bluuebunny/crossref_metadata_2025 huggingface dataset:
Abolishing Gender
Authors: Earp Brian D.
Published: October 2021

This chapter evaluates the abolition of gender. There is a powerful set of assumptions in Western culture that influences how many of us think about sex and gender, even if we are not always fully aware of it. This set of assumptions can be called the “Dominant Gender Ideology” (DGI). Some people think it would better if sex was not linked to socially enforced gender roles that prescribe how people should be and behave on the basis of their sex. And their proposal for how to bring about this better future is to banish gender roles — and associated cultural norms — altogether. However, not everyone is a gender abolitionist. Many people think that gender roles are appropriate or worthwhile, perhaps even “natural” and inevitable. On one end of this spectrum are socially conservative religious people. At the other end of the spectrum are (some) progressive people who believe that gender can help members of certain disadvantaged groups make sense of their own minds and bodies in our social world.
Avatars
Authors: Neely Erica L.
Published: October 2021

This chapter assesses the ethical issues pertaining to avatars and their users. Many of the ethical issues involve questions of customization: how much should a user be able to customize their avatar? The chapter argues that the designers of virtual worlds have an ethical obligation to afford all users the same range of customization options. Historically, avatars (and virtual worlds themselves) could be entirely text-based, but nowadays most are visual. Thus, an avatar can be thought of as a visual representation of the person using the world. This representation could, in theory, be almost anything; they may not be actually human. Virtual worlds which are not games (generally referred to as “social worlds”) contain a wide variety of humanoid representations as well. Even the human avatars may not look much like their users; when given the chance to customize their avatars, it is perhaps unsurprising that people tend to create avatars similar to themselves, but more attractive. Indeed, avatars are frequently idealizations of who we are, rather than exact copies. This is because virtual spaces are not free of social pressures or biases.
Conspiracy Theories?
Authors: Clarke Steve
Published: October 2021

This chapter examines what, if anything, governments in Western liberal democratic societies should do to reduce rates of acceptance of unwarranted conspiracy theories. It begins by addressing three concerns. One is that it is unclear what counts as a conspiracy theory. A second is that it might be supposed that the acceptance of unwarranted conspiracy theories is not harmful. And if the acceptance of unwarranted conspiracy theories is not harmful then it is unclear why governments should be trying to reduce their rates of acceptance. A third concern is that it is unclear that we should be encouraging governments to undertake the project of reducing the popularity of unwarranted conspiracy theories, given that sometimes governments themselves have been known to mislead us about conspiracy theories. The chapter then looks at short-term and long-term strategies to reduce the popularity of unwarranted conspiracy theories. Long-term strategies include promoting critical reasoning skills through schooling and other forms of public education; promoting knowledge of the media and how it works; and making government operations more transparent and accountable.
Heroes, Villains, and Victims
Authors: Cheded Mohammed , Hopkinson Gillian
Published: October 2021

This chapter explores the construction of dramaturgic characters in social movement narratives surrounding breast cancer. It contributes to developing a better understanding of the role of plotting and characterization in these social movement narratives by highlighting three primary functions. First, the authors elaborate on the functions of the plotting of the central characters of a social movement narrative and their emotional appeal, in contributing to mobilizing collective action as well as operating a disciplining tool for the biological citizen. Second, they shed light on the effects of the simplification versus complexification of the characterization of the villain on mobilizing the audience’s emotions. Finally, they discuss the role of the individualization and collectivization dynamics in the various social movement narratives in stabilizing and/or destabilizing certain political realities.
Philanthropy and the Development of Modern India
Authors: Kumar Arun
Published: October 2021

Through their philanthropy, Indian elites have played an influential role in the country’s development in the twentieth century. Presenting an innovative history of postcolonial development, the book plots elites’ formulations and formations of modernity and its entanglement with the national question. In an unusual move that reads more familiar forms of modernization from the second half of the twentieth century alongside earlier ideas of nationalist reform, it interrogates the influence of anti-colonial nationalism in India on contemporary development. It also brings into relief the longer historical trajectory of popular development ideas such as ‘self-care’ and ‘responsibility’. The book covers the differences and shifts in elites’ imaginaries of development across a range of sites—self, community, science and technology, and civil society. It concludes that as elites privileged their imaginaries of development over others, they have come to assume a pedagogic role for themselves as they justify their development choices and its exclusions: in the name of nation.
Self
Authors: Kumar Arun
Published: October 2021

As part of national-modern development, elites have invested extensively in individual selves. The meritorious have always been a popular but expected choice as elites invested in their training, education, and in endowing modern institutions for them, etc. As the meritorious were expected to lead India’s development, they were also expected to undergo cultural modernization. Alongside which, elites also turned their attention on to India’s masses, disciplining their minds and bodies, as well as training them in new skills and cultural attitudes in order to transform the masses into citizens of a modern country. Towards the end of the twentieth century and as the irresolutions of development were laid bare, elites began to invest in building the capacities of the masses to make them market-ready.
Theory and Practice of the Armed Struggle
Authors: Klausen Jytte
Published: October 2021

Chapter 8 shows how the jihadists set themselves apart from other insurgent groups or revolutionary movements by calling for de-territorialized defensive warfare. According to the official ideology, the Muslim nation – the global ummah – is under attack by the “Crusader nations,” and it is being betrayed by Muslim “tyrants.” The fundamental jihadist tenet is the “individual obligation” to engage in the armed jihad to defend “Muslim lands.” How that works in practice was explained in an interview by a veteran Danish foreign fighter, Slimane Hajj Abderrahmane, a former prisoner in Guantanamo Bay. He also offered characteristic jihadist justifications of suicide attacks and for killing civilians. Slimane died fighting in Syria for Jabhat al-Nusra, an Al Qaeda affiliate, in February 2013.
Made in the USA
Authors: Klausen Jytte
Published: October 2021

Chapter 9 discusses the significance of Bin Laden’s diary, discovered in the Abbottabad compound in 2011, which shows that he was urging the recruitment of American citizens, not necessarily Muslims, who were from minority ethnic groups, particularly African-Americans and Latinos. The chapter uses data collected by the Western Jihadism Project to assess the demographic background of American jihadists and test a regression model relating role choices to demographic variables in order to determine the most common roles to which the Americans aspired in the global movement. The findings contradict many popular assumptions about which Americans joined the global jihadists movement, and why they did so. A third have been converts who turn to Islam as they radicalize. The converts are overwhelmingly American citizens (94%). White Americans are the largest subset of converts (43%). And the first thing that these converts want to do is to travel abroad to join a foreign terrorist group. Doing “something” at home, as Bin Laden had hoped, is often a backup option, only selected when going abroad fails. Close to half of the Americans in the study became foreign fighters or attempted to join a terrorist organization abroad. Evidently, what drives them above all is not anger against their circumstances at home but rather an adventure-seeking urge to fight abroad in the name of jihad.
The Never-Ending Forever War
Authors: Klausen Jytte
Published: October 2021

In Chapter 12, the war on terror is addressed—what critics call a “forever war.” Jihadism has never attracted more than a tiny proportion of the world’s Muslims, but the movement is extremist, intractable, well organized, and amply funded, and it developed a strike power out of all proportion to its size. It flourishes by exploiting the mechanics of a globalization that it aims to destroy. ISIS has been badly wounded, and the “Caliphate” has been defeated, but the war on terror cannot be brought to a close by a unilateral withdrawal from what has become a global fight. ISIS has reverted to its origins as a guerilla organization. A resurgent Al Qaeda has many more armed fighters under its command than it did in 2001 or in 2010, and may now be more dangerous than ISIS. Affiliates of both the main jihadist organizations control territories and fighter brigades in Africa, the Middle East and Asia. Their supporters in Western democracies are more numerous than ever. Containing global terrorism requires a steady hand, a robust system of international alliances, and continuity from administration to administration. The United States has to learn to live with the threat and embrace a policy of collaborative containment.
Introduction: Quarter Past Eleven, One Hundred Days, a Thousand Years
Authors: Fritzsche Peter
Published: October 2021

This introductory chapter begins by describing Adolf Hitler's appointment as Germany's new chancellor on January 30, 1933. This appointment led to the greatest man-made disaster in twentieth-century history: the rise of Hitler, the establishment of the Third Reich, and the Nazis' war on the world. Why the sense of urgency to make a decision on January 30, 1933? And why the apparent sudden shift in national mood in favor of the Nazis in the one hundred days that followed? To begin to answer these questions one must step back in time, first to the crisis of the Great Depression and then further back to the end of World War I and the November Revolution that established the Weimar Republic in 1918. Ultimately, the drama of the first hundred days centers on an apparent seismic shift in public sympathies as Germans became Nazis. To this day, scholars argue about the degrees of deception and self-deception and the scales of desire, opportunism, and coercion that made up the phenomenon of National Socialism.
The Filth of Grain and the Pain of Drink
Authors: McHugh James
Published: October 2021

Chapter 7 contains a lengthy account of various approaches to drink and drinking that we today might classify as ethical or legal, often for religious reasons. The chapter begins with the Vedas, investigating what they have to say about the morality of drinking. Then it examines texts that present drinking more as a vice of kings than as a sin—a practice to be moderated rather than shunned. There follow detailed sections on Hindu, Buddhist, and Jain legal and moral texts on drinking. The chapter then examines some texts that praise drinking in orthodox terms or satirize the morality (or hypocrisy) associated with drinking and abstinence.
The Teleologies of Leibniz and Kant
Authors: Guyer Paul
Published: October 2021

In his response to the polemical writings of the Leibnizian Eberhard, Kant claims that the Critique of Pure Reason might well be the true apology for Leibniz. While that view might be an exaggeration, this chapter argues that there are important similarities and revealing differences between Leibniz and Kant on another point mentioned in that text: namely, between the Leibnizian view of the harmony between the realms of nature and grace and the Kantian view of the union between our concept of nature and our concept of freedom, the central thought of the third Critique, and of the necessary realizability of the kingdom of ends in nature in the form of the highest good because of the common authorship of the laws of both nature and freedom, the culminating thought of the second Critique.
A correlative light electron microscopy approach reveals plasmodesmata ultrastructure at the graft interface
Authors: Chambaud Clément , Cookson Sarah Jane , Ollat Nathalie , Bayer Emmanuelle , Brocard Lysiane
Published: October 2021

Despite recent progress in our understanding of graft union formation, we still know little about the cellular events underlying the grafting process. This is partially due to the difficulty of reliably targeting the graft interface in electron microscopy to study its ultrastructure and three-dimensional architecture. To overcome this technological bottleneck, we developed a correlative light electron microscopy (CLEM) approach to study the graft interface with high ultrastructural resolution. Grafting hypocotyls of Arabidopsis thaliana lines expressing yellow FP or monomeric red FP in the endoplasmic reticulum (ER) allowed efficient targeting of the grafting interface for examination under light and electron microscopy. To explore the potential of our method to study sub-cellular events at the graft interface, we focused on the formation of secondary plasmodesmata (PD) between the grafted partners. We showed that four classes of PD were formed at the interface and that PD introgression into the cell wall was initiated equally by both partners. Moreover, the success of PD formation appeared not systematic with a third of PD not spanning the cell wall entirely. Characterizing the ultrastructural characteristics of these incomplete PD gives us insights into the process of secondary PD biogenesis. We found that the establishment of successful symplastic connections between the scion and rootstock occurred predominantly in the presence of thin cell walls and ER–plasma membrane tethering. The resolution reached in this work shows that our CLEM method advances the study of biological processes requiring the combination of light and electron microscopy.
Public Attitudes toward Internal and Foreign Migration
Authors: Singer David A , Quek Kai
Published: October 2021

We explore attitudes toward internal and foreign migration in China using an original survey experiment. If labor-market competition drives attitudes, then residents will be opposed to migrants with comparable skill levels, regardless of migrant origin. If residents fear a dilution of national identity, then they will be more opposed to foreign than internal migration. We conduct a national survey in Mainland China, where we randomly assign respondents to answer questions about migrants with different skill levels and from either foreign countries or other provinces in China. We find that attitudes cleave over skill level, but the foreign-internal dimension is, on its own, not a salient cleavage in preferences. However, when considering high-skilled migrants, respondents are more supportive of foreign than internal migration; when considering low-skilled migrants, they are more opposed to foreign than internal migration. The results cast doubt on material explanations for attitudes toward migration and suggest a reevaluation of cultural threat arguments that privilege national borders.
‘It’s the value that we bring’: performance pay and top income earners’ perceptions of inequality
Authors: Hecht Katharina
Published: October 2021

Though the literature on perceptions of inequality and studies of ‘elites’ have identified the importance of meritocratic beliefs in legitimating inequality, little is known about the role of pay setting processes in sustaining ideals of meritocracy. Drawing on 30 in-depth interviews with UK-based top income earners working mainly in finance, I analyse how top income earners perceive economic inequality. My study highlights the crucial role of performance pay for perceptions that top incomes are meritocratically deserved. Participants expressed the view that performance pay, an increasingly prevalent pay-setting practice, ensures that top incomes reflect a share of economic ‘value created’ for shareholders, clients or investors. Focusing on narrow, economic criteria of evaluation perceived as objective, the majority of respondents (‘performance pay meritocrats’) justified any income difference as deserved if it reflects economic contribution. Meanwhile, a minority of respondents (‘social reflexivists’) applied broader evaluative criteria including distributive justice and social contributions.
Cognitive behavioral therapy for insomnia has sustained effects on insomnia, fatigue, and function among people with chronic heart failure and insomnia: the HeartSleep Study
Authors: Redeker Nancy S , Yaggi Henry Klar , Jacoby Daniel , Hollenbeak Christopher S , Breazeale Stephen , Conley Samantha , Hwang Youri , Iennaco Joanne , Linsky Sarah , Nwanaji-Enwerem Uzoji , O’Connell Meghan , Jeon Sangchoon
Published: October 2021

Study Objectives

Insomnia is common among adults with chronic heart failure (HF) and associated with daytime symptoms and decrements in function. The purpose of this randomized controlled trial (RCT) was to evaluate the sustained effects over one year of CBT-I (Healthy Sleep: HS) compared with HF self-management education (Healthy Hearts; attention control: HH) on insomnia severity, sleep characteristics, symptoms, and function among people with stable HF. The primary outcomes were insomnia severity, actigraph-recorded sleep efficiency, and fatigue.

Methods

We randomized adults with stable HF with preserved or reduced ejection fraction who had at least mild insomnia (Insomnia severity index >7) in groups to HS or HH (4 sessions/8 weeks). We obtained wrist actigraphy and measured insomnia severity, self-reported sleep characteristics, symptoms (fatigue, excessive daytime sleepiness, anxiety, depression), and six-minute walk distance at baseline, within one month of treatment, and at 6 and 12 months. We used general linear mixed models (GLMM) and generalized estimating equations (GEE) to evaluate the effects.

Results

The sample included 175 participants (M age = 63 ± 12.9 years; 43% women; 18% Black; 68% New York Heart Association Class II or II; 33%; LVEF < 45%) randomized to HS (n = 91) or HH (n = 84). HS had sustained effects on insomnia severity, sleep quality, self-reported sleep latency and efficiency, fatigue, excessive daytime sleepiness, and six-minute walk distance at 12 months.

Conclusions

CBT-I produced sustained improvements in insomnia, fatigue, daytime sleepiness, and objectively measured physical function among adults with chronic HF, compared with a robust HF self-management program that included sleep hygiene education.

Clinical Trial Information

Insomnia Self-Management in Heart Failure; https://clinicaltrials.gov/ct2/show/NCT02660385; NCT02660385.
Evaluation of microencapsulated organic acids and botanicals on growth performance of nursery and growing-finishing pigs
Authors: Hutchens Wade M , Tokach Mike D , Woodworth Jason C , DeRouchey Joel M , Goodband Robert D , Gebhardt Jordan T , Calderon Hilda I , Keppy Kaylee , Maynard Philip , Grilli Ester
Published: October 2021

A total of 1,215 pigs (L337 × 1050, PIC, Hendersonville, TN) were used to determine the effect of microencapsulated organic acids and botanicals (MOB; AviPlus; Vetagro, Inc. Chicago, IL), on growth performance from weaning to market. Pigs were weaned at approximately 21 d of age and placed in pens based on initial body weight (BW) with 27 pigs per pen in a randomized complete block design. During the 42-d nursery period, pigs were allotted to one of two treatments in an unbalanced treatment structure with 15 pens (replications) fed the control diet and 30 pens (replications) fed diets containing 0.30% MOB from days 0 to 21 and 0.10% from days 21 to 42. On day 42, pigs were transported as intact pens from the nursery to the finishing facility. During the finishing period, three treatments were applied which included: 1) pigs on the control diet in nursery remained on control diets; 2) 50% of pigs provided MOB in nursery were then fed 0.05% MOB throughout finishing, and 3) 50% of pigs provided MOB in nursery were then fed the control diet throughout finishing. All pens of pigs on treatments 2 and 3 were allotted based on ending nursery BW to the finishing treatment. There were 15 replications per treatment in the finishing period. From days 0 to 21, pigs fed diets with MOB had a tendency for increased (P < 0.058) gain:feed (G:F) when compared to pigs fed the control diet; however, there was no evidence of difference (P > 0.05) for average daily gain (ADG), average daily feed intake (ADFI), or day 21 BW. From days 21 to 42, there was no evidence of difference (P > 0.05) for ADG, ADFI, or G:F. For the overall nursery period (days 0 to 42), pigs fed diets with MOB had increased (P < 0.05) G:F (660 vs. 670 g/kg) when compared with pigs fed the control diet, but there was no evidence of difference (P > 0.05) for day 42 BW, ADG, or ADFI between treatments. From d 42 to 106, there was no evidence of difference (P > 0.05) for ADG, ADFI, and G:F. For the overall finishing period (days 42 to 156) and overall experimental period (days 0 to 156), there was no evidence of difference (P > 0.05) for BW, ADG, ADFI, or G:F. For mortality and removals, there was no evidence of difference (P > 0.05) observed during the nursery, finishing, or overall. In summary, providing MOB during the nursery phase increased G:F in the early and overall nursery phase, but there was no effect on overall wean-to-finish performance.
Distinguishing early patterns of physical activity goal attainment and weight loss in online behavioral obesity treatment using latent class analysis
Authors: Stansbury Melissa L , Harvey Jean R , Krukowski Rebecca A , Pellegrini Christine A , Wang Xuewen , West Delia S
Published: October 2021

Physical activity (PA) goal adherence is consistently associated with greater weight loss during behavioral obesity treatment, and early weight loss response predicts future weight loss success. However, it remains unclear which behaviors during the initial weeks of treatment distinguish responders from nonresponders and might be effective targets for improving treatment outcomes. To characterize subgroups with distinct patterns of PA goal adherence during the initial 2 months of an online, group-based weight control program and determine associations between these patterns and 6-month weight loss. Participants received an online behavioral obesity intervention with PA goals and daily self-monitoring. Weekly adherence to step goals and moderate-to-vigorous PA (MVPA) minute goals based on self-monitoring records were examined using latent class analysis. Body weight was objectively measured at 0, 2, and 6 months. Participants (N = 212; 91.5% female, 31.6% race/ethnic minority, mean body mass index: 35.8 ± 5.9 kg/m2) clustered into three subgroups based on early goal attainment: “Both PA Goals,” “MVPA Goals Only,” and “Neither PA Goal.” The “Both PA Goals” class had significantly greater 6-month weight loss (estimated mean weight loss [95% CI]: −9.4% [7.4 to 11.5]) compared to the “MVPA Goals Only” (−4.8% [3.4 to 6.1]) and “Neither PA Goal” classes (−2.5% [1.4 to 3.6]). Individuals meeting both PA goals early in treatment achieve greater weight losses than those meeting MVPA but not step goals, pointing to the need to explore factors associated with nonadherence to each of the PA goals to better understand these potential targets for treatment refinement and adaptive interventions.
Key points of investigation and analysis on traffic accidents involving intelligent vehicles
Authors: Yuan Quan , Peng Yong , Xu Xiaodong , Wang Xinghua
Published: October 2021

Intellectualization is regarded as the future mainstream development trend of the automobile industry. The automation level of intelligent vehicles is relatively low so far, and the road traffic system will be in a mixed state of non-autonomous vehicles and vehicles with different levels of automation for a long time. Therefore, the road traffic system will be more complex with more diverse accidents. This paper analysed the characteristics and causal factors of intelligent vehicle accidents. Based on the problems existing in investigation, analysis and liability identification of intelligent vehicle accident, the study proposed a preliminary accident investigation framework and method, summarized the key points of accident analysis from the perspectives of technical defects, information security and passive safety, and specified the liability subjects for intelligent vehicle accidents and their corresponding legal liability. The results from this study contributed to the development of intelligent vehicle accident investigation and disposal, and provided the reference for the improvement of vehicle safety and accident prevention.
Developing Telemedicine Curriculum Competencies for Graduate Medical Education: Outcomes of a Modified Delphi Process
Authors: Hart Alexander , Romney Douglas , Sarin Ritu , Mechanic Oren , Hertelendy Attila J. , Larson Deanna , Rhone Kelly , Sidel Kristi , Voskanyan Amalia , Ciottone Gregory R.
Published: October 2021

Purpose

Telemedical applications have only recently begun to coalesce into the field of telemedicine due to varying definitions of telemedicine and issues around reimbursement. This process has been accelerated by the COVID-19 pandemic and the ensuing expansion of telemedicine delivery. This article demonstrates the development of a set of proposed competencies for a telemedicine curriculum in graduate medical education.

Method

A modified Delphi process was used to create a panel of competencies. This included a systematic review of the telemedicine literature through November 2019 to create an initial set of competencies, which were analyzed and edited by a focus group of experts in January 2020. Initial competencies were distributed in a series of 3 rounds of surveys to a group of 23 experts for comments and rating from April to August 2020. Competencies that obtained a score of 4.0 or greater on a 5-point Likert scale in at least 2 rounds were recommended.

Results

Fifty-five competencies were developed based on the systematic review. A further 32 were added by the expert group for a total of 87. After 3 rounds of surveys, 34 competencies reached the recommendation threshold. These were 10 systems-based practice competencies, 7 professionalism, 6 patient care, 4 practice-based learning and improvement, 4 interpersonal and communication skills, and 3 medical knowledge competencies.

Conclusions

Half (17/34) of the competencies approved by the focus group and surveyed expert panel pertained to either systems-based practice or professionalism. Both categories exhibit more variation between telemedicine and in-person practice than other categories. The authors offer a set of proposed educational competencies that can be used in the development of curricula for a wide range of providers and are based on the best evidence and expert opinion available.
A Novel Online Curriculum and Coaching Strategy to Expand the Addiction Medicine Workforce: The Michigan Collaborative Addiction Resources and Education System
Authors: Poland Cara , Bennett Lia , Strutz Kelly L. , Plantegenest Geraud , Greenwald Mark K.
Published: October 2021

Problem

There is a shortage of addiction medicine (AM) physicians and a 9-year period (2017–2025) in which to build the workforce via a practice pathway enabling physicians to combine experiential hours with passing a board exam to become board-certified AM physicians. Afterward, AM specialists will need to complete the traditional fellowship pathway, requiring additional training.

Approach

The Michigan Collaborative Addiction Resources and Education System (MI CARES) was developed from February to June 2019 to support physicians in obtaining AM certification via the practice pathway. This program was originally planned for Michigan physicians but was quickly expanded nationally. This novel, asynchronous, self-directed online curriculum follows the knowledge blueprint for the board exam, including continuing medical education credits. The program also provides 1:1 coaching support to educate physicians on how to properly document their experiential hours on the application for the AM board exam. The first module, which describes the practice pathway, was released in January 2020, and 7 substance-specific content modules were released monthly from February to August 2020.

Outcomes

As of October 31, 2020, 231 physicians from 13 American Board of Medical Specialties in 37 U.S. states were enrolled in MI CARES. The longer a module was available, the more participants visited the module. Three early program adopters were approved to sit for the 2019 board exam, and 51 participants passed the board exam in 2020. Of these 51, 5 had previously been denied approval before participating in MI CARES.

Next Steps

It will be important to replicate preliminary evidence of feasibility for this novel model for expanding the workforce in a newly approved and underrepresented specialty to see if it holds promise for replication as other subspecialties are identified. The curriculum is being expanded to include modules on additional topics and adapted for graduate and undergraduate medical education students.
Institutional Accountability for Students With Disabilities: A Call for Liaison Committee on Medical Education Action
Authors: Meeks Lisa M. , Stergiopoulos Erene , Petersen Kristina H.
Published: October 2021

Medical educators and leaders have called for greater diversity among the physician workforce, including those with disabilities. However, many students with disabilities are precluded from entering and completing medical training due to historically restrictive technical standards and poor internal practices to protect student privacy. This limits the possibilities for growing this part of the workforce and making progress toward the ultimate goal of having a physician workforce that better represents the patients it serves. To achieve diversity among the physician workforce, medical education must create environments that allow students with disabilities to apply to, flourish in, and feel well supported in medical school.

Recent additions to Accreditation Council for Graduate Medical Education requirements have helped to catalyze work in the area of disability inclusion by incorporating disability-focused mandates into graduate medical education accreditation standards. However, similar mandates for undergraduate medical education have not yet materialized. In this article, the authors call for the Liaison Committee on Medical Education (LCME) to elevate disability as a valued part of medical school diversity in its accreditation standards and to include protections for disabled students. The authors propose that the LCME can take 5 actions to promote institutional accountability toward students with disabilities: (1) define disability as diversity, (2) mandate disability support, (3) protect from conflicts of interest, (4) protect privacy, and (5) verify schools’ technical standards comply with the Americans with Disabilities Act. By adopting these recommendations, the LCME would send the powerful message that students with disabilities bring welcome expertise and value to the medical community.
Frailty and cardiac surgery: to operate or not?
Authors: Emmert Daniel A. , Arcario Mark J. , Maranhao Bruno , Reidy Andrea B.
Published: October 2021

Purpose of review

With an aging cardiac surgery population, prefrail and frail patients are becoming more common. Anesthesiologists will be faced with the decision of how best to provide care to frail patients. Identification, management, and outcomes in frail patients will be discussed in this review.

Recent findings

Frailty is associated with a variety of poor outcomes, such as increased hospital length of stay, medical resource utilization, readmission rates, and mortality. Prehabilitation may play a greater role in the management of frail cardiac surgery patients.

As frailty will likely only increase amongst cardiac surgery patients, it is important to develop multicenter trials to study management and treatment options. Until those studies are performed, the care of frail cardiac surgery patients may be best provided by high-volume surgical centers with expertise in the management of frail patients.
Elastomeric Respirators for COVID-19 and the Next Respiratory Virus Pandemic: Essential Design Elements
Authors: Bowdle T. Andrew , Jelacic Srdjan , Munoz-Price L. Silvia , Cohen Marty , M. Sai Krishna , Brosseau Lisa
Published: October 2021

Respiratory viruses are transmitted via respiratory particles that are emitted when people breath, speak, cough, or sneeze. These particles span the size spectrum from visible droplets to airborne particles of hundreds of nanometers. Barrier face coverings (“cloth masks”) and surgical masks are loose-fitting and provide limited protection from airborne particles since air passes around the edges of the mask as well as through the filtering material. Respirators, which fit tightly to the face, provide more effective respiratory protection. Although healthcare workers have relied primarily on disposable filtering facepiece respirators (such as N95) during the COVID-19 pandemic, reusable elastomeric respirators have significant potential advantages for the COVID-19 and future respiratory virus pandemics. However, currently available elastomeric respirators were not designed primarily for healthcare or pandemic use and require further development to improve their suitability for this application. The authors believe that the development, implementation, and stockpiling of improved elastomeric respirators should be an international public health priority.
Spinal Anesthesia with Targeted Sedation based on Bispectral Index Values Compared with General Anesthesia with Masked Bispectral Index Values to Reduce Delirium: The SHARP Randomized Controlled Trial
Authors: Brown Charles H. , Edwards Charles , Lin Charles , Jones Emily Ledford , Yanek Lisa R. , Esmaili Melody , Gorashi Yara , Skelton Richard , Kaganov Daniel , Curto Ryan , Lessing Noah L. , Cha Stephanie , Colantuoni Elizabeth , Neufeld Karin , Sieber Frederick , Dean Clayton L. , Hogue Charles W.
Published: October 2021

Background

Reducing depth of anesthesia and anesthetic exposure may help prevent delirium, but trials have been conflicting. Most studies were conducted under general anesthesia or in cognitively impaired patients. It is unclear whether reducing depth of anesthesia beyond levels consistent with general anesthesia reduces delirium in cognitively intact patients. The authors’ objective was to determine whether a bundled approach to reduce anesthetic agent exposure as determined by Bispectral Index (BIS) values (spinal anesthesia with targeted sedation based on BIS values) compared with general anesthesia (masked BIS) reduces delirium.

Methods

Important eligibility criteria for this parallel-arm randomized trial were patients 65 yr or greater undergoing lumbar spine fusion. The intervention group received spinal anesthesia with targeted sedation to BIS greater than 60 to 70. The control group received general anesthesia (masked BIS). The primary outcome was delirium using the Confusion Assessment Method daily through postoperative day 3, with blinded assessment.

Results

The median age of 217 patients in the analysis was 72 (interquartile range, 69 to 77). The median BIS value in the spinal anesthesia with targeted sedation based on BIS values group was 62 (interquartile range, 53 to 70) and in the general anesthesia with masked BIS values group was 45 (interquartile range, 41 to 50; P < 0.001). Incident delirium was not different in the spinal anesthesia with targeted sedation based on BIS values group (25.2% [28 of 111] vs. the general anesthesia with masked BIS values group (18.9% [20 of 106]; P = 0.259; relative risk, 1.22 [95% CI, 0.85 to 1.76]). In prespecified subgroup analyses, the effect of anesthetic strategy differed according to the Mini-Mental State Examination, but not the Charlson Comorbidity Index or age. Two strokes occurred among patients receiving spinal anesthesia and one death among patients receiving general anesthesia.

Conclusions

Spinal anesthesia with targeted sedation based on BIS values compared with general anesthesia with masked BIS values did not reduce delirium after lumbar fusion.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New
Threshold-based Monitoring of Compound Muscle Action Potentials for Percutaneous Pedicle Screw Placement in the Lumbosacral Spine
Authors: Tani Yoichi , Saito Takanori , Taniguchi Shinichiro , Ishihara Masayuki , Paku Masaaki , Adachi Takashi , Ando Muneharu , Kohara Nobuo , Kimura Jun
Published: October 2021

Study Design.

A prospective analysis.

Objective.

To test if threshold-based monitoring of compound muscle action potentials (CMAPs) by stimulating the screw loaded to uninsulated extender sleeve provides a valid safety warning for percutaneous pedicle screw (PPS) placements in the lumbosacral spine.

Summary of Background Data.

Utility of the CMAP monitoring to PPS procedures remains controversial.

Methods.

A series of 202 patients underwent a total of 1664 lumbosacral PPS placements under CMAP monitoring without fluoroscopic guidance. The monitoring consisted of stimulating the PPS assembled to uninsulated extender sleeve and recording CMAPs from the vastus medialis, biceps femoris, tibialis anterior, and medial gastrocnemius. Automated steps of a threshold hunting algorithm using 0.2-ms duration pulses of increasing intensities delivered at 2/s allowed quick determination of a minimum stimulation current to evoke >100-μV amplitude CMAPs.

Results.

At L2 through S1 spines, postoperative CT scans identified 51 medial or inferior pedicle wall breaches of 1536 screws (3.3%) without neurologic complications. The receiver operating characteristic curve analysis determined the critical cutoff threshold value of 27 mA (74% sensitivity and 95% specificity) for predicting 35 breaches of 627 screws (5.6%) at L2 and L3, and of 17 mA (100% sensitivity and 98% specificity) for 16 of 909 (1.8%) at L4 through S1. While advancing the screw, three breaches (5.9%) showed a particularly low threshold of ≤6-mA, allowing the surgeon to immediately redirect the screw and retest the new trajectory as safe.

Conclusion.

Screw stimulation with threshold hunting algorithm has a distinct advantage over the time-consuming insulated pilot hole stimulation, allowing an uninterrupted flow of the surgery. The present findings have documented practical usefulness and reliability of CMAP monitoring using direct stimulation of the PPS assembled to uninsulated extender sleeve.
Simplified Pediatric Index of Mortality 3 Score by Explainable Machine Learning Algorithm
Authors: Baloglu Orkun , Nagy Matthew , Ezetendu Chidiebere , Latifi Samir Q. , Nazha Aziz
Published: October 2021

OBJECTIVES:

Pediatric Index of Mortality 3 is a validated tool including 11 variables for the assessment of mortality risk in PICU patients. With the recent advances in explainable machine learning algorithms, we aimed to assess feasibility of application of these machine learning models to simplify the Pediatric Index of Mortality 3 scoring system in order to decrease time and labor required for data collection and entry for Pediatric Index of Mortality 3.

DESIGN:

Single-center, retrospective cohort study. Data from the Virtual Pediatric Systems for patients admitted to Cleveland Clinic Children`s PICU between January 2008 and December 2019 was obtained. Light Gradient Boosting Machine Regressor (a gradient boosting decision tree algorithm) was used for building the machine learning models. Variable importance was analyzed by SHapley Additive exPlanations. All of the 11 Pediatric Index of Mortality 3 variables were used as input variables in the machine learning models to predict Pediatric Index of Mortality 3 risk of mortality as the outcome variable. Mean absolute error, root mean squared error, and R-squared were calculated for each of the 11 machine learning models as model performance parameters.

SETTING:

Quaternary children’s hospital.

PATIENTS:

PICU patients.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Five-thousand sixty-eight patients were analyzed. The machine learning models were able to maintain similar predictive error until the number of input variables decreased to four. The machine learning model with five input variables (mechanical ventilation in the first hour of PICU admission, very-high-risk diagnosis, surgical recovery from a noncardiac procedure, low-risk diagnosis, and base excess) produced lowest mean root mean squared error of 1.49 (95% CI, 1.05–1.93) and highest R-squared of 0.73 (95% CI, 0.6–0.86) with mean absolute error of 0.43 (95% CI, 0.35–0.5) among all the 11 machine learning models.

CONCLUSIONS:

Explainable machine learning methods were feasible in simplifying the Pediatric Index of Mortality 3 scoring system with similar risk of mortality predictions compared to the original Pediatric Index of Mortality 3 model tested in a single-center dataset.
Use of Antifibrinolytics in Pediatric Life-Threatening Hemorrhage: A Prospective Observational Multicenter Study
Authors: Spinella Philip C. , Leonard Julie C. , Gaines Barbara A. , Luther James F. , Wisniewski Stephen R. , Josephson Cassandra D. , Leeper Christine M. ,   for the MAssive Transfusion epidemiology and outcomes In Children (MATIC) Investigators and BloodNet
Published: October 2021

OBJECTIVES:

To assess the impact of antifibrinolytics in children with life-threatening hemorrhage.

DESIGN:

Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.

SETTING:

Twenty-four children’s hospitals in the United States, Canada, and Italy.

PATIENTS:

Children 0–17 years old who received greater than 40 mL/kg of total blood products over 6 hours or were transfused under activation of massive transfusion protocol.

Intervention/Exposure:

Children were compared according to receipt of antifibrinolytic medication (tranexamic acid or aminocaproic acid) during the bleeding event.

MEASUREMENTS AND MAIN RESULTS:

Patient characteristics, medications administered, and clinical outcomes were analyzed using Cox proportional hazard and Kaplan-Meier survival analysis. The primary outcome was 24-hour mortality. Of 449 patients analyzed, median age was 7 years (2–15 yr), and 55% were male. The etiology of bleeding was 46% traumatic, 34% operative, and 20% medical. Twelve percent received antifibrinolytic medication during the bleeding event (n = 54 unique subjects; n = 18 epsilon aminocaproic acid, n = 35 tranexamic acid, and n = 1 both). The antifibrinolytic group was comparable with the nonantifibrinolytic group on baseline demographic and physiologic parameters; the antifibrinolytic group had longer massive transfusion protocol duration, received greater volume blood products, and received factor VII more frequently. In the antifibrinolytic group, there was significantly less 6-hour mortality overall (6% vs 17%; p = 0.04) and less 6-hour mortality due to hemorrhage (4% vs 14%; p = 0.04). After adjusting for age, bleeding etiology, Pediatric Risk of Mortality score, and plasma deficit, the antifibrinolytic group had decreased mortality at 6- and 24-hour postbleed (adjusted odds ratio, 0.29 [95% CI, 0.09–0.93]; p = 0.04 and adjusted odds ratio, 0.45 [95% CI, 0.21–0.98]; p = 0.04, respectively).

CONCLUSIONS:

Administration of antifibrinolytic medications during the life-threatening event was independently associated with improved 6- and 24-hour survivals in bleeding children. Consideration should be given to use of antifibrinolytics in pediatric patients with life-threatening hemorrhage.
Resistance mechanisms to osimertinib and emerging therapeutic strategies in nonsmall cell lung cancer
Authors: Zeng Yue , Yu Danlei , Tian Wentao , Wu Fang
Published: October 2021

Purpose of review

This review aims to introduce the resistance mechanisms to osimertinib, discuss the therapeutic strategies, and make clinical updates in overcoming resistance to osimertinib.

Recent findings

Osimertinib has shown favorable efficacy on second-line and first-line treatments in EGFR-mutant advanced nonsmall cell lung cancer (NSCLC). However, the presence of primary and acquired resistance to osimertinib restricts its clinical benefits. The primary resistance mainly consists of BIM deletion polymorphism and EGFR exon 20 insertions. Meanwhile, the heterogeneous mechanisms of acquired resistance include EGFR-dependent (on-target) and EGFR-independent (off-target) mechanisms. EGFR C797S mutation, MET amplification, HER2 amplification, and small cell lung cancer transformation were identified as frequent resistance mechanisms. Recently, more novel mechanisms, including rare EGFR point mutations and oncogenic fusions, were reported. With the results of completed and on-going clinical trials, the emerging therapeutic strategies of postosimertinib progression are summarized.

The resistance mechanisms to osimertinib are heterogeneous and gradually perfected. The combination of osimertinib with bypass targeted therapy and other therapeutic approaches emerge as promising strategies.
Mild Renal Dysfunction and Risk of Thromboembolism and Bleeding in Patients with Atrial Fibrillation: The Chinese Atrial Fibrillation Registry Study
Authors: Li Jingye , Li Sitong , Jiang Chao , Du Jing , Guo Xueyuan , Li Songnan , Jiang Chenxi , Tang Ribo , Sang Caihua , Long Deyong , Du Xin , Dong Jianzeng , Ma Changsheng
Published: October 2021

Objective:

Previous studies indicated that patients with atrial fibrillation (AF) and moderate-to-severe chronic kidney disease (CKD) are at a higher risk of thromboembolism and bleeding during anticoagulation. Whether mild CKD is associated with an increased risk of thromboembolism and bleeding in AF patients remains unknown. This study aimed to evaluate the impact of mild CKD on thromboembolism and major bleeding among patients with AF.

Methods:

Baseline serum creatinine was available in 17,559 of 25,512 patients enrolled in the China-AF study between August 2011 and December 2018. After excluding those who underwent AF ablation or with moderate-to-severe CKD, 7191 non-valvular AF patients (2059 with mild CKD and 5132 with normal renal function) with regular follow-up for at least 6 months were included. Primary outcomes were the time to the first occurrence of thromboembolic and major bleeding events.

Results:

Over a mean follow-up of (44.4 ± 23.4) months, 639 thromboembolism and 231 major bleeding events occurred. The crude incidence rates of thromboembolism were higher in the mild CKD group than that of the normal renal function group (3.0/100 person-years vs. 2.2/100 person-years, P < 0.0001), while the crude incidence rates of major bleeding were comparable between the two groups (1.0/100 person-years vs. 0.8/100 person-years, P = 0.076). After multivariate analyses, mild CKD was not associated with an increased risk of thromboembolism (HR = 1.05, 95% CI: 0.89–1.25, P = 0.547) or major bleeding (HR = 1.11, 95% CI: 0.84–1.47, P = 0.476).

Conclusions:

Mild CKD was not an independent risk factor of thromboembolism or major bleeding in patients with AF.