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Abstract When an hypothesized peer effect (also termed social influence or contagion) is believed to act between units (e.g., hospitals) above the level at which data is observed (e.g., patients), a network autocorrelation model may be embedded within a hierarchical data structure thereby formulating the peer effect as a dependency between latent variables. In such a situation, a patient’s own hospital can be thought of as a mediator between the effects of peer hospitals and their outcome. However, as in mediation analyses, there may be interest in allowing the effects of peer units to directly impact patients of other units. To accommodate these possibilities, we develop two hierarchical network autocorrelation models that allow for direct and indirect peer effects between hospitals when modeling individual outcomes of the patients cared for at the hospitals. A Bayesian approach is used for model estimation while a simulation study assesses the performance of the models and sensitivity of results to different prior distributions. We construct a United States New England region patient-sharing hospital network and apply newly developed Bayesian hierarchical models to study the diffusion of robotic surgery and hospital peer effects in patient outcomes using a cohort of United States Medicare beneficiaries in 2016 and 2017. The comparative fit of models to the data is assessed using Deviance information criteria tailored to hierarchical models that include peer effects as latent variables.

We conducted surveillance for carbapenem-resistant Enterobacterales (CRE) during 2016–2020 at 10 US sites and extended-spectrum β-lactamase–producing Enterobacterales (ESBL-E) during 2019–2020 at 6 US sites. Among 159 CRE cases in children (median age 5 years), CRE was isolated from urine for 131 (82.4%) and blood from 20 (12.6%). Annual CRE incidence rate (cases/100,000 population) was 0.47–0.87. Among 207 ESBL-E cases in children (median age 6 years), ESBL-E was isolated from urine of 196 (94.7%) and blood of 8 (3.9%). Annual ESBL-E incidence rate was 26.5 in 2019 and 19.63 in 2020. CRE and ESBL-E rates were >2-fold higher among infants than other age groups. Most CRE and ESBL-E cases were healthcare-associated community-onset (68 [43.0%] for CRE vs. 40 [23.7%] for ESBL-E) or community-associated (43 [27.2%] for CRE vs. 109 [64.5%] for ESBL-E). Programs to detect, prevent, and treat multidrug-resistant infections must include pediatric populations (particularly the youngest) and outpatient settings.

The purpose of this research was to use a historical method and core principles from scientific philosophy to explain why mistakes were made in the development of the lactic acidosis construct. On a broader scope, this research explains what science is, why some scientists despite good intention, often get it wrong, and why it takes so long (decades) to correct these errors. Science is a human behaviour that consists of the identification of a problem based on the correct application of prior knowledge, the development of a method to best resolve or test the problem, completion of these methods to acquire results, and then a correct interpretation of the results. If these steps are done correctly there is an increased probability (no guarantee) that the outcome is likely to be correct. Thomas Kuhn proposed that you can understand what science is from how it has been performed, and from his essays he revealed a very dysfunctional form of science that he called ‘normal’ (due the preponderance of its presence) science. Conversely, Karl Popper was adamant that the practice of ‘normal’ science revealed numerous flaws that deviate from fundamental principles that makes science, science. Collectively, the evidence reveals that within the sports medicine and health sciences, as with all disciplines, errors in science are more frequent than you might expect. There is an urgent need to improve how we educate and train scientists to prevent the pursuit of ‘normal’ science and the harm it imparts on humanity.

The morphological diversity of the inflorescence determines flower and seed production, which is critical for plant adaptation. Hall's panicgrass (Panicum hallii, P. hallii) is a wild perennial grass that has been developed as a model to study perennial grass biology and adaptive evolution. Highly divergent inflorescences have evolved between the 2 major ecotypes in P. hallii, the upland ecotype (P. hallii var hallii, HAL2 genotype) with compact inflorescence and large seed and the lowland ecotype (P. hallii var filipes, FIL2 genotype) with an open inflorescence and small seed. Here we conducted a comparative analysis of the transcriptome and DNA methylome, an epigenetic mark that influences gene expression regulation, across different stages of inflorescence development using genomic references for each ecotype. Global transcriptome analysis of differentially expressed genes (DEGs) and co-expression modules underlying the inflorescence divergence revealed the potential role of cytokinin signaling in heterochronic changes. Comparing DNA methylome profiles revealed a remarkable level of differential DNA methylation associated with the evolution of P. hallii inflorescence. We found that a large proportion of differentially methylated regions (DMRs) were located in the flanking regulatory regions of genes. Intriguingly, we observed a substantial bias of CHH hypermethylation in the promoters of FIL2 genes. The integration of DEGs, DMRs, and Ka/Ks ratio results characterized the evolutionary features of DMR-associated DEGs that contribute to the divergence of the P. hallii inflorescence. This study provides insights into the transcriptome and epigenetic landscape of inflorescence divergence in P. hallii and a genomic resource for perennial grass biology.

Active learning is a technique used to help transfer passive knowledge into true learning of material, which can be very beneficial when learning challenging topics. The endocrine system is a complex series of topics that can be challenging to tackle in the short amount of time allotted to it in the medical school curriculum or an undergraduate anatomy and physiology course. Pedagogical strategies that use art as a tool have been shown to motivate and induce students to self-learn such complex physiology topics. The hormone project was designed to help students manage the vast amount of information and acquire knowledge in a meaningful and creative way. Students were asked to create a visual project to depict an endocrine disorder that incorporated art into their learning of the endocrine system. Based on post-session survey results, students found the activity to be beneficial to their learning and they enjoyed engaging in the activity. Providing students with opportunities to engage with material in a creative, artistic manner can be both engaging and enjoyable. This activity provided students with a chance to develop their own memory hooks to facilitate easier recall of the complex topics in the endocrine system. A pilot study of this activity shows great promise to be a staple in curricula that embrace active learning.

Problem-based learning (PBL) is a type of active learning modality involving a student-centered approach that encompasses small group settings in order to promote learning via critical thinking and discussion as opposed to via direct presentation of facts and concepts. Through PBL, students engage actively in their learning. Facilitated PBL sessions put an emphasis on active learning by students as they explore their knowledge and understanding of medically related concepts as well as their own attitudes and values. This paper provides an introduction to the PBL modality and tips for developing a facilitation approach. Also included are examples of formative and summative feedback and implementation strategies that can be used by PBL facilitators. An example of a training exercise for PBL facilitation feedback is also presented.

Influencers are individuals or entities that meaningfully contribute through a socially constructed process to the formation of educational aspirations and possibly to their attainment. The effect of a specific influencer may differ within the context of multiple influencers. The aim of the current mixed methods study was to investigate how various influencers shape the development of educational aspirations and may contribute to goal setting and eventual attainment of an early aspiration. One-on-one, semi-structured interviews were conducted with 44 participants who attended high school in Ontario, Canada. Most participants identified as Canadian (54.5%) with a mean age of 29 years and median income of $48,504 Canadian Dollars. Participants were asked about the educational aspirations they had in high school. Retrospective accounts provided the opportunity to ask in the interviews not only who the influencers were but also if aspirations were pursued, changed, or attained. Coding and thematic analysis revealed 11 categories of influencers. Further analysis revealed that individuals with a diverse set of influencers attained their educational goals with an important exception. Young adults with 3-5 types of influencers were the largest percentage (61.9%) who achieved their goals, whereas among those with 1, 2, or more than 5 influencers only 21.7% achieved their aspirations. Two influencers that have received little empirical attention emerged: Self and Society/Culture. Findings have implications for encouraging young people and influencers to consider not only how parents and teachers affect educational aspirations but also the composition and size of socio-educational networks.

Flipped classrooms have been shown to improve engagement in undergraduate classrooms, in general, but there have been fewer studies reporting on how they are received in the undergraduate medical education classroom. This perspective piece reflects on one instructor's experience with flipping the classroom as a pilot study when teaching medical students. Some preliminary survey data reveals student feedback with regard to the effectiveness of the flipped classroom sessions for first year medical students. While the response rate was very low for the survey, it still provided an indication of the usefulness of the sessions, as well as some helpful open-ended feedback from the participants. This pilot study will be repeated in the Spring 2023 semester.

Children of families involved with child welfare services are considered high-risk and are vulnerable to developing problems in a number of domains. In particular, educational achievement among this population tends to be lower relative to general population peers. The goal of this qualitative study was to understand the educational aspirations and subsequent pathways of young adults with former child welfare involvement. Semi-structured interviews were conducted with seven young adults (mean age of 31 years) from Ontario, Canada about their educational aspirations in high school and factors that served as facilitators and obstacles to their achievement. The results indicate youth had high hopes and dreams for their future in high school. However, complex challenges impeded the realization of these dreams. Although all seven participants initiated post-secondary programs, only one reached successful completion. None of the young adults achieved the educational and occupational dreams they had in high school. Nevertheless, returning to school remains a prominent future goal for most participants. Despite significant challenges and unrealized educational aspirations, youth with child welfare experiences continue to place high value on education in inspiring hope and optimism for the future. Addressing barriers to educational achievement for youth with child welfare involvement remains an important focus to help educational aspirations become a reality.

ABSTRACT Introduction Improved access to rehabilitation is highlighted as a key pathway to achieving the World Health Organisation's (WHO) goal of ensuring healthy lives and promoting well‐being for all (Sustainable Development Goal 3). This article is the second in a two‐part series outlining the findings from the Rehabilitation Choices study, which aimed to identify how health professionals and consumers in Australia are informed to make decisions about rehabilitation, and their experience with barriers and enablers to accessing that rehabilitation. In this study, we present the perspectives of consumers with different health conditions and a range of experiences with rehabilitation services. Methods This was a qualitative study using focus groups and semi‐structured interviews. People with self‐reported lived experience of rehabilitation and carers were recruited using maximum variation sampling. Thematic analysis of data was conducted using an inductive approach. Results Fifty‐six consumers with diverse lived experiences of rehabilitation (19–80 years, 49 patients, 7 carers) participated in focus groups and interviews to discuss how they sourced information about rehabilitation and their experiences of what made it hard or easy to access rehabilitative care to meet their needs. Four themes were produced from the data: (1) service‐centricity of options limits access, (2) access is the patient's responsibility, (3) enabling decision‐making about rehabilitation with appropriate information and (4) provision of a psychologically safe environment. Conclusions Any planned (re)design of services to improve consumer access to rehabilitation should consider the themes identified in this study. This will ensure that consumers are provided with rehabilitation options that suit their holistic and unique needs beyond consideration of their medical diagnoses, and are actively supported to navigate this access, provided with information to help them make informed choices and provided a psychologically safe environment to engage effectively with rehabilitation. Patient or Public Contribution Three consumer research partners with lived experience of rehabilitation as patients or carers were core team members. They were involved in the design and implementation of the recruitment and communications strategies, design of the interview approach and discussion guide, contributed to the interpretation and contextualisation of findings and writing of this manuscript and are included as co‐authors (A. O., T. W. and S. W.).

BackgroundAlthough long-acting, injectable cabotegravir (CAB-LA) pre-exposure prophylaxis (PrEP) has proven efficacious for HIV prevention in clinical trials, research is needed to guide effective implementation in real-world settings. Formative work with community members and health care providers (HCPs) is important to provide insight into the needs and contexts of specific populations and reveal potential barriers and facilitators for implementation projects. ObjectiveWe aimed to describe the results from formative work to develop an implementation package for CAB-LA PrEP within the ImPrEP CAB Brasil study. MethodsImPrEP CAB Brasil is an implementation study of same-day delivery of CAB-LA PrEP for young sexual and gender minority (SGM) groups (aged 18-30 years) in 6 existing oral PrEP public health clinics. We conducted formative research to prepare for the implementation of ImPrEP CAB Brasil through community mobilization, process mapping with HCPs with experience in CAB-LA, and focus group discussions (FGDs) with young SGM groups (n=92) and HCPs (n=20) to identify initial perceptions of facilitators and barriers for CAB-LA PrEP implementation, refine the mobile health (mHealth) educational tool, and evaluate the acceptability of using a text message appointment reminder intervention through WhatsApp. FGDs were recorded, transcribed, systematically coded, and analyzed with thematic categorization by trained researchers using a qualitative data analysis program ATLAS.ti (version 7). ResultsA community mobilization team comprising 34 SGM community leaders collaborated in creating a prototype for an mHealth educational tool and contributed to the planning of peer education activities. We created 3 process maps for each site to describe the initial visit, follow-up visits, and laboratory flow. The main challenge identified for same-day CAB-LA PrEP delivery was the extended duration of clinic visits due to the numerous laboratory tests and HIV counseling steps required. Proposed solutions included having point-of-care HIV rapid tests instead of laboratory tests and additional counseling staff. Barriers for CAB-LA PrEP implementation identified through FGDs were the training of HCPs, support for adherence to injection appointments, and stigma or discrimination against SGM groups and persons using PrEP. The mHealth educational tool and WhatsApp reminders were highly acceptable by SGM groups and HCPs, indicating their potential to support PrEP choice and adherence. Content analysis on the cultural appropriateness of the language and overall clarity of the material contributed to the refinement of the mHealth tool. ConclusionsStructured formative work with SGM persons and HCPs generated important refinements to context-specific materials and plans to launch ImPrEP CAB Brasil in public health clinics. Ongoing implementation monitoring will use the process maps to identify additional barriers and potential solutions to same-day delivery of CAB-LA PrEP. Summative evaluations are needed to measure the effectiveness of the mHealth educational tool to support PrEP choice and the use of WhatsApp appointment reminders.

Background: Zone II and III fifth metatarsal (5-MT) fractures among athletes are typically managed with percutaneous fixation following anatomic reduction. However, screw head discomfort and refracture after bone union can occur because of the loads placed on the foot during play. Several hardware systems that use a smaller screw head compared to traditional hardware systems have been developed to minimize the rate of postoperative hardware complications. This study compares clinical and radiographic outcomes of 5-MT fractures in elite athletes treated with a solid headless screw vs a solid headed screw. We hypothesized that the headless screw would be associated with faster union rates, faster clearance times, and lower incidence of symptomatic hardware compared to the headed screw. Methods: Athletes competing at a collegiate level or higher treated for a zone II or III 5-MT fracture between 2016 and 2022 by 2 surgeons fellowship-trained in foot and ankle orthopaedics were screened. Operative notes were reviewed to determine the hardware system used. Subjects were divided based on the hardware system used during operation: headed screw and headless screw. Time to radiographic union, time to full clearance, and return to competition were determined. Postoperative complications, including nonunions, need for revision, need for hardware removal, and refractures were also noted. Results: Forty eligible patients (44 feet) were identified. The solid headed screw group included 20 patients (21 fractures), and the solid headless screw group included 20 patients (23 fractures). Average time to union for the headed screw group was 11.78 (range, 5.86-19.00) weeks; average time to union for the headless screw group was 11.65 (range, 6.00-22.57) weeks ( P = .93). Nineteen out of twenty (95%) patients were able to return to competition in both groups. Average time to return to competition for the headed screw group was 26.9 (range, 10.00-47.86) weeks, while average time for the headless screw group was 21.2 (range, 6.86-55.00) weeks ( P = .55). The overall complication rate for the headed screw was 23.8%, which was not statistically different from the overall complication rate for the headless screw of 13.0% ( P = .35). Conclusion: In this relatively small sample of elite athletes undergoing operative fixation of a 5-MT fracture, fixation using either a headless or headed screw system had similar good outcomes in regard to times to union, return to competition, and complication rate regardless of solid screw head type used. Level of Evidence: Level III, retrospective cohort study.

Summary: Despite extensive global research into genetic predisposition for severe COVID-19, knowledge on the role of rare host genetic variants and their relation to other risk factors remains limited. Here, 52 genes with prior etiological evidence were sequenced in 1,772 severe COVID-19 cases and 5,347 population-based controls from Spain/Italy. Rare deleterious TLR7 variants were present in 2.4% of young (

The objective of this study was to analyze complement activation in antiphospholipid antibody (aPL)-positive patients without other systemic autoimmune rheumatic diseases, using C3/C4 and cell-bound complement activation products (CB-CAPs) (B-lymphocytes [BC4d], erythrocytes [EC4d], and platelets [PC4d]). Persistently aPL-positive patients with or without aPL-related clinical manifestations (thrombotic APS [TAPS], microvascular APS [MAPS], obstetric APS, thrombocytopenia [TP], and/or hemolytic anemia [HA]) were enrolled in a single center study. Blood and clinical data were collected at baseline; a subgroup of patients completed 6- or 12-month follow-up. At baseline, 4/31 (13%) patients had decreased C3/C4, while 7/29 (24%) had elevated BC4d, 11/33 (33%) EC4d, and 12/32 (38%) PC4d. Based on different aPL profiles, all patients with decreased C3/C4 or elevated BC4d, EC4d, and PC4d had triple aPL or isolated lupus anticoagulant positivity. Based on different aPL clinical phenotypes, the number of patients with strongly positive EC4d and PC4d were proportionally higher in those with MAPS/TP/HA, compared to TAPS or no APS. Compared to baseline, the frequencies of BC4d, EC4d, and PC4d positivity were not significantly different in the subgroup of patients during their 6- or 12-month follow-up. There was a weak correlation between C3/C4 and CB-CAPs, especially for PC4d. In summary, complement activation in aPL-positive patients varies based on aPL profiles and clinical phenotypes. Given the higher percentage of aPL-positive patients with abnormal CB-CAPs, compared to C3/C4, and the poor inverse correlation between CB-CAPs and C3/C4, our study generates the hypothesis that CB-CAPs have a role in assessing disease activity and thrombosis risk in aPL-positive patients.

The global loss of coastal habitats is putting communities at risk of erosion and flooding, as well as impacting ecosystem function, cultural values, biodiversity, and other services. Coastal habitat restoration can provide a nature-based solution to the increasing need for climate adaptation on the coast while recovering lost ecosystems. Despite the benefits of using nature-based coastal protection to manage coastal hazards, there are scientific, socio-political and economic barriers to the broad use of this approach. Understanding the details of these barriers from the perspective of multiple stakeholders is essential to identifying solutions to overcome them. Using a workshop with participants that are key partners and stakeholders (from government, engineering consulting firms, and non-governmental organisations) in the management, design, and delivery of a coastal protection solution we aimed to: (1) gain a better understanding of the barriers faced by multiple stakeholders involved in the implementation of nature-based coastal protection; and (2) identify tangible solutions to these barriers to increase or support implementation, help focus attention on areas for future research, and inform pathways forward for the governance of nature-based coastal protection. We defined 19 barriers to nature-based coastal protection, but the primary ones that are experienced during the delivery of a project are a lack of: education and awareness; community support; necessary expertise and technical guidance; and uncertainty around: the risk reduction that can be achieved; planning and regulatory processes; and ownership of the structure. Two barriers that do not persist during the design stages of a project but are overarching as to whether nature-based coastal protection is considered in the first place, are government support and the availability of funding. The importance of these primary barriers changes depending on the method of nature-based coastal protection. We conclude by identifying both immediate actions and long-term solutions for enabling nature-based coastal protection in response to each of the primary barriers.

Rehabilitation protocols post-Achilles tendon repair vary widely, particularly regarding weight bearing (WB) and immobilization duration, impacting recovery trajectories significantly. This commentary focuses on rehabilitation strategies following acute Achilles tendon repair (ATR), emphasizing early mobilization and progressive loading. Techniques such as blood flow restriction training (BFRT) and progressive loading to restore strength and tendon mechanical properties are discussed in the context of optimizing recovery, minimizing tendon elongation and facilitating safe return to sport (RTS). This manuscript highlights current evidence and clinical insights to guide practitioners in optimizing rehabilitation protocols for athletes recovering from ATR, aiming to improve functional outcomes and support safe return to athletic activity.

ABSTRACT: Background: Surgical site infection (SSI) is a common yet serious complication of cervical spine surgery. While initially thought to be clinically insignificant, Cutibacterium acnes (C. acnes) is an important cause of infection. The purpose of this study was to investigate the ability of a hydrogen peroxide (H2O2) application during standard presurgical skin preparation to reduce the burden of C. acnes in patients undergoing cervical spine surgery. Methods: This was a retrospective review of prospectively collected data. Subjects were randomly assigned to either standard surgical preparation plus H2O2 (experimental) or without H2O2 (control). Prescrub, postscrub, and dermal cultures were obtained to assess the C. acnes burden after cultures on an aerobic and anaerobic growth medium were held for 21 days. Multivariate analysis was conducted to determine factors associated with presence of C. acnes. Outcome measures included the results of intraoperative cultures and the development of a SSI within 90 days postoperatively. Results: Patients (n=86) undergoing elective 2- or 3-level fusion via anterior approach were included. Prior to application of the antiseptic solution, 65% (28/43) of the experimental cohort and 77% (33/43) of the control cohort had positive C. acnes cultures (p=.34). Following application of antiseptic solution, there were no differences in positive C. acnes culture rates between the experimental and control cohorts in the epidermal (30% vs. 28%, p=1.00) or dermal (40% vs. 42%, p=1.00) cultures. No differences in the rates of C. acnes eradication from preantiseptic to postantiseptic application occurred for epidermal (p=1.00) or dermal (p=1.00) skin layers. None of the factors were associated with positive C. acnes epidermal cultures on multivariable logistic regression analysis (p>.05). Conclusions: While there is potential for H2O2 to reduce the positive culture rate of C. acnes in cervical spine patients, no difference was seen when compared to standard surgical skin preparation.

Lignocellulose forms plant cell walls, and its three constituent polymers, cellulose, hemicellulose and lignin, represent the largest renewable organic carbon pool in the terrestrial biosphere. Insights into biological lignocellulose deconstruction inform understandings of global carbon sequestration dynamics and provide inspiration for biotechnologies seeking to address the current climate crisis by producing renewable chemicals from plant biomass. Organisms in diverse environments disassemble lignocellulose, and carbohydrate degradation processes are well defined, but biological lignin deconstruction is described only in aerobic systems. It is currently unclear whether anaerobic lignin deconstruction is impossible because of biochemical constraints or, alternatively, has not yet been measured. We applied whole cell-wall nuclear magnetic resonance, gel-permeation chromatography and transcriptome sequencing to interrogate the apparent paradox that anaerobic fungi (Neocallimastigomycetes), well-documented lignocellulose degradation specialists, are unable to modify lignin. We find that Neocallimastigomycetes anaerobically break chemical bonds in grass and hardwood lignins, and we further associate upregulated gene products with the observed lignocellulose deconstruction. These findings alter perceptions of lignin deconstruction by anaerobes and provide opportunities to advance decarbonization biotechnologies that depend on depolymerizing lignocellulose.