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The aim of this article is to familiarize the reader with one system's approach to creating an aligned academic health system that facilitates delivery of academic health care in community hospitals.A wide variety of approaches to this challenge include viewing the community facilities as strictly feeders to the academic centers with no shared governance, to viewing them as branding opportunities with aligned governance, to a more integrated model such as ours, and to creating exclusive centers of excellence in the community facilities by consolidating services initially dispersed across competing hospitals into one center.We leveraged service lines and domains to standardize care across all hospital settings which facilitated delivery of complex tertiary care in community hospitals, thus increasing capacity in the Academic Medical Center for complex quarternary care.Through creating a more completely integrated, patient centric health system that leverages the community partners we minimized the need for people to travel from their community hospitals to the Academic Medical Center while still ensuring they received the expertise of a leading academic institution.

Mislevy’s sociocognitive perspective on assessment argues that examinees’ linguistic, cultural, and substantive (LCS) patterns serve to organize their ways of knowing and their knowledge construction. In this study, we used a purposefully designed prompt to obtain essays from 70 Chinese undergraduate English majors and 66 American undergraduate students to illustrate LCS patterns conveyed in texts produced by students in collectivistic and individualistic cultures (i.e., China and United States). We found that linguistically, compared to American students, Chinese students used more adjectives, adverbs, modal verbs of obligation, and were more direct in offering value judgements; culturally, while the texts from the two groups yielded overlapping themes, there were clear group difference in the rank order of number of codes for the themes and in the supporting text for each theme; substantively, there were noticeable group difference in the conceptualizations of how the themes were related to each other. Because it remains unknown how cultural and substantive features expressed in L2 essays may affect writing assessment, these differences presented both challenges and opportunities for the field of writing assessment. Implications for the equity and validity of L2 writing assessment were discussed.

Objective To describe optical coherence tomography angiography (OCTA) reflectance artifacts secondary to retinal pigment epithelial detachment (RPED). Design Retrospective review. Methods Four eyes from 4 subjects were included. Three presented with RPED and 1 eye was a normal control. Two eyes diagnosed with RPED and the normal eye were evaluated using en face OCTA centred at the fovea acquired using the RTVue XR Avanti (Optovue Inc). In the third eye with RPED, OCTA imaging was performed using a CIRRUS 5000 prototype modified to do OCTA imaging on a spectral domain OCT platform provided by Carl Zeiss Meditec, Inc. The segmented OCTA angiograms were overlaid to determine if the flow patterns seen at the edge of the RPEDs were due to reflectance from the inner retinal vessels, also known as “decorrelation tails.” Results OCTA projection artifacts were noted when segmentation lines intersected with the boundary of the RPED. The overlaid segmented OCTA from the 3 RPED eyes imaged using each system revealed the same vasculature pattern at the edges of the RPED as that of the inner retina, demonstrating the “decorrelation tails” artifact, which caused the RPED to appear as a bright ring on the segmented OCTA. Conclusions OCTA images are susceptible to various known artifacts. This series describes the impact of the projection artifact seen at the edges of an RPED that simulates appearance of flow but is actually due to reflectance of the inner retinal vasculature on the RPED.

Background The potassium channel I Ks , which is encoded by the KCNQ1 gene, is expressed in organ systems including the inner ear, kidneys, lungs, intestine, and stomach in addition to the heart. Increasing evidence indicates that I Ks in the stomach plays an essential role in enabling gastric acid production. It is not known whether gastric acid production is disordered in patients with long QT type 1. Serum gastrin levels become elevated in subjects with disordered gastric acid production. Objective The purpose of this study was to evaluate serum gastrin levels, as a surrogate for impaired gastric acid secretion, in patients with KCNQ1 mutations, and to see if gastrin levels correlate with severity of cardiac disease. Methods Fasting serum gastrin levels were measured using a standardized immunometric technique in an index case and 12 subjects with known KCNQ1 mutations. Results An adult female with Jervell and Lange-Nielsen syndrome (JLNS; with KCNQ1 nonsense mutations p.Arg518X and p.Arg190AlafsX95 ) presented with multiple gastric carcinoid tumors and grossly elevated serum gastrin levels (943–1,570 pmol/L; normal 6–55 pmol/L) and absent acid secretion. Gastrin levels in two girls with JLNS, unrelated to the index case (missense mutations p.Leu266Pro and Gly269Ser), also were high (305 and 229 pmol/L). Gastrin levels were normal in 10 KCNQ1 heterozygous single mutation carriers, even in those with severe long QT syndrome, including three heterozygous family members of the JLNS subjects. Conclusion JLNS may be associated with elevated gastrin levels, impaired acid secretion, and risk of gastric carcinoid tumors. Among KCNQ1 single mutation carriers, gastrin levels were normal and did not appear to be linked to the severity of clinical expression of long QT syndrome.

A global definition of K-nice subgroup is formulated, which generalizes both the notion of a nice subgroup in the context of torsion groups and the notion of a K-nice submodule used in a recent study of p-local balanced projective groups. It is shown, analogous to Hill's treatment of totally projective p-groups, that the (global) balanced projective groups of Warfield are precisely those mixed abelian groups that satisfy the Third Axiom of Countability for K-nice subgroups. A variety of equivalent characterizations of balanced projectives are derived by methods independent of the uniqueness and existence theorems previously established for these groups.

By generalizing Hill's theorem giving a necessary and sufficient condition for an isotype subgroup of a totally projective p -group to be itself totally projective, we are able to give a condition which will determine the balanced-projective dimension of an arbitrary p -local abelian group when that dimension is finite. We rely on our recent third axiom of countability characterization for p -local balanced projectives and are able to carry over almost routinely the arguments given recently by Fuchs and Hill which were used to determine the balanced-projective dimension of an arbitrary abelian p -group. We are then able to prove that the balanced-projective dimension of any countable p -local abelian group and of any p -local Warfieid group is less than or equal to 1.