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In South Carolina (SC), 42% of youth are overweight or obese. Two sets of modifiable behaviors contributing to obesity are physical activity (PA) and dietary habits. School-based interventions have successfully improved these behaviors. The purpose of this study was to identify SC public school personnel perspectives on the most common barriers and facilitators to regular PA and healthy eating behaviors in schools.A needs assessment survey was conducted with school personnel statewide. There were 17 questions on the survey that addressed: (1) demographic information about participants' educational backgrounds, (2) barriers to regular PA and healthy eating behaviors in schools, and (3) facilitators to regular PA and healthy eating behaviors in schools. Univariate and bivariate descriptive statistical analyses were performed using IBM SPSS Statistics 27.Participants (N = 1311) indicated insufficient time for regular PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating (n = 271, 20.7%) as main barriers. The primary facilitators were support from administrators for regular PA (n = 264, 20.1%) and support from cafeteria staff for healthy eating (n = 234, 17.8%). Further analyses explored how factors compared based on roles in schools, academic levels, and school district classifications.Results suggest that overarching barriers and facilitators to school-based interventions addressing childhood obesity exist, so common strategies to mitigate challenges and maximize supports can be used in schools. Future studies are needed to examine how decreasing barriers and enhancing facilitators affect the implementation and outcomes of these school-based interventions.

Objective To integrate an auto-notification system into clinical workflow, so timely communication of sentinel events (elective surgery, hospital admission, or ER visit) in immunosuppressed rheumatic disease patients happened by design. Methods We developed an algorithm that triggered auto-notification within the electronic medical record to rheumatology when a patient experienced a sentinel event. A telephone encounter was created that included event type, baseline therapy, and event date. This was forwarded to the rheumatologist, who recorded guideline-driven recommendations and returned it to nursing. Instructions were included to communicate recommendations to the patient, inpatient rheumatology team, or other clinician. This was studied over four months at a multi-specialty medical practice in Central Pennsylvania. Primary outcomes were percentage of total notifications, notifications by sentinel event type where a change in care plan was recommended, as well as percentage of time where rheumatologists were notified of sentinel events, compared to prior to the intervention. Secondary outcomes were staff work effort. Results 240 notifications were received - 57% for elective surgeries, 39% for ER visits, and 4% for admissions. The need for change in care plan was only 17% for ER visits but was 25% for hospital admissions and 44% for elective surgeries. The percentage of time rheumatologists were notified of events increased from 57.6% to 100%. The average number of messages received per week was 2.2, requiring a weekly average of 13 minutes of work per physician. Conclusion We developed an easy, well-received process that "hardwires" rheumatologist notification sentinel events to facilitate timely care.

School-based interventions and strategies targeting physical activity (PA) and eating patterns have successfully addressed unhealthy behaviors contributing to excess weight in school-age children. The purpose of this study was to investigate South Carolina (SC) public school administrators' perceptions of and experiences with weight-related issues in schools and associated barriers and facilitators to awareness, selection, and implementation of school-based healthy PA and eating interventions and strategies.This qualitative descriptive study, guided by the Social Ecological Model and the Steps in Quality Intervention Development Model, involved semistructured interviews with SC public school administrators from all academic levels (N = 28). Data were analyzed using thematic analysis.Four themes were identified from interviews (N = 28): weight-related terminology or stigma, experiences with school-based healthy PA and eating interventions and strategies, barriers to school-based healthy PA and eating interventions and strategies, and facilitators to school-based healthy PA and eating interventions and strategies.Schools are well-positioned to provide interventions and strategies to improve PA and dietary habits leading to childhood obesity. School administrators, while knowledgeable and experienced with weight-related issues and school-based interventions and strategies, encounter barriers and facilitators that impact offerings and delivery. Understanding these challenges and supports is important in the development, adaptation, and implementation of school-based interventions and strategies focused on healthy PA and eating behaviors.

Deep-water access is arguably the most effective, but under-studied, mechanism that plants employ to survive during drought. Vulnerability to embolism and hydraulic safety margins can predict mortality risk at given levels of dehydration, but deep-water access may delay plant dehydration. Here, we tested the role of deep-water access in enabling survival within a diverse tropical forest community in Panama using a novel data-model approach. We inversely estimated the effective rooting depth (ERD, as the average depth of water extraction), for 29 canopy species by linking diameter growth dynamics (1990-2015) to vapor pressure deficit, water potentials in the whole-soil column, and leaf hydraulic vulnerability curves. We validated ERD estimates against existing isotopic data of potential water-access depths. Across species, deeper ERD was associated with higher maximum stem hydraulic conductivity, greater vulnerability to xylem embolism, narrower safety margins, and lower mortality rates during extreme droughts over 35years (1981-2015) among evergreen species. Species exposure to water stress declined with deeper ERD indicating that trees compensate for water stress-related mortality risk through deep-water access. The role of deep-water access in mitigating mortality of hydraulically-vulnerable trees has important implications for our predictive understanding of forest dynamics under current and future climates.

Refactoring is widely recognized as one of the efficient techniques to manage technical debt and maintain a healthy software project through enforcing best design practices or coping with design defects. Previous refactoring surveys have shown that code refactoring activities are mainly executed by developers who have sufficient knowledge of the system's design and disposing of leadership roles in their development teams. However, these surveys were mainly limited to specific projects and companies. In this paper, we explore the generalizability of the previous results by analyzing 800 open-source projects. We mine their refactoring activities, and we identify their corresponding contributors. Then, we associate an experience score to each contributor in order to test various hypotheses related to whether developers with higher scores tend to 1) perform a higher number of refactoring operations 2) exhibit different motivations behind their refactoring, and 3) better document their refactoring activity. We found that (1) although refactoring is not restricted to a subset of developers, those with higher contribution scores tend to perform more refactorings than others; (2) while there is no correlation between experience and motivation behind refactoring, top contributed developers are found to perform a wider variety of refactoring operations, regardless of their complexity; and (3) top contributed developer tend to document less their refactoring activity. Our qualitative analysis of three randomly sampled projects shows that the developers who are responsible for the majority of refactoring activities are typically in advanced positions in their development teams, demonstrating their extensive knowledge of the design of the systems they contribute to.

Land surface models and Earth system models that include Arctic landscapes must capture the abrupt hydrological transitions that occur during the annual thaw and deepening of the active layer. In this work, stable water isotopes (δ²H and δ¹⁸O) are used to appraise hydrologically significant transitions during annual landscape thaw at the Barrow Environmental Observatory (Utqiaġvik, Alaska). These hydrologically significant periods are then linked to annual shifts in the landscape energy balance, deduced from meteorological data and described by the microclimatic periods: Winter, Pre‐Melt, Melt, Post‐Melt, Summer, and Freeze‐Up. The tight coupling of the microclimatic periods with the hydrological transitions supports the use of microclimatic periods as a means of linking polygonal surface water hydrology to meteorological datasets, which provides a mechanism for improving the representation of polygonal surface water hydrology in process‐based models. Rayleigh process reconstruction of the isotopic changes revealed that 19% of winter precipitation was lost to sublimation prior to melting and that 23% of surface water was lost to evaporation during the first 10 days post‐melt. This agrees with evaporation rates reported in a separate study using an eddy covariance flux tower located nearby. An additional 17% was lost to evaporation during the next 33 days. Stable water isotopes are also used to identify the dominant sources of surface water to various hydrogeomorphological features prevalent in polygonal terrain (a lake, a low centre polygon centre, troughs within the rims of low centre polygons, flat centre polygon troughs, a high centre polygon trough, and drainages). Hydrogeomorphologies that retained significant old water or acted as snow drifts are isotopically distinct during the Melt Period and therefore are easily distinguished. Biogeochemical changes related to the annual thaw are also reported and coupled to the hydrological transitions, which provides insight into the sources and sinks of these ions to and from the landscape.

The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults was made public on November 13, 2017 (http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults).1 The American College of Cardiology (ACC)/American Heart Association (AHA) and other societies, including the American Society for Preventive Cardiology (ASPC), participated in its development. Guidelines are complex work products; they require compromise and a deep evaluation and understanding of current and past evidence. They are intended to help clinicians, patients, payers, and policymakers in their respective decision-making process. Given the sometimes disparate interests of these stakeholders, construction of guidelines can be extraordinarily complex. Defined by the Institute of Medicine in 1990, guidelines are “systemically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”2 Though intended to improve patient care, guidelines can be unintentionally misused by clinicians, patients, payers, and policymakers, all of whom may fail to recognize the guidelines' limitations. They were created to assist, not dictate, decision making. As an example, patients may decline a therapeutic strategy if it is not in a guideline, even when their physician understands why they might best be served by management that falls outside of a guideline. Payers may extract statements without context to support restricting access to novel or costly therapies. Application of guidelines can also be limited by undue complexity. Finally, the unharmonized nature of competing guidelines for the same disease state can increase confusion instead of reducing it. The 2017 guideline appears to be different. Though a long document, its message is rather simple and straightforward; high blood pressure causes complications, and treating it reduces them. Simple blood pressure cut-points with associated clear therapeutic recommendations make this guideline easy to follow. Clinical flexibility is also fundamental to the document, respecting clinical acumen in shared decision making, a vital aspect of optimal healthcare. Finally, the involvement of multiple organizations in the construction and endorsement of the document may reduce the risk of confusion driven by diverse high blood pressure guidelines. In sum, what one will find from this guideline is a clinical breath of fresh air; it represents compromise, coordination among groups, and a simple message for patients and clinicians alike. We have chosen to examine this guideline in the context of history: what is old and what is new. By doing so, we hope to highlight salient, clinically relevant changes in blood pressure management.

BACKGROUND Magnetic resonance imaging (MRI) studies have shown differences in volume and structure in the brains of individuals with alcohol use disorder (AUD). Most research has focused on neuropathological effects of alcohol that appear after years of chronic alcohol misuse. However, few studies have investigated white matter (WM) microstructure and diffusion MRI-based (DWI) connectivity during early stages of AUD. Therefore, the goal of this work was to investigate WM integrity and structural connectivity in emerging adulthood AUD subjects using both conventional DWI metrics and a novel connectomics approach. METHODS Twenty-two AUD and 18 controls (CON) underwent anatomic and diffusion MRI. Outcome measures were scalar diffusion metrics and structural network connectomes. Tract-Based Spatial Statistics was used to investigate group differences in diffusion measures. Structural connectomes were used as input into a community structure procedure to obtain a coclassification index matrix (an indicator of community association strength) for each subject. Differences in coclassification and structural connectivity (indexed by streamline density) were assessed via the Network Based Statistics Toolbox. RESULTS AUD had higher fractional anisotropy (FA) values throughout the major WM tracts, but also had lower FA values in WM tracts in the cerebellum and right insula (pTFCE

Preclinical studies have shown effects of chronic exposure to addictive drugs on glutamatergic-mediated neuroplasticity in frontostriatal circuitry. These initial findings have been paralleled by human functional magnetic resonance imaging (fMRI) research demonstrating weaker frontostriatal resting-state functional connectivity (rsFC) among individuals with psychostimulant use disorders. However, there is a dearth of human imaging literature describing associations between long-term prescription opioid use, frontostriatal rsFC, and brain morphology among chronic pain patients. We hypothesized that prescription opioid users with chronic pain, as compared with healthy control subjects, would evidence weaker frontostriatal rsFC coupled with less frontostriatal gray matter volume (GMV). Further, those opioid use-related deficits in frontostriatal circuitry would be associated with negative affect and drug misuse. Prescription opioid users with chronic pain (n = 31) and drug-free healthy controls (n = 30) underwent a high-resolution anatomical and an eyes-closed resting-state functional scan. The opioid group, relative to controls, exhibited weaker frontostriatal rsFC, and less frontostriatal GMV in both L.NAc and L.vmPFC. Frontostriatal rsFC partially mediated group differences in negative affect. Within opioid users, L.NAc GMV predicted opioid misuse severity. The current study revealed that prescription opioid use in the context of chronic pain is associated with functional and structural abnormalities in frontostriatal circuitry. These results suggest that opioid use-related abnormalities in frontostriatal circuitry may undergird disturbances in affect that may contribute to the ongoing maintenance of opioid use and misuse. These findings warrant further examination of interventions to treat opioid pathophysiology in frontostriatal circuitry over the course of treatment.

Rationale, aims, and objectives Health literacy (HL) has been widely referenced as a determinant of health outcomes, making the assessment of low HL a fundamental step to plan educational interventions. This study aimed to translate and adapt the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E) questionnaire into European Portuguese. Methods The SAHL-S&E questionnaire was translated using the recommendations of the International Society for Pharmacoeconomics and Outcomes Research. One hundred fifty-three Portuguese native speakers aged over 18 years old were included in this study, enrolled among users of community pharmacies in the Algarve region (Portugal). Results The translation of the questionnaire used showed a good internal consistency (Cronbach alpha: .812), and a statistically significant (F= 5.05P< .001) interrater reliability. Over a third of subjects (37.9%) achieved a score less than or equal to 14, which is indicative of low HL. Conclusion This tool, intended to be used in the European Portuguese population, can be used for low HL screening. info:eu-repo/semantics/publishedVersion

Objective To highlight the opportunities and challenges of developing and implementing performance outcome measures in rheumatology for accountability purposes. Methods We constructed a hypothetical performance outcome measure to demonstrate the benefits and challenges of designing quality measures that assess patient outcomes. We defined the data source, measure cohort, reporting period, period at risk, measure outcome, outcome attribution, risk adjustment, reliability and validity, and reporting approach. We discussed outcome measure challenges specific to rheumatology and to fields where patients have predominantly chronic, complex, ambulatory care–sensitive conditions. Results Our hypothetical outcome measure was a measure of rheumatoid arthritis disease activity intended for evaluating Accountable Care Organization performance. We summarized the components, benefits, challenges, and tradeoffs between feasibility and usability. We highlighted how different measure applications, such as for rapid cycle quality improvement efforts versus pay for performance programs, require different approaches to measure development and testing. We provided a summary table of key take-home points for clinicians and policymakers. Conclusion Performance outcome measures are coming to rheumatology, and the most effective and meaningful measures can only be created through the close collaboration of patients, providers, measure developers, and policymakers. This study provides an overview of key issues and is intended to stimulate a productive dialogue between patients, practitioners, insurers, and government agencies regarding optimal performance outcome measure development.

Objective To examine the potential value of a theory-based, interactive decision support tool in clinical practice for patients with rheumatoid arthritis who are candidates for biologic agents. Methods We conducted an 8-week, 2-arm, parallel, single-blind pilot trial in which candidates for treatment escalation with a biologic agent were randomized to receive either a link to a web-based tool or usual care. Outcomes included changes in objective knowledge, subjective knowledge, values clarification, and satisfaction with risk communication as well as the proportion of subjects defined as making an informed choice to escalate care at 2 weeks. Results A total of 125 subjects were randomized. Significant between-group differences at 2 weeks favoring the intervention group were seen for changes in objective knowledge, subjective knowledge, and values clarification. No significant between-group differences were found in subjects’ satisfaction with risk communication. Among those deciding to escalate care, a greater percentage met the criteria for an informed choice at 2 weeks in the intervention group compared to the control group (32% versus 13%; P = 0.02). Improvements in subjective knowledge and values clarification persisted at 8 weeks. There were no between-group differences in objective knowledge at 8 weeks. Conclusion In this study, use of a decision support tool at the time of decision-making resulted in improved objective and subjective knowledge, as well as values clarity, compared to usual care. Not all improvements were sustained, emphasizing the need to offer educational support should additional escalation of care be required over the course of the illness.

Objective Electronic health records (EHRs) are not optimized for chronic disease management. To improve the quality of care for patients with rheumatic disease, we developed electronic data capture, aggregation, display, and documentation software. Methods The software integrated and reassembled information from the patient (via a touchscreen questionnaire), nurse, physician, and EHR into a series of actionable views. Core functions included trends over time, rheumatology-related demographics, and documentation for patient and provider. Quality measures collected included patient-reported outcomes, disease activity, and function. The software was tested and implemented in 3 rheumatology departments, and integrated into routine care delivery. Post-implementation evaluation measured adoption, efficiency, productivity, and patient perception. Results Over 2 years, 6,725 patients completed 19,786 touchscreen questionnaires. The software was adopted for use by 86% of patients and rheumatologists. Chart review and documentation time trended downward, and productivity increased by 26%. Patient satisfaction, activation, and adherence remained unchanged, although pre-implementation values were high. A strong correlation was seen between use of the software and disease control (weighted Pearson's correlation coefficient 0.5927, P = 0.0095), and a relative increase in patients with low disease activity of 3% per quarter was noted. Conclusion We describe innovative software that aggregates, stores, and displays information vital to improving the quality of care for patients with chronic rheumatic disease. The software was well-adopted by patients and providers. Post-implementation, significant improvements in quality of care, efficiency of care, and productivity were demonstrated.

The Whitecourt meteorite impact crater, Alberta, Canada is a rare example of a well-preserved small impact structure, with which thousands of meteorite fragments are associated. As such, this crater represents a unique opportunity to investigate the effect of a low-energy impact event on an impacting iron bolide. Excellent documentation of meteorite fragment locations and characteristics has generated a detailed distribution map of both shrapnel and regmaglypted meteorite types. The meteorites' distribution, and internal and external characteristics support a low-altitude breakup of the impactor which caused atmospherically ablated (regmaglypted) meteorites to fall close to the crater and avoid impact-related deformation. In contrast, shrapnel fragments sustained deformation at macro- and microscales resulting from the catastrophic disruption of the impactor. The impactor was significantly fragmented along pre-existing planes of weakness, including kamacite lamellae and inclusions, resulting in a bias toward low-mass (

A portable sensor based on a microband design for arsenic detection in drinking water is presented. The work was focused to minimize interference encountered with a standard screen-printed electrodes featuring an onboard gold working electrode, carbon counter and silver−silver chloride pseudo-reference electrodes as composite coatings on plastic surface. The interference effect was identified as chloride ions interacting with the silver surface of the reference electrode and formation of soluble silver chloride complexes such as AgCl43−. By modification of the reference electrodes with Nafion membrane (5 % in alcohols), the interference was entirely eliminated. However, membrane coverage and uniformity can impact the electrodes reproducibility and performance. Hence, the sensor design was further considered and a microband format was produced lending favorable diffusive to capacitive current characteristics. Using the microband electrodes allowed As(III) detection with limit of detection of 0.8 ppb (in 4 M HCl electrolyte), inherently avoiding the problems of electrode fouling and maximizing analyte signal in river water samples. This is below the World Health Organization limit of 10 μg L−1 (ppb). The electrolyte system was chosen so as to avoid problems from other common metal ions, most notably Cu(II). The presented electrode system is cost effective and offers a viable alternative to the colorimetric test kits presently employed for arsenic analysis in drinking water.

Properly quantifying evapotranspiration (ET) is a critical step in determining water and energy balances, especially in Arctic landscapes where spatial and temporal heterogeneity in soil water content and inundation is pronounced. Although the eddy covariance technique has gained popularity as an approach for estimating ET at aggregate scales, obtaining ET estimates at finer spatial scales remains problematic. Thus, ET is poorly estimated for highly variable tundra landscapes, despite the importance of this process for parameterization and validation of models. To overcome this methodological limitation, we developed an approach to measure diurnal ET by modifying a LI-8100A (LI-COR, Lincoln, NE, USA), a chamber-based instrument typically used for measuring soil CO2 fluxes. To enable the use of the LI-8100A for ET determinations, a calibration method was designed and implemented through laboratory and independent field measurements in Arctic and semi-arid locations. Once calibrated, the instrument was deployed June–September 2013 for diel measurements of ET on the Arctic coastal plain near Barrow, Alaska, USA. We validated the system by comparison to four adjacent plots measured by a LI-6400-09 soil CO2 flux system that was also calibrated to calculate water vapour flux. In conclusion, we determined that with calibration, the LI-8100A can make long-term, high-frequency measurements of ET, even in low flux, continuous-permafrost landscapes. This technique provides an opportunity to assess fine-scale ET and its topographic controls across low-centre and high-centre polygons and to rigorously compare such measurements with aggregate fluxes obtained with eddy covariance. Copyright © 2014 John Wiley & Sons, Ltd.

Tritium concentrations in river and stream waters from different locations can be compared by normalizing them using the ratio of tritium concentrations in precipitation and surface water (Cp/Cs) in the study area. This study uses these ratios in a hydrological residence time context to make regional- and global-scale comparisons about river basin dynamics. Prior to the advent of nuclear weapons testing, the Cp/Cs ratio was greater than or equal to 1 everywhere because of the decay of tritium in the watershed after it was deposited by precipitation. After an initial increase in the ratios during the bomb peak, the ratio dropped to less than 1 for most surface waters in the following years. This post-bomb change in the ratio is due to the retention of the bomb-pulse water in watersheds on timescales that are long relative to the residence time of tritium in the atmosphere. Ratios were calculated for over 6500 measurements of tritium in river and stream waters compiled by the International Atomic Energy Agency. These measurements span the post-nuclear era (1940s to present) and include many long-term datasets, which make it possible to examine residence times of waters in watersheds on a global basis. Plotting Cp/Cs versus time shows that ratios tended to reach a minimum in approximately one to two decades after the bomb peak for most locations. This result suggests that changes affecting quantity and quality of river flows need to be assessed on a multi-decadal timescale. These long lag times have significant implications for assessing climate or land-use change impacts on a large number of river systems around the world. The continuing value of tritium in studying surface water systems for both the Southern and Northern Hemisphere is also demonstrated. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

A substantial and growing portion of the pediatric population has long-term health conditions. Children with special health care needs (CSHCN) are those children who have, or are at risk for, health problems and require greater numbers of health services than children in general (McPherson et al., 1998). Children with complex chronic conditions (CCC) are a subset of CSHCN with more complex health problems and greater health care needs; although their prevalence is estimated at 3.2% of CSHCN and .4% of children in general (Kuo, Cohen, Agrawal, Berry, & Casey, 2011), children with CCC have a high impact on health care. According to Feudtner, Christakis, and Connell (2000) children with CCC have a health condition that is expected to last at least 12 months, affecting one or more body systems substantially enough that specialty care and hospitalization are necessary. These children have increasingly high pediatric inpatient days and hospital charges (Simon et al., 2010), high rates of pediatric ED visits, and high rates of hospital admissions resulting from pediatric ED visits (O’Mahony et al., 2013). As a result of the high health care utilization rates, cost burdens of care for this population are disproportionately high and the increasing numbers of hospital admissions in children can be attributed to children with CCC (Burns et al., 2010; Simon et al., 2010). Buescher, Whitmire, Brunssen, and Kluttz-Hile (2006) estimated the annual Medicaid claims for a child with CCC and technological dependence to be approximately $69,906 per year compared with an average Medicaid claims cost of $3,159 per year for a child without a CCC solely receiving well services. Investigation into the factors contributing to health care utilization among this population is necessary because of the high health care utilization and costs for children with CCC. The purpose of this exploratory study was to assess the feasibility of the data collection and analysis plan and to investigate the following research questions: Which of the demographic and clinical variables collected in a sample of children with CCC influence hospital admissions and emergency department (ED) visits? Which of these variables should be prospectively examined for their potential to predict hospital admissions and ED visits?

Since the winter season of 2004–2005, annual snow assessments have been conducted for the major watersheds of Afghanistan using multispectral (AVHRR and MODIS) and passive microwave (SSM/I and AMSR-E) remote sensing technologies. Because of limited ground-based observations of precipitation and snow pack conditions, remote sensing provides a unique opportunity to assess these conditions at different scales offering an appraisal of current conditions from a historical context. This paper describes the methodology that has been developed over the past seven winter seasons, wherein bi-weekly snow products and assessments are produced including the following: current snow-covered area (SCA) at regional and watershed scales; estimation of SCA by elevation band; current snowpack volume [snow water equivalent (SWE)] for each watershed with a historical perspective (1987–present); snow condition outlook by watershed; general summary of snow conditions based on remote sensing products and limited ground-based observations; and if warranted, a snow melt flooding advisory. Further analysis of these snow products and assessments are presented. Moreover, comparisons between both available passive microwave estimates of SWE (SSM/I and AMSR-E) for all watersheds differ in magnitude yet exhibit similar historical trends. The SSM/I versus AMSR-E historical differences in SWE for each of the major Afghanistan watersheds are quantified and show a strong relationship (R2 = 96%) to the mean elevation of the watershed. Copyright © 2012 John Wiley & Sons, Ltd.

Objective While questionnaires have been developed to capture patient-reported outcomes (PROs) in rheumatology practice, these instruments are not widely used. We developed a touchscreen interface designed to provide reliable and efficient data collection. Using the touchscreen to obtain PROs, we compared 2 different workflow models implemented separately in 2 rheumatology clinics. Methods The Plan-Do-Study-Act methodology was used in 2 cycles of workflow redesign. Cycle 1 relied on off-the-shelf questionnaire builder software, and cycle 2 relied on a custom programmed software solution. Results During cycle 1, clinic 1 (private practice model, resource replete, simple flow) demonstrated a high completion rate at the start, averaging between 74% and 92% for the first 12 weeks. Clinic 2 (academic model, resource deficient, complex flow) did not achieve a consistent completion rate above 60%. The revised cycle 2 implementation protocol incorporated a 15-minute “nurse visit,” an instant messaging system, and a streamlined authentication process, all of which contributed to substantial improvement in touchscreen questionnaire completion rates of ∼80% that were sustained without the need for any additional clinic staff support. Conclusion Process redesign techniques and touchscreen technology were used to develop a highly successful, efficient, and effective process for the routine collection of PROs in a busy, complex, and resource-depleted academic practice and in typical private practice. The successful implementation required both a touchscreen questionnaire, human behavioral redesign, and other technical solutions.

African American women in urban, high poverty neighborhoods have high rates of smoking, difficulties with quitting, and disproportionate tobacco-related health disparities. Prior research utilizing conventional "outsider driven" interventions targeted to individuals has failed to show effective cessation outcomes. This paper describes the application of a community-based participatory research (CBPR) framework to inform a culturally situated, ecological based, multi-level tobacco cessation intervention in public housing neighborhoods. The CBPR framework encompasses problem identification, planning and feasibility/pilot testing, implementation, evaluation, and dissemination. There have been multiple partners in this process including public housing residents, housing authority administrators, community health workers, tenant associations, and academic investigators. The advisory process has evolved from an initial small steering group to our current institutional community advisory boards. Our decade-long CBPR journey produced design innovations, promising preliminary outcomes, and a full-scaled implementation study in two states. Challenges include sustaining engagement with evolving study partners, maintaining equity and power in the partnerships, and long-term sustainability of the intervention. Implications include applicability of the framework with other CBPR partnerships, especially scaling up evolutionary grassroots involvement to multi-regional partnerships.

Lersivirine is a potent non-nucleoside reverse transcriptase inhibitor with exceptional mutant resilience. Here, we compare the pharmacological and pharmacokinetic profile of lersivirine with its pyrazole and imidazole isomers and briefly explore the profile of these series. This work establishes lersivirine as the outstanding molecule in this set.

The stereoelectronic features of the pentacyclic phosphane (1S,4R,4aS,5aR,6R,9S,9aS,10aR)-4,6,11,11,12,12-hexamethyl-10-phenyldodecahydro-1,4:6,9-dimethanophenoxaphosphinine (phenop) have been explored through a range of empirical methods including single-crystal X-ray structure determinations of the sulfide derivative phenopS (1), the selenide phenopSe (2), [Fe(CO)4(κ1-phenop)] (3), [W(CO)5(κ1-phenop)] (4) and trans-[Rh(κ1-phenop)(CO)Cl] (5). Cone angles derived from the structural data range from 164–203° with the smaller values being observed for the compounds possessing a phenyl group that is orthogonal to the P–Z bond and the larger values for the compounds expressing a parallel phenyl ring orientation. The cone angle data suggest a moderately bulky phosphane comparable, in steric terms, to PCy3. This is further borne out on inspection of the M–P bond lengths which tend towards the longer end of the known scale. Some flexibility is observed in the central ring which approximates to a boat conformation at one extreme and an envelope at the other depending on the nature of the P-substituent. The electronic properties of κ1-phenop have been assessed using a combination of infrared and NMR spectroscopy. The absolute value of the one-bond coupling constants 1JP-Se and 1JP-Rh are very close to those reported for PPh3, suggesting a close analogy between κ1-phenop and the well known triphenylphosphane. In addition, relevant υ(CO) stretches in the IR spectra of the metal carbonyl complexes also closely mimic those for the analogous complexes containing PPh3. These conclusions are supported by molecular electrostatic potential calculations at the DFT level which place phenop close to PPh3 in terms of lone pair availability

Introduction In recent years, the American College of Rheumatology (ACR) has focused increasingly on the development, review, dissemination, and implementation of quality measures. To help position rheumatology providers as the leading force in defining the quality of rheumatology care, the ACR convened a Quality Measures White Paper Development Workgroup. This diverse workgroup’s charge included synthesizing the information most relevant to the ACR membership regarding quality measurement. As described in this manuscript, the workgroup ultimately participated in a consensus development initiative to craft a set of criteria for quality measures submitted to the ACR for approval. The criteria are intended to guide measure developers and discourage adoption of subpar measures. This White Paper is written for rheumatologists interested in quality measurement, groups undertaking quality measure development, and policy makers. It is organized into the following main sections: a brief introduction provides context and describes the ACR’s national role and positions; section 1 outlines quality measure domains and reviews measure attributes; and section 2 describes and reports results of an ACR workgroup–led process to develop specific criteria for ACR approval of quality measures.

Purpose: Middle school has been identified as the prime age group to begin nursing recruitment efforts because students have malleable perceptions about nursing as a future career choice. The purpose of this integrative review is to present a brief overview of research processes related to middle school students’ perceptions of nursing as a future career choice and to critically evaluate the current instruments used to measure middle and high school students’ perceptions of nursing as a career choice. Design: An integrative review of the years 1989 to 2009 was conducted searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), National Library of Medicine PubMed service (PubMed), and Ovid MEDLINE databases using the key words career, choice, future, ideal, nursing, and perception. Reference lists of retrieved studies were hand searched, yielding a total of 22 studies. Methods: Inclusion criteria were (a) sample of middle school students, (b) sample of high school students, (c) mixed sample including middle or high school students, and (4) samples other than middle or high school students if the instrument was tested with middle or high school students in a separate study. Ten studies met these criteria. Findings: Of the 10 studies, samples were 30% middle school students; 40% high school students; 10% mixed, including school-aged students; and 20% college students with an instrument tested in middle school students. Eighty percent of participants were White females. Overall, participants’ socioeconomic status was not identified. A single study included a theoretical framework. Five instruments were identified and each could be completed in 15 to 30 min. The most commonly used instrument is available free of charge. Seventy percent of the studies used Cronbach's α to report instrument reliability (0.63 to 0.93), whereas 30% failed to report reliability. Fifty percent of the studies established validity via a “panel of experts,” with three of those studies further describing the panel of experts. Conclusions: Samples of white females may hinder generalization. Socioeconomic status was not consistently reported and may be an important factor with regard to perceptions of nursing as a career choice. An overall absence of theoretical framework hinders empirical data from being applied to nursing theories that in turn may support nursing concepts. The reporting of reliability and validity may be improved by further defining panel of experts and expanding the number of experts (more than seven). More in-depth evaluation of the psychometric properties of the instruments with more diverse populations is needed. Clinical Relevance: Rigorously tested instruments may be useful in determining middle school students’ perceptions about nursing. Therefore, future researchers should consider testing existing instruments in the middle school population, adhering to theoretical frameworks, diversifying the sample population, and clearly reporting reliability and validity to gain knowledge about middle school students’ perceptions about a nursing career.

Partitioning evapotranspiration into its evaporation and transpiration components is critical for understanding ecohydrologic processes in drylands. Existing partitioning estimates, however, have not adequately accounted for the heterogeneity associated with woody plant canopy patches and intercanopy patches so characteristic of dryland ecosystems. We measured water contents, stable isotopes (δ 2 H and δ 18 O), Cl − , and NO 3 − from core samples collected during an intense drought in canopy and intercanopy patches in a semiarid, pinon–juniper [ Pinus edulis Engelm.– Juniperus monosperma (Engelm.) Sarg.] woodland in northern New Mexico to assess patch-scale heterogeneity and evapotranspiration partitioning. Soil zone residence times based on Cl − ranged from 6 to 37 yr, highlighting the long time scale of percolation in these woodlands. The average NO 3 − concentration was nearly seven times lower in canopy patches, indicating substantial biogeochemical heterogeneity. Average δ 2 H values from shallow soil ( − inventories in canopy patches indicate up to four to six times more total evapotranspiration. Taken together, lower evaporation and greater evapotranspiration suggest that canopy patches have substantially larger transpiration rates and lower evaporation/transpiration ratios than intercanopy patches. Our results support a basic but untested conceptual model of patch connectivity where woody plants utilize substantial amounts of intercanopy water that has been redistributed from intercanopy to canopy patches via hydraulic gradients created by root uptake—a finding not generally modeled but potentially relevant to globally extensive patchy-structured drylands.

The effects of vegetation root distribution on near-surface water partitioning can be two-fold. On the one hand, the roots facilitate deep percolation by root-induced macropore flow; on the other hand, they reduce the potential for deep percolation by root-water-uptake processes. Whether the roots impede or facilitate deep percolation depends on various conditions, including climate, soil, and vegetation characteristics. This paper examines the effects of root distribution on deep percolation into the underlying permeable bedrock for a given soil profile and climate condition using HYDRUS modelling. The simulations were based on previously field experiments on a semiarid ponderosa pine (Pinus ponderosa) hillslope. An equivalent single continuum model for simulating root macropore flow on hillslopes is presented, with root macropore hydraulic parameterization estimated based on observed root distribution. The sensitivity analysis results indicate that the root macropore effect dominates saturated soil water flow in low conductivity soils (Kmatrix below 10 � 7 m/s), while it is insignificant in soils with a Kmatrix larger than 10 � 5 m/s, consistent with observations in this and other studies. At the ponderosa pine site, the model with simple rootmacropore parameterization reasonably well reproduces soil moisture distribution and some major runoff events. The results indicate that the clay-rich soil layer without root-induced macropores acts as an impeding layer for potential groundwater recharge. This impeding layer results in a bedrock percolation of less than 1% of the annual precipitation. Without this impeding layer, percolation into the underlying permeable bedrock could be as much as 20% of the annual precipitation. This suggests that at a surface with low-permeability soil overlying permeable bedrock, the root penetration depth in the soil is critical condition for whether or not significant percolation occurs. Copyright  2010 John Wiley & Sons, Ltd.

Vocalizations between pairs of adult female “Gothic-arch” squirrel monkeys were tape-recorded, along with identification of the vocalizer and social context. The major purpose the study was to identify and describe acoustic characteristics of certain call types, and to attempt to correlate these characteristics with social context. The call type analyzed in this paper was the Twitter or Trill, an FM sound containing a limited set of repeated sound elements. Spectrographic analysis of these elements, or “syllables”, revealed that all Twitters were made up of a subset of the same 12 syllable types. Certain rules were identified which determine the sequential position of each syllable type in a Twitter. Syllable usage varied between individuals and with changes in social context.

Objective This retrospective study was conducted to evaluate the outcome for cattle with diaphyseal fractures of the femur, but not including capital physeal injuries. Methods Sources of information were medical records of cattle having a definitive diagnosis of diaphyseal femoral fractures and telephone survey of owners. Results Medical records for 26 cattle with femoral fracture were found; of the 20 aged less than 2 months, 15 were treated surgically, 4 conservatively (stall rest) and 1 was euthanased without treatment. The surgical treatment varied according to the configuration of the fracture and the surgeon's experience. Surgery for mid-diaphyseal fractures had a significantly better surgical outcome then distal diaphyseal fractures (P

Objective To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications. Methods A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites. Results PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001). Conclusion The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.

Background Sleep disorders are common in individuals with neurodevelopmental disorders and may adversely affect daytime functioning. Children with Williams syndrome have been reported to have disturbed sleep; however, no studies have been performed to determine if these problems continue into adolescence and adulthood. Methods This study examined overnight sleep patterns and daytime sleepiness in 23 adolescents and adults with Williams syndrome age 25.5 (8.0) years [mean (SD)]. Interviewer-administered sleep questionnaires were used to evaluate nighttime sleep behaviours and daytime sleepiness. Wrist actigraphy was used to evaluate sleep patterns. Results Although individuals in our sample averaged 9 h in bed at night, daytime sleepiness and measures of sleep disruption were common and comparable to those of other populations with neurodevelopmental disorders. These measures included reduced sleep efficiency [74.4 (7.0)%] with prolonged sleep latency [37.7 (37.3) min], increased wake time after sleep onset [56.1 (17.6) min], and an elevated movement and fragmentation index [14.3 (4.6)]. Conclusion Adolescents and young adults with Williams syndrome were found to be sleepy despite averaging 9 h in bed at night. Implications are discussed for associated causes of sleep disruption and future polysomnographic evaluation.

Summary objectives To assess the efficacy of amodiaquine-artesunate in an area with high chloroquine resistance in western Kenya. methods Twenty-eight day in-vivo efficacy trial of amodiaquine-artesunate in 103 children aged 6‐59 months in western Kenya with smear-confirmed uncomplicated Plasmodium falciparum malaria. results The 28-day uncorrected adequate clinical and parasitological response (ACPR) was 69.0%, with 15.5% Late Clinical Failure and 15.5% Late Parasitologic Failure rates. The PCR-corrected 28-day ACPR was 90.2%. Clinical risk factors for recurrent infection (recrudescences and reinfections) were lower axillary temperature at enrolment and low weight-for-age Z-score. The presence of single nucleotide polymorphisms pfcrt 76T and pfmdr1 86Y at baseline was associated with increased risk of recurrent infections, both reinfections and recrudescences. conclusion Although artemether-lumefantrine (Coartem � ) is the first line ACT in Kenya, amodiaquine-artesunate is registered as an option for treatment of uncomplicated P. falciparum and remains an

Objective To measure how rheumatologists across our health system performed with the American College of Rheumatology (ACR) quality indicators (QIs) for rheumatoid arthritis (RA) and methotrexate (MTX) drug safety, and to develop opportunities for improvement. Methods An electronic health record (EHR) review of 1,062 unique RA patients seen by 15 rheumatologists in a 1-year period was performed. Percentage of each QI met, reasons why the metric was not met, and performance of rheumatologists based on years of experience were evaluated. Results The percentage met was high for QI-2 (RA disease-modifying antirheumatic drug use; 94%), QI-3 (intervention if RA worse; 85%), and QI-4 (MTX risks discussion; 87%). Percentage met was lower for QI-1 (RA core data set; 69%), QI-5 (MTX baseline studies; 41%), and QI-6 (MTX followup studies; 46%). QI-1 and QI-5 were low due to most physicians missing a single test, and QI-6 was low because of few physicians driving the percentage down. Better QI performance was seen in rheumatologists with ≤10 years versus >10 years of experience for QI-1 (90% versus 64%; odds ratio [OR] 4.21, P = 0.004) and QI-3 (96% versus 82%; OR 4.47, P = 0.019). EHR chart review for this population required 179.3 hours. Conclusion Measurement allows us to better understand the quality of care that we deliver. In this systematic benchmarking of the ACR QIs in a large RA cohort, performance was excellent in RA treatment–related QIs. Significant variability was noted in RA and MTX monitoring measures, which can be addressed using process redesign techniques.

Soil water dynamics reflect the integrated effects of climate conditions, soil hydrological properties and vegetation at a site. Consequently, changes in tree density can have important ecohydrological implications. Notably, stand density in many semi-arid forests has increased greatly because of fire suppression, such as that in the extensive ponderosa pine (Pinus ponderosa Laws.) forests that span much of western USA. Few studies have quantified how soil water content varies in low- versus high-density stands both by depth and years, or the inter-relationships between water content, stand density, and ecohydrological processes. Over a 4-year period, we measured the soil water content throughout the soil profiles in both low-density (250 trees/ha) and high-density (2710 trees/ha) ponderosa pine stands. Our results document significantly greater soil water contents in the low-density stands over a wide range of conditions (wet, dry, winter, summer). We observed substantial differences in water contents at depths greater than are typically measured. Our results also show that differences in monthly average soil water contents between the low- and high-density stands fluctuated between 0·02 and 0·08 m3 m−3 depending on the time of year, and reflect a dynamic coupling between infiltration and stand evapotranspiration processes. The difference in soil water availability between low- and high-density stands is substantially amplified when expressed as plant-available water on a per tree, per biomass or per leaf area basis. Our findings highlight important ecohydrological couplings and suggest that restoration and monitoring plans for semi-arid forests could benefit from adopting a more ecohydrological focus that explicitly considers soil water content as a determinant of the ecosystem process. Copyright © 2008 John Wiley & Sons, Ltd.

Pharmacotherapies to lower blood pressure and cholesterol are effective in the primary prevention of cardiovascular disease (CVD). The use of fixed-dose medication combinations has not been well studied. The authors created a Markov model to analyze the cost-effectiveness of 4 fixed-dose medications for primary CVD prevention in men. The initial decision node was to treat or not treat men older than 55 years, without CVD, hypertension, or dyslipidemia with a combination of simvastatin, captopril, hydrochlorothiazide, and atenolol. Probability, costs, and effectiveness were derived from the literature. The outcome variable was marginal cost per quality-adjusted life-year (QALY). Sensitivity analyses were performed. The average cost of treatment was $70,000 compared with $93,000 for non-treatment. Treatment resulted in 13.62 QALYs vs 12.96 QALYs without treatment. Primary prevention of CVD with fixed-dose medications dominated "no-treatment." The use of a fixed-dose polypharmacy approach to CVD prevention in men older than 55 years may be cost-effective.

A major problem associated with non-nucleoside reverse transcriptase inhibitors (NNRTIs) for the treatment of HIV is their vulnerability to mutations in the allosteric binding site of reverse transcriptase that can result in the development of a resistant virus. Herein we present the optimization of a series of 5-aryloxy imidazoles, which possess a balanced pharmacological profile against both wild-type enzyme and the clinically relevant mutations K103N and Y181C. Subtle structural changes were used to probe structure-activity relationships relating to both potency and metabolic stability, which led to an imidazole derivative with an impressive overall profile.

A set of four unconfined (earthen-walled) lysimeters in the San Dimas Experimental Forest near Los Angeles, CA, provides a unique opportunity to examine the effect of species-level vegetation on root zone hydrology under highly controlled experimental conditions. The 28.1-m 2 by 2.1-m deep lysimeters were specifically designed to minimize variation of all environmental conditions except vegetation. Monocultures of buckwheat ( Eriogonum fasciculatum Benth. var. foliolosum Nutt.), chamise ( Adenstomata fasciculatum Hooke & Arn.), scrub oak ( Quercus dumosa Nutt.), and Coulter pine ( Pinus coulteri D. Don.) were planted in 1946. In 1997 two sets of soil cores were sampled from each lysimeter to evaluate species level effects resulting from 50 yr of growth. The cores were analyzed for water content, soil water potential, and pore water chloride. The chloride mass balance approach was used to estimate long-term average fluxes and residence times of water in the lysimeters. One core from each lysimeter was also analyzed for pore water stable isotope (δ 2 H) composition. Only small differences were observed between the four species in terms of the shapes of the depth profiles and the absolute values of the hydrologic characteristics and fluxes. However, some differences were statistically significant. For example, differences in some characteristics were found between the chamise and the other species. We also observed differences between the lowest aboveground biomass group (buckwheat and chamise) versus the highest aboveground biomass group (oak and pine). These results suggest that although species- and biomass-level differences in root zone hydrologic behavior appear to be minor, there are detectible differences in how these vegetation types affect the water budget in chaparral ecosystems.

A microchip device is demonstrated for the electrophoretic separation and UV-absorbance spectral detection of four toxic alkaloids: colchicine, aconitine, strychnine, and nicotine. A fused-silica (quartz) microchip containing a simple cross geometry is utilized to perform the separations, and a miniature, fiber-optic CCD spectrometer is coupled to the microchip for detection. Sensitive UV-absorbance detection is achieved via the application of online preconcentration techniques in combination with the quartz microchip substrate which contains an etched bubble-cell for increased pathlength. The miniature CCD spectrometer is configured to detect light between 190 and 645 nm and LabView programming written in-house enables absorbance spectra as well as separations to be monitored from 210 to 400 nm. Consequently, the configuration of this microchip device facilitates qualitative and quantitative separations via simultaneous spatial and spectral resolution of solutes. UV-absorbance limits of quantification for colchicine, 20 microM (8 mg/L); strychnine, 50 microM (17 mg/L); aconitine, 50 microM (32 mg/L); and nicotine, 100 microM (16 mg/L) are demonstrated on the microchip. With the exception of aconitine, these concentrations are > or =20-times more sensitive than lethal dose monitoring requirements. Finally, this device is demonstrated to successfully detect each toxin in water, skim milk, and apple juice samples spiked at sublethal dose concentrations after a simple, SPE procedure.

CE is a promising technique for the investigation of molecular interactions because it affords evaluation of multiple interaction modes, does not require immobilization of molecules, and has no dead time. In order to perform these investigations, numerous methods have been developed for determining binding constants and other thermodynamic parameters. These methods have been reviewed extensively in recent years. However, methods for determining the rates of reaction are less prolific. Nonetheless, numerous theoretical and experimental advances have been made in recent years to address this discrepancy. Some of these methods employ computer simulations to determine first-order or second-order rate constants numerically, whereas other methods calculate rate constants directly as solutions to analytical equations. It is the object of this review to provide descriptions of these methods in terms of their underlying assumptions, experimental methodology, calculation of rate constants, and inherent limitations.

Outfalls from high explosives (HE) production facilities at Los Alamos National Laboratory discharged HE-contaminated waters onto a semiarid mesa on the Pajarito Plateau for about 50 yr. As part of an initial hydrogeologic characterization to examine the impact of HE contamination, four boreholes were drilled into the vadose zone to depths between 38.1 and 63.3 m. The study objectives were to characterize contaminant nature and extent and to identify potential source areas and transport pathways. Besides providing an example of HE transport in the vadose zone, this study shows the value of integrating chloride and stable isotope tracer approaches with contaminant distribution information, and it provides insights on semiarid vadose zone behavior in the little studied, but widespread ponderosa pine forests of the American Southwest. Chloride-based vadose zone residence time estimates (1950–6080 yr) suggest that downward flow and transport over much of the mesa is limited. However, the presence of HE-contaminated transient saturated zones in two boreholes indicates that localized fast pathways also occur. Stable isotope data (δ18O and δD) suggest that the source areas for contamination are former HE outfall discharge ponds that provide focused recharge to the transient saturated zones.