South Atlantic Region Research Articles

Long-term trends in abundance and potential drivers for eight species of coastal birds in the U.S. South Atlantic

The U.S. South Atlantic coastal region is used by many marine birds for foraging, reproduction, and migration. We developed standardized indices of relative abundance from long–term (1980–2016), semi-structured monitoring data (eBird) for eight species: Brown Pelican (Pelecanus occidentalis), Double-Crested Cormorant (Nannopterum auritum), White Ibis (Eudocimus albus), Wood Stork (Mycteria americana), Piping Plover (Charadrius melodus), American Oystercatcher (Haematopus palliatus), Clapper Rail (Rallus crepitans), and Northern Gannet (Morus bassanus). Following a period of stable or declining abundance from the 1980s through the 1990s, most species have shown stable or slightly upward trends through the late 2000s; Brown Pelican and Piping Plover have shown some evidence of recent declines. Species–specific correlations between abundance indices developed from presence/absence data and those developed from count data were positive for all species and ranged from 0.53 to 0.86. Dynamic factor analysis identified common trends in abundance among several species, in particular, Brown Pelican, Double–Crested Cormorant, and White Ibis. Model performance was improved with inclusion of an indicator of sea level rise, but not forage fish abundance or temperature, indicating habitat availability mediated by changing water levels may explain some of the underlying abundance trends. Our results provide baseline information on long–term trends for several important coastal birds that can help inform research, monitoring and conservation efforts in the U.S. South Atlantic region.

Evaluation of CMIP5 and CMIP6 Models Based on Weather Types Applied to the South Atlantic Ocean

ABSTRACTChanges in climate in the South Atlantic region and adjacent regions have been described in numerous works using projections from global climate models from CMIP5 and CMIP6. This paper presents an evaluation of the ability of these models to reproduce the atmospheric circulation patterns (weather types) and their seasonal and inter‐annual variability. The analyses are performed based on the probability of occurrence of weather types in the historical period and in future projections. The scatter index and the relative entropy are the statistical parameters used to evaluate the models' performance in the historical period. Future projections consist of RCP2.6, 4.5 and 8.5 scenarios for the CMIP5 models and the SSP126, 245, 370 and 585 scenarios for the CMIP6 and are assessed at different time intervals: short term (2015–2039), mid‐term (2040–2069) and long term (2070–2100). The performance of projections is measured by analysing their consistency, that is, based on the similarity between projections of the same scenario in different models. The results show that the reproduction of the probability of occurrence of historical weather types and their seasonal and interannual variability was better performed by ACCESS1‐0, HadGEM2‐ES, HadGEM2‐CC, CMCC‐CM and MPI‐ESM‐P when assessing the models from CMIP5, and by HadGEM3‐GC31‐MM, ACCESS‐ESM1‐5, ACCESS‐ CM2 and MRI‐ESM‐P when assessing the models from CMIP6. As for future projections, only the BESM‐AO2‐5, GFDL‐ESM4 and HadGEM3‐GC31‐MM models showed inconsistency in one or more scenarios.

Representation of online LGBTQ+ support in general surgery residency programs

BackgroundLesbian, Gay, Bisexual, Transgender, Queer, and more(LGBTQ+) trainees are underrepresented in medicine, and their experiences in surgery have not been well studied. We sought to examine the practices of general surgery residency programs by region regarding representation of LGBTQ+ ​support online. MethodsRetrospective, two-person review of 100 general surgery residency programs stratified by Electronic Residency Application Service(ERAS) region comparing data on Diversity, Equity, and Inclusion(DEI) and LGBTQ+ ​-specific webpages. ResultsThe Middle Atlantic and South Atlantic regions had 20% of programs each, with fewer programs found in other regions. Of the 100 institutions, 92% had DEI webpages, and 43% had LGBTQ+ ​-specific webpages. There was a significant difference in the likelihood of a program being an Human Rights Campaign(HRC) LGBTQ+ ​leader when compared by region(p ​< ​0.01). ConclusionsFew general surgery residency programs share LGBTQ+-specific DEI content online with no regional difference observed. Recommendations such as updating websites to highlight LGBTQ+ ​inclusion should aid recruitment of a diverse, surgical residency as well as create a welcoming environment for prospective residents.

Neighborhood environment, socioeconomic conditions, and intergenerational mobility

Intergenerational mobility (IM) has recently generated significant attention. However, the mechanisms of IM, including the neighborhood effects, are still not well understood. This research aims to advance the research on IM by emphasizing the role of neighborhood environments and their mediating effects in the United States. Our results suggest that childhood neighborhood conditions significantly affect IM, and IM is determined by childhood physical and socioeconomic status (SES) or conditions and outmigration. Specifically, we find that natural and built environments affect IM indirectly through neighborhood SES, and, therefore, the effect of SES has been overestimated. Moreover, there are complex pathways linking neighborhood SES to IM. A dense, mixed-use, and walkable neighborhood may show lower IM because such neighborhoods usually have higher concentrations of poor people and single parents. We also find that outmigration is a pathway to IM. Desirable childhood neighborhood environments and high outmigration returns lead to higher IM in rural areas than in urban areas, and also higher IM in the West North Central region than in the East South Central and South Atlantic regions, although these regions have similarly low SES. Our study highlights the significant effects of the neighborhood environment on IM.

Travel distance does not affect overall survival in patients with appendiceal adenocarcinoma undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

IntroductionCytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a potentially curative approach for appendiceal cancer (AC) with peritoneal dissemination and is most often employed at tertiary referral centers. Regionalization may provide geographic barriers to care for vulnerable patients. The aim of this study was to examine the effect of travel distance on oncologic outcomes of patients with AC treated with CRS-HIPEC. MethodsThe National Cancer Database (NCDB) was reviewed from 2006 through 2020 for patients with AC who underwent CRS-HIPEC. The primary comparison variable was distance (<50 miles vs ≥ 50 miles from the CRS-HIPEC facility). Demographic and tumor characteristics were analyzed. Primary outcome was overall survival (OS). Secondary outcomes were 30-day and 90-day mortality, readmission, and length of stay (LOS). ResultsDuring the study period, 1703 patients met inclusion criteria, with 1000 patients travelling < 50 miles for CRS-HIPEC (59 %) and 703 travelling ≥ 50 miles (41 %). Patients who traveled ≥ 50 miles were more likely to be non-Hispanic White (p < 0.001), have annual income less than $74,062, be treated at an academic center and live in the South-Atlantic region of the United States. There was no significant difference in OS between groups (Figure 1). There were no significant differences in 30-day postoperative survival, 90-day survival, or 30-day readmission. Post-operative LOS was 8.0 versus 9.0 days (p < 0.001). ConclusionsTravel distance ≥ 50 miles was not significantly associated with decreased OS or increased postoperative mortality, suggesting that regionalization of care does not worsen oncologic outcomes for patients with AC undergoing CRS-HIPEC.

Small cell osteosarcoma: An NCDB analysis of demographic and socioeconomic factors of diagnosed patients.

e23504 Background: Small cell osteosarcoma (SCOS) is a rare subtype of osteosarcoma accounting for roughly 1.5% of all osteosarcomas. Its prognosis is slightly worse than conventional osteosarcoma. Exploring demographic trends in patients with a confirmed SCOS diagnosis may provide insight into its epidemiology and allow for earlier diagnosis. The National Cancer Database (NCDB) was analyzed to research the demographic factors in patients diagnosed with SCOS. Methods: A retrospective cohort analysis utilizing the 2004–2020 National Cancer Database (NCDB) included patients with a histologically-confirmed diagnosis of SCOS (ICD-O-3 9185). Demographic factors (age, sex, race, Hispanic status, educational attainment, insurance status, facility type, distance from facility, and Charles-Deyo score) were analyzed via descriptive statistics. Incidence trends were interpreted in regression analysis. The mean survival was compared using the Log Rank (Mantel-Cox) test. Results: A cohort of 102 cases of SCOS were retrieved from the NCDB between 2004–2020. The primary sites for SCOS were the long bones of the lower limb (41%). Most patients were male (69%), White (63%), non-Hispanic (84%) with a mean age for diagnosis of 28 (SD = 18). The mean survival for males was 117 months (95% CI [93,141]), more than twice as long as females with 58 months (95% CI [31,85]). The Log Rank (Mantel-Cox) test reported a chi-square (χ²) value of 6.434, indicating a statistically significant difference between survival curves of males and females (p = 0.01). Residence in a metropolitan area (86%) was more common than other rural or urban areas. The greatest proportion of patients lived in the Middle or South Atlantic region of the United States (68%). The majority of patients were insured (86%), with the most covered by private insurance (64%) or Medicaid (22%). The median household income for each patient was most commonly in the highest quartile of over $74,063 (29%). Patients were diagnosed with SCOS at a steady rate between 2004 to 2020 (R² = 0.0956). Using the AJCC Cancer Staging System, most patients were Stage II (40%) or Stage IV (21%) at diagnosis. As a primary treatment, 87% of patients received chemotherapy. Most patients (91%) had no comorbidities with a Charlson-Deyo score of 0. Conclusions: This is the first time that demographic and socioeconomic factors of SCOS patients have been analyzed from the NCDB, revealing that the mean survival time of patients after receiving a diagnosis was more than double for males than females. SCOS patients are also more likely to live in metropolitan areas, particularly within the Middle or South Atlantic United States. Consistent with earlier reports, SCOS is typically diagnosed in young adults in the long bones of lower limbs. To better understand the impact of demographic factors on the diagnosis, treatment, and overall survival of patients with SCOS, further research is recommended.

295 High Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor

INTRODUCTION: Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. METHODS: The 2016-2020 National Inpatient Sample (NIS) was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with high case load (greater than two standrad deviations above the mean, or &gt;140 cases) were categorized as high-volume centers (HVC). Value of care was computed by adding one point for each of the following variables: lower length of stay, lower total charges, discharge to home, and lack of major comorbidity or complication, as defined per DRG codes. RESULTS: A total of 118,390 patients underwent resection of malignant brain tumors in 3,009 hospitals. HVC criteria was met by 91 (3%) hospitals, which represented 20,230 (17.1%) of total cases. The Mid-Atlantic and South Atlantic regions had the highest percentage of cases (22.7% and 20.2%, respectively) and number of HVC (21 and 17, respectively). Value of care was higher at HVC (OR = 1.35 95%CI 1.31-1.39 p &lt; 0.01). After controlling for baseline risk factors and high risk admissions, HVC was associated with decreased complications of intracranial hemorrhage, deep venous thrombosis, aspiration pneumonitis, acute kidney injury, and external ventricular drain requirement (p &lt; 0.01 for all). HVC was also associated with decreased length of stay and increased rate of discharge to home (p &lt; 0.01 for both). CONCLUSIONS: Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVC. Trends of centralization are likely a reflection of the benefits of multidisciplinary treatment for these patients. Improvement of access to care at these institutions may improve the efficiency of the delivery of care for these patients.

Trends in medical device company payments in neurosurgery: a nationwide, multidatabase, geospatial analysis.

Industry partnerships help advance the field of neurosurgery. Given the nature of the field and its close relationship with innovation, neurosurgeons frequently partner with the medical device industry to advance technology and improve outcomes. However, this can create important ethical concerns for patients. In this paper, the authors sought to comprehensively study how physician payments from medical device companies have changed and what geographic parameters influence the trends observed over the years. The authors queried and merged several large databases, including Medicare and Medicaid provider usage data and databases from the Open Payments Program, National Plan and Provider Enumeration System, and US Census Bureau. Geospatial analysis was performed using Moran's I and II clustering. Univariate and multivariable analyses were performed using the Mann-Whitney U-test and geospatially weighted multivariable regression for hot spot and cold spot membership. Data for 952 counties across the continental United States were analyzed. Ninety-seven counties constituted geographic hot spots. These hot spots were primarily concentrated in Florida, the New York-Pennsylvania region, central Colorado, and southwestern United States. Independent predictors of hot spot membership included greater unemployment rates, the percentage of White patients, the presence of mobile homes, and the percentage of county Hispanic and Black populations. Company-based differences were examined. The vast majority of Medtronic's payments were in the form of royalties and licensing (86.6%). Royalties and licensing accounted for the majority of payments for DePuy (69.4%), Globus Medical (62%), and NuVasive (77.1%). In contrast, other companies, such as Boston Scientific, opted to pay physicians in the form of ownership and investment interests (42.1%). The impact of the COVID-19 pandemic was also assessed. During the onset of the pandemic in 2020, physician payments fell or remained the same across all regions with the exception of the South Atlantic region. However, it was observed that nearly all regions rebounded, with stark elevations in physician payments immediately in 2021. This analysis demonstrates that there are national hot spots and cold spots of physician payments, and offers some social, economic, and company-dependent predictors that may influence the magnitude of payments. Further analysis is needed to better understand this clinical-commercial partnership in healthcare, specifically within neurosurgical practice.

A comparison of ionospheric TEC between the South Atlantic anomaly region and the Indian Ocean region based on TIEGCM simulations in 2002

Using the Thermosphere-Ionosphere-Electrodynamic General Circulation Model (TIEGCM), a comparison of the ionospheric total electron content (TEC) between the South Atlantic anomaly (SAA) and the Indian Ocean (IO) at solar maximum is performed in this study. The results show that the average total electron content in the SAA is greater than that in the Indian Ocean in general. In order to further analyze the difference between the two regions, the empirical orthogonal function (EOF) are used to investigate the temporal and spatial characteristics of TEC. The empirical orthogonal function method separate part of the global four-peak structure (an equatorial ionization anomaly structure, distributed in Southeast Asia, South America, Africa, and central Pacific) and spatial variations in both regions. Moreover, the first mode of EOF shows the different distribution of Equatorial ionization anomaly in South America and central Pacific caused by deviation of geomagnetic field and tides between two regions, and the enhancement of TEC in SAA region at dusk is emphasized, but the enhancement of TEC in IO region at dawn is emphasized. The second mode performs the distribution of EIA in Africa related to solar radiation and E×B drift. The third mode indicates the similar spatiotemporal variations from the geomagnetic field. Besides, the correlation between TEC and Dst in two regions indicate that there are some deficiencies in simulation to the specificity of SAA, and the deficiencies are likely caused by the model’s inaccurate simulation of the magnetic field and particle deposition in the SAA region.

Modulation of Western South Atlantic Marine Heatwaves by Meridional Ocean Heat Transport

AbstractMarine heatwaves and cold spells are extreme surface temperature events that have been associated with adverse societal and ecosystem impacts in several regions around the globe. Predicting these events presents a challenge because of their generally short‐lived nature and dependence on air‐sea interactions, both locally and remotely. Here we analyze oceanic propagating features that promote the occurrence of marine heatwaves and cold spells in the western subtropical South Atlantic. The main interannual feature detected from satellite sea level data since 1993 shows a westward propagating zonal pattern with a periodicity of 3–5 years. The pattern has a significant in‐phase correlation with sea surface temperature (SST) anomalies in the western South Atlantic, explaining 82% of the daily extreme warm (90th percentile) and cold (10th percentile) SST anomalies and consequently modulating interannual variations in the intensity and duration of marine heatwave and cold spell events. It is found that meridional oceanic advection plays an important role in the regional heat budget associated with the westward‐propagating mode, modulating the meridional exchange of tropical (warm) and extratropical (cold) waters in the western subtropical South Atlantic region and thereby setting a baseline for temperature extremes on interannual timescales. This propagating mode is well correlated (r &gt; 0.6) with the strength of the meridional overturning circulation at 25°S and 30°S with a lag of approximately 3–9 months. The lagged response provides a potential source of predictability of extreme events in the western South Atlantic.

High-Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor

Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. To evaluate associations of outcomes with hospital characteristics in patients undergoing resection of malignant brain tumors. The 2016-2020 National Inpatient Sample (NIS) was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with case loads greater than two standard deviations above the mean (140 cases) were categorized as high-volume centers (HVC). Value of care (VoC) was evaluated by adding one point for each of the following: short length of stay, low total charges, favorable discharge disposition, and lack of major comorbidity or complication. A total of 118,390 patients underwent resection of malignant brain tumors in 3009 hospitals. HVC criteria was met by 91 (3%) hospitals. HVC were more likely to treat patients of younger age or higher socioeconomic status (p < 0.01 for all). The Mid-Atlantic and South Atlantic regions had the highest percentage of cases and number of HVC. VoC was higher at HVC (p < 0.01). HVC was associated with decreased complications (p < 0.01 for all) and improved patient outcomes (p < 0.01 for all). Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVC. Trends of centralization may be a reflection of the benefits of multidisciplinary treatment, geographic preferences, publicity, and cultural impact. Improvement of access to care is an important consideration as this trend continues.

Chemotherapy Refusal Patterns in Multiple Myeloma Patients: An in-Depth Analysis of the NCDB Data from 2004 to 2020

Background: Chemotherapy is a cornerstone in the treatment of multiple myeloma (MM), contributing to prolonged patient survival. However, despite its proven efficacy, some individuals opt to decline chemotherapy, leading to variations in treatment strategies and outcomes. Understanding the factors associated with the decision to decline chemotherapy in MM patients is crucial for optimizing patient-centered care and ensuring equitable access to appropriate treatments. Our investigation aims to illuminate potential areas for targeted interventions, with the goal of enhancing patient engagement and optimizing treatment strategies to improve overall outcomes in MM management. Methods: N=152,299 patients diagnosed with MM between 2004 and 2020 were identified using the NCDB, all of whom were recommended for chemotherapy. Overall survival (OS) of patients who received chemotherapy compared to those who did not receive it was evaluated and presented using Kaplan-Meier (KM) curves. Multivariate logistic regression analysis with backward elimination was used to identify factors associated with refusal of chemotherapy. SAS version 9.4 was used to analyze the data. Results: Among 152,299 patients who received a recommendation for chemotherapy from their physicians, 3,289 individuals (2.16%) opted to refuse the treatment. Descriptive statistics for patients who refused chemotherapy are presented in Table 1. The median OS for patients who received chemotherapy was 61.37 months, in contrast to 8.8 months for those who declined this treatment (Figure 1). Our multivariate logistic regression analysis revealed several significant factors associated with chemotherapy refusal in MM patients. Age exhibited a statistically significant association, with increasing odds of refusal observed in patients aged 60-69 years (OR=1.29, p=0.045), 70-79 years (OR=2.26, p&amp;lt;0.0001), and 80 years and older (OR=7.29, p&amp;lt;0.0001) compared to those younger than 50 years. Male patients exhibited lower odds for refusal (OR=0.85, p&amp;lt;0.0001) compared to female patients. Black patients had higher odds for refusal (OR=1.26, p&amp;lt;0.0001) compared to White patients. Patients with Medicare, Medicaid/other government insurance, and no insurance had higher likelihood of refusal (OR=1.71, 1.89 and 3.13 respectively, p&amp;lt;0.0001) than patients with private insurance. The Charlson-Deyo score demonstrated a significant association, with higher scores correlating with increased odds of refusal (p&amp;lt;0.0001). Patients treated at non-academic facilities had higher odds of refusal (OR=1.47, p&amp;lt;0.0001) compared to academic facilities. Education was significantly associated with refusal, with patients having lower education levels exhibiting increased odds of refusal. Patients living in areas where more than 21% of the area residents have no high school diploma (HSD) had higher odds of chemotherapy refusal compared to patients living in areas where less than 7% have no HSD (OR=1.28, p=0.0026). The year of diagnosis was also linked to refusal, with patients diagnosed between 2004-2007, 2008-2011, and 2012-2015 having higher odds of refusal compared to those diagnosed between 2016-2020 (OR=1.62, 1.25 and 1.27 respectively, p&amp;lt;0.0001). It is also important to note that geographical location played a role, with patients treated in the East North Central, Mountain, and Pacific regions exhibiting significantly higher odds for refusal compared to the South Atlantic region (OR=1.17, 1.35 and 1.16 respectively, p=0.01, 0.002 and 0.03 respectively). Conclusion: Our comprehensive analysis of MM patients shows that the chemotherapy refusal rate in the real-world setting is low at 2.16%. Despite the low rate of refusal, this study did identify several important factors significantly associated with chemotherapy refusal in this patient population. Older age, female sex, Black race, non-private insurance, higher comorbidities, lower education level, non-academic facility type, earlier year of diagnosis, and East North Central, Mountain, and Pacific facility locations were associated with higher likelihood of declining chemotherapy. Our findings emphasize the importance of considering socioeconomic (level of education, insurance status), as well as racial and regional factors, while developing targeted interventions to address disparities in order to enhance engagement in myeloma care.

Effects of meteo-oceanographic conditions on the weathering processes of oil spills in northeastern Brazil

This paper presents the graphical results of the Lagrangian-model and the weathering processes associated with oil spills in the tropical South Atlantic, taking into account the meteorological and oceanographic conditions of the study region. The scenarios were created in the Brazilian-NE waters adjacent, with simulation times of 670 h, and densities of 35, 25, and 15API with volume of 1590 m3 were considered. The main results showed that the meteo-oceanographic characteristics of the study region influence the trajectories and weathering processes in the oil spill. The trajectories varied for each launch point and reached the continent severely in January and October. The associated weathering processes showed higher rates in September and lower rates in April, indicative of the influence of phenomena such as Intertropical Tropical Convergence Zone and warm pool in the South Atlantic region. Sea surface temperature and wind speed are key factors that correlate positively with these months.

A 50-year cycle of sea surface temperature regulates decadal precipitation in the tropical and South Atlantic region

Northeast Brazil and Western Africa are two regions geographically separated by the Atlantic Ocean, both home to vulnerable populations living in semi-arid areas. Atlantic Ocean modes of variability and their interactions with the atmosphere are the main drivers of decadal precipitation in these Atlantic Ocean coastal areas. How these low-frequency modes of variability evolve and interact with each other is key to understanding and predicting decadal precipitation. Here we use the Self-Organizing Maps neural network with different variables to unravel causality between the Atlantic modes of variability and their interactions with the atmosphere. Our study finds an 82% (p<0.05) anti-correlation between decadal rainfall in Northeast Brazil and Western Africa from 1979 to 2005. We also find three multi-decadal cycles: 1870-1920, 1920-1970, and 1970-2019 (satellite era), pointing to a 50-year periodicity governing the sea surface temperature anomalies of Tropical and South Atlantic. Our results demonstrate how Northeast Brazil and Western Africa rainfall anti-correlation was formed in the satellite era and how it might be part of a 50-year cycle from the Tropical and South Atlantic decadal variability.

Healthcare resource utilisation and safety outcomes in patients undergoing transcatheter mitral valve repair - A nationwide analysis

Abstract Background Since the publication of the EVEREST II, MITRA-FR and COAPT trials, the domain of transcatheter edge-to-edge repair (TEER) for mitral regurgitation has been rapidly progressing. However, real-world data on peri-procedural outcomes are still limited. Purpose To analyse outcomes of peri-procedural healthcare resource utilisation and in-hospital safety after TEER between 2016 and 2019 in the United States. Methods The US National Inpatient Sample was utilised to identify adult patients undergoing TEER. Primary outcomes (hospital resource utilisation) were hospital length of stay (LOS), hospital costs and adverse discharge disposition to a nursing or rehabilitation facility. Secondary outcomes (safety) were in-hospital mortality, post-procedural bleedings, vascular complications, ischemic strokes, cardiogenic shocks, cardiac arrests and pericardial tamponades. Multivariable regression models were used to analyse outcomes. Results 4,020 adult patients undergoing a TEER procedure were included. The included population was relatively frail: average age of 78.1 years (±9.7), average Charlson Comorbidity Index of 3 [IQR 1-4], average number of cardiovascular risk factors of 3 [2-4] per patient, average CHA2DS2-VASc score of 4 [3-5] and average simplified HAS-BLED score of 2 [2-3]. Distribution of the procedure was balanced between both sexes: 2,159 (53.7%) males vs. 1,861 (46.3%) females. Procedures were predominantly performed in large hospitals with 3,052 cases (75.9%), as well as in regional "hubs" at both US coastal regions with 543 cases (13.5%) in the Middle Atlantic region, 832 cases (20.7%) in the South Atlantic region, 535 cases (13.3%) in the East North Central region and 690 cases (17.2%) in the Pacific region. TEER procedure showed relatively save outcomes: 34 in-hospital deaths (0.8%), 119 (3.0%) post-procedural bleedings, 1 vascular complication requiring surgery, 24 (0.6%) ischemic strokes, 64 (1.6%) cardiogenic shocks, 20 (0.5%) cardiac arrests and 13 (0.3%) pericardial tamponades. Between 2016 and 2019, hospital LOS decreased by 22% [95% Confidence Interval (CI) 0.73-0.83], hospital costs by 6% [95% CI 0.90-0.98] and post-procedural discharge rates to a nursing or rehabilitation facility by 40% [95% CI 0.41-0.88]; each P&amp;lt;0.001 (Figure). Post-procedural bleedings and cardiac arrests were reduced by 55% [95% CI 0.27-0.76] and 87% [95% CI 0.02-0.61] during the study period, respectively. In-hospital mortality, ischemic stroke, cardiogenic shock and pericardial tamponade decreased numerically but were not statistically significant (due to low overall event rates). Of note, there was a linear increase in all adverse outcomes with increasing patient comorbidity level (P for trend &amp;lt;0.001), particularly in patients with atrial fibrillation or flutter. Conclusion TEER procedure has become a safer and more efficient procedure. Careful considerations should be taken when performing the procedure in patients with multiple comorbidities.

Exploring Autologous Hematopoietic Stem Cell Transplantation (HSCT) Utilization and HSCT Refusal Trends in Multiple Myeloma Patients: A Comprehensive Examination of NCDB Data from 2004 to 2020

Background: Autologous hematopoietic stem cell transplantation (HSCT) remains standard of care in multiple myeloma (MM) in eligible patients and is proven to improve survival. However, a significant number of patients can decline HSCT as part of their treatment. Understanding the patterns and factors behind HSCT refusal is crucial for optimizing patient care and tailoring effective interventions. Methods: A total of 43,653 patients MM patients recommended for HSCT from 2004 to 2020 were identified via the NCDB, after excluding cases with incomplete values. KM curves compared overall survival (OS) between HSCT and non-HSCT patients, with both groups receiving induction chemotherapy. Factors influencing HSCT refusal were determined using multivariate logistic regression with backward elimination. SAS version 9.4 was used to analyze the data. Results: Among 43,653 patients recommended for HSCT only 1.95% (850 individuals) refused HSCT and 98.05% received HSCT. The patient characteristics are presented in Table 1. As noted in Figure 1, the median OS of MM patients who opted for induction chemotherapy followed by HSCT, had a much higher OS of 124 months, compared to the MM patients who declined HSCT and had chemotherapy alone with a median OS of 95 months. On multivariate logistic regression analysis patients aged 60-69 and those aged 70 and above demonstrated higher odds of refusing HSCT compared to those below 50 years, with OR of 1.50 (p = 0.0120) and 3.26 (p &amp;lt; 0.0001), respectively. Male patients exhibited decreased odds of HSCT refusal compared to females, with an OR of 0.84 (p = 0.0329). Black patients showed a higher likelihood of HSCT refusal than White patients (OR = 1.38, p = 0.0022). Hispanic patients were less likely to refuse HSCT compared to non-Hispanic patients (OR = 0.65, p = 0.0296). Patients without insurance, those covered by Medicaid/other government insurance and Medicare, exhibited increased odds of HSCT refusal compared to private insurance with ORs of 2.23 (p = 0.0066), 1.38 (p = 0.0366) and 1.34 (p = 0.0048), respectively. Moreover, patients with a Charlson-Deyo score of 2 or 3 had a higher likelihood of HSCT refusal compared to those with a score of 0 (OR = 1.48, p = 0.0024). Patients treated at non-academic facilities were more likely to refuse HSCT than those treated at academic facilities (OR = 2.67, p &amp;lt; 0.0001). Furthermore, patients with a median household income less than $38,000 had increased odds of HSCT refusal compared to those earning $63,000 or more (OR = 1.62, p = 0.0002). Patients with incomes in the ranges of $38,000-$47,999 and $48,000-$62,999 also demonstrated higher odds of refusal with ORs of 1.39 (p = 0.0043) and 1.34 (p = 0.0050), respectively. The year of diagnosis exhibited a significant association with the likelihood of HSCT refusal: patients diagnosed in 2004-2007, 2008-2011 and 2012-2015 had lower odds of refusing HSCT compared to those diagnosed in the reference period (2016-2020), with ORs of 0.16 (p &amp;lt; 0.0001), 0.56 (p &amp;lt; 0.0001) and 0.75 (p = 0.0024), respectively. Geographic location significantly influenced HSCT refusal, with the South Atlantic region (SA) as the reference category. Lower odds of refusal were observed in West South Central (OR 0.29, p &amp;lt; 0.0001), Mountain (OR 0.53, p = 0.001), East South Central (OR 0.63, p = 0.025), and East North Central (OR 0.72, p = 0.01) regions. Conclusion: Our analysis of large real-world database shows that the HSCT significantly improves survival in MM and should be recommended for eligible patients. Furthermore, the study shows that the HSCT refusal rate in real-world is low at ~2% but still represents a missed opportunity to provide standard of care with room for improvement. Older patients (age &amp;gt;60), females, Blacks, non-Hispanics, patients with non-private health insurance, higher comorbidities, non-academic facilities, and lower income (&amp;lt;$63,000/yr), were found to be associated with increased odds of declining HSCT. There was also geographic variation across the USA with higher HSCT refusal in the South Atlantic region compared to other regions. In addition, the increasing trend in HSCT refusal from 2004 to 2020 is likely due to advances in MM therapeutics due to the availability of novel agents and anti-CD38-immunotherapy. Our study suggests significant racial, economic, and geographic variation regarding the utilization of HSCT across the US which should be further studied in prospective studies.

A first archeomagnetic record from the South Atlantic: Investigation of a lime kiln on St. Helena

The geomagnetic field is anomalously weak in the region of the South Atlantic causing a reduced shielding effect against energetic cosmic particles and malfunctions of satellite communication. The evolution of this so-called South Atlantic Anomaly can be reconstructed for past times by means of archeomagnetic investigations conducted on suitable recorders of the ancient geomagnetic field. Here we present a first archeomagnetic study from the South Atlantic region on a lime kiln operated until the middle of the 19th century on the island of St. Helena. The laboratory experiments comprised basic rock magnetic investigations as well as demagnetization and archeointensity experiments using the MT4 protocol along with cooling rate and anisotropy corrections. Reconstructed field directions show a rather large scatter mainly due to the limited number of samples. While the effects of anisotropy are found to be negligible, cooling rate effects account for ∼11% on average yielding a corrected intensity slightly lower than expected from instrumental measurements performed at St. Helena. Nevertheless, the comparison with historical records and field models yields a good agreement with respect to the obtained archeomagnetic field components and associated uncertainties. Furthermore, the new full-vector record represents an important complement for archeomagnetic databases and, therefore, will constrain archeomagnetic field modelling approaches in the South Atlantic more accurately.

South American Monsoon Lifecycle Projected by Statistical Downscaling with CMIP6-GCMs

This study analyzed the main features (onset, demise, and length) of the South American Monsoon System (SAMS) projected in different time slices (2020–2039, 2040–2059, 2060–2079, and 2080–2099) and climate scenarios (SSP2–4.5 and SSP5–8.5). Eight global climate models (GCMs) from the Coupled Model Intercomparison Project Phase 6 (CMIP6) that perform well in representing South America’s historical climate (1995–2014) were initially selected. Thus, the bias correction–statistical downscaling (BCSD) technique, using quantile delta mapping (QDM), was applied in each model to obtain higher-resolution projections than their original grid. The horizontal resolution adopted was 0.5° of latitude × longitude, the same as the Climate Prediction Center precipitation analysis used as a reference dataset in BCSD. The QDM technique improved the monsoon onset west of 60° W and the simulated demise and length in southwestern Amazonia. Raw and BCSD ensembles project an onset delay of approximately three pentads compared to the historical period over almost all regions and a demise delay of two pentads northward 20° S. Additionally, the BCSD ensemble projects a reduced length with statistical significance in most South Atlantic Convergence Zone regions and a delay of three pentads in the demise over the Brazilian Amazon from the second half of the 21st century.

Rising snow line: Ocean acidification and the submergence of seafloor geomorphic features beneath a rising carbonate compensation depth

Due to burning of fossil fuels, carbon dioxide is being absorbed by the ocean where its chemical conversion to carbonic acid has already caused the surface ocean to become more acidic than it has been for at least the last 2 million years. Global ocean modeling suggests that the carbonate compensation depth (CCD) has already risen by nearly 100 m on average since pre-industrial times and will likely rise further by several hundred meters more this century. Potentially millions of square kilometres of ocean floor will undergo a rapid transition in terms of the overlying water chemistry whereby calcareous sediment will become unstable causing the carbonate “snow line” to rise.We carried out a spatial analysis of seafloor geomorphology to assess the area newly submerged below the rising CCD. We found that shoaling of the CCD since the industrial revolution has submerged 12,432,096 km2 of ocean floor (3.60% of total ocean area) below the CCD. Further hypothetical shoaling of the CCD by 100 m increments illustrated that the surface area of seafloor submerged below the CCD has risen by 14% with 300 m of shoaling, such that 51% of the ocean area will be below the CCD. All categories of geomorphic feature mapped in one global database intersect the lysocline and will be (or already are) submerged below the CCD with much regional variation since the rise in CCD depth during the last 150 years varies significantly between different ocean regions. For seamounts, the highest percentages of increase in area submerged below the CCD occurred in the Southern Indian Ocean and the South West Atlantic regions (6.3% and 5.9%, respectively). For submarine canyons we found the South West Atlantic increased from 3.9% in pre-industrial times to 8.0% at the present time, the highest percentage of canyons found below the CCD in any ocean region.We also carried out a relative risk assessment for future submergence of ocean floor below the CCD in 17 ocean regions. In our assessment we assumed that the change in CCD from pre-industrial times to the present is an indicator of the likelihood and the change in percentage of seafloor submerged below the CCD due to a hypothetical 300 m rise in the CCD is an indicator of the consequences. We found that the western equatorial Atlantic is at high risk and 9 other Ocean Regions are at moderate risk. Overall, geomorphic features in the Atlantic Ocean and southern Indian Ocean are at greater risk of impact from a rising CCD than Pacific and other Indian Ocean regions.A separate analysis of the Arctic Ocean points to the possible submergence of glacial troughs incised on the continental shelf within a mid-depth (400–800 m) acidified water mass. We also found that the area of national Exclusive Economic Zones submerged below the rising CCD exhibits extreme variability; with 300 m of CCD shoaling we found a > 12% increase in area submerged below the CCD for 23 national EEZs, whereas there was virtually no change for other countries.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study.

It is estimated that 11% to 60% of unilateral slipped capital femoral epiphysis (SCFE) patients will develop contralateral pathology, usually within 18 months after the first event. Despite this, prophylactic fixation remains controversial, and there is significant variability in surgeon preferences. Thus, this study aimed to determine which factors predict surgeon preferences for prophylactic contralateral pinning in SCFE patients. We designed a survey for pediatric orthopedic surgeons to collect data on (1) surgeon and hospital characteristics, (2) individual preference for contralateral SCFE pinning in three disparate hypothetical scenarios, and (3) personal risk-aversion traits. The questionnaire was distributed across the United States by the POSNA Evidence-Based Orthopaedics Committee. All POSNA members were eligible to respond. We performed analyses to evaluate the role of patient risk factors in hypothetical surgical decision-making and to determine if surgical training, hospital characteristics, and geographic region influenced prophylactic pinning in a surgeon's real-life practice. A total of 126 POSNA members responded to the survey. In the last year, a median of 6.5 SCFE patients was seen per surgeon (1243 patients total). A median of 10% of those patients underwent prophylactic contralateral fixation. In multiple analyses, surgeons were influenced by body mass index, open triradiate cartilage, patient race, various endocrine abnormalities, and specific radiographic measurements when deciding to fix the contralateral side prophylactically. Moreover, in multivariate regression, more years in practice and a hospital size of 500+ beds predicted fewer prophylactic fixation procedures (all P <0.05). Surgeons practicing in the South Atlantic, New England, and Mountain regions of the United States estimated the highest rate of contralateral pinning. This study's findings suggest that multiple factors influence surgeons' decisions to prophylactically fix the contralateral side in SCFE patients. Surgical training, hospital characteristics, and geographical regions played a role in decision-making. N/A.