Pliocene decoupling of equatorial Pacific temperature and pH gradients.

Ocean dynamics in the equatorial Pacific drive tropical climate patterns that affect marine and terrestrial ecosystems worldwide. How this region will respond to global warming has profound implications for global climate, economic stability and ecosystem health. As a result, numerous studies have investigated equatorial Pacific dynamics during the Pliocene (5.3-2.6 million years ago) and late Miocene (around 6 million years ago) as an analogue for the future behaviour of the region under global warming1-12. Palaeoceanographic records from this time present an apparent paradox with proxy evidence of a reduced east-west sea surface temperature gradient along the equatorial Pacific1,3,7,8-indicative of reduced wind-driven upwelling-conflicting with evidence of enhanced biological productivity in the east Pacific13-15 that typically results from stronger upwelling. Here we reconcile these observations by providing new evidence for a radically different-from-modern circulation regime in the early Pliocene/late Miocene16 that results in older, more acidic and more nutrient-rich water reaching the equatorial Pacific. These results provide a mechanism for enhanced productivity in the early Pliocene/late Miocene east Pacific even in the presence of weaker wind-driven upwelling. Our findings shed new light on equatorial Pacific dynamics and help to constrain the potential changes they will undergo in the near future, given that the Earth is expected to reach Pliocene-like levels of warming in the next century.

Constraints on Paleoproterozoic atmospheric oxygen levels.

The oxygenation of Earth's surface environment dramatically altered key biological and geochemical cycles and ultimately ushered in the rise of an ecologically diverse biosphere. However, atmospheric oxygen partial pressures (pO2) estimates for large swaths of the Precambrian remain intensely debated. Here we evaluate and explore the use of carbonate cerium (Ce) anomalies (Ce/Ce*) as a quantitative atmospheric pO2 proxy and provide estimates of Proterozoic pO2 using marine carbonates from a unique Precambrian carbonate succession-the Paleoproterozoic Pethei Group. In contrast to most previous work, we measure Ce/Ce* on marine carbonate precipitates that formed in situ across a depth gradient, building on previous detailed sedimentology and stratigraphy to constrain the paleo-depth of each sample. Measuring Ce/Ce* across a full platform to basin depth gradient, we found only minor depleted Ce anomalies restricted to the platform and upper slope facies. We combine these results with a Ce oxidation model to provide a quantitative constraint on atmospheric pO2 1.87 billion years ago (Ga). Our results suggest Paleoproterozoic atmospheric oxygen concentrations were low, near 0.1% of the present atmospheric level. This work provides another crucial line of empirical evidence that atmospheric oxygen levels returned to low concentrations following the Lomagundi Event, and remained low enough for large portions of the Proterozoic to have impacted the ecology of the earliest complex organisms.

Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population.

BACKGROUND: Improved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1. METHODS: A retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05). RESULTS: Of those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]). CONCLUSION: Most patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.

Knowledge of radiation exposure associated with common trauma imaging modalities among orthopaedic surgeons, emergency medicine physicians, and general surgeons in the United States.

BACKGROUND: Few contemporary studies have assessed physicians' knowledge of radiation exposure associated with common imaging studies, especially in trauma care. The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal (MSK) imaging studies routinely utilized in the trauma setting. METHODS: An electronic survey was distributed to United States orthopaedic surgery, general surgery, and emergency medicine (EM) residency programs. Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis, lumbar spine, and lower extremity, in terms of chest X-ray (CXR) equivalents. Physician estimates were compared to the true effective radiation doses. Additionally, participants were asked to report the frequency of discussing radiation risk with patients. RESULTS: A total of 218 physicians completed the survey; 102 (46.8%) were EM physicians, 88 (40.4%) were orthopaedic surgeons, and 28 (12.8%) were general surgeons. Physicians underestimated the effective radiation doses of nearly all imaging modalities, most notably for pelvic computed tomaography (CT) (median 50 CXR estimation vs. 162 CXR actual) and lumbar CT (median 50 CXR estimation vs. 638 CXR actual). There was no difference between physician specialties regarding estimation accuracy (P=0.133). Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure (P=0.007). CONCLUSION: The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking. Further investigation with larger scale studies is warranted, and additional education in this area may improve care.

Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion.

PURPOSE: The goal of this study was to compare our institution's recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores. METHODS: This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis. RESULTS: We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P<0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P < 0.01). We found no difference in pain scores between the two groups. CONCLUSION: Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients.

Onabotulinum toxin type A injection into the triceps unmasks elbow flexion in infant brachial plexus birth palsy: A retrospective observational cohort study.

Brachial plexus birth palsy (BPBP) is a neurologic injury that can result in mild to full paralysis of the affected upper extremity. In severe cases, nerve surgery is often performed before age 1 year. Several studies report gains in elbow flexion with onabotulinum toxin type A (OBTT-A) injections to the triceps; however, its use in infants is not widely reported. The purpose of this study is to present our experience using these injections before 6 months of age to therapeutically unmask elbow flexion and diagnostically guide surgical decision making.This is a retrospective observational cohort study. The cohort included infants with BPBP who received OBTT-A injection to the triceps before age 6 months. Indications for the injections include trace elbow flexion and palpable co-contraction of the biceps and triceps. Elbow flexion was evaluated using the Toronto Test score. Therapeutic success was defined as an increase in post-injection scores. These scores were then used diagnostically as an indication for surgery if the infant did not achieve full elbow flexion by 8 months. A treatment algorithm for OBTT-A triceps injection was developed based on all treatment options offered to infants with elbow flexion deficits seen in the clinic.Of the 12 infants that received OBTT-A triceps injections, 10 (83%) had improved Toronto test elbow flexion scores post-injection. Gains in elbow flexion once attained were maintained. Of the 9 OBTT-A infants with at least 2 years follow-up, 4 achieved full elbow flexion without surgery; the remainder after surgery. No complications with OBTT-A injections were noted and patients were followed on average 6 years. The average age at time of injection was 4 months (range: 2-5 months). Compared to other treatments given, OBTT-A infants tended to present with more elbow flexion than the 4 infants requiring immediate surgical intervention and less elbow flexion than the 16 infants treated conservatively.OBTT-A injection to the triceps in infants with BPBP before 6 months of age therapeutically improved elbow flexion and diagnostically guided surgical decisions when full elbow flexion was not achieved by 8 months of age with no known complications.

The Relationship Between U.S. East Coast Sea Level and the Atlantic Meridional Overturning Circulation: A Review.

Scientific and societal interest in the relationship between the Atlantic Meridional Overturning Circulation (AMOC) and U.S. East Coast sea level has intensified over the past decade, largely due to (1) projected, and potentially ongoing, enhancement of sea level rise associated with AMOC weakening and (2) the potential for observations of U.S. East Coast sea level to inform reconstructions of North Atlantic circulation and climate. These implications have inspired a wealth of model- and observation-based analyses. Here, we review this research, finding consistent support in numerical models for an antiphase relationship between AMOC strength and dynamic sea level. However, simulations exhibit substantial along-coast and intermodel differences in the amplitude of AMOC-associated dynamic sea level variability. Observational analyses focusing on shorter (generally less than decadal) timescales show robust relationships between some components of the North Atlantic large-scale circulation and coastal sea level variability, but the causal relationships between different observational metrics, AMOC, and sea level are often unclear. We highlight the importance of existing and future research seeking to understand relationships between AMOC and its component currents, the role of ageostrophic processes near the coast, and the interplay of local and remote forcing. Such research will help reconcile the results of different numerical simulations with each other and with observations, inform the physical origins of covariability, and reveal the sensitivity of scaling relationships to forcing, timescale, and model representation. This information will, in turn, provide a more complete characterization of uncertainty in relevant relationships, leading to more robust reconstructions and projections.

Regulation of peripheral B cell maturation.

Although it is clear that the final phases of B cell maturation occur after newly formed B cells exit the bone marrow, the mechanisms underpinning the maturation, selection, and long-term survival of immature peripheral B cells remain poorly understood. Here, we review recent advances in our understanding of how B cell receptor (BCR)-mediated signaling events integrate with additional environmental cues to promote the selection and differentiation of immature B cells into functionally distinct subpopulations of mature B cells. We pay particular attention to the role of the Baff cytokine family and the Notch receptor-ligand family and their unique roles in promoting B cell survival and differentiation into follicular and marginal zone B cells.

c-Myb is critical for B cell development and maintenance of follicular B cells.

The c-Myb transcription factor is crucial during definitive hematopoiesis. However, the embryonic lethality of Myb traditional null mutations has precluded analysis of c-Myb function in lymphocytes. Using tissue-specific inactivation at the Myb locus, we demonstrate that loss of Myb causes a partial block during B cell development at the pro-B to pre-B cell transition, resulting in greatly decreased output of new B cells from the bone marrow. Furthermore, we demonstrate that Myb is not essential for the proliferation of splenic B cells, but that loss of c-Myb function prevents normal B cell homeostasis due to decreased splenic B cell survival. Decreased survival is accompanied by hyporesponsiveness to the B cell survival factor BLyS (also termed BAFF), decreased expression of the BLyS receptor 3 (BR3), and altered regulation of PKCdelta nuclear accumulation. Thus, c-Myb is important during multiple stages of B-lymphopoiesis.