Symbiont plasticity as a driver of plant success

We discuss which plant species are likely to become winners, that is achieve the highest global abundance, in changing landscapes, and whether plant-associated microbes play a determining role. Reduction and fragmentation of natural habitats in historic landscapes have led to the emergence of patchy, hybrid landscapes, and novel landscapes where anthropogenic ecosystems prevail. In patchy landscapes, species with broad niches are favoured. Plasticity in the degree of association with symbiotic microbes may contribute to broader plant niches and optimization of symbiosis costs and benefits, by downregulating symbiosis when it is unnecessary and upregulating it when it is beneficial. Plasticity can also be expressed as the switch from one type of mutualism to another, for example from nutritive to defensive mutualism with increasing soil fertility and the associated increase in parasite load. Upon dispersal, wide mutualistic partner receptivity is another facet of symbiont plasticity that becomes beneficial, because plants are not limited by the availability of specialist partners when arriving at new locations. Thus, under conditions of global change, symbiont plasticity allows plants to optimize the activity of mutualistic relationships, potentially allowing them to become winners by maximizing geographic occupancy and local abundance.

Niche types and community assembly

Studies of niche differentiation and biodiversity often focus on a few niche dimensions due to the methodological challenge of describing hyperdimensional niche space. However, this may limit our understanding of community assembly processes. We used the full spectrum of realized niche types to study arbuscular mycorrhizal fungal communities: distinguishing abiotic and biotic, and condition and resource, axes. Estimates of differentiation in relation to different niche types were only moderately correlated. However, coexisting taxon niches were consistently less differentiated than expected, based on a regional null model, indicating the importance of habitat filtering at that scale. Nonetheless, resource niches were relatively more differentiated than condition niches, which is consistent with the effect of a resource niche-based coexistence mechanism. Considering niche types, and in particular distinguishing resource and condition niches, provides a more complete understanding of community assembly, compared with studying individual niche axes or the full niche.

GlobalAMFungi: a global database of arbuscular mycorrhizal fungal occurrences from high-throughput sequencing metabarcoding studies

Arbuscular mycorrhizal (AM) fungi are crucial mutualistic symbionts of the majority of plant species, with essential roles in plant nutrient uptake and stress mitigation. The importance of AM fungi in ecosystems contrasts with our limited understanding of the patterns of AM fungal biogeography and the environmental factors that drive those patterns. This article presents a release of a newly developed global AM fungal dataset (GlobalAMFungi database, https://globalamfungi.com) that aims to reduce this knowledge gap. It contains almost 50 million observations of Glomeromycotinian AM fungal amplicon DNA sequences across almost 8500 samples with geographical locations and additional metadata obtained from 100 original studies. The GlobalAMFungi database is built on sequencing data originating from AM fungal taxon barcoding regions in: i) the small subunit rRNA (SSU) gene; ii) the internal transcribed spacer 2 (ITS2) region; and iii) the large subunit rRNA (LSU) gene. The GlobalAMFungi database is an open source and open access initiative that compiles the most comprehensive atlas of AM fungal distribution. It is designed as a permanent effort that will be continuously updated by its creators and through the collaboration of the scientific community. This study also documented applicability of the dataset to better understand ecology of AM fungal taxa.

Environmental modulation of plant mycorrhizal traits in the global flora

Mycorrhizal symbioses are known to strongly influence plant performance, structure plant communities and shape ecosystem dynamics. Plant mycorrhizal traits, such as those characterising mycorrhizal type (arbuscular (AM), ecto-, ericoid or orchid mycorrhiza) and status (obligately (OM), facultatively (FM) or non-mycorrhizal) offer valuable insight into plant belowground functionality. Here, we compile available plant mycorrhizal trait information and global occurrence data (∼ 100 million records) for 11,770 vascular plant species. Using a plant phylogenetic mega-tree and high-resolution climatic and edaphic data layers, we assess phylogenetic and environmental correlates of plant mycorrhizal traits. We find that plant mycorrhizal type is more phylogenetically conserved than plant mycorrhizal status, while environmental variables (both climatic and edaphic; notably soil texture) explain more variation in mycorrhizal status, especially FM. The previously underestimated role of environmental conditions has far-reaching implications for our understanding of ecosystem functioning under changing climatic and soil conditions.

Soil community composition in dynamic stages of semi-natural calcareous grassland

European dry thin-soil calcareous grasslands (alvars) are species-rich semi-natural habitats. Cessation of traditional management, such as mowing and grazing, leads to shrub and tree encroachment and the local extinction of characteristic alvar species. While soil microbes are known to play a critical role in driving vegetation and ecosystem dynamics, more information is needed about their composition and function in grasslands of different dynamic stages. Here we assess the composition of soil fungal, prokaryotic, and plant communities using soil environmental DNA from restored alvar grasslands in Estonia. The study areas included grasslands that had experienced different degrees of woody encroachment prior to restoration (woody plant removal and grazing), as well as unmanaged open grasslands. We found that, in general, different taxonomic groups exhibited correlated patterns of between-community variation. Previous forest sites, which had prior to restoration experienced a high degree of woody encroachment by ectomycorrhizal Scots pine, were compositionally most distinct from managed open grasslands, which had little woody vegetation even prior to restoration. The functional structure of plant and fungal communities varied in ways that were consistent with the representation of mycorrhizal types in the ecosystems prior to restoration. Compositional differences between managed and unmanaged open grasslands reflecting the implementation of grazing without further management interventions were clearer among fungal, and to an extent prokaryotic, communities than among plant communities. While previous studies have shown that during woody encroachment of alvar grassland, plant communities change first and fungal communities follow, our DNA-based results suggest that microbial communities reacted faster than plant communities during the restoration of grazing management in alvar grassland. We conclude that while the plant community responds faster to cessation of management, the fungal community responds faster to restoration of management. This may indicate hysteresis, where the eventual pathway back to the original state (grazed ecosystem) differs from the pathway taken towards the alternative state (abandoned semi-natural grassland ecosystem).

Plant-symbiotic fungal diversity tracks variation in vegetation and the abiotic environment along an extended elevational gradient in the Himalayas

Arbuscular mycorrhizal (AM) fungi can benefit plants under environmental stress, and influence plant adaptation to warmer climates. However, very little is known about the ecology of these fungi in alpine environments. We sampled plant roots along a large fraction (1941-6150 m asl (above sea level)) of the longest terrestrial elevational gradient on Earth and used DNA metabarcoding to identify AM fungi. We hypothesized that AM fungal alpha and beta diversity decreases with increasing elevation, and that different vegetation types comprise dissimilar communities, with cultured (putatively ruderal) taxa increasingly represented at high elevations. We found that the alpha diversity of AM fungal communities declined linearly with elevation, whereas within-site taxon turnover (beta diversity) was unimodally related to elevation. The composition of AM fungal communities differed between vegetation types and was influenced by elevation, mean annual temperature, and precipitation. In general, Glomeraceae taxa dominated at all elevations and vegetation types; however, higher elevations were associated with increased presence of Acaulosporaceae, Ambisporaceae, and Claroideoglomeraceae. Contrary to our expectation, the proportion of cultured AM fungal taxa in communities decreased with elevation. These results suggest that, in this system, climate-induced shifts in habitat conditions may facilitate more diverse AM fungal communities at higher elevations but could also favour ruderal taxa.

Psychosocial care in DHB-based stroke services in Aotearoa: a survey of current practice

AIM

Stroke has significant psychosocial impacts which contribute to burden for the person with stroke and affect stroke outcomes. The Psychosocial Working Group of the National Stroke Network (NSN) sought to survey current practices for assessing and supporting psychosocial needs within district health board (DHB) based stroke services to inform national service delivery initiatives.

METHODS

The survey was conducted in 2021. It was distributed to senior clinicians in all DHBs via the NSN.

RESULTS

Thirty-seven responses were received from stroke services, representing 90% of DHBs. Sixty-three percent of services reported some process for screening for psychosocial needs. Of these, only 11% used validated screens. Variability in the type of psychosocial support was evident. Seven percent of services had routine access to psychology, while 53% could access psychology on referral. There was limited evidence of specific screening and support processes for Māori, Pacific peoples, or those with communication impairments. Respondents identified training and resources needs to enable better psychosocial care.

CONCLUSION

Stroke services are not consistently meeting national guidelines which require all services have a process for screening for psychosocial needs. This survey has informed a work programme to support psychosocial care practices in stroke services in Aotearoa New Zealand.

Patient attitudes to nebulised antibiotics in the treatment of bronchiectasis: a mixed-methods study

Background

Regular daily nebulised antibiotics are widely used in managing bronchiectasis. This patient population typically has severe bronchiectasis requiring multiple other medications. Given that little is known about patients' views and preferences for such therapies, this was the focus of our study.

Methods

To explore patient lived-experience using nebulised antibiotics, focus groups and semi-structured interviews were conducted with patients and carers; these were audio-recorded and transcribed to enable thematic analysis. QSR NVivo software facilitated data management. The themes developed from the qualitative data analysis were then used to co-design a questionnaire to capture attitudes and preferences towards nebulised therapy. Questionnaires were completed by patients and statistical analysis was performed. Ethical approval was obtained (13/WS/0036).

Results

The study's focus groups comprised 13 patients and carers, and 101 patients completed the questionnaire. Patients described nebulised therapy as an imposition on their daily routine, in turn affecting reported rates of adherence. Results demonstrated that 10% of all patients using nebulised antibiotics found these hard/very hard to administer. Further, 53% of participants strongly agreed/agreed that they would prefer an antibiotic delivered by an inhaler over a nebuliser, if it were as effective at preventing exacerbations. Notably, only 10% of participants wished to remain on nebulised therapy.

Conclusions

Inhaled antibiotics delivered via dry powder devices were deemed quicker and easier to use by patients. Providing they were at least as effective as current nebulised treatments, patients deemed inhaled antibiotics to be a preferable treatment option.

Exploring the psychometric properties of the Intellectual Disability versions of the Short Warwick-Edinburgh Mental Wellbeing Scale and Kidscreen10, self-reported by adolescents with intellectual disability

BACKGROUND

There are no validated self-report measures that can be used to assess health and wellbeing in adolescents with intellectual disability (ID).

METHOD

The aim of this study was to explore the psychometric properties of two newly adapted self-report health-related quality of life (HRQoL) and mental wellbeing measures: the Intellectual Disability versions of the Short Warwick-Edinburgh Mental Wellbeing Scale (ID-SWEMWBS) and Kidscreen10 (ID-Kidscreen10). For this, we used data from a sample of 427 adolescents (aged 11-19) with ID recruited from special school settings.

RESULTS

Confirmatory factor analysis (CFA) was conducted to validate the factor structure of both measures. Internal consistency was assessed using Cronbach's alpha and test-retest reliability was analysed using intra-class correlation coefficients. The internal consistency measured using Cronbach's alpha was found to be in the range of 0.70-0.78, test-retest reliabilities were expressed using intra-class correlation coefficients that were found to be high for both measures (ID-SWEMWBS, 0.758; ID-Kidscreen10, 0.723), and the CFA supported the unidimensional structure of both measures.

CONCLUSIONS

The results of this study indicate that the ID-SWEMWBS and ID-Kidscreen10 have very good psychometric properties and can be used as self-report measures to assess HRQoL and mental wellbeing in adolescents with ID.

The multiscale feedback theory of biodiversity

Plants and their environments engage in feedback loops that not only affect individuals, but also scale up to the ecosystem level. Community-level negative feedback facilitates local diversity, while the ability of plants to engineer ecosystem-wide conditions for their own benefit enhances local dominance. Here, we suggest that local and regional processes influencing diversity are inherently correlated: community-level negative feedback predominates among large species pools formed under historically common conditions; ecosystem-level positive feedback is most apparent in historically restricted habitats. Given enough time and space, evolutionary processes should lead to transitions between systems dominated by positive and negative feedbacks: species-poor systems should become richer due to diversification of dominants and adaptation of subordinates; however, new monodominants may emerge due to migration or new adaptations.

Global diversity and distribution of nitrogen-fixing bacteria in the soil

Our knowledge of microbial biogeography has advanced in recent years, yet we lack knowledge of the global diversity of some important functional groups. Here, we used environmental DNA from 327 globally collected soil samples to investigate the biodiversity patterns of nitrogen-fixing bacteria by focusing on the nifH gene but also amplifying the general prokaryotic 16S SSU region. Globally, N-fixing prokaryotic communities are driven mainly by climatic conditions, with most groups being positively correlated with stable hot or seasonally humid climates. Among soil parameters, pH, but also soil N content were most often shown to correlate with the diversity of N-fixer groups. However, specific groups of N-fixing prokaryotes show contrasting responses to the same variables, notably in Cyanobacteria that were negatively correlated with stable hot climates, and showed a U-shaped correlation with soil pH, contrary to other N-fixers. Also, the non-N-fixing prokaryotic community composition was differentially correlated with the diversity and abundance of N-fixer groups, showing the often-neglected impact of biotic interactions among bacteria.

Food Insecurity Is Common in the Orthopedic Trauma Population at a Rural Academic Trauma Center

Background

Food insecurity is an increasingly recognized public health issue. Identifying risk factors for food insecurity would support public health initiatives to provide targeted nutrition interventions to high-risk individuals. Food insecurity has not been investigated in the orthopedic trauma population.

Methods

From April 27, 2021 to June 23, 2021, we surveyed patients within six months of operative pelvic and/or extremity fracture fixation at a single institution. Food insecurity was assessed using the validated United States Department of Agriculture Household Food Insecurity questionnaire generating a food security score of 0 to 10. Patients with a food security score ≥ 3 were classified as Food Insecure (FI) and patients with a food security score < 3 were classified as Food Secure (FS). Patients also completed surveys for demographic information and food consumption. Differences between FI and FS for continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe the relationship between food security score and participant characteristics. Logistic regression was used to determine the relationship between patient demographics and odds of FI.

Results

We enrolled 158 patients (48% female) with a mean age of 45.5 ± 20.3 years. Twenty-one patients (13.3%) screened positive for food insecurity (High security: n=124, 78.5%; Marginal security: n=13, 8.2%; Low security: n=12, 7.6%; Very Low security: n=9, 5.7%). Those with a household income level of ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Widowed/single/divorced patients were 10.2 times more likely to be FI (95% CI 2.3-45.6). Median time to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) than for FS patients (t=7 minutes, p=0.0202). Age (r= -0.08, p=0.327) and hours working (r= -0.10, p=0.429) demonstrated weak to no correlation with food security score.

Conclusion

Food insecurity is common in the orthopedic trauma population at our rural academic trauma center. Those with lower household income and those living alone are more likely to be FI. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a more diverse trauma population and to better understand its impact on patient outcomes. Level of Evidence: III.

Metabarcoding of soil environmental DNA to estimate plant diversity globally

Introduction

Traditional approaches to collecting large-scale biodiversity data pose huge logistical and technical challenges. We aimed to assess how a comparatively simple method based on sequencing environmental DNA (eDNA) characterises global variation in plant diversity and community composition compared with data derived from traditional plant inventory methods.

Methods

We sequenced a short fragment (P6 loop) of the chloroplast trnL intron from from 325 globally distributed soil samples and compared estimates of diversity and composition with those derived from traditional sources based on empirical (GBIF) or extrapolated plant distribution and diversity data.

Results

Large-scale plant diversity and community composition patterns revealed by sequencing eDNA were broadly in accordance with those derived from traditional sources. The success of the eDNA taxonomy assignment, and the overlap of taxon lists between eDNA and GBIF, was greatest at moderate to high latitudes of the northern hemisphere. On average, around half (mean: 51.5% SD 17.6) of local GBIF records were represented in eDNA databases at the species level, depending on the geographic region.

Discussion

eDNA trnL gene sequencing data accurately represent global patterns in plant diversity and composition and thus can provide a basis for large-scale vegetation studies. Important experimental considerations for plant eDNA studies include using a sampling volume and design to maximise the number of taxa detected and optimising the sequencing depth. However, increasing the coverage of reference sequence databases would yield the most significant improvements in the accuracy of taxonomic assignments made using the P6 loop of the trnL region.

Early Versus Delayed Surgery for Midshaft Clavicle Fractures: A Systematic Review

Background

Orthopaedic surgeons debate the timing of and necessity for surgical intervention when treating displaced midshaft clavicle fractures (MCFs). This systematic review evaluates the available literature regarding functional outcomes, complication rates, nonunion, and reoperation rates between patients undergoing early versus delayed surgical management of MCFs.

Methods

Search strategies were applied in PubMed (Medline), CINAHL (EBSCO), Embase (Elsevier), Sport Discus (EBSCO), and Cochrane Central Register of Controlled Trials (Wiley). Following an initial screening and full-text review, demographic and study outcome data was extracted for comparison between the early fixation and delayed fixation studies.

Results

Twenty-one studies were identified for inclusion. This resulted in 1158 patients in the early group and 44 in the delayed. Demographics were similar between groups except for a higher percentage of males in the early group (81.6% vs. 61.4%) and longer time to surgery in the delayed group (4.6 days vs. 14.5 months). Disability of the arm, shoulder, and hand scores (3.6 vs. 13.0) and Constant-Murley scores (94.0 vs. 86.0) were better in the early group. Percentages of initial surgeries resulting in complication (33.8% vs. 63.6%), nonunion (1.2% vs. 11.4%), and nonroutine reoperation (15.8% vs. 34.1%) were higher in the delayed group.

Conclusion

Outcomes of nonunion, reoperation, complications, DASH scores, and CM scores favor early surgery over delayed surgery for MCFs. However, given the small cohort of delayed patients who still achieved moderate outcomes, we recommend a shared decision-making style for treatment recommendations regarding individual patients with MCFs. Level of Evidence: II.

Family case studies: absence of Pseudomonas aeruginosa transmission in bronchiectasis

Bronchiectasis, sometimes referred to as non-cystic fibrosis bronchiectasis (NCFB), is a chronic lung disease in which one or more bronchi become permanently dilated, resulting in mucus retention and airway inflammation [1]. It is characterised by repeated infective exacerbations and bacterial colonisation. In bronchiectasis, Pseudomonas aeruginosa is a significant pathogen, associated with increased mortality and acute hospital admission [2]. P. aeruginosa is an aerobic Gram-negative rod-shaped bacterium and a common nosocomial pathogen [3].

Two case reports show lack of Pseudomonas aeruginosa transmission, despite household contact, in non-cystic fibrosis bronchiectasis (NCFB). This supports evidence that in NCFB, P. aeruginosa is poorly transmitted. This affects management strategies.https://bit.ly/3PeOcHy

Involving adolescents with intellectual disability in the adaptation of self-reported subjective well-being measures: participatory research and methodological considerations

BACKGROUND

The measurement of subjective well-being is challenging with samples of adolescents with intellectual disability (ID) given the cognitive and linguistic difficulties they face in comprehending standardised measures, and as such is primarily based on proxy reports. The lack of appropriate tools needs to be addressed so that adolescents with ID can self-report on their own well-being. The current study reports on the use of participatory research methods to adapt and modify two standardised self-report measures of subjective well-being suitable for completion by adolescents with ID.

METHOD

Two special schools were recruited for this study. At each school, staff (n = 15) and pupils aged 11-17 years (n = 35) participated. A series of co-design workshops were conducted to adapt two standardised subjective well-being measures: Kidscreen-10 and short-form Warwick-Edinburgh Mental Well-being Scale.

RESULTS

Specific aspects for measure adaption were identified: simplifying the item wording and phrasing; inclusion of pictorial communication symbols and visual prompts to represent the meaning of items; changing of tense of questions from past to present; asking questions rather than statements; reducing 5-point Likert scales to 3-point or dichotomous; presenting one item at a time during administration; and developing alternate formats of the survey to ensure inclusivity.

CONCLUSIONS

This paper illustrates the value of using participatory research methods when working alongside adolescents with ID and offers methodological, as well as practical, guidance in the context of adapting subjective self-report measures for this target group, serving as a guide to fellow researchers and clinicians interested in modifying or developing self-report measures for adolescents with ID.

Food Insecurity Is Common in the Orthopedic Trauma Population: A Multicenter Cross-Sectional Study

Objectives

Malnutrition increases the risk for adverse outcomes after musculoskeletal trauma. Food insecurity is an increasingly recognized risk factor for malnutrition. The purpose of this investigation is to evaluate the prevalence and risk factors for food insecurity in a diverse population treated for operative fracture fixation.

Methods

A two-center study (Midwest and Pacific Northwest) enrolled participants of any age within 6 months of operative fixation of pelvis or extremity fractures. Food insecurity was assessed using the USDA Household Food Insecurity questionnaire. A score ≥3 indicated food insecurity, 1 or 2 indicated marginal food security, and 0 indicated high food security. Subgroup analysis was performed for participants with available demographic, income, and food access data. Differences between food insecure and food secure participants in continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe associations between food security scores and participant characteristics. Logistic regression was used to relate patient demographics and odds of food insecurity.

Results

Of the 476 participants enrolled, 53 (11%) were food insecure, 48 (10%) had marginal food security, and 375 (79%) were food secure. Those with food insecurity were more commonly female (p &lt; 0.0001). Participants with a household income ≤$15,000 were 5.7 times more likely to be food insecure (95% CI 1.8–18.1). Widowed/single/divorced participants were 10.2 times more likely to experience food insecurity than married/partnered participants (95% CI 2.3–45.6). Median time to the nearest full-service grocery store was significantly longer for food insecure (t = 10 minutes) than for food secure participants (t = 7 minutes, p = 0.0202). Time to store demonstrated a weak correlation with food security score (r = 0.23, p = 0.0041). Age (r = −0.08, p = 0.327) and hours working (r = −0.10, p = 0.429) demonstrated no correlation with food security score.

Conclusions

Food insecurity is common in the musculoskeletal trauma population. Those with lower household incomes and living alone are more likely to experience food insecurity. Food insecurity is a potentially modifiable risk factor for malnutrition-related complications after operative fracture fixation.

Funding Sources

None.

Significant Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture

Objectives

Femoral fragility fractures in the elderly result in devastating loss of physical function and muscle mass, which is a direct result of immobilization and nutrient deficiencies during healing. A better understanding of how muscle mass responds to injury is needed to critically evaluate nutrition interventions designed to prevent muscle loss and optimize function. The purpose of this study was to document sarcopenia, nutrition status, and changes in muscle mass after femoral fragility fractures.

Methods

A two-center prospective observational study enrolled individuals ≥65 years old admitted for operative fixation of a low-energy femoral fracture. Body composition was assessed within 72 hours of admission using bioelectrical impedance and repeated 6 and 12 weeks after injury. Sarcopenia was defined by gender-specific cutoffs for appendicular skeletal muscle mass index. Malnutrition was defined by Mini Nutritional Assessment®. Wilcoxon Signed Rank test was used to assess 6 and 12-week change from baseline in skeletal muscle mass (SMM). Wilcoxon Rank Sum test was used to compare the change in SMM in those with vs without malnutrition and sarcopenia. SMM results are presented as median (interquartile range).

Results

Thirty participants (27% male) age 76.9 ± 8.9 years were enrolled. At baseline, 11 (37%) were sarcopenic, and 17 (59%) were at risk of malnutrition. SMM decreased 1.75kg (−3.30 to −0.40, p < 0.001) by 6 weeks post-injury. By 12 weeks, participants lost 3.04 kg of SMM (−4.49 to −1.45), p < 0.001). Participants with adequate baseline nutrition status lost more SMM at 6 weeks compared to those with at risk of malnutrition (−3.56 kg (−4.65 to −1.60) versus −1.22 kg (−2.00 to −0.20), P = 0.01). No difference was observed in SMM loss between those with vs without sarcopenia at baseline.

Conclusions

Femoral fragility fractures result in devastating losses of skeletal muscle mass. Most were at risk of malnutrition, but participants with adequate baseline nutrition lost more muscle mass, indicating that future investigations of interventions to prevent muscle loss should focus on all fragility fracture patients regardless of nutrition status. These results highlight the need for further investigation into interventions to mitigate muscle loss after injury.

Funding Sources

Orthopedic Trauma Association.

Comparison of Early versus Late Below Knee Amputation After Trauma With Standardized Prosthetic Care

BACKGROUND

High energy, lower extremity trauma is associated with longstanding pain and functional limitations. The clinical decision to proceed with early amputation or limb salvage is often controversial. This study was designed to compare differences in complications, costs, and clinical outcomes of below knee amputation (BKA) performed early after injury or after attempted limb salvage in a hospital with standardized prosthetic care following amputation.

METHODS

This is a retrospective comparative study of subjects who underwent BKA for a traumatic injury at a single level 1 trauma center and received standardized prosthetic care from a single manufacturer from 1999-2016 with minimum 2-year post-amputation follow up. Outcomes collected included demographics, surgical management, unplanned re-operations, and hospital and prosthetic cost data 2 years from time of injury.

RESULTS

Overall, 79 subjects met criteria. Early amputation (EA) was defined by median duration between injury and amputation (6 weeks) with 41 subjects in the EA group and 38 subjects in the late amputation (LA) group. Subjects in the EA group were more likely to have open fractures, high energy mechanism, and less likely to have medical comorbidities. Post-amputation infection was common in both groups (17/41 (42%) vs 17/38 (45%), p=0.77). Subjects undergoing EA were more likely to require unplanned post-amputation revision, 22/41 (54%) versus 10/38 (27%), p=0.017. Hospital costs and prosthetics/orthotics costs from the time of injury to two years following amputation were comparable, with mean hospital EA costs $136,044 versus LA costs $125,065, p=0.38. Mean prosthetics/orthotics costs of EA subjects were $33,252 versus LA costs $37,684, p=0.59.

CONCLUSION

Unplanned post-amputation revision surgeries were more common when BKA was performed early after trauma. Otherwise, outcomes and cost were comparable when amputation was performed early versus late. Level of Evidence: IV.

Malnutrition is Common and Increases the Risk of Adverse Medical Events in Older Adults With Femoral Fragility Fractures

BACKGROUND

Femoral fragility fractures are one of the most common injuries managed by orthopedic surgeons. Malnutrition influences the poor outcomes observed in this population. Our purpose was to assess the annual trends of malnutrition diagnosis and determine risk factors for malnutrition and complications in patients 65 years and older presenting with femoral fragility fractures. We hypothesized that malnutrition would increase the risk of postoperative wound infection, wound dehiscence, non-union, and mortality.

METHODS

The PearlDiver database was reviewed from 2010 to 2020. Patients ≥ 65-years-old with femur fractures treated with operative fixation were identified by CPT code. A preoperative diagnosis of malnourished state was defined by ICD-9 and ICD-10 codes and patients were divided into malnourished and non-malnourished cohorts. Patients were tracked for one year following operative fixation of a femoral fragility fracture for the occurrence of infection, wound dehiscence, nonunion and mortality. The rates of these complications were compared between malnourished and nonmalnourished cohorts.

RESULTS

There were 178,283 total femoral fragility fractures identified in patients aged 65-years or older. The overall prevalence of malnutrition diagnosis in this geriatric population was 12.8%. Documented malnutrition in femoral fragility fractures increased from 1.6% to 32.9% from 2010-2020 (P<0.0001). Compared to patients without malnutrition, patients with malnutrition are at increased risk of mortality (OR 1.31, 95% CI 1.2558 - 1.3752, p < 0.0001), are more likely to develop a wound infection (OR 1.49; 95% CI 1.252 - 1.7626; p < 0.0001), more likely to have a wound dehiscence (OR 1.55; 95% CI 1.3416 - 1.7949; p < 0.0001), and more likely to develop non-union (1.89; 95% CI 1.6946 - 2.1095; p < 0.0001). Multiple demographic variables were associated with malnutrition diagnosis including higher age, higher Charlson Comorbidity Index, female sex, dementia, and institutionalization. Parkinson's disease, feeding difficulty and institutionalization demographic variables had the highest risk of malnutrition.

CONCLUSION

The current study found that malnutrition diagnosis significantly increases the risk of adverse medical events in elderly adults with femoral fragility fractures. The rates of malnutrition increased steadily from 2010-2020. This trend is likely a result of increased awareness and testing for malnutrition, not reflecting an actual increased prevalence of malnutrition. Multiple expected demographic variables are associated with diagnosis of malnutrition. Level of Evidence: III.

Reliability of Multifrequency Bioelectrical Impedance Analysis to Quantify Body Composition in Patients After Musculoskeletal Trauma

BACKGROUND

Changes in body composition, especially loss of lean mass, commonly occur in the orthopedic trauma population due to physical inactivity and inadequate nutrition. The purpose of this study was to assess inter-rater and intra-rater reliability of a portable bioelectrical impedance analysis (BIA) device to measure body composition in an orthopedic trauma population after operative fracture fixation. BIA uses a weak electric current to measure impedance (resistance) in the body and uses this to calculate the components of body composition using extensively studied formulas.

METHODS

Twenty subjects were enrolled, up to 72 hours after operative fixation of musculoskeletal injuries and underwent body composition measurements by two independent raters. One measurement was obtained by each rater at the time of enrollment and again between 1-4 hours after the initial measurement. Reliability was assessed using intraclass correlation coefficients (ICC) and minimum detectable change (MDC) values were calculated from these results.

RESULTS

Inter-rater reliability was excellent with ICC values for body fat mass (BFM), lean body mass (LBM), skeletal muscle mass (SMM), dry lean mass (DLM), and percent body fat (PBF) of 0.993, 0.984, 0.984, 0.979, and 0.986 respectively. Intra-rater reliability was also high for BFM, LBM, SMM, DLM, and PBF, at 0.994, 0.989, 0.990, 0.983, 0.987 (rater 1) and 0.994, 0.988, 0.989, 0.985, 0.989 (rater 2). MDC values were calculated to be 4.05 kg for BFM, 4.10 kg for LBM, 2.45 kg for SMM, 1.21 kg for DLM, and 4.83% for PBF.

CONCLUSION

Portable BIA devices are a versatile and attractive option that can reliably be used to assess body composition and changes in lean body mass in the orthopedic trauma population for both research and clinical endeavors. Level of Evidence: III.

Dominance, diversity, and niche breadth in arbuscular mycorrhizal fungal communities

Classical theory identifies resource competition as the major structuring force of biotic communities and predicts that: (i) levels of dominance and richness in communities are inversely related, (ii) narrow niches allow dense 'packing' in niche space and thus promote diversity, and (iii) dominants are generalists with wide niches, such that locally abundant taxa also exhibit wide distributions. Current empirical support, however, is mixed. We tested these expectations using published data on arbuscular mycorrhizal (AM) fungal community composition worldwide. We recorded the expected negative relationship between dominance and richness and, to a degree, the positive association between local and global dominance. However, contrary to expectation, dominance was pronounced in communities where more specialists were present; and, conversely, richness was higher in communites with more generalists. Thus, resource competition and niche packing appear of limited importance in AM fungal community assembly; rather patterns of dominance and diversity seem more consistent with habitat filtering and stochastic processes. This article is protected by copyright. All rights reserved.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial

BACKGROUND

Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures.

METHODS

Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM.

RESULTS

Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points.

CONCLUSIONS

Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

An observational study of Pseudomonas aeruginosa in adult long-term ventilation

Introduction

Pseudomonas aeruginosa increases morbidity and mortality in respiratory disease. To date the long-term ventilation population does not have clear guidelines regarding its management.

Method

We undertook a retrospective observational study in a regional long-term ventilation population (837 patients). We defined the primary outcome as P. aeruginosa isolation. In addition positive cultures for copathogens (Serratia, Proteus species, Stenotrophomonas, Burkholderia cepacia complex and nontuberculous mycobacteria) were recorded. Logistic regression and odds ratios were calculated.

Results

17.6% of the cohort isolated P. aeruginosa, and this pathogen was cultured more frequently in patients with a tracheostomy (logistic regression coefficient 2.90, p≤0.0001) and cystic fibrosis/bronchiectasis (logistic regression coefficient 2.48, p≤0.0001). 6.3% of patients were ventilated via tracheostomy. In the P. aeruginosa positive cohort 46.9% of patients were treated with a long-term macrolide, 36.7% received a nebulised antibiotic and 21.1% received both. Tracheostomised P. aeruginosa positive patients received a nebulised antibiotic more frequently (OR 2.63, 95% CI 1.23–5.64, p=0.013). Copathogens were isolated in 33.3% of the P. aeruginosa cohort. In this cohort patients with a tracheostomy grew a copathogen more frequently than those without (OR 2.75, 95% CI 1.28–5.90).

Conclusions

P. aeruginosa isolation is common within the adult long-term ventilation population and is significantly associated with tracheostomy, cystic fibrosis and bronchiectasis. Further research and international guidelines are needed to establish the prognostic impact of P. aeruginosa and to guide on antimicrobial management. The increased risk of P. aeruginosa should be considered when contemplating long-term ventilation via tracheostomy.

Pseudomonas aeruginosa isolation is common (17%) in long-term ventilated adults and significantly associated with tracheostomy, cystic fibrosis and bronchiectasis. Tracheostomy patients with P. aeruginosa isolates culture copathogens more frequently.https://bit.ly/3vvxBbB

Global taxonomic and phylogenetic assembly of AM fungi

Arbuscular mycorrhizal (AM) fungi are a ubiquitous group of plant symbionts, yet processes underlying their global assembly - in particular the roles of dispersal limitation and historical drivers - remain poorly understood. Because earlier studies have reported niche conservatism in AM fungi, we hypothesized that variation in taxonomic community composition (i.e., unweighted by taxon relatedness) should resemble variation in phylogenetic community composition (i.e., weighted by taxon relatedness) which reflects ancestral adaptations to historical habitat gradients. Because of the presumed strong dispersal ability of AM fungi, we also anticipated that the large-scale structure of AM fungal communities would track environmental conditions without regional discontinuity. We used recently published AM fungal sequence data (small-subunit ribosomal RNA gene) from soil samples collected worldwide to reconstruct global patterns in taxonomic and phylogenetic community variation. The taxonomic structure of AM fungal communities was primarily driven by habitat conditions, with limited regional differentiation, and there were two well-supported clusters of communities - occurring in cold and warm conditions. Phylogenetic structure was driven by the same factors, though all relationships were markedly weaker. This suggests that niche conservatism with respect to habitat associations is weakly expressed in AM fungal communities. We conclude that the composition of AM fungal communities tracks major climatic and edaphic gradients, with the effects of dispersal limitation and historic factors considerably less apparent than those of climate and soil.

Employing the theory of planned behaviour to design an e-cigarette education resource for use in secondary schools

Background

An extended version of the theory of planned behaviour (TPB) was used to inform the design of a framework for an educational resource around e-cigarette use in young people.

Methods

A sequential exploratory design was employed. In Phase 1, elicited behavioural, normative and control beliefs, via 7 focus groups with 51 participants, aged 11–16 years, identified salient beliefs around e-cigarette use. These were used to construct a questionnaire administered to 1511 young people aged 11–16 years, which determined predictors of e-cigarette use and ever use. In Phase 2, sociodemographic variables, e-cigarette knowledge, access, use, marketing and purchasing of e-cigarettes and smoking behaviour were also gathered. The composite findings from Phase 1 and 2 informed the design of a post primary educational resource in Phase 3 around e-cigarette use.

Results

Current e-cigarette use was 4%, with almost 23% reporting ever use, suggesting current use is stable but experimentation may be increasing in this cohort. Sociodemographic variables, knowledge of e-cigarettes, smoking behaviour and TPB variables (direct and indirect measures of attitudes, subjective norm, and perceived behavioural control) accounted for 17% of the variance in current e-cigarette use, with higher intentions to use e-cigarettes within the next month, having the strongest impact on use (p < 0.001), followed by self-efficacy (p = 0.016). Sociodemographic and TPB variables accounted for 65% of the variance in intentions to use e-cigarettes in the next month; current e-cigarette use (p < 0.001), more positive attitudes (p < 0.001), stronger social influence (p < 0.001), higher self-efficacy (p < 0.001), higher control beliefs (p < 0.001) and greater motivation to use e-cigarettes (p < 0.001) were the main predictors of intentions. Phases 1 and 2 informed the mapping of key predictors of intentions and use of e-cigarettes onto the Theoretical Domains Framework, which identified appropriate intervention functions and behaviour change techniques.

Conclusions

This paper is the first to bridge the theoretical-practice gap in an area of significant public health importance through the development of a framework for a novel theory driven school-based educational resource aimed at reducing experimentation and uptake of e-cigarette use in young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12674-3.

A patient case demonstrating the efficacy of benralizumab in uncontrolled severe eosinophilic asthma refractory to omalizumab and mepolizumab treatment

Severe eosinophilic asthma is associated with a heavy burden and impact on daily living in patients experiencing uncontrolled symptoms, exacerbations, and treatment side effects. This case study reports a 49-year-old woman who presented to the severe asthma center with uncontrolled severe asthma despite multiple maintenance medications and omalizumab treatment. On presentation, the patient had experienced two to three hospitalizations per year, frequent asthma exacerbations requiring courses of oral corticosteroids, and symptoms that impacted her quality of life. Omalizumab was previously discontinued, and bronchial thermoplasty was also unsuccessful. The patient stabilized on injectable steroids and commenced mepolizumab once available on prescription. Owing to continued exacerbations and an inability to reduce steroid treatment without exacerbating, mepolizumab was discontinued and the patient commenced benralizumab (30 mg subcutaneously every 4 weeks for the first three doses, every 8 weeks thereafter) under the sole care of the severe asthma center. Benralizumab treatment resulted in a reduction in steroid treatment, zero asthma exacerbations, improved asthma control and lung function, and a marked improvement in activity levels that allowed the patient to participate in a long-distance running event. Additionally, 7 months following the initiation of benralizumab treatment, her blood eosinophils were completely depleted. These findings support the use of benralizumab in patients with refractory uncontrolled severe eosinophilic asthma despite previous biologic treatment with omalizumab and mepolizumab, as improvements in clinical and patient outcomes, including quality of life, can be achieved in difficult-to-treat cases.

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Blood eosinophils reduced to zero in this severe eosinophilic asthma case study.

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Benralizumab allowed a substantial reduction in maintenance corticosteroid use.

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Benralizumab improved exacerbations, asthma control, and quality of life.

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Benralizumab had efficacy after inadequate biologic therapy/bronchial thermoplasty.

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A positive patient-clinician relationship can enhance patient outcomes.

Changes in Muscle Volume and Composition After Treatment of Hip Dysplasia with Periacetabular Osteotomy

BACKGROUND

Periacetabular osteotomy (PAO) is a common treatment for pre-arthritic hip dysplasia in young adults. The purpose of this study was to better understand changes in muscle volume and composition after PAO visualized using magnetic resonance imaging (MRI).

METHODS

A prospectively collected series of individuals that underwent PAO for hip dysplasia were reviewed to identify subjects with pre- and postoperative MRI. In our practice, MRI was obtained preoperatively and greater than 6 months after PAO for persistent hip pain. MRI sequences were selected to optimize visualization of the muscle volume, fatty infiltration, and hip joint cartilage. MRI images were selected at predetermined bony landmarks and analyzed using 3D Slicer (©2021, www.slicer.org) software to measure muscle diameter and calculate muscle cross-sectional area (CSA) in 17 individual muscles surrounding the hip. Muscle atrophy was graded using the Goutallier classification for fatty infiltration and acetabular cartilage condition was graded using the Outerbridge classification. We compared pre- and postoperative muscle area and composition as well as cartilage for each case.

RESULTS

A series of six female patients met our inclusion criteria. Mean age was 26 years at time of surgery. All cases had MRI sequences adequate for muscle volume measurements. Fatty infiltration and cartilage changes were recorded in four subjects with appropriate MRI sequences. Separating muscle groups, external rotators underwent the largest volume increase. Hip flexors demonstrated mild volume decrease. CSA change among external rotators averaged +12%, hip flexors -9.3%, and hip abductors -9.2% after PAO. All muscles had either the same or increased fatty infiltration after surgery, with gluteus medius and iliacus undergoing the most average increase. Similarly, cartilage condition worsened by a small margin in this series.

CONCLUSION

Our results provide preliminary indication that PAO may have noticeable effects on muscle characteristics and cartilage in the early postoperative period. This was a limited case series of subjects with adequate pre- and post-operative MRI imaging.Level of Evidence: IV.

854 Mortality Associated with Conversion of Total Hip Arthroplasty for Failed Fixation/Hemiarthroplasty for Neck of Femur Fractures

Aim

To identify the mortality associated with failed internal fixation and hemiarthroplasty of neck of femur fractures.

Method

Patients undergoing conversion of internal fixation / hemi arthroplasty were identified from theatre records and surgical databases. Data was stored in Microsoft Excel spreadsheet. Clinical outcomes at 30 days, 1 year and 5 years post conversion total hip replacement.

Results

60 cases were collected between June 2006 and November 2016. 46 females and 14 males involved in the case. The mean age of male patients was 66.5 and for females 67.9. 32 patients had previous sliding hip screw fixation,12 had intra-medullary nails, 8 had cannulated screw fixation and 5 patients had hemiarthroplasty. The mean time to failure was 22 months (Range: 2 weeks to 60 months) and there were 6 cases of late posttraumatic arthritis (range 4 yrs to 23 yrs). Average time from documented failure to conversion THR was 2 months. There were 2 superficial wound infections which were successfully treated with antibiotics. There were 2 cases of deep infection which required multiple debridement, washout, and prolonged inpatient stay. Average duration of hospital stay was 5.7days. 18 patients died before 5 years for reasons unrelated to their hip. All had a functional prosthesis at time of last review. 42 patients alive at 5 years had a functional prosthesis at last review

Conclusions

Total Hip Arthroplasty is a successful procedure for failed fixation / hemiarthroplasty despite the technical challenges. A 3–5-year mortality rate of 33.33 % reflects well against the NHFD 1year mortality of 30 %.

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications

OBJECTIVES

To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13).

DESIGN

Retrospective comparative cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy).

INTERVENTION

Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy.

MAIN OUTCOME MEASURE

Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI).

RESULTS

Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001).

CONCLUSIONS

Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Temperature and pH define the realised niche space of arbuscular mycorrhizal fungi

The arbuscular mycorrhizal (AM) fungi are a globally distributed group of soil organisms that play critical roles in ecosystem function. However, the ecological niches of individual AM fungal taxa are poorly understood. We collected > 300 soil samples from natural ecosystems worldwide and modelled the realised niches of AM fungal virtual taxa (VT; approximately species-level phylogroups). We found that environmental and spatial variables jointly explained VT distribution worldwide, with temperature and pH being the most important abiotic drivers, and spatial effects generally occurring at local to regional scales. While dispersal limitation could explain some variation in VT distribution, VT relative abundance was almost exclusively driven by environmental variables. Several environmental and spatial effects on VT distribution and relative abundance were correlated with phylogeny, indicating that closely related VT exhibit similar niche optima and widths. Major clades within the Glomeraceae exhibited distinct niche optima, Acaulosporaceae generally had niche optima in low pH and low temperature conditions, and Gigasporaceae generally had niche optima in high precipitation conditions. Identification of the realised niche space occupied by individual and phylogenetic groups of soil microbial taxa provides a basis for building detailed hypotheses about how soil communities respond to gradients and manipulation in ecosystems worldwide.

Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT

BACKGROUND

Falls and fractures are a major problem.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions.

DESIGN

Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice.

SETTING

Primary care.

PARTICIPANTS

People aged ≥ 70 years.

INTERVENTIONS

All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling.

MAIN OUTCOME MEASURES

The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit.

RESULTS

Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported.

LIMITATIONS

The rate of fractures was lower than anticipated.

CONCLUSIONS

Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective.

FUTURE WORK

Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71002650.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.

Predictors of wound leakage in patients undergoing surgery for neck of femur fractures

AIMS

Persistent wound leakage following joint arthroplasty is a known risk for periprosthetic joint infection. Little is known of the predictors of wound leakage, particularly in patients with a fractured neck of femur. We aimed to determine patient and surgical risk factors for wound leakage in this cohort.

MATERIALS AND METHODS

All patients undergoing surgery for a fractured neck of femur at Leicester Royal Infirmary between May and August 2017 were included. Patients were identified from a prospective database and placed into two groups: those with wound leakage later than three days postoperatively and those without leakage. All previously reported potential risk factors for wound leakage were compared between groups using a chi-square test and logistic regression. A Kattan-style nomogram was also created to allow probabilities output for the regression predictive models in a visual representation.

RESULTS

Two hundred patients underwent surgery for a fractured neck of femur. Overall, 17% of patients (33/200) developed a persistent leaky wound. A multivariable model highlighted increased age (p = 0.01), raised body mass index (BMI; > 25 kg/m²; p = 0.047), diabetes (p = 0.03) and intramedullary hip screw fixation (p = 0.03) as significant risk factors for wound leakage. Patients with persistent wound leakage had significantly longer hospital admission than those without (p = 0.001).

DISCUSSION

Our analysis identified four perioperative risk factors for wound leakage following fractured neck of femur surgery. We also developed a novel tool to identify those patients at highest risk of leakage. Once identified, the aggressive management of certain medical comorbidities in these patients may help to reduce their incidence of wound issues and the prolonged admissions that result.

Respiratory outpatient clinics during and post COVID-19: the use of patient satisfaction and preference data to redesign service delivery

We used a survey to evaluate patient satisfaction with a remote system for the delivery of respiratory clinics and to capture future preferences. 98% of responders were satisfied with their current appointment being held remotely in order to reduce the risks from COVID-19. Regarding future preferences beyond the pandemic, 41% of respondents preferred a face-to-face appointment, 35% preferred a remote appointment and 24% had no preference of one modality over another. Additional qualitative data suggest that a flexible system allowing patients to choose the mode of attendance shortly before the appointment would be welcomed.

Neuroradiologic Phenotyping of Galactosemia: From the Neonatal Form to the Chronic Stage

Galactosemia is a rare genetic condition caused by mutation of enzymes involved in galactose and glucose metabolism. The varying clinical spectrum reflects the genetic complexity of this entity manifesting as acute neonatal toxicity syndrome, requiring prompt diagnosis and treatment, to more insidious clinical scenarios as observed in the subacute and chronic presentations. The current literature predominantly focuses on the long-standing sequelae of this disease. The purpose of this multicenter clinical report comprising 17 patients with galactosemia is to highlight the MR imaging patterns encompassing the whole spectrum of galactosemia, emphasizing the 3 main clinical subtypes: 1) acute neonatal presentation, with predominant white matter edema; 2) subacute clinical onset with a new finding called the "double cap sign"; and 3) a chronic phase of the disease with heterogeneous imaging findings. The knowledge of these different patterns together with MR spectroscopy and the clinical presentation may help in prioritizing galactosemia over other neonatal metabolic diseases and prevent possible complications.

User-friendly bioinformatics pipeline gDAT (graphical downstream analysis tool) for analysing rDNA sequences

High-throughput sequencing (HTS) of multiple organisms in parallel (metabarcoding) has become a routine and cost-effective method for the analysis of microbial communities in environmental samples. However, careful data treatment is required to identify potential errors in HTS data, and the large volume of data generated by HTS requires in-house experience with command line tools for downstream analysis. This paper introduces a pipeline that incorporates the most common command line tools into an easy-to-use graphical interface-gDAT. By using the Python scripting language, the pipeline is compatible with the latest Windows, macOS and Linux operating systems. The pipeline supports analysis of Sanger, 454, IonTorrent, Illumina and PacBio sequences, allows custom modification of quality filtering steps, and implements both open and closed-reference operational taxonomic unit-picking for sequence identification. Predefined parameters are optimized for analysis of small subunit (SSU) rRNA gene amplicons from arbuscular mycorrhizal fungi, but the pipeline is widely applicable to metabarcoding studies targeting a broad range of organisms. The pipeline was additionally tested with data using general eukaryotic primers from the SSU gene region and fungal primers from the internal transcribed spacer (ITS) marker region. We describe the pipeline design and evaluate its performance and speed by conducting analysis of example data sets using different marker regions sequenced on Illumina platforms. The graphical interface, with the option to use the command line if needed, provides an accessible tool for rapid data analysis with repeatability and logging capabilities. Keeping the software open-source maximizes code accessibility, allowing scrutiny and bug fixes by the community.

Light availability and light demand of plants shape the arbuscular mycorrhizal fungal communities in their roots

Plants involved in the arbuscular mycorrhizal (AM) symbiosis trade photosynthetically derived carbon for fungal-provided soil nutrients. However, little is known about how plant light demand and ambient light conditions influence root-associating AM fungal communities. We conducted a manipulative field experiment to test whether plants' shade-tolerance influences their root AM fungal communities in open and shaded grassland sites. We found similar light-dependent shifts in AM fungal community structure for experimental bait plant roots and the surrounding soil. Yet, deviation from the surrounding soil towards lower AM fungal beta-diversity in the roots of shade-intolerant plants in shade suggested preferential carbon allocation to specific AM fungi in conditions where plant-assimilated carbon available to fungi was limited. We conclude that favourable environmental conditions widen the plant biotic niche, as demonstrated here with optimal light availability reducing plants' selectivity for specific AM fungi, and promote compatibility with a larger number of AM fungal taxa.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Muscle Wasting in Orthopedic Trauma Patients

Objectives

Increased metabolic demand and inadequate oral intake after musculoskeletal trauma results in catabolic skeletal muscle wasting, which limits potential for functional recovery after injury. This study compared standard perioperative nutrition and oral supplementation with conditionally essential amino acids (CEAA) on changes in lean body mass after operative fixation of acute fractures.

Methods

Patients sustaining operative pelvis and extremity fractures presenting to a Level 1 trauma center were prospectively enrolled in a single blinded-randomized clinical trial. Demographics, injury classification, and comorbidities were collected at baseline. Fat Free Mass (FFM) was measured within 72 hours of surgery using A-Mode Ultrasound. Patients were randomly chosen to receive standard nutrition (Control) or standard nutrition plus an oral supplement (CEAA) containing 14 g of amino acids to be taken 2x daily for 2 weeks. FFM was re-assessed at 6 weeks and 3 months post-surgery. Statistical analysis was performed comparing Least Squared Mean FFM (P &lt; .05).

Results

222 subjects (Control: 112, CEAA: 120) were included in this analysis. There were no differences in age, gender, BMI, or baseline FFM between Control and CEAA subjects (all P &gt; .05). Median supplement compliance was 22/28 servings (78.6%, sd ± 36.9%). At 6 weeks, average change in FFM among Controls was −1.28 kg (P = .004) and -.56 kg among CEAA (P = .19). Changes were not significant between groups (P = .23). At 12 weeks, there were non-significant changes in FFM from baseline in both groups (Controls: -.02 kg P = .96, CEAA: +.36 kg P = .44). From 6–12 weeks, FFM changes were + 1.26 kg (P = .012) and + .91 kg (P = .06) respectively.

Conclusions

Patients randomized to standard nutrition had significant FFM loss compared to those receiving additional CEAA supplementation 6 weeks after surgery. At 12 weeks, the control group decreased FFM further from baseline while the CEAA group mostly recovered their loss. Although 12-week FFM changes were not significant, results indicate CEAA supplementation prevents FFM loss in the acute post-operative phase. Further investigation is needed to compare FFM changes, clinical outcomes, complication rates, and the impact of baseline nutrition status.

Funding Sources

American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Perioperative Nutritional Screening Tools Are Not Associated with Poor Outcomes After Musculoskeletal Trauma

Objectives

Malnutrition is predictive of poor outcomes after trauma. Side effects of both pain and narcotics often limit postoperative dietary intake increasing nutritional deficiencies and limiting wound healing. The purpose of this study was to compare the predictive ability of a dietician nutritional evaluation and a patient reported nutritional screening tool for post-operative complications after musculoskeletal trauma.

Methods

Adults with operative pelvis or long bone fractures were prospectively enrolled in a single-blinded RCT and included in this analysis. Subjects were evaluated with the Patient Generated Subjective Global Assessment (PG-SGA) survey at baseline. Dietician Nutritional Assessment Screening (NAS) was performed for patients ≥65 years with low Albumin or Vitamin D, or admitted to the ICU. Complication analysis included subjects having minimum 6-month follow-up and/or ≥1 complication within six months. Spearman's Correlation was used to evaluate agreement between screening methods. Comparison using X analysis was done of complications between pre-operative assignment of malnutrition for each screening tool.

Results

Agreement of NAS and self-reported PG-SGA for 265 subjects demonstrated a weak correlation of rho = 0.23, P = 0.0002. Neither screening method had significant correlation for rates of non-union, mortality, medical, or surgical complications between designations of malnutrition (all P &gt; .05). Among study subjects, incidence of those having a medical or surgical complication not screened by a dietician was 31.3% and 37.7% respectively.

Conclusions

Results indicate inconsistency in methods for assigning malnutrition in trauma population. Additionally, designation of malnutrition by either method was not associated with post-operative complication rates. The high incidence of those with a complication who were not evaluated by a dietician during initial hospitalization (1/3rd) support the need to develop better methods for screening malnutrition after trauma.

Funding Sources

American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Amino Acid Supplementation Is Associated with Reduced Mortality and Complications Following Acute Fracture Fixation: Results of a Prospective, Randomized Controlled Trial

Objectives

Acute musculoskeletal trauma patients experience immobilization and under-nutrition resulting in catabolic skeletal muscle wasting and compromised wound healing. We conducted a prospective RCT to assess the effect of supplementation with conditionally essential amino acids (CEAA) on postoperative outcomes in patients with acute orthopedic trauma. We hypothesized that supplementation with CEAA would decrease postoperative complications.

Methods

Adults with operative pelvis or long bone fractures, excluding distal radius fractures, were prospectively enrolled in this single-blinded RCT. Patients were assigned by stratified by injury severity and randomized to standard preoperative nutrition (control) or standard nutrition with oral supplement containing CEAA for two weeks after surgery (CEAA). Subjects with minimum 6-months follow up were included in this analysis. Postoperative complication rates were analyzed with X,2 using intention-to-treat analysis.

Results

243 patients met inclusion criteria (Control: 117, CEAA: 126). Median supplement compliance in CEAA patients was 84% of 28 prescribed CEAA servings with no reported supplement-related adverse events. 7 of 117 patients within the control group died during follow up vs. 1 of 126 in CEAA group (P = 0.031). Total complication rate was 55% control patients and 41% CEAA patients (P = 0.040). Surgical site infection (SSI) rates were 24% in control vs. 14% in CEAA (P = 0.055). Medical complication rates were 35% in control vs. 23% in CEAA (P = 0.039). Nonunion rates were 3% in control vs. 5% in CEAA (P = 0.751).

Conclusions

Patients receiving CEAA supplementation following acute fracture fixation had significantly lower mortality, overall complications, and medical complications. There was a trend toward decreased surgical site infections among patients receiving CEAA, although this did not reach statistical significance. Postoperative oral supplementation with CEAA is a low-cost, low-risk intervention associated with reductions in postoperative mortality and complications. Further work is warranted to improve preoperative risk stratification and further define which individuals receive greatest benefit from this intervention.

Funding Sources

American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Postoperative Dietary Quality is Poor after Major Musculoskeletal Trauma

Objectives

Musculoskeletal trauma often leads to prolonged functional deficits. Adequate dietary intake and supplementation improves clinical outcomes after surgical fixation of hip fracture in older adults. The role of post-operative nutrition after acute fracture has not been elucidated. Our objective was to describe dietary deficiencies after operative fixation of acute fracture in young adults.

Methods

An observational, cohort study identified patients aged 18–55 years presenting to a Level 1 trauma center with pelvic or extremity fracture indicated for operative fixation. Dietary intake was measured using Automated Self- Administered 24-hour dietary recall (ASA24®) in weeks 1, 2, and 4 postoperatively. Individual macro- and micro-nutrients for each subject were summarized using arithmetic means. Inadequate nutritional intake was determined using Dietary Reference Intake (DRI) values reported by the Institute of Medicine. The Healthy Eating Index 2015 (HEI-2015) score was calculated based on ASA24® data as described by the USDA.

Results

Most subjects were healthy preoperatively, 98% had ≤1 comorbidity. Eighty-four % of injures were to the lower extremities, and 59% were isolated. The majority of subjects (78%) discharged home. An average of 3.9 surveys were filled out per subject. Dietary intake overall was inadequate; 72% did not meet calorie needs. Protein intake was inadequate in 66%. All subjects did not meet DRIs for fiber, vitamin E, or potassium. More than 50% did not meet DRI for calcium, iron, magnesium, folate, vitamins C, A, or K. Added sugar and saturated fat intake exceeded recommendations in 38% and 41% of subjects respectively. Intake of beneficial foods such as whole grains and vegetables were inadequate in 100% of subjects; fruit intake was inadequate in 88%. The mean HEI-2015 score was 44.7 (±11.4 SD) across all time points.

Conclusions

In a population of previously healthy, young adults with major musculoskeletal trauma, dietary quality was poor compared to the average for the US population, 44.7 vs 59 HEI-2015. Diet analysis revealed a concerning lack of vegetables, whole grains, multiple micronutrients, and total calories. This data provides goals for adequate nutritional supplementation after musculoskeletal trauma.

Funding Sources

No payments were received to conduct this research study.

Different wheat cultivars exhibit variable responses to inoculation with arbuscular mycorrhizal fungi from organic and conventional farms

The present study aimed to investigate the effects of arbuscular mycorrhizal (AM) fungal communities originating from organic and conventional agriculture on wheat growth and yield. Six different spring wheat cultivars released in different years in north and central European countries were considered. We hypothesised that AM fungal inoculum collected from organic agricultural fields would elicit a greater positive growth response than inoculum collected from conventional agricultural fields; and that older cultivars, which were developed under conditions of low fertilizer input, would exhibit overall greater growth responses to the presence of AM fungi, compared with more recent cultivars, and that AM fungal inoculum from conventional fields might have the most beneficial effect on the growth and yield of recent cultivars. The results showed that the overall effects on the growth and yield of spring wheat grown with organic and conventional AM fungal inocula did not differ greatly. However, the inoculation growth response, showing the difference of the effects of organic and conventional inocula, varied between particular wheat cultivars. Inoculation growth response of the cultivar Pikker (released in 1959) was the most positive, while that of the cultivar Arabella (released in 2012) was the most negative. The use of AM fungal inoculum from organic fields resulted in slightly taller plant individuals. Pikker showed relatively higher yield and stronger growth when the organic AM fungal inoculum was used. Arabella exhibited relatively lower yield and weaker growth when the organic inoculum was used. Whether the positive response of Pikker to Estonian organic inoculation reflects adaptation to the locally occurring AM fungal community needs to be established by further studies of the communities of AM fungi colonizing wheat roots.