstorm day. These higher risks were found mainly among children and adults < 65  years of age. We observed similar results on lightning days. However, we did not find similar associations for non-thunderstorm or non-lightning days. Daily maximum O 3 and PM 2.5 levels were not significantly associated with asthma ED visits on thunderstorm days., Discussion: Higher precipitation and lower temperature on thunderstorm days appear to contribute to asthma attacks among people with asthma, suggesting they should consider taking precautions during thunderstorms. EDs should consider preparing for a potential increase of asthma-related visits and ensuring sufficient stock of emergency medication and supplies for forecasted severe thunderstorm days. https://doi.org/10.1289/EHP10440.

The outcomes of drought can be difficult to assess due to the complexity of its effects. While most risk assessments of drought are developed for agriculture or water resources, the associations with human health are not well studied due to unclear and complex pathways. This study is the first to assess potential changes in health risk from droughts during the last decade in the contiguous United States. To assess the risk, we spatially superimposed vulnerability variables associated with drought on historical drought exposure over the last decade. Different variations in Local Moran's I statistics were used to assess the spatial distribution of health vulnerability, risk of drought, and changes in the two five-year study periods (2010-2014 and 2015-2019). Our results show large clusters of the western United States had a significant increase in risk during the latter part of the study period due to increases in vulnerability and hazard. In addition, southern areas of the United States were consistently above the national average in drought risk. Since our vulnerability variables include agriculture, drinking water, and sociodemographic indicators, the results of this study can help various experts interested in drought preparedness efforts associated with human health.

Firearm injury is a public health crisis in the United States. Selective media coverage may contribute to incomplete public understanding of firearm injury. To better understand how firearm injury is communicated to the public, we analyzed media coverage of intentional, interpersonal shootings in 3 U.S. cities. We hypothesized that multiple shootings and fatal shootings would be more likely to make the news, as would shootings affecting children, women, and white individuals. We compared police department data on shootings to media reports drawn from the Gun Violence Archive (GVA) for 2017 in Philadelphia, PA, Rochester, NY, and Cincinnati, OH. GVA reports were matched to police data by shooting date, location, victim age, and gender. Matched victims were compared to unmatched using chi 2 tests for categorical variables and Kruskal Wallis tests for continuous variables. Philadelphia police reported 1216 firearm assault victims; Cincinnati police reported 407; and Rochester police reported 178. News reports covered 562 (46.2%), 222 (54.6%), and 116 (65.2%) victims, respectively. Fatal shootings were more often reported as were shootings involving multiple victims or women. Half of shooting victims did not make the news. Selective reporting likely limits awareness of the public health impact of firearm injury. Researchers and policy makers should work with journalists and editors to improve the quantity and content of reporting on firearm injury., (Copyright © 2020 Elsevier Inc. All rights reserved.)

During the 1930s Dust Bowl drought in the central United States, species with the C 3 photosynthetic pathway expanded throughout C 4 -dominated grasslands. This widespread increase in C 3 grasses during a decade of low rainfall and high temperatures is inconsistent with well-known traits of C 3 vs. C 4 pathways. Indeed, water use efficiency is generally lower, and photosynthesis is more sensitive to high temperatures in C 3 than C 4 species, consistent with the predominant distribution of C 3 grasslands in cooler environments and at higher latitudes globally. We experimentally imposed extreme drought for 4 y in mixed C 3 /C 4 grasslands in Kansas and Wyoming and, similar to Dust Bowl observations, also documented three- to fivefold increases in C 3 /C 4 biomass ratios. To explain these paradoxical responses, we first analyzed long-term climate records to show that under nominal conditions in the central United States, C 4 grasses dominate where precipitation and air temperature are strongly related (warmest months are wettest months). In contrast, C 3 grasses flourish where precipitation inputs are less strongly coupled to warm temperatures. We then show that during extreme drought years, precipitation-temperature relationships weaken, and the proportion of precipitation falling during cooler months increases. This shift in precipitation seasonality provides a mechanism for C 3 grasses to respond positively to multiyear drought, resolving the Dust Bowl paradox. Grasslands are globally important biomes and increasingly vulnerable to direct effects of climate extremes. Our findings highlight how extreme drought can indirectly alter precipitation seasonality and shift ecosystem phenology, affecting function in ways not predictable from key traits of C 3 and C 4 species., Competing Interests: The authors declare no competing interest.

Background: Readmission following total joint arthroplasty has become a closely watched metric for many hospitals in the United States due to financial penalties imposed by Centers for Medicare and Medicaid Services. The purpose of this study was to identify both preoperative and postoperative reasons for readmission within 30 days following primary total hip and total knee arthroplasty (TKA)., Methods: Retrospective data were collected for patients who underwent elective primary total hip arthroplasty (THA; CPT code 27130) and TKA (27447) from 2008 to 2013 at our institution. The sample was separated into readmitted and nonreadmitted cohorts. Demography, comorbidities, Charlson comorbidity index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis., Results: There were 42 (3.4%) and 28 (2.2%) readmissions within 30 days for THA and TKA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among THA and TKA patients, including body mass index, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA., Conclusion: Patient comorbidities and preoperative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered and we recommend the use of CCI and METs in risk adjustment models that use 30-day readmission as a marker for quality of patient care., Level of Evidence: Level III/Retrospective cohort study.

Background: Little is known about the effect of drought on all-cause mortality, especially in higher income countries such as the United States. As the frequency and severity of droughts are likely to increase, understanding the connections between drought and mortality becomes increasingly important., Methods: Our exposure variable was an annual cumulative drought severity score based on the 1-month, county-level Standardized Precipitation Evapotranspiration Index. The outcome variables of demographic subgroup-specific all-cause mortality count data per year were obtained from the National Vital Statistics System. Any counts below 10 deaths were censored in that demographic group per county. We modeled county-stratum-year mortality using interval-censored negative binomial regression with county-level random intercepts, for each combined age-race-sex stratum either with or without further stratification by climate regions. Fixed effects meta-regression was used to test the associations between age, race, sex, and region with the drought-mortality regression coefficients. Predictive margins were then calculated from the meta-regression model to estimate larger subgroup (e.g., 'race' or 'sex') associations of drought with mortality., Results: Most of the results were null for associations between drought severity and mortality, across joint strata of race, age, sex and region, but incidence rate ratios (IRRs) for 17 subgroups were significant after accounting for the multiple testing; ten were < 1 indicating a possible protective effect of drought on mortality for that particular subpopulation. The meta-regression indicated heterogeneity in the association of drought with mortality according to race, climate region, and age, but not by sex. Marginal means of the estimated log-incidence rate ratios differed significantly from zero for age groups 25-34, 35-44, 45-54 and 55-64; for the white race group; and for the South, West and Southwest regions, in the analysis that included wet county-years. The margin of the meta-regression model suggested a slightly negative, but not statistically significant, association of drought with same-year mortality in the overall population., Conclusions: There were significant, heterogeneous-direction associations in subpopulation-stratified models, after controlling for multiple comparisons, suggesting that the impacts of drought on mortality may not be monolithic across the United States. Meta-regression identified systematic differences in the associations of drought severity with all-cause mortality according to climate region, race, and age. These findings suggest there may be important contextual differences in the effects of drought severity on mortality, motivating further work focused on local mechanisms. We speculate that some of the estimated negative associations of drought severity with same-year mortality could be consistent with either a protective effect of drought on total mortality in the same year, or with a delayed health effect of drought beyond the same year. Further research is needed to clarify associations of drought with more specific causes of death and with sublethal health outcomes, for specific subpopulations, and considering lagged effects occurring beyond the same year as the drought.

Background The routine use of angiotensin-converting enzyme inhibitors (ACEI) during palliation of hypoplastic left heart syndrome is controversial. We sought to describe ACEI prescription in the interstage between stage 1 palliation (stage I Norwood procedure) discharge and stage 2 palliation (stage II superior cavopulmonary anastomosis procedure) admission using the NPC-QIC (National Pediatric Cardiology Quality Improvement Collaborative) registry. Methods and Results Analysis of all patients (n=2180) enrolled in NPC-QIC from 2008 to 2016 included preoperative anatomy, risk factors, and echocardiographic data. ACEI were prescribed at stage I Norwood procedure discharge in 38% of patients. ACEI prescription declined from 2011 to 2016 compared with pre-2010 (36.8% versus 45%; P =0.005) with significant variation across centers (range 7-100%; P <0.001) and decreased prescribing rates associated with increased center volume ( P =0.004). There was no difference in interstage mortality ( P =0.662), change in atrioventricular valve regurgitation ( P =0.101), or change in ventricular dysfunction ( P =0.134) between groups. In multivariable analysis of all patients, atrioventricular septal defect (odds ratio [OR], 1.84; 95% CI, 1.28-2.65) or double outlet right ventricle (OR, 1.47; CI, 1.02-2.11), and preoperative mechanical ventilation (OR, 1.37; 95% CI, 1.12-1.68) were associated with increased ACEI prescription. In multivariable analysis of patients with complete echocardiographic data (n=812), ACEI prescription was more common with at least moderate atrioventricular valve regurgitation (OR, 1.88; 95% CI, 1.22-2.31). Conclusions ACEI prescription remains common in the interstage despite limited evidence of benefit. ACEI prescription is associated with preoperative mechanical ventilation, double outlet right ventricle, and atrioventricular valve regurgitation with marked inter-center variation. ACEI prescription is not associated with reduction in mortality, ventricular dysfunction, or atrioventricular valve regurgitation during the interstage.

Background: The United States is in an obesity epidemic. Obesity has multiple common comorbid conditions, including lower extremity arthritis. We sought to examine the course of treatment for a population with body mass index (BMI) ≥40 kg/m 2 and osteoarthritis (OA) of the hip or knee. We investigated decision criteria that influenced arthroplasty surgeons to recommend nonoperative management vs total joint arthroplasty (TJA). For those patients who ultimately received TJA, we compared outcomes in this population to those with BMI <40 kg/m 2 ., Methods: This study retrospectively reviewed 158 new patients with BMI ≥40 kg/m 2 and moderate/severe OA of the hip or knee. Demographics, comorbidity profiles, and weight loss were compared between groups that underwent TJA and those that did not. The arthroplasty database was used to identify patients who underwent TJA during 2016-2018 (N = 1473). Comorbidities, readmissions, surgical site infections, and overall complications were compared between those with BMI ≥40 kg/m 2 and BMI <40 kg/m 2 ., Results: About 51.3% of new patients with BMI ≥40 kg/m 2 and moderate/severe OA did not return for a second clinic visit. Of those who did return, 42.9% eventually underwent surgery. BMI was higher in single visit patients vs those with multiple visits (49.5 vs 46.3 kg/m 2 , P < .001), no difference in those scheduled on an "as-needed" basis vs a specific return date (P = .18), and did not change significantly during the 2-year follow-up (P = .41). Patients who underwent TJA had a lower mean BMI at presentation than their nonoperative counterparts (44.5 vs 47.6 kg/m 2 , P < .01) and demonstrated significant weight loss prior to surgery (44.5 vs 42.6 kg/m 2 , P < .05). When comparing patients with BMI ≥40 kg/m 2 vs BMI <40 kg/m 2 , overall complications were not higher in the BMI ≥40 kg/m 2 group, although surgical site infections were higher in those undergoing total hip arthroplasty with BMI ≥40 kg/m 2 (0.3% vs 3.1%, P < .05)., Conclusion: A majority of patients with BMI ≥40 kg/m 2 and moderate/advanced OA will be lost to orthopedic follow-up. A relatively lower BMI indicates a greater chance of retention in care, and ultimately surgery, but does not influence surgeons' recommendations to continue orthopedic management. Patients who persist in seeking treatment, lose significant weight, and exhaust nonoperative alternatives may be suitable for TJA despite a BMI ≥40 kg/m 2 , with an overall complication rate of 4.3%. However, only 9% of patients at 2-year follow-up achieved BMI <40 kg/m 2 and only 20% of surgeries were performed on patients who had achieved this proposed cutoff., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: As the population ages, rate of total knee arthroplasty increases and thus, it is important to maximize efficiency and minimize risk. Identifying patients who are at higher risk for transfusion can help streamline care provided and minimize superfluous, costly hemoglobin monitoring in low risk patients., Methods: Adult patients who underwent total knee arthroplasty (TKA) in 2015 were identified in the National Surgical Quality Improvement Project (NSQIP) database. Patients were divided into two cohorts: those who required transfusion post operatively and those who did not. Patient demographics and comorbidities were compared using univariate analysis; and multivariate analysis was used to determine risk factors for short-term complications., Results: Of 48,055 TKA patients, 3.0% required transfusion. The patients who required transfusion were older, had higher BMI, higher rates of comorbidities and were more frequently ASA class 3-4 (p<0.005). Univariate analysis revealed that patients who required transfusion had higher rates of any complication (9.19% v. 4.23%, p<0.001). Multivariate regression analysis identified the following as risk factors for transfusion requirement: Black race (adjusted odds ratio [OR] 1.2, 95% confidence interval [CI] 1.01-1.4), COPD (OR 1.6, 95% CI 1.3-2.0), corticosteroids (OR 1.4, 95% CI 1.1-1.8), bleeding disorder (OR 1.4, CI 1.1-1.9), ASA class 4 (OR 2.3, CI 1.5-4.8), operative time >2 hours (OR 1.3, 95% CI 1.2-1.5) and lack of functional independence (OR 1.6, 95% CI 1.1-2.3)., Conclusions: In a cohort of patients undergoing primary TKA in 2015, history of COPD, black race, operative time, steroid use, bleeding disorder, lack of functional independence and ASA class 3-4 were independent predictors of need for blood transfusion. Additionally, we found that patients who received transfusion demonstrated a significantly higher rate of the following: any complication, pneumonia, urinary tract infection, septic shock, deep vein thrombosis, renal insufficiency, cardiac arrest, myocardial infarction, unplanned readmission, reoperation and mortality. Presence of these risk factors in TKA patients could represent an indication for hemoglobin monitoring post-operatively. Level of Evidence: IV ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2020.)

In the past decade, more students than ever entered medical school with the desire, if not the expectation, of participating in meaningful global health experiences. Schools must now weigh benefits to students of global experiences against burdens of students' learning experiences on institutions and individuals with whom schools partner. Most often, global health training is done as offsite immersion rotations in research or clinical settings. This article explores ethical dimensions of expanding global health offerings while respecting local partners' goals by focusing on the experience of the University of Pennsylvania's global health training programs., (© 2019 American Medical Association. All Rights Reserved.)

Background: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting., Methods: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively., Results: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07)., Conclusion: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures., Design: Retrospective cohort., Setting: American College of Surgeons Level I trauma center., Patients/participants: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period., Main Outcome Measurements: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia., Results: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%., Conclusion: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.