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Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who 'knows me as a person and considers all the factors that affect my health.' After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting., Research over decades has shown that health systems with strong primary care have better health outcomes, better equity in outcomes, and lower costs. (1,2) Yet, worldwide, countries have struggled with [...]

The design of neural networks typically involves trial-and-error, a time-consuming process for obtaining an optimal architecture, even for experienced researchers. Additionally, it is widely accepted that loss functions of deep neural networks are generally non-convex with respect to the parameters to be optimised. We propose the Layer-wise Convex Theorem to ensure that the loss is convex with respect to the parameters of a given layer, achieved by constraining each layer to be an overdetermined system of non-linear equations. Based on this theorem, we developed an end-to-end algorithm (the AutoNet) to automatically generate layer-wise convex networks (LCNs) for any given training set. We then demonstrate the performance of the AutoNet-generated LCNs (AutoNet-LCNs) compared to state-of-the-art models on three electrocardiogram (ECG) classification benchmark datasets, with further validation on two non-ECG benchmark datasets for more general tasks. The AutoNet-LCN was able to find networks customised for each dataset without manual fine-tuning under 2 GPU-hours, and the resulting networks outperformed the state-of-the-art models with fewer than 5% parameters on all the above five benchmark datasets. The efficiency and robustness of the AutoNet-LCN markedly reduce model discovery costs and enable efficient training of deep learning models in resource-constrained settings.

Congress enacted 8 U.S.C. [section] 1440 to provide noncitizens serving in the U.S. armed forces with an expedited path to naturalization during periods of hostility. Congress expressly required the executive to make two threshold determinations before a military member can be considered for naturalization under this statute. First, the executive must certify that an applicant has 'served honorably.' Second, the President must designate by executive order that the armed forces are 'engaged in military operations involving armed conflict with a hostile foreign force.' Since the War on Terrorism began in 2001, the military had authorized any noncitizen serving in the military to qualify for expedited naturalization by certifying their service as 'honorable ' after just one day in the military. However, in 2017, the Trump administration implemented new regulations that required noncitizens to serve for at least six months prior to the military certifying their service as 'honorable.' This policy spurred a number of legal challenges, creating a court split over the justiciability of the executive's determination of 'honorable service.' This court split not only renews critical questions on the scope of judicial review over matters of military affairs, but it also provides an important preview into the amount of discretion that may be afforded to the executive to determine whether the U.S. remains in 'a period of armed conflict with a hostile foreign force. ', TABLE OF CONTENTS I. INTRODUCTION 1062 II. NATURALIZING THROUGH MILITARY SERVICE 1063 A. HISTORICAL STATUTORY FRAMEWORK 1063 B. MODERN STATUTORY FRAMEWORK 1064 III. JUSTICIABILITY OF MILITARY AFFAIRS 1066 A. SCOPE [...]

How can Africa encourage and nurture the entrepreneurship that it needs to meet the challenges of a turbulent century ? This was the question that Jim Clifton, chairman of global [...]

Preclinical rheumatoid arthritis (Pre‐RA) is defined as the early stage before the development of clinical RA. While cachexia is a well‐known and potentially modifiable complication of RA, it is not known if such an association exists also in the Pre‐RA stage. To investigate such issue, we aimed to compare the longitudinal alterations in the muscle composition and adiposity of participants with Pre‐RA with the matched controls. In this observational cohort study, the Osteoarthritis Initiative (OAI) participants were categorized into Pre‐RA and propensity score (PS)‐matched control groups. Pre‐RA was retrospectively defined as the absence of RA from baseline to year‐2, with progression to physician‐diagnosed clinical RA between years 3–8 of the follow‐up period. Using a validated deep learning algorithm, we measured MRI biomarkers of thigh muscles and adiposity at baseline and year‐2 follow‐ups of the cohort. The outcomes were the differences between Pre‐RA and control groups in the 2‐year rate of change for thigh muscle composition [cross‐sectional area (CSA) and intramuscular adipose tissue (Intra‐MAT)] and adiposity [intermuscular adipose tissue (Inter‐MAT) and subcutaneous adipose tissue (SAT)]. Linear mixed‐effect regression models were used for comparison. After 1:3 PS‐matching of the groups for confounding variables (demographics, risk factors, co‐morbidities, and knee osteoarthritis status), 408 thighs (102 Pre‐RA and 306 control) of 322 participants were included (age mean ± SD: 61.7 ± 8.9 years; female/male: 1.8). Over a 2‐year period, Pre‐RA was associated with a larger decrease in total thigh muscle CSA [estimate, 95% confidence interval (CI): −180.13 mm2/2‐year, −252.80 to −107.47, P‐value < 0.001]. Further examination of thigh muscle composition showed that the association of the presence of Pre‐RA with a larger decrease in muscle CSA over 2 years was noticeable in the quadriceps, flexors, and sartorius muscle groups (P‐values < 0.05). Comparison of changes in total adipose tissue showed no difference between Pre‐RA and control participants (estimate, 95% CI: 48.48 mm2/2‐year, −213.51 to 310.47, P‐value = 0.691). However, in the detailed analysis of thigh adiposity, Pre‐RA presence was associated with a larger increase in Inter‐MAT (estimate, 95% CI: 150.55 mm2/2‐year, 95.58 to 205.51, P‐value < 0.001). Preclinical rheumatoid arthritis is associated with a decrease in muscle cross‐sectional area and an increase in intermuscular adipose tissue, similar to rheumatoid cachexia in clinical rheumatoid arthritis. These findings suggest the presence of cachexia in the preclinical phase of rheumatoid arthritis. Given that cachexia, which can exacerbate health outcomes, is potentially modifiable, this study emphasizes the importance of early identification of patients in their preclinical phase.

Wireless network emulators are being increasingly used for developing and evaluating new solutions for Next Generation (NextG) wireless networks. However, the reliability of the solutions tested on emulation platforms heavily depends on the precision of the emulation process, model design, and parameter settings. To address, obviate, or minimize the impact of errors of emulation models, in this work, we apply the concept of Digital Twin (DT) to large-scale wireless systems. Specifically, we demonstrate the use of Colosseum, the world's largest wireless network emulator with hardware-in-the-loop, as a DT for NextG experimental wireless research at scale. As proof of concept, we leverage the Channel emulation scenario generator and Sounder Toolchain (CaST) to create the DT of a publicly available over-the-air indoor testbed for sub-6 GHz research, namely, Arena. Then, we validate the Colosseum DT through experimental campaigns on emulated wireless environments, including scenarios concerning cellular networks and jamming of Wi-Fi nodes, on both the real and digital systems. Our experiments show that the DT is able to provide a faithful representation of the real-world setup, obtaining an average similarity of up to 0.987 in throughput and 0.982 in Signal to Interference plus Noise Ratio (SINR).

While vulvar lichen sclerosus (VLS) causes intense pruritus, associated risks of mood disorders and prescription patterns and impact of concurrent sexual dysfunction are unknown. We queried TriNetX Diamond Network between 2009 and 2022, conducting three comparisons after propensity-score matching for demographics and relevant comorbidities: (1) women with lichen sclerosus (LS) sparing the vulva vs. women with VLS; (2) VLS patients who received treatment within 6 months of diagnosis vs. patients who did not and (3) VLS patients with vs. without sexual dysfunction. Outcomes included new depressive episodes, anxiety disorder, major depressive disorder (MDD), and prescriptions of antidepressants or benzodiazepines. After matching, VLS was associated with increased depressive episode [risk ratio (RR) 1.39], anxiety disorder (RR 1.93), and MDD (RR 2.00) diagnoses compared to LS sparing the vulva. Next, VLS treatment was associated with decreased risk of depressive episode (RR 0.60) and anxiety disorder (RR 0.72). Finally, concurrent sexual dysfunction was associated with increased benzodiazepine (RR 3.50), vaginal estrogen (RR 6.20), antipruritic agents (RR 3.90), and topical anti-inflammatory (RR 2.61) prescriptions. In conclusion, vulvar involvement is associated with increased risk of antidepressant and benzodiazepine prescriptions, and diagnosis of depressive episode, anxiety disorder, or MDD.

ABSTRACTSocial norms are based on expectations of what others believe and do, and so they can shift in response to what trendsetters—highly visible media or political leaders—say or do. There is evidence that former President Trump as a trendsetter has weakened norms against expressing anti-immigrant attitudes in the US. As such, we ask: can trendsetters affect anti-immigrant norms across national borders? Can such spillovers be mitigated by countervailing norms attached to a national identity? We conduct two survey experiments to determine if there is potential for a Trump spillover effect in Canada and whether it can be mitigated by norms attached to Canadian identity. We find that priming Trump can weaken norms against expressing anti-immigrant sentiment in Canada. We also find that priming Canadian identity can mitigate the Trump as trendsetter effect, and attaching pro-immigrant norms to Canadian identity can strengthen norms against expressing anti-immigrant attitudes. The potential for a political trendsetter to have effects on immigration attitudes across national borders and the potential for national identity norms to mitigate such effects are important to understand given the recent global spread of anti-immigrant sentiment.

Natural Language Generation (NLG) accepts input data in the form of images, videos, or text and generates corresponding natural language text as output. Existing NLG methods mainly adopt a supervised approach and rely heavily on coupled data-to-text pairs. However, for many targeted scenarios and for non-English languages, sufficient quantities of labeled data are often not available. As a result, it is necessary to collect and label data-text pairs for training, which is both costly and time-consuming. To relax the dependency on labeled data of downstream tasks, we propose an intuitive and effective zero-shot learning framework, ZeroNLG, which can deal with multiple NLG tasks, including image-to-text (image captioning), video-to-text (video captioning), and text-to-text (neural machine translation), across English, Chinese, German, and French within a unified framework. ZeroNLG does not require any labeled downstream pairs for training. During training, ZeroNLG (i) projects different domains (across modalities and languages) to corresponding coordinates in a shared common latent space; (ii) bridges different domains by aligning their corresponding coordinates in this space; and (iii) builds an unsupervised multilingual auto-encoder to learn to generate text by reconstructing the input text given its coordinate in shared latent space. Consequently, during inference, based on the data-to-text pipeline, ZeroNLG can generate target sentences across different languages given the coordinate of input data in the common space. Within this unified framework, given visual (imaging or video) data as input, ZeroNLG can perform zero-shot visual captioning; given textual sentences as input, ZeroNLG can perform zero-shot machine translation. We present the results of extensive experiments on twelve NLG tasks, showing that, without using any labeled downstream pairs for training, ZeroNLG generates high-quality and “believable” outputs and significantly outperforms existing zero-shot methods.

Glucocorticoids exert pleiotropic effects on all tissues to regulate cellular and metabolic homeostasis. Synthetic forms are used therapeutically in a wide range of conditions for their anti-inflammatory benefits, at the cost of dose and duration-dependent side effects. Significant variability occurs between tissues, disease states, and individuals with regard to both the beneficial and deleterious effects. The glucocorticoid receptor (GR) is the site of action for these hormones and a vast body of work has been conducted understanding its function. Traditionally, it was thought that the anti-inflammatory benefits of glucocorticoids were mediated by transrepression of pro-inflammatory transcription factors, while the adverse metabolic effects resulted from direct transactivation. This canonical understanding of the GR function has been brought into question over the past 2 decades with advances in the resolution of scientific techniques, and the discovery of multiple isoforms of the receptor present in most tissues. Here we review the structure and function of the GR, the nature of the receptor isoforms, and the contribution of the receptor to glucocorticoid sensitivity, or resistance in health and disease.Graphical Abstract

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors derived from neural crest cells from adrenal medullary chromaffin tissues and extra-adrenal paraganglia, respectively. Although the current treatment for PPGLs is surgery, optimal treatment options for advanced and metastatic cases have been limited. Hence, understanding the role of the immune system in PPGL tumorigenesis can provide essential knowledge for the development of better therapeutic and tumor management strategies, especially for those with advanced and metastatic PPGLs. The first part of this review outlines the fundamental principles of the immune system and tumor microenvironment, and their role in cancer immunoediting, particularly emphasizing PPGLs. We focus on how the unique pathophysiology of PPGLs, such as their high molecular, biochemical, and imaging heterogeneity and production of several oncometabolites, creates a tumor-specific microenvironment and immunologically “cold” tumors. Thereafter, we discuss recently published studies related to the reclustering of PPGLs based on their immune signature. The second part of this review discusses future perspectives in PPGL management, including immunodiagnostic and promising immunotherapeutic approaches for converting “cold” tumors into immunologically active or “hot” tumors known for their better immunotherapy response and patient outcomes. Special emphasis is placed on potent immune-related imaging strategies and immune signatures that could be used for the reclassification, prognostication, and management of these tumors to improve patient care and prognosis. Furthermore, we introduce currently available immunotherapies and their possible combinations with other available therapies as an emerging treatment for PPGLs that targets hostile tumor environments.Graphical Abstract

The COVID pandemic forced us to spend more time in our homes than ever before. As a result, we're taking a closer look at residential design and lighting, and none [...]

The Animated Screensaver and the Culture of Always-On Computing In 2000, an exhibition at the Iris & B. Gerald Cantor Art Center at Stanford University presented a suite of moving-image [...]

The prevalence of alcohol use disorder (AUD) has significantly increased over the last decade, leading to an increase in alcohol-associated liver disease (ALD) rates worldwide. Despite this prominence, AUD in ALD remains undertreated and carries significant implications in the progression to end-stage ALD and increased mortality. In efforts to bridge this gap, interprofessional and integrated AUD treatment is necessary for patients with ALD to ensure early detection and an appropriately targeted level of care. Although pharmacotherapy, psychotherapy, and psychosocial interventions independently play a role in treating AUD, a combination of these evidence-based modalities often results in lasting change.

INTRODUCTION In August 2020, the commercial vessel Maersk Etienne rescued twenty-seven migrants off a sinking vessel in the Mediterranean Sea. (1) Over the next thirty-eight days, the Maersk shipping company [...]

ABSTRACTIntravenous alpha-2-adrenergic receptor agonists reduce energy expenditure and lower the temperature when shivering begins in humans, allowing a decrease in core body temperature. Because there are few data about similar effects from oral drugs, we tested whether single oral doses of the sedative dexmedetomidine (1 µg/kg sublingual or 4 µg/kg swallowed) or the muscle relaxant tizanidine (8 mg or 16 mg), combined with surface cooling, reduce energy expenditure and core body temperature in humans. A total of 26 healthy participants completed 41 one-day laboratory studies measuring core body temperature using an ingested telemetry capsule and measuring energy expenditure using indirect calorimetry for up to 6 hours after drug ingestion. Dexmedetomidine induced a median 13% – 19% peak reduction and tizanidine induced a median 15% – 22% peak reduction in energy expenditure relative to baseline. Core body temperature decreased a median of 0.5°C – 0.6°C and 0.5°C – 0.7°C respectively. Decreases in temperature occurred after peak reductions in energy expenditure. Energy expenditure increased with a decrease in core temperature in control participants but did not occur after 4 µg/kg dexmedetomidine or 16 mg tizanidine. Plasma levels of dexmedetomidine but not tizanidine were related to mean temperature change. Decreases in heart rate, blood pressure, respiratory rate, cardiac stroke volume index, and cardiac index were associated with the change in metabolic rate after higher drug doses. We conclude that both oral dexmedetomidine and oral tizanidine reduce energy expenditure and allow decrease in core temperature in humans.

Isatuximab is a CD38 monoclonal antibody approved for relapsed or refractory multiple myeloma. We aimed to evaluate the addition of isatuximab to weekly carfilzomib (K), lenalidomide (R), and dexamethasone (d; Isa-KRd) in transplant-eligible patients with newly diagnosed multiple myeloma and stratified maintenance by cytogenetic risk.

In this convergent mixed methods design study, single-subject and qualitative data were collected concurrently to provide an in-depth picture of the impact of a modified schema-based instructional intervention. The intervention was delivered using instructional trials embedded across general education math lessons and a modified concrete-semi-concrete-abstract instructional sequence. This study investigated the impact of the intervention on the word-problem-solving, strategy use, and concept acquisition of three students with extensive support needs. The paraprofessional-delivered intervention was implemented in elementary general education mathematics classrooms using embedded instruction and focused on teaching students to solve addition and subtraction word-problems. Single-subject data indicated that all three students learned to solve word-problems given concrete materials but needed more time to master the use of semi concrete supports. Qualitative data indicated that students used taught and untaught strategies to solve word-problems, and mastered addition word-problems before subtraction when they were taught simultaneously. Data were integrated in narrative format to explore how strategy use and concept acquisition related to student word-problem-solving performance. Limitations and implications for research are discussed.

Experiencing meaningful work is strongly linked to occupational health, and organizational leaders can play a role in facilitating meaningful work through various practices. However, studies identifying and classifying specific leadership practices that foster meaningful work are limited. In this article, we distill and clarify major ways leaders might enable meaningful work and contribute a new tool to assess them. In three studies of employees in various work contexts (N= 689; N= 647, N= 351), we administered a set of items measuring numerous practices leaders use to cultivate meaningful work elicited from a qualitative study of organizational leaders and a literature review. Dimensionality reduction techniques distilled these practices into six distinct domains. We then validated a diagnostic instrument to measure the extent to which leaders engage in each practice (the Practices for Meaning Diagnostic) and explored associations with employee experiences of meaningful work, psychological meaningfulness, and related variables, finding strong relationships. The six identified leadership practices are: communicating the work’s bigger impact, recognizing and nurturing potential, fostering personal connections, discussing values and organizational purpose during hiring, enacting integrity through modeling values-based behaviors, and giving employees freedom. Our results provide a way for leaders to assess practices intended to foster meaningful work and a way for researchers to test the practices’ effectiveness. We also describe contributions to research, theory, and practice.

This article from Missouri Life magazine offers a range of day trip options for library patrons looking to explore neighboring states from Missouri. The trips include visits to natural spots, Dutch heritage sites, geode hunting locations, historical figures' landmarks, haunted locations, and outdoor activities. The article emphasizes the unique attractions and exploration opportunities each trip offers, while also encouraging readers to appreciate the hospitality of neighboring states and highlighting the beauty and attractions of Missouri. The document provides travel itineraries for locations in Missouri, Kansas, Iowa, and Nebraska, showcasing historical sites, museums, natural landmarks, and local restaurants. Its aim is to offer readers a variety of options for exploring the region and to encourage them to visit these diverse destinations. [Extracted from the article]

This edition of New Directions for Community Colleges describes current relationships between two-year colleges and the media across the country. The issue addresses three themes: the history of community colleges' relationships with press members; media's relationships with community college practitioners; and strategic college marketing through media outlets. This issue contains the following articles: "Community Colleges and the Media: Defining Identity" (Janel Henriksen Hastings); "The Importance of Being Honest: Building Relationships Between Media and College Personnel" (Clifton Truman Daniel); "Building Relationships with the Media: A Brief Working Guide for Community College Leaders" (Neal A. Raisman); "Community Colleges and the Media: Getting Effective Coverage for Your Institution" (Tim Thornton); "Community College Advancement through Relationships with the Newspaper Media" (Anthony Marquez); "Working with Media Outlets To Communicate with the Public" (Mark L. Wallace); "Using Demographics and Statistics To Inform Target Audiences" (Janel Henriksen Hastings); "Making the Case for 'Public Journalism'" (Lucy Lee); "The Media as Teacher: Helping Advisers, Mentoring Young Journalists" (Christine Tatum); "Your Site or Mine? Courting the Press Along the Information Superhighway" (Clifton Truman Daniel); and "Sources and Information: Media Relations in Community Colleges" (Barbara Tobolowsky). (VWC)

How you and your staff react to a threat is paramount to the success of your response. The inability to react effectively may damage your facility or collections and could [...]

I. INTRODUCTION A. Criminal Versus Civil Penalties B. Criminal Enforcement C. Interaction with Other Criminal Violations II. GENERAL ISSUES A. Overview of the Elements of an Environmental Criminal Violation B. [...]

Collective Punishment has Always Been the Stated Goal of Iran Sanctions Hawks Eli Clifton THE CORONAVIRUS pandemic's impact in Iran, which already claimed over 1,800 lives and infected more than [...]

As the Army continues the pursuit of a competitive advantage through large-scale ground combat operations (LSGCO), our ability to make connections between doctrine, mission essential task lists, and training is [...]

Perhaps the Middle East is More Stable When the U.S. Stays Away? IT HAS BEEN A MANTRA of U.S. foreign policy for a decade or more that, without the United [...]

New tuberculosis treatments are needed to address drug resistance, lengthy treatment duration and adverse reactions of available agents. GSK3036656 (ganfeborole) is a first-in-class benzoxaborole inhibiting the Mycobacterium tuberculosisleucyl-tRNA synthetase. Here, in this phase 2a, single-center, open-label, randomized trial, we assessed early bactericidal activity (primary objective) and safety and pharmacokinetics (secondary objectives) of ganfeborole in participants with untreated, rifampicin-susceptible pulmonary tuberculosis. Overall, 75 males were treated with ganfeborole (1/5/15/30 mg) or standard of care (Rifafour e-275 or generic alternative) once daily for 14 days. We observed numerical reductions in daily sputum-derived colony-forming units from baseline in participants receiving 5, 15 and 30 mg once daily but not those receiving 1 mg ganfeborole. Adverse event rates were comparable across groups; all events were grade 1 or 2. In a participant subset, post hoc exploratory computational analysis of 18F-fluorodeoxyglucose positron emission tomography/computed tomography findings showed measurable treatment responses across several lesion types in those receiving ganfeborole 30 mg at day 14. Analysis of whole-blood transcriptional treatment response to ganfeborole 30 mg at day 14 revealed a strong association with neutrophil-dominated transcriptional modules. The demonstrated bactericidal activity and acceptable safety profile suggest that ganfeborole is a potential candidate for combination treatment of pulmonary tuberculosis.

As community-based pharmacy continues to evolve from a focus on product distribution to a practice focused on patient care, a key requirement is for pharmacists to document their patient care activities. Some community-based pharmacies are working to routinely use the Pharmacist eCare Plan standard in documenting their new care activities.