Woodrow Wilson International Center for Scholars

Background Tranexamic acid (TA), a synthetic lysine derivative, is known for its antifibrinolytic effect and potential to reduce bleeding in surgeries like arthroplasty, cardio-aortic procedures, and liver transplantation. This meta-analysis seeks to provide robust clinical evidence on TA's effectiveness in reducing blood loss and transfusion needs during orthotopic liver transplantation. Methods The systematic review and meta-analysis included the relevant randomized controlled trials (RCTs) retrieved from PubMed, EMBASE, Web of Science, Cochrane, and SCOPUS databases until August 2024. The meta-analysis was done using (RevMan 5.4.1). PROSPERO ID: CRD42024589151. Results Our meta-analysis of seven RCTs with 1875 patients found no significant differences between TA and control groups in total red blood cell units transfused (MD: −3.74 units; 95% CI [−8.49, 1.01]; P = .12), perioperative transfusions (MD: −0.42 units; 95% CI [−3.17, 2.32]; P = .76), or overall blood loss (MD: −167.81 mL; 95% CI [−415.29, 79.67]; P = .18). For safety outcomes, TA was associated with a higher rate of venous thromboembolism events (RR: 1.71; 95% CI [1.01, 2.87]; P = .05; event rate: 4.89% vs 2.91%), while no significant differences were found in other surgical complications (RR: 1.12; 95% CI [0.92, 1.37]; P = .26). Conclusion TA does not reduce blood loss or the need for postoperative transfusions in orthotopic liver transplantation and may raise thrombotic risk. Caution is required to interpret these results due to variations in the study/hospital-specific transfusion protocol details. Larger studies are needed to confirm these findings, and future research should explore the effects of multiple dosing regimens on blood loss and transfusion requirements.

Background Risk scores have been used to assess stroke risk in atrial fibrillation (AF) for reducing ischemic stroke and bleeding risk. Information gain ratio (IGR) is an entropy-based parameter that shows which clinical score is more informative for prediction of the clinical endpoint. Objective Herein, we aimed to generate and validate a stroke risk score based on the TuRkish Atrial Fibrillation (TRAF) data. Methods We used a split-sample approach to develop and internally validate the new stroke risk score. Based on multivariate logistic regression analysis, we generated CHADS-F in the anticoagulation naïve TRAF cohort (274,631 patients). CHADS-F stands for Cardiac failure (1 point), hypertension (1 point), age (≥ 65–69 = 1 point, ≥ 70–74 = 2 points ≥ 75 = 3 points), diabetes (1 point), stroke (2 points), and older female (1 point) (≥ 65). External validation was performed in the “Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF)” Registry. Informative capacity and accuracy of the CHADS-F score was compared with CHADS2 and CHA2DS2-VASc scores. Results In anticoagulation naïve cohort, CHADS-F (IGR for all cohort: 0.7526) outperforms both the CHADS2 (IGR for all cohort: 0.6340) and CHA2DS2-VASc (IGR for all cohort: 0.6969) in terms of the IGR for ischemic stroke and systemic embolism. Receiver operating characteristic curves revealed highest accuracy for the CHADS-F score [area under curve for CHADS-F: 0.743, CHADS2: 0.722, and CHA2DS2-VASc: 0.722]. CHADS-F had good discriminative abilities at predicting clinical endpoints in the GARFIELD-AF registry. Conclusion The CHADS-F score had higher informative capacity and accuracy than the current CHADS2 and CHA2DS2-VASc scores for predicting stroke and systemic embolism. Graphical abstract

The transatlantic relationship is undergoing a period of critical recalibration, marked by the return of a more transactional US administration and a world order moving towards multipolarity. The return of Donald Trump to the helm of the White House with an ‘America First’ doctrine raises serious questions about US involvement in the transatlantic alliance. President Trump’s repeated claims that the EU was set up to ‘screw’ the US reflect both that his administration is unwilling to engage productively with the EU and that it distrusts multilateral forums, preferring bilateral, nation-to-nation contacts. This article seeks to bring clarity to the future US–EU relationship by identifying some of the points of contention and offering a perspective on how the transatlantic partnership can move forward constructively.

Background Type 1 diabetes mellitus (T1DM) represents a considerable global health burden, affecting approximately 5%–10% of individuals with diabetes. Once‐weekly basal insulin could substantially reduce the number of injections for T1DM patients from 365 daily to 52 weekly doses annually. Therefore, this meta‐analysis compares the safety and efficacy of once‐weekly insulin formulations. Methods The systematic review and meta‐analysis included the relevant randomised controlled trials (RCTs) retrieved from PubMed, EMBASE, Web of Science, Cochrane, and SCOPUS databases until September 2024. The meta‐analysis was performed using (RevMan 5.4.1). The study protocol was registered on PROSPERO (CRD42024603022). Results Three RCTs comprising 1724 participants were included. Once‐daily insulin significantly decreased glycated haemoglobin (HbA1c) compared to once‐weekly insulin (estimated treatment difference: 0.09%, 95% CI [0.07, 0.11], p < 0.00001). Fasting blood glucose levels were comparable between the once‐weekly and once‐daily insulin groups (estimated treatment difference: 0.44 mg/dL, 95% CI [−0.64, 1.52], p = 0.42). Once‐weekly insulin was associated with a significant increase in the incidence of injection site reactions (RR: 3.48 with 95% CI [1.30, 9.31], p = 0.01), serious adverse events (RR: 1.55 with 95% CI [1.09, 2.19], p = 0.01), and treatment‐emergent adverse events (RR: 1.12 with 95% CI [1.02, 1.23], p = 0.02), while no significant difference was observed in hypersensitivity reactions (RR: 1.04 with 95% CI [0.78, 1.38], p = 0.79). Conclusion Once‐daily insulin has demonstrated slightly superior HbA1c reduction, while once‐weekly insulin offers potential advantages in patient adherence. However, these benefits must be weighed against an increased risk of injection site reactions and nocturnal hypoglycemia. Although once‐weekly insulin is more convenient, treatment decisions should consider individual patient factors such as hypoglycemia risk and tolerance to injection reactions.

Kantian philosophy, despite its historical origins in the eighteenth century, continues to inspire modern philosophers and stimulate the research of historians of philosophy. This holds true for Ukraine, where, over the past four decades, Kantian studies have become a dynamic area of philosophical inquiry. In this article, the author traces the trajectory of these studies’ advancement, outlining their inception in the 1970s–1980s, their liberation from ideological constraints in the 1990s, their culmination in the initial decade of the twenty-first century, and their ongoing evolution in the face of the numerous challenges encountered by Ukrainian scholars in recent years. Additionally, this paper refers to the translation of Kant’s works into Ukrainian and the debates they sparked among the members of the Kant Society of Ukraine.

During the latter half of the eighteenth century, the British Royal Navy struggled to recruit sailors, particularly during conflicts such as the Seven Years’ War and the American War of Independence. While the Navy primarily relied on voluntary enlistment, its insufficiency led to the widespread use of impressment–a coercive practice of forcibly enlisting sailors. This article examines the impact of impressment on recruitment, analysing the aggressive tactics press gangs employed on land and at sea to secure experienced mariners. It also explores the recruitment of diverse groups, particularly Black sailors, within the Royal Navy, highlighting regional disparities in treatment and opportunities. Drawing on the works of scholars such as Charles R. Foy and W. Jeffrey Bolster, this study offers a nuanced perspective on recruitment practices and the experiences of marginalized groups. By integrating historical analysis and scholarly insights, it underscores the agency and resilience of Black maritime workers within the complex sociopolitical landscape of the Atlantic World during the Age of Sail.

The Arctic is warming faster than the rest of the globe, posing risks to climate tipping elements such as the collapse of the Greenland Ice Sheet, winter Arctic sea ice loss, weakening of the Atlantic Meridional Overturning Circulation, and permafrost collapse. Stratospheric aerosol injection (SAI) has shown potential to ameliorate these effects by reducing surface temperatures. Due to the potential for an asymmetric hemispheric response in precipitation, Arctic-only SAI is not recommended. Given the challenges associated with an Antarctic SAI program, including the lack of nearby large airports, however, we designed and simulated an Arctic-only logistically constrained SAI scenario, considering limitations imposed by factors affecting the planning, execution, and management of operations. Our scenario is constrained by aircraft development and delivery timelines. SAI deployment begins in 2032 and increases to a maximum annual injection of 6.7 TgSO2 by 2053 through 2070. The scenario is simulated in a modified version of the Energy Exascale Earth System Model. Results indicate that Arctic-only SAI can reduce Northern Hemisphere temperatures and slow sea ice loss, though the early years of deployment may show limited cooling due to low ramp-in injection magnitudes. The Arctic-only SAI introduces minimal impact on Southern Hemisphere (SH) temperatures but significant shifts in the hydrologic cycle, particularly around the equator. SH changes are low within the first two decades, suggesting that asymmetries in Arctic-only SAI deployment could be sustained without severe adverse climate impacts for the first couple of decades. These asymmetries matter given the challenges associated with an Antarctic SAI program. Our findings underscore the necessity of incorporating logistical constraints on deployment and the need for multi-model assessments in the evaluation of polar SAI scenarios. This approach would ensure a strong scientific understanding of polar SAI and facilitates policy and decision-maker understanding of the risks and benefits of SAI.

𝗕𝗮𝗰𝗸𝗴𝗿𝗼𝘂𝗻𝗱 Type 2 diabetes mellitus (T2DM) is a major risk factor for cardiovascular disease and atrial fibrillation. Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) have demonstrated benefit in reducing T2DM-related morbidity and mortality, but their effects in individuals with concomitant T2DM and atrial fibrillation remain unclear. This meta-analysis is the first to evaluate impact of SGLT-2i in this patient population. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀 PubMed/MEDLINE, Cochrane Library, and reference lists of the included articles were systematically searched. Results were pooled using a random-effects model and outcomes were reported as risk ratios (RR) with 95 % confidence intervals (CIs). Meta-regression analyses based on baseline characteristics were conducted to assess potential sources of heterogeneity. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀 Seven retrospective cohort studies and one randomized controlled trial corresponding to 37,229 patients were included, of whom 13,030 received SGLT-2i and 24,199 received other oral anti-diabetic drugs. Follow-up ranged from 2 to 5 years. SGLT-2i use was associated with decreased risk of all-cause mortality (RR = 0.37; 95 % CI: 0.28–0.50), heart failure (RR = 0.66; 95 % CI: 0.53–0.83), stroke (RR = 0.76; 95 % CI: 0.66–0.88), and cardiovascular mortality (RR = 0.57; 95 % CI: 0.44–0.74). No significant difference was observed for myocardial infarction (RR = 0.94; 95 % CI: 0.78–1.12). Results were largely consistent across shorter (<3 years) and longer (≥3 years) follow-up durations. Meta-regression demonstrated no significant associations with baseline patient characteristics. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻 SGLT-2i reduced all-cause mortality, heart failure, stroke, and cardiovascular mortality in individuals with T2DM and atrial fibrillation. Large-scale, randomized controlled trials are warranted to confirm these findings.

Background There is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource‐scarce environments (RSE): mass casualty incidents, low‐ to middle‐income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE. Method Experts rated their agreement with each statement on a 7‐point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤ 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process was repeated in the third round. Statements attaining consensus were moved to the final report. The remaining statements did not attain consensus. Results Seventy‐seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty‐three statements attained consensus. Twenty‐one statements did not attain consensus. Conclusion A modified Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty‐three statements attained consensus and can be incorporated into guidelines to advance the ethical treatment of the E&ME in RSEs.

Introduction: Intraprofessional collaboration between family physicians (FPs) and specialist physicians (SPs) is posited to improve patient outcomes but is hindered by power dynamics. Research informing intraprofessional training on hospital wards often conceptualizes power at an interactional level. However, less is known about how social structures make these power dynamics possible. This study explores how structural forms of power shape how FP and SP supervisors engage with and teach intraprofessional collaboration in outpatient settings and to what effect. Methods: Using diabetes as a case study of intraprofessional collaboration, we conducted a discourse analysis of formal documents (written to guide how collaboration should be practiced) and interview transcripts with 15 FP and SP supervisors. Informed by governmentality and the sociology of professions, we analysed how discourses governing diabetes care shape FPs' and SPs' clinical and teaching behaviours, implications for jurisdictional boundaries and the nature of their collaborative relationships. Results: Discourses of evidence-based medicine construct a hierarchical social structure in medicine that permeates how physicians engage with and teach intraprofessional collaboration. FPs and SPs enact and teach these hierarchical roles when collaborating in the referral-consultation process in ways that establish and reinforce jurisdictional boundaries. The interactions at the intersection of these boundaries foster a form of collaboration characterized by SPs surveilling and regulating FPs' practices. Discussion: As currently constructed, intraprofessional collaboration in outpatient settings may be practiced and taught in ways that reinforce asymmetric power dynamics between FPs and SPs. Without awareness of this unintentional effect, educational attempts to advance this constructed notion of collaboration may ironically impede the achievement of collaborative ideals. Outlining the processes by which structural power permeates FPs' and SPs' collaborative behaviours opens space for educators to acknowledge and mitigate the effects of social structures on intraprofessional training in other clinical and educational contexts.

Purpose The development of the Diabetic Wound Assessment Learning Tool (DiWALT) has previously been described. However, an examination of its application to a larger, more heterogeneous group of participants is lacking. In order to allow for a more robust assessment of the psychometric properties of the DiWALT, we applied it to a broader group of participants. Materials and Methods We built validity evidence for the tool by assessing 74 clinician participants' during two simulated wound care scenarios: Two assessors independently rated each participant using our tool, with a total of five raters providing scores. We evaluated validity evidence using generalizability theory analyses and by comparing performance scores across the three experience levels using ANOVA. Results The tool differentiated between novices and the other two groups well ( p < 0.01) but not between intermediates and experts ( p = 0.34). Our generalizability coefficient was 0.87, and our phi coefficient was 0.87. Conclusion The accumulated validity evidence suggests our tool can be used to assess novice clinicians' competence in initial diabetic wound management during simulated cases. Further work is required to clarify the DiWALT's performance in a broader universe of generalisation and to examine evidence for its extrapolation and implications inferences.

Amidst the global challenges of the 21st century, an urgent call emerges to redefine global public health in response to the multifaceted threats of climate change, political denial, and systemic barriers. This study employs a critical analysis approach, combining a narrative literature review with Action Research, to assess the health impacts of climate change and identify pathways for resilience. Direct and indirect implications—ranging from heat-related illnesses and vector-borne diseases to mental health challenges and displacement—are highlighted, alongside barriers posed by governance structures and economic disparities. A novel collaborative framework, CLIMBED COOL, is introduced, emphasizing adaptation, transformation, and transition as key strategies to address these challenges. Findings also underscore the importance of robust education, simulation-based training, and structured data-sharing mechanisms through regional Centers for Disease Control and Prevention and global databases. This study advocates for a paradigm shift in global governance and collaboration, ensuring holistic and sustainable solutions for future generations.

The Antarctic Treaty System (ATS) has for over a half century provided a sound basis for international cooperation. It is currently subject to increased stress, following the Russian invasion of Ukraine in 2022, as well as tensions between China, the United States, and other global powers. The ATCM and CCAMLR, the two main Antarctic diplomatic bodies, continue to hold their annual meetings and accomplish much of their work. Science continues to be conducted across Antarctica, and there is no appreciable increased risk of armed conflict there. Yet, Antarctic diplomacy faces an unusually difficult period, primarily due to the Ukraine crisis, which has created a political divide among key states active in Antarctica and sown wider discord among international bodies globally. To consider the extent to which recent geopolitical tensions have changed relations in Antarctica, the successes and problems that existed before the current acute period of international tension need to be understood. Achieving agreement among numerous states in a consensus-based system was already difficult; the intrusion of new geopolitical factors has contributed negatively to the normal run of disagreements over Antarctic policy, making cooperation less assured and pointing to increasing challenges for the ATS in the years ahead.

Pressure recovery (PR) is a well-known phenomenon; however, its clinical implications are not well-illustrated. In this study, we present a case series involving three patients exhibiting the PR phenomenon following transcatheter aortic valve replacement (TAVR). We aim to explore the clinical significance of this phenomenon in post-TAVR patients.

Objectives The SDMPH 10-year anniversary conference created an opportunity for a researcher to present at a professional association conference to advance their research by seeking consensus of statements using Delphi methodology. Methods Conference attendees and SDMPH members who did not attend the conference were identified as Delphi experts. Experts rated their agreement of each statement on a 7- point linear numeric scale. Consensus amongst experts was defined as a standard deviation < = 1. Presenters submitted statements relevant to advancing their research to the authors to edit to fit Delphi statement formatting. Statements attaining consensus were included in the final report after the first round. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for opportunity to reconsider their rating for that round. If reconsideration attained consensus, these statements were included in the final report. This process repeated in a third and final round. Results37 Experts agreed to participate in the first round; 35 completed the second round, and 34 completed the third round; 35 statements attained consensus; 3 statements did not attain consensus. ConclusionsA Delphi technique was used to establish expert consensus of statements submitted by the SDMPH conference presenters to guide their future education, research, and training.