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Background Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. Objective To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. Methods From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. Results The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. Conclusions GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

PURPOSE Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs. METHOD U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care. RESULTS PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01). CONCLUSIONS Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.

The explosive demand for a wide range of data processing has sparked interest towards a new logic gate platform as the existing electronic logic gates face limitations in accurate and fast computing. Accordingly, optoelectronic logic gates (OELGs) using photodiodes are of significant interest due to their broad bandwidth and fast data transmission, but complex configuration, power consumption, and low reliability issues are still inherent in these systems. Herein, we present a novel all-in-one OELG based on the bipolar spectral photoresponse characteristics of a self-powered perovskite photodetector (SPPD) having a back-to-back p⁺-i-n-p-p⁺ diode structure. Five representative logic gates (“AND”, “OR”, “NAND”, “NOR”, and “NOT”) are demonstrated with only a single SPPD via the photocurrent polarity control. For practical applications, we propose a universal OELG platform of integrated 8 × 8 SPPD pixels, demonstrating the 100% accuracy in five logic gate operations irrelevant to current variation between pixels.

ImportancePrevious studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.ObjectiveTo examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.Design, Setting, and ParticipantsThis retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)–accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.Main Outcomes and MeasuresThe primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.ResultsThe study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: −1.27 [0.38]; P P P Conclusions and RelevanceIn this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

Jee Wook Kim,1,2 Min Soo Byun,3 Dahyun Yi,3 Jun Ho Lee,4 Kang Ko,4 Gijung Jung,5 Dong Young Lee3,4,6 On behalf of the KBASE Research Group 1Department of Neuropsychiatry, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea; 2Department of Psychiatry, Hallym University College of Medicine, Chuncheon, Republic of Korea; 3Institute of Human Behavioral Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea; 4Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea; 5Department of Nursing, Graduate School, Kyung Hee University, Seoul, Republic of Korea; 6Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Purpose: We aimed to investigate the relationships of cerebral amyloid beta (Aβ) deposition and neurodegeneration (ND) with subjective memory complaints (SMCs) in cognitively normal (CN) individuals, focusing specially on the modulating effects of vascular risk (VR) on those relationships. Participants and methods: A total of 230 CN elderly individuals underwent comprehensive clinical assessments including the Subjective Memory Complaints Questionnaire (SMCQ), VR assessment, and multimodal brain imaging including [11C] Pittsburgh compound B positron emission tomography (PET), [18F] fluorodeoxyglucose-PET, and magnetic resonance imaging. Results: We found a significant overall positive association between cerebral Aβ retention and SMCQ score. In addition, we found a significant cerebral Aβ retention × VR interaction effect on the SMCQ score. Subgroup analyses showed that the Aβ–SMC association was found only in VR-negative, and not in VR-positive, individuals. We found no relationship between ND and SMCQ. Conclusion: Our findings suggest that SMC in CN elderly individuals reflects early accumulation of Aβ in the brain. Given the modulating effect of VR on the Aβ–SMC relationship, SMC can be used as a meaningful marker of early Aβ deposition in individuals without VR. Keywords: subjective memory complaints, amyloid beta, vascular risk, Alzheimer’s disease, cognitively normal

Objective: Recurrence after meningioma surgery may occur even after complete tumor resection (Simpson grade I). One possible cause may be the presence of remnant tumor cells that were left behind and not identified using microscope`s white light. Almost all meningiomas are aminolevulinic acid (5-ALA)[for full text, please go to the a.m. URL], 72. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Polnischen Gesellschaft für Neurochirurgie

A growing population of older adults and improved effective treatments for inflammatory rheumatic diseases will increase the demand for more healthcare resources that already struggle with staggering outpatient clinic waiting times. Transformative delivery care models that provide sustainable healthcare services are urgently needed to meet these challenges. In this mini-review article, a proposed Lifelong Treatment Model for a decentralized follow-up of outpatient clinic patients living with rheumatoid arthritis is presented and discussed.Our conceptual model follows four steps for a transformative care delivery model supported by an Integrated Practice Unit; (1) Diagnosis, (2) Treatment, (3) Patient Empowered Disease Management, and (4) Telehealth. Through an Integrated Practice Unit, a multidisciplinary team could collaborate with patients with rheumatoid arthritis to facilitate high-value care that addresses most important outcomes of the patients; (1) Early Remission, (2) Decentralization, (3) Improved Quality of Life, and (4) Lifelong Sustain Remission.The article also addresses the growing challenges for the healthcare delivery system today for patients with rheumatoid arthritis and proposes how to reduce outpatient clinic visits without compromising quality and safety.

Water isotopologues, as natural tracers of the hydrological cycle on Earth, provide a unique way to assess the skill of climate models in representing realistic atmospheric-terrestrial water pathways. This study presents the newly developed WRF-Hydro-iso, which is a version of the coupled atmospheric-hydrological WRF-Hydro model enhanced with a joint soil-vegetation-atmospheric description of water isotopologue motions. It allows the consideration of isotopic fractionation processes during water phase changes in the atmosphere, the land surface, and the subsurface. For validation, WRF-Hydro-iso is applied to two different climate zones, namely Europe and Southern Africa under the present climate conditions. Each case is modeled with a domain employing a 5 km grid-spacing coupled with a terrestrial subgrid employing a 500 m grid-spacing in order to represent lateral terrestrial water flow. A 10-year slice is simulated for 2003–2012, using ERA5 reanalyses as driving data. The boundary condition of isotopic variables is prescribed with mean values from a 10-year simulation with the Community Earth System Model Version 1. WRF-Hydro-iso realistically reproduces the climatological variations of the isotopic concentrations σ$_{P}$$^{18}$O and σ$_{P}$$^{2}$H from the Global Network of Isotopes in Precipitation. In a sensitivity analysis, it is found that land surface evaporation fractionation increases the isotopic concentrations in the rootzone soil moisture and slightly decreases the isotopic concentrations in precipitation. Lateral terrestrial water flow minorly affects these isotopic concentrations through changes in evaporation-transpiration partitioning.

We analyse the Planck full-mission cosmic microwave background (CMB) temperature and E-mode polarization maps to obtain constraints on primordial non-Gaussianity (NG). We compare estimates obtained from separable template-fitting, binned, and optimal modal bispectrum estimators, finding consistent values for the local, equilateral, and orthogonal bispectrum amplitudes. Our combined temperature and polarization analysis produces the following final results: flocal NL = −0.9±5.1; fequil NL = −26±47; and fortho NL = −38±24 (68% CL, statistical). These resultsinclude low-multipole (4 ≤ ` < 40) polarization data that are not included in our previous analysis. The results also pass an extensive battery of tests (with additional tests regarding foreground residuals compared to 2015), and they are stable with respect to our 2015 measurements (with small fluctuations, at the level of a fraction of a standard deviation, which is consistent with changes in data processing). Polarizationonly bispectra display a significant improvement in robustness; they can now be used independently to set primordial NG constraints with a sensitivity comparable to WMAP temperature-based results and they give excellent agreement. In addition to the analysis of the standard local, equilateral, and orthogonal bispectrum shapes, we consider a large number of additional cases, such as scale-dependent feature and resonance bispectra, isocurvature primordial NG, and parity-breaking models, where we also place tight constraints but do not detect any signal. The nonprimordial lensing bispectrum is, however, detected with an improved significance compared to 2015, excluding the null hypothesis at 3.5σ. Beyondestimatesofindividualshapeamplitudes,wealsopresentmodel-independentreconstructionsandanalysesofthePlanckCMBbispectrum. Our final constraint on the local primordial trispectrum shape is glocal NL = (−5.8±6.5)×104 (68% CL, statistical), while constraints for other trispectrum shapes are also determined. Exploiting the tight limits on various bispectrum and trispectrum shapes, we constrain the parameter spaceofdifferentearly-UniversescenariosthatgenerateprimordialNG,includinggeneralsingle-fieldmodelsofinflation,multi-fieldmodels(e.g. curvaton models), models of inflation with axion fields producing parity-violation bispectra in the tensor sector,and inflationary models involving vector-like fields with directionally-dependent bispectra. Our results provide a high-precision test for structure-formation scenarios, showing completeagreementwiththebasicpictureofthe ΛCDMcosmologyregardingthestatisticsoftheinitialconditions,withcosmicstructuresarising from adiabatic, passive, Gaussian, and primordial seed perturbations. Key words. cosmic background radiation – cosmology: observations – cosmology: theory – early Universe – inflation – methods: data analysis

© 2020 EDP Sciences. All rights reserved. We analyse the Planck full-mission cosmic microwave background (CMB) temperature and E-mode polarization maps to obtain constraints on primordial non-Gaussianity (NG). We compare estimates obtained from separable template-fitting, binned, and optimal modal bispectrum estimators, finding consistent values for the local, equilateral, and orthogonal bispectrum amplitudes. Our combined temperature and polarization analysis produces the following final results: flocalNL= -0.9 ± 5.1; fequilNL= -26 ± 47; and forthoNL= -38 ± 24 (68% CL, statistical). These results include low-multipole (4 ≤ ℓ < 40) polarization data that are not included in our previous analysis. The results also pass an extensive battery of tests (with additional tests regarding foreground residuals compared to 2015), and they are stable with respect to our 2015 measurements (with small fluctuations, at the level of a fraction of a standard deviation, which is consistent with changes in data processing). Polarizationonly bispectra display a significant improvement in robustness; they can now be used independently to set primordial NG constraints with a sensitivity comparable to WMAP temperature-based results and they give excellent agreement. In addition to the analysis of the standard local, equilateral, and orthogonal bispectrum shapes, we consider a large number of additional cases, such as scale-dependent feature and resonance bispectra, isocurvature primordial NG, and parity-breaking models, where we also place tight constraints but do not detect any signal. The nonprimordial lensing bispectrum is, however, detected with an improved significance compared to 2015, excluding the null hypothesis at 3.5σ. Beyond estimates of individual shape amplitudes, we also present model-independent reconstructions and analyses of the Planck CMB bispectrum. Our final constraint on the local primordial trispectrum shape is glocalNL= (-5.8 ± 6.5) × 104(68% CL, statistical), while constraints for other trispectrum shapes are also determined. Exploiting the tight limits on various bispectrum and trispectrum shapes, we constrain the parameter space of different early-Universe scenarios that generate primordial NG, including general single-field models of inflation, multi-field models (e.g. curvaton models), models of inflation with axion fields producing parity-violation bispectra in the tensor sector, and inflationary models involving vector-like fields with directionally-dependent bispectra. Our results provide a high-precision test for structure-formation scenarios, showing complete agreement with the basic picture of the CDM cosmology regarding the statistics of the initial conditions, with cosmic structures arising from adiabatic, passive, Gaussian, and primordial seed perturbations.

There is a paucity of treatments that are capable of reliably and robustly improving cognitive function in adults with mood disorders. Glucagon-like peptide-1 is synthesized centrally and its receptors are abundantly expressed in neural circuits subserving cognitive function. We aimed to determine the effects of liraglutide, a GLP-1 receptor (GLP-1R) agonist, on objective measures of cognition in adults with a depressive or bipolar disorder.In this 4-week, pilot, open-label, domain-based study (e.g. cognition), we recruited 19 individuals with major depressive disorder (MDD) or bipolar disorder (BD) and an impairment in executive function, defined as a below-average performance in the Trail Making Test-B (TMTB). Liraglutide 1.8mg/day was added as an adjunct to existing pharmacotherapy.Participants had significant increases from baseline to week 4 in the TMTB standard score (age and education corrected) (Cohen's d=0.64, p=0.009) and in a composite Z-score comprising multiple cognitive tests (i.e. Digit Symbol Substitution Test, Rey Auditory Verbal Learning Test, Stroop test) (Cohen's d=0.77, p0.001). Neither changes in mood rating scales nor metabolic parameters were associated with changes in cognitive performance (all p0.05); however baseline insulin resistance (IR) and body mass index (BMI) moderated the changes in the composite Z-score (p=0.021 and p=0.046, respectively), indicating larger responses in individuals with higher IR and BMI at baseline. There was a significant increase in lipase (p0.001), but individual values were above the upper limit of normality.Small sample size, open-label design, lack of a placebo group.Liraglutide was safe and well tolerated by a sample of non-diabetic individuals with mood disorders and had beneficial effects on objective measures of cognitive function. Larger studies with controlled trial designs are necessary to confirm and expand the results described herein.

On behalf of the GDL team, we announce the 0.9.9 release of GDL, the GNU Data Language. GDL is a free and open-source drop-in replacement for IDL, the Interactive Data Language, which has served the astronomical community for many years. This release comes 15 years after Marc Schellens first made GDL public, and it marks several milestones attesting to the maturity of the project. Among these are updates to the plotting functionalities, major advances in the Windows implementation, a native support for IDL save files, and performance improvements. The presentation will summarize current availability of packaged versions of GDL, compatibility with popular IDL-written astronomy-related software, potential directions for the upcoming releases, and the key areas where GDL could benefit from further user feedback and new contributions.

Background Serrated polyposis syndrome (SPS) has been associated with an increased risk of colorectal cancer (CRC). Accordingly, intensive surveillance with annual colonoscopy is advised. The aim of this multicenter study was to describe the risk of advanced lesions in SPS patients undergoing surveillance, and to identify risk factors that could guide the prevention strategy. Methods From March 2013 to April 2015, 296 patients who fulfilled criteria I and/or III for SPS were retrospectively recruited at 18 centers. We selected patients in whom successful clearing colonoscopy had been performed and who underwent subsequent endoscopic surveillance. Advanced neoplasia was defined as CRC, advanced adenoma, or advanced serrated lesion that were >= 10 mm and/or with dysplasia. Cumulative incidence of advanced neoplasia was calculated and independent predictors of advanced neoplasia development were identified. Results In 152 SPS patients a total of 315 surveillance colonoscopies were performed (median 2, range 1-7). The 3-year cumulative incidence of CRC and advanced neoplasia were 3.1% (95% confidence interval [CI] 0-6.9) and 42.0% (95%CI 32.4-51.7), respectively. Fulfilling both I+III criteria and the presence of advanced serrated lesions at baseline colonoscopy were independent predictors of advanced neoplasia development (odds ratio [OR] 1.85, 95%CI 1.03-3.33, P = 0.04 and OR 2.62, 95%CI 1.18-5.81, P = 0.02, respectively). During follow-up, nine patients (5.9%) were referred for surgery for invasive CRC (n=4, 2.6%) or because of polyp burden (n=5, 3.3%). After total colectomy, 17.9% patients developed advanced neoplasia in the retained rectum. Conclusions Patients with SPS have a substantial risk of developing advanced neoplasia under endoscopic surveillance, whereas CRC incidence is low. Personalized endoscopic surveillance based on polyp burden and advanced serrated histology could help to optimize prevention in patients with SPS.

Background Morel-Lavallee lesions (MLLs) are rare internal degloving injuries typically caused by blunt traumatic injuries and most commonly occur around the hips and in association with pelvic or acetabular fractures. MLL is often overlooked in the setting of poly-trauma; therefore, clinicians must maintain a high degree of suspicion and be familiar with the management of such injuries, especially in obese poly-trauma patients. Case presentation We present a 30-year-old female pedestrian struck by a motor vehicle who sustained multiple long bone fractures, a mesenteric hematoma, and full-thickness abdominal skin friction burn which masked a significant underlying abdominal MLL. The internal degloving caused significant devascularization of the overlying soft tissue and skin which required surgical drainage of hematoma, abdominal wall reconstruction with tangential excision, allografting, negative pressure wound therapy, and ultimately autografting. Conclusion MLL is a rare, often overlooked, internal degloving injury. Surgeons must maintain a high index of suspicion when dealing with third degree friction burns as they may mask underlying injuries such as MLL, and a delay in diagnosis can lead to increased morbidity.

Background Secure messages exchanged between patients and family medicine residents via an electronic health record (EHR) could be used to assess residents' clinical and communication skills, but the mechanism is not well understood. Objective To design and test a secure messaging competency assessment for family medicine residents in a patient-centered medical home (PCMH). Methods Using the existing literature and evidence-based guidelines, we designed an assessment tool to evaluate secure messaging competency for family medicine residents training in a PCMH. Core faculty performed 2-stage validity and reliability testing (n = 2 and n = 9, respectively). A series of randomly selected EHR secure messages (n = 45) were assessed from a sample of 10 residents across all years of training. Results The secure message assessment tool provided data on a set of competencies and a framework for resident feedback. Assessment showed 10% (n = 2) of residents at the novice level, 50% (n = 10) as progressing, and 40% (n = 8) as proficient. The most common deficiencies for residents' secure messages related to communication rather than clinical competencies (n = 37 [90%] versus n = 4 [10%]). Interrater reliability testing ranged from 60% to 78% agreement and 20% to 44% disagreement. Disagreement centered on interpersonal communication factors. After 2 stages of testing, the assessment using residents' secure messages was incorporated into our existing evaluation process. Conclusions Assessing family medicine residents' secure messaging for patient encounters closed an evaluation gap in our family medicine program, and offered residents feedback on their clinical and communication skills in a PCMH.

Brazing characteristics of a Zr(Ti)–Cu(Fe)–Al glassy alloy was investigated using a Zircaloy-4 alloy as a base metal. A low melting temperature (solidus: 840 °C, liquidus: 880 °C) of the brazing alloy was obtained at the near-eutectic composition of Zr 55 Ti 5 Cu 25 Fe 5 Al 10 (at.%) designed by a partial replacement of Zr by Ti, and Cu by Fe from a well-known Zr 60 Cu 30 Al 10 ternary alloy. This quinary brazing alloy exhibited excellent melting and wetting characteristics and good compatibility with the base metal. At brazing temperatures below the liquidus of the brazing alloy, the joint consisted of a relatively fine dendritic structure ( α -Zr + Zr 2 Cu) with a massive segregation of Zr 2 Cu in the central zone by a eutectic solidification of the molten brazing alloy during a cooling stage, whereas a homogeneous joint was obtained at 890 °C with a predominant formation of acicular α -Zr phases holding an intercellular lamellar mixture ( α -Zr + Zr 2 Cu), which was produced by an isothermal solidification during a brazing holding time. The mechanical properties of the joints were strongly dependent on a degree of joint homogeneity, and the bonding strength of the joints was high enough to cause a fracture in the Zircaloy-4 base metal, when the central segregation of massive Zr 2 Cu was completely eliminated at the brazing temperature of 890 °C.

INTRODUCTION Competence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents. METHODS The PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time. RESULTS Residents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores. CONCLUSION Comprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.

Implementing an innovation, such as offering new types of patient-physician encounters through the patient-centered medical home (PCMH) model while maintaining Accreditation Council for Graduate Medical Education (ACGME) accreditation standards (e.g., patient encounter minimums for trainees), is challenging.In 2009, the Group Health Family Medicine Residency (GHFMR) received an ACGME Program Experimentation and Innovation Project (PEIP) exception that redefined the minimum Family Medicine Resident Review Committee requirement to 1,400 face-to-face visits and 250 electronic visits (1 electronic visit defined as 3 secure message or telephone encounters). The authors report GHFMR residents' continuity clinic encounters, specifically volume, from 2006 through 2013 via pre- and post-PCMH implementation. They discuss the implications for leaders of high-performing practices who desire to innovate while maintaining accreditation.Post-PCMH residents had 20% more overall patient contact. The largest change in care delivery method included a large increase in secure messages between patients and residents. Pre-PCMH residents had more face-to-face encounters; however, post-PCMH residents had more contact for all types of patient care encounters (face-to-face, secure messaging, and telephone) per hour of clinic time.The ACGME PEIP exception, allowing the incorporation of the PCMH, facilitated an increase in patient access and immersed residents in primary care innovation (namely, practicing in a PCMH model during graduate medical education training). The next steps are to assess the effect of the PCMH on resident learning and clinical outcomes and to continue residents' access to training that keeps pace with today's health care delivery needs.

A Zr–Ti–Cu–Fe quaternary eutectic alloy was employed as a new Be-free brazing filler metal for Zircaloy-4 to supersede physically vapor-deposited Be coatings used conventionally with several disadvantages. The quaternary eutectic composition of Zr 58 Ti 16 Cu 10 Fe 16 (at.%) showing a low melting temperature range from 832 °C to 853 °C was designed by a partial substitution of Zr with Ti based on a Zr–Cu–Fe ternary eutectic system. By applying an alloy ribbon with the determined composition, a highly reliable joint was obtained with a homogeneous formation of predominantly grown α -Zr phases owing to a complete isothermal solidification, exhibiting strength higher than that of Zircaloy-4. The homogenization of the joint was rate-controlled by the diffusion of the filler elements (Ti, Cu, and Fe) into the Zircaloy-4 base metal, and the detrimental segregation of the Zr 2 Fe phase in the central zone was completely eliminated by an isothermal holding at a brazing temperature of 920 °C for 10 min.

Cognitive deficits are a core feature across psychiatric disorders. Emerging evidence indicates that metabolic pathways are highly relevant for the substrates and phenomenology of the cognitive domain. Herein, we aimed to determine the effects of liraglutide, a GLP-1R agonist, on brain structural/volumetric parameters in adults with a mood disorder. This is the secondary analysis of a 4-week, pilot, proof-of-concept, open-label study. Participants (N=19) exhibiting impairments in executive function with either major depressive disorder (MDD) or bipolar disorder (BD) were recruited. Liraglutide 1.8mg/day was added as an adjunct to existing pharmacotherapy. Structural magnetic resonance imaging (MRI) scanning was obtained at baseline and endpoint. Results showed that at endpoint there was significant weight loss (mean: 3.15%; p

International audience; The effect of hydrostatic pressure on complex magnetic phase diagram of LuFe2O4 has been investigated by various magnetic measurements in the range of 0-12 kbar. The temperature of the ferrimagnetic (fM) transition (T-N approximate to 245 K) practically does not change with increasing pressure, while the temperature of the appearance of mixed fM and antiferromagnetic (AFM) state at similar to 200 K increases with the rate dT(C)/dP approximate to 0.8 K/kbar. Moreover, an applied pressure suppresses the magnetization, enhances the field of metamagnetic transition, and extends the range of existence of mixed fM and AFM state. Suppression of the ordered magnetic moment under pressure induces a transition from a counterclockwise (CCW) thermal hysteresis below T approximate to 220 K to a clockwise (CW) thermal hysteresis in a magnetic field H = 1 kOe. Nevertheless, field induced metamagnetic transition from mixed fM and AFM state to fM state results in a narrowing of the temperature range of thermal hysteresis and in restoring of CCW type of thermal hysteresis. As a consequence of metamagnetic transition, the thermal hysteresis completed at H = 10 kOe remains one of the CCW type under applied pressure.

International audience; Exchange bias effect in CaMn1-xRexO3 (x

This study aimed to assess the types of vertebral segments at the thoracolumbar junction, as they relate to the most caudal ribs, to evaluate the reliability of this assessment using axial CT with curved planar reformatting (CPR) images, to describe the morphologic characteristics of a thoracolumbar transitional vertebra (TLTV), to introduce a new classification system for the TLTV and to evaluate the reliability of the classification system using axial CT with CPR images.This was a retrospective review of 744 consecutive patients who underwent spine CT imaging that included the thoracolumbar junction. Two radiologists (Readers 1 and 2) independently evaluated the axial CT with CPR images for all cases (n = 744). Each radiologist differentiated the vertebral segments at the thoracolumbar junction as TLTV or non-TLTV (thoracic segment or lumbar segment). In addition, each radiologist classified the 94 patients with the TLTV using a novel classification system. Interobserver agreement between the two radiologists regarding the differentiation of vertebral segments at the thoracolumbar junction was analysed with kappa statistics. Similarly, intra- and interobserver agreement regarding TLTV classification was analysed with kappa statistics.Interobserver agreement between the two readers with respect to the differentiation of vertebral segments at the thoracolumbar junction via axial CT with CPR images was nearly perfect (κ-value: 0.959). Interobserver agreement between the two readers with respect to TLTV classification using axial CT with CPR images was nearly perfect (κ-value: 0.846). In addition, intraobserver agreement for Reader 1 was also nearly perfect (κ-value: 0.877).Morphologic analysis of the thoracolumbar junction may help accurate spinal enumeration.Consideration of various variants at the thoracolumbar junction should help radiologists and clinicians to interpret the morphology of the thoracolumbar junction. This may facilitate communication with the referring clinician, thereby reducing the error in spinal enumeration.

Magnetic pulsed compaction (MPC) was introduced to consolidate conventional iron-based powders for the production of high-density steel parts in powder metallurgical (PM) processing. Highly dense steel components of Fe–1.5Cr–0.2Mo–0.25 C (wt.%) were obtained with green and sintered densities of 7.63 g/cm 3 and 7.75 g/cm 3 (full density: 7.8 g/cm 3 ). This anomalous densification in the MPC process was attributed to the complementary kinetic effect by the high impact pressure in a very short duration, allowing the enhanced particle rearrangement and plastic deformation in the compacted powders. Owing to this superior compactability, the intact compacts were fabricated efficiently even with the small addition of lubricant (less than 0.05 wt.%). Also, die wall lubrication was effective for preventing surface damage as well as for promoting homogeneous densification during the MPC. These results show a potential for application of the MPC process to high-density steel PM parts.

Presented here is an apparatus consisting of an atmospheric resistive-barrier discharge for the sterilization of medical tools wrapped in typical hospital cloths, for the sterilization of manufactured drugs in typical packaging materials, and for the sterilization of biologically-contaminated articles. The sterilization apparatus consists of layers of the resistive-barrier discharge device operating at room temperature, a sterilization chamber, and an ozone destruction device. An electrical discharge in the resistive-barrier discharge system generates an atmospheric plasma in oxygen gas, generating ozone, which in turn efficiently sterilizes medical tools and biologically contaminated articles at room temperature. A sterilization experiment was carried out at an apparatus volume of 100 liters, with a sterilization chamber volume of 60 liters, and a discharge device volume of 40 liters. The sterilization in this experiment required 60 W of power for 5 hours of residence time. For a given sterilization time, the required electrical power was proportional to the apparatus volume. Ozone in the sterilization chamber was destroyed safely after sterilization.

Microstructural evolution of the Ti–Cu dissimilar joints brazed by a Zr 41.2 Ti 13.8 Cu 12.5 Ni 10.0 Be 22.5 (at.%) amorphous alloy filler was investigated at a temperature of 820 °C for 1–20 min. As the brazing time increased, the overall composition of the joint sensitively changed from Ti-rich to Cu-rich owing to the different reactivity of the Zr in the filler with the Ti and Cu in the base metals. Based on such time-dependent compositional change, the formation of the intermetallic phases in the joint was basically divided into three stages; Stage (1): formation of interfacial Ti 2 Cu, Stage (2): formation of two-phase structure with Ti 2 Cu/TuCu and Cu 2 TiZr, and Stage (3): transformation to Cu-rich phases. At Stage (2), the joint was fully produced isothermally by directional phase transformations with fine dendritic and columnar two-phase structures, revealing the highest bonding strength due to its controlled intermetallic morphology.

BACKGROUND Transforming growth factor beta (TGF-beta) plays an important role in diabetic retinopathy. betaIG-H3 is a downstream target molecule of TGF-beta that may participate in the pathogenesis of diabetic retinopathy and in particular in the loss of pericytes during early pathological changes. METHODS We observed bovine retinal pericytes apoptosis and the increased expression of TGF-beta and betaIG-H3 induced by high concentrations of glucose in the cell culture media. An anti-TGF-beta antibody was used to block glucose-induced retinal pericytes apoptosis. Retinal pericytes were also transfected with cDNA encodings either wild-type or mutant betaIG-H3 lacking Arg-Gly-Asp (RGD) sequences in order to validate the effects of betaIG-H3 and RGD signalling on retinal pericytes apoptosis. RESULTS A cell death-detecting enzyme-linked immunosorbent assay revealed that 25 mM glucose significantly increased cell death compared with 5.5 mM glucose after 5 or 7 days of exposure (P < 0.01). High glucose significantly increased the TGF-beta levels as compared with 5.5 mM glucose after 5 days, and betaIG-H3 levels after 3, 5 and 7 days of exposure (P < 0.01). TGF-beta increased cell death and betaIG-H3 levels in a dose-dependent manner, with a maximal effect observed at 1 ng/mL. An anti-TGF-beta antibody nearly completely blocked high glucose-induced cell death. Wild-type betaIG-H3-transfected cells showed a significant increase in cell death as compared with mutant betaIG-H3-transfected (Mycb-c) cells, untransfected or mock-transfected cells. CONCLUSION These results suggest that hyperglycaemia-induced expression of TGF-beta and betaIG-H3 contributes to accelerated retinal pericytes apoptosis. betaIG-H3 induces pericytes apoptosis through its RGD motif, which may constitute an important pathogenic mechanism leading to pericytes loss in diabetic retinopathy.

Highly dense and homogeneous yttria (Y2O3) thin-wall tubes have been successfully fabricated by applying tape-casting and radial magnetic pulsed compaction (RMPC) followed by thermal sintering. Since a homogeneous density distribution was obtained in the RMPCed compact, by using the Y2O3-based tape instead of a stuck of raw powder, cracking and bending were inhibited throughout the process up to the final sintered body. The relative density of the resultant tube reached 99.9%, and the structure was very fine with grain sizes of 25 mm. Moreover, when the granulated powder was used as the precursor of the tape, the thermal densification was promoted due to its enhanced sinterability as compared to the raw powder. [doi:10.2320/matertrans.M2010113]

In this research, fine-structure TiO bulks were fabricated in a combined application of magnetic pulsed compaction (MPC) and subsequent sintering and their densification behavior was investigated. The obtained density of TiO bulk prepared via the combined processes increased as the MPC pressure increased from 0.3 to 0.7 GPa. Relatively higher density (88%) in the MPCed specimen at 0.7 GPa was attributed to the decrease of the inter-particle distance of the pre-compacted component. High pressure and rapid compaction using magnetic pulsed compaction reduced the shrinkage rate (about 10% in this case) of the sintered bulks compared to general processing (about 20%). The mixing conditions of PVA, water, and TiO nano powder for the compaction of TiO nano powder did not affect the density and shrinkage of the sintered bulks due to the high pressure of the MPC.

Titanium (Ti) was successfully brazed at low temperatures below 800 °C by employing a Zr41.2Ti13.8Ni10.0Cu12.5Be22.5 (at.%) bulk metallic glass (BMG) alloy as a filler. Through the use of this alloy filler, the detrimental segregation of Zr–Cu–Ni filler elements was completely eliminated by heating to well below 800 °C, so the resultant joint was quite homogeneous with a coarse acicular structure. The disappearance of the Zr–Cu–Ni segregated region was rate-controlled by the diffusion of the filler elements in the Ti base metal. Remarkably, the mechanical property and corrosion resistance of the homogeneous joint brazed at 800 °C for 10 min were mostly comparable to those of bulk Ti.

Strong bonding between titanium (Ti) and stainless steel (STS) was achieved by employing a commercially available Ag–28Cu (wt.%) filler, and more importantly with a help of an Ag interlayer. A mass transport of the Ti elements from the substrate into the molten filler was completely prevented through the use of the Ag interlayer, so the resultant brazed joint was free from any brittle Ti-based intermetallic compounds. Notably, this Ti–STS dissimilar joint displayed a remarkable improvement in its bonding strength, demonstrating the potential application of an Ag interlayer for joining Ti and its alloys to various structural steels.

In this study, the effects of precompaction on the density, microstructure, mechanical and electrical properties of α-Al 2 O 3 bulks fabricated by the combined application of magnetic pulsed compaction (MPC) and a sintering process were reported. The obtained density of the α-Al 2 O 3 bulks prepared by the combined processes increased with the increasing MPC pressure and precompaction pressure. The resultant higher hardness and breakdown voltage of the consolidated bulks following combined application of the magnetic pulsed compaction, precompaction and sintering process could be attributed to the homogeneously distributed ultra-fine microstructure than that of general processing, suggesting that the grain growth was remarkably reduced during the MPC processes.

The microstructure and mechanical properties of Ti joints brazed with a Zr41.2Ti13.8Ni10.0Cu12.5Be22.5 (at.%) amorphous filler were investigated. With a Zr-based amorphous filler, in this study, Ti joints with a homogeneous composition could be obtained by heating to well below the α-β transformation temperature for a short time, so that the undesirable effects of the high temperature heating are considerably diminished. The joints brazed at 790 °C for 10 min consisted of the coarse acicular structure rather than the fine Widmanstätten structure which generally deteriorates the ductility of the joints. The joints with the homogenous coarse acicular structure, i.e. without a residual liquid region, show almost the same mechanical properties as those required for base metals without heating. Although the residual liquid region in the joints deteriorates the ductility of the joints, this region could be successfully removed by a diminution in the quantity of the filler.

In this study, joining characteristics of dissimilar Ti and Cu metals have been investigated, when using both an Ag-based eutectic alloy as a filler and an Ag layer present on Ti base metal as a diffusion barrier. The observed microstructures were classified into three characteristic types, depending on the presence of a Ag layer at the Ti interface, e.g. first, the sample retaining thick continuous intermetallic layers, e.g. Ti2Cu, TiCu, Ti3Cu4, Ti2Cu3, and TiCu4 by a significant dissolution of the Ti atoms into the molten filler, in the absence of a Ag coating layer onto the Ti base metal, second, the sample with relatively thin Ti-Cu intermetallic layers by the reduced reaction of Ti with Cu due to a prominent decrease in the Ti dissolution, owing to the role of the Ag coating layer as a diffusion barrier, and finally, the sample without any brittle Ti-Cu intermetallics in the joint by a complete suppression of both the dissolution of the Ti atoms and its reaction with the Cu elements in the molten filler due to the presence of a Ag layer.

The fracture property improvement of Zr-based bulk amorphous alloy containing ductile crystalline particles was explained by directly observing microfracture processes using an in situ loading stage installed inside a scanning electron microscope (SEM) chamber. Strength and apparent fracture toughness measured from the in situ fracture test of the amorphous alloy containing crystalline particles were lower than those of the monolithic amorphous alloy, whereas its ductility was higher. According to the microfracture observation, shear bands were initiated from ductile crystalline particles, and the propagation of the shear bands or cracks was blocked by crystalline particles, thereby resulting in stable crack growth which could be confirmed by the fracture resistance curve (R-curve) behavior. This increase in fracture resistance with increasing crack length improved fracture properties of the alloy containing crystalline particles, and could be explained by mechanisms of blocking of crack or shear band propagation, formation of multiple shear bands, crack blunting, and shear band branching.

Microfracture mechanisms of Zr-based bulk metallic glass (BMG) alloy containing ductile crystalline particles were investigated by directly observing microfracture processes using an in situ loading stage. Strength of the BMG alloy containing crystalline particles was lower than that of the monolithic BMG alloy, while ductility was higher. According to the direct microfracture observation, crystalline particles initiated shear bands, acted as blocking sites of shear band or crack propagation, and provided the stable crack growth which could be confirmed by the R-curve analysis, although they negatively affected apparent fracture toughness. This increase in fracture resistance with increasing crack length improved overall fracture properties of the alloy containing crystalline particles, and could be explained by mechanisms of blocking of crack or shear band propagation, formation of multiple shear bands, crack blunting, and shear band branching.

In this study, effects of various crystalline particles formed in strip-cast Zr-base amorphous matrix composites on deformation behavior were investigated. The compressive and fracture toughness test results indicated that the ductility of the strip-cast alloys containing hard/brittle crystalline particles as well as containing ductile β-phase particles was higher than that of the monolithic amorphous alloy. From finite element calculations and in situ microfracture observations, this ductility improvement could be explained by the role of the particles to initiate shear bands and to block the shear band propagation. However, this improvement could be obtained only when the size and volume fraction of crystalline particles and characteristics of amorphous matrix were optimized by controlling the strip casting conditions.

Development of wrought Mg alloys, particularly in sheet form, is essential to support the growing interest for lightweight components in the automotive industry. However, development of Mg alloy sheets has been quite slow due to the complexity of sheet production originated from limited deformability of Mg. In this respect, twin-roll strip casting, a one-step processing of flat rolled products, can be an alternative for the production of Mg alloy sheets. In this study, AZ31 and experimental ZM series alloys are twin-roll strip cast into 2 mm thick sheets. The microstructure of the as-cast AZ31 alloy sheet consists of columnar zones near the roll side and equiaxed zones in the mid-thickness region. On the other hand, as-cast ZM series alloy sheets show equiaxed dendritic structure through the thickness of sheet. These alloys were subjected to various thermo-mechanical treatments and their tensile properties were evaluated. Twin-roll strip cast AZ31 alloy in H24 condition has equivalent yield and tensile strengths with similar ductility compared to commercial ingot cast AZ31-H24 alloy, indicating that twin-roll strip casting is a viable process for the fabrication of Mg alloy sheets. The experimental ZM series alloys have a large volume fraction of fine dispersoid particles in the microstructure, resulting from the beneficial effect of twin-roll strip casting on microstructural refinement. It has been shown that the experimental ZM series alloys have superior tensile properties compared to commercial ingot cast AZ31-H24 alloy, suggesting the possibility of the development of new wrought Mg alloy sheets by twin-roll strip casting.

Homogeneous glow plasma at atmospheric pressure without streamers and arcing was generated by making use of a radio-frequency (RF, 13.56 MHz) power supply. Oxygen gas was added to Ar/He gas as reactive agents for photo-resist (PR) ashing. The input power, flow rate, oxygen concentration, treatment time, substrate temperature are controlled for high ashing rate and uniform ashing. Thickness of PR film was measured by NANOSPEC (AFT200) and α -Step (P-10). An unstable discharge occurs destroying the uniformity, when the input power exceeds a threshold value determined from the distance between the substrate and plasma source. An increase of oxygen quantity or temperature increase makes high ashing rate, but the ashing surface is rugged. The PR ashing rate was related to oxygen atom in plasma. The number of treatment may not be important in PR ashing at the atmospheric pressure.

Highly dense Y2O3 ceramics have been fabricated by a magnetic pulsed compaction (MPC) which is capable of reaching a sufficiently high pressure (~1GPa) in a very short duration (a few microseconds), and a subsequent pressureless sintering at 1600°C. The Y2O3 green bodies with a relative density of about 68% were achieved by the application of the MPC process due to the effect of an enhanced rearrangement and a high speed movement of the particles, without the help of ceramic binder. Those compacts showed densities greater than 95%, which is very close to the theoretical density, after the subsequent pressureless sintering process at 1600 oC. The shrinkage rates of the diameter for the samples compacted by the MPC process were markedly reduced, when compared to those for the ones by the conventional compaction (CC) process.

In this study, three Fe-base amorphous alloys with quite different critical cooling rates were subjected to twin-roll strip casting to see the possibility of fabricating amorphous sheet by the same process. Continuous cooling transformation (CCT) diagrams of the alloys were calculated using the heterogeneous nucleation theory coupled with thermal data obtained during cooling to evaluate their critical cooling rates and glass forming abilities (GFAs). It shows that the GFAs calculated by CCT diagram are in agreement with the experimental results, while the well known empirical thermal parameters do not agree with the experimental results. Optimum twin-roll strip casting conditions have been determined based on the calculated critical cooling rates and the simulated thermal behavior of the sheet during twin-roll strip casting.

Twin-roll strip casting was utilized to fabricate the sheet products of Zr- and Cu-base bulk amorphous alloys with quite different glass forming abilities (GFAs). Simulation of the solidification behavior of the these amorphous forming alloys during twin-roll strip casting shows that suitable cooling rate can be achieved by twin-roll strip casting to form amorphous structure through the thickness of sheet. Optimum twin-roll strip casting conditions have been suggested based on the simulation results. Actual twin-roll strip casting shows that both Zr-base alloy with high GFA and Cu-base alloy with much less GFA can be strip cast forming amorphous structure. The results indicate that the twin-roll strip casting is a viable process for continuous fabrication of sheets of bulk amorphous alloys with a wide range of critical cooling rates.

Objective To assess the attitudes of Korean physicians toward hormone therapy (HT) after publication of the Women's Health Initiative (WHI) study. Design Self-administered questionnaires, consisting of 22 items, were sent by mail to the members of the Korean Society of Menopause. Results More than 95% of Korean physicians were aware of the WHI study. The HT prescription rate decreased by 16% after publication of the WHI report; approximately half of the physicians who continued prescribing HT changed their prescriptions. The largest decreases occurred in regimens using conjugated equine estrogens and medroxyprogesterone acetate, for which prescriptions of sequential and continuous-combined regimens decreased by 20.7% and 22.7%, respectively. In contrast, the prescription rate for tibolone increased by 3.6%. Approximately 30% of physicians changed from standard to low doses, and 67.8% shortened the duration of HT. After publication of the WHI report, the main reasons for not prescribing or discontinuing HT were patient refusal and increased risk of cardiovascular disease, rather than breast cancer risk. After publication of the WHI report, the number of physicians who prescribed alternative or complementary medicines increased, the rate of HT prescription for the prevention of osteoporosis decreased, and the number of postmenopausal outpatients decreased. Conclusions Despite the results of the WHI report, most Korean physicians who participated in this study continued prescribing HT; however, approximately half of those who continued prescribing HT changed their prescriptions. The greatest change occurred in regimens using conjugated equine estrogens and medroxyprogesterone acetate.