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Background: metatarsal fractures are a commonly encountered musculoskeletal injury. Scant literature exists to support current treatment guidelines and few studies describe the functional or occupational outcomes of patients with lesser metatarsal fractures. The purpose of this study is to describe occupational outcomes for traumatic lesser metatarsal fractures in relation to current treatment guidelines. Methods: a retrospective review of metatarsal fractures in adult military patients 18 years and older was performed. Data included: patient demographics, fracture angulation and displacement, treatment modality, associated injuries, rate of return to active duty, requirement for additional surgeries, ability to run a 2-mile physical fitness test, and presence of permanent activity limitations. Treatment guideline criteria were applied and compared with the occupational outcomes measured. Results: 38 fractures were included. The mean age was 27.2 ± 7.8 (19–48). Here, 28 fractures were initially treated non-operatively. Fractures selected for non-operative treatment had a mean displacement of 1.7 +/− 1.1 mm and a mean angulation of 3.3 +/− 3.5° at initial presentation. Fractures selected for operative treatment had a mean displacement of 4.5 +/− 2.4 mm and a mean angulation of 15.7 +/− 13.8° at initial presentation. The return to run rate was 89% in non-operatively treated patients and 50% in operatively treated patients (p = 0.02). Non-operative patients returned to running at a mean of 119 +/− 103 days and operative patients returned to running at a mean of 306 +/− 191 days (p = 0.0039). 50% of operatively treated patients and 11% of non-operatively treated patents were unable to remain in the military due to their metatarsal fractures. Conclusions: patients treated non-operatively were more likely to return to running and returned to running sooner than operatively treated patients. Current treatment guidelines could not be supported or refuted based upon the study results. The occupational and functional outcomes demonstrated in this study may assist surgeons in counseling patients on their planned treatment and anticipated recovery following a lesser metatarsal fracture.

This review aims to describe and compare porcine models of metabolic syndrome. This syndrome and its associated secondary comorbidities are set to become the greatest challenge to healthcare providers and policy makers in the coming century. However, an incomplete understanding of the pathogenesis has left significant knowledge gaps in terms of efficacious therapeutics. To further our comprehension and, in turn, management of metabolic syndrome, appropriate high-fidelity models of the disease complex are of great importance. In this context, our review aims to assess the most promising porcine models of metabolic syndrome currently available for their similarity to the human phenotype. In addition, we aim to highlight the strengths and shortcomings of each model in an attempt to identify the most appropriate application of each. Although no porcine model perfectly recapitulates the human metabolic syndrome, several pose satisfactory approximations. The Ossabaw miniature swine in particular represents a highly translatable model that develops each of the core parameters of the syndrome with many of the associated secondary comorbidities. Future high-fidelity porcine models of metabolic syndrome need to focus on secondary sequelae replication, which may require extended induction period to reveal.

Background Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. Aim To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability. Methods A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings. Results A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (P = 0.043). Conclusion Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle instability.

Following closed reduction of distal radius fractures, formal radiographs are often obtained despite previous verification on fluoroscopy. A prospective collection of 60 consecutive distal radius fractures was obtained to compare the quality of the fluoroscopic images obtained from a mini C-arm versus formal radiographs. The images were reviewed by six orthopedic surgeons and one radiologist. The likelihood that further imaging was deemed necessary to guide treatment decisions was 1.9 times higher in the mini C-arm imaging cohort (95% CI: 1:34, 2.69). While mini C-arm remains a useful reduction aid, formal radiographs should still be obtained to document post-reduction alignment and to guide treatment decisions.

The recent widespread interest of policy in entrepreneurial ecosystems has been complemented by a burgeoning academic research output. This research to date may be broadly categorized as focusing on place, actors, governance, and evolution. Of these groupings, evolutionary processes have been paid least attention despite their centrality to a dynamic ecosystem phenomenon that evolves from an origin through processes of growth, adaptation, and resilience. To redress this imbalance, we frame a future research agenda on evolutionary processes of entrepreneurial ecosystems. Foremost amongst these are the competing lens for the evolutionary processes, the appropriate and evolving geographic scope and boundaries of the ecosystem, and the evolving visible or invisible modes of governance. Methodologically, we call for greater use of longitudinal studies of such evolutionary processes.

We propose a way to separate variables in a rational integrable $$\mathfrak {gl}(\mathsf {n})$$ spin chain with an arbitrary finite-dimensional irreducible representation at each site and with generic twisted periodic boundary conditions. Firstly, we construct a basis that diagonalises a higher-rank version of the Sklyanin $$\mathbf{B} $$ -operator; the construction is based on recursive usage of an embedding of a $$\mathfrak {gl}(k)$$ spin chain into a $$\mathfrak {gl}(k+1)$$ spin chain which is induced from a Yangian homomorphism and controlled by dual diagonals of Gelfand–Tsetlin patterns. Then, we show that the same basis can be equivalently constructed by action of Backlund-transformed fused transfer matricies, whence the Bethe wave functions factorise into a product of ascending Slater determinants in Baxter Q-functions. Finally, we construct raising and lowering operators—the conjugate momenta—as normal-ordered Wronskian expressions in Baxter Q-operators evaluated at zeros of $$\mathbf{B} $$ —the separated variables. It is an immediate consequence of the proposed construction that the Bethe algebra comprises the maximal possible number of mutually commuting charges—a necessary property for Bethe equations to be complete.

PurposeThe purpose of this research is to develop a dynamic conceptual framework depicting factors related to the adoption of a healthy diet, which will underpin the development of an agent-based model (ABM) to uncover the dynamic interplay between these factors.Design/methodology/approachThe conceptual framework was developed in three steps using available empirical data from a semi-structured in-depth interview qualitative study, comprehensive systematic literature searches, existing theories and models and expert opinions from across the world.FindingsThe conceptual framework explicitly presents intention as the key determinant of the tendency to adopt a healthy diet. Intention is determined by demographic, psychological and behavioural factors and individual dietary mindset factors and dynamically affected by social environment and the person's past behaviour. The relationship between intention and behaviour is dynamically moderated by perceived control factors (price and accessibility of healthy food and time).Originality/valueThe conceptual framework developed in this study is well supported by evidence and experts' opinions. This conceptual framework will be used to design the ABM of this study, and it can be used in future investigations on the tendency to adopt healthy diet and food choices.

Objective: Inconsistent results regarding the association between the Body Mass Index (BMI) and brain disorders have been reported. We performed this study to investigate the association between BM...

Background The relationship between body mass index (BMI) and risk of venous thromboembolism (VTE) and pulmonary embolism (PE) is a controversial issue. This dose-response meta-analysis was performed to investigate the association between BMI and risk of VTE and PE incidence based on cohort studies. Method A comprehensive systematic search was conducted up to August 2019 in MEDLINE/PubMed, SCOPUS, and Cochrane. DerSimonian and Laird random-effects models were run to estimate combined hazard ratios (HRs) with 95% confidence intervals (CIs). Dose-response analysis was also carried out based on BMI values. Results Eleven articles with 16 arms and 3,910,747 participants were eligible for inclusion in this systematic review and meta-analysis. Pooled results showed a positive association between BMI and risk of VTE in the obese participants compared to participants classified in the normal BMI category (HR: 1.62, 95% CI: 1.29–2.04, I2 = 95%). Furthermore, results showed a significant association between lower BMI (underweight versus normal BMI category) and reduced risk of PE (HR: 0.80, 95% CI: 0.70–0.92, I2 = 9%) and higher risk of PE in obese versus normal BMI participants (HR: 2.24, 95% CI: 1.93–2.60, I2 = 0%). There was a significant linear relationship between BMI and risk of VTE (p Conclusions This systematic review and dose-response meta-analysis with 3,910,747 participants highlights obesity as a significant risk factor related to the incidence of VTE and PE.

Coronavirus disease 2019 (COVID‐19), the worst pandemic in more than a century, has claimed >125,000 lives worldwide to date. Emerging predictors for poor outcomes include advanced age, male sex, preexisting cardiovascular disease, and risk factors including hypertension, diabetes, and, more recently, obesity. This article posits new obesity‐driven predictors of poor COVID‐19 outcomes, over and above the more obvious extant risks associated with obesity, including cardiometabolic disease and hypoventilation syndrome in intensive care patients. This article also outlines a theoretical mechanistic framework whereby adipose tissue in individuals with obesity may act as a reservoir for more extensive viral spread, with increased shedding, immune activation, and cytokine amplification. This paper proposes studies to test this reservoir concept with a focus on specific cytokine pathways that might be amplified in individuals with obesity and COVID‐19. Finally, this paper underscores emerging therapeutic strategies that might benefit subsets of patients in which cytokine amplification is excessive and potentially fatal.

Purpose: Tenofovir (TDF) and entecavir (ETV) are both equally recommended as first-line treatments for patients with chronic hepatitis B (CHB). They have comparable efficacy in virologic response, but their effect on the development of hepatocellular carcinoma (HCC) in CHB is controversial. Therefore, we aimed to compare TDF and ETV evaluating the risk of HCC development in CHB patients. Methods: A systematic literature search was conducted up to November 2019 in MEDLINE/PubMed, SCOPUS, and Web of Science databases without language and time restrictions. DerSimonian and Laird random-effects models were used to estimate combined hazard ratios (HRs) and 95% CIs. Results: Seven studies containing 35,785 participants were included in this systematic review and meta-analysis. The pooled HR (95% CI) of HCC in the patients who used TDF versus patients who used ETV was 0.75 (0.56–0.96). There was no significant heterogeneity detected among the included studies results (I2 = 47.5%). There was no significant publication bias detected among the included studies (Begg’s p = 0.88 and Egger’s regression test p = 0.96). Conclusions: Evidence to date suggests that TDF treatment is associated with significantly fewer cases of HCC when compared to ETV.

Background: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. Purpose: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. Results: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). Conclusion: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Relationship between liver enzymes such as gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), aspartate transaminase (AST) and alkaline phosphatase and risk of gestational diabetes mellitus (GDM) is a controversial issue. The aim of this systematic review and dose–response meta-analysis was to investigate the association between liver enzymes and risk of GDM in observational studies. A comprehensive systematic literature search was conducted in MEDLINE/PubMed, SCOPUS and Web of Science databases up to September 2019. Combined odds ratios (ORs) with 95% confidence intervals (CIs) were evaluated by DerSimonian and Laird random-effects models. Dose–response analyses of these relationships were also carried out. Eight studies with 25,451 participants containing 2549 cases were included in this study. Pooled results showed a significant association between GGT levels and risk of GDM (OR 2.10, 95% CI 1.14–3.86, I2 84%). In addition, random-effects model indicated a dramatic and direct significant association between GGT and risk of GDM in nonlinear (p

Objective There is compelling clinical evidence implicating certain dietary components in the development and clinical course of progression in ulcerative colitis (UC). This study aimed to assess whether any association exists between ulcerative colitis and scores on a healthy eating index. Methods In this case-control study patients with UC were recruited and assessed together with healthy controls. The participants completed a validated 168-item food frequency questionnaire, the results of which were subsequently used to generate individual healthy eating index (HEI-2015) scores. Results Altogether 58 patients with UC and 123 healthy controls were recruited. After controlling for confounding factors, participants who were in the highest quartile of the HEI-2015 had a 66% lower odds ratio (OR) of UC than the lowest quartile (OR = 0.34, 95% confidence interval 0.12-0.96). Conclusion HEI-2015 was associated with UC in this cohort. Further elucidation of the role of key dietary elements is now warranted.

Adequate reduction of posterior malleolar fractures leads to better outcomes. Arthroscopic reduction and internal fixation presents an opportunity for excellent reduction with a minimally invasive approach. Herein, we present a technique with some discussion on outcomes.

Osteochondral lesions of the talus (OLTs) continue to be a challenge for the treating surgeon, especially when lesions are refractory to marrow stimulation techniques. The purpose of this study is to evaluate the outcomes of lesions treated with osteochondral allograft transplantation. A review was performed of 30 athletes with 31 OLTs that were refractory to marrow stimulation or predicted to be refractory based on size and location of the lesion. Results were evaluated in terms of occupational outcomes and numeric pain scales. Lesions treated had a mean area of 1.37 (range 0.36 to 3.3) cm2. Overall excellent outcomes were achieved in 11 (35%) ankles. Nineteen (61%) ankles achieved good or excellent occupational outcomes, and 12 (39%) ankles demonstrated poor occupational outcomes and the patients were unable to continue their previous active occupations. Patients were found to have a mean pain scale score of 3 (range 0 to 7) of 10 at a mean of 21 (range 10 to 24) months after operative management. Osteochondral allograft transplantation is an option for the treatment of selected athletes with large OLTs, as well as lesions that are refractory to marrow stimulation techniques. The results of this study may help active young patients and their surgeons to better understand outcomes and options in their shared decision-making process.

Due to its innately intriguing nature and recent genomic technological advances, gut microbiome research has been at the epicentre of medical research for over a decade now. Despite the degree of publicisation, a comprehensive understanding and, therefore, acceptance of the area as a whole may be somewhat lacking within the broader medical community. This paper summarises the main analytical techniques and tools currently applied to compositional microbiome research. In addition, we outline five major lessons learnt from a decade of infant microbiome research, along with the current research gaps. Finally, we aim to provide an introduction and general guidelines relating to infant gut microbiome research for the practising paediatrician.

A 41-year-old woman presented by ambulance with a 1-day history of new-onset paralysis and nausea and vomiting ongoing for 48 hours. She had no history of any similar episodes. Biochemical analysis showed profound hypokalaemia with a non-anion gap metabolic acidosis. Her initial serum chloride was within the normal range. She had significant electrocardiographic changes on admission with ST depression, U waves and a prolonged QT interval. Urinary anion gap supported the diagnosis of a distal renal tubular acidosis. Subsequent connective tissue disease serology confirmed previously undiagnosed Sjogren’s syndrome. Successful recovery for this patient required multidisciplinary input from the intensive care, nephrology and neurology teams.

Background The prevalence and severity of COVID-19 are greatly reduced in children, yet some pediatric patients develop a syndrome resembling Kawasaki Disease (KD), termed Multisystem Inflammatory Syndrome in Children (MIS-C). With an estimated incidence of 2/100,000 children, MIS-C is relatively rare but can be fatal. Clinical features can include fever, hyperinflammatory state, gastrointestinal symptoms, myocardial dysfunction, and shock. The pathogenesis of MIS-C, although yet to be completely elucidated, appears to be distinct from KD in terms of epidemiology, severity, and biochemical signature. Aim of Review Although efficacy of treatments for MIS-C have largely not yet been investigated, we aim to conduct a comprehensive literature search of numerous medical databases (AMED, EBM Reviews, Embase, Healthstar, MEDLINE, ERIC, and Cochrane) to highlight treatments used around the world, their rationale, and outcomes to better inform guidelines in the future. Using the findings, an approach to MIS-C management will be outlined. Key Scientific Concepts of Review • MIS-C appears to be a SARS-CoV-2 related post-infection phenomenon that is distinct from Kawasaki disease. • Although outcomes are largely favorable, there is significant variation in MIS-C treatment. Most management regimens reported to date mirror that of KD; however, targeted therapy based on specific MIS-C phenotypes may have the potential to improve outcomes. • We recommend close monitoring by a multidisciplinary team, symptomatic treatment (e.g., intravenous immunoglobulin for KD-like symptoms, steroids/immunotherapy for multisystem inflammation), and long-term follow-up. • Further research is required to evaluate the effectiveness of current MIS-C treatments and to determine more refined therapies.

BackgroundCOVID-19 has resulted in the death of over 1 million people to date. Following government-implemented regulations, there has been concern over the apparent decline in emergency department (ED) attendances and the resultant health legacy. Therefore, we aimed to characterise the attendances to an Irish tertiary hospital ED following the implementation of these regulations during the COVID-19 pandemic.MethodsThis retrospective observational study investigated all attendances to the Cork University Hospital ED from 15 February to 11 April in 2020 and 2017–2019. Attendances were stratified into four periods: Before COVID (BC) (15 February to 5 March), After COVID (AC) (6 March to 12 March), Educational Closure (EC) (13 March to 27 March) and Stay Home (SH) (28 March to 11 April), as per government regulations. Triage presentations of abdominal pain, shortness of breath, chest pain, headache and trauma were examined. Data were analysed by independent t-tests and χ2analysis.ResultsThere were 8261 attendances to the ED in the 2020 time period compared with a mean of 10 389 attendances during the corresponding periods in 2017–2019. There was a significant decrease in daily attendances in 2020 compared with 2017–2019 in the AC (142 vs 188, p=0.02), EC (122 vs 184, p).ConclusionOur findings suggest that the combination of government-imposed restrictions and perceived risk of attending an ED during a pandemic may contribute to reduced attendances. Public confidence in EDs is necessary to reduce collateral damage caused by failure to seek medical attention during a pandemic; adequate infrastructure to allow social distancing and isolation capacity in EDs is a necessity.

Objective This study was aimed to establish a reference interval for high-sensitivity cardiac troponin I (hs-cTnI) in umbilical cord blood of infants and to assess its association with the risk of predetermined early neonatal outcomes in a high-acuity tertiary care hospital. Study Design Umbilical cord-blood samples were collected and hs-cTnI was measured in all infants born between August 2015 and September 2015 at McMaster Children's Hospital (n = 256). Gestational age, birth weight, Apgar's scores, age in days at which feeding was established, neonatal intensive care unit (NICU) admission, and discharge in days after birth were recorded. Results The 90th, 95th, and 99th percentiles for the term infant subcohort were 19.75, 41.45, and 166.30 ng/L, respectively. We observed decreased mean gestational ages and birth weights in both the 90th (37.7 weeks; 2,961.4 g) and 95th percentiles (37.1 weeks; 2,709.9 g) when compared with the remaining infants. Moreover, levels of hs-cTnI were significantly higher in infants with respiratory distress requiring intervention (p Conclusion This study establishes the reference values for cord-blood hs-cTnI in infants at a tertiary care center. Premature and sick infants requiring NICU admission had significantly higher levels of hs-cTnI. Key Points

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using “leave 1 out” techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online ( https://osf.io/ctmnd/ ), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Senior individuals can suffer from immunosenescence and novel strategies to bolster the immune response could contribute to healthy ageing. In this double-blind, randomised, controlled pilot trial, we investigated the ability of non-digestible polysaccharide (NPS) preparations to enhance the immune response in a human vaccination model. In total, 239 subjects (aged 50–79 years) were randomised to consume one of five different NPS (yeast β-glucan (YBG), shiitake β-glucan (SBG), oat β-glucan (OBG), arabinoxylan (AX), bacterial exopolysaccharide (EPS)) or control (CTRL) product daily for five weeks. After two weeks of intervention, subjects were vaccinated with seasonal influenza vaccine. The post-vaccination increases in haemagglutination inhibition antibody titres and seroprotection rate against the influenza strains were non-significantly enhanced in the NPS intervention groups compared to CTRL. Specifically, a trend towards a higher mean log2 fold increase was observed in the AX group (uncorrected p = 0.074) combined with a trend for an increased seroprotection rate, AX group (48.7%) compared to CTRL (25.6%) (uncorrected p = 0.057), for the influenza A H1N1 strain. Subjects consuming AX also had a reduced incidence of common colds compared to CTRL (1 vs. 8, p = 0.029 in Fisher exact test). No adverse effects of NPS consumption were reported. The findings of this pilot study warrant further research to study AX as an oral adjuvant to support vaccine efficacy.

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic screw fixation is frequently required in rotational ankle injuries. Fibular malreduction after syndesmotic screw fixation occurs in as many as 52% of cases, which has been shown to detrimentally affect subjective outcomes and increase the probability of developing arthritis. The glidepath technique has been proposed as a useful technique to prevent malreduction. We hypothesize that the glidepath technique reduces the occurrence of fibular malreduction and results in improved outcomes compared to clamping. Methods: A retrospective cohort study comparing 25 patients reduced with a clamp compared to 18 patient using the glidepath technique. The glidepath technique, described by Needleman, the fibula is manually reduced and a Kirschner wire is placed through the fibula and tibia along the transmalleolar axis, parallel to the superior border of the ankle mortise. CT scans of the injured and contralateral ankles were obtained postoperatively to assess reduction. Malreduction is defined as >2mm difference between the anterior or posterior incisura-fibular distance of the injured ankle compared to the contralateral side. Prospective outcomes were assessed using the AOFAS and VR-12 scores at preoperative, 3 month, 6 month and 1 year followup of the glidepath cohort only. Results: We found a statistically significant reduction in malreduced syndesmoses using the glidepath technique when compared with the clamping technique. In our study, 17% (3/18) were malreduced using the glidepath technique, compared with 48% (12/25 patients) with clamping (p=0.005). The three malreductions seen in our study were anterior, we had no posterior malreductions. Compared with the clamping cohort that had 10/25 posterior malreductions and 2/25 anterior malreductions. Mean outcomes at 3,6 and 1 year scores were AOFAS 76, 86,86; VR-12 46,53,50/ 42,44,47 (physical/mental) respectively. Conclusion: Historically, malreduction for syndesmotic fixation is as high as 52%. The glidepath technique is a viable reduction maneuver that has lower rates of malreduction compared to clamping in our study. This is the first ever CT confirmed study measuring syndesmosis reduction utilizing manual reduction. The value of this technique is that is does not require an open reduction, arthroscopic visualization/reduction or CT guidance to achieve syndesmotic reduction.

Implication Statement In order to best treat a patient, the carer must be able to clearly see their point of view. In the case of the complexities of insulin pump therapy, physicians may not fully understand the common challenges that drive patients to non-adherence. The author undertook a three-day simulation using wearable technology to explore this experience. This form of simulation represents a simple yet effective means by which to foster cognitive empathy in undergraduate and postgraduate medical education settings alike.