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Abstract Background Macauba (Acrocomia aculeata) is a non-domesticated neotropical palm that has been attracting attention for economic use due to its great potential for oil production comparable to the commercially used oil palm (Elaeis guineensis). The discovery of associations between quantitative trait loci and economically important traits represents an advance toward understanding its genetic architecture and can contribute to accelerating macauba domestication. Pursuing this advance, this study performs single-trait and multi-trait GWAS models to identify candidate genes associated with vegetative and oil production traits in macauba. Eighteen phenotypic traits were evaluated from 201 palms within a native population. Genotyping was performed with SNP markers, following the protocol of genotyping-by-sequencing. Given that macauba lacks a reference genome, SNP calling was performed using three different strategies: using i) de novo sequencing, ii) the Elaeis guineenses Jacq. reference genome and iii) the macauba transcriptome sequences. After quality control, we identified a total of 27,410 SNPs in 153 individuals for the de novo genotypic dataset, 10,444 SNPs in 158 individuals using the oil palm genotypic dataset, and 4,329 SNPs in 167 individuals using the transcriptome genotypic dataset. The GWAS analysis was then performed on these three genotypic datasets. Results Statistical phenotypic analyses revealed significant differences across all studied traits, with heritability values ranging from 63 to 95%. This indicates that the population contains promising genotypes for selection and the initiation of breeding programs. Genetic correlations between the 18 traits ranged from -0.47 to 0.99. The total number of significant SNPs in the single-trait and multi-trait GWAS was 92 and 6 using the de novo genotypic dataset, 19 and 11 using the oil palm genotypic dataset, and 1 and 2 using the transcriptome genotypic dataset, respectively. Gene annotation identified 12 candidate genes in the single-trait GWAS and four in the multi-trait GWAS, across the 18 phenotypic traits studied, in the three genotypic datasets. Gene mapping of the macauba candidate genes revealed similarities with Elaeis guineensis and Phoenix dactylifera. The candidate genes detected are responsible for metal ion binding and transport, protein transportation, DNA repair, and other cell regulation biological processes. Conclusions We provide new insights into genomic regions that map candidate genes associated with vegetative and oil production traits in macauba. These potential candidate genes require confirmation through targeted functional analyses in the future, and multi-trait associations need to be scrutinized to investigate the presence of pleiotropic or linked genes. Markers linked to traits of interest could serve as valuable resources for the development of marker-assisted selection in macauba for its domestication and pre-breeding.

Purpose: This study aimed to explore how race and the socioeconomic index (SES) of residential zip codes influenced COVID-19 testing rates in St. Louis during the early and peak phases of the pandemic. Method: An ecological study was conducted using COVID-19 testing data from March to November 2020 in St. Louis City, including 16,915 tests from 30 residential zip codes. Geographical mapping identified areas lacking testing, descriptive statistics characterized testing rates by race and SES, and robust linear regression modeled the association between testing rates and race, controlling for SES. Results: The overall testing rate was 303.97 per 10,000 population. Testing rates among Blacks, Whites, American Indians/Alaskan Natives, and Asians were 374.26, 247.77, 360.63, and 242.41 per 10,000, respectively. Higher rates were observed in low- and middle-SES zip codes compared with high-SES areas. Adjusted for SES, testing rates per 10,000 were higher by 125 (1.25%), 448 (4.48%), and 32 (0.32%) among Blacks, American Indians/Alaskan Natives, and Asians compared with Whites. Testing rates decreased by 56 (0.56%) per unit SES improvement. There was statistically significant SES finding and that of the difference between American Indians/Alaskan Natives and Whites. Geographical mapping showed higher rates in the inner core and lower rates in the periphery of St. Louis. Conclusions: Race and SES influence testing rates. Targeted interventions are needed in areas with low testing rates in St. Louis.

Category: Other Introduction/Purpose: Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on an online review website. Methods: We conducted a retrospective analysis of negative one-star reviews on Vitals.com with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described. Results: Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients. Conclusion: Complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs.

Category: Hindfoot; Other Introduction/Purpose: Middle facet subluxation (MFS) and middle facet incongruence angle (MFIA) are established indicators of peritalar subluxation (PTS) in evaluating Progressive Collapsing Foot Deformity (PCFD) using Weight-Bearing CT (WBCT). Traditionally, MFS and MFIA are assessed in the coronal plane, which is not perpendicular to the plane of the middle facet (MF). However, the angle between the plane of the medial facet and the plane of measurement changes with plantar flexion of the talus. This approach may lead over- or underestimating the MFS and MFIA as well as a over-dysplastic appearance of the middle facet. We hypothesized that measuring these parameters in a plane perpendicular to the MF would result in changes in MFS, MFIA, and the incidence of diagnosed dysplastic joints. Methods: In this retrospective case-control study, 89 patients with PCFD and 11 controls without PCFD who underwent WBCT were evaluated. Measurements of MFS, MFIA, and middle facet dysplasia were conducted using both the classical method and the new method. The classical method consisted of identifying the center point of the middle facet on sagittal view and taking measurements in the coronal plane as described in the literature. The new method comprised of taking measurements after rotation of the coronal plane around the axis defined by the center of the middle facet on sagittal view until the coronal plane was perpendicular on sagittal view. The inclination of the MF in the sagittal plane was also recorded. Additional WBCT parameters (Foot and Ankle Offset (FAO), Talo-navicular coverage angle (TNCA), Talus-first metatarsal angle axial) were also measured. The Shapiro-Wilk test assessed data normality. A p-value of < 0.05 was considered statistically significant. Results: Significant differences were observed between the two methods across all parameters for PCFD. For controls, only the MFIA was significantly different (p:0.0045) between the two methods. Regarding the PCFD the new method demonstrated lower MFS (25.4% vs. 40.3%, p< 0.0001), lower MFIA (4.7 degrees vs. 13.1 degrees, p< 0.0001), and fewer dysplastic joints (1% vs. 37%, p< 0.0001) when compared to the classical method. However, multivariate analysis did not show inclination angle as predictive of MFS. TNCA (p < 0.05) talus-first metatarsal angle axial (p < 0.05) and FAO (p < 0.05) were stronger predictors of MFS than the inclination of the talus. Conclusion: This study confirms that MFS is a complex deformity influenced by multiple parameters but not talar inclination. The new method showed lower MFS, MFIA, and dysplasia measurements compared to current classical method. Future research should compare these two measuring techniques to more comprehensive modalities (coverage mapping). When assessing MFS, surgeons should be mindful that the plane of measurement relative to the structure is critical, and any change in the inclination of the talus may influence the appearance of MFS. We suggest using a plane of measurement perpendicular to the plane of the middle facet when assessing its subluxation.

Category: Other Introduction/Purpose: Although female students comprise over half of U.S. undergraduate and medical school enrollment, representation among residents and practicing surgeons in orthopaedics remains disproportionately low at 15% and 6%, respectively. The decline in residency may stem from a lack of early exposure to female mentors. This study investigates female representation in speaker roles at American Orthopaedic Foot & Ankle Society (AOFAS) meetings over time. Methods: The annual AOFAS meeting programs for 2012, 2017, and 2022 were reviewed by three independent raters. Each speaker, moderator, and panelist was classified based on sex and role; 15% of the data was cross-checked and evaluated using Fleiss Multirater Kappa validation. Sessions discussing surgical or biomedical topics were categorized as “technical”, and all other sessions (i.e., welcome sessions) were categorized as “nontechnical.” Individual-year odds ratios (ORs) and confidence intervals (CIs) evaluating sex versus session status, as well as sex versus speaker role, are provided. Combined results controlling for year were calculated using the Cochran-Mantel-Haenszel method. Results: A total of 403 speaking sessions were analyzed; 12% of sessions were led by female speakers. On average, female speakers were significantly more likely than males to assume nontechnical speaking roles across the three years combined (OR 3.84; 95% CI, 1.43 to 10.33). Female speakers led 12.7% of the 381 technical sessions. Females also comprised 9.8% and 16.7% of moderator and panelist roles, respectively. Conclusion: Although our study reveals an increasing trend in female speakers, panelists, and moderators from 2012 to 2022, these data demonstrate a persistent lack of sex diversity at AOFAS annual meetings, especially within technical sessions and moderator roles. Increasing female representation at conferences while fostering mentorship opportunities for medical students may serve as a valuable opportunity to address disparities between males and females within orthopaedics. Female Representation in Speaker Roles at AOFAS and Session Category Odds Ratios

Category: Ankle; Ankle Arthritis Introduction/Purpose: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft-tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative lateral weightbearing radiographs. Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 out of 323 patients). Patients requiring revision had significantly greater tibial-tissue (3.54 vs. 2.48 cm; p=0.02) and talus-tissue (2.79 vs. 2.42 cm; p=0.02) thickness compared to those who did not require revision. Both the Tibial-Tissue thickness (Odds Ratio: 1.16 [1.12-1.20]; p < 0.01) and the Talus-Tissue thickness (Odds Ratio: 1.10 [1.05-1.15]; p < 0.01) measurements were significant predictors of revision TAA in multivariable logistic regression models. In contrast, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability. Conclusion: Greater soft tissue thickness, as measured radiographically, was a better predictor of revision TAA compared to BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate these findings and explore the potential impact on clinical practice. Figure 1. Radiographical Assessment of Tissue Thickness The figure illustrates the method for obtaining the radiographic measurements on weightbearing lateral radiographs. (A) A line was drawn from the posterior distal tibia to the anterior distal tibia (Red Line), and the distance of the parallel segment extending from the anterior cortex of the tibia to the end of the soft tissue shadow was measured to determine the Tibial-Tissue thickness. A line was drawn from the lateral process of the talus to the head/neck junction of the talus (Yellow Line), and the distance of the parallel segment, extending from the head/neck junction of the talus to the end of the soft tissue shadow, was measured to determine the Talus-Tissue thickness.

Category: Hindfoot; Ankle Introduction/Purpose: Collapse of the talus and peri-talar arthritis pose treatment challenges due to the anatomy and location of the talus as a keystone of the foot and ankle. Custom 3D-printed total talus replacement (TTR) and combined total ankle total talus replacement (TATTR) have emerged as treatment options for peri-talar arthritis, avascular necrosis of the talus and talus insufficiency. However, long-term data on the safety and efficacy of these implants is unknown due to the limited number of cases and short follow-up durations. Methods: This was a retrospective study to assess surgical outcomes of patients who underwent a TTR and TATTR with or without subtalar fusion. Patient demographics, intraoperative parameters, device related surgical and non-surgical events, imaging and clinical evaluations, and patient reported outcome (PRO) measures were compiled for each case. The Odds Ratio (OR) for secondary surgery was calculated for each binary outcome using univariate and multivariate logistic regression. The multivariable model included significant variables from the univariate analysis to address potential confounders. Pre- and postoperative radiographic measurements and range of motion were compared using pairwise t-tests. Pain VAS, PROMIS Pain Interference (PI), and PROMIS Physical Function (PF) scores were compared across all timepoints using one-way ANOVA (p< 0.05 significance level). Results: A total of 38 patients received a custom 3D-printed implant with mean follow-up time of 22.1 (range: 12-45) months. In this cohort, 7 (18.4%) required secondary surgery and 3 (7.9%) required removal of the implant. The mean time to secondary surgery was 19.9 (range: 11-32) months. Multivariate logistic regression revealed that patient diagnosis of depression was a significant predictor of secondary surgery with an OR 17.50 (p= 0.037). Significant postoperative improvements were observed in talocalcaneal height (p=0.005) and talar declination angle (p=0.013) for the TATTR group. VAS and PROMIS PI scores demonstrated an initial significant decrease in pain, but this improvement did not maintain significance at most recent follow-up. However, there was a significant increase in the PROMIS PF scores (p=0.037) at most recent follow-up. Conclusion: These results demonstrate that TTR and TATTR provide improvement in radiographic foot and ankle alignment and physical function. PRO findings suggest that patients are more active despite steady pain increase over time. Surgeons considering proceeding with either of these procedures should counsel patients about pain and functional outcomes as well as realistic expectations in patients with depression. Larger cohorts of patients should be studied to identify other high-risk groups and possible interventions. Future studies should investigate the association between diagnoses like depression and PROs.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Nitinol is a metal alloy with high elastic flexibility and shape memory characteristics, making it effective in orthopedic surgery. Although nitinol staples have shown similar efficacy to traditional implants for foot and ankle surgery, the literature is limited regarding nitinol screws. The purpose of this study is to determine whether there is a difference in outcomes and complications between nitinol screws and traditional screws used for foot and ankle surgery. Methods: A multicenter retrospective cohort study was conducted for patients who underwent a foot and ankle procedure utilizing traditional compression screws or nitinol compression screws, between February 1st, 2021, and July 1st, 2023. Demographic factors, type of implant, and outcomes were recorded. Student’s t-test and Wilcoxon rank sum test were used to compare continuous variables, while the chi-squared test was used to compare categorical variables. Results: A total of 163 patients were included in the study, with 106 patients treated with traditional screws and 58 treated with nitinol screws. There was no significant difference between those treated with nitinol screws and those treated with traditional screws in complication rate (8.6% vs 11.3%, P=0.78), non-union rate (5.2% vs 8.5%, P=0.54), revision surgeries (1.7% vs 2.8%, P=1), hardware removal (3.4% vs 11.3%, P=0.14), or 90-day hospital readmissions (0% vs 2.8%, P=0.55) for foot and ankle surgery. Conclusion: Our study found no difference in terms of complications or postoperative outcomes between those treated with nitinol screws and those treated with traditional screws for elective foot and ankle procedures. Our findings suggest that nitinol screws appear to be safe and effective for foot and ankle surgery with positive postoperative outcomes and a trend in lower complication and non-union rates. However further investigation is warranted to assess if faster time to union and quicker weight bearing may be possible with this type of fixation.

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: The literature demonstrating outcomes after foot and ankle surgery has traditionally focused on clinical and functional outcomes. Recent interest has increased regarding the contribution of racial and ethnic factors on outcomes after foot and ankle surgery. However, the existing research is limited. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics based on race and ethnicity after foot and ankle surgery. Methods: Outcomes after foot and ankle surgery based on race and ethnicity were searched in MEDLINE, Embase, Cochrane, Web of Science, SportsDISCUS, and Scopus from the date of inception to March 23, 2023. Inclusion criteria consisted of studies that directly evaluated the outcomes of race or ethnicity on foot and ankle surgery, including the risk or need for an index procedure. Manuscripts in non-English languages and isolated abstracts were excluded. We collected Visual Analog Scale (VAS), Patient-Reported Outcomes Information System (PROMIS) pain scale, and Short Musculoskeletal Function Assessment (SMFA) from the included studies for pooled meta-analysis. Results: The literature search identified 33 relevant studies from an initial pool of 3,451 references. These studies included a diverse demographic of 557,734 patients, assessing outcomes in foot and ankle surgery across various racial and ethnic groups. Due to heterogeneity in outcome reporting, only six studies were included in the finalmeta-analysis. Functional scores from the VAS, PROMIS pain scale, and SMFA varied in their assessment of pain and functional outcomes based on ethnicity. Resource utilization studies indicated disparities in the rates of surgical fixations and arthroplasties based on race. Conclusion: Non-White and minority patients exhibited higher rates of foot and ankle fractures, lower limb surgeries, worse functional outcomes, increased pain, longer hospital stays, and a higher incidence of complications compared to their White counterparts. While consistent with existing literature in various orthopaedic specialties, some studies contradicted these findings, suggesting the need for further research to better understand these discrepancies.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a commonly performed surgical procedure to address end-stage arthritis. Previous studies have suggested that the radiographic soft tissue thickness may be a predictor of complications including periprosthetic joint infection (PJI) after orthopedic surgery. However, there has been limited studies exploring the use of radiographic soft tissue thickness in TAA. The purpose of this study was to evaluate the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. Methods: A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient characteristics, including age, sex, body mass index (BMI), and comorbidities such as diabetes, smoking status, and etiology of ankle injury were recorded. Preoperative radiographic measurements, including the Tibial-Tissue and Talus-Tissue distances were recorded. Other perioperative information included prosthesis type, tourniquet time, and time to last follow-up. Logistic regression was utilized to examine the relationship between these factors and the occurrence of PJI. Results: Of the 323 patients, there were 6 patients (1.86%) who developed a PJI. The logistic regression analysis revealed that neither Tibial-Tissue (Odds Ratio: 0.975 [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (Odds Ratio: 0.976 [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p=0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p=0.36) compared to the non-infected cohort. Conclusion: Despite an association between radiographic soft tissue thickness and infection in other orthopedic surgeries, measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes.

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneal fractures are a common work-related injury that can be treated both operatively and nonoperatively. Operative management typically consists of open reduction with internal fixation via either an extensile lateral or sinus tarsi approach. Conservative treatment employs a combination of immobilization, rest, and elevation. Given that return to work is a critical milestone for many of these patients, it is crucial that the best management option is chosen. While there have been studies that compared operative versus conservative treatment, there has been no summative review on this topic. Thus, the goal of this study was to conduct a systematic review and meta-analysis on the impact of operative versus nonoperative management on return to work outcomes. Methods: MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library were searched for the concepts of calcaneal fracture and return to work. Inclusion criteria consisted of studies that reported on operative or nonoperative treatment of calcaneal fractures and outcomes relating to timing of return to work. Abstract only studies, biomechanical studies, cadaveric studies, case reports, studies involving pediatric patients, and non-English texts were excluded. Factors that were extracted included fracture type, pre-injury workload, mechanism of injury, treatment, return to work, functional outcomes, and complications. Revman 5.3 software was used for meta-analysis. Studies that did not qualify for meta-analyses were described qualitatively. Results: 2462 studies were identified on initial search. 52 texts met inclusion and exclusion criteria. A total of 3338 patients were included. Operative management had significantly improved return to work outcomes compared to nonoperative treatment, with an overall mean difference of 40.79 days [95% Confidence Interval (CI), -69.55 to -12.03, p < 0.05]. Operative treatment was also associated with significantly lower pain scores [Mean difference: -1.14; 95% CI, -2.24 to -0.04, p < 0.05] and higher SF-36 scores [Mean difference: 13.89; 95% CI, 7.69 to 20.10, p < 0.0001]. Operative treatment did have expectedly higher risk of all complications compared to the nonoperative group [Risk Ratio: 1.80; 95% CI, 1.22 to 2.66, p < 0.05]. Conclusion: While operative management was associated with higher risk of complications, patients had improved return to work, pain, and functional outcomes compared to nonoperative treatment. Careful consideration should be taken when determining treatment options for calcaneal fracture patients. Further research is needed to better elucidate differences between operative treatment options.

Category: Ankle; Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide for the management of end-stage arthritis, patient selection and medical optimization are crucial for the mitigation of infection risk. Diabetes increases the risk of infection due to compromised immunity and impaired wound-healing mechanisms. However, there is limited research on how diabetic management, inclusive of medications and glucose control, may impact infection risks post-TAA. This study aims to demonstrate the impact of diabetic management on the occurrence of periprosthetic joint infection (PJI) following TAA. Methods: This was a retrospective study of patients who underwent a TAA at a single academic institution from March 2002 to May 2022. Patients with diabetes who developed an intraarticular infection following TAA were propensity score matched to diabetic patients who did not. Data collection included demographics, implant types, diabetic medications, and preoperative hemoglobin A1c. PJI was diagnosed based on Musculoskeletal Infection Society (MSIS) criteria. Statistical analyses assessed differences in medication use, glucose control, and infection rates between groups. Results: Of the 1,863 patients who underwent TAA, 177 patients had a diagnosis of diabetes. The infection rate in patients with diabetes (2.8%) was higher than the total cohort rate (0.8%). Five patients with diabetes developed a PJI at an average of 2.2 months postoperatively. This cohort (n=5) was compared to propensity score-matched controls (n=15). There was no significant difference in diabetic medication use. Patients who developed PJI had higher rates of uncontrolled diabetes (60.0% vs. 6.7%) and average A1c levels (7.02% vs. 6.29%) compared to controls. Conclusion: Our findings suggest that the elevated risk of PJI observed in individuals with diabetes subsequent to TAA may be attributed not solely to the presence of diabetes, but to inadequate glycemic control. Effectively managing blood glucose levels is imperative for achieving favorable outcomes following TAA.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. While various patient demographics, comorbidities, and surgical factors have been associated with an increased risk of infection, evidence is limited, and further research is required to better understand infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA. Methods: A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified and matched using propensity-score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher's exact test. The outcomes following infection were identified and summarized using descriptive statistics. Results: A total of 1,863 patients who underwent primary TAA were identified, and 19 (1%) were diagnosed with an infection. After PSM, there were no significant differences in age, gender, BMI, and smoking status between the cohorts. There was a statistically significant increase in the rate of diabetes in the infected cohort (26.3 vs. 15.3; p =0.01). Subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Two-stage revision to total ankle replacement was performed in 7 cases (36.8%), while revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases (21.1%). One patient had to undergo amputation, however, at the time of the most recent follow-up (5.3%). All patients were found to be free of infection. Conclusion: This study demonstrated significantly increased rates of smoking and diabetes in the infected TAA cohort. Two-stage revision to TAR and revision to arthrodesis with isolated polyethylene exchange were successful in eradicating infection. Overall, a high rate of limb salvage was reported.

Category: Other Introduction/Purpose: The increasing prevalence of foot and ankle procedures in the United States has coincided with rising costs of care, exposing socioeconomic disparities within this area of orthopedics. Insurance payor status is one such factor that can affect the quality and accessibility of medical care and has been implicated in orthopedic patient outcomes. While previous studies in other fields of orthopedics have demonstrated an association between insurance status and access to treatment, length of hospital stay, postoperative outcomes and complication rates, no comprehensive review has explores this relationship in foot and ankle surgery. Thus, the goal of this study is to examine the association between insurance payor status and outcomes in foot and ankle procedures. Methods: A systematic review of five databases was conducted, focusing on the interplay between insurance coverage and foot/ankle procedures. Included studies reported on insurance payor status and patient outcomes following foot and ankle surgery. Extracted outcomes included time to be seen by a provider, complication and revision rates, post-operative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to work/activity, and follow-up. Meta-analyses were performed using the Revman 5.3 software. Studies that did not qualify for meta-analyses were described qualitatively. Results: Of 1401 studies identified, 24 texts met inclusion and exclusion criteria. Across the 24 studies, there were a total of 20,950 patients. Noninsured patients had a 59% higher risk of ED/urgent care utilization within 30 days of surgery compared to insured patients [Risk Ratio (RR) = 1.59, 95% Confidence Interval (CI) = 1.18 to 2.12, p < 0.05]. Privately insured patients were seen 3.65 days earlier than patients with government insurance [95% CI = 2.02 to 5.27, p < 0.0001]. Worker’s Compensation patients tended to have poorer outcomes, higher pain scores, and lower functional scores. Similarly, Medicaid patients also fared worse on functional scores and had delayed access to appointments and treatments. Conclusion: Patients without private insurance have worser pain and functional outcomes, delayed access to care, and increased utilization of emergency resources following foot and ankle procedures. It is crucial for providers to be cognizant of these discrepancies when caring for patients. Further research is needed to better understand the nuances of these insurance-related disparities within foot and ankle subspecialties.

Category: Ankle; Ankle Arthritis Introduction/Purpose: While the utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, there has been a subsequent increase in the occurrence of revision TAA procedures due to implant failure. The INBONE II system has risen in popularity specifically for the use in revision TAA cases, however there has been limited patient performance data for this specific indication. Given the growing number of TAA revision procedures and increasing focus on motion-preserving salvage options, this study aims to comprehensively examine the clinical outcomes associated with revision TAA using the INBONE II system. Methods: A retrospective analysis was conducted on a group of 60 patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis. Results: The study revealed high complication rates but generally fair clinical outcomes for revision TAA utilizing the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n=6), nerve injury/impingement (n=5), infection (n=3), fracture (n=3), implant failure (n=3), impaired wound healing (n=2), and osteolysis (n=3). The three-year implant survivorship rate from reoperation was 92.0% [82.7%-100.0%] while the three-year survivorship rate from major complications was 90.4% [80.8%-100.0%]. Conclusion: Our study demonstrates that revision TAA is an option to preserve joint function following primary TAA failure. Although there are high complication rates associated with revision TAA, patients generally fair clinical outcomes for revision TAA using the INBONE II system. Further study with longer-term follow-up is needed to ensure that revision TAA is durable at longer time intervals and remains a favorable option for the salvage of the failed total ankle.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Surgical management of ankle osteoarthritis (AOA) includes Ankle Arthrodesis (AA) or Total Ankle Arthroplasty (TAA). Existing literature has been inconclusive regarding a clear standard of treatment for AOA. The purpose of this study was to analyze data from the National Surgical Quality Improvement Project (NSQIP) to elucidate differences in outcomes between TAA and AA. Methods: Patients who underwent TAA or AA from January 2010 to December 2020 in the NSQIP database were included in this analysis. All patients were followed for at least 30 days following surgery. The independent variable was procedure type: AA or TAA. The dependent variables were complications. Independent sample t-tests and chi square tests were used to determine if there was a difference between groups. A binary logistic regression was performed to determine the odds ratio (OR) and 95% confidence intervals. Results: The matched cohorts included 359 patients in the arthroplasty group (57.2±13.3 years, 56.8% male, 33.0±7.3 kg/m 2 ) and 359 patients in the arthrodesis group (57.4±13.9 years, 58.5% male, 32.7±7.9 kg/m 2 ). There was an increase in transfusions, UTI, and return to the operating room in the arthrodesis group compared to the arthroplasty group (1.95%, 0.28%, p=0.038; 1.11%, 0.00%, p=0.045, 3.90%, 1.11%, p=0.017). The multivariate regression revealed that length of hospital stay (OR = 1.157) and insulin dependent diabetes (OR = 6.043) had an increased risk of any adverse event. Conclusion: The overall rate of any adverse event for ankle arthroplasty or arthrodesis was relatively low at 4.18% in the 30-day postoperative period. There was no adverse event that reached statistical significance, that was more likely in the TAA group compared to the AA group. Identification of these complication rates after TAA and AA, along with patient risk factors for adverse events can assist surgeons and patients in their choice of treatment for AOA.

ABSTRACT Background and Aim To investigate the pattern of progression of myopia among a Ghanaian clinical cohort. Methods A retrospective cohort analysis of a clinical data set of all healthy myopic participants attending a tertiary eye care center was performed. Participants' biennial refraction examinations were tracked for refractive changes 4 years after the date of the first visit. This covered the period from January 2015 to December 2019. Myopia progression was defined as a difference in spherical equivalent between consecutive biennial visits equal to, or greater than −0.50 D of myopia. Results The medical records of 169 myopic participants were reviewed, with the majority (53.8%) being female. Most of the participants (51.4%) were younger than 36 years, and at the end of the study period, 96 participants (56.8%), who made up the majority, showed progression of myopia Univariate regression revealed that the 36–59‐year‐old age range is associated with a 60% [cOR = 0.40, 95% CI: –0.17, 0.97; p = 0.04] reduced likelihood compared to those belonging to the 0–17‐year‐old age group, and the Mole‐Dagbon ethnicity is associated with an almost fourfold [cOR = 3.80; 95% CI: –1.40, 10.316; p = 0.01] increased likelihood of experiencing myopia progression compared to those of Ga‐Adangbe ethnicity. Multivariate regression revealed that the Mole‐Dagbon ethnicity is associated with an increased likelihood of experiencing myopia progression 4 years after their initial visit [aOR = 3.49; 95% CI: –1.27, 9.63; p = 0.02] compared to those of Ga‐Adangbe ethnicity. Conclusion Our study provides important insights into myopia progression in Ghana, with findings that are consistent with global trends. The association of myopia progression with age, place of residence, degree of myopia, and ethnicity highlights the need for tailored interventions to manage this growing public health concern in African populations.

Category: Ankle; Sports Introduction/Purpose: Osteochondral Defects (OCD) can be a painful condition that frequently affect the ankle joint, with talar OCD being more frequent than the tibia ones. Changes in bone density (BD) have been described around the lesion, particularly with sclerosis at the subchondral and cancellous bone of the talus. However, there is a paucity of data describing what happens with the distal tibia bone adjacent to a talar OCD. Weightbearing computed tomography (WBCT) offers a method for quantifying BD via calculation of tomographic Hounsfield units (HU), a quantitative scale for describing radiodensity. The aim of this study was to assess WBCT HU around talar OCD, investigating the pattern of BD distribution in the talus and adjacent tibia secondary to locally altered mechanics and stress concentration. Methods: In this retrospective comparative study, we included patients with talar OCD, either as primary diagnosis or as incidental finding, that underwent WBCT imaging of the foot and ankle. The Volume of Interest (VOI) represented a cube positioned around the talar OCD (width/depth) and length expanding 5mm below the OCD, the OCD, the joint space, and 5mm above the tibial plafond. The HU distribution was obtained along three parallel lines (anterior, central, and posterior aspects of the OCD) positioned inside the VOI, and aligned perpendicular to the joint surface. The same VOI and exact same process was then repeated on the opposite non-lesion side of the talus, that served as a control for normal HU distribution of talus, joint space and tibia. Graphical plots for HU distributions were generated for each line, separating the HU values and distributions in 3 control or 4 segments: talus, osteochondral lesion, joint space and tibia. Results: Thirty-two talar OCD patients (10 males, 22 females) were included. The mean age was 54 years old (range: 22-82 years). Fifty-two percent were symptomatic, and 48% had an incidental OCD finding. There was not significant difference in mean HU along the three lines (anterior, central, and posterior) in any segment (talus, OCL, joint space and tibia) when comparing the symptomatic and incidental OCD patients. However, when comparing talar OCD patients and controls, the mean HU followed a different distribution pattern. In controls, the talus had higher HU average than the tibia, but in OCD patients the tibia demonstrated higher HU than the talus. When comparing the HU in the tibia between OCD and controls, the OCD patients demonstrated significantly increased BD (p

Category: Basic Sciences/Biologics; Midfoot/Forefoot Introduction/Purpose: Interfragmentary stability and compression are ideal for bone healing in fracture repair and arthrodesis procedures. The primary purpose of orthopaedic plate and screw hardware is to provide interfragmentary stability with a lesser focus on interfragmentary compression as this is typically achieved with lag screw fixation outside of the plate, before plate application. Modern plates afford variable screw angulation with the intended purposes to capture bony fragments or avoid other hardware but not for compression. We hypothesized that variable angle technology can be used to pull bony fragments together, thereby optimizing interfragmentary compression and contact area. However, there is no data to support this rationale. This study aimed to elucidate the impact of “highly-angled” screw angulation to optimize interfragmentary compression and contact area for bony healing. Methods: Interfragmentary fixation was simulated using interlocking orthopedic plates on simulated fractures in foam bone models (SawBones). To ensure findings were not specific to plate model, two orthopedic plate models were tested (Plate 1 = 4-hole plate, Max Screw Angle=15°, Plate 2 = 4-hole plate, Max Screw Angle=30°). Plates were applied to the bone fragments according to manufacturer instructions FigA. Screws were inserted (1) perpendicular to the plate (0°), (2) angled 15° away from fracture line, or (3) angled 30° away from fracture line (Plate 2 only as this exceeds max angulation of Plate 1). Interfragmentary compression and contact area were measured following application of all screws using pressure sensing film (TekScan Evolution). Data were analyzed using a two-way ANOVA with plate model and screw angle as main effects. Results: Interfragmentary compression markedly and significantly increased with increasing screw angle (p< 0.001,Fig1B). Specifically, mean interfragmentary compression across both plate groups increased by 470% in the 15° screw angle group as compared to the 0° group. When screws were applied at 30° offset from fracture plane, compression was increased by 956% as compared to the 0° group. The Plate 2 group demonstrated significantly increased compression across all screw angles as compared to the Plate 1 group (p=0.045,FigB). Contact area increased significantly with increased screw angle (p< 0.001, FigC). No significant differences in contact area were noted between plate groups (p=0.81, FigC). Conclusion: Our findings underscore the critical role of screw angulation in achieving optimal interfragmentary compression and contact area. Specifically, even a modest 15° screw angle significantly enhanced interfragmentary compression and contact area by 470% and 212%, respectively. Importantly, these data highlight that maximum allowable screw angulation provided by plate models is a key factor in enhancing fixation quality. Surgeons should consider utilizing plates offering greater that offer maximum angulation flexibility to optimize fixation quality. This approach not only affords improved compression but also allows for improved adaptation to the anatomical and intraoperative challenges, offering a substantial advancement in fracture stabilization techniques.

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Recently, there has been a gradual rise in the utilization of patient-specific metallic implants within foot and ankle orthopedics, with the total ankle/total ankle replacement (TATTR) serving as a prime example. A critical decision made by surgeons in conjunction with the TATTR procedure involves the potential arthrodesis of the subtalar joint. This decision hinges upon numerous factors encompassing surgeon preference, radiographic indications, and clinical evaluations. However, no study has compared surgeon decision to the true joint health. The primary aim of this study was to determine if surgeon decision correlated with true three-dimensional joint health. It was hypothesized that arthrodesis of the subtalar joint with the TATTR procedure would be correlated with measures of sinus tarsi impingement or reduced joint space evident on 3D imaging. Methods: In this retrospective study, a 172 TATTR dataset was analyzed. Each patient underwent a bilateral computed tomography (CT) scan. Cases were semi-automatically segmented, and cases involving extensive anatomical damage were excluded. To assess joint health, a semi-automated distance mapping algorithm was written in MATLAB. Specific surfaces of the subtalar joint were manually selected. This included the posterior and middle/anterior talocalcaneal facets on the talus, and the sinus tarsi, anterior, middle, and posterior facets on the calcaneus. Distance mapping was performed by projecting a vector perpendicular from one bone triangulation until it intersected with its opposing triangulation. For detailed analysis, the sinus tarsi and posterior facet were divided into four and nine regions, respectively. Statistical analysis involved calculating the difference in means and Welch's t-test to assess significance. For visual analysis, rank plots were generated to determine if there was a clear distinction in joint spacing for fused and articulating procedures. Results: A total of 46 TATTR cases were included. No significance was found between groups for the four large regions (sinus tarsi, anterior, middle, and posterior facet), but when analyzing by specific regions, significance was found on the lateral portion of the posterior sinus tarsi as well as at both the medial portion of the anterior and middle sections of the posterior facet. When analyzing on rank plots for the posterior facet (anterior/medial), a clear cutoff was found around 2mm of joint space width (Figure 2). Table 1 summaries these results, and figures 1, 2, and 3 demonstrate our findings visually. Conclusion: In this study, surgeon decision to fuse the subtalar joint along with a TATTR procedure was compared to 3D imaging data of the pre-operative joint. Our findings indicate that patients in the fused+TATTR group, there was a noticeable anterior/medial downward shift of the talus. Moreover, our initial assumption regarding sinus tarsi impingement in fused cases was validated, as there was a significant reduction in sinus tarsi JSW. Future following of individualized surgeon decision could begin to establish trends in surgeon decision. Utilizing this tool prior to surgery in conjunction with the surgeon’s clinical decision-making process could potentially enhance patient outcomes.

Objective Treatment of posttraumatic stress disorder (PTSD) is hindered by limited uptake, early drop-out and non-response. This pilot study aimed to explore the feasibility, acceptability, and usability of a mobile app as part of a blended approach to treating frontline workers experiencing PTSD.Method A single-group pre-post study was conducted with 10 adult frontline workers (firefighters, police, correctional workers) receiving trauma-focused cognitive-behavioural therapy for PTSD. Participants used an app (Support Base) designed to consolidate session content and encourage independent skills practice. At post-treatment, feasibility was assessed via app usage data and participant feedback, usability via the mHealth App Usability Questionnaire, and acceptability via items from the Mobile Application Rating Scale: user version.Results Usability ratings were above average and the app received an overall mean rating of 3.4/5. Despite generally positive attitudes towards using technology in therapy, participants had low levels of confidence/experience with wellbeing apps and almost half preferred using the standard treatment workbook. Clinicians highlighted a range of client barriers to app use, including difficulties in clinician/client collaboration. Overall, there was significant pre- to post-treatment improvement in clinical measures of PTSD and depression, but this change cannot be tied to app use.Conclusions Although Support Base was viewed by participants as usable and acceptable, there were feasibility issues which must be further considered in delivering this form of care. Due to the uncontrolled study design, any additive effects of the app beyond standard clinical treatment could not be assessed. The development of a more integrated blended care model is a potential avenue for future research.

Abstract Background A clear understanding of public perceptions of the social determinants of health remains lacking. This paper aimed to describe the relationship between income and urbanicity levels and public views of the determinants of health in eight middle-and high-income countries that varied across multiple characteristics. Methods We conducted a cross-sectional online survey in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States. Respondents were asked to select what they considered to be most important for health out of a list of ten determinants. We stratified the results by income and urbanicity levels and tested significance of differences between groups using two-tailed χ2 tests. Multivariable logistic regression models tested associations between demographic factors and the likelihood of respondents selecting the genetics, healthcare, income and wealth, or social support determinants. Results Here we show 8753 respondents across eight countries. Rankings of determinants are similar across income groups, except for two determinants. Respondents in the highest income group rank genetics in higher proportions (32.4%, 95%CI: 29.0%,35.8%) compared to other income groups. Conversely, those in lowest income group rank social support more frequently (27.9%, 95%CI: 25.3%,30.7%) than other income groups. Those living in urban settings rank healthcare in higher proportions (61.2%, 95%CI: 59.0%,63.4%) compared to non-urban respondents; meanwhile, higher proportions (26.6%, 95%CI: 24.9%,28.3%) of non-urban respondents rank social support as important for health compared to urban respondents. Conclusion Demographic factors play a role in shaping public views of what affects health. Advancing public understanding about determinants of health requires tailoring public health messaging to account for socioeconomic position within a population.

Abstract This study on severe malarial anemia (SMA: Hb < 6.0 g/dL), a leading global cause of childhood morbidity and mortality, compares the entire expressed whole blood host transcriptome between Kenyan children (3-48 mos.) with non-SMA (Hb ≥ 6.0 g/dL, n = 39) and SMA (n = 18). Differential expression analyses reveal 1403 up-regulated and 279 down-regulated transcripts in SMA, signifying impairments in host inflammasome activation, cell death, and innate immune and cellular stress responses. Immune cell profiling shows decreased memory responses, antigen presentation, and immediate pathogen clearance, suggesting an immature/improperly regulated immune response in SMA. Module repertoire analysis of blood-specific gene signatures identifies up-regulation of erythroid genes, enhanced neutrophil activation, and impaired inflammatory responses in SMA. Enrichment analyses converge on disruptions in cellular homeostasis and regulatory pathways for the ubiquitin-proteasome system, autophagy, and heme metabolism. Pathway analyses highlight activation in response to hypoxic conditions [Hypoxia Inducible Factor (HIF)−1 target and Reactive Oxygen Species (ROS) signaling] as a central theme in SMA. These signaling pathways are also top-ranking in protein abundance measures and a Ugandan SMA cohort with available transcriptomic data. Targeted RNA-Seq validation shows strong concordance with our entire expressed transcriptome data. These findings identify key molecular themes in SMA pathogenesis, offering potential targets for new malaria therapies.

ABSTRACT Electrofulguration (EF) of areas of chronic cystitis in women with antibiotic-recalcitrant recurrent urinary tract infections (RUTIs) can result in improvement of their urinary tract infections (UTIs). We compared urine culture (UC) findings in patients before and after EF, as well as how they vary with cystitis stage at the time of EF, to evaluate for persistent species. After obtaining institutional review board approval, we retrospectively reviewed a prospectively maintained database of EF patients for those with positive UC findings in the 3–6 months preceding EF. Patient pre-EF UC was then compared with first positive UC after EF prompted by a new symptomatic UTI episode, with the hypothesis that the same species will be identified before and after EF. Exclusion criteria included UC from outside institution, neurogenic bladder, and need for catheterization. Ninety-nine women with pre- or post-EF UC-recorded organisms met the study criteria. The median age was 65 years (interquartile range 64–74), with a median time to first positive culture following fulguration of 9.7 months. For 26 patients with positive cultures both pre- and post-EF, the same organism was present in both cultures in 73% of the patients, with predominantly Escherichia coli. EF was effective at reducing the rate of UTIs in this population. For women undergoing EF for antibiotic-recalcitrant RUTIs and associated chronic cystitis lesions, 73% of those with a UC obtained at the time of a first symptomatic recurrent UTI episode post-EF expressed the same organism as before EF. Further study is needed to better understand the evolution of the microbiome post-EF.IMPORTANCEAmong women who experience a recurrent urinary tract infection after a fulguration procedure on areas of chronic cystitis in their bladder, there are no data available on whether the bacterial species found in urine cultures are the same or different from those present before fulguration. By removing the inflamed surface layer of cystitis during fulguration, it is possible that the procedure unmasks deep-seated bacteria. The bacterial kingdom in the bladder wall of these chronically infected women may be different from what is expressed sporadically in urine cultures. Confirming prior studies, we found that fulguration in women with antibiotic-recalcitrant recurrent urinary tract infections and cystitis lesions was effective at reducing the rate of urinary tract infections. At the time of a first symptomatic recurrent UTI episode post-fulguration, 73% expressed the same organism in urine culture as before fulguration. Further study is needed to better understand the evolution of the microbiome post-EF. This article evaluates persistent infections after electrofulguration of areas with chronic cystitis in post-menopausal women with antibiotic-recalcitrant recurrent urinary tract infections. Pre-fulguration urine cultures were compared with the first positive urine culture prompted by a new symptomatic UTI episode after electrofulguration, with the hypothesis that the same species will be identified before and after the fulguration procedure. Electrofulguration was effective at reducing the rate of UTIs in this population. However, 73% of those with a urine culture obtained at the time of a first symptomatic recurrent UTI episode post-electrofulguration expressed the same organism (predominantly Escherichia coli) as before the fulguration procedure. Further study is needed to better understand the evolution of the microbiome after electrofulguration.

BackgroundTeaching medical students in the clinical setting is frequently perceived as a demanding commitment by attending physicians. There is a paucity of data measuring the duration and efficacy of teaching during clinical rounds.AimThe aim of this study was to assess both the quantity and quality of clinical teaching time dedicated to medical students on hospital ward rounds.MethodsA cross-sectional direct structured observational study was conducted during the morning rounds of attending physicians involved in teaching undergraduate medical students at three different clinical facilities in three different specialties. A validated observational tool was used by four observers to record teaching time and quality indicators.ResultsIn terms of teaching duration, it was observed that 25% of the total morning round time was allocated to teaching. However, this measure varied widely between different physicians and specialties. As for teaching quality, actions categorized as active teaching by the teachers were observed in 19% of the interactions observed per round, while active learning by the students was observed in 17% of the interactions per round. Teacher high-cognition interactions were similarly observed in 23% of actions per round, while student high-cognition interactions occurred in 16% of actions per round. Internal Medicine tended to score higher than both Pediatrics and Surgery in terms of percentage teaching time as well as percentage of active teaching observed per round. Using liberal criteria, rounds characterized overall as predominantly active or high-cognition by both teachers and students were observed in only 21% of the total number of rounds observed.ConclusionThese results indicate that the percentage of teaching time during ward rounds is highly variable, and that round teaching generally consists of passive and low-cognition interactions. Future work is needed to train clinical faculty to achieve a desired level of teaching quality, and to determine if there are any changes in teaching time commitments and student outcomes.

Abstract Spindle-shaped waves of oscillations emerge in EEG scalp recordings during human and rodent non-REM sleep. The association of these 10–16 Hz oscillations with events during prior wakefulness suggests a role in memory consolidation. Human and rodent depth electrodes in the brain record strong spindles throughout the cortex and hippocampus, with possible origins in the thalamus. However, the source and targets of the spindle oscillations from the hippocampus are unclear. Here, we employed an in vitro reconstruction of four subregions of the hippocampal formation with separate microfluidic tunnels for single axon communication between subregions assembled on top of a microelectrode array. We recorded spontaneous 400–1000 ms long spindle waves at 10–16 Hz in single axons passing between subregions as well as from individual neurons in those subregions. Spindles were nested within slow waves. The highest amplitudes and most frequent occurrence suggest origins in CA3 neurons that send feed-forward axons into CA1 and feedback axons into DG. Spindles had 50–70% slower conduction velocities than spikes and were not phase-locked to spikes suggesting that spindle mechanisms are independent of action potentials. Therefore, consolidation of declarative-cognitive memories in the hippocampus may be separate from the more easily accessible consolidation of memories related to thalamic motor function.

Abstract Substantial literature documents the impact of mass traumatic events on post-traumatic stress disorder (PTSD) in populations. However, the trajectory of PTSD in the US population during the pandemic and the association between assets, Covid-19 related stressors, and PTSD over time remains unclear. The Covid-19 and Life Stressors Impact on Mental Health and Well-Being (CLIMB) is a nationally representative, longitudinal panel of US adults in Spring 2020 (N = 1270), 2021 (N = 1182), and 2022 (N = 1091). Using the four-item PC-PTSD-4, we assessed the prevalence of probable PTSD in the US population over three years. Using generalized estimating equations (GEE) and logistic regression at each wave, we estimated associations of demographics, assets, and stressors with probable PTSD. Here we report that the overall prevalence of PTSD decreases from 22.2% in 2020 to 16.8% in 2022 (p = 0.02). Persons with household incomes below $20,000 report higher prevalence of probable PTSD compared to other income groups. The GEE model shows higher odds of probable PTSD among persons with household incomes below $20,000 (OR = 2.17 (95%CI: 1.35,3.50)) relative to $75,000 or more; and high stressor scores (OR = 2.33 (95%CI: 1.72,3.15)) compared to low stressor scores. High stressor scores are associated with higher odds of probable PTSD in 2020 (OR = 2.69 (95%CI: 1.56,4.66)), 2021 (OR = 4.58 (95%CI: 2.52,8.30)), and 2022 (OR = 3.89 (95%CI: 2.05,7.38)) compared to low stressor scores. This analysis highlights the pandemic’s prolonged influence on population mental health, particularly among persons with fewer economic assets and those experiencing more pandemic-related stressors. Reducing mental health disparities requires interventions to address inequities.

Abstract Occult hemorrhages after trauma can be present insidiously, and if not detected early enough can result in patient death. This study evaluated a hemorrhage model on 18 human subjects, comparing the performance of traditional vital signs to multiple off-the-shelf non-invasive biomarkers. A validated lower body negative pressure (LBNP) model was used to induce progression towards hypovolemic cardiovascular instability. Traditional vital signs included mean arterial pressure (MAP), electrocardiography (ECG), plethysmography (Pleth), and the test systems utilized electrical impedance via commercial electrical impedance tomography (EIT) and multifrequency electrical impedance spectroscopy (EIS) devices. Absolute and relative metrics were used to evaluate the performance in addition to machine learning-based modeling. Relative EIT-based metrics measured on the thorax outperformed vital sign metrics (MAP, ECG, and Pleth) achieving an area-under-the-curve (AUC) of 0.99 (CI 0.95–1.00, 100% sensitivity, 87.5% specificity) at the smallest LBNP change (0–15 mmHg). The best vital sign metric (MAP) at this LBNP change yielded an AUC of 0.6 (CI 0.38–0.79, 100% sensitivity, 25% specificity). Out-of-sample predictive performance from machine learning models were strong, especially when combining signals from multiple technologies simultaneously. EIT, alone or in machine learning-based combination, appears promising as a technology for early detection of progression toward hemodynamic instability.

Abstract Real-time lab analysis is needed to support clinical decision making and research on human missions to the Moon and Mars. Powerful laboratory instruments, such as flow cytometers, are generally too cumbersome for spaceflight. Here, we show that scant test samples can be measured in microgravity, by a trained astronaut, using a miniature cytometry-based analyzer, the rHEALTH ONE, modified specifically for spaceflight. The base device addresses critical spaceflight requirements including minimal resource utilization and alignment-free optics for surviving rocket launch. To fully enable reduced gravity operation onboard the space station, we incorporated bubble-free fluidics, electromagnetic shielding, and gravity-independent sample introduction. We show microvolume flow cytometry from 10 μL sample drops, with data from five simultaneous channels using 10 μs bin intervals during each sample run, yielding an average of 72 million raw data points in approximately 2 min. We demonstrate the device measures each test sample repeatably, including correct identification of a sample that degraded in transit to the International Space Station. This approach can be utilized to further our understanding of spaceflight biology and provide immediate, actionable diagnostic information for management of astronaut health without the need for Earth-dependent analysis.

Abstract Background Despite the established need to prioritize professionalism-training in developing future physicians, very few medical programs in the Gulf Region embed in their curricula discrete contextualized courses aimed at developing the corresponding competencies, while fostering self-directed learning. This study aims at exploring the perception of undergraduate medical students in a multi-cultural, multi-ethnic setting regarding their understanding of, and personal experience with professionalism through their engagement with the content of an innovative curriculum-based professionalism course, offered at a Medical School in Dubai, United Arab Emirates. Methods The study used a qualitative phenomenological research design. Out of 33 students, 29 students had submitted reflective essays. The content of these essays was inductively analyzed following a six-step framework for conducting thematic analysis. The framework’s steps include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Findings The inductive qualitative analysis generated the Professionalism Learning Journey model. This conceptual model includes four interconnected themes: Awareness, Acknowledgement, Realization, and Application. The generated model depicts the trajectory that the learners appear to experience while they are engaging with the content of the course. Conclusion Integrating a professionalism-training course into an undergraduate medical curriculum is likely to be positively appraised by the learners. It raises their awareness, enables them to value the subject matter and the sophistication of its application, and empowers them to put into practice the taught principles, on an individual basis and collectively. This is especially true when the course is entrenched in constructivism experiential learning theory and designed to foster self-directed learning. The introduced conceptual model, in conjunction with the innovative professionalism-training course curriculum, can serve as a template for other competencies and other schools.

This study investigates 3D extrusion bioinks for cartilage tissue engineering by characterizing the physical properties of 3D-printed scaffolds containing varying alginate and polyvinyl alcohol (PVA) concentrations. We systematically investigated the effects of increasing PVA and alginate concentrations on swelling, degradation, and the elastic modulus of printed hydrogels. Swelling decreased significantly with increased PVA concentrations, while degradation rates rose with higher PVA concentrations, underscoring the role of PVA in modulating hydrogel matrix stability. The highest elastic modulus value was achieved with a composite of 5% PVA and 20% alginate, reaching 0.22 MPa, which approaches that of native cartilage. These findings demonstrate that adjusting PVA and alginate concentrations enables the development of bioinks with tailored physical and mechanical properties, supporting their potential use in cartilage tissue engineering and other biomedical applications.

White coats, traditionally symbols of physicians’ hygiene and professionalism, are now scrutinized for potential infection risks during patient interactions. This review investigates whether wearing white coats is linked to microbial contamination, infection transmission, and patient expectations. An umbrella review of peer-reviewed studies and guidelines was conducted, with searches in PubMed/Medline and Scopus using terms related to medical attire, infection control, patient perceptions, and discrimination. Ten records were included, and a bibliometric analysis was performed with VOS Viewer. Bias appraisal was conducted using the JBI Bias Assessment Toolset, and a SWOT analysis was developed to support evidence-based decision-making. Findings indicate that white coats may harbor pathogens such as Staphylococcus aureus, Gram-positive cocci, Gram-negative rods, and MRSA. To mitigate contamination risks, it is recommended that physicians roll up coat sleeves during examinations and that the coats receive daily laundering in healthcare settings. However, evidence supporting a coatless policy is yet to be published. Patients tend to expect physicians to wear identifiable attire, like white coats or scrubs for surgeons. Recent research in this field shifts the focus from infection control to the impact of attire on patient trust and physician–patient relationships.

Heterogeneity and overuse of precautionary allergen labelling (PAL) in prepackaged foods have eroded its risk communication efficacy. Experts recommend applying PAL based on allergen concentration thresholds, but adoption remains limited. The aim of this study was to quantitatively assess the potential impact of this approach using Monte Carlo risk simulations. Four allergens and 9 food categories were considered in 2 scenarios: (1) consumption of products currently carrying PAL in Canada where individuals with food allergy (FA) are assumed to consume them, and (2) consumption of products without PAL, in a hypothetical context where PAL is applied based on thresholds that would protect 99 % (ED01) and 95 % (ED05) of individuals with FA, and individuals with FA systematically avoid products with PAL. In scenario (1), although several cases studied would cause 20 reactions/10 000 e.o. Cross-contact milk posed the highest risk (max. 1120 reactions/10 000 e.o.), and peanut, the least (max. 10 reactions/10 000 e.o.). In scenario (2), consumption of products without PAL, when using thresholds for PAL based on ED01, could lead to a maximum of 15 reactions/10 000 e. o. for all studied cases, and based on ED05, to 57 (if excluding dark chocolate with milk PAL). In most cases, the estimated number of reactions per 10 000 e.o. attributed to products with PAL currently on the market would be higher (p

Mental health problems among the working population represent a growing concern with huge impacts on individuals, organizations, compensation authorities, and social welfare systems. The workplace presents both psychosocial risks and unique opportunities for intervention. Although there has been rapid expansion of workplace mental health interventions over recent decades, clear direction around appropriate, evidence-based action remains limited. While numerous workplace mental health models have been proposed to guide intervention, general models often fail to adequately consider both the evidence base and where best-practice principles alone inform action. Further, recommendations need to be updated as new discoveries occur. We seek to update the Framework for Mentally Healthy Workplaces based on new evidence of intervention effectiveness while also incorporating evidence-based principles. The updated model also integrates concepts from existing alternate models to present a comprehensive overview of strategies designed to enhance wellbeing, minimize harm, and facilitate recovery. Examples of available evidence and obstacles to implementation are discussed. The Framework is designed to support employers and managers in determining which strategies to apply and to guide future avenues of research.

We report platinum-group element (PGE) and Re concentrations, and Re−Os isotopic data for peridotites and podiform chromitite from the mid-Jurassic Coast Range ophiolite (CRO), California. Our aim is to provide insights into the formation and evolution of the CRO in a fore-arc tectonic setting. The CRO peridotites are divided into two groups: abyssal and supra-subduction zone (SSZ). They have Ir-group PGE concentrations similar to estimates for the primitive mantle and nearly chondritic relative abundances [(Os/Ir)N ≈ 1.1]. Abyssal-type peridotites have slightly subchondritic Pd-group PGE (PPGE)−Re abundances and flat chondrite-normalized patterns, whereas the SSZ-type ones are depleted overall with highly fractionated PPGE−Re patterns. The CRO peridotites have 187Os/188Os values of 0.1188 to 0.1315 (γOs = −8.3 to 1.4) and 187Re/188Os ranging from 0.022 to 0.413. The oxygen fugacity based on the V/Yb ratios of the CRO peridotites is equivalent to the fayalite−magnetite−quartz buffer. The abyssal-type peridotites are residues after ≤5% melting of the primitive upper mantle and represent a remnant of oceanic lithosphere trapped in an SSZ setting but before it was re-melted or modified by subduction processes. The abyssal-type peridotites yield an aluminachron model age of ~1.5 Ga, implying that the CRO mantle had experienced episode(s) of melt extraction before the CRO crust was formed. The SSZ-type peridotites are refractory residues after ~5% to 15% melting. Extraction of fore-arc basalts generated mainly by decompression melting resulted in the SSZ-type peridotites. The chromitite has 187Os/188Os value of 0.1250 (γOs = −3.5) and PGE−Re patterns complementary to that of boninite, indicating a genetic link to fore-arc magmatism.

The use of midfoot wedges for the correction of flatfeet disorders, such as progressive collapsing foot disorder, has increased greatly in recent years. However, the wedge material/composition has yet to be standardized. Metallic wedges offer advantages such as comparable elasticity to bone, reduced infection risk, and minimized osseous resorption, but a comprehensive review is lacking in the literature. Therefore, the objective of this systematic review was to organize all studies pertaining to the use of metallic wedges for flatfoot correction to better understand their efficacy and safety. This systematic review adhered to PRISMA guidelines, and articles were searched in multiple databases (PubMED, SPORTDiscus, CINAHL, MEDLINE, and Web of Science) until August 2023 using a defined algorithm. Inclusion criteria encompassed midfoot surgeries using metallic wedges, observational studies, and English-language full-text articles. Data extraction, article quality assessment, and statistical analyses were performed. Among 11 included articles, a total of 444 patients were assessed. The average follow-up duration was 18 months. Radiographic outcomes demonstrated that patients who received metallic wedges experienced improvements in lateral calcaneal pitch angle and Meary’s angle, with an enhancement of up to 15.9 degrees reported in the latter. Success rates indicated superior outcomes for metallic wedges (99.3%) compared to bone allograft wedges (89.9%), while complications were generally minor, including hardware pain and misplacement. Notably, there were no infection complications due to the inert nature of the metallic elements. This review summarizes the effectiveness, success rates, and safety of metallic wedges for flatfoot correction. Radiographic improvements and high success rates highlight their efficacy. Minor complications, including pain and mispositioning, were reported, but the infection risk remained low. Our results demonstrate that metallic midfoot wedges may be a viable option over allograft wedges with proper planning. Future research should prioritize long-term studies and standardized measures.

The hypothesis that ice-sheet evolution is only controlled by the long-term non-Newtonian viscous behavior of ice has been challenged by observations indicating that effects like brittle failure, stick-slip sliding, tides and wave action may affect ice-sheet evolution on sub-daily timescales. Over these timescales, the quasi-static-creep approximation is no longer appropriate and elastic effects become important. Simulating elastic effects in ice-sheet models over relevant timescales, however, remains challenging. Here, we show that by including a visco-elastic rheology and reintroducing the oft neglected acceleration term back into the ice-sheet stress balance, we can create a visco-elastic system where the velocity is locally determined and information propagates at the elastic wave speed. Crucially, the elastic wave speed can be treated like an adjustable parameter and set to any value to reproduce a range of phenomena, provided the wave speed is large compared to the viscous velocity. We illustrate the system using three examples. The first two examples demonstrate that the system converges to the steady-state viscous and elastic limits. The third example examines ice-shelf rifting and iceberg calving. This final example hints at the utility of the visco-elastic formulation in treating both long-term evolution and short-term environmental effects.

The main components of the essential cellular process of eukaryotic ribosome biogenesis are highly conserved from yeast to humans. Among these, the U3 Associated Proteins (UTPs) are a small subunit processome subcomplex that coordinate the first two steps of ribosome biogenesis in transcription and pre-18S processing. While we have identified the human counterparts of most of the yeast Utps, the homologs of yeast Utp9 and Bud21 (Utp16) have remained elusive. In this study, we find that NOL7 is the likely ortholog of Bud21. Previously described as a tumour suppressor through regulation of antiangiogenic transcripts, we now show that NOL7 is required for early pre-rRNA accumulation and pre-18S rRNA processing in human cells. These roles lead to decreased protein synthesis and induction of the nucleolar stress response upon NOL7 depletion. Beyond Bud21’s nonessential role in yeast, we establish human NOL7 as an essential UTP that is necessary to maintain both early pre-rRNA levels and processing.

Background: Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications. Objective: To evaluate the local oncologic efficacy of thermal ablation (TA) for renal cell carcinoma (RCC) in the ipsilateral kidney following PN. Design, setting, participation: We included patients who underwent ablation for renal tumors in the ipsilateral kidney after PN between January 2005 and December 2019. Demographics, tumor size, procedural details, complications, pathology, local oncologic outcomes, and survival outcomes are described. Outcome measurements and statistical analysis: The procedural, pathologic, and oncologic outcomes are described. Survival rates were estimated using the Kaplan-Meier method. Results and limitations: A total of 66 patients (46 male and 20 female) with a median age of 62 yr (interquartile range [IQR] 52–69) met our inclusion criteria. In these patients, 74 TA procedures were performed for 86 lesions (median tumor size 1.9 cm, IQR 1.6–2.5). Radiofrequency ablation and cryoablation accounted for 60 (81%) and 14 (19%) procedures, respectively. Three patients (3.7%) had Clavien-Dindo grade III complications. Of 65 lesion biopsies, 62 (95.5%) were diagnostic. The most common subtype was clear cell RCC (n = 37). The median imaging follow-up duration was 60 mo (IQR 43–88). Recurrence in the ablation zone occurred for four lesions (4.6%) at a median of 6.9 mo (IQR 6.4–10.7). The rates of overall, recurrence-free, and disease-free survival were 93.1%, 94.4%, and 65.6% at 5 yr, and 71.6%, 94.4%, and 60.1% at 10 yr, respectively. Limitations include the retrospective design and the lack of a control group. Conclusions: TA is effective for the treatment of RCC in the ipsilateral kidney following PN. Patient summary: Heat treatment to remove tumor tissue is an effective option for small kidney masses recurring after partial kidney removal for cancer. Long-term follow-up data revealed that this treatment resulted in low recurrence and complication rates.

Severe malarial anemia (SMA, Hb < 6.0 g/dL) is a leading cause of childhood morbidity and mortality in holoendemic Plasmodium falciparum transmission zones. This study explored the entire expressed human transcriptome in whole blood from 66 Kenyan children with non-SMA (Hb ≥ 6.0 g/dL, n = 41) and SMA (n = 25), focusing on host immune response networks. RNA-seq analysis revealed 6862 differentially expressed genes, with equally distributed up-and down-regulated genes, indicating a complex host immune response. Deconvolution analyses uncovered leukocytic immune profiles indicative of a diminished antigenic response, reduced immune priming, and polarization toward cellular repair in SMA. Weighted gene co-expression network analysis revealed that immune-regulated processes are central molecular distinctions between non-SMA and SMA. A top dysregulated immune response signaling network in SMA was the HSP60-HSP70-TLR2/4 signaling pathway, indicating altered pathogen recognition, innate immune activation, stress responses, and antigen recognition. Validation with high-throughput gene expression from a separate cohort of Kenyan children (n = 50) with varying severities of malarial anemia (n = 38 non-SMA and n = 12 SMA) confirmed the RNA-seq findings. Proteomic analyses in 35 children with matched transcript and protein abundance (n = 19 non-SMA and n = 16 SMA) confirmed dysregulation in the HSP60-HSP70-TLR2/4 signaling pathway. Additionally, glutamine transporter and glutamine synthetase genes were differentially expressed, indicating altered glutamine metabolism in SMA. This comprehensive analysis underscores complex immune dysregulation and novel pathogenic features in SMA.

Abstract Background Plasmodium falciparum malaria is a leading cause of pediatric morbidity and mortality in holoendemic transmission areas. Severe malarial anemia [SMA, hemoglobin (Hb) G and rs11575837:C > T) and their haplotypes. The prospective observational study was conducted over a 36 mos. follow-up period in a cohort of children (n = 1,515, aged 1.9–40 mos.) residing in a holoendemic P. falciparum transmission region, Siaya, Kenya. Results Poisson regression modeling, controlling for anemia-promoting covariates, revealed a significantly increased risk of malaria in carriers of the homozygous mutant allele genotype (TT) for rs11575837 after multiple test correction [Incidence rate ratio (IRR) = 1.540, 95% CI = 1.114–2.129, P = 0.009]. Increased risk of SMA was observed for rs2736191 in children who inherited the CG genotype (IRR = 1.269, 95% CI = 1.009–1.597, P = 0.041) and in the additive model (presence of 1 or 2 copies) (IRR = 1.198, 95% CI = 1.030–1.393, P = 0.019), but was not significant after multiple test correction. Modeling of the haplotypes revealed that the CC haplotype had a significant additive effect for protection against SMA (i.e., reduced risk for development of SMA) after multiple test correction (IRR = 0.823, 95% CI = 0.711–0.952, P = 0.009). Although increased susceptibility to SMA was present in carriers of the GC haplotype (IRR = 1.276, 95% CI = 1.030–1.581, P = 0.026) with an additive effect (IRR = 1.182, 95% CI = 1.018–1.372, P = 0.029), the results did not remain significant after multiple test correction. None of the NCR3 genotypes or haplotypes were associated with all-cause mortality. Conclusions Variation in NCR3 alters susceptibility to malaria and SMA during the acquisition of naturally-acquired malarial immunity. These results highlight the importance of NK cells in the innate immune response to malaria.

Charcot neuroarthropathy (CN) is a rare but serious sequela of diabetes and other diseases that cause peripheral neuropathy. It is most commonly characterized by degeneration of the foot and/or ankle joints leading to progressive deformity and altered weight-bearing. If left untreated, the deformities of CN lead to ulceration, infection, amputation, and even death. Because of the associated peripheral neuropathy and proprioception deficits that accompany CN, patients typically do not perceive the onset of joint destruction. Moreover, in the hands of the untrained clinician, the initial presentation of CN can easily be mistaken for infection, osteoarthritis, gout, or inflammatory arthropathy. Misdiagnosis can lead to the aforementioned serious sequelae of CN. Thus, an early accurate diagnosis and off-loading of the involved extremity, followed by prompt referral to a specialist trained in the care of CN are crucial to prevent the late-term sequelae of the disease. The purpose of this article was to create an opportunity for enhanced understanding between orthopedic surgeons and emergency physicians, to improve patient care through the optimization of diagnosis and early management of CN in the emergent setting.

Abstract The market share of foods carrying labels suggesting absence of animal ingredients has significantly increased in recent years. The purpose of this study was to document the purchasing behaviour of egg- or milk-allergic consumers vis-à-vis food marketed as “vegan” and “plant-based”, and to evaluate the associated allergenic risk. A survey was conducted among egg- and milk-allergic consumers and revealed that 86% (margin of error 5.4%; confidence level 95%) would buy “vegan” products, indicating this label may be perceived as a substitute for “free from milk and eggs”. To assess the risk posed by these products, 87 prepackaged foods with “vegan” and/or “plant-based” claims purchased in Quebec were tested for milk proteins, and 64 for egg proteins. Overall, 5.7% and 0% occurrence of milk and egg proteins, respectively, were observed, suggesting that the analysed prepackaged foods carrying “vegan” and/or “plant-based” labels pose little risk to egg- or milk-allergic consumers. However, this is likely due to allergen management practices applied by the Canadian manufacturers of the products tested, and should not be attributed to the use of “vegan” or similar labels. Enhanced regulatory requirements for the use of these labels, and an education campaign on their meaning with respect to allergy-related risks, are necessary to better inform and protect egg- and milk-allergic consumers.

Abstract Background Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and the coronavirus 19 (COVID‐19) pandemic have had a lasting impact on the care of cancer patients. The impact on patients with gastrointestinal (GI) malignancies remains incompletely understood. We aimed to assess the impact of COVID‐19 on mortality, length of stay (LOS), and cost of care among patients with GI malignancies, and identify differences in outcomes based on primary tumor site. Methods We analyzed discharge encounters collected from the National Inpatient Sample (NIS) between March 2020 and December 2020 using propensity score matching (PSM) and COVID‐19 as the treatment effect. Results Of the 87,684 patient discharges with GI malignancies, 1892 were positive for COVID‐19 (C+) and eligible for matching in the PSM model. Following PSM analysis, C+ with GI tumors demonstrated increased incidence of mortality compared to their COVID‐19‐negative (C‐) counterparts (21.3% vs. 11.9%, p

Abstract Background Survival differences between left‐sided colon cancer (LSCC) and right‐sided colon cancer (RSCC) has been previously reported with mixed results, with various study periods not accounting for other causes of mortality. Purpose We sought to assess the trends in colon cancer cause‐ specific survival (CSS) and overall survival (OS) based on sidedness. Method Fine‐Gray competing risk and Cox models were used to analyze Surveillance, Epidemiology, and End Results (SEER) population‐based cohort from 1975 to 2019. Various interval periods were identified based on the timeline of clinical adoption of modern chemotherapy (1975–1989, interval period A; 1990–2004, B; and 2005–2019, C). Results Of the 227,637 patients, 50.1% were female and 46.2% were RSCC. RSCC was more common for African Americans (51.5%), older patients (age ≥65; 51.4%), females (50.4%), while LSCC was more common among Whites (53.1%; p

A solution blow spinning (SBS) process was utilized to create nanofibers of TiO2/C and TiO2/C/N with potential applications in photocatalysis and dye adsorption. Polyvinylpyrrolidone was used as a carbon and nitrogen source. Their content in the TiO2 structure decreased as the temperature increased from 350 to 550 °C. Physical-chemical, morphological, and structural features were investigated. Adsorption and photodegradation experiments revealed that the material calcined at 400 °C had higher dye removal (98%) under dark settings, whereas the greater photodegradation efficiency under visible and UV light was 56% and 98%, respectively, for the sample calcined at 550 °C. The results suggest that the SBS has the potential to develop an efficient adsorbent and photocatalyst for use in treatments of contaminated water.

3,5-Diphenyl-4H-1,2,6-thiadiazin-4-one treated with meta-chloroperoxybenzoic acid undergoes an oxidative ring contraction to give 2-benzoyl-4-phenyl-1,2,5-thiadiazol-3(2H)-one 1,1-dioxide in a 29% yield, the structure of which is supported by single-crystal X-ray diffraction analysis and the available spectroscopic data.

Wildlife microbiome studies are being used to assess microbial links with animal health and habitat. The gold standard of sampling microbiomes directly from captured animals is ideal for limiting potential abiotic influences on microbiome composition, yet fails to leverage the many benefits of non-invasive sampling. Application of microbiome-based monitoring for rare, endangered, or elusive species creates a need to non-invasively collect scat samples shed into the environment. Since controlling sample age is not always possible, the potential influence of time-associated abiotic factors was assessed. To accomplish this, we analyzed partial 16S rRNA genes of fecal metagenomic DNA sampled non-invasively from Rocky Mountain elk (Cervus canadensis) near Yellowstone National Park. We sampled pellet piles from four different elk, then aged them in a natural forest plot for 1, 3, 7, and 14 days, with triplicate samples at each time point (i.e., a blocked, repeat measures (longitudinal) study design). We compared fecal microbiota of each elk through time with point estimates of diversity, bootstrapped hierarchical clustering of samples, and a version of ANOVA–simultaneous components analysis (ASCA) with PCA (LiMM-PCA) to assess the variance contributions of time, individual and sample replication. Our results showed community stability through days 0, 1, 3 and 7, with a modest but detectable change in abundance in only 2 genera (Bacteroides and Sporobacter) at day 14. The total variance explained by time in our LiMM-PCA model across the entire 2-week period was not statistically significant (p>0.195) and the overall effect size was small (

Abstract Background The clinical placements of our medical students are almost equally distributed across private and public sectors. This study aims to assess medical students’ perceptions of their Clinical learning Environment (CLE) across these two different healthcare settings, using the Undergraduate Clinical Education Environment Measure (UCEEM). Methods 76 undergraduate medical students (Year 5 and 6), were invited to participate. Data were collected using an online UCEEM with additional questions related to demographics and case load exposure. The UCEEM consists of two overarching domains of experiential learning and social participation, with four subdomains of learning opportunities, preparedness, workplace interaction, and inclusion. Results 38 questionnaires were received. Of 225 responses to the individual UCEEM items, 51 (22.6%) scored a mean of ≥ 4 (range 4-4.5, representing strong areas), 31 (13.7%) scored a mean of ≤ 3 (range 2.1-3, needing attention) and 143 (63.6%) scored a mean of 3.1–3.9 (areas that could be improved). The majority (63%) of the case load exposure responses scored a mean of ≥ 4 (range 4-4.5). Compared to the private sittings, there is a significant reduction in total UCEEM (p = 0.008), preparedness for student entry (p = 0.003), and overarching dimension of social participation (p = 0.000) scores for the public sector. Similarly, both workplace interaction patterns and student inclusion and equal treatment scored significantly lower for the public sector (p = 0.000 and p = 0.011 respectively). Two out of three case load exposure items scored significantly higher for the public sector (p = 0.000). Discussion The students’ CLE perceptions were generally positive. The lower UCEEM ratings in the public sector items were related to student entry preparedness, workplace interactions, student inclusiveness and workforce equity of treatment. In contrast the students were exposed to more variety and larger number of patients in the public sector. These differences indicated some significantly different learning environments between the two sectors.