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Accurate equilibrium reconstruction and detailed stability analysis of a strongly shaped, double-null, βT=11% discharge shows that the plasma core is in the second stable regime to ideal ballooning modes. The equilibrium reconstruction using all the available data (coil currents, poloidal magnetic loops, motional Stark effect data, the kinetic pressure profile, the magnetic axis location, and the location of the two q=1 surfaces) shows a region of negative magnetic shear near the magnetic axis, an outer positive shear region, and a low shear region connecting the two. The inner negative shear region allows a large positive shear region near the boundary, even at low q (q95=2.6), permitting a large outer region pressure gradient to be first regime stable. The inner region is in the second stable regime, consistent with the observed axial beta [βT(0)=44%]. In the low shear region p′ vanishes, consistent with Mercier stability. This is one way to extend the ballooning limit in shaped plasmas while maintaining stability against external kinks. The n=1 analysis shows that the plasma is unstable to an ideal internal mode, consistent with the experimental observations of a saturated internal m/n=l/l mode. The core plasma pressure, not being limited by ballooning stability, appears to be reaching a local equilibrium limit at the magnetic axis. © 1992 American Institute of Physics.

BackgroundPeripheral artery disease (PAD) affects 8 to 10 million Americans, who face significantly elevated risks of both mortality and major limb events such as amputation. Unfortunately, PAD is relatively underdiagnosed, undertreated, and underresearched, leading to wide variations in treatment patterns and outcomes. Efforts to improve PAD care and outcomes have been hampered by persistent difficulties identifying patients with PAD for clinical and investigatory purposes. ObjectiveThe aim of this study is to develop and validate a model-based algorithm to detect patients with peripheral artery disease (PAD) using data from an electronic health record (EHR) system. MethodsAn initial query of the EHR in a large health system identified all patients with PAD-related diagnosis codes for any encounter during the study period. Clinical adjudication of PAD diagnosis was performed by chart review on a random subgroup. A binary logistic regression to predict PAD was built and validated using a least absolute shrinkage and selection operator (LASSO) approach in the adjudicated patients. The algorithm was then applied to the nonsampled records to further evaluate its performance. ResultsThe initial EHR data query using 406 diagnostic codes yielded 15,406 patients. Overall, 2500 patients were randomly selected for ground truth PAD status adjudication. In the end, 108 code flags remained after removing rarely- and never-used codes. We entered these code flags plus administrative encounter, imaging, procedure, and specialist flags into a LASSO model. The area under the curve for this model was 0.862. ConclusionsThe algorithm we constructed has two main advantages over other approaches to the identification of patients with PAD. First, it was derived from a broad population of patients with many different PAD manifestations and treatment pathways across a large health system. Second, our model does not rely on clinical notes and can be applied in situations in which only administrative billing data (eg, large administrative data sets) are available. A combination of diagnosis codes and administrative flags can accurately identify patients with PAD in large cohorts.

Sudden cardiac death has become a significant clinical concern when prescribing antipsychotic drugs, especially to older people with dementia. Sudden death syndrome has been known for decades to occur in association with taking first-generation antipsychotic medications, but it has become more prominent recently due to safety reviews about the use of second-generation antipsychotic medications. In 2005, the United States Food and Drug Administration disseminated information about cardiac fatalities, which led to black box warnings in second-generation, antipsychotic, drug-prescribing literature about higher mortality when administering to elderly persons with dementia-related psychoses. In this population, treatment results in death rates of 4.5 percent, as compared to 2.6 percent in subjects taking a placebo. Actually, patients treated with both the first- and second-generation versions experienced an increased incidence of fatalities. Before utilizing these agents, a careful workup must be completed. The presence of a psychosis or mania should be the only conventional indication for prescribing first- and second-generation antipsychotic medications. Physicians should always evaluate patients for comorbid conditions, especially heart disease and metabolic abnormalities, and all currently used medications to assure a risk-to-benefit ratio favoring the application of an antipsychotic medication. An electrocardiogram is a part of the evaluation of the cardiac status and determines the base line QT interval. While prescribing these medications in elderly patients, physicians must provide individualized clinical, electrocardiographic, and pharmaceutical monitoring. [ABSTRACT FROM AUTHOR]

A 34-year-old man with a seizure disorder had not been taking anticonvulsant medications regularly. A previous pattern of recurrent seizures resolved after restarting anticonvulsant drugs. Recent seizure episodes were followed by delirium and presentation of Capgras syndrome. A variety of functional and organic etiologies for Capgras syndrome are known. This syndrome has been documented in cases of postictal delirium. These symptoms along with delirium ended with seizure control once back on anticonvulsant medicines. [ABSTRACT FROM AUTHOR]

A 21-year-old man presented in a state of delirium with compulsive, pathologic laughter and no focal neurologic findings. Brain imaging revealed a lenticulostriate artery infarct of the caudate nucleus. The absence of neurological signs made the diagnosis difficult, but the presence of delirium was a clue to the existence of structural brain disease. [ABSTRACT FROM AUTHOR]

Persistent postural perceptual dizziness (PPPD) is a functional neurological disorder characterized by troublesome feelings of dizziness and might be precipitated by vestibular events, postural changes, psychopathologies, and/or a person's perceptual experiences. The diagnosis is confirmed by assessing a patient's history. A variety of psychiatric symptoms are associated with PPPD; anxiety and depression are the most common. Psychotherapy and pharmacotherapy can be clinically helpful in reducing psychiatric symptoms and dizziness. Early intervention improves prognosis., Competing Interests: DISCLOSURES: The authors have no conflicts of interest relevant to the contents of this article., (Copyright © 2023. Matrix Medical Communications. All rights reserved.)

Zeroing in on the right drug regimen requires a look at an agent's clinical benefits, tolerability profile, and risk of drug interactions, as well as the patient's comorbidities.

Background: Aging simulation games are established educational interventions to make older patients' perspectives noticeable, raise awareness about their needs, and positively influence attitudes toward older adults. Due to the COVID-19 pandemic restrictions imposed on education, we replaced a classroom-based aging simulation course with a simple online equivalent. This consisted of short introductory screencasts, four downloadable Portable Document Format (PDF) files containing issue-specific audio and video links, quizzes, case studies, and prompts for reflection. We explored how well our self-directed simple online simulation succeeded in providing students with relevant insights and experiences, raising awareness about age-related difficulties, and enhancing understanding of older patients., Methods: In this cross-sectional study, an anonymous post hoc online survey was conducted among 277 5th-year medical students eligible for the course at the Leipzig University in May 2020. The questionnaire addressed overall course evaluations, assessments of the individual PDF components (working enjoyment, personal insights, professional learning gain, enhanced understanding, increased interest in working with older patients), and students' main insights from the course (free text). Descriptive statistical and qualitative content analyses were performed., Results: The response rate was 92.4% (n = 256, mean age 25.7 ± 3.4 years, 59.8% women). Nearly all respondents reported that the course was well structured, easily understandable, and that processing was intuitive. The majority (82.8%) perceived the course as practice-oriented, 88.3% enjoyed processing, 60.3% reported having gained new professional knowledge, and 75.4% had new personal insights. While only 14.8% agreed that the online course could generally replace the real-world simulation, 71.1% stated that it enabled them to change their perspective and 91.7% reported enhanced understanding of older patients. PDF components containing audio and video links directly imitating conditions (visual or hearing impairment) were rated highest. Qualitative data revealed manifold insights on the part of the students, most frequently referring to aspects of professional doctor-patient interaction, knowledge about conditions and diseases, role reversal, and enhanced empathy., Conclusion: Simple online aging simulations may be suitable to provide students with relevant insights and enhance their understanding of older patients. Such simulations could be alternatively implemented in health professionals' education where resources are limited., (© 2022. The Author(s).)

In this work, an attempt was made to improve the corrosion resistance of dilute Fe-Al alloys (1.0 mass% Al) by preheating treatment at 1073 K in H 2 atmosphere. In comparison with pure Fe and unpreheated Fe-Al alloys, the resistance to oxidation at 673 K in pure O 2 and to electrochemical corrosion in 5 wt.% NaCl solution is significantly improved for preheated Fe-Al alloys. This improvement is attributed to the formation of a 20 nm thin, but dense Al 2 O 3 protective layer on the surface of preheated Fe-Al alloys.

Independent from initial severity, many patients develop persistent symptoms after infection with SARS-CoV-2, described as long COVID syndrome. Most of these patients are treated by general practitioners (GPs). As evidence-based treatment recommendations are still sparse, GPs must make their therapy decisions under uncertainty. We investigated (1) the most frequently observed long COVID symptoms in general practices and (2) GPs' applied treatment and rehabilitation plans for these symptoms. In total, 143 German GPs participated in an online-based survey between 05/2021 and 07/2021. We found that each GP practice was treating on average 12 patients with long COVID symptoms. Most frequently seen symptoms were fatigue and reduced performance. Current therapy options were rated as poor and loss of smell and taste, fatigue, or lack of concentration were perceived to be especially difficult to treat. The use of drug and non-drug therapies and specialist referrals focused primarily on physiological and less on psychosomatic/psychological rehabilitation and followed guidelines of similar conditions. Our results provide first insights into how GPs approach a newly emerging condition in the absence of guidelines, evidence-based recommendations, or approved therapies, and might inform about GP preparedness in future pandemics. Our results also emphasize a gap between the current knowledge of the long COVID manifestation and knowledge about effective rehabilitation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Schrimpf, Braesigk, Lippmann and Bleckwenn.)

Background: Among the various factors identified as relevant for primary care career choice, financial considerations have been consistently shown to have an impact. In Germany, reliable and easily understandable information on physicians' earning opportunities in self-employed settings is difficult to obtain for medical students, leading to substantial misperceptions that may negatively affect respective career considerations. This study investigated medical students' evaluation of a 45-min evidence-based workshop on earning opportunities, workload and job satisfaction in different specialties and settings to examine its effect on the perceived attractiveness of working self-employed and working in general practice., Methods: The workshop was implemented as part of a mandatory general practice clerkship in the fourth study year (of six). Post-hoc evaluations of all participants between October 2017 and September 2018 (one cohort) were analysed cross-sectionally including descriptive statistics, subgroup comparisons and qualitative analysis of free-text answers regarding students' main insights., Results: Response rate was 98.1% (307/313). Participants were on average 25.0 years old, and 68.3% were women. Based on a ten-point scale ranging from 1 = 'no influence' to 10 = 'very big influence', 91.9% confirmed at least some (> = 2) and 57.3% a rather high (> = 5) influence of earning expectations on their career choice process. Regarding the workshop, 86.1% were overall satisfied, and 89.5% indicated they had gained new insights, primarily regarding earning opportunities in different specialties and work settings, and frequently regarding job satisfaction, workload and the structure of revenues and expenditures in a doctor's office (according to qualitative analysis). In the opinion of 89.8% of students, the provided learning content should be part of the undergraduate curriculum. More than half of participants reported an increase regarding the attractiveness of working self-employed and working as a general practitioner, most frequently regarding earning opportunities, but also in general and in respect to job satisfaction, cost-benefit ratio and workload. This increase was significantly higher among students favouring or at least considering a general practice career., Conclusions: The workshop and its content were appreciated by the students and showed clear potential to usefully complement undergraduate curricula aiming at increasing or reinforcing students' interest in working self-employed and working in general practice., (© 2022. The Author(s).)

The COVID-19 pandemic affected regular health care for patients with chronic diseases. However, the impact of the pandemic on primary care for patients with coronary artery disease (CAD) who are enrolled in a structured disease management program (DMP) in Germany is not clear. We investigated whether the pandemic affected primary care and health outcomes of DMP-CAD patients ( n = 750) by using a questionnaire assessing patients' utilization of medical care, CAD symptoms, as well as health behavior and mental health since March 2020. We found that out of concern about getting infected with COVID-19, 9.1% of the patients did not consult a medical practitioner despite having CAD symptoms. Perceived own influence on infection risk was lower and anxiety was higher in these patients compared to symptomatic CAD patients who consulted a physician. Among the patients who reported chest pain lasting longer than 30 min, one third did not consult a medical practitioner subsequently. These patients were generally more worried about COVID-19. Patients with at least one worsening CAD symptom (chest pain, dyspnea, perspiration, or nausea without apparent reason) since the pandemic showed more depressive symptoms, higher anxiety scores, and were less likely to consult a doctor despite having CAD symptoms out of fear of infection. Our results provide evidence that the majority of patients received sufficient medical care during the COVID-19 pandemic in Germany. However, one in ten patients could be considered particularly at risk for medical undersupply and adverse health outcomes. The perceived infection risk with COVID-19 might have facilitated the decision not to consult a medical doctor., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Maehl, Bleckwenn, Riedel-Heller, Mehlhorn, Lippmann, Deutsch and Schrimpf.)

Introduction: Post stroke management has moved into the focus as it represents the only way to secure acute treatment effects in the long term. Due to individual courses, post stroke management appears rather challenging and is hindered by existing barriers between treatment sectors. As a novel concept, the PostStroke-Manager combines digital and sensor-based technology with personal assistance to enable intersectoral cooperation, best possible reduction of stroke-related disability, optimal secondary prevention, and detection of physical and psychological comorbidities., Methods: This prospective single-center observational study aims to investigate the feasibility of the PostStroke-Manager concept in an outpatient setting. Ninety patients who have suffered an ischemic or hemorrhagic stroke or transient ischemic attack will be equipped with a tablet and mobile devices recording physical activity, blood pressure, and electrocardiographic signals. Through a server-based platform, patients will be connected with the primary care physician, a stroke pilot and, if necessary, other specialists who will use web-based platforms. Via the tablet, patients will have access to an application with 10 newly designed components including, for instance, a communication tool, medication schedule, medical records platform, and psychometric screenings (e.g., depression, anxiety symptoms, quality of life, adherence, cognitive impairment). During the 1-year follow-up period, clinical visits are scheduled at three-month intervals. In the interim, communication will be secured by an appropriate tool that includes text messenger, audio, and video telephony. As the primary endpoint, feasibility will be measured by a 14-item questionnaire that addresses digital components, technical support, and personal assistance. The PostStroke-Manager will be judged feasible if at least 50% of these aspects are rated positively by at least 75% of patients. Secondary endpoints include feedback from professionals and longitudinal analyses on clinical and psychometric parameters., Perspective: This study will answer the question of whether combined digital and personal support is a feasible approach to post stroke management. Furthermore, the patient perspective gained regarding digital support may help to specify future applications. This study will also provide information regarding the potential use of remote therapies and mobile devices in situations with limited face-to-face contacts., Trial Registration: German Register for Clinical Trials ( DRKS00023213 .), registered 27 April 2021., (© 2021. The Author(s).)

Competing Interests: Funding/financial disclosures.: The authors have no conflict of interest relevant to the content of this letter. No funding was received for the preparation of this letter.

Background: Peripheral artery disease (PAD) is underrecognized, undertreated, and understudied: each of these endeavors requires efficient and accurate identification of patients with PAD. Currently, PAD patient identification relies on diagnosis/procedure codes or lists of patients diagnosed or treated by specific providers in specific locations and ways. The goal of this research was to leverage natural language processing to more accurately identify patients with PAD in an electronic health record system compared with a structured data-based approach., Methods: The clinical notes from a cohort of 6861 patients in our health system whose PAD status had previously been adjudicated were used to train, test, and validate a natural language processing model using 10-fold cross-validation. The performance of this model was described using the area under the receiver operating characteristic and average precision curves; its performance was quantitatively compared with an administrative data-based least absolute shrinkage and selection operator (LASSO) approach using the DeLong test., Results: The median (SD) of the area under the receiver operating characteristic curve for the natural language processing model was 0.888 (0.009) versus 0.801 (0.017) for the LASSO-based approach alone (DeLong P <0.0001). The median (SD) of the area under the precision curve was 0.909 (0.008) versus 0.816 (0.012) for the structured data-based approach. When sensitivity was set at 90%, the precision for LASSO was 65% and the machine learning approach was 74%, while the specificity for LASSO was 41% and for the machine learning approach was 62%., Conclusions: Using a natural language processing approach in addition to partial cohort preprocessing with a LASSO-based model, we were able to meaningfully improve our ability to identify patients with PAD compared with an approach using structured data alone. This model has potential applications to both interventions targeted at improving patient care as well as efficient, large-scale PAD research. Graphic Abstract: A graphic abstract is available for this article.

Migraine headaches remain a significant medical concern; lots of people are adversely affected. Many existing pharmacotherapies have disappointing results. The pathophysiology is related to calcitonin gene-related peptide (CGRP) pathways. There is hope for better efficacy from the now-available CGRP inhibitor drugs made available to patients suffering these cephalgias., Competing Interests: FUNDING:No funding was provided for this study. DISCLOSURES:The author has no conflicts of interest relevant to the content of this article., (Copyright © 2020. Matrix Medical Communications. All rights reserved.)

Background: Several studies report a substantial impact of financial considerations on the process of specialty choice and the willingness to establish one's own practice. In Germany, reliable information on self-employed physicians' earning opportunities is basically available, but not easily accessible and understandable for medical students. Misperceptions might contribute to recruitment problems in some fields, particularly in general practice. In order to identify a possible need for action, we investigated current German medical students' level of information regarding future earnings, and whether net earnings of general practitioners and other physicians working self-employed are estimated realistically. Additionally, we explored students' self-assessments regarding the extent of the impact of expected earnings on their personal career choice process., Methods: We conducted a cross-sectional questionnaire survey among fourth year (of six) medical students at one medical school (Leipzig). The participants estimated the net earnings of different physicians working self-employed. These estimations were compared with actual earnings data derived from a large German practice panel., Results: Response rate was 73.6% (231/314). The participants' mean age was 24.9 years and 59.1% were women. On a 10-point scale ranging from 1 = 'no influence' to 10='very big influence', 92.6% of the participants described at least some (≥2) influence of earning expectations on their career choice process, and 66.2% stated this influence to be 5 or higher. Every fourth student (26.4%) would rather or definitely reject a certain specialty because of expected low earning opportunities. While 60.4% had already thought about future earnings, only 26.8% had obtained concrete information. Compared with the data derived from the practice panel, the participants substantially underestimated the earning opportunities in self-employed settings, including general practice (median: 4500 vs. 6417€). However, depending on the single estimations, between 87.7 and 95.6% of the students stated they were 'rather uncertain' or 'very uncertain' regarding their estimations., Conclusions: Despite confirming a relevant impact of financial considerations on career choice, German fourth year medical students are not well informed about earning opportunities in self-employed settings. Providing easily understandable information could enhance transparency and might help students to consider financial issues of career choice on a realistic basis.

Objectives: This study investigates students' adoption of LeiKA, a new extracurricular longitudinal general practice (GP) teaching project. LeiKA aims to attract a broad range of students, not only those who are already planning to become GPs. This study compares participants' and non-participants' characteristics, career preferences and job-related value orientations to assess the programme's initial potential to increase the number of students subsequently entering GP careers. Additionally, students' motives for taking part in the programme were explored., Design: We analysed administrative data and data from a cross-sectional questionnaire survey for the first three cohorts. LeiKA participants were compared with non-participants regarding baseline characteristics, career intentions and attitudes associated with GP careers. There was also a qualitative analysis of the reasons for taking part., Setting: Faculty of Medicine, University of Leipzig, Germany., Participants: First-semester medical students in the years 2016-2018., Results: In the first 3 years, 86 of 90 LeiKA slots were taken, 9.0% (n=86/960) of those eligible to apply. LeiKA participants were a mean of 0.6 years older (LeiKA: 21.5 vs whole cohort: 20.9 years, p<0.001) and slightly more interested in long-term doctor-patient relationships (3.6 vs 3.3, scale from 1 'unimportant' to 5 'very important', p=0.018), but did not differ regarding other characteristics and attitudes. Although more participants definitely favoured a GP career (13.1% vs 4.9%, p=0.001), it was a possible option for most students in both groups (78.6% vs 74.0%). Early acquisition of skills and patient contact were the main motives for taking part, stated by 60.7% and 41.7% of the participants, respectively., Conclusions: The extracurricular programme was taken up by a broad range of students, indicating its potential to attract more students to become GPs. The reasons for taking part that we identified may guide the planning of other similar projects., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

From awareness to advocacy, here's what you need to know to prevent burnout from taking hold.

Children who are inadequately treated for depression often experience greater dysfunction. Problems can include conduct disorders, substance abuse, physical illness, and poor performance at school, work, or in psychosocial contexts. Depression can lead to a greater risk of suicide. Suicide is the third most common cause of death among adolescents, with more than 500,000 attempts made by children each year. Suicide is the third most frequent cause of death among young people ages 10 to 19 years old. Thus, proper treatment is important. Major depressive disorder in adolescents is often followed by frequent recurrences in adulthood. Imaging studies document underactivity in the left dorsolateral prefrontal cortex in subjects suffering from depression. Activation of the brain with high-frequency transcranial magnetic stimulation increases neuronal excitability and induces the growth of new connections. Though larger, randomized, controlled trials with more patients and longer follow-up are needed, the favorable side effect profile and efficacy of TMS seen so far in the literature support the use of TMS as a therapeutic intervention in children and adolescents with depression., Competing Interests: FUNDING:No funding was provided for this study. DISCLOSURES:The authors have no conflicts of interest relevant to the content of this article., (Copyright © 2019. Matrix Medical Communications. All rights reserved.)