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Background: In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). Objectives: The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. Design: Quality improvement project with longitudinal qualitative data collection. Program Description: The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. Approach & Participants: We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. Key Results: The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. Conclusions: These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility. [ABSTRACT FROM AUTHOR]

Several modifiable lifestyle factors have been linked to cognitive ability and the risk of developing Alzheimer's disease and related dementias (ADRD). Health coaching (HC) is an intervention that addresses lifestyle factors associated with cognition. The effectiveness of an HC protocol was evaluated and compared with a health education (HE) intervention, representing the current standard of care, in a sample of 216 adults between the ages of 45 and 75 years who were at-risk for developing ADRD. Outcomes examined were global cognition, neuropsychological cognition, and Alzheimer's risk. HC participants received personalized coaching from a health coach focusing on nutrition, physical activity, sleep, stress, social engagement, and cognitive activity. HE participants received biweekly education materials focusing on the same modifiable lifestyle factors addressed by HC. Participants were assessed at baseline and again 4 months later. Self-reported global cognition scores improved only in the HC group (16.18 to 15.52, p =.03) and neuropsychological cognitive ability improved in the HE group (104.48 to 108.76, p <.001). When non-adherence in the HC group was accounted for, however, the mean change in neuropsychological score was similar between groups (p >.05), self-reported global cognition demonstrated an even larger mean improvement in the HC group (16.20 to 15.41, p =.01), and the HC group saw an improvement in ADRD protective risk score (− 10.39 to − 11.45, p =.007). These results indicate that HC and HE can both improve cognition, but HC may be more effective and may yield increased protection against ADRD risk. [ABSTRACT FROM AUTHOR]

Purpose: Excellent metabolic improvement following one anastomosis gastric bypass (OAGB) remains compromised by the risk of esophageal bile reflux and theoretical carcinogenic potential. No 'gold standard' investigation exists for esophageal bile reflux, with diverse methods employed in the few studies evaluating it post-obesity surgery. As such, data on the incidence and severity of esophageal bile reflux is limited, with comparative studies lacking. This study aims to use specifically tailored biliary scintigraphy and upper gastrointestinal endoscopy protocols to evaluate esophageal bile reflux after OAGB, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Methods: Fifty-eight participants underwent OAGB (20), SG (15) or RYGB (23) between November 2018 and July 2020. Pre-operative reflux symptom assessment and gastroscopy were performed and repeated post-operatively at 6 months along with biliary scintigraphy. Results: Gastric reflux of bile was identified by biliary scintigraphy in 14 OAGB (70%), one RYGB (5%) and four SG participants (31%), with a mean of 2.9% (SD 1.5) reflux (% of total radioactivity). One participant (OAGB) demonstrated esophageal bile reflux. De novo macro- or microscopic gastroesophagitis occurred in 11 OAGB (58%), 8 SG (57%) and 7 RYGB (30%) participants. Thirteen participants had worsened reflux symptoms post-operatively (OAGB, 4; SG, 7; RYGB, 2). Scintigraphic esophageal bile reflux bore no statistical association with de novo gastroesophagitis or reflux symptoms. Conclusion: Despite high incidence of gastric bile reflux post-OAGB, esophageal bile reflux is rare. With scarce literature of tumour development post-OAGB, frequent low-volume gastric bile reflux likely bears little clinical consequence; however, longer-term studies are needed. Clinical Trial Registry: Australian New Zealand Clinical Trials Registry number ACTRN12618000806268. [ABSTRACT FROM AUTHOR]

Select graduate medical education (GME) programs have created training pathways in quality improvement (QI).[1] The goal of these pathways is to provide residents interested in QI and leadership with training, mentorship, and education to prepare them for QI careers. Internal Medicine-Pediatrics Combined Residency Graduates. While career outcomes following GME training pathways in other areas have been described, outcomes following QI pathways are unknown.[2],[3],[4],[5] We aimed to describe the early career outcomes and professional activities of graduates of a residency-based QI leadership track. [Extracted from the article]

The columns display the monthly percent of all scheduled post-discharge primary care visits that were telemedicine. Among patients discharged after June 1, 2020, those who had telemedicine visits scheduled were more likely to be Black, female, and slightly younger compared to patients who had in-person follow-up scheduled (Table 1). The average time from discharge to first scheduled appointment was 1.4 days shorter for telemedicine than in-person visits ( I p i < 0.0001), the rate of scheduled follow-up within 7 days was 8.2% higher ( I p i < 0.001), visit completion rates were 22.5% higher ( I p i < 0.001), and the rate of seeing one's assigned PCP was 2.6% higher ( I p i = 0.04). [Extracted from the article]

Determining when and under what conditions a species is active is essential to understanding its natural history and ecological niche. Estimating daily activity periods traditionally requires substantial field effort, especially for small mammals that are difficult to observe. Camera traps provide exact activity times but can be challenging to apply effectively for small mammals. We used a relatively new approach for camera trap surveys, the Adapted-Hunt Drift Fence Technique (AHDriFT), and for the first time demonstrate its efficacy to determine small mammal activity periods. We set 15 AHDriFT arrays in northern Ohio wet meadows from 10 March to 06 October 2019. We produced high-resolution daily activity periods for 10 small mammal species. We also modeled how temporal, weather, and spatial covariates influenced the activity of the five most frequently observed species. We generally found that small mammals at our study sites were most active from late summer into fall and decreased their activity on days with heavy precipitation. Jumping mice and deer mice were most active in the relatively sparse vegetation of forest-meadow edges, while voles and shrews displayed opposite trends. Five species had more nuanced daily activity periods than their historic descriptions, suggesting that AHDriFT can refine broad activity categorizations. We provide a precise hourly assessment of the daily activity periods for some of the most abundant and widespread North American small mammals. [ABSTRACT FROM AUTHOR]

Introduction: Oesophageal bile reflux after bariatric surgery may trigger development of Barrett's oesophagus. Gastro-oesophageal reflux of bile is captured by hepatobiliary iminodiacetic acid (HIDA) scintigraphy; however, anatomical and physiological changes after bariatric surgery warrant protocol modifications to optimise bile reflux detection. Methods: HIDA scintigraphy occurred 6 months after either sleeve gastrectomy, Roux-en-Y gastric bypass or one-anastomosis gastric bypass. Standard HIDA scanning involves (i) 6-h fast and 24-h abstinence from opioids; (ii) IV administration of 99mTc di-isopropyl iminodiacetic acid; and (iii) dual anterior/posterior 60-min dynamic scanning of the duodenum, stomach and oesophagus. Three challenges were identified, and modifications were implemented, namely, (1) anatomical localisation of refluxed bile on planar scintigraphy was improved by adding a SPECT/CT for 3D imaging; (2) impaired cholecystokinin-controlled gallbladder emptying, following bypassed duodenum, was addressed by ingestion of a 'fatty meal'; and (3) intestinal hypomotility after gastric bypass was counteracted by longer scan duration (75–90 min) to allow bile to pass beyond the gastro-jejunal anastomosis. Results: HIDA scan was undertaken in 18 patients, 13 of whom underwent the modified protocol. The tailored protocol ameliorated issues identified with the standard HIDA scan protocol; thus, accurate anatomical localisation was achieved in all patients, no delayed gallbladder emptying was observed, and bile was observed beyond the gastro-jejunal anastomosis in all gastric bypass patients. The modified technique was well tolerated by patients. Conclusion: A tailored HIDA scan protocol with addition of a SPECT-CT scan, ingestion of a fatty meal and prolonged scanning duration results in enhanced bile reflux detection in post-bariatric surgical patients. [ABSTRACT FROM AUTHOR]

Duodeno-gastro-esophageal reflux, or bile reflux, is a condition for which there is no diagnostic gold standard, and it remains controversial in terms of carcinoma risk. This is pertinent in the context of an increasingly overweight population who are undergoing weight-loss operations that theoretically further increase the risk of bile reflux. This article reviews investigations for bile reflux based on efficacy, patient tolerability, cost, and infrastructure requirements. At this time, whilst no gold standard exists, hepatobiliary scintigraphy is the least invasive investigation with good-patient tolerability, sensitivity, and reproducibility to be considered first-line for diagnosis of bile reflux. This review will guide clinicians investigating bile reflux. [ABSTRACT FROM AUTHOR]

Toxicologists are often called upon to assist in environmental, industrial, occupational and public health assessments. Accordingly, medical toxicologists may find it prudent to be aware of applicable federal toxicological regulations and reporting requirements and of the roles of relevant federal agencies. These regulations are numerous, complex, and have evolved and expanded over time, making it difficult for toxicologists to sustain a current knowledge base. This article reviews the pertinent federal toxicological reporting requirements with regards to the Toxic Substances Control Act (TSCA), the Atomic Energy Act (AEA), the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), the Resource Conservation and Recovery Act (RCRA), the Clean Air Act, the Clean Water Act, the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), the Emergency Planning and Community Right to Know Act (EPCRA), the Occupational Safety and Health Act, the Department of Transportation, and information about the National Response Center. We reference internet-based government resources and offer direct links to applicable websites in an attempt to offer rapid and current sources of practical information. The format of the article is a series of hypothetical scenarios followed by commentary. Discussions of the Safe Drinking Water Act and the Food, Drug, and Cosmetic Act and the Dietary Supplement Health and Education Act are beyond the scope of this paper. For those desiring a more in depth discussion of the relevant federal environmental laws and statutes, and applicable case law, the reader is directed to resources such as the Environmental Law Handbook, the websites of individual laws found at and the decisions of individual courts of appeal. It is our hope that this article provides not only useful practical information for the practicing toxicologist, but also serves as a key reference for Medical Toxicology core content on environmental laws and regulations. [ABSTRACT FROM AUTHOR]

Toxicologists are often called upon to assist in environmental, industrial, occupational and public health assessments. Accordingly, medical toxicologists may find it prudent to be aware of applicable federal toxicological regulations and reporting requirements and of the roles of relevant federal agencies. These regulations are numerous, complex, and have evolved and expanded over time, making it difficult for toxicologists to sustain a current knowledge base. This article reviews the pertinent federal toxicological reporting requirements with regard to the Toxic Substances Control Act (TSCA), the Atomic Energy Act (AEA), the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), the Resource Conservation and Recovery Act (RCRA), the Clean Air Act, the Clean Water Act, the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), the Emergency Planning and Community Right to Know Act (EPCRA), the Occupational Safety and Health Act, the Department of Transportation, and information about the National Response Center. We reference internet-based government resources and offer direct links to applicable websites in an attempt to offer rapid and current sources of practical information. The format of the article is a series of hypothetical scenarios followed by commentary. Discussions of the Safe Drinking Water Act, the Food, Drug, and Cosmetic Act, and the Dietary Supplement Health and Education Act are beyond the scope of this paper. For those desiring a more in-depth discussion of the relevant federal environmental laws and statutes and applicable case law, the reader is directed to resources such as the Environmental Law Handbook, the websites of individual laws found at and the decisions of individual courts of appeal. It is our hope that this article provides not only useful practical information for the practicing toxicologist but also serves as a key reference for medical toxicology core content on environmental laws and regulations. [ABSTRACT FROM AUTHOR]

Background: Handoffs among post-graduate year 1 (PGY1) trainees occur with high frequency. Peer assessment of handoff competence would add a new perspective on how well the handoff information helped them to provide optimal patient care. Objective: The goals of this study were to test the feasibility of the approach of an instrument for peer assessment of handoffs by meeting criteria of being able to use technology to capture evaluations in real time, exhibiting strong psychometric properties, and having high PGY1 satisfaction scores. Design: An iPad® application was built for a seven-item handoff instrument. Over a two-month period, post-call PGY1s completed assessments of three co-PGY1s from whom they received handoffs the prior evening. Participants: Internal Medicine PGY1s at the University of Pennsylvania. Main Measures: ANOVA was used to explore interperson score differences (validity). Generalizability analyses provided estimates of score precision (reproducibility). PGY1s completed satisfaction surveys about the process. Key Results: Sixty-two PGY1s (100 %) participated in the study. 59 % of the targeted evaluations were completed. The major limitations were network connectivity and inability to find the post-call trainee. PGY1 scores on the single item of 'overall competency' ranged from 4 to 9 with a mean of 7.31 (SD 1.09). Generalizability coefficients approached 0.60 for 10 evaluations per PGY1 for a single rotation and 12 evaluations per PGY1 across multiple rotations. The majority of PGY1s believed that they could adequately assess handoff competence and that the peer assessment process was valuable (70 and 77 %, respectively). Conclusion: Psychometric properties of an instrument for peer assessment of handoffs are encouraging. Obtaining 10 or 12 evaluations per PGY1 allowed for reliable assessment of handoff skills. Peer evaluations of handoffs using mobile technology were feasible, and were well received by PGY1s. [ABSTRACT FROM AUTHOR]

We ascertained a nuclear family in which three of four siblings were affected with an unclassified autosomal recessive myopathy characterized by severe weakness, respiratory impairment, scoliosis, joint contractures, and an unusual combination of dystrophic and myopathic features on muscle biopsy. Whole genome sequence from one affected subject was filtered using linkage data and variant databases. A single gene, MEGF10, contained nonsynonymous mutations that co-segregated with the phenotype. Affected subjects were compound heterozygous for missense mutations c.976T > C (p.C326R) and c.2320T > C (p.C774R). Screening the MEGF10 open reading frame in 190 patients with genetically unexplained myopathies revealed a heterozygous mutation, c.211C > T (p.R71W), in one additional subject with a similar clinical and histological presentation as the discovery family. All three mutations were absent from at least 645 genotyped unaffected control subjects. MEGF10 contains 17 atypical epidermal growth factor-like domains, each of which contains eight cysteine residues that likely form disulfide bonds. Both the p.C326R and p.C774R mutations alter one of these residues, which are completely conserved in vertebrates. Previous work showed that murine Megf10 is required for preserving the undifferentiated, proliferative potential of satellite cells, myogenic precursors that regenerate skeletal muscle in response to injury or disease. Here, knockdown of megf10 in zebrafish by four different morpholinos resulted in abnormal phenotypes including unhatched eggs, curved tails, impaired motility, and disorganized muscle tissue, corroborating the pathogenicity of the human mutations. Our data establish the importance of MEGF10 in human skeletal muscle and suggest satellite cell dysfunction as a novel myopathic mechanism. [ABSTRACT FROM AUTHOR]

Abstract. In recent papers we demonstrated by means of a modeling study that the smoothness of hand paths and the bell-shaped character of hand velocity profiles which have been experimentally observed in point-to-point arm movements can be largely attributed to the biomechanical properties of the arm rather than to specific planning by the central nervous system. In this paper we present a study of the robustness of our earlier results comprising two goals: (i) the determination of the range of model parameters for which such observations remain valid, (ii) the identification of possible relationships between model parameters and kinematic variables. The results of this study imply three conclusions: (i) the valid range of the tested model parameters (namely the main muscle parameters) is large, (ii) the modeled phenomena are well behaved in that parametric changes do not give rise to bifurcations or other behavioral discontinuities in the analyzed ranges, (iii) there exist precise relationships between certain muscle parameters and the time course of the hand velocity. These results point out that the phenomena observed in our previous work are indeed robust and can lead to useful insights into the mechanisms comprising the regulatory action of the central nervous system as well as into the design principles for biologically inspired artificial arms. [ABSTRACT FROM AUTHOR]

A prospective double-blind randomized trial was initiated to examine two types of laparoscopic fundoplication (Nissen and anterior). Thirty-two patients with proven gastroesophageal reflux disease presenting for primary laparoscopic antireflux surgery were randomized to undergo either Nissen fundoplication (N = 13) or anterior hemifundoplication (N = 19). Postoperative fluoroscopic and manometric examination was carried out concomitantly. Nissen fundoplication resulted in significantly greater elevation of resting (33.5 vs 23 mm Hg) and residual lower esophageal sphincter pressures (17 vs 6.5 mm Hg) and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than the anterior partial fundoplication. A smaller radiologically measured sphincter opening diameter was seen following Nissen fundoplication (9 mm) compared with anterior fundoplication (12 mm). Lower esophageal ramp pressure correlated weakly (r = 0.37, P = 0.04) with postoperative dysphagia. It is concluded that the type of fundoplication performed significantly influences postoperative manometric and video barium radiology outcomes. The clinical relevance of this requires further investigation. [ABSTRACT FROM AUTHOR]

The article focuses a study which evaluates handoff education literature using a three-part study that analyzes internal medicine resident attitudes on the handoffs process. Results suggested that 70% of residents thought handoffs must be problem-based while 30% of them thought that they must provide a chance to discuss treatments and diagnoses. It adds that residents with best handoff skills were identified by their peers and used as a basis for the redesign of handoff best practices.

A personal narrative is presented of the author's experiences as an intern of the 2011 Association for Educational Communications and Technology (AECT) International Convention, noting opportunities for mentoring, leadership education, and professional networking at the convention.