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Little has been published about the process of decision-making between prosthetists and people with lower limb amputation (LLA). The purpose of this study is to identify decisions and factors influencing decision-making in prosthetic rehabilitation from the perspectives of prosthetists and prosthesis users, to identify barriers and opportunities for shared decision-making (SDM).Qualitative semi-structured individual interviews were conducted with 13 prosthetists and 14 prosthesis users from three clinics in three states of the Rocky Mountain and Southwest regions of the United States. Transcripts were analyzed using thematic analysis.Four main themes were identified:Opportunities for improving SDM between prosthetists and prosthesis users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.IMPLICATIONS FOR REHABILITATIONMany people with lower limb amputation experience poor physical function and psychosocial outcomes, which may be further compounded by under informed prosthesis-user expectations for function with a prosthesis.Shared decision-making offers an opportunity for improving realistic prosthesis-user expectations, reducing healthcare costs, and improving prosthesis-user satisfaction and adherence to care plans.Opportunities for improving shared decision-making between prosthetists and prosthesis-users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.

To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function.Cross-sectional, observational study SETTING: General community.Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119).Not applicable.We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire.Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [β]=-0.15, P=.02), even after adjusting for depressive symptoms (β=-0.31, P.001), prosthesis satisfaction (β=0.34, P.001), number of chronic conditions (β=-0.19, P=.006), and assistive device use (βCognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

Activating transcription factor 4 (ATF4) is a multifunctional transcription regulatory protein in the basic leucine zipper superfamily. ATF4 can be expressed in most if not all mammalian cell types, and it can participate in a variety of cellular responses to specific environmental stresses, intracellular derangements, or growth factors. Because ATF4 is involved in a wide range of biological processes, its roles in human health and disease are not yet fully understood. Much of our current knowledge about ATF4 comes from investigations in cultured cell models, where ATF4 was originally characterized and where further investigations continue to provide new insights. ATF4 is also an increasingly prominent topic of in vivo investigations in fully differentiated mammalian cell types, where our current understanding of ATF4 is less complete. Here, we review some important high-level concepts and questions concerning the basic biology of ATF4. We then discuss current knowledge and emerging questions about the in vivo role of ATF4 in one fully differentiated cell type, mammalian skeletal muscle fibers.

Aging slowly erodes skeletal muscle strength and mass, eventually leading to profound functional deficits and muscle atrophy. The molecular mechanisms of skeletal muscle aging are not well understood. To better understand mechanisms of muscle aging, we investigated the potential role of ATF4, a transcription regulatory protein that can rapidly promote skeletal muscle atrophy in young animals deprived of adequate nutrition or activity. To test the hypothesis that ATF4 may be involved in skeletal muscle aging, we studied fed and active muscle-specific ATF4 knockout mice (ATF4 mKO mice) at 6 months of age, when wild-type mice have achieved peak muscle mass and function, and at 22 months of age, when wild-type mice have begun to manifest age-related muscle atrophy and weakness. We found that 6-month-old ATF4 mKO mice develop normally and are phenotypically indistinguishable from 6-month-old littermate control mice. However, as ATF4 mKO mice become older, they exhibit significant protection from age-related declines in strength, muscle quality, exercise capacity, and muscle mass. Furthermore, ATF4 mKO muscles are protected from some of the transcriptional changes characteristic of normal muscle aging (repression of certain anabolic mRNAs and induction of certain senescence-associated mRNAs), and ATF4 mKO muscles exhibit altered turnover of several proteins with important roles in skeletal muscle structure and metabolism. Collectively, these data suggest ATF4 as an essential mediator of skeletal muscle aging and provide new insight into a degenerative process that impairs the health and quality of life of many older adults.

Widespread species often harbor unrecognized genetic diversity, and investigating the factors associated with such cryptic variation can help us better understand the forces driving diversification. Here, we identify potential cryptic species based on a comprehensive dataset of COI mitochondrial DNA barcodes from 2,333 individual Panamanian birds across 429 species, representing 391 (59%) of the 659 resident landbird species of the country, as well as opportunistically sampled waterbirds. We complement this dataset with additional publicly available mitochondrial loci, such as ND2 and cytochromeb,obtained from whole mitochondrial genomes from 20 taxa. Using barcode identification numbers (BINs), we find putative cryptic species in 19% of landbird species, highlighting hidden diversity in the relatively well-described avifauna of Panama. Whereas some of these mitochondrial divergence events corresponded with recognized geographic features that likely isolated populations, such as the Cordillera Central highlands, the majority (74%) of lowland splits were between eastern and western populations. The timing of these splits are not temporally coincident across taxa, suggesting that historical events, such as the formation of the Isthmus of Panama and Pleistocene climatic cycles, were not the primary drivers of cryptic diversification. Rather, we observed that forest species, understory species, insectivores, and strongly territorial species—all traits associated with lower dispersal ability—were all more likely to have multiple BINs in Panama, suggesting strong ecological associations with cryptic divergence. Additionally, hand-wing index, a proxy for dispersal capability, was significantly lower in species with multiple BINs, indicating that dispersal ability plays an important role in generating diversity in Neotropical birds. Together, these results underscore the need for evolutionary studies of tropical bird communities to consider ecological factors along with geographic explanations, and that even in areas with well-known avifauna, avian diversity may be substantially underestimated.LAY SUMMARY- What factors are common among bird species with cryptic diversity in Panama? What role do geography, ecology, phylogeographic history, and other factors play in generating bird diversity?- 19% of widely-sampled bird species form two or more distinct DNA barcode clades, suggesting widespread unrecognized diversity.- Traits associated with reduced dispersal ability, such as use of forest understory, high territoriality, low hand-wing index, and insectivory, were more common in taxa with cryptic diversity.Filogeografía comparada revela amplia diversidad críptica causada por la ecología en las aves de PanamáRESUMENEspecies extendidas frecuentemente tiene diversidad genética no reconocida, y investigando los factores asociados con esta variación críptica puede ayudarnos a entender las fuerzas que impulsan la diversificación. Aquí, identificamos especies crípticas potenciales basadas en un conjunto de datos de códigos de barras de ADN mitocondrial de 2,333 individuos de aves de Panama en 429 especies, representando 391 (59%) de las 659 especies de aves terrestres residentes del país, además de algunas aves acuáticas muestreada de manera oportunista. Adicionalmente, complementamos estos datos con secuencias mitocondriales disponibles públicamente de otros loci, tal como ND2 o citocroma b, obtenidos de los genomas mitocondriales completos de 20 taxones. Utilizando los números de identificación de código de barras (en ingles: BINs), un sistema taxonómico numérico que proporcina una estimación imparcial de la diversidad potencial a nivel de especie, encontramos especies crípticas putativas en 19% de las especies de aves terrestres, lo que destaca la diversidad oculta en la avifauna bien descrita de Panamá. Aunque algunos de estos eventos de divergencia conciden con características geográficas que probablemente aislaron las poblaciones, la mayoría (74%) de la divergencia en las tierras bajas se encuentra entre las poblaciones orientales y occidentales. El tiempo de esta divergencia no coincidió entre los taxones, sugiriendo que eventos históricos tales como la formación del Istmo de Panamá y los ciclos climáticos del pleistoceno, no fueron los principales impulsores de la especiación. En cambio, observamos asociaciones fuertes entre las características ecológicas y la divergencia mitocondriale: las especies del bosque, sotobosque, con una dieta insectívora, y con territorialidad fuerte mostraton múltiple BINs probables. Adicionalmente, el índice mano-ala, que está asociado a la capacidad de dispersión, fue significativamente menor en las especies con BINs multiples, sugiriendo que la capacidad de dispersión tiene un rol importamente en la generación de la diversidad de las aves neotropicales. Estos resultos demonstran la necesidad de que estudios evolutivos de las comunidades de aves tropicales consideren los factores ecológicos en conjunto con las explicaciones geográficos.Palabras clave:biodiversidad tropical, biogeografía, códigos de barras, dispersión, especies crípticas

Background In most countries, more females than males attempt suicide, yet suicide mortality is typically higher for males. The aim of this study was to investigate how suicide method choice contributed to gender disparity in suicide mortality. Methods This study used population-based data collected in Hong Kong (HK) and the United States of America (USA) (2007-2014), comprising suicide deaths and medically treated suicide attempts. We calculated suicide rates, suicide act rates, and case fatality rates (CFRs), by gender and suicide method in HK and the USA respectively. Decomposition analysis was used to quantify the contribution of gender differences in method choice and method-specific CFRs to the excess male suicide rates in each region. Results Gender disparity in suicide mortality was mostly driven by gender differences in method used in suicide acts. In HK, gender difference in choosing jumping as the method in suicide acts explained 44.5% of the gender imbalance in suicide rates, whilst in USA, 62.4% of male excess in suicide rates was explained by gender difference in using firearms in suicide acts. Limitations Cases of suicide attempts in this study were restricted to those severe enough to require medical attention. Conclusion Gender-specific suicide method choice largely determined gender patterns in suicide. Our findings highlighted the importance of developing locally tailored suicide prevention strategies targeting commonly used and highly lethal suicide methods. Future research is needed to explore underlying reasons for gender differences in method choice.

Persons with cognitive impairment without dementia are at high risk of adverse health outcomes. Tailored intervention targeting moderate–vigorous physical activity (MVPA) may reduce these risks. To identify the prevalence and predictors of physical inactivity among older adults with cognitive impairment, no dementia (CIND); and estimate the proportion of inactive people with CIND who are capable of greater MVPA. We studied 1875 community dwelling participants (over age 65) with CIND in the Health and Retirement Study. Physical inactivity was defined as MVPA ≤ 1x/week. Associations of physical inactivity with sociodemographic, health, and physical function were examined using chi-square and modified Poisson regression. We considered physically inactive participants capable of greater MVPA if they reported MVPA at least 1–3x/month, no difficulty walking several blocks, or no difficulty climbing several flights of stairs. Fifty-six percent of participants with CIND were physically inactive. Variables with the highest age, sex, and race/ethnicity adjusted risk ratio (ARR) for physical inactivity were self-rated health (poor [76.9%]vs. excellent [34.2%]; ARR [95% CI] 2.27 [1.56–3.30]), difficulty walking (across the room [86.5%] vs. none [40.5%]; ARR [95% CI] 2.09 [1.87–2.35]), total assets (lowest quartile [62.6%] vs. highest quartile [43.1%]; ARR [95% CI] 1.54 [1.29–1.83]), and lower education attainment (less than high school [59.6%] vs college graduate [42.8%]; ARR [95% CI] 1.46 [1.17–1.83]). Among physically inactive older adults with CIND, 61% were estimated to be capable of greater MVPA. Although physical inactivity is prevalent among older adults with CIND, many are capable of greater MVPA. Developing tailored physical activity interventions for this vulnerable population may improve cognitive, health, and quality of life outcomes.

In this article, we aim to unpack some of the hidden curriculum in publishing successfully in the

Geographic speciation models assume that time in allopatry should result in greater reproductive isolation between populations. Here we test the prediction that greater time in allopatry results in greater reproductive isolation using comparative ultraconserved element (UCE) data from ten bird lineages in secondary contact in Panama, measuring both genome-wide divergence and the geographic extent of hybridization. The best-fit models for the proportion of fixed Z-linked and autosomal loci to our data includes a combination of both time (as measured by mtDNA divergence) and hand-wing index, emphasizing that the role of time is tempered by dispersal capability. Furthermore, time does not predict the extent of genome-wide introgression as measured by the median width of diagnostic loci clines or the degree of variation in cline centers or widths. These metrics of the outcome of secondary contact were best predicted by ecological and genomic factors, including diet, hand-wing index, and genome-wideFSTrespectively, that are understood to serve as proxies for dispersal, the variability of population size, and overall genomic divergence. We find a primary role for ecological factors instead of isolation time in determining secondary contact outcomes for a lineage, highlighting how ecology shapes the development of reproductive isolation.

Background The purpose of this study was to determine the association between glenohumeral osteoarthritis (GHOA) and three-dimensional acromial and glenoid morphology. Methods In this retrospective study, we compared computed tomographic studies of three groups of scapulae: normal healthy, mild GHOA (Samilson-Prieto grade 1), and severe GHOA (Samilson-Prieto grade 3). All scans were segmented to create three-dimensional reconstructions. From these models, critical shoulder angle and acromial offset were measured, as normalized to scapular height. The coronal plane inclination of the glenoid was measured using a glenoid sphere-fit method. Reliability was confirmed via intraclass correlation coefficients > 0.75. Results Eighty scapulae were included: 30 normal, 20 mild GHOA, and 30 severe GHOA. There were no differences in acromial offset between the normal group and either the mild-GHOA group or the severe-GHOA group. The severe-GHOA group had a smaller critical shoulder angle than either the normal (30 ± 5° vs. 34 ± 4°, P = .003) or mild-GHOA groups (34 ± 4°, P = .020), but the normal and mild-GHOA groups did not differ (P = .965). The severe-GHOA group had more inferiorly inclined glenoids than either the normal (7 ± 6° vs. 12 ± 5°, P = .002) or mild-GHOA groups (14 ± 5°, P ≤ .001), but the normal and mild-GHOA groups did not differ (P = .281). Conclusion Normal and severe-GHOA shoulders differ in critical shoulder angle and glenoid inclination but not acromial offset. The lack of a difference in critical shoulder angle or inferior inclination between mild-GHOA and normal groups calls into question whether inclination and critical shoulder angle differences predate severe GHOA.

Background: The purpose of this study was to determine whether greater tuberosity morphology (1) could be measured reliably on magnetic resonance imaging (MRI), (2) differed between patients with rotator cuff tears (RCTs) compared with those without tears or glenohumeral osteoarthritis, or (3) differed between patients with rotator cuff repairs (RCR) who healed and those that did not. Methods: This is a retrospective comparative study. (1) We measured greater tuberosity width (coronal and sagittal), lateral offset, and angle on MRI corrected into the plane of the humerus. To determine reliability, these measurements were made by two observers and intraclass correlation coefficients were calculated. (2) We compared these measurements between patients with a full-thickness RCT and patients aged >50 years without evidence of a RCT or glenohumeral osteoarthritis. (3) We then compared these measurements between those patients with healed RCRs and those with evidence of retear on MRI. In this portion, we only included patients with both a preoperative and postoperative MRI at least 1 year from RCR. Postoperative MRIs were obtained to assess healing rates, not because of concern for failure. Those without tendon defects were considered healed. Results: (1) In a validation cohort of 50 patients with MRI, all inter-rater intraclass correlation coefficients were greater than 0.75. (2) There were no differences between our RCT group of 110 patients and our comparison group of 100 patients in tuberosity coronal width, sagittal width, or lateral offset. The RCT group had a significantly smaller greater tuberosity angle (63 ± 4° vs 65 ± 5°, P = .003). (3) In our group of 110 RCRs, postoperative MRI scans were obtained at a mean follow-up of 23.6 ± 15.7 months showing 84 (76%) patients had healed RCRs. Larger coronal tuberosity width was associated with healing (1.3 ± 0.2 vs 1.2 ± 0.2 cm, P = .032), as was smaller tear width (P

Objective The purpose of this study was to examine telehealth physical therapy utilization 1 year into the COVID-19 pandemic and identify factors that influence physical therapists’ delivery of telehealth in an urban academic medical center. Methods Electronic medical record data were extracted within the dates of interest (March 22, 2021 to May 15, 2021), the proportion of physical therapy sessions delivered via telehealth were identified, and patient characteristics were compared by telehealth volume (0 vs ≥1 session, 1 vs >1 session). Qualitative data also were collected from physical therapists via semi-structured interviews, and a directed content analysis was conducted, informed by the Capability, Opportunity, Motivation, and Behavior model, to identify factors influencing telehealth delivery. Results Telehealth was used for 3793 of 8038 (47.2%) physical therapist sessions, and 1028 unique patients had at least 2 physical therapist sessions (without telehealth: 6.6% [n = 68], telehealth once: 39.1% [n = 402], telehealth more than once: 54.3% [n = 558]). Patients without telehealth were older, non-English speaking, had non-commercial insurance, and had at least 1 chronic health condition. Patients with telehealth more than once had a neurologic diagnosis and lived farther from the treating clinic. Capabilities that influenced telehealth delivery were physical therapist clinical skills and knowledge, technical proficiency, telehealth-specific interpersonal skills, and cognitive flexibility. Factors external to physical therapists—including the environment, patient equipment and technology proficiency, physical therapist equipment, clinic factors, and patient and referring provider perspectives—also influenced telehealth delivery. Finally, patient needs and telehealth as a beneficial tool guided physical therapist intention to use telehealth. Conclusion Sustained telehealth utilization outcomes 1 year into the COVID-19 pandemic and an interaction among physical therapist, patient, and environmental factors support the long-term potential of telehealth physical therapy in an urban academic medical center. Impact These findings support the long-term potential of telehealth approaches and can be used to inform telehealth physical therapist training programs and clinical implementation, future research, and health policy.

Background The purpose of this study was to determine factors associated with early symptomatic acromial and scapular spine fractures in patients who underwent reverse total shoulder arthroplasty (RTSA). Methods We retrospectively evaluated all RTSAs performed by the senior author between 1/1/2013 and 6/1/2019. We evaluated patient demographics including gender, age, prevalence of comorbidities including osteoporosis, inflammatory arthritis, diabetes, and endocrine disorders such as hypothyroidism. We also evaluated preoperative and 2-week postoperative radiographs for center of rotation medialization (CORM) as distance between the center of the humeral head or glenosphere and the line of the deltoid, and distalization via the acromial-greater tuberosity distance (AGT). We evaluated inter- and intra-rater reliability via intraclass correlation coefficients. Results We included 335 RTSAs with a minimum of 3 months of follow-up in the analysis. Reliability was acceptable with all intraclass correlation coefficients> 0.75. Symptomatic acromial and scapular spine stress fractures were significantly more common in those with inflammatory arthritis than those without (18% vs. 5%, P = 0.016). The rate of fracture was highest in patients with rheumatoid arthritis (24% vs. 5.2%, P = 0.003). There was no statistically significant association between symptomatic fractures and preoperative CORM or AGT (P = 0.557, P = 0.528) or postoperative CORM or AGT (P = 0.56, P = 0.102). There also was no statistically significant correlation between symptomatic stress fracture and patient age, gender, BMI, smoking, osteoporosis, gout, medical comorbidity, or previous shoulder surgery. Conclusion In this retrospective analysis of postoperative RTSA, symptomatic acromial and scapular stress fractures were significantly more common in patients with rheumatoid arthritis and thus precautions should be taken in these patients.

BACKGROUND: Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability. OBJECTIVE: To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later. DESIGN: Cross-sectional study. SETTING: General community. PARTICIPANTS: Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates. RESULTS: The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model. CONCLUSIONS: Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.

Study objective We evaluate whether a counseling intervention implemented at the hospital level resulted in safer firearm and medication storage by caregivers of youths aged 10 to 17 years after their child’s evaluation in the emergency department (ED) for a behavioral health concern. Methods We used a stepped-wedge clustered design rolled out at 4 hospital sites to assess primary preregistered outcomes (self-reported storage changes caregivers made to household firearms and medications), assessed by survey 2 weeks after the ED visit. Three logistic models provided estimates of the intervention effect: an unadjusted model, a model with hospital-level fixed effects, and a model that further adjusts for time. Results Of the 575 caregiver participants, 208 were firearm owners (123 in usual care, 85 in the intervention). Baseline (pre-ED visit) characteristics did not differ between usual care and intervention phases. During the 2-year study period, twice as many caregivers whose child visited the ED after (compared with before) a hospital adopted the intervention improved firearm storage and 3 times as many improved medication storage (odds ratio [OR]=2.1 [95% confidence interval {CI} 1.0 to ∞] and OR=3.0 [95% CI 2.2 to ∞], respectively). After adjusting for time, the intervention effect for medications persisted (OR=2.0 [95% CI 1.0 to ∞]); the effect on firearms did not (OR=0.7 [95% CI 0.1 to ∞]). Conclusion To our knowledge, this study is the first controlled trial to estimate the effectiveness of an intervention on firearm and medication storage in homes of youths at elevated risk of suicide. We found evidence that caregivers’ medication storage improved after their child’s ED visit, with evidence suggestive of improvement for firearm storage.

BACKGROUND: Between-limb step length asymmetry is common following transtibial amputation (TTA) and contributes to negative health consequences. There are limited evidence-based interventions targeting reduced gait asymmetry for people with TTA. Split-belt treadmill walking with asymmetrical belt speeds has successfully reduced gait asymmetry in other patient populations. However, individuals with non-traumatic TTA have critical health-related impairments that may influence the ability to respond to split-belt treadmill walking. RESEARCH QUESTION: Do people with acquired, non-traumatic TTA adapt and retain a more symmetrical gait pattern in response to split-belt treadmill walking? METHODS: Step length asymmetry was measured during split-belt treadmill walking. Eight participants walked under two alternating belt speed conditions: symmetrical (3 sets; Baseline, TIED1, TIED2) and asymmetrical belt speeds (5 sets; SPLIT1–5). One-way repeated-measures ANOVA with post-hoc Tukey’s HSD tests were used to assess adaptation and short-term retention of step length symmetry. Adaptation was assessed as the level of asymmetry during TIED walking following repeated exposure to SPLIT walking. Retention was measured as the change in level of asymmetry during each set of SPLIT walking. RESULTS: Significant adaptation to split-belt walking was observed from late Baseline to early TIED1 and early TIED2. Between-limb step length asymmetry decreased from late Baseline (5.3±3.4) to early TIED1 (−9.4±3.6) and this change was sustained between early TIED1 and early TIED2 (−11.2±3.1) (ANOVA F=73.043, p