The impact of hematology electronic consultations on the management of iron deficiency.

OBJECTIVES: Delays in the evaluation and treatment of iron deficiency can lead to increased disease-related morbidity and mortality. Electronic consultation (e-consult) is a referral modality that allows providers quicker access to recommendations from a specialist based on electronic chart review. While the use of e-consult is expanding in classical hematology, gaps exist in the understanding of patient outcomes related to its use for iron deficiency. METHODS: We randomly selected 200 e-consults and 200 traditional referrals from 3,336 hematology referrals for iron deficiency at a single center. The primary outcomes of the retrospective analysis were: time to completion of the referral, and time to treatment with intravenous iron. Secondary outcomes included recurrence of iron deficiency, need for repeat e-consult, conversion to in-person evaluation, and assessment of whether the etiology of iron deficiency was addressed. RESULTS: E-consults significantly reduced the time from referral to intravenous iron repletion (e-consult, 33 days; traditional referral, 68 days; p < .05). Assessment of the underlying etiology occurred in 70.7% of the e-consult encounters compared to 92.5% of traditional referrals (p < .05). CONCLUSIONS: These findings highlight advantages of e-consults in improving care delivery in iron deficiency, and identifying gaps that can be improved through practice standardization to ensure equitable, high-value care.

A Rare Case of Therapy-Related B-cell Acute Lymphoblastic Leukemia Arising From Acute Myeloid Leukemia.

Therapy-related acute lymphoblastic leukemia (t-ALL) is a rare potential complication of chemotherapy. We describe the case of a 47-year-old male patient who was originally diagnosed with t(8;21) positive acute myeloid leukemia (AML) in 2019, received chemotherapy, achieved remission, and was disease-free for the next two years. During a routine follow-up in 2022, he was found to have developed subclinical pancytopenia, and further studies indicated a diagnosis of pH-negative, near-tetraploid B-cell acute lymphoblastic leukemia (B-ALL) that was positive for a Tier 1 TP53 mutation, consistent with t-ALL. The patient had a prolonged treatment course complicated by social factors, such as the impact of both disease and treatment on his ability to work enough to make a living and live life with the quality he desired. The patient elected to pause treatment and resume it at a later date, after which, unfortunately, significant disease progression occurred and the patient died from complicating neutropenic sepsis and variceal bleeding. This case illustrates the challenges of managing social circumstances and patient goals in the setting of medically necessary but potentially harsh treatment courses. Given the aggressive nature of t-ALL and its overall poor prognosis, goals of care must be re-evaluated and discussed often to ensure alignment of therapy with a patient's wishes.

Cell Type-Specific Biomarkers of Systemic Sclerosis Disease Severity Capture Cell-Intrinsic and Cell-Extrinsic Circuits.

OBJECTIVE: Systemic sclerosis (SSc) is a multifactorial autoimmune fibrotic disorder involving complex rewiring of cell-intrinsic and cell-extrinsic signaling coexpression networks involving a range of cell types. However, the rewired circuits as well as corresponding cell-cell interactions remain poorly understood. To address this, we used a predictive machine learning framework to analyze single-cell RNA-sequencing data from 24 SSc patients across the severity spectrum as quantified by the modified Rodnan skin score (MRSS). METHODS: We used a least absolute shrinkage and selection operator (LASSO)-based predictive machine learning approach on the single-cell RNA-sequencing data set to identify predictive biomarkers of SSc severity, both across and within cell types. The use of L1 regularization helps prevent overfitting on high-dimensional data. Correlation network analyses were coupled to the LASSO model to identify cell-intrinsic and cell-extrinsic co-correlates of the identified biomarkers of SSc severity. RESULTS: We found that the uncovered cell type-specific predictive biomarkers of MRSS included previously implicated genes in fibroblast and myeloid cell subsets (e.g., SFPR2+ fibroblasts and monocytes), as well as novel gene biomarkers of MRSS, especially in keratinocytes. Correlation network analyses revealed novel cross-talk between immune pathways and implicated keratinocytes in addition to fibroblast and myeloid cells as key cell types involved in SSc pathogenesis. We then validated the uncovered association of key gene expression and protein markers in keratinocytes, KRT6A and S100A8, with SSc skin disease severity. CONCLUSION: Our global systems analyses reveal previously uncharacterized cell-intrinsic and cell-extrinsic signaling coexpression networks underlying SSc severity that involve keratinocytes, myeloid cells, and fibroblasts.

Military activity and wetland-dependent wildlife: A warfare ecology perspective.

Wetlands provide unique habitat functions that benefit society by provisioning food, recreation, and ecosystem sustainability. Warfare affects the habitats of wetland-dependent reptiles, amphibians, and birds in both positive and negative ways, and opportunities exist to improve the management of wildlife habitat using a warfare ecology framework. Recent events in Ukraine highlight these relationships and provide stimulus to further consider the implications of current events for natural resources. In response, this commentary highlights both degradational and positive impacts of warfare on wetland fauna during the cyclical preparation, active conflict, and recovery phases. For example, the active conflict phase often initiates ecological disturbance regimes that couple large-scale landscape alteration with the release of chemicals and other materials into wetlands, leading to reduced reproductive potential and population declines in wetland-dependent species (e.g., amphibians, waterfowl) along with decreased overall wetland biodiversity and habitat quality. In contrast, wetland-dependent wildlife can benefit from (1) conservation activities occurring on military installations maintained to support training activities and (2) restoration efforts initiated after the cessation of combat. For example, many threatened and endangered reptiles and amphibians find refugia on military lands in the USA and internationally, and international protections for wetland resources (including the Ramsar Convention) have been established to promote their sustainability and wise use. Additional research is needed to improve the protection of valuable wetland resources by further enhancing ongoing conservation and planning efforts and improving strategies to mitigate the negative impacts of warfare on wetland dependent species throughout each phase of the warfare ecology cycle. Integr Environ Assess Manag 2023;00:1-9. Published 2023. This article is a US Government work and is in the public domain in the USA. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Indicator of Reduction in Soil (IRIS) devices: A review.

Documenting anaerobic conditions is critical for understanding soil processes, identifying hydric soils, delineating wetlands, and managing aquatic resources. Several techniques exist to evaluate the oxidation-reduction status of soils including platinum electrodes, chemical dyes, and analyses of porewater chemistry. Since 2002, Indicator of Reduction in Soils (IRIS) devices have proven a novel, reliable, and cost-effective technique to document anaerobic conditions. This technology involves the application of redox active Fe or Mn oxide based paints onto a durable substrate (e.g., Polyvinyl Chloride pipes or plastic films) which are inserted into the soil. If anaerobic conditions occur during deployment, some or all of the redox active paint will be depleted from the IRIS device surface via chemical reduction and the extent of paint removal can be quantified using a number of approaches. Over the last two decades, IRIS technology has evolved to improve the identification of anaerobic conditions in soils and provide a proxy measure of multiple soil biogeochemical processes (e.g., denitrification, elemental sorption, iron sulfide formation). This review paper provides an overview of developments in IRIS instrumental design and interpretation of results, describes current IRIS applications and benefits, and identifies potential future areas of IRIS device research.

Nitrogen and phosphorus removal using tile-treatment wetlands: A 12-year study from the midwestern United States.

Nutrient enrichment from tile-drained agricultural lands to the Mississippi River is a leading cause of hypoxia in the Gulf of Mexico. Small edge-of-field wetlands can effectively treat nitrate-nitrogen (NO3 -N) export from tiles, although less research exists on their capacity to treat phosphorus (P). Additionally, long-term data are needed to incorporate variability of weather and farming practices into assessments of wetland performance longevity. Research conducted over 12 yr quantified size-effectiveness of wetlands to reduce NO3 -N and dissolved P (orthophosphate [ORP]) loadings from subsurface tile systems. Nitrate-N export was significantly higher during corn (Zea mays L.) than soybean [Glycine max (L.) Merr.] production years, during which 80-84% of mean annual loadings were exported during spring. Wetlands representing 3% (W1) of tile-drained farmland area reduced 15-38% of NO3 -N export, with cumulative reductions of 39-49 and 49-57% observed in wetlands representing 6 (W2) and 9% (W3) areas, respectively. Mass NO3 -N removal ranged from 28 to 52%. Twelve-year total ORP load reductions for W1 ranged from 53 to 81%, with cumulative reductions of 35-91% and 32-95% for W2 and W3 wetlands, respectively. Mass ORP removal ranged from 71 to 85%. Results emphasize how incorporating constructed wetlands into state and watershed-level conservation planning can significantly contribute toward reducing excess N and P export to river systems and ultimately to the Gulf of Mexico.

How patients experience endocrine therapy for breast cancer: an online survey of side effects, adherence, and medical team support.

PURPOSE: Many patients with hormone receptor-positive (HR+) breast cancer do not adhere to endocrine therapy (ET), and treatment-related side effects are often discussed by participants in online breast cancer forums. Our aim was to survey this unique group of patients about their ET-related experiences. METHODS: We partnered with patients active in breast cancer social media communities to develop a survey assessing ET-related side effects and medical team communication. Patients with a history of HR+ breast cancer who had received a recommendation to take ET were eligible to participate in the anonymous, online survey. RESULTS: Respondents included 2353 women and 54 men. Aromatase inhibitors were the most commonly used medication. Side effects were reported by 91.2%, were more often experienced by women than men (p < 0.001), and were primarily related to medication type. Approximately one-third of respondents discontinued therapy early. While most felt supported by their medical team, 31.5% reported that their side effects were dismissed or minimized. Survey respondents most frequently reported that a healthy diet and exercise, yoga/acupuncture, and vitamins/supplements were helpful in managing ET-related side effects. CONCLUSIONS: ET-related side effects are very common, and one-third discontinued treatment early. Lifestyle changes and complementary therapies can be important tools for side effect management. One-third of patients did not feel that their side effects were taken seriously. IMPLICATIONS FOR CANCER SURVIVORS: This is the largest survey of ET use by participants in online breast cancer communities. Further research is needed to identify strategies to improve treatment adherence and to better manage ET-related side effects.

Quantifying Wildlife and Navigation Benefits of a Dredging Beneficial-Use Project in the Lower Atchafalaya River: A Demonstration of Engineering with Nature®.

The US Army Corps of Engineers (USACE) operates and maintains numerous projects in support of its various civil works missions including flood damage risk reduction, navigation, and ecosystem restoration. Originally authorized on an economic basis, these projects may produce a broad array of unaccounted for ecosystem services (ESs) that contribute to overall human, societal, and environmental well-being. Efforts are underway to capture the full array of environmental, economic, and social impacts of these projects. Methods are needed to identify relevant ESs generated by these nature-based projects and to measure their contribution to societal well-being with an emphasis placed on use of readily available data. Performance metrics were collected to capture the benefits of strategic placement of dredged material in river systems to allow formation of islands that produce a wide array of ESs. These performance metrics can be converted to ESs with market value or combined in a decision analytical approach to demonstrate the relative gain in utility. This approach is demonstrated on a riverine island created on the Atchafalaya River, Louisiana, as a result of the strategic placement of dredged material. The outcomes foster integration of ES assessment into project design and management practices and support more comprehensive project evaluation and widespread application. Integr Environ Assess Manag 2018;14:759-768. Published 2018. This article is a US Government work and is in the public domain in the USA.

Investigation of biogeochemical functional proxies in headwater streams across a range of channel and catchment alterations.

Historically, headwater streams received limited protection and were subjected to extensive alteration from logging, farming, mining, and development activities. Despite these alterations, headwater streams provide essential ecological functions. This study examines proxy measures of biogeochemical function across a range of catchment alterations by tracking nutrient cycling (i.e., inputs, processing, and stream loading) with leaf litter fall, leaf litter decomposition, and water quality parameters. Nutrient input and processing remained highest in second growth forests (the least altered areas within the region), while recently altered locations transported higher loads of nutrients, sediments, and conductivity. Biogeochemical functional proxies of C and N input and processing significantly, positively correlated with rapid assessment results (Pearson coefficient = 0.67-0.81; P = 0.002-0.016). Additionally, stream loading equations demonstrate that N and P transport, sediment, and specific conductivity negatively correlated with rapid assessment scores (Pearson coefficient = 0.56-0.81; P = 0.002-0.048). The observed increase in stream loading with lower rapid assessment scores indicates that catchment alterations impact stream chemistry and that rapid assessments provide useful proxy measures of function in headwater ecosystems. Significant differences in nutrient processing, stream loading, water quality, and rapid assessment results were also observed between recently altered (e.g., mined) headwater streams and older forested catchments (Mann-Whitney U = 24; P = 0.01-0.024). Findings demonstrate that biogeochemical function is reduced in altered catchments, and rapid assessment scores respond to a combination of alteration type and recovery time. An analysis examining time and economic requirements of proxy measurements highlights the benefits of rapid assessment methods in evaluating biogeochemical functions.

Aluminum polymers formed following alum treatment of lake water.

Alum (aluminum sulfate) is increasingly being used in lake management to control internal recycling of phosphorus from bottom sediments. Alum added to water undergoes rapid hydrolysis reactions, forming an amorphous Al(OH)3 floc with a high capacity for sorption of phosphorus. While it is known that the Al(OH)3 floc transforms over time to more ordered microcrystalline and crystalline gibbsite phases, there remains an incomplete understanding of the forms of Al present immediately following alum addition to lake water. A laboratory study was thus undertaken to evaluate the forms of Al present following alum addition using ferron (8-hydroxy-7-iodo-5-quinolinesulfonic acid) timed-colorimetric and 27Al-NMR measurements. A polymeric Al species with moderate reactivity with ferron (Alb2) was initially formed, although it rapidly transformed to a less ferron-reactive colloidal form (Alc) and also decomposed at low alum doses to monomeric Al (Ala) in response to pH increases associated with outgassing of CO2. The Ala fraction in these solutions could be adequately estimated based upon measured pH assuming Al solubility was controlled by an amorphous Al(OH)3 phase. Al13 was inferred from ferron measurements to be present, but only at quite low concentrations in the alum-treated waters.

Influence of aging on phosphorus sorption to alum floc in lake water.

Alum is often added to eutrophic lakes to limit the release of phosphorus from sediments. This study quantified the effect of age and extent of crystallization on the phosphate (PO4-P) sorption capacity of alum floc. Aluminum hydroxide flocs were formed from alum addition at a dose of 25 mg/L of Al3+ to Big Bear Lake waters returned to the laboratory; flocs were then aged for 4, 20, 50, 120, and 180 days in the treated lake waters. The physical and mineralogical properties of the alum floc were characterized using surface area and thermal analyses. Phosphate sorption to the floc was evaluated using filtered lake water and NaCl/NaHCO3 solutions spiked with PO4-P concentrations ranging from 0 to 100 mg/L. The Langmuir model provided reasonable fits to data (r2 = 0.97-1.00), from which sorption constants and sorption maxima were determined. Phosphate sorption decreased with increased floc age and crystallinity and decreased surface area. Phosphate sorption maximum of the alum floc aged for 6 months was about 50% lower than freshly precipitated floc, while the binding constant, Kads, decreased approximately 65% over this same time period.

Laboratory investigation of aluminum solubility and solid-phase properties following alum treatment of lake waters.

Water samples from two southern California lakes adversely affected by internal nutrient loading were treated with a 20 mg/L dose of Al3+ in laboratory studies to examine Al solubility and solid-phase speciation over time. Alum [Al2(SO4)3 . 18 H2O] applications to water samples from Big Bear Lake and Lake Elsinore resulted in a rapid initial decrease in pH and alkalinity followed by a gradual recovery in pH over several weeks. Dissolved Al concentrations increased following treatment, reaching a maximum of 2.54 mg/L after 17 days in Lake Elsinore water and 0.91 mg/L after 48 days in Big Bear Lake water; concentrations in both waters then decreased to <0.25 mg/L after 150 days. The solid phase was periodically collected and analyzed using X-ray diffraction (XRD), differential scanning calorimetry-thermogravimetric analysis (DSC-TGA), scanning electron microscopy (SEM), and surface area analyses to investigate the nature of the reaction products and crystallinity development over time. Poorly ordered, X-ray amorphous solid phases transformed over time to relatively well-ordered gibbsite, with strong diffraction peaks at 4.8 and 4.3 A. XRD also indicated the formation of a second (possibly aluminosilicate) crystalline phase after 150 days in Lake Elsinore water. Surface areas also decreased over time as crystals reordered to form gibbsite/microcrystalline gibbsite species. DSC-TGA results suggested that the initially formed amorphous Al(OH)3 underwent transformation to >45% gibbsite. These results were supported by geochemical modeling using Visual MINTEQ, with Al solubility putatively controlled by amorphous Al(OH)3 shortly after treatment and approaching that of microcrystalline gibbsite after about 150 days. These findings indicate that Al(OH)3 formed after alum treatment undergoes significant chemical and mineralogical changes that may alter its effectiveness as a reactive barrier to phosphorus release from lake sediments.

Determination of the solids retainment effectiveness of disposable swim diapers.

In light of recent and increasing incidences of pathogenic E. coli outbreaks at public bathing facilities attributable to non-toilet-trained infants and toddlers, many such facilities are restricting water contact for this age group. A number of manufacturers are now offering disposable "swim diapers," which claim to effectively retain fecal material under typical pool play conditions. The study reported here examined the solids retention effectiveness of three major brands of swim diapers as well as of conventional disposable diapers, under simulated water play conditions. Swim diapers of all three brands exhibited an approximately equal fine-solids retention capability of about 98 to 99 percent over 30 minutes of water immersion activity. Conventional disposable diapers invariably fell down or came apart during the experiments, resulting in very limited solids retention. This study indicates that commercially available swim diapers represent a vast improvement in reducing the potential for fecal material release in public pool facilities, but that some release will still generally occur with these products.