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There is a growing drive to improve the heterogeneity of medical school cohorts. However, those from lower socio-economic groups remain under-represented. Understanding the methods used by applicants to prepare for medical school selection, and the challenges they face with respect to opportunities and access, may provide important insights to this lack of diversity. This research considered the influence of socio-demographic background on preparation for medical school selection and on the successful offer of a place.All eligible applicants to a large UK medical school were invited to complete an anonymous online survey (international and mature applicants excluded), detailing demographic data and experiences of preparing for selection and challenges faced (n = 1885). Selection outcomes across all UK medical schools were examined for consenting students (n = 955). Univariate and multivariate analyses explored the associations of preparatory activities and demographic data with subsequent offer of a place at a UK medical school.The survey response rate was 66.4%. Clinical work experience (hospital or general practice), fee-based courses for admissions tests and school preparation courses for interview were activities significantly associated with the offer of a place (P .05). Those attending independent (private) schools most frequently reported school support and fee-based courses to support preparation (P .01). Applicants from state non-selective (SNS) schools and lower socio-economic groups more frequently reported challenges in accessing fee-based support, school interview courses and clinical work experience (P ≤ .02).Clinical work experience, commercial courses for admissions tests and school-based support for interview represent areas of preparation that are associated with success. However, they also represent areas that are more challenging to access for demographic groups traditionally under-represented in medicine. Addressing complex issues of fairness in highly selective higher education settings can appear an insurmountable task. These preparatory activities represent key areas for applicants, schools and institutions to explore and address.

Introduction The efficacy of virtual reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine whether VR improves surgical competence over traditional procedural preparation when performing a UKA. Methods Twenty-two orthopaedic surgery trainees were randomized to two surgical preparation cohorts: (1) "Guide" group (control) with access to manufacture's technique guide and surgical video and (2) "VR" group with access to an immersive commercially available VR learning module. Surgical performance of UKA on a SawBone model was assessed through time and the Objective Structured Assessment of Technical Skills (OSATS) validated rating system. Results Participants were equally distributed among all training levels and previous exposure to UKA. No difference in mean surgical times was observed between Guide and VR groups (Guide = 42.4 minutes versus VR = 43.0 minutes; P = 0.9) or mean total OSATS (Guide = 15.7 versus VR = 14.2; P = 0.59). Most trainees felt VR would be a useful tool for resident education (77%) and would use VR for case preparation if available (86.4%). Conclusion In a randomized controlled trial of trainees at a single, large academic center performing a complex, multistep, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence compared with the use of traditional technique guides, as measured by surgical time and OSATS scores. Most of the trainees found the VR technology beneficial. This study suggests that VR technology may be considered as an adjunct to traditional surgical preparation/training methods.

To assess the value of preoperative joint aspiration in detecting periprosthetic joint infection (PJI) in patients undergoing revision hip arthroplasty and to compare these with the clinical findings, serum markers, and intraoperative findings. Fluoroscopically guided hip aspirations in patients with pain after hip arthroplasty were retrospectively reviewed from January 2014 to December 2018. All hips underwent subsequent revision hip arthroplasty. Antibiotics were discontinued at least 2 weeks before the aspiration. The 2018 Musculoskeletal Infection Society (MSIS) criteria served as a standard of reference for PJI. Clinical, serum, synovial, and intraoperative parameters were recorded in all patients. Correlations between all parameters with PJI diagnosis were analyzed using linear and logistic regression models with ROC analysis. In 202 hips that included 91 septic hips, hip aspiration (AUC = 0.78) and intraoperative (0.80) parameters performed better than serum-based tests (0.64) and clinical parameters (0.68) in detecting PJI. Using MSIS criteria as a standard of reference, hip aspiration had a sensitivity of 64.0% and an accuracy of 78.5% for cultures and a sensitivity of 74.2% and an accuracy of 82.1% for synovial polymorphonuclear neutrophils% (PMN%). Results substantially improved sensitivity after excluding patients that were treated with antibiotics, particularly culture results. Preoperative hip aspiration showed good diagnostic performance in diagnosing PJI compared with MSIS criteria as a standard of reference. But a negative result from aspirate could not rule out PJI. Based on our findings, hip aspiration is an essential test for treatment planning in patients with pain after hip arthroplasty.

We present Atacama Large Millimeter/submillimeter Array (ALMA) observations of $\mathrm{^{13}CO(J=1-0)}$ line and 104 GHz continuum emission from NGC 604, a giant HII region (GHR) in the nearby spiral galaxy M33. Our high spatial resolution images ( 3.2"$\times$ 2.4", corresponding to $13 \times 10$ pc physical scale) allow us to detect fifteen molecular clouds. We find spatial offsets between the $^{13}CO$ and 104 GHz continuum emission and also detect continuum emission near the centre of the GHR. The identified molecular clouds have sizes ranging from 5-21 pc, linewidths of 0.3-3.0 $\mathrm{kms^{-1}}$ and luminosity-derived masses of (0.4-80.5) $\times 10^3$ M$_{\bigodot}$. These molecular clouds are in near virial equilibrium, with a spearman correlation coefficient of 0.98. The linewidth-size relationship for these clouds is offset from the corresponding relations for the Milky Way and for NGC 300, although this may be an artefact of the dendrogram process., The article has 9 pages, 7 figures and 1 table

Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol. We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017. A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups. With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population. III, therapeutic.

Although disparities exist in patient access to and outcomes after total knee arthroplasty (TKA), there are limited data regarding the relationship between travel distance and patient demographics or postoperative complications.We identified patients who underwent TKA in Florida and New York between 2006 and 2014 using the Healthcare Cost and Utilization Project State Inpatient Databases. The American Hospital Association and UnitedStatesZipCodes.org Enterprise databases were further used to calculate distance traveled from patient population-weighted zip code centroid points to the hospitals at which they underwent TKA. Patients were grouped by travel distance: 25 to 50, 50 to 100, 100 to 500 miles, and greater than 500 miles. Patient demographic characteristics and postoperative outcomes were compared between the travel distance groups.Older age, increased medical comorbidities, White race, Medicare insurance coverage, and living in zip codes with greater mean income levels were associated with greater travel distance (P0.001). There were no clinically significant relationships between various postoperative complications and distance traveled.Certain demographic variables are associated with increased travel distance to undergo TKA. These relationships were most pronounced at the extremes of distance traveled (500 miles). These differences may indicate that specific patient groups are either electing to or being forced to travel notable distances for orthopaedic care. Additional research is needed to determine the causative mechanisms underlying these findings.

Full list of authors: Issaoun, Sara; Wielgus, Maciek; Jorstad, Svetlana; Krichbaum, Thomas P.; Blackburn, Lindy; Janssen, Michael; Chan, Chi-kwan; Pesce, Dominic W.; Gomez, Jose L.; Akiyama, Kazunori; Moscibrodzka, Monika; Marti-Vidal, Ivan; Chael, Andrew; Lico, Rocco; Liu, Jun; Ramakrishnan, Venkatessh; Lisakov, Mikhail; Fuentes, Antonio; Zhao, Guang-Yao; Moriyama, Kotaro; Broderick, Avery E.; Tiede, Paul; MacDonald, Nicholas R.; Mizuno, Yosuke; Traianou, Efthalia; Loinard, Laurent; Davelaar, Jordy; Gurwell, Mark; Lu, Ru-Sen; Alberdi, Antxon; Alef, Walter; Algaba, Juan Carlos; Anantua, Richard; Asada, Keiichi; Azulay, Rebecca; Bach, Uwe; Baczko, Anne-Kathrin; Ball, David; Balokovic, Mislac; Barrett, John; Baubock, Michi; Benson, Bradford A.; Bintley, Dan; Blundell, Raymond; Boland, Wilfred; Bouman, Katherine L.; Bower, Geoffrey C.; Boyce, Hope; Bremer, Michael; Brinkerink, Christiaan D.; Brissenden, Roger; Britzen, Silke; Broguiere, Dominique; Bronzwaer, Thomas; Bustamante, Sandra; Byun, Do-Young; Carlstrom, John E.; Ceccobello, Chiara; Chatterjee, Koushik; Chatterjee, Shami; Chen, Ming-Tang; Chen, Yongjun; Cho, Ilje; Christian, Pierre; Conroy, Nicholas S.; Conway, John E.; Cordes, James M.; Crawford, Thomas M.; Crew, Geoffrey B.; Cruz-Osorio, Alejandro; Cui, Yuzhu; De Laurentis, Mariafelicia; Deane, Roger; Dempsey, Jessica; Desvignes, Gregory; Dexter, Jason; Doeleman, Sheperd S.; Dhruv, Vedant; Quijano, Sergio Abraham Dzib; Eatough, Ralph P.; Emami, Razieh; Falcke, Heino; Farah, Joseph; Fish, Vincent L.; Fomalont, Ed; Ford, H. Alyson; Fraga-Encinas, Raquel; Freeman, William T.; Friberg, Per; Fromm, Christian M.; Galison, Peter; Gammie, Charles F.; Garcia, Roberto; Gentaz, Olivier; Georgiev, Boris; Goddi, Ciriaco; Gold, Roman; Gomez-Ruiz, Arturo, I; Gu, Minfeng; Hada, Kazuhiro; Haggard, Daryl; Hecht, Michael H.; Hesper, Ronald; Ho, Luis C.; Ho, Paul; Honma, Mareki; Huang, Chih-Wei L.; Huang, Lei; Hughes, David H.; Ikeda, Shiro; Impellizzeri, C. M. Violette; Inoue, Makoto; James, David J.; Jannuzi, Buell T.; Jeter, Britton; Jiang, Wu; Jimenez-Rosales, Alejandra; Johnson, Michael D.; Joshi, Abhishek, V; Jung, Taehyun; Karami, Mansour; Karuppusamy, Ramesh; Kawashima, Tomohisa; Keating, Garrett K.; Kettenis, Mark; Kim, Dong-Jin; Kim, Jae-Young; Kim, Jongsoo; Kim, Junhan; Kino, Motoki; Koay, Jun Yi; Kocherlakota, Prashant; Kofuji, Yutaro; Koch, Patrick M.; Koyama, Shoko; Kramer, Carsten; Kramer, Michael; Kuo, Cheng-Yu; La Bella, Noemi; Lauer, Tod R.; Lee, Daeyoung; Lee, Sang-Sung; Leung, Po Kin; Levis, Aviad; Li, Zhiyuan; Lindahl, Greg; Lindqvist, Michael; Liu, Kuo; Liuzzo, Elisabetta; Lo, Wen-Ping; Lobanov, Andrei P.; Lonsdale, Colin; Mao, Jirong; Marchili, Nicola; Markoff, Sera; Marrone, Daniel P.; Marscher, Alan P.; Matsushita, Satoki; Matthews, Lynn D.; Medeiros, Lia; Menten, Karl M.; Michalik, Daniel; Mizuno, Izumi; Mizuno, Yosuke; Moran, James M.; Mueller, Cornelia; Mus, Alejandro; Musoke, Gibwa; Myserlis, Ioannis; Nadolski, Andrew; Nagai, Hiroshi; Nagar, Neil M.; Nakamura, Masanori; Narayan, Ramesh; Narayanan, Gopal; Natarajan, Iniyan; Nathanail, Antonios; Neilsen, Joey; Neri, Roberto; Ni, Chunchong; Noutsos, Aristeidis; Nowak, Michael A.; Oh, Junghwan; Okino, Hiroki; Olivares, Hector; Ortiz-Leon, Gisela N.; Oyama, Tomoaki; Ozel, Feryal; Palumbo, Daniel C. M.; Paraschos, Georgios Filippos; Park, Jongho; Parsons, Harriet; Patel, Nimesh; Pen, Ue-Li; Pietu, Vincent; Plambeck, Richard; PopStefanija, Aleksandar; Porth, Oliver; Potzl, Felix M.; Prather, Ben; Preciado-Lopez, Jorge A.; Psaltis, Dimitrios; Pu, Hung-Yi; Rao, Ramprasad; Rawlings, Mark G.; Raymond, Alexander W.; Rezzolla, Luciano; Ricarte, Angelo; Ripperda, Bart; Roelofs, Freek; Rogers, Alan; Ros, Eduardo; Romero-Canizales, Cristina; Roshanineshat, Arash; Rottmann, Helge; Roy, Alan L.; Ruiz, Ignacio; Ruszczyk, Chet; Rygl, Kazi L. J.; Sanchez, Salvador; Sanchez-Arguelles, David; Sanchez-Portal, Miguel; Sasada, Mahito; Satapathy, Kaushik; Savolainen, Tuomas; Schloerb, F. Peter; Schuster, Karl-Friedrich; Shao, Lijing; Shen, Zhiqiang; Small, Des; Sohn, Bong Won; SooHoo, Jason; Souccar, Kamal; Sun, He; Tazaki, Fumie; Tetarenko, Alexandra J.; Tilanus, Remo P. J.; Titus, Michael; Torne, Pablo; Trent, Tyler; Trippe, Sascha; van Bemmel, Ilse; van Langevelde, Huib Jan; van Rossum, Daniel R.; Vos, Jesse; Wagner, Jan; Ward-Thompson, Derek; Wardle, John; Weintroub, Jonathan; Wex, Norbert; Wharton, Robert; Wiik, Kaj; Witzel, Gunther; Wondrak, Michael; Wong, George N.; Wu, Qingwen; Yamaguchi, Paul; Yoon, Doosoo; Young, Andre; Young, Ken; Younsi, Ziri; Yuan, Feng; Yuan, Ye-Fei; Zensus, J. Anton; Zhang, Shuo; Zhao, Shan-Shan.-- This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited., The blazar J1924–2914 is a primary Event Horizon Telescope (EHT) calibrator for the Galactic center's black hole Sagittarius A*. Here we present the first total and linearly polarized intensity images of this source obtained with the unprecedented 20 μas resolution of the EHT. J1924–2914 is a very compact flat-spectrum radio source with strong optical variability and polarization. In April 2017 the source was observed quasi-simultaneously with the EHT (April 5–11), the Global Millimeter VLBI Array (April 3), and the Very Long Baseline Array (April 28), giving a novel view of the source at four observing frequencies, 230, 86, 8.7, and 2.3 GHz. These observations probe jet properties from the subparsec to 100 pc scales. We combine the multifrequency images of J1924–2914 to study the source morphology. We find that the jet exhibits a characteristic bending, with a gradual clockwise rotation of the jet projected position angle of about 90° between 2.3 and 230 GHz. Linearly polarized intensity images of J1924–2914 with the extremely fine resolution of the EHT provide evidence for ordered toroidal magnetic fields in the blazar compact core. © 2022. The Author(s). Published by the American Astronomical Society., The Event Horizon Telescope Collaboration thanks the following organizations and programs: the Academy of Finland (projects 274477, 284495, 312496, 315721); the Agencia Nacional de Investigación y Desarrollo (ANID), Chile via NCN19_058 (TITANs) and Fondecyt 3190878, the Alexander von Humboldt Stiftung; an Alfred P. Sloan Research Fellowship; Allegro, the European ALMA Regional Centre node in the Netherlands, the NL astronomy research network NOVA and the astronomy institutes of the University of Amsterdam, Leiden University and Radboud University; the black hole Initiative at Harvard University, through a grant (60477) from the John Templeton Foundation; the China Scholarship Council; Consejo Nacional de Ciencia y Tecnología (CONACYT, Mexico, projects U0004-246083, U0004-259839, F0003-272050, M0037-279006, F0003-281692, 104497, 275201, 263356); the Delaney Family via the Delaney Family John A. Wheeler Chair at Perimeter Institute; Dirección General de Asuntos del Personal Académico-Universidad Nacional Autónoma de México (DGAPA-UNAM, projects IN112417 and IN112820); the European Research Council Synergy Grant "BlackHoleCam: Imaging the Event Horizon of Black Holes" (grant 610058); the Generalitat Valenciana postdoctoral grant APOSTD/2018/177 and GenT Program (project CIDEGENT/2018/021); MICINN Research Project PID2019-108995GB-C22; the Gordon and Betty Moore Foundation (grant GBMF-3561); the Istituto Nazionale di Fisica Nucleare (INFN) sezione di Napoli, iniziative specifiche TEONGRAV; the International Max Planck Research School for Astronomy and Astrophysics at the Universities of Bonn and Cologne; Joint Princeton/Flatiron and Joint Columbia/Flatiron Postdoctoral Fellowships, research at the Flatiron Institute is supported by the Simons Foundation; the Japanese Government (Monbukagakusho: MEXT) Scholarship; the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for JSPS Research Fellowship (JP17J08829); the Key Research Program of Frontier Sciences, Chinese Academy of Sciences (CAS, grants QYZDJ-SSW-SLH057, QYZDJSSW- SYS008, ZDBS-LY-SLH011); the Leverhulme Trust Early Career Research Fellowship; the Max-Planck-Gesellschaft (MPG); the Max Planck Partner Group of the MPG and the CAS; the MEXT/JSPS KAKENHI (grants 18KK0090, JP18K13594, JP18K03656, JP18H03721, 18K03709, 18H01245, 25120007); the Malaysian Fundamental Research Grant Scheme (FRGS) FRGS/1/2019/STG02/UM/02/6; the MIT International Science and Technology Initiatives (MISTI) Funds; the Ministry of Science and Technology (MOST) of Taiwan (105-2112-M-001-025-MY3, 106-2112-M-001-011, 106-2119- M-001-027, 107-2119-M-001-017, 107-2119-M-001-020, 107-2119-M-110-005, 108-2112-M-001-048, and 109-2124-M-001-005); the National Aeronautics and Space Administration (NASA, Fermi Guest Investigator grant 80NSSC20K1567, NASA Astrophysics Theory Program grant 80NSSC20K0527, NASA NuSTAR award 80NSSC20K0645); the National Institute of Natural Sciences (NINS) of Japan; the National Key Research and Development Program of China (grant 2016YFA0400704, 2016YFA0400702); the National Science Foundation (NSF, grants AST-0096454, AST-0352953, AST-0521233, AST-0705062, AST-0905844, AST-0922984, AST-1126433, AST-1140030, DGE-1144085, AST-1207704, AST-1207730, AST-1207752, MRI-1228509, OPP-1248097, AST-1310896, AST-1555365,AST-1615796, AST-1715061, AST-1716327, AST-1903847,AST-2034306); the Natural Science Foundation of China (grants 11573051, 11633006, 11650110427, 10625314, 11721303, 11725312, 11933007, 11991052, 11991053); a fellowship of China Postdoctoral Science Foundation (2020M671266); the Natural Sciences and Engineering Research Council of Canada (NSERC, including a Discovery Grant and the NSERC Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program); the National Youth Thousand Talents Program of China; the National Research Foundation of Korea (the Global PhD Fellowship Grant: grants NRF-2015H1A2A1033752, 2015- R1D1A1A01056807, the Korea Research Fellowship Program: NRF-2015H1D3A1066561, Basic Research Support Grant 2019R1F1A1059721); the Netherlands Organization for Scientific Research (NWO) VICI award (grant 639.043.513) and Spinoza Prize SPI 78-409; the New Scientific Frontiers with Precision Radio Interferometry Fellowship awarded by the South African Radio Astronomy Observatory (SARAO), which is a facility of the National Research Foundation (NRF), an agency of the Department of Science and Technology (DST) of South Africa; the Onsala Space Observatory (OSO) national infrastructure, for the provisioning of its facilities/observational support (OSO receives funding through the Swedish Research Council under grant 2017-00648) the Perimeter Institute for Theoretical Physics (research at Perimeter Institute is supported by the Government of Canada through the Department of Innovation, Science and Economic Development and by the Province of Ontario through the Ministry of Research, Innovation and Science); the Spanish Ministerio de Economía y Competitividad (grants PGC2018-098915-B-C21, AYA2016-80889-P, PID2019-108995GB-C21); the State Agency for Research of the Spanish MCIU through the "Center of Excellence Severo Ochoa" award for the Instituto de Astrofísica de Andalucía (SEV-2017-0709); the Toray Science Foundation; the Consejería de Economía, Conocimiento, Empresas y Universidad of the Junta de Andalucía (grant P18-FR-1769), the Consejo Superior de Investigaciones Científicas (grant 2019AEP112); the US Department of Energy (USDOE) through the Los Alamos National Laboratory (operated by Triad National Security, LLC, for the National Nuclear Security Administration of the USDOE (Contract 89233218CNA000001); the European Union's Horizon 2020 research and innovation program under grant agreement No 730562 RadioNet; ALMA North America Development Fund; the Academia Sinica; Chandra DD7-18089X and TM6-17006X; the GenT Program (Generalitat Valenciana) Project CIDEGENT/2018/021. This work used the Extreme Science and Engineering Discovery Environment (XSEDE), supported by NSF grant ACI-1548562, and CyVerse, supported by NSF grants DBI-0735191, DBI-1265383, and DBI-1743442. XSEDE Stampede2 resource at TACC was allocated through TG-AST170024 and TG-AST080026N. XSEDE JetStream resource at PTI and TACC was allocated through AST170028. The simulations were performed in part on the SuperMUC cluster at the LRZ in Garching, on the LOEWE cluster in CSC in Frankfurt, and on the HazelHen cluster at the HLRS in Stuttgart. This research was enabled in part by support provided by Compute Ontario (http://computeontario.ca), Calcul Quebec (http://www.calculquebec.ca) and Compute Canada (http://www.computecanada.ca).

As part of an institutional quality improvement (QI) initiative for the 2018-2019 academic year, orthopedic residents at our tertiary center were incentivized to bring over 75% of hip fracture patients with American Society of Anesthesiologists (ASA) Class 2 or less to surgery in under 24 hours, compared to the baseline rate of 55.9%. The time between admission and surgery for hip fracture patients with ASA class 2 or less was prospectively recorded. At the end of the study period, a retrospective comparison was performed between patients treated before and after the resident QI initiative. The percentage of patients who underwent surgery within 24 hours of admission increased significantly in the Study Cohort compared to the Baseline Cohort (78.6% vs. 55.9%, p = .037). Length of stay was shorter in the Study Cohort compared to the Baseline Cohort (3 days vs. 4 days, p = .01), whereas readmissions (3.6% vs. 4.4%, p = .85) and discharges to skilled nursing facilities (60.7% vs. 57.4%, p = .76) were comparable between both cohorts. A goal-directed, resident-led QI initiative was associated with a significantly increased percentage of hip fragility fracture patients who underwent surgery in less than 24 hours.

Background While many factors have been shown to influence patient willingness to have total joint arthroplasty, factors associated with changes in patient willingness to have arthroplasty have not been studied. The objective of this research is to identify predictors of change in patient willingness to have total knee arthroplasty (TKA). Methods Patient willingness to have TKA as well as questionnaire, clinical, and radiographic data, were obtained from the Osteoarthritis Initiative (OAI) for individuals with, or at high risk for developing knee OA. Mixed effects ordinal logistic regressions were employed to assess the relationships between 40 predictors and change in willingness to have surgery. Predictors significant in univariate models were included in a multivariable analysis. Results Three thousand three hundred and ninety-four OAI patients were included in our analysis. Between baseline and follow-up, 462 (13.6%) became more willing and 533 (15.7%) became less willing to have TKA. After controlling for demographic factors in multivariable analysis, patients with higher income and expected difficulty with postoperative walking were more likely to increase their willingness to have TKA. General health, race, and knee injections within the past six months approached significance with regard to increasing willingness to have TKA over time. Conclusion Income and expectations of difficulty walking postoperatively were significantly associated with changes in patient willingness to have TKA independent of age, sex, health coverage, employment, marriage status, and knee pain. Understanding factors influencing patient willingness to have surgery may be instrumental in counseling and addressing the mismatch of OA disease burden to surgical utilization.

Surgical-site delivery of local anesthetics decreases pain and opioid consumption after total knee arthroplasty (TKA). The optimal route of administration is unknown. We compared local anesthetic delivery using periarticular soft-tissue infiltration to delivery using a combination of preimplantation immersion and intra-articular injection (combination treatment). The records of patients who underwent unilateral, cemented, primary TKA with spinal anesthesia and adductor canal blocks at a single Veterans Affairs Medical Center were retrospectively reviewed. Three subgroups were compared, including controls who did not receive additional local anesthetics, patients who received periarticular infiltration, and patients who received combination treatment. Mean daily pain scores and mean 24-hour opioid consumption on postoperative days (PODs) 0 and 1 were calculated, and analysis of variance was used to assess for significant differences. Factors that were associated with lower pain scores and opioid consumption were then identified using multivariate stepwise regression. There were 26 controls, 25 periarticular infiltration patients, and 39 combination patients. The periarticular infiltration cohort had significantly lower mean pain scores and opioid consumption than controls on POD 0, but not on POD 1. The combination cohort had significantly lower mean pain scores and opioid consumption than controls on PODs 0 and 1. There were no significant differences between the infiltration and combination groups on either day. Multivariate regression analysis showed that infiltration was associated with significantly decreased opioid consumption on both days and decreased pain on POD 0. Combination treatment was associated with significantly decreased pain and opioid consumption on both days. Both local anesthetic periarticular infiltration and combination treatment are associated with decreased pain and opioid consumption after TKA. The stronger effects of the combination treatment compared with periarticular infiltration on POD 1 suggests that combination delivery may have a longer duration of action.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Full list of authors: Akiyama, Kazunori; Alberdi, Antxon; Alef, Walter; Algaba, Juan Carlos; Anantua, Richard; Asada, Keiichi; Azulay, Rebecca; Bach, Uwe; Baczko, Anne-Kathrin; Ball, David; Balokovic, Mislav; Barrett, John; Baubock, Michi; Benson, Bradford A.; Bintley, Dan; Blackburn, Lindy; Blundell, Raymond; Bouman, Katherine L.; Bower, Geoffrey C.; Boyce, Hope; Bremer, Michael; Brinkerink, Christiaan D.; Brissenden, Roger; Britzen, Silke; Broderick, Avery E.; Broguiere, Dominique; Bronzwaer, Thomas; Bustamante, Sandra; Byun, Do-Young; Carlstrom, John E.; Ceccobello, Chiara; Chael, Andrew; Chan, Chi-kwan; Chatterjee, Koushik; Chatterjee, Shami; Chen, Ming-Tang; Chen, Yongjun; Cheng, Xiaopeng; Cho, Ilje; Christian, Pierre; Conroy, Nicholas S.; Conway, John E.; Cordes, James M.; Crawford, Thomas M.; Crew, Geoffrey B.; Cruz-Osorio, Alejandro; Cui, Yuzhu; Davelaar, Jordy; De Laurentis, Mariafelicia; Deane, Roger; Dempsey, Jessica; Desvignes, Gregory; Dexter, Jason; Dhruv, Vedant; Doeleman, Sheperd S.; Dougal, Sean; Dzib, Sergio A.; Eatough, Ralph P.; Emami, Razieh; Falcke, Heino; Farah, Joseph; Fish, Vincent L.; Fomalont, Ed; Ford, H. Alyson; Fraga-Encinas, Raquel; Freeman, William T.; Friberg, Per; Fromm, Christian M.; Fuentes, Antonio; Galison, Peter; Gammie, Charles F.; Garcia, Roberto; Gentaz, Olivier; Georgiev, Boris; Goddi, Ciriaco; Gold, Roman; Gomez-Ruiz, Arturo, I; Gomez, Jose L.; Gu, Minfeng; Gurwell, Mark; Hada, Kazuhiro; Haggard, Daryl; Haworth, Kari; Hecht, Michael H.; Hesper, Ronald; Heumann, Dirk; Ho, Luis C.; Ho, Paul; Honma, Mareki; Huang, Chih-Wei L.; Huang, Lei; Hughes, David H.; Ikeda, Shiro; Impellizzeri, C. M. Violette; Inoue, Makoto; Issaoun, Sara; James, David J.; Jannuzi, Buell T.; Janssen, Michael; Jeter, Britton; Jiang, Wu; Jimenez-Rosales, Alejandra; Johnson, Michael D.; Jorstad, Svetlana; Joshi, Abhishek, V; Jung, Taehyun; Karami, Mansour; Karuppusamy, Ramesh; Kawashima, Tomohisa; Keating, Garrett K.; Kettenis, Mark; Kim, Dong-Jin; Kim, Jae-Young; Kim, Jongsoo; Kim, Junhan; Kino, Motoki; Koay, Jun Yi; Kocherlakota, Prashant; Kofuji, Yutaro; Koch, Patrick M.; Koyama, Shoko; Kramer, Carsten; Kramer, Michael; Krichbaum, Thomas P.; Kuo, Cheng-Yu; La Bella, Noemi; Lauer, Tod R.; Lee, Daeyoung; Lee, Sang-Sung; Leung, Po Kin; Levis, Aviad; Li, Zhiyuan; Lico, Rocco; Lindahl, Greg; Lindqvist, Michael; Lisakov, Mikhail; Liu, Jun; Liu, Kuo; Liuzzo, Elisabetta; Lo, Wen-Ping; Lobanov, Andrei P.; Loinard, Laurent; Lonsdale, Colin J.; Lu, Ru-Sen; Mao, Jirong; Marchili, Nicola; Markoff, Sera; Marrone, Daniel P.; Marscher, Alan P.; Marti-Vidal, Ivan; Matsushita, Satoki; Matthews, Lynn D.; Medeiros, Lia; Menten, Karl M.; Michalik, Daniel; Mizuno, Izumi; Mizuno, Yosuke; Moran, James M.; Moriyama, Kotaro; Moscibrodzka, Monika; Muller, Cornelia; Mus, Alejandro; Musoke, Gibwa; Myserlis, Ioannis; Nadolski, Andrew; Nagai, Hiroshi; Nagar, Neil M.; Nakamura, Masanori; Narayan, Ramesh; Narayanan, Gopal; Natarajan, Iniyan; Nathanail, Antonios; Fuentes, Santiago Navarro; Neilsen, Joey; Neri, Roberto; Ni, Chunchong; Noutsos, Aristeidis; Nowak, Michael A.; Oh, Junghwan; Okino, Hiroki; Olivares, Hector; Ortiz-Leon, Gisela N.; Oyama, Tomoaki; Palumbo, Daniel C. M.; Paraschos, Georgios Filippos; Park, Jongho; Parsons, Harriet; Patel, Nimesh; Pen, Ue-Li; Pesce, Dominic W.; Pietu, Vincent; Plambeck, Richard; PopStefanija, Aleksandar; Porth, Oliver; Potzl, Felix M.; Prather, Ben; Preciado-Lopez, Jorge A.; Pu, Hung-Yi; Ramakrishnan, Venkatessh; Rao, Ramprasad; Rawlings, Mark G.; Raymond, Alexander W.; Rezzolla, Luciano; Ricarte, Angelo; Ripperda, Bart; Roelofs, Freek; Rogers, Alan; Ros, Eduardo; Romero-Canizales, Cristina; Roshanineshat, Arash; Rottmann, Helge; Roy, Alan L.; Ruiz, Ignacio; Ruszczyk, Chet; Rygl, Kazi L. J.; Sanchez, Salvador; Sanchez-Arguelles, David; Sanchez-Portal, Miguel; Sasada, Mahito; Satapathy, Kaushik; Savolainen, Tuomas; Schloerb, F. Peter; Schonfeld, Jonathan; Schuster, Karl-Friedrich; Shao, Lijing; Shen, Zhiqiang; Small, Des; Sohn, Bong Won; SooHoo, Jason; Souccar, Kamal; Sun, He; Tazaki, Fumie; Tetarenko, Alexandra J.; Tiede, Paul; Tilanus, Remo P. J.; Titus, Michael; Torne, Pablo; Traianou, Efthalia; Trent, Tyler; Trippe, Sascha; Turk, Matthew; van Bemmel, Ilse; van Langevelde, Huib Jan; van Rossum, Daniel R.; Vos, Jesse; Wagner, Jan; Ward-Thompson, Derek; Wardle, John; Weintroub, Jonathan; Wex, Norbert; Wharton, Robert; Wielgus, Maciek; Wiik, Kaj; Witzel, Gunther; Wondrak, Michael F.; Wong, George N.; Wu, Qingwen; Yamaguchi, Paul; Yoon, Doosoo; Young, Andre; Young, Ken; Younsi, Ziri; Yuan, Feng; Yuan, Ye-Fei; Zensus, J. Anton; Zhang, Shuo; Zhao, Guang-Yao; Zhao, Shan-Shan; Ozel, Feryal; Agurto, Claudio; Allardi, Alexander; Amestica, Rodrigo; Araneda, Juan Pablo; Arriagada, Oriel; Berghuis, Jennie L.; Bertarini, Alessandra; Berthold, Ryan; Blanchard, Jay; Brown, Ken; Cardenas, Mauricio; Cantzler, Michael; Caro, Patricio; Castillo-Dominguez, Edgar; Chan, Tin Lok; Chang, Chih-Cheng; Chang, Dominic O.; Chang, Shu-Hao; Chang, Song-Chu; Chen, Chung-Chen; Chilson, Ryan; Chuter, Tim C.; Ciechanowicz, Miroslaw; Colin-Beltran, Edgar; Coulson, Iain M.; Crowley, Joseph; Degenaar, Nathalie; Dornbusch, Sven; Duran, Carlos A.; Everett, Wendeline B.; Faber, Aaron; Forster, Karl; Fuchs, Miriam M.; Gale, David M.; Geertsema, Gertie; Gonzalez, Edouard; Graham, Dave; Gueth, Frederic; Halverson, Nils W.; Han, Chih-Chiang; Han, Kuo-Chang; Hasegawa, Yutaka; Hernandez-Rebollar, Jose Luis; Herrera, Cristian; Herrero-Illana, Ruben; Heyminck, Stefan; Hirota, Akihiko; Hoge, James; Schimpf, Shelbi R. Hostler; Howie, Ryan E.; Huang, Yau-De; Jiang, Homin; Jinchi, Hao; John, David; Kimura, Kimihiro; Klein, Thomas; Kubo, Derek; Kuroda, John; Kwon, Caleb; Lacasse, Richard; Laing, Robert; Leitch, Erik M.; Li, Chao-Te; Liu, Ching-Tang; Liu, Kuan-Yu; Lin, Lupin C-C; Lu, Li-Ming; Mac-Auliffe, Felipe; Martin-Cocher, Pierre; Matulonis, Callie; Maute, John K.; Messias, Hugo; Meyer-Zhao, Zheng; Montana, Alfredo; Montenegro-Montes, Francisco; Montgomerie, William; Nolasco, Marcos Emir Moreno; Muders, Dirk; Nishioka, Hiroaki; Norton, Timothy J.; Nystrom, George; Ogawa, Hideo; Olivares, Rodrigo; Oshiro, Peter; Perez-Beaupuits, Juan Pablo; Parra, Rodrigo; Phillips, Neil M.; Poirier, Michael; Pradel, Nicolas; Qiu, Richard; Raffin, Philippe A.; Rahlin, Alexandra S.; Ramirez, Jorge; Ressler, Sean; Reynolds, Mark; Rodriguez-Montoya, Ivan; Saez-Madain, Alejandro F.; Santana, Jorge; Shaw, Paul; Shirkey, Leslie E., Jr.; Silva, Kevin M.; Snow, William; Sousa, Don; Sridharan, T. K.; Stahm, William; Stark, Anthony A.; Test, John; Torstensson, Karl; Venegas, Paulina; Walther, Craig; Wei, Ta-Shun; White, Chris; Wieching, Gundolf; Wijnands, Rudy; Wouterloot, Jan G. A.; Yu, Chen-Yu; Yu, Wei; Zeballos, Milagros; Event Horizon Telescope Collaboration., We present the first Event Horizon Telescope (EHT) observations of Sagittarius A* (Sgr A*), the Galactic center source associated with a supermassive black hole. These observations were conducted in 2017 using a global interferometric array of eight telescopes operating at a wavelength of λ = 1.3 mm. The EHT data resolve a compact emission region with intrahour variability. A variety of imaging and modeling analyses all support an image that is dominated by a bright, thick ring with a diameter of 51.8 ± 2.3 μas (68% credible interval). The ring has modest azimuthal brightness asymmetry and a comparatively dim interior. Using a large suite of numerical simulations, we demonstrate that the EHT images of Sgr A* are consistent with the expected appearance of a Kerr black hole with mass ∼4 × 106 M⊙, which is inferred to exist at this location based on previous infrared observations of individual stellar orbits, as well as maser proper-motion studies. Our model comparisons disfavor scenarios where the black hole is viewed at high inclination (i > 50°), as well as nonspinning black holes and those with retrograde accretion disks. Our results provide direct evidence for the presence of a supermassive black hole at the center of the Milky Way, and for the first time we connect the predictions from dynamical measurements of stellar orbits on scales of 103–105 gravitational radii to event-horizon-scale images and variability. Furthermore, a comparison with the EHT results for the supermassive black hole M87* shows consistency with the predictions of general relativity spanning over three orders of magnitude in central mass. © 2022. The Author(s). Published by the American Astronomical Society., The Event Horizon Telescope Collaboration thanks the following organizations and programs: the Academia Sinica; the Academy of Finland (projects 274477, 284495, 312496, 315721); the Agencia Nacional de Investigación y Desarrollo (ANID), Chile via NCN19_058 (TITANs) and Fondecyt 1221421, the Alexander von Humboldt Stiftung; an Alfred P. Sloan Research Fellowship; Allegro, the European ALMA Regional Centre node in the Netherlands, the NL astronomy research network NOVA and the astronomy institutes of the University of Amsterdam, Leiden University and Radboud University; the ALMA North America Development Fund; the Black Hole Initiative, which is funded by grants from the John Templeton Foundation and the Gordon and Betty Moore Foundation (although the opinions expressed in this work are those of the author(s) and do not necessarily reflect the views of these Foundations); Chandra DD7-18089X and TM6-17006X; the China Scholarship Council; China Postdoctoral Science Foundation fellowship (2020M671266); Consejo Nacional de Ciencia y Tecnología (CONACYT, Mexico, projects U0004-246083, U0004-259839, F0003-272050, M0037-279006, F0003-281692, 104497, 275201, 263356); the Consejería de Economía, Conocimiento, Empresas y Universidad of the Junta de Andalucía (grant P18-FR-1769), the Consejo Superior de Investigaciones Científicas (grant 2019AEP112); the Delaney Family via the Delaney Family John A. Wheeler Chair at Perimeter Institute; Dirección General de Asuntos del Personal Académico-Universidad Nacional Autónoma de México (DGAPA-UNAM, projects IN112417 and IN112820); the Dutch Organization for Scientific Research (NWO) VICI award (grant 639.043.513) and grant OCENW.KLEIN.113; the Dutch National Supercomputers, Cartesius and Snellius (NWO Grant 2021.013); the EACOA Fellowship awarded by the East Asia Core Observatories Association, which consists of the Academia Sinica Institute of Astronomy and Astrophysics, the National Astronomical Observatory of Japan, Center for Astronomical Mega-Science, Chinese Academy of Sciences, and the Korea Astronomy and Space Science Institute; the European Research Council (ERC) Synergy Grant "BlackHoleCam: Imaging the Event Horizon of Black Holes" (grant 610058); the European Union Horizon 2020 research and innovation programme under grant agreements RadioNet (No 730562) and M2FINDERS (No 101018682); the Generalitat Valenciana postdoctoral grant APOSTD/2018/177 and GenT Program (project CIDEGENT/2018/021); MICINN Research Project PID2019-108995GB-C22; the European Research Council for advanced grant "JETSET: Launching, propagation and emission of relativistic jets from binary mergers and across mass scales" (Grant No. 884631); the Institute for Advanced Study; the Istituto Nazionale di Fisica Nucleare (INFN) sezione di Napoli, iniziative specifiche TEONGRAV; the International Max Planck Research School for Astronomy and Astrophysics at the Universities of Bonn and Cologne; DFG research grant "Jet physics on horizon scales and beyond" (Grant No. FR 4069/2-1); Joint Princeton/Flatiron and Joint Columbia/Flatiron Postdoctoral Fellowships, research at the Flatiron Institute is supported by the Simons Foundation; the Japan Ministry of Education, Culture, Sports, Science and Technology (MEXT; grant JPMXP1020200109); the Japanese Government (Monbukagakusho: MEXT) Scholarship; the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for JSPS Research Fellowship (JP17J08829); the Joint Institute for Computational Fundamental Science, Japan; the Key Research Program of Frontier Sciences, Chinese Academy of Sciences (CAS, grants QYZDJ-SSW-SLH057, QYZDJSSW-SYS008, ZDBS-LY-SLH011); the Leverhulme Trust Early Career Research Fellowship; the Max-Planck-Gesellschaft (MPG); the Max Planck Partner Group of the MPG and the CAS; the MEXT/JSPS KAKENHI (grants 18KK0090, JP21H01137, JP18H03721, JP18K13594, 18K03709, JP19K14761, 18H01245, 25120007); the Malaysian Fundamental Research Grant Scheme (FRGS) FRGS/1/2019/STG02/UM/02/6; the MIT International Science and Technology Initiatives (MISTI) Funds; the Ministry of Science and Technology (MOST) of Taiwan (103-2119-M-001-010-MY2, 105-2112-M-001-025-MY3, 105-2119-M-001-042, 106-2112-M-001-011, 106-2119-M-001-013, 106-2119-M-001-027, 106-2923-M-001-005, 107-2119-M-001-017, 107-2119-M-001-020, 107-2119-M-001-041, 107-2119-M-110-005, 107-2923-M-001-009, 108-2112-M-001-048, 108-2112-M-001-051, 108-2923-M-001-002, 109-2112-M-001-025, 109-2124-M-001-005, 109-2923-M-001-001, 110-2112-M-003-007-MY2, 110-2112-M-001-033, 110-2124-M-001-007, and 110-2923-M-001-001); the Ministry of Education (MoE) of Taiwan Yushan Young Scholar Program; the Physics Division, National Center for Theoretical Sciences of Taiwan; the National Aeronautics and Space Administration (NASA, Fermi Guest Investigator grant 80NSSC20K1567, NASA Astrophysics Theory Program grant 80NSSC20K0527, NASA NuSTAR award 80NSSC20K0645); NASA Hubble Fellowship grant HST-HF2-51431.001-A awarded by the Space Telescope Science Institute, which is operated by the Association of Universities for Research in Astronomy, Inc., for NASA, under contract NAS5-26555; the National Institute of Natural Sciences (NINS) of Japan; the National Key Research and Development Program of China (grant 2016YFA0400704, 2017YFA0402703, 2016YFA0400702); the National Science Foundation (NSF, grants AST-0096454, AST-0352953, AST-0521233, AST-0705062, AST-0905844, AST-0922984, AST-1126433, AST-1140030, DGE-1144085, AST-1207704, AST-1207730, AST-1207752, MRI-1228509, OPP-1248097, AST-1310896, AST-1440254, AST-1555365, AST-1614868, AST-1615796, AST-1715061, AST-1716327, AST-1716536, OISE-1743747, AST-1816420, AST-1935980, AST-2034306); NSF Astronomy and Astrophysics Postdoctoral Fellowship (AST-1903847); the Natural Science Foundation of China (grants 11650110427, 10625314, 11721303, 11725312, 11873028, 11933007, 11991052, 11991053, 12192220, 12192223); the Natural Sciences and Engineering Research Council of Canada (NSERC, including a Discovery Grant and the NSERC Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program); the National Youth Thousand Talents Program of China; the National Research Foundation of Korea (the Global PhD Fellowship Grant: grants NRF-2015H1A2A1033752, the Korea Research Fellowship Program: NRF-2015H1D3A1066561, Brain Pool Program: 2019H1D3A1A01102564, Basic Research Support Grant 2019R1F1A1059721, 2021R1A6A3A01086420, 2022R1C1C1005255); Netherlands Research School for Astronomy (NOVA) Virtual Institute of Accretion (VIA) postdoctoral fellowships; Onsala Space Observatory (OSO) national infrastructure, for the provisioning of its facilities/observational support (OSO receives funding through the Swedish Research Council under grant 2017-00648); the Perimeter Institute for Theoretical Physics (research at Perimeter Institute is supported by the Government of Canada through the Department of Innovation, Science and Economic Development and by the Province of Ontario through the Ministry of Research, Innovation and Science); the Spanish Ministerio de Ciencia e Innovación (grants PGC2018-098915-B-C21, AYA2016-80889-P, PID2019-108995GB-C21, PID2020-117404GB-C21); the University of Pretoria for financial aid in the provision of the new Cluster Server nodes and SuperMicro (USA) for a SEEDING GRANT approved towards these nodes in 2020; the Shanghai Pilot Program for Basic Research, Chinese Academy of Science, Shanghai Branch (JCYJ-SHFY-2021-013); the State Agency for Research of the Spanish MCIU through the "Center of Excellence Severo Ochoa" award for the Instituto de Astrofísica de Andalucía (SEV-2017- 0709); the Spinoza Prize SPI 78-409; the South African Research Chairs Initiative, through the South African Radio Astronomy Observatory (SARAO, grant ID 77948), which is a facility of the National Research Foundation (NRF), an agency of the Department of Science and Innovation (DSI) of South Africa; the Toray Science Foundation; Swedish Research Council (VR); the US Department of Energy (USDOE) through the Los Alamos National Laboratory (operated by Triad National Security, LLC, for the National Nuclear Security Administration of the USDOE (Contract 89233218CNA000001); and the YCAA Prize Postdoctoral Fellowship. APEX is a collaboration between the Max-Planck-Institut für Radioastronomie (Germany), ESO, and the Onsala Space Observatory (Sweden). The SMA is a joint project between the SAO and ASIAA and is funded by the Smithsonian Institution and the Academia Sinica. The JCMT is operated by the East Asian Observatory on behalf of the NAOJ, ASIAA, and KASI, as well as the Ministry of Finance of China, Chinese Academy of Sciences, and the National Key Research and Development Program (No. 2017YFA0402700) of China and Natural Science Foundation of China grant 11873028. Additional funding support for the JCMT is provided by the Science and Technologies Facility Council (UK) and participating universities in the UK and Canada. The LMT is a project operated by the Instituto Nacional de Astrófisica, Óptica, y Electrónica (Mexico) and the University of Massachusetts at Amherst (USA). The IRAM 30-m telescope on Pico Veleta, Spain is operated by IRAM and supported by CNRS (Centre National de la Recherche Scientifique, France), MPG (Max-Planck-Gesellschaft, Germany) and IGN (Instituto Geográfico Nacional, Spain). The SMT is operated by the Arizona Radio Observatory, a part of the Steward Observatory of the University of Arizona, with financial support of operations from the State of Arizona and financial support for instrumentation development from the NSF. Support for SPT participation in the EHT is provided by the National Science Foundation through award OPP-1852617 to the University of Chicago. Partial support is also provided by the Kavli Institute of Cosmological Physics at the University of Chicago. The SPT hydrogen maser was provided on loan from the GLT, courtesy of ASIAA. This work used the Extreme Science and Engineering Discovery Environment (XSEDE), supported by NSF grant ACI-1548562, and CyVerse, supported by NSF grants DBI-0735191, DBI-1265383, and DBI-1743442. XSEDE Stampede2 resource at TACC was allocated through TG-AST170024 and TG-AST080026N. XSEDE JetStream resource at PTI and TACC was allocated through AST170028. This research is part of the Frontera computing project at the Texas Advanced Computing Center through the Frontera Large-Scale Community Partnerships allocation AST20023. Frontera is made possible by National Science Foundation award OAC-1818253. This research was carried out using resources provided by the Open Science Grid, which is supported by the National Science Foundation and the U.S. Department of Energy Office of Science. Additional work used ABACUS2.0, which is part of the eScience center at Southern Denmark University. Simulations were also performed on the SuperMUC cluster at the LRZ in Garching, on the LOEWE cluster in CSC in Frankfurt, on the HazelHen cluster at the HLRS in Stuttgart, and on the Pi2.0 and Siyuan Mark-I at Shanghai Jiao Tong University. The computer resources of the Finnish IT Center for Science (CSC) and the Finnish Computing Competence Infrastructure (FCCI) project are acknowledged. This research was enabled in part by support provided by Compute Ontario (http://computeontario.ca), Calcul Quebec (http://www.calculquebec.ca) and Compute Canada (http://www.computecanada.ca).

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Full list of authors: Akiyama, Kazunori; Alberdi, Antxon; Alef, Walter; Algaba, Juan Carlos; Anantua, Richard; Asada, Keiichi; Azulay, Rebecca; Bach, Uwe; Baczko, Anne-Kathrin; Ball, David; Balokovic, Mislav; Barrett, John; Baubock, Michi; Benson, Bradford A.; Bintley, Dan; Blackburn, Lindy; Blundell, Raymond; Bouman, Katherine L.; Bower, Geoffrey C.; Boyce, Hope; Bremer, Michael; Brinkerink, Christiaan D.; Brissenden, Roger; Britzen, Silke; Broderick, Avery E.; Broguiere, Dominique; Bronzwaer, Thomas; Bustamante, Sandra; Byun, Do-Young; Carlstrom, John E.; Ceccobello, Chiara; Chael, Andrew; Chan, Chi-kwan; Chatterjee, Koushik; Chatterjee, Shami; Chen, Ming-Tang; Chen, Yongjun; Cheng, Xiaopeng; Cho, Ilje; Christian, Pierre; Conroy, Nicholas S.; Conway, John E.; Cordes, James M.; Crawford, Thomas M.; Crew, Geoffrey B.; Cruz-Osorio, Alejandro; Cui, Yuzhu; Davelaar, Jordy; De Laurentis, Mariafelicia; Deane, Roger; Dempsey, Jessica; Desvignes, Gregory; Dexter, Jason; Dhruv, Vedant; Doeleman, Sheperd S.; Dougal, Sean; Dzib, Sergio A.; Eatough, Ralph P.; Emami, Razieh; Falcke, Heino; Farah, Joseph; Fish, Vincent L.; Fomalont, Ed; Ford, H. Alyson; Fraga-Encinas, Raquel; Freeman, William T.; Friberg, Per; Fromm, Christian M.; Fuentes, Antonio; Galison, Peter; Gammie, Charles F.; Garcia, Roberto; Gentaz, Olivier; Georgiev, Boris; Goddi, Ciriaco; Gold, Roman; Gomez-Ruiz, Arturo, I; Gomez, Jose L.; Gu, Minfeng; Gurwell, Mark; Hada, Kazuhiro; Haggard, Daryl; Haworth, Kari; Hecht, Michael H.; Hesper, Ronald; Heumann, Dirk; Ho, Luis C.; Ho, Paul; Honma, Mareki; Huang, Chih-Wei L.; Huang, Lei; Hughes, David H.; Ikeda, Shiro; Impellizzeri, C. M. Violette; Inoue, Makoto; Issaoun, Sara; James, David J.; Jannuzi, Buell T.; Janssen, Michael; Jeter, Britton; Jiang, Wu; Jimenez-Rosales, Alejandra; Johnson, Michael D.; Jorstad, Svetlana; Joshi, Abhishek, V; Jung, Taehyun; Karami, Mansour; Karuppusamy, Ramesh; Kawashima, Tomohisa; Keating, Garrett K.; Kettenis, Mark; Kim, Dong-Jin; Kim, Jae-Young; Kim, Jongsoo; Kim, Junhan; Kino, Motoki; Koay, Jun Yi; Kocherlakota, Prashant; Kofuji, Yutaro; Koch, Patrick M.; Koyama, Shoko; Kramer, Carsten; Kramer, Michael; Krichbaum, Thomas P.; Kuo, Cheng-Yu; La Bella, Noemi; Lauer, Tod R.; Lee, Daeyoung; Lee, Sang-Sung; Leung, Po Kin; Levis, Aviad; Li, Zhiyuan; Lico, Rocco; Lindahl, Greg; Lindqvist, Michael; Lisakov, Mikhail; Liu, Jun; Liu, Kuo; Liuzzo, Elisabetta; Lo, Wen-Ping; Lobanov, Andrei P.; Loinard, Laurent; Lonsdale, Colin J.; Lu, Ru-Sen; Mao, Jirong; Marchili, Nicola; Markoff, Sera; Marrone, Daniel P.; Marscher, Alan P.; Marti-Vidal, Ivan; Matsushita, Satoki; Matthews, Lynn D.; Medeiros, Lia; Menten, Karl M.; Michalik, Daniel; Mizuno, Izumi; Mizuno, Yosuke; Moran, James M.; Moriyama, Kotaro; Moscibrodzka, Monika; Muller, Cornelia; Mus, Alejandro; Musoke, Gibwa; Myserlis, Ioannis; Nadolski, Andrew; Nagai, Hiroshi; Nagar, Neil M.; Nakamura, Masanori; Narayan, Ramesh; Narayanan, Gopal; Natarajan, Iniyan; Nathanail, Antonios; Fuentes, Santiago Navarro; Neilsen, Joey; Neri, Roberto; Ni, Chunchong; Noutsos, Aristeidis; Nowak, Michael A.; Oh, Junghwan; Okino, Hiroki; Olivares, Hector; Ortiz-Leon, Gisela N.; Oyama, Tomoaki; Ozel, Feryal; Palumbo, Daniel C. M.; Paraschos, Georgios Filippos; Park, Jongho; Parsons, Harriet; Patel, Nimesh; Pen, Ue-Li; Pesce, Dominic W.; Pietu, Vincent; Plambeck, Richard; PopStefanija, Aleksandar; Porth, Oliver; Potzl, Felix M.; Prather, Ben; Preciado-Lopez, Jorge A.; Psaltis, Dimitrios; Pu, Hung-Yi; Ramakrishnan, Venkatessh; Rao, Ramprasad; Rawlings, Mark G.; Raymond, Alexander W.; Rezzolla, Luciano; Ricarte, Angelo; Ripperda, Bart; Roelofs, Freek; Rogers, Alan; Ros, Eduardo; Romero-Canizales, Cristina; Roshanineshat, Arash; Rottmann, Helge; Roy, Alan L.; Ruiz, Ignacio; Ruszczyk, Chet; Rygl, Kazi L. J.; Sanchez, Salvador; Sanchez-Arguelles, David; Sanchez-Portal, Miguel; Sasada, Mahito; Satapathy, Kaushik; Savolainen, Tuomas; Schloerb, F. Peter; Schonfeld, Jonathan; Schuster, Karl-Friedrich; Shao, Lijing; Shen, Zhiqiang; Small, Des; Sohn, Bong Won; SooHoo, Jason; Souccar, Kamal; Sun, He; Tazaki, Fumie; Tetarenko, Alexandra J.; Tiede, Paul; Tilanus, Remo P. J.; Titus, Michael; Torne, Pablo; Traianou, Efthalia; Trent, Tyler; Trippe, Sascha; Turk, Matthew; van Bemmel, Ilse; van Langevelde, Huib Jan; van Rossum, Daniel R.; Vos, Jesse; Wagner, Jan; Ward-Thompson, Derek; Wardle, John; Weintroub, Jonathan; Wex, Norbert; Wharton, Robert; Wielgus, Maciek; Wiik, Kaj; Witzel, Gunther; Wondrak, Michael F.; Wong, George N.; Wu, Qingwen; Yamaguchi, Paul; Yoon, Doosoo; Young, Andre; Young, Ken; Younsi, Ziri; Yuan, Feng; Yuan, Ye-Fei; Zensus, J. Anton; Zhang, Shuo; Zhao, Guang-Yao; Zhao, Shan-Shan; Event Horizon Telescope Collaboration., Astrophysical black holes are expected to be described by the Kerr metric. This is the only stationary, vacuum, axisymmetric metric, without electromagnetic charge, that satisfies Einstein's equations and does not have pathologies outside of the event horizon. We present new constraints on potential deviations from the Kerr prediction based on 2017 EHT observations of Sagittarius A* (Sgr A*). We calibrate the relationship between the geometrically defined black hole shadow and the observed size of the ring-like images using a library that includes both Kerr and non-Kerr simulations. We use the exquisite prior constraints on the mass-to-distance ratio for Sgr A* to show that the observed image size is within ∼10% of the Kerr predictions. We use these bounds to constrain metrics that are parametrically different from Kerr, as well as the charges of several known spacetimes. To consider alternatives to the presence of an event horizon, we explore the possibility that Sgr A* is a compact object with a surface that either absorbs and thermally reemits incident radiation or partially reflects it. Using the observed image size and the broadband spectrum of Sgr A*, we conclude that a thermal surface can be ruled out and a fully reflective one is unlikely. We compare our results to the broader landscape of gravitational tests. Together with the bounds found for stellar-mass black holes and the M87 black hole, our observations provide further support that the external spacetimes of all black holes are described by the Kerr metric, independent of their mass. © 2022. The Author(s). Published by the American Astronomical Society., The Event Horizon Telescope Collaboration thanks the following organizations and programs: the Academia Sinica; the Academy of Finland (projects 274477, 284495, 312496, 315721); the Agencia Nacional de Investigación y Desarrollo (ANID), Chile via NCN19_058 (TITANs) and Fondecyt 1221421, the Alexander von Humboldt Stiftung; an Alfred P. Sloan Research Fellowship; Allegro, the European ALMA Regional Centre node in the Netherlands, the NL astronomy research network NOVA and the astronomy institutes of the University of Amsterdam, Leiden University and Radboud University; the ALMA North America Development Fund; the Black Hole Initiative, which is funded by grants from the John Templeton Foundation and the Gordon and Betty Moore Foundation (although the opinions expressed in this work are those of the author(s) and do not necessarily reflect the views of these Foundations); Chandra DD7-18089X and TM6-17006X; the China Scholarship Council; China Postdoctoral Science Foundation fellowship (2020M671266); Consejo Nacional de Ciencia y Tecnología (CONACYT, Mexico, projects U0004-246083, U0004-259839, F0003-272050, M0037-279006, F0003-281692, 104497, 275201, 263356); the Consejería de Economía, Conocimiento, Empresas y Universidad of the Junta de Andalucía (grant P18-FR-1769), the Consejo Superior de Investigaciones Científicas (grant 2019AEP112); the Delaney Family via the Delaney Family John A. Wheeler Chair at Perimeter Institute; Dirección General de Asuntos del Personal Académico-Universidad Nacional Autónoma de México (DGAPA-UNAM, projects IN112417 and IN112820); the Dutch Organization for Scientific Research (NWO) VICI award (grant 639.043.513) and grant OCENW.KLEIN.113; the Dutch National Supercomputers, Cartesius and Snellius (NWO Grant 2021.013); the EACOA Fellowship awarded by the East Asia Core Observatories Association, which consists of the Academia Sinica Institute of Astronomy and Astrophysics, the National Astronomical Observatory of Japan, Center for Astronomical Mega-Science, Chinese Academy of Sciences, and the Korea Astronomy and Space Science Institute; the European Research Council (ERC) Synergy Grant "BlackHoleCam: Imaging the Event Horizon of Black Holes" (grant 610058); the European Union Horizon 2020 research and innovation programme under grant agreements RadioNet (No 730562) and M2FINDERS (No 101018682); the Generalitat Valenciana postdoctoral grant APOSTD/2018/177 and GenT Program (project CIDEGENT/2018/021); MICINN Research Project PID2019-108995GB-C22; the European Research Council for advanced grant 'JETSET: Launching, propagation and emission of relativistic jets from binary mergers and across mass scales' (Grant No. 884631); the Institute for Advanced Study; the Istituto Nazionale di Fisica Nucleare (INFN) sezione di Napoli, iniziative specifiche TEONGRAV; the International Max Planck Research School for Astronomy and Astrophysics at the Universities of Bonn and Cologne; DFG research grant "Jet physics on horizon scales and beyond" (Grant No. FR 4069/2-1); Joint Princeton/Flatiron and Joint Columbia/Flatiron Postdoctoral Fellowships, research at the Flatiron Institute is supported by the Simons Foundation; the Japan Ministry of Education, Culture, Sports, Science and Technology (MEXT; grant JPMXP1020200109); the Japanese Government (Monbukagakusho: MEXT) Scholarship; the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for JSPS Research Fellowship (JP17J08829); the Joint Institute for Computational Fundamental Science, Japan; the Key Research Program of Frontier Sciences, Chinese Academy of Sciences (CAS, grants QYZDJ-SSW-SLH057, QYZDJSSW-SYS008, ZDBS-LY-SLH011); the Leverhulme Trust Early Career Research Fellowship; the Max-Planck-Gesellschaft (MPG); the Max Planck Partner Group of the MPG and the CAS; the MEXT/JSPS KAKENHI (grants 18KK0090, JP21H01137, JP18H03721, JP18K13594, 18K03709, JP19K14761, 18H01245, 25120007); the Malaysian Fundamental Research Grant Scheme (FRGS) FRGS/1/2019/STG02/UM/02/6; the MIT International Science and Technology Initiatives (MISTI) Funds; the Ministry of Science and Technology (MOST) of Taiwan (103-2119-M-001-010-MY2, 105-2112-M-001-025-MY3, 105-2119-M-001-042, 106-2112-M-001-011, 106-2119-M-001-013, 106-2119-M-001-027, 106-2923-M-001-005, 107-2119-M-001-017, 107-2119-M-001-020, 107-2119-M-001-041, 107-2119-M-110-005, 107-2923-M-001-009, 108-2112-M-001-048, 108-2112-M-001-051, 108-2923-M-001-002, 109-2112-M-001-025, 109-2124-M-001-005, 109-2923-M-001-001, 110-2112-M-003-007-MY2, 110-2112-M-001-033, 110-2124-M-001-007, and 110-2923-M-001-001); the Ministry of Education (MoE) of Taiwan Yushan Young Scholar Program; the Physics Division, National Center for Theoretical Sciences of Taiwan; the National Aeronautics and Space Administration (NASA, Fermi Guest Investigator grant 80NSSC20K1567, NASA Astrophysics Theory Program grant 80NSSC20K0527, NASA NuSTAR award 80NSSC20K0645); NASA Hubble Fellowship grant HST-HF2-51431.001-A awarded by the Space Telescope Science Institute, which is operated by the Association of Universities for Research in Astronomy, Inc., for NASA, under contract NAS5-26555; the National Institute of Natural Sciences (NINS) of Japan; the National Key Research and Development Program of China (grant 2016YFA0400704, 2017YFA0402703, 2016YFA0400702); the National Science Foundation (NSF, grants AST-0096454, AST-0352953, AST-0521233, AST-0705062, AST-0905844, AST-0922984, AST-1126433, AST-1140030, DGE-1144085, AST-1207704, AST-1207730, AST-1207752, MRI-1228509, OPP-1248097, AST-1310896, AST-1440254, AST-1555365, AST-1614868, AST-1615796, AST-1715061, AST-1716327, AST-1716536, OISE-1743747, AST-1816420, AST-1935980, AST-2034306); NSF Astronomy and Astrophysics Postdoctoral Fellowship (AST-1903847); the Natural Science Foundation of China (grants 11650110427, 10625314, 11721303, 11725312, 11873028, 11933007, 11991052, 11991053, 12192220, 12192223); the Natural Sciences and Engineering Research Council of Canada (NSERC, including a Discovery Grant and the NSERC Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program); the National Youth Thousand Talents Program of China; the National Research Foundation of Korea (the Global PhD Fellowship Grant: grants NRF-2015H1A2A1033752, the Korea Research Fellowship Program: NRF-2015H1D3A1066561, Brain Pool Program: 2019H1D3A1A01102564, Basic Research Support Grant 2019R1F1A1059721, 2021R1A6A3A01086420, 2022R1C1C1005255); Netherlands Research School for Astronomy (NOVA) Virtual Institute of Accretion (VIA) postdoctoral fellowships; Onsala Space Observatory (OSO) national infrastructure, for the provisioning of its facilities/observational support (OSO receives funding through the Swedish Research Council under grant 2017-00648); the Perimeter Institute for Theoretical Physics (research at Perimeter Institute is supported by the Government of Canada through the Department of Innovation, Science and Economic Development and by the Province of Ontario through the Ministry of Research, Innovation and Science); the Spanish Ministerio de Ciencia e Innovación (grants PGC2018-098915-B-C21, AYA2016-80889-P, PID2019-108995GB-C21, PID2020-117404GB-C21); the University of Pretoria for financial aid in the provision of the new Cluster Server nodes and SuperMicro (USA) for a SEEDING GRANT approved towards these nodes in 2020; the Shanghai Pilot Program for Basic Research, Chinese Academy of Science, Shanghai Branch (JCYJ-SHFY-2021-013); the State Agency for Research of the Spanish MCIU through the "Center of Excellence Severo Ochoa" award for the Instituto de Astrofísica de Andalucía (SEV-2017-0709); the Spinoza Prize SPI 78-409; the South African Research Chairs Initiative, through the South African Radio Astronomy Observatory (SARAO, grant ID 77948), which is a facility of the National Research Foundation (NRF), an agency of the Department of Science and Innovation (DSI) of South Africa; the Toray Science Foundation; Swedish Research Council (VR); the US Department of Energy (USDOE) through the Los Alamos National Laboratory (operated by Triad National Security, LLC, for the National Nuclear Security Administration of the USDOE (Contract 89233218CNA000001); and the YCAA Prize Postdoctoral Fellowship. APEX is a collaboration between the Max-Planck-Institut für Radioastronomie (Germany), ESO, and the Onsala Space Observatory (Sweden). The SMA is a joint project between the SAO and ASIAA and is funded by the Smithsonian Institution and the Academia Sinica. The JCMT is operated by the East Asian Observatory on behalf of the NAOJ, ASIAA, and KASI, as well as the Ministry of Finance of China, Chinese Academy of Sciences, and the National Key Research and Development Program (No. 2017YFA0402700) of China and Natural Science Foundation of China grant 11873028. Additional funding support for the JCMT is provided by the Science and Technologies Facility Council (UK) and participating universities in the UK and Canada. The LMT is a project operated by the Instituto Nacional de Astrófisica, Óptica, y Electrónica (Mexico) and the University of Massachusetts at Amherst (USA). The IRAM 30-m telescope on Pico Veleta, Spain is operated by IRAM and supported by CNRS (Centre National de la Recherche Scientifique, France), MPG (Max-Planck-Gesellschaft, Germany) and IGN (Instituto Geográfico Nacional, Spain). The SMT is operated by the Arizona Radio Observatory, a part of the Steward Observatory of the University of Arizona, with financial support of operations from the State of Arizona and financial support for instrumentation development from the NSF. Support for SPT participation in the EHT is provided by the National Science Foundation through award OPP-1852617 to the University of Chicago. Partial support is also provided by the Kavli Institute of Cosmological Physics at the University of Chicago. The SPT hydrogen maser was provided on loan from the GLT, courtesy of ASIAA. This work used the Extreme Science and Engineering Discovery Environment (XSEDE), supported by NSF grant ACI-1548562, and CyVerse, supported by NSF grants DBI-0735191, DBI-1265383, and DBI-1743442. XSEDE Stampede2 resource at TACC was allocated through TG-AST170024 and TG-AST080026N. XSEDE JetStream resource at PTI and TACC was allocated through AST170028. This research is part of the Frontera computing project at the Texas Advanced Computing Center through the Frontera Large-Scale Community Partnerships allocation AST20023. Frontera is made possible by National Science Foundation award OAC-1818253. This research was carried out using resources provided by the Open Science Grid, which is supported by the National Science Foundation and the U.S. Department of Energy Office of Science. Additional work used ABACUS2.0, which is part of the eScience center at Southern Denmark University. Simulations were also performed on the SuperMUC cluster at the LRZ in Garching, on the LOEWE cluster in CSC in Frankfurt, on the HazelHen cluster at the HLRS in Stuttgart, and on the Pi2.0 and Siyuan Mark-I at Shanghai Jiao Tong University. The computer resources of the Finnish IT Center for Science (CSC) and the Finnish Computing Competence Infrastructure (FCCI) project are acknowledged. This research was enabled in part by support provided by Compute Ontario (http://computeontario.ca), Calcul Quebec (http://www.calculquebec.ca) and Compute Canada (http://www.computecanada.ca).

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Full list of authors: Akiyama, Kazunori; Alberdi, Antxon; Alef, Walter; Algaba, Juan Carlos; Anantua, Richard; Asada, Keiichi; Azulay, Rebecca; Bach, Uwe; Baczko, Anne-Kathrin; Ball, David; Balokovic, Mislav; Barrett, John; Baubock, Michi; Benson, Bradford A.; Bintley, Dan; Blackburn, Lindy; Blundell, Raymond; Bouman, Katherine L.; Bower, Geoffrey C.; Boyce, Hope; Bremer, Michael; Brinkerink, Christiaan D.; Brissenden, Roger; Britzen, Silke; Broderick, Avery E.; Broguiere, Dominique; Bronzwaer, Thomas; Bustamante, Sandra; Byun, Do-Young; Carlstrom, John E.; Ceccobello, Chiara; Chael, Andrew; Chan, Chi-kwan; Chatterjee, Koushik; Chatterjee, Shami; Chen, Ming-Tang; Chen, Yongjun; Cheng, Xiaopeng; Cho, Ilje; Christian, Pierre; Conroy, Nicholas S.; Conway, John E.; Cordes, James M.; Crawford, Thomas M.; Crew, Geoffrey B.; Cruz-Osorio, Alejandro; Cui, Yuzhu; Davelaar, Jordy; De Laurentis, Mariafelicia; Deane, Roger; Dempsey, Jessica; Desvignes, Gregory; Dexter, Jason; Dhruv, Vedant; Doeleman, Sheperd S.; Dougal, Sean; Dzib, Sergio A.; Eatough, Ralph P.; Emami, Razieh; Falcke, Heino; Farah, Joseph; Fish, Vincent L.; Fomalont, Ed; Ford, H. Alyson; Fraga-Encinas, Raquel; Freeman, William T.; Friberg, Per; Fromm, Christian M.; Fuentes, Antonio; Galison, Peter; Gammie, Charles F.; Garcia, Roberto; Gentaz, Olivier; Georgiev, Boris; Goddi, Ciriaco; Gold, Roman; Gomez-Ruiz, Arturo, I; Gomez, Jose L.; Gu, Minfeng; Gurwell, Mark; Hada, Kazuhiro; Haggard, Daryl; Haworth, Kari; Hecht, Michael H.; Hesper, Ronald; Heumann, Dirk; Ho, Luis C.; Ho, Paul; Honma, Mareki; Huang, Chih-Wei L.; Huang, Lei; Hughes, David H.; Ikeda, Shiro; Impellizzeri, C. M. Violette; Inoue, Makoto; Issaoun, Sara; James, David J.; Jannuzi, Buell T.; Janssen, Michael; Jeter, Britton; Jiang, Wu; Jimenez-Rosales, Alejandra; Johnson, Michael D.; Jorstad, Svetlana; Joshi, Abhishek, V; Jung, Taehyun; Karami, Mansour; Karuppusamy, Ramesh; Kawashima, Tomohisa; Keating, Garrett K.; Kettenis, Mark; Kim, Dong-Jin; Kim, Jae-Young; Kim, Jongsoo; Kim, Junhan; Kino, Motoki; Koay, Jun Yi; Kocherlakota, Prashant; Kofuji, Yutaro; Koch, Patrick M.; Koyama, Shoko; Kramer, Carsten; Kramer, Michael; Krichbaum, Thomas P.; Kuo, Cheng-Yu; La Bella, Noemi; Lauer, Tod R.; Lee, Daeyoung; Lee, Sang-Sung; Leung, Po Kin; Levis, Aviad; Li, Zhiyuan; Lico, Rocco; Lindahl, Greg; Lindqvist, Michael; Lisakov, Mikhail; Liu, Jun; Liu, Kuo; Liuzzo, Elisabetta; Lo, Wen-Ping; Lobanov, Andrei P.; Loinard, Laurent; Lonsdale, Colin J.; Lu, Ru-Sen; Mao, Jirong; Marchili, Nicola; Markoff, Sera; Marrone, Daniel P.; Marscher, Alan P.; Marti-Vidal, Ivan; Matsushita, Satoki; Matthews, Lynn D.; Medeiros, Lia; Menten, Karl M.; Michalik, Daniel; Mizuno, Izumi; Mizuno, Yosuke; Moran, James M.; Moriyama, Kotaro; Moscibrodzka, Monika; Muller, Cornelia; Mus, Alejandro; Musoke, Gibwa; Myserlis, Ioannis; Nadolski, Andrew; Nagai, Hiroshi; Nagar, Neil M.; Nakamura, Masanori; Narayan, Ramesh; Narayanan, Gopal; Natarajan, Iniyan; Nathanail, Antonios; Fuentes, Santiago Navarro; Neilsen, Joey; Neri, Roberto; Ni, Chunchong; Noutsos, Aristeidis; Nowak, Michael A.; Oh, Junghwan; Okino, Hiroki; Olivares, Hector; Ortiz-Leon, Gisela N.; Oyama, Tomoaki; Palumbo, Daniel C. M.; Paraschos, Georgios Filippos; Park, Jongho; Parsons, Harriet; Patel, Nimesh; Pen, Ue-Li; Pesce, Dominic W.; Pietu, Vincent; Plambeck, Richard; PopStefanija, Aleksandar; Porth, Oliver; Potzl, Felix M.; Prather, Ben; Preciado-Lopez, Jorge A.; Pu, Hung-Yi; Ramakrishnan, Venkatessh; Rao, Ramprasad; Rawlings, Mark G.; Raymond, Alexander W.; Rezzolla, Luciano; Ricarte, Angelo; Ripperda, Bart; Roelofs, Freek; Rogers, Alan; Ros, Eduardo; Romero-Canizales, Cristina; Roshanineshat, Arash; Rottmann, Helge; Roy, Alan L.; Ruiz, Ignacio; Ruszczyk, Chet; Rygl, Kazi L. J.; Sanchez, Salvador; Sanchez-Arguelles, David; Sanchez-Portal, Miguel; Sasada, Mahito; Satapathy, Kaushik; Savolainen, Tuomas; Schloerb, F. Peter; Schonfeld, Jonathan; Schuster, Karl-Friedrich; Shao, Lijing; Shen, Zhiqiang; Small, Des; Sohn, Bong Won; SooHoo, Jason; Souccar, Kamal; Sun, He; Tazaki, Fumie; Tetarenko, Alexandra J.; Tiede, Paul; Tilanus, Remo P. J.; Titus, Michael; Torne, Pablo; Traianou, Efthalia; Trent, Tyler; Trippe, Sascha; Turk, Matthew; van Bemmel, Ilse; van Langevelde, Huib Jan; van Rossum, Daniel R.; Vos, Jesse; Wagner, Jan; Ward-Thompson, Derek; Wardle, John; Weintroub, Jonathan; Wex, Norbert; Wharton, Robert; Wielgus, Maciek; Wiik, Kaj; Witzel, Gunther; Wondrak, Michael F.; Wong, George N.; Wu, Qingwen; Yamaguchi, Paul; Yoon, Doosoo; Young, Andre; Young, Ken; Younsi, Ziri; Yuan, Feng; Yuan, Ye-Fei; Zensus, J. Anton; Zhang, Shuo; Zhao, Guang-Yao; Zhao, Shan-Shan; Chang, Dominic O.; Event Horizon Telescope Collaboration., In this paper we quantify the temporal variability and image morphology of the horizon-scale emission from Sgr A*, as observed by the EHT in 2017 April at a wavelength of 1.3 mm. We find that the Sgr A* data exhibit variability that exceeds what can be explained by the uncertainties in the data or by the effects of interstellar scattering. The magnitude of this variability can be a substantial fraction of the correlated flux density, reaching ∼100% on some baselines. Through an exploration of simple geometric source models, we demonstrate that ring-like morphologies provide better fits to the Sgr A* data than do other morphologies with comparable complexity. We develop two strategies for fitting static geometric ring models to the time-variable Sgr A* data; one strategy fits models to short segments of data over which the source is static and averages these independent fits, while the other fits models to the full data set using a parametric model for the structural variability power spectrum around the average source structure. Both geometric modeling and image-domain feature extraction techniques determine the ring diameter to be 51.8 ± 2.3 μas (68% credible intervals), with the ring thickness constrained to have an FWHM between ∼30% and 50% of the ring diameter. To bring the diameter measurements to a common physical scale, we calibrate them using synthetic data generated from GRMHD simulations. This calibration constrains the angular size of the gravitational radius to be ${4.8}_{-0.7}^{+1.4}$ μas, which we combine with an independent distance measurement from maser parallaxes to determine the mass of Sgr A* to be ${4.0}_{-0.6}^{+1.1}\times {10}^{6}$ M⊙. © 2022. The Author(s). Published by the American Astronomical Society., The Event Horizon Telescope Collaboration thanks the following organizations and programs: the Academia Sinica; the Academy of Finland (projects 274477, 284495, 312496, 315721); the Agencia Nacional de Investigación y Desarrollo (ANID), Chile via NCN19_058 (TITANs) and Fondecyt 1221421, the Alexander von Humboldt Stiftung; an Alfred P. Sloan Research Fellowship; Allegro, the European ALMA Regional Centre node in the Netherlands, the NL astronomy research network NOVA and the astronomy institutes of the University of Amsterdam, Leiden University and Radboud University; the ALMA North America Development Fund; the Black Hole Initiative, which is funded by grants from the John Templeton Foundation and the Gordon and Betty Moore Foundation (although the opinions expressed in this work are those of the author(s) and do not necessarily reflect the views of these Foundations); Chandra DD7-18089X and TM6-17006X; the China Scholarship Council; China Postdoctoral Science Foundation fellowship (2020M671266); Consejo Nacional de Ciencia y Tecnología (CONACYT, Mexico, projects U0004-246083, U0004-259839, F0003-272050, M0037-279006, F0003-281692, 104497, 275201, 263356); the Consejería de Economía, Conocimiento, Empresas y Universidad of the Junta de Andalucía (grant P18-FR-1769), the Consejo Superior de Investigaciones Científicas (grant 2019AEP112); the Delaney Family via the Delaney Family John A. Wheeler Chair at Perimeter Institute; Dirección General de Asuntos del Personal Académico-Universidad Nacional Autónoma de México (DGAPA-UNAM, projects IN112417 and IN112820); the Dutch Organization for Scientific Research (NWO) VICI award (grant 639.043.513) and grant OCENW.KLEIN.113; the Dutch National Supercomputers, Cartesius and Snellius (NWO Grant 2021.013); the EACOA Fellowship awarded by the East Asia Core Observatories Association, which consists of the Academia Sinica Institute of Astronomy and Astrophysics, the National Astronomical Observatory of Japan, Center for Astronomical Mega-Science, Chinese Academy of Sciences, and the Korea Astronomy and Space Science Institute; the European Research Council (ERC) Synergy Grant "BlackHoleCam: Imaging the Event Horizon of Black Holes" (grant 610058); the European Union Horizon 2020 research and innovation programme under grant agreements RadioNet (No 730562) and M2FINDERS (No 101018682); the Generalitat Valenciana postdoctoral grant APOSTD/2018/177 and GenT Program (project CIDEGENT/2018/021); MICINN Research Project PID2019-108995GB-C22; the European Research Council for advanced grant 'JETSET: Launching, propagation and emission of relativistic jets from binary mergers and across mass scales' (Grant No. 884631); the Institute for Advanced Study; the Istituto Nazionale di Fisica Nucleare (INFN) sezione di Napoli, iniziative specifiche TEONGRAV; the International Max Planck Research School for Astronomy and Astrophysics at the Universities of Bonn and Cologne; DFG research grant "Jet physics on horizon scales and beyond" (Grant No. FR 4069/2-1); Joint Princeton/Flatiron and Joint Columbia/Flatiron Postdoctoral Fellowships, research at the Flatiron Institute is supported by the Simons Foundation; the Japan Ministry of Education, Culture, Sports, Science and Technology (MEXT; grant JPMXP1020200109); the Japanese Government (Monbukagakusho: MEXT) Scholarship; the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for JSPS Research Fellowship (JP17J08829); the Joint Institute for Computational Fundamental Science, Japan; the Key Research Program of Frontier Sciences, Chinese Academy of Sciences (CAS, grants QYZDJ-SSW-SLH057, QYZDJSSW-SYS008, ZDBS-LY-SLH011); the Leverhulme Trust Early Career Research Fellowship; the Max-Planck-Gesellschaft (MPG); the Max Planck Partner Group of the MPG and the CAS; the MEXT/JSPS KAKENHI (grants 18KK0090, JP21H01137, JP18H03721, JP18K13594, 18K03709, JP19K14761, 18H01245, 25120007); the Malaysian Fundamental Research Grant Scheme (FRGS) FRGS/1/2019/STG02/UM/02/6; the MIT International Science and Technology Initiatives (MISTI) Funds; the Ministry of Science and Technology (MOST) of Taiwan (103-2119-M-001-010-MY2, 105-2112-M-001-025-MY3, 105-2119-M-001-042, 106-2112-M-001-011, 106-2119-M-001-013, 106-2119-M-001-027, 106-2923-M-001-005, 107-2119-M-001-017, 107-2119-M-001-020, 107-2119-M-001-041, 107-2119-M-110-005, 107-2923-M-001-009, 108-2112-M-001-048, 108-2112-M-001-051, 108-2923-M-001-002, 109-2112-M-001-025, 109-2124-M-001-005, 109-2923-M-001-001, 110-2112-M-003-007-MY2, 110-2112-M-001-033, 110-2124-M-001-007, and 110-2923-M-001-001); the Ministry of Education (MoE) of Taiwan Yushan Young Scholar Program; the Physics Division, National Center for Theoretical Sciences of Taiwan; the National Aeronautics and Space Administration (NASA, Fermi Guest Investigator grant 80NSSC20K1567, NASA Astrophysics Theory Program grant 80NSSC20K0527, NASA NuSTAR award 80NSSC20K0645); NASA Hubble Fellowship grant HST-HF2-51431.001-A awarded by the Space Telescope Science Institute, which is operated by the Association of Universities for Research in Astronomy, Inc., for NASA, under contract NAS5-26555; the National Institute of Natural Sciences (NINS) of Japan; the National Key Research and Development Program of China (grant 2016YFA0400704, 2017YFA0402703, 2016YFA0400702); the National Science Foundation (NSF, grants AST-0096454, AST-0352953, AST-0521233, AST-0705062, AST-0905844, AST-0922984, AST-1126433, AST-1140030, DGE-1144085, AST-1207704, AST-1207730, AST-1207752, MRI-1228509, OPP-1248097, AST-1310896, AST-1440254, AST-1555365, AST-1614868, AST-1615796, AST-1715061, AST-1716327, AST-1716536, OISE-1743747, AST-1816420, AST-1935980, AST-2034306); NSF Astronomy and Astrophysics Postdoctoral Fellowship (AST-1903847); the Natural Science Foundation of China (grants 11650110427, 10625314, 11721303, 11725312, 11873028, 11933007, 11991052, 11991053, 12192220, 12192223); the Natural Sciences and Engineering Research Council of Canada (NSERC, including a Discovery Grant and the NSERC Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program); the National Youth Thousand Talents Program of China; the National Research Foundation of Korea (the Global PhD Fellowship Grant: grants NRF-2015H1A2A1033752, the Korea Research Fellowship Program: NRF-2015H1D3A1066561, Brain Pool Program: 2019H1D3A1A01102564, Basic Research Support Grant 2019R1F1A1059721, 2021R1A6A3A01086420, 2022R1C1C1005255); Netherlands Research School for Astronomy (NOVA) Virtual Institute of Accretion (VIA) postdoctoral fellowships; Onsala Space Observatory (OSO) national infrastructure, for the provisioning of its facilities/observational support (OSO receives funding through the Swedish Research Council under grant 2017-00648); the Perimeter Institute for Theoretical Physics (research at Perimeter Institute is supported by the Government of Canada through the Department of Innovation, Science and Economic Development and by the Province of Ontario through the Ministry of Research, Innovation and Science); the Spanish Ministerio de Ciencia e Innovación (grants PGC2018-098915-B-C21, AYA2016-80889-P, PID2019-108995GB-C21, PID2020-117404GB-C21); the University of Pretoria for financial aid in the provision of the new Cluster Server nodes and SuperMicro (USA) for a SEEDING GRANT approved towards these nodes in 2020; the Shanghai Pilot Program for Basic Research, Chinese Academy of Science, Shanghai Branch (JCYJ-SHFY-2021-013); the State Agency for Research of the Spanish MCIU through the "Center of Excellence Severo Ochoa" award for the Instituto de Astrofísica de Andalucía (SEV-2017- 0709); the Spinoza Prize SPI 78-409; the South African Research Chairs Initiative, through the South African Radio Astronomy Observatory (SARAO, grant ID 77948), which is a facility of the National Research Foundation (NRF), an agency of the Department of Science and Innovation (DSI) of South Africa; the Toray Science Foundation; Swedish Research Council (VR); the US Department of Energy (USDOE) through the Los Alamos National Laboratory (operated by Triad National Security, LLC, for the National Nuclear Security Administration of the USDOE (Contract 89233218CNA000001); and the YCAA Prize Postdoctoral Fellowship. APEX is a collaboration between the Max-Planck-Institut für Radioastronomie (Germany), ESO, and the Onsala Space Observatory (Sweden). The SMA is a joint project between the SAO and ASIAA and is funded by the Smithsonian Institution and the Academia Sinica. The JCMT is operated by the East Asian Observatory on behalf of the NAOJ, ASIAA, and KASI, as well as the Ministry of Finance of China, Chinese Academy of Sciences, and the National Key Research and Development Program (No. 2017YFA0402700) of China and Natural Science Foundation of China grant 11873028. Additional funding support for the JCMT is provided by the Science and Technologies Facility Council (UK) and participating universities in the UK and Canada. The LMT is a project operated by the Instituto Nacional de Astrófisica, Óptica, y Electrónica (Mexico) and the University of Massachusetts at Amherst (USA). The IRAM 30-m telescope on Pico Veleta, Spain is operated by IRAM and supported by CNRS (Centre National de la Recherche Scientifique, France), MPG (Max-Planck-Gesellschaft, Germany) and IGN (Instituto Geográfico Nacional, Spain). The SMT is operated by the Arizona Radio Observatory, a part of the Steward Observatory of the University of Arizona, with financial support of operations from the State of Arizona and financial support for instrumentation development from the NSF. Support for SPT participation in the EHT is provided by the National Science Foundation through award OPP-1852617 to the University of Chicago. Partial support is also provided by the Kavli Institute of Cosmological Physics at the University of Chicago. The SPT hydrogen maser was provided on loan from the GLT, courtesy of ASIAA. This work used the Extreme Science and Engineering Discovery Environment (XSEDE), supported by NSF grant ACI-1548562, and CyVerse, supported by NSF grants DBI-0735191, DBI-1265383, and DBI-1743442. XSEDE Stampede2 resource at TACC was allocated through TG-AST170024 and TG-AST080026N. XSEDE JetStream resource at PTI and TACC was allocated through AST170028. This research is part of the Frontera computing project at the Texas Advanced Computing Center through the Frontera Large-Scale Community Partnerships allocation AST20023. Frontera is made possible by National Science Foundation award OAC-1818253. This research was carried out using resources provided by the Open Science Grid, which is supported by the National Science Foundation and the U.S. Department of Energy Office of Science. Additional work used ABACUS2.0, which is part of the eScience center at Southern Denmark University. Simulations were also performed on the SuperMUC cluster at the LRZ in Garching, on the LOEWE cluster in CSC in Frankfurt, on the HazelHen cluster at the HLRS in Stuttgart, and on the Pi2.0 and Siyuan Mark-I at Shanghai Jiao Tong University. The computer resources of the Finnish IT Center for Science (CSC) and the Finnish Computing Competence Infrastructure (FCCI) project are acknowledged. This research was enabled in part by support provided by Compute Ontario (http://computeontario.ca), Calcul Quebec (http://www.calculquebec.ca) and Compute Canada (http://www.computecanada.ca).

There are data that disparities exist in access to total hip arthroplasty (THA). However, to date, no study has examined the relationship between distance traveled to undergo THA and patient demographic characteristics, such as race, insurance provider, and income level as well as postoperative outcomes.Data from the Healthcare Cost and Utilization Project, American Hospital Association, and the United States Postal Service were used to calculate the geographic distance between 211,806 patients' population-weighted zip code centroid points to the coordinates of the hospitals at which they underwent THA. We then used Healthcare Cost and Utilization Project data to examine the relationships between travel distance and both patient demographic indicators and postoperative outcomes after THA.White patients traveled farther on average to undergo THA as compared with their non-White counterparts (17.38 vs 13.05 miles) (P0.0001). Patients with commercial insurance (17.19 miles) and Medicare (16.65 miles) traveled farther on average to receive care than did patients with Medicaid insurance coverage (14.00 miles) (P = 0.0001). Patients residing in zip codes in the top income quartile traveled farther to receive care (18.73 miles) as compared with those in the lowest income quartile (15.31 miles) (P0.0001). No clinically significant association was found between travel distance and adverse postoperative outcomes after THA.Race, insurance provider, and zip code income quartile are associated with differences in the distance traveled to undergo THA. These findings may be indicative of underlying disparities in access to care across patient populations.