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Background: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis, but it carries a known risk for wound complications. Several products have been investigated to mitigate this risk; however, most are either costly or invasive. Noninvasive skin expansion strips (NSESs) were designed to transfer tension away from the incision and induce new skin growth at the edges of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. Methods: This is a prospective cohort study of 41 patients at a single institution (3 surgeons) treated with NSESs after undergoing TAR-AA. An additional 41 consecutive historical patients treated without NSESs were retrospectively included as a control group. Patients received application of NSESs in the operating room after routine wound closure and again 2 weeks postoperatively. No other changes were made to the surgeons’ wound closure technique, immobilization, follow-up timing, or rehabilitation protocols. Primary outcomes included (1) additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication, and (3) deep infection. Results: Baseline demographics did not differ significantly from our 41 consecutively treated historical controls. Additional clinic visits for suture removal or wound evaluation were significantly lower for patients treated with NSESs (15%, 6 of 41) compared to the control group (49%, 20 of 41) ( P = .001). There was also a significant difference in the superficial wound complication rate in the treatment group vs control group, 2% and 12%, respectively ( P = .04). There were no deep infections in either group. Conclusion: Noninvasive skin expansion strips placed after TAR-AA with an anterior approach have the potential to decrease wound complications and unplanned clinic visits. Further high-volume or randomized studies are needed to clarify their cost effectiveness and effect on long-term outcomes. Level of Evidence: Level II, prospective cohort study.

Heterogeneous uptake of hydroperoxyl radicals (HO2) onto aerosols has been proposed to be a significant sink of HOx, hence impacting the atmospheric oxidation capacity. Accurate calculation of the HO2 uptake coefficient γHO2 is key to quantifying the potential impact of this atmospheric process. Laboratory studies show that γHO2 can vary by orders of magnitude due to changes in aerosol properties, especially aerosol soluble copper (Cu) concentration and aerosol liquid water content (ALWC). In this study we present a state-of-the-art model called MARK to simulate both gas- and aerosol-phase chemistry for the uptake of HO2 onto Cu-doped aerosols. Moreover, a novel parameterization of HO2 uptake was developed that considers changes in relative humidity (RH) and condensed-phase Cu ion concentrations and which is based on a model optimization using previously published and new laboratory data included in this work. This new parameterization will be applicable to wet aerosols, and it will complement current IUPAC recommendations. The new parameterization is as follows (the explanations for symbols are in the Appendix): 1γHO2=1αHO2+3×υHO24×106×RdHcorrRT×(5.87+3.2×ln⁡(ALWC/[PM]+0.067))×[PM]-0.2×Cu2+eff0.65+υHO2l4RTHorgDorgε. All parameters used in the paper are summarized in Table A1. Using this new equation, field data from a field campaign were used to evaluate the impact of the HO2 uptake onto aerosols on the ROx (= OH + HO2 + RO2) budget. Highly variable values for HO2 uptake were obtained for the North China Plain (median value

Background: Two common operative fixation techniques for insertional Achilles tendinopathy are the use of all-soft suture anchors vs synthetic anchors with a suture bridge. Despite increasing emphasis on early postoperative mobilization, the biomechanical profile of these repairs is not currently known. We hypothesized that the biomechanical profiles of single-row all-soft suture anchor repairs would differ when compared to double-row suture bridge repairs. Methods: Achilles tendons were detached from their calcaneal insertions on 6 matched-pair, fresh-frozen cadaver through-knee amputation specimens. Group 1 underwent a single-row repair with all-soft suture anchors. Group 2 was repaired with a double-row bridging suture bridge construct. Achilles-calcaneal displacement was tracked while specimens were cyclically loaded from 10 to 100 N for 2000 cycles and then loaded to failure. Linear mixed models were used to analyze the independent effects of age, body mass index, tendon morphology, repair construct, and footprint size on clinical and ultimate failure loads, Achilles-calcaneal displacement, and mode of failure. Results: The suture bridge group was independently associated with an approximately 50-N increase in the load to clinical failure (defined as more than 5 mm tendon displacement). There was no difference in ultimate load to failure or tendon/anchor displacement between the 2 groups. Conclusion: This cadaveric study found that a double-row synthetic bridge construct had less displacement during cyclic loading but was not able to carry more load before clinical failure when compared to a single-row suture anchor construct for the operative repair of insertional Achilles tendinopathy. Clinical Relevance: Our data suggest that double-row suture bridge constructs increase the load to clinical failure for operative repairs of insertional Achilles tendinopathy. It must be noted that these loads are well below what occurs during gait and the repair must be protected postoperatively without early mobilization. This study also identified several clinical factors that may help predict repair strength and inform further research.

Background: Ankle fractures are one of the most common orthopedic injuries, and although most patients have a satisfactory outcome following operative fixation, there are patients that have persistent pain despite anatomic reduction. Intra-articular injuries have been suggested as one potential cause of these suboptimal outcomes. Our study assesses the clinical impact of performing an ankle arthroscopy during ankle fracture open reduction and internal fixation (ORIF). Methods: This was a retrospective chart review of all patients who underwent operative fixation of a bimalleolar or trimalleolar ankle fracture at our institution from 2014 through 2018. We extracted all demographic data, fracture pattern, operative procedures performed, tourniquet times, arthroscopic findings and any arthroscopic interventions. We then conducted a phone and e-mail survey. Our study included 213 total patients (142 traditional ORIF, 71 ORIF plus arthroscopy) with an average age of 40 years. The average follow-up was 32.4 months with a survey follow-up rate of 50.7% (110/213). Results: The average tourniquet time for the arthroscopy cohort was 10 minutes longer (89 minutes vs 79 minutes). During the arthroscopy, there was a 28% (20/71) rate of full-thickness osteochondral lesions, 33% (24/71) rate of loose bodies, and a 49% (35/71) rate of partial-thickness cartilage injury. The mean Patient Reported Outcome Information System (PROMIS) physical function score among Weber B fibula fractures was 45.8 and 42.3 in the arthroscopy and nonarthroscopy groups, respectively ( P = .012). In addition, the patient satisfaction rate in Weber B fibula fractures was higher in those patients who underwent arthroscopy compared with ORIF alone (93% vs 75%, P = .05). Patients who had a tibiotalar joint dislocation at the time of the ankle fracture had a significantly higher PROMIS physical function score (46.6 vs 40.2, P = .005) when their surgery included arthroscopy. Conclusion: Ankle arthroscopy at the time of ORIF led to statistically significant improvements in patient-reported outcomes for Weber B fibula fractures and ankle dislocations. There was no increase in complication rates and the arthroscopy took 10 minutes longer on average. Level of Evidence: Level III, retrospective cohort study.

Marine aerosols strongly influence climate through their interactions with solar radiation and clouds. However, significant questions remain regarding the influences of biological activity and seawater chemistry on the flux, chemical composition, and climate-relevant properties of marine aerosols and gases. Wave channels, a traditional tool of physical oceanography, have been adapted for large-scale ocean-atmosphere mesocosm experiments in the laboratory. These experiments enable the study of aerosols under controlled conditions which isolate the marine system from atmospheric anthropogenic and terrestrial influences. Here, we present an overview of the 2019 Sea Spray Chemistry and Particle Evolution (SeaSCAPE) study, which was conducted in an 11 800 L wave channel which was modified to facilitate atmospheric measurements. The SeaSCAPE campaign sought to determine the influence of biological activity in seawater on the production of primary sea spray aerosols, volatile organic compounds (VOCs), and secondary marine aerosols. Notably, the SeaSCAPE experiment also focused on understanding how photooxidative aging processes transform the composition of marine aerosols. In addition to a broad range of aerosol, gas, and seawater measurements, we present key results which highlight the experimental capabilities during the campaign, including the phytoplankton bloom dynamics, VOC production, and the effects of photochemical aging on aerosol production, morphology, and chemical composition. Additionally, we discuss the modifications made to the wave channel to improve aerosol production and reduce background contamination, as well as subsequent characterization experiments. The SeaSCAPE experiment provides unique insight into the connections between marine biology, atmospheric chemistry, and climate-relevant aerosol properties, and demonstrates how an ocean-atmosphere-interaction facility can be used to isolate and study reactions in the marine atmosphere in the laboratory under more controlled conditions. This journal is

Category: Other; Ankle; Hindfoot; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: The automation and integration of patient reported outcomes (PROs) into standard of care practice and electronic health systems is becoming increasingly viable. While often collected as a quality assurance measure for a practice and surgical decision-making, PROs are also valuable to assess the relative treatment outcomes. In order for physicians to gain the most insight from PROs, more baseline outcomes are needed to serve as a benchmark of anticipated patient improvement following surgical interventions. The goal of this study is to evaluate differences in patient improvement among validated physical and mental health PROs in a foot and ankle surgery practice. Methods: Consecutive patients undergoing foot and ankle surgery were enrolled into the U-COSMOS pathway. All PROs are automatically distributed and tracked through a secure, HIPAA-compliant, online PRO data capture tool. All patients are invited to complete the PROMIS Physical Function (PF) Computer Adaptive Test (CAT), PROMIS Pain Interference CAT (PI), Foot and Ankle Single Assessment Numeric Evaluation (SANE), PROMIS Global Physical Health (GPH), PROMIS Global Mental Health (GMH), PROMIS Depression, and a brief resiliency scale (BRS). PROs are collected pre-operatively, and post-operatively at 3- months, 6-months, 12-months, and 24-months. In this study, differences between pre- and post-operative scores for each PRO are evaluated using an unpaired Mann-Whitney U Test. Results: To date, 3154 patients have been enrolled into the U-COSMOS foot and ankle surgery pathway. Overall survey compliance was 77%. A significant improvement was seen in PF, PI, SANE, and GPH at 6-months, 12-months, and 24-months (p < 0.0001, see Table 1). There was no significant improvement in PF or GPH at the 3-month mark, supporting reduction of pain interference may be observed before return of physical function. All PROs measuring changes in mental health or resilience (Depression, GMH, BRS) did not significantly change at any post-operative visit relative to baseline. We found a mild positive correlation between BRS and improved 12-month PF and PI outcomes and a mild inverse correlation between pre-operative depression and 12-month PI and PF scores. Conclusion: Our data suggests that foot and ankle surgery leads to significant improvement in physical outcomes such as function or pain interference, but mental health and resilience outcomes remain somewhat unchanged throughout treatment on average. Within physical outcomes, we also find significant improvement in pain interference precedes functional and general measures. Early findings from the U-COSMOS outcomes pathway demonstrates greater overall improvement in physical health PROs, and a sustained improvement up to 24 months post-op. Future investigation of outcomes specific to procedures and conditions within the U-COSMOS pathway will help elucidate anticipated variation from general trends.

Category: Trauma; Ankle; Hindfoot; Sports Introduction/Purpose: Achilles tendon ruptures are challenging injuries and complications following Achilles repair surgery can lead to poor patient outcomes. The objective of this study was to determine if time to surgery and an open versus closed surgical technique were related to postoperative complications. We hypothesized that an increased time to surgery and an open surgical technique would correlate with an increase in complications. Methods: One hundred ninety-four patients at a single institution who underwent Achilles rupture repair surgery between October 2016 and November 2020 were included. All patients had a minimum follow-up of 3 months +- 14 days. A retrospective review was performed collecting data which included injury and treatment timepoints, surgical technique (open or percutaneous), and complications. Patients were separated into 3 categories based on time to surgery: acute (6 weeks). Complications were categorized as minor (wounds and/or infections that resolved with outpatient care), major (wounds and/or infections requiring operative intervention), re-rupture, DVT, and all other complications. A Fisher's exact test was used to determine if there was a statistically significant relationship between time to surgery and post-surgical complications as well as surgical technique and post-surgical complications. Results: In total, 194 patients were included for analysis: 134 with an acute rupture (69%), 36 sub-acute (18.6%), and 24 chronic (12.4%). 45 complications were observed in 37 patients (19.0% of patients); 8 patients had a minor complication (4.1%), 8 major (4.1%), 7 re-ruptures (3.6%), 12 DVTs (6.2%), and 8 others (4.1%). 25 acute ruptures had complications (18.7%), 6 sub-acute (16.7%), and 6 chronic (25%). No statistical differences were determined between time to surgery or surgical technique and complications among groups. There was an increase in complications in the chronic group, the most notable being Achilles tendon re-rupture (P = 0.06). The mean re-rupture time from the date of original injury to surgery was 47 days (range 3-131 days), and mean time from surgery to re-rupture was 49 days (range 7-133 days). Conclusion: This study did not demonstrate any statistically significant relationship between time to surgery or open versus percutaneous surgical technique and post-surgical complications following operative treatment of Achilles ruptures. Though not statistically significant, complications and re-ruptures were more frequent in patients undergoing surgery >6 weeks following injury. These results suggest increased time to surgery may be a predictor of increased risk for postoperative complications following Achilles repair surgery, however further research including studies with larger patient populations is needed to support this determination.

Category: Ankle; Sports; Trauma Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLT) are challenging to treat, and large lesions (>10mm) with concomitant subchondral bony defects are particularly challenging. Standard treatments such as bone stimulation are limited and are often restricted to smaller lesions. Particulate and fragmented chondral allograft techniques face limitations with uncontained lesions. Structural allograft/autograft techniques often require removal of regions of native, uninjured bone and may encounter donor issues. Postoperatively, ensuring reliable osseous and cartilaginous healing responses can be difficult. Articular Regional Reconstruction (ARR) is a novel technique combining viable osteochondral allograft with morselized autograft bone to address large OLT lesions with bony defects, whether contained or uncontained. We describe a consecutive series of patients undergoing ARR here. Methods: Patients indicated for the ARR procedure had preoperative MRI and CT imaging identifying large (>10mm), unstable osteochondral lesions with bony defects; 11 consecutive patients that had undergone ARR were identified. OLT lesions were initially inspected arthroscopically, and then converted to open debridement. Medial malleolar osteotomies were used for access when necessary. A stable bony base and viable cartilage rim was established, removing all damaged cartilage and nonstructural material from the OLT and bony defect. Talar body structure and morphology was restored using iliac crest or tibial morselized autograft bone placed in the bony defect. Viable osteochondral allograft (Cartiform) was shaped and then secured over the autograft using suture anchors placed at the lesion periphery. Patient Reported Outcome (PRO) measures included PROMIS- physical function (PROMIS-PF), PROMIS-pain interference (PROMIS-PI), and single assessment numeric evaluation (SANE). Three patients without PRO data were excluded, leaving eight patients with preoperative and postoperative PRO data for analysis. Results: The ARR patients averaged 40 years old (range 28-60) with a mean follow up of 19 months (range 10-38). The lesion surface areas averaged 1.95 cm2 (range 1.17-2.99 cm2) with a depth of 7.25mm (range 5-9mm). Four were uncontained corner lesions. Postoperative PROMIS-PF improved from 41 to 47 (p = 0.036), and PROMIS- PI improved from 60 to 53 (p = 0.093). Average SANE scores improved from 60 to 69 (p = 0.148). No complications occurred. No revision OLT surgeries were required, though three patients returned to the OR (Two for osteotomy screw removal, one for anterior impingement of opposite corner). During these 'second looks', the implanted cartilage layer was found intact. In a recent survey, all patients indicated they would undergo the procedure again. Conclusion: Articular Regional Reconstruction (ARR) is a reproducible procedure with demonstrated potential for improvement in pain and physical function among patients with symptomatic, large osteochondral lesions of the talus with bony defects, whether 'contained' or 'uncontained'. It has particular utility as an alternative to bulk structural graft salvage procedures among patients who have failed prior procedures, as 5 of the 8 patients had undergone unsuccessful prior surgical intervention for their OLT by outside providers. Further studies on ARR of the talus are necessary to elucidate the prognosis of this procedure, establish indication boundaries, and strengthen long-term outcome data.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle replacement (TAR) is an effective procedure to help patients with end-stage osteoarthritis regain mobility and function. While previous studies have suggested that pre-operative factors such as stress or depression may influence the success of TAR, there is limited literature investigating this relationship. The goal of this study is to evaluate differences in functional and pain outcomes following TAR from patients with high and average PROMIS depression scores. Methods: Patients enrolled in the Orthopaedic Foot and Ankle Outcomes Research (OFAR) platform who underwent total ankle replacement were retrospectively analyzed. Patients were included if they had PROMIS outcomes collected both pre- and 12- months post-operatively. Patients were grouped as 'no/low depression' if they scored below 60 on the PROMIS depression scale, and 'high depression' if they scored greater than or equal to 60 (one standard deviation from the population mean). Statistical differences were evaluated non-parametrically using Wilcoxon rank tests and Mann-Whitney U tests. Results: 36 patients who underwent TAR met inclusion criteria for analysis. Based on pre-operative PROMIS depression scores, 28 patients were categorized 'no/low depression' (ND), and 8 were categorized as 'high depression' (HD). Both groups showed significant improvement in PROMIS physical function and PROMIS pain interference at 12-months. While the HD group had a significantly higher baseline PROMIS pain interference (65.8) compared to the ND group (58.4, p < 0.05), there was no significant difference between the two groups at 12-months (50.5 vs. 47.6, respectively). Similarly, while there was a significant difference in PROMIS depression score pre-operatively between HD and ND (62.5 vs. 48.3, p < 0.05), there was no significant difference 12- months post-operatively (52.5 vs. 45.8). Conclusion: Our data suggests that patients with high pre-operative PROMIS depression scores may have worse baseline physical function and pain interference compared to other patients but see greater overall improvement after total ankle arthroplasty. Patients in the 'high depression' group also showed a significant improvement in PROMIS depression score 12- months post-operatively. Additional investigation of large, non-commercial outcomes databases, such as OFAR, may also help determine which surgical interventions impact mental health outcomes.

Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Haglund's syndrome is a common cause of posterior heel pain and can be associated with retrocalcaneal bursitis and degenerative Achilles tendinosis. Open approaches for resection of the Haglund's lesion have long been employed in patients that fail to improve with conservative treatment. This often involves partial elevation of the Achilles insertion with reattachment. More recently, endoscopic surgical techniques have evolved, enabling more rapid rehabilitation with less tendon disruption. The decision on the surgical approach is influenced by the degree of insertional Achilles tendinosis with endoscopic techniques preferred in the absence of insertional pathology. The primary objective of this investigation was to report on a large series of patients treated surgically for symptomatic Haglund's lesions. Methods: We reviewed the outcomes of Haglund's syndrome surgical cases at our institution over a five-year period. We included cases with insertional Achilles tendinosis and retrocalcaneal bursitis related to the Haglund's lesion, but excluded revisions and cases involving flexor hallucis longus tendon transfers. We recorded patient demographics, sport and activity level, comorbidities, BMI, duration of symptoms, surgical technique, tourniquet time, rehabilitation protocol, postoperative complications, and duration of postoperative follow-up. We also reviewed relevant preoperative imaging and recorded the presence of Achilles insertional degenerative calcification or an insertional calcaneal enthesophyte on radiographs. We then prospectively administered questionnaires regarding return to sport and patient-reported outcome measures including the SANE, PASS, VISA-A and PROMIS (Physical Function, Pain Interference and Global Health domains). Results: In total, 17 of the 77 (22%) included cases were performed with the endoscopic surgical technique. Six patients underwent bilateral Haglund surgeries during the study period, accounting for 12 of the 77 cases. The open Haglund resection group had a higher rate of concomitant Achilles insertional degenerative calcification on radiographs and MRI (72%). In addition, the open group was older than the endoscopic group (average age 54 vs 45), had a higher rate of comorbidities, higher rate of postoperative complications, and a higher rate of return to the operating room for revision surgery (11% vs 0% for endoscopic). Seventeen patients were elite distance running athletes and were preferentially treated by endoscopic techniques (11/17, 64%). At 24-month follow-up, the majority of patients report return to baseline activity. Conclusion: Patients treated surgically for Haglund's syndrome and insertional Achilles tendinopathy generally have good outcomes. Outcomes are better for endoscopically treated patients compared to open treatment, although these patients tend to be younger, healthier, and have less Achilles tendons disease. Still, some degree of Achilles tendinopathy and limited intrasubstance calcification can be successfully addressed with the endoscopic technique. We are endeavoring to better define indications for, and limitations of, the endoscopic technique for insertional Haglund's disease.

Currently, there is insufficient knowledge about the benefits of anticoagulant use for primary prevention of venous thromboembolism (VTE) and its inherent risk of bleeding adverse events in patients undergoing surgery distal to the knee.The study included patients who had undergone an orthopaedic procedure distal to the tibial articular surface when they were 18 years of age or older. Using retrospective information from a tertiary care referral center, we compared patient demographics, clinical findings, diagnostic reports, procedures performed, and the rate of symptomatic VTE and bleeding adverse events between patients who had and those who had not received anticoagulant prophylaxis. Propensity score matching was used to minimize selection bias due to prophylactic treatment allocation.A total of 5,286 patients who had received anticoagulant prophylaxis for below-the-knee surgery were successfully matched with 5,286 patients who had not received anticoagulant prophylaxis for such surgery. After propensity score matching, the standardized difference between the groups was0.1 for all baseline characteristics, indicating a negligible difference between the groups. Patients who received anticoagulant prophylaxis had a significantly lower risk of developing a VTE compared with patients who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio (OR) of 0.38 (95% confidence interval [CI], 0.25 to 0.56; p0.001). In contradistinction, patients who received anticoagulant prophylaxis had a significantly higher risk of developing a bleeding adverse event than those who did not (115 [2.2%] versus 55 [1.0%]; OR, 2.18 [95% CI, 1.55 to 3.09]; p0.001).Anticoagulant prophylaxis reduced the risk of VTE after surgery distal to the tibial articular surface by 3-fold but resulted in a concomitant 2-fold increase in the risk of a bleeding adverse event. Large-scale, prospective studies are necessary to better understand the true incidence of such events, associated patient-specific risk factors, efficacy of various thromboprophylactic regimens, and patient-reported implications of such events.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis arises throughout the foot and ankle in various forms and due to numerous causes, with a thousand US cases per year estimated for the ankle alone. Although research continues to elucidate specific mechanisms at work, the pathophysiology remains poorly understood. Nevertheless, the various osteonecrosis pathways converge on osteocyte death, and bony lesions follow a pattern of progression. Understanding the specific anatomy and biomechanics associated with common forms of foot and ankle osteonecrosis should help guide diagnosis and interventions, particularly at earlier stages of disease where etiology-specific approaches might become optimal.

Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. Copyright (C) 2021 World Health Organization; licensee Elsevier.

Category: Arthroscopy; Ankle; Trauma Introduction/Purpose: Ankle fractures are one of the most common types of fractures, yet there is currently no consensus about how best to treat these patients. The treatment approach typically includes open reduction-internal fixation (ORIF), but not all patients have a good clinical outcome. Intra-articular injuries have been suggested as one potential cause of these sub-optimal outcomes. Use of arthroscopy at the time of surgery is useful in identifying intra-articular lesions in acute ankle fractures, however, there is no evidence that arthroscopic intervention changes the patient’s outcome. Ankle arthroscopy increases the duration and potential complications of anesthesia administration and also increases cost. Our study assesses the clinical impact of arthroscopy accompanying an ankle fracture ORIF, which is essential to promote positive outcomes, while decreasing unnecessary complications and costs. Methods: This is a retrospective chart review. We queried all patients that underwent operative fixation of a bimalleolar or trimalleolar ankle fracture at our institution from January 1, 2014 through November 1, 2018. From this list, we excluded patients less than 18 years old and patients that had concomitant injuries to other body parts that required surgery. In addition, we only included Weber B and Weber C fibula fracture to homogenize the data. We then performed a chart review to extract all demographic data, fracture pattern, surgical procedures performed, tourniquet times, any revision surgeries, arthroscopic findings and any interventions performed due to the arthroscopic portion of the procedure. We then conducted a phone and email survey utilizing the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form and the two question Patient Acceptable Symptom State (PASS). Results: Our study included 213 total patients (142 traditional ORIF, 71 ORIF plus arthroscopy) with an average age of 40 (standard deviation 14.2). The average follow up was 32.4 (13.1) months with a survey follow up rate of 50.7%. The demographic information between the two cohorts was statistically similar. The average tourniquet time for the arthroscopy cohort is 10 minutes longer (89 minutes versus 79 minutes). During the arthroscopy, there was a 28.2% rate of full thickness osteochondral lesions, 33.8% rate of loose bodies, and a 49.2% rate of small cartilage injury not requiring intervention. The mean PROMIS physical function score amongst Weber B fibula fractures was 45.8 and 42.3 in the arthroscopy and non-arthroscopy groups respectively (P value 0.012). In addition, the patient satisfaction rate in Weber B fibula fractures was higher in those patients that underwent arthroscopy as compared to ORIF alone (93.1% versus 75.5%, P value of 0.05). Patients that suffered a tibiotalar joint dislocation at the time of the ankle fracture had a significantly higher PROMIS physical function score (46.6 versus 40.2, P value 0.005) when their surgery included arthroscopy. Conclusion: Ankle arthroscopy at the time of ORIF led to higher mean patient reported outcomes for every tested metric but this reached statistical significance only when looking at the Weber B fibula fractures and ankle dislocations. There was no increase in complication rate and the arthroscopy took only 10 minutes longer on average. [Table: see text]

Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Other Introduction/Purpose: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis. This approach carries significant risk for wound complications. Several products have been investigated to mitigate this risk, but these are either costly or invasive. Noninvasive skin expansion strips (NSESs) have two nonelastic adhesive strips, one on either side of the incision, with an elastic band connecting them. These were designed to induce new skin growth at the edges of the strips for plastic surgery applications. In the postoperative setting, the NSES functions to transfer tension away from the site of the incision to the edge of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. Methods: This is a prospective cohort study with retrospectively identified historical controls designed to evaluate the effectiveness of NSESs. Prospectively enrolled patients undergoing TAR-AA at a single institution (3 surgeons) received application of NSESs in the operating room after routine wound closure. At their two-week postoperative visit, each wound was assessed and new NSESs were applied. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up cadence, or rehabilitation protocols. Patients following up with providers outside the institution were excluded. Thirty five consecutive historical controls were identified for comparison. Primary outcomes included (1) Additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication before 8 weeks, and (3) deep infection before 8 weeks. Z-score test was used to calculate statistically significant (pResults: To date, 20 patients (62.5 +- 11.8 years; 6 females, 14 males) received application of NSESs. Baseline demographics did not differ significantly from our 35 consecutively identified historical controls (62.2 +- 13.3 years; 16 females, 19 males). Additional clinic visits for suture removal were needed for 15% (3/20) of patients in the treatment group compared to 46% (14/35) of patients in the control group (p=0.021). There were significantly fewer unplanned visits per patient in the treatment group compared to the control group (0.15 vs. 0.54, p=0.004). The superficial wound complication rate in the treatment group vs. control group was 0% and 11%, respectively (p=0.12). There were no deep infections in either group. Conclusion: Noninvasive skin expansion strips are an effective means to improve early wound healing and decrease unplanned clinic visits for wound checks or delayed suture removal after TAR-AA. There was a trend toward significance for NSESs decreasing superficial wound complications. Further high volume studies are needed to clarify their cost effectiveness and effect on deep infections.

Lower limb dysfunction associated with upper motor neuron syndrome can be complex due to interaction of muscle overactivity, weakness, impaired motor control, and contracture. Treatment should be goal-directed and address the patient's passive and active functional impairments in addition to their symptoms. Therefore, a comprehensive, multidisciplinary team approach tailored to each patient's unique needs and functional goals is warranted. This article reviews the evaluation and management of issues related to lower limb muscle overactivity and how this approach was applied to 3 challenging cases.

The purpose of this paper is to investigate environmental policy issues in ports concerning how and how much an environmental policy affects the cost-benefit structure in a port from the economic and environmental perspectives. To mitigate negative environmental impacts in ports, there are stricter regulations that target creative designs for minimizing pollution. Nevertheless, such policies to mitigate environmental impacts result in a cost for the relevant parties, especially the ports themselves. To analyze the impact of environmental policy on ports, a simulation technique based on system dynamics is introduced with the case of Busan port as an illustration. Results show that both the environmental policies (EPs) and the policy options (POs) create positive effects and negative effects on ports. Although EPs and POs seem to increase the negative effects on the port in the short term, they are helpful to strengthen the competitiveness of ports by the vitalization of port activities and the port cluster.

Background To assist with visualization, orthopaedic surgeons often apply ankle distraction during arthroscopic procedures. The study aimed to investigate whether ankle distraction suppresses fibular motion in cadaveric specimens with an unstable syndesmotic injury. Methods Fourteen fresh-frozen above knee specimens underwent arthroscopic assessment with 1) intact ligaments, 2) after sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, and the posterior inferior tibiofibular ligament, and 3) after sectioning of the deep and superficial deltoid ligament. In all scenarios, the lateral hook test, anterior-posterior hook test, and posterior-anterior hook test were applied. Each test was performed with and without ankle distraction. Coronal plane anterior and posterior tibiofibular diastasis as well as sagittal plane tibiofibular translation due to the applied load were arthroscopically measured. Findings Tibiofibular diastasis in the coronal plane, as measured at both the anterior and posterior third of the incisura, was found to be significantly less when ankle distraction was applied, as compared to arthroscopic evaluation in the absence of distraction. In contrast, measurement of sagittal plane tibiofibular translation was not affected by ankle distraction. Interpretation Since arthroscopic findings of syndesmotic instability are subtle the differential values of the syndesmotic measurements taken on and off distraction are clinically relevant. To optimally assess syndesmotic instability one should evaluate the syndesmosis without distraction or focus on fibular motion in the sagittal plane when distraction is required.

Icetexane diterpenoids are richly complex polycyclic natural products that have been described with a variety of biological activities. We report here a general synthetic approach toward the 6-7-6 tricyclic core structure of these interesting synthetic targets based on a two-step enolate alkylation and ring-closing metathesis reaction sequence.

Osteonecrosis arises throughout the foot and ankle in various forms and due to numerous causes, with a thousand US cases per year estimated for the ankle alone. Although research continues to elucidate specific mechanisms at work, the pathophysiology remains poorly understood. Nevertheless, the various osteonecrosis pathways converge on osteocyte death, and bony lesions follow a pattern of progression. Understanding the specific anatomy and biomechanics associated with common forms of foot and ankle osteonecrosis should help guide diagnosis and interventions, particularly at earlier stages of disease where etiology-specific approaches might become optimal.

The hooded pitcher plant, Sarracenia minor, is a carnivorous facultative wetland species native to the southeastern USA and is listed as threatened by the state of Florida. Pitchers of S. minor possess white, semitranslucent spots (areoles), which have been hypothesized to aid in the capture of prey (= visual lures) by increasing the amount of light entering the back of the hood, which persuades insects to enter and fall into the base of the pitcher. In this study, the role of the areoles in prey capture abundance and diversity were experimentally investigated under variable lighting conditions in situ. Plants in two populations experiencing different light intensities, which varied in the amount of canopy cover and incident light reaching the plants, were experimentally manipulated by coloring varying percentages of areoles, ranging from 0 to 100 % (in increments of 25 %), with indelible ink. After 2 months, pitchers were collected and dissected to determine the number and identity of prey captured (approximately 18,000 prey were sampled). Although total prey abundance was approximately five times higher at McGirt’s Creek (sunny site) compared to UNF (shaded site), the effect of areoles on prey capture rates and biodiversity was site dependent. Reducing the number of visual lures of plants at the sunny site produced a significant decrease in the number of prey captured, but prey biodiversity (community composition) was unaffected. However, total prey capture was unaffected at the shaded site, while prey biodiversity was negatively correlated with the percent of areoles colored. Results from the current study suggest that areoles conditionally act as visual lures, but their overall importance is dependent on local environmental variables—especially canopy cover and the amount of incident sunlight reaching the plants.

Category: Ankle; Sports Introduction/Purpose: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injuries by orthopedic foot and ankle specialists around the world in six athlete scenarios with increasing degrees of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis, and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact, and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails distributed two weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to six months post-op. 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although flexible fixation devices are the preferred choice among all respondents, there was considerable variability in device choices. Fellowship training also appears to affect the preferred fixation method. There was no overall difference between device preference between North American and International respondents (Fig1). There also exists substantial variability in expected return to play for every athlete scenario. The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding the management of syndesmotic injuries.

One geoengineering mitigation strategy for global temperature rises resulting from the increased concentrations of greenhouse gases is to inject particles into the stratosphere to scatter solar radiation back to space, with TiO2 particles emerging as a possible candidate. Uptake coefficients of HO2, γ(HO2), onto sub-micrometre TiO2 particles were measured at room temperature and different relative humidities (RH) using an atmospheric pressure aerosol flow tube coupled to a sensitive HO2 detector. Values of γ(HO2) increased from 0.021 ± 0.001 to 0.036 ± 0.007 as the RH was increased from 11 % to 66 %, and the increase in γ(HO2) correlated with the number of monolayers of water surrounding the TiO2 particles. The impact of the uptake of HO2 onto TiO2 particles on stratospheric concentrations of HO2 and O3 was simulated using the TOMCAT three-dimensional chemical transport model. The model showed that by injecting the amount of TiO2 required to achieve the same cooling effect as the Mt. Pinatubo eruption, heterogeneous reactions between HO2 and TiO2 would have a negligible effect on stratospheric concentrations of HO2 and O3.

This study aims to characterize the trends in disease presentation for robot-assisted radical prostatectomy (RARP) over a 12-year period in Melbourne, Australia.All patients undergoing an RARP between 2004 and October 2016 while under the care of six high-volume surgeons were included in this study. Data were collected prospectively regarding patient demographics and clinical details of their cancer.Over the 12-year time span of the study, 3075 men underwent an RARP with a median age of 63.01 years. Temporal analysis demonstrated that the median age of patients undergoing prostatectomy advanced with time with the median age in 2016 being 65.51 years compared with 61.0 years in 2004 (P0.001). There was also a significant trend to increased D'Amico risk groups over time with the percentage procedures for high-risk patients increasing from 12.6% to 28.10% from 2004 to 2016 (P0.001). Upgrade rates between biopsy and pathological Gleason grade scoring significantly trended down over the period of the study (P0.001). There was also a shift to increased pathological stage over the 12 years with 22.1% of men having T3 disease in 2004 compared with 49.8% in 2016.Our analysis demonstrates increasing treatment of older men with higher risk tumours, consistent with international trends. While this largely reflects a shift in case selection, further work is needed to assess whether the stage shift may relate partially to a decline in screening and increased presentation of higher risk disease.

Background: Clubfoot treatment commonly fails and often results in impaired quality of life. An understanding of the soft-tissue abnormalities associated with both treatment-responsive and treatment-resistant clubfoot is important to improving the diagnosis of clubfoot, the prognosis for patients, and treatment. Methods: Twenty patients with clubfoot treated with the Ponseti method were recruited for magnetic resonance imaging (MRI) of their lower extremities. Among these were seven patients (six unilateral cases) with treatment-responsive clubfoot and thirteen patients (five unilateral cases) with treatment-resistant clubfoot. Demographic information and physical examination findings were recorded. A descriptive analysis of the soft-tissue abnormalities was performed for both patient cohorts. For the patients with unilateral clubfoot, we calculated the percentage difference in cross-sectional area between the affected limb and the unaffected limb in terms of muscle, subcutaneous fat, intracompartment fat, and total area. With use of the Wilcoxon signed-rank test, we compared inter-leg differences in cross-sectional areas and the intracompartment adiposity index (IAI) between treatment-responsive and treatment-resistant groups. The IAI characterizes the cross-sectional area of fat within a muscle compartment. Results: Extensive soft-tissue abnormalities were more present in patients with treatment-resistant clubfoot than in patients with treatment-responsive clubfoot. Treatment-resistant clubfoot abnormalities included excess epimysial fat and intramuscular fat replacement as well as unique patterns of hypoplasia in specific muscle groups that were present within a subset of patients. Among the unilateral cases, treatment-resistant clubfoot was associated with a significantly greater difference in muscle area between the affected and unaffected limb (−47.8%) compared with treatment-responsive clubfoot (−26.6%) (p = 0.02), a significantly greater difference in intracompartment fat area between the affected and unaffected limb (402.6%) compared with treatment-responsive clubfoot (9%) (p = 0.01), and a corresponding higher inter-leg IAI ratio (8.7) compared with treatment-responsive clubfoot (1.5) (p = 0.01). Conclusions: MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. Correlations between MRI, physical examination, and treatment responsiveness may aid in the development of a prognostic classification system for clubfoot. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Increasing atmospheric CO₂ concentrations alter leaf physiology, with effects that cascade to communities and ecosystems. Yet, responses over cycles of disturbance and recovery are not well known, because most experiments span limited ecological time. We examined the effects of CO₂ on root growth, herbivory and arthropod biodiversity in a woodland from 1996 to 2006, and the legacy of CO₂ enrichment on these processes during the year after the CO₂ treatment ceased. We used minirhizotrons to study root growth, leaf censuses to study herbivory and pitfall traps to determine the effects of elevated CO₂ on arthropod biodiversity. Elevated CO₂ increased fine root biomass, but decreased foliar nitrogen and herbivory on all plant species. Insect biodiversity was unchanged in elevated CO₂. Legacy effects of elevated CO₂ disappeared quickly as fine root growth, foliar nitrogen and herbivory levels recovered in the next growing season following the cessation of elevated CO₂. Although the effects of elevated CO₂ cascade through plants to herbivores, they do not reach other trophic levels, and biodiversity remains unchanged. The legacy of 10 yr of elevated CO₂ on plant-herbivore interactions in this system appear to be minimal, indicating that the effects of elevated CO₂ may not accumulate over cycles of disturbance and recovery.

Ecological restoration is becoming an increasingly important tool in humanity's attempt to manage, conserve, and repair the world's ecosystems. In the current study, the objective was to compare the effects of two restoration methods on arthropod biodiversity and community composition in two former pine plantations; these treatments included both intensive restoration effort (= cleared) and moderate restoration effort (= thinned). For the cleared treatment, vegetation was clear-cut to the soil surface, and all vegetation was removed from the plots, while the thinned treatment consisted of reducing the Pinus elliotii (Slash Pine) density to that of a native ecosystem and removing of all exotic plants from the plots as well. Arthropods were sampled by employing pitfall traps, sticky traps, and sweep netting and identified to family and morphospecies; species richness, diversity, and community similarity were compared between treatments and sites. Experimental treatments quickly reached or exceeded ...

1. The flow of energy and nutrients across ecosystem boundaries can have significant community-wide effects, but the role of productivity of the recipient habitat in mediating these effects remains unclear. This is especially true when organisms moving across ecosystem boundaries serve simultaneously as predators and prey. 2. In this study, the effects of odonates, primarily Enallagma civile (Hagen), on a salt marsh system were examined. Cages were used to exclude odonate predators, but not other arthropods, from experimental plots of the sea oxeye daisy, Borrichia frutescens (L.) in high and low productivity areas. The effects were assessed on the in situ arthropod community and the host plant. 3. There were strong direct effects of predation on the herbivores Pissonotus quadripustulatus Van Duzee and Asphondylia borrichiae Rossi and Strong, with higher densities where damselflies were excluded. Damselflies also served as prey for web-building spiders. This resulted in lower spider densities inside cages, and a positive indirect effect on grasshopper densities. 4. Direct and indirect effects of odonates were greater in the high productivity area, resulting in a trophic cascade, with greater damage and reduced flowering and density of the host plant inside cages. 5. The results of this study support the subsidy hypothesis and show that theoretical models of trophic dynamics, which were developed to explain exchanges within ecosystems, may have predictive and explanatory value for exchanges across ecosystems as well.

1. Stressful abiotic conditions and mycorrhizal fungi have both been shown to influence plant quality significantly, yet the interactive effects of these factors on relationships among plants, herbivores, and natural enemies remain unclear. 2. In this study, the results of a factorial field experiment are reported in which the effects of plant stress and mycorrhizae on density and parasitism of three herbivores of Baccharis halimifolia L. were examined. 3. Plant stress was increased by adding salt to the soil, and association with mycorrhizal fungi was increased by inoculating plant roots. 4. Inoculation with mycorrhizal fungi resulted in increased density of all three herbivore species, but the effects of mycorrhizae on parasitism varied by species and with soil salinity levels. For the gall maker Neolasioptera lathami Gagne, mycorrhizae decreased parasitism regardless of soil salinity levels. For the leaf miners Amauromyza maculosa Malloch and Liriomyza trifolii Burgess, mycorrhizae effectively negated the decrease in parasitism resulting from increased salinity. 5. The results of this study show that the effects of mycorrhizae on parasitism may be context dependent, and can be positive or negative depending upon species and environmental conditions.

Apoptosis is observed during a spectrum of conditions including exogenous virus infection and endogenous cellular turnover. Adult femaleAedes albopictusmosquitoes challenged with increasing titres of Sindbis virus (SINV) via intrathoracic inoculation demonstrated that the injection dosage did not result in significantly different levels of virus growth or mosquito survival at day 10 post-infection. Tissues probed for apoptosis using anin situTUNEL assay revealed SINV-associated apoptotic cells scattered throughout the proximal and distal regions of the salivary gland (SG) lateral lobes but which were not detected in the median lobe or the midgut and hindgut. Apoptosis was also identified in SG duct cells in both infected and uninfected mosquitoes, suggesting routine tissue homeostasis. SINV-associated apoptosis sequestered to the SG lateral lobes indicates a differential epithelial cell response to an arbovirus and provides insight into mosquito defence mechanisms against pathogens and SG infection barriers, hurdles to transmission of arboviruses of public health concern.

As human populations encroach on more remote areas, tree plantations are frequently converted into suburban developments or conservation lands. The purpose of the current study was to compare the effects of restoration treatments on the abundance and biodiversity of two former pine plantations in northeast Florida. Restoration methods, which varied greatly in both environmental impact and effort from minimal (non-manipulated control plots) to thinned (removal of 90–97% of Slash Pines and exotic plant species) to cleared (mechanical removal of all vegetation to the substrate surface), were compared using replicated 100-m2 plots. Although sites exhibited variation in plant densities and relative guild abundance, restoration treatment produced a significant increase in plant abundance and relative composition of plant guilds. Plant abundance was 2–3 times higher in cleared plots compared to thinned and control plots, respectively; not surprisingly this was because cleared plots had large numbers of ...

Intraguild predation is an important interaction in which predators feed on a shared prey as well as on each other. It occurs frequently between larval odonates in freshwater lentic communities, and understanding the factors influencing this interaction remains an important objective. An experiment carried out in mesocosms and utilizing a factorial design investigated the strength of intraguild interactions between the dragonfly, Sympetrum vicinum, and the damselfly, Enallagma civile, under two levels each of habitat complexity (high or low), prey abundance (high or low) and prey type (amphipods or blackworms). Effects of treatments on size, mortality and emergence of larval odonates were evaluated. Shared prey abundance had little impact on intraguild interactions, affecting only the mass of the intraguild prey E. civile. Habitat complexity affected the size of E. civile damselflies, as length and wet mass were significantly greater in low complexity mesocosms. Prey type seemed to be the most important factor in the experiment, influencing all response variables measured. When shared prey consisted of larger, more active blackworms, intraguild predation decreased, and E. civile damselflies experienced lower mortality, achieved greater length and mass, and had greater emergence success. Results of this study suggest that prey type and habitat complexity can be more important than prey abundance in mediating intraguild predation.

1. Although in recent years there have been a number of studies demonstrating trophic cascades in terrestrial systems, it is still unclear what environmental conditions enable or enhance such cascades, especially among four trophic levels. 2. In this study, the influence of environmental stress (increased soil pore water salinity) on a four trophic level study system in a Florida salt marsh was examined by experimentally increasing soil pore water salinity. Effects of increased salinity on the quality of the host plant, Batis maritima, were assessed, as were resulting effects on the lepidopteran herbivore Ascia monuste, and the primary parasitoids and hyperparasitoids of its caterpillars. 3. Increased salinity altered host-plant quality, which subsequently affected the consumer species. These effects of altered plant quality cascaded up through the herbivore and primary parasitoid to the hyperparasitoid Hypopteromalus inimicus, influencing its density, sex ratio, body size, and initial egg load. 4. These results demonstrate how heterogeneity in environmental stress can result in effects that cascade up through four trophic levels. We suggest that such strong effects at higher trophic levels may be more likely in systems in which relationships are more specific and intimate such as those among hosts, parasitoids, and hyperparasitoids.

The St. Johns River is one of the premiere waterways in the southeastern United States, but it is increasingly affected by anthropogenic disturbances and influences such as excessive loading of nutrients. In the current pilot project, small native plant communities (“garden sites”) were established along sections of riparian corridors of five first-order tributaries in residential-commercial areas that drain into the lower St. Johns River in north Florida. In addition, four “non-garden” (control) tributaries were monitored for comparison. Garden sites included five species native to the area; 20 plants of each species on both banks (200 total plants). These sites were used to assess the ability of partially restored riparian areas to ameliorate nutrient loading and water quality and determine their impact on local biodiversity in disturbed suburban drainage systems. Partially restored sites showed a significant reduction in both NO3- and P concentrations in both soil and water samples compared to control sites. For instance, soil NO3- levels were reduced by 14% in garden sites, while water samples were 30% lower. Moreover, both plant species richness and Shannon diversity (H’) were significantly higher at partially restored sites, 33 and 19% respectively, compared to control streams after two years. Garden sites also had significantly higher terrestrial and invertebrate diversity than non-restored tributaries. Intermittent patches of partially restored habitat along suburban riparian corridors may provide a practical cost-effective technique for improving ecosystem function, water quality and increasing biodiversity along these frequently disturbed lotic habitats. Trends detected in the current study may have general implications for riparian restoration and reduction of nutrient loading in these small tributaries and, ultimately, effect water quality of the lower St. Johns River basin.

1. Plant stress and association with mycorrhizal fungi have been shown to significantly influence plant quality, yet their roles in influencing plant–insect interactions remain unclear. Even less is known about how these factors might interact with or be modified by within-trophic level interactions. 2. In the present study, the results of a factorial field experiment are reported in which the effects of within-trophic-level interactions, plant stress, and mycorrhizae on three herbivores of Baccharis halimifolia were examined. 3. Plant stress was increased by adding salt to the soil, and availability of mycorrhizal fungi was increased by inoculating plant roots. These treatments were applied to plants with either low or high densities of a competitor (Trirhabda baccharidis). 4. For the two leaf miners, Amauromyza maculosa and Liriomyza trifolii, increased soil salinity and high densities of the competitor Trirhabdabaccharidis resulted in significant decreases in density. Neither of these treatments affected the gall maker Neolasioptera lathami. 5. Mycorrhizal fungi increased the densities of all three herbivores, possibly by increasing foliar nitrogen levels. For the two leaf miners, there was also evidence that mycorrhizae ameliorated the negative effects of salt stress. There was also evidence that high levels of competition dampened the positive effects of mycorrhizae on the two leaf miners.

The effects of elevated CO 2 on plant growth and insect herbivory have been frequently investigated over the past 20 years. Most studies have shown an increase in plant growth, a decrease in plant nitrogen concentration, an increase in plant secondary metabolites and a decrease in herbivory. However, such studies have generally overlooked the fact that increases in plant production could cause increases of herbivores per unit area of habitat. Our study investigated leaf production, herbivory levels and herbivore abundance per unit area of leaf litter in a scrub-oak system at Kennedy Space Center, Florida, under conditions of ambient and elevated CO 2 , over an 11-year period, from 1996 to 2007. In every year, herbivory, that is leafminer and leaftier abundance per 200 leaves, was lower under elevated CO 2 than ambient CO 2 for each of three species of oaks, Quercus myrtifolia, Quercus chapmanii and Quercus geminata. However, leaf litter production per 0.1143 m 2 was greater under elevated CO 2 than ambient CO 2 for Q. myrtifolia and Q. chapmanii, and this difference increased over the 11 years of the study. Leaf production of Q. geminata under elevated CO 2 did not increase. Leafminer densities per 0.1143 m 2 of litterfall for Q. myrtifolia and Q. chapmanii were initially lower under elevated CO 2 . However, shortly after canopy closure in 2001, leafminer densities per 0.1143 m 2 of litter fall became higher under elevated CO 2 and remained higher for the remainder of the experiment. Leaftier densities per 0.1143 m 2 were also higher under elevated CO 2 for Q. myrtifolia and Q. chapmanii over the last 6 years of the experiment. There were no differences in leafminer or leaftier densities per 0.1143 m 2 of litter for Q. geminata. These results show three phenomena. First, they show that elevated CO 2 decreases herbivory on all oak species in the Florida scrub-oak system. Second, despite lower numbers of herbivores per 200 leaves in elevated CO 2 increased leaf production resulted in higher herbivore densities per unit area of leaf litter for two oak species. Third, they corroborate other studies which suggest that the effects of elevated CO 2 on herbivores are species specific, meaning they depend on the particular plant species involved. Two oak species showed increases in leaf production and herbivore densities per 0.1143 m 2 in elevated CO 2 over time while another oak species did not. Our results point to a future world of elevated CO 2 where, despite lower plant herbivory, some insect herbivores may become more common.

The relationship between carnivorous pitcher plants (Family Sarraceniaceae) is not well understood. While a limited amount of such data are available for some pitcher plant species such as Sarracenia purpurea, very little is know about others such as S. minor. This study examined the relationship between the hooded pitcher plant S. minor and its most common herbivore, the pitcher plant mining moth Exyra semicrocea, in northeast Florida. At the beginning of the growing season, moth densities were positively correlated with plant height, number of pitchers per plant and the proportion of non-pitcher leaves. Over the growing season, plants with higher moth densities decreased in size, while plants with lower moth densities increased. Plants with higher moth densities also produced fewer phyllodia than plants with fewer moths. Data from this study suggest that herbivory by E. semicrocea moth larvae may have a significant negative impact on the hooded pitcher plant and that this effect could be stronger for larger higher quality plants.

We hypothesize that in pregnancy and at the time of delivery, the vagina and supportive tissues undergo dramatic alterations to accommodate passage of the fetus. In this study, we sought to characterize these changes in the rat using an established biomechanical testing protocol.Seventy-four 3-month-old Long Evans rats divided into virgin, mid and late pregnant, vaginal delivery (immediate and 4-week postpartum), and abdominal delivery (immediate and 4-week postpartum) groups were killed. The biomechanical properties of the vagina and supportive tissues were tested intact as a complex under loading conditions that simulate downward distension. Data were analyzed using analysis of variance and post hoc comparisons.Mean linear stiffness (ability of the specimen to resist distension) and ultimate load at failure (maximal resistance of the specimen to distension before disruption) were decreased in pregnancy and at delivery, regardless of delivery route (Ps.001). Maximal distension was increased at time of delivery (Ps.001). Four weeks after vaginal delivery, all biomechanical characteristics returned to at least virgin values.In the rat, the biomechanical characteristics affording distensibility of the vagina and supportive tissues increased in pregnancy and even further at delivery. It is likely that these represent maternal tissue adaptations that facilitate delivery of the fetus(es).

1. Both host plant nutrition and mortality from natural enemies have been predicted to significantly impact host plant selection and oviposition behaviour of phytophagous insects. It is unclear, however, if oviposition decisions maximise fitness. 2. This study examined whether the salt marsh planthopper Pissonotus quadripustulatus prefers higher quality host plants for oviposition, and if oviposition decisions are made so as to minimise mortality at the egg stage. 3. A controlled laboratory experiment and 4 years of field data were used to assess the rates of planthopper oviposition on higher quality ‘green’ and lower quality ‘woody’ stems of the host plant Borrichia frutescens. The numbers and percentages of healthy eggs and eggs that were killed by parasitoids or the host plant were recorded. 4. In all years, including the laboratory experiment, Pissonotus planthoppers laid more eggs on lower quality woody stems than on higher quality green stems. While host plant related egg mortality was higher in woody stems, the percentage of eggs parasitised was much greater in green stems. This resulted in a lower total mortality of eggs on woody stems. 5. The results of this study demonstrate that, although Pissonotus prefers lower quality host plants for oviposition, this actually increases fitness. These data seem to support the enemy free space hypothesis, and suggest that for phytophagous insects that experience the majority of mortality in the egg stage, oviposition choices may be made such that mortality is minimised.

Decomposition of Quercus myrtifolia leaf litter in a Florida scrub oak community was followed for 3 years in two separate experiments. In the first experiment, we examined the effects CO2 and herbivore damage on litter quality and subsequent decomposition. Undamaged, chewed and mined litter generated under ambient and elevated (ambient 1350ppmV) CO2 was allowed to decompose under ambient conditions for 3 years. Initial litter chemistry indicated that CO2 levels had minor effects on litter quality. Litter damaged by leaf miners had higher initial concentrations of condensed tannins and nitrogen (N) and lower concentrations of hemicellulose and C:N ratios compared with undamaged and chewed litter. Despite variation in litter quality associated with CO2, herbivory, and their interaction, there was no subsequent effect on rates of decomposition under ambient atmospheric conditions. In the second experiment, we examined the effects of source (ambient and elevated) of litter and decomposition site (ambient and elevated) on litter decomposition and N dynamics. Litter was not separated by damage type. The litter from both elevated and ambient CO2 was then decomposed in both elevated and ambient CO2 chambers. Initial litter chemistry indicated that concentrations of carbon (C), hemicellulose, and lignin were higher in litter from elevated than ambient CO2 chambers. Despite differences in C and fiber concentrations, litter from ambient and elevated CO2 decomposed at comparable rates. However, the atmosphere in which the decomposition took place resulted in significant differences in rates of decomposition. Litter decomposing under elevated CO2 decomposed more rapidly than litter under ambient CO2, and exhibited higher rates of mineral N accumulation. The results suggest that the atmospheric conditions during the decomposition process have a greater impact on rates of decomposition and N cycling than do the atmospheric conditions under which the foliage was produced.

Biomechanical testing protocols for ligaments can be extensive and span two or more days. During this time, a specimen may have to undergo more than one cycle of freezing and thawing. Thus, the objective of this study was to evaluate the effects of refreezing on the viscoelastic and tensile properties of ligaments. The femur-medial collateral ligament-tibia complexes (FMTC) from six pairs of rabbit knees were used for this study. Following sacrifice, one leg in each pair was assigned to the fresh group and the FMTC was immediately dissected and prepared for testing. The contralateral knees were fresh-frozen at -20 degrees C for 3 weeks, thawed, dissected and then refrozen for one additional week before being tested as the refrozen group. The cross-sectional area and shape of the medial collateral ligament (MCL) was measured using a laser micrometer system. Stress relaxation and cyclic stress-relaxation tests in uniaxial tension were performed followed by a load to failure test. When the viscoelastic behavior of the MCL was described by the quasi-linear viscoelastic (QLV) theory, no statistically significant differences could be detected for the five constants (A, B, C, tau1, and tau2) between the fresh and refrozen groups (p > or = 0.07) based on our sample size. In addition, the structural properties of the FMTCs and the mechanical properties of the MCLs were also found to be similar between the two groups (p > or = 0.68). These results suggest that careful refreezing of the specimens had little or no effect on the biomechanical properties measured.