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Closely related species often exhibit similarities in appearance and behaviour, yet when related species exist in sympatry, signals may diverge to enhance species recognition. Prior comparative studies provided mixed support for this hypothesis, but the relationship between sympatry and signal divergence is likely nonlinear. Constraints on signal diversity may limit signal divergence, especially when large numbers of species are sympatric. We tested the effect of sympatric overlap on plumage colour and song divergence in wood-warblers (Parulidae), a speciose group with diverse visual and vocal signals. We also tested how number of sympatric species influences signal divergence. Allopatric species pairs had overall greater plumage and song divergence compared to sympatric species pairs. However, among sympatric species pairs, plumage divergence positively related to the degree of sympatric overlap in males and females, while male song bandwidth and syllable rate divergence negatively related to sympatric overlap. In addition, as the number of species in sympatry increased, average signal divergence among sympatric species decreased, which is likely due to constraints on warbler perceptual space and signal diversity. Our findings reveal that sympatry influences signal evolution in warblers, though not always as predicted, and that number of sympatric species can limit sympatry's influence on signal evolution.

Background: Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment., Methods: This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group., Discussion: Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members., Trial Registration: ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.

Objective: To explore clinical characteristics in individuals with patellofemoral osteoarthritis (PFOA) compared to individually-matched asymptomatic controls. We also explored associations between functional performance and patient-reported symptoms with patellofemoral alignment., Methods: We assessed 15 individuals with PFOA and 15 individually-matched asymptomatic controls. In addition to physical examination and patient-reported questionnaires, we evaluated functional performance, lower extremity strength and range of motion, and patellar alignment (using MRI). We analysed group differences with Wilcoxon's matched-pairs signed rank tests, and within-group associations with Spearman's rank correlations., Results: We included 24 (80%) women with median (IQR) age of 56 (9) years and BMI of 22.8 (5.9) kg/m 2 . Individuals with PFOA reported lower quality of life (8/100 points lower EQ-5D-5L, p=0.02), and performed worse on two functional tests: repeated one-leg rises (median 16 fewer rises, p=0.04) and timed stair climb (1.2 s slower, p=0.03). There were no differences in strength tests performed or range of motion. Patellar proximal translation correlated with worse functional performance and worse patient-reported pain, function and self-efficacy, while lateral translation and lateral tilt correlated with worse knee-related quality of life (Spearman's r ranging from 0.5 to 0.7)., Conclusion: Functional performance was worse in individuals with PFOA, despite those individuals having no significant differences on lower extremity strength testing. Patellofemoral alignment was associated with worse functional performance as well as worse patient-reported outcomes, and it may represent one mechanism underpinning PFOA-related symptoms., Competing Interests: Competing interests: At the time of manuscript review, KMK was editor-in-chief for the British Journal of Sports Medicine., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Meaningful engagement of Alaska Native (AN) tribes and tribal health organizations is essential in the conduct of socially responsible and ethical research. As genomics becomes increasingly important to advancements in medicine, there is a risk that populations not meaningfully included in genomic research will not benefit from the outcomes of that research. AN people have historically been underrepresented in biomedical research; AN underrepresentation in genomics research is compounded by mistrust based on past abuses, concerns about privacy and data ownership, and cultural considerations specific to this type of research. Working together, the National Human Genome Research Institute and two Alaska Native health organizations, Southcentral Foundation and the Alaska Native Health Board, cosponsored a workshop in July 2018 to engage key stakeholders in discussion, strengthen relationships, and facilitate partnership and consideration of participation of AN people in community-driven biomedical and genomic research. AN priorities related to translation of genomics research to health and health care, return of genomic results, design of research studies, and data sharing were discussed. This report summarizes the perspectives that emerged from the dialogue and offers considerations for effective and socially responsible genomic research partnerships with AN communities.

Background: Imaging cannot be performed during natural weightbearing in biomechanical studies using conventional closed-bore MRI, which has necessitated simulating weightbearing load on the joint. Upright, open MRI (UO-MRI) allows for joint imaging during natural weightbearing and may have the potential to better characterize the biomechanical effect of tibiofemoral pathology involving soft tissues. However open MRI scanners have lower field strengths than closed-bore scanners, which limits the image quality that can be obtained. Thus, there is a need to establish the reliability of measurements in upright weightbearing postures obtained using UO-MRI., Methods: Knees of five participants with prior anterior cruciate ligament (ACL) rupture were scanned standing in a 0.5 T upright open MRI scanner using a 3D DESS sequence. Manual segmentation of cartilage regions in contact was performed and centroids of these contact areas were automatically determined for the medial and lateral tibiofemoral compartments. Inter-rater, test-retest, and intra-rater reliability were determined and quantified using intra-class correlation (ICC 3,1 ), standard error of measurement (SEM), and smallest detectable change with 95% confidence (SDC 95 ). Accuracy was assessed by using a high-resolution 7 T MRI as a reference., Results: Contact area and centroid location reliability (inter-rater, test-retest, and intra-rater) for sagittal scans in the medial compartment had ICC 3,1 values from 0.95-0.99 and 0.98-0.99 respectively. In the lateral compartment, contact area and centroid location reliability ICC 3,1 values ranged from 0.83-0.91 and 0.95-1.00 respectively. The smallest detectable change in contact area was 1.28% in the medial compartment and 0.95% in the lateral compartment. Contact area and centroid location reliability for coronal scans in the medial compartment had ICC 3,1 values from 0.90-0.98 and 0.98-1.00 respectively, and in the lateral compartment ICC 3,1 ranged from 0.76-0.94 and 0.93-1.00 respectively. The smallest detectable change in contact area was 0.65% in the medial compartment and 1.41% in the lateral compartment. Contact area was accurate to within a mean absolute error of 11.0 mm 2 ., Conclusions: Knee contact area and contact centroid location can be assessed in upright weightbearing MRI with good to excellent reliability. The lower field strength used in upright, weightbearing MRI does not compromise the reliability of tibiofemoral contact area and centroid location measures.

Introduction: More than 90% of orthopaedic surgery graduates pursue fellowship training after residency. Previous investigations have examined factors considered important by orthopaedic sports medicine and hand surgery fellowship program directors (PDs). This study sought to identify which factors orthopaedic trauma fellowship PDs deem most important when evaluating applicants., Methods: A web-based survey was sent to all 59 orthopaedic trauma fellowship PDs. PDs were given a list of 12 factors, which they ranked in order of importance. A weighted score for each factor was calculated. PDs could also write-in additional factors they considered important when ranking applicants., Results: The overall response rate was 83% (49/59 PDs). Forty-five percent of responding PDs listed the interview as the most important factor when ranking applicants. Other factors considered most important included letters of recommendation, personal connections to the applicant and/or letter writers, and the applicant's background in trauma. Results of the weighted score calculation again identified the interview as the most important factor when ranking applicants, followed by letters of recommendation, personal connections to the applicant/letter writers, the applicant's residency program, strength of the applicant's background in trauma, and research experience., Discussion: Orthopaedic trauma fellowship PDs consider the interview, letters of recommendation, and personal connections to the applicant/letter writers to be the most important factors when ranking fellowship applicants., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Acoustic signals show immense variation among passerines, and several hypotheses have been proposed to explain this diversity. In this study, we tested, for the first time, the relationships of song structure to phylogeny, habitat type, and morphology in the vireos and allies (Vireonidae). Every measure of song structure considered in this study had moderate and significant phylogenetic signal. Furthermore, two song-constraining morphological traits, bill shape and body mass, also exhibited significant phylogenetic signal. Song length showed the largest within-clade similarity; longer songs were highly conserved in part of the greenlet (Hylophilus) clade, whereas shorter songs characterized the remaining seven genera. We found no differences in song structure among vireonids living in different habitat types. However, vireonids with shorter, stouter bills and larger bodies sang songs with lower minimum and maximum peak frequency, compared with species with longer, thinner bills and smaller bodies. We conclude that Vireonidae song evolution is driven partially by phylogenetically conserved morphological traits. Our findings support the phylogenetic signal and morphological constraints hypotheses explaining structural diversity in avian acoustic signals., (© 2020 The Authors. Evolution © 2020 The Society for the Study of Evolution.)

The role of military leaders to promote resilience has never been more relevant. The following case highlights a Navy Nurse Corps Officer's challenges with deployment stressors and building resilience during a ship-based Global Health Engagement. The case also highlights a follow-on project to enhance the resilience of deployed service members., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The coronavirus pandemic constitutes a global challenge to society and medicine. Here, we review evolutionary insights that are relevant for the understanding of how people respond to the pandemic and what to expect in the aftermath of the crisis. Specifically, we argue that the behavioral immune system (BIS) and sickness behavior (SB) comprise two adaptive responses to impending and actual infection, respectively, and that individuals activating their BIS differ from those showing SB in important ways that may have implications for the prevention and treatment of COVID-19. Moreover, we reframe some of the behavioral health issues associated with the pandemic in a game-theoretical scenario, illustrating the difficulties that arise when public health is treated as a 'public good'. Lay summary: The coronavirus pandemic constitutes a global challenge to society and medicine. In this article, we employ evolutionary theory to improve our understanding of how people respond to the pandemic. Specifically, we argue that human behavior is guided by ancient mechanisms involving either the avoidance of infection or defense against attacks in times of enhanced vulnerability. Moreover, we reframe some of the behavioral health issues associated with the pandemic in a game-theoretical scenario. This helps understand why most people comply with rules of social distancing, while a minority fails to do so for very different reasons. The evolutionary perspective also allows making some predictions for the course of the pandemic., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Foundation for Evolution, Medicine, and Public Health.)

Objective: The purpose of the study was to determine the prevalence of femoroacetabular impingement syndrome (FAIS) in white adults 20 to 49 years of age., Methods: Participants were white men and women aged 20-49 years, recruited through random digit dialing from the population of Metro Vancouver, British Columbia, Canada. Participants filled out a self-administered questionnaire and underwent a physical examination and radiographs of both hips. FAIS was defined as a combination of hip symptoms, physical signs of impingement, and radiological findings of cam or pincer morphology as recommended by the Warwick Agreement. All analyses were weighted to reflect the population from which the sample was drawn., Results: Data were obtained for 500 participants. In the study population, 48.9% were males and the age distribution was 32.2%, 31.4%, and 36.4% in the groups 20-29, 30-39, and 40-49 years, respectively. The physical signs of impingement correlated significantly with symptoms, but there was no significant association between either symptoms or physical examination with radiographic findings. FAIS on either side was found in 3.0% (95% CI 1.5-4.5) of the population., Conclusion: In this study, FAIS was present in 3% of whites aged 20-49 years. Further research is needed to develop consistent criteria for assessing hip symptoms, physical signs, and hip joint morphology, and to better understand the relationships between them.

Purpose: To assess the effect of upright, seated, and supine postures on lumbar muscle morphometry at multiple spinal levels and for multiple muscles., Methods: Six asymptomatic volunteers were imaged (0.5 T upright open MRI) in 7 postures (standing, standing holding 8 kg, standing 45° flexion, seated 45° flexion, seated upright, seated 45° extension, and supine), with scans at L3/L4, L4/L5, and L5/S1. Muscle cross-sectional area (CSA) and muscle position with respect to the vertebral body centroid (radius and angle) were measured for the multifidus/erector spinae combined and psoas major muscles., Results: Posture significantly affected the multifidus/erector spinae CSA with decreasing CSA from straight postures (standing and supine) to seated and flexed postures (up to 19%). Psoas major CSA significantly varied with vertebral level with opposite trends due to posture at L3/L4 (increasing CSA, up to 36%) and L5/S1 (decreasing CSA, up to 40%) with sitting/flexion. For both muscle groups, radius and angle followed similar trends with decreasing radius (up to 5%) and increasing angle (up to 12%) with seated/flexed postures. CSA and lumbar lordosis had some correlation (multifidus/erector spinae L4/L5 and L5/S1, r = 0.37-0.45; PS L3/L4 left, r =  - 0.51). There was generally good repeatability (average ICC(3, 1): posture = 0.81, intra = 0.89, inter = 0.82)., Conclusion: Changes in multifidus/erector spinae muscle CSA likely represent muscles stretching between upright and seated/flexed postures. For the psoas major, the differential level effect suggests that changing three-dimensional muscle morphometry with flexion is not uniform along the muscle length. The muscle and spinal level-dependent effects of posture and spinal curvature correlation, including muscle CSA and position, highlight considering measured muscle morphometry from different postures in spine models.

Introduction: Since the influenza A/H1N1 pandemic of 2009 to 2010, numerous studies have described the clinical course and outcome of the different subtypes of influenza (A/H1N1, A/H3N2, and B). A recent systematic literature review concluded that there were no appreciable differences in either clinical presentation or disease severity among these subtypes, but study parameters limit the applicability of these results to military populations. We sought to evaluate differences in disease severity among influenza subtypes in a cohort of healthy, primarily outpatient adult U.S. Department of Defense beneficiaries., Materials and Methods: From 2009 to 2014, we enrolled otherwise healthy adults age 18 to 65 years with influenza-like illness in an observational cohort study based in 5 U.S. military medical centers. Serial nasopharyngeal swabs were collected for determination of etiology and viral shedding by polymerase chain reaction. The presence and severity of symptoms was assessed by interview and patient diary., Results: Over a 5-year period, a total of 157 adults with laboratory-confirmed influenza and influenza subtype were enrolled. Of these, 69 (44%) were positive for influenza A(H1N1), 69 (44%) for influenza A(H3N2), and 19 (12%) for influenza B. About 61% were male, 64% were active duty military personnel, and 72% had received influenza vaccine in the past 8 months. Almost 10% were hospitalized with influenza. Seasonal influenza virus distribution among enrollees mirrored that of nationwide trends each year of study. Individuals with A/H1N1 had upper respiratory composite scores that were lower than those with A/H3N2. Multivariate models indicated that individuals with A(H1N1) and B had increased lower respiratory symptom scores when compared to influenza A(H3N2) (A[H1N1]: 1.51 [95% CI 0.47, 2.55]; B: 1.46 [95% CI 0.09, 2.83]), whereas no other differences in symptom severity scores among influenza A(H1N1), influenza A(H3N2), and influenza B infection were observed. Overall, influenza season (maximum in 2012-2013 season) and female sex of the participant were found to be associated with increased influenza symptom severity., Conclusions: Our study of influenza in a cohort of otherwise healthy, outpatient adult Department of Defense beneficiaries over 5 influenza seasons revealed few differences between influenza A(H1N1), influenza A(H3N2), and influenza B infection with respect to self-reported disease severity or clinical outcomes. This study highlights the importance of routine, active, and laboratory-based surveillance to monitor ongoing trends and severity of influenza in various populations to inform prevention measures., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In 2017, Mississippi had the third highest age-adjusted prevalence of hypertension in the United States. We estimated the prevalence of hypertension by sociodemographic characteristics and occupation and examined the association between hypertension with occupation and sociodemographic characteristics among Mississippi workers. We calculated adjusted prevalence and adjusted prevalence ratios (APRs) by sociodemographic characteristics and occupation among Mississippi adult workers. We analyzed combined 2013, 2015, and 2017 data from the Mississippi Behavioral Risk Factor Surveillance System for 6,965 workers in ten Standard Occupational Classification System major groups. Of the estimated 1.1 million Mississippi workers during the three survey years, 31.4% (95% confidence interval (CI), 30.0-32.8) had hypertension. The likelihood of having hypertension was significantly higher among workers aged 30-44 years, 45-64 years, blacks, and those classified as overweight and obese workers compared to their counterparts. The likelihood of having hypertension among workers in the fields of installation, repair and maintenance, and production were 26% higher (APR, 1.26; 95% CI, 1.03-1.55) and 33% higher (APR, 1.33; 95% CI, 1.11-1.58), respectively, than workers in all other occupational groups. Among Mississippi workers, hypertension prevalence varied by sociodemographic characteristics and occupational groups. Age, race, obesity status, installation, repair, maintenance, and production occupation groups are associated with an increased likelihood of hypertension. Novel and/or community-based or linked programs are needed that could target workers at risk of hypertension that are outside of a single-site workplace., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Vincent L. Mendy et al.)

The USNS Mercy (T-AH 19) on Pacific Partnership 2018 was the first mobile, expeditionary platform to utilize the da Vinci Surgical System. Using a de-identified, web-based survey, the impact of this new technology on Pacific Partnership 2018 on the attitudes of host nation surgeons was examined., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The mechanism by which cationic polymers containing titratable amines mediate effective endosomal escape and cytosolic delivery of nucleic acids is not well understood despite the decades of research devoted to these materials. Here, we utilize multiple assays investigating the endosomal escape step associated with plasmid delivery by polyethylenimine (PEI) and poly(β-amino esters) (PBAEs) to improve the understanding of how these cationic polymers enable gene delivery. To probe the role of these materials in facilitating endosomal escape, we utilized vesicle membrane leakage and extracellular pH modulation assays to demonstrate the influence of polymer buffering capacity and effective p K a on the delivery of the plasmid DNA. Our results demonstrate that transfection with PBAEs is highly sensitive to the effective p K a of the overall polymer, which has broad implications for transfection. In more acidic environments, PBAE-mediated transfection was inhibited, while PEI was relatively unaffected. In neutral to basic environments, PBAEs have high buffering capacities that led to dramatically improved transfection efficacy. The cellular uptake of polymeric nanoparticles overall was unchanged as a function of pH, indicating that microenvironmental acidity was important for downstream intracellular delivery efficiency. Overall, this study motivates the use of polymer chemical characteristics, such as effective p K a values, to more efficiently evaluate new polymeric materials for enhanced intracellular delivery characteristics.

The CRISPR-Cas9 system is a powerful gene-editing tool with wide-ranging applications, but the safe and efficient intracellular delivery of CRISPR components remains a challenge. In this study, we utilized biodegradable poly(beta-amino ester) nanoparticles to codeliver plasmid DNA encoding Cas9 and short guide RNA (sgRNA), respectively, to enable gene knockout following a CRISPR-mediated cleavage at one genomic site (1-cut edit), as well as gene deletion following DNA cleavage at two sites flanking a region of interest (2-cut edits). We designed a reporter system that allows for easy evaluation of both types of edits: gene knockout can be assessed by a decrease in near-infrared fluorescent protein (iRFP) fluorescence, whereas deletion of an expression stop cassette turns on a red-enhanced nanolantern fluorescence/luminescence dual reporter. Nanoparticles enabled up to 70% gene knockout due to small indels, as well as 45% gain-of-function expression after a 600-bp deletion edit. The efficiency of 2-cut edits is more sensitive than 1-cut edits to Cas9 and the sgRNA expression level. We demonstrate promising biodegradable nanoparticle formulations for gene editing. Our findings also provide new insights into the screening and transfection requirements for different types of gene edits, which are applicable for designing nonviral delivery systems for the CRISPR-Cas9 platform., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Femoroacetabular impingement is a patho-mechanical hip condition that can lead to restrictions in hip motion, particularly in end-range hip flexion, adduction and/or internal rotation. Radiographic evidence of femoroacetabular impingement - cam and/or pincer morphology - is prevalent in the general and athletic populations. There is, however, a lack of studies that have analyzed the performance of sport-specific movements in people possessing these morphologies. Therefore, the purpose of this study was to compare cross-body lunge biomechanics between individuals with and without painful cam and/or pincer morphology., Methods: This was an exploratory, cross-sectional study where nine participants with cam and/or pincer morphology and symptoms, thirteen participants with asymptomatic cam and/or pincer morphology, and eleven pain-free controls performed the cross-body lunge during a single session. Trunk, pelvis, hip, knee and ankle kinematics, as well as hip, knee and ankle kinetics and vertical ground reaction forces were examined., Findings: Overall, the groups performed the movement similarly, with most variables statistically similar between groups. However, pelvis sagittal plane excursion throughout the entire cross-body lunge was significantly larger in those with cam and/or pincer morphology and symptoms compared to those with asymptomatic cam and/or pincer morphology (P = .046, effect size = 0.98)., Interpretation: The results of this study show that cross-body lunge performance is similar across individuals with and without painful cam and/or pincer morphology. However, future research should aim to better understand pelvis biomechanics during sporting activities, as pelvis sagittal plane excursion may have important implications in rehabilitation and sport performance., Competing Interests: Declaration of Competing Interest DW reports an Arthritis Society of Canada [SOG-15-297] grant and a Canadian Institutes of Health Research [reference number 148828] grant during the conduct of this study. JC reports a Canadian Institutes of Health Research [PAF-107513] grant during the conduct of the IMPAKT-HIP study. MH reports a Natural Sciences and Engineering Research Council of Canada [418025-2013-RGPIN] grant during the conduct of this study., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Cancer immunotherapy has been the subject of extensive research, but highly effective and broadly applicable methods remain elusive. Moreover, a general approach to engender endogenous patient-specific cellular therapy, without the need for a priori knowledge of tumor antigen, ex vivo cellular manipulation, or cellular manufacture, could dramatically reduce costs and broaden accessibility. Here, we describe a biotechnology based on synthetic, biodegradable nanoparticles that can genetically reprogram cancer cells and their microenvironment in situ so that the cancer cells can act as tumor-associated antigen-presenting cells (tAPCs) by inducing coexpression of a costimulatory molecule (4-1BBL) and immunostimulatory cytokine (IL-12). In B16-F10 melanoma and MC38 colorectal carcinoma mouse models, reprogramming nanoparticles in combination with checkpoint blockade significantly reduced tumor growth over time and, in some cases, cleared the tumor, leading to long-term survivors that were then resistant to the formation of new tumors upon rechallenge at a distant site. In vitro and in vivo analyses confirmed that locally delivered tAPC-reprogramming nanoparticles led to a significant cell-mediated cytotoxic immune response with systemic effects. The systemic tumor-specific and cell-mediated immunotherapy response was achieved without requiring a priori knowledge of tumor-expressed antigens and reflects the translational potential of this nanomedicine., Competing Interests: Competing interest statement: J.J.G., R.A.M., S.Y.T., and D.R.W. disclose inventorship on patent filings related to this manuscript filed by Johns Hopkins University., (Copyright © 2020 the Author(s). Published by PNAS.)

Introduction: The purpose of this study was to identify the location of the peroneal tendons in relationship to the fibular groove in an asymptomatic population of elite U.S. Military Service members., Materials and Methods: The peroneal tendons of 41 active duty U.S. Army Rangers were examined. Subjects were placed in a lateral recumbent position with the ankle in a resting neutral position to visualize the tendon in a retromalleolar short-axis view. Maximum active ankle eversion followed by gravity inversion was facilitated while the ultrasound probe was maintained in its original position. Distance from the fibrous lateral ridge of the retromalleolar groove to the anterior aspect of the peroneal brevis was measured in the short axis in neutral, eversion, and inversion., Results: The mean sagittal distance and standard deviation was 0.48 ± 0.9 mm. No subjects demonstrated greater than 1 mm difference between positions, and no dislocations were identified. Side-to-side difference and dominant vs nondominant differences were not statistically significant., Conclusion: The study demonstrates that the distance between the peroneal brevis and the lateral fibular ridge is consistent throughout extremes of motion. These results further the understanding of peroneal tendon function under dynamic examination. Our findings also establish side-to-side consistency prompting a bilateral examination to help identify abnormal pathology., (© The Author 2020. Published by Oxford University Press Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Immunotherapies have attracted lots of research interests recently. The need to understand the underlying mechanisms of immunotherapies and to develop precision immunotherapy regimens has spurred great interest in characterizing immune cell composition within the tumor microenvironment. Several methods have been developed to estimate immune cell composition using gene expression data from bulk tumor samples. However, these methods are not flexible enough to handle aberrant patterns of gene expression data, e.g., inconsistent cell type-specific gene expression between purified reference samples and tumor samples. We propose a novel statistical method for expression deconvolution called ICeD-T (Immune Cell Deconvolution in Tumor tissues). ICeD-T automatically identifies aberrant genes whose expression are inconsistent with the deconvolution model and down-weights their contributions to cell type abundance estimates. We evaluated the performance of ICeD-T versus existing methods in simulation studies and several real data analyses. ICeD-T displayed comparable or superior performance to these competing methods. Applying these methods to assess the relationship between immunotherapy response and immune cell composition, ICeD-T is able to identify significant associations that are missed by its competitors.

Together, medulloblastoma (MB) and atypical teratoid/rhabdoid tumors (AT/RT) represent two of the most prevalent pediatric brain malignancies. Current treatment involves radiation, which has high risks of developmental sequelae for patients under the age of three. New safer and more effective treatment modalities are needed. Cancer gene therapy is a promising alternative, but there are challenges with using viruses in pediatric patients. We developed a library of poly(beta-amino ester) (PBAE) nanoparticles and evaluated their efficacy for plasmid delivery of a suicide gene therapy to pediatric brain cancer models-specifically herpes simplex virus type I thymidine kinase (HSVtk), which results in controlled apoptosis of transfected cells. In vivo, PBAE-HSVtk treated groups had a greater median overall survival in mice implanted with AT/RT (P = 0.0083 vs. control) and MB (P < 0.0001 vs. control). Our data provide proof of principle for using biodegradable PBAE nanoparticles as a safe and effective nanomedicine for treating pediatric CNS malignancies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The study of gene expression quantitative trait loci (eQTL) is an effective approach to illuminate the functional roles of genetic variants. Computational methods have been developed for eQTL mapping using gene expression data from microarray or RNA-seq technology. Application of these methods for eQTL mapping in tumor tissues is problematic because tumor tissues are composed of both tumor and infiltrating normal cells (e.g. immune cells) and eQTL effects may vary between tumor and infiltrating normal cells. To address this challenge, we have developed a new method for eQTL mapping using RNA-seq data from tumor samples. Our method separately estimates the eQTL effects in tumor and infiltrating normal cells using both total expression and allele-specific expression (ASE). We demonstrate that our method controls type I error rate and has higher power than some alternative approaches. We applied our method to study RNA-seq data from The Cancer Genome Atlas and illustrated the similarities and differences of eQTL effects in tumor and normal cells.

Efficient cytosolic protein delivery is necessary to fully realize the potential of protein therapeutics. Current methods of protein delivery often suffer from low serum tolerance and limited in vivo efficacy. Here, we report the synthesis and validation of a previously unreported class of carboxylated branched poly(β-amino ester)s that can self-assemble into nanoparticles for efficient intracellular delivery of a variety of different proteins. In vitro, nanoparticles enabled rapid cellular uptake, efficient endosomal escape, and functional cytosolic protein release into cells in media containing 10% serum. Moreover, nanoparticles encapsulating CRISPR-Cas9 ribonucleoproteins (RNPs) induced robust levels of gene knock-in (4%) and gene knockout (>75%) in several cell types. A single intracranial administration of nanoparticles delivering a low RNP dose (3.5 pmol) induced robust gene editing in mice bearing engineered orthotopic murine glioma tumors. This self-assembled polymeric nanocarrier system enables a versatile protein delivery and gene editing platform for biological research and therapeutic applications., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution License 4.0 (CC BY).)

Marine invertebrates that move too slowly to evade unfavorable environmental change may instead exhibit phenotypic plasticity, allowing them to adjust to varying conditions. The orange-footed sea cucumber Cucumaria frondosa is a slow-moving suspension feeder that is preyed on by the purple sunstar Solaster endeca . The sea cucumber's antipredator behavior involves changing shape and detaching from the substratum, which might increase its probability of being displaced by water motion into an unsuitable environment. We hypothesized that sea cucumbers' antipredator responses would be diminished under stronger hydrodynamic forces, and that behavioral strategies would be flexible so that individuals could adjust to frequent changes in water flows. In a natural orange-footed sea cucumber habitat, individuals lived along a pronounced hydrodynamic gradient, allowing us to measure antipredator behavior under different water flow strengths. We placed purple sunstars in physical contact with sea cucumbers living at various points along the gradient to elicit antipredator responses. We then repeated this procedure in a laboratory mesocosm that generated weak and strong hydrodynamic forces similar to those observed at the field site. Subjects in the mesocosm experiment were tested in both wave conditions to determine if their antipredator behavior would change in response to sudden environmental change, as would be experienced under deteriorating sea conditions. Antipredator responses did not covary with hydrodynamic forces in the field. However, antipredator responses in the mesocosm experiment increased when individuals were transplanted from strong to weak forces and decreased when transplanted from weak to strong forces. Overall, our results indicate environmentally induced plasticity in the antipredator behavior of the orange-footed sea cucumber., (© The Author(s) (2019). Published by Oxford University Press on behalf of Editorial Office, Current Zoology.)

Introduction: Global health engagement missions are conducted to improve and protect the health of populations worldwide. Recognizing the strong link between health and security, the Armed Forces have increased the number of global health engagement missions over the last decade to support force health protection, medical readiness, enhance interoperability, improve host nation capacity building, combat global health threats (i.e., emerging infectious diseases), support humanitarian assistance and disaster relief efforts, as well as build trust and deepen professional medical relationships worldwide. These missions additionally support the US Global Health Security Agenda, US National Security Strategy, US National Defense Strategy and National Military Strategy.Although global health engagement missions are conducted by armed forces with numerous military units and geographical locations, military healthcare personnel assigned to US Naval hospital ships also perform a wide range of these missions. These missions comprise some of the largest global health engagement missions conducted, encompassing hundreds of subject matter expert exchanges, community health exchanges, medical symposiums, and side-by-side partnered healthcare in countries around the world. Military healthcare personnel who have completed past missions possess valuable knowledge related to ship-based global health engagement missions. Capturing and transferring this knowledge to future deployed personnel is important for future successful missions, but has remained a significant challenge. The purpose of this study was to capture and examine first-person accounts of experiential learning among active duty physicians, nurses, and hospital corpsmen who had participated in recent hospital ship-based global heath engagement missions., Materials and Methods: We used the interpretive, ethnographic method of interviewing and data analysis described by Benner. Interviews elicited detailed, narrative examples of experiences from military health care personnel who had participated in previous global health engagement missions aboard hospital ships (N = 141). Our approach to gaining meaning from these narratives was guided by three central strategies: (1) identify paradigm cases, (2) identify themes within and across participant narratives of meaningful patterns, and (3) identify exemplars to represent common patterns of meaning and common situations. Additionally, we collected demographic information., Results: Our findings provide firsthand descriptions of five essential elements to prepare military healthcare personnel for shipboard global health engagement missions. These essential elements are mission clarity, preparedness, experiential knowledge, lessons learned, and flexibility/adaptability., Conclusions: Widespread dissemination of the lessons learned from military global health engagement missions is crucial to shaping forces that operate effectively in a rapidly changing global environment. Sharing lessons learned increases efficiency, adaptability, and agility, while decreasing variance in processes and the need to relearn mission-specific lessons., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Introduction: Physiological events (PEs) are a growing problem for US military aviation with detrimental risks to safety and mission readiness. Seeking causative factors is, therefore, of high importance. There is no evidence to date associating carbon dioxide (CO2) pre-flight exposure and decompression sickness (DCS) in aviators., Materials and Methods: This study is a case series of six aviators with PE after being exposed to a rapid decompression event (RDE) with symptoms consistent with type II DCS. The analysis includes retrospective review of flight and environmental data to further assess a possible link between CO2 levels and altitude physiologic events (PEs). IRB approval was obtained for this study., Results: This case series presents six aviators with PE after being exposed to a rapid decompression event (RDE) with symptoms consistent with type II DCS. Another three aviators were also exposed to a RDE, but remained asymptomatic. All events involved tactical jet aircraft flying at an average of 35,600' Mean Sea Level (MSL) when a RDE occurred, Retrospective reviews led to the discovery that the affected individuals were exposed, pre-flight, to poor indoor air quality demonstrated by elevated levels of measured CO2., Conclusion: PEs are a growing safety concern for the aviation community in the military. As such, increasing measures are taken to ensure safety of flight and completion of the mission. To date, there is no correlation of CO2 exposure and altitude DCS. While elevated CO2 levels cannot be conclusively implicated as causative, this case series suggests a potential role of CO2 in altitude DCS through CO2 direct involvement with emboli gas composition, as well as pro-inflammatory cascade. Aviators exposed to elevated CO2 in poorly ventilated rooms developed PE symptoms consistent with DCS, while at the same command, aviators that were exposed to a well ventilated room did not. This report is far from an answer, but does demonstrate an interesting case series that draws some questions about CO2's role in these aviator's DCS experience. Other explanations are plausible, including the accurate diagnosis of DCS, health variables amongst the aviators, and differences in aircraft and On-Board Oxygen Generation Systems (OBOGS). For a better understanding, the role of environmental CO2 and pre-flight exposure as a risk of DCS should be reviewed., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Understanding hip osteoarthritis requires new investigational tools for quantitative studies of biophysical and biomechanical properties as well as for determination of structure. Three new protocols to study pathological changes in cartilage and to measure cartilage thickness in intact human hips are described using synchrotron contrast enhanced computed tomography (sCECT) with the iodinated contrast agent CA4+. Ten human cadaver hips were prepared and injected with CA4+ using three different methods, all of which included rotation and distraction of the joint. CA4+ diffusion into cartilage was monitored using sCECT. The thickness of acetabular and femoral cartilage was also measured. Diffusion times ranged from 2 h to 75 h, depending on the injection protocol and the cartilage region. Direct single injection of the contrast through the labrum resulted in the fastest diffusion times. The iodine attenuation coefficient, which reflects the contrast agent distribution in the cartilage, ranged from 0.0142/cm to 0.1457/cm. Three injections at the head/neck conjunction area yielded the highest iodine attenuation coefficients in cartilage. The femoral cartilage in the Superior-Medial compartment was significantly thicker than in the other 3 femoral compartments, and femoral cartilage in the Superior-Anterior compartment was significantly thinner than the other 3 femoral compartments. The acetabular cartilage in the Superior compartment was significantly thicker than that in the Superior-Posterior compartment. sCECT with CA4+ allows assessment of hip cartilage thickness with 0.1 mm isotropic voxel size, sufficient for evaluating cartilage pathology and biomechanics., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

OBJECTIVE. The purpose of this study was to evaluate the effects of clinical 3-T MRI during pregnancy on fetal growth and neonatal hearing in neonates at low risk of congenital hearing impairment or of brain or chromosomal abnormalities. MATERIALS AND METHODS. This single-center retrospective case-control study included consecutively born healthy neonates exposed in utero to 3-T MR during MRI for maternal or fetal indications and born between January 2008 and March 2015. Each exposed neonate was randomly matched 1:2 by birth date to healthy control neonates who had not been exposed to MR. Infant birth weights were compared by unpaired t test. Hearing impairment between groups was compared by Fisher exact test. RESULTS. There was no significant difference in mean birth weight between the MR-exposed (3398 g) and control (3510 g) neonates ( p = 0.06). There was no significant difference in prevalence of hearing impairment ( p = 0.55) between the MR-exposed (0% [0/81]) and control (1.8% [3/162]) groups. CONCLUSION. This study showed no adverse effects with regard to neonatal hearing or fetal growth in healthy neonates who were variably exposed to 3-T MR in utero during MRI for various clinical maternal or fetal indications at any gestational age.

Introduction: The Indo-Asia-Pacific region has the highest incidence of natural disasters world-wide. Since 2000, approximately 1.6 billion people in this region have been affected by earthquakes, volcanos, tsunamis, typhoons, cyclones, and large-scale floods. The aftermath of disasters can quickly overwhelm available resources, resulting in loss of basic infrastructure, shelter, health care, food and water, and ultimately, loss of life.Over the last 12 years, US military forces have collaborated with countries throughout the Indo-Asia-Pacific region to enhance disaster preparedness and management during shipboard global health engagement missions. Military health care personnel are integral in this effort and have planned subject-matter expert exchanges, multidisciplinary conferences, courses, and hyper realistic simulated military-to-military training exercises related to disaster preparedness.Military health care providers are essential not only to providing international education and training, but also to ensuring optimal readiness to respond to future disasters in the Indo-Asia-Pacific region and worldwide. The ability to effectively respond to disasters and collaborate with other nations promotes international stability. Yet, few studies have examined disaster preparedness among US military health care personnel. This study aimed to assess knowledge, skills, and preparedness for disaster management among US military health care personnel preparing to deploy on a global health engagement mission., Materials and Methods: A descriptive, cross-sectional study utilizing the Disaster Preparedness Evaluation Tool (DPET) examined self-reported perceptions of disaster preparedness among US military health care personnel preparing to deploy on a shipboard global health engagement mission. The DPET assessed perceived knowledge of disaster preparedness, disaster mitigation and response, and disaster recovery. Three hundred Hospital Corpsmen/Medics and officers in the Nurse Corps, Medical Corps, Medical Service Corps, and Dental Corps were invited to participate. One hundred fifty-four surveys were completed (response rate, 51%). Nineteen surveys were excluded from the analysis due to incomplete responses. Participants rated responses to 46 Likert items (scale of 1-6) and responded to 23 descriptive items. The study protocol was approved by the Naval Medical Center San Diego Institutional Review Board, protocol number NMCSD.2017.0061, in compliance with all applicable federal regulations governing the protection of human subject research., Results: All item mean scores on each of the three DPET subscales resulted in moderate levels of perceived disaster preparedness among military healthcare personnel (disaster preparedness means ranged from 3.04 to 4.67, disaster response means ranged from 3.76 to 4.29, and disaster recovery means ranged from 3.47 to 4.29). The final regression model had 6 significant variables that predicted DPET scores: previous disaster drills (p = 0.00), experiencing a real disaster (p = 0.002), bioterrorism training (p = 0.02), education level (p = 0.025), years in specialty (p = 0.019), and previous global health engagement missions (p = 0.016), with R2 = 0.39, R2adj = 0.36, F (7, 127) = 12.04., Conclusions: Disaster preparedness among military healthcare personnel could be improved to function optimally for future global health engagement missions. This study expands current understandings of disaster preparedness among US military health care providers and identifies ways to improve and enhance training., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Running is an easy way of meeting physical activity recommendations for individuals with knee osteoarthritis (KOA); however, it remains unknown how their cartilage reacts to running. The objective of this pilot study was to compare the effects of 30 min of running on T2 and T1ρ relaxation times of tibiofemoral cartilage in female runners with and without KOA., Methods: Ten female runners with symptomatic KOA (mean age 52.6 ± 7.6 years) and 10 without KOA (mean age 52.5 ± 7.8 years) ran for 30 min on a treadmill. Tibiofemoral cartilage T2 and T1ρ relaxation times were measured using magnetic resonance imaging prior to and immediately after the bout of running. Repeated-measures analyses of covariance (ANCOVA) were conducted to examine between-group differences across scanning times., Results: No Group × Time interactions were found for T2 (P ≥ 0.076) or T1ρ (P ≥ 0.288) relaxation times. However, runners with KOA showed increased T2 values compared with pre-running in the medial and lateral femur 55 min post-running (5.4 to 5.5%, P < 0.022) and in all four tibiofemoral compartments 90 min post-running (6.9 to 11.1%, P < 0.01). A significant group effect was found for T1ρ in the medial femur, with greater values in those with KOA compared with controls., Conclusion: While Group × Time interactions in T2 and T1ρ relaxation times remained statistically insignificant, the observed significant increases in T2 in runners with tibiofemoral osteoarthritis TFOA may suggest slower and continuing changes in the cartilage and thus a need for longer recovery after running. Future research should investigate the effects of repeated exposure to running., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: In response to a physician shortage in Ethiopia, the number of medical students admitted to public universities was rapidly increased through a "flooding" policy., Objectives: To assess medical student perceptions on the impact of the "flooding" policy on medical education and e-learning initiatives, as well as plans for future emigration., Design: A cross-sectional survey of medical students at AAU was implemented in 2014. Attitude and practice items were assessed using a Likert scale. Logistic regression analysis was performed to identify characteristics associated with an interest in future emigration., Results: 673 (99.6%) of 676 students approached completed the survey, representing 39.5% of all 1705 medical students enrolled at AAU in 2014. Most students felt the "flooding" policy had a negative impact on their medical education and >90% felt there was not adequate infrastructure to support the increased student body. E-learning activities to accommodate increased class size included distribution of electronic tablets, but at the time of the survey only 34.8% of students still had a working tablet and 82.3% reported problems with internet connectivity. Most preclinical students (85.1%) who had attended live-streamed lectures preferred traditional classroom lectures. Half of the students (49.5%) intended to practice medicine in Ethiopia. Independent risk factors for planning to emigrate included age <21 years (aOR = 1.30, 95% CI 1.04, 1.97); having applied to medical school for reasons other than "wanting to be a physician" (aOR = 1.55, 95% CI 1.14, 2.20), and not believing that "flooding" policy would increase the number of physicians working in Ethiopia (aOR = 1.87, 95% CI 1.33, 2.58)., Conclusions: The "flooding" policy lead to significant educational challenges that were not fully alleviated by e-learning initiatives. Concomitant increases in resources for infrastructure development and faculty expansion are needed to maintain quality medical education. Additional research is needed on factors that influence medical graduates decision to emigrate., Competing Interests: The authors have declared that no competing interests exist.

Safe and effective delivery of DNA to post-mitotic cells, especially highly differentiated cells, remains a challenge despite significant progress in the development of gene delivery tools. Biodegradable polymeric nanoparticles (NPs) offer an array of advantages for gene delivery over viral vectors due to improved safety, carrying capacity, ease of manufacture, and cell-type specificity. Here we demonstrate the use of a high-throughput screening (HTS) platform to synthesize and screen a library of 148 biodegradable polymeric nanoparticles, successfully identifying structures that enable efficient transfection of human pluripotent stem cell differentiated human retinal pigment epithelial (RPE) cells with minimal toxicity. These NPs can deliver plasmid DNA (pDNA) to RPE monolayers more efficiently than leading commercially available transfection reagents. Novel synthetic polymers are described that enable high efficacy non-viral gene delivery to hard-to-transfect polarized human RPE monolayers, enabling gene loss- and gain-of-function studies of cell signaling, developmental, and disease-related pathways. One new synthetic polymer in particular, 3,3'-iminobis(N,N-dimethylpropylamine)-end terminated poly(1,5-pentanediol diacrylate-co-3 amino-1-propanol) (5-3-J12), was found to form self-assembled nanoparticles when mixed with plasmid DNA that transfect a majority of these human post-mitotic cells with minimal cytotoxicity. The platform described here can be utilized as an enabling technology for gene transfer to human primary and stem cell-derived cells, which are often fragile and resistant to conventional gene transfer approaches., Competing Interests: CONFLICT OF INTEREST STATEMENT DJZ is on the scientific advisory board of Spark Therapeutics, which is interested in developing optimized approaches for retinal gene delivery.

Purpose: Direct-to-consumer (DTC) genetic ancestry companies have rapidly increased in popularity, with top testing services maintaining genetic databases of several million consumers. While genetic ancestry tests are often characterized as recreational, companies invoke deeply personal concepts of individual identity, group membership, and kinship when marketing their services. In particular, many companies claim to be able to determine Native American heritage, claims that are not supported by the state of the science and may have significant cultural and political consequences for US tribal communities. This study aims to fill the gaps in empirical work on this issue and characterize how genetic ancestry companies articulate indigenous identity through their marketing strategies., Methods: We conducted a qualitative content analysis of the public facing websites for 25 DTC genetic ancestry companies that offer services measuring Native American ancestry., Results: Our findings describe how genetic ancestry companies promote a causal relationship between genetics and self-identity through marketing language such as "Discover Yourself" and "Are you Native American?" and how this may affect US tribal communities., Conclusion: Genetic ancestry company claims regarding genetic ancestry, personal identity, and cultural membership are problematic and challenge how US tribal nations currently identify and create potential obstacles for tribal sovereignty.

Widowed parents play a critical role in promoting family adaptation and facilitating their children's adjustment to the loss of a parent; yet the psychological wellbeing of these parents has received scant attention. In this study we examined depressive symptoms and grief intensity in 252 spousally bereaved men with dependent-age children. Participants learned of the study and completed initial surveys at variable time points during their first 2 years of bereavement. Depressive and grief symptoms remained persistently high, with 45% of the sample exceeding screening thresholds for clinically significant depressive symptoms two years after the death of their spouses. In linear regression models, higher intensity or frequency of depression and grief symptoms were associated with poorer psychological adaptation, lower parenting self-efficacy, and lower parenting satisfaction scores. Relationships between fathers' distress and potentially modifiable end-of-life variables regarding their spouses were examined. Notably, those who reported that their wives were at peace with dying had lower depressive and grief scores at various intervals. Overall, the magnitude and duration of the depressive and grief symptoms suggests that widowed fathers' psychological distress does not quickly abate over the first 2 years of bereavement, which may be attributable to the unique set of bereavement challenges facing widowed parents such as facilitating their children's grief, assuming sole parenting responsibilities, and managing a household on their own. The findings underscore the need to further examine emotional distress in widowed parents and how their wellbeing impacts family functioning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Lower extremity joint arthroplasty surgery remains one of the most successful interventions in orthopaedics. While improvements in patient mobility and physical functioning following surgery are well-documented, there remains significant post-operative functional deficits in many patients. This highlights a need and an opportunity towards improving functional and patient-reported outcomes of arthroplasty surgery. This review summarizes key opportunities arising from the recent 2018 Orthopaedic Research Society Meeting in New Orleans, USA. In this review, the Canadian Orthopaedic Research Society (i.e., CORS) highlights key research advances, case examples, scientific messages, and personalized medical care approaches toward improving physical functioning in our knee and hip joint arthroplasty patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1754-1759, 2019., (© 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Introduction: Oral statins reduce intimal hyperplasia (IH) after arterial injury by only ∼25%. Alternative drug delivery systems have gained attention as carriers for hydrophobic drugs. We studied the effects of simvastatin (free vs hyaluronic acid-tagged polysialic acid-polycaprolactone micelles) on vascular smooth muscle cell (VSMC) migration, VSMC proliferation and intimal hyperplasia. We hypothesized both free and micelle containing simvastatin would inhibit VSMC chemotaxis and proliferation, and local statin treatment would be more effective than oral in reducing IH in rats following carotid balloon injury., Methods: VSMCs pretreated with free simvastatin (20 minutes or 20 hours) or simvastatin-loaded micelles underwent chemotaxis and proliferation to platelet-derived growth factor. Next, rats that underwent balloon injury of the common carotid artery received statin therapy-intraluminal simvastatin-loaded micelles prior to injury, periadventitial pluronic gel following injury, or combinations of gel, micelle, and oral simvastatin. After 14 days, morphometric analysis determined the -intimal to medial ratio. Findings were compared to controls receiving oral simvastatin or no statin therapy. Statistical analysis was by analysis of variance for the in vitro experiments and a factorial general linear model for the in vivo experiments., Results: The simvastatin-loaded micelles and free simvastatin inhibited VSMC chemotaxis (54%-60%). IH was induced in all injured vessels. Simvastatin in pluronic gel or micelles reduced IH compared to untreated controls (0.208 ± 0.04 or 0.160 ± 0.03 vs 0.350 ± 0.03, respectively); however, neither gel nor simvastatin-loaded micelles were superior to oral statins (0.261 ± 0.03). Addition of oral statins or combining both local therapies did not provide additional benefit. Micelles were the single greatest contributing factor in IH attenuation., Conclusions: Intraluminally or topically delivered statins reduced IH. The efficacy of single-dose, locally delivered statin alone may lead to novel treatments to prevent IH. The different routes of administration may allow for treatment during endovascular procedures, without the need for systemic therapy.

Intracellular delivery of nucleic acids to mammalian cells using polyplex nanoparticles (NPs) remains a challenge both in vitro and in vivo, with transfections often suffering from variable efficacy. To improve reproducibility and efficacy of transfections in vitro using a next-generation polyplex transfection material poly(beta-amino ester)s (PBAEs), the influence of multiple variables in the preparation of these NPs on their transfection efficacy was explored. The results indicate that even though PBAE/pDNA polyplex NPs are formed by the self-assembly of polyelectrolytes, their transfection is not affected by the manner in which the components are mixed, facilitating self-assembly in a single step, but timing for self-assembly of 5-20 min is optimal. In addition, even though the biomaterials are biodegradable in water, their efficacy is not affected by up to eight freeze-thaw cycles of the polymer. It was found that there is a greater stability of nucleic acid-complexed polymer as a polyplex nanoparticle compared with free polymer. Finally, by exploring multiple buffer systems, it was identified that utilization of divalent cation magnesium or calcium acetate buffers at pH 5.0 is optimal for transfection using these polymeric materials, boosting transfection several folds compared with monovalent cations. Together, these results can improve the reproducibility and efficacy of PBAE and similar polyplex nanoparticle transfections and improve the robustness of using these biomaterials for bioengineering and biotechnology applications., (© 2019 Wiley Periodicals, Inc.)

Senescent cells (SnCs) are increasingly recognized as central effector cells in age-related pathologies. Extracellular vesicles (EVs) are potential cellular communication tools through which SnCs exert central effector functions in the local tissue environment. To test this hypothesis in a medical indication that could be validated clinically, we evaluated EV production from SnCs enriched from chondrocytes isolated from human arthritic cartilage. EV production increased in a dose-responsive manner as the concentration of SnCs increased. The EVs were capable of transferring senescence to nonsenescent chondrocytes and inhibited cartilage formation by non-SnCs. microRNA (miR) profiles of EVs isolated from human arthritic synovial fluid did not fully overlap with the senescent chondrocyte EV profiles. The effect of SnC clearance was tested in a murine model of posttraumatic osteoarthritis. miR and protein profiles changed after senolytic treatment but varied depending on age. In young animals, senolytic treatment altered expression of miR-34a, -30c, -125a, -24, -92a, -150, and -186, and this expression correlated with cartilage production. The primary changes in EV contents in aged mice after senolytic treatment, which only reduced pain and degeneration, were immune related. In sum, EV contents found in synovial fluid may serve as a diagnostic for arthritic disease and indicator for therapeutic efficacy of senolytic treatment.

Functional codelivery of plasmid DNA and RNA oligonucleotides in the same nanoparticle system is challenging due to differences in their physical properties as well as their intracellular locations of function. In this study, we synthesized a series of reducible branched ester-amine quadpolymers (rBEAQs) and investigated their ability to coencapsulate and deliver DNA plasmids and RNA oligos. The rBEAQs are designed to leverage polymer branching, reducibility, and hydrophobicity to successfully cocomplex DNA and RNA in nanoparticles at low polymer to nucleic acid w/w ratios and enable high delivery efficiency. We validate the synthesis of this new class of biodegradable polymers, characterize the self-assembled nanoparticles that these polymers form with diverse nucleic acids, and demonstrate that the nanoparticles enable safe, effective, and efficient DNA-siRNA codelivery as well as nonviral CRISPR-mediated gene editing utilizing Cas9 DNA and sgRNA codelivery.

Patellofemoral (PF) osteoarthritis (OA) is a prevalent and clinically important knee OA subgroup. Malalignment may be an important risk factor for PF OA. However, little is known about alignment in PF OA, particularly in an upright, weightbearing environment. Using a vertically-oriented open-bore MR scanner, we evaluated 3D knee alignment in 15 PF OA cases and 15 individually matched asymptomatic controls. We imaged one knee per participant while they stood two-legged at four flexion angles (0°, 15°, 30°, 45°), and also while they stood one-legged at 30° knee flexion. We calculated 3D patellofemoral and tibiofemoral alignment. Using mixed effects models, four of the five patellofemoral measures differed by group. For key measures, PF OA patellae were 6.6° [95%CI 5.0, 8.2] more laterally tilted, 2.4 mm [1.3, 3.5] more laterally translated, and at least 3.7 mm [0.2, 7.2] more proximally translated compared to controls (more with knees flexed). Alignment did not differ between two-legged stance and one-legged stance in either group. Statement of Clinical Significance: Our study demonstrated significant and clinically relevant differences in alignment between PF OA cases and controls in upright standing and squatting positions. Our findings were similar to those in previous studies of PF OA using traditional MR scanners in supine positions, supporting the clinical usefulness of existing methods aimed at identifying individuals who may benefit from interventions designed to correct malalignment. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. 9999:1-9, 2019., (© 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society.)

Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: En Route Care (ERC) is often an ad hoc mission for the USN. In a review of 428 Navy patient transports, a Flight Surgeon (FS) was the sole provider or a member of crew in 118 of the transports. Naval FSs receive approximately 4 hours of didactic ERC training during their 24-week Naval FS course. Regardless, an FS may be caring for a critically ill patient in a helicopter. We conducted a survey to evaluate FS confidence in their ability to perform ERC and to establish their understanding of the training of Search and Rescue Medical Technicians (SMT)., Materials and Methods: A convenience sample of FSs completed a needs analysis survey as part of a process improvement project. Flight Surgeons surveyed were actively assigned or had been assigned within the past year to a squadron with Search and Rescue/MEDEVAC capabilities., Results: A total of 25 surveys were completed. An average of 13 (range 0-100) patient transport missions were performed by the respondents. Twenty-five percent reported feeling confident in their ability to provide ERC without senior level direction, while 41% stated they would require direction. Nearly 70% of the FSs surveyed expressed "minimal" or less understanding of the training of the SMT., Conclusions: Our survey results reveal most FSs are confident in neither their ability to perform ERC nor the ability of their hospital corpsman to provide care during patient movement., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Genome-editing technologies such as zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENS), and the clustered regularly interspaced short palindromic repeat (CRISPR)-associated protein system have revolutionized biological research. Each biotechnology consists of a DNA-binding protein that can be programmed to recognize and initiate double-strand breaks (DSBs) for site-specific gene modification. These technologies have the potential to be harnessed to cure diseases caused by aberrant gene expression. To be successful therapeutically, their functionality depends on their safe and efficient delivery into the cell nucleus. This review discusses the challenges in the delivery of genome-editing tools, and highlights recent innovations in non-viral delivery that have potential to overcome these limitations and advance the translation of genome editing towards patient care., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background Context: Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life., Purpose: The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research., Study Design/setting: Systematic review of the literature., Methods: A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs., Results: Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES., Conclusions: Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: On average, more than 1,700 people in Mississippi die from stroke annually, but data on trends by age, sex, and race in Mississippi are limited. We examined trends in the stroke death rate among adults in Mississippi aged 35 or older by age, sex, and race., Methods: We used Mississippi Vital Statistics data to calculate age-specific death rates for stroke among people in Mississippi aged 35 or older from 2000 to 2016. We identified cases according to underlying cause-of-death codes from the International Classification of Diseases, Tenth Revision (ICD-10). We used Joinpoint software to calculate annual percentage change (APC) and the average annual percentage change (AAPC) in death rates for stroke by age, sex, and race (non-Hispanic black and non-Hispanic white)., Results: Among adults aged 35 or older, the age-adjusted stroke death rate declined 30.7% from 141.3 per 100,000 population in 2000 to 97.9 per 100,000 population in 2016, with an AAPC of -2.4% (95% confidence interval, -3.1% to -1.6%). Stroke death rates declined significantly among both men and women in the first trend segment (2000-2009 for men and 2000-2007 for women) but did not decline in the second trend segment (2009-2016 for men and 2007-2016 for women). Non-Hispanic black men had the smallest decline in stroke death rates during the full study period. Among people aged 55 to 64 and non-Hispanic white men, rates shifted from a significant annual decline during the first segment to a significant annual increase during the second segment., Conclusion: Age-adjusted stroke death rates among adults in Mississippi aged 35 or older declined significantly between 2000 and 2016, but trends differed by age, race, and sex. Clinical and community interventions aimed at reducing stroke risk factors, particularly for adults aged 55 to 64, are needed in Mississippi.