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Проведено исследование вязкости суспензий, применяемых при литье по выплавляемым моделям, как одного из самых важных свойств. Представлены результаты измерений вязкости суспензии на основе этилсиликата и плавленого кварца разных фирм-производителей. В ходе работы сделаны выводы о необходимости проведения входного контроля суспензий на литейных предприятиях.

The work is devoted to studying of possibility to manufacture cast ball valves of sucker rod oil pumps instead of those manufactured by the powder metallurgy method from Stellite 20 alloy. It is shown that Stellite 20 cast alloy includes about 20% μ and σ brittle phases, destruction whereof, in case of impact-abrasion wear, when excavating oil, leads to quick failure of the valve pair. A new cast cobalt alloy not containing brittle phases has been developed instead of Stellite 20 alloy, which allowed to improve wear resistance of cast valve pairs to the level of valves produced by the powder metallurgy method.

OBJECTIVE To improve outcomes of patients with adult type 2 diabetes by decreasing HbA1c undertesting, reducing the proportion of patients with poor glycemic control, and lowering mean HbA1c levels using a quality improvement (QI) program. RESEARCH DESIGN AND METHODS Six years of outpatient electronic health record (EHR) data were analyzed for care gaps before and 2 years after implementing a QI initiative in an urban academic medical center. QI strategies included 1) individual provider and departmental outcome reports, 2) patient outreach programs to address timely follow-up care, 3) a patient awareness campaign to improve understanding of achieving clinical goals, 4) improving EHR data capture to improve population monitoring, and 5) professional education. RESULTS Analysis (January 2010 to May 2018) of 7,798 patients from Tulane Medical Center (mean age 61 years, 57% female, 62% black, 97% insured) with 136,004 visits showed target improvements. A Cox proportional hazards model controlling for age, sex, race, and HbA1c level showed a statistically significant reduction in HbA1c undertesting >6 months (hazard ratio 1.20 ± 0.07). Statistical process control charts showed 15.5% relative improvement in the patient proportion with HbA1c >9% (75 mmol/mol) from 13% to 11% (P < 10−6) following QI interventions and a 2.1% improvement of population mean HbA1c from 7.4% (57 mmol/mol) to 7.2% (55 mmol/mol) (P < 10−6). CONCLUSIONS Multidisciplinary QI teams using EHR data to design interventions for providers and patients produced statistically significant improvements in both care process and clinical outcome goals.

Resistance to thyroid hormone alpha (RTHα) is caused by mutations in thyroid hormone receptor α (THRA). Little is known about the natural history and treatment of RTHα, and diagnosis before the age of 1 year has not been previously reported. A de novo heterozygous THRA mutation (pC380SfsX9) was identified in a 10-month-old female investigated for developmental delay, hypotonia, macrocephaly, and severe constipation. Treatment with levothyroxine was accompanied by an appropriate rise in thyroxine (T4), triiodothyronine (T3), as well as decrease in thyrotropin levels and in the T3/T4 ratio with a trend toward normalization of peripheral markers of thyroid hormone action. THRA pC380SfsX9 results in extreme RTHα.

Much has been written about the importance of giving personal attention to children’s written work. The focus has been on the effect of this feedback on the writing and on the child. Drawin...

OBJECTIVE We successfully implemented the American Diabetes Association’s (ADA) Diabetes INSIDE (INspiring System Improvement with Data-Driven Excellence) quality improvement (QI) program at a university hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (HbA1c >8.0% [64 mmol/mol]). In this study, we estimated the 5-year risk reduction in complications and mortality associated with the QI program. RESEARCH DESIGN AND METHODS The QI implementation period was 1 year, followed by the postintervention period of 6 months to evaluate the impact of QI on clinical measures. We measured the differences between the baseline and postintervention clinical outcomes in 2,429 individuals with HbA1c >8% (64 mmol/mol) at baseline and used the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits persist over time. An alternative assumption that intervention benefits diminish by 30% every year was also tested. RESULTS The QI program was associated with reductions in HbA1c (−0.84%) and LDL cholesterol (LDL-C) (−5.94 mg/dL) among individuals with HbA1c level >8.0% (64 mmol/mol), with greater reduction in HbA1c (−1.67%) and LDL-C (−6.81 mg/dL) among those with HbA1c level >9.5% at baseline (all P < 0.05). The implementation of the Diabetes INSIDE QI program was associated with 5-year risk reductions in major adverse cardiovascular events (MACE) (relative risk [RR] 0.78 [95% CI 0.75–0.81]) and all-cause mortality (RR 0.83 [95% CI 0.82–0.85]) among individuals with baseline HbA1c level >8.0% (64 mmol/mol), and MACE (RR 0.60 [95% CI 0.56–0.65]) and all-cause mortality (RR 0.61 [95% CI 0.59–0.64]) among individuals with baseline HbA1c level >9.5% (80 mmol/mol). Sensitivity analysis also identified a substantially lower risk of diabetes-related complications and mortality associated with the QI program. CONCLUSIONS Our modeling results suggest that the ADA’s Diabetes INSIDE QI program would benefit the patients and population by substantially reducing the 5-year risk of complications and mortality in individuals with diabetes.

Patients with multiple myeloma are at elevated risk of venous thromboembolism (VTE), the second leading cause of death in patients with cancer, but physician adherence to VTE prevention guidelines is low. Several organizations partnered in designing and implementing a 2-year quality improvement (QI) program in a tertiary care/academic cancer center, to increase awareness of VTE prophylaxis for patients with multiple myeloma and thus improve adherence to prophylaxis guidelines and protocols. The QI arm included 2 chart audits, conducted 2 years apart, of unmatched cohorts of 100 patients with multiple myeloma. An Education arm included 2 grand rounds presentations, 3 web-based case discussions, and a patient education module. Twenty providers took part in the continuous QI arm. More than 1100 learners participated in the online cases; the patient education curriculum reached 112 multiple myeloma patients. The initiative proved helpful in defining barriers to guideline adherence and identifying data-driven practice improvement strategies for VTE prophylaxis. It also increased learner awareness of VTE guidelines, patient risk stratification, and optimal thromboprophylaxis strategies. There was a reduction in VTE events (primary clinical outcome) from 10% at baseline to 4% in the follow-up cohort, although this was not statistically significant. Higher rates of guideline-based prophylaxis were observed in low-risk patients, and a lower incidence of VTE was observed in multiple myeloma patients with a prior history of VTE. Additional research is needed to refine prophylaxis guidelines. With appropriate institutional support, this type of QI program can be readily adopted by other organizations to address practice improvement needs.

The American Diabetes Association (ADA) and the American Heart Association launched a multi-faceted national partnership in 2018, Know Diabetes by Heart™, to reduce cardiovascular disease (CVD) deaths, heart attacks and strokes in people living with type 2 diabetes. To support this initiative, the ADA’s Diabetes INSIDE® (DI) program formed a mid-Atlantic quality improvement (QI) collaborative of five academic medical centers and a health information exchange (HIE) with partners from primary care, endocrinology, cardiology, nephrology, nursing, pharmacy, health IT, diabetes education, population health and industry. The collaborative’s goal is to accelerate clinical adoption of recent CVD findings using population health analytics, care system redesign, shared learning, provider and patient training, education, and community resources. DI works with each partner to identify, design and monitor quantifiable QI programs to address care quality gaps. The collaborative shared their initial findings and goals at a November 2019 meeting. Three systems identified opportunities to improve low use of SGLT2 inhibitors and GLP-1 agonists in eligible patients (∼12%) or departmental prescribing gaps between primary care and cardiology vs. endocrinology (SGLT2 5% vs. 11%; GLP-1 7.5% vs. 24.6%). Other gaps included coordinating care teams and communication between inpatient and outpatient settings both within and across overlapping health systems, a gap the HIE aims to address. Other systems are implementing DM screening in cardiology clinics or training cardiologists to assume a larger role in managing patients with DM and CVD. A system with a large racial/ethnic minority population is qualitatively evaluating the social, cultural, economic, and literacy factors that facilitate or inhibit optimal care. This regional collaborative across overlapping health systems offers increased opportunity to accelerate improvement of DM and CVD care for all patients and may serve as a model for other regions. Disclosure R.E. Furman: None. F. Hill-Briggs: None. A. Iwamaye: None. C. Knight: None. T. Kouvatsos: None. Y. Lev: None. I. Lorincz: None. W.M. Marella: None. D.J. Rubin: None. M.H. Schutta: Employee; Spouse/Partner; Merck & Co., Inc. D.A. Swavely: None. L. Ward: None. E.C. Furman: None. G. Liptak: Employee; Spouse/Partner; Janssen Pharmaceuticals, Inc. Funding Know Diabetes By Heart™; Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance; Novo Nordisk; Sanofi; AstraZeneca; Bayer

Development of scenarios and training materials for Standardized Patient (SP) based activities is a process in which multiple components need to be considered including educational objectives, level of the learner, healthcare content, and SP methodology expertise. The process for developing the content for human simulation activities is simplified by the use of a template including administrative details for recruiting SPs, defining the needs for the planned activity and materials for training the SPs. This chapter incorporates the Association of Standardized Patient Educators (ASPE) template and provides tips when developing cases and associated training materials. Suggestions when creating cases for interprofessional team assessment, and simulated families (and other groups) will be discussed.

Propósito: El Examen Clínico Objetivo Estructurado (ECOE) es una estrategia de evaluación que implica desafíos logísticos y de recursos humanos con ciertos requisitos de preparación y planeación para su implementación. El objetivo de este estudio es describir una colaboración entre tres escuelas de medicina para el diseño de escenarios, procesos y productos académicos. Método: Tres escuelas de medicina mexicanas obtuvieron una subvención del Programa de Premios Latinoamericanos de la National Board of Medical Examiners (NBME). El proyecto implicó el desarrollo de un ECOE formativo para evaluar la competencia clínica en estudiantes de medicina de pregrado al final del internado médico, y obtener evidencia de validez del examen para su uso. Se creó un consorcio formal para desarrollar y compartir estaciones ECOE. Se implementaron talleres de capacitación del profesorado. Resultados: El consorcio de las tres escuelas diseñó un ECOE de nueve estaciones. Se capacitaron a 81 examinadores y a 36 pacientes estandarizados. Se desarrolló una rúbrica y se creó una aplicación de software para capturar los datos. Se aplicó una prueba piloto con 93 estudiantes de medicina. El alfa de Cronbach fue 0.94 y el coeficiente G 0.80. Se crearon varios productos académicos para divulgar los resultados. Conclusiones: La experiencia formativa entre tres instituciones de educación médica permitió el desarrollo conjunto de escenarios para evaluación de la competencia clínica de estudiantes. La implementación conjunta además hizo posible la conceptualización e implementación de nuevas herramientas de evaluación. Esta oportunidad abre la invitación para aprovechar las oportunidades que brindan las organizaciones internacionales para participar en convocatorias que desarrollen a las escuelas de medicina en México. Los aprendizajes se pueden desplegar con otras escuelas de medicina en el país y América Latina.

Following case development, Standardized Patient training is the most important task required for delivering high fidelity human simulations. The SPs have a difficult job, as they are expected to juggle an authentic, accurate patient portrayal with assessing learners. Portrayal accuracy is more than memorizing a script. As an SP Educator, we help the SP bring the character to life so the learner can be immersed in a realistic experience. How does one handle the training tasks associated with this difficult job? While there is no evidence to suggest there is “one” right way to train SPs, this chapter provides general tips for SP training for lifelike portrayal and touches on training techniques for recording accuracy. Suggestions for creating a training partnership with SP are presented. Finally, we outline a 10 Step Framework for a flexible training approach firmly anchored in the ASPE Standards of Best Practices.

We have successfully implemented the ADA’s Diabetes INSIDE® QI program at a University hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (A1c>8.0%). We extrapolated clinical outcomes of the QI program on a 5-year risk of complications, utilizing a validated risk prediction model: Building, Relating, Assessing, Validating of Outcomes (BRAVO) simulation model. We measured the differences between the baseline and post-intervention values of risk factors in 2,429 individuals with A1c >8% at baseline and used the BRAVO model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits diminished with time. The intervention period was defined as one year and the post-intervention period as the subsequent six months. The QI program was associated with reductions in A1c (-0.84%) and LDL-C (-5.94 mg/dl) among individuals with A1c level >8.0%, with greater reduction in A1c (-1.67%) and LDL-C (-6.81 mg/dl) among those with A1c level > 9.5% at baseline (all p Disclosure H. Shao: None. L. Shi: None. R.E. Furman: None. L. Meneghini: Advisory Panel; Self; AstraZeneca, Novo Nordisk Inc., Sanofi-Aventis. Consultant; Self; Sanofi-Aventis. Other Relationship; Self; American Diabetes Association. T.S. Harlan: None. V. Fonseca: Board Member; Self; American Association of Clinical Endocrinologists. Consultant; Self; Abbott, Asahi Kasei Corporation, Novo Nordisk Inc., Sanofi US, Takeda Pharmaceutical Company Limited. Research Support; Self; Bayer US. Stock/Shareholder; Self; Amgen Inc., Bravo4health, Mellitus Health. Funding Lilly USA, LLC; Novo Nordisk; Sanofi

As a participant in the ADA’s Diabetes INSIDE program, a 19-member multidisciplinary QI team identified care quality gaps after reviewing 6 years (1/2010 to 5/2016) of EHR data on 3,136 T2DM outpatients seen by 190 PCPs in an urban academic medical center. The team set goals to increase HbA1c testing frequency (reduce 45% of patients with HbA1c intervals > 6 months) and to reduce HbA1c levels in both the overall population and patients with HbA1c > 9%. Implemented strategies included 1) a provider outreach program of departmental and individualized actionable data reports of HbA1c testing intervals and outcomes, 2) a patient outreach program to address individual timely follow-up care, 3) a patient awareness campaign to improve understanding of following and improving clinical outcomes, 4) improving structured EHR data capture to improve population monitoring, and 5) standardizing workflow across clinics for pre-visit planning, patient outreach, patient education, checking completion of appointment goals, and post-visit follow-up. Eight-years of EHR follow-up data (1/2010 to 5/2018) on 7,798 patients (mean age 61 years, 57% female, 62% black, 97% insured) with 136,004 visits showed target improvements. Population characteristics were stable over time. A department-stratified Cox proportional hazards model controlling for age, gender, race, and HbA1c level showed a statistically signification 20% reduction in HbA1c testing intervals > 6 months (HR = 1.20±0.07). Statistical process control charts (6 years pre- and 2 years post-intervention) showed statistically significant 15.5% relative improvement in the patient proportion with HbA1c > 9% from 13% to 11% following QI interventions and a significant 2.1% improvement of population mean HbA1c from 7.4% to 7.2%. Disclosure R.E. Furman: None. T.S. Harlan: None. L. LeBlanc: None. E. Furman: None. V. Fonseca: Board Member; Self; American Association of Clinical Endocrinologists. Consultant; Self; Abbott, Asahi Kasei Corporation, Novo Nordisk Inc., Sanofi US, Takeda Pharmaceutical Company Limited. Research Support; Self; Bayer US. Stock/Shareholder; Self; Amgen Inc., BRAVO4HEALTH, Mellitus Health. Funding Eli Lilly and Company; Novo Nordisk; Sanofi

To improve outcomes of patients with adult type 2 diabetes by decreasing HbASix years of outpatient electronic health record (EHR) data were analyzed for care gaps before and 2 years after implementing a QI initiative in an urban academic medical center. QI strategies includedAnalysis (January 2010 to May 2018) of 7,798 patients from Tulane Medical Center (mean age 61 years, 57% female, 62% black, 97% insured) with 136,004 visits showed target improvements. A Cox proportional hazards model controlling for age, sex, race, and HbAMultidisciplinary QI teams using EHR data to design interventions for providers and patients produced statistically significant improvements in both care process and clinical outcome goals.

In collaboration with the ADA, we implemented a QI project to improve glycemia in patients with type 2 diabetes (T2D) and poor glycemic control (A1C > 9%) receiving care in a large urban safety net health system. The 18-month initiative focused on developing shared medical appointments for insulin initiation and management, supported by a primary care QI committee, educational interventions and development of EMR tools to facilitate diabetes management and documentation. We report 2-year data following implementation of the QI intervention. Of 23,611 individuals (mean age 58 years) with 73,849 A1C data points over a period of 3 years 60% were female; 57% Hispanic white, 27% non-Hispanic Black, 9% non-Hispanic white; 62% received charity care, 30% Medicare/Medicaid, 5% commercial insurance. Control charts first demonstrated statistically significant increases in insulin use in poorly controlled patients followed by statistically significant improvement in population glycemic control (A1C average) and proportion of patients with A1c>9% (see figure). A primary care-based QI initiative targeting patients with T2D and A1C > 9% led to appropriate increases in insulin prescriptions, which was followed by a system-wide improvement in diabetes control. Disclosure U. Gunasekaran: None. R.E. Furman: Consultant; Self; Novo Nordisk Inc.. K.M. Rodriguez: None. E. Obialo: None. S. Kassa: None. N.O. Santini: None. E. Furman: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Sanofi US, Novo Nordisk Inc.. Advisory Panel; Self; Intarcia Therapeutics, Inc.. Other Relationship; Self; American Diabetes Association.

Recently, a new method called image reconstruction by integrating exchangeable single-molecule localization (IRIS) was developed (Kiuchi et al., Nat. Methods 2015, 12, 743-746). IRIS ensures high-density labeling for super-resolution microscopy but can be applied for fixed cells only. Here, we extended the IRIS conception to live cell imaging. We applied Lifeact and MAP4 transiently binding to microfilaments and microtubules, respectively. Green-to-red photoconvertible fluorescent protein Dendra2 was chosen as an efficient tag for single-molecule localization microscopy. Live-cell single-molecule localization imaging with Dendra2-Lifeact and Dendra2-MAP4 was performed. As a result, super-resolved images of actin and tubulin in dynamics in living cells were reconstructed. Importantly, Dendra2-Lifeact provided a higher number of individual localizations and denser labeling of microfilaments in comparison with commonly used Dendra2-actin.

A 2-year-old domestic shorthair cat was presented with a history of hematuria, stranguria and intermittent urethral obstruction. Urine sediment showed hematuria, pyuria, and yellow-brown, amorphous and spherical crystals. Upon surgical correction of the obstructed urethra by perineal urethrostomy, many dark yellow to grey, irregular, gravel-like to millet grain-sized uroliths, consisting of 100% xanthine by crystallography were found. The urinary xanthine concentration was high. The cat subsequently developed bilateral nephroliths, recurrent urinary tract infection, and chronic kidney failure. Dietary management with a low-purine diet failed in part due to poor compliance, and the cat was euthanized at 6 years of age. Xanthinuria is rare inborn error of metabolism in cats and other species but should be considered as a differential diagnosis in cases of feline urolithiasis. No associated molecular genetic defect has been elucidated, and management of these cases is difficult. In the absence of calculi for analysis, measuring urinary xanthine concentration can help in diagnosing this metabolic defect.

SummaryTransient Fanconi syndrome without azotemia was diagnosed in a dog and was associated with ingestion of Chinese chicken jerky treats. Fanconi syndrome is a proximal renal tubular defect and a diagnosis was made based upon severe glucosuria with normoglycemia, and severe generalized aminoaciduria. The clinical signs of polyuria and polydipsia as well as the massive urinary metabolic abnormalities resolved after jerky treat withdrawal. While frequently seen in North America and Australia, this is the first report of jerky treat induced Fanconi syndrome in continental Europe. Clinicians should be aware of this potential intoxication and be vigilant for a history of jerky treat consumption in a dog with glucosuria.

In this paper, I connect John Dewey’s notion that growth occurs through interaction with a diverse community to contemporary discussions of inclusive education. I highlight the importance of materials that offer different access points, the chance for students to listen to one another, and the teacher's openness to each child’s potential. Though I became a teacher already committed to a classroom community that celebrated a range of capacities, I wasn’t initially able to translate this belief into practice. Integrating practice and philosophy, I share my path to provide insights for other teachers seeking to create a more inclusive classroom.

Early response of cancer cells to chemical compounds and chemotherapeutic drugs were studied using novel fluorescence tools and microscopy techniques. We applied confocal microscopy, two-photon fluorescence lifetime imaging microscopy and super-resolution localization-based microscopy to assess structural and functional changes in cancer cells in vitro. The dynamics of energy metabolism, intracellular pH, caspase-3 activation during staurosporine-induced apoptosis as well as actin cytoskeleton rearrangements under chemotherapy were evaluated. We have showed that new genetically encoded sensors and advanced fluorescence microscopy methods provide an efficient way for multiparameter analysis of cell activities

Background Frequency and classification of anemia in terms of regeneration status and erythrocyte indices are not well described in cats. Objective To determine frequency and regenerative status of anemia in samples from adult cats, to assess the sensitivity and specificity of macrocytosis and hypochromasia for detecting regenerative anemia (RA), and to evaluate the association of anemia with increased serum creatinine concentration (SC). Study Population Laboratory records from 30,503 blood samples from cats (2003–2011). Methods Clinicopathologic data reviewed retrospectively. Anemia defined as hematocrit (Ht) ≤27%, red blood cell count (RBC) ≤5.5 × 106/μL and hemoglobin (Hb) ≤9.0 g/dL. RA defined by manual absolute reticulocyte count >50 × 103/μL. Macrocytosis was defined as mean corpuscular volume (MCV) >55 fL and hypochromasia as mean corpuscular hemoglobin concentration (MCHC)

Background The International Preparedness & Response to Emergencies & Disasters (IPRED) conferences are conducted bi-annually in order to share insights and lessons learned from diverse crises. The aim of the article is to bring the IPRED conferences into better professional attention and to share the main insights that were presented in IPRED IV, which was held in January 2016. Main body The major lessons learned included: Planning, regional/global collaboration and public–private cooperation should be implemented in developing novel technologies. International humanitarian action necessitates coordination between diverse actors concerning all potential threats. Leadership/coordination and decision-making capacities of emergency response leaders should be enhanced to ensure quality of care. Ethics in disaster management: Triage decisions must not discriminate against terrorists, even when attackers and victims are treated simultaneously. Resilience management: Establishing family and community networks increases resilience of individuals and society. Training programs & exercises must be evaluated considering cost–benefits. Human resources: Teams of experts should be transformed into expert teams. Communication: A common disaster-management language needs to be established. Social media is useful due to bi-directional communication. Civil–military cooperation should be established to facilitate a coordinated response including common terminologies and exercises. Animal sheltering: First responders and pet owners are jeopardized if animals are not included in emergency planning. Re-unification of animals with their owners should be included in response models. Conclusions IPRED conferences provide a platform for sharing insights and lessons learned from diverse emergencies and disasters. The conferences offer a unique opportunity to share knowledge aimed at improving emergency preparedness, networking between various parties, and substantiates the knowledge and experience of all professionals who take part in the proceedings.

Background The rearrangement of actin cytoskeleton is being increasingly considered a marker of cancer cell activity, but the fine structure and remodeling of microfilaments within tumor tissue still remains unclear. Materials and methods We used the recently introduced silicon-rhodamine (SiR)-actin dye to visualize endogenous actin within tissues by confocal or total internal reflection fluorescence microscopy. We established imaging conditions for robust blinking of SiR-actin, which makes this dye applicable for super-resolution localization microscopy, as well as for an efficient background elimination. Results We studied tumor tissue samples in two mouse models at high resolution and revealed a complex network of thick curved bundles of actin in cancer cells in tumors. This actin pattern differed strongly from that in cancer cells in vitro and in normal tissues. Conclusion Localization microscopy with SiR-actin provides an efficient way to visualize fine actin structure in tumor tissues. It is potentially applicable to a variety of biological and clinical samples.