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AbstractIntroductionDoctors with disability are likely to face major life crises, challenges and distressing emotions from unforeseen circumstances that threaten their physical well-being. We aimed to identify the existence of work-related pain and discomfort that may cause surgeon’s disability. Surgeons who were struck with unpredictable disasters leading to disabilities were also reviewed.MethodsWe conducted a 10-year literature review. In addition, citations about surgeons’ physical disabilities were complemented with commentaries about disabled surgeons from gray literature. The quantitative citations were quality assessed by MERSQI scores and evidence graded according to GRADE. For the qualitative study part, the severely traumatized surgeons were analysed by means of Cullberg’s crisis phases (CCP) and analysed from Tedeschi and Calhoun’s post-traumatic growth perspective (PTG).ResultsAltogether 3593 citations from PubMed were studied, and 10 citations met inclusion criteria with a total of 11591 participants. We included 6 surgeons subjected to highly traumatic events complicating their medical career. Our quantitative citations’ mean MERSQI score was 11.73 (SD .79) and the citations’ evidence value completed grade II (moderate quality: 11.26 to 12.00 scores). Work-related musculoskeletal pain and occupational injuries may lead to physical disabilities. The accidentally traumatized surgeons fought through the four CCP phases and reached successfully the PTG stage.ConclusionsThe surgical workforce is at high risk of work-related musculoskeletal morbidity which can progress to chronic pain and disruption of surgeon’s career. Surgeons with disabilities faced serious barriers in their career. Institutions and healthcare systems must urgently develop support strategies for surgeons with disabilities.

The versatility and computation efficiency of an analytical propagation model for on-body communication is presented. The model is used to maximize the on-body path gain by on-body radiation pattern optimization. The reduced calculation time of the model, allows for such a study to be performed. It is found that the direction towards the front of the head is favored in terms of directivity of the radiation pattern. The prediction accuracy is demonstrated to be improved, by adopting an advanced on-body far-field formulation in the calculation of the antenna gain and electric field phase. It is seen that the accuracy of the model is improved by several decibels.

Preventing lower-extremity amputations (LEAs) is pivotal. In the present study, we aimed to examine the recent trends in nontraumatic LEAs seen in the Northern Danish Region.

Identifying genes linked to extreme phenotypes in humans has the potential to highlight biological processes not shared with all other mammals. Here, we report the identification of homozygous loss-of-function variants in the primate-specific gene ZNF808as a cause of pancreatic agenesis. ZNF808 is a member of the KRAB zinc finger protein family, a large and rapidly evolving group of epigenetic silencers which target transposable elements. We show that loss of ZNF808 in vitro results in aberrant activation of regulatory potential contained in the primate-specific transposable elements it represses during early pancreas development. This leads to inappropriate specification of cell fate with induction of genes associated with liver identity. Our results highlight the essential role of ZNF808in pancreatic development in humans and the contribution of primate-specific regions of the human genome to congenital developmental disease.

Understanding what controls global leaf type variation in trees is crucial for comprehending their role in terrestrial ecosystems, including carbon, water and nutrient dynamics. Yet our understanding of the factors influencing forest leaf types remains incomplete, leaving us uncertain about the global proportions of needle-leaved, broadleaved, evergreen and deciduous trees. To address these gaps, we conducted a global, ground-sourced assessment of forest leaf-type variation by integrating forest inventory data with comprehensive leaf form (broadleaf vs needle-leaf) and habit (evergreen vs deciduous) records. We found that global variation in leaf habit is primarily driven by isothermality and soil characteristics, while leaf form is predominantly driven by temperature. Given these relationships, we estimate that 38% of global tree individuals are needle-leaved evergreen, 29% are broadleaved evergreen, 27% are broadleaved deciduous and 5% are needle-leaved deciduous. The aboveground biomass distribution among these tree types is approximately 21% (126.4 Gt), 54% (335.7 Gt), 22% (136.2 Gt) and 3% (18.7 Gt), respectively. We further project that, depending on future emissions pathways, 17–34% of forested areas will experience climate conditions by the end of the century that currently support a different forest type, highlighting the intensification of climatic stress on existing forests. By quantifying the distribution of tree leaf types and their corresponding biomass, and identifying regions where climate change will exert greatest pressure on current leaf types, our results can help improve predictions of future terrestrial ecosystem functioning and carbon cycling.

Linkage and candidate gene studies have identified several breast cancer susceptibility genes, but the overall contribution of coding variation to breast cancer is unclear. To evaluate the role of rare coding variants more comprehensively, we performed a meta-analysis across three large whole-exome sequencing datasets, containing 26,368 female cases and 217,673 female controls. Burden tests were performed for protein-truncating and rare missense variants in 15,616 and 18,601 genes, respectively. Associations between protein-truncating variants and breast cancer were identified for the following six genes at exome-wide significance (P<2.5 × 10−6): the five known susceptibility genes ATM, BRCA1, BRCA2, CHEK2and PALB2, together with MAP3K1. Associations were also observed for LZTR1, ATRIPand BARD1with P< 1 × 10−4. Associations between predicted deleterious rare missense or protein-truncating variants and breast cancer were additionally identified for CDKN2Aat exome-wide significance. The overall contribution of coding variants in genes beyond the previously known genes is estimated to be small.

Introduction: Racial/ethnic discrimination indicates the stereotyped or unkind conduct of superiority towards other persons based on their race or skin color. The UK General Medical Council published a statement supporting zero-tolerance approach to racism in the workplace. We aimed to systematically review racial discrimination in surgery and answer the following questions: (1) Does racial/ethnic discrimination in surgery exist in citations from the last 5 years. (2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery? Methods: The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. Search terms were ‘racial discrimination and surgery’, ‘racism OR discrimination AND surgery’, ‘racism OR discrimination AND surgical education’. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE. Results: A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. There was evidence of racial discrimination in the last 5 years and the results were justified on strong scientific evidence constituting the basis for evidence grade I. The second question’s answer was ‘yes’ which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II. Conclusion: There was sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual as well as on the level of the surgical team performance. The existence of the discussed problems must be managed in more countries with diverse healthcare systems.

Many bacteria and archaea harbor the adaptive CRISPR-Cas system, which stores small nucleotide fragments from previous invasions of nucleic acids via viruses or plasmids. This molecular archive blocks further invaders carrying identical or similar nucleotide sequences. However, few of these systems have been confirmed experimentally to be active in gut bacteria. Here, we demonstrate experimentally that the type I-C CRISPR-Cas system of the prevalent gut bacterium Eggerthella lentacan specifically target and cleave foreign DNA in vitro by using a plasmid transformation assay. We also show that the CRISPR-Cas system acquires new immunities (spacers) from the genome of a virulent E. lentaphage using traditional phage assays in vitro but also in vivo using gnotobiotic (GB) mice. Both high phage titer and an increased number of spacer acquisition events were observed when E. lentawas exposed to a low multiplicity of infection in vitro, and three phage genes were found to contain protospacer hotspots. Fewer new spacer acquisitions were detected in vivo than in vitro. Longitudinal analysis of phage-bacteria interactions showed sustained coexistence in the gut of GB mice, with phage abundance being approximately one log higher than the bacteria. Our findings show that while the type I-C CRISPR-Cas system is active in vitro and in vivo, a highly virulent phage in vitro was still able to co-exist with its bacterial host in vivo. Taken altogether, our results suggest that the CRISPR-Cas defense system of E. lentaprovides only partial immunity in the gut.

Many bacteria and archaea harbor the adaptive CRISPR-Cas system, which stores small nucleotide fragments from previous invasions of nucleic acids via viruses or plasmids. This molecular archive blocks further invaders carrying identical or similar nucleotide sequences. However, few of these systems have been confirmed experimentally to be active in gut bacteria. Here, we demonstrate experimentally that the type I-C CRISPR-Cas system of the prevalent gut bacterium Eggerthella lentacan specifically target and cleave foreign DNA in vitro by using a plasmid transformation assay. We also show that the CRISPR-Cas system acquires new immunities (spacers) from the genome of a virulent E. lentaphage using traditional phage assays in vitro but also in vivo using gnotobiotic (GB) mice. Both high phage titer and an increased number of spacer acquisition events were observed when E. lentawas exposed to a low multiplicity of infection in vitro, and three phage genes were found to contain protospacer hotspots. Fewer new spacer acquisitions were detected in vivo than in vitro. Longitudinal analysis of phage-bacteria interactions showed sustained coexistence in the gut of GB mice, with phage abundance being approximately one log higher than the bacteria. Our findings show that while the type I-C CRISPR-Cas system is active in vitro and in vivo, a highly virulent phage in vitro was still able to co-exist with its bacterial host in vivo. Taken altogether, our results suggest that the CRISPR-Cas defense system of E. lentaprovides only partial immunity in the gut.

Background: The limited research on prognosis after nonsurgical management of anterior cruciate ligament (ACL) injury has focused on physical factors. We aimed to assess relationships between key patient-reported outcomes, in line with a biopsychosocial approach, and returning to preinjury sport at 12 months after ACL injury treated without reconstruction.Hypothesis: We hypothesized that biopsychosocial factors would be associated with returning to preinjury sport at 12 months after ACL injury.Study Design: Prospective single cohort study.Level of Evidence: Level 2.Methods: Patients who had an ACL injury and did not have reconstruction during the first year after injury were recruited from healthcare clinics in Sweden, and followed up at 3, 6, and 12 months after injury. Return to preinjury sport at 12 months was the primary outcome. Explanatory variables were psychological readiness to return to sport, knee-related quality of life, and self-reported knee function. Using generalized estimating equations, we evaluated the relationships between the explanatory variables and the primary outcome at each timepoint.Results: Data were analyzed for 88 participants with a median age of 27 years (15-40 years). Soccer was the most frequently reported preinjury sport (n = 22). Forty participants (46%) had returned to their preinjury sport at 12 months after ACL injury. The odds of returning to preinjury sport at 12 months increased with higher self-reported knee function at 6 months (odds ratio [OR], 1.1; 95% CI, 1.0-1.1), and the odds of being returned to the preinjury sport at 12 months doubled for every 1-point increase (1-10 scale) in psychological readiness to return to sport measured at 12 months (OR, 1.9; 95% CI, 1.2-3.2).Conclusion: Superior self-reported knee function at 6 months and greater psychological readiness to return to sport at 12 months were associated with returning to the preinjury sport 1 year after ACL injury treated without reconstruction.Clinical Relevance: Consider highlighting the relevance of biopsychosocial factors to returning to preinjury sport after ACL injury when discussing prognosis during shared decision-making.

Collaboration and intraprofessional relationships are essential for healthy work environments; they affect everyday practice, quality of care, patient outcomes, and nurses’ welfare. Little is known about how nurses experience nurse—nurse collaboration.

Forests are a substantial terrestrial carbon sink, but anthropogenic changes in land use and climate have considerably reduced the scale of this system1. Remote-sensing estimates to quantify carbon losses from global forests2–5are characterized by considerable uncertainty and we lack a comprehensive ground-sourced evaluation to benchmark these estimates. Here we combine several ground-sourced6and satellite-derived approaches2,7,8to evaluate the scale of the global forest carbon potential outside agricultural and urban lands. Despite regional variation, the predictions demonstrated remarkable consistency at a global scale, with only a 12% difference between the ground-sourced and satellite-derived estimates. At present, global forest carbon storage is markedly under the natural potential, with a total deficit of 226 Gt (model range = 151–363 Gt) in areas with low human footprint. Most (61%, 139 Gt C) of this potential is in areas with existing forests, in which ecosystem protection can allow forests to recover to maturity. The remaining 39% (87 Gt C) of potential lies in regions in which forests have been removed or fragmented. Although forests cannot be a substitute for emissions reductions, our results support the idea2,3,9that the conservation, restoration and sustainable management of diverse forests offer valuable contributions to meeting global climate and biodiversity targets.

Determining the drivers of non-native plant invasions is critical for managing native ecosystems and limiting the spread of invasive species1,2. Tree invasions in particular have been relatively overlooked, even though they have the potential to transform ecosystems and economies3,4. Here, leveraging global tree databases5–7, we explore how the phylogenetic and functional diversity of native tree communities, human pressure and the environment influence the establishment of non-native tree species and the subsequent invasion severity. We find that anthropogenic factors are key to predicting whether a location is invaded, but that invasion severity is underpinned by native diversity, with higher diversity predicting lower invasion severity. Temperature and precipitation emerge as strong predictors of invasion strategy, with non-native species invading successfully when they are similar to the native community in cold or dry extremes. Yet, despite the influence of these ecological forces in determining invasion strategy, we find evidence that these patterns can be obscured by human activity, with lower ecological signal in areas with higher proximity to shipping ports. Our global perspective of non-native tree invasion highlights that human drivers influence non-native tree presence, and that native phylogenetic and functional diversity have a critical role in the establishment and spread of subsequent invasions.

AimsThe aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.MethodsIn this longitudinal register-based observational study, we identified 72,069 patients with hip and knee OA in the Better Management of Patients with Osteoarthritis Register (BOA), who were referred for first-line OA intervention, between May 2008 and December 2016. Patients were followed until the first primary arthroplasty surgery before 31 December 2016, stratified into a hip and a knee OA cohort. Data were analyzed with Kaplan-Meier and multivariable-adjusted Cox regression.ResultsAt five years, Kaplan-Meier estimates showed that 46% (95% confidence interval (CI) 44.6 to 46.9) of those with hip OA, and 20% (95% CI 19.7 to 21.0) of those with knee OA, had progressed to arthroplasty. The strongest prognostic factors were desire for surgery (hazard ratio (HR) hip 3.12 (95% CI 2.95 to 3.31), HR knee 2.72 (95% CI 2.55 to 2.90)), walking difficulties (HR hip 2.20 (95% CI 1.97 to 2.46), HR knee 1.95 (95% CI 1.73 to 2.20)), and frequent pain (HR hip 1.56 (95% CI 1.40 to 1.73), HR knee 1.77 (95% CI 1.58 to 2.00)). In hip OA, the probability of progression to surgery was lower among those with comorbidities (e.g. ≥ four conditions; HR 0.64 (95% CI 0.59 to 0.69)), with no detectable effects in the knee OA cohort. Instead, being overweight or obese increased the probability of OA progress in the knee cohort (HR 1.25 (95% CI 1.15 to 1.37)), but not among those with hip OA.ConclusionPatients with hip OA progressed faster and to a greater extent to arthroplasty than patients with knee OA. Progression was strongly influenced by patients’ desire for surgery and by factors related to severity of OA symptoms, but factors not directly related to OA symptoms are also of importance. However, a large proportion of patients with OA do not seem to require surgery within five years, especially among those with knee OA.Cite this article: Bone Joint J2022;104-B(7):792–800.

Over 70% of studies measuring ACL-RSI scores were judged to have high risk of bias (i.e., low internal validity), leading to a certainty of evidence rating of weak for all analyses.ACL-RSI scores do not appear to increase during typical rehabilitation periods after anterior cruciate ligament reconstruction.Age, sex, and time from injury to surgery (i.e., treatment approach) appear prognostic for early ACL-RSI scores, but their prognostic ability diminishes for later ACL-RSI scores.

•Denmark was one of the first countries to implement universal screening for defective mismatch-repair (dMMR) in colorectal cancer. Implementation rates and completeness of the screening cascade remains undefined.•A decade of national, population-based registries of universal dMMR screening in colorectal cancer was accessed in terms of uptake rate, detection rate and referral to genetic counselling and/or genetic diagnostics.•The study shows high uptake of dMMR analysis, but reveals disparities in access related to sex, age, tumour location and health care provider. Referral to genetic counselling and/or diagnostics in accordance with clinical guidelines for hereditary cancer was suboptimal.•These findings have practice implications related to equity of care and missed opportunities for cancer prevention and early diagnostics due incomplete diagnostic work-up.•The results provide added value for decision-makers and health professionals related to the design and monitoring of dMMR screening programs in cancer to ensure robust and resource-efficient implementation.

Cognitive skills are a strong predictor of a wide range of later life outcomes. Genetic and epigenetic associations across the genome explain some of the variation in general cognitive abilities in the general population and it is plausible that epigenetic associations might arise from prenatal environmental exposures and/or genetic variation early in life. We investigated the association between cord blood DNA methylation at birth and cognitive skills assessed in children from eight pregnancy cohorts within the Pregnancy And Childhood Epigenetics (PACE) Consortium across overall (total N= 2196), verbal (total N= 2206) and non-verbal cognitive scores (total N= 3300). The associations at single CpG sites were weak for all of the cognitive domains investigated. One region near DUSP22on chromosome 6 was associated with non-verbal cognition in a model adjusted for maternal IQ. We conclude that there is little evidence to support the idea that variation in cord blood DNA methylation at single CpG sites is associated with cognitive skills and further studies are needed to confirm the association at DUSP22.

ABSTRACTAltered maternal haemoglobin levels during pregnancy are associated with pre-clinical and clinical conditions affecting the fetus. Evidence from animal models suggests that these associations may be partially explained by differential DNA methylation in the newborn with possible long-term consequences. To test this in humans, we meta-analyzed the epigenome-wide associations of maternal haemoglobin levels during pregnancy with offspring DNA methylation in 3,967 newborn cord blood and 1,534 children and 1,962 adolescent whole-blood samples derived from 10 cohorts. DNA methylation was measured using Illumina Infinium Methylation 450K or MethylationEPIC arrays covering 450,000 and 850,000 methylation sites, respectively. There was no statistical support for the association of maternal haemoglobin levels with offspring DNA methylation either at individual methylation sites or clustered in regions. For most participants, maternal haemoglobin levels were within the normal range in the current study, whereas adverse perinatal outcomes often arise at the extremes. Thus, this study does not rule out the possibility that associations with offspring DNA methylation might be seen in studies with more extreme maternal haemoglobin levels.

Although research on evidence-based practice (EBP) has been available for several decades, EBP has not been implemented successfully by nursing management. Evidence-based practice is a key area of knowledge management (KM), and EBP and KM are subject to similar challenges. However, there has only been limited research on KM and EBP within the context of nursing. The aim of this study was to describe and explain nurses’ perceptions of their own readiness for EBP, and their perceptions of the managerial and organizational support for enhancing competency and EBP. The study design was a cross-sectional survey carried out in accordance with STROBE. Data were collected from 125 nurses using two international instruments and one instrument developed for this study. The data were then analyzed using descriptive and multivariate statistics. Less than half of the nurses reported that their practices were often evidence-based, and only a third had often searched for evidence. The nurses perceived the weakest areas of management leadership to be arranging resources, solving problems and encouraging discussion in the context of EBP, and anticipation of nurses’ competency needs, ensuring competency and intervening when competency was inadequate in the context of KM. The results emphasize the need to develop nurse training, management leadership and an operational environment conducive to KM and EBP. Managers should take a more visible role in mentoring nurses for EBP and in identifying the developmental needs of nurses’ competencies.

Surgery is known to be a craft profession requiring individuals with specific innate aptitude for manipulative skills, and visuospatial and psychomotor abilities. The present-day selection process of surgical trainees does not include aptitude testing for the psychomotor and manual manipulative skills of candidates for required abilities. We aimed to scrutinize the significance of innate aptitudes in surgical practice and impact of training on skills by systematically reviewing their significance on the surgical task performance. A systematic review was performed in compliance with PRISMA guidelines. An initial search was carried out on PubMed/Medline for English language articles published over 20 years from January 2001 to January 2021. Search strategy and terms to be used included ‘aptitude for surgery’, ‘innate aptitude and surgical skills, ‘manipulative abilities and surgery’, and ‘psychomotor skills and surgery’. MERSQI score was applied to assess the quality of quantitatively researched citations. The results of the present searches provided a total of 1142 studies. Twenty-one studies met the inclusion criteria out of which six citations reached high quality and rejected our three null hypothesis. Consequently, the result specified that all medical students cannot reach proficiency in skills necessary for pursuing a career in surgery; moreover, playing video games and/or musical instruments does not promote skills for surgery, and finally, there may be a valid test with predictive value for novices aspiring for a surgical career. MERSQI mean score was 11.07 (SD = 0.98; range 9.25–12.75). The significant findings indicated that medical students with low innate aptitude cannot reach skills necessary for a competent career in surgery. Training does not compensate for pictorial-skill deficiency, and a skill is needed in laparoscopy. Video-gaming and musical instrument playing did not significantly promote aptitude for microsurgery. The space-relation test has predictive value for a good laparoscopic surgical virtual-reality performance. The selection process for candidates suitable for a career in surgery requests performance in a simulated surgical environment.