The Public Health Leader Who Brought Antisepsis to William Halsted.

William Halsted wrote to aging surgeon, Stephen Smith, in 1919, that he remembered the lessons Smith had taught him, "when I walked with you through the wards of Bellevue Hospital." Smith was an early advocate of Joseph Lister's antiseptic method, and because of his public health work, he was also an early advocate of environmental hygiene and microbial control based on the unproved germ theory. While Lister's work at the time emphasized germ-killing around the operative site with carbolic acid (antisepsis), Smith adopted and encouraged surgical practices at Bellevue that would be hallmarks of the germ-preventing (asepsis) surgical approach that fully developed after German bacteriologic discoveries in the mid-1880s, and with which Halsted is historically identified. Some physicians and historians have emphasized temporal and conceptual differences between Lister's antisepsis and German asepsis, but Smith and Halsted's experiences argue that surgical asepsis was the evolutionary outcome of germ theory-based surgical changes that began well before scientific proof arrived.

The Union Army's Surgical Handbook and the Positive Story of Civil War Surgery.

Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but there has been little discussion of whether these handbooks have been used or improved outcomes. Recent research shows that the Union Army's American Civil War (1861-1865) surgical case fatality rates improved as the war progressed, much like the US Army's experience in later wars, and were generally superior to comparable European results. These positive Civil War outcomes have been attributed to field experience, adoption of best practices, and enhanced communication, without consideration of New York surgeon Stephen Smith's widely-used Hand-Book of Surgical Operations. The Army of the Potomac added Smith's pocket-sized Hand-Book to its supply table in 1862. Northern medical journals applauded it, and Smith's contemporaries documented its wide use. Smith's handbook explained and demonstrated surgical techniques that were adopted as the war progressed, such as the use of general anesthesia and limb-sparing resection (debridement) of gunshot wounds. It offered pithy, well-documented advice from recognized experts along with numerous illustrations, which allowed untrained physicians to visualize anatomical relationships and see contemporary best practices in a way that no other wartime publication provided, making it an exemplar of a mass-media surgical improvement change agent.

Emily Blackwell's Medical School Betrayal: "Duplicity and Double Dealing Somewhere".

Elizabeth Blackwell's younger sister, Emily (1826-1910), was the third woman to graduate from a regular U.S. medical college in 1854. Unlike the experience of the two women who preceded her, the Chicago medical school that accepted Emily refused to allow her to complete her studies and graduate, forcing her to hastily find an alternative. There was no explanation at the time and the Chicago Tribune, which investigated the incident, could only speculate about the source of such a dishonorable act: "It is very evident there is duplicity and double dealing somewhere. Who is guilty?" Generations of historians have attributed it to Illinois Medical Society pressure against Rush Medical College, but there was no contemporary evidence of such pressure. A closer examination of Blackwell's journal and historical records suggests that Rush founder, president, and professor of surgery, Daniel Brainard engineered her dismissal. One possible motive was a misplaced romantic approach by Brainard. Rush's actions had the paradoxical result of temporarily opening the doors of the Cleveland Medical College (now Case Western Reserve) to four more women medical students.

Reply to Van Valkenburgh et al.

DeSantis et al. respond to the concerns raised by Van Valkenburgh et al. on their original study.

Causes and Consequences of Pleistocene Megafaunal Extinctions as Revealed from Rancho La Brea Mammals.

The fossils preserved in the Rancho La Brea "tar" seeps in southern California span the past ∼50,000 years and provide a rare opportunity to assess the ecology of predators (e.g., the American lion, sabertooth cats, cougars, dire wolves, gray wolves, and coyotes), including clarifying the causes and consequences of the terminal Pleistocene extinction event. Here, a multi-proxy approach elucidates dietary responses of carnivorans to changing climates and megafaunal extinctions. Using sample sizes that are unavailable anywhere else in the world, including hundreds of carnivoran and herbivore specimens, we clarify the paleobiology of the extinct sabertooth cats and dire wolves-overturning the idea that they heavily competed for similar prey. Canids (especially the dire wolf) consumed prey from more open environments than felids, demonstrating minimal competition for prey throughout the latest Pleistocene and largely irrespective of changing climates, including just prior to their extinction. Coyotes experienced a dramatic shift in dietary behavior toward increased carcass utilization and the consumption of forest resources (prey and/or plant resources) after the terminal Pleistocene megafaunal extinction. Extant predators' ability to effectively hunt smaller prey and/or utilize carcasses may have been a key to their survival, especially after a significant reduction in megafaunal prey resources. Collectively, these data suggest that dietary niches of carnivorans are not always static and can instead be substantially affected by the removal of top predators and abundant prey resources.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Macroscopic Freestanding Nanosheets with Exceptionally High Modulus.

Macroscopic single-wall carbon nanotube (SWCNT) films of nanoscale thickness have significant potential for an array of applications that demand thin, transparent, conductive coatings. Using macroscopic micrometer thick polystyrene sheets as a reference, we characterize the elastic response of freestanding multifunctional SWCNT nanosheets possessing both exceptionally high Young's modulus and good durability. Thin SWCNT films (20-200 nm thick) asymmetrically "doped" with dilute concentrations of superparamagnetic colloids were suspended in ethanol as freestanding nanosheets. Through repeated and controlled deformation in an external magnetic field, we measure the temporal relaxation of nanosheet curvature back to equilibrium. From the relaxation time and its dependence on nanosheet thickness and length, we extract the SWCNT nanosheet modulus through a simple viscoelastic model. Our results are consistent with nearly ideal SWCNT rigidity percolation with moduli approaching 200 GPa and limited plasticity for sufficiently thick sheets, which we attribute to the screening of van der Waals interactions by the surrounding solvent and the macroscopic nature of the deformation.

Aridity and hominin environments.

Aridification is often considered a major driver of long-term ecological change and hominin evolution in eastern Africa during the Plio-Pleistocene; however, this hypothesis remains inadequately tested owing to difficulties in reconstructing terrestrial paleoclimate. We present a revised aridity index for quantifying water deficit (WD) in terrestrial environments using tooth enamel δ18O values, and use this approach to address paleoaridity over the past 4.4 million years in eastern Africa. We find no long-term trend in WD, consistent with other terrestrial climate indicators in the Omo-Turkana Basin, and no relationship between paleoaridity and herbivore paleodiet structure among fossil collections meeting the criteria for WD estimation. Thus, we suggest that changes in the abundance of C4 grass and grazing herbivores in eastern Africa during the Pliocene and Pleistocene may have been decoupled from aridity. As in modern African ecosystems, other factors, such as rainfall seasonality or ecological interactions among plants and mammals, may be important for understanding the evolution of C4 grass- and grazer-dominated biomes.

It Is Time to Cancel Medicine's Social Contract Metaphor.

There is agreement that the complex relationship between medicine and society is best described as a metaphorical social contract and that professionalism is the medical profession's contribution to this contract. Metaphors can help clarify abstract concepts, but they can also be abused if the counterfactual attributes of a metaphor become attributed to its subject. This seems to be happening with medical professionalism, which has sometimes been reduced to a contracted deliverable and a bargaining chip. The undesirable attributes of the social contract metaphor may be hindering efforts to understand and teach medical professionalism.Despite its theoretical weaknesses, the social contract metaphor has historical credibility because of its alleged association with the 1847 Code of Medical Ethics and the subsequent ascension of regular (allopathic) medicine in the early 20th century. However, the record does not support an argument that the intended purpose of the 1847 Code was to create a social contract or that one ever arose. The alternative account that a contract did arise, but physicians were poor partners, is neither satisfying nor explanatory.As now used, medicine's social contract metaphor has serious theoretical and historic weaknesses. Medical educators should remove this narrow and overworked metaphor from their discussions of professionalism. By doing this, educators and the profession in general would only lose the ability to threaten themselves with the cancellation of their social contract. In return they would open the door to a more complex and fruitful consideration of medical professionalism and medicine's relationship with society.

Changes in biomass allocation buffer low CO2 effects on tree growth during the last glaciation.

Isotopic measurements on junipers growing in southern California during the last glacial, when the ambient atmospheric [CO2] (ca) was ~180 ppm, show the leaf-internal [CO2] (ci) was approaching the modern CO2 compensation point for C3 plants. Despite this, stem growth rates were similar to today. Using a coupled light-use efficiency and tree growth model, we show that it is possible to maintain a stable ci/ca ratio because both vapour pressure deficit and temperature were decreased under glacial conditions at La Brea, and these have compensating effects on the ci/ca ratio. Reduced photorespiration at lower temperatures would partly mitigate the effect of low ci on gross primary production, but maintenance of present-day radial growth also requires a ~27% reduction in the ratio of fine root mass to leaf area. Such a shift was possible due to reduced drought stress under glacial conditions at La Brea. The necessity for changes in allocation in response to changes in [CO2] is consistent with increased below-ground allocation, and the apparent homoeostasis of radial growth, as ca increases today.

Orchestrating ACO success: how top performers achieve shared savings.

Leaders of the top-performing accountable care organizations in the Medicare Shared Savings Program attribute the success of their organizations in large part to seven strategies: Seek action-oriented leadership. Transform primary care physician practices. Keep patients out of the emergency department. Ensure all transitions are smooth. Make effective use of available data. Share information on physician performance. Keep patients engaged.

Impact of SWCNT processing on nanotube-silicon heterojunctions.

Single-wall carbon nanotube (SWCNT) films are ideal components for thin, flexible, and durable electronic devices. Here, we use a variety of processing approaches to fabricate SWCNT-silicon heterojunctions from both unsorted and chirality-enriched SWCNTs. Through measured structure/processing/property relationships, we quantify the influence of SWCNT purity, alignment and residual doping on device performance and diode characteristics. Our results show that mixed-type unaligned SWCNTs processed in super-acid solvents can achieve state-of-the-art performance. The devices perform comparably to those fabricated from type or chiral-purified SWCNTs, despite what appear to be significant deviations from ideal diode behavior. Our results clarify a direct route for processing nanotube-silicon heterojunctions while providing additional insight into the underlying nature of these devices.

Dietary changes of large herbivores in the Turkana Basin, Kenya from 4 to 1 Ma.

A large stable isotope dataset from East and Central Africa from ca. 30 regional collection sites that range from forest to grassland shows that most extant East and Central African large herbivore taxa have diets dominated by C4 grazing or C3 browsing. Comparison with the fossil record shows that faunal assemblages from ca. 4.1-2.35 Ma in the Turkana Basin had a greater diversity of C3-C4 mixed feeding taxa than is presently found in modern East and Central African environments. In contrast, the period from 2.35 to 1.0 Ma had more C4-grazing taxa, especially nonruminant C4-grazing taxa, than are found in modern environments in East and Central Africa. Many nonbovid C4 grazers became extinct in Africa, notably the suid Notochoerus, the hipparion equid Eurygnathohippus, the giraffid Sivatherium, and the elephantid Elephas. Other important nonruminant C4-grazing taxa switched to browsing, including suids in the lineage Kolpochoerus-Hylochoerus and the elephant Loxodonta. Many modern herbivore taxa in Africa have diets that differ significantly from their fossil relatives. Elephants and tragelaphin bovids are two groups often used for paleoecological insight, yet their fossil diets were very different from their modern closest relatives; therefore, their taxonomic presence in a fossil assemblage does not indicate they had a similar ecological function in the past as they do at present. Overall, we find ecological assemblages of C3-browsing, C3-C4-mixed feeding, and C4-grazing taxa in the Turkana Basin fossil record that are different from any modern ecosystem in East or Central Africa.

James Edmund Reeves (1829-1896) and the contentious 19th century battle for medical professionalism in the United States.

During his life, Dr James E Reeves was a national figure in the US. His work included multiple professional publications, civic and professional leadership positions, and the drafting of a landmark law that confirmed the right of states to regulate the medical profession. While much of Reeves' work supported the successful struggle of 19th century regular physicians to gain control of the practice of medicine, he challenged his colleagues when their self-interests conflicted with his perception of the public good. He was frequently lauded for this work by physicians and the public but he also made professional enemies. Perhaps for this reason, his considerable accomplishments were forgotten after his death. His story reminds us of the difficult contradiction that exists within the regulation of medicine, guarding the public's welfare while protecting the interests of medical professionals. It also reminds us that history may temporarily overlook those who fight our difficult battles.

Wrinkling and folding of nanotube-polymer bilayers.

The influence of a polymer capping layer on the deformation of purified single-wall carbon nanotube (SWCNT) networks is analyzed through the wrinkling of compressed SWCNT-polymer bilayers on polydimethylsiloxane. The films exhibit both wrinkling and folding under compression and we extract the elastoplastic response using conventional two-plate buckling schemes. The formation of a diffuse interpenetrating nanotube-polymer interface has a dramatic effect on the nanotube layer modulus for both metallic and semiconducting species. In contrast to the usual percolation exhibited by the pure SWCNT films, the capped films show a crossover from "composite" behavior (the modulus of the SWCNT film is enhanced by the polymer) to "plasticized" behavior (the modulus of the SWCNT film is reduced by the polymer) as the SWCNT film thickness increases. For almost all thicknesses, however, the polymer enhances the yield strain of the nanotube network. Conductivity measurements on identical films suggest that the polymer has a modest effect on charge transport, which we interpret as a strain-induced polymer penetration of interfacial nanotube contacts. We use scaling, Flory-Huggins theory, and independently determined nanotube-nanotube and nanotube-polymer Hamaker constants to model the response.

Attempted DNA extraction from a Rancho La Brea Columbian mammoth (Mammuthus columbi): prospects for ancient DNA from asphalt deposits.

Fossil-bearing asphalt deposits are an understudied and potentially significant source of ancient DNA. Previous attempts to extract DNA from skeletons preserved at the Rancho La Brea tar pits in Los Angeles, California, have proven unsuccessful, but it is unclear whether this is due to a lack of endogenous DNA, or if the problem is caused by asphalt-mediated inhibition. In an attempt to test these hypotheses, a recently recovered Columbian mammoth (Mammuthus columbi) skeleton with an unusual pattern of asphalt impregnation was studied. Ultimately, none of the bone samples tested successfully amplified M. columbi DNA. Our work suggests that reagents typically used to remove asphalt from ancient samples also inhibit DNA extraction. Ultimately, we conclude that the probability of recovering ancient DNA from fossils in asphalt deposits is strongly (perhaps fatally) hindered by the organic compounds that permeate the bones and that at the Rancho La Brea tar pits, environmental conditions might not have been ideal for the general preservation of genetic material.

Purifying colloidal nanoparticles through ultracentrifugation with implications for interfaces and materials.

Liquid-phase processing and colloidal self-assembly will be critical to the successful implementation of nanotechnology in the next generation of materials and devices. A key hurdle to realizing this will be the development of efficient methods to purify nanomaterials composed of a variety of shapes, including nanocrystals, nanotubes, and nanoplates. Although density-gradient ultracentrifugation (DGU) has long been appreciated as a valuable tool for separating biological macromolecules and components, the method has recently emerged as an effective way to purify colloidal nanoparticles by size and optical and electronic properties. In this feature article, we review our recent contributions to this growing field, with an emphasis on some of the implications that our results have for interfaces and materials. Through transient or isopycnic DGU performed in both aqueous and organic environments, we demonstrate some explicit examples of how the mechanical, electronic, and optical properties of thin films assembled from two specific colloidal nanomaterials--single-walled carbon nanotubes and silicon nanocrystals--can be modified in response to fractionation.