bluuebunny/crossref_metadata_2025 huggingface dataset:
Proteomic characterization of obesity-related nephropathy
Authors: Wendt Ralph , He Tianlin , Latosinska Agnieszka , Siwy Justyna , Mischak Harald , Beige Joachim
Published: January 2020

Background

Nephropathy related to obesity lacks a pathophysiological understanding and definite diagnostic pathways by biomarkers.

Methods

In this study we investigated the association between urinary peptides and body mass index (BMI) and renal function in proteome data sets from 4015 individuals.

Results

A total of 365 urinary peptides were identified to be significantly associated with BMI. The majority of these peptides were collagen fragments. In addition, most of the peptides also demonstrated a significant concordant association with estimated glomerular filtration rate (eGFR) in the investigated cohort, with the presence of diabetes exhibiting no significant association. A new classifier was developed, based on 150 urinary peptides, that enabled the distinction of non-obese subjects with preserved kidney function from obese, non-diabetic subjects with eGFR >45 mL/min/1.73 m2 in an independent cohort, with an area under the curve of 0.93.

Conclusions

On a molecular level, the data strongly suggest a link between obesity and fibrosis, which may be a major cause of obesity-related nephropathy.
Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease
Authors: Ramspek Chava L , Verberne Wouter R , van Buren Marjolijn , Dekker Friedo W , Bos Willem Jan W , van Diepen Merel
Published: January 2020

Background

Conservative care (CC) may be a valid alternative to dialysis for certain older patients with advanced chronic kidney disease (CKD). A model that predicts patient prognosis on both treatment pathways could be of value in shared decision-making. Therefore, the aim is to develop a prediction tool that predicts the mortality risk for the same patient for both dialysis and CC from the time of treatment decision.

Methods

CKD Stage 4/5 patients aged ≥70 years, treated at a single centre in the Netherlands, were included between 2004 and 2016. Predictors were collected at treatment decision and selected based on literature and an expert panel. Outcome was 2-year mortality. Basic and extended logistic regression models were developed for both the dialysis and CC groups. These models were internally validated with bootstrapping. Model performance was assessed with discrimination and calibration.

Results

In total, 366 patients were included, of which 126 chose CC. Pre-selected predictors for the basic model were age, estimated glomerular filtration rate, malignancy and cardiovascular disease. Discrimination was moderate, with optimism-corrected C-statistics ranging from 0.675 to 0.750. Calibration plots showed good calibration.

Conclusions

A prediction tool that predicts 2-year mortality was developed to provide older advanced CKD patients with individualized prognosis estimates for both dialysis and CC. Future studies are needed to test whether our findings hold in other CKD populations. Following external validation, this prediction tool could be used to compare a patient’s prognosis on both dialysis and CC, and help to inform treatment decision-making.
Association between perivascular inflammation and downstream myocardial perfusion in patients with suspected coronary artery disease
Authors: Nomura Cesar H , Assuncao-Jr Antonildes N , Guimarães Patricia O , Liberato Gabriela , Morais Thamara C , Fahel Mateus G , Giorgi Maria C P , Meneghetti José C , Parga Jose R , Dantas-Jr Roberto N , Cerri Giovanni G
Published: January 2020

Aims

To investigate the association between pericoronary adipose tissue (PCAT) computed tomography (CT) attenuation derived from coronary computed tomography angiography (CTA) and coronary flow reserve (CFR) by positron emission tomography (PET) in patients with suspected coronary artery disease (CAD).

Methods and results

PCAT CT attenuation was measured in proximal segments of all major epicardial coronary vessels of 105 patients with suspected CAD. We evaluated the relationship between PCAT CT attenuation and other quantitative/qualitative CT-derived anatomic parameters with CFR by PET. Overall, the mean age was 60 ± 12 years and 93% had intermediate pre-test probability of obstructive CAD. Obstructive CAD (≥50% stenosis) was detected in 37 (35.2%) patients and impaired CFR (<2.0) in 32 (30.5%) patients. On a per-vessel analysis (315 vessels), obstructive CAD, non-calcified plaque volume, and PCAT CT attenuation were independently associated with CFR. In patients with coronary calcium score (CCS) <100, those with high-PCAT CT attenuation presented significantly lower CFR values than those with low-PCAT CT attenuation (2.47 ± 0.95 vs. 3.13 ± 0.89, P = 0.003). Among those without obstructive CAD, CFR was significantly lower in patients with high-PCAT CT attenuation (2.51 ± 0.95 vs. 3.02 ± 0.84, P = 0.021).

Conclusion

Coronary perivascular inflammation by CTA was independently associated with downstream myocardial perfusion by PET. In patients with low CCS or without obstructive CAD, CFR was lower in the presence of higher perivascular inflammation. PCAT CT attenuation might help identifying myocardial ischaemia particularly among patients who are traditionally considered non-high risk for future cardiovascular events.
1. Globalization and global politics
Authors: McGrew Anthony
Published: January 2020

This chapter examines the characteristics of contemporary globalization and how they are reshaping world politics. It explains why globalization challenges some of our traditional ways of thinking and theorizing about world politics. It asks whether there are limits to globalization or whether it is inevitable. It also considers the extent to which globalization is responsible for the emerging shift in the structure of world power, namely the ‘decline of the West’ and the ‘rise of the rest’. Two case studies are presented: one is about the iPhone and the iPad, and illustrates the implications of global production networks for national economic sovereignty; the other is about the global recycling system. There is also an Opposing Opinions box that tackles the question of whether globalization is eroding the power of the state.
3. International history of the twentieth century
Authors: Scott Len
Published: January 2020

This chapter focuses on some of the principal developments in world politics from 1900 to 1999: the development of total war, the advent of nuclear weapons, the onset of cold war, and the end of European imperialism. It shows how the confrontation between the United States and the Soviet Union became the key dynamic in world affairs, replacing the dominance of—and conflict among—European states in the first half of the twentieth century. It also examines the ways that the cold war promoted or prevented global conflict, how decolonization became entangled with East–West conflicts, and how dangerous the nuclear confrontation between East and West was. Finally, the chapter considers the role of nuclear weapons in specific phases of the cold war, notably in détente, and then with the deterioration of Soviet–American relations in the 1980s.
4. From the end of the cold war to a new world dis-order?
Authors: Cox Michael
Published: January 2020

This chapter provides a broad overview of the international system between the end of the cold war— when many claimed that liberalism and the West had triumphed— through to the second decade of the twenty-first century, when the West itself and the liberal economic order it had hitherto promoted appeared to be coming under increased pressure from political forces at home and new challenges abroad. But before we turn to the present, the chapter will look at some of the key developments since 1989—including the Clinton presidency, the George W. Bush administration’s foreign policy following the attacks of 9/11, the 2008 financial crash, the crisis in Europe, the transitions taking place in the global South, the origins of the upheavals now reshaping the Middle East, the political shift from Barack Obama to Donald Trump, the emergence of Asia, and the rise of China. The chapter then concludes by examining two big questions: first, is power now shifting away from the West, and second, to what extent does the current wave of populism in the West threaten globalization and the liberal order?
5. Rising powers and the emerging global order
Authors: Hurrell Andrew
Published: January 2020

This chapter examines the global order, led by the United States, that emerged at the end of the cold war and asks whether it has been effectively challenged by rising powers. It begins with a discussion of the challenges to the idea of a U.S.-dominated global order, focusing in particular on the role of large, emerging developing countries as well as the idea of the BRICS (Brazil, Russia, India, China, and South Africa) in the context of the future of the global economy. The chapter then considers the more recent economic slowdown in the emerging world, along with the political and social challenges facing many emerging societies. It also analyses some of the major theoretical arguments about the impact of rising powers on international relations and whether they are powerful enough to affect international order.
8. Realism
Authors: Dunne Tim , Schmidt Brian C.
Published: January 2020

This chapter examines the claim that realism offers the most powerful explanation for the state of war that is the regular condition of life in the international system. It first provides an overview of the theory of realism before discussing whether there is one realism or a variety of realisms. It argues that despite some important differences, all realist theories share a set of core assumptions and ideas. It goes on to consider these common elements, namely self-help, statism, and survival. The chapter concludes with an analysis of the extent to which realism is relevant for understanding the globalization of world politics. To illustrate the main ideas tackled in this chapter, two case studies are presented: one relating to the Melian dialogue and the other to strategic partnerships with ‘friendly’ dictators. There is also an Opposing Opinions box that asks whether U.S. hegemony is durable or fleeting.
13. International ethics
Authors: Shapcott Richard
Published: January 2020

This chapter examines how we should think about ethics, starting with three framing questions: Do states and their citizens have significant moral duties to the members of other countries? Should states and their militaries be morally constrained in the conduct of war? Who is morally responsible for the alleviation of global poverty? The chapter proceeds by defining ethics and considering three significant and difficult ethical issues entailed by globalization: cosmopolitanism, statism, and realist ethics. It concludes by examining the ethical dimensions of global poverty and just war. Two case studies are presented, one dealing with the ethics of migration and the other with the ethics of just war. There is also an Opposing Opinions box that debates who bears most responsibility for addressing global warming.
15. International and global security
Authors: Baylis John
Published: January 2020

This chapter examines whether international relations, especially in an era of increasing globalization, are likely to be as violent in the future as they have been in the past. It asks whether globalization increases or decreases international security, which International Relations theories best help to provide an understanding of global security and insecurity, and what are the most important contemporary threats to international security. The chapter first considers existing disagreements about the causes of war and whether violence is always likely to remain with us. It then discusses traditional/classical realist and more contemporary neorealist and neoliberal perspectives on international security, along with a range of alternative approaches. It also explores recent debates about globalization and geopolitics and presents two case studies, one on the conflict in the Democratic Republic of Congo and the other on growing tensions in the South and East China Seas.
17. Gender
Authors: Kirby Paul
Published: January 2020

This chapter examines the power of gender in global politics. It considers the different ways in which gender shapes world politics today, whether men dominate global politics at the expense of women, whether international—and globalized—gender norms should be radically changed, and if so, how. The chapter also discusses sex and gender in international perspective, along with global gender relations and the gendering of global politics, global security, and the global economy. Two case studies are presented, one dealing with the participation of female guerrillas in El Salvador's civil war, and the other with neo-slavery and care labour in Asia. There is also an Opposing Opinions box that asks whether war is inherently masculine.
28. Terrorism and globalization
Authors: Kiras James D.
Published: January 2020

This chapter examines how globalization has contributed to the growth of terrorism as a global phenomenon. It considers whether global terrorism is the price states pay for entry into and continued access to a globalized system, why violent Islamic extremism continues to be the primary motivator for global terrorist violence, and whether freedoms should be restricted to ensure greater security against the threat of global terrorism. The chapter first looks at the definitions of terrorism before tracing the transformation of terrorism from a transnational to a global phenomenon. It then explores the role of technology in terrorism and ways of combating terrorism. Two case studies are presented, one dealing with three generations of violent Islamic extremists and the other with the 2016 Lahore terrorist attack. There is also an Opposing Opinions box that asks whether states targeted by terrorism should aggressively address the threat beyond their national borders.
31. Human rights
Authors: Kapur Ratna
Published: January 2020

This chapter looks at human rights, analysing the structure and politics of human rights in the twenty-first century. In particular, the chapter examines the influence of liberal internationalism on human rights and how this is shaped by the legacies of colonialism, slavery, apartheid, and engagements with sexual, religious, and racial differences. The chapter encourages questions about whether rights are universal instruments of emancipation, or whether the rights are more complex, contradictory, and contingent in their functioning. The chapter also sets out the dominant understandings of human rights as progressive, universal, and based on a common human subject. Human rights advocates sometimes differ on the strategies to be adopted to address violations; these can have material, normative, and structural consequences that are not always empowering. These competing positions are illustrated through two case studies: one on the Islamic veil bans in Europe and the second on LGBT human rights interventions.
Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care
Authors: de Man Yvonne , Groenewoud Stef , Oosterveld-Vlug Mariska G , Brom Linda , Onwuteaka-Philipsen Bregje D , Westert Gert P , Atsma Femke
Published: January 2020

Objective

To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use.

Design

Cross-sectional claims data study.

Setting

The Netherlands.

Participants

Patients deceased in 2013–2015 with lung cancer (N = 25 553).

Main Outcome Measures

We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization.

Results

The utilization of hospital services in high-using regions is 2.3–3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level.

Conclusions

Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.
Machine learning for predicting long-term deflections in reinforce concrete flexural structures
Authors: Pham Anh-Duc , Ngo Ngoc-Tri , Nguyen Thi-Kha
Published: January 2020

Prediction of deflections of reinforced concrete (RC) flexural structures is vital to evaluate the workability and safety of structures during its life cycle. Empirical methods are limited to predict a long-term deflection of RC structures because they are difficult to consider all influencing factors. This study presents data-driven machine learning (ML) models to early predict the long-term deflections in RC structures. An experimental dataset was used to build and evaluate single and ensemble ML models. The models were trained and tested using the stratified 10-fold cross-validation algorithm. Analytical results revealed that the ML model is effective in predicting the deflection of RC structures with good accuracy of 0.972 in correlation coefficient (R), 8.190 mm in root mean square error (RMSE), 4.597 mm in mean absolute error (MAE), and 16.749% in mean absolute percentage error (MAPE). In performance comparison against with empirical methods, the prediction accuracy of the ML model improved significantly up to 66.41% in the RMSE and up to 82.04% in the MAE. As a contribution, this study proposed the effective ML model to facilitate designers in early forecasting long-term deflections in RC structures and evaluating their long-term serviceability and safety.
Exploring the International Criminal Court’s Deterrent Potential
Authors: Hodgson Natalie
Published: January 2020

Despite proclamations that the International Criminal Court (ICC) will deter the commission of international crimes, empirical support for such a proposition is mixed and there is much that is still unknown about the ICC’s deterrent potential. In this article, I add to knowledge on the ICC and deterrence with a case study of the ICC’s impact on government decision-making in Australia. Through a thematic analysis of Australian parliamentary records, I explore four instances where the potential for prosecution at the ICC was raised because of a government decision or policy, with a focus on the possibility of Australian politicians being prosecuted concerning Australia’s refugee policy. The fact that the risk of prosecution at the ICC was raised in parliamentary debates suggests that the ICC is capable of featuring in government decision-making and thus could have a deterrent effect. However, with respect to Australia’s refugee policy, the risk of prosecution at the ICC was outweighed by domestic political considerations, and hence this study found that the ICC had little to no deterrent effect on the government in that case. The perceived uncertainty of ICC prosecution was a key factor hindering the ICC’s potential for deterrence, and I suggest that this could have a flow-on effect, hindering the potential for extralegal sanctions to produce any deterrent effect and additionally undermining attempts at positive complementarity. For the ICC to realize its deterrent potential, the perceived certainty of prosecution must be increased.
Fichte on Summons and Self-Consciousness
Authors: Kosch Michelle
Published: January 2020

J. G. Fichte held that a form of intersubjectivity—what he called a ‘summons’—is a condition of possibility of self-consciousness. This thesis is widely taken to be one of Fichte’s most influential contributions to the European philosophy of the last two centuries. But what the thesis actually states is far from obvious; and existing interpretations either are poorly supported by the texts or else render the thesis trivial or implausible. I propose a new interpretation, on which Fichte’s claim is that reflective self-consciousness arises in the context of ad hoc efforts to coordinate action.
Mass from a third star: transformations of close compact-object binaries within hierarchical triples
Authors: Di Stefano R
Published: January 2020

Close-orbit binaries consisting of two compact objects are a centre of attention because of the detection of gravitational-radiation-induced mergers. The creation of close, compact-object binaries involves physical processes that are not yet well understood; there are open questions about the manner in which two compact objects come to be close enough to merge within a Hubble time. Here, we explore an important, and likely common physical process: mass transfer from a third star in a wider, hierarchical orbit. Mass added to the close binary’s components can reduce the time to merger and can even change the nature of an accretor, transforming a white dwarf to a neutron star and/or a neutron star to a black hole. Some accreting WDs in close binaries may even explode as Type Ia supernovae. Given the ubiquity of higher order multiples, the evolutionary channels we lay out may be important pathways to gravitational mergers, including Type Ia supernovae. Fortunately, these pathways also lead to testable predictions.
Searching for a dusty cometary belt around TRAPPIST-1 with ALMA
Authors: Marino S , Wyatt M C , Kennedy G M , Kama M , Matrà L , Triaud A H M J , Henning Th
Published: January 2020

Low-mass stars might offer today the best opportunities to detect and characterize planetary systems, especially those harbouring close-in low-mass temperate planets. Among those stars, TRAPPIST-1 is exceptional since it has seven Earth-sized planets, of which three could sustain liquid water on their surfaces. Here we present new and deep ALMA observations of TRAPPIST-1 to look for an exo-Kuiper belt which can provide clues about the formation and architecture of this system. Our observations at 0.88 mm did not detect dust emission, but can place an upper limit of 23 µJy if the belt is smaller than 4 au, and 0.15 mJy if resolved and 100 au in radius. These limits correspond to low dust masses of ∼10−5 to 10−2 M⊕, which are expected after 8 Gyr of collisional evolution unless the system was born with a >20 M⊕ belt of 100 km-sized planetesimals beyond 40 au or suffered a dynamical instability. This 20 M⊕ mass upper limit is comparable to the combined mass in TRAPPIST-1 planets, thus it is possible that most of the available solid mass in this system was used to form the known planets. A similar analysis of the ALMA data on Proxima Cen leads us to conclude that a belt born with a mass ≳1 M⊕ in 100 km-sized planetesimals could explain its putative outer belt at 30 au. We recommend that future characterizations of debris discs around low-mass stars should focus on nearby and young systems if possible.
Implementing Large Genomic Single Nucleotide Polymorphism Data Sets in Phylogenetic Network Reconstructions: A Case Study of Particularly Rapid Radiations of Cichlid Fish
Authors: Olave Melisa , Meyer Axel
Published: January 2020

The Midas cichlids of the Amphilophus citrinellus spp. species complex from Nicaragua (13 species) are an extraordinary example of adaptive and rapid radiation ($<$24,000 years old). These cichlids are a very challenging group to infer its evolutionary history in phylogenetic analyses, due to the apparent prevalence of incomplete lineage sorting (ILS), as well as past and current gene flow. Assuming solely a vertical transfer of genetic material from an ancestral lineage to new lineages is not appropriate in many cases of genes transferred horizontally in nature. Recently developed methods to infer phylogenetic networks under such circumstances might be able to circumvent these problems. These models accommodate not just ILS, but also gene flow, under the multispecies network coalescent (MSNC) model, processes that are at work in young, hybridizing, and/or rapidly diversifying lineages. There are currently only a few programs available that implement MSNC for estimating phylogenetic networks. Here, we present a novel way to incorporate single nucleotide polymorphism (SNP) data into the currently available PhyloNetworks program. Based on simulations, we demonstrate that SNPs can provide enough power to recover the true phylogenetic network. We also show that it can accurately infer the true network more often than other similar SNP-based programs (PhyloNet and HyDe). Moreover, our approach results in a faster algorithm compared to the original pipeline in PhyloNetworks, without losing power. We also applied our new approach to infer the phylogenetic network of Midas cichlid radiation. We implemented the most comprehensive genomic data set to date (RADseq data set of 679 individuals and $>$37K SNPs from 19 ingroup lineages) and present estimated phylogenetic networks for this extremely young and fast-evolving radiation of cichlid fish. We demonstrate that the MSNC is more appropriate than the multispecies coalescent alone for the analysis of this rapid radiation. [Genomics; multispecies network coalescent; phylogenetic networks; phylogenomics; RADseq; SNPs.]
Electronic medical documentation
Authors: Smith Phillip
Published: January 2020

Objective:

To quantify PA attitudes about electronic-assisted documentation in the outpatient setting.

Method:

Survey data were collected from PAs to determine the documentation method used to record outpatient encounters. For clinicians using electronic-assisted documentation, information on the documentation style (including format of documentation, accuracy of generated encounters, and overall readability of encounters) was quantitatively measured.

Results:

129 PAs completed the survey and met the inclusion criteria of documenting outpatient encounters using an electronically assisted format. A statistically significant shift (P < .001) in documentation style from free-text formatted entries to structured data entry was seen as the volume of daily patient encounters increased. A statistically significant (P < .001) decrease in both accuracy and readability was noted with encounters using a structured data entry format.

Conclusion:

In outpatient settings, a volume-dependent shift to structured data element documentation despite self-assessed deficiencies in both accuracy and readability was noted. This shift has the potential to negatively affect the integrity of medical documentation and raises patient safety concerns.
Perinatal Counseling Following a Diagnosis of Trisomy 13 or 18
Authors: Leuthner Steven R. , Acharya Krishna
Published: January 2020

Background:

Families with a prenatal diagnosis of trisomy 13 or 18 are told many things, some true and some myths. They present with differing choices on how to proceed that may or may not be completely informed.

Purpose:

To provide the prenatal counselor with a review of the pertinent obstetrical and neonatal outcome data and ethical discussion to help them in supporting families with the correct information for counseling.

Methods/Search Strategy:

This article provides a review of the literature on facts and myths and provides reasonable outcome data to help families in decision making.

Findings/Results:

These disorders comprise a heterogeneous group regarding presentation, outcomes, and parental goals. The authors maintain that there needs to be balanced decision-making between parents and providers for the appropriate care for the woman and her infant.

Implications for Practice:

Awareness of this literature can help ensure that prenatal and palliative care consultation incorporates the appropriate facts and parental values and in the end supports differing choices that can support the infant's interests.
Abnormal Splanchnic Regional Saturations in a Preterm Infant That Developed Necrotizing Enterocolitis Following a Red Blood Cell Transfusion
Authors: Baserga Mariana , Reich Brixen , Braski Katherine
Published: January 2020

Background:

Necrotizing enterocolitis (NEC) has been associated with red blood cell (RBC) transfusions in preterm infants. Near-infrared spectroscopy (NIRS) can be used to noninvasively monitor regional oxygen saturations (rSO2).

Clinical Findings:

This former 28-week female premature infant, 29 days old, received an RBC transfusion due to increased apneic spells and a hematocrit of 27%. Within 24 hours she developed abdominal distension and passed a bloody stool (Bell's stage 2 NEC on abdominal x-ray). She completed 7 days of antibiotics and nothing-by-mouth status and was discharged home on room air and oral feedings on day of life 70.

Primary Diagnosis:

We describe the presentation of NEC following a RBC transfusion in a preterm infant monitored with cerebral and splanchnic NIRS.

Interventions:

Mean rSO2 (cerebral and splanchnic) measurements were continuously recorded and calculated in 30-minute periods at baseline (prior to packed RBC transfusion), every hour during the RBC transfusion, and every 3 hours for the following 48 hours.

Outcomes:

In this infant, average baseline splanchnic rSO2 was low at 46.5%, and increased during transfusion to 65%. However, following the RBC transfusion and an enteral feeding, splanchnic rSO2 dramatically decreased to 26%, and remained low until the time of NEC diagnosis.

Practice Recommendations:

To develop awareness of the increased risk for NEC in premature infants with significant anemia that receive packed RBC transfusions. With further studies and education, NIRS could be a valuable tool for the nurses and medical team to identify these at-risk neonates.
Vitamin D status in children and adolescents: A prospective cohort study
Authors: Buhr Neeley , Oeffinger Donna , Kryscio Richard , Milbrandt Todd A. , Muchow Ryan D. , Talwalkar Vishwas R. , Iwinski Henry J. , Riley Scott A. , Walker Janet L.
Published: January 2020

Background:

The National Health and Nutritional Examination Survey III, 2009 reported that 48% of adolescents in the United States are vitamin D insufficient/deficient. Nutritional and environmental factors are implicated. The purpose of this study was to measure the prevalence of vitamin D insufficiency in orthopaedic patients and typical children and identify risk factors to aid in screening.

Methods:

This prospective study recruited 138 patients and 30 typical children ages 2 to <18 yr. Those with known problems with abnormal vitamin D metabolism or diminished ability to play outside were excluded. Height, weight, and serum 25-OH vitamin D levels were measured. Questionnaires assessed skin type, sunscreen use, diet, and physical activity.

Results:

Statistical analysis failed to detect any differences between patients and controls. Therefore, they were combined for statistical analysis (N=168). The mean age was 11.9±4.2 yr. The mean vitamin D level was 26.5±7.8 ng/mL, which was deficient (<20 ng/mL, n=33) or insufficient (≥21 to <30 ng/mL, n=84) for 71% of participants. Children with sufficient vitamin D levels were younger than those with insufficient/deficient levels (P=0.02). Multivariate analysis showed that vitamin D levels were negatively affected in ethnic minority groups, those with higher body mass index, those with Medicaid or no insurance status, and those with outside playtime of less than 20 min/day (P=0.0006, P=0.001, P=0.0004, P=0.0005, respectively).

Conclusions:

Vitamin D insufficiency in 71% of our population is much greater than that being reported. The high rate of vitamin D insufficiency suggests that routine screening may be necessary to prevent long-term effects on bone growth and fragility. Characteristics of those at highest risk are ethnic minority, older age, obesity, time spent outdoors of less than 20 min per day, and no private health insurance.

Level of Evidence:

Level II.
Do Hyponatremia or Its Underlying Mechanisms Associate With Mortality Risk in Observational Data?
Authors: Danziger John , Lee Joon , Mark Roger G. , Celi Leo Anthony , Mukamal Kenneth J.
Published: January 2020

Objectives:

Whether unaccounted determinants of hyponatremia, rather than water excess per se, primarily associate with mortality in observational studies has not been explicitly examined.

Design:

Retrospective cohort study of the association between hyponatremia and mortality, stratified by outpatient diuretic use in three strata.

Setting:

An inception cohort of 13,661 critically ill patients from a tertiary medical center.

Measurements and Main Results:

Admission serum sodium concentrations, obtained within 12 hours of admission to the ICU, were the primary exposure. Hyponatremia was associated with 1.82 (95% CI, 1.56–2.11; p < 0.001) higher odds of mortality, yet differed according to outpatient diuretic use (multiplicative interaction between thiazide and serum sodium < 133 mEq/L; p = 0.002). Although hyponatremia was associated with a three-fold higher (odds ratio, 3.11; 95% CI, 2.32–4.17; p < 0.001) odds of mortality among those prescribed loop diuretics, no increase of risk was observed among thiazide diuretic users (odds ratio, 0.87; 95% CI, 0.47–1.51; p = 0.63). When examined as a continuous variable, each one mEq/L higher serum sodium was associated with 8% (odds ratio, 0.92; 95% CI, 0.90–0.94; p < 0.001) lower odds of mortality in loop diuretic patients and 5% (odds ratio, 0.95; 95% CI, 0.93–0.96, p < 0.001) lower in diuretic naïve patients, but was not associated with mortality risk among thiazide users (odds ratio, 0.99; 95% CI, 0.95–1.02; p = 0.45).

Conclusions:

Hyponatremia is not uniformly associated with increased mortality, but differs according to diuretic exposure. Our results suggest that the underlying pathophysiologic factors that lead to water excess, rather water excess itself, account in part for the association between hyponatremia and poor outcomes. More accurate estimations about the association between hyponatremia and outcomes might influence clinical decision-making.
Is Being Left Handed an Advantage toward a Plastic Surgery Residency?
Authors: Shay Tamir , Kaufman Tal , Cohen Avi A. , Ad-El Dean
Published: January 2020

Background:

Left hand dominance is a minority trait historically regarded as disadvantageous for surgeons. Contemporary scientific literature and folklore have shed new light on left handedness as a “boutique trait” and possible marker of gifted and exceptional individuals. Our subjective impression that left handedness is prevalent in the unique field of plastic surgery raised questions regarding the scope and possible causality of this phenomenon.

Methods:

One hundred eleven medical doctors in our medical center filled out a 13-item questionnaire regarding hand dominance, medical speciality, and various creative outlets or hobbies.

Results:

Sixty-four percent of the participating plastic surgeons were left handed (significantly higher than the approximate 12% of the general population; P = 0.007). Many of the left-handed doctors admitted to practicing musical instruments and various arts, crafts, and other hobbies.

Conclusions:

Plastic surgery is a unique profession requiring astute minds capable of creative and “outside-the-box” thinking; traits we have learned in recent decades may be particularly keen in left-handed individuals, perhaps suggest a causal relationship to the conglomeration of a majority of left-handed plastic surgeons.
Extended Prophylactic Antibiotics for Mastectomy with Immediate Breast Reconstruction: A Meta-analysis
Authors: Hai Yang , Chong Weelic , Lazar Melissa A.
Published: January 2020

Background:

The risk of surgical site infection (SSI) for breast surgery in patients without additional risk factors is low, below 5%. Evidence shows the risk of SSI is significantly elevated in patients undergoing immediate breast reconstruction (IBR). However, there is no consensus regarding the use of extended antibiotic prophylaxis. We aim to determine the effect of extended antibiotic prophylaxis on the incidence of SSI after IBR.

Methods:

PubMed and Scopus were searched by 2 independent reviewers. Data abstracted included types of study, basic characteristics, detailed antibiotic prophylaxis information, SSI event, and other secondary outcomes. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study and used a random-effects model to estimate the results. Study quality, bias, and heterogeneity were also analyzed.

Results:

A total of 11 studies (15,966 mastectomy procedures) were included. We found an overall 5.99% SSI rate in our population. Three studies comparing topical antibiotics with no topical antibiotics demonstrated statistical significance (RR = 0.26, 95% CI: 0.12–0.60, P = 0.001), whereas 8 studies comparing extended systemic antibiotics with standard of care found no statistical significance (RR = 0.80, 95% CI: 0.60–1.08, P = 0.13).

Conclusions:

In the setting of IBR following mastectomy, there is insufficient evidence for the use of extended prophylactic antibiotics to reduce SSI rates. Well-designed randomized controlled trials in patients undergoing IBR should be conducted to determine the appropriate regimen and/or duration of prophylactic antibiotics on SSI outcomes.
Elevated levels of the secreted wingless agonist R-spondin 3 in preeclamptic pregnancies
Authors: Ueland Thor , Estensen Mette-Elise , Grindheim Guro , Bollerslev Jens , Henriksen Tore , Aukrust Pål , Aakhus Svend , Gullestad Lars , Lekva Tove
Published: January 2020

Objective:

Preeclampsia is a syndrome characterized by hypertension and poor placental development. The developmental wingless (Wnt) pathway plays an important role in placental development and we hypothesized that Wnt signaling would be dysregulated in preeclampsia.

Methods:

To elucidate aberrations in the Wnt signaling pathway we conducted a pathway analysis on placental mRNA in late-onset preeclampsia and normal pregnancy from the STORK study [n = 10 in each group, RNA sequencing (RNAseq)] to identify differentially expressed genes. In addition, we compared circulating levels of secreted Wnt agonists and antagonists at term pregnancy and 6 months postpartum from an acute preeclampsia study (preeclampsia n = 34, normal pregnancy n = 61).

Results:

We found circulating and placental mRNA levels of the secreted Wnt agonist R-spondin 3 (RSPO3) at term elevated in preeclampsia. Increased plasma RSPO3 was associated with high mean arterial pressure. Further, pathway analysis of placental tissue revealed elevated mRNA levels of upstream ligands WNT6 and WNT10A and frizzled receptors 2 and 4 in preeclampsia and downstream activation of the noncanonical Ca2+/NFAT pathway. Finally, plasma dickkopf 3 was decreased in preeclampsia 6 months postpartum.

Conclusion:

We identify a potential role for RSPO3 and activation of noncanonical Wnt signaling in preeclampsia.
Hypertension in military veterans is associated with combat exposure and combat injury
Authors: Howard Jeffrey T. , Stewart Ian J. , Kolaja Claire A. , Sosnov Jonathan A. , Rull Rudolph P. , Torres Isaias , Janak Jud C. , Walker Lauren E. , Trone Daniel W. , Armenta Richard F.
Published: January 2020

Background:

Although the long-term effects of combat injury are not well understood, there is emerging concern that exposure to combat environments and subsequent injury may increase the risk of hypertension through changes in inflammatory responses, psychological stress and mental health, and health behaviors.

Methods:

Data from the Millennium Cohort Study and the Department of Defense Trauma Registry were used to identify combat-exposed and combat-injured participants. Incident hypertension diagnoses were ascertained from the Millennium Cohort survey. The associations between combat exposure/injury and hypertension risk was estimated using multivariable complementary log-log survival models.

Results:

The final analysis sample consisted of 38 734 participants. Of these, 50.8% deployed but were not exposed to combat, 48.6% deployed and were exposed to combat, and 0.6% had combat injury. Overall prevalence of hypertension was 7.6%. Compared with participants who deployed but did not experience combat (mild exposure), elevated odds of hypertension were observed among those who experienced combat but not wounded (moderate exposure; AOR, 1.28; 95% CI, 1.19–1.38) and those wounded in combat (high exposure; AOR, 1.46; 95% CI, 1.07–2.00). Sleep duration of less than 4 h (AOR, 1.21; 95% CI, 1.03–1.43), sleep duration of 4–6 h (AOR, 1.16; 95% CI, 1.05–1.29), posttraumatic stress disorder (AOR, 1.54; 95% CI, 1.26–1.87), and overweight (AOR, 1.77; 95% CI, 1.61–1.95) and obese (AOR, 2.77; 95% CI, 2.45–3.12) status were also associated with higher odds of hypertension.

Conclusion:

Results support the hypotheses that combat exposure increases hypertension risk and that combat injury exacerbates this risk.
Low Use of Vitamin A in Children Hospitalized for Measles in the United States
Authors: Hester Gabrielle Z. , Nickel Amanda J. , Stinchfield Patricia A. , Spaulding Alicen B.
Published: January 2020

Vitamin A reduces measles morbidity/mortality and and is recommended for management. We studied 142 patients hospitalized at US Children’s hospitals for measles between January 1, 2004, and March 31, 2019, and found only 47 (33%) received vitamin A. Patients with complex chronic conditions were less likely to be treated. This study highlights a concerning gap between recommendations and practice for hospital management of measles.
Orbital Leakage of Intraocular Silicone Oil: Case Reports and Literature Review
Authors: Lemaitre Stephanie , Vahdani Kaveh , Escalas Pierre , Rose Geoffrey E.
Published: January 2020

Silicone oil migration into the periorbital tissues occurs rarely after vitreo-retinal surgery and two cases are reported. The first case was a 48-year-old woman who presented with a blind painful right eye, upper eyelid swelling, and ptosis after multiple vitreo-retinal surgeries. Diffuse infiltration of silicone oil in the upper eyelid and anterior orbit was found during evisceration, mainly around the plate of a Baerveldt glaucoma valve. In the second case, a 69-year-old man with prior right scleral rupture underwent silicone oil tamponade for retinal detachment and presented with right upper eyelid swelling due to multiple silicone oil granulomas within the orbit. Open globe injury and glaucoma drainage devices both appear to facilitate extraocular migration of silicone oil that results in marked orbital infiltration and inflammatory response.
Intraorbital Graphite Foreign Body With a Delayed Presentation of Optic Neuropathy
Authors: Liaboe Chase A. , Mehta Viraj J. , Harrison Andrew R. , Mokhtarzadeh Ali
Published: January 2020

Traumatic penetrating injuries to the orbit from pencils, while uncommon, have a plethora of presentations, both acute and delayed. With the most incidents occurring in the pediatric population where obtaining a detailed history is difficult, the ability to effectively evaluate and diagnose these injuries is cumbersome, yet important. The authors report a patient who presented with optic neuropathy, blepharoptosis, and strabismus 10 months after an orbital injury with pencil graphite.
Routine disaccharidase testing: are we there yet?
Authors: Opekun Antone R. , Chumpitazi Bruno P. , Abdulsada Mustafa M. , Nichols Buford L.
Published: January 2020

Purpose of review

Disaccharidase testing, as applied to the evaluation of gastrointestinal disturbances is available but it is not routinely considered in the diagnostic work-up. The purpose of this review was to determine if disaccharidase testing is clinically useful and to consider how the results could alter patient management.

Recent findings

Indicate that carbohydrate maldigestion could contribute functional bowel disorders and negatively impact the fecal microbiome. Diagnostic techniques include enzyme activity assays performed on random endoscopically obtained small intestinal biopsies, immunohistochemistry, stable isotope tracer and nonenriched substrate load breath testing, and genetic testing for mutations. More than 40 sucrase--isomaltase gene variants coding for defective or reduced enzymatic activity have been reported and deficiency conditions are more common than previously thought.

The rationale for disaccharidase activity testing relates to a need to fully assess unexplained recurrent abdominal discomfort and associated symptoms. All disaccharidases share the same basic mechanism of mucosal expression and deficiency has far reaching consequences. Testing for disaccharidase expression appears to have an important role in symptom evaluation, but there are accuracy and logistical issues that should be considered. It is likely that specific recommendations for patient management, dietary modification, and enzyme supplementation would come from better testing methods.
Long‐term Outcomes and Health Perceptions in Pediatric‐onset Portal Hypertension Complicated by Varices
Authors: Luoto Topi T. , Koivusalo Antti I. , Pakarinen Mikko P.
Published: January 2020

Objectives:

Outcomes of pediatric‐onset portal hypertension are poorly defined. We aimed to assess population‐based long‐term outcomes of pediatric‐onset portal hypertension complicated by varices.

Methods:

All children with esophageal varices (n = 126) were identified from 14,144 single nationwide referral center endoscopy reports during 1987 to 2013, and followed up through national health care and death registers. A questionnaire was sent to survivors (n = 94) of whom 65 (69%) responded.

Results:

Nineteen underlying disorders included biliary atresia (35%), extrahepatic portal vein obstruction (35%), autosomal recessive polycystic kidney disease (7%), and other disorders (23%). During median follow‐up of 15.2 (range 0.5–43.1) years patients underwent median 9 (1–74) upper gastrointestinal endoscopies. Esophageal varices were first observed at a median age of 4.0 (0.3–18.2) years, 112 (89%) patients underwent median 6 (1–56) sclerotherapy/banding sessions, and 61 (48%) experienced median 2 (range 1–20) variceal bleeding episodes. Forty‐eight surgical shunt procedures were performed to 41 (36%) patients and 38% underwent liver transplantation. Portal hypertensive biliopathy was diagnosed in 4 patients. Hepatopulmonary syndrome necessitated liver transplantation in 2 patients, hepatic encephalopathy in 2, and hepatorenal syndrome in 1. No patient died of variceal bleeding. Patient‐reported perception of health on a scale of 1 to 10 was 9 (range 4–10), and 86% reported no current symptoms attributable to esophageal varices.

Conclusions:

Pediatric‐onset portal hypertension is a heterogeneous disease with significant long‐term morbidity, requiring multimodal approach with considerable resources and continuation of follow‐up in adulthood. Although mortality to variceal bleeding was avoided, bleeding episodes recurred also in adulthood, while patient‐reported health of long‐term survivors was encouraging.