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Simpson-Golabi-Behmel syndrome (SGBS) is a rare congenital overgrowth condition characterized by macrosomia, macroglossia, coarse facial features, and development delays. It is caused by pathogenic variants in the GPC3 gene on chromosome Xq26.2. Here, we performed a comprehensive literature review and phenotyping of known patients with molecularly confirmed SGBS and reviewed a novel cohort of 22 patients. Using these data, we characterized the tumor risk for Wilms tumor and hepatoblastoma to suggest appropriate screening for this patient population. In addition, we discuss the phenotypic overlap between SGBS and Beckwith-Wiedemann Spectrum., (© 2024 The Author(s). American Journal of Medical Genetics Part A published by Wiley Periodicals LLC.)

Background and Hypothesis: Osteochondral allograft (OCA) transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions (HSLs). Traditionally, OCAs are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. Recently, an all-arthroscopic approach to Hill-Sachs OCA transplantation using premade plugs was described, eliminating the need for size-matching and graft harvest. The purpose of this study was to evaluate postoperative outcomes of patients who have undergone arthroscopic treatment of HSLs using premade OCA plugs. We hypothesized that these patients would have improved pain and function without recurrent instability., Methods: A retrospective chart review was performed using operative reports for a single surgeon with search terms Hill-Sachs and allograft. Patients were excluded if an open approach was used or if graft harvest was performed. Postoperative imaging was reviewed to assess for graft incorporation and reconstitution of the HSL. Recurrent instability and reoperation were recorded. Patients completed surveys including the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and the Western Ontario Shoulder Instability Index (WOSI)., Results: Five patients were identified through chart review and met inclusion criteria. All patients underwent concurrent labral repair and 2 patients underwent a concurrent open Latarjet procedure. Postoperative radiographs showed reconstitution of the HSLs in all patients. There were no complications in the postoperative period with no recurrent instability or reoperations in any patient. The average ASES score was 87% (higher score indicating better outcome) with standard deviation 9.7, and the average WOSI score was 27% (lower score indicating better outcome) with standard deviation 8.3., Conclusion: Favorable outcomes can be expected after arthroscopic treatment of Hill-Sachs lesions using premade OCA plugs. Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to identify variables that portend early construct failure requiring surgical revision in patients undergoing instrumented fusion for spine metastases., Methods: A detailed retrospective chart review was performed. Demographic, surgical, and oncologic variables were collected and analyzed via independent samples t-testing, chi-square testing, and Kaplan-Meier method with log-rank testing. Significance was determined as p < 0.05., Results: 482 spinal fusion operations for solid tumor metastases were performed between 2012 and 2022. Of these, 24 (5.0%) required revision surgery for construct failure. There were no major differences between the revision and non-revision patients in terms of several surgical characteristics. Thirteen (54.1%) were revised within 3 months of index surgery. These early construct failures were more likely to have functional neurological deficits at surgery (6/13 vs. 0/11 [p = 0.009]), longer constructs (mean 6.4±2.4 vs. 4.2 ± 1.4 levels [p = 0.015]), and cement-augmented pedicle screws (4/13 vs. 0/11 [p = 0.044)) compared to late construct failures (> 3 months after index surgery). Additionally, 17 symptomatic failures were identified, compared to 7 asymptomatic failures which were identified incidentally with routine follow-up imaging. All 7 asymptomatic construct failures occurred in the early revisions group [p = 0.004]. Revision surgery for early construct failure was associated with significantly reduced median overall survival compared to late failure (p = 0.010)., Conclusion: Construct failures in our cohort were not associated with any classical characteristics of patients undergoing revision spine surgery. Early revision (< 3 months) portends a reduction in overall survival when compared with late revisions, and early revised patients were more likely to have had more extensive surgery and poorer neurological status at the time of index cases., Competing Interests: Declarations. Ethical approval: This study was approved by local IRB [#2019H0446]. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Infection with pathogens can increase the fecundity and other fitness-related traits of insect vectors for their own advantage. Our previous research has reported the pivotal role of DcKr-h1 in the fecundity improvement of Diaphorina citri induced by the bacterium, " Candidatus Liberibacter asiaticus" ( C Las), and the fungus, Cordyceps fumosorosea ( Cf ). However, the posttranscriptional regulation of this process remains poorly understood. Given the significance of miRNAs in gene regulation, we delved into their roles in shaping phenotypes and their underlying molecular mechanisms. Our results indicated that two miRNAs, miR-2 and novel-miR-109, jointly inhibited DcKr-h1 expression by binding to its 3' untranslated region (UTR). In the D. citri-C Las interaction, the expression levels of miR-2 and novel-miR-109 in the ovaries of C Las-positive psyllids were lower compared to C Las-negative individuals. Overexpression of miR-2 or novel-miR-109 significantly decreased fecundity and C Las titer in ovaries and caused reproductive defects reminiscent of DcKr-h1 knockdown. Similarly, in the D. citri-Cf interaction, the levels of miR-2 and novel-miR-109 markedly decreased in the ovaries. Upregulation of miR-2 or novel-miR-109 also resulted in reduced fecundity and ovary defects similar to those caused by DcKr-h1 silencing. Moreover, feeding antagomir-2 or antagomir-109 partially rescued the defective phenotypes caused by DcKr-h1 silencing in both model systems, and miR-2 and novel-miR-109 were repressed by juvenile hormone (JH) and regulated the genes associated with egg development. This study shows a conserved regulatory mechanism, whereby JH suppresses the expression of miR-2 and novel-miR-109 which, together with JH-induced transcription of DcKr-h1 , increases female fecundity induced by both symbiotic bacteria and pathogenic fungi., Importance: Infection with pathogens can increase the fecundity and other fitness-related traits of insect vectors for their own advantage. Our previous research has reported that DcKr-h1 plays a critical role in the increase in fecundity of Diaphorina citri induced by the bacterium, "Candidatus Liberibacter asiaticus" ( C Las) and the fungus, Cordyceps fumosorosea ( Cf ). However, the posttranscriptional regulation of this process remains poorly understood. Given the significance of miRNAs in gene regulation, we delved into their roles in shaping phenotypes and their underlying molecular mechanisms. Our results indicated that two miRNAs, miR-2 and novel-miR-109, jointly inhibited DcKr-h1 expression by binding to its 3' untranslated region (UTR). In both D. citri - C Las and D. citri - Cf interactions, the increased juvenile hormone (JH) titer and reduced abundance of miR-2 and novel-miR-109 ensure high levels of DcKr-h1 expression, consequently stimulating ovarian development and enhancing fecundity. These observations provide evidence that miR-2 and miR-109 are crucial players in the JH-dependent increase in fecundity in psyllids induced by infection with different pathogens., Competing Interests: The authors declare no conflict of interest.

Background: Distal triceps rupture is a rare injury that is commonly surgically repaired to improve elbow strength and function. Most patients are active and have goals to return to specific activities and sports. There is no gold standard rehabilitation protocol for return to sport (RTS) after distal triceps repair., Purpose: To identify in the literature any criteria used for RTS after distal triceps repair., Study Design: Scoping review; Level of evidence, 4., Methods: Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, level 1 to 4 studies that examined distal triceps repair and had a minimum follow-up duration of 12 months were deemed eligible for study inclusion. Exclusion criteria encompassed studies that employed nonoperative treatment, lacked specific RTS criteria, or involved revision cases. The selected studies underwent assessment regarding RTS outcomes, timelines, rates, and methodological quality., Results: Of the initial 378 unique studies, 6 studies (including 116 patients involved in 16 different sports) met the inclusion criteria. Four of the studies reported RTS rates, with a mean of 89.3%. The duration of time for returning to sport was reported in 2 studies and varied from 4 to 6 months. The parameters most emphasized in the rehabilitation protocols were progressive range of motion exercises, followed by early immobilization and progressive strengthening exercises. Supervised therapy was reported in only 2 (33%) studies. Although all studies included a rehabilitation protocol and 5 studies included a timeline for RTS, only 1 study provided subjective criteria, and no studies utilized specific objective measurement criteria. The overall study quality was fair., Conclusion: This review demonstrated that the overall RTS rate after distal triceps repair was high (89.3%), with no consensus on RTS criteria. Most studies included initial immobilization followed by progressive range of motion and strengthening. Timing after surgery was used as a measure to RTS in the minority of studies and varied between 4 and 6 months. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Background: An easy-to-use tool to objectively measure intraoral anatomy with meaningful clinical correlations may improve care for patients with Beckwith-Wiedemann syndrome (BWS), who commonly have symptomatic macroglossia., Methods: Children aged 2-17 years with BWS were enrolled between 12/2021 and 01/2024. Digital intraoral photographs with a laser ruler were taken, and morphometric measurements were made using ImageJ software. Relationships between morphometrics and outcomes including BWS clinical score, percentage mosaicism, and incidence of tongue reduction surgery were examined using t-tests and multivariate linear models., Results: Pharyngeal morphometric measurements were obtained in 49 patients with BWS. Mouth area, width, and height differed significantly across BWS molecular subtypes. Right-to-left tongue width and mouth width were larger in those with loss of methylation at imprinting control region 2 (IC2 LOM) than other BWS variants. Patients with paternal uniparental isodisomy of chromosome 11p15 (pUPD11) had narrower mouths than others. Those with tongue reduction surgery had more tongue ridging than those without surgery. There were correlations between mouth area and BWS clinical score, tongue width and BWS clinical score, and tongue length and percentage mosaicism., Conclusion: Intraoral morphometric measurements are associated with phenotypic burden in BWS. Tongue morphology varies across the BWS spectrum, with IC2 LOM having wider tongues and mouths, and pUPD11 having narrower mouths. Tongue ridging is more common in those selected for surgery. Intraoral morphometric measurements may be safely obtained at low costs across centers caring for children with BWS or others at risk of upper airway obstruction., (© 2024. The Author(s).)

Beckwith-Wiedemann spectrum (BWSp) is caused by genetic and epigenetic alterations on chromosome 11 that regulate cell growth and division. Considering the diverse phenotypic landscape in BWSp, the characterization of the CDKN1C molecular subtype remains relatively limited. Here, we investigate the role of CDKN1C in the broader BWSp phenotype. Notably, patients with CDKN1C variants appear to exhibit a different tumor risk than other BWSp molecular subtypes. We performed a comprehensive literature review using the search term "CDKN1C Beckwith" to identify 113 cases of patients with molecularly confirmed CDKN1C-BWSp. We then assessed the genotype and phenotype in a novel cohort of patients with CDKN1C-BWSp enrolled in the BWS Research Registry. Cardinal and suggestive features were evaluated for all patients reported, and tumor risk was established based on available reports. The most common phenotypes included macroglossia, omphalocele, and ear creases/pits. Tumor types reported from the literature included neuroblastoma, acute lymphocytic leukemia, superficial spreading melanoma, and intratubular germ cell neoplasia. Overall, this study identifies unique features associated with CDKN1C variants in BWSp, enabling more accurate clinical management. The absence of Wilms tumor and hepatoblastoma suggests that screening for these tumors may not be necessary, while the neuroblastoma risk warrants appropriate screening recommendations., (© 2024 The Author(s). American Journal of Medical Genetics Part A published by Wiley Periodicals LLC.)

Objective: Patients with Beckwith-Wiedemann syndrome commonly have macroglossia, which can negatively affect dentoskeletal development, breathing, speaking, and eating. Tongue reduction surgery can improve symptoms, but there is no standardized surgical approach., Methods: A video and observational commentary highlighting the effectiveness of a tongue reduction technique for BWS were presented., Results: The peripheral resection with a keyhole approach safely reduced tongue volume, maintained the lateral neurovascular pedicles, optimized intraoperative visualization, and limited bleeding., Conclusions: The peripheral resection with a keyhole tongue reduction surgical technique is effective for treating symptomatic macroglossia in BWS., Competing Interests: J.A.T. is a co-founder of Ostiio, LLC. The remaining authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

The phloem-limited bacterium ' Candidatus Liberibacter asiaticus' ( C Las) is the putative causal pathogen of the severe Asiatic form of huanglongbing (citrus greening) and is most commonly transmitted by the Asiatic citrus psyllid Diaphorina citri . C Las severely affects many Citrus species and hybrids and has been recorded in the Citrus relative, orange jasmine, Murraya paniculata (L.) Jack (syn. M . exotica L.). In this study, 13 accessions of three Murraya species ( M. paniculata , M. sumatrana Roxb., and M. lucida [G.Forst.] Mabb.) and the Papuan form of a putative hybrid ( M. omphalocarpa Hayata) were identified morphologically and molecularly based on sequence identity of the matK-5'trnK region of the chloroplast genome, and infection on these plants under field conditions was determined by PCR and quantitative real-time PCR (qPCR) on two to four occasions over 14 months. C Las was repeatedly detected in leaflet midribs by PCR and qPCR on four and three accessions of M . paniculata and M. sumatrana , respectively. It was not detected in leaflet midribs of single accessions of M. lucida and M. omphalocarpa . The species identification of the C Las-positive accessions was further confirmed using all the molecular taxonomic markers consisting of the six fragments of the maternally inherited chloroplast genome and part of the nuclear-encoded internal transcribed spacer (ITS) region. The results indicated that natural infection of M. paniculata and M. sumatrana with C Las can occur in Java. To our knowledge, this is the first demonstration of the natural infection of M. sumatrana with C Las. Further studies are required to determine whether infections persist in the absence of D. citri ., Competing Interests: The author(s) declare no conflict of interest.

Background and Purpose: Oligomeric amyloid β 1-42 (oAβ 1-42 ) exhibits agonist-like action at human α7- and α7β2-containing nicotinic receptors. The N-terminal amyloid β 1-15 fragment (N-Aβ fragment) modulates presynaptic calcium and enhances hippocampal-based synaptic plasticity via α7-containing nicotinic receptors. Further, the N-Aβ fragment and its core sequence, the N-amyloid-beta core hexapeptide (N-Aβcore), protect against oAβ 1-42 -associated synapto- and neurotoxicity. Here, we investigated how oAβ 1-42 , the N-Aβ fragment, and the N-Aβcore regulate the single-channel properties of α7- and α7β2-nicotinic receptors., Experimental Approach: Single-channel recordings measured the impact of acetylcholine, oAβ 1-42 , the N-Aβ fragment, and the N-Aβcore on the unitary properties of human α7- and α7β2-containing nicotinic receptors expressed in nicotinic-null SH-EP1 cells. Molecular dynamics simulations identified potential sites of interaction between the N-Aβ fragment and orthosteric α7+/α7- and α7+/β2- nicotinic receptor binding interfaces., Key Results: The N-Aβ fragment and N-Aβcore induced α7- and α7β2-nicotinic receptor single-channel openings. Relative to acetylcholine, oAβ 1-42 preferentially enhanced α7β2-nicotinic receptor single-channel open probability and open-dwell times. Co-application with the N-Aβcore neutralized these effects. Further, administration of the N-Aβ fragment alone, or in combination with acetylcholine or oAβ 1-42 , selectively enhanced α7-nicotinic receptor open probability and open-dwell times (compared to acetylcholine or oAβ 1-42 )., Conclusions and Implications: Amyloid-beta peptides demonstrate functional diversity in regulating α7- and α7β2-nicotinic receptor function, with implications for a wide range of nicotinic receptor-mediated functions in Alzheimer's disease. The effects of these peptides on α7- and/or α7β2-nicotinic receptors revealed complex interactions with these subtypes, providing novel insights into the neuroprotective actions of amyloid β-derived fragments against the toxic effects of oAβ 1-42 ., (© 2024 The Authors. British Journal of Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Apoptosis is a form of programmed cell death that is mediated by intrinsic and extrinsic pathways. Dysregulation of and resistance to cell death are hallmarks of cancer. For over three decades, the development of therapies to promote treatment of cancer by inducing various cell death modalities, including apoptosis, has been a main goal of clinical oncology. Apoptosis pathways also interact with other signaling mechanisms, such as the p53 signaling pathway and the integrated stress response (ISR) pathway. In addition to agents directly targeting the intrinsic and extrinsic pathway components, anticancer drugs that target the p53 and ISR signaling pathways are actively being developed. In this Review, we discuss selected and promising anticancer therapies in various stages of development, including drug targets, mechanisms, and resistance to related treatments, focusing especially on B cell lymphoma 2 (BCL-2) inhibitors, TRAIL analogues, DR5 antibodies, and strategies that target p53, mutant p53, and the ISR.

Diaphorina citri serves as the primary vector for ' Candidatus Liberibacter asiaticus ( C Las),' the bacterium associated with the severe Asian form of huanglongbing. C Las-positive D. citri are more fecund than their C Las-negative counterparts and require extra energy expenditure. Therefore, understanding the molecular mechanisms linking metabolism and reproduction is of particular importance. In this study, we found adipokinetic hormone ( DcAKH ) and its receptor ( DcAKHR ) were essential for increasing lipid metabolism and fecundity in response to C Las infection in D. citri . Knockdown of DcAKH and DcAKHR not only resulted in the accumulation of triacylglycerol and a decline of glycogen, but also significantly decreased fecundity and C Las titer in ovaries. Combined in vivo and in vitro experiments showed that miR-34 suppresses DcAKHR expression by binding to its 3' untranslated region, whilst overexpression of miR-34 resulted in a decline of DcAKHR expression and C Las titer in ovaries and caused defects that mimicked DcAKHR knockdown phenotypes. Additionally, knockdown of DcAKH and DcAKHR significantly reduced juvenile hormone (JH) titer and JH signaling pathway genes in fat bodies and ovaries, including the JH receptor, methoprene-tolerant ( DcMet ), and the transcription factor, Krüppel homolog 1 (DcKr-h1 ), that acts downstream of it, as well as the egg development related genes vitellogenin 1-like ( DcVg-1-like ), vitellogenin A1-like ( DcVg-A1-like ) and the vitellogenin receptor ( DcVgR ). As a result, C Las hijacks AKH/AKHR-miR-34-JH signaling to improve D. citri lipid metabolism and fecundity, while simultaneously increasing the replication of C Las, suggesting a mutualistic interaction between C Las and D. citri ovaries., Competing Interests: JL, PH, GB, SW, JH, ST, DW, YH, YC, XN No competing interests declared, (© 2024, Li et al.)

Two novel cyclometalated ruthenium complexes, RC-4 and RC-5, featuring 1-phenylisoquinoline and phenyl quinazoline as ancillary ligands, respectively, were synthesized to investigate their viability with the environmentally friendly copper (Cu) redox mediator, [Cu(bpye) 2 ] 2+/+ . The modification of the ligand environment resulted in variations in the energetics, photophysical properties, and photovoltaic performance of RC-4 and RC-5 sensitizers. Despite RC-5 sensitizer possessing a more positive ground state potential of 1.19 V versus the NHE, the RC-4 sensitizer, with a lower HOMO level of 0.72 V versus NHE, exhibited superior photovoltaic performance along with the Cu electrolyte, attributed to its enhanced light harvesting ability, improved lifetime and reduced back electron transfer, contributing to higher J sc , V oc , and PCE., (© 2024 American Society for Photobiology.)

Objective/ Summary Background Data: We propose the first classification scheme for macroglossia in patients with Beckwith-Wiedemann Syndrome (BWS), the BWS Index of macroGlossia (BIG)., Methods: Patients with molecularly confirmed BWS seen from 2004-2023 were included to develop this system. Relationships among BIG scores, tongue reduction surgery, BWS clinical score, percent mosaicism, and polysomnography findings were examined., Results: Patients were classified from BIG0 to BIG3. BIG0 includes those without macroglossia; BIG1 includes those with macroglossia not protruding beyond the teeth/alveolus; BIG2 includes those with tongue protrusion past the teeth/alveolus to the lips but that can be contained within the mouth; and BIG3 includes those with tongues that protrude beyond the teeth/alveolus and lips but that cannot be closed within the mouth. Of the 459 patients with molecularly confirmed BWS, 266 (58.0%) patients were scored. One hundred and eleven (41.7%) were BIG0, 44 (16.5%) were BIG1, 90 (33.8%) were BIG2, and 21 (7.9%) were BIG3. As scores increased, patients had an increased incidence of tongue reduction surgery (BIG0: 0% versus BIG1: 20.5% versus BIG2: 51.1% versus BIG3: 100%; r=0.66, P <0.01). Higher BIG scores were associated with elevated BWS clinical scores (r=0.68, P <0.01) and increased tissue mosaicism (r=0.50, P <0.01) as well as trends towards worse obstructive apnea-hypopnea indices (r=0.29, P =0.02) and lower SpO 2 nadirs (r=-0.29, P =0.02)., Conclusion: In this large series of patients with Beckwith-Wiedemann Syndrome, increased BIG score correlates with undergoing tongue reduction surgery and increased phenotypic severity. Adoption of the BIG scoring system may facilitate communication and risk stratification across institutions., Competing Interests: Financial Disclosure Statement: The authors declare no conflicts of interest, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Fused Granular Fabrication Additive Manufacturing (FGF AM) has the capability to create tooling that is lower cost than conventionally manufactured tooling and still has sufficient properties for many applications. A vacuum infusion (VI) mold was printed from fiberglass-acrylonitrile butadiene styrene (ABS) and evaluated for wear and suitability for small VI runs. The mold was designed to accentuate high wear as a "worst case" scenario. The mold was able to produce 10 parts successfully before any noticeable change occurred to the surface finish. By 14 parts, the surface finish had roughened sufficiently that demolding was difficult and resulted in damage to the part. Profilometry measurements showed a 7 × increase in roughness over the run. No significant tool wear or change in geometry was detected. Even longer life would be expected for typical tooling designs since the test mold was deliberately designed to accentuate wear and demolding issues. Based on these results, similar FGF molds are a feasible option for short run VI production for prototyping or low-volume composites manufacturing, possibly at lower cost and quicker turnaround time than machined aluminum molds., Competing Interests: No competing financial interests exist., (Copyright 2024, Mary Ann Liebert, Inc., publishers.)

Introduction Research is an important aspect of residency and fellowship programs across the country. Developing strategies to foster research productivity is worthwhile. An annual research project is one strategy that some programs implement. Methods All resident and fellow (Sports Medicine, Adult Reconstruction, Spine) presentations at an orthopedic surgery department's annual research symposium from June 2016 through June 2021 were identified. Abstract titles, title keywords, and author names were searched in PubMed and Google Scholar to identify the presence of a peer-reviewed publication. Using the total number of research symposium presentations given, the publication rate was calculated for each year, as well as collectively for 2016 to 2021. In addition to publication rate, first author percent, number of citations, Altmetric score, and journal impact factor were recorded. Current PGY-2 through PGY-5 residents completed a survey to assess the perceived value of the annual research symposium. Results Ninety-eight research symposium presentations were reviewed (69 residents, 29 fellows). Forty (58%) resident studies were published and 28 were first-author publications (70%). Thirteen (45%) fellow studies were published and seven were first-author publications (54%). Combining residents and fellows, the overall publication rate was 54% (53/98), and 66% of these (35/53) were first-author publications. There was a wide range of published manuscript journal impact factors, Altmetric scores, and number of citations. All residents surveyed reported finding value in the research symposium. Conclusion The overall publication rate of presentations at an annual orthopedic surgery department research symposium between 2016 and 2021 was 54%, consistent with publication rates reported at National Orthopedic Surgery Society meetings. All residents reported finding value in the annual research symposium. The results of this study support the academic value of implementing a required annual research project and may provide a useful gauge to inform residency and fellowship curricula at other institutions., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2024, George et al.)

Early in 2022 the first pig to human cardiac xenotransplant was performed. The graft initially performed well, and rejection was well controlled. However, the graft failed, and the patient died 60 days after the procedure. The ethical issues relating to xenotransplantation include the risk/benefit to the individual, the risk of porcine-derived infectious agents crossing into humans, animal welfare and rights, issues of human and animal identity and concerns relating to fair allocation of organs and appropriate use of resources.These ethical issues are often addressed using emotional arguments, or through consequentialist or deontological lens. An alternative is to use approaches based on virtue ethics to understand the moral purpose ( telos ) of the research and the virtues (character traits) needed to be a good research clinician. In this review we will consider the virtues of justice, courage, temperance and practical wisdom, as well as the role of clinical curiosity, and their application to xenotransplantation. This provides an alternative approach for the clinical academic and others involved in the research to reflect on their practice., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrew has previously carried out research on xenotransplantation. He is involved in the ethical review process in the UK as a member of the Health Research Authority board. He is co-chair of the UK Committee on Research Integrity. He is writing in a personal capacity.

Plastic pollution pervades both marine and terrestrial ecosystems, fragmenting over time into microplastics (MPs) and nano-plastics (NPs). These particles infiltrate organisms via ingestion, inhalation, and dermal absorption, predominantly through the trophic interactions. This review elucidated the impacts of MPs/NPs on the reproductive viability of various species. MPs/NPs lead to reduced reproduction rates, abnormal larval development and increased mortality in aquatic invertebrates. Microplastics cause hormone secretion disorders and gonadal tissue damage in fish. In addition, the fertilization rate of eggs is reduced, and the larval deformity rate and mortality rate are increased. Male mammals exposed to MPs/NPs exhibit testicular anomalies, compromised sperm health, endocrine disturbances, oxidative stress, inflammation, and granulocyte apoptosis. In female mammals, including humans, exposure culminates in ovarian and uterine deformities, endocrine imbalances, oxidative stress, inflammation, granulosa cell apoptosis, and tissue fibrogenesis. Rodent offspring exposed to MPs experience increased mortality rates, while survivors display metabolic perturbations, reproductive anomalies, and weakened immunity. These challenges are intrinsically linked to the transgenerational conveyance of MPs. The ubiquity of MPs/NPs threatens biodiversity and, crucially, jeopardizes human reproductive health. The current findings underscore the exigency for comprehensive research and proactive interventions to ameliorate the implications of these pollutants., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The evolution of insect vector-pathogen relationships has long been of interest in the field of molecular ecology. One system of special relevance, due to its economic impacts, is that between Diaphorina citri and 'Candidatus Liberibacter asiaticus' (CLas), the cause of the severe Asian form of huanglongbing. CLas-positive D. citri are more fecund than their CLas-negative counterparts, boosting opportunities for pathogens to acquire new vector hosts. The molecular mechanism behind this life-history shift remains unclear. Here, we found that CLas promoted ovarian development and increased the expression of the vitellogenin receptor (DcVgR) in ovaries. DcVgR RNAi significantly decreased fecundity and CLas titer in ovaries, extended the preoviposition period, shortened the oviposition period and blocked ovarian development. Given their importance in gene regulation, we explored the role of miRNAs in shaping these phenotypes and their molecular triggers. Our results showed that one miRNA, miR-275, suppressed DcVgR expression by binding to its 3' UTR. Overexpression of miR-275 knocked down DcVgR expression and CLas titer in ovaries, causing reproductive defects that mimicked DcVgR knockdown phenotypes. We focused, further, on roles of the Juvenile Hormone (JH) pathway in shaping the observed fecundity phenotype, given its known impacts on ovarian development. After CLas infection, this pathway was upregulated, thereby increasing DcVgR expression. From these combined results, we conclude that CLas hijacks the JH signalling pathway and miR-275, thereby targeting DcVgR to increase D. citri fecundity. These changes simultaneously increase CLas replication, suggesting a pathogen-vector host mutualism, or a seemingly helpful, but cryptically costly life-history manipulation., (© 2023 John Wiley & Sons Ltd.)

This study was undertaken to identify and characterize the first ligands capable of selectively identifying nicotinic acetylcholine receptors containing α7 and β2 subunits (α7β2-nAChR subtype). Basal forebrain cholinergic neurons express α7β2-nAChR. Here, they appear to mediate neuronal dysfunction induced by the elevated levels of oligomeric amyloid-β associated with early Alzheimer's disease. Additional work indicates that α7β2-nAChR are expressed across several further critically important cholinergic and GABAergic neuronal circuits within the central nervous system. Further studies, however, are significantly hindered by the inability of currently available ligands to distinguish heteromeric α7β2-nAChR from the closely related and more widespread homomeric α7-only-nAChR subtype. Functional screening using two-electrode voltage-clamp electrophysiology identified a family of α7β2-nAChR-selective analogs of α-conotoxin PnIC (α-CtxPnIC). A combined electrophysiology, functional kinetics, site-directed mutagenesis, and molecular dynamics approach was used to further characterize the α7β2-nAChR selectivity and site of action of these α-CtxPnIC analogs. We determined that α7β2-nAChR selectivity of α-CtxPnIC analogs arises from interactions at a site distinct from the orthosteric agonist-binding site shared between α7β2- and α7-only-nAChR. As numerous previously identified α-Ctx ligands are competitive antagonists of orthosteric agonist-binding sites, this study profoundly expands the scope of use of α-Ctx ligands (which have already provided important nAChR research and translational breakthroughs). More immediately, analogs of α-CtxPnIC promise to enable, for the first time, both comprehensive mapping of the distribution of α7β2-nAChR and detailed investigations of their physiological roles., (© 2023 The Authors. The FASEB Journal published by Wiley Periodicals LLC on behalf of Federation of American Societies for Experimental Biology.)

Gastrointestinal diseases exert a profound impact on global health, leading to millions of healthcare interventions and a significant number of fatalities annually. This, coupled with escalating healthcare expenditures, underscores the need for identifying and addressing potential exacerbating factors. One emerging concern is the pervasive presence of microplastics and nano-plastics in the environment, largely attributed to the indiscriminate usage of disposable plastic items. These nano-plastics, having infiltrated our food chain, pose a potential threat to gastrointestinal health. To understand this better, we co-cultured human gastric fibroblasts (HGF) with polystyrene nano-plastics (PS-NPs) of diverse sizes (80, 500, 650 nm) and meticulously investigated their cellular responses over a 24-hour period. Our findings revealed PS particles were ingested by the cells, with a notable increase in ingestion as the particle size decreased. The cellular death induced by these PS particles, encompassing both apoptosis and necrosis, showcased a clear dependence on both the particle size and its concentration. Notably, the larger PS particles manifested more potent cytotoxic effects. Further analysis indicated a concerning reduction in cellular membrane potential, alongside a marked increase in ROS levels upon PS particles exposure. This suggests a significant disruption of mitochondrial function and heightened oxidative stress. The larger PS particles were especially detrimental in causing mitochondrial dysfunction. In-depth exploration into the PS particles impact on genes linked with the permeability transition pore (PTP) elucidated that these PS particles instigated an internal calcium rush. This surge led to a compromise in the mitochondrial membrane potential, which in tandem with raised ROS levels, further catalyzed DNA damage and initiated cell death pathways. In essence, this study unveils the intricate mechanisms underpinning cell death caused by PS particles in gastric epithelial cells and highlighting the implications of PS particles on gastrointestinal health. The revelations from this research bear significant potential to shape future healthcare strategies and inform pertinent environmental policies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Although the 50% inhibitory concentration (IC50) is a commonly used measurement of chemosensitivity in cancer cells, it has been known to vary with the density of the treated cells (in that more densely seeded cells are more resistant to chemotherapeutic agents). Indeed, density-dependent chemoresistance may be a significant independent mechanism of therapy resistance. We examine the nature of cell density-dependent chemoresistance and explore possible underlying mechanisms. CellTiter-Glo assays and ethidium homodimer staining revealed that response to chemotherapy is density-dependent in all cancer cell lines tested. Our results prompted us to develop a novel cancer cell seeding density index of chemosensitivity, the ISDS (IC50-Seeding Density Slope), which we propose can serve as an improved method of analyzing how cancer cells respond to chemotherapeutic treatment compared to the widely-used IC50. Furthermore, western blot analysis suggests that levels of autophagy and apoptotic markers are modulated by cancer cell density. Cell viability experiments using the autophagy inhibitor chloroquine showed that chloroquine's efficacy was reduced at higher cell densities and that chloroquine and cisplatin exhibited synergy at both higher and lower cell densities in TOV-21G cells. We discuss alternative mechanisms of density-dependent chemoresistance and in vivo /clinical applications, including challenges of adjuvant chemotherapy and minimal residual disease. Taken together, our findings show that cell density is a significant contributor in shaping cancer chemosensitivity, that the ISDS (aka the Ujwal Punyamurtula/Wafik El-Deiry or Ujwal-WAF Index) can be used to effectively assess cell viability and that this phenomenon of density-dependent chemoresistance may be leveraged for a variety of biologic and cancer therapeutic applications., Competing Interests: None., (AJCR Copyright © 2023.)

Background: Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum., Hypothesis/purpose: The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS., Methods: Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment., Results: All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months)., Conclusion: The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols., (© 2023 The Authors.)

Pancreatic cancer is a devastating disease with a poor prognosis. Novel chemotherapeutics in pancreatic cancer have shown limited success, illustrating the urgent need for new treatments. Lurbinectedin (PM01183; LY-01017) received FDA approval in 2020 for metastatic small cell lung cancer on or after platinum-based chemotherapy and is currently undergoing clinical trials in a variety of tumor types. Lurbinectedin stalls and degrades RNA Polymerase II and introduces breaks in DNA, causing subsequent apoptosis. We now demonstrate lurbinectedin's highly efficient killing of human-derived pancreatic tumor cell lines PANC-1, BxPC-3, and HPAF-II as a single agent. We further demonstrate that a combination of lurbinectedin and irinotecan, a topoisomerase I inhibitor with FDA approval for advanced pancreatic cancer, results in the synergistic killing of pancreatic tumor cells. Western blot analysis of combination therapy indicates an upregulation of γH2AX, a DNA damage marker, and the Chk1/ATR pathway, which is involved in replicative stress and DNA damage response. We further demonstrate that the triple combination between lurbinectedin, irinotecan, and 5-fluorouracil (5-FU) results in a highly efficient killing of tumor cells. Our results are developing insights regarding molecular mechanisms underlying the therapeutic efficacy of a novel combination drug treatment for pancreatic cancer.

Osteochondral allograft transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions. Traditionally, osteochondral allografts are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. This Technical Note describes an all-arthroscopic approach to Hill-Sachs osteochondral allograft transplantation using premade osteochondral allograft plugs, eliminating the need for size-matching and graft harvest. This approach works not by anatomically filling the defect, but rather by bridging the defect to prevent it from engaging the glenoid., (© 2023 The Authors.)

Decreased mechanical loading after orthopaedic surgery predisposes patients to develop muscle atrophy. The purpose of this review was to assess whether the evidence supports oral protein supplementation can help decrease postoperative muscle atrophy and/or improve patient outcomes following orthopaedic surgery. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). PubMed (MEDLINE), Embase, Scopus, and Web of Science were searched for randomized controlled trials that assessed protein or amino acid supplementation in patients undergoing orthopaedic surgery. Two investigators independently conducted the search using relevant Boolean operations. Primary outcomes included functional or physiologic measures of muscle atrophy or strength. Fourteen studies including 611 patients (224 males, 387 females) were analyzed. Three studies evaluated protein supplementation after ACL reconstruction (ACLR), 3 after total hip arthroplasty (THA), 5 after total knee arthroplasty (TKA), and 3 after surgical treatment of hip fracture. Protein supplementation showed beneficial effects across all types of surgery. The primary benefit was a decrease in muscle atrophy compared to placebo as measured by muscle cross sectional area. Multiple authors also demonstrated improved functional measures and quicker achievement of rehabilitation benchmarks. Protein supplementation has beneficial effects on mitigating muscle atrophy in the postoperative period following ACLR, THA, TKA, and surgical treatment of hip fracture. These effects often correlate with improved functional measures and quicker achievement of rehabilitation benchmarks. Further research is needed to evaluate long-term effects of protein supplementation and to establish standardized population-specific regimens that maximize treatment efficacy in the postoperative period., Competing Interests: The authors have no interests that are in direct conflict with the conduction of the study., (© 2023 Chengdu Sport University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.)

p53 is a transcription factor that regulates the expression of genes involved in tumor suppression. p53 mutations mediate tumorigenesis and occur in approximately 50% of human cancers. p53 regulates hundreds of target genes that induce various cell fates including apoptosis, cell cycle arrest, and DNA damage repair. p53 also plays an important role in anti-tumor immunity by regulating TRAIL, DR5, TLRs, Fas, PKR, ULBP1/2, and CCL2; T-cell inhibitory ligand PD-L1; pro-inflammatory cytokines; immune cell activation state; and antigen presentation. Genetic alteration of p53 can contribute to immune evasion by influencing immune cell recruitment to the tumor, cytokine secretion in the TME, and inflammatory signaling pathways. In some contexts, p53 mutations increase neoantigen load which improves response to immune checkpoint inhibition. Therapeutic restoration of mutated p53 can restore anti-cancer immune cell infiltration and ameliorate pro-tumor signaling to induce tumor regression. Indeed, there is clinical evidence to suggest that restoring p53 can induce an anti-cancer immune response in immunologically cold tumors. Clinical trials investigating the combination of p53-restoring compounds or p53-based vaccines with immunotherapy have demonstrated anti-tumor immune activation and tumor regression with heterogeneity across cancer type. In this Review, we discuss the impact of wild-type and mutant p53 on the anti-tumor immune response, outline clinical progress as far as activating p53 to induce an immune response across a variety of cancer types, and highlight open questions limiting effective clinical translation., Competing Interests: WSE-D is a co-founder of Oncoceutics, Inc., a subsidiary of Chimerix. WSE-D has disclosed his relationship with Oncoceutics/Chimerix and potential conflict of interest to his academic institution/employer and is fully compliant with NIH and institutional policy that is managing this potential conflict of interest. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Carlsen, Zhang, Tian, De La Cruz, George, Arnoff and El-Deiry.)

Objectives: Needle electromyography (EMG) may be used to characterise the severity of the injury in acute peripheral facial nerve palsy (FNP) to predict recovery and guide management, but its prognostic value and clinical utility remain controversial. The aim of this systematic review was to evaluate the role of EMG to prognosticate the recovery of facial motor function in patients with acute peripheral FNP., Design: A comprehensive search strategy was applied in PubMed, Embase, and Web of Science based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main outcome measure was the accuracy of EMG in predicting long-term facial function at least 6 months following symptom onset., Results: Eleven studies were included comprising 3837 participants, with 91.6% of these diagnosed with Bell's palsy (BP). In BP patients, the positive predictive value and negative predictive value for a good outcome based on EMG findings ranged from 82.1% to 100% and 66.7% to 80.5%, respectively, with two out of three studies finding that EMG remained a significant predictor of the outcome on multivariate analysis. Three studies addressed the role of EMG in non-idiopathic FNP with two of these studies supporting EMG to predict prognosis., Conclusions: EMG is a useful tool to gain insight into the likely outcome to guide management decisions and counsel patients on their expectations, particularly in BP. However, given inconsistencies in its application and lack of evidence around non-idiopathic FNP, it should not currently be relied on to predict recovery. Ultimately, its prognostic value and widespread adoption are dependent on the implementation of a clear and standardised protocol in future high-quality studies and routine clinical settings., (© 2023 John Wiley & Sons Ltd.)

Background: Some dendrobatid poison frogs sequester the toxin epibatidine as a defense against predators. We previously identified an amino acid substitution (S108C) at a highly conserved site in a nicotinic acetylcholine receptor β2 subunit of dendrobatid frogs that decreases sensitivity to epibatidine in the brain-expressing α4β2 receptor. Introduction of S108C to the orthologous high-sensitivity human receptor similarly decreased sensitivity to epibatidine but also decreased sensitivity to acetylcholine, a potential cost if this were to occur in dendrobatids. This decrease in the acetylcholine sensitivity manifested as a biphasic acetylcholine concentration-response curve consistent with the addition of low-sensitivity receptors. Surprisingly, the addition of the β2 S108C into the α4β2 receptor of the dendrobatid Epipedobates anthonyi did not change acetylcholine sensitivity, appearing cost-free. We proposed that toxin-bearing dendrobatids may have additional amino acid substitutions protecting their receptors from alterations in acetylcholine sensitivity. To test this, in the current study, we compared the dendrobatid receptor to its homologs from two non-dendrobatid frogs., Results: The introduction of S108C into the α4β2 receptors of two non-dendrobatid frogs also does not affect acetylcholine sensitivity suggesting no additional dendrobatid-specific substitutions. However, S108C decreased the magnitude of neurotransmitter-induced currents in Epipedobates and the non-dendrobatid frogs. We confirmed that decreased current resulted from fewer receptors in the plasma membrane in Epipedobates using radiolabeled antibodies against the receptors. To test whether S108C alteration of acetylcholine sensitivity in the human receptor was due to (1) adding low-sensitivity binding sites by changing stoichiometry or (2) converting existing high- to low-sensitivity binding sites with no stoichiometric alteration, we made concatenated α4β2 receptors in stoichiometry with only high-sensitivity sites. S108C substitutions decreased maximal current and number of immunolabeled receptors but no longer altered acetylcholine sensitivity., Conclusions: The most parsimonious explanation of our current and previous work is that the S108C substitution renders the β2 subunit less efficient in assembling/trafficking, thereby decreasing the number of receptors in the plasma membrane. Thus, while β2 S108C protects dendrobatids against sequestered epibatidine, it incurs a potential physiological cost of disrupted α4β2 receptor function., (© 2023. The Author(s).)

Patient-reported vaccine reactivity (PRVR) is a major contributor to COVID-19 vaccine hesitancy. PRVR responses to the COVID-19 vaccine may be affected by several modifiable and non-modifiable factors that influence immune function. Understanding the effects of these factors on PRVR can aid in better educating patients on expectations, as well as formulating public health strategies to increase the levels of community vaccination.

Populations of Diaphorina citri decline with elevation and, in a study in Bhutan, were rarely found above 1200 m ASL. The impact of ultraviolet (UV) radiation, particularly UV-B, on immature stages of the psyllid was proposed as limiting factor. As no studies have been undertaken on the influences of UV radiation on the development of D. citri , we examined the effects of UV-A and UV-B on different stadia of the psyllid. In addition, compliance with the Bunsen-Roscoe reciprocity law was examined. Irradiation with UV-A marginally reduced egg hatch and the survival times of emerging nymphs. Early instar nymphs were little affected by this waveband, but the survival of adults was reduced at the higher doses used. With UV-B, egg hatch and the survival times of early and late instar nymphs declined in proportion to UV-B dose. A dose of 57.6 kJ m -2 d -1 reduced the survival time of only adult females. Female fecundity was reduced at high UV-A and UV-B doses but increased at low doses. The Bunsen-Roscoe law held true for eggs and early instar nymphs for different durations and irradiances of UV-B. Eggs and nymphs had ED 50 values for UV-B lower than the daily fluxes of this wavelength experienced worldwide. Thus, UV-B could be a factor causing the psyllid to be scarce at high elevations.

Initiated by findings that Alzheimer's disease is associated with a profound loss of cholinergic markers in human brain, decades of studies have examined the interactions between specific subtypes of nicotinic acetylcholine receptors and amyloid-β [derived from the amyloid precursor protein (APP), which is cleaved to yield variable isoforms of amyloid-β]. We review the evolving understanding of amyloid-β's roles in Alzheimer's disease and pioneering studies that highlighted a role of nicotinic acetylcholine receptors in mediating important aspects of amyloid-β's effects. This review also surveys the current state of research into amyloid-β / nicotinic acetylcholine receptor interactions. The field has reached an exciting point in which common themes are emerging from the wide range of prior research and a range of accessible, relevant model systems are available to drive further progress. We highlight exciting new areas of inquiry and persistent challenges that need to be considered while conducting this research. Studies of amyloid-β and the nicotinic acetylcholine receptor populations that it interacts with provide opportunities for innovative basic and translational scientific breakthroughs related to nicotinic receptor biology, Alzheimer's disease, and cholinergic contributions to cognition more broadly., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests that could bias the contents of this article., (Published by Elsevier Ltd.)

This evaluation assessed the effectiveness of graphic-based (i.e., pictorial) report-back materials in communicating the presence of toxic metals in private well water and soil samples. It also explored associations between recommendations in the report-back materials and appropriate actions to protect health taken by a subset of participants in an environmental monitoring pilot study. Overall, 39 residents of Stokes County, North Carolina, participated in the Well Empowered pilot study, which included water and soil testing and analysis. All participants received materials explaining the extent to which toxic metals were present in their well water and soil. A subset of participants ( n = 14) responded to a follow-up evaluation, which showed that many found at least one component of their test results "very easy to understand." The existence of a federal standard for comparison appeared to influence participant recall of results, which was more accurate for contaminants with a federal maximum contaminant level. Our evaluation results suggest that a simple pictorial format, in combination with more detailed supporting text, can be useful in highlighting results that require action.

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Immune checkpoint inhibitors (ICIs) have become the new reference standard in first-line HCC treatment, replacing tyrosine kinase inhibitors (TKIs) such as sorafenib. Many clinical trials with different combinations are already in development to validate novel immunotherapies for the treatment of patients with HCC. Adoptive cell therapy (ACT), also known as cellular immunotherapy, with chimeric antigen receptors (CAR) or gene-modified T cells expressing novel T cell receptors (TCR) may represent a promising alternative approach to modify the immune system to recognize tumor cells with better clinical outcomes. In this review, we briefly discuss the overview of ACT as a promising treatment modality in HCC, along with recent updates of ongoing clinical trials.

Reflection on professional practice (either individually or in dialogue with peers or seniors) will often focus on doctors' skills. This approach emphasises compliance and competence. This paper suggests that an alternative and useful lens for professional reflection and development can be drawn from the framework of virtue ethics to encourage consideration of the ultimate purpose of medicine, and the character or virtues needed to be a good doctor. This alternative approach supports doctors to reflect on and develop their virtues, including practical wisdom, which orchestrates the doctor's skills and virtues. This emphasis on purpose and character within professional reflection promotes excellence, rather than just competency, and engages with what motivated most doctors to enter medicine., Competing Interests: AJTG is a non-executive director of Health Education England. He is writing in a personal capacity., (© Royal College of Physicians 2023. All rights reserved.)