Evaluation of Total Daily Dose and Glycemic Control for Patients Taking U-500 Regular Insulin Admitted to the Hospital

OBJECTIVE: Patients using U-500 regular insulin are severely insulin resistant, requiring high doses of insulin. It has been observed that a patient\u27s insulin requirements may dramatically decrease during hospitalization. This study sought to systematically investigate this phenomenon. METHODS: We performed a retrospective chart review of patients with U-500 insulin outpatient regimens who were admitted to the San Antonio Military Medical Center over a 5-year period. Each patient\u27s outpatient total daily dose (TDD) of insulin was compared to the average inpatient TDD. The outpatient estimated average glucose (eAG) was calculated from the glycated hemoglobin (HbA1c) and compared to the average inpatient glucose. RESULTS: There were 27 patients with a total of 62 separate admissions. The average age was 64.4 years, with a mean body mass index of 38.9 kg/m CONCLUSION: U-500 insulin is prone to errors in the hospital setting, so conversion to U-100 insulin is a preferred option. Despite a significant reduction in insulin TDD, these patients had clinically similar glucose levels. Therefore, patients taking U-500 insulin as an outpatient can be converted to a U-100 basal-bolus regimen with at least a 50% reduction of their outpatient TDD. ABBREVIATIONS: BG = blood glucose eAG = estimated average glucose HbA1c = glycated hemoglobin NPO = nil per os SPSS = Statistical Package for the Social Sciences TDD = total daily dose

Current deformation in Central Afar and triple junction kinematics deduced from GPS and InSAR measurements

Kinematics of divergent boundaries and Rift-Rift-Rift junctions are classically studied using long-term geodetic observations. Since significant magma-related displacements are expected, short-term deformation provides important constraints on the crustal mechanisms involved both in active rifting and in transfer of extensional deformation between spreading axes. Using InSAR and GPS data, we analyse the surface deformation in the whole Central Afar region in detail, focusing on both the extensional deformation across the Quaternary magmato-tectonic rift segments, and on the zones of deformation transfer between active segments and spreading axes. The largest deformation occurs across the two recently activated Asal-Ghoubbet (AG) and Manda Hararo-Dabbahu (MH-D) magmato-tectonic segments with very high strain rates, whereas the other Quaternary active segments do not concentrate any large strain, suggesting that these rifts are either sealed during interdyking periods or not mature enough to remain a plate boundary. Outside of these segments, the GPS horizontal velocity field shows a regular gradient following a clockwise rotation of the displacements from the Southeast to the East of Afar, with respect to Nubia. Very few shallow creeping structures can be identified as well in the InSAR data. However, using these data together with the strain rate tensor and the rotations rates deduced from GPS baselines, the present-day strain field over Central Afar is consistent with the main tectonic structures, and therefore with the long-term deformation. We investigate the current kinematics of the triple junction included in our GPS data set by building simple block models. The deformation in Central Afar can be described by adding a central microblock evolving separately from the three surrounding plates. In this model, the northern block boundary corresponds to a deep EW-trending trans-tensional dislocation, locked from the surface to 10–13 km and joining at depth the active spreading axes of the Red Sea and the Aden Ridge, from AG to MH-D rift segments. Over the long-term, this plate configuration could explain the presence of the en-échelon magmatic basins and subrifts. However, the transient behaviour of the spreading axes implies that the deformation in Central Afar evolves depending on the availability of magma supply within the well-established segments

Deep Placental Vessel Segmentation for Fetoscopic Mosaicking

During fetoscopic laser photocoagulation, a treatment for twin-to-twin transfusion syndrome (TTTS), the clinician first identifies abnormal placental vascular connections and laser ablates them to regulate blood flow in both fetuses. The procedure is challenging due to the mobility of the environment, poor visibility in amniotic fluid, occasional bleeding, and limitations in the fetoscopic field-of-view and image quality. Ideally, anastomotic placental vessels would be automatically identified, segmented and registered to create expanded vessel maps to guide laser ablation, however, such methods have yet to be clinically adopted. We propose a solution utilising the U-Net architecture for performing placental vessel segmentation in fetoscopic videos. The obtained vessel probability maps provide sufficient cues for mosaicking alignment by registering consecutive vessel maps using the direct intensity-based technique. Experiments on 6 different in vivo fetoscopic videos demonstrate that the vessel intensity-based registration outperformed image intensity-based registration approaches showing better robustness in qualitative and quantitative comparison. We additionally reduce drift accumulation to negligible even for sequences with up to 400 frames and we incorporate a scheme for quantifying drift error in the absence of the ground-truth. Our paper provides a benchmark for fetoscopy placental vessel segmentation and registration by contributing the first in vivo vessel segmentation and fetoscopic videos dataset.Comment: Accepted at MICCAI 202

Leadership Training in Endocrinology Fellowship? A Survey of Program Directors and Recent Graduates

Context: There is growing recognition that more physician leaders are needed to navigate the next era of medicine. Objective: To determine current opinions about leadership training in endocrinology fellowship programs. Design/Participants: Twenty-seven-question survey addressing various aspects of leadership training to current nationwide fellowship program directors (PDs) and fellowship graduates since 2010. Intervention: In partnership with the Endocrine Society, the electronic survey was advertised primarily via direct e-mail. It was open from March through July 2016. Main Outcome Measures: The survey addressed leadership traits, importance of leadership training, preferred timing, and content of leadership training. Results: Forty-six of 138 PDs (33.3%) and 147 of 1769 graduates (8.3%) completed the survey. Among PDs and graduates, there was strong agreement (\u3e95%) about important leadership characteristics, including job knowledge, character traits, team-builder focus, and professional skills. PDs (64.5%) and graduates (60.8%) favored teaching leadership skills during fellowship, with PDs favoring mentoring/coaching (75.0%), direct observation of staff clinicians (72.5%), and seminars (72.5%). Graduates favored a variety of approaches. Regarding topics to include in a leadership curriculum, PDs responded that communication skills (97.5%), team building (95.0%), professional skills (90.0%), clinic management (87.5%), strategies to impact the delivery of endocrinology care (85.0%), and personality skills (82.5%) were most important. Graduates responded similarly, with \u3e80% agreement for each topic. Finally, most PDs (89%) expressed a desire to incorporate more leadership training into their programs. Conclusions: Our survey suggests a need for leadership training in endocrinology fellowships. More work is needed to determine how best to meet this need

Crustal structure of active deformation zones in Africa: Implications for global crustal processes

The Cenozoic East African rift (EAR), Cameroon Volcanic Line (CVL), and Atlas Mountains formed on the slow-moving African continent, which last experienced orogeny during the Pan-African. We synthesize primarily geophysical data to evaluate the role of magmatism in shaping Africa's crust. In young magmatic rift zones, melt and volatiles migrate from the asthenosphere to gas-rich magma reservoirs at the Moho, altering crustal composition and reducing strength. Within the southernmost Eastern rift, the crust comprises ~20% new magmatic material ponded in the lower crust sills, and intruded as sills and dikes at shallower depths. In the Main Ethiopian rift, intrusions comprise 30% of the crust below axial zones of dike-dominated extension. In the incipient rupture zones of the Afar rift, magma intrusions fed from crustal magma chambers beneath segment centers create new columns of mafic crust, as along slow-spreading ridges. Our comparisons suggest that transitional crust, including seaward-dipping sequences, is created as progressively smaller screens of continental crust are heated and weakened by magma intrusion into 15-20 km-thick crust. In the 30Ma-Recent CVL, which lacks a hotspot age-progression, extensional forces are small, inhibiting the creation and rise of magma into the crust. In the Atlas orogen, localized magmatism follows the strike of the Atlas Mountains from the Canary Islands hotspot towards the Alboran Sea. CVL and Atlas magmatism has had minimal impact on crustal structure. Our syntheses show that magma and volatiles are migrating from the asthenosphere through the plates, modifying rheology and contributing significantly to global carbon and water fluxes

Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers.

OBJECTIVE: To investigate the antenatal management and outcome in a large international cohort of monochorionic twin pregnancies with spontaneous or post-laser twin anemia-polycythemia sequence (TAPS). METHODS: This study analyzed data of monochorionic twin pregnancies diagnosed antenatally with spontaneous or post-laser TAPS in 17 fetal therapy centers, recorded in the TAPS Registry between 2014 and 2019. Antenatal diagnosis of TAPS was based on fetal middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) in the TAPS donor and < 1.0 MoM in the TAPS recipient. The following antenatal management groups were defined: expectant management, delivery within 7 days after diagnosis, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), laser surgery and selective feticide. Cases were assigned to the management groups based on the first treatment that was received after diagnosis of TAPS. The primary outcomes were perinatal mortality and severe neonatal morbidity. The secondary outcome was diagnosis-to-birth interval. RESULTS: In total, 370 monochorionic twin pregnancies were diagnosed antenatally with TAPS during the study period and included in the study. Of these, 31% (n = 113) were managed expectantly, 30% (n = 110) with laser surgery, 19% (n = 70) with IUT (± PET), 12% (n = 43) with delivery, 8% (n = 30) with selective feticide and 1% (n = 4) underwent termination of pregnancy. Perinatal mortality occurred in 17% (39/225) of pregnancies in the expectant-management group, 18% (38/215) in the laser group, 18% (25/140) in the IUT (± PET) group, 10% (9/86) in the delivery group and in 7% (2/30) of the cotwins in the selective-feticide group. The incidence of severe neonatal morbidity was 49% (41/84) in the delivery group, 46% (56/122) in the IUT (± PET) group, 31% (60/193) in the expectant-management group, 31% (57/182) in the laser-surgery group and 25% (7/28) in the selective-feticide group. Median diagnosis-to-birth interval was longest after selective feticide (10.5 (interquartile range (IQR), 4.2-14.9) weeks), followed by laser surgery (9.7 (IQR, 6.6-12.7) weeks), expectant management (7.8 (IQR, 3.8-14.4) weeks), IUT (± PET) (4.0 (IQR, 2.0-6.9) weeks) and delivery (0.3 (IQR, 0.0-0.5) weeks). Treatment choice for TAPS varied greatly within and between the 17 fetal therapy centers. CONCLUSIONS: Antenatal treatment for TAPS differs considerably amongst fetal therapy centers. Perinatal mortality and morbidity were high in all management groups. Prolongation of pregnancy was best achieved by expectant management, treatment by laser surgery or selective feticide. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology

Event trees and epistemic uncertainty in long‐term volcanic hazard assessment of Rift Volcanoes: the example of Aluto (Central Ethiopia)

Aluto is a peralkaline rhyolitic caldera located in a highly populated area in central Ethiopia. Its postcaldera eruptive activity has mainly consisted of self‐similar, pumice‐cone‐building eruptions of varying size and vent location. These eruptions are explosive, generating hazardous phenomena that could impact proximal to distal areas from the vent. Volcanic hazard assessments in Ethiopia and the East African Rift are still limited in number. In this study, we develop an event tree model for Aluto volcano. The event tree is doubly useful: It facilitates the design of a conceptual model for the volcano and provides a framework to quantify volcanic hazard. We combine volcanological data from past and recent research at Aluto, and from a tool to objectively derive analog volcanoes (VOLCANS), to parameterize the event tree, including estimates of the substantial epistemic uncertainty. Results indicate that the probability of a silicic eruption in the next 50 years is highly uncertain, ranging from 2% to 35%. This epistemic uncertainty has a critical influence on event‐tree estimates for other volcanic events, like the probability of occurrence of pyroclastic density currents (PDCs) in the next 50 years. The 90% credible interval for the latter is 5–16%, considering only the epistemic uncertainty in conditional eruption size and PDC occurrence, but 2–23% when adding the epistemic uncertainty in the probability of eruption in 50 years. Despite some anticipated challenges, we envisage that our event tree could be translated to other rift volcanoes, making it an important tool to quantify volcanic hazard in Ethiopia and elsewhere

Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases.

The aim of this study was to investigate the management and outcome in the post-laser twin anemia polycythemia sequence (TAPS). Data of the international TAPS Registry, collected between 2014 and 2019, were used for this study. The primary outcomes were perinatal mortality and severe neonatal morbidity. Secondary outcomes included a risk factor analysis for perinatal mortality and severe neonatal morbidity. A total of 164 post-laser TAPS pregnancies were included, of which 92% (151/164) were diagnosed antenatally and 8% (13/164) postnatally. The median number of days between laser for TTTS and detection of TAPS was 14 (IQR: 7-28, range: 1-119). Antenatal management included expectant management in 43% (62/151), intrauterine transfusion with or without partial exchange transfusion in 29% (44/151), repeated laser surgery in 15% (24/151), selective feticide in 7% (11/151), delivery in 6% (9/151), and termination of pregnancy in 1% (1/151). The median gestational age (GA) at birth was 31.7 weeks (IQR: 28.6-33.7; range: 19.0-41.3). The perinatal mortality rate was 25% (83/327) for the total group, 37% (61/164) for donors, and 14% (22/163) for recipients (p < 0.001). Severe neonatal morbidity was detected in 40% (105/263) of the cohort and was similar for donors (43%; 51/118) and recipients (37%; 54/145), p = 0.568. Independent risk factors for spontaneous perinatal mortality were antenatal TAPS Stage 4 (OR = 3.4, 95%CI 1.4-26.0, p = 0.015), TAPS donor status (OR = 4.2, 95%CI 2.1-8.3, p < 0.001), and GA at birth (OR = 0.8, 95%CI 0.7-0.9, p = 0.001). Severe neonatal morbidity was significantly associated with GA at birth (OR = 1.5, 95%CI 1.3-1.7, p < 0.001). In conclusion, post-laser TAPS most often occurs within one month after laser for TTTS, but may develop up to 17 weeks after initial surgery. Management is mostly expectant, but varies greatly, highlighting the lack of consensus on the optimal treatment and heterogeneity of the condition. Perinatal outcome is poor, particularly due to the high rate of perinatal mortality in donor twins

Archaeology, Architecture, and the Postcolonial Critique

Peer reviewe

Effect of maternal administration of betamethasone on peripheral arterial development in fetal rabbit lungs

Objectives: Glucocorticoids promote lung maturation and reduce the incidence of respiratory distress syndrome in premature newborns. We hypothesized that betamethasone (BM), which is known to induce thinning of the alveolar walls, would also thin the arterial media and adventitia of intra-parenchymatic vessels in developing rabbit lungs. Study Design: 112 fetuses from 21 time-mated, pregnant, giant white rabbits received maternal injections of BM at either 0.05 or 0.1 mg/kg/day on days 25-26 of gestational age. Controls received either saline (10 does, 56 fetuses) or no injection (10 does, 59 fetuses). Fetuses were harvested from day 27 onwards until term (day 31). 44 additional fetuses (8 does) were harvested between days 23 and 26. Endpoints were wet lung-to-body weight ratio, vascular morphometric indices and immunohistochemistry staining for α-smooth muscle actin, Flk-1, vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS). ANOVA (Tukey's test) and independent t test (p < 0.05) were used for comparison between BM and saline groups. Results: Maternal BM injected on days 25-26 to pregnant rabbits induced a significant decrease in fetal body and lung weight and the lung-to-body weight ratio in the preterm pups shortly after injection. BM led to a dose-dependent thinning of the arterial media and adventitia (pulmonary arteries with an external diameter (ED) of <100 μm), to an increase in the percentage of non-muscularized peripheral vessels (ED <60 μm), in eNOS and VEGF immunoreactivity of the endothelial and smooth muscle cells in the pulmonary vessels and to an increase in Flk-1-positive pulmonary epithelial cell density. Conclusions: Maternal administration of BM caused thinning of the arterial wall of pulmonary vessels (ED <100 μm) and a decrease in muscularization in peripheral vessels (ED <60 μm). This coincided with increased expression of Flk-1 in the endothelium and smooth muscle cells of the pulmonary arteries. All the effects studied were dose-dependent. Copyrigh