Systematic nature positive markets.

Environmental markets are a rapidly emerging tool to mobilize private funding to incentivize landholders to undertake more sustainable land management. How units of biodiversity in these markets are measured and subsequently traded creates key challenges ecologically and economically because it determines whether environmental markets can deliver net gains in biodiversity and efficiently lower the costs of conservation. We developed and tested a metric for such markets based on the well-established principle of irreplaceability from systematic conservation planning. Irreplaceability as a metric avoids the limitations of like-for-like trading and allows one to capture the multidimensional nature of ecosystems (e.g., habitats, species, ecosystem functioning) and simultaneously achieve cost-effective, land-manager-led investments in conservation. Using an integrated ecological modeling approach, we tested whether using irreplaceability as a metric is more ecologically and economically beneficial than the simpler biodiversity offset metrics typically used in net gain and no-net-loss policies. Using irreplaceability ensured no net loss, or even net gain, of biodiversity depending on the targets chosen. Other metrics did not provide the same assurances and, depending on the flexibility with which biodiversity targets can be achieved, and how they overlap with development pressure, were less efficient. Irreplaceability reduced the costs of offsetting to developers and the costs of ecological restoration to society. Integrating economic data and systematic conservation planning approaches would therefore assure land managers they were being fairly rewarded for the opportunity costs of conservation and transparently incentivize the most ecologically and economically efficient investments in nature recovery.

Mercados sistemáticos que favorecen a la naturaleza Resumen Los mercados ambientales se están convirtiendo rápidamente en una herramienta para movilizar el financiamiento privado que incentiva a los terratenientes a realizar un manejo de suelo más sustentable. La forma de medir las unidades de biodiversidad y su intercambio subsecuente en estos mercados genera retos ecológicos y económicos importantes pues determina si el mercado ambiental puede generar ganancias netas de biodiversidad y reducir eficientemente el costo de la conservación. Desarrollamos y probamos una medida para dichos mercados con base en el principio bien establecido del carácter irremplazable tomado de la planeación sistemática de la conservación. Si se usa como medida, este carácter evita las limitantes del comercio en términos comparables y permite que se capture la naturaleza multidimensional de los ecosistemas (p. ej.: hábitats, especies, funcionamiento) y a la vez consigue inversiones rentables llevadas por el gestor para la conservación. Usamos una estrategia de modelado ecológico integrado para probar si usar el carácter irremplazable como medida tiene más beneficios ecológicos y económicos que las medidas más simples de compensación de la biodiversidad que se usan comúnmente en las políticas sin pérdida neta y de ganancia neta. El uso del carácter irremplazable aseguró que no hubiera pérdida neta o incluso ganancia neta de la biodiversidad según el objetivo elegido. Las otras medidas no proporcionaron la misma seguridad y fueron menos eficientes según la flexibilidad con la cual se logran los objetivos de biodiversidad y cómo se traslapan con la presión del desarrollo. El carácter irremplazable redujo los costos de la compensación para los desarrolladores y los costos de la restauración ecológica para la sociedad. Por lo tanto, la integración de los datos económicos y las estrategias de planeación sistemática de la conservación les asegurarían a los gestores de los terrenos que se les está compensando de manera justa por los costos de oportunidad de conservación e incentivaría con transparencia las inversiones con mayor eficiencia ecológica y económica en la recuperación de la naturaleza.

Sex Representation Among Principal Investigators in Cardiac Surgery Clinical Trials in the United States: The Glass Ceiling and Room for Improvement.

OBJECTIVE: The aim of this study was to determine the sex representation among principal investigators (PIs) in US cardiac surgery clinical trials. SUMMARY BACKGROUND DATA: Being a principal investigator in a US clinical trial confers national recognition among peers. Sex representation among principal investigators (PIs) in US cardiac surgery clinical trials has not been evaluated. METHODS: We evaluated 124 US cardiac surgery trials registered on Clin-icalTrials.gov from 2014 to 2019. Sixty trials included PIs (n = 266) from 128 institutions that had a combined total of 1040 adult cardiac surgeons. We examined sex representation among junior-level (instructor or assistant professor) and senior-level (associate, full, or Emeritus professor) PIs by calculating the participation-to-prevalence ratio (PPR), whereby a PPR range of 0.8 to 1.2 reflects equitable representation. RESULTS: The pool representation percentage was 6.1% (63/1040) for women and 93.9% (977/1040) for men. A total of 266 PI positions were assigned to adult cardiac surgeons: 6 (9.5%; PPR = 0.37) from the female pool and 260 (26.6%; PPR = 1.04) from the male pool ( P = 0.004). The percentage of PIs with studies funded by industry was 9.5% ofthe female pool (PPR = 0.39) and 25.0% of the male pool (PPR = 1.04) ( P = 0.009). No National Institutes of Health-funded or other funded trials had female PIs. An overall trend was observed toward disproportionally more men than women among PIs, especially at the senior level ( P = 0.027). CONCLUSIONS: Equitable opportunities for PI positions are available for junior-level but not senior-level cardiothoracic surgeons. These results suggest a need for active engagement and promotion of equal opportunities in cardiac surgery.

Ecological and economic implications of alternative metrics in biodiversity offset markets.

Policy tools are needed that allow reconciliation of human development pressures with conservation priorities. Biodiversity offsetting can be used to compensate for ecological losses caused by development activities. Landowners can choose to undertake conservation actions, including habitat restoration, to generate biodiversity offsets. Consideration of the incentives facing landowners as potential biodiversity offset providers and developers as potential buyers of credits is critical when considering the ecological and economic landscape-scale outcomes of alternative offset metrics. There is an expectation that landowners will always seek to conserve the least profitable land parcels, and, in turn, this determines the spatial location of biodiversity offset credits. We developed an ecological-economic model to compare the ecological and economic outcomes of offsetting for a habitat-based metric and a species-based metric. We were interested in whether these metrics would adequately capture the indirect benefits of offsetting on species not considered under a no-net-loss policy. We simulated a biodiversity offset market for a case study landscape, linking species distribution modeling and an economic model of landowner choice based on economic returns of the alternative land management options (restore, develop, or maintain existing land use). Neither the habitat nor species metric adequately captured the indirect benefits of offsetting on related habitats or species. The underlying species distributions, layered with the agricultural and development rental values of parcels, resulted in very different landscape outcomes depending on the metric chosen. If policy makers are aiming for the metric to act as an indicator to mitigate impacts on a range of closely related habitats and species, then a simple no-net-loss target is not adequate. Furthermore, to achieve the most ecologically beneficial design of offsets policy, an understanding of the economic decision-making processes of the landowners is needed.

Se necesitan herramientas políticas que permitan la reconciliación entre las presiones del desarrollo humano y las prioridades de conservación. La compensación de biodiversidad puede usarse para reponer las pérdidas ecológicas causadas por las actividades de desarrollo. Los terratenientes pueden elegir realizar acciones de conservación, incluyendo la restauración del hábitat, para generar dichas compensaciones. Es importante considerar los incentivos para los terratenientes como proveedores potenciales de compensaciones de biodiversidad y para los desarrolladores como compradores potenciales de créditos cuando se contemplan los resultados ecológicos y económicos a escala de paisaje de estas medidas alternativas de compensación. Existe la expectativa de que los terratenientes siempre buscarán conservar los lotes menos rentables y, por lo tanto, esto determina la ubicación espacial de los créditos por compensación de biodiversidad. Desarrollamos un modelo para comparar los resultados ecológicos y económicos de la compensación en una medida basada en el hábitat y una basada en la especie. Nos interesaba saber si estas medidas indicarían adecuadamente los beneficios indirectos de la compensación para las especies no consideradas bajo una política de pérdida neta cero. Simulamos un mercado voluntario de biodiversidad para un estudio de casode un paisaje, el cual vinculó el modelado de la distribución de especies con el modelo económico de las elecciones de los terratenientes basadas en las ganancias económicas de las opciones alternativas de manejo de suelo (restaurar, desarrollar o mantener el uso de suelo existente). Ninguna de las dos medidas indicó adecuadamente los beneficios indirectos de la compensación para las especies o hábitats relacionados. La distribución subyacente de especies, en conjunto con los valores de renta agrícolas y de desarrollo de los lotes, derivó en resultados muy diferentes de paisaje según la medida seleccionada. Cuando los formuladores de políticas buscan que la medida actúe como un indicador para mitigar impactos en una gama de especies y hábitats relacionados cercanamente, no es adecuado un objetivo simple de pérdida neta cero. Además, para lograr el diseño con el mayor beneficio ecológico, se requiere comprender los procesos de decisión de los terratenientes.

Have environmental preferences and willingness to pay remained stable before and during the global Covid-19 shock?

This study tests the stability of environmental preferences and willingness to pay (WTP) values using a discrete choice experiment (DCE) across three countries pre and post the peak of the first wave of the Covid-19 pandemic. A DCE examining the public's preferences for alternative environmental management plans on the high seas, in the area of the Flemish Cap, was carried out in Canada, Scotland and Norway in late 2019 and was rerun in early May 2020 shortly after the Covid-19 pandemic had officially peaked in the three countries. The same choice set sequence is tested across the two periods, using different but nationally representative samples in each case. Entropy balancing, a multivariate reweighting method, is used to achieve covariate balance between the pre and post Covid samples in the analysis. The results suggest that both preferences and WTP remain relatively stable in the face of a major public health crisis and economic upheaval.

Abnormal Small Intestinal Epithelial Microvilli in Patients With Crohn's Disease.

BACKGROUND & AIMS: Crohn disease (CD) presents as chronic and often progressive intestinal inflammation, but the contributing pathogenic mechanisms are unclear. We aimed to identify alterations in intestinal cells that could contribute to the chronic and progressive course of CD. METHODS: We took an unbiased system-wide approach by performing sequence analysis of RNA extracted from formalin-fixed paraffin-embedded ileal tissue sections from patients with CD (n = 36) and without CD (controls; n = 32). We selected relatively uninflamed samples, based on histology, before gene expression profiling; validation studies were performed using adjacent serial tissue sections. A separate set of samples (3 control and 4 CD samples) was analyzed by transmission electron microscopy. We developed methods to visualize an overlapping modular network of genes dysregulated in the CD samples. We validated our findings using biopsy samples (110 CD samples for gene expression analysis and 54 for histologic analysis) from the UNITI-2 phase 3 trial of ustekinumab for patients with CD and healthy individuals (26 samples used in gene expression analysis). RESULTS: We identified gene clusters that were altered in nearly all CD samples. One cluster encoded genes associated with the enterocyte brush border, leading us to investigate microvilli. In ileal tissues from patients with CD, the microvilli were of decreased length and had ultrastructural defects compared with tissues from controls. Microvilli length correlated with expression of genes that regulate microvilli structure and function. Network analysis linked the microvilli cluster to several other down-regulated clusters associated with altered intracellular trafficking and cellular metabolism. Enrichment of a core microvilli gene set also was lower in the UNITI-2 trial CD samples compared with controls; expression of microvilli genes was correlated with microvilli length and endoscopy score and was associated with response to treatment. CONCLUSIONS: In a transcriptome analysis of formalin-fixed and paraffin-embedded ileal tissues from patients with CD and controls, we associated transcriptional alterations with histologic alterations, such as differences in microvilli length. Decreased microvilli length and decreased expression of the microvilli gene set might contribute to epithelial malfunction and the chronic and progressive disease course in patients with CD.

Neuropharmacological lesion localization in idiopathic Horner's syndrome in Golden Retrievers and dogs of other breeds.

OBJECTIVE: To investigate whether idiopathic Horner's syndrome (HS) in Golden Retrievers is an exclusively preganglionic disorder based on denervation hypersensitivity pharmacological testing with phenylephrine. ANIMALS STUDIED: Medical records of dogs presented with HS between 2000 and 2012. Dogs presented with additional ocular or systemic signs were excluded. PROCEDURES: Clinical data examined included age, sex, duration of clinical signs, ancillary diagnostic test results, and time to mydriasis on topical ocular application of 1% phenylephrine. Lesions were diagnosed as postganglionic (mydriasis within 20 min) or preganglionic (mydriasis between 20 and 45 min). RESULTS: Medical records of 21 dogs of nine different breeds were included. An etiopathogenesis for Horner's syndrome was determined in five dogs, none of which were Golden Retrievers. All diagnoses correlated with pharmacological lesion localization. Ten Golden Retrievers were included (eight male and two female) with a mean age of 8.5 years (range: 4-13). Lesion localization was diagnosed as postganglionic in eight (mean: 10 min [range: 6-18]) and preganglionic in two Golden Retrievers (20 and 24 min). All cases were unilateral and had completely resolved within 15 weeks (range: 11-20). Recurrence was not reported in any of the patients. CONCLUSIONS: Idiopathic postganglionic HS was diagnosed in eight of 10 Golden Retrievers contradicting previous reports of a purely preganglionic localization. Etiopathogenesis of canine idiopathic HS remains to be determined; nevertheless, a vascular etiology cannot be excluded. Future studies using magnetic resonance angiography may aid in clarifying the pathogenesis.

Racial disparities in thoracic aortic surgery: Myth or reality?

OBJECTIVE: We examined the relationship between Black or White race and adverse outcomes in patients who underwent surgery of the ascending aorta, aortic root, or aortic arch at our center. METHODS: We analyzed 2335 consecutive patients who identified as Black (n = 217, 9.3%) or White (n = 2118, 90.7%) and underwent proximal aortic surgery. Patient zip codes were used to determine community socioeconomic (CSE) characteristics. The composite adverse outcome comprised mortality, persistent neurologic injury, and renal failure necessitating dialysis at discharge. We performed multivariable analysis, Kaplan-Meier analysis, and propensity score matching adjusted for CSE factors. RESULTS: Median follow-up time was 3.7 years. Compared with White patients, Black patients lived in areas characterized by a higher percentage living below poverty level, lower income, and lower education level (P < .0001). Black patients had higher rates of emergency presentation (P < .0001) and lower 5- and 10-year survival rates (P = .0002). Short-term outcomes were similar between groups, except for respiratory failure and length of stay (P < .0001), which were higher in the Black population. After propensity score matching adjusted for CSE factors, Black and White patients (n = 204 each) had similar short-term outcomes and 5- and 10-year survival rates (P = .30). Multivariable analysis stratified by race showed that CSE factors independently predicted adverse outcomes in Black but not White patients. CONCLUSIONS: This is among few studies that have analyzed the relationship between race and proximal aortic surgery. Although outcomes were similar between Black and White patients in our cohort after adjusting for CSE factors, unfavorable CSE factors predicted adverse outcomes in Black but not White patients. More patient-specific studies are needed.

Unplanned readmissions, community socioeconomic factors, and their effects on long-term survival after complex thoracic aortic surgery.

OBJECTIVE: We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch). METHODS: Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender). RESULTS: Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found. CONCLUSIONS: Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important.

Fabrication of liquid and vapor protective cotton fabrics.

Through microwave-assisted techniques, cotton textiles treated with heptadecafluoro-1,1,2,2-tetrahydrodecyltrimethoxysilane in the presence of high surface area silica nanoparticles create a material capable of repelling bulk liquid challenges while simultaneously adsorbing organic vapors from bulk liquid droplets. Characterizing the contradictory behavior of adsorption of vapors and repellency of liquids is the primary focus of this article. These procedures reveal a quick and simple method for a one-step deposition of a vapor-sorptive, liquid-repellent, Cassie-Baxter surface onto textiles. Packed column breakthrough and single swatch permeation experiments showed that treated materials possess a high affinity for 3-hepten-2-one vapor, while goniometry revealed contact angles in excess of 120° for surface-deposited, 5 µL droplets of several test liquids. Scanning electron micrograph images confirm a lotus-like, nanorough surface, while ATR-FTIR spectra confirm surface fluorocarbon moieties. The performance of so-treated materials lends itself to the application of chemical protective apparel, while the simplicity of the treatment bodes well for potential commercialization.

The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery.

OBJECTIVE: We evaluated the relationship among community socioeconomic factors (poverty, income, and education), gender, and outcomes in patients who underwent ascending aortic, root, and arch surgery. METHODS: For 2634 consecutive patients, we associated patients' ZIP codes with community socioeconomic factors. The composite adverse outcome comprised death, persistent neurological injury, and renal failure necessitating dialysis at discharge. Multivariable analysis and Kaplan-Meier survival curves were used. Men and women from the full cohort and from the elective patients were propensity matched. RESULTS: Median follow-up was 3.6 years (interquartile range, 1.2-9.3). Men lived in areas characterized by less poverty (P = .03), higher household income (P = .01), and more education (P = .02) than women; likewise, in the elective cohort, all community socioeconomic factors favored men (P ≤ .009). Female gender predicted composite adverse outcome (P = .006). In the propensity-matched women and men (820 pairs), the composite adverse outcome rates were 14.2% and 11%, respectively (P = .06). In 583 propensity-matched pairs of elective patients, men had less composite adverse outcome (P = .02), operative mortality (P = .04), and renal (P = .02) and respiratory failure (P = .0006). The 5- and 10-year survivals for these men and women were 74.2% versus 71.4% and 50.2% versus 48.2%, respectively (P = .06). All community socioeconomic factors in both propensity-matched groups nonsignificantly favored men. CONCLUSIONS: This study is among the first to examine the association among community socioeconomic factors, gender, and outcomes in patients who undergo proximal aortic surgery. Female gender predicted a composite adverse outcome. In the elective patients, most adverse outcomes were significantly less in men. In the propensity-matched patients, all community socioeconomic factors favored men, although not significantly. Larger studies with patient-level socioeconomic information are needed.

Farmers' valuation and willingness to pay for vaccines to protect livestock resources against priority infectious diseases in Ghana.

INTRODUCTION: Livestock vaccination coverage rates remain low in many lower and middle income countries despite effective vaccines being commonly available. Consequently, many preventable infectious livestock diseases remain highly prevalent, causing significant animal mortalities and threatening farmers' livelihood and food security. This study sought to assess farmers' maximum willingness to pay (WTP) for contagious bovine pleuropneumonia (CBPP), and peste-des-petits-ruminants (PPR) vaccination of cattle, and sheep and goats, respectively. METHODS: Overall, 350 ruminant livestock farmers were randomly selected from three districts located in the northern, middle and southern farming belts of Ghana. We implemented a double-bounded dichotomous contingent valuation experiment, where farmers indicated their WTP for vaccinating each livestock specie(s) owned at randomly assigned price points. WTP responses were analyzed using maximum likelihood estimation, and factors influencing WTP were assessed using censored regression analysis accounting for village-level clustering. RESULTS: Mean WTP for CBPP vaccination was USD 1.43 or Ghanaian Cedi (GHC) 8.63 (95% CI: GHC 7.08-GHC 10.19) per cattle. Mean WTP for PPR vaccination was USD 1.17 or GHC 7.02 (95% CI: GHC 5.99-GHC 8.05) per sheep, and USD 1.1 or GHC 6.66 (95% CI: GHC 5.89-GHC 7.44) per goat. WTP was positively associated with resilience, limited knowledge about vaccines (assessed prior to WTP experiment), farmland size, and male gender, after adjusting for other covariates. To attain 70% vaccination coverage in Ghana, vaccination costs should be no larger than GHC 5.30 (USD 0.88) for CBPP per cattle and GHC 3.89 (USD 0.65) and GHC 3.67 (USD 0.61), respectively, for PPR vaccines per sheep and goat. CONCLUSIONS: Ruminant livestock farmers in Ghana value vaccination highly, and are, on average, willing to pay vaccination costs that exceed the prevailing market prices (GHC 6 for CBPP and GHC 5 for PPR vaccination) to protect their livestock resources. To achieve 70% coverage, only minor subsidies would likely be required. These results suggest that effective disease control in these settings should be possible with appropriate distribution strategies.

Perceptions and expectations of cardiothoracic residents and attending surgeons.

BACKGROUND: With our specialty going through a critical phase of re-evaluation and adaptation, our aim was to evaluate and compare the perceptions and expectations among residents and faculty regarding cardiothoracic training. METHODS: A content-validated, 13-item survey was distributed electronically from August 14 to August 24, 2010 to 728 cardiothoracic surgery residents, recent program graduates (on or after June 2006), cardiothoracic surgery chairpersons, and program directors identified in the Cardiothoracic Surgery Network database. RESULTS: The response rate was 34% (244 of 728). Of the respondents, 76% reported being "satisfied" or "very satisfied" with their program. Faculty willingness to teach in the operating room was ranked as the most valuable aspect of a training program, and strict adherence to the 80-h work week ranked as least valuable. Most respondents believed that a resident performing at least 75% of a case was acceptable for low-complexity procedures (92% of residents, 77% of attending physicians) and at least 25% for high-complexity procedures (91% of residents, 73% of attending physicians). However, residents wanted to perform more of the operations than the attending physicians considered necessary (P < 0.05). Finally, 63% of respondents (73% of residents, 56% of attending physicians) indicated that the increasing scrutiny of outcomes has adversely affected training. Other differences between the residents' and attending physicians' perceptions regarded the importance of participation in preoperative and postoperative care, what constitutes "scut work," and the value of auxiliary staff. CONCLUSIONS: Reconciling residents' expectations with the realities of duty-hour restrictions and high-stakes procedures will require the development of novel educational approaches to improve resident learning.

Exploration of a panel of urine biomarkers of kidney disease in two paediatric cohorts with Type 1 diabetes mellitus of differing duration.

BACKGROUND: The pathogenesis of diabetic kidney disease (DKD) is complex and involves both glomerular and tubular dysfunction. A global assessment of kidney function is necessary to stage DKD, a progressive kidney disease that is likely to begin in childhood. The present study evaluated whether kidney injury biomarkers identified as early DKD biomarkers in adults have any prognostic value in the very early stages of childhood diabetes. METHODS: We measured urine free Retinol-binding protein 4 (UfRBP4), albumin (UAlb), Kidney injury molecule-1 (KIM-1) and the microRNAs miR-155, miR-126 and miR-29b in two cohorts of paediatric T1DM patients without evidence of DKD, but with diabetes of short-duration, ≤ 2.5 years (SD, n = 25) or of long-duration, ≥ 10 years (LD, n = 29); non-diabetic siblings (H, n = 26) were recruited as controls. A p value < 0.05 was considered significant for all results. RESULTS: UfRBP4 and UAlb were not significantly different across the three groups. No differences were found in KIM-1 excretion between any of the three groups. UfRBP4 was correlated with UAlb in all three groups (r 0.49; p < 0.001), whereas KIM-1 showed no correlation with albumin excretion. Among microRNAs, miR-29b was higher in all diabetic children compared with the H control group (p = 0.03), whereas miR-155 and miR-126 were not significantly different. No differences were found between the SD and LD groups for all three microRNAs. No associations were identified between these biomarkers with sex, age, BMI, eGFR, T1DM duration or glycaemic control. CONCLUSIONS: UfRBP4, KIM-1, miR-155, and miR-126 were unaffected by the presence and duration of diabetes, whereas miR-29b showed a modest elevation in diabetics, regardless of duration. These data support the specificity of a panel of urine biomarkers as DKD biomarkers, rather than any relationship to diabetes per se or its duration, and not as early DKD biomarkers in a paediatric setting.

Demographic Landscape of Cardiothoracic Surgeons and Residents at United States Training Programs.

BACKGROUND: Recruiting and promoting women and racial/ethnic minorities could help enhance diversity and inclusion in the academic cardiothoracic (CT) surgery workforce. However, the demographics of trainees and faculty at US training programs have not yet been studied. METHODS: Traditional, integrated (I-6), and fast-track (4+3) programs listed in the Accreditation Council for Graduate Medical Education (ACGME) public database were analyzed. Demographics of trainees and surgeons, including gender, race/ethnicity, subspecialty, and academic appointment (if applicable), were obtained from ACGME Data Resource Books, institutional websites, and public profiles. Chi-square and Cochran-Armitage trend tests were performed. RESULTS: In July 2020, 78 institutions had at least 1 CT surgery training program; 40 (51%) had only a traditional program, 20 (26%) traditional and I-6, 6 (8%) all 3 types of program, and 4 (5%) only I-6. The proportion of female trainees increased significantly from 2011 to 2019 (19% vs 24%, P < .001), with female I-6 trainees outnumbering female traditional trainees since 2018. Significant increases by race/ethnicity were observed overall and by program type, notably for Asian and Hispanic individuals in I-6 programs and Black individuals in traditional programs. Finally, of the 1175 CT surgeons identified, 633 (54%) were adult cardiac surgeons, 360 (37%) assistant professors, 116 (10%) women, and 33 (3%) Black. CONCLUSIONS: The demographic landscape of CT surgery trainees and faculty across multiple training pathways reflects increasing representation by gender and race/ethnicity. However, we must continue to work toward equitable representation in the workforce to benefit the diverse patients we treat.

Gq signaling in α cells is critical for maintaining euglycemia.

Glucagon, a hormone released from pancreatic α cells, plays a key role in maintaining euglycemia. New insights into the signaling pathways that control glucagon secretion may stimulate the development of novel therapeutic agents. In this study, we investigated the potential regulation of α cell function by G proteins of the Gq family. The use of a chemogenetic strategy allowed us to selectively activate Gq signaling in mouse α cells in vitro and in vivo. Acute stimulation of α cell Gq signaling led to elevated plasma glucagon levels, accompanied by increased insulin release and improved glucose tolerance. Moreover, chronic activation of this pathway greatly improved glucose tolerance in obese mice. We also identified an endogenous Gq-coupled receptor (vasopressin 1b receptor; V1bR) that was enriched in mouse and human α cells. Agonist-induced activation of the V1bR strongly stimulated glucagon release in a Gq-dependent fashion. In vivo studies indicated that V1bR-mediated glucagon release played a key role in the counterregulatory hyperglucagonemia under hypoglycemic and glucopenic conditions. These data indicate that α cell Gq signaling represents an important regulator of glucagon secretion, resulting in multiple beneficial metabolic effects. Thus, drugs that target α cell-enriched Gq-coupled receptors may prove useful to restore euglycemia in various pathophysiological conditions.

Sex, Racial, and Ethnic Disparities in U.S. Cardiovascular Trials in More Than 230,000 Patients.

BACKGROUND: The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups' inclusion in U.S. cardiovascular trials. METHODS: Using publicly available data from ClinicalTrials.gov, we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients' and racial and ethnic minorities' representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation. RESULTS: All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57). CONCLUSIONS: Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.

Western diet induces Paneth cell defects through microbiome alterations and farnesoid X receptor and type I interferon activation.

Intestinal Paneth cells modulate innate immunity and infection. In Crohn's disease, genetic mutations together with environmental triggers can disable Paneth cell function. Here, we find that a western diet (WD) similarly leads to Paneth cell dysfunction through mechanisms dependent on the microbiome and farnesoid X receptor (FXR) and type I interferon (IFN) signaling. Analysis of multiple human cohorts suggests that obesity is associated with Paneth cell dysfunction. In mouse models, consumption of a WD for as little as 4 weeks led to Paneth cell dysfunction. WD consumption in conjunction with Clostridium spp. increased the secondary bile acid deoxycholic acid levels in the ileum, which in turn inhibited Paneth cell function. The process required excess signaling of both FXR and IFN within intestinal epithelial cells. Our findings provide a mechanistic link between poor diet and inhibition of gut innate immunity and uncover an effect of FXR activation in gut inflammation.

The role of gut hormones and the hypothalamus in appetite regulation.

The World Health Organisation has estimated that by 2015 approximately 2.3 billion adults will be overweight and more than 700 million obese. Obesity is associated with an increased risk of diabetes, cardiovascular events, stroke and cancer. The hypothalamus is a crucial region for integrating signals from central and peripheral pathways and plays a major role in appetite regulation. In addition, there are reciprocal connections with the brainstem and higher cortical centres. In the arcuate nucleus of the hypothalamus, there are two major neuronal populations which stimulate or inhibit food intake and influence energy homeostasis. Within the brainstem, the dorsal vagal complex plays a role in the interpretation and relaying of peripheral signals. Gut hormones act peripherally to modulate digestion and absorption of nutrients. However, they also act as neurotransmitters within the central nervous system to control food intake. Peptide YY, pancreatic polypeptide, glucagon-like peptide-1 and oxyntomodulin suppress appetite, whilst ghrelin increases appetite through afferent vagal fibres to the caudal brainstem or directly to the hypothalamus. A better understanding of the role of these gut hormones may offer the opportunity to develop successful treatments for obesity. Here we review the current understanding of the role of gut hormones and the hypothalamus on food intake and body weight control.

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients.

OBJECTIVE: The frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality. METHODS: We searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage. RESULTS: Thirty-five studies (total N = 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P < .001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P = .46), stroke 9.3% versus 6.6% (P = .51), and overall adverse events 22.0% versus 16.5% (P = .41). CONCLUSIONS: As the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided.

Comparison of Brief Summary Formats Through a Health Literacy Lens.

BACKGROUND: Print pharmaceutical advertisements in the United States require inclusion of a brief summary of side effects, warnings, precautions, and contraindications from the labeling. The full package insert, which sponsors have traditionally used to fulfill the brief summary requirement, does not adhere to health literacy best practices, limiting its value to consumers. This study compared the understandability and usability of brief summaries in 3 formats designed to be more consumer friendly. METHODS: Three brief summary formats were tested: (1) 2-column "Question and Answer"; (2) "Prescription Drug Facts Box," similar to current US over-the-counter drug facts labeling; and (3) "Health Literacy," based on clear communication principles. Researchers evaluated the formats using the Suitability Assessment of Materials (SAM) tool and conducted structured, scripted, one-on-one interviews (usability tests) with participants with estimated low to average education levels. This research was replicated across 2 therapeutic areas (type 2 diabetes and plaque psoriasis). RESULTS: SAM scores showed that the Health Literacy format outperformed the Question and Answer format and the Prescription Drug Facts Box format in both therapeutic areas, with both Health Literacy brief summaries rated on the SAM as "superior." Qualitative usability tests supported the SAM findings, with the Health Literacy format preferred consistently over the Question and Answer format, and more often than not over the Prescription Drug Facts Box format. CONCLUSIONS: Sponsors can employ a user-tested Health Literacy format to improve the understandability and usability of brief summaries with patients.