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Fibular collateral ligament (FCL) tears rarely occur in isolation and are typically injured in conjunction with another ligament, including the anterior cruciate ligament (ACL). Reconstruction of both ACL and the FCL is critical to restore proper knee biomechanics and stability. This technique describes an anatomic reconstruction of both the ACL using a bone–patellar tendon–bone autograft and the FCL using a semitendinosus hamstring autograft. Previous biomechanical studies have reported on the effect of ACL and FCL tears on lateral gapping and the importance of reconstruction to restore near native stability. Outcomes studies have reported positive patient outcomes for both techniques individually and together.

Background: Obtaining intravenous access in hypotensive patients is challenging and may critically delay resuscitation. The Graduated Vascular Access for Hypotensive Patient (GAHP) protocol leverages intraosseous fluid boluses to specifically dilate proximal veins. This study aims to evaluate the efficacy of GAHP in maximizing venous targets through early distal intraosseous access and a small fluid bolus. Methods: This was a prospective randomized cadaveric pilot study to evaluate extremity venous engorgement during intraosseous infusion. Cadavers (n = 23) had an intraosseous needle inserted into four sites: distal radius, proximal humerus, distal femur, and distal tibia. Intraosseous saline was rapidly infused, venous optimization was measured using real-time ultrasound. Primary outcome was maximum vessel circumference increase with intraosseous infusion. Secondary outcomes were: time to maximum circumference, and infusion volume required. Statistical analyses included Levene’s test for equality of variances, Wilcoxon signed-rank test, and generalized estimating equation. Results: There was a significant mean increase of 1.03 cm (95% CI 0.86, 1.20), representing a difference of 102%. We found no significant difference in time to optimize vessel circumference across sites, but volume required significantly differed. Conclusion: GAHP quickly and effectively increased the circumference of anatomically adjacent veins. Anatomical sites did not differ on time to reach maximum enlargement of vessels following intraosseous infusion but did differ in terms of volume required to maximize vessel circumference. Further research is needed using live, hypotensive patients.

Our study employs multi-level agent-based modeling and computational techniques to explore education as a complex system. With an underlying focus that education should be underpinned by a scientific understanding of student learning, we created computational models that simulated learning dynamics in classrooms, integrating both quantitative and qualitative insights. Through these models, we conducted experiments aligned with real classroom data to address key questions, such as “How can we effectively support the academic progress of underperforming students, who are disproportionately from low socio-economic status (SES) backgrounds, to close their multi-year achievement gap in mathematics?” Our study analyzes various instructional approaches for mathematical learning, and our findings highlight the potential effectiveness of Productive Failure as an instructional approach. Considerations of the broader applicability of computational methods in advancing educational research are also provided.

Historically, ecosystem models have treated rainfall as the primary moisture source driving litter decomposition. In many arid and semi-arid lands, however, non-rainfall moisture (fog, dew, and water vapor) plays a more important role in supporting microbial activity and carbon turnover. To date though, we lack a robust approach for modeling the role of non-rainfall moisture in litter decomposition. We developed a series of simple litter decay models with different moisture sensitivity and temperature sensitivity functions to explicitly represent the role of non-rainfall moisture in the litter decay process. To evaluate model performance, we conducted a 30-month litter decomposition study at 6 sites along a fog and dew gradient in the Namib desert, spanning almost an eightfold difference in non-rainfall moisture frequency. Litter decay rates in the field correlated with fog and dew frequencies but not with rainfall. Including either temperature or non-rainfall moisture sensitivity functions improved model performance, but the combination of temperature and moisture sensitivity together provided more realistic estimates of litter decomposition than relying on either alone. Model performance was similar regardless of whether we used continuous moisture sensitivity functions based on relative humidity or a simple binary function based on the presence of moisture, although a Gaussian temperature sensitivity outperformed a monotonically increasing Q10 temperature function. We demonstrate that explicitly modeling non-rainfall moisture and temperature together is necessary to accurately capture litter decay dynamics in a fog-affected dryland system and provide suggestions for how to incorporate non-rainfall moisture into existing Earth system models.

Background: Serum prostate-specific antigen (PSA), used in prostate cancer screening, is nonspecific for cancer and is affected by age and prostate volume. More specific biomarkers could be more accurate for early detection of prostate cancer and reduce unnecessary prostate biopsies. Objective: To evaluate the association of age and prostate volume with urinary MyProstateScore (MPS) in a screened, longitudinal cohort without evidence of prostate cancer. Design, setting, and participants: The Olmsted County Study included men aged 40–79 yr who underwent biennial prostate cancer screening. PSA ≥4.0 ng/ml or abnormal rectal examination triggered prostate biopsy, and patients with cancer were excluded. The remaining men submitted urinary specimens for PCA3 and TMPRSS2:ERG testing. Outcome measurements and statistical analysis: MPS was calculated using the validated, locked model for grade group ≥2 cancer that includes serum PSA, urinary PCA3, and urinary TMPRSS2:ERG. The associations of age and volume with biomarkers were assessed in multivariable regression models. The t statistic was used to quantify the strength of associations independent of the unit of measurement, and R2 values were used to estimate the proportion of biomarker variance explained by each factor. Results and limitations: The study included 314 screened men without evidence of cancer. In multivariable models including age and volume, PCA3 score was significantly associated with age (t = 7.51; p

Most available verification metrics for ensemble forecasts focus on univariate quantities. That is, they assess whether the ensemble provides an adequate representation of the forecast uncertainty about the quantity of interest at a particular location and time. For spatially indexed ensemble forecasts, however, it is also important that forecast fields reproduce the spatial structure of the observed field and represent the uncertainty about spatial properties such as the size of the area for which heavy precipitation, high winds, critical fire weather conditions, etc., are expected. In this article we study the properties of the fraction of threshold exceedance (FTE) histogram, a new diagnostic tool designed for spatially indexed ensemble forecast fields. Defined as the fraction of grid points where a prescribed threshold is exceeded, the FTE is calculated for the verification field and separately for each ensemble member. It yields a projection of a – possibly high-dimensional – multivariate quantity onto a univariate quantity that can be studied with standard tools like verification rank histograms. This projection is appealing since it reflects a spatial property that is intuitive and directly relevant in applications, though it is not obvious whether the FTE is sufficiently sensitive to misrepresentation of spatial structure in the ensemble. In a comprehensive simulation study we find that departures from uniformity of the FTE histograms can indeed be related to forecast ensembles with biased spatial variability and that these histograms detect shortcomings in the spatial structure of ensemble forecast fields that are not obvious by eye. For demonstration, FTE histograms are applied in the context of spatially downscaled ensemble precipitation forecast fields from NOAA's Global Ensemble Forecast System.

Background Persons who accumulate chronic conditions at a rate faster than their peers may experience accelerated aging and poor health outcomes, including functional limitations. Methods Adults aged ≥40 years who resided in Olmsted County, Minnesota on 1 January 2006 were identified. The prevalence of 21 chronic conditions was ascertained, and age-specific quartiles of the number of chronic conditions was estimated within 4 age groups: 40–54, 55–64, 65–74, and ≥75 years. Difficulty with nine patient-reported functional limitations (including basic and instrumental activities of daily living and mobility activities) were ascertained through 31 October 2018. Cox regression was used to model associations of chronic condition quartiles with new-onset functional limitations considered separately. We estimated absolute risk differences and hazard ratios stratified by age group, and adjusted for sex, race, ethnicity, marital status, education, and the residual effect of age. Results Among 39,624 persons (44.5% men, 93.2% white), the most common reported new functional limitations were difficulty with climbing stairs, walking, and housekeeping. For all functional limitations, the absolute risk differences were largest among the oldest age group (≥75 years). Approximately twofold increased hazard ratios were observed among those in the highest vs. lowest quartile for the three oldest age groups, and approximately threefold or higher hazard ratios were observed for persons aged 40-54 years. Conclusion Persons with increased accumulation of chronic conditions experience increased risks of developing functional limitations compared to their peers. These findings underscore the importance of assessing health status and of employing interventions to prevent and effectively manage multi-morbidity at all ages.

Background: Average-risk colorectal cancer (CRC) screening remains underutilized in the US. Provider recommendation is strongly associated with CRC screening completion. To inform interventions aimed at improving screening uptake, we examined providers’ perspectives on patient and health system barriers to CRC screening adherence, along with associated system-level interventions to improve uptake. Methods: We conducted an online survey between November and December 2019 with a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a validated panel of US clinicians (814 PCCs, 159 GIs; completion rates: 25.3% for PCCs, 29.6% for GIs). Clinicians rated the extent to which each patient and health system factor interferes with patient adherence with CRC screening recommendations and the availability of practice interventions to improve screening rates. Results: Provider-reported top barriers to CRC screening included patient discomfort with offered screening method (66%), cost (62–64%), and perceived low importance of screening (62%). Additional barriers included providers prioritizing urgent health concerns over screening (45–48%), not offering a choice of screening options (42–48%), lacking time to educate patients about screening (38–45%), and lacking education about available screening options (37–40%). Most frequently reported system-level interventions to improve CRC screening rates included patient education materials (57–62%) and point of care prompts (56–61%). Other interventions were less frequently reported, although variations existed by clinical specialty regarding barriers and interventions. Conclusions: Addressing barriers to CRC screening requires system-level interventions, including provider training on shared decision-making, automated scheduling and reminder processes, and policies to increase clinician time for preventive screening consultations.

Objective: This study determined the incidence rates for obesity among adult patients ages 20 and older empaneled in primary care practice in Midwest United States to potentially identify an optimum timeframe for initiating intervention. Background: Primary care practice patients are likely to reflect underlying community trends in overweight and obesity; however, data on overweight and obesity in primary care patients is limited. While childhood incidence rates of obesity have been well reported, there is still a paucity of data on the incidence of obesity among adult population; literature has mainly focused on its prevalence. Methods: Medical record review of identified cohort with BMI data was conducted. Population was stratified by age and sex and overweight category was subdivided into tertiles. Results: Majority of 40 390 individuals who comprised the final population and had follow-up data, consisted of adults ages 40 to 69 years (47.5%), female (59.8%) of non-Hispanic ethnicity (95.9%) with 21 379 (52.8%) falling in weight category of overweight. Incidence of obesity was 7% at 1 year and 16% at 3 years follow-up. Highest percentages of individuals who became obese at 1 and 3 years were in age category of 40 to 69 years among men and 20 to 39 years among women. In Cox regression analysis, there was statistically significant association to developing obesity among all tertile groups in the overweight category. Age and particularly gender appeared to be modifying factors to likelihood of developing obesity. Conclusion: Study results suggest that while obesity incidence is higher among certain age groups in both genders, middle-aged women, and men in all tertiles of overweight category are at highest risk and may be the optimum population to target for weight loss interventions. Findings support the initiation of population-based interventions before onset of obesity.

This paper develops a regional dataset of change at 381 settlements for Lycia-Pamphylia in southwest Anatolia (Turkey) from volume 8 of the Tabula Imperii Byzantini–a compilation of historical toponyms and archaeological evidence. This region is rich in archaeological remains and high-quality paleo-climatic and -environmental archives. Our archaeological synthesis enables direct comparison of these datasets to discuss current hypotheses of climate impacts on historical societies. A Roman Climatic Optimum, characterized by warmer and wetter conditions, facilitating Roman expansion in the 1st-2nd centuries CE cannot be supported here, as Early Byzantine settlement did not benefit from enhanced precipitation in the 4th-6th centuries CE as often supposed. However, widespread settlement decline in a period with challenging archaeological chronologies (c. 550–650 CE) was likely caused by a “perfect storm” of environmental, climatic, seismic, pathogenic and socio-economic factors, though a shift to drier conditions from c. 460 CE appears to have preceded other factors by at least a century.

Colorectal cancer (CRC) screening continues to be underutilized in the United States. A better understanding of existing barriers is critical for improving uptake of, and adherence to, CRC screening. Using data from a population-based panel survey, we examined barriers to utilization of three commonly used screening options (FIT/gFOBT, mt-sDNA, and screening colonoscopy) and assessed differences by socio-demographic characteristics, healthcare access, and health status. Data were obtained from a questionnaire developed by the authors and implemented through a U.S. national panel survey conducted in November 2019. Among 5,097 invited panelists, 1,595 completed the survey (31.3%). Analyses were focused on individuals ages 50–75 at average risk for CRC. Results showed that among respondents who reported no prior CRC screening with FIT/gFOBT, mt-sDNA, or colonoscopy, the top barriers were lack of knowledge (FIT/gFOBT: 42.1%, mt-sDNA: 44.9%, colonoscopy: 34.7%), lack of provider recommendation (FIT/gFOBT: 32.1%, mt-sDNA: 27.3%, colonoscopy: 18.6%), and suboptimal access (FIT/gFOBT: 20.8%, mt-sDNA: 17.8%, colonoscopy: 26%). Among participants who had used one or two of the screening options, the top barriers to FIT/gFOBT and mt-sDNA were lack of provider recommendation (31.6% & 37.5%) and lack of knowledge (24.6% & 25.6%), while for colonoscopy top barriers were psychosocial barriers (31%) and lack of provider recommendation (22.7%). Differences by sex, race/ethnicity, income level, and health status were observed. Our research identified primary barriers to the utilization of three endorsed CRC screening options and differences by patient characteristics, highlighting the importance of improving CRC screening education and considering patient preferences in screening recommendations.

The fluctuating climatic conditions of the Saharo-Arabian deserts are increasingly linked to human evolutionary events and societal developments. On orbital timescales, the African and Indian Summer Monsoons were displaced northward and increased precipitation to the Arabian Peninsula which led to favorable periods for human occupation in the now arid interior. At least four periods of climatic optima occurred within the last 130,000 years, related to Marine Isotope Stages (MIS) 5e (128–121 ka BP), 5c (104–97 ka BP), 5a (81–74 ka BP) and 1 (10.5–6.2 ka BP), and potentially early MIS 3 (60–50 ka BP). Stalagmites from Southern Arabia have been key to understanding climatic fluctuations and human-environmental interactions; their precise and high-resolution chronologies can be linked to evidence for changes in human distribution and climate/environment induced societal developments. Here, we review the most recent advances in the Southern Arabian Late Pleistocene and Early Holocene stalagmite records. We compare and contrast MIS 5e and Early Holocene climates to understand how these differed, benchmark the extremes of climatic variability and summarize the impacts on human societal development. We suggest that, while the extreme of MIS 5e was important for H. sapeins dispersal, subsequent, less intense, wet phases mitigate against a simplistic narrative. We highlight that while climate can be a limiting and important factor, there is also the potential of human adaptability and resilience. Further studies will be needed to understand spatio-temporal difference in human-environment interactions in a climatically variable region.

Abstract Background Persons with low socioeconomic status may be disproportionately at risk for multimorbidity. Methods Adults aged ≥20 years on 4/1/2015 from 7 counties in Minnesota were identified using the Rochester Epidemiology Project (population-based sample). A composite measure of neighborhood socioeconomic disadvantage, the area deprivation index (ADI), was estimated at the census block group level (n = 251). The prevalence of 21 chronic conditions was obtained to calculate the proportion of persons with multimorbidity (≥2 chronic conditions) and severe multimorbidity (≥5 chronic conditions). Hierarchical logistic regression was used to estimate the association of ADI with multimorbidity and severe multimorbidity using odds ratios (OR). Results Among 198,941 persons (46.7% male, 30.6% aged ≥60 years), the age- and sex-standardized (to the United States 2010 census) median prevalence (Q1, Q3) was 23.4% (21.3%, 25.9%) for multimorbidity and 4.8% (4.0%, 5.7%) for severe multimorbidity. Compared with persons in the lowest quintile of ADI, persons in the highest quintile had a 50% increased risk of multimorbidity (OR 1.50, 95% CI 1.39–1.62) and a 67% increased risk of severe multimorbidity (OR 1.67, 95% CI 1.51–1.86) after adjusting for age, sex, race, and ethnicity. Associations were stronger after further adjustment for individual level of education; persons in the highest quintile had a 78% increased risk of multimorbidity (OR 1.78, 95% CI 1.62–1.96) and a 92% increased risk of severe multimorbidity (OR 1.92, 95% CI 1.72–2.13). There was evidence of interactions between ADI and age, between ADI and sex, and between ADI and education. After age 70 years, no difference in the risk of multimorbidity was observed across quintiles of ADI. The pattern of increasing multimorbidity with increasing ADI was more pronounced in women. Finally, there was less variability across quintiles of ADI for the most highly educated group. Conclusions Higher ADI was associated with increased risk of multimorbidity, and the associations were strengthened after adjustment for individual level of education, suggesting that neighborhood context plays a role in health above and beyond individual measures of socioeconomic status. Furthermore, associations were more pronounced in younger persons and women, highlighting the importance of interventions to prevent chronic conditions in younger women, in particular.

Proton conducting SmNiO3 (SNO) thin films were grown on (001) LaAlO3 substrates for systematically investigating the proton transport properties. X-ray Diffraction and Atomic Force Microscopy studies reveal that the as-grown SNO thin films have good single crystallinity and smooth surface morphology. The electrical conductivity measurements in air indicate a peak at 473 K in the temperature dependence of the resistance of the SNO films, probably due to oxygen loss on heating. A Metal-Insulator-Transition occurs at 373 K for the films after annealing at 873 K in air. In a hydrogen atmosphere (3% H2/97% N2), an anomalous peak in the resistance is found at 685 K on the first heating cycle. Electrochemical Impedance Spectroscopy studies as a function of temperature indicate that the SNO films have a high ionic conductivity (0.030 S/cm at 773 K) in a hydrogen atmosphere. The activation energy for proton conductivity was determined to be 0.23 eV at 473–773 K and 0.37 eV at 773–973 K respectively. These findings demonstrate that SNO thin films have good proton conductivity and are good candidate electrolytes for low temperature proton-conducting Solid Oxide Fuel Cells. Keywords: SmNiO3, Thin film, Transport properties, Ionic conductivity, Impedance measurements

Objectives Sex as a biological variable affects response to opioids. However, few reports describe the prevalence of specific adverse reactions to commonly prescribed opioids in men and women separately. A large cohort was used to investigate sex differences in type and occurrence of adverse reactions associated with use of codeine, tramadol, oxycodone and hydrocodone.Design Retrospective cohort study.Setting Participants in the Right Drug, Right Dose, Right Time (RIGHT) Study.Participants The medical records of 8457 participants in the RIGHT Study who received an opioid prescription between 1 January 2004 and 31 December 2017 were reviewed 61% women, 94% white, median age (Q1–Q3)=58 (47–66).Primary and secondary outcome measures Adverse reactions including gastrointestinal, skin, psychiatric and nervous system issues were collected from the allergy section of each patient’s medical record. Sex differences in the risk of adverse reactions due to prescribed opioids were modelled using logistic regression adjusted for age, body mass index, race and ethnicity.Results From 8457 participants (of which 449 (5.3%) reported adverse reactions), more women (6.5%) than men (3.4%) reported adverse reactions to at least one opioid (OR (95% CI)=2.3 (1.8 to 2.8), p

All perennial plants harbor diverse endophytic fungal communities, but why they tolerate these complex asymptomatic symbioses is unknown. Using a multi-pronged approach, we conclusively found that a dryland grass supports endophyte communities comprised predominantly of latent saprophytes that can enhance localized nutrient recycling after senescence. A perennial bunchgrass, Stipagrostis sabulicola, which persists along a gradient of extreme abiotic stress in the hyper-arid Namib Sand Sea, was the focal point of our study. Living tillers yielded 20 fungal endophyte taxa, 80% of which decomposed host litter during a 28-day laboratory decomposition assay. During a 6-month field experiment, tillers with endophytes decomposed twice as fast as sterilized tillers, consistent with the laboratory assay. Furthermore, profiling the community active during decomposition using next-generation sequencing revealed that 59–70% of the S. sabulicola endophyte community is comprised of latent saprophytes, and these dual-niche fungi still constitute a large proportion (58–62%) of the litter community more than a year after senescence. This study provides multiple lines of evidence that the fungal communities that initiate decomposition of standing litter develop in living plants, thus providing a plausible explanation for why plants harbor complex endophyte communities. Using frequent overnight non-rainfall moisture events (fog, dew, high humidity), these latent saprophytes can initiate decomposition of standing litter immediately after tiller senescence, thus maximizing the likelihood that plant-bound nutrients are recycled in situ and contribute to the nutrient island effect that is prevalent in drylands.

Objective To assess the validity of the US Department of Health and Human Services (DHHS) definition of multimorbidity using International Classification of Diseases, ninth edition (ICD-9) codes from administrative data.Design Cross-sectional comparison of two ICD-9 billing code algorithms to data abstracted from medical records.Setting Olmsted County, Minnesota, USA.Participants An age-stratified and sex-stratified random sample of 1509 persons ages 40–84 years old residing in Olmsted County on 31 December 2010.Study measures Seventeen chronic conditions identified by the US DHHS as important in studies of multimorbidity were identified through medical record review of each participant between 2006 and 2010. ICD-9 administrative billing codes corresponding to the 17 conditions were extracted using the Rochester Epidemiology Project records-linkage system. Persons were classified as having each condition using two algorithms: at least one code or at least two codes separated by more than 30 days. We compared the ICD-9 code algorithms with the diagnoses obtained through medical record review to identify persons with multimorbidity (defined as ≥2, ≥3 or ≥4 chronic conditions).Results Use of a single code to define each of the 17 chronic conditions resulted in sensitivity and positive predictive values (PPV) ≥70%, and in specificity and negative predictive values (NPV) ≥70% for identifying multimorbidity in the overall study population. PPV and sensitivity were highest in persons 65–84 years of age, whereas NPV and specificity were highest in persons 40–64 years. The results varied by condition, and by age and sex. The use of at least two codes reduced sensitivity, but increased specificity.Conclusions The use of a single code to identify each of the 17 chronic conditions may be a simple and valid method to identify persons who meet the DHHS definition of multimorbidity in populations with similar demographic, socioeconomic, and health care characteristics.

Non-rainfall moisture (fog, dew, and water vapor; NRM) is an important driver of plant litter decomposition in grasslands, where it can contribute significantly to terrestrial carbon cycling. However, we still do not know whether microbial decomposers respond differently to NRM and rain, nor whether this response affects litter decomposition rates. To determine how local moisture regimes influence decomposer communities and their function, we examined fungal communities on standing grass litter at an NRM-dominated site and a rain-dominated site 75 km apart in the hyper-arid Namib Desert using a reciprocal transplant design. Dominant taxa at both sites consisted of both extremophilic and cosmopolitan species. Fungal communities differed between the two moisture regimes with environment having a considerably stronger effect on community composition than did stage of decomposition. Community composition was influenced by the availability of air-derived spores at each site and by specialization of fungi to their home environment; specifically, fungi from the cooler, moister NRM Site performed worse (measured as fungal biomass and litter mass loss) when moved to the warmer, drier rain-dominated site while Rain Site fungi performed equally well in both environments. Our results contribute to growing literature demonstrating that as climate change alters the frequency, magnitude and type of moisture events in arid ecosystems, litter decomposition rates may be altered and constrained by the composition of existing decomposer communities.

Average-risk colorectal cancer (CRC) screening is broadly recommended, using one of several endorsed test options. However, CRC screening participation rates remain below national goals. To gain further insights regarding recent, population-based patterns in overall and test-specific CRC screening participation, we conducted a retrospective study of adults, ages 50–75 years, utilizing comprehensive data resources from the Rochester Epidemiology Project (REP).Among residents of Olmsted County, MN eligible and due for CRC screening, we identified 5818 residents across three annual cohorts who completed screening between 1/1/2016 and 12/31/2018. We summarized CRC screening rates as incidence per 1000 population and used Poisson regression to test for overall and mode-specific CRC trends. We also analyzed rates of follow-up colonoscopy within 6-months after a positive stool-based screening result.While no significant differences over time were observed in overall CRC screening incidence rates among those due for screening, we observed a statistically significant increase in mt-sDNA test and statistically significant decreases in screening colonoscopy and FIT/FOBT test completion rates; differences in screening overall and by modality were observed by age, sex, and race/ethnicity. The diagnostic colonoscopy follow-up rate within six months after a positive stool-based test was significantly higher following mt-sDNA (84.9%) compared to FIT/FOBT (42.6%).In this retrospective, population-based study, overall CRC screening incidence rates remained stable from 2016 to 2018, while test-specific rates for mt-sDNA significantly increased and decreased for colonoscopy and FIT/FOBT. Adherence with follow-up colonoscopy after a positive stool-based test was significantly higher among patients who underwent mt-sDNA screening compared to FIT/FOBT.

Abstract Background Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates. Methods Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates. Discussion Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes. Trial registration ClinicalTrials.gov, NCT03501992, registered April 18, 2018.

This single arm prospective study assessed the impact of individualized wellness coaching intervention for primary care patients with prediabetes on self-reported changes in physical activity level and food choices. Five hundred sixty adult patients 18 years and older with prediabetes, seen in primary care clinic, were invited to participate in 12 weeks wellness coaching sessions delivered by certified coaches. Responses from questionnaires at baseline, 6 and 12 weeks were analyzed. Of 168 consented patients, 99 completed at least one coaching session; majority was elderly, female, overweight or obese. At baseline, 50% had

Unfavorable lipid levels during childhood are associated with subsequent development of atherosclerotic cardiovascular disease. The American Academy of Pediatrics and National Heart, Lung and Blood Institute in 2011 recommended universal lipid screening for children between ages 9–11years and between ages 17–21years. The objective of the study was to determine temporal trends in lipid testing among children and young adults in a mid-western population. The Rochester Epidemiology Project database was used to identify lipid testing in ages 2–21years (n=51,176) in the Olmsted County population from January 1, 2008 through December 31, 2014. Generalized estimating equations with Poisson distribution were used to test for temporal trends in lipid testing across the age groups. There was modest increase in lipid testing in children in the age groups, 9–11years and 17–21years (1.5% in 2008 to 2.2% in 2014, P

Abstract Background Communication between patients with limited English proficiency (LEP) and telephone triage services has not been previously explored. The purpose of this study was to determine the utilization characteristics of a primary care triage call center by patients with LEP. Methods This was a retrospective cohort study of the utilization of a computer-aided, nurse-led telephone triage system by English proficiency status of patients empaneled to a large primary care practice network in the Midwest United States. Interpreter Services (IS) need was used as a proxy for LEP. Results Call volumes between the 587 adult patients with LEP and an age-frequency matched cohort of English-Proficient (EP) patients were similar. Calls from patients with LEP were longer and more often made by a surrogate. Patients with LEP received recommendations for higher acuity care more frequently (49.4% versus 39.0%; P

Computer-aided design (CAD)-based Monte Carlo radiation transport is of value to the nuclear engineering community for its ability to conduct transport on high-fidelity models of nuclear systems, but it is more computationally expensive than native geometry representations. This work describes the adaptation of a rendering data structure, the signed distance field, as a geometric query tool for accelerating CAD-based transport in the direct-accelerated geometry Monte Carlo toolkit. Demonstrations of its effectiveness are shown for several problems. The beginnings of a predictive model for the data structure's utilization based on various problem parameters is also introduced.

Objective: To understand the interaction of multimorbidity and functional limitations in determining health-care utilization and survival in older adults. Methods: Olmsted County, Minnesota, residents aged 60–89 years in 2005 were categorized into four cohorts based on the presence or absence of multimorbidity (≥3 chronic conditions from a list of 18) and functional limitations (≥1 limitation in an activity of daily living from a list of 9), and were followed through December 31, 2016. Andersen–Gill and Cox regression estimated hazard ratios (HRs) for emergency department (ED) visits, hospitalizations, and death using persons with neither multimorbidity nor functional limitations as the reference (interaction analyses). Results: Among 13,145 persons, 34% had neither multimorbidity nor functional limitations, 44% had multimorbidity only, 4% had functional limitations only, and 18% had both. Over a median follow-up of 11 years, 5906 ED visits, 2654 hospitalizations, and 4559 deaths occurred. Synergistic interactions on an additive scale of multimorbidity and functional limitations were observed for all outcomes; however, the magnitude of the interactions decreased with advancing age. The HR (95% confidence interval) for death among persons with both multimorbidity and functional limitations was 5.34 (4.40–6.47) at age 60–69, 4.16 (3.59–4.83) at age 70–79, and 2.86 (2.45–3.35) at age 80–89 years. Conclusion: The risk of ED visits, hospitalizations, and death among persons with both multimorbidity and functional limitations is greater than additive. The magnitude of the interaction was strongest for the youngest age group, highlighting the importance of interventions to prevent and effectively manage multimorbidity and functional limitations early in life.