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Objective: Concomitant chest wall resection for locally advanced lung cancer is traditionally performed via an open approach. The safety and effectiveness of minimally invasive approaches for chest wall resections are unknown. Methods: We used the National Cancer Database to identify patients undergoing lobectomy/bi-lobectomy with concomitant chest wall resection from 2010 to 2020. We stratified patients into those undergoing a minimally invasive resection (video-assisted thoracoscopic surgery [VATS]/robotic) or open, while accounting for conversions. We also compared VATS with robotic approaches. The main outcomes were length of stay, mortality, readmissions, and overall survival. We used multivariable, Kaplan-Meier and Cox proportional models to identify associations. Results: Of 2837 patients, 756 procedures (26.6%) were started minimally invasive, of which 23.1% were robotic. There were 237 (31.3%) conversions. Patients undergoing a minimally invasive operation were similar in terms of age (65.2 ± 9.8 years vs 66.0 ± 9.9 years), sex, race, tumor histology, and location (all P > .05) but had smaller cancers (5.4 ± 2.6 cm vs 6.2 ± 4.3 cm; P

Abstract Breast Cancer is the most common cancer among women globally. Despite significant improvements in overall survival, many tumours are refractory to therapy and so novel approaches are required to improve patient outcomes. We have evaluated patient-derived explants (PDEs) as a novel preclinical platform for breast cancer (BC) and implemented cutting-edge digital pathology and multi-immunofluorescent approaches for investigating biomarker changes in both tumour and stromal areas at endpoint. Short-term culture of intact fragments of BCs as PDEs retained an intact immune microenvironment, and tumour architecture was augmented by the inclusion of autologous serum in the culture media. Cell death/proliferation responses to FET chemotherapy in BC-PDEs correlated significantly with BC patient progression-free survival (p = 0.012 and p = 0.0041, respectively) and cell death responses to the HER2 antibody therapy trastuzumab correlated significantly with HER2 status (p = 0.018). These studies show that the PDE platform combined with digital pathology is a robust preclinical approach for informing clinical responses to chemotherapy and antibody-directed therapies in breast cancer. Furthermore, since BC-PDEs retain an intact tumour architecture over the short-term, they facilitate the preclinical testing of anti-cancer agents targeting the tumour microenvironment.

Summary: Background: Fewer minoritized patients with end-stage kidney disease (ESKD) receive kidney transplantation (KT); efforts to mitigate disparities have thus far failed. Pinpointing the specific stage(s) within the transplant care continuum (being informed of KT options, joining the waiting list, to receiving KT) where disparities emerge among each minoritized population is pivotal for achieving equity. We therefore quantified racial and ethnic disparities across the KT care continuum. Methods: We conducted a retrospective cohort study (2015–2020), with follow-up through 12/10/2021. Patients with incident dialysis were identified using the US national registry data. The exposure was race and ethnicity (Asian, Black, Hispanic, and White). We used adjusted modified Poisson regression to quantify the adjusted prevalence ratio (aPR) of being informed of KT, and cause-specific hazards models to calculate adjusted hazard ratios (aHR) of listing, and transplantation after listing. Findings: Among 637,951 adults initiating dialysis, the mean age (SD) was 63.8 (14.6), 41.8% were female, 5.4% were Asian, 26.3% were Black, 16.6% were Hispanic, and 51.7% were White (median follow-up in years [IQR]:1.92 [0.97–3.39]). Black and Hispanic patients were modestly more likely to be informed of KT (Black: aPR = 1.02, 95% confidence interval [CI]:1.01–1.02; Hispanic: aPR = 1.03, 95% CI: 1.02–1.03) relative to White patients. Asian patients were more likely to be listed (aHR = 1.18, 95% CI: 1.15–1.21) but less likely to receive KT (aHR = 0.56, 95% CI: 0.54–0.58). Both Black and Hispanic patients were less likely to be listed (Black: aHR = 0.87, 95% CI: 0.85–0.88; Hispanic: aHR = 0.85, 95% CI: 0.85–0.88) and receive KT (Black: aHR = 0.61, 95% CI: 0.60–0.63; Hispanic: aHR = 0.64, 95% CI: 0.63–0.66). Interpretation: Improved characterization of the barriers in KT access specific to each racial and ethnic group, and the interventions to address these distinct challenges throughout the KT care continuum are needed; our findings identify specific stages most in need of mitigation. Funding: National Institutes of Health.

Introduction:. Natural radiation exposure in the general population averages 3 milliSieverts (mSv) annually; however, radiation exposure in orthopaedic residents is not well defined. Despite protective measures, evidence of radiation-related diseases in orthopaedic surgeons is increasing. The purpose of this study was to quantify radiation exposure in orthopaedic residents and to determine the variability of exposure among post graduate year (PGY) of residency. Methods:. Monthly radiation exposure was measured prospectively over a 12-month period in orthopaedic surgery residents from a single program. Participants wore dosimeters above (“exposed”) and beneath (“shielded”) protective lead. The primary outcome measure was the absolute value of radiation exposure in mSv. Repeated measures analysis was used to assess exposure with age, sex, year of training, operating room (OR) days, and height. Results:. Mean annual occupational radiation exposure was 3.30 ± 0.64 mSv over an average of 107 ± 38 OR days. Mean exposure per OR day was 0.033 ± 0.008 mSv. PGY-2 and PGY-3 residents had the highest cumulative exposure, and PGY-5 residents had the highest mean exposure per OR day (0.044 ± 0.009 mSv/d). Number of OR days per month and PGY level were significant predictors of radiation exposure (p < 0.05). Sex, age, and height were not significant in predicting radiation of the exposed dosimeter. Conclusions:. Orthopaedic residents' exposure to radiation is nearly twice the general population's exposure. Given that yearly radiation exposure was highest during early residency years, but exposure based on number of OR days was highest in the final year of training, it is essential for resident education regarding radiation safety and safe clinical practices throughout their training.

Acute exposure to high concentrations of hydrogen sulfide (H2S) leads to sudden death and, if survived, lingering neurological disorders. Clinical signs include seizures, loss of consciousness, and dyspnea. The proximate mechanisms underlying H2S-induced acute toxicity and death have not been clearly elucidated. We investigated electrocerebral, cardiac and respiratory activity during H2S exposure using electroencephalogram (EEG), electrocardiogram (EKG) and plethysmography. H2S suppressed electrocerebral activity and disrupted breathing. Cardiac activity was comparatively less affected. To test whether Ca2+ dysregulation contributes to H2S-induced EEG suppression, we developed an in vitro real-time rapid throughput assay measuring patterns of spontaneous synchronized Ca2+ oscillations in cultured primary cortical neuronal networks loaded with the indicator Fluo-4 using the fluorescent imaging plate reader (FLIPR-Tetra®). Sulfide >5 ppm dysregulated synchronous calcium oscillation (SCO) patterns in a dose-dependent manner. Inhibitors of NMDA and AMPA receptors magnified H2S-induced SCO suppression. Inhibitors of L-type voltage gated Ca2+ channels and transient receptor potential channels prevented H2S-induced SCO suppression. Inhibitors of T-type voltage gated Ca2+ channels, ryanodine receptors, and sodium channels had no measurable influence on H2S-induced SCO suppression. Exposures to > 5 ppm sulfide also suppressed neuronal electrical activity in primary cortical neurons measured by multi-electrode array (MEA), an effect alleviated by pretreatment with the nonselective transient receptor potential channel inhibitor, 2-APB. 2-APB also reduced primary cortical neuronal cell death from sulfide exposure. These results improve our understanding of the role of different Ca2+ channels in acute H2S-induced neurotoxicity and identify transient receptor potential channel modulators as novel structures with potential therapeutic benefits.

Hematopoietic stem cell transplantation (HSCT) can replace endogenous microglia with circulation-derived macrophages but has high mortality. To mitigate the risks of HSCT and expand the potential for microglia replacement, we engineered an inhibitor-resistant CSF1R that enables robust microglia replacement. A glycine to alanine substitution at position 795 of human CSF1R (G795A) confers resistance to multiple CSF1R inhibitors, including PLX3397 and PLX5622. Biochemical and cell-based assays show no discernable gain or loss of function. G795A- but not wildtype-CSF1R expressing macrophages efficiently engraft the brain of PLX3397-treated mice and persist after cessation of inhibitor treatment. To gauge translational potential, we CRISPR engineered human-induced pluripotent stem cell-derived microglia (iMG) to express G795A. Xenotransplantation studies demonstrate that G795A-iMG exhibit nearly identical gene expression to wildtype iMG, respond to inflammatory stimuli, and progressively expand in the presence of PLX3397, replacing endogenous microglia to fully occupy the brain. In sum, we engineered a human CSF1R variant that enables nontoxic, cell type, and tissue-specific replacement of microglia.

BACKGROUND: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patients outcome at 6-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. RESULTS: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. CONCLUSION: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

BackgroundSleep disorders are common and disproportionately affect marginalized populations. Technology, such as wearable devices, holds the potential to improve sleep quality and reduce sleep disparities, but most devices have not been designed or tested with racially, ethnically, and socioeconomically diverse patients. Inclusion and engagement of diverse patients throughout digital health development and implementation are critical to achieving health equity.ObjectiveThis study aims to evaluate the usability and acceptability of a wearable sleep monitoring device-SomnoRing-and its accompanying mobile app among patients treated in a safety net clinic.MethodsThe study team recruited English- and Spanish-speaking patients from a mid-sized pulmonary and sleep medicine practice serving publicly insured patients. Eligibility criteria included initial evaluation of obstructed sleep apnea, which is most appropriate for limited cardiopulmonary testing. Patients with primary insomnia or other suspected sleep disorders were not included. Patients tested the SomnoRing over a 7-night period and participated in a 1-hour semistructured web-based qualitative interview covering perceptions of the device, motivators and barriers to use, and general experiences with digital health tools. The study team used inductive or deductive processes to code interview transcripts, guided by the Technology Acceptance Model.ResultsA total of 21 individuals participated in the study. All participants owned a smartphone, almost all (19/21) felt comfortable using their phone, and few already owned a wearable (6/21). Almost all participants wore the SomnoRing for 7 nights and found it comfortable. The following four themes emerged from qualitative data: (1) the SomnoRing was easy to use compared to other wearable devices or traditional home sleep testing alternatives, such as the standard polysomnogram technology for sleep studies; (2) the patient's context and environment, such as family and peer influence, housing status, access to insurance, and device cost affected the overall acceptance of the SomnoRing; (3) clinical champions motivated use in supporting effective onboarding, interpretation of data, and, ongoing technical support; and (4) participants desired more assistance and information to best interpret their own sleep data summarized in the companion app.ConclusionsRacially, ethnically, and socioeconomically diverse patients with sleep disorders perceived a wearable as useful and acceptable for sleep health. Participants also uncovered external barriers related to the perceived usefulness of the technology, such as housing status, insurance coverage, and clinical support. Future studies should further examine how to best address these barriers so that wearables, such as the SomnoRing, can be successfully implemented in the safety net health setting.

Abstract Background An international panel of obesity medicine experts from multiple professional organizations examined patterns of obesity care and current obesity treatment guidelines to identify areas requiring updating in response to emerging science and clinical evidence. Aims The panel focused on multiple medical health and societal issues influencing effective treatment of obesity and identified several unmet needs in the definition, assessment, and care of obesity. Methods The panel was held in Leesburg, Virginia in September 2019. Results The panelists recommended addressing these unmet needs in obesity medicine through research, education, evaluation of delivery and payment of care, and updating clinical practice guidelines (CPG) to better reflect obesity’s pathophysiological basis and heterogeneity, as well as the disease’s health, sociocultural, and economic complications; effects on quality of life; need for standards for quantitative comparison of treatment benefits, risks, and costs; and the need to more effectively integrate obesity treatment guidelines into routine clinical practice and to facilitate more direct clinician participation to improve public understanding of obesity as a disease with a pathophysiological basis. The panel also recommended that professional organizations working to improve the care of people with obesity collaborate via a working group to develop an updated, patient‐focused, comprehensive CPG establishing standards of care, addressing identified needs, and providing for routine, periodic review and updating. Conclusions Unmet needs in the definition, assessment and treatment of obesity were identified and a blueprint to address these needs developed via a clinical practice guideline that can be utilized worldwide to respond to the increasing prevalence of obesity.

Summary: Diabetic kidney disease (DKD), the most common cause of kidney failure, is a frequent complication of diabetes and obesity, and yet to date, treatments to halt its progression are lacking. We analyze kidney single-cell transcriptomic profiles from DKD patients and two DKD mouse models at multiple time points along disease progression—high-fat diet (HFD)-fed mice aged to 90–100 weeks and BTBR ob/ob mice (a genetic model)—and report an expanding population of macrophages with high expression of triggering receptor expressed on myeloid cells 2 (TREM2) in HFD-fed mice. TREM2high macrophages are enriched in obese and diabetic patients, in contrast to hypertensive patients or healthy controls in an independent validation cohort. Trem2 knockout mice on an HFD have worsening kidney filter damage and increased tubular epithelial cell injury, all signs of worsening DKD. Together, our studies suggest that strategies to enhance kidney TREM2high macrophages may provide therapeutic benefits for DKD.

Identifying the influential variables that provide early warning of financial network instability is challenging, in part due to the complexity of the system, uncertainty of a failure, and nonlinear, time-varying relationships between network participants. In this study, we introduce a novel methodology to select variables that, from a data-driven and statistical modeling perspective, represent these relationships and may indicate that the financial network is trending toward instability. We introduce a novel variable selection methodology that leverages Shapley values and modified Borda counts, in combination with statistical and machine learning methods, to create an explainable linear model to predict relationship value weights between network participants. We validate this new approach with data collected from the March 2023 Silicon Valley Bank Failure. The models produced using this novel method successfully identified the instability trend using only 14 input variables out of a possible 3160. The use of parsimonious linear models developed by this method has the potential to identify key financial stability indicators while also increasing the transparency of this complex system.

We conducted a systematic review to assess outcomes in Hispanic donors and explore how Hispanic ethnicity was characterized. We searched PubMed, EMBASE, and Scopus through October 2021. Two reviewers independently screened study titles, abstracts, and full texts; they also qualitatively synthesized results and independently assessed quality of included studies. Eighteen studies met our inclusion criteria. Study sample sizes ranged from 4007 to 143,750 donors and mean age ranged from 37 to 54 years. Maximum follow-up time of studies varied from a perioperative donor nephrectomy period to 30 years post-donation. Hispanic donors ranged between 6% and 21% of the donor populations across studies. Most studies reported Hispanic ethnicity under race or a combined race and ethnicity category. Compared to non-Hispanic White donors, Hispanic donors were not at increased risk for post-donation mortality, end-stage kidney disease, cardiovascular disease, non-pregnancy-related hospitalizations, or overall perioperative surgical complications. Compared to non-Hispanic White donors, most studies showed Hispanic donors were at higher risk for diabetes mellitus following nephrectomy; however, mixed findings were seen regarding the risk for post-donation chronic kidney disease and hypertension. Future studies should evaluate cultural, socioeconomic, and geographic differences within the heterogeneous Hispanic donor population, which may further explain variation in health outcomes.

BackgroundLytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described.PurposeTo describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting.Study designCohort study; Level of evidence, 3.MethodsA total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics.ResultsA total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group.ConclusionTunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Abstract Global Navigation Satellite System Interferometric Reflectometry (GNSS‐IR) using low‐cost antennas is a practical solution for monitoring water levels from rivers, lakes and seas that does not require submerging any instruments in water. Here we present a novel method for obtaining real‐time water levels using multiple low‐cost antennas that we validate by comparing with measurements from a co‐located pressure gauge at two sites with variable tides. Additionally, we use survey measurements to show that there is a site‐dependant mean bias in GNSS‐IR measurements up to a few centimeters, but this mean bias can be effectively removed by using a correction for the effect of tropospheric delay. We conclude that GNSS‐IR water level sensors could be a powerful tool for real‐time applications such as flood or storm surge monitoring and water resource management, as well as for improving the spatial coverage of sensors in remote regions.

BACKGROUND: Excessive gestational weight gain has been associated with increased total body fat (TBF), metabolic syndrome, and abdominal obesity. However, little is known about the relationship of gestational weight gain with changes in metabolically active visceral or ectopic (hepatic and skeletal muscle) lipid stores. OBJECTIVES: In a prospective study of 50 healthy, pregnant women, we assessed whether changes in weight were associated with changes in total, visceral, and ectopic lipid stores. METHODS: Participants (ages 19-39) were primarily White (84%). The mean preconception BMI was 25.8 kg/m2 (SD, 4.5 kg/m2; min-max, 17.1-35.9 kg/m2). Measurements were completed at visits 1 and 2 at means of 16 and 34 weeks gestation, respectively, and included TBF using BOD POD; abdominal subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) using MRI; and intrahepatic lipids (IHL), intramyocellular lipids (IMCL), and extramyocellular lipids (EMCL) using magnetic resonance spectroscopy. We used paired t-tests to examine changes in adipose tissue and Pearsons correlation to examine associations of adipose tissue changes and weight changes. We also examined whether changes in adipose tissue stores differed by preconception BMI (normal, overweight, and obese), using 1-way ANOVA. RESULTS: The TBF (mean change, +3.5 kg; 95% CI: 2.4-4.6 kg), SAT (mean change, +701 cm3; 95% CI: 421-981 cm3), VAT (mean change, +275 cm3; 95% CI: 170-379 cm3), and IHL (percentage water peak; median, +0.15; IQR = -0.01 to 0.32) values increased significantly; the IMCL and EMCL values did not change. Changes varied by BMI strata, with the least increase (or, for SAT, net loss) among women with obesity. Weight change was positively correlated with changes in TBF (r = 0.83; P

Abstract Mosasaurs (Squamata, Mosasauridae) were large aquatic reptiles from the Late Cretaceous that filled a range of ecological niches within marine ecosystems. The type-Maastrichtian strata (68–66 Ma) of the Netherlands and Belgium preserve remains of five species that seemed to have performed different ecological roles (carnivores, piscivores, durophages). However, many interpretations of mosasaur diet and niche partitioning are based on qualitative types of evidence that are difficult to test explicitly. Here, we apply three-dimensional dental microwear texture analysis (DMTA) to provide quantitative dietary constraints for type-Maastrichtian mosasaurs, and to assess levels of niche partitioning between taxa. DMTA indicates that these mosasaurs did not exhibit neatly defined diets or strict dietary partitioning. Instead, we identify three broad groups: (i) mosasaurs Carinodens belgicus and Plioplatecarpus marshi plotting in the space of modern reptiles that are predominantly piscivorous and/or consume harder invertebrate prey, (ii) Prognathodon saturator and Prognathodon sectorius overlapping with extant reptiles that consume larger amounts of softer invertebrate prey items, and (iii) Mosasaurus hoffmanni spanning a larger plot area in terms of dietary constraints. The clear divide between the aforementioned first two groups in texture-dietary space indicates that, despite our small sample sizes, this method shows the potential of DMTA to test hypotheses and provide quantitative constraints on mosasaur diets and ecological roles.

Robotics and autonomous systems are reshaping the world, changing healthcare, food production and biodiversity management. While they will play a fundamental role in delivering the UN Sustainable Development Goals, associated opportunities and threats are yet to be considered systematically. We report on a horizon scan evaluating robotics and autonomous systems impact on all Sustainable Development Goals, involving 102 experts from around the world. Robotics and autonomous systems are likely to transform how the Sustainable Development Goals are achieved, through replacing and supporting human activities, fostering innovation, enhancing remote access and improving monitoring. Emerging threats relate to reinforcing inequalities, exacerbating environmental change, diverting resources from tried-and-tested solutions and reducing freedom and privacy through inadequate governance. Although predicting future impacts of robotics and autonomous systems on the Sustainable Development Goals is difficult, thoroughly examining technological developments early is essential to prevent unintended detrimental consequences. Additionally, robotics and autonomous systems should be considered explicitly when developing future iterations of the Sustainable Development Goals to avoid reversing progress or exacerbating inequalities.

The foundation industries in the UK were responsible for emitting 42 Mt CO2eq in 2020, which is approximately 10% of the yearly territorial greenhouse gas emissions. The UK government decarbonisation roadmap issued in 2015 predicted that high-tech strategies such as carbon capture and utilisation, hydrogen and biofuels, as well as electrification of processes are key for achieving the climate mitigating targets by 2050. In this study, a critical assessment was performed on the limitations to achieve these high-tech strategies such as biomass availability, capital investment, and technology readiness. The study is the first to use the UK carbon budget values as the resource limit for the high-tech decarbonisation strategies. The findings show that the significant uncertainty associated with the high-tech scenarios limits their decarbonisation potential by 2050. More importantly, to stay within the mid-century carbon budget for the foundation industries, 20–40% reduction in production, through circular economic strategies such as material efficiency and/or changes in product specifications, is required in order to achieve the decarbonisation targets.

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the number of total ankle replacements (TAR) performed annually increases, there is an increased demand for implants that can be used in revision scenarios when primary TARs fail. As indications for TAR expand, there is increased reliance on modular systems to treat challenging conditions including bone loss, avascular necrosis, and instability. The INVISION Total Ankle Arthroplasty System (Wright Medical Technology/Stryker, Memphis, TN), released in 2018, includes modular augmented tibial trays and talar plates of varied heights to compensate for bone loss. There is limited data on early survivorship and clinical outcomes of the INVISION. This novel study aims to determine the early implant survivorship, complications, patient-reported outcomes (PROMIS), and radiographic outcomes of the INVISION implant used in both the primary and revision arthroplasty setting. Methods: This study is a single-institution retrospective review of adult patients who underwent primary or revision TAR with the INVISION implant with minimum 2-year follow-up. Demographics, reason for use of INVISION, surgical data, complications, pre- operative and 2 year post-operative radiographic data, and pre-operative and 2-year post-operative patient-reported outcome scores were collected. The primary outcome was survivorship (retention of both tibial/talar components at final follow-up). Secondary outcomes were reoperation (return to OR with retention of both tibial and talar components), radiographic complications (peri-implant lucency, cysts, or subsidence), and patient-reported outcomes (PROMIS pre-operative and 2-year post-operative). PROMIS scores were collected across the following domains: physical function, pain interference, pain intensity, global mental health, and depression score. Results: Twenty-six patients (primary=7; revision=19) underwent INVISION TAR (mean age 62 years, weight 81.kg, BMI 29.3 kg/m 2 , 15/26 male) with mean follow-up 3.5 years. Reason for INVISION primary TAR included tibial (n=1) or talar (n=5) bone loss, and take-down fusion (n=1); INVISION revision TAR was used for tibial (n=6) or talar (n=7) component subsidence, recurrent tibiotalar malalignment (valgus=1, varus=3), and post-infection bone loss (n=2). Two-year implant survivorship was 100%. There were 2 reoperations (7.7%): 1 gutter debridement and 1 irrigation, debridement and polyethylene exchange for infection. Two-year follow-up PROMIS domains improved significantly (p < 0.05) from pre-operative in both the primary (pain interference, pain intensity) and revision cohorts (pain interference, pain intensity, global physical function). Two-year radiographic follow-up yielded 1 tibial peri-implant lucency and 1 tibial cyst. Conclusion: In this single-institution series, there was excellent short-term survivorship of the INVISION TAR implant with no failures in primary or revision cases. There were significant improvements in patient-reported outcomes scores. There were low rates of peri-implant lucencies and cysts. The results of this study support the use of the INVISION implant in both the complex primary and revision TAR setting. INVISION may offer an alternate surgical solution to fusion, custom printed cage implants, and total talus replacement in this complex patient population. Further research and follow-up data are warranted to report the longer-term outcomes and survivorship of this implant.

BackgroundAlthough graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.HypothesisIn the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.Study designCohort study; Level of evidence, 2.MethodsPatients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.ResultsA total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).ConclusionBTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

The underlying theme throughout this series of studies authored by the Multicenter anterior cruciate ligament (ACL) Revision Study consortium has been to determine the modifiable predictors or risk factors of long-term outcomes of revision ACL reconstruction. The observational studies described and summarized in the manuscript are both clinically relevant and of great interest in finding out the long-term consequences of the intervention and its relationship to the original injury. The successful completion of these studies has important implications for both therapy and future clinical trials. The identification of modifiable risk factors will play an important role in secondary prevention, while the identification of nonmodifiable risk factors will aid us in counseling our patients and making surgical decisions. Thus, we expect a profound clinical impact on patients' care. More importantly, this project represents an important step forward in bringing evidence to bear in clinical decision making in orthopedic surgery.