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The Implicit Association Test (IAT) is a validated tool used to measure implicit biases, which are mental associations shaped by one's environment that influence interactions with others. Direct evidence of implicit gender biases about women in medicine has yet not been reported, but existing evidence is suggestive of subtle or hidden biases that affect women in medicine. To use data from IATs to assess (1) how health care professionals associate men and women with career and family and (2) how surgeons associate men and women with surgery and family medicine. This data review and cross-sectional study collected data from January 1, 2006, through December 31, 2017, from self-identified health care professionals taking the Gender-Career IAT hosted by Project Implicit to explore bias among self-identified health care professionals. A novel Gender-Specialty IAT was also tested at a national surgical meeting in October 2017. All health care professionals who completed the Gender-Career IAT were eligible for the first analysis. Surgeons of any age, gender, title, and country of origin at the meeting were eligible to participate in the second analysis. Data were analyzed from January 1, 2018, through March 31, 2019. Measure of implicit bias derived from reaction times on the IATs and a measure of explicit bias asked directly to participants. Almost 1 million IAT records from Project Implicit were reviewed, and 131 surgeons (64.9% men; mean [SD] age, 42.3 [11.5] years) were recruited to complete the Gender-Specialty IAT. Healthcare professionals (n = 42 991; 82.0% women; mean [SD] age, 32.7 [11.8] years) held implicit (mean [SD] D score, 0.41 [0.36]; Cohen d = 1.14) and explicit (mean [SD], 1.43 [1.85]; Cohen d = 0.77) biases associating men with career and women with family. Similarly, surgeons implicitly (mean [SD] D score, 0.28 [0.37]; Cohen d = 0.76) and explicitly (men: mean [SD], 1.27 [0.39]; Cohen d = 0.93; women: mean [SD], 0.73 [0.35]; Cohen d = 0.53) associated men with surgery and women with family medicine. There was broad evidence of consensus across social groups in implicit and explicit biases with one exception. Women in healthcare (mean [SD], 1.43 [1.86]; Cohen d = 0.77) and surgery (mean [SD], 0.73 [0.35]; Cohen d = 0.53) were less likely than men to explicitly associate men with career (B coefficient, -0.10; 95% CI, -0.15 to -0.04; P < .001) and surgery (B coefficient, -0.67; 95% CI, -1.21 to -0.13; P = .001) and women with family and family medicine. The main contribution of this work is an estimate of the extent of implicit gender bias within surgery. On both the Gender-Career IAT and the novel Gender-Specialty IAT, respondents had a tendency to associate men with career and surgery and women with family and family medicine. Awareness of the existence of implicit biases is an important first step toward minimizing their potential effect.

Total knee arthroplasty (TKA) has been performed by orthopedic surgeons for decades, but the cementless TKA has only recently gained much interest in the world of arthroplasty. Initially, early designs had multiple complications, particularly with aseptic loosening due to osteolysis and micromotion. However, modifications have shown good outcomes and excellent survivorship. Over the last several decades, changes in implant designs as well as implant materials/coatings have helped with bone in growth and stability. Furthermore, surgeons have been performing TKA in younger and more obese patients as these populations have been increasing. Good results from the cementless TKA compared to cemented TKA may be a better option in these more challenging populations, as several studies have shown greater survivorship in patients that are younger and have a greater BMI. Additionally, a cementless TKA may be more cost effective, which remains a concern in today’s healthcare environment. Overall, cemented and cementless TKA have great results in modern times and there is still a debate as to which implant is superior.

Background: Patients with borderline acetabular dysplasia are a controversial patient population in hip preservation, as some have primarily impingement-based symptoms and others have instability-based symptoms. Borderline dysplasia is most commonly defined as a lateral center-edge angle (LCEA) of 20° to 25°. However, its prevalence has not been well established in the literature. Purpose: To (1) define the prevalence of borderline hip dysplasia in the general population as well as in populations presenting with hip pain using a systematic review and meta-analysis of the literature and (2) describe differences between male and female patients as well as differences in prevalence from that of classic acetabular dysplasia. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of the literature was performed using search terms to capture borderline dysplasia, or studies reporting prevalence by LCEA. The search yielded 1932 results, of which 11 articles met inclusion criteria and were included in the final systematic review. Studies were grouped by patient cohort as (1) asymptomatic general population, (2) asymptomatic targeted population (eg, athletes in a specific sport), and (3) symptomatic hip pain population. The reporting of prevalence rates by subject or by hip was recorded. In a study, the rates of borderline dysplasia were compared with those of classic acetabular dysplasia (LCEA, <20°). Results: The 11 studies included 19,648 hips (11,754 patients). In the asymptomatic general population, the pooled estimate of the prevalence of borderline dysplasia was 19.8% by subject and 23.3% by hip (range, 16.7%-46.0%). The targeted subpopulation group included 236 athletes with subgroups in ballet, football, hockey, volleyball, soccer, and track and field with prevalence ranging from 17.8% to 51.1%. The prevalence of borderline dysplasia in groups presenting with hip pain was 12.8% (range, 12.6%-16.0%). Borderline acetabular dysplasia was 3.5 times more common than classic acetabular dysplasia in the asymptomatic general population. Conclusion: This study demonstrated a prevalence of borderline dysplasia of 19.8% to 23.3% in the asymptomatic general population. Additionally, an estimated prevalence of 12.8% of hips in symptomatic patients highlights the common decision-making challenges in this population.

Background: Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results. Purpose/Hypothesis: The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT. Study Design: Systematic review; Level of evidence, 1. Methods: In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)–Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool. Results: The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571). Conclusion: In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.

Background: Given the lack of established, externally validated criteria for the diagnosis of unstable hips, the Femoro-Epiphyseal Acetabular Roof (FEAR) index has been proposed as a useful tool for identifying hips with instability in the setting of borderline acetabular dysplasia. Purposes: To (1) determine the external performance of the FEAR index in identifying hips with a clinical diagnosis of instability in the setting of borderline dysplasia and (2) assess the performance of the FEAR index compared with acetabular inclination or physeal scar angle alone. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The authors reviewed 176 patients with borderline acetabular dysplasia (lateral center-edge angle, 20°-25°). A positive FEAR index was defined as ≥5°. An alternative threshold ≥2° was also assessed. Significant instability was determined by the senior surgeon based on the combination of patient and radiographic features; unstable hips were treated with periacetabular osteotomy (with or without hip arthroscopy), and stable hips were treated with isolated hip arthroscopy. Results: Only 18% of borderline hips had a positive FEAR index. The ≥5° positive FEAR index threshold had a sensitivity of 33% (23/70) and specificity of 92% (98/106) in predicting the clinical diagnosis of instability. The ≥2° FEAR index threshold had a sensitivity of 39% (27/70) and specificity of 89% (94/106) in predicting the clinical diagnosis of instability. No alternative threshold for the FEAR index resulted in high levels of sensitivity and specificity. A threshold of –5° was required to reach an adequate sensitivity of 74%. The FEAR index remained a significant predictor of hip instability even after controlling for acetabular inclination (odds ratio, 1.12; P < .001) or physeal scar angle (odds ratio, 1.6; P < .001). Conclusion: In the current study, a positive FEAR index was generally indicative of the presence of clinical instability, but the FEAR index alone remained inadequate to fully define the instability of a given hip, as it demonstrated low sensitivity (only 33%) in the external validation. The FEAR index is best used in the context of other clinical and radiographic features.

Long-term analyses of biodiversity data highlight a ‘biodiversity conservation paradox’: biological communities show substantial species turnover over the past century 1 , 2 , but changes in species richness are marginal 1 , 3 – 5 . Most studies, however, have focused only on the incidence of species, and have not considered changes in local abundance. Here we asked whether analysing changes in the cover of plant species could reveal previously unrecognized patterns of biodiversity change and provide insights into the underlying mechanisms. We compiled and analysed a dataset of 7,738 permanent and semi-permanent vegetation plots from Germany that were surveyed between 2 and 54 times from 1927 to 2020, in total comprising 1,794 species of vascular plants. We found that decrements in cover, averaged across all species and plots, occurred more often than increments; that the number of species that decreased in cover was higher than the number of species that increased; and that decrements were more equally distributed among losers than were gains among winners. Null model simulations confirmed that these trends do not emerge by chance, but are the consequence of species-specific negative effects of environmental changes. In the long run, these trends might result in substantial losses of species at both local and regional scales. Summarizing the changes by decade shows that the inequality in the mean change in species cover of losers and winners diverged as early as the 1960s. We conclude that changes in species cover in communities represent an important but understudied dimension of biodiversity change that should more routinely be considered in time-series analyses. Time-series data including 1,794 plant species from 7,738 vegetation plots in Germany between 1927 and 2020 reveal patterns of change in biodiversity, and suggest that more species declined than increased in abundance during this period.

•Episodic memory integration is often impaired in stress-related mental disorders.•Stress reduced medial temporal activity related to insight into linked events.•Stress abolished insight-driven increase in hippocampal pattern dissimilarity.•Stress-related neural changes were linked to subsequent memory. Memories are not stored in isolation. Insight into the relationship of initially unrelated events may trigger a flexible reconfiguration of the mnemonic representation of these events. Such representational changes allow the integration of events into coherent episodes and help to build up-to-date-models of the world around us. This process is, however, frequently impaired in stress-related mental disorders resulting in symptoms such as fragmented memories in PTSD. Here, we combined a real life-like narrative-insight task, in which participants learned how initially separate events are linked, with fMRI-based representational similarity analysis to test if and how acute stress interferes with the insight-driven reconfiguration of memories. Our results showed that stress reduced the activity of medial temporal and prefrontal areas when participants gained insight into the link between events. Moreover, stress abolished the insight-related increase in representational dissimilarity for linked events in the anterior part of the hippocampus as well as its association with measures of subsequent memory that we observed in non-stressed controls. However, memory performance, as assessed in a forced-choice recognition test, was even enhanced in the stress group. Our findings suggest that acute stress impedes the neural integration of events into coherent episodes but promotes long-term memory for these integrated narratives and may thus have implications for understanding memory distortions in stress-related mental disorders.

Maintaining an accurate model of the world relies on our ability to update memory representations in light of new information. Previous research on the integration of new information into memory mainly focused on the hippocampus. Here, we hypothesized that the angular gyrus, known to be involved in episodic memory and imagination, plays a pivotal role in the insight-driven reconfiguration of memory representations. To test this hypothesis, participants received continuous theta burst stimulation (cTBS) over the left angular gyrus or sham stimulation before gaining insight into the relationship between previously separate life-like animated events in a narrative-insight task. During this task, participants also underwent EEG recording and their memory for linked and non-linked events was assessed shortly thereafter. Our results show that cTBS to the angular gyrus decreased memory for the linking events and reduced the memory advantage for linked relative to non-linked events. At the neural level, cTBS targeting the angular gyrus reduced centro-temporal coupling with frontal regions and abolished insight-induced neural representational changes for events linked via imagination, indicating impaired memory reconfiguration. Further, the cTBS group showed representational changes for non-linked events that resembled the patterns observed in the sham group for the linked events, suggesting failed pruning of the narrative in memory. Together, our findings demonstrate a causal role of the left angular gyrus in insight-related memory reconfigurations.

Background Primary and specialist healthcare services are critical to ensuring high-quality care for people living in long-term residential aged care facilities (LTCFs). In Australia, these government-subsidized services include general practitioner attendances, health assessments, management plans, allied health services, pain medicine specialists, and mental healthcare, among others. Although the utilization of these services is known to be suboptimal, the extent and nature of variation in their use across LTCFs nationally remain unknown. Importantly, variation that is not attributable to resident needs or planned system design—termed unwarranted variation —has been shown to negatively impact health outcomes and warrants investigation. To address this gap, this population-based study aims to examine the national variation in primary and selected specialist healthcare services utilization and continuity of care in residential aged care facilities and characteristics of facility utilization outliers. Methods A national cross-sectional study of 173,275 non-Indigenous residents aged ≥65 years from 2,744 Australian facilities in 2019 was conducted. To evaluate continuity of care, the cohort was restricted to LTCF residents who entered care in 2019 and were alive for at least six months ( N  = 41,654 individuals in 2,680 LTCFs). Adjusted median service and continuity of care utilization per 100 residents were calculated. National variation in the rate of healthcare service utilization was quantified using inlier-ranges, categorized as minimal = 0, low < 20, moderate = 20–79, high = 80–99, and maximal = 100. Results Maximal variation for services with moderate utilization (median = 22.1–60.6/100 residents) was observed for after-hours attendances, urgent after-hours attendances, health assessments, management plans, podiatry, and optometric services. Continuity of care had low-to-moderate utilization (median = 13.4–26.6/100) and moderate-to-high variation (inlier-range = 68–95.5). Some services had high (median = 99.9/100, general attendances) or low (median < 8.2/100, specialist attendances) utilization and low-to-moderate variation. A small number of mostly high-utilization outliers were identified. Conclusions There is substantial variation in utilization of healthcare services and continuity of care amongst residential aged care facilities nationally. While some facilities deliver high levels of preventive and disease management healthcare services supporting residents to have high continuity of care, many facilities face challenges facilitating access to adequate healthcare for their residents.

Bacteria secrete a wide variety of polysaccharides that have critical functions in, e.g., fitness, surface colonization, and biofilm formation and in beneficial and pathogenic human-, animal-, and plant-microbe interactions. In Gram-negative bacteria, export of these chemically diverse polysaccharides across the outer membrane depends on two known translocons, i.e., an outer membrane OPX protein in Wzx/Wzy- and ABC transporter-dependent pathways and an outer membrane 16- to 18-stranded β-barrel protein in synthase-dependent pathways. Here, using a combination of experiments in Myxococcus xanthus , phylogenomics, and computational structural biology, we provide evidence supporting that a third type of translocon can export polysaccharides across the outer membrane. In Gram-negative bacteria, secreted polysaccharides have multiple critical functions. In Wzx/Wzy- and ABC transporter-dependent pathways, an outer membrane (OM) polysaccharide export (OPX) type translocon exports the polysaccharide across the OM. The paradigm OPX protein Wza of Escherichia coli is an octamer in which the eight C-terminal domains form an α-helical OM pore and the eight copies of the three N-terminal domains (D1 to D3) form a periplasmic cavity. In synthase-dependent pathways, the OM translocon is a 16- to 18-stranded β-barrel protein. In Myxococcus xanthus , the secreted polysaccharide EPS (exopolysaccharide) is synthesized in a Wzx/Wzy-dependent pathway. Here, using experiments, phylogenomics, and computational structural biology, we identify and characterize EpsX as an OM 18-stranded β-barrel protein important for EPS synthesis and identify AlgE, a β-barrel translocon of a synthase-dependent pathway, as its closest structural homolog. We also find that EpsY, the OPX protein of the EPS pathway, consists only of the periplasmic D1 and D2 domains and completely lacks the domain for spanning the OM (herein termed a D1D2 OPX protein). In vivo , EpsX and EpsY mutually stabilize each other and interact in in vivo pulldown experiments supporting their direct interaction. Based on these observations, we propose that EpsY and EpsX make up and represent a third type of translocon for polysaccharide export across the OM. Specifically, in this composite translocon, EpsX functions as the OM-spanning β-barrel translocon together with the periplasmic D1D2 OPX protein EpsY. Based on computational genomics, similar composite systems are widespread in Gram-negative bacteria. IMPORTANCE Bacteria secrete a wide variety of polysaccharides that have critical functions in, e.g., fitness, surface colonization, and biofilm formation and in beneficial and pathogenic human-, animal-, and plant-microbe interactions. In Gram-negative bacteria, export of these chemically diverse polysaccharides across the outer membrane depends on two known translocons, i.e., an outer membrane OPX protein in Wzx/Wzy- and ABC transporter-dependent pathways and an outer membrane 16- to 18-stranded β-barrel protein in synthase-dependent pathways. Here, using a combination of experiments in Myxococcus xanthus , phylogenomics, and computational structural biology, we provide evidence supporting that a third type of translocon can export polysaccharides across the outer membrane. Specifically, in this translocon, an outer membrane-spanning β-barrel protein functions together with an entirely periplasmic OPX protein that completely lacks the domain for spanning the OM. Computational genomics support that similar composite systems are widespread in Gram-negative bacteria.