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Data, Materials, and Software Availability: All study data are included in the article and/or supporting information available online at https://www.pnas.org/lookup/doi/10.1073/pnas.2220124120#supplementary-materials . Copyright © 2023 the Author(s). To address claims of human exceptionalism, we determine where humans fit within the greater mammalian distribution of reproductive inequality. We show that humans exhibit lower reproductive skew (i.e., inequality in the number of surviving offspring) among males and smaller sex differences in reproductive skew than most other mammals, while nevertheless falling within the mammalian range. Additionally, female reproductive skew is higher in polygynous human populations than in polygynous nonhumans mammals on average. This patterning of skew can be attributed in part to the prevalence of monogamy in humans compared to the predominance of polygyny in nonhuman mammals, to the limited degree of polygyny in the human societies that practice it, and to the importance of unequally held rival resources to women’s fitness. The muted reproductive inequality observed in humans appears to be linked to several unusual characteristics of our species—including high levels of cooperation among males, high dependence on unequally held rival resources, complementarities between maternal and paternal investment, as well as social and legal institutions that enforce monogamous norms. This work was conducted as a part of the “Emergence of Hierarchy and Leadership in Mammalian Societies” group at the National Institute for Mathematical and Biological Synthesis, supported by NSF Award DBI-1300426 and the University of Tennessee, Knoxville. It was supported by NSF awards SMA-1329089 and SMA-1743019, and the Santa Fe Institute, as well as the Max Planck Institute for Evolutionary Anthropology, Department of Human Behavior, Ecology and Culture. S.G. was supported by the US Army Research Office grants W911NF-14-1-0637, W911NF-17-1-0150, and the Office of Naval Research grant W911NF-18-1-0138. Additional funding for data collection was provided by the Wenner-Gren Foundation for Anthropological Research awards: 8913 and 7970, by NSF awards: BCS-0924630, BCS-0925910, BCS-0848360, BCS-0514559, BCS-0613226, BCS-0827277, SES-9870429, and DDRIG-1357209, by the National Geographic Society awards: HJ-099R-17, 20113909, 8671-09, and 7968-06, by the Kone Foundation awards: 086809, 088423, and 088423, and by the Jacobs Foundation, the UCSB Broom Center for Demography, and the UCSB Department of Anthropology.

Propagation of interplanetary (IP) shocks, particularly those driven by coronal mass ejections (CMEs), is still an outstanding question in heliophysics and space weather forecasting. Here we address effects of the ambient solar wind on the propagation of two CME-driven shocks from Sun to Earth. The two CME-driven shock events (CME03: April 3, 2010 and CME12: July 12, 2012) have the following properties: (1) driven by a halo CME (i.e., source location is near Sun-Earth line), (2) a southern hemispheric CME source location, (3) similar propagation speed (e.g., took ~2 days reach the Earth), (4) occurred in the non-quiet solar period, and (4) leading to a severe geomagnetic storm. What is interesting is that the initial (near the Sun) propagation speed, as measured by coronagraph images, of CME03 was slower (~300 km/s) than CME12, but it took about same time for both events to reach the Earth. According to in-situ solar wind observations from Wind, the CME03-driven shock was associated with a faster solar wind upstream of the shock than the CME12. This is also demonstrated in our global MHD simulations. This study emphasizes the importance of the background solar wind in the propagation of CME-driven shocks. Not only the initial propagation speed near the Sun but also the ambient solar wind speed is the key to timing the arrival of CME events. The present study also demonstrated that global MHD simulations with realistic solar wind inputs is able to precisely predict the arrival of CME events.

As part of a large program conducted between years 2010 and 2018, a number of ion beam surface treatments and proprietary coatings formed on advanced space polymers by direct ion beam deposition were developed at Integrity Testing Laboratory (ITL) Inc, in Canada. This technology allowed producing surfaces with controlled surface resistivity in a wide range of charge dissipation values, with negligibly low additional RF losses and other important functional properties, that allowed using such treated materials and products in modern space antennae, solar arrays and other external applications on spacecrafts in GEO environment. This paper will present an overview of results achieved throughout the years on enhancement of radiation stability of space polymers that were ion beam treated and coated with special multifunctional thin coatings by direct ion beam deposition. The treated/coated subjects have been ground-based tested in a range of radiation conditions, simulating the GEO radiation environment, conducted in three world-recognized GEO simulation facilities.

Portal venous thrombosis (PVT) is an uncommon disease associated with highly morbid conditions such as intestinal ischemia and portal hypertension. Patients at higher risk of developing PVT include those with cirrhosis, malignancy, or prothrombotic states. The mainstay of treatment is early initiation of anticoagulation. The first case is a 49-year-old female diagnosed with a cecal mass and PVT. She was started on anticoagulation and underwent a right hemicolectomy with several small bowel resections. She developed portal hypertension that required TIPS and mechanical thrombectomy. The second patient is a 65-year-old female found to have PVT. She was anticoagulated with heparin and given systemic TPA. She developed intestinal ischemia and portal hypertension requiring small bowel resection, TIPS, and mechanical thrombectomy. These cases give insight into the impact of a multidisciplinary team approach to PVT. The role and timing of endovascular treatment is not well established and needs to be further investigated.

Geomagnetic storms are one of the most important terrestrial space weather events and often commence in association with the arrival of coronal mass ejections (CMEs). When a CME is explosively released into the heliosphere, a shock wave can be formed in front of the dense, supersonic CME material. Thus, the first indication of the arrival of a CME at the Earth is a sudden increase in the global magnetic intensity due to magnetospheric compression by the CME-driven shock. Predictions of the arrival of the shock are a key element in space weather forecasting. Several different variety of methods, including numerical simulations, have been applied to predict the shock arrival time but with mediocre results, with an average uncertainty of ~10 hr. In this study we will use magnetohydrodynamic (MHD) simulations (Wu et al., 2020) to examine a number of input parameters such as the CME initial speed and release time in MHD simulation of CMEs and demonstrate their effect on the shock arrival time. We also explore effects of CME-CME interactions on the propagation of the CME/shock events. The multiple CME events that occurred during 6-29 July 2012 are simulated to highlight the importance of these factors on the prediction of shock arrival time using MHD simulations.

Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

National audience; The suite of derived human traits, including enlarged brains, elevated fertility rates, and long developmental periods and life spans, imposes extraordinarily high energetic costs relative to other great apes. How do human subsistence strategies accommodate our expanded energy budgets? We found that relative to other great apes, human hunter-gatherers and subsistence farmers spend more energy but less time on subsistence, acquire substantially more energy per hour, and achieve similar energy efficiencies. These findings revise our understanding of human energetic evolution by indicating that humans afford expanded energy budgets primarily by increasing rates of energy acquisition, not through energy-saving adaptations such as economical bipedalism or sophisticated tool use that decrease subsistence costs and improve the energetic efficiency of subsistence. We argue that the time saved by human subsistence strategies provides more leisure time for social interaction and social learning in central-place locations and would have been critical for cumulative cultural evolution.

Background: More than 1.2 million emergency department (ED) visits for syncope occur each year in the US. Many associated admissions and diagnostic studies may be unnecessary. Objective: To determine the effectiveness of a novel protocol for syncope care in the ED in reducing unnecessary admissions and diagnostic testing. Methods: A multi-disciplinary team developed a decision aid for ED syncope management guided by focused history, physical, and diagnostic testing. Clear indications for diagnostic testing were laid out in the protocol and incorporated into the ED workflow through education and medical record system integration. Patients considered safe for discharge were provided an expedited appointment in a specialty clinic. Rates of admission, utilization of diagnostic studies (head CT, carotid ultrasound, echocardiogram), and rates of return presentation to the ED within 30 days were compared before and after implementation. Results: Between September 2019 and December 2019, 308 syncope patients presented to the ED. Between January 2020 and June 2020 (following implementation), 321 syncope patients presented to the ED. The proportion admitted decreased (44.6% to 30.0%, p Conclusion: Implementation of an ED syncope care pathway with utilization of a syncope specialty clinic was associated with significantly reduced hospital admissions. Utilization of diagnostic testing and rates of return ED presentation within thirty days were unchanged. Additional studies to evaluate the scalability and cost benefits of this program are warranted.

A left ventricular aneurysm is a rare post myocardial infarction complication. Ventricular aneurysms form as post-ischemic cardiac remodeling creates a weaker, fibrotic area that may bulge outwards against interventricular pressures over time. Patients with ventricular aneurysms have increased mortality and are at higher risk of various cardiac complications, such as cardiac arrest, arrhythmias, thrombus formation, reduced cardiac output, or aneurysmal rupture. Prompt diagnosis and treatment are critically important in these patients. We highlight the hospital course of a patient with an extensive cardiac history presenting for syncope with the discovery of a left ventricular aneurysm. The radiographic features of the left ventricular aneurysm are described, as well as formation, risk factors, and complications.

INTRODUCTION: CYP2C19 genotype-guided selection of P2Y12 inhibitor therapy after percutaneous coronary intervention (PCI) is associated with improved clinical outcomes, but clinical utility in older patients in a real-world setting is unknown. OBJECTIVES: To compare the clinical effectiveness of genotype-guided P2Y12 inhibitor selection following PCI in older patients (≥70 years) and younger patients (

Value demonstration in health care remains a challenge. This paper examines traditional approaches to pricing and the evolution of value-based pricing (VBP), and proposes a new framework for evidence-based valuation (EBV). The main objective of EBV is to estimate the value-based pricing range for the new medicine, identify key product attributes that drive value as perceived by various stakeholders, and then elucidate the requisite evidence to support those value claims.EBV centers on a structured framework for estimating a drug's price based on its perceived value to various stakeholders. The EBV framework consists of identifying key value attributes that drive adoption of a drug in a given therapeutic area; gaining insights into stakeholder value considerations and evidence requirements; and quantifying stakeholders' perceptions of specific value attributes within pricing premiums.An example demonstrates the application of the EBV framework in a simplified manner for 3 drugs indicated for renal cell carcinoma, 3 drugs for prostate cancer, and 1 drug for melanoma. HTAs, published trial results, and publications archived in PubMed between 2005 and 2013 were analyzed to identify key value attributes. The following 5 attributes were considered: overall survival (OS), progression-free survival (PFS), population size, trial comparator, and adverse events.The method described offers a means to appraise pharmaceuticals in an environment increasingly focused on evidence-based medicine and value-based health care.

International audience; SIHLA (Spatial/Spectral Imaging of Heliospheric Lyman Alpha pronounced as ‘Scylla’ [e.g. Homer, Odyssey, ~675-725 BCE] investigates fundamental physical processes that determine the interaction of the Sun with the interstellar medium (ISM); the Sun with the Earth; and the Sun with comets and their subsequent evolution. To accomplish these goals, SIHLA studies the shape of the heliosphere and maps the solar wind in 3D; characterizes changes in Earth’s extended upper atmosphere (the hydrogen ‘geocorona’); discovers new comets and tracks the composition changes of new and known ones as they pass near the Sun.SIHLA is a NASA Mission of Opportunity that has just completed its Phase A study (the Concept Study Report or CSR). At the time of the writing of this abstract NASA has not decided whether to fly this small satellite mission or its competitor (GLIDE: PI Prof. Lara Waldrop). SIHLA observes the ion-neutral interactions of hydrogen, the universe’s most abundant element, from the edge of the solar system to the Earth, to understand the fundamental properties that shaped our own home planet Earth and the heliosphere. From its L1 vantage point, well outside the Earth’s obscuring geocoronal hydrogen cloud, SIHLA maps the entire sky using a flight-proven, compact, far ultraviolet (FUV) hyperspectral imager with a Hydrogen Absorption Cell (HAC). The hyperspectral scanning imaging spectrograph (SIS) in combination with the spacecraft roll, creates 4 maps >87% of the sky each day, at essentially monochromatic lines over the entire FUV band (115 to 180nm) at every point in the scan. During half of these daily sky maps, the hydrogen absorption cell (HAC) provides a 0.001nm notch rejection filter for the H Lyman a. Using the HAC, SIHLA builds up the lineshape profile of the H Lyman a emissions over the course of a year. SIHLA’s SIS/HAC combination enables us to image the result of the ion-neutral interactions in the heliosheath, 100 AU away, in the lowest energy, highest density, part of the neutral atom spectrum – H atoms with energies below 10eV.The novel aspects of SIHLA are the scope of the science done within a MoO budget. The SIHLA projected costs were below the $75M cap with a 31.3% reserve for Phase B-D. The re-purposing of a spectrographic that was part of the DMSP SSUSI line (a copy was flown and NASA TIMED/GUVI and as NASA NEAR/NIS). Risk is extremely low in this Class-D mission with all major elements at least at TRL6 at this time.SIHLA has a high potential for discovery. We expect that we will 1) First detection of the hot H atoms produced directly from the ion-neutral interactions at the heliopause; 2) First detection of structures in Interplanetary Medium H emission, 3) First detection of response of the Earth’s extended (out to lunar orbit) geocorona to solar/geomagnetic drivers, 4) New UV-bright comets as they enter the inner solar system.SIHLA is a hyperspectral imager; at every point in the sky SIHLA obtains the entire FUV spectrum. This enables SIHLA to easily flag pixels contaminated by stars; obtain the spectrum of the Earth, viewed as an ‘exoplanet’ and observed the response of the exosphere and the thermosphere to solar/geomagnetic events; detect comets and determine their composition and how it varies at they enter and leave the inner solar system.

Author(s): Della-Giustina, David; Kamran, Ali; Wood, D. Brian; Goldflam, Katja | Abstract: Introduction: The focus of residency training is to ensure that graduates attain a minimum level of skills and knowledge in order to be able to practice independently. While there are multiple formal methods to evaluate a resident, there is a paucity of literature that describes whether programs have residents perform individual self-assessment (ISA) with the development of individualized learning plans (ILP) to better themselves. We sought to investigate the current state of emergency medicine (EM) residency programs using ISA and determine whether these assessments are used to develop an ILP for each resident.Methods: An electronic survey was developed by educators at our institution and sent to all program leaders of United States EM residencies approved by the Accreditation Council for Graduate Medical Education. An individualized email request was sent to non-responders. Results were obtained from February–May 2019.Results: Of 240 programs we contacted, 119 (49.5%) completed the survey. Seventy-nine percent of programs reported that they had all residents perform an ISA. These were completed semiannually in 69% of the programs surveyed, annually in 19%, less than annually in 8%, and quarterly or more frequently in 4%. Of those programs requiring a resident ISA, only 21% required that all residents develop an ILP; 79% had only those residents requiring additional help or no residents develop an ILP.Conclusion: Most programs that completed the survey reported having residents complete an individual self-assessment, but there was variation in the areas assessed. The majority of programs had only lower performing, or no residents, develop an ILP based on this.

This short report describes field and lab experiments used to determine the energy content of 1 kg of baobab fruit in two forms: 1) whole unprocessed fruit and 2) semi-processed fruit that has had the outer shell removed. These goal of this report is to permit researchers to accurately estimate the energy content of baobab fruit as weighed during anthropological research with Hadza hunter-gatherers of northern Tanzania. The estimates assume that the seed of the baobab is being cracked open and the “nutmeat” consumed, as is customarily done by Hadza. The baobab fruit is an economically important wild plant food in many parts of Africa, and global demand for the fruit is growing, and thus these results have value for a variety of audiences. Based on the analyses reported below, I estimate that 1 kilogram of whole unprocessed baobab represents an expected energy value of 1057 kcal. One kilogram of semi-processed baobab has an expected energy value of 1791 kcal. Incorporating the relative fraction of baobab that is brought to camp by Hadza in these two forms, I estimate that 1 kilogram of field-weighed baobab has an average energy content of 1339 kcal, or 1.339 kcal / gram.

Author(s): Wood, D. Brian; Jordan, Jaime; Cooney, Rob; Goldflam, Katja; Bright, Leah; Gottlieb, Michael | Abstract: Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

Advance care planning (ACP) is associated with benefits for seriously ill patients, caregivers, and clinicians. As ACP usage expands, there should be greater emphasis on supporting an ongoing communication process among patients, families, and clinicians, as well as removing barriers for advance directive document completion and retrieval.

Author(s): Harrison, Raquel; Tsyrulnik, Alina; Wood, David Brian; Coughlin, Ryan F.; Della-Giustina, David; Goldflam, Katja | Abstract: Introduction: In 2012 the Accreditation Council for Graduate Medical Education implemented trainee milestones as tools for clinical competency committees to use for evaluation, feedback, remediation, and promotion purposes. Prior to this innovation, there has not been an adequate method to capture, organize, and graphically illustrate the evaluations by attendings in a simple, fast and organized fashion.Methods: We created a novel, web-based, mobile-friendly evaluation tool to help fill this identified gap. The survey-based program creates a milestone-based evaluation, takes only a few minutes to complete, and easily collates the results in a graphic format creating an individualized “dashboard.” The dashboard is then used by both trainees and their evaluators as a feedback platform.Results: With the implementation of the dashboard, educational leadership has noted an increase in the number of submitted evaluations of residents and the amount of face-to-face feedback given by attendings to residents. A post-implementation survey of the residents revealed that they found the dashboard-provided feedback more helpful than prior modes of feedback, although the number of evaluations was still too few.Conclusion: The use of our feedback dashboard is useful to multiple targeted end-users, including general faculty evaluators, program leadership, and the residents themselves for gathering formative feedback that is specific and timely. This tool is adaptable and likely generalizable to other residency programs and specialties.

Owing to concerns that experiences of general internal medicine are exacerbating the supply problems in specialty training posts, our research aimed to identify what factors are associated with intentions to choose specialties that contain a general internal medicine component in higher training, and to describe those factors. Cross sectional survey study …