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Background The quality of cancer care affects patient outcomes. It is therefore important to understand what factors and/or barriers shape a cancer patient’s decision about where to seek care. We sought to understand factors influencing decision-making for historically marginalized communities in a large metropolitan area with multiple options for cancer care, including a National Cancer Institute (NCI)-designated comprehensive cancer center.Methods We conducted semi-structured interviews with cancer patients from economically marginalized neighborhoods in Washington D.C., and with healthcare professionals who work with patients from these areas. Participants were recruited through flyers, social media posts, and word of mouth. Two researchers analyzed the data using a combination of inductive and deductive approaches supported by the ATLAS. ti software.Results A total of 15 interviews were conducted. Analysis revealed 3 major factors influencing where patients decide to seek care: health insurance, transportation, and prioritization of needs. Participants repeatedly identified navigating the bureaucracy of insurance enrollment and high medical costs as prohibitive to seeking care. Transportation was often mentioned in terms of convenience of use and proximity to the care center. Prioritization of needs refers to circumstances such as unstable housing, poverty, and mental illness, that some patients prioritize over seeking quality cancer care. Across these themes 2 findings arose: a discrepancy between stated and actual factors in choosing an oncologist, and the extent to which a cancer patient is able to choose their oncologist.Conclusion This study helps explain some of the factors that influence how cancer patients in urban settings choose an oncology center, and the barriers which prohibit access.Aims of the Study This study aimed to understand how cancer patients decide where to seek treatment.

* THE PATIENT 36-year-old man * SIGNS & SYMPTOMS --Left knee pain when squatting --No mechanical symptoms (catching, popping, or locking) --No previous injury or trauma to the area * [...]

ABSTRACTPast debates surrounding wilderness have not led to constructive dialogue but instead have created a rift between dueling sides. Far from academic, this debate has important ethical, policy, and practical implications. We outline out the major fault lines of the debate between wilderness realists and constructivists and also identify common ground between them. From this starting point, we offer three potential bridges between them and conclude by proposing a preliminary vision of a 21stCentury wilderness ethic focused on social-ecological connection, re-commoning, and social justice. Returning to the ‘great wilderness debate’ can lead to a synthesis of the realist and constructivist positions and a renewed wilderness ethic in an era of neoliberalism, hyper-nationalism, and intensified environmental crises.

The engineering of novel protein–ligand binding interactions, particularly for complex drug-like molecules, is an unsolved problem, which could enable many practical applications of protein biosensors. In this work, we analyzed two engineered biosensors, derived from the plant hormone sensor PYR1, to recognize either the agrochemical mandipropamid or the synthetic cannabinoid WIN55,212-2. Using a combination of quantitative deep mutational scanning experiments and molecular dynamics simulations, we demonstrated that mutations at common positions can promote protein–ligand shape complementarity and revealed prominent differences in the electrostatic networks needed to complement diverse ligands. MD simulations indicate that both PYR1 protein–ligand complexes bind a single conformer of their target ligand that is close to the lowest free-energy conformer. Computational design using a fixed conformer and rigid body orientation led to new WIN55,212-2 sensors with nanomolar limits of detection. This work reveals mechanisms by which the versatile PYR1 biosensor scaffold can bind diverse ligands. This work also provides computational methods to sample realistic ligand conformers and rigid body alignments that simplify the computational design of biosensors for novel ligands of interest.

IMPORTANCE: Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients. OBJECTIVE: To develop recommendations for the care of adults with MAC. EVIDENCE REVIEW: A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins. FINDINGS: In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management. CONCLUSIONS AND RELEVANCE: The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy.

A33-year-old man was using the winch on his car to tow a palate of piping. Under extreme tension, the 11-mm kernmantel rope broke. Its free end lashed back with such [...]

'Employees are usually glowing about this gift and can't wait to share the news with others at the company.' 'This can put the employee in a place where they have [...]

The Supreme Court's decision in the Lindsay Earls case ("Expanded Drug Tests in Schools?" 5/6/02) facilitates new aggressive and radical techniques to curb drug abuse in schools. What happened to […]

ObjectiveTo analyse the effectiveness of mentalization‐oriented outpatient group therapy following 5‐month day hospital treatment.

Results on charmonium states and searches for pentaquark states at the BaBar experiment are presented. [Copyright &y& Elsevier]

As global climate change brings an increasing number of ecosystems closer to critical thresholds, land managers face new challenges regarding how to avoid and/or adapt to these dramatic changes. This paper focuses on park management for wildlife species in Olympic National Park, United States. The Olympic Marmot (Marmota olympus) and anadromous fish species are of specific concern, as ecosystems near thresholds due to warming temperatures, change in species interactions, and the loss or degradation of critical habitat. Interviews with 30 park managers and government agency staff indicate that there are many barriers to successfully navigating ecological thresholds. Park managers have limited resources for monitoring and priorities still focus on current conditions rather than anticipating future ecosystem change. In addition, many drivers of ecological change take place outside of park boundaries and require larger-scale approaches. In order to proactively navigate thresholds and protect wildlife species, park managers will need more resources, flexibility, and cooperation outside of park boundaries.