Hip-Spine Syndrome in the Nonarthritic Patient.

Hip-spine syndrome refers to concurrent hip and spine pathology with overlapping symptoms. Most of the literature has studied it in relation to total hip arthroplasty literature and has been shown to increase dislocation risk. Lumbar spine and pelvic mobility have been studied less frequently in relation to nonarthritic pathologic hip states. Understanding the biomechanical relationship between the lumbar spine, pelvis, and hip can help elucidate how hip-spine syndrome affects the nonarthritic hip and how it impacts outcomes of hip arthroscopy. Changes in lumbar spine motion may be the reason certain predisposed patients develop symptomatic femoroacetabular impingement (FAI) or ischiofemoral impingement. Some athletes may be "hip users" with a low pelvic incidence, making them more reliant on hip motion due to less-intrinsic lumbopelvic motion. When these patients have FAI morphology, their increased reliance on hip motion makes them prone to experiencing femoroacetabular contact and concurrent symptoms. Other athletes may be "spine users," with larger pelvic incidence and more baseline lumbopelvic motion, making them less reliant on hip motion and therefore less prone to experiencing hip impingement even with hip FAI morphology. Hip-spine syndrome also appears to have an impact on patient selection, role of nonoperative treatment, and hip arthroscopy surgical outcomes. Identifying patients with concurrent pathology may allow surgeons to recommend targeted physical therapy or counsel patients better on their expectations after surgery.

Dispersal syndromes drive the formation of biogeographical regions, illustrated by the case of Wallace's Line.

AIM: Biogeographical regions (realms) reflect patterns of co-distributed species (biotas) across space. Their boundaries are set by dispersal barriers and difficulties of establishment in new locations. We extend new methods to assess these two contributions by quantifying the degree to which realms intergrade across geographical space and the contributions of individual species to the delineation of those realms. As our example, we focus on Wallace's Line, the most enigmatic partitioning of the world's faunas, where climate is thought to have little effect and the majority of dispersal barriers are short water gaps. LOCATION: Indo-Pacific. TIME PERIOD: Present day. MAJOR TAXA STUDIED: Birds and mammals. METHODS: Terrestrial bird and mammal assemblages were established in 1-degree map cells using range maps. Assemblage structure was modelled using latent Dirichlet allocation, a continuous clustering method that simultaneously establishes the likely partitioning of species into biotas and the contribution of biotas to each map cell. Phylogenetic trees were used to assess the contribution of deep historical processes. Spatial segregation between biotas was evaluated across time and space in comparison with numerous hard realm boundaries drawn by various workers. RESULTS: We demonstrate that the strong turnover between biotas coincides with the north-western extent of the region not connected to the mainland during the Pleistocene, although the Philippines contains mixed contributions. At deeper taxonomic levels, Sulawesi and the Philippines shift to primarily Asian affinities, resulting from transgressions of a few Asian-derived lineages across the line. The partitioning of biotas sometimes produces fragmented regions that reflect habitat. Differences in partitions between birds and mammals reflect differences in dispersal ability. MAIN CONCLUSIONS: Permanent water barriers have selected for a dispersive archipelago fauna, excluded by an incumbent continental fauna on the Sunda shelf. Deep history, such as plate movements, is relatively unimportant in setting boundaries. The analysis implies a temporally dynamic interaction between a species' intrinsic dispersal ability, physiographic barriers, and recent climate change in the genesis of Earth's biotas.

Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

PURPOSE: To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes. METHODS: PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data. RESULTS: A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction. CONCLUSIONS: Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR. LEVEL OF EVIDENCE: IV, systematic review and meta-analysis.

Ecological Limits as the Driver of Bird Species Richness Patterns along the East Himalayan Elevational Gradient.

Variation in species richness across environmental gradients results from a combination of historical nonequilibrium processes (time, speciation, extinction) and present-day differences in environmental carrying capacities (i.e., ecological limits affected by species interactions and the abundance and diversity of resources). In a study of bird richness along the subtropical east Himalayan elevational gradient, we test the prediction that species richness patterns are consistent with ecological limits using data on morphology, phylogeny, elevational distribution, and arthropod resources. Species richness peaks at midelevations. Occupied morphological volume is roughly constant from low elevations to midelevations, implying that more species are packed into the same space at midelevations compared with low elevations. However, variance in beak length and differences in beak length between close relatives decline with elevation, which is a consequence of the addition of many small insectivores at midelevations. These patterns are predicted from resource distributions: arthropod size diversity declines from low elevations to midelevations, largely because many more small insects are present at midelevations. Weak correlations of species mean morphological traits with elevation also match predictions based on resources and habitats. Elevational transects in the tropical Andes, New Guinea, and Tanzania similarly show declines in mean arthropod size and mean beak length and, in these cases, likely contribute to declining numbers of insectivorous bird species richness along these gradients. The results imply that conditions for ecological limits are met, although historical nonequilibrium processes are likely to also contribute to the pattern of species richness.

Machine Learning Using Digitized Herbarium Specimens to Advance Phenological Research.

Machine learning (ML) has great potential to drive scientific discovery by harvesting data from images of herbarium specimens-preserved plant material curated in natural history collections-but ML techniques have only recently been applied to this rich resource. ML has particularly strong prospects for the study of plant phenological events such as growth and reproduction. As a major indicator of climate change, driver of ecological processes, and critical determinant of plant fitness, plant phenology is an important frontier for the application of ML techniques for science and society. In the present article, we describe a generalized, modular ML workflow for extracting phenological data from images of herbarium specimens, and we discuss the advantages, limitations, and potential future improvements of this workflow. Strategic research and investment in specimen-based ML methods, along with the aggregation of herbarium specimen data, may give rise to a better understanding of life on Earth.

Characteristics of Frequent Users of Emergency Medical Services in Singapore.

OBJECTIVES: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. METHODS: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n = 243), with admission the primary outcome. RESULTS: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p = 0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p = 0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p < 0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p < 0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p < 0.001). Many were picked up from public areas (45.5% vs. 19.6%, p < 0.001), and had lower acuity triage scores at both EMS (p < 0.001) and ED (p = 0.001). They had lower admission rates (40.5% vs. 78.7%, p < 0.001) and shorter length of stay (4.3 vs. 5.9 days, p < 0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. CONCLUSION: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission.

Time to Reimplantation: Waiting Longer Confers No Added Benefit.

BACKGROUND: While the preferred surgical treatment for chronic periprosthetic joint infection (PJI) in North America is a 2-stage exchange arthroplasty, the optimal time between first-stage and reimplantation surgery remains unknown. This study was conceived to examine the association between time to reimplantation and treatment failure. METHODS: Using an institutional database, we identified PJI cases treated with 2-stage exchange arthroplasty between 2000 and 2016. Musculoskeletal Infection Society criteria were used to define PJI, and treatment failure was defined using Delphi criteria. The interstage interval between first-stage and reimplantation surgery for each case was collected, alongside demographics, patient-related and organism-specific data. Multivariate logistic regression analyses were used to examine association with treatment failure. RESULTS: Our final analysis consisted of 282 patients with an average time to reimplantation of 100.2 days (range, 20-648). Sixty-three patients (22.3%) failed at 1 year based on Delphi criteria. Time to reimplantation was not significantly associated with failure in both univariate (P = .598) and multivariate (P = .397) models. However, patients reimplanted at >26 weeks were twice as likely to fail in comparison to those reimplanted within <26 weeks (43.8% vs 21.1%), and this finding reached marginal significance (P = .057). Patients who failed had significantly more comorbidities (P = .008). Charlson comorbidity index was the only variable significantly associated with treatment failure in regression analysis (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = .019). CONCLUSION: The length of the interstage interval was not a statistically significant predictor of failure in patients undergoing 2-stage exchange arthroplasty for PJI.

Integrating Social Media and Anterior Cruciate Ligament Surgery: An Analysis of Patient, Surgeon, and Hospital Use.

PURPOSE: The purpose of this observational study of social media in sports medicine was to investigate and analyze the presence and shared content of anterior cruciate ligament (ACL) patients, sports surgeons, and top orthopaedic hospitals on popular social media streams. METHODS: A search of 2 public domains (Instagram and Twitter) was performed over a 6-month period. ACL surgery ("#aclsurgery") was selected for the Instagram-based patient analysis after exclusion of veterinary ACL operations. A binary scoring system was used for media format, time (preoperatively or postoperatively), perioperative period (within 1 week of surgery), tone (positive or negative), return-to-work reference, return-to-play reference, rehabilitation reference, surgical-site reference, satisfaction reference, and dissatisfaction reference; perspective of the media was noted as well. A sample of 97 National Football League team surgeons was used for analysis of physician use in social media outlets and quantified by the number of posts. Hospital analysis categorized a sample of the top 50 orthopaedic hospitals by average number of posts and monthly posting rates with regard to orthopaedics, research, education, and personnel focus. RESULTS: In the patient analysis, 3,145 public posts of human subjects were shared on Instagram. Of these, 92% were personal recovery stories, with an emphasis on postoperative photographs (93%) with a positive tone (88%) more than 1 week after surgery (73%). Posts focused on surgical site (25%), return to play (30%), and postoperative rehabilitation (37%). Of the physicians, 16% had Twitter accounts, with an average of 94 posts per surgeon; none had Instagram accounts. Of the hospitals, 96% had Twitter accounts and 32% had Instagram accounts. Most of the hospital-based Instagram content in the sample was centered on patients or celebrities. CONCLUSIONS: Orthopaedic surgery has a large social media presence. Patients emphasize wound appearance, the rehabilitation process, and return to play. Ninety-six percent of hospitals are represented in social media outlets, whereas physicians are relatively under-represented. CLINICAL RELEVANCE: Social media offers a unique window into what truly matters to patients after surgery and may help us better manage expectations, enhance health care delivery, and improve marketing strategies.

Geographical Barriers and Dispersal Propensity Interact to Limit Range Expansions of Himalayan Birds.

Range expansions are limited by two key factors. These are (1) dispersal, which includes a species' intrinsic mobility, geographical barriers, and their interaction; and (2) the ability of a species to persist beyond its current range. I evaluate the role of these in affecting bird species distributions across the Himalayas, under a hypothesis that many species have recently expanded their range out of an eastern Pleistocene refuge. I measured wing shape as a proxy for dispersal ability and topographic complexity across the Himalayas as a proxy for dispersal barriers. As a factor affecting the potential for persistence in novel locations, I compared similarity of a species' climatic envelope in the east, the hypothesized historical refuge, and the west, the location of recent colonization. Climatic similarity, wing shape, and the interaction of topographic complexity with wing shape all contribute significantly to the range extent of a given species. The result highlights the important interaction between morphological and landscape factors in affecting successful range expansions. The two dispersal-related parameters together explain two times the variance explained by climate, but I present additional evidence that other factors besides climate-notably biotic interactions-affect the ability of a species to persist beyond its range.

Unifying latitudinal gradients in range size and richness across marine and terrestrial systems.

Many marine and terrestrial clades show similar latitudinal gradients in species richness, but opposite gradients in range size-on land, ranges are the smallest in the tropics, whereas in the sea, ranges are the largest in the tropics. Therefore, richness gradients in marine and terrestrial systems do not arise from a shared latitudinal arrangement of species range sizes. Comparing terrestrial birds and marine bivalves, we find that gradients in range size are concordant at the level of genera. Here, both groups show a nested pattern in which narrow-ranging genera are confined to the tropics and broad-ranging genera extend across much of the gradient. We find that (i) genus range size and its variation with latitude is closely associated with per-genus species richness and (ii) broad-ranging genera contain more species both within and outside of the tropics when compared with tropical- or temperate-only genera. Within-genus species diversification thus promotes genus expansion to novel latitudes. Despite underlying differences in the species range-size gradients, species-rich genera are more likely to produce a descendant that extends its range relative to the ancestor's range. These results unify species richness gradients with those of genera, implying that birds and bivalves share similar latitudinal dynamics in net species diversification.

Effect of Medial Patellofemoral Complex Reconstruction Technique on Patellofemoral Contact Pressure, Contact Area, and Kinematics.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is considered by many to be the gold standard to treat lateral patellar instability; however, some investigators have reported good clinical results after isolated medial quadriceps tendon-femoral ligament (MQTFL) reconstruction or a combined MPFL/MQTFL reconstruction. A handful of studies have preliminarily investigated the biomechanical consequences of these various medial patellar stabilizing procedures. Despite this, no existing study has included multiple medial patellofemoral complex (MPFC) reconstructions and assessment of lateral patellar translation at distinct flexion angles. HYPOTHESIS: Combined MPFL/MQTFL reconstruction would restore patellofemoral contact areas, forces, and kinematics closest to the native state compared with isolated reconstruction of the MPFL or MQTFL alone. STUDY DESIGN: Controlled laboratory study. METHODS: Ten adult cadaveric knee specimens were prepared and analyzed under 5 different conditions: (1) intact state, (2) transected MPFC, (3) isolated MPFL reconstruction, (4) isolated MQTFL reconstruction, and (5) combined MPFL/MQTFL reconstruction. Patellar tilt, lateral patellar translation, patellofemoral contact forces, and patellofemoral contact areas were measured in each condition from 0° to 80° through simulated knee flexion using a custom servohydraulic load frame with pressure sensor technology and a motion capture system for kinematic data acquisition. RESULTS: The isolated MPFL, isolated MQTFL, and combined MPFL/MQTFL reconstruction conditions produced significantly less lateral patellar tilt compared with the transected MPFC state (P < .05). No statistically significant differences were found when each reconstruction technique was compared with the intact state in patellar tilt, lateral patellar translation, contact forces, and contact areas. CONCLUSION: All 3 reconstruction techniques (isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction) restored native knee kinematics, contact forces, and contact areas without overconstraint. CLINICAL RELEVANCE: Isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction all restore patellofemoral stability comparable with the intact MPFC state without the overconstraint that could be concerning for increasing risk of patellofemoral arthritis.

The Top 50 Most Cited Publications in Meniscus Research.

Injuries to the menisci of the knee are common in orthopedic sports medicine. Bibliometric studies can identify the core literature on a topic and help further our collective knowledge for both clinical and educational purposes. The purpose of the current study was to (1) identify and describe the 50 most cited articles in meniscus research over an 80-year time period to capture a wide range of influential articles and (2) identify the "citation classics" and milestone articles related to the meniscus of the knee. The Science Citation Index Expanded subsection of the Web of Science Core Collection was systematically searched for the 50 most cited meniscus articles. Data pertaining to bibliometric and publication characteristics were extracted and reported using descriptive statistics. The top 50 articles were published between the years 1941 and 2014 and collectively cited 13,152 times. The median (interquartile [IQR]) number of total citations per article was 203.5 (167.0-261.8), while the median citation rate was 9.6 (7.4-13.9) citations per year. The most cited article was "Knee joint changes after meniscectomy," published in 1948. The article with the highest citation rate of 78.4 citations per year was "The long-term consequence of anterior cruciate ligaments and meniscus injuries - osteoarthritis," published in 2007. The majority of articles were clinical outcome studies (n = 28, 56%). The top 50 most cited meniscus articles represent a compilation of highly influential articles which may augment reading curriculums and provide a strong knowledge base for orthopaedic surgery residents and fellows. The decade with the most articles was the 2000s, representing a recent acceleration in meniscus-based research. This is a level IV, cross-sectional study.

Application of a deep learning image classifier for identification of Amazonian fishes.

Given the sharp increase in agricultural and infrastructure development and the paucity of widespread data available to support conservation management decisions, a more rapid and accurate tool for identifying fish fauna in the world's largest freshwater ecosystem, the Amazon, is needed. Current strategies for identification of freshwater fishes require high levels of training and taxonomic expertise for morphological identification or genetic testing for species recognition at a molecular level. To overcome these challenges, we built an image masking model (U-Net) and a convolutional neural net (CNN) to classify Amazonian fish in photographs. Fish used to generate training data were collected and photographed in tributaries in seasonally flooded forests of the upper Morona River valley in Loreto, Peru in 2018 and 2019. Species identifications in the training images (n = 3068) were verified by expert ichthyologists. These images were supplemented with photographs taken of additional Amazonian fish specimens housed in the ichthyological collection of the Smithsonian's National Museum of Natural History. We generated a CNN model that identified 33 genera of fishes with a mean accuracy of 97.9%. Wider availability of accurate freshwater fish image recognition tools, such as the one described here, will enable fishermen, local communities, and citizen scientists to more effectively participate in collecting and sharing data from their territories to inform policy and management decisions that impact them directly.

Dado el aumento del desarrollo agrícola e infraestructura y la escasa información disponible para apoyar la toma de decisiones con respecto al manejo y la conservación de la fauna, es necesario contar con una herramienta más rápida y precisa para la identificación de peces en el ecosistema de agua dulce más grande del mundo, la Amazonía. Las estrategias actuales para la identificación de peces de agua dulce requieren altos niveles de capacitación y experiencia taxonómica para la identificación morfológica o las pruebas genéticas para el reconocimiento de especies a nivel molecular. Para superar estos desafíos, construimos un modelo de enmascaramiento de imágenes (U­Net) y una red neuronal convolucional (CNN) para clasificar los peces amazónicos en las fotografías. Los peces utilizados para generar datos de entrenamiento fueron recolectados y fotografiados en afluentes de bosques inundables de la cuenca alta del río Morona en Loreto, Perú en 2018 y 2019. Las identificaciones de especies en las imágenes de entrenamiento (n = 3.068) fueron verificadas por ictiólogos expertos. Estas imágenes se complementaron con fotografías tomadas de ejemplares adicionales de peces amazónicos alojados en la colección ictiológica del Museo Nacional de Historia Natural del Smithsonian en Washington, DC. Se generó un modelo CNN que identificó 33 géneros de peces con una precisión media del 97,9%. Una mayor disponibilidad de herramientas precisas de reconocimiento de imágenes de peces de agua dulce, como la que se describe aquí, permitirá a los pescadores, las comunidades amazónicas y los "científicos ciudadanos" participar de manera más efectiva en la recopilación y el intercambio de datos de sus territorios para informar las políticas y decisiones de gestión que los afectan directamente.

Does witness type affect the chance of receiving bystander CPR in out-of-hospital cardiac arrest?

OBJECTIVES: The relationship between the bystander witness type and receipt of bystander CPR (BCPR) is not well understood. Herein we compared BCPR administration between family and non-family witnessed out-of-hospital cardiac arrest (OHCA). BACKGROUND: In many communities, interventions in the past decade have contributed to an increased receipt of BCPR, for example in Singapore from 15% to 60%. However, BCPR rates have plateaued despite sustained and ongoing community-based interventions, which may be related to gaps in education or training for various witness types. The purpose of this study was to investigate the association between witness type and BCPR administration. METHODS: Singapore data from 2010-2020 was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) network registry (n = 25,024). All adult, layperson witnessed, non-traumatic OHCAs were included in this study. RESULTS: Of 10,016 eligible OHCA cases, 6,895 were family witnessed and 3,121 were non-family witnessed. After adjustment for potential confounders, BCPR administration was less likely for non-family witnessed OHCA (OR 0.83, 95% CI 0.75, 0.93). After location stratification, non-family witnessed OHCAs were less likely to receive BCPR in residential settings (OR 0.75, 95% CI 0.66, 0.85). In non-residential settings, there was no statistically significant association between witness type and BCPR administration (OR 1.11, 95% CI 0.88, 1.39). Details regarding witness type and bystander CPR were limited. CONCLUSION: This study found differences in BCPR administration between family and non-family witnessed OHCA cases. Elucidation of witness characteristics may be useful to determine populations that would benefit most from CPR education and training.

Impact of COVID-19 on barriers to dispatcher-assisted cardiopulmonary resuscitation in adult out-of-hospital cardiac arrests in Singapore.

OBJECTIVE: Fewer out-of-hospital cardiac arrest (OHCA) patients received bystander cardiopulmonary resuscitation during the COVID-19 pandemic in Singapore. We investigated the impact of COVID-19 on barriers to dispatcher-assisted cardiopulmonary resuscitation (DA-CPR). METHODS: We reviewed audio recordings of all calls to our national ambulance service call centre during the pandemic (January-June 2020) and pre-pandemic (January-June 2019) periods. Our primary outcome was the presence of barriers to DA-CPR. Multivariable logistic regression was used to assess the effect of COVID-19 on the likelihood of barriers to and performance of DA-CPR, adjusting for patient and event characteristics. RESULTS: There were 1241 and 1118 OHCA who were eligible for DA-CPR during the pandemic (median age 74 years, 61.6 % males) and pre-pandemic (median age 73 years, 61.1 % males) periods, respectively. Compared to pre-pandemic, there were more residential and witnessed OHCA during the pandemic (87 % vs 84.9 % and 54 % vs 38.1 %, respectively); rates of DA-CPR were unchanged (57.3 % vs 61.1 %). COVID-19 increased the likelihood of barriers to DA-CPR (aOR 1.47, 95 % CI: 1.25-1.74) but not performance of DA-CPR (aOR 0.86, 95 % CI: 0.73 - 1.02). Barriers such as 'patient status changed' and 'caller not with patient' increased during COVID-19 pandemic. 'Afraid to do CPR' markedly decreased during the pandemic; fear of COVID-19 transmission made up 0.5 % of the barriers. CONCLUSION: Barriers to DA-CPR were encountered more frequently during the COVID-19 pandemic but did not affect callers' willingness to perform DA-CPR. Distancing measures led to more residential arrests with increases in certain barriers, highlighting opportunities for public education and intervention.

The Effect of Nonsteroidal Anti-inflammatory Drugs and Selective COX-2 Inhibitors on Bone Healing.

A recently published study, "Risk of Nonunion With Nonselective NSAIDs, COX-2 Inhibitors, and Opioids" by George et al (J Bone Joint Surg Am. 2020;102:1230-1238), assesses whether the use of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective cyclooxygenase 2 (COX-2) enzyme inhibitors, or opioids was associated with a risk of long bone fracture nonunion in Optum's deidentified private health database. This review analyzes the study, including strengths, weaknesses, and areas for future research. The study found an association between COX-2 inhibitor and opioid use with fracture nonunion but not with nonselective NSAID use. Although the literature on this topic is varied, these results are at least partially aligned with several animal studies that show COX-2 inhibitors to be associated with fracture nonunion. The George et al study design has several important limitations, indicating that further research is needed on this topic.

An essential review of Singapore's response to out-of-hospital cardiac arrests: improvements over a ten-year period.

Care for patients who experience out-of-hospital cardiac arrest (OHCA) has rapidly evolved in the past decade. Increased sophistication of care in the community, emergency medical services (EMS) and hospital setting is associated with improved patient-centred outcomes. Notably, Utstein survival doubled from 11.6% to 23.1% between 2011 and 2016. These achievements involved collaboration between policymakers, clinicians and researchers, and were made possible by a strategic interplay of policy, research and implementation. We review the development and current state of OHCA in Singapore using primary population-based data from the Pan-Asian Resuscitation Outcomes Study and an unstructured search of research databases. We discuss the roles of important milestones in policy, community, dispatch, EMS and hospital interventions. Finally, we relate these interventions to relevant processes and outcomes, such as the relationship between the strategic implementation of bystander cardiopulmonary resuscitation and placement of automated external defibrillator with return of spontaneous circulation, survival to discharge and survival with favourable neurological outcomes.

Generating segmentation masks of herbarium specimens and a data set for training segmentation models using deep learning.

PREMISE: Digitized images of herbarium specimens are highly diverse with many potential sources of visual noise and bias. The systematic removal of noise and minimization of bias must be achieved in order to generate biological insights based on the plants rather than the digitization and mounting practices involved. Here, we develop a workflow and data set of high-resolution image masks to segment plant tissues in herbarium specimen images and remove background pixels using deep learning. METHODS AND RESULTS: We generated 400 curated, high-resolution masks of ferns using a combination of automatic and manual tools for image manipulation. We used those images to train a U-Net-style deep learning model for image segmentation, achieving a final Sørensen-Dice coefficient of 0.96. The resulting model can automatically, efficiently, and accurately segment massive data sets of digitized herbarium specimens, particularly for ferns. CONCLUSIONS: The application of deep learning in herbarium sciences requires transparent and systematic protocols for generating training data so that these labor-intensive resources can be generalized to other deep learning applications. Segmentation ground-truth masks are hard-won data, and we share these data and the model openly in the hopes of furthering model training and transfer learning opportunities for broader herbarium applications.

Regional influences on community structure across the tropical-temperate divide.

Many models to explain the differences in the flora and fauna of tropical and temperate regions assume that whole clades are restricted to the tropics. We develop methods to assess the extent to which biotas are geographically discrete, and find that transition zones between regions occupied by tropical-associated or temperate-associated biotas are often narrow, suggesting a role for freezing temperatures in partitioning global biotas. Across the steepest tropical-temperate gradient in the world, that of the Himalaya, bird communities below and above the freezing line are largely populated by different tropical and temperate biotas with links to India and Southeast Asia, or to China respectively. The importance of the freezing line is retained when clades rather than species are considered, reflecting confinement of different clades to one or another climate zone. The reality of the sharp tropical-temperate boundary adds credence to the argument that exceptional species richness in the tropics reflects species accumulation over time, with limited transgressions of species and clades into the temperate.