Vomeronasal organ volume increases with body size and is dissociated with the loss of a visual signal in Sceloporus lizards.

Many organisms communicate using signals in different sensory modalities (multicomponent or multimodal). When one signal or component is lost over evolutionary time, it may be indicative of changes in other characteristics of the signalling system, including the sensory organs used to perceive and process signals. Sceloporus lizards predominantly use chemical and visual signals to communicate, yet some species have lost the ancestral ventral colour patch used in male-male agonistic interactions and exhibit increased chemosensory behaviour. Here, we asked whether evolutionary loss of this sexual signal is associated with larger vomeronasal organ (VNO) volumes (an organ that detects chemical scents) compared with species that have retained the colour patch. We measured VNO coronal section areas of 7-8 adult males from each of 11 Sceloporus species (4 that lost and 7 that retained the colour patch), estimated sensory and total epithelium volume, and compared volumes using phylogenetic analysis of covariance, controlling for body size. Contrary to expectations, we found that species retaining the ventral patch had similar relative VNO volumes as did species that had lost the ancestral patch, and that body size explains VNO epithelium volume. Visual signal loss may be sufficiently compensated for by increased chemosensory behaviour, and the allometric pattern may indicate sensory system trade-offs for large-bodied species.

Effects of dietary crude protein content and resistant starch supplementation on growth performance, intestinal histomorphology and microbial metabolites in weaned pigs.

A 4-week study was conducted to evaluate the effects of dietary crude protein (CP) content and resistant starch (RS) supplementation on growth performance, intestinal histomorphology and microbial metabolites of weaned pigs. A total of 96 pigs (7.06 ± 0.45 kg body weight) were assigned to 1 of 4 diets in a randomised complete block design involving a 2 (CP levels) × 2 (without or with RS) factorial arrangement to give 8 replicate pens and 3 pigs per pen. Body weight and feed disappearance were recorded weekly, and the faecal consistency score was determined every morning. Blood was sampled on days 1, 14 and 28 from one pig per pen, and the same pig was euthanised on day 28 to collect ileal tissue and ileal and colon digesta. Data were analysed using the MIXED procedure of SAS. The average daily gain and gain:feed ratio were lower (p < 0.05) in pigs fed low crude protein (LCP) diets compared to those fed high CP (HCP) diets during week 3 and overall period. The analysed Lys, Met+Cys and Thr in feed were lower than calculated values, particularly in LCP diets, which may have affected performance. Pigs fed the LCP diets had longer (p < 0.05) ileal villi and higher villus height to crypt depth ratios than those fed the HCP diets, and RS supplementation increased (p < 0.05) ileal villus height. Interactions (p < 0.05) between dietary CP content and RS inclusion were observed for short-chain fatty acid concentration in the ileum and colon in phase 2. There was no difference in propionic acid (ileum) or butyric acid (colon) concentrations among pigs fed HCP diets, however, the butyric acid concentration increased in pigs fed the LCP diet when supplemented with RS. Reducing dietary CP lowered (p < 0.05) faecal score, plasma urea nitrogen and digesta ammonia content. Overall, feeding LCP diets reduced growth performance but improved gut morphology in weaned pigs. Feeding the LCP diet with RS supplementation modulated concentrations of ileal propionic acid and colonic butyric acid in weaned pigs.

Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial.

IMPORTANCE: Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJECTIVE: To determine whether excluding aspirin as part of the antithrombotic regimen with a fully magnetically levitated LVAD is safe and decreases bleeding. DESIGN, SETTING, and PARTICIPANTS: This international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/d) vs placebo with VKA therapy in patients with advanced heart failure with an LVAD was conducted across 51 centers with expertise in treating patients with advanced heart failure across 9 countries. The randomized population included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD (314 in the placebo group and 314 in the aspirin group), of whom 296 patients in the placebo group and 293 in the aspirin group were in the primary analysis population, which informed the primary end point analysis. The study enrolled patients from July 2020 to September 2022; median follow-up was 14 months. Intervention: Patients were randomized in a 1:1 ratio to receive aspirin (100 mg/d) or placebo in addition to an antithrombotic regimen. MAIN OUTCOMES AND MEASURES: The composite primary end point, assessed for noninferiority (-10% margin) of placebo, was survival free of a major nonsurgical (>14 days after implant) hemocompatibility-related adverse events (including stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months. The principal secondary end point was nonsurgical bleeding events. RESULTS: Of the 589 analyzed patients, 77% were men; one-third were Black and 61% were White. More patients were alive and free of hemocompatibility events at 12 months in the placebo group (74%) vs those taking aspirin (68%). Noninferiority of placebo was demonstrated (absolute between-group difference, 6.0% improvement in event-free survival with placebo [lower 1-sided 97.5% CI, -1.6%]; P < .001). Aspirin avoidance was associated with reduced nonsurgical bleeding events (relative risk, 0.66 [95% confidence limit, 0.51-0.85]; P = .002) with no increase in stroke or other thromboembolic events, a finding consistent among diverse subgroups of patient characteristics. CONCLUSIONS AND RELEVANCE: In patients with advanced heart failure treated with a fully magnetically levitated LVAD, avoidance of aspirin as part of an antithrombotic regimen, which includes VKA, is not inferior to a regimen containing aspirin, does not increase thromboembolism risk, and is associated with a reduction in bleeding events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04069156.

Diverged subpopulations in tropical Urochloa (Brachiaria) forage species indicate a role for facultative apomixis and varying ploidy in their population structure and evolution.

BACKGROUND: Urochloa (syn. Brachiaria) is a genus of tropical grasses sown as forage feedstock, particularly in marginal soils. Here we aimed to clarify the genetic diversity and population structure in Urochloa species to understand better how population evolution relates to ploidy level and occurrence of apomictic reproduction. METHODS: We explored the genetic diversity of 111 accessions from the five Urochloa species used to develop commercial cultivars. These accessions were conserved from wild materials collected at their centre of origin in Africa, and they tentatively represent the complete Urochloa gene pool used in breeding programmes. We used RNA-sequencing to generate 1.1 million single nucleotide polymorphism loci. We employed genetic admixture, principal component and phylogenetic analyses to define subpopulations. RESULTS: We observed three highly differentiated subpopulations in U. brizantha, which were unrelated to ploidy: one intermixed with U. decumbens, and two diverged from the former and the other species in the complex. We also observed two subpopulations in U. humidicola, unrelated to ploidy; one subpopulation had fewer accessions but included the only characterized sexual accession in the species. Our results also supported a division of U. decumbens between diploids and polyploids, and no subpopulations within U. ruziziensis and U. maxima. CONCLUSIONS: Polyploid U. decumbens are more closely related to polyploid U. brizantha than to diploid U. decumbens, which supports the divergence of both polyploid groups from a common tetraploid ancestor and provides evidence for the hybridization barrier of ploidy. The three differentiated subpopulations of apomictic polyploid U. brizantha accessions constitute diverged ecotypes, which can probably be utilized in hybrid breeding. Subpopulations were not observed in non-apomictic U. ruziziensis. Sexual Urochloa polyploids were not found (U. brizantha, U. decumbens) or were limited to small subpopulations (U. humidicola). The subpopulation structure observed in the Urochloa sexual-apomictic multiploidy complexes supports geographical parthenogenesis, where the polyploid genotypes exploit the evolutionary advantage of apomixis, i.e. uniparental reproduction and clonality, to occupy extensive geographical areas.

Heart transplantation in Val142Ile mutation in the modern era: A single center experience.

Little is known about the post heart transplantation management of extra cardiac manifestations in patients with hereditary transthyretin amyloid cardiomyopathy (hATTR-CM) in the new era of disease modifying treatment for ATTR amyloidosis. This is a retrospective study of all patients with hATTR-CM associated with the Val142Ile variant who underwent heart transplantation (HT) from January 2014 to February 2022. All 10 patients with the Val142Ile mutation were successfully transplanted, with a 1 year survival post heart transplantation (HT) of 90%, comparable to an age, sex, and race matched cohort of patients transplanted for non-amyloid indications. However, 4 (40%) of these patients developed progressive extracardiac manifestations requiring initiation of TTR silencer therapy with the small interfering RNA (siRNA) drug patisiran, which was well tolerated with no significant side effects in this population. We recommend formal neurologic evaluation and assessment of extracardiac manifestations annually as part of routine post-transplant care, and disease modifying therapy, aimed at TTR stabilization or silencing, should be initiated in the context of previously untreated extracardiac manifestations or evidence of subclinical neuropathy to prevent progression.

Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies.

BACKGROUND: Caregiver support is considered necessary after heart transplant (HT) and left ventricular assist device (LVAD) for patients with end-stage heart failure (HF). Few studies have demonstrated how caregivers differ by gender and race, and whether that impacts therapy eligibility. METHODS: We examined caregiver relationships among 674 patients (32% women, 55% Black) evaluated at Emory University from 2011 to 2017. Therapy readiness was assessed using the Stanford Integrated Assessment for Transplant (SIPAT). Evaluation outcome according to caregiver relationship was compared using χ2 analysis. Multivariable logistic regression determined the association between caregiver and eligibility according to gender and race. RESULTS: Women and Black patients were less likely to have spouses as their support person (P < .001). Women were less likely to be considered eligible for advanced therapies (adjusted odds ratio [aOR] .64, 95% confidence interval [CI] .46-.89; P = .008), with Black women having lower eligibility than White women (aOR .28, 95% CI .11-.72; P = .008). Social support and SIPAT scores did not significantly influence eligibility by gender or race. CONCLUSION: Lack of caregiver support is considered a relative contraindication to advanced therapies. Type of caregiver in our cohort varied according to race and gender but did not explain differences in eligibility for advanced therapies.

Increased superfetation precedes the evolution of advanced degrees of placentotrophy in viviparous fishes of the family Poeciliidae.

The causes and consequences of the evolution of placentotrophy (post-fertilization nutrition of developing embryos of viviparous organisms by means of a maternal placenta) in non-mammalian vertebrates are still not fully understood. In particular, in the fish family Poeciliidae there is an evolutionary link between placentotrophy and superfetation (ability of females to simultaneously bear embryos at distinct developmental stages), with no conclusive evidence for which of these two traits facilitates the evolution of more advanced degrees of the other. Using a robust phylogenetic comparative method based on Ornstein-Uhlenbeck models of adaptive evolution and data from 36 poeciliid species, we detected a clear causality pattern. The evolution of extensive placentotrophy has been facilitated by the preceding evolution of more simultaneous broods. Therefore, placentas became increasingly complex as an adaptive response to evolutionary increases in the degree of superfetation. This finding represents a substantial contribution to our knowledge of the factors that have shaped placental evolution in poeciliid fishes.

Evolutionary loss of a signalling colour is linked to increased response to conspecific chemicals.

Behavioural responses to communicative signals combine input from multiple sensory modalities and signal compensation theory predicts that evolutionary shifts in one sensory modality could impact the response to signals in other sensory modalities. Here, we conducted two types of field experiments with 11 species spread across the lizard genus Sceloporus to test the hypothesis that the loss of visual signal elements affects behavioural responses to a chemical signal (conspecific scents) or to a predominantly visual signal (a conspecific lizard), both of which are used in intraspecific communication. We found that three species that have independently lost a visual signal trait, a colourful belly patch, responded to conspecific scents with increased chemosensory behaviour compared to a chemical control, while species with the belly patch did not. However, most species, with and without the belly patch, responded to live conspecifics with increased visual displays of similar magnitude. While aggressive responses to visual stimuli are taxonomically widespread in Sceloporus, our results suggest that increased chemosensory response behaviour is linked to colour patch loss. Thus, interactions across sensory modalities could constrain the evolution of complex signalling phenotypes, thereby influencing signal diversity.

Revisiting Polymer-Particle Interaction in PEO Solutions.

We have measured the electrophoretic mobility and diffusion coefficient of carboxylate-modified and sulfate-modified polystyrene latex particles in poly(ethylene oxide) aqueous solutions. Carboxylate-modified polystyrene particles have shown a bound polymeric layer as the surface net charge vanishes even at very low poly(ethylene oxide) concentration. The polymeric layer causes a lower electrophoretic mobility and slower Brownian diffusion than that corresponding to the bare particles. We show that the diffusion is the result of a significantly increased effective particle size 2rheff = 30 nm. This bound layer is not present in sulfate-modified polystyrene latex particles. The interaction between the carboxylate-modified particle surface and the macromolecules has been confirmed by means of atomistic computer simulations. The grafted acrylate copolymers, which come from the preparation procedure of the latex particles, confer more hydrophobic surface ready to interact with the polymer. The simulations suggest that the interaction is modulated not only by the nature of the acrylic acid monomer but also by the length of the grafted copolymer. Our results have important implications for particle selection in microrheology experiments.

Doppler changes in umbilical artery, middle cerebral artery, cerebroplacental ratio and ductus venosus during open fetal microneurosurgery for intrauterine open spina bifida repair.

OBJECTIVE: To describe changes in fetal Doppler parameters during a novel technique for open fetal microneurosurgery for open spina bifida (OSB) repair. METHODS: This was a prospective study of 44 fetuses undergoing open fetal surgery for OSB repair using a novel microneurosurgery approach that is characterized by a mini-hysterotomy (diameter of 15 mm), minimal fetal manipulation and maintenance of a constant normal amniotic fluid volume throughout the procedure. Doppler velocimetry of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) was performed before the start of surgery and at prespecified timepoints during fetal surgery. UA pulsatility index (PI) > 95th percentile, DV-PI > 95th percentile, MCA-PI < 5th percentile and cerebroplacental ratio (CPR) < 5th percentile were considered abnormal. RESULTS: Median gestational age at fetal surgery was 25.2 weeks (range, 22.9-27.9 weeks). Doppler recordings were successfully obtained in all cases during all timepoints throughout the surgery. As compared with Doppler values before surgery, there was a significant increase in the proportion of fetuses with MCA-PI < 5th percentile (63.6% vs 13.6%; P < 0.001), CPR < 5th percentile (65.9% vs 15.9%; P < 0.001) and DV-PI > 95th percentile (22.7% vs 0%; P = 0.01) and a non-significant increase in the proportion of fetuses with UA-PI > 95th percentile (11.4% vs 0%; P = 0.12) during fetal surgery. None of the fetuses showed absent or reversed end-diastolic velocity in the UA or absent or reversed DV a-wave at any stage during OSB repair. All abnormal Doppler parameters returned to normal after surgery. CONCLUSIONS: During open fetal surgery for OSB repair, a small hysterotomy, reduced fetal manipulation and maintenance of a normal amniotic fluid volume seem to prevent severe fetal Doppler abnormalities. The mild Doppler changes observed during fetal surgery could be a manifestation of fetal adaptation to the stress of fetal surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Steroid hormones, ectoparasites, and color: Sex, species, and seasonal differences in Sceloporus lizards.

Testosterone, in addition to promoting the expression of sexual ornaments can negatively affect immune function, leaving individuals more susceptible to parasites (immunocompetence handicap hypothesis). Immunosuppressive effects of testosterone also can occur indirectly, through increased glucocorticoid hormones (corticosterone, cortisol). Therefore, the expression of sexual ornaments and the ability to respond to parasites and diseases may be influenced by the interaction between testosterone and corticosterone. In this study we examined correlations of both testosterone and corticosterone with ectoparasite load and with expression of colorful sexual ornaments (patches on belly and throat) in three species of Sceloporus lizards (S. grammicus, S. megalepidurus, S. torquatus). In addition, we evaluated contributions of sex, body condition, and reproductive season. We expected that individuals with higher testosterone and lower corticosterone levels would have more colorful ornaments than individuals with higher corticosterone levels. In addition, if testosterone has negative effects on immune function but only at higher corticosterone levels, individuals with higher levels of testosterone and corticosterone should have higher ectoparasite loads. Contrary to these expectations, we did not detect an interaction between testosterone and corticosterone statistically affecting either ectoparasite load or the expression of colorful ornaments. Further, we did not find a positive association of either testosterone or corticosterone on ectoparasite loads in any of the three study species. Only in S. grammicus males was a hormone statistically associated with ectoparasite load, but it was a negative association with testosterone. The relationships between both hormones and different aspects of the colorful patches (brightness and chroma) varied drastically among the three species as well as between sexes. Hence, even among congeneric species, we did not observe consistent patterns among color, steroid hormones and ectoparasites. Different associations between these variables may reflect different physiological strategies for the production of colorful signals and immune defense.

Assessing Adherence by Combining the Test of Adherence to Inhalers With Pharmacy Refill Records.

BACKGROUND AND OBJECTIVE: The Global Initiative for Asthma (GINA) recommends the concurrent use of self-report and pharmacy refill data to assess treatment adherence. However, clinical evidence to support this combined approach is limited. Objective: To determine nonadherence to inhaler medication based on a validated questionnaire (Test of Adherence to Inhalers; TAI) and prescription refill data in a community sample of patients with chronic obstructive pulmonary disease (COPD) or asthma. Secondarily, we sought to determine the degree of concordance between these two measures. METHODS: Cross-sectional, observational multicenter study in patients with asthma or COPD. Sociodemographic and clinical data were obtained from clinical records. Refill data were retrieved from electronic pharmacy databases. Participants completed the 12-item TAI during a single visit as part of routine care. Nonadherence was defined as TAI <50 or <80% pharmacy refill rate (PRR) in the previous 6 months. RESULTS: A total of 816 patients (mean age, 60) were included. Nonadherence rates were 58.1% (TAI) and 28.6% (PRR) compared with 64.6% for the combined data (P<.0001). Concordance between the 2 measures was weak (к=0.205). CONCLUSIONS: These findings confirm the GINA recommendations, indicating that concomitant use of the TAI and pharmacy refill data identifies a higher percentage of nonadherent asthma or COPD patients than either instrument alone.

Developing a Training Web Application for Improving the COVID-19 Diagnostic Accuracy on Chest X-ray.

In December 2019, a new coronavirus known as 2019-nCoV emerged in Wuhan, China. The virus has spread globally and the infection was declared pandemic in March 2020. Although most cases of coronavirus disease 2019 (COVID-19) are mild, some of them rapidly develop acute respiratory distress syndrome. In the clinical management, chest X-rays (CXR) are essential, but the evaluation of COVID-19 CXR could be a challenge. In this context, we developed COVID-19 TRAINING, a free Web application for training on the evaluation of COVID-19 CXR. The application included 196 CXR belonging to three categories: non-pathological, pathological compatible with COVID-19, and pathological non-compatible with COVID-19. On the training screen, images were shown to the users and they chose a diagnosis among those three possibilities. At any time, users could finish the training session and be evaluated through the estimation of their diagnostic accuracy values: sensitivity, specificity, predictive values, and global accuracy. Images were hand-labeled by four thoracic radiologists. Average values for sensitivity, specificity, and global accuracy were .72, .64, and .68. Users who achieved better sensitivity registered less specificity (p < .0001) and those with higher specificity decreased their sensitivity (p < .0001). Users who sent more answers achieved better accuracy (p = .0002). The application COVID-19 TRAINING provides a revolutionary tool to learn the necessary skills to evaluate COVID-19 on CXR. Diagnosis training applications could provide a new original manner of evaluation for medical professionals based on their diagnostic accuracy values, and an efficient method to collect valuable data for research purposes.

Beyond Pairwise Interactions: Multispecies Character Displacement in Mexican Freshwater Fish Communities.

Competition has long been recognized as a central force in shaping evolution, particularly through character displacement. Yet research on character displacement is biased, as it has focused almost exclusively on pairs of interacting species while ignoring multispecies interactions. Communities are seldom so simple that only pairs of species interact, and it is not clear whether inferences from pairwise interactions are sufficient to explain patterns of phenotypes in nature. Here, we test for character displacement in a natural system of freshwater fishes in western Mexico that contains up to four congeneric species of the genus Poeciliopsis. We analyzed body shape differences between populations with different numbers of competitors while accounting for confounding environmental variables. Surprisingly, we found evidence for convergent character displacement in populations of P. prolifica, P. viriosa, and P. latidens. We also found that the convergence in body shape was not consistently in the same direction, meaning that when three or more competitors co-occurred, we did not find more extreme body shapes compared with when there were only two competitors. Instead, when three or more competitors co-occurred, body shape was intermediate between the shape found with a pair of species and the shape found with no competitor present. This intermediate shape suggests that evolution in multispecies communities likely occurs in response to several competitors rather than to simple pairwise interactions. Overall, our results suggest that competition among multiple species is more complex than simple pairwise competitive interactions.

Closing Gaps of a Quantum Advantage with Short-Time Hamiltonian Dynamics.

Demonstrating a quantum computational speed-up is a crucial milestone for near-term quantum technology. Recently, sampling protocols for quantum simulators have been proposed that have the potential to show such a quantum advantage, based on commonly made assumptions. The key challenge in the theoretical analysis of this scheme-as of other comparable schemes such as boson sampling-is to lessen the assumptions and close the theoretical loopholes, replacing them by rigorous arguments. In this work, we prove two open conjectures for a simple sampling protocol that is based on the continuous time evolution of a translation-invariant Ising Hamiltonian: anticoncentration of the generated probability distributions and average-case hardness of exactly evaluating those probabilities. The latter is proven building upon recently developed techniques for random circuit sampling. For the former, we exploit the insight that approximate 2-designs for the unitary group admit anticoncentration. We then develop new techniques to prove that the 2D time evolution of the protocol gives rise to approximate 2-designs. Our work provides the strongest theoretical evidence to date that Hamiltonian quantum simulators are classically intractable.

Sex differences in eligibility for advanced heart failure therapies.

OBJECTIVES: We investigated sex-based differences in eligibility for and outcomes after receipt of advanced heart failure (HF) therapies. BACKGROUND: Although women are more likely to die from HF than men, registry data suggest that women are less likely to receive heart transplant (HT) or left ventricular assist device (LVAD) for largely unknown reasons. METHODS: We performed a single-center retrospective cohort study of patients evaluated for advanced HF therapies from 2012 to 2016. Logistic regression was used to determine the association of sex with eligibility for HT/LVAD. Competing risks and Kaplan-Meier analysis were used to examine survival. RESULTS: Of 569 patients (31% women) evaluated, 223 (39.2%) were listed for HT and 81 (14.2%) received destination (DT) LVAD. Women were less likely to be listed for HT (adjusted odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61; P < .0001), based on allosensitization (P < .0001) and obesity (P = .02). Women were more likely to receive DT LVAD (adjusted OR 2.29, 95% CI 1.23-4.29; P = .01). Survival was similar between men and women regardless of whether they received HT and DT LVAD or were ineligible for therapy. CONCLUSION: Women are less likely to be HT candidates, but more likely to receive DT LVAD.

Validating patient prioritization in the 2018 Revised United Network for Organ Sharing Heart Allocation System: A single-center experience.

The 2018 Revised United Network for Organ Sharing Heart Allocation System (HAS) was proposed to reclassify status 1A candidates into groups of decreasing acuity; however, it does not take into account factors such as body mass index (BMI) and blood group which influence waitlist (WL) outcomes. We sought to validate patient prioritization in the new HAS at our center. We retrospectively evaluated patients listed for heart transplantation (n = 214) at Emory University Hospital from 2011 to 2017. Patients were reclassified into the 6-tier HAS. Multistate modeling and competing risk analysis were used to compare outcomes of transplantation and WL death/deterioration between new tiers. Additionally, a stratified sensitivity analysis by BMI and blood group was performed. Compared with tier 4 patients, there was progressively increasing hazard of WL death/deterioration in tier 3 (HR: 2.52, 95% CI: 1.37-4.63, P = .003) and tier 2 (HR: 5.03, 95% CI: 1.99-12.70, P < .001), without a difference in transplantation outcome. When stratified by BMI and blood group, this hierarchical association was not valid in patients with BMI ≥30 kg/m2 and non-O blood groups in our cohort. Therefore, the 2018 HAS accurately prioritizes the sickest patients in our cohort. Factors such as BMI and blood group influence this relationship and iterate that the system can be further refined.

The lateral ankle ligaments are interconnected: the medial connecting fibres between the anterior talofibular, calcaneofibular and posterior talofibular ligaments.

PURPOSE: A deep knowledge of lateral ankle ligaments is necessary to understand its function, pathophysiology and treatment options. The ankle lateral collateral ligament is formed by the anterior talofibular ligament (ATFL), the calcaneofibular (CFL) and the posterior talofibular ligament (PTFL). Although previous studies have reported connections between these ligaments on its lateral side, no studies have specifically assessed connections on the medial side. The aim of this study was to assess the morphology and consistency of the medial connections between the components of the lateral collateral ligament complex of the ankle. METHODS: Forty fresh-frozen ankle specimens were dissected to look for connections between the three lateral ankle ligaments. After visualization of the lateral ligaments was achieved, the fibula was amputated and ligament insertions were released at the talar and calcaneal insertion points. Observation of the connections and video analysis of the dynamic relationships of ligament connections were performed. RESULTS: Connections were found in all cases between the ATFL and PTFL, the ATFL and CFL, and the CFL and PTFL. Connections between ATFL and PTFL were not homogeneous. Although connections between the ATFLif and PTFL were noted in all cases (40), only 17 ankles (42.5%) had connections between the ATFLsf and PTFL. The amount of fibres of connection was also variable. CONCLUSION: Connections between the three components of the lateral collateral ligament of the ankle may be observed from the medial aspect of the ankle, and this may have important implications for arthroscopic lateral ligament repair.

Anatomic lectures on structures at risk prior to cadaveric courses reduce injury to the superficial peroneal nerve, the commonest complication in ankle arthroscopy.

PURPOSE: To assess the effectiveness of cadaveric ankle arthroscopy courses in reducing iatrogenic injuries. METHODS: A total of 60 novice surgeons enrolled in a basic cadaveric ankle arthroscopy course were divided into two groups. Group A (n = 32) was lectured on portal placement and use of the arthroscope, whereas group B (n = 28) was in addition lectured on specific portal-related complications. Following the performance of anterior ankle arthroscopy and hindfoot endoscopy, the specimens were dissected and carefully assessed for detection of any iatrogenic injuries. RESULTS: The rate of injury to the superficial peroneal nerve (SPN) was reduced from 25 to 3.6%, in group A compared with B (p = 0.033). Injuries to the peroneus tertius or extensor digitorum longus, the flexor hallucis longus and the tibial nerve or the Achilles tendon were also reduced in group B. Overall, the number of uninjured specimens was 50% (n = 30) and higher in group B (57%) than group A (44%). Lesions to the plantaris tendon, the sural nerve or the posterior tibial artery were more common in group B, however, without reaching statistical significance. Overall, 25 (13.9%) anatomic structures were injured in anterior arthroscopy compared to 18 (5%) in hindfoot endoscopy, out of a potential total of 180 and 360, respectively (p = 0.001). CONCLUSION: Dedicated lectures on portal-related complications have proven useful in reducing the risk of injury to the SPN, the commonest iatrogenic injury encountered in ankle arthroscopy. Hindfoot endoscopy is significantly safer than anterior ankle arthroscopy in terms of injury to anatomical structures.

Pressure changes in the Kager fat pad at the extremes of ankle motion suggest a potential role in Achilles tendinopathy.

INTRODUCTION: The Kager fat pad is one of the largest soft tissue structures local to the ankle joint, yet it is poorly understood. It has been hypothesised to have a role in Achilles tendinopathy. This study aimed to investigate the pressure areas in the Kager fat pad adjacent to the Achilles tendon and to assess the anatomy and deformation of the Kager fat pad in cadavers. METHODS: Twelve fresh frozen cadaveric ankles (mean age 44 years, range 38-51) were mounted in a customized testing rig, enabling plantar flexion and dorsiflexion of the ankle, with the Achilles tendon loaded. A needle tipped pressure sensor was inserted in two areas of the Kager fat pad under ultrasound guidance (retrocalcaneal bursa and at 3 cm proximal from Achilles insertion). Pressure readings were recorded at different flexion angles. Following testing, the specimens were dissected to expose the Kager fat pad and retrieve it for analysis. MRI images were also taken from three healthy volunteers and the Kager fat pad deformation examined. RESULTS: Mean pressures significantly increased in all specimens at terminal ankle plantar and dorsi flexion in both regions (p < 0.05). The Kager fat pad was consistently adherent to the Achilles at its posterior aspect for a mean length of 7.7 cm (SD 0.27, 89% of KFP length). The most distal part of the Kager fat pad was the exception and it detached from the Achilles to give way to the retroalcaneal bursa for a mean length of 0.92 cm (SD 0.24, 11% of KFP length). The bursal space is partially occupied by a constant 'wedge' extension of Kager fat pad. The mean volume of the whole Kager fat pad was 10.6 ml (SD 3.37). Video and MRI demonstrated that the Kager fat pad undergoes significant deformation during plantar flexion as it is displaced superiorly by the Achilles, with the wedge being forced into the retrocalcaneal bursal space. CONCLUSION: The Kager fat pad does not remain static during ankle range of motion, but deforms and its pressure also changes. This observation supports the theory that it acts as a shock-absorber to the Achilles tendon and pathological changes to the fat pad may be clinically important in the development of Achilles tendinopathy.