Benefits of Meeting the Healthy People 2030 Youth Sports Participation Target.

INTRODUCTION: Healthy People 2030, a U.S. government health initiative, has indicated that increasing youth sports participation to 63.3% is a priority in the U.S. This study quantified the health and economic value of achieving this target. METHODS: An agent-based model developed in 2023 represents each person aged 6-17 years in the U.S. On each simulated day, agents can participate in sports that affect their metabolic and mental health in the model. Each agent can develop different physical and mental health outcomes, associated with direct and indirect costs. RESULTS: Increasing the proportion of youth participating in sports from the most recent participation levels (50.7%) to the Healthy People 2030 target (63.3%) could reduce overweight/obesity prevalence by 3.37% (95% CI=3.35%, 3.39%), resulting in 1.71 million fewer cases of overweight/obesity (95% CI=1.64, 1.77 million). This could avert 352,000 (95% CI=336,200, 367,500) cases of weight-related diseases and gain 1.86 million (95% CI=1.86, 1.87 million) quality-adjusted life years, saving $22.55 billion (95% CI=$22.46, $22.63 billion) in direct medical costs and $25.43 billion (95% CI= $25.25, $25.61 billion) in productivity losses. This would also reduce depression/anxiety symptoms, saving $3.61 billion (95% CI=$3.58, $3.63 billion) in direct medical costs and $28.38 billion (95% CI=$28.20, $28.56 billion) in productivity losses. CONCLUSIONS: This study shows that achieving the Healthy People 2030 objective could save third-party payers, businesses, and society billions of dollars for each cohort of persons aged 6-17 years, savings that would continue to repeat with each new cohort. This suggests that even if a substantial amount is invested toward this objective, such investments could pay for themselves.

Commentary: Demystifying Doppler - revisiting a vital diagnostic tool.

Doppler is the most commonly utilised vascular assessment tool by podiatrists in Australia and the United Kingdom. Doppler is a key component of many international guidelines for vascular assessment. Used alongside pressure measurements such as ankle and toe-brachial indices, Doppler assists podiatrists to diagnose, triage and subsequently manage patients with peripheral arterial disease. This commentary aims to clarify the importance, technique, and interpretation of continuous wave handheld Doppler in podiatry practice. This commentary presents discussion on the equipment and optimal test conditions for use of Doppler, and guidance on the technique required in podiatry clinical practice. Furthermore, there is a focus on interpretation of the output from Doppler including both audio and visual output. There is in depth discussion about identifying pathology and integration into the clinical management plan.

A commentary on podiatry during the Covid-19 pandemic : Podiatry during the Covid-19 pandemic.

BACKGROUND: The arrival of the novel coronavirus (SARS-CoV-2) has impacted the many aspects of modern life, especially, in the immediate term, the delivery of healthcare. CONTEXT: This commentary examines the profession of podiatry and how it has adapted and responded to the emerging crisis. It focusses on but is not exclusive to the position in the United Kingdom (UK) and the edicts and direction from the UK Government. PODIATRY ROLES DURING THE PANDEMIC: It describes the role of podiatry in the pandemic and highlights the deployment of podiatry resources to fight the pandemic beyond traditional podiatric practice. It also looks at the shift from conventional consultation to digital solutions for managing patients in an effort to achieve the goals of maintenance of foot health whilst reducing the spread of the virus. The commentary summarises the emerging data related to a possible foot related presentation of the coronavirus. CONCLUSION: The podiatry profession proved its flexibility and adaptability during the pandemic, to adjust rapidly to ensure that patients were able to access treatment to reduce risk of infection, ulceration and amputation. Dermatological presentations on the feet have been associated with Covid-19 in adolescents as is often the case in viral infections. CPD webinars to support clinicians and manage and prevent the spread of Covid-19 have been widely disseminated along with algorithms to ensure that patients that need treatment are being treated appropriately. Podiatrists have embraced remote technology to ensure that patients are correctly and safely triaged and, signposted and given appropriate self-care advice. MSK podiatrists have the ability to play an intrinsic role within the post discharge rehabilitation pathway.

Lower limb vascular assessment techniques of podiatrists in the United Kingdom: a national survey.

BACKGROUND: Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments. METHODS: A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used. RESULTS: Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient's general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed. CONCLUSION: The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors.

Management of peripheral arterial disease in diabetes: a national survey of podiatry practice in the United Kingdom.

BACKGROUND: We aimed to investigate podiatry practice in diagnosing peripheral arterial disease (PAD) in diabetes, decision making once PAD is suspected and limitations of referral pathways. METHODS: A survey, comprising 26 questions was distributed to podiatrists across the UK via mailing lists of collaborating organizations including the College of Podiatry (UK). Response rates were estimated based on NHS workforce data. Analysis of responses from the open-ended questions was performed using inductive content analysis. RESULTS: Data from 283 respondents were analyzed. Response rate for all NHS podiatrists across the UK was estimated to be 6%. For the detection of arterial disease only 18.8% (n = 49/260) of participants reported using a full combination of history, pulse palpation, Doppler and ABPI assessment. Self-reported confidence in detecting arterial disease was highest amongst podiatrists who felt they had received adequate training compared to podiatrists who felt they had not (median 85 (IQR 75-90) vs 67 (50-77), respectively; p < 0.001) as well as those who see > 20 diabetic patients per week compared to those who see < 20 (median 80 (IQR 70-90) vs 72 (60-82.8), respectively; p < 0.001). Over one third of respondents (35.8%, n = 93/260) were aware of missed cases of PAD in the past year and 17.5% (n = 38/217) believed that this resulted in an amputation in some cases.The survey highlighted a lack of clarity amongst podiatrists regarding referral guidelines. Additionally, 69% (n = 169/242) reported that their patients had to wait longer than 2-weeks for specialist vascular assessment and 67.6% (n = 54/80) reported similar waits for a Duplex Ultrasound scan. There was a statistically significant variation in DUS waiting time across the UK (X2 (10, N = 80) = 21.59, p = 0.017). Inability to make a direct referral to vascular services and long delays were reported as major limitations of the referral pathway. CONCLUSION: We have identified important targets for further investigation and quality improvement.

Survey of ultrasound practice amongst podiatrists in the UK.

BACKGROUND: Ultrasound in podiatry practice encompasses musculoskeletal ultrasound imaging, vascular hand-held Doppler ultrasound and therapeutic ultrasound. Sonography practice is not regulated by the Health and Care Professions Council (HCPC), with no requirement to hold a formal qualification. The College of Podiatry does not currently define ultrasound training and competencies.This study aimed to determine the current use of ultrasound, training received and mentorship received and/or provided by podiatrists using ultrasound. METHODS: A quantitative study utilising a cross-sectional, on-line, single-event survey was undertaken within the UK. RESULTS: Completed surveys were received from 284 podiatrists; 173 (70%) use ultrasound as part of their general practice, 139 (49%) for musculoskeletal problems, 131 (46%) for vascular assessment and 39 (14%) to support their surgical practice. Almost a quarter (n = 62) worked for more than one organisation; 202 (71%) were employed by the NHS and/or private sector (n = 118, 41%).Nearly all (93%) respondents report using a hand-held vascular Doppler in their daily practice; 216 (82%) to support decisions regarding treatment options, 102 (39%) to provide diagnostic reports for other health professionals, and 34 (13%) to guide nerve blocks.Ultrasound imaging was used by 104 (37%) respondents primarily to aid clinical decision making (n = 81) and guide interventions (steroid injections n = 67; nerve blocks n = 39). Ninety-three percent stated they use ultrasound imaging to treat their own patients, while others scan at the request of other podiatrists (n = 28) or health professionals (n = 18). Few use ultrasound imaging for research (n = 7) or education (n = 2).Only 32 (11%) respondents (n = 20 private sector) use therapeutic ultrasound to treat patients presenting with musculoskeletal complaints, namely tendon pathologies.Few respondents (18%) had completed formal post-graduate CASE (Consortium for the Accreditation of Sonographic Education) accredited ultrasound courses.Forty (14%) respondents receive ultrasound mentorship; the majority from fellow podiatrists (n = 17) or medical colleagues (n = 15). Over half (n = 127) who do not have ultrasound mentorship indicated they would like a mentor predominantly for ultrasound imaging. Fifty-five (19%) report they currently provide ultrasound mentorship for others. CONCLUSIONS: Understanding the scope of ultrasound practice, the training undertaken and the requirements for mentorship will underpin the development of competencies and recommendations defined by the College of Podiatry to support professional development and ensure safe practice.

"No more amputations": a complex scientific problem and a challenge for effective preventive strategy implementation on vascular field.

Lower limb vascular amputations represent serious problem in the vascular care. As a consequence of critical limb ischemia, often associated with diabetes, it is highly critical to health care service aiming at prevention of limb loss. Understanding of the nature and complexity of amputation scenario is paramount for the effective preventive strategy planning and implementation. Amputation incidence and data of the trends show high variability in the international reports. Variability is also remarkable in a more granular, regional comparison. Different calculation methods for incidence fraction, varying epidemiological, demographic features of the populations, different socio-economic, cultural backgrounds and disparity in vascular care are the main factors contributing to this variability in reports. Lower limb amputations can be considered as a valuable healthcare quality indicator with some limitations. One of these limitations is the lower actionability that corresponds to the reduced ability of health care providers to intervene influencing the burden of amputations. Lower limb vascular amputations represent a lifetime risk, therefore not only the effective revascularization is to be achieved but the importance of the early recognition of peripheral arterial disease, no delay in referral to special vascular care, effective vascular risk prevention and collaboration in multidisciplinary teams should be also emphasized.

Organocatalytic Asymmetric Conjugate Additions to Cyclopent-1-enecarbaldehyde: A Critical Assessment of Organocatalytic Approaches towards the Telaprevir Bicyclic Core.

In the context of a programme directed at the manufacture of telaprevir, eight possible approaches to its bicyclic α-amino acid core, based on organocatalytic enantioselective conjugate additions to cyclopent-1-enecarbaldehyde, were identified and preliminarily explored. Four reactions, delivering advanced intermediates en route to the target amino acid, were selected for a thorough optimisation. Three of this reactions involved iminium ion catalysis with a prolinol catalyst (addition of nitromethane, nitroacetate and acetamidomalonate) and one was based on a Cinchona-derived phase-transfer catalyst (addition of glycine imines). A careful choice of additives allowed lowering of the catalyst loading to 0.5 mol% in some cases. The preparation of intermediates that would give access to the core of telaprevir in good yields and enantioselectivities by exploiting readily available substrates and catalysts, highlights the potential of organocatalytic technology for a cost-effective preparation of pharmaceuticals.

An enantioselective formal synthesis of montelukast sodium.

A formal synthesis of the antiasthma drug montelukast sodium is described, wherein the key chiral diol intermediate was accessed with greater convergence of the C-C bond-forming steps as compared to previous routes. Improved synthetic efficiency was achieved by deploying homogeneous metal-based catalysis in two pivotal steps. In the first, a tandem Mizoroki-Heck reaction and double-bond isomerization between a previously known allyl alcohol intermediate and a hindered 2-(2-halophenyl)propan-2-ol secured direct access to the 3-(2-(2-hydroxypropan-2-yl)phenyl)-1-phenylpropan-1-one moiety in the product. In the second step, asymmetric hydrogenation of the ketone functionality in the Mizoroki-Heck reaction product provided a convenient method to introduce the benzylic alcohol chiral center and obtain the desired chiral diol precursor of montelukast sodium. A detailed catalyst screening led to the identification of ((R)-Xyl-BINAP)((R,R)-DPEN)RuCl2 as a catalyst that afforded an enantioselectivity of 99% ee in the hydrogenation step on a multigram lab scale at a molar substrate:catalyst loading of 5000:1.

The role of the community clinician in early detection, referral and treatment of critical limb ischaemia.

Critical limb ischaemia (CLI) is a significant public health issue worldwide, with an ever-growing incidence among people over 65. Awareness of CLI is low, particularly among non-vascular clinicians, leading to underdiagnosis and undertreatment. A diagnosis of CLI is known to have a grave effect on a person's quality of life, with devastating outcomes for both their life and limb, often resulting in uncontrolled pain, amputation or early death from a cardiovascular event. Community nurses and podiatrists are key clinicians who can play a crucial and active role in earlier identification, rapid referral and ongoing non-surgical care for this overlooked population.

Dynamic kinetic resolution of dehydrocoronamic acid.

Dehydrocoronamic acid can be racemised by dehydration of an N-acyl derivative to an azlactone, which undergoes facile racemisation. For the N-trifluoroacetyl derivative, the racemisation process was combined with an enzymatic resolution, to achieve a dynamic kinetic resolution process by which the racemate can be converted to either enantiomer.

Beveled femtosecond laser astigmatic keratotomy for the treatment of high astigmatism post-penetrating keratoplasty.

PURPOSE: To use beveled femtosecond laser astigmatic keratotomy (FLAK) incisions to treat high astigmatism after penetrating keratoplasty. METHODS: Paired FLAK incisions at a bevel angle of 135 degrees, 65% to 75% depth, and arc lengths of 60 to 90 degrees were performed using a femtosecond laser. One case of perpendicular FLAK was presented for comparison. Vector analysis was used to calculate the changes in astigmatism. Fourier domain optical coherence tomography was used to examine incision morphology. RESULTS: Wound gaping requiring suturing was observed in the case of perpendicular FLAK. Six consecutive cases of beveled FLAK were analyzed. Fourier domain optical coherence tomography showed that beveled FLAK caused a mean forward shift of Bowman layer anterior to the incisions of 126 ± 38 µm, with no wound gaping. The mean magnitude of preoperative keratometric astigmatism was 9.8 ± 2.9 diopters (D), and postoperatively it was 4.5 ± 3.2 D (P < 0.05). Uncorrected visual acuity improved from 1.24 ± 0.13 logarithm of the minimum angle of resolution preoperatively to 0.76 ± 0.38 postoperatively (P < 0.05). Best spectacle-corrected visual acuity improved from 0.43 ± 0.33 logarithm of the minimum angle of resolution preoperatively to 0.27 ± 0.24 postoperatively (P = 0.22). Visual results were reduced in 2 patients by cataract progression. Between 1 and 3 months after beveled FLAK, the keratometric cylinder was stable (<1 D change) in 5 of 6 patients, and regressed in 1 patient. No complications occurred. CONCLUSIONS: Beveled FLAK incisions at varied depth are effective in the management of postkeratoplasty astigmatism. Early postoperative changes stabilized within 1 month in most patients. Further studies are needed to assess long-term outcomes.

A PAD service led by nurses and podiatrists.

Peripheral arterial disease (PAD) is serious but its significance has only recently been reflected in NICE guidance. A trust launched a PAD service led by nurses and podiatrists. The service is cost-effective and ensures that most patients receive treatment in the community, with referrals made to secondary care as appropriate. A care pathway standardises care.

Phylogenetic analyses of a combined data set suggest that the Attheya lineage is the closest living relative of the pennate diatoms (Bacillariophyceae).

A Bayesian analysis of a seven gene data set was conducted to reconstruct phylogenetic relationships among a sample of centric and pennate diatoms and to test alternative hypotheses about the closest living relative of Bacillariophyceae. A lineage, composed of two Attheya species, was inferred to share the most recent common ancestor with Bacillariophyceae--a relationship that was also corroborated by the combined parsimony analysis. All competing hypotheses about the closest living relative of Bacillariophyceae were rejected because 100% of the trees in the post-burn-in sample in the Bayesian analysis supported the Attheya-Bacillariophyceae clade. According to a partitioned Bremer support analysis, the majority of the genes in the combined data matrix supported the Attheya--Bacillariophyceae relationship. The global topology of the phylogenetic tree indicated that a monophyletic group consisting of Thalassiosirales and Toxarium undulatum formed the deepest branch followed by a node uniting a clade composed of Bacillariophyceae/Attheya species and a lineage made up of Eucampia zoodiacus, Chaetocerotales, Lithodesmiales, Triceratiales, Biddulphiales and Cymatosirales. Except for the phylogenetic positions of Lithodesmiales, Thalassiosira sp and Skeletonema costatum, the optimal tree obtained from the combined parsimony analysis showed the same branching order of taxa as those seen in the consensus tree inferred from three independent Markov chain Monte Carlo analyses. Noteworthy findings are that Toxarium undulatum shares a strongly supported node with Thalassiosirales and that the genus Attheya is not a member of the Chaetocerotales lineage.

Hexagonal adaptive filtering on compound ultrasound images.

This paper describes an approach to improve the contrast and signal to noise ratio on ultrasound images. Images with sub-pixel lateral displacements were re-sampled using a hexagonal grid, registered and compounded. The resultant image was filtered using a hexagonal adaptive masking filter. This approach was evaluated with simulated images and real images from a breast phantom. The results show total improvements in signal to noise ratio of up to 313% in simulated images, and 182% in phantom images. Contrast to noise ratio was improved by 286% in simulated images and 56% in phantom images.

Distance regularized level set evolution and its application to image segmentation.

Level set methods have been widely used in image processing and computer vision. In conventional level set formulations, the level set function typically develops irregularities during its evolution, which may cause numerical errors and eventually destroy the stability of the evolution. Therefore, a numerical remedy, called reinitialization, is typically applied to periodically replace the degraded level set function with a signed distance function. However, the practice of reinitialization not only raises serious problems as when and how it should be performed, but also affects numerical accuracy in an undesirable way. This paper proposes a new variational level set formulation in which the regularity of the level set function is intrinsically maintained during the level set evolution. The level set evolution is derived as the gradient flow that minimizes an energy functional with a distance regularization term and an external energy that drives the motion of the zero level set toward desired locations. The distance regularization term is defined with a potential function such that the derived level set evolution has a unique forward-and-backward (FAB) diffusion effect, which is able to maintain a desired shape of the level set function, particularly a signed distance profile near the zero level set. This yields a new type of level set evolution called distance regularized level set evolution (DRLSE). The distance regularization effect eliminates the need for reinitialization and thereby avoids its induced numerical errors. In contrast to complicated implementations of conventional level set formulations, a simpler and more efficient finite difference scheme can be used to implement the DRLSE formulation. DRLSE also allows the use of more general and efficient initialization of the level set function. In its numerical implementation, relatively large time steps can be used in the finite difference scheme to reduce the number of iterations, while ensuring sufficient numerical accuracy. To demonstrate the effectiveness of the DRLSE formulation, we apply it to an edge-based active contour model for image segmentation, and provide a simple narrowband implementation to greatly reduce computational cost.

Microevolution and speciation in Thalassiosira weissflogii (Bacillariophyta).

In this study five different molecular markers were used to: (1) infer the phylogeographic differentiation of Thalassiosira weissflogii in the Atlantic and Pacific Oceans; and (2) address the biological species status of the inferred geographic lineages. The results of the ribosomal RNA data analyses suggested that the Hawaiian isolate evolved first after which the Indonesian and the Atlantic/California strains diverged. In contrast, the tree derived from the partial sexually induced gene 1 (Sig1) data exhibited an initial divergence between the Eastern Atlantic/Western Atlantic/California and the Hawaiian/Indonesian groups after which the latter evolved into the Hawaiian and Indonesian lineages. The partial beta-tubulin phylogeny discerns an early "split" between an Eastern Atlantic/Western Atlantic clade and an Indonesia/California/Hawaii group which later differentiated into distinct Hawaiian and Indonesian/California "branches". The number of compensatory base changes (CBCs) in the ITS2 indicated that the "Atlantic group", including the California isolate, constituted a single reproductive unit and that the Indonesian and Hawaiian T. weissflogii are two different biological species with regard to each other and to the "Atlantic clade". The beta-tubulin tree contradicts the reproductive units recovered by the compensatory base change analysis due to the close affinity of the California and Indonesia strains whereas the sexually induced gene 1 phylogeny supports the existence of three biological species, despite exhibiting a temporal sequence of geographic diversification that is different from that seen in topologies derived from the ribosomal RNA data. It is hypothesized that the tree derived from the sexually induced gene 1 reflects the relative order of the evolution of reproductive isolation in the different T. weissflogii strains while the lineages in the other phylogenies depict time elapsed since common ancestry. The current investigation is the first to have shown concordance in the pattern of variation between a reasonably good biological species marker (CBCs in the ITS2) and a protein hypothesized to be involved in sperm-egg recognition/adhesion in diatoms (Sig1). It was further discussed that the Pacific/Indonesian T. weissflogii species complex most likely evolved in the presence of gene flow and "local" environmental selection. Three hypotheses which potentially can explain the genetic diversification/similarity between the Atlantic T. weissflogii samples and the isolate obtained off the coast of California were proposed and discussed.

A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs.

OBJECTIVE: To evaluate studies that examined the impact of interactive, computer-based education (ICBE) programs on patient education. METHODS: The Medline and CINAHL databases were searched to identify randomized controlled studies that evaluated the impact of ICBE programs. RESULTS: The 25 studies that met the selection criteria generally supported the ability of ICBE programs to promote knowledge gains. Results related to economic or clinical outcomes were less consistent. Significant variations were noted across studies in program features, implementation and integration strategies, and in comparison program attributes and quality. It is likely that these differences contributed to the disparity in findings across studies. CONCLUSION: Although significant inconsistencies in results were noted, the research provided collective evidence that ICBE programs had the potential to add great value to the patient education process. Programs must be properly designed and implementation and integration processes effectively planned in order to achieve consistently positive outcomes. PRACTICE IMPLICATIONS: Consideration of the "best practices" derived from the research and noted in this report will assist healthcare providers in designing, selecting, and implementing effective ICBE programs.

Paired-angle multiplicative compounding.

Ultrasound compounding is a method of combining multiple images from different angles in order to create a single image with improved resolution and reduced angular-dependent artifactual detail. Compounding methods traditionally calculate each pixel in the compound image as a simple functional relationship between pixel elements in the component image set. In order to achieve an even better resolution and further reduce angular-dependent artifacts, this paper investigates a new type of compounding we call paired angle multiplicative compounding (PAMC), in which compound images are produced by a summation of multiplied pairs of component images acquired at different angles. A PAMC image of a breast phantom demonstrates improved delineation ofmicrocalcifications in comparison to the mean operation. Images of the forearm are used to investigate larger angles of paired multiplication, the best improving contrast ratio (28%) and signal to noise ratio (24%) when compared to the mean method. The PAMC method is found to be similar to the MEM and median compounding operations, the largest difference being that it is better preserving contributions from normal incidence but at the expense of needing a larger angular range.