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Category: Other; Hindfoot Introduction/Purpose: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 classes that can occur simultaneously. Classes A-E indicate various deformities: hindfoot valgus, midfoot/forefoot abduction, forefoot varus/medial column instability, and ankle joint instability/valgus tilting in the ankle mortise, respectively. While the relationship between each of the PCFD deformities in the classification system to one another has been studied, to our knowledge, the correlation between the various classes and patient-reported outcomes has not been assessed. The purpose of this study was to evaluate whether the PCFD classification system is predictive of patient-reported outcomes and overall prognosis following surgery. The hypothesis was that patients with more severe deformity would have worse patient-reported outcomes. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 74 patients aged 18 or older who were treated surgically for PCFD between October 2018 and October 2021 with preoperative, 1-year, and 2-year postoperative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures completed. Using radiographs, weight-bearing computed tomography (WBCT), and office notes, patients were classified using the PCFD classification system. Patients were divided into two groups depending on whether subclasses D and/or E were present, indicating more severe deformity. Linear mixed models were used to assess longitudinal change in PROMIS scores between groups over time. Results: Patient demographic and classification characteristics are presented in Table 1. 47 patients were allocated to the Class D/E group and 27 patients were allocated to the No Class D/E group. Patients in the Class D/E group had worse pre-operative Global Physical Health (GPH) (p=0.018) and depression scores (p=0.012); however, post-operatively, there was only a difference in the PROMIS domain of Physical Function (PF) at both 1-Year (p=0.019) and 2-Year (p=0.038) time points (Table 2). There were no statistical differences between the two groups for any other domain at any timepoint (Table 2). Conclusion: Patients with more severe PCFD had clinically significant improvement in physical function at both 1- and 2-years post-operatively, but had worse outcomes compared to those with less severe deformity. The findings regarding preoperative GPH and depression suggest that while Class D/E patients did not perform as well functionally, they may be satisfied with their overall quality of life due to the similar scores postoperatively when compared to the patients with less severe deformity. Future studies are needed to better determine if the novel PCFD classification system is predictive of overall prognosis following surgery based on the various deformities present.

Category: Ankle Arthritis; Ankle Introduction/Purpose: The current fourth generation of total ankle arthroplasty (TAA) continues to build upon previous advances in implant design. In contrast to these implants, which utilize a traditional anterior approach for implantation, the Zimmer Trabecular Metal Total Ankle (Zimmer-Biomet, Warsaw, IN) is unique in that it utilizes a transfibular approach to the ankle. This allows for a shallow resection depth, and the insertion of a curved prosthesis design, mimicking the native tibiotalar joint. While previous case-series have reported on implant survivorship, a comprehensive midterm study of the clinical and radiographic outcomes of this system is limited. Here we present the largest midterm study to date by a single-surgeon, and analyze the survivorship, clinical, and radiographic outcomes of the transfibular TAA at a minimum of 5-years follow-up. Methods: Retrospective review was performed on prospectively followed patients who underwent primary transfibular TAA by a single surgeon from October 2012 to December 2018. Inclusion criteria included: minimum 5-years of follow-up. patient-reported outcomes measures (PROM), and radiographic follow-up. Patient demographics and perioperative data were collected. PROMs included: 12-item Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores, Ankle Osteoarthritis Scale (OAS), and Visual Analog Scale (VAS). Functional outcomes included range of motion (ROM) measured on weightbearing ROM radiographs. Radiographic outcomes included coronal and sagittal alignment, and evaluation of periprosthetic lucency utilizing a 12-zone system. Adverse events and reoperations were reported using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). A total of 130 ankles (122 patients) with average follow-up of 5.9 years (range, 5.0-10.1) were included in the study. The average age was 60.8 years-old, with 50.8% being females. Results: Postoperative PROMs included SF-12 PCS: 41.5; SF-12 MCS: 54.9; VAS: 2.3; AOS Pain: 19.1; AOS Disability: 28.5. Postoperative tibiopedal ROM was 17.7° dorsiflexion and 21.8° plantarflexion. Postoperative tibiotalar ROM was 7.4° dorsiflexion and 17.3° plantarflexion. A total of 26 (20%) ankles had a single zone of lucency, while 7 (5.4%) ankles had 6 or more; none had more than 7 zones. There were no cases of cysts, subsidence, septic/aseptic loosening, or fibular non-union. Reoperation rate was 36.2% (n=47) at average 26.7 months, most commonly removal of fibula hardware (n=28, 21.5%), medial gutter debridement (n=18, 13.8%). There were 5 (3.8%) cases of acute infection treated with I&D and metal component retention. Overall implant survival, defined by retention of the metal components, was 100%. Conclusion: Transfibular TAA is an effective durable treatment option for end-stage ankle arthritis with excellent implant survivorship, providing sustained improvements in clinical and radiographic outcomes at the midterm. Reoperations were mostly elective removal of fibular hardware or medial impingement. There was 100% retention of the metal components. Deformity correction was achieved and maintained. The majority of ankles had no radiographic lucencies and only 20% had a single zone out of 12 zones which did not correlate with clinical outcomes. There were no cysts, subsidence, or fibular non-unions.

Category: Other Introduction/Purpose: The level of amputation for patients with non-traumatic foot pathologies is a complex decision that limb salvage surgeons face, with ambulation playing a crucial role in the quality of life and long-term survival of amputees. In recent years, gait sensors have been used to access ambulation. This study investigates functional outcomes of digit, ray, transmetarsal (TMA), and below-knee amputations (BKA) using wearable gait sensors. Methods: Between December 2021 and January 2024, adult patients who were able to ambulate unassisted, without experiencing pain, and without an open wound or lower extremity surgery in the preceding three months, were selected for participation. Inclusion was voluntary and offered to all patients who presented to the wound care center for a period of 3 years. Out of 451 patients, 77 patients who had undergone amputations at levels including digit amputation, ray resection, TMA, or BKA, were included in this analysis. Patient characteristics, preoperative factors, and surgical history were collected. Participants completed a standardized assessment protocol using wearable gait sensors. This involved completing a 120-second walk test at a self-selected pace. The data collected from the sensors were analyzed using the Motility Lab software, with statistical significance set at p < 0.05. Results: A total of 77 patients were included for analysis, comprising 30 (38.9%) digit, 12 ray (15.6%), 12 TMA (15.6%), and 23 BKA (29.9%). The average age (61.3 1.19 years), body mass index (30.8 0.71 kg/m 2 ), and Charlson Comorbidity Index (4.9 0.2) did not differ between groups. Proportion of smokers (n=30, 34.8%), diabetes mellitus type II (n=54, 62.8%), chronic kidney disease (n=24, 29.1%), end stage renal disease (n=7, 8.1%) was similar across all four groups. There were no differences in gait speed (0.80 0.02 m/s, p=0.414), elevation mid-swing (1.62 0.14 cm, p=0.063), step duration (0.63 0.01s, p=0.066), cadence (96.2 1.2 steps/min, p=0.434), single limb support (34.4 0.3%, p=0.185), double limb support (29.2 0.6%, p=0.089), and stride length (0.97 0.02 m, p=0.225) across level of amputations. Conclusion: Our study shows comparable ambulatory function across all levels of amputation. This may highlight the importance of selecting the right amputation per patient, multidisciplinary limb salvage, and improvements in wearable aids. We encourage other large limb salvage centers to utilize wearable sensors to assess functionality of non-traumatic amputations.

Objectives: To describe and compare caregiver perceptions of their emergency department (ED) experiences with and without child life specialist (CLS) involvement in their child's overall care. Study design: A descriptive cross-sectional survey of caregivers of children aged 0-17 years at a tertiary care pediatric ED was completed from March to August 2021. Survey themes included perceived experience and satisfaction and the impact of child life specialists. Results: A total of 179 caregivers completed the survey; mean age was 38.9 years (SD 8.4), and 68.1% (122/179) were mothers. Caregivers of children with CLS involvement (CLS+) ranked their overall experience (P = .021) and satisfaction (P = .009) greater than without CLS involvement (CLS–). More CLS+ caregivers ranked their experience (55.7%, 34/61) and their satisfaction (77.0%, 47/61) as excellent (5/5 Likert scale rating) compared with CLS– caregivers (34.8%, 40/115 and 52.2%, 60/115 respectively). CLS+ families were more likely to be offered nonpharmacologic interventions (eg, iPad, sensory lights, toys) (98.4% vs 31.3%, P = .003); they were also more likely to have a health care worker explore their feelings and fears (52.5% vs 27.0%, P = .0008), help them prepare for a procedure or examination (73.8% vs 31.3%, P

Patient-reported outcome measures (PROs) are increasingly used in clinical assessment. Research on how patient support systems contribute to physician understanding of patient condition is limited. Thus, insights from significant others may provide value, especially when concerns exist regarding patient response validity. Patients recruited from the pre-operative environment undergoing orthopaedic hand procedures responded to PROMIS-Pain Interference (PI), PROMIS-Upper Extremity (UE), PROMIS-Depression (D), and QuickDASH. They then selected a significant other (SO) to do the same. Patients and SOs were also asked to complete the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) as a measure of support-related responses. Patient and SO responses were compared, and support-related responses were added in subsequent analyses to examine their effect on SO PRO assessment.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Revision of failed total ankle replacement (TAR), such as in the setting of implant subsidence, aseptic loosening, or avascular necrosis (AVN) of the talus can be challenging and associated with increased morbidity. As TAR becomes a more commonly performed procedure in the treatment of end-stage ankle arthritis (ESAA), naturally there arises the need for revision options. In this case series, we describe the short-term clinical and radiographic outcomes of using a patient-specific custom 3D-printed total ankle total talus (TATR) prosthesis in the treatment of this unique subset of patients. Methods: 29 patients with ESAA who underwent TATR by a single surgeon at our institution from 2019 to 2022 were retrospectively identified. Average age was 61.3 (range, 39-77) years, with average follow-up of 22.5 (range, 12 to 57) months. All patients were indicated for revision of primary STAR implant (Stryker, Kalamazoo, MI) for failed TAR in the setting of aseptic loosening/subsidence and/or talar AVN. All patients underwent replacement with 3D-printed titanium implants based on preoperative CT analysis (Additive Orthopaedics, Little Silver, NJ). Custom components included a combined total talus and stemmed tibial component through an anterior approach (Figure). Pre- and postoperative patient-reported outcome were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Pre- and postoperative implant alignment was assessed using medial distal tibial angle (MDTA) and tibiotalar angle (TTA) on anteroposterior, and sagittal tibial angle (STA) on lateral weightbearing plain films. Incidence of revision and reoperations were recorded. Results: At final follow-up, all custom implants were intact without evidence of hardware failure or implant subsidence. There was significant improvement in all six PROMIS domains (Table). Two patients (6.9%) had postoperative complications; one patient underwent open reduction internal fixation of the tibia for a tibial periprosthetic fracture 1 month postoperatively, another patient underwent medial gutter debridement and tarsal tunnel release for recurrent pain 14 months postoperatively. There were no significant differences in pre- to postoperative radiographic coronal or sagittal alignment in terms of MDTA (88.4 vs 88.8), TTA (87.3 vs 88.0), or STA (85.1 vs 85.9). Conclusion: As ankle replacement becomes a more popular surgical treatment for ESAA, there is a growing need to identify durable revision solutions. This study demonstrates the promising utility of custom 3D-printed TATR in the setting of revision TAR. At short-term follow-up, there was significant improvement in pain and physical function, with an acceptable postoperative complication rate. While preliminary, custom 3D-printed TATR offer an alternative solution for a unique subset of patients where there are limited options available for revision following failed primary TAR. Further longer-term follow-up with a larger cohort is underway.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has surpassed arthrodesis as the gold standard for treatment of end-stage ankle arthritis. The Zimmer Trabecular Metal Total Ankle Implant (Zimmer-Biomet, Warsaw, IN) differs from other newer- generation implants in the transfibular approach, non-mobile-bearing prosthesis, high-molecular-weight polyethylene, curved surface at every interface in the sagittal plane, and shallow resection depth. There is limited mid-term follow-up for this system. Therefore, we sought to report mid-term clinical, functional, and radiographic results we well as complications and survival for patients treated with the transfibular TAA at a minimum of 5-years follow-up. Methods: A retrospective review was performed on patients who underwent primary transfibular TAA by a single surgeon from October 2012 to January 2018. Inclusion criteria was a minimum of 5-years of follow-up with a completed consent for participation in the study and patient-reported outcome measures (PROM). Patient demographics and perioperative data were collected. PROMS included: 12-item Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores; Ankle Osteoarthritis Scale (OAS); and Visual Analog Scale (VAS). Functional outcomes included range of motion (ROM) measured on weightbearing ROM radiographs. Radiographic outcomes included coronal and sagittal alignment. Adverse events and reoperations were reported using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). Of the consecutive 151 TAAs, 83 (55.0%) ankles are included in this study, evaluated at a mean of 5.8 years clinical and 6.3 years radiographic follow-up. Results: The average age was 60.6 years-old. Preoperative tibiotalar coronal deformity included 27 valgus (10°, range 2-20°) and 25 varus ankles (-9°, range -2--25°), successfully corrected to neutral postoperatively. The postoperative PROMs were: SF-12 PCS: 40.4, SF-12 MCS: 56.0, VAS: 2.3, AOS Pain: 17.0, and AOS Disability: 24.9. Radiographic postoperative tibiopedal ROM was 17.8° dorsiflexion and 21.8° degrees plantarflexion. The overall reoperation rate was 38.6%(n=32) at an average of 28.7 months postoperative. Most common were removal of the fibula hardware (n=21,25.3%) and medial gutter debridement (n=15, 18.1%). There were 3 (3.6%) cases of acute postoperative infection (< 3 months) treated with operative irrigation and debridement but retention of the metal components. There were no cases of septic or aseptic loosening or subsidence. The overall implant survival, defined by retention of the metal components, was 100%. Conclusion: Transfibular TAA is a safe and effective treatment for end-stage ankle arthritis at 5-year mid-term follow-up. This study confirms excellent clinical results including PROMs and ROM as well as radiographic alignment correction and maintenance. The survival rate was 100% for retention of the trabecular metal components. The survival rate to reoperation was 60.7% with patients commonly requiring removal of the fibula hardware or medial gutter debridement. Patients should be counseled on the risk of reoperation preoperatively for postoperative expectation management.

Background: We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. Methods: Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. Results: Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P

Background: The diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears. Methods: Forty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting. Results: Of the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07). Discussion: Only 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

Background: Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods: This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results: Involvement of more malleoli was associated with worse PROMIS Physical Function ( P = .04), Global Physical Health ( P = .04), and Global Mental Health ( P

Category: Ankle; Ankle Arthritis Introduction/Purpose: Prior studies on the INBONE II and Salto Talaris total ankle arthroplasty (TAA) systems have reported favorable outcomes for both implants. However, it is unclear whether there were significant differences in survivorship between and if this led to subsequent differences in clinical or radiographic outcomes the two. To date, no similar comparisons have been done in the literature, although it is important to understand the clinically relevant distinctions between these more recent third generation TAA systems. This retrospective study aimed to compare the midterm differences between INBONE II and Salto Talaris TAA. Methods: Between 2007 and 2015, 44 INBONE II consecutive cases and 85 Salto Talaris consecutive cases had minimum 5-year clinical and radiographic follow-up. The endpoints for survivorship were revision, defined as removal or replacement of any implant component, and reoperation, defined as a non-revision surgery. Preoperative and midterm postoperative Foot and Ankle Outcome Score (FAOS), which has been validated for ankle osteoarthritis, and radiographic measures including tibiotalar alignment (TTA) and medial distal tibial angle (MDTA) were compared. Talar inclination angle (TIA) was compared to examine subsidence and cysts were examined for osteolysis. Average midterm follow-up for these patients was 6.4 +- 1.1 (range, 5-9) years for the INBONE II group, and 7 +- 1.9 (range, 5-12.7) years for the Salto Talaris group. Results: Survivorship to revision was 97.6% (95% CI, 93.1%-100%) for the INBONE II group and 97% (95% CI, 93%-100%) for the Salto Talaris group (P = .93). Survivorship to reoperation was significantly different; 95.5% for the INBONE II and 76.4% for Salto Talaris (P = .021) (Figure 1). All FAOS improved postoperatively (P < .001), although the INBONE II had superior postoperative scores in pain (P = .01), symptoms (P = .004), and sports activity (P = .02). There were no differences between groups in postoperative radiographic alignment, despite the INBONE group having greater preoperative deformity. There was one instance of subsidence in each group and similar rates of cyst occurrence across the INBONE II (18.2%) and Salto Talaris (21.2%) groups. Conclusion: Although both implants had similar longevity and postoperative alignment, the INBONE II resulted in greater clinical improvement and fewer reoperations than the Salto Talaris at midterm follow-up. The majority of reoperations in the Salto Talaris group were due to gutter impingement. The contrasting reoperation rates between groups may be explained by differences in implant design and technique, such as rotational malpositioning of the talus and the lateral sulcus design of the Salto Talaris. Additionally, the INBONE II TAA system was able to correct deformity and improve clinical outcomes even though this cohort exhibited greater preoperative deformity.

Category: Ankle; Other Introduction/Purpose: Periprosthetic joint infection (PJI) is a devastating complication of arthroplasty. The well known PJI risk factors are useful for identifying high-risk patients but would be even more helpful for clinical decision-making if they are converted to a risk assessment scores. The Mayo Prosthetic Joint Infection Risk Score was based on the data of total hip and knee arthroplasty and has not been validated for application for total ankle arthroplasty. Methods: A series of 398 consecutive cases of total ankle arthroplasty, with minimal follow-up of 6 months, was reviewed for Mayo Periprosthetic Joint Infection Risk Score (Mayo score) and PJI. The patients' Mayo scores and PJI was examined by logistic regression. T-test was performed to compare the Mayo score between the non-infected TAA cases and infected cases. Receiver Operating Characteristic (ROC) was used to identify the critical value of Mayo score for total ankle arthroplasty. Results: There were 12 cases of PJI or 3.0% in the series. Of the 398 patients, the Mayo scores were in the range from -4 to 13 (median 2; interquartile range (IQR) 0-4). Preliminary analysis showed that, by logistic regression, the probability of PJI was increased as increases of the Mayo scores (Fig A). The mean Mayo score of the PJI patients (8.6+-1.8) was significantly greater than the rest of the patients (mean Mayo score 1.9+-3.4; p < .0001). ROC analysis showed that, when a Mayo score was greater than 5, the patient has a high probability of PJI (sensitivity = 100%; specificity = 86.9%; Fig B). Conclusion: This study showed a high correlation between the Mayo score and PJI in total ankle arthroplasty, which is the same trend as in total knee and hip arthroplasty. The preliminary results suggest that strategically focusing on the patients, who have a Mayo score > 5, could be a more efficient approach to prevent PJI after total ankle arthroplasty.

“Brain-predicted age” quantifies apparent brain age compared to normative neuroimaging trajectories. Advanced brain-predicted age has been well established in symptomatic Alzheimer disease (AD), but is underexplored in preclinical AD. Prior brain-predicted age studies have typically used structural MRI, but resting-state functional connectivity (FC) remains underexplored. Our model predicted age from FC in 391 cognitively normal, amyloid-negative controls (ages 18–89). We applied the trained model to 145 amyloid-negative, 151 preclinical AD, and 156 symptomatic AD participants to test group differences. The model accurately predicted age in the training set. FC-predicted brain age gaps (FC-BAG) were significantly older in symptomatic AD and significantly younger in preclinical AD compared to controls. There was minimal correspondence between networks predictive of age and AD. Elevated FC-BAG may reflect network disruption during symptomatic AD. Reduced FC-BAG in preclinical AD was opposite to the expected direction, and may reflect a biphasic response to preclinical AD pathology or may be driven by inconsistency between age-related vs. AD-related networks. Overall, FC-predicted brain age may be a sensitive AD biomarker.

A patient with hypertrophic cardiomyopathy and a cardio-defibrillator implanted for primary prevention would like to compete on the ski team at his school. This case illustrates how a shared decision-making approach can be applied when counseling patients with hypertrophic cardiomyopathy about exercise and sports participation. (Level of Difficulty: Intermediate.)

A patient with alveolar capillary dysplasia has survived more than 56 months with medical therapy. Intrauterine exposure to metformin potentially modified the severity of disease. In combination with other agents, endothelin receptor antagonists and amlodipine have been key medications in lowering pulmonary arterial pressure and managing right heart failure. (Level of Difficulty: Beginner.)

Category: Hindfoot; Midfoot/Forefoot; Sports Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a condition encompassing multiple interrelated, progressive bony and soft tissue deformities, often requiring surgical correction. Patients are often debilitated, with postoperative goals commonly cited as walking and low-impact activities without pain. However, some patients engage in sports and more rigorous activities. Surgeons may struggle to set expectations after surgery since few studies investigate returns to activity following flatfoot reconstruction and every patient is different. Existing studies are limited by small sample sizes, lack of data of activity-specific data, and cohorts confined to one or two of the many possible concomitant procedures in flatfoot reconstruction. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible PCFD. Methods: Patients who underwent reconstructive surgery from February 2016-May 2019 for flexible-stage PCFD were identified by registry review and contacted with IRB approval. 70/119 patients (72/121 feet, 60%) were reached at mean 3.1 (range, 2.0 to 5.4) years post-operatively with mean age 43.5 (range, 18 to 59) years at surgery. Concomitant procedures were noted. Physical activity was evaluated with a previously published questionnaire that assessed participation in 15 sports and activities, allowed patients to list additional activities, and classified activities as high or low-impact. Patients specified postoperative number of sessions per week, session duration, return times to participation and maximal activity, relative pre/postoperative difficulty, and satisfaction with outcome regarding sports. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Multivariable regressions assessed associations between PROMIS domain changes and survey responses and linear models measured association of sports participation with the most performed procedures, controlling for concomitant procedures. Results: Patients experienced significant improvements in all PROMIS domains except Depression and surpassed previously reported minimal clinically important differences for PCFD in Physical Function and Pain Interference scores. Patients reported participation in 21 specific sports and activities (Table 1). Compared to preoperatively, patients rated 16.7% (45/270) of activities as more difficult postoperatively, 33.3% (90/270) as equally difficult, and 50% (135/270) as less difficult. Median return times were 6-9 months for participation in activities and 13-18 months to reach maximum preoperative participation. Patients spent a median 7.6 (range, 0-29.8) hours/week engaged in physical activity. 3% of patients (2/72) were sedentary, 31% (22/72) were moderately active, 28% (20/72), were highly active and 36% (26/72) were extremely active. Improvements in Physical Function ( P =.021), Pain Interference ( P =.001), and Global Physical Health ( P =.001) were associated with increased outcome satisfaction regarding physical activities. No associations were found between procedures performed and any PROMIS domains or return parameters. Conclusion: This is the largest and most comprehensive analysis of patient participation in sports and physical activities following flatfoot reconstruction. Results suggest that flatfoot reconstruction surgery generally results in good returns to physical activity in terms of return time, pre-postoperative difficulty changes, and satisfaction. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to some athletic limitations. However, ninety percent of patients reported satisfaction with their surgical outcomes with respect to returns to physical activity, indicating that, for most patients, flatfoot reconstruction provides meaningful relief from debilitation.

Category: Ankle Arthritis; Sports Introduction/Purpose: While osteochondral autograft transplantation (OAT) offers favorable results in most patients with osteochondral lesions of the talus (OLT), some patients continue to experience persistent pain following the procedure. Information regarding the etiology of this pain and outcomes of revision surgery are limited. This study aimed to report results of revision surgery with realignment procedures in patients with failed OAT who demonstrated concomitant malalignment at the distal tibia or hindfoot. Methods: Eight ankles with persistent pain following OAT underwent revision surgery with realignment procedures. All patients underwent primary OAT for treatment of medial OLTs. Patients were divided into two groups based on the main location of deformity; the Supramalleolar realignment group (SRG, five ankles) and the Hindfoot realignment group (HRG, three ankles). No direct procedure was performed on the osteochondral lesion at the time of revision surgery. Ankle and hindfoot alignment were evaluated using six parameters in weightbearing radiographs. Computed tomography (CT) was used to assess for medial gutter narrowing, spur formation, and cyst volume around transplanted osteochondral plug pre-and postoperatively. Clinical outcomes were assessed using foot function index and visual analogue scale. Results: All patients had medial gutter narrowing or spur formation, which are early signs of ankle arthritis. The SRG had varus distal tibial alignment with a median medial distal tibial angle of 85.7 degrees (Interquartile range [IQR], 3.2). The HRG had valgus hindfoot alignment and a lower medial longitudinal arch with a median hindfoot moment arm of 8.4 mm (IQR, 6.1) and a median Meary angle of 11.8 degrees (IQR, 1.4). Spontaneous restoration of the osteochondral lesion was observed after realignment surgery, with cyst volume decreasing from 0.2592cm3 to 0.0873cm3 (p

Background: Many foot pathologies have been associated with foot type. However, the association of first ray hypermobility remains enigmatic. The purpose of this study was to investigate first ray hypermobility among participants with planus and rectus foot types and its influence on static measures of foot structure. Methods: Twenty asymptomatic participants with planus (n = 23 feet) and rectus (n = 17 feet) foot types were enrolled. Several parameters of static foot structure (arch height index, arch height flexibility, first metatarsophalangeal joint flexibility, and first ray mobility) were measured. Participants were further stratified into groups with nonhypermobile (n = 26 feet) and hypermobile (n = 14 feet) first rays. First ray mobility ≥ 8 mm was used to define “first ray hypermobility”. Generalized estimating equations, best-fit regression lines, and stepwise linear regression were used to identify significant differences and predictors between the study variables Results: Overall, 86% of subjects categorized with first ray hypermobility exhibited a planus foot type. Arch height flexibility, weightbearing first ray mobility, and first metatarsophalangeal joint flexibility showed no significant between-group differences. However, weightbearing ray mobility and first metatarsophalangeal joint laxity were associated with partial weightbearing first ray mobility, accounting for 38% of the model variance. Conclusion: The planus foot type was found to be associated with first ray hypermobility. Furthermore, weightbearing first ray mobility and first metatarsophalangeal joint laxity were predictive of partial weightbearing first ray mobility, demonstrating an interaction between the translation and rotational mechanics of the first ray. Clinical Relevance: Association of first ray hypermobility with foot type and first metatarsophalangeal joint flexibility may help understand the sequela to symptomatic pathologies of the foot.

Objective To evaluate the concerns and needs of patients and survivors of head and neck cancer (HNC) in the COVID-19 era. Study Design Prospective cross-sectional survey. Setting Contact lists of 5 North American HNC advocacy groups. Methods A 14-question survey was distributed to the contact lists of 5 HNC advocacy groups evaluating patient and survivor needs and concerns related to their cancer care and COVID-19. Results There were 171 respondents, with 75% in the posttreatment period. The most common concern was contraction of COVID-19 (49%). More patients in active treatment preferred in-person visits than those in the early (≤5 years) and late (>5) survivorship period (72% vs 61% vs 40%, P < .001). A higher percentage of late survivors preferred virtual visits (38% vs 28%, P = .001). In total, 91 (53.2%) respondents sought emotional support outside of immediate family and friends. This included cancer support groups (36.2%), the medical team (29.7%), and other sources outside of these (34.1%), including faith-based organizations and online communities. A higher proportion of women than men (62% vs 41%, P = .001) were seeking emotional support outside of immediate family and friends. Conclusions During the early stages of the COVID-19 pandemic, patients with HNC who were actively undergoing treatment had increased need for support resources and preferred in-person provider visits. Alternatively, a higher percentage of patients >5 years from treatment preferred virtual visits. Emotional support outside of family and friends was sought out by a majority of respondents. Further research is needed to determine what support and educational resources are needed to best aid these various populations.

Background:. The purpose of our study is to investigate differences in normative PROMIS upper extremity function (PROMIS-UE), physical function (PROMIS-PF), and pain interference (PROMIS-PI) scores across age cohorts in individuals without upper extremity disability. Methods:. Individuals without upper extremity disability were prospectively enrolled. Subjects were administered PROMIS-UE, PROMIS-PF, and PROMIS-PI forms. Retrospective PROMIS data for eligible subjects were also utilized. The enrolled cohort was divided into age groups: 20–39, 40–59, and 60–79 years old. ANOVA, ceiling and floor effect analysis, and kurtosis and skewness statistics were performed to assess PROMIS scores trends with age. Results:. This study included 346 individuals. In the 20–39 age group, mean PROMIS scores were 56.2 ± 6.1, 59.8 ± 6.9, and 43.1 ± 6.7 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. In the “40–59” age group, mean PROMIS computer adaptive test scores were 53.3 ± 7.5, 55.3 ± 7.6, and 46.6 ± 7.8 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. In the 60–79 age group, mean PROMIS scores were 48.4 ± 7.6, 48.5 ± 5.6, and 48.7 ± 6.9 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. Differences in mean PROMIS scores were significant across all PROMIS domains and age cohorts (P < 0.001). Conclusion:. Younger individuals without hand or upper extremity disability show higher normative PROMIS-UE and PROMIS-PF scores and lower PROMIS-PI scores, indicating greater function and less pain than older counterparts. A universal reference PROMIS score of 50 appears suboptimal for clinical assessment and decision-making in the hand and upper extremity clinic.

Background: To present the inherent and unique challenges associated with utilizing fracture healing as an outcome measure in foot and ankle orthopedics, specifically the statistical methods used in assessing time to union. Methods: In a previously published manuscript assessing the effect of delayed weightbearing on time to union following intramedullary (IM) screw fixation of Jones (Zone 2 fifth metatarsal base) fractures, patients were divided into early weightbearing (EWB, n=20) and delayed weightbearing (DWB, n=21) cohorts (within or beyond 2 weeks, respectively). Time to union was determined and compared between the 2 cohorts using cumulative link model analysis, with delayed union (12.5 weeks) defined from established literature. Results: Cumulative link model analysis demonstrated no significant differences in time to union (EWB: 25% by 6th week, 55% by 12th week; DWB: 33% by 6th week, 43% by 12th week; P = .819) or delayed unions (EWB, 20% vs DWB, 24%; P > .999). Conclusion: Our analysis using cumulative link models, or ordinal regression, in the statistical analysis of time to union, determined that that early weightbearing following IM screw fixation in Jones fractures appeared to be safe without delaying fracture healing. This statistical approach can be considered when describing a continuous outcome captured by infrequent observations.

Summary:. Mass communication has undergone a “new media” revolution, which includes the rise of digital, online, and social media. The impact of new media on academic processes, however, has been underappreciated. The rise of Web-based virtual platforms has profoundly impacted the way plastic surgeons publish, store, exchange, and analyze scholarly biomedical information. This new media academic phenomenon refers to electronic mechanisms with the capacity to supplant traditional publication methods, which typically rely on printed documents in the physical domain. Although such tools can be efficient and user-friendly, they also make users vulnerable to exploitation. Notable examples reveal a relative lack of regulation, oversight, reliable rating scales, user authentication, and ethical accountability in the virtual space. As with any new technique, education is key and knowledge is power. In this article, online resources related to healthcare and the practice of plastic surgery are reviewed and summarized, including open access, mega-indices, whitelists, and electronic alerts. New media provides powerful knowledge-sharing tools that can help execute scholarly endeavors, communicate between professionals, and educate the public. However, it is essential for plastic surgeons to appreciate the caveats of new media academic processes to avoid unscrupulous practices of those that may seek to manipulate these Web-based systems. This article outlines the key pitfalls associated with online information streams to better inform plastic surgeons how to navigate new media-based scholarly processes.

Background:. To demonstrate our use of advanced 3-dimensional (3D) computer technology in the analysis, virtual surgical planning (VSP), 3D modeling (3DM), and treatment of complex congenital and acquired craniofacial deformities. Methods:. We present a series of craniofacial defects treated at a tertiary craniofacial referral center utilizing state-of-the-art 3D computer technology. All patients treated at our center using computer-assisted VSP, prefabricated custom-designed 3DMs, and/or 3D printed custom implants (3DPCI) in the reconstruction of craniofacial defects were included in this analysis. Results:. We describe the use of 3D computer technology to precisely analyze, plan, and reconstruct 31 craniofacial deformities/syndromes caused by: Pierre-Robin (7), Treacher Collins (5), Apert’s (2), Pfeiffer (2), Crouzon (1) Syndromes, craniosynostosis (6), hemifacial microsomia (2), micrognathia (2), multiple facial clefts (1), and trauma (3). In select cases where the available bone was insufficient for skeletal reconstruction, 3DPCIs were fabricated using 3D printing. We used VSP in 30, 3DMs in all 31, distraction osteogenesis in 16, and 3DPCIs in 13 cases. Utilizing these technologies, the above complex craniofacial defects were corrected without significant complications and with excellent aesthetic results. Conclusion:. Modern 3D technology allows the surgeon to better analyze complex craniofacial deformities, precisely plan surgical correction with computer simulation of results, customize osteotomies, plan distractions, and print 3DPCI, as needed. The use of advanced 3D computer technology can be applied safely and potentially improve aesthetic and functional outcomes after complex craniofacial reconstruction. These techniques warrant further study and may be reproducible in various centers of care.

Clonidine given i.v. at a dose of 0.1 mg and 0.2 mg was found to cause miosis in a placebo controlled double-blind study in six healthy volunteers. In a further single-blind placebo controlled study in three of these volunteers, the alpha 2-adrenoreceptor antagonist RX 781094 at a dose of 0.1 mg/kg i.v. reversed the miosis induced by i.v. clonidine 0.2 mg. At a dose of 0.05 mg/kg the miosis was partially reversed. [ABSTRACT FROM AUTHOR]

Introduction: This work aimed to establish the largest UK and Ireland consensus on myopia management in children and young people (CYP)., Methods: A modified Delphi consensus was conducted with a panel of 34 optometrists and ophthalmologists with expertise in myopia management., Results: Two rounds of voting took place and 131 statements were agreed, including that interventions should be discussed with parents/carers of all CYP who develop myopia before the age of 13 years, a recommendation for interventions to be publicly funded for those at risk of fast progression and high myopia, that intervention selection should take into account the CYP's hobbies and lifestyle and that additional training for eye care professionals should be available from non-commercial sources. Topics for which published evidence is limited or lacking were areas of weaker or no consensus. Modern myopia management contact and spectacles are suitable first-line treatments. The role and provision of low-concentration atropine needs to be reviewed once marketing authorisations and funding decisions are in place. There is some evidence that a combination of low-concentration atropine with an optical intervention can have an additive effect; further research is needed. Once an intervention is started, best practice is to monitor non-cycloplegic axial length 6 monthly., Conclusion: Research is needed to identify those at risk of progression, the long-term effectiveness of individual and combined interventions, and when to discontinue treatment when myopia has stabilised. As further evidence continues to emerge, this consensus work will be repeated to ensure it remains relevant., (© 2024 The Author(s). Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Men who have sex with men (MSM) are disproportionately affected by HIV. Given that over 70% of MSM meet sexual partners via dating apps, such apps may be an effective platform for promoting HIV pre-exposure prophylaxis (PrEP) use. We aimed to describe preferences among MSM for PrEP advertisements displayed on dating apps. We conducted individual in-depth interviews with 16 MSM recruited from a mobile sexual health unit in Boston, Massachusetts. Two focus groups were also held: one with mobile unit staff ( N  = 3) and one with mobile unit users ( N  = 3). Content analysis was used to identify themes related to advertisement content and integration with app use. Mean participant age was 28 (SD 6.8); 37% identified as White and 63% as Latinx. 21% of interviews were conducted in Spanish. Preferences were organized around four themes: (1) relevant and relatable advertisements, (2) expansion of target audiences to promote access, (3) concise and captivating advertisements, and (4) PrEP advertisements and services as options, not obligations. MSM are supportive of receiving information about PrEP on dating apps, but feel that existing advertisements require modification to better engage viewers. Dating apps may be an underutilized tool for increasing PrEP awareness and knowledge among MSM.

Background: HIV preexposure prophylaxis (PrEP) uptake among men who have sex with men (MSM), a group disproportionately impacted by HIV, is not commensurate with need. Settings which reduce or remove barriers to accessing care are promising venues to support PrEP uptake. PrEP provision at mobile clinics represents a novel strategy to increase PrEP access; however, the acceptability and feasibility of this approach have not been well studied., Methods: Our objective was to understand patient and staff experiences of a mobile clinic van offering PrEP and sexual health services in Boston, Massachusetts, USA. We interviewed mobile unit users and conducted focus groups with mobile unit staff and users. Data were organized using Dedoose software, and content analysis was used to identify themes of access, community, and stigma., Results: Nineteen individuals (16 patients and 3 staff members) participated in interviews (N = 13) or focus groups (N = 6). All patients identified as MSM, 63% were Hispanic or Latino, and 21% of patient interviews were conducted in Spanish. Logistical and psychological convenience facilitated service use, while the community-oriented environment improved satisfaction with care. Overall, participants supported expansion of mobile unit services and recommended changes to improve access to longitudinal care. However, some barriers to PrEP persisted, including low HIV risk perception and stigma about sexual behavior., Conclusions: Mobile units can promote sexual health and PrEP uptake, particularly for populations facing social and logistical barriers to care in traditional settings., (© 2023. The Author(s).)

Mikania micrantha is one of the worst invasive species globally and can cause significant negative impacts on agricultural and forestry economics, particularly in Asia and the Pacific region. The rust Puccinia spegazzinii has been used successfully as a biological control agent in several countries to help manage M. micrantha . However, the response mechanisms of M. micrantha to P. spegazzinii infection have never been studied. To investigate the response of M. micrantha to infection by P. spegazzinii , an integrated analysis of metabolomics and transcriptomics was performed. The levels of 74 metabolites, including organic acids, amino acids, and secondary metabolites in M. micrantha infected with P. spegazzinii , were significantly different compared to those in plants that were not infected. After P. spegazzinii infection, the expression of the TCA cycle gene was significantly induced to participate in energy biosynthesis and produce more ATP. The content of most amino acids, such as L-isoleucine, L-tryptophan and L-citrulline, increased. In addition, phytoalexins, such as maackiain, nobiletin, vasicin, arachidonic acid, and JA-Ile, accumulated in M. micrantha . A total of 4978 differentially expressed genes were identified in M. micrantha infected by P. spegazzinii . Many key genes of M. micrantha in the PTI (pattern-triggered immunity) and ETI (effector-triggered immunity) pathways showed significantly higher expression under P. spegazzinii infection. Through these reactions, M. micrantha is able to resist the infection of P. spegazzinii and maintain its growth. These results are helpful for us to understand the changes in metabolites and gene expression in M. micrantha after being infected by P. spegazzinii . Our results can provide a theoretical basis for weakening the defense response of M. micrantha to P. spegazzinii , and for P. spegazzinii as a long-term biological control agent of M. micrantha .

The Neotropical invasive plant Chromolaena odorata R.M. King and H. Robinson (Asteraceae) is a serious weed in West and Central Africa and two biological control agents that have been introduced into West Africa to help reduce its impacts on agriculture and biodiversity, have established. The stem-galling fly, Cecidochares connexa (Macquart) (Diptera: Tephritidae), has spread widely across West Africa since its release in only Côte d'Ivoire, occurring in six countries. This study aimed to investigate whether the gall fly had spread further across West Africa and into Central Africa. Here, we surveyed C. odorata for C. connexa galls in Cameroon between October 2018 and October 2020, along roadsides, on farms, residential areas, and abandoned plots, encompassing various vegetation types. Additional surveys were conducted across four countries (Ghana, Togo, Benin Republic and Nigeria) in West Africa that we considered the probable pathway for the spread of the gall fly into Central Africa. Cecidochares connexa was present at five of the six locations surveyed in Cameroon, albeit in varying abundance. In Africa, these findings represent the first-ever report of C. connexa outside of West Africa. In West Africa, we recorded significant expansion in the geographic range of C. connexa, as reflected in the absent-present record of C. connexa in two locations in Nigeria and one in Ghana, as well as its occurrence in all locations surveyed in Benin Republic and Togo. Clearly, Ghana, Togo, Benin Republic and Nigeria served as the dispersal pathway of C. connexa from the release sites in Côte d'Ivoire into Cameroon, covering over 2,300 km. Following the spread and establishment of C. connexa into Cameroon, we anticipate that it will continue to spread further into other parts of Central Africa which are climatically suitable. Cecidochares connexa is currently the only biological control agent for C. odorata in Central Africa. Given that it has significantly reduced populations of C. odorata in other countries where it has established, it is expected to have a similar impact in Central Africa., Competing Interests: The authors have declared that no competing interests exist.

This article examines the legal doctrine and ethical norm of informed consent and its deficiencies, particularly its concentration on physician disclosure of information rather than on patient understanding, which led to the development of shared decision making as a way to enhance informed consent. As a vague and imprecise rubric, shared decision making encompasses several different approaches. Narrower approaches presuppose an individualistic account of autonomy, while broader approaches view autonomy as relational and hold that clinician-patient relationships grounded in good communication can assist decision making and foster autonomous choices. Shared decision making faces conceptual, normative, and practical challenges, but, with its goal of respecting, protecting, and promoting patients' autonomous choices, it represents an important cultural change in medicine., (© 2020 American Medical Association. All Rights Reserved.)

The family Cactaceae Juss. contains some of the most widespread and damaging invasive alien plant species in the world, with Australia (39 species), South Africa (35) and Spain (24) being the main hotspots of invasion. The Global Cactus Working Group (IOBC GCWG) was launched in 2015 to improve international collaboration and identify key actions that can be taken to limit the impacts caused by cactus invasions worldwide. Based on the results of an on-line survey, information collated from a review of the scientific and grey literature, expertise of the authors, and because invasiveness appears to vary predictably across the family, we (the IOBC GCWG): (1) recommend that invasive and potentially invasive cacti are regulated, and to assist with this propose five risk categories; (2) recommend that cactus invasions are treated physically or chemically before they become widespread; (3) advocate the use of biological control to manage widespread invasive species; and (4) encourage the development of public awareness and engagement initiatives to integrate all available knowledge and perspectives in the development and implementation of management actions, and address conflicts of interest, especially with the agricultural and ornamental sectors. Implementing these recommendations will require global co-operation. The IOBC GCWG aims to assist with this process though the dissemination of information and experience.

Background/significance: Because of their decreased physical reserve and increased risk of complications, the geriatric trauma patient (GTP) population warrants heightened awareness by clinical staff., Purpose: The purpose of this study is to determine whether the institution of a third-tier trauma protocol results in a change in GTP outcomes, complications, and mortality rates., Methods: Researchers conducted a retrospective review of 2 years of data from the trauma registry, hospital quality improvement audits, and patient charts to examine what, if any, patient outcomes were impacted by the institution of the expanded GTP protocol., Results: Sample homogeneity was determined. Emergency department (ED) length of stay and time to the operating room decreased in the protocol cohort. The rate of complications decreased from 16.4% preprotocol to 1.6% postprotocol. Discharge to home rates in the GTP population improved from 31% preprotocol to nearly 77% postimplementation of the protocol., Discussion: The expanded GTP protocol front loads evaluation and resuscitation to be consistent with ED trauma protocols already in place. By fast-tracking radiology and laboratory testing, patients injuries are identified and the appropriate consultations are initiated. Appropriate inpatient nursing unit placement is identified or treatment and discharge from the ED are expedited., Conclusion: The expanded GTP protocol provided early and comprehensive evaluation and interventions for GTPs who fall outside of traditional trauma alert criteria. Patients spend less time in the ED and the hospital. Patients had decreased length of stay in the ED, less complications, and return to home rates showed significant improvement after the protocol was implemented.

Stories have always been central to medicine, but during the twentieth century bioscience all but eclipsed narrative's presence in medical practice. In Doctors' Stories, published in 1991, Kathryn Montgomery excavated medicine's narrative foundations and functions to reveal new possibilities for how to conceive and characterize medicine. Physicians' engagement with stories has since flourished, especially through the narrative medicine movement, although in the twenty-first century this has been challenged by the health care industry's business-minded and data-driven clinical systems. But doctors' stories-and Montgomery's text-remain crucial, schooling clinicians in reflection, ethical awareness, and resilience. Physicians who write even short, 55-word reflective stories can hold to humanistic and ethical understandings of patient care and of themselves as healers even as they practice in systematized settings and employ evidence-based expertise., (© 2017 American Medical Association. All Rights Reserved.)

Geriatric trauma patients (GTPs) suffering minor injuries have suboptimal outcomes compared with younger populations. Patients 65 years or older account for 10% of all traumas but 28% of all trauma deaths. This trauma center established a third tier trauma alert specifically targeting GTPs at risk for poor outcomes. A Delta Alert is activated when GTPs suffer injuries that fall outside traditional trauma alert guidelines. Early identification and treatment of injuries and expedited referral to specialty groups have improved our GTPs' outcomes including decreased mortality and length of stay and increased percentage of GTPs who are discharged home.

The evolutionary mechanisms generating the tremendous biodiversity of islands have long fascinated evolutionary biologists. Genetic drift and divergent selection are predicted to be strong on islands and both could drive population divergence and speciation. Alternatively, strong genetic drift may preclude adaptation. We conducted a genomic analysis to test the roles of genetic drift and divergent selection in causing genetic differentiation among populations of the island fox (Urocyon littoralis). This species consists of six subspecies, each of which occupies a different California Channel Island. Analysis of 5293 SNP loci generated using Restriction-site Associated DNA (RAD) sequencing found support for genetic drift as the dominant evolutionary mechanism driving population divergence among island fox populations. In particular, populations had exceptionally low genetic variation, small Ne (range = 2.1-89.7; median = 19.4), and significant genetic signatures of bottlenecks. Moreover, islands with the lowest genetic variation (and, by inference, the strongest historical genetic drift) were most genetically differentiated from mainland grey foxes, and vice versa, indicating genetic drift drives genome-wide divergence. Nonetheless, outlier tests identified 3.6-6.6% of loci as high FST outliers, suggesting that despite strong genetic drift, divergent selection contributes to population divergence. Patterns of similarity among populations based on high FST outliers mirrored patterns based on morphology, providing additional evidence that outliers reflect adaptive divergence. Extremely low genetic variation and small Ne in some island fox populations, particularly on San Nicolas Island, suggest that they may be vulnerable to fixation of deleterious alleles, decreased fitness and reduced adaptive potential., (© 2016 John Wiley & Sons Ltd.)

Rapid and inexpensive methods for genomewide single nucleotide polymorphism (SNP) discovery and genotyping are urgently needed for population management and conservation. In hybridized populations, genomic techniques that can identify and genotype thousands of species-diagnostic markers would allow precise estimates of population- and individual-level admixture as well as identification of 'super invasive' alleles, which show elevated rates of introgression above the genomewide background (likely due to natural selection). Techniques like restriction-site-associated DNA (RAD) sequencing can discover and genotype large numbers of SNPs, but they have been limited by the length of continuous sequence data they produce with Illumina short-read sequencing. We present a novel approach, overlapping paired-end RAD sequencing, to generate RAD contigs of >300-400 bp. These contigs provide sufficient flanking sequence for design of high-throughput SNP genotyping arrays and strict filtering to identify duplicate paralogous loci. We applied this approach in five populations of native westslope cutthroat trout that previously showed varying (low) levels of admixture from introduced rainbow trout (RBT). We produced 77 141 RAD contigs and used these data to filter and genotype 3180 previously identified species-diagnostic SNP loci. Our population-level and individual-level estimates of admixture were generally consistent with previous microsatellite-based estimates from the same individuals. However, we observed slightly lower admixture estimates from genomewide markers, which might result from natural selection against certain genome regions, different genomic locations for microsatellites vs. RAD-derived SNPs and/or sampling error from the small number of microsatellite loci (n = 7). We also identified candidate adaptive super invasive alleles from RBT that had excessively high admixture proportions in hybridized cutthroat trout populations., (© 2013 John Wiley & Sons Ltd.)

Artificial ecosystem selection is an experimental technique that treats microbial communities as though they were discrete units by applying selection on community-level properties. Highly diverse microbial communities associated with humans and other organisms can have significant impacts on the health of the host. It is difficult to find correlations between microbial community composition and community-associated diseases, in part because it may be impossible to define a universal and robust species concept for microbes. Microbial communities are composed of potentially thousands of unique populations that evolved in intimate contact, so it is appropriate in many situations to view the community as the unit of analysis. This perspective is supported by recent discoveries using metagenomics and pangenomics. Artificial ecosystem selection experiments can be costly, but they bring the logical rigor of biological model systems to the emerging field of microbial community analysis.