Exploring healthcare provider retention in a rural and frontier community in Northern Idaho.

BACKGROUND: A shortage of healthcare providers, particularly in primary care and mental health, exists in the predominately rural state of Idaho. There are also barriers to retaining healthcare providers to work in rural and remote communities. Limited research using U.S. samples has explored factors that may affect the retention of healthcare providers in rural areas. Additionally, due to differences between communities, it is important to conduct community-level investigations to better understand how these factors may affect retention in rural areas. Therefore, the purpose of this study was to explore factors affecting healthcare provider retention in a rural community in Northern Idaho. METHODS: A modified version of the Nursing Community Apgar Questionnaire (NCAQ) was completed by 30 healthcare providers in a rural and frontier community in Northern Idaho to assess factors influencing healthcare provider retention. Factors were classified into classes including geographic, economic, scope of practice, medical support, and facility and community support classes. Retention factors were assessed on their perceived importance to retention as well as whether they were perceived as an advantage or challenge to retention based on Likert scales. A "Community Apgar" score was also created by combining the importance and advantage/challenge factors. RESULTS: Overall, items in the medical support group had the highest importance of any other class and included factors such as nursing workforce. Additionally, the facility and community support class, which included factors such as televideo support, was rated the highest advantage class and had the highest Apgar score, indicating it contained the factor that healthcare providers identified as the most important advantage (i.e., medical reference resources). CONCLUSION: Our study identified multiple factors that healthcare providers deemed as important advantages or disadvantages to retaining healthcare providers in rural areas. Overall, facility and community support factors were found to have the highest advantage in the retention of rural providers. Rural healthcare organizations looking to increase healthcare provider retention should target retention efforts towards these factors. Additional research should also be conducted on other rural samples across the U.S. to make comparisons of findings.

Millennia-long epigenetic fluctuations generate intragenic DNA methylation variance in Arabidopsis populations.

Methylation of CG dinucleotides (mCGs), which regulates eukaryotic genome functions, is epigenetically propagated by Dnmt1/MET1 methyltransferases. How mCG is established and transmitted across generations despite imperfect enzyme fidelity is unclear. Whether mCG variation in natural populations is governed by genetic or epigenetic inheritance also remains mysterious. Here, we show that MET1 de novo activity, which is enhanced by existing proximate methylation, seeds and stabilizes mCG in Arabidopsis thaliana genes. MET1 activity is restricted by active demethylation and suppressed by histone variant H2A.Z, producing localized mCG patterns. Based on these observations, we develop a stochastic mathematical model that precisely recapitulates mCG inheritance dynamics and predicts intragenic mCG patterns and their population-scale variation given only CG site spacing. Our results demonstrate that intragenic mCG establishment, inheritance, and variance constitute a unified epigenetic process, revealing that intragenic mCG undergoes large, millennia-long epigenetic fluctuations and can therefore mediate evolution on this timescale.

Longitudinal Invariance Testing Of The Knee Injury Osteoarthritis Outcome Score For Joint Replacement Scale (KOOS-JR).

Background: The Knee Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) is a seven-item patient reported outcome measure used to assess perceived knee health. Though commonly used, the longitudinal psychometric properties of the KOOS-JR have not been established and further characterization of its structural validity and multi-group invariance properties is warranted. Purpose: The purpose of this study was to evaluate psychometric properties of the KOOS-JR in a large sample of patients who received care for knee pathology. Study Design: Original research. Methods: Longitudinal data extracted from the Surgical Outcome System (SOS) database of 13,470 knee pathology patients who completed the KOOS-JR at baseline, three-months, six- months, and one-year. Scale structure was assessed with confirmatory factor analysis (CFA), while multi-group and longitudinal invariance properties were assessed with CFA-based procedures. Latent group means were compared with statistical significance set at α ≤ .05 and Cohen's d effect size as d = 0.2 (small), d = 0.5 (medium), and d = 0.8 (large). Results: CFA results exceeded goodness-of-fit indices at all timepoints. Multi-group invariance properties passed test requirements. Longitudinal analysis identified a biased item resulting in removal of item #1; the retained six-item model (KOOS-JR-6) passed longitudinal invariance requirements. KOOS-JR-6 scores significantly changed over time (p ≤ .001, Mdiff = 1.08, Cohen's d = 0.57): the highest scores were at baseline examination and the lowest at 12-month assessment. Conclusions: The KOOS-JR can be used to assess baseline differences between males and females, middle and older aged adults, and patients receiving total knee arthroplasty or non-operative care. Caution is warranted if the KOOS-JR is used longitudinally due to potential measurement error associated with item #1. The KOOS-JR-6 may be a more viable option to assess change over time; however, more research is warranted. Level of Evidence: 3© The Author(s).

Physician-level determinants of HCV screening during pregnancy in a U.S. sample.

PURPOSE: The purpose of this study was to assess the association between select determinants and HCV screening guideline adherence among physicians who provide prenatal care. RESEARCH QUESTION: What factors may act as determinants of guideline adherence to HCV screening among physicians who provide prenatal care? METHODS: We surveyed a national sample of physicians who provided prenatal care in 2021. The survey included questions from the Clinician Guideline Determinant (CGD) questionnaire, demographic characteristics, and medical practice characteristics. We estimated odds ratios and 95% confidence intervals (CIs) using semi-Bayesian logistic regression for the association between determinants and guideline adherence. RESULTS: Participants included 224 physicians in the United States who reported providing prenatal care. Most physicians practiced in private practice (65%) and the majority were members of the American College of Obstetricians and Gynecologists (ACOG; 91%). Less than half (43%; 95% CI: 36%-49%) of physicians reported regular use of the HCV screening guideline. Physicians who reported general knowledge about HCV (OR = 9.0, 95% CI 3.1-30) or endorsed agreement with ease of implementation (OR = 8.0, 95% CI 2.7-25) had higher odds of adherence to the HCV screening guideline. CONCLUSION: Our study suggests that less than half of practicing prenatal care physicians adhere to HCV screening guidelines for pregnant patients. Our results may be useful as a preliminary screening of select determinants of guideline use for further investigation.

Evaluating a Project Extension for Community Health Outcomes Pediatric Behavioral Health Series in a Rural and Frontier State: An Exploratory Investigation.

Background: Idaho, a predominately rural state, has a high prevalence of mental illness with minimal access to care. Barriers in diagnosis and treatment of pediatric behavioral health disorders could be mitigated with an accessible and effective specialty training program. Methods: A 10-session Project Extension for Community Health Outcomes (ECHO) series was designed to expand provider knowledge about pediatric behavioral health conditions and improve perceived clinical practice skills. Pre- and postseries evaluation surveys and individual session evaluations were used to assess the program. Results: A total of 148 individuals attended at least 1 of the 10 sessions. Participants reported high satisfaction with individual sessions and indicated that attendance positively impacted their knowledge and competency. Participants also reported that the knowledge and skills gained from the series would benefit more than half of their patients or clients. Conclusion: The short ECHO series appears to be a viable and valuable option to provide Idaho providers with effective specialty training that is well attended and well received.

Genomics and biochemical analyses reveal a metabolon key to ß-L-ODAP biosynthesis in Lathyrus sativus.

Grass pea (Lathyrus sativus L.) is a rich source of protein cultivated as an insurance crop in Ethiopia, Eritrea, India, Bangladesh, and Nepal. Its resilience to both drought and flooding makes it a promising crop for ensuring food security in a changing climate. The lack of genetic resources and the crop's association with the disease neurolathyrism have limited the cultivation of grass pea. Here, we present an annotated, long read-based assembly of the 6.5 Gbp L. sativus genome. Using this genome sequence, we have elucidated the biosynthetic pathway leading to the formation of the neurotoxin, ß-L-oxalyl-2,3-diaminopropionic acid (ß-L-ODAP). The final reaction of the pathway depends on an interaction between L. sativus acyl-activating enzyme 3 (LsAAE3) and a BAHD-acyltransferase (LsBOS) that form a metabolon activated by CoA to produce ß-L-ODAP. This provides valuable insight into the best approaches for developing varieties which produce substantially less toxin.

Health Literacy Correlates to HPV Vaccination Among US Adults Ages 27-45.

Human papillomavirus (HPV) vaccination is now available for adults aged 27-45 as a shared clinical decision. Health literacy skills (i.e., accessing, understanding, appraising, applying information) may facilitate vaccine decision-making for adults with a provider recommendation. This study assessed associations between health literacy skills and willingness to get a provider-recommended HPV vaccine among newly eligible US adults. In 2020, US participants (51% women), aged 27-45 years, were surveyed online (n = 691). The outcome was willingness (willing/not willing) to get the HPV vaccine with provider recommendation. Measures were adapted from Sørensen's multidimensional European Health Literacy Scale, which assesses health literacy among four domains (i.e., access, understanding, appraisal, application). Adjusted odds ratios were calculated for the outcome and each health literacy domain, adjusting for personal health determinants (e.g., age, sex). The sample consisted of primarily non-Hispanic (91.2%), White (74.4%), and married (60.7%) adults. Approximately 65% of participants were willing to get a provider-recommended HPV vaccine. Higher willingness to vaccinate with provider recommendation was significantly associated with increased HPV knowledge (understanding; aOR = 1.13, 95% CI 1.04, 1.24), ability to understand HPV information (understanding; aOR = 1.96, 95% CI 1.09, 3.52), increased perceived vulnerability to HPV-related cancer (appraising; aOR = 3.22, 95% CI 1.83, 5.69), and the need for more information on vaccine safety to seek vaccination (applying; aOR = 3.25; 95% CI 2.05, 5.16). Utilizing a multidimensional health literacy framework to evaluate facilitators to HPV vaccination uptake among adults aged 27-45 can help guide future interventions by targeting accurate, easy-to-understand HPV information that connects vaccination efficacy to reduction in HPV cancer risk.

Many-faceted rasch calibration of the foot function index-revised short form.

BACKGROUND: The Foot Function Index Revised Short version (FFI-RS) is a foot- and ankle- patient-reported outcome measure (PROM), developed from the Foot Function Index (FFI). Previous studies, estimating item parameters and multidimensional properties, have limitations properly establishing the measurement properties of the FFI-RS. A multi-faceted Rasch analysis with a larger sample would allow for a more robust validation approach to improve the clinical interpretation of the FFI-RS using a multidimensional perspective. Therefore, the purpose of this study was to assess the psychometric properties of the FFI-RS as a PROM of foot function. METHOD: A total of 2184 patients with foot pathology who completed the FFI-RS were included in the data. Data were extracted from the cloud-based orthopedic and sports medicine global registry Surgical Outcome System (SOS). The psychometric properties of the FFI-RS were assessed using a many-faceted Rasch analysis that included model-data fit, rating scale function, item-person map (distribution of item difficulty and person ability), and item difficulty of the subscale. RESULTS: Two misfit items were discovered and deleted; 32-items from the original FFI-RS were retained. The 4-item Likert scale functioned effectively and item difficulty (-0.58 to 1.48), subscale difficulty (-0.58 to 1.15), and person's foot function (-6.62 to 6.24) had wide distributions. CONCLUSIONS: Many-faceted Rasch analysis revealed the FFI-RS had sound psychometric properties using the many-faceted Ranch analysis and retained 32 of the original items. Clinicians and researchers should consider weaknesses identified with items in the 'Difficulty" subscale and future work should be conducted to modify or develop items that will more accurately evaluate a wide range of foot function levels.

The Development and Psychometric Evaluation of the Mid-adult Human Papillomavirus Vaccine Knowledge Scale in the United States.

BACKGROUND: Previous human papillomavirus (HPV) and HPV vaccine knowledge scales have focused on young adults in the vaccination catch-up age range or parents of vaccine eligible adolescents. Previous scales are not specific to the new guidelines for HPV vaccination in mid-adults. The study aimed to develop and validate a mid-adult HPV vaccine knowledge scale informed by the latest vaccine recommendations. METHODS: Self-reported data were collected using a cross-sectional survey of adults aged 27 to 45 years with no history of HPV vaccination (n = 706). Exploratory and confirmatory factor analyses identified latent constructs in a 13-item mid-adult HPV vaccine knowledge scale. Sociodemographic differences in the HPV vaccine knowledge were also assessed. RESULTS: The mean of correct responses across all items was 5.9 (SD, 2.8; range, 0-13). Exploratory and confirmatory factor analyses revealed a 3-factor structure best explained the data with a good construct validity and reliability. The first factor contained 6 items about HPV infection, the second factor contained 3 items about HPV prevention through vaccination, and the third factor contained items about HPV vaccination misinformation. Analysis of variance and t test found significant group level differences in knowledge among sex, race, educational level, annual income, health insurance, and marital status. CONCLUSIONS: Our study supports the use of a knowledge scale for US mid-adults to assess HPV and HPV vaccination knowledge because the patient requires some baseline knowledge of this recommendation to discuss the vaccine with their health care provider. The mid-adult HPV vaccine knowledge scale can measure basic HPV knowledge important to informed decision making.

Exploring novel strategies for social media HPV vaccine information.

To respond to potential public health impacts of social media influencing vaccine confidence, Facebook proposed that prior to proceeding to any link about Human Papillomavirus (HPV) vaccination, a pop-up will prompt the user to visit a reputable website on vaccine information. This study explored the acceptability of a pop-up Facebook message for HPV vaccine information. A national sample of U.S. adults (n = 579) was surveyed online. Most participants rated the pop-up messages as acceptable, useful, and factual. Regression results indicated that being male, seeing HPV content on social media in the past month, believing that information on social media is credible, holding positive HPV vaccination attitudes, and having shared HPV content on their own social media were associated with greater likelihood of clicking on a pop-up. While the pop-up approach may be acceptable, there are many factors that may be associated with being less likely to click on the pop-up.

Therapeutic cancer vaccines: reasons to believe.

Our hopes of using the power of the immune system to control tumours have been partially fulfilled with anti-PD1 antibodies and other checkpoint inhibitors and the use of engineered T cells targeting lineage-specific surface markers with chimeric antigen receptors. Can these successes be generalised? Therapeutic cancer vaccines aim to educate or re-educate the immune system to recognise tumour specific or tumour associated antigens. After many false dawns, some positive data for the effectiveness of such an approach is starting to emerge in advanced solid tumours, albeit as combination therapies with checkpoint inhibitors. But is the field targeting the right antigens? Interventions using the most effective vaccine platforms to target certain sets of antigens in patients with low disease burden might bring impressive long-term benefits to patients as single agents.

Remyelination: what are the prospects for regenerative therapies in multiple sclerosis?

Multiple sclerosis (MS) involves the immune system attacking the myelin sheaths surrounding axons and is a major cause of disability in working-age adults. Various approved therapies now provide reasonably good control over MS neuroinflammation, but none have a pronounced impact on the neurodegeneration associated with the disease. One prominent approach to fulfilling the unmet need for neuroprotective therapies, is the search for agents that promote 'remyelination', namely the generation of new oligodendrocytes that can form replacement myelin sheaths around denuded axons. In this article, I discuss some emerging targets for remyelinating therapies, mainly being pursued by recently formed small companies translating academic findings.

Time-series transcriptomics reveals a BBX32-directed control of acclimation to high light in mature Arabidopsis leaves.

The photosynthetic capacity of mature leaves increases after several days' exposure to constant or intermittent episodes of high light (HL) and is manifested primarily as changes in chloroplast physiology. How this chloroplast-level acclimation to HL is initiated and controlled is unknown. From expanded Arabidopsis leaves, we determined HL-dependent changes in transcript abundance of 3844 genes in a 0-6 h time-series transcriptomics experiment. It was hypothesized that among such genes were those that contribute to the initiation of HL acclimation. By focusing on differentially expressed transcription (co-)factor genes and applying dynamic statistical modelling to the temporal transcriptomics data, a regulatory network of 47 predominantly photoreceptor-regulated transcription (co-)factor genes was inferred. The most connected gene in this network was B-BOX DOMAIN CONTAINING PROTEIN32 (BBX32). Plants overexpressing BBX32 were strongly impaired in acclimation to HL and displayed perturbed expression of photosynthesis-associated genes under LL and after exposure to HL. These observations led to demonstrating that as well as regulation of chloroplast-level acclimation by BBX32, CRYPTOCHROME1, LONG HYPOCOTYL5, CONSTITUTIVELY PHOTOMORPHOGENIC1 and SUPPRESSOR OF PHYA-105 are important. In addition, the BBX32-centric gene regulatory network provides a view of the transcriptional control of acclimation in mature leaves distinct from other photoreceptor-regulated processes, such as seedling photomorphogenesis.

The Evolutionary History of Wild, Domesticated, and Feral Brassica oleracea (Brassicaceae).

Understanding the evolutionary history of crops, including identifying wild relatives, helps to provide insight for conservation and crop breeding efforts. Cultivated Brassica oleracea has intrigued researchers for centuries due to its wide diversity in forms, which include cabbage, broccoli, cauliflower, kale, kohlrabi, and Brussels sprouts. Yet, the evolutionary history of this species remains understudied. With such different vegetables produced from a single species, B. oleracea is a model organism for understanding the power of artificial selection. Persistent challenges in the study of B. oleracea include conflicting hypotheses regarding domestication and the identity of the closest living wild relative. Using newly generated RNA-seq data for a diversity panel of 224 accessions, which represents 14 different B. oleracea crop types and nine potential wild progenitor species, we integrate phylogenetic and population genetic techniques with ecological niche modeling, archaeological, and literary evidence to examine relationships among cultivars and wild relatives to clarify the origin of this horticulturally important species. Our analyses point to the Aegean endemic B. cretica as the closest living relative of cultivated B. oleracea, supporting an origin of cultivation in the Eastern Mediterranean region. Additionally, we identify several feral lineages, suggesting that cultivated plants of this species can revert to a wild-like state with relative ease. By expanding our understanding of the evolutionary history in B. oleracea, these results contribute to a growing body of knowledge on crop domestication that will facilitate continued breeding efforts including adaptation to changing environmental conditions.

Quality over quantity: human papillomavirus vaccine information on social media and associations with adult and child vaccination.

Human Papillomavirus (HPV) vaccination is recommended for adults aged 27-45 as a shared clinical decision with their healthcare provider. With the rise of social media as a vaccine information source, this study examined the extent of exposure to HPV vaccine content by social media platform and evaluated associations between HPV vaccine content on social media and HPV vaccine intent among both 27-45 year olds and their eligible children. U.S. participants (51% women, 9% Black, 8% Hispanic/Latinx), aged 27-45, were cross-sectionally surveyed online from April to May 2020 (n = 691). Outcomes included HPV vaccination intention (intend/do not intend) for themselves and, among participants with unvaccinated children aged 9-17 (n = 223), their eligible children. Adjusted odds ratios for HPV vaccine content and both outcomes were calculated. Extent of HPV vaccination exposure on social media was not associated with intention to vaccinate for HPV. Seeing mostly negative/mixed information about the HPV vaccine on social media was associated with lower odds of vaccination intention for adults (aOR = 0.34, 95% CI 0.15, 0.79) and adolescents (aOR = 0.34, 95% CI 0.21, 0.53). Viewing HPV vaccine information from social media as not credible was associated with lower odds of vaccine intent for adults (aOR = 0.17, 95% CI 0.07, 0.41) and adolescents (aOR = 0.16, 95% CI 0.10, 0.29). Although extent of HPV vaccine exposure on social media was not associated with vaccination outcomes, findings support developing quality social media strategies that increase the dissemination of positive and credible information in favor of HPV vaccination.

Decision support needs for shared clinical decision-making regarding HPV vaccination among adults 27-45 years of age.

OBJECTIVE: Identify HPV information needs and shared clinical decision-making preferences among adults 27-45 and describe differences in needs and preferences among underserved and vulnerable populations. METHODS: Participants 27-45 years old with no history of HPV vaccination completed a cross-sectional web-based survey between April-May 2020 (N = 702). Preferred role in shared clinical decision making was described across demographic groups and sociodemographic correlates of HPV vaccine information needs. RESULTS: Most (77.6%) reported a preference to make a medical decision on their own or after consulting with a healthcare provider, while the remaining respondents preferred to make a joint decision (17.0%) or for their doctor to make the decision (5.4%). Over 80% needed more information about safety, effectiveness, personal benefit, provider recommendation, side effects, and risks. Education was the strongest demographic factors associated with higher information needs (p<0.05). CONCLUSION: The majority of individuals across demographic groups were individually focused with regard to their healthcare decisions and wanted more information about HPV vaccine safety, side effects, and risks, in addition to personalized information about benefits from HPV vaccination. PRACTICAL IMPLICATIONS: Patient-centered interventions are needed to engage adults in shared decision-making regarding HPV vaccination.

Correlates of HPV Vaccination Intentions Among Adults Ages 27-45 Years Old in the U.S.

HPV vaccine is recommended for 27-45 year olds in the U.S. based on a shared clinical decision. This study examined knowledge, attitudes, and beliefs of adults 27-45 years old and the association with the likelihood of asking a healthcare provider about the HPV vaccine and the likelihood of getting the HPV vaccine. We conducted a cross-sectional survey of U.S. adults aged 27-45 years between April-May 2020 (n = 691). Primary outcomes were likelihood of asking their provider about the HPV vaccine and likelihood of getting the HPV vaccine. Demographic variables, knowledge, attitudes, and beliefs were covariates. Adjusted models were estimated for each outcome variable with a Poisson distribution and log function. More than half (55.7%) were likely to ask their provider about the HPV vaccine, but less than half (42.9%) were likely to get the HPV vaccine. Likelihood of asking their provider about the HPV vaccine was significantly associated with perceived likelihood of benefitting from the vaccine (aOR = 2.45; 95%CI = 1.69-3.57). Likelihood of receiving the vaccine was associated with attitudes (aOR = 1.04; 95%CI = 1.01-1.07), perceived effectiveness against HPV infection (aOR = 4.03; 95%CI = 1.20-13.53), and perceived likelihood of benefitting from the vaccine (aOR = 4.31; 95%CI = 2.64-7.03). Our findings suggest increasing positive attitudes, perceived effectiveness against infection, and perceived likelihood of benefitting from the vaccination are important factors to address when facilitating a shared clinical decision for HPV vaccination. Understanding factors associated with likelihood of discussing and receiving the HPV vaccine among people aged 27-45 years is important to successfully implement the guidelines for shared clinical decision-making.

Identification of microbial signatures linked to oilseed rape yield decline at the landscape scale.

BACKGROUND: The plant microbiome plays a vital role in determining host health and productivity. However, we lack real-world comparative understanding of the factors which shape assembly of its diverse biota, and crucially relationships between microbiota composition and plant health. Here we investigated landscape scale rhizosphere microbial assembly processes in oilseed rape (OSR), the UK's third most cultivated crop by area and the world's third largest source of vegetable oil, which suffers from yield decline associated with the frequency it is grown in rotations. By including 37 conventional farmers' fields with varying OSR rotation frequencies, we present an innovative approach to identify microbial signatures characteristic of microbiomes which are beneficial and harmful to the host. RESULTS: We show that OSR yield decline is linked to rotation frequency in real-world agricultural systems. We demonstrate fundamental differences in the environmental and agronomic drivers of protist, bacterial and fungal communities between root, rhizosphere soil and bulk soil compartments. We further discovered that the assembly of fungi, but neither bacteria nor protists, was influenced by OSR rotation frequency. However, there were individual abundant bacterial OTUs that correlated with either yield or rotation frequency. A variety of fungal and protist pathogens were detected in roots and rhizosphere soil of OSR, and several increased relative abundance in root or rhizosphere compartments as OSR rotation frequency increased. Importantly, the relative abundance of the fungal pathogen Olpidium brassicae both increased with short rotations and was significantly associated with low yield. In contrast, the root endophyte Tetracladium spp. showed the reverse associations with both rotation frequency and yield to O. brassicae, suggesting that they are signatures of a microbiome which benefits the host. We also identified a variety of novel protist and fungal clades which are highly connected within the microbiome and could play a role in determining microbiome composition. CONCLUSIONS: We show that at the landscape scale, OSR crop yield is governed by interplay between complex communities of both pathogens and beneficial biota which is modulated by rotation frequency. Our comprehensive study has identified signatures of dysbiosis within the OSR microbiome, grown in real-world agricultural systems, which could be used in strategies to promote crop yield. Video abstract.

The Podiatric Medical Profession: A Gender Comparison.

The number of women in podiatric medicine and surgery has increased steadily over the past 4 decades; however, there appears to be a large and continued gender gap with respect to representation in academic medicine and other positions of power. National and state level organizational data were obtained from multiple podiatry professional societies to evaluate the rate at which women achieved leadership roles within the podiatric profession over time. A secondary questionnaire was also developed and electronically mailed to 8684 doctors of podiatric medicine to help capture additional leadership information and to provide further insight into the trends observed. The response rate was 26% (2276/8684). Female representation in academia, research/publications, most leadership positions, and board certifications has increased over time, but at a slower rate than the number of women entering the profession. We observed a decreasing trend of females completing fellowships, speaking at national meetings, becoming residency directors, and receiving American College of Foot and Ankle Surgeons- and American Podiatric Medical Association-sponsored grants/awards. Based on the survey results, female podiatric physicians were more likely to be single, have fewer children, spend more time in a clinical setting, be less satisfied with work, and experience higher work stress levels than their male colleagues. Of the female respondents, 73% described experiencing gender discrimination at some point in their career, and 42% reported experiencing sexual harassment, compared with only 6% and 5% of men, respectively. There continues to be a gender gap in leadership roles, which may be explained partially by work/life balance issues, gender discrimination, and other issues.