bluuebunny/crossref_metadata_2025 huggingface dataset:
Monitoring of rivaroxaban levels in patients with class III obesity
Authors: Pahlmeyer Laura , Huang James
Published: May 2020

Purpose

There is little evidence to guide the use of direct oral anticoagulants (DOACs) in patients with class III obesity. Clinicians face the dilemma that using DOACs in patients with class III obesity may not provide adequate anticoagulation, while avoiding DOACs may deprive them of a useful therapeutic option. We present 2 cases describing our experience navigating rivaroxaban use in patients with class III obesity and review available case reports of measurement of rivaroxaban levels using a calibrated anti–factor Xa assay.

In patient case 1, the rivaroxaban trough level was within the reference range, and therapy was continued. In patient case 2, the rivaroxaban trough level was below the reference range, and the patient’s anticoagulation therapy was switched to warfarin. No thromboembolic events were noted in the 2 patients more than 1 year (15 and 22 months, respectively) after initiation of anticoagulation therapy. Because of the many advantages associated with use of DOACs instead of vitamin K antagonists, further research is critical to enabling clinicians to use DOACs more confidently in a broader population.

Conclusion

When monitoring rivaroxaban therapy in patients with class III obesity, there is uncertainty regarding clinical interpretation of drug levels that fall outside of established reference ranges, and monitoring is not standardized or widely available. In addition to case reports found in the literature, the presented cases highlight these challenges and differing clinical decisions made when evaluating rivaroxaban levels in patients with class III obesity.
A Topsy-Turvy Novel: “Coloring Gestures” in Tender Is the Night
Authors: Antonelli Sara
Published: May 2020

This essay addresses the black presence in F. Scott Fitzgerald’s Tender Is the Night (1934) not simply as an episode but as the very backbone of the plot. Inserting Fitzgerald into an unexpected lineage that originates with James Weldon Johnson and moves to Ishmael Reed and Toni Morrison, it argues that Fitzgerald shares with these writers a complex fusion of racial disorder, musical contagion, and intergenerational rivalry. Like Johnson and Reed, Fitzgerald also uses the figure of Harriet Beecher Stowe’s Topsy to announce the various permutations of race in the novel and to uncover the white characters’ fear of miscegenation and incest. Tender Is the Night is a “topsy-turvy” novel because of the dynamic patterning of black and white imagery Fitzgerald employs to reveal the slippery racial surface of the 1920s.
Does habitat partitioning by sympatric plovers affect nest survival?
Authors: Overduijn Kelly S , Handel Colleen M , Powell Abby N
Published: May 2020

The vertical structure and composition of vegetation can influence the quantity and quality of potential nesting sites for birds. Interspecific competition for high-quality nesting habitat may force some individuals into suboptimal habitat and lead to reduced reproductive success, eventually leading to changes in distribution or abundance. Large climate-mediated shifts in vegetation, including the rapid expansion of shrubs onto tundra, are occurring in the Arctic across important breeding grounds of many shorebird species of conservation concern. We investigated effects of vegetation structure and composition on nest-site selection and nest success of sympatrically breeding American Golden-Plovers (Pluvialis dominica) and Pacific Golden-Plovers (P. fulva), which nest along an elevational gradient ranging from coastal tundra meadows to alpine tundra. Both species strongly selected nest sites with less cover of tall shrubs and other tall vegetation than available at random sites within their territories. American Golden-Plovers selected territories and nest sites that were higher in elevation and had more rocky substrates and less graminoid vegetation than those selected by Pacific Golden-Plovers. The daily nest survival rate was equivalent in the 2 species (0.966, 95% CI: 0.955, 0.975) and similar to that found in other Arctic-breeding shorebirds; however, contrary to predictions, nest survival was not associated with habitat features selected for nest sites for either species. Strong selection of open habitat for nest sites suggests that continued climate-related shrub expansion may reduce the amount of suitable breeding habitat for both species, but partitioning along the elevational gradient and differences in body size suggest that impacts may be more severe for Pacific Golden-Plovers. Additional research is needed to determine if differential selection of nesting habitat is related to survival of the adults or their young.
Estimating egg mass–body mass relationships in birds
Authors: Rotenberry John T , Balasubramaniam Priya
Published: May 2020

The mass of a bird’s egg is a critical attribute of the species’ life history and represents a fundamental component of reproductive effort. Indeed, the tradeoff between the number of eggs in a clutch and clutch mass lies at the heart of understanding how environmental attributes such as nest predation or adult mortality influence reproductive investment. However, egg masses have not been reported for the majority of avian species. We capitalized on the strong allometric relationship between avian body mass and egg mass to produce egg mass estimates for over 5,500 species previously lacking such information. These estimates are accompanied by measures of the robustness of the regressions used to produce them (e.g., sample size, root mean square error [RMSE] of estimation, coefficient of determination, and degree of extrapolation), thus allowing independent evaluation of the suitability of any estimate to address a particular research question relating to avian life history. Most estimates (~5,000) were based on family-level egg mass–body mass regressions, with the remainder derived from other relationships such as ordinal regressions. We compared estimating regressions based on adult vs. female body masses and, after finding little difference between the 2, based our final estimates on adult masses as those were more numerous in the literature. What small differences between adult- and female-based regressions that did occur were not related to sexual size dimorphism across families. These new estimates, coupled with ~5,000 egg masses reported in the literature, provide a foundation of over 10,000 species for wider investigations assessing variation in reproductive effort in birds over a broad array of ecological and evolutionary contexts.
Testing the simple and complex versions of Gloger’s rule in the Variable Antshrike (Thamnophilus caerulescens, Thamnophilidae)
Authors: Marcondes Rafael S , Stryjewski Katherine Faust , Brumfield Robb T
Published: May 2020

Gloger’s rule is a classic ecogeographical principle that, in its simplest version, predicts animals should be darker in warmer and wetter climates. In a rarely tested more complex version, it also predicts animals should be more rufous in warmer and drier climates. The Variable Antshrike (Thamnophilus caerulescens) is a widely distributed South American passerine that presents an impressive amount of plumage color variation and occupies a wide variety of climatic conditions. Moreover, genetic and vocal evidence indicate ongoing hybridization in south-central Bolivia among 3 populations with very distinct plumages. We collected color data from 232 specimens from throughout this species’ distribution to test the predictions of Gloger’s rule. We found a negative correlation between brightness and precipitation, consistent with the simple version of Gloger’s rule. In contrast, we found that birds were darker in cooler climates, contrary to the simple version of Gloger’s rule, but consistent with recent findings in other taxa. We found support for both predictions of the complex Gloger’s rule and suggest it might be driven by background matching. We conclude by concurring with a recent suggestion that the simple version of Gloger’s rule should be reformulated exclusively in terms of humidity.
Monoclonal gammopathy of undetermined significance coexisting in patients undergoing kidney transplantation does not adversely influence post-graft clinical outcome
Authors: Clari Roberta , Tarella Corrado , Giraudi Roberta , Torazza Maria Cristina , Gallo Ester , Lavacca Antonio , Fop Fabrizio , Mella Alberto , Dolla Caterina , Biancone Luigi
Published: May 2020

Background

Management of patients with oncohaematological disorders such as monoclonal gammopathy of undetermined significance (MGUS) is a frequent problem in pre-transplant work-up. Insights on disease progression and long-term functional outcomes are still lacking in this setting.

Methods

This was a retrospective analysis on all patients with MGUS who underwent kidney transplant (KT) at our centre between 1 January 2000 and 31 December 2017 (cases, n = 65). Patients were matched with a control group (KTs with similar characteristics but without history of haematological disease, controls, n = 1079). Primary endpoints were graft and patient survival; secondary endpoints were causes of graft failure, patient death, occurrence of allograft rejection, post-transplant neoplasia (not correlated to previous disorder) and/or infectious episodes.

Results

The MGUS and control groups had a similar mean age [60 (29–79) versus 55.2 (19.3–79.5) years, respectively] and percentage of males (69.2% versus 64.6%, respectively). Median follow-up time since KT was 3.5 years (0–14) in cases and 8.3 years (0–14.9) in controls. All MGUS patients underwent KT following extensive multidiscliplinary investigations. No differences were found between cases and controls regarding patient and graft survival or post-transplant complications except for lower incidence of infections (58.7% versus 69.8%, P = 0.019) and increased use of mTOR inhbitors (30.3% versus 14.7%, P = 0.001) in MGUS. MGUS isotype did not influence graft and patient survival. The absence of difference in patients and graft survival was also confirmed in an adjunctive analysis where MGUS were compared with controls (ratio 1:2) matched for recipient age, gender, number of transplantations and transplant period.

Conclusion

Patients with MGUS may undergo KT without significantly increased risks of complications, provided that appropriate diagnostic procedures are carefully followed. Multidiscipline-based studies are crucial for establishing well designed pre- and post-transplant protocols for the best management of patients with coexisting MGUS and end-stage renal disease.
Prognostically safe stress-only single-photon emission computed tomography myocardial perfusion imaging guided by machine learning: report from REFINE SPECT
Authors: Hu Lien-Hsin , Miller Robert J H , Sharir Tali , Commandeur Frederic , Rios Richard , Einstein Andrew J , Fish Mathews B , Ruddy Terrence D , Kaufmann Philipp A , Sinusas Albert J , Miller Edward J , Bateman Timothy M , Dorbala Sharmila , Di Carli Marcelo , Liang Joanna X , Eisenberg Evann , Dey Damini , Berman Daniel S , Slomka Piotr J
Published: May 2020

Aims

Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) stress-only protocols reduce radiation exposure and cost but require clinicians to make immediate decisions regarding rest scan cancellation. We developed a machine learning (ML) approach for automatic rest scan cancellation and evaluated its prognostic safety.

Methods and results 

In total, 20 414 patients from a solid-state SPECT MPI international multicentre registry with clinical data and follow-up for major adverse cardiac events (MACE) were used to train ML for MACE prediction as a continuous probability (ML score), using 10-fold repeated hold-out testing to separate test from training data. Three ML score thresholds (ML1, ML2, and ML3) were derived by matching the cancellation rates achieved by physician interpretation and two clinical selection rules. Annual MACE rates were compared in patients selected for rest scan cancellation between approaches. Patients selected for rest scan cancellation with ML had lower annualized MACE rates than those selected by physician interpretation or clinical selection rules (ML1 vs. physician interpretation: 1.4 ± 0.1% vs. 2.1 ± 0.1%; ML2 vs. clinical selection: 1.5 ± 0.1% vs. 2.0 ± 0.1%; ML3 vs. stringent clinical selection: 0.6 ± 0.1% vs. 1.7 ± 0.1%, all P < 0.0001) at matched cancellation rates (60 ± 0.7, 64 ± 0.7, and 30 ± 0.6%). Annualized all-cause mortality rates in populations recommended for rest cancellation by physician interpretation, clinical selection approaches were higher (1.3%, 1.2%, and 1.0%, respectively) compared with corresponding ML thresholds (0.6%, 0.6%, and 0.2%).

Conclusion

ML, using clinical and stress imaging data, can be used to automatically recommend cancellation of rest SPECT MPI scans, while ensuring higher prognostic safety than current clinical approaches.
Intergenerational Mobility and Unequal School Opportunity
Authors: Arenas Andreu , Hindriks Jean
Published: May 2020

We analyse the impact of unequal school opportunity on intergenerational income mobility and human capital accumulation. Building upon the classical Becker–Tomes–Solon framework, we use a regime-switch model allowing for differences in income transmission across groups. We find that unequal school opportunity raises average human capital because of assortative matching. However, because income dispersion tends to be higher at the top, in most cases unequal school opportunity decreases intergenerational mobility. Calibrating the model to the USA, simulations suggest that school equalisation and desegregation policies have positive effects on mobility at relatively small efficiency costs.
Regional Associations of Cortical Thickness With Gait Variability—The Tasmanian Study of Cognition and Gait
Authors: Jayakody Oshadi , Breslin Monique , Beare Richard , Blumen Helena M , Srikanth Velandai K , Callisaya Michele L
Published: May 2020

Background

Gait variability is a marker of cognitive decline. However, there is limited understanding of the cortical regions associated with gait variability. We examined associations between regional cortical thickness and gait variability in a population-based sample of older people without dementia.

Method

Participants (n = 350, mean age 71.9 ± 7.1) were randomly selected from the electoral roll. Variability in step time, step length, step width, and double support time (DST) were calculated as the standard deviation of each measure, obtained from the GAITRite walkway. Magnetic resonance imaging (MRI) scans were processed through FreeSurfer to obtain cortical thickness of 68 regions. Bayesian regression was used to determine regional associations of mean cortical thickness and thickness ratio (regional thickness/overall mean thickness) with gait variability.

Results

Smaller global cortical thickness was only associated with greater step width and step time variability. Smaller mean thickness in widespread regions important for sensory, cognitive, and motor functions were associated with greater step width and step time variability. In contrast, smaller thickness in a few frontal and temporal regions were associated with DST variability and the right cuneus was associated with step length variability. Smaller thickness ratio in frontal and temporal regions important for motor planning, execution, and sensory function and greater thickness ratio in the anterior cingulate was associated with greater variability in all measures.

Conclusions

Examining individual cortical regions is important in understanding the relationship between gray matter and gait variability. Cortical thickness ratio highlights that smaller regional thickness relative to global thickness may be important for the consistency of gait.
Novel Service Delivery Approach to Address Reproductive Health Disparities within Immigrant Latino Communities in Geographic Hot Spots: An Implementation Study
Authors: Parker Amittia , Johnson-Motoyama Michelle , Mariscal E Susana , Guilamo-Ramos Vincent , Reynoso Elizabeth , Fernandez Cielo
Published: May 2020

Latinx youths continue to have the highest rates of teenage births in the United States and are at increased risk of acquiring sexually transmitted infections, including HIV/AIDS. A community-based research partnership piloted Families Talking Together, a brief, parent-based sexual risk reduction program using a novel and culturally relevant approach. This mixed-methods study examined the feasibility and acceptability of Spanish-speaking promotoras de salud (that is, community health workers) as implementers of an evidence-based intervention (EBI) to reach underserved immigrant communities. Findings suggest that promotoras are capable of implementing the EBI with positive organizational, client, and implementation outcomes. Furthermore, promotoras hold particular promise for addressing reproductive health disparities as they are indigenous and trusted members of the community who can reach members of marginalized Latino populations.
Confined to Obscurity: Health Challenges of Pregnant Women in Jail
Authors: Rose Susan J , LeBel Thomas P
Published: May 2020

Research about pregnant women in jail is scant. This exploratory study begins to fill this gap by examining the demographics; background characteristics; and self-reported physical health, mental health, and substance use challenges reported by 27 pregnant women incarcerated in a large midwestern county jail. It further reports on the prenatal care before and during their incarceration, plans of these pregnant women for delivery of their child, caring for their infant after their release from jail, and their expectations of paternal or family support post-release. Among the sample, 66.7 percent reported a physical health care problem, 48.2 percent had received mental health treatment, and 18.5 percent had substance use treatment in the previous year, but only 51.9 percent had seen a health care professional before their incarceration. All women expected the father of their child to provide financial support, but only 76.9 percent expected the father to be involved with the child. The authors also discuss implications of the findings for jail health care services and reintegration policy and practice for pregnant women.
‘I have only One Country, it is the World’: Madame Cama, Anticolonialism, and Indian-Russian Revolutionary Networks in Paris, 1907–17
Authors: Laursen Ole Birk
Published: May 2020

In September 1912, the Russian author Maxim Gorky wrote to the Paris-based Indian revolutionary Madame Cama and asked her to write an article on Indian women and their role in the Indian freedom struggle. Their correspondence highlights several issues: Cama’s central role among Indian and anticolonial nationalists from across the world in early twentieth-century Paris; the inspiration from the 1905 Russian Revolution and alliances between exiled Indian and Russian revolutionaries; the role of women in revolutionary movements. Focusing on Indian-Russian networks in early twentieth century Paris, this article examines Cama’s thoughts on feminism and socialism, and the inspiration from Russian revolutionaries in Cama’s anticolonial activities.
Cognitive Phenotype and Differential Gene Expression in a Hippocampal Homologue in Two Species of Frog
Authors: Liu Yuxiang , Jones Corbin D , Day Lainy B , Summers Kyle , Burmeister Sabrina S
Published: May 2020

Synopsis

The complexity of an animal’s interaction with its physical and/or social environment is thought to be associated with behavioral flexibility and cognitive phenotype, though we know little about this relationship in amphibians. We examined differences in cognitive phenotype in two species of frog with divergent natural histories. The green-and-black poison frog (Dendrobates auratus) is diurnal, displays enduring social interactions, and uses spatially distributed resources during parental care. Túngara frogs (Physalaemus=Engystomops pustulosus) are nocturnal, express only fleeting social interactions, and use ephemeral puddles to breed in a lek-type mating system. Comparing performance in identical discrimination tasks, we find that D. auratus made fewer errors when learning and displayed greater behavioral flexibility in reversal learning tasks than túngara frogs. Further, túngara frogs preferred to learn beacons that can be used in direct guidance whereas D. auratus preferred position cues that could be used to spatially orient relative to the goal. Behavioral flexibility and spatial cognition are associated with hippocampal function in mammals. Accordingly, we examined differential gene expression in the medial pallium, the amphibian homolog of the hippocampus. Our preliminary data indicate that genes related to learning and memory, synaptic plasticity, and neurogenesis were upregulated in D. auratus, while genes related to apoptosis were upregulated in túngara frogs, suggesting that these cellular processes could contribute to the differences in behavioral flexibility and spatial learning we observed between poison frogs and túngara frogs.
Rebecca George OBE BCS President 2020
Authors: Runciman Brian
Published: May 2020

Rebecca George OBE is the new BCS President. She recently spoke to Brian Runciman MBCS for the BCS Gem of all Mechanisms podcast. Here are some highlights from that conversation.
The Gem of all Mechanisms Computing in society
Authors: Runciman Brian
Published: May 2020

The new BCS Gem of all Mechanisms podcast is a place where we will be interviewing those in the know — from academics and computer scientists to policymakers and philosophers — about the effects of 21st century tech on us all. Brian Runciman MBCS reports on some of the highlights to date.
Blockchain: The Facts and Fiction
Authors: Ballard Ron
Published: May 2020

If you look at any indicator of what the data management world is interested in right now, blockchain will be at the top of the list, writes Ron Ballard, database consultant and author.
From Baking to Business Computing
Authors: Cooper Martin
Published: May 2020

The LEO Computers Society tell Martin Cooper MBCS RITTech about their memories of a computer, created by a catering company, that revolutionised business computing.
A Guide to Money Laundering
Authors: Lucas Matt
Published: May 2020

Matt Lucas, IBM’s Enablement Lead for Blockchain, investigates the darker side of blockchain and how the same technology is being used to fix it.
The Language of the Unheard? Ethno-Political Exclusion and Ethnic Riots in Africa
Authors: Abbs Luke
Published: May 2020

Ethnic riots are sporadic and localized incidents of low-intensity violence, with civilians from one ethnic group engaging in vicious attacks on a rival ethnic group. While systematic research on ethnic violence has almost exclusively focused on organized armed conflict, comparably little quantitative research has considered the causes of low-intensity ethnic violence. Building on existing case-based research on inequality and ethnic riots, this article argues that ethnic rioting can be explained by collective motivations for group violence that emerge from highly unequal local ethno-political configurations, where politically dominant groups coexist with groups that are discriminated or have recently lost political power. To test this argument, the article deploys a spatially disaggregated analysis of all African states between 1990 and 2008, combining new dyadic data capturing the location of ethnic riots with disaggregated grid-level data on ethno-political representation. I find ethnic riots are more likely to occur in discriminated group areas, in locations where a group has recently lost political representation and where such groups live in close proximity of politically dominant groups.
Systematic revision of the Indo-West Pacific mangrove-associated snails of the genus Bakawan (Cephalaspidea: Haminoeidae)
Authors: Oskars Trond R , Malaquias Manuel António E
Published: May 2020

The genus Bakawan includes species of haminoeid snails associated with mangrove habitats and mud flats in the Indo-West Pacific. Here, we revise the diversity and systematics of the genus Bakawan based on our recent molecular phylogeny (Oskars & Malaquias, 2019) and detailed analysis of morphological characters. We examined a range of morphological characters (the shells, external morphology of the animal, jaw, radula, gizzard plate and male reproductive system) using light and scanning electron microscopy. We also carried out a species delimitation analysis (we used the automatic barcode gap discovery method) based on cytochrome c oxidase subunit I DNA sequence data. Four distinct species were recognized: Bakawan rotundata (A. Adams, 1850), which is the type species of the genus and ranges from the eastern Indian Ocean to the western Pacific; B. fusca (A. Adams, 1850), currently known only from the Philippines; and two species new to science, B. puti n. sp., known only from the Philippines, and B. hedleyi n. sp., restricted to tropical eastern Australia.
Effects of macronutrient intake in obesity: a meta-analysis of low-carbohydrate and low-fat diets on markers of the metabolic syndrome
Authors: Willems Anouk E M , Sura–de Jong Martina , van Beek André P , Nederhof Esther , van Dijk Gertjan
Published: May 2020

The metabolic syndrome (MetS) comprises cardiometabolic risk factors frequently found in individuals with obesity. Guidelines to prevent or reverse MetS suggest limiting fat intake, however, lowering carbohydrate intake has gained attention too. The aim for this review was to determine to what extent either weight loss, reduction in caloric intake, or changes in macronutrient intake contribute to improvement in markers of MetS in persons with obesity without cardiometabolic disease. A meta-analysis was performed across a spectrum of studies applying low-carbohydrate (LC) and low-fat (LF) diets. PubMed searches yielded 17 articles describing 12 separate intervention studies assessing changes in MetS markers of persons with obesity assigned to LC (<40% energy from carbohydrates) or LF (<30% energy from fat) diets. Both diets could lead to weight loss and improve markers of MetS. Meta-regression revealed that weight loss most efficaciously reduced fasting glucose levels independent of macronutrient intake at the end of the study. Actual carbohydrate intake and actual fat intake at the end of the study, but not the percent changes in intake of these macronutrients, improved diastolic blood pressure and circulating triglyceride levels, without an effect of weight loss. The homeostatic model assessment of insulin resistance improved with both diets, whereas high-density lipoprotein cholesterol only improved in the LC diet, both irrespective of aforementioned factors. Remarkably, changes in caloric intake did not play a primary role in altering MetS markers. Taken together, these data suggest that, beyond the general effects of the LC and LF diet categories to improve MetS markers, there are also specific roles for weight loss, LC and HF intake, but not reduced caloric intake, that improve markers of MetS irrespective of diet categorization. On the basis of the results from this meta-analysis, guidelines to prevent MetS may need to be re-evaluated.
The Gendered Relationship between Parental Religiousness and Children’s Marriage Timing
Authors: Brauner-Otto Sarah R , Pearce Lisa
Published: May 2020

In this article, we examine whether mother’s and father’s self-reported religiousness relates differently to the timing of their children’s marriages. Conceptualizing religion as one source of cultural schema about marriage that is likely to conflict with other schemas for living, and theorizing that women are more likely to experience structured ambivalence over religious schema and their enactment than men, we predict father’s religiousness will be associated with children’s marriage in accordance with religious dogma, whereas the experience of structured ambivalence yields a more complex relationship between mother’s religiousness and their children’s marriage. Using longitudinal data from the Chitwan Valley Family Study in Nepal, a primarily Hindu and Buddhist setting, we find contrasting associations between son’s marriage timing and mothers’ and fathers’ religiousness. This provides empirical support for theoretical frameworks that emphasize the gendered nature of religious identity and suggests the influence of religion on other aspects of life is gendered.
Update on HIV prevention and preexposure prophylaxis
Authors: Baker Jonathan , Rolls Joanne
Published: May 2020

HIV preexposure prophylaxis (PrEP) is an opportunity for clinicians to curb the 40,000 HIV infections occurring annually in the United States. PrEP is medication used by HIV-negative patients to reduce their risk of acquiring the virus. This article provides a baseline understanding of PrEP indications, prescribing, and monitoring, including a review of previously approved medication and an update on newly approved drugs, including emtricitabine/tenofovir alafenamide (F/TAF). Sexual and gender minorities are often underrepresented in the literature about PrEP, but clinicians should address risk focused on specific behaviors rather than population-level characteristics. As one of few professions with prescriptive authority, PAs have an obligation to understand and manage PrEP.
Uncovering the Process of Reasonable Academic Accommodations for Prelicensure Nursing Students With Learning Disabilities
Authors: Yarbrough Amy E. , Welch Susan R.
Published: May 2020

AIM

The purpose of the study was to explore the process by which nursing faculty make reasonable academic accommodations in the classroom setting for students with learning disabilities.

BACKGROUND

Nursing students with identified learning disabilities require academic accommodations. The process of reasonable academic accommodations for nursing students with learning disabilities has not been examined within nursing education literature and clarification is needed.

METHOD

Constructivist grounded theory methods, as described by Charmaz, guided data collection and analysis.

RESULTS

Literature supports the categories, themes, and subthemes of the academic accommodations process found in this investigation. However, further research is necessary regarding the academic accommodations process and faculty development to support nursing students with identified learning disabilities.

CONCLUSION

Nursing education needs standards of academic accommodations for students with learning disabilities.
Encouraging Entrustment: A Qualitative Study of Resident Behaviors That Promote Entrustment
Authors: Pingree Elizabeth W. , Huth Kathleen , Harper Beth D. , Nakamura Mari M. , Marcus Carolyn H. , Cheston Christine C. , Schumacher Daniel J. , Winn Ariel S.
Published: May 2020

Purpose

To explore resident and attending physician perceptions of resident behaviors and skills that demonstrate trustworthiness and promote entrustment by supervisors.

Method

Using grounded theory methodology, the authors conducted 3 focus groups with pediatric residents from the Boston Combined Residency Program and 3 focus groups with attending physicians who were either general pediatric hospitalists or other pediatric subspecialists at Boston Children’s Hospital and Boston Medical Center in Boston, Massachusetts, from May to December 2018. Data were collected and analyzed iteratively until theoretical saturation was achieved. Three independent reviewers coded each transcript. Codes were grouped into dominant themes to develop a conceptual model.

Results

Twelve residents and 18 attending physicians participated in the focus groups. Participants described actions that they felt actively demonstrated residents’ trustworthiness within previously described domains of trustworthiness. Four modifiers emerged that affect a resident’s progression from trustworthiness to entrustment: (1) self-management, (2) relationships, (3) self-advocacy, and (4) patient-centeredness. Findings were synthesized into a conceptual model depicting how trainees can promote their own entrustment by supervisors.

Conclusions

Trainees must actively demonstrate their trustworthiness to be entrusted. This study proposes that trainees can further gain entrustment through self-management, relationships, self-advocacy, and patient-centeredness. When they understand the actions and behaviors that promote entrustment, trainees may be better able to foster autonomy and progress toward more independent clinical practice. These findings add to existing evidence regarding entrustment and provide a novel, actionable framework for trainees to increase their own entrustment.
Pass/Fail Score Reporting for USMLE Step 1: An Opportunity to Redefine the Transition to Residency Together
Authors: Lin Grant L. , Nwora Christle , Warton Lucas
Published: May 2020

The upcoming transition of the United States Medical Licensing Examination Step 1 to pass/fail score reporting has wide-ranging implications for the medical education community. The decision to discontinue 3-digit numeric score reporting comes following advocacy to change the exam because of its disproportionate importance in the residency match process, the negative impact the exam has on student well-being, and the prominent influence the exam has on medical school curricula. Shifting to pass/fail score reporting for Step 1 creates significant uncertainties to be addressed by the stakeholders in the transition from undergraduate medical education to graduate medical education. In this Invited Commentary, the authors reflect on the positive implications of this scoring change, potential negative ramifications that need to be proactively addressed, and future ways that the transition to residency can be optimized. The transition to pass/fail score reporting for Step 1 creates an opportunity to redefine the residency match process, to support applicant decision making, and to encourage a holistic review of applicants. These changes to the review process will require grace and trust among stakeholders, including students, as well as active support for students who might be negatively impacted during a complex implementation phase. By removing the dominance of Step 1 numeric scores from the residency selection process, the change to pass/fail scoring provides a unique opportunity for all stakeholders to work together and redefine the transition to residency while protecting students from unintended negative consequences.
Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians’ Choice of Antimicrobial Therapy
Authors: Abdoler Emily A. , O’Brien Bridget C. , Schwartz Brian S.
Published: May 2020

Purpose

Physicians frequently prescribe antimicrobials inappropriately, leading to an increase in the rate of resistance, which in turn, harms patients. To better understand why physicians prescribe specific antimicrobials in particular cases, the authors investigated the decision-making processes underlying physicians’ antimicrobial choice (i.e., their antimicrobial reasoning).

Method

Applying a clinical reasoning framework, the authors conducted semi-structured, qualitative interviews with a purposive sample of attending physicians in infectious diseases and hospital medicine at 2 hospitals in fall 2018. An interviewer asked participants to describe how they would choose which antimicrobial to prescribe in 3 clinical vignettes, to recall how they chose an antimicrobial in an example from their own practice, and to indicate their steps in antimicrobial selection generally. The authors identified steps and factors in antimicrobial reasoning through thematic analysis of interviews and the note cards that participants used to delineate their general antimicrobial reasoning processes.

Results

Sixteen participants described 3 steps in the antimicrobial reasoning process: naming the syndrome, delineating pathogens, and selecting the antimicrobial (therapy script). They mentioned 25 different factors in their reasoning processes, which the authors grouped into 4 areas: preexisting patient characteristics, current case features, provider and health care system factors, and treatment principles. Participants used antimicrobial (therapy) scripts that included 14 different drug characteristics. The authors present the steps and factors in a framework for antimicrobial reasoning.

Conclusions

Through this exploratory study, the authors identified steps and factors involved in physicians’ antimicrobial reasoning process, as well as the content of their antimicrobial (therapy) scripts. They organized all these findings into a framework for antimicrobial decision making. This information may ultimately be adapted into educational tools to improve antimicrobial prescribing across the spectrum of learners and practicing physicians.
Delayed Diagnosis in Esophageal Atresia and Tracheoesophageal Fistula
Authors: Scott Joanne E. , Hawley Alisa , Brooks Jo-Anne
Published: May 2020

Background:

Timely identification of esophageal atresia is challenging. Diagnosis may be suspected antenatally with a combination of polyhydramnios, associated with a small or absent stomach bubble or other anomalies. Esophageal atresia can be suspected postnatally in the presence of tachypnea, increased oral secretions, and an inability to advance an orogastric tube. Failure to recognize an esophageal atresia can have life-threatening implications.

Clinical Findings:

A 5-day-old infant with a history of failure to thrive and respiratory distress presented in a community emergency department following a prolonged apnea associated with a breastfeed.

Primary Diagnosis:

Delayed postnatal diagnosis of esophageal atresia and tracheoesophageal fistula.

Interventions:

During stabilization in the emergency department, a nasogastric tube was placed to decompress the stomach. A subsequent chest and abdominal radiograph identified the nasogastric tube curled in the upper esophagus, confirming an esophageal atresia. The abdominal radiograph demonstrated gaseous distension, suggesting the presence of a distal tracheoesophageal fistula.

Outcomes:

The neonate had a primary esophageal anastomosis and fistula ligation in a surgical neonatal unit. He was discharged home at 29 days of life.

Practice Recommendations:

Understanding the challenges of an antenatal diagnosis and awareness of postnatal presentation with a view to improving postnatal recognition and better-quality outcomes for infants with an esophageal atresia and tracheoesophageal fistula.
Singleton, Term, Vertex Cesarean Delivery on a Midwife Service Compared With an Obstetrician Service
Authors: Damiano Ella A. , Auty Samantha G. , Von Mertens Jaylon , Gerjevic Kristen A.
Published: May 2020

OBJECTIVE:

To evaluate the difference in odds of cesarean delivery in term, singleton, vertex pregnancies between the midwife and obstetrician-led services at the same rural tertiary care center.

METHODS:

A retrospective cohort study of term, singleton, and vertex deliveries in patients without a history of cesarean delivery was performed. Patients self-selected a delivery service. The primary outcome was the odds of cesarean delivery between midwife and obstetrician-led services. After propensity score matching, logistic regression was performed on the matched sample to assess the adjusted odds of cesarean delivery.

RESULTS:

From January 2015 to December 2017, 1,787 (80.2% of total) deliveries were analyzed with management of 956 (53.5%) by the midwife service and 831 (46.5%) by the obstetrician-led service. The rate of cesarean delivery was 20.7% (n=172) in the obstetrician-led service and 13.1% (n=125) in the midwife service. In the matched sample, the odds of cesarean delivery were lower in the midwife service compared with the obstetrician-led service in unadjusted and adjusted analyses (odds ratio [OR] 0.62, 95% CI 0.47–0.81; adjusted odds ratio [aOR] 0.58, 95% CI 0.44–0.80). Older maternal age (OR 1.02, 95% CI 1.00–1.06; aOR 1.07, 95% CI 1.04–1.10) and higher delivery body mass index (OR 1.06, 95% CI 1.04–1.08; aOR 1.07, 95% CI 1.04–1.09) were associated with higher odds of cesarean delivery. Increased parity was associated with decreased odds of cesarean delivery (OR 0.41, 95% CI 0.31–0.55; aOR 0.35, 95% CI 0.26–0.48). There were no differences in neonatal outcomes.

CONCLUSION:

At a single rural tertiary care center, patients on the midwife service have significantly lower adjusted odds of cesarean delivery than patients on the obstetrician-led service.
Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism
Authors: Floyd Jessica L. , Beasley Anitra D. , Swaim Laurie S. , Turrentine Mark A. , Nijjar J. Biba
Published: May 2020

OBJECTIVE:

To estimate the rate of readmissions for postpartum venous thromboembolism (VTE) during the first 30 days postdelivery between women with and without the immediate postpartum insertion of the etonogestrel contraceptive implant.

METHODS:

The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum insertion of the etonogestrel contraceptive implant, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared with the number of women readmitted within 30 days for VTE who did not have the contraceptive implant placed during delivery admission.

RESULTS:

Of 3,387,120 deliveries, 8,369 women underwent etonogestrel contraceptive implant placement during the delivery admission. There was no difference identified in the rate of readmission for VTE between exposed and unexposed women. Of these, seven had received a postpartum etonogestrel contraceptive implant (0.85/1,000; 95% CI 0.22–1.45/1,000 deliveries), compared with 1,192 without an etonogestrel contraceptive implant (0.35/1,000; 95% CI 0.33–0.37/1,000 deliveries); odds ratio (OR) 2.41; 95% CI 0.58–9.89. The rates of diabetes, thrombophilia, systemic lupus erythematosus, and cesarean birth did not differ between groups. Women who underwent etonogestrel contraceptive implant placement were younger and were more likely to have government-sponsored health insurance, a smoking history, hypertension, peripartum infection, or postpartum hemorrhage than women who did not receive an etonogestrel contraceptive implant (P<.001). After adjusting for these confounders, there remained no difference in rates of VTE, adjusted OR 1.81; 95% CI 0.44–7.45.

CONCLUSION:

The immediate postpartum placement of the etonogestrel contraceptive implant was not associated with an increased rate of VTE; however, our sample size was underpowered to determine no difference.
Mild Thrombocytopenia and Postpartum Hemorrhage in Nulliparous Women With Term, Singleton, Vertex Deliveries
Authors: Govindappagari Shravya , Moyle Kimberly , Burwick Richard M.
Published: May 2020

OBJECTIVE:

To assess whether mild thrombocytopenia (platelet count 100–149 k/microliter) is associated with an increased risk of postpartum hemorrhage.

METHODS:

Nulliparous women with term, singleton, vertex pregnancies undergoing labor at our institution between August 2016 and September 2017 were included. The primary exposure was mild thrombocytopenia, defined as platelet count 100–149 k/microliter, and the comparator was normal platelet count (150 k/microliter or greater). Those with severe thrombocytopenia (platelet count less than 100 k/microliter) were excluded from analysis. The primary outcome was postpartum hemorrhage, determined by International Classification of Diseases, Tenth Revision codes and the hospital discharge problem list. Secondary outcomes included use of uterotonic agents (methylergonovine maleate or carboprost tromethamine), total blood loss 1,000 mL or greater, and blood transfusion. Data were analyzed by t test, χ2 or Fisher exact test, and multivariable logistic regression, with significance at α <0.05.

RESULTS:

We evaluated 2,845 eligible women, of whom 2,579 (90.2%) had normal platelet count 150 k/microliter or greater, 266 (9.3%) had platelet count 100–149 k/microliter (mild thrombocytopenia), and 13 (0.5%) had platelet count less than 100 k/microliter (severe thrombocytopenia). Compared with women with normal platelet count, those with mild thrombocytopenia had a higher rate of postpartum hemorrhage (16.9% vs 8.5%, P<.001) and were more likely to have total blood loss 1,000 mL or greater (4.5% vs 1.7%, P=.002) and receive methylergonovine maleate (10.5% vs 5.9%, P=.003) or carboprost tromethamine (6.0% vs 1.6%, P<.001) or both (3.8% vs 1.0%, P<.001), but rates of blood transfusion were no different (1.9% vs 1.5%, P=.59). The association between mild thrombocytopenia and postpartum hemorrhage persisted after multivariable adjustment for potential confounders (adjusted odds ratio 2.2, 95% CI 1.5–3.2, P<.001).

CONCLUSION:

Among nulliparous women with term, singleton, vertex pregnancies undergoing labor, those with mild thrombocytopenia (platelet count 100–149 k/microliter) had a twofold greater likelihood of postpartum hemorrhage compared with those with normal platelet count.
Fetal Bradycardia in Response to Maternal Hypothermia
Authors: Spires Benjamin P. , Towers Craig V.
Published: May 2020

BACKGROUND:

Fetal tachycardia can occur with maternal fever (hyperthermia); therefore, a low maternal temperature (hypothermia) might produce fetal bradycardia.

CASES:

Five cases of fetal bradycardia are presented in gestations complicated by maternal hypothermia. The fetal heart rate (FHR) tracings demonstrated stable baselines of 88–96 beats per minute with moderate variability and accelerations. All baselines returned to normal after maternal warming measures.

CONCLUSION:

A possible cause for fetal bradycardia with a stable baseline and moderate variability is maternal hypothermia, a pattern not indicative of fetal hypoxia. Delivery is not indicated, and maternal warming results in FHR baseline normalization.
Maternal Mortality in the United States Compared With Ethiopia, Nepal, Brazil, and the United Kingdom
Authors: Darney Philip D. , Nakamura-Pereira Marcos , Regan Lesley , Serur Feiruz , Thapa Kusum
Published: May 2020

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics’ Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.