bluuebunny/crossref_metadata_2025 huggingface dataset:
Trans/forming White Noise
Authors: Krell Elias
Published: June 2019

This chapter amplifies vocal “noise” as a polyvalent marker for the complex nexus of oppressive and liberatory effects of Joe Stevens’s voice. A white, upper-middle-class, transgender, disabled Americana/folk singer, Stevens’s visibility provides critical redress for white trans men. Yet the discussion cautions that the emergence of visibly able-bodied white trans men as the new face of transgenderism risks (re)producing Others who are too Brown, Black, disabled, poor, or otherwise strange to fully “count” as trans. Drawing from four years of ethnographic fieldwork between 2009 and 2013, the chapter deploys noise literally, metaphorically, and metonymically. On a literal level, noise signals timbral changes to Stevens’s voice as a result of growing up in a society that renders transgender an unlivable subject position. Through coping mechanisms of smoking and drinking, Stevens’s voice literally became “noisy,” to borrow a communication science term for hoarseness or breathiness. The chapter also considers the effects of testosterone hormone therapy on the voice. Metaphorically, noise makes audible underrepresented narratological and affective aspects of transgenderism in Stevens’s music. The discussion harnesses noise’s metonymic capabilities to think through the effects of Stevens’s music on a wider popular trans imaginary. The research nuances Stevens’s race and class privileges by considering how chronic illness and addiction trouble his claims to status or power. Employing a theoretical methodology of “trans-ing,” the discussion analyzes Stevens’s race, class, gender, sex and sexuality, and disability, all from a voice-centered perspective.
What Was the Voice?
Authors: Shane Butler Nancy H.
Published: June 2019

This chapter considers what classical antiquity understood the voice to be, as well as how that understanding has influenced subsequent Western thought. The chapter begins with discussion of song, a term that antiquity applied to written poetry as well as to song proper. It then turns to more general questions about how the Greeks and Romans theorized the relationship of the voice to language. After explaining some of the principal terms for “voice” in both Greek and Latin, the author reviews the vocal theories of various schools of ancient philosophy. He then considers the role of the voice in oratory and the special problems generated by the growing circulation of speeches in written form. He turns finally to a celebrated if perhaps apocryphal vocal performance by a pantomime in Rome in order to consider the tension between the particular voice of an individual and the more generic vocality of antiquity itself
Singing High
Authors: Jones Alisha Lola
Published: June 2019

Drawing on a case study of African American countertenor Patrick Dailey and an ethnography of his live performance, this chapter is an ethnomusicological assessment of his social and theological navigation of gendered vocal sound. African American gospel singing challenges the binary gender framework that the American public expects, with men singing low and women singing high. As a man who sings high, Dailey has to demonstrate performance competence in African American worship. Dailey deftly negotiates the tensions and intersections between these dual processes of musical performance. He does so with an aspiration to deliver a presentation that is what he refers to as “anointed”: music that is from and for God. Dailey’s performance also engages African American audiences’ various types of cultural familiarity to portray competency as a worship leader and trained artist. Thus, while making a mark in sacred music history, more generally, Patrick Dailey’s performance reveals the subtle ways Western art music conventions of classifying vocalists are utilized and revised in the interpretation of cross-cultural performance in African American churches.
Building the Broadway Voice
Authors: Johnson Jake
Published: June 2019

This chapter investigates how differing pressures on the Broadway musical theater industry can contribute to certain vocal stylistic choices. The author considers the ways in which collegiate and professional training programs have responded to these needs through their musical theater curricula. The chapter brings into relief how vocal training in such programs ensures a sonic conformity, which presumably improves the marketability of the performer in an industry demanding predictable sounds. Specifically, it considers the pedagogical philosophies prevalent in Midwestern musical theater training programs where the author has worked as a vocal coach and where many Broadway performers cut their teeth. The chapter takes no position for or against the vocal ideas taught in these or other musical theater training programs, but makes some observations for the unique demands attached to such training and what demands those pressures make on singers today. Furthermore, the chapter suggests that the growth of the Broadway musical as a tourist attraction, the rise of the megamusical, and the formation of this Broadway sound are all interrelated phenomena enabled by a new corporatizing ideology in musical theater that has disciplined the body of the Broadway performer for decades and continues to shape the industry’s sound today.
When Robots Speak on Screen
Authors: Fleeger Jennifer
Published: June 2019

This chapter argues that the audible signifiers of gender, class, and race in the voices that give life to Hollywood’s robots make audiences comfortable with the robot as worker and, by extension, with the labor practices of an industry in which it is not always possible to distinguish images of and by real people from those generated by a computer. The cinematic robot’s voice unifies an era’s dream of the ideal worker and its hopes for the perfect human. Yet as the tools available to filmmakers change, so do representations of the cinematic robot’s humanity and its relationship to work. By examining a range of robots on screen that begin chronologically with the wildly passionate gestures, dances, and speeches of the artificial Maria in Fritz Lang’s German silent film Metropolis (1927) and end with two recent Hollywood robotic rebels, Ava from Ex Machina (2014) and Vision from Avengers: Age of Ultron (2015), this chapter analyzes robot voices in relation to the economic and technological changes affecting the film industry to reveal the troubling connotations in the selection and use of the actors who play them. First the chapter looks at Lang’s Metropolis as an origin tale for the cinematic fembot, then turns to accents to explore the sounds of social class in mechanical beings, and finally examines the role played by race in the construction of the expendable robotic body.
Voice Dipped in Black
Authors: Reid-Brinkley Shanara R.
Published: June 2019

At the turn of the century, the University of Louisville’s Malcolm X Debate Program, a mostly Black student group, founded a small grassroots movement in competitive college debate. Louisville battled a resistant majority white academic community for years. During their winning 2003–2004 season, the team transformed into what became commonly referred to as the Louisville Project. The development of an acclaimed Louisville Method of Debate would have significant reverberations through both the college and high school debate communities more than fifteen years later. By not avoiding but rather pointing to Blackness, Louisville’s argumentative and performative attacks on traditional debate practice force the community to turn its analytical tools on the racialization of debate itself. White discomfort in policy debate, in reaction to Louisville’s strategy and performance, has run the gamut of denial, anger, frustration, sympathy, engagement, and rejection. Troubling the assumption of neutrality, Louisville’s performance and argumentation highlight the hypocrisy of traditional debate performance, its relationship to anti-Blackness, and the normative performance of whiteness as the marker of achievement. The Louisville team delves into the neoliberal ordering of American democracy, making visible the hypocrisy of white liberalism and its attendant antagonism—subtle and overt—toward Blackness.
Acoustic Slits and Vocal Incongruences in Los Angeles Union Station
Authors: Eidsheim Nina Sun
Published: June 2019

Over the last decades, much has been said and written about urban renewal and gentrification in Los Angeles. However, the issues addressed have been associated with the types of sounds present or created and musics played. This chapter examines the process of opera in relation to downtown Los Angeles’ gentrification. More specifically, drawing on Tim Choy’s and Ben Anderson’s notion of the “atmospheric” and “air politics,” this chapter addresses the ways in which considering the very acoustic part of the soundscape can offer entry into understanding of the process of gentrification. The listening into the acoustic realization of sound and the reverberation of distinct space can give evidence into broader and deeper shifts in the space’s value, otherwise often difficult to discern. The author does so by considering director Yuval Sharon’s and sound designer Martin Gimenez’s setting of Invisible Cities (composed by Christopher Cerrone) within Union Station’s waiting hall and courtyard. While each singer sang within the everyday soundscape and acoustics of the station, their voices were treated with a thorough sound design and offered up to audiences via wireless headphones. This partial interaction and selectively available product marks a project of “upgrading” the Los Angeles downtown acoustic soundscape—a process, the author proposes, that can be understood as an indicator of the late stage of gentrification.
Tuning a Throat Song in Inner Asia
Authors: Beahrs Robert O.
Published: June 2019

This chapter seeks to distinguish musician Valeriy Kechilovich Mongush’s vocal gifts of xöömei, kargyraa, and sygyt from the so-called throat-singing or overtone singing practices that have circulated internationally (especially since the fall of the Soviet Union in 1991) and become dissociated from local meanings and values in the Tyva Republic. In particular, the author is concerned that the global awareness of these practices has focused on the “acoustic facts” of voice production to the exclusion of the histories and responsibilities that these gifts carry—the knowledge of where these practices originate, what they mean, how their history reflects a changing and sometimes repressive political landscape, the intentionality of voicing as action, and the aesthetic and ethical dimensions of voicing song as a social practice. The chapter asks what Valeriy is doing—both real and imagined—when he is doing xöömei, kargyraa, or sygyt. What stories does he tell himself and others? How do his vocal practices reflect a changing political landscape? And what, in Valeriy’s estimation, should practitioners of these “three main techniques” (üsh kol xevir) do in order to understand them as vocal gifts and use them with a sense of purpose, care, and respect for local traditions? The author poses these questions and Valeriy answers with more stories, told from his own perspective.
Voiceness in Musical Instruments
Authors: Fales Cornelia
Published: June 2019

This chapter presents the results of a pilot study of “voiceness” in instrumental musical sound across cultures. This study grew from the proposition that not only is the voice of primal importance in music, but “voiceness” in nonvocal musical sounds is a quality that seems to exert a particular fascination to music cultures around the world. The objective is to look at the use of voiceness in music across cultures in order to discover something about the constituents of voiceness. Since it is normally not the case that voice-like instruments, either alone or in combination, sound like voices per se, it must be the case that the quality they convey as voiceness consists of some distillation of acoustic features, presumably proper to “real” vocal sound. A primary question addressed in the chapter is whether the voiceness in music of specific cultures varies in a way consistent with that culture’s primary language, or whether there are features that convey voiceness across cultures independent of language. Unlike many other instruments, the voice is capable of immense timbral variation, and the magnitude of difference across individual voices can be as great as the difference between instrument classes. The author has taken the results of the study as a preliminary indication of an abstract auditory category of voiceness consisting of perceived commonalities across several levels of vocal variation. The chapter focuses on sounds from just three cultures that are particularly illuminating in regard to these issues.
Secular trends of sustained remission in rheumatoid arthritis, a nationwide study in Sweden
Authors: Einarsson Jon T , Willim Minna , Saxne Tore , Geborek Pierre , Kapetanovic Meliha C
Published: June 2019

Objectives

The aim of this study of patients with RA in Sweden was to investigate secular trends in achieving sustained remission (SR), i.e. DAS28 <2.6 on at least two consecutive occasions and lasting for at least 6 months.

Methods

All adult RA patients registered in the Swedish Rheumatology Quality register through 2012, with at least three registered visits were eligible, a total of 29 084 patients. Year of symptom onset ranged from 1955, but for parts of the analysis only patients with symptom onset between 1994 and 2009 were studied. In total, 95% of patients fulfilled the ACR 1987 classification criteria for RA. Odds of reaching SR for each decade compared with the one before were calculated with logistic regression and individual years of symptom onset were compared with life table analysis.

Results

Of patients with symptom onset in the 1980s, 1990s and 2000s, 35.0, 43.0 and 45.6% reached SR, respectively (P < 0.001 for each increment), and the odds of SR were higher in every decade compared with the one before. The hazard ratio for reaching SR was 1.15 (95% CI 1.14, 1.15) for each year from 1994 to 2009 compared with the year before. Five years after symptom onset in 2009, 45.3% of patients had reached SR compared with 15.9% in 1999.

Conclusion

There is a clear secular trend towards increased incidence of SR in patients with RA in Sweden. This trend most likely reflects earlier diagnosis and treatment start, and adherence to national and international guidelines recommending the treat to target approach.
Cervical screening uptake and rates of cervical dysplasia in the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis
Authors: Chadwick Laura , Kearsley-Fleet Lianne , Brown Nina ,   BSRBR-RA Control Centre Consortium,   BSRBR-RA Contributors Group, Watson Kath D , Lunt Mark , Symmons Deborah P M , Hyrich Kimme L.
Published: June 2019

Objectives

To compare cervical screening attendance and cytology (high- and low-grade cervical dysplasia [HGCD and LGCD]) between women with RA and the English general population and between biologic DMARD (bDMARD)-naïve and exposed women.

Methods

The British Society for Rheumatology Biologics Register for RA (BSRBR-RA), a national prospective study of RA treatment outcomes, was linked to the National Health Service Cervical Screening Programme, providing data for 12 785 women to compare with national screening data. Rates of HGCD/LGCD were compared with rates of negative smears using risk difference calculations between BSRBR-RA and national statistics. Within the BSRBR-RA, coverage was compared between those with low and high physical disability scores, while coverage and cytology results were compared between bDMARD-naïve and -exposed RA patients.

Results

The mean 5 year screening coverage was significantly higher in BSRBR-RA (83%) compared with the general population (79%), but lower in women with high disability (78%) compared with lesser disability (85%). Risk differences for HGCD were lower in the BSRBR-RA compared with national statistics, whereas risk differences for LGCD were higher. There was no statistically significant difference in the rates of HGCD or LGCD between bDMARD-exposed and -naïve women.

Conclusion

This first-ever British analysis of cervical screening rates in RA has shown that women with RA have higher screening rates than the general population. Disability negatively impacts attendance, but treatment type does not. Women with RA did not have an increased risk of HGCD compared with national statistics, which was also not influenced by bDMARD exposure.
Residual symptoms after natural remission of insomnia: associations with relapse over 4 years
Authors: Ji Xiaowen , Ivers Hans , Savard Josée , LeBlanc Mélanie , Morin Charles M
Published: June 2019

Study Objectives

Chronic insomnia tends to “wax and wane” over lifetime. The presence of residual insomnia symptoms is common, especially among naturally remitted individuals. This study aims to examine the features of these residual symptoms and their potential association with future relapse.

Methods

A population-based data set on the natural history of insomnia was used for this secondary analysis. Residual insomnia symptoms were investigated in those who had insomnia symptoms/syndrome at baseline and achieved full remission (according to predetermined diagnostic algorithm) within the following 1 year. Cox regressions were used to determine the hazard ratio (HR) of each residual symptom for predicting relapse in the next 4 years. The nature and severity of residual symptoms were examined with an extended version of the Insomnia Severity Index (ISI), which incorporates additional items on sleep quality and specific sleep-related daytime impairments (on daytime fatigue, cognitive functioning, mood, interpersonal relationship, and daily activities). In addition, the presence of depressive symptoms and medical conditions were controlled for in investigating risks of insomnia relapse.

Results

A total of 434 participants were included in this study (age ranges from 18 to 94; 65.9% female); 248 of them had relapsed within 4 years. The response rate ranged from 78% to 83%. The most frequently reported residual symptoms with at least moderate severity (ISI items ≥2 on 0–4 ISI item scale) were poor “Quality of sleep” (39.2 %), followed by “difficulty maintaining sleep” (DMS; 27%). The most common residual daytime impairments related to insomnia were fatigue (24.7 %), mood disturbances (23%) and cognitive disturbances (22.6%). After controlling for baseline insomnia and depression severity and concurrent physical diseases, impairments of cognition (HR = 1.46), poor quality of sleep (HR = 1.43), disturbed mood (HR = 1.39), being female (HR = 1.36), DMS (HR = 1.35), and fatigue (HR = 1.24) were significantly associated with insomnia relapse in the next 4 years. Moreover, residual poor sleep quality and daytime insomnia symptoms were independent of DMS in predicting relapse. Subgroup regressions according to sex showed that for male participants, residual cognition impairments (HR = 1.98) was the most significant predictors of future relapse, whereas residual DMS (HR = 1.46) significantly predicted relapse for women only.

Conclusion

A wide range of residual symptoms exists in individuals with naturally remitted insomnia. Notably, residual DMS is the most common residual nighttime symptom and the only nighttime symptom associated with insomnia relapse. Additionally, perceived poor sleep quality and cognitive, mood, and somatic impairments attributed to sleep disturbances are also related to future relapse. Attention to these residual symptoms when initiating insomnia treatment is warranted to minimize future relapse.
Effects of extended-release eprinomectin on fescue toxicosis, performance, and reproduction on fall-calving beef cows
Authors: Volk Mareah J , Krause Taylor R , Stokes Rebecca S , Ireland Frank A , Shike Daniel W
Published: June 2019

The objective of this experiment was to evaluate effects of extended-release eprinomectin on fescue toxicosis and impacts on performance and reproduction in fall-calving beef cows. Fall-calving Angus × Simmental multiparous cows [n = 335; age = 5.8 ± 2.1 yr; 586.5 ± 6.0 kg body weight (BW); 5.48 ± 0.05 body condition score (BCS)] were stratified by BW, age, and BCS and randomly assigned to one of three treatments. Treatments included a spring injection of extended-release eprinomectin (SERE) on day 0, a fall injection of extended-release eprinomectin injection (FERE) on day 84, and a saline control (CON). All treatments were administered at a rate of 1 mL/50 kg BW. Prior to the experiment, all cows were treated with oral fenbendazole to minimize parasite load. Cows grazed endophyte-infected tall fescue. Hair coat score (HCS), BW, and BCS were recorded on all cattle. Fecal egg count (FEC), respiration rate (RR), horn fly and tick count, hematocrit (% packed cell volume, PCV), and serum prolactin were analyzed on a subset of cows (35/treatment). On day 194, cows were artificially inseminated (AI) and 11 d following AI were exposed to bulls for 51 d. Milk production was estimated on day 210 on a subset of 85 cow–calf pairs (28–29/treatment). There was a tendency for a treatment × time interaction (P = 0.07) for FEC likely driven by an increase in FEC of the CON cattle at day 126 compared to SERE and FERE. There was a tendency for a treatment × time interaction (P = 0.06) for cow BW, largely driven by time differences; however, there was no effect of treatment (P = 0.84) on BW. There was no difference (P ≥ 0.13) in cow PCV, fly and tick count, BCS, HCS, RR, and serum prolactin throughout the experiment. Additionally, there was no difference (P ≥ 0.46) in Julian calving date, calf birth BW, or milk production between treatments. Interestingly, heifer calves born to FERE dams tended to have greater (P = 0.06) weaning BW compared to heifer calves born to CON dams. In addition, there was no difference (P ≥ 0.17) in heat patch scores, AI conception rates, or overall pregnancy rates between treatments. Extended-release eprinomectin did not impact cow growth performance, reproductive performance or fescue toxicity symptoms when grazing endophyte-infected tall fescue; however, calf weaning BW tended to be improved.
Effects of Absence of Constitutive Androstane Receptor (CAR) on Bile Acid Homeostasis in Male and Female Mice
Authors: Lickteig Andrew J , Zhang Youcai , Klaassen Curtis D , Csanaky Iván L
Published: June 2019

Accumulation of bile acids (BAs) in hepatocytes has a role in liver disease and also in drug-induced liver injury. The constitutive androstane receptor (CAR) has been shown to protect against BA-induced liver injury. The polymorphism of CAR has recently been shown to modify the pharmacokinetics and pharmacodynamics of various drugs. Thus, it was hypothesized that polymorphism of CAR may also influence BA homeostasis. Using CAR-null and WT mice, this study modeled the potential consequences of CAR polymorphism on BA homeostasis. Our previous study showed that chemical activation of CAR decreases the total BA concentrations in livers of mice. Surprisingly the absence of CAR also decreased the BA concentrations in livers of mice, but to a lesser extent than in CAR-activated mice. Neither CAR activation nor elimination of CAR altered the biliary excretion of total BAs, but CAR activation increased the proportion of 6-OH BAs (TMCA), whereas the lack of CAR increased the excretion of taurocholic acid, TCDCA, and TDCA. Serum BA concentrations did not parallel the decrease in BA concentrations in the liver in either the mice after CAR activation or mice lacking CAR. Gene expression of BA synthesis, transporter and regulator genes were mainly similar in livers of CAR-null and WT mice. In summary, CAR activation decreases primarily the 12-OH BA concentrations in liver, whereas lack of CAR decreases the concentrations of 6-OH BAs in liver. In bile, CAR activation increases the biliary excretion of 6-OH BAs, whereas absence of CAR increases the biliary excretion of 12-OH BAs and TCDCA.
Effect of Short-Term Morbidities, Risk Factors and Rate of Growth Failure in Very Low Birth Weight Preterms at Discharge
Authors: Yapicioglu Yildizdas Hacer , Simsek Huseyin , Ece Umit , Ozlu Ferda , Sertdemir Yasar , Narli Nejat , Satar Mehmet
Published: June 2019

Background

Very low birth weight (VLBW) infants often demonstrate postnatal growth failure (PGF). We aimed to analyze incidence and risk factors for PGF in surviving VLBW infants hospitalized more than 28 days.

Materials and Methods

Fenton growth chart (2013) was used for Z-scores for birth weight (BW) and discharge weight. Infants with a decrease in their Z-scores at discharge >1 were considered as ‘PGF group’ and with a decrease >2 were considered as ‘severe PGF group’.

Results

One hundred and forty-one of 148 (95.3%) infants had PGF, 88 of 141 (62.4%) had severe PGF. There were significant differences in gestational age, birth and discharge weight, and days to regain BW, age of first and full enteral feeding, duration of parenteral nutrition, lipid emulsions, intubation and hospitalization between groups (p < 0.05). Vasopressor treatment, nosocomial infection, patent ductus arteriosus and bronchopulmonary dysplasia rates were significantly higher in severe PGF group (p < 0.05).

Conclusion

PGF remains a serious problem in our unit. All VLBW preterm infants should be followed for PGF.
Time to Fight: Molecular Mechanisms of Age-Related Resistance
Authors: Hu Lanxi , Yang Li
Published: June 2019

Plant age is a crucial factor in determining the outcome of a host−pathogen interaction. In successive developmental stages throughout their life cycles, plants face dynamic changes in biotic and abiotic conditions that create distinct ecological niches for host−pathogen interactions. As an adaptive strategy, plants have evolved intrinsic regulatory networks that integrate developmental signals with those from pathogen perception and defense activation. As a result, amplitude and timing of defense responses are optimized, so as to balance the cost and benefit of immunity activation. A general term “age-related resistance” refers to a gain of disease resistance against a certain pathogen when plants reach a relatively mature stage. Age-related resistance is a common observation on fruits, vegetables, and row crops for their resistance against viruses, bacteria, fungi, oomycetes pathogens, and insects. This review focuses on the recent advances in understanding the molecular mechanisms of how plants coordinate developmental timing and immune response.
25-Hydroxyvitamin D Deficiency: Impacting Deep-Wound Infection and Poor Healing Outcomes in Patients With Diabetes
Authors: Smart Hiske , AlGhareeb Ahmed Mohamed , Smart Sally-Anne
Published: June 2019

BACKGROUND

The Kingdom of Bahrain has a high incidence of diabetes and associated foot complications. Simultaneously, low 25-hydroxyvitamin D (25[OH]D) levels are common in this population and may be associated with the traditional clothing used in desert climates.

METHODS

This investigation compared 25(OH)D levels and glycemic control with quantifiable wound healing parameters in a prospective, analytic, nonexperimental, cross-sectional pilot study. Consecutive consenting adult patients (N = 80) who presented to the regional wound care unit in January 2016 with either an existing or new wound were included. Collected data included three-dimensional wound photography, NERDS and STONEES criteria, and an X-ray with a positive probe-to-bone test. Blood values for 25(OH)D and hemoglobin A1c (HbA1c) were collected simultaneously.

RESULTS

Diabetes mellitus (types 1 and 2) was present in 90% of the sample patients. No patient had sufficient 25(OH)D levels; 15% had insufficient levels (30–50 ng/mL), and deficiency (levels <#20 ng/mL) was found in 85% of the sample. Males were slightly less affected by 25(OH)D deficiency compared with females (82.4% vs 91.3%). Poor glycemic control (HbA1c levels >#6.8%) was found in 69.4% (n = 50) of the persons with diabetes included in the sample. Those with both diabetes mellitus and a 25(OH)D deficiency (76.3%; n = 61) were more likely to demonstrate healing difficulty (40.9%; n = 25) or present with a stalled or deteriorating wound (44.2%, n = 27). A 3° F or higher periwound surface temperature elevation over a mirror image site was present in 82.5% of all wounds. Exposed bone in the ulcer base was found in 50% of the cases. For persons with diabetes, general linear modeling statistical analysis (adjusted R
2 value = 47.9%) linked poor wound healing with three studied variables: 25(OH)D deficiency, poor glycemic control, and an exposed bone in the wound bed.

CONCLUSIONS

Vitamin D may be an overlooked factor in the pathophysiology of diabetic foot ulcer development and subsequent delay in wound healing outcomes. The authors recommend adding 25(OH)D deficiency to the list of multifactorial aggravating factors providers should consider correcting in this subgroup of patients.
The Role of Academic Health Centers in Addressing Health Equity and Social Determinants of Health
Authors: Karpf Michael
Published: June 2019

Elsewhere in this issue, Park and colleagues argue that academic health centers (AHCs) must partner with communities to address health disparities and social determinants of health (SDOH). Who is ultimately responsible for addressing them is in question. Countries that have been successful in improving the health of their populations have made these efforts a national priority by, among other things, ensuring universal health care coverage. To date, the United States has failed to adequately address these issues. Health care providers will have an important role to play in doing so, albeit a limited one. Under fee-for-service reimbursement, health care providers are paid for health care services and not for improving the health of populations. Capitated reimbursement might provide more of an incentive to focus on population health. Furthermore, AHCs are a heterogeneous group. Some are research-intensive referral centers, some are community providers, others are safety net providers, and still others are hybrids. Different types of AHCs will address SDOH differently. The scourge of poverty and associated health disparities and their underlying SDOH in the United States must be addressed. Providing affordable, comprehensive, universal health care must be a necessary first step. AHCs must educate about these issues, research and develop new approaches to ameliorate these inequities, and undertake appropriate demonstration projects in dealing with these disparities in well-defined populations. Health care providers, including AHCs, cannot take principal responsibility for issues beyond their scope and financial capabilities.
Understanding Professional Identity Formation in Early Clerkship: A Novel Framework
Authors: Jarvis-Selinger Sandra , MacNeil Kimberley A. , Costello Gregory R.L. , Lee Kenneth , Holmes Cheryl L.
Published: June 2019

Purpose

Medical educators should foster students’ professional attitudes because individuals are more likely to act in accordance with medicine’s professional values if these values have been internalized. Still, there is much to be learned about how students examine and negotiate their emerging identities. This study examined third-year medical students’ experiences of professional identity formation (PIF) during clinical clerkship.

Method

The authors relied on an interpretivist perspective, informed by a grounded theory approach, to analyze data, which were collected from a pilot course designed to support medical students’ efforts to “unhide” the hidden curriculum in relation to their development as medical students and emerging professionals.

Results

Twelve third-year medical students engaged in 10 collaborative discussions with 3 faculty members, a resident, and a fourth-year student (2015–2016). Discussions facilitated students’ reflection on their professional journeys. Analysis of transcribed discussions resulted in a conceptual framework useful for exploring and understanding students’ reflections on their PIF. Through analyzing students’ experiences, the authors identified 4 components that constituted PIF stories: context, focus, catalyst, process.

Conclusions

The analysis resulted in the development of a conceptual framework and distinct identity formation themes. Discrete reflections focused on either students’ current identity (being) or their sense of future self (becoming). The study identified catalysts that sparked participants’ introspection about, or their processing of, identity. The moments that generate profound feelings of awareness in students are often moments that would not be recognizable (even post hoc) as remarkable by others.
Addressing the Minority Tax: Perspectives From Two Diversity Leaders on Building Minority Faculty Success in Academic Medicine
Authors: Campbell Kendall M. , Rodríguez José E.
Published: June 2019

This Invited Commentary explores disparities in academic medicine, known as the minority tax, through the careers of 2 men in senior positions, who are underrepresented minorities in medicine (URMMs), with the goal of sharing real-world experiences that other URMM faculty can use to their benefit. The authors use their lived experiences to document the realities of various aspects of the minority tax (i.e., isolation, mentorship, diversity efforts, and clinical assignments) and introduce a new aspect of the minority tax that has affected both of their inner decision-making processes and personal ambitions: the gratitude tax. By sharing these experiences, the authors are also able to recognize individual mentors and sponsors as well as changes in their knowledge, skills, and attitudes that affected their ability to accomplish career goals, leading to their current academic positions. Sharing experiences is a meaningful way of providing examples for other URMM faculty to follow, as well as illustrating ways in which senior leadership can help mitigate the effect of the minority tax on URMM faculty, thereby increasing equity in academic medicine.
Complement, infection, and autoimmunity
Authors: Conigliaro Paola , Triggianese Paola , Ballanti Eleonora , Perricone Carlo , Perricone Roberto , Chimenti Maria Sole
Published: June 2019

Purpose of review

Complement system dysfunction in terms of upregulation, downregulation, or dysregulation can create an imbalance of both host defense and inflammatory response leading to autoimmunity. In this review, we aimed at describing the role of complement system in host defense to inflection and in autoimmunity starting from the evidence from primary and secondary complement system deficiencies.

Recent findings

Complement system has a determinant role in defense against infections: deficiencies of complement components are associated with increased susceptibility to infections. Primary complement system deficiencies are rare disorders that predispose to both infections and autoimmune diseases. Secondary complement system deficiencies are the result of the complement system activation with consumption. Complement system role in enhancing risk of infective diseases in secondary deficiencies has been demonstrated in patients affected by systemic autoimmune disorders, mainly systemic lupus erythematosus and vasculitis.

The relationship between the complement system and autoimmunity appears paradoxical as both the deficiency and the activation contribute to inducing autoimmune diseases. In these conditions, the presence of complement deposition in affected tissues, decreased levels of complement proteins, and high levels of complement activation fragments in the blood and vessels have been documented.
General Health Quality of Life Instruments Underestimate the Impact of Bilateral Cochlear Implantation
Authors: McRackan Theodore R. , Fabie Joshua E. , Bhenswala Prashant N. , Nguyen Shaun A. , Dubno Judy R.
Published: June 2019

Objective:

To determine the extent to which bilateral cochlear implantation increases patient-reported benefit as compared with unilateral implantation and no implantation.

Data Sources:

PubMed, Scopus, CINAHL, and Cochrane databases searches were performed using the keywords (“Cochlear Implant” or “Cochlear Implantation”) and (“bilateral”).

Study Selection:

Studies assessing hearing/CI-specific (CI) and general-health-related (HR) quality of life (QOL) in adult patients after bilateral cochlear implantation were included.

Data Extraction:

Of the 31 articles meeting criteria, usable QOL data were available for 16 articles (n = 355 bilateral CI recipients).

Data Synthesis:

Standardized mean difference (Δ) for each measure and weighted effects were determined. Meta-analysis was performed for all QOL measures and also independently for hearing/CI-specific QOL and HRQOL.

Conclusion:

When measured using hearing/CI-specific QOL instruments, patients reported very large improvements in QOL comparing before cochlear implantation to bilateral CI (Δ=2.07 [1.76–2.38]) and medium improvements comparing unilateral CI to bilateral CI (Δ=0.51 [0.32– 0.71]). Utilization of parallel versus crossover study design did not impact QOL outcomes (χ2 = 0.512, p = 0.47). No detectable improvements were observed in either CI transition when using HRQOL instruments (no CI to bilateral CI: Δ=0.40 [−0.02 to 0.81]; unilateral CI to bilateral CI: Δ=0.22 [−0.02 to 0.46]).

The universal nature of HRQOL instruments may render them insensitive to the medium to large QOL improvements reported by patients using hearing/CI-specific QOL instruments. Given that HRQOL instruments are used to determine the economic benefit of health interventions, these measurement differences suggest that the health economic value of bilateral cochlear implantation has been underestimated.
Mechanical Blood-Immersed Bearings in Continuous-Flow Rotary Blood Pumps
Authors: Ranganath Neel K. , Rashidi Majid , Antaki James F. , Phillips Katherine G. , Kon Zachary N. , Smith Deane E. , Reyentovich Alex , Moazami Nader
Published: June 2019

Mechanical blood-immersed bearings have been used in many continuous-flow rotary blood pumps to reduce friction between relatively moving parts, but their use has been associated with a significant incidence of pump thrombosis. As newer cardiac assist devices with more advanced bearings become available, the rate of pump thrombosis will likely decrease. Nevertheless, it is important to understand the design limitations of mechanical bearings as pumps utilizing them are still in use as chronic support devices and especially in the acute setting for temporary support devices. A properly designed journal bearing should support the spinning rotor with no surface-to-surface contact between the bearing and journal surfaces. The journal continuously undergoes orbital motion within the bearing, which can be “stable” or “unstable.” Unstable orbital motion causes the journal to move progressively off-center until it collides with the bearing, and even minor variations in manufacturing can create off-design operation and dynamic instability of the journal. Since blood is the lubricant in most clinically-used rotary blood pumps, lubricant viscosity can vary abruptly in response to changes in hematocrit or plasma protein concentration. Additionally, shear stress from the high-speed rotor can cause hemolysis and plasma protein denaturation. We reviewed theoretical design and operating principles of mechanical bearings and discuss why the phenomenon of mechanical bearing thrombosis may be an inherent design issue dependent on variables that are beyond the control of clinicians.
Reverse Ramp Testing in Left Ventricular Assist Device Support and Myocardial Recovery
Authors: Holzhauser Luise , Lang Roberto M. , Raikhelkar Jayant , Sayer Gabriel , Uriel Nir
Published: June 2019

Mechanical unloading with left ventricular assist device (LVAD) support can lead to clinically meaningful reversal of stress-related compensatory mechanisms. However, true assessment of left ventricular ejection fraction (LVEF) is not possible, whereas the left ventricle is unloaded by LVAD therapy making identification of patients with myocardial recovery even more challenging. We introduce our new protocol, the “reverse ramp test” for HeartWare HVAD, HeartMate II, and HeartMate 3. The reverse ramp is transthoracic echo (TTE) and right heart catheterization (RHC)-based protocol with LVAD turn down steps to minimal support allowing for a more accurate assessment of myocardial function.
Outcomes Associated with Obesity in Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review and Meta-Analysis
Authors: Khan Muhammad Shahzeb , Yuzefpolskaya Melana , Memon Muhammad Mustafa , Usman Muhammad Shariq , Yamani Naser , Garan A. Reshad , Demmer Ryan T. , Colombo Paolo C.
Published: June 2019

Current data suggest that obesity does not impact survival, but may predispose patients to a higher rate of adverse events during left ventricular assist device (LVAD) support. We performed a systematic review and meta-analysis to assess the effects of obesity on clinical outcomes in LVAD recipients. We searched Medline, Scopus, Cochrane library, and clinicaltrials.gov from inception to February 2019 for studies comparing outcomes in obese (body mass index [BMI]> or ≥30 kg/m2) and nonobese (BMI< or ≤30 kg/m2) heart failure (HF) patients after LVAD implantation. Our primary endpoint was short-term (≤1 year) and long-term (>1 year) all-cause mortalities. The estimates are presented as random-effects risk ratios (RR) with 95% confidence intervals. In this meta-analysis of 15 observational studies (n = 26,842), obese patients receiving LVAD had significantly decreased 6 months (RR = 0.79 [0.73, 0.86]; p < 0.001, I
2 = 0%) and 1 year all-cause mortality (RR = 0.87 [0.79, 0.97]; p = 0.008, I
2 = 69%) compared with nonobese patients. However, both groups showed no significant difference in all-cause mortality at 2 years (RR = 0.95 [0.87, 1.04]; p = 0.12, I
2 = 55%) or 3 years (RR = 0.84 [0.61, 1.15]; p = 0.28, I
2 = 43%). Obese patients had significantly higher risk of device-related infections (RR = 1.48 [1.25, 1.75]; p < 0.001, I
2 = 37%), right heart failure (RR = 1.41 [1.21, 1.65]; p < 0.001, I
2 = 28%), and pump thrombosis (RR = 1.55 [1.37, 1.76]; p < 0.001, I
2 = 0%) compared with nonobese patients. This meta-analysis suggests that obese patients with HF have short- but not long-term survival benefit after LVAD implantation when compared to nonobese patients, although bias may have impacted these findings.
Prognostic significance of blood inflammatory biomarkers NLR, PLR, and LMR in cancer—A protocol for systematic review and meta-analysis
Authors: Kumarasamy Chellan , Sabarimurugan Shanthi , Madurantakam Royam Madhav , Lakhotiya Kartik , Samiappan Suja , Baxi Siddhratha , Nachimuthu Ramesh , Gothandam Kodiveri Muthukaliannan , Jayaraj Rama
Published: June 2019

Background:

The neutrophil-lymphocyte-ratio, platelet-lymphocyte-ratio, and monocyte-lymphocyte-ratio have been explored as a simple, inexpensive, and effective method for cancer prognosis. However, there are no studies that have investigated the comparative utility of these markers, in multiple cancers.

Methods:

The preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines were used to design this meta-analysis protocol. The final study will also be conducted under the PRISMA guidelines for systematic reviews and meta-analyses. The core bibliographic database search will be carried out by 2 reviewers working individually, with each conducting an initial screening based on titles and abstracts. The shortlisted articles will be selected for review and quantitative analysis, based on predefined inclusion and exclusion criteria. Study characteristics, relevant clinicopathological characteristics, and statistical data required for meta-analysis (hazard ratios [HRs] and 95% confidence intervals [CIs]) will be extracted and compiled into a MS Excel datasheet. Meta-analysis will be performed, using a random-effects model, and the results (pooled HR and 95% CI) will be presented in the form of a forest plot. Publication bias will also be assessed by use of Egger bias indicator test and funnel plot symmetry. If statistical data from included studies is insufficient, a qualitative literature review will be pursued.

PROSPERO registration: PROSPERO CRD42019121008.
Feasibility of a craniometry in a comminuted zygomaticomaxillary complex fracture
Authors: Hsu Shao-Yun , Shih Pin-Keng
Published: June 2019

Few studies have reported on using craniometry for comminuted zygomaticomaxillary complex (ZMC) fracture management. We present our experiences with this procedure and a review of the related literature.

From September 2011 to October 2018, 43 patients with comminuted ZMC fracture receiving open reduction internal fixation under coronal incision were enrolled. Data on gender, age, operation time, hospital stay, duration of follow-up, vertical/horizontal differences, and complications were collected. Between-group differences (C-arm imaging vs craniometry) were evaluated using nonparametric Mann–Whitney test for continuous data and chi-square test for categorical data.

No significant difference were found between the groups regarding gender, age, hospital duration, follow-up duration, and postoperative complications, except for operation time. The averaged operation time was significantly shorter in the C-arm imaging group (4.217 h) than in the craniometry group (6.193 h). The C-arm imaging group had two cases with horizontal differences >3 mm and one case with vertical differences >3 mm. The craniometry group had four cases with horizontal differences >3 mm and four cases with vertical differences >3 mm. There were no significant differences between the two groups in horizontal differences and vertical differences.

Craniometry may achieve the same outcomes as C-arm imaging in comminuted ZMC fracture management; however, the former requires more time than the latter.
The Syntaxin-1A gene single nucleotide polymorphism rs4717806 associates with the risk of ischemic heart disease
Authors: Guerini Franca R. , Ripamonti Enrico , Costa Andrea S. , Zanzottera Milena , Agliardi Cristina , Bolognesi Elisabetta , Clerici Mario , Racca Vittorio
Published: June 2019

Ischemic heart disease (IHD) has a genetic predisposition and a number of cardiovascular risk factors are known to be affected by genetic factors. Development of metabolic syndrome and insulin resistance, strongly influenced by lifestyle and environmental factors, frequently occur in subjects with a genetic susceptibility. The definition of genetic factors influencing disease susceptibility would allow to identify individuals at higher risk and thus needing to be closely monitored.

To this end, we focused on a complex of soluble-N-ethylmaleimide-sensitive factor attachment protein receptors (SNAREs), playing an important role in metabolic syndrome and insulin resistance, involved in endothelial dysfunction and heart disease. We assessed if genetic variants of the SNARE genes are associated with IHD.

SNAP25 rs363050,Stx-1A rs4717806,rs2293489, andVAMP2 26bp ins/delgenetic polymorphisms were analyzed in a cohort of 100 participants who underwent heart surgery; 56 of them were affected by IHD, while 44 were not. A statistical association of plasma glycemia and insulin resistance, calculated as Triglyceride glucose (TyG) index, was observed in IHD (P < .001 andP = .03, respectively) after binomial logistic stepwise regression analysis, adjusted by age, gender, diabetes positivity, waist circumference, and cholesterol plasma level. Among genetic polymorphisms,rs4717806(A)andrs2293489(T), as well as thers4717806 – rs2293489 (A-T)haplotype were associated with higher risk for IHD (Pc = .02;Pc = .02;P = .04, respectively). Finally, a statistical association ofrs4717806(AA)genotype with higher TyG index in IHD patients (P = .03) was highlighted by multiple regression analysis considering log-transformed biochemical parameters as dependent variable and presence of coronary artery disease, age, gender, waist circumference, presence of diabetes as predictors. These results point to a role of theStx-1A rs4717806SNP in IHD, possibly due to its influence on Stx-1A expression and, as a consequence, on insulin secretion and glucose metabolism.