JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.Clinical evaluation of fracture healing is often limited to an assessment of fracture bridging from radiographic images, without consideration for other aspects of bone quality. However, recent advances in HRpQCT offer methods to accurately monitor microstructural bone remodeling throughout the healing process. In this study, local bone formation and resorption were investigated during the first year post fracture in both the fractured (n = 22) and contralateral (n = 19) radii of 34 conservatively treated patients  who presented with a unilateral radius fracture at the Innsbruck University Hospital, Austria. HRpQCT images and clinical metrics were acquired at six time points for each patient. The standard HRpQCT image acquisition was captured for all radii, with additional distal and proximal image acquisitions for the fractured radii. Measured radial bone densities were isolated with a voxel‐based mask and images were rigidly registered to images from the previous imaging session using a pyramid‐based approach. From the registered images, bone formation and resorption volume fractions were quantified for multiple density‐based thresholds and compared between the fractured and contralateral radius and relative to demographics, bone morphometrics, and fracture metrics using regression. Compared with the contralateral radius, both bone formation and resorption were significantly increased in the fractured radius throughout the study for nearly all evaluated thresholds. Higher density cortical bone formation continually increased throughout the duration of the study and was significantly greater than resorption during late‐stage healing in both the fractured and intact regions of the radius. With the small and diverse study population, only weak relationships between fracture remodeling and patient‐specific parameters were unveiled. However this study provides methods for the analysis of local bone remodeling during fracture healing and highlights relevant considerations for future studies, specifically that remodeling postfracture is likely to continue beyond 12‐months postfracture. © 2021 The Authors.  The clinical assessment of healing in these fractures often includes patient‐reported pain and function combined with radiographic assessment of cortical bridging. Although measures of pain and function are subjective and cannot provide direct insight to fracture union, radiographic assessment provides visualization of cortical bridging that directly indicates healing. Unfortunately, the lack of standardization and the absence of density‐based calibration prevents the use of radiographic images to observe bone quality through the process of fracture healing, which may be relevant given the increased prevalence of these fractures in older patients with increased risk of osteoporosis or other bone metabolic diseases affecting cortical and/or trabecular bone compartments.Distal radius fractures are the most common fracture in adults and, when resultant of low‐energy trauma, are indicative of possibly underlying osteoporosis and decreased bone quality.2, 3 HRpQCT imaging has provided the data necessary to observe changes in both bone density and microarchitecture during the first 3‐months postfracture and to confirm that these aspects of bone health resemble those of the contralateral radius by 2‐years postfracture. Importantly, these analyses of density and microarchitecture may provide insight into the healing process and are part of the standard patient evaluation built‐in to the scanner software. However, recent studies have shown that preprocessing of the images using rigid 3D registration provides a more accurate method to assess changes in bone microarchitecture because the same region of interest (ROI) can be analyzed in longitudinally acquired images. Longitudinal imaging and 3D‐image registration are tools provided in the scanner software, but have yet to be adopted into the standard patient evaluation for HRpQCT images. Although these techniques have allowed for quantification of localized microstructural remodeling in cohorts of 10 or fewer patients with decreased bone quality and disease, the methods used to date in patients have diverged from the methods used to quantify formation and resorption in animal studies and have been inconsistent in the specific parameters used for quantification of remodeling . However, concurrent research has also shown that 3D‐image registration can be applied to fractured radii and even help to monitor changes in BMD in localized regions of the fracture. Importantly though, these studies have been limited to proof of concept because of their evaluation of only small ROIs and three or four patients, respectively. Thus, by applying the combined techniques of 3D‐image registration and quantification of bone formation and resorption to images of healing fractured radii, we may be able to specifically and locally quantify microstructural changes in BMD and structure throughout the duration of fracture healing.Three‐dimensional (3D) imaging with calibrated CT provides insight into both bone density and structure; however, the adoption of CT imaging in the assessment of fracture healing has been limited, likely because of the increased radiation in comparison with radiographs and the difficulty in assessing cortical bridging caused by low image resolution. Recently, HRpQCT, which boasts both lower radiation and higher resolution than clinical CT, has been adopted to observe microstructural and morphological changes throughout both early‐ and late‐stage postfracture fracture healing.6, 7The purpose of this study was to develop and apply an analysis protocol similar to that used in animal studies aimed at facilitating the use of time‐lapse HRpQCT imaging of the distal radius to investigate local bone formation and resorption during fracture healing, both in the fracture region and in the surrounding intact bone. We hypothesized that through use of this analysis protocol in combination with results from the contralateral radius, we would observe increased formation followed by resorption in the fracture region and that remodeling during fracture healing would be influenced by bone quantity and quality, patient demographics, and clinical outcome measures.A subset of 34 patients of the 106 recruited for a time‐lapse HRpQCT imaging study were included herein based on the availability of high‐quality data from imaging sessions  images were acquired 1‐week, 3‐weeks, 5‐weeks, 3‐months, 6‐months, and 12‐months postfracture . At each imaging session, three adjacent, nonoverlapping image acquisitions or stacks  were acquired for the fractured arm and one standard image stack  was acquired for the contralateral arm. The effective radiation dose of all acquired HRpQCT images was 0.837 to 0.909 mSv per study participant, which is far below the 50 mSv yearly limit for radiation workers. All images were acquired relative to a reference line placed at the inflection between the articulating surface of the radius with the scaphoid and lunate . Only patients with sufficient quality images (VGS 1–3) for all six time points of either the fractured or contralateral radius were included in this analysis, which excluded 72 of the total 106 patients recruited for the study and resulted in the inclusion of 22 fractured radii and 19 contralateral radii, with seven participants included in both the fracture and contralateral subgroups. Bone‐to‐soft tissue signal‐to‐noise ratio (BST‐SNR) was calculated using the mean mineralized density value within the cortical mask and the SD of the region immediately surrounding the radius for all registered images. Although this varies from the definition of SNR, where the SD of only background is used, it better represents the analyzed portion of the images because it highlights the contrast between bone tissue and its environment consisting of mineralizing callus and soft tissue.Image quality was assessed relative to the visual grading score (VGS), which ranges on a scale from 1 (no motion artifact) to 5  by one researcher and one clinician.16 All) and the injury mechanism was classified as either a high‐ or low‐impact fall. Patient function was measured using the Disabilities of the Arm, Shoulder, and Hand (DASH), Patient‐Rated Wrist Evaluation (PRWE), and the Michigan Hand Questionnaire (MHQ) grading systems. Patients were asked to report baseline function before fracture and then completed questionnaires again at the 3‐, 6‐, and 12‐month imaging sessions. Range of motion (ROM) in all three planes of motion and grip strength was measured at the 3‐, 6‐, and 12‐month imaging sessions and used to assess fracture healing.DXA images of the lumbar spine, proximal femur, and contralateral radius  were acquired 3‐weeks postfracture and T scores were recorded. Standard distal radiographic images of the fractured forearm were acquired at the time of fracture, as well as at each imaging session. Dorsal‐palmar inclination, ulnar variance, and radial inclination were measured on each radiograph. Fractures were classified using the Orthopedic Trauma Association (OTA) fracture and dislocation classification, which iteratively aligned adjacent images to allow for direct comparisons of BMD , which is part of the scanner manufacturer software. Densitometric indices, including volumetric BMD (vBMD) for the whole bone (Tt.vBMD), trabecular (Tb.vBMD), and cortical (Ct.vBMD) regions, and morphometric indices, including bone volume fraction (BV/TV), cortical porosity (Ct.Po), trabecular number (Tb.N), trabecular separation (Tb.Sp), and mean thickness of the trabecular (Tb.Th) and cortical (Ct.Th) regions, were evaluated to quantify bone quantity and quality of each study participant and compare subgroups of patients. Without available validation of commonly reported densitometric and morphometric measures on fractured and healing bone, only a single image stack of the contralateral arm was used for measurement of densitometry and static morphometry of each study participant. Further, since high quality contralateral images (VGS 1 through VGS 3) were not available at all time points for the fracture subgroup, a single image stack was used for consistency across all participants whether included in the fracture or contralateral subgroup. The evaluated contralateral image was chosen based on image quality, where higher quality was preferred based on known errors resultant of motion artifact.20 How the investigation of remodeling in humans has instead used formation and resorption bone‐volume fractions, which do not include the aspect of time between evaluated images. Although the specific reasoning behind this decision is unknown, the increased image noise of lower resolution clinical images from HRpQCT, in comparison with μCT images, would result in greater false‐positive and false‐negative remodeling events. Thus, the calculation of rates of change, such as bone formation rate and bone resorption rate, would be biased to the time interval between measurements. For this reason, in conjunction with the varied time intervals of our study, we have reported remodeling in terms of formation and resorption volume fractions.Although bone formation rate and bone resorption rate have been the standards in reporting dynamic morphometry in animal studies,22 the3 with an interval of 120 mg HA/cm3 were applied to the Gaussian‐filtered images. Voxels at each density threshold were summed for the central slice of each analyzed image stack to assess the distribution of bone density in the various ROIs. Bone formation and resorption volume fractions were then calculated for each density as the volume of bone formed or resorbed divided by the total volume of bone of that density at the earlier imaging session. All formation and resorption calculations were completed relative to the following time point, such that formation and resorption bone‐volume fractions presented for 1‐week postfracture are relative to 3‐weeks postfracture and those for 3‐weeks postfracture are relative to 5‐weeks postfracture. At any given density threshold, formation voxels were those in the latter image, but not the former, whereas resorption voxels were in the former image, but not the latter image. The cortical region of evaluation was additive between each set of two time points evaluated such that any voxel labeled as cortex in either image would be considered cortex. The trabecular mask then included all noncortical voxels within the set of periosteal contours. All of the density thresholds were evaluated for the cortical region, whereas only densities ranging from 200 to 680 mg HA/cm3 were evaluated for the trabecular region, based on the lower mineralized density of trabecular bone and minimal trabecular bone volume measured at higher densities.Before the calculation of formation and resorption volume fractions, registered density images were filtered with a constrained Gaussian filter . Thresholds of densities between 200 and 960 mg hyaluronic acid (HA)/cm session.13 All Non‐normally distributed results were presented as median (interquartile range) and compared using Spearman's Rank correlation coefficient and a Wilcoxon or Mann–Whitney U test, as appropriate, whereas normally distributed results were presented as mean ± SD and compared using Pearson's correlation coefficient and a paired or unpaired Student's t test, as appropriate. Statistical analyses that compared the fracture and contralateral data accounted for the potential dependence between the fracture and contralateral radii of the seven participants included in both subgroups with the use of a partially paired analysis, as described by Derrick and colleagues, which consider both the paired and independent samples without an introduction of bias. The ANOVA was used to determine group differences relative to multiple factors, where the Kruskal‐Wallis H test was used to evaluate group differences for nonparametric results. All comparisons of formation and resorption were calculated on the magnitude of the volume fraction. Corrections for multiple comparisons were applied to results that compared metrics of healing  using the Python Statsmodels function library implementation of the Holm‐Bonferroni correction. Differences in BST‐SNR were evaluated across appointments and between groups using a mixed linear regression model in the Python Statsmodels function library to determine relevant factors that affected BST‐SNR.Using the Python SciPy function library, results were evaluated using the Shapiro–Wilk test of normality and then evaluated using the appropriate analysis for non‐normally or normally distributed results.23 Non), femur and lumbar spine DXA‐measured T scores, observed differences in radiographic measures, prescribed medication , ipsilateral formation and resorption volume fractions, and density threshold using the Python Scikit‐Learn function library. Thresholds used only for the cortical regions, ROM, grip strength, and radius T scores were not considered in the PLS regression model because of the difficulties of assessing incomplete data sets . All variables were scaled and centered before analysis such that they had a center value of 0 and a SD of 1. Leave‐one‐out cross validation was used to calculate the predictive power of the model because of the small number of data points and large number of variables evaluated. The number of model components was determined based on the Q2 value of the cross validation, such that additional components were only included if significant improvements to the model occurred, which were identified by increases in Q2 of at least 0.0975. The variables were sorted by variable influence on projection and the model was run iteratively, including additional variables until the Q2 score no longer improved.Repeated‐measures ANOVA was used to identify whether time frame, bone type , density threshold, direction of remodeling (formation or resorption), and region (fracture or intact) affected the magnitude of the formation or resorption volume fractions for both the contralateral and fractured radius. To further investigate the specific parameters that had the largest effect on formation and resorption, partial least squares (PLS) regression was performed on each formation and resorption volume fraction including variables of demographics, morphometric data, injury descriptors , fp = 0.042; Table  All patients had good fracture healing outcomes without radiographic evidence of delayed or nonunion. Function before fracture was reported to be 0.00 (3.12) on the DASH and 0.0 (1.5) on the PRWE, both of which approached a score of 0, which indicates no disability. On the MHQ, function before fracture was reported to be 99.43 (6.77) for the contralateral and 99.36 (3.87) for the fractured arm that approached a score of 100, which indicates no disability for the MHQ. For the DASH and PRWE, these baseline measures were used for comparison of the scores at later time points, whereas for the MHQ, the contralateral arm scores were used, which showed no significant difference compared with the fractured arm before fracture (p = 0.952 at baseline). Questionnaire results, measures of strength, and ROM indicated functional recovery by 6‐months postfracture . The two subgroups of patients evaluated did not differ in demographics or measures from densitometry, morphometry, or DXA, except for Tb.vBMD , two began calcium therapy (5‐weeks postfracture), and eight began a combined vitamin D and calcium therapy (3‐ to 5‐weeks postfracture); one patient who was included in both the contralateral and fracture subgroups was taking vitamin D, calcium, and Actonel (antiresorptive therapy) throughout the study.Patients from both the fracture and contralateral radius subgroups showed no differences in timing of follow‐up appointments Table . The frap < 0.001 for each) and the 3‐week (p = 0.026) and 12‐month (p = 0.001) imaging sessions to be relevant in the prediction of BST‐SNR , but not for the images of the casted or cast‐free fractured radius.The evaluation of BST‐SNR relative to three categories of images  and the six imaging sessions identified the three categories  and 0.286 (0.121), respectively, whereas cortical formation and resorption volume fractions were 0.086 (0.070) and 0.087 (0.065), respectively, for the contralateral radius  or a registered image (p = 0.031 for VGS 2 and p > 0.001 for VGS 3), but no differences were observed between VGS 2 and VGS 3.Although generally only high‐quality images (VGS 1–3) were included herein, the image quality of both the target and registered image of each pair of registered images affected both formation and resorption volume fractions . Time frame, bone type, region, threshold, remodeling direction, and the interactions between several of these variables had an effect on formation and resorption volume‐fraction magnitude  that occurs before specific anabolism (formation). To better understand this mechanism, bone remodeling during early fracture healing should likely be investigated further with smaller time intervals and perhaps alternative imaging modalities that could better capture early‐phase bone healing.An important consideration for the evaluation of microstructural fracture healing is that of fracture fragment movement, which can result in erroneous/artifactual observations of increased formation and resorption volume fractions. Qualitatively, fracture‐fragment movement was observed predominantly between 1‐week and 3‐weeks postfracture with only subtle fragment motion observed between 3‐ and 5‐weeks postfracture Fig. . Previou14; ho The short‐term images in healthy subjects were used to determine the parameters for analysis with the goal of matching previously observed reproducibility of geometry and density measured using HRpQCT. Thereby, a voxel‐by‐voxel subtraction within the largest common volume  was combined with a difference threshold of 225 mg HA/cm3 to determine clusters of formation and resorption, which were considered to be noise and were removed if <30 voxels in size. A follow‐on study by the same research group further analyzed a similar cohort of 82 μm voxel images from postmenopausal women at intervals of 2, 4, and 6 years using the same method; however, here only clusters <five voxels were considered to be noise. The most recent study used three combined 10.2‐mm image stacks, acquired with 25% overlap, of 61‐μm voxel images of the second and third metacarpophalangeal joints of patients with rheumatoid arthritis after 6 months. This study used within‐acquisition overlap between adjacent image stacks from the same imaging session for ladder‐based registration, then applied a difference threshold of 125 mg HA/cm3 and considered clusters of voxels <five voxels in size to be noise. A scan–rescan analysis was then used as a negative control for comparison.To date, there have only been three studies evaluating longitudinal bone remodeling in humans. The first, from 2014, analyzed 82‐μm voxel HRpQCT images of the radius and tibia in patients with osteoporosis at baseline and 2‐year follow‐up as well as healthy subjects within 1‐month intervals.9 The  these previous studies applied a single, albeit varied, threshold to the difference in density between sequential images. For reference, we have included analysis of our data using the thresholded difference methods of Brunet and colleagues to support the following discussion on methodological differences ied Fig. .3 in the only three published studies. Additionally, the removal of small clusters of formation or resorption voxels may inadvertently bias observations of the interplay between cortical and trabecular remodeling caused by differences in morphology and density of the two bone types and our observation that both formation and resorption volume fractions varied with mineralized density.Another important difference of our method in comparison to previous research is that we did not remove small clusters of voxels in an attempt to remove noise, as this subjective removal of small clusters of formation and resorption may instead ignore subtle changes in bone formation and resorption. The justification for removal of these clusters has largely been a desire to lower observed formation and resorption volume fractions to values of reproducibility of other metrics from HRpQCT and the implementation has been inconsistent, with the size of removed clusters ranging from 1.1 to 16.5 μmIt is, however, important to note that with our method there is an inherently increased risk of false‐positive identification of formation and resorption, especially at lower density thresholds because of the increased image noise of HRpQCT in comparison with the μCT used in animal studies. Thus, we used the contralateral radius as a reference to identify differences in remodeling associated with fracture healing and avoid any unexpected biasing of the results caused by threshold choice and our lack of noise removal. Although the proportions of density‐based cortical bone volume Fig.  and calc through the comparison of densitometrics and morphometrics. In comparison with no cast, plaster casts have been associated with decreases in Tb.vBMD of 4% to 6%, Ct.vBMD of 5% to 7%, and Ct.Th of 2% to 10%. Interestingly, we observed the differences in BST‐SNR with respect to the inclusion of a plaster cast to be isolated to the noise of the soft tissue  to influence patient outcome postdistal radius fracture,36 othy Tables  and 5 thPenny Atkins: Data curation; formal analysis; investigation; methodology; software; visualization; writing‐original draft; writing‐review & editing. Kerstin Stock: Data curation; resources; writing‐review & editing. Nicholas Ohs: Methodology; software; writing‐review & editing. Caitlyn Collins: Methodology; writing‐review & editing. Lukas Horling: Data curation; resources. Stefan Benedikt: Data curation; resources. Gerald Degenhart: Data curation; writing‐review & editing. Kurt Lippuner: Funding acquisition; writing‐review & editing. Michael Blauth: Conceptualization; funding acquisition. Patrik Christen: Conceptualization; funding acquisition. Ralph Mueller: Conceptualization; funding acquisition; writing‐review & editing.https://publons.com/publon/10.1002/jbm4.10493.The peer review history for this article is available at Appendix S1: Supporting informationClick here for additional data file.


Offshore wind energy is a growing industry in the United States, and renewable energy from offshore wind is estimated to double the country's total electricity generation. There is growing concern that land‐based wind development in North America is negatively impacting bat populations, primarily long‐distance migrating bats, but the impacts to bats from offshore wind energy are unknown. Bats are associated with the terrestrial environment, but have been observed over the ocean. In this review, we synthesize historic and contemporary accounts of bats observed and acoustically recorded in the North American marine environment to ascertain the spatial and temporal distribution of bats flying offshore. We incorporate studies of offshore bats in Europe and of bat behavior at land‐based wind energy studies to examine how offshore wind development could impact North American bat populations. We find that most offshore bat records are of long‐distance migrating bats and records occur during autumn migration, the period of highest fatality rates for long‐distance migrating bats at land‐based wind facilities in North America. We summarize evidence that bats may be attracted to offshore turbines, potentially increasing their exposure to risk of collision. However, higher wind speeds offshore can potentially reduce the amount of time that bats are exposed to risk. We identify knowledge gaps and hypothesize that a combination of operational minimization strategies may be the most effective approach for reducing impacts to bats and maximizing offshore energy production. Much has been learned about bat interactions with land‐based turbines in North America over the past 15 years, but little is known about potential risks and impacts to bats in the maritime environment despite a sociopolitical push to develop this resource. We synthesize historic and contemporary records of bats observed and acoustically recorded in North American waters to gain a better understanding of the offshore occurrence and behavior of North American bats and to place this in the context of offshore wind energy development in the United States. We aim to elucidate which North American bat species are most at risk, when and where we might expect the highest fatalities assuming the risk to bats by offshore is similar to terrestrial wind energy development, and whether aspects of offshore bat behavior can help inform mitigation strategies for reducing impacts by offshore wind energy development. Three r3.9It is unknown what impact, if any, that offshore wind development might have on bat populations or whether any mitigation is needed. In the absence of empirical data, the similar species composition and patterns of bat activity in onshore and offshore environments suggest that bats flying offshore are at some risk of collision. To date, no fatalities of bats have been documented at offshore wind energy facilities worldwide. However, searching for carcasses beneath offshore turbines is not possible, and monitoring of offshore turbines using camera technologies  that could witness collisions is at very early stages of development and has only been recently pilot‐tested , observers describe bats landing on the rigging, on other parts of the ship, and even on people Table , presumaMyotis bats—not typically associated with long‐distance flight—110 km offshore for a 24‐h period  feeds on fish and crustaceans captured in the ocean , and California bats  were shot and collected while flying low and dipping into saltwater off the coast  systems were recently deployed at the Coastal Virginia Offshore Wind facility as part of a pilot project  by 78% and 54%, respectively, but had no effect on fatalities for northern yellow bats  from the manufactured speed  by 1.5–3.0 m/s, a process known as curtailment ; Data curation (lead); Investigation (lead); Writing‐original draft (lead); Writing‐review & editing . Christian M. Newman: Conceptualization (supporting); Funding acquisition (lead); Supervision (lead); Writing‐review & editing .https://doi.org/10.5281/zenodo.5514327.This article has earned an Open Data badge for making publicly available the digitally‐shareable data necessary to reproduce the reported results. The data is available at Table S1Click here for additional data file.Table S2Click here for additional data file.


Impingement of the LHB can directly lead to articular‐sided supraspinatus tears. When pain persists despite arthroscopic debridement, we recommend taking the arm out of traction intraoperatively and placing it in the 90‐90 position. Impingement of the LHB can directly lead to articular‐sided supraspinatus tears. When pain persists despite arthroscopic debridement, we recommend taking the arm out of traction intraoperatively and placing it in the 90‐90 position. Diagnostic arthroscopy revealed an articular‐sided supraspinatus tear. When the shoulder was taken out of traction and placed in 90 degrees of abduction and external rotation, we visualized the biceps tendon directly impinging the undersurface of the supraspinatus tendon.As shoulder arthroscopy progressed, surgeons noticed an association between partial articular‐sided rotator cuff tears and superior labral lesions.Over time, additional theories have emerged to explain the common association between articular‐sided rotator cuff tears and superior labral lesions. Burkhart et al proposed that these lesions develop over time due to the excessive shear and torsional forces placed on the shoulder by repetitive abduction and external rotation.The prevalence of internal impingement has not been well established due to the constellation of findings that characterize this condition and its strong association with other pathological lesions of the shoulder.2A 19‐year‐old right‐handed female presented to our clinic with a chief complaint of left shoulder activity‐related pain of approximately 6 months' duration. She subsequently underwent 6 months of physical therapy and received two subacromial cortisone injections with minimal relief. On physical examination, she reported pain over the anterior and lateral shoulder. She had pain with resisted supraspinatus testing but full strength. She also had moderate discomfort with abduction and external rotation (posterior impingement sign). There was mild tenderness to palpation over the biceps tendon in the groove as well. She had full range of motion and no anterior or posterior shoulder instability. Subscapularis and infraspinatus tests were normal and she had a negative O'Brien's test, negative jerk test, and negative subacromial impingement test. There was no scapular dyskinesis or glenohumeral internal rotation deficit (GIRD). The remainder of her exam was unremarkable.An MRI showed a partial supraspinatus tendon tear and moderate tendinosis of the intra‐articular portion of the long head of the biceps (LHB). There was no evidence of anterior or superior labral tear. The upper border of the subscapularis tendon was intact. She opted for surgical management after a thorough discussion of operative and nonoperative treatment options.2.1Left shoulder arthroscopy was performed in the lateral decubitus position with 10 pounds of longitudinal traction. Diagnostic arthroscopy revealed a 1 cm  by 5 mm (anterior‐posterior) lesion of the undersurface of the anterior aspect of the supraspinatus tendon  by 5 mm (anterior‐posterior) lesion of the undersurface of the anterior aspect of the supraspinatus tendon Figures  and 3. TThe patient wore a shoulder sling for 4 weeks postoperatively and was instructed to avoid active biceps flexion. She began light resistive biceps strengthening at 8 weeks postoperatively and progressed to full activity at 3 months postoperatively. At 6 months, she had regained full strength and range of motion and had returned to competitive swimming and water polo. She has remained asymptomatic at 2 years of follow‐up.3Previous biomechanical and clinical studies have demonstrated the concept of internal impingement.The association between partial articular‐sided rotator cuff tears and superior labral lesions is well documented in the literature.Posterior biceps instability and friction may represent an under‐diagnosed and under‐recognized source of internal impingement. This may especially be true among patients whose symptoms persist despite adequate treatment of concomitant pathology. Partial articular‐sided rotator cuff tears and type‐1 labral lesions are typically treated nonoperatively with good results.Multiple anatomic changes and pathologic conditions contribute to biceps instability in throwing athletes. Increased external rotation with repetitive throwing is achieved by shoulder adaptations including anterior capsule laxity and posterior capsule tightening.In addition, abduction and external rotation in the late cocking phase of throwing is known to shift the biceps tendon posteriorly.Several clinical studies have demonstrated an association between rotator cuff tears and biceps instability.The are several weaknesses of this case report. First, this is an isolated case and it remains to be seen whether this approach is valid when applied to a larger patient population. Second, the patient underwent an additional debridement at the time of her second surgery, which may have contributed to the positive results. Third, biceps tenodesis is an effective treatment for biceps pathology. It is possible that the rotator cuff lesion was incidental and that the true pathology was intrinsic to the biceps tendon.In summary, we present an interesting case report of a small, partial articular‐sided supraspinatus tendon tear initially treated with arthroscopic debridement Figure . Unfortu4In this case report, we propose a novel biomechanical source of internal impingement: direct impingement of the biceps tendon on the undersurface of the supraspinatus tendon. We believe that impingement of the LHB can either directly lead to, or potentially aggravate, articular‐sided tears of the supraspinatus tendon. This proposed mechanism of impingement may help explain why debridement alone can produce suboptimal results.Dr Chen is an educator for Arthrex Inc The authors declare no conflicts of interest related to the subject of this article. No outside funding or grants were received for this study. Alexander Rosinski, MS: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. James Chen, MD, MPH: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. Patrick McGahan, MD: This author, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.Informed consent was obtained from the patient regarding the report and publication of the case in an anonymous way.


Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta‐analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease.There is no significant difference in all‐cause mortality or cardiovascular mortality between invasive and medical arms.We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients . Primary outcome was all‐cause mortality. Secondary outcomes included major adverse cardiac events (MACE) , cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all‐cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy.p = .84). There were statistically significant lower rates of MACE  in the revascularization arm when compared to conservative arm.There was no statistically significant difference in primary outcome of all‐cause mortality between either arm . Multiple trials2We performed a systematic literature search on PubMed, Cochrane, Embase and Ovid MEDLINE database from January 2000 to June 2020. Search terms included (stable coronary artery disease OR stable angina OR angina) AND  AND (PCI OR expanded PCI OR revascularization OR CABG OR surgery). Inclusion criteria were randomized controlled trials (RCTs), trials in humans and English language. Non‐randomized trials, including observational studies, were excluded. Trials investigating treatment strategies other than directly comparing intervention to medical therapy were excluded. This led to exclusion of three major trials namely: ORBITAPrimary outcome was all‐cause mortality. Secondary outcomes included MACE , cardiovascular mortality, MI and stroke. Additional subgroup analysis for all‐cause mortality was performed comparing2 index tests were computed. Two‐sided p value of ≤ .05 was considered significant. Effect size estimates were presented using the calculated odds ratios and corresponding 95% confidence intervals (CI). Sensitivity analysis was also performed with sequential exclusion of individual studies. We assessed the risk of bias for each study using criteria outlined in the Cochrane Handbook for Systematic Reviews of InterventionsData was extracted on an intention‐to‐treat basis. Measures of heterogeneity, including Cochran's Q‐statistic and I3Our literature search yielded seven RCTs. We analyzed a total of 12 013 patients . The mean age was 65 years in both arms. The longest follow up available was 10 years. The baseline characteristics of the included patients in each trial are given in Table 3.1p = .84) , cardiovascular death  and MI  in the revascularization arm when compared to conservative arm. There was no statistically significant difference in stroke  between the two arms. , 0.83–1.08; ) Figure . There w3.2p = .31) or drug eluting stents .Subgroup analyses Figure  showed n4This meta‐analysis of over 12 000 patients shows no difference in primary outcome of all‐cause mortality between revascularization with medical therapy and conservative therapy for patients with symptomatic but stable CAD. However, secondary outcomes analyses showed that revascularization is associated with reduced incidence of MACE  which is driven by a nearly 14% reduction in MI and cardiovascular death when compared to conservative therapy alone.Current ACC/AHA/AATS/PCNA/SCAI/STS guidelines on stable CAD support coronary revascularization if the patients continue to have ischemic symptoms on optimal medical therapy or in whom revascularization may alter prognosis, such as in patients with reduced EF, where revascularization has a mortality benefit over conservative therapy.Heart disease has remained the leading cause of death in the United States for more than four decades. However, there has been a significant decline in mortality over the years. Aggressive risk factor modification for primary and secondary prevention in CAD has contributed to this remarkable decline in mortality. Previous to the year 2000, trials addressing treatment of stable CAD predominantly used plain old balloon angioplasty (POBA) as the interventional treatment strategy. The outcomes of patients undergoing POBA are marred by the significant rates of restenosis in up to 30%–50% of patients.Although the field of coronary interventions has come a long way in PCI techniques and equipment, multiple prior meta‐analyses have either shown limitedThe International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)Our analysis updates the current available literature and includes the 5 years follow‐up data from the FAME 2The finding of no survival benefit between the two groups has been consistent among all of the included trials and prior analyses. One of the major findings in our analysis was higher incidence of MI in patients treated with conservative therapy alone. Those results are predominantly driven by ISCHEMIACoronary artery disease should be considered under the category of chronic coronary syndrome to reflect this multi‐faceted disease process that requires interventions on multiple frontiers for a desired response. Atherosclerotic plaque deposition begins in early years of childhood and adolescence as fatty streaks,Our analysis, in alignment with prior individual trials and analyses, failed to show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable CAD. The reduced incidence of spontaneous MIs in the revascularization arm is promising. Although numerically, the decrease in spontaneous MI are offset by an increase in peri‐procedural MI, periprocedural MI and spontaneous MI do not carry the same weight in prognostic significance5The current meta‐analysis of seven contemporary RCTs did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable CAD. There was a significantly lower risk of MACE in the revascularization group, predominantly driven by reduced spontaneous M. Shared clinical decision making based on patient's symptoms should be pursued to determine further management options.6The results of our meta‐analysis need to be interpreted with some inherent limitations. We did not have access to patient level data. Patients with stable ischemic heart disease and low left ventricular ejection fraction or left main disease were excluded from all trials and hence the results should not be applied in those disease states. Although, the aim of our meta‐analysis was to assess the benefit of revascularization for stable CAD, the results predominantly reflect use of PCI, given small number of patients who underwent CABG. We were unable to stratify the results of revascularization based on CABG versus PCI. Choice of CABG over PCI may reflect higher burden of disease and ischemia and expectedly outcomes like stroke and periprocedural MI could be different. Additionally, the type of troponin assay used and definitions of peri‐procedural MI have been varied in different trials and has been mostly linked to biomarker elevation in the absence of addressable symptoms.Table S1: Outcomes of interest in the included trials.Click here for additional data file.


This study presents a comprehensive collision avoidance framework based on three‐dimension (3D) computer‐aided design (CAD) modeling, a graphical user interface (GUI) as peripheral to the radiation treatment planning (RTP) environment, and patient‐specific plan parameters for intensity‐modulated proton therapy (IMPT).A stand‐alone software application was developed leveraging the Varian scripting application programming interface (API) for RTP database object accessibility. The Collision Avoider software models the Hitachi ProBeat‐V half gantry design and the Kuka robotic couch with triangle mesh structures. Patient‐specific plan parameters are displayed in the collision avoidance software for potential proximity evaluation. The external surfaces of the patients and the immobilization devices are contoured based on computed tomography (CT) images. A “table junction‐to‐CT‐origin” (JCT) measurement is made for every patient at the time of CT simulation to accurately provide reference location of the patient contours to the treatment couch. Collision evaluations were performed virtually with the program during treatment planning to prevent four major types of collisional events: collisions between the gantry head and the treatment couch, gantry head and the patient's body, gantry head and the robotic arm, and collisions between the gantry head and the immobilization devices.The Collision Avoider software was able to accurately model the proton treatment delivery system and the robotic couch position. Commonly employed clinical beam configuration and JCT values were investigated. Brain and head and neck patients require more complex gantry and patient positioning system configurations. Physical measurements were performed to validate 3D CAD model geometry. Twelve clinical proton treatment plans were used to validate the accuracy of the software. The software can predict all four types of collisional events in our clinic since its full implementation in 2020.A highly efficient patient‐specific collision prevention program for scanning proton therapy has been successfully implemented. The graphical program has provided accurate collision detection since its inception at our institution. Collision events during treatment sessions  negatively impact the quality of patients’ treatment experience and pose a potentially significant safety concern. The primary solution after a collision event occurs is to immediately replan with a set of new validated gantry or couch angles for the remaining fractions. An unforeseen replanning event adds inefficiencies or workflow perturbations to a busy proton clinic and, more importantly, has the potential to impact patients’ prognoses. For example, for single‐fraction stereotactic radiosurgery or hypofractionated stereotactic body radiotherapy (RT) proton treatments, a collision event could further complicate the biological effectiveness, if one or more of the treatment fields must be replanned and delivered later. Or, patients’ RT treatment start date or treatment fractionation schedule may be impacted. The purpose of this study is to present a clinically validated collision avoidance framework that has been implemented at our clinic.Currently, there are two categories of collision detection solutions available in the field of radiation therapy. First, vendor provided software modules, either based on a simple treatment machine geometry modeling or a more sophisticated three‐dimension (3D) computer‐aided design (CAD) modeling. The second class of solutions is a group of user‐initiated, practical in‐house techniques including: mathematical approximation of collision‐free space,In 1995, Kessler et al. published the first interactive CAD‐based simulation method to account for collision issues between a LINAC gantry and its treatment couch.Categorically, there are mainly four types of collision scenarios during a proton therapy treatment delivery for a half gantry proton system: (1) collisions between the gantry nozzle and the couch top, (2) collisions between the gantry nozzle and the patient, (3) collisions between the gantry nozzle with the robotic patient positioning system (PPS), and (4) collisions between the gantry and the patient immobilization devices. For shallow treatment volumes, a range shifter device needs to be manually attached to the downstream or exit side of the proton nozzle, compounding collision hazards. With the four collisional settings in mind, we aim to present a comprehensive collision avoidance framework that has been fully integrated with our clinical workflow. We created a stand‐alone Windows application known as “Collision Avoider” using the Eclipse Scripting API  and Microsoft Visual Studio .22.1The Collision Avoider contains a detailed 3D CAD model of the Hitachi ProBeat‐V proton gantry head and PPS provided by the manufacturer , which is currently installed at two campuses, namely Mayo Clinic Rochester, Minnesota, and Mayo Clinic Phoenix, Arizona. We defined the gantry and PPS to be moved according to the International Electrotechnical Commission convention. The Hitachi gantry has a half gantry design capable of rotating from 355° to 185° Figure . The ext2.2The Collision Avoider software was created using C#/.NET in the MVS development environment , incorporating published libraries from the Varian ESAPI. The Collision Avoider software package was created as a stand‐alone executable .NET application. The advantage of a stand‐alone executable deployment scheme is mainly efficiency: while the ESAPI plug‐in scripts (which are necessarily deployed inside the Eclipse GUI) are confined to one active loaded patient file at a time, the stand‐alone executables can gain access to the entire Eclipse radiation treatment planning (RTP) patient database and access any ESAPI‐handled RTP objects from any existing patient. Users can run multiple collision checks in series without interfering with their planning progress in the Eclipse treatment planning system.The graphical user interface (GUI) of the Collision Avoider is shown in Figure The patient‐specific RTP objects or parameters are queried automatically through the Eclipse patient database using the patient ID . The software user then identifies the proton plan by selecting the corresponding course name and plan name. A list of the beams is then populated automatically according to the selected proton plan. The 3D graphical display will then automatically rotate the gantry and the robotic couch according to the selected beam. The Collision Avoider retrieves all patient‐derived structures  from the Aria database (associated with the selected plan) and displays up to four structures at a time. The RT structures were converted into 3D mesh objects to support their 3D representation within the GUI. All structures are automatically positioned to the corresponding planned beam isocenter. The most useful patient structure to evaluate potential interference between the proton gantry head and the patient is the external or body contour (outer skin boundary). Our clinical practice also includes dosimetrists contouring patient‐specific rigid immobilization as well as tertiary range shifter (or range pullback) devices, including but not limited to a custom Vac‐Lok (CIVCO) or Klarity Cushion  supporting the patient, foam padding for patient comfort, in‐house designed and fabricated bolus helmets,2.3As part of standard clinical workflow, a “table junction‐to‐computed tomography (CT) origin”  measurement is made at the time of CT simulation for every proton patient by the therapists and entered manually into the electronic medical record. This junction value is defined as the distance between the couch extension connection junction and the CT simulation reference or isocenter mark Figure . The CT The dosimetrist will create an external body or boundary contour based on the CT simulation images. This body structure is logically the primary 3D geometry used for collision evaluation with the Hitachi gantry head. Any immobilization devices that extend outside of the treatment couch will need to be contoured in the treatment planning system. Based on the specific clinical workflow employed at Mayo Clinic Rochester, once the dosimetrist completes the contouring process and picks the appropriate beam angles, the preliminary treatment plan will be sent for a “pre‐plan check” by a medical physicist. As part of this task, the Collision Avoider software is run by both the dosimetrist and the medical physicist to graphically verify the beam angles, which are achievable before the optimization process starts in Eclipse. Once the plan has been approved by the physician, clinical workflow stipulates that a secondary medical physicist performs the final plan check which includes re‐running the Collision Avoider software to confirm that the beams are deliverable prior to the first fraction patient treatment. During either the pre‐plan check or the final plan check, if a beam fails the collision evaluation, a new beam angle is selected, and a new plan will be created. The clinical collision detection process has been summarized in Figure As additional safety precaution, we employ a 3‐cm buffer margin such that when the distance between the 3D CAD models or patient contours becomes less than 3 cm, the user should send the beam configuration in question for a physical "angle check" on the treatment machine at the end of the day. The therapists generally perform this task independently  using the junction reference length and the beam parameters from plan. The supplied junction parameter provides an indexing reference mark where the patient would be on the treatment couch top. If additional three‐point shifts are required (to the isocenter location), the therapists will shift the PPS coordinate according to the treatment plan. In most angle‐check scenarios, patient immobilization devices such as the Orfit thermoplastic mask, breast board, or the Vac‐Lok are placed on the couch to evaluate potential impacts.2.4To define the beam angle complexity for each disease site, we investigated the commonly employed RTP couch and gantry angles, using spreadsheet records manually maintained by our dosimetrists and RTP Aria database queries from prior publication.33.1The validation of the Collision Avoider software consists of both 3D CAD model validation and evaluation with clinical treatment plans. Rigorous measurements were performed in the gantry rooms to validate the 3D CAD models. The following geometric validation was performed with gantry head and touch guard dimension, ERS45 device dimension, dimensions of the couch tops, dimensions of the robotic arms, distance between the laser isocenter and the base of the robotic arms, distance between the laser isocenter and the ERS45 device, and distance between the laser isocenter and the face of the gantry nozzle. Based on the validation, we estimated that uncertainty associated with the CAD models are less than 1 cm. The biggest uncertainty comes from the couch top modeling, since additional 1‐cm margin was built into the model as an additional safety precaution in the longitudinal direction. The initial testing of the Collision Avoider was performed using clinical treatment plans from 12 patients , four of which with known true positive colliding beam configurations . The Collision Avoider was able to predict all four true positive colliding beam configurations and eight true negative cases. No false positive configurations were reported. The four major types of collisional scenarios are reported in Table 3.2Table 3.3With the official updated clinical release of the Collision Avoider software between May of 2020 and June of 2021, a total of 1418 unique treatment courses have occurred at our facility. No on‐treatment collision events have been reported due to the inaccuracy of the Collision Avoider software. Our virtual collision check process with the software was able to correctly predict and prevent collisional events. Based on anecdotal experience, the time it requires to run a beam angle check with the Collision Avoider software is typically less than 10 min. The total time it takes to perform an actual angle check on the machine is 10–20 min depending on plan complexity.4We have successfully implemented a virtual collision detection process at our proton center to increase clinical efficiency and improve patient treatment safety. The reported methods can prevent problematic beam configurations with respect to the four common types of collisional scenarios encounter in our proton therapy clinic. Our collision avoidance workflow is quite thoroughly integrated with our current clinical workflow. Similar CAD modeling‐based proton studies have been reported before,Although it is relatively uncommon that immobilization devices protrude outside of the treatment couch top boundary, collision incidents are more likely to occur if these devices are not considered in the Collision Avoider software. Our clinical practice requires these Vac‐Lok devices to be included in the CT scan and contoured by our dosimetrists if they are adjacent to the treatment target. Such practice requires little effort up front but provides important benefits later in collision prevention.Being able to confidently predict where potential collision might occur can potentially increase a planner's creativity in selecting better beam configurations. Of all the treatment disease sites, IMPT treatment planning for the head and neck and brain targets require the most complex noncoplanar beam configurations. Our Collision Avoider GUI provides additional interactive methods for planners to select potential feasible gantry and couch angles based on a patient's external body contour and immobilization devices. We have estimated the number of modifications to the beam configuration is disease site dependent. The percent modification is the highest for the head and neck disease site with 30% of the beam configuration needed modification during the planning process based on the feedback from the Collision Avoider.We should mention that the deployment of the Collision Avoider software has been implemented in two separate phases. The initial beta testing version released prior to 2020 has been extremely important in eliciting user feedback from all workgroups in our department. The validated clinical version released in May 2020 was enhanced based on the feedback collected. The Collision Avoider software currently only provides graphical validations through user input selections; a simple "pass" or "fail" output can be generated to decrease user interaction for each beam configuration. In addition, it may be beneficial to add a separate module to automatically detect low density immobilization devices in the CT image set to alert users.Furthermore, original inception of Collision Avoider relied on a local install of Aria  software; more recently, Collision Avoider was deployed as a stand‐alone Citrix application to all radiation oncology stakeholders and is now being maintained by information technology staff, which improves accessibility and scalability within our busy clinical environment.In a broader context, the future fully or semi‐automated beam angle optimization (BAO) for a half gantry proton system relies on a highly accurate and efficient collision avoidance solution. A rich database of prior workable beam configurations can be established for complex disease sites per clinic‐specific practice. Synchronization between the mathematical solutions to BAO problem and a practical beam configuration database can potentially aid the design of a fully automated treatment planning system that is disease site and patient specific.5A highly efficient patient‐specific collision prevention program for scanning proton therapy has been successfully implemented. The graphical program has provided accurate collision detection since its operation at our institution.The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.Jingjing M. Dougherty, Thomas J. Whitaker, Erik J. Tryggestad conceived and planned the studies. Jingjing M. Dougherty, Thomas J. Whitaker, Daniel W. Mundy, Erik J. Tryggestad, and Chris J. Beltran contributed to the interpretation of the results. Jingjing M. Dougherty took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.


This research aimed to assess women's willingness to receive advice about cervical and bowel cancer screening participation and advice on cancer symptom awareness when attending breast cancer screening.n = 322) aged 60–64 years, living in the United Kingdom, who had previously taken part in breast cancer screening were recruited via a market research panel. They completed an online survey assessing willingness to receive advice, the potential impact of advice on breast screening participation, prospective acceptability and preferences for mode and timing of advice.Women  and bowel cancer screening (90%) and early symptoms of other cancers (92%) at a breast cancer screening appointment. Those who were not up to date with cervical cancer screening were less willing. Prospective acceptability was high for all three forms of advice and was associated with willingness to receive advice. Women would prefer to receive advice through a leaflet (41%) or discussion with the mammographer (30%) either before the appointment (27%), at the appointment (44%) or with their results (22%).While there is high willingness and high acceptability towards using breast cancer screening as a teachable moment for advice about prevention and early detection of other cancers, some women find it unacceptable and this may reduce their likelihood of attending a breast screening appointment.This study focused on gaining women's insights into potential future initiatives to encourage screening and early diagnosis of cancer. Members of the public were also involved in piloting the questionnaire. In England, when breast cancer is detected at an early stage, the 5‐year survival rate approaches 98%. In contrast, women who are diagnosed with advanced‐stage breast cancer have a 26% five‐year survival rate.One means of prevention and early detection of cancer is participation in screening programmes to detect asymptomatic cancer or precancer. Another is raising awareness and encouraging timely help‐seeking for those with symptoms. In England, the majority of cancers are diagnosed via presentation with symptoms (80%) rather than through screening (6%).In the United Kingdom, screening programmes exist for breast, cervical and bowel cancer. For breast cancer, women aged 50–70 years are invited to undergo an X‐ray of the breasts (mammogram) every 3 years. Cervical cancer screening is targeted at women aged 25–64 years. Women are initially invited every 3 years, and then every 5 years from age 50. Cervical screening originally involved a Pap smear with cytology testing. More recently, this has moved to initial human papillomavirus (HPV) testing with cytology triage for those who are HPV positive. Bowel cancer screening is offered to all adults aged 60–74 years (50–74 in Scotland) and requires a stool sample every 2 years . Previously, flexible sigmoidoscopy (‘bowel scope’) screening was offered at age 55 years, but this is no longer included in the NHS bowel cancer screening programme. The uptake of cancer screening is variable, with the lowest uptake for bowel cancer screening. Although it is higher for breast and cervical screening, coverage has been decreasing over time.A recent study investigated how many women aged 60–65 years  participated in all three during their last invitation round.One way to increase participation in cancer screening is through reminders such as personalized phone calls, letters and text messages.There is some existing research on willingness to receive lifestyle advice within screening programmes. The results revealed that the majority of participants expressed willingness to receive lifestyle advice at cervical, breast, lung and bowel cancer screenings. However, a smaller number indicated that they would be less likely to take part in lung cancer screening if lifestyle advice was provided.This study focuses on breast cancer screening as a teachable moment to encourage screening and early detection of other cancers. We aimed to investigate and compare women's willingness to receive advice about cervical cancer screening participation, bowel cancer screening participation and advice on cancer symptom awareness when attending breast cancer screening and women's prospective acceptability of receiving such advice. A secondary objective was to develop a measure of acceptability underpinned by the TFA, to support these investigations.22.1The study involved a cross‐sectional online survey of women eligible for all three national screening programmes.2.2Women fulfilled the inclusion criteria if they were aged between 60 and 64 years, lived in the United Kingdom and had previously taken part in the UK national breast cancer screening programme.2.3www.Dynata.com), was used to recruit participants to the online survey in June 2020. The agency circulated the study link to women in the United Kingdom aged 60–64 years. Through Office 365 Microsoft Forms, women were presented with an online information sheet explaining the purpose of the study and were asked to complete a consent form before starting the questionnaire .2.4.4Yes, definitely; Yes, probably) and not willing  for the analysis.Willingness to receive advice about early detection of other cancers was measured using three versions of the item developed by Stevens et al.2.4.5‘If you knew you would receive advice about cervical cancer screening [bowel cancer screening/early symptoms of different types of cancer] as part of a breast cancer screening appointment, would this make you less likely to attend breast screening?’ This is adapted from the measure used by Stevens et al.No, definitely not; No probably not] and ‘Possible adverse impact on attendance’ ).Participants were asked three versions of the following item: 2.4.6Acceptability of receiving advice on cervical screening, bowel screening and cancer symptoms was measured using two subscales reflecting cognitive acceptability and affective acceptability. Every item was asked in relation to each type of advice. This was a newly developed measure for this study. Items were developed to capture the domains of the TFA2.4.7α = .88), bowel cancer screening (Cronbach's α = .90) and symptoms of cancer (Cronbach's α = .92).Eight items assessed cognitive acceptability, reflecting the TFA2.4.8α = .92), bowel cancer screening (Cronbach's α = .93) and symptoms of cancer (Cronbach's α = .92).Five reverse‐scored items assessed affective acceptability reflecting the perceived emotional consequence of the intervention. Higher scores on this subscale (range: 5–25) indicate lower levels of negative emotions and, as such, a higher level of affective acceptability. This subscale demonstrated good internal reliability in relation to receiving advice about cervical cancer screening  were also excluded.Two quality assurance measures for online surveys were used before data analysis. First, ‘speeders’, participants who completed the online survey in less than a quarter of the average survey time, were excluded from analyses. Second, participants who did not respond correctly to a direct question . Where significance testing was necessary for the interpretation of results, p< .05 was used.Using previous estimates of willingness to receive lifestyle advice at breast cancer screening,3N = 367 women fulfilled the inclusion criteria and completed the questionnaire. Forty‐five participants were removed from analysis following the quality assurance checks , resulting in a sample of n = 322. Table n = 208, 65%), of White ethnicity  and educated to below bachelor's degree level . A substantial proportion were current or ex‐smokers . The majority of women did not meet the recommended guidelines for fruit/vegetable consumption . A total of 24% (n = 78) participants indicated that they did no physical exercise at all. The majority of participants were up to date with breast cancer screening ; somewhat fewer were up to date with cervical screening  and bowel screening .3.1Q indicated that willingness to receive advice at a breast cancer screening appointment differed according to the content of that advice . While the proportion of women willing to receive advice about bowel cancer screening (90%) and early symptoms of cancer (92%) was similar, willingness to receive advice about cervical cancer screening was significantly lower .Over 85% of women indicated that they would be willing to receive information about cervical cancer screening, bowel cancer screening and early symptoms of other cancers at a breast cancer screening appointment (see Table The preferred ways to receive advice were by leaflet (preferred by 41% of women) and discussion with the mammographer (preferred by 30% of women) and before the appointment (preferred by 27% of women), at the appointment (preferred by 44% of women) or with results , which in turn was higher than that for receiving advice about cervical cancer screening . Affective acceptability was similar across the three types of advice.Cognitive and affective acceptability were high for all three forms of advice see File . The Wil3.2Q = 5.8, df = 2; p= .056) indicated that the prospect of receiving advice about bowel cancer screening or early symptoms of other cancers could reduce the likelihood of participation in the breast cancer screening programme.Thirteen percent  of women indicated that the prospect of receiving advice about cervical cancer may reduce their likelihood of attending a breast screening appointment. A similar proportion  and cognitive acceptability  were independent factors associated with willingness to receive advice about cervical cancer screening.Univariate logistic regression .With regard to advice about bowel cancer screening, in the univariate analysis, women who were not up to date with bowel screening were less willing to receive advice about bowel cancer screening, although this was not significant at the multivariable level. Higher cognitive and affective acceptability were associated with increased willingness to receive advice about bowel cancer screening, and these remained independent factors in the multivariable analysis , and cognitive  and affective acceptability  remained significantly associated at the multivariable level.With regard to willingness to receive information about symptoms of other cancers, women were less willing to receive this advice if they were not up to date with bowel and cervical cancer screening. Again, higher cognitive and affective acceptability were associated with increased willingness to receive advice. No cervical cancer screening within the last 5 years (OR = 0.34, 95% CI: 0.13–0.88; 4In this survey of women eligible for all three UK national cancer screening programmes, there were high levels of willingness and acceptability towards receiving advice about screening and early detection of other cancers alongside breast cancer screening. Women would prefer such advice to be provided through a leaflet or discussion with the mammographer at the breast cancer screening appointment although some would prefer the information to be provided before the appointment or with their breast screening results. Existing interventions that have utilized the breast cancer screening programme as a teachable moment have focused on early detection of breast cancer by raising awareness and encouraging early presentation of symptomsThe new measures of cognitive and affective acceptability underpinned by the TFAWomen were less willing to receive advice about cervical cancer screening compared to advice about bowel cancer screening or symptoms of other cancers, and the prospect of receiving advice about cervical cancer screening was found to be the least acceptable. This suggests that there are certain issues with cervical screening advice that may not be present in advice about bowel screening and early symptoms of different types of cancer. This could be because women in this age group see cervical screening as less necessary or it could be a result of a range of previously documented concerns about cervical screening,In contrast to previous research that has highlighted that education and ethnicity may affect willingness to receive advice about lifestyle,4.1These findings extend the existing literature, providing a better understanding about whether or not women find it acceptable to receive advice about screening and early detection of other cancers while at a breast cancer screening appointment, and how that in turn may affect their willingness to receive the advice. Use of the TFA to examine acceptability was helpful in identifying women's beliefs about the provision of advice. The findings from this study can help to understand the use of breast cancer screening as a teachable moment.However, this study has limitations: The study used a self‐reported questionnaire in a cross‐sectional design; therefore, causation cannot be established. Women were not asked about hysterectomy: A proportion of respondents may have been ineligible for cervical screening, which in turn may have affected recent screening attendance and willingness to receive advice about cervical cancer screening. The data were also collected in June 2020 when the national breast cancer screening programme had been paused in the United Kingdom due to the COVID‐19 pandemic. It is unknown how this may have affected the data. Despite this, relationships could be deduced, and the sample size provided power to detect associations. A further limitation is that the sample included very few women from ethnic backgrounds other than White. It is therefore not possible to generalize the findings to the wider population, especially as women from ethnic minority backgrounds tend to show lower screening uptake.5On the one hand, there is high willingness and high acceptability towards using breast cancer screening as a teachable moment. However, the few women who find it unacceptable and are less willing to receive the advice about screening and early diagnosis may be the intended target of such an intervention and the very women who would benefit the most.The authors declare that there are no conflicts of interest.Supporting information.Click here for additional data file.


Although bilateral pheochromocytoma is prevalent in patients with multiple endocrine neoplasia type 2, extra‐adrenal tumors rarely occur in the aortocaval area.RET codon Cys634Arg mutation) underwent bilateral adrenalectomy for metachronous pheochromocytoma. After bilateral adrenalectomy, urinary metanephrines decreased below the measurement sensitivity. The levels of urinary metanephrines were serially elevating to a peak of 187 ng/mgCr during the 11‐year follow‐up period; however, urinary normetanephrine levels remained almost stable. 123I‐metaiodobenzylguanidine single‐photon emission computed tomography revealed abnormal accumulation with a mass of 25 × 18 mm in diameter in the aortocaval space cranially to the renal vessels. The extra‐adrenal paraganglioma was successfully resected using transperitoneal laparoscopic surgery.A 35‐year‐old man with multiple endocrine neoplasia type 2A (The serial increase in urinary metanephrine levels was useful for the detection of the recurrent tumor in a patient who had undergone bilateral adrenalectomy. Although the prognosis of MEN2 depends mainly on medullary thyroid cancer aggressiveness, pheochromocytoma is a major component of the syndrome, known to have an increased incidence with age.et␣al. reported that extra‐adrenal tumors occurred in 5 out of 563 patients with pheochromocytomas associated with MEN2. All the tumors were in the aortocaval space close to the adrenal glands, in five patients who already had bilateral pheochromocytomas.et␣al. reported that the urinary metanephrine (MN) concentration after bilateral adrenalectomy was lower than that in the reference population,MEN2 is an autosomal dominant genetic disorder caused by mutations in the RET codon Cys634Arg mutation) by genetic testing. In 2016, he was referred to our hospital because of elevated urinary MNs measured by spot urine samples. The levels of urinary MNs were serially elevated from 51 to 187 ng/mg Cr between 2016 and 2019 with no apparent symptoms , and the changes in urinary MNs persisted during follow‐up.et␣al. reported that recurrent pheochromocytoma could be detected before the onset of symptoms, based on an increase in urinary MN plus NMN.Although the adrenal medulla and sympathetic nervous system represent the sources of catecholamine production in healthy individuals, the single largest source of MNs is the adrenal medulla.Extra‐adrenal paraganglioma in MEN2 can rarely occur, but predominantly in the aortocaval space close to the adrenal glands.RET codon 634. Imai et␣al. reported that most patients with a RET codon 634 mutation develop pheochromocytomas as well as medullary thyroid carcinoma during their lifetimes.RET codon 634 mutation is associated with a risk of aggressive medullary thyroid carcinoma.RET mutations and the potential risk of extra‐adrenal paraganglioma is unknown, the aggressive nature of codon 634 requires careful follow‐up.In the present case, the patient had a mutation in An aortocaval paraganglioma was successfully resected using transperitoneal laparoscopic surgery. A serial increase in urinary MN levels can be a useful marker for the early detection of recurrent tumors in patients who have undergone bilateral adrenalectomy.The authors declare no conflict of interest.Not applicable.All human subjects provided written informed consent with guarantees of confidentiality.Not applicable.


N = 230), infant crying variables based on maternal reports were not associated with PIM at 1 week, but LPS was. However, a mother's expectation that her infant would cry more than other infants was associated with increased odds of reporting PIM at 2 and 4 weeks, as were delayed onset of lactation and previous LPS. At 1 week, crying variables  were associated with LPS along with percent weight change. Delayed onset of lactation, infant care style, number of breastfeeds and previous LPS were longitudinally associated with change in LPS from 1 to 2 weeks and 2 to 4 weeks. Our data suggest that reported infant crying is associated with PIM and LPS in the first 4 weeks of life. Guidance on what to expect in crying behaviour and the impact of infant care style may be beneficial in reducing PIM and LPS in the first month.Breastfeeding mothers often report perceived insufficient milk (PIM) believing their infant is crying too much, which leads to introducing formula and the early abandonment of breastfeeding. We sought to determine if infant crying was associated with reported PIM (yes/no) and number of problems associated with lactation  before formula introduction. Primiparous breastfeeding mothers were recruited at birth and visited at 1, 2 and 4 weeks. Among those fully breastfeeding at 1 week ( Reported infant crying is associated with perceived insufficient milk and reported lactation problems among women fully breastfeeding at 1 and/or 2 weeks of life.Higher lactation problem score precedes later reports of perceived insufficient milk, highlighting the need for extra support with lactation as early as possible, especially among women experiencing delayed onset of lactation.Giving new mothers anticipatory guidance on crying behaviour and a wider array of coping strategies, especially among mothers who expect it to be challenging for them, has the potential to reduce early lactation problems.1Exclusive breastfeeding has wide‐reaching benefits to infants, mothers and societies , a delay of more than 72 h postpartum in production of copious breast milk after colostrum, is also a risk factor for PIM  both cross‐sectionally (at 1 week) and longitudinally within the first month of life.Our aims were to explore the associations between different aspects of infant crying, PIM and perceived lactation problems among mothers fully breastfeeding according to the definition by Labbok and Krasovec . This in22.1This is part of a larger longitudinal study of mother‐infant dyads followed from birth to 24 weeks of infant age , full‐term (≥37 weeks of gestation) infants who planned to breastfeed their child and not undertake paid employment until the infant's 6 month birth day. This is because we did not want to include women who planned to stop breastfeeding or introduce formula because they were returning to work. Ethical approval was obtained from the relevant institutions in the United Kingdom, the United States and Mexico.Trained project field workers collected data related to the baby's measurements and delivery from the women's medical charts at the time women gave informed written consent to participate in the study. Women were weighed and measured by project fieldworkers at the hospital and arrangements were made to visit them in their homes. Lactation support was provided by hospital nurses prior to hospital discharge. At each home visit, women were interviewed using the questionnaires described below. Infants were weighed to the nearest 10 g ; measurements were taken in duplicate, following published guidelines, and an average weight was used. The full study consisted of nine visits in the first 6 months of life. In this paper, we include data from recruitment in the hospital and at the first three visits . This is because the first week postpartum is an important time for the initial establishment of lactation . This was followed by a request to describe the problems in an open‐ended question (‘Please explain’). If their explanations included concerns related to breast milk adequacy , these were classified as a report of PIM (yes/no) in a dichotomous variable. Any additional references related to the quantity or quality of breast milk made by the mother on other related questions  were also counted as a report of PIM. PIM and LPS at 1, 2 and 4 weeks were our main outcome variables.Our outcome variables were derived from questions related to lactation problems. The LPS originated from the question  did report PIM, and some mothers reporting a higher LPS score  did not report PIM. We thus hypothesized that our PIM and LPS measures were measuring different constructs and that crying might be associated with PIM as well as LPS.very easily to with great difficulty) and allowing to self‐soothe was estimated from the question ‘How often do you let your baby cry alone until s/he soothes her/himself?’  answered by mothers at each follow‐up visit.Our main explanatory variables of interest were those related to infant crying: (a) general crying expectation, (b) crying frequency, (c) difficulty in soothing and (d) allowing to self‐soothe. We adapted the Crying Patterns Questionnaire . This 39‐item questionnaire had been developed during formative qualitative research in this population and is included in its original format in the completely disagree to completely agree. A total percent score was calculated from all the items. Higher scores indicated a more distal approach to infant care. The alpha coefficient of the scale in this sample of mothers was 0.80.on‐time—within 3 days of the infant's birth; or delayed—4 or more days since the infant's birth. However, this question was only included after the study had begun, resulting in missing data on this variable for roughly one‐third of our study sample.DOL was also assessed at 1 week using the question: ‘When did your milk come in?’ The number of days was then calculated using the infant's birth date and was classified as a dichotomous variable: I'm unable do this) to 6 (I'm perfectly able to do this). A score was then calculated by adding all the responses and a percentage was obtained based on a maximum total score of 60 points for 10 items.We measured maternal self‐efficacy following the methodology described by Olioff and Aboud . Each woNumber of breast feeds was obtained from 3‐day infant feeding recalls. Average daily percent weight change in the infant was assessed by calculating the percent difference in measurements taken divided by the number of days between each visit.2.3Our hypotheses related to crying and PIM were that:One or more of our four crying variables would be cross‐sectionally associated with report of PIM in the first week of breastfeeding ;One or more of our four crying variables would be longitudinally associated with the report of PIM.2.Our hypotheses related to crying and LPS were that:One or more of our four crying variables would be cross‐sectionally associated with LPS at 1 week of age;Crying at one time‐point would be associated with a change in LPS from one visit to the next.proximal or distal) and/or maternal self‐efficacy  at visit 1 (Hypotheses N = 230 at week 1 and N = 244 at week 2).For the cross‐sectional analyses we only included mothers fully breastfeeding  as well as other predictor variables potentially associated with PIM or LPS . RCSISBM score and number of breastfeeds were conceptualized as confounding variables associated both with crying variables and with PIM. We decided to adjust for potential confounders including maternal education, age, mode of delivery and maternal self‐efficacy as these have been found to be associated with exclusive and predominant breastfeeding  National Research Commission and the University of Surrey Ethics Committee (CGA Ref No. UEC2019 023FHMS (RC4062)).3A total of 475 women were recruited to the study. Roughly one‐fourth of the women 26%) were lost‐to‐follow‐up after recruitment  and DOL  was significantly higher among those not fully breastfeeding than among those who were. LPS was also higher among those not fully breastfeeding , but average daily percent weight change and maternal self‐efficacy were not. Among those fully breastfeeding, those who experienced DOL had significantly lower RCSISBM scores  than those reporting timely onset of lactation .Two hundred ninety women were visited at 1 week. Twenty‐one percent had already begun adding formula to their infant's diet. The main lactation problems described were PIM , painful or cracked nipples , inverted nipples  and infant sleepy or rejecting the breast . Fifteen women reported PIM in other open‐ended questions not directly related to lactation problems. The report of PIM  are listed in Table Maternal and infant baseline characteristics of those fully breastfeeding . On the other hand, there was no significant differences by mode of delivery in the percentage of women reporting PIM  or in LPS scores  at 1 week.Infants fully breastfed at 1 week and delivered by caesarean had lower percent weight change  in the first 7 days of life than those delivered vaginally . The proportion of women reporting DOL in our sample was also significantly higher among those who delivered by caesarean as compared with those delivering vaginally .Reported DOL was significantly associated with lower number of breastfeeds at 1 week in this sample of fully breastfeeding women  and lower LPS at 1 week  were also each negatively associated with maternal self‐efficacy in univariate analyses. Hypothesis 2.1Cross‐sectional associations between crying and LPS at 1 week.Expecting the infant to cry more in comparison with other infants  was associated with higher odds of reporting PIM at 2 or 4 weeks. Higher LPS at the previous visit and DOL were also associated with higher odds of reporting PIM at 2 and 4 weeks. Interestingly, although maternal self‐efficacy was not significantly associated with reports of PIM, both higher general crying expectations  was associated with higher odds of LPS staying the same or increasing.Allowing the infant to self‐soothe more frequently at the previous visit was associated with lower odds of LPS remaining the same or increasing from 1 to 2 weeks or 2 to 4 weeks, as were higher LPS and higher number of breastfeeds at the previous visit. Women reporting DOL had higher odds of LPS staying the same or increasing as compared with those reporting timely onset of lactation. In addition, a unit increase in percent RCSISBM score  and the absence of data on the onset of lactation for the entire sample. The sample characteristics of this population were also relatively homogeneous (mid‐to‐lower class first‐time Mexican mothers) and may be of limited generalizability to other populations. On the other hand, PIM is a world‐wide phenomenon, and similar associations between infant care styles and breastfeeding have also been observed in different countries.There is a need for future research to explore if interventions providing women with anticipatory guidance on normal infant crying behaviour, the pros and cons of adopting a more proximal or distal infant care style, as well as challenges which they may be unfamiliar with but which are often encountered in the first days of breastfeeding  would result in fewer lactation problems, a decrease in the number of women reporting PIM and an increase in the number of women exclusive breastfeeding.The authors declare that they have no conflicts of interest.LM and LC designed the study. LM conducted the study with support from LC and HM. LM analysed the data and drafted the manuscript with support from PH, SB, MR and MMR. All authors  revised the manuscript and approved its final version. LM has primary responsibility for the final content.Data S1 Supporting InformationClick here for additional data file.


Eumaeus atala Poey) resulted in colony failure during winter due to lack of food. To overcome this barrier, we developed a modified freeze‐dried host plant diet to support the colony. The diet consisted of reconstituted freeze‐dried leaves and stems from fresh‐growth coontie (Zamia integrifolia), the host plant for the Atala butterflies. We fed larvae less than 9 mm on this freeze‐dried diet and transferred them to live coontie plants after they were more than 9 mm. We reared a colony of Atala butterflies using these methods for 859 days, resulting in more than 3400 animals released into the wild. Comparing colony counts during that time period to the 548 days we reared them without modified freeze‐dried diet showed a clear benefit in using freeze‐dried diet. A growth trial (N = 40) of larvae fed on only freeze‐dried diet compared to larvae fed on fresh coontie cuttings found no significant difference in larval or pupal development between groups . We, therefore, conclude that the freeze‐dried diet provided an appropriate alternative for Atala colonies when fresh growth from the host plant is unavailable, and we recommend use of this technique for raising other host plant‐dependent insect species of conservation concern.Raising insects in a laboratory for release into the wild is a common conservation practice, but maintaining breeding colonies year‐round can be limited by seasonal food availability. Food availability is particularly challenging for insects which depend on specific host plants. For example, our early efforts to rear the imperiled Atala hairstreak butterfly  using methods that could potentially be replicated for other butterfliesAfter a colony failure due to food shortage, we created a modified freeze‐dried diet for the imperiled Atala hairstreak butterfly (The diet was highly successful, leading to the rearing and release of over 3800 adult butterflies back into the wildKey to the methods was using pure, new‐growth host plant, and switching larger larvae back to mature leaves For example, a 2017 study found that flying insect biomass in protected areas throughout Germany had declined 76% in just 27 years .The present study explored the effect of using processed and stored host plant material on the rearing and development of Atala hairstreak caterpillars in a laboratory setting and we present possible methods to overcome a seasonal dearth of the host plant supply to support a butterfly colony year‐round. In particular, we focused on the creation of a modified freeze‐dried diet to support the ex situ propagation and release of Atala hairstreak butterflies  in the continental USA is restricted to a single species of host plant for oviposition and larval consumption: Zamia integrifolia (synonyms include Zamia pumila and Zamia floridana), commonly known (and hereafter referred to) as “coontie.” Atala butterflies are able to use some other species of cycad, such as Zamia erosa , but coontie is the only native cycad for Atala butterflies in the continental United States. The starchy root of coontie is edible, and around the turn of the twentieth century, European settlers greatly overharvested coontie for food  using the Research Proposal Form designed by the AZA Research and Technology Committee. These methods describe our current rearing practices for Atala butterflies, which we applied through the duration of this study (from October 2017 to March 2020). Before the development of the freeze‐dried diet described in the present manuscript, we fed the colony live coontie plants only. Since the development of the freeze‐dried diet, we use fresh growth coontie whenever it is available, and freeze‐dried diet as needed when fresh growth is not available .We raised the insects in a temperature and humidity‐controlled environment  in the invertebrate husbandry building at Disney's Animal Kingdom . The invertebrate husbandry building uses the following light schedule: white light from 0700 to 1700, red light from 1700 to 1930, and dark from 1930 to 0700. We collected fresh growth coontie during the optimal portion of the growing season . Fresh growth is new plant material that has grown within, approximately, the prior 2–3 weeks. It can be distinguished by its light shade of green and relative softness compared to other parts of the plant. In total, we harvested enough fresh growth coontie over one summer to create 1221 g of freeze‐dried food for winter use. We cut the fronds off at the base plant near the soil using gardening sheers, placed the fronds in plastic sealable freezer bags, and placed the bags in a walk‐in freezer at −17.8°C to −6.7°C for at least 24 h. The frozen plants were lyophilized (freeze‐dried) using a Virtis Genesis SQ 35XL freeze dryer system (SP Scientific). The plants were brought from −50°C to room temperature over a 60‐h period at a consistent vacuum pressure of approximately 300mTorr. Freeze‐dried plants were crushed into a fine green powder  with a Ninja Mater Prep Professional QB1004 food grinder (SharkNinja Operating LLC.). To maximize longevity, we stored the freeze‐dried powder in sealed plastic bags at −28.9°C. Photos of the final powder can be found in Appendices and Supporting Information.Before feeding the modified freeze‐dried diet to Atala larvae, we rehydrated the pulverized, freeze‐dried coontie powder with water using a ratio of 1 g dried coontie powder to 4.25 g water, resulting in a thick paste. Although leaf moisture has been shown to be a critical component affecting the growth rate of insect larvae  atala larvae. We spread 0.5–1.0 tsp. of the paste at a thickness of 0.5 cm onto upturned 8 oz. natural polypropylene jars or “feeding trays”  (see photos in Appendices and Supporting Information). Each day we used “bridges” of either mature coontie leaves or wooden sticks to encourage the larvae to crawl on their own from the old feeding tray to the fresh one (see photos in Appendices and Supporting Information). Larvae walked over the bridges to the fresh feeding trays, and the used trays were removed. We used soft, damp brushes to transfer any larvae that remained or wandered in the wrong direction.After the Atala larvae became larger than approximately 9 mm, we moved them to a diet of mature coontie leaves. By restricting the use of the modified freeze‐dried diet to the smallest larvae, we increased efficiency and reduced labor costs for diet preparation. After the insects completed metamorphosis, we placed the adult butterflies in a flight cage with a coontie plant to encourage egg laying and an artificial nectar feeder (see photos in Appendices and Supporting Information). Note that we eventually replaced the whole plant with sprigs. We try to keep at least 60 adult Atala butterflies in the adult flight enclosure, and the enclosure also has lights and a fan to promote air circulation  were randomly assigned to an experimental group and half (N = 20) were assigned to a control group. Larvae in the experimental group were fed only hydrated freeze‐dried diet. We reared them using the same methods described previously: we spread food paste onto upturned polypropylene jars and used “bridges” to encourage the larvae to crawl from the old feeding tray to the fresh one. The 20 larvae in this preliminary experimental group were never transferred to a diet of coontie clippings and were instead fed the freeze dried diet until pupation. Larvae in the control group were reared using the exact same methods and conditions as the experimental group but were only fed clipped sprigs of fresh‐growth coontie (see photos in Appendices and Supporting Information). The sprigs of coontie were kept fresh and hydrated using floral water picks. We counted larvae, pupae, and adults each day during the experimental trial.Before changing the entire colony to a new diet, we reared an experimental growth trial group of 40 small (<5 mm) larvae. Half  pupated, spending a range of 14–16 days in the larval stage  Figure . We usedWe suggest three major lines of follow‐up research. First, based on the success of the freeze‐dried diet with the Atala butterfly colony, the freeze‐drying method could be used to create diets for maintaining colonies of other species dependent on seasonal host plants and provide opportunities for supplementing the diet of other imperiled species in managed care. For example, rearing the endangered Miami blue butterfly requires constant fresh knicker bean, and most monarch conservation plans require milkweed planting CEC, . Special5Our methods of using modified freeze‐dried to feed larvae less than 9 mm and fresh plants to feed larger larvae were successful in maintaining a colony of Atala hairstreak butterfliesThe larvae fed on freeze‐dried diet did not differ from larvae fed fresh coontie in pupation and emergence ratesMethods for creating this simple diet could potentially be applied to other specialized butterfliesPotential further research for this species includes: optimal diet storage parameters, egg viability, nutrient content, toxicity of larvae, and greater detail on growth rates and weights of larvae fed on freeze‐dried dietThe authors declare that there are no conflict of interests.Supporting information.Click here for additional data file.