Search

Abstract A growing population of older adults and improved effective treatments for inflammatory rheumatic diseases will increase the demand for more healthcare resources that already struggle with staggering outpatient clinic waiting times. Transformative delivery care models that provide sustainable healthcare services are urgently needed to meet these challenges. In this mini-review article, a proposed Lifelong Treatment Model for a decentralized follow-up of outpatient clinic patients living with rheumatoid arthritis is presented and discussed. Our conceptual model follows four steps for a transformative care delivery model supported by an Integrated Practice Unit; (1) Diagnosis, (2) Treatment, (3) Patient Empowered Disease Management, and (4) Telehealth. Through an Integrated Practice Unit, a multidisciplinary team could collaborate with patients with rheumatoid arthritis to facilitate high-value care that addresses most important outcomes of the patients; (1) Early Remission, (2) Decentralization, (3) Improved Quality of Life, and (4) Lifelong Sustain Remission. The article also addresses the growing challenges for the healthcare delivery system today for patients with rheumatoid arthritis and proposes how to reduce outpatient clinic visits without compromising quality and safety.

Jee Wook Kim,1,2 Min Soo Byun,3 Dahyun Yi,3 Jun Ho Lee,4 Kang Ko,4 Gijung Jung,5 Dong Young Lee3,4,6 On behalf of the KBASE Research Group 1Department of Neuropsychiatry, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea; 2Department of Psychiatry, Hallym University College of Medicine, Chuncheon, Republic of Korea; 3Institute of Human Behavioral Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea; 4Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea; 5Department of Nursing, Graduate School, Kyung Hee University, Seoul, Republic of Korea; 6Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Purpose: We aimed to investigate the relationships of cerebral amyloid beta (Aβ) deposition and neurodegeneration (ND) with subjective memory complaints (SMCs) in cognitively normal (CN) individuals, focusing specially on the modulating effects of vascular risk (VR) on those relationships. Participants and methods: A total of 230 CN elderly individuals underwent comprehensive clinical assessments including the Subjective Memory Complaints Questionnaire (SMCQ), VR assessment, and multimodal brain imaging including [11C] Pittsburgh compound B positron emission tomography (PET), [18F] fluorodeoxyglucose-PET, and magnetic resonance imaging. Results: We found a significant overall positive association between cerebral Aβ retention and SMCQ score. In addition, we found a significant cerebral Aβ retention × VR interaction effect on the SMCQ score. Subgroup analyses showed that the Aβ–SMC association was found only in VR-negative, and not in VR-positive, individuals. We found no relationship between ND and SMCQ. Conclusion: Our findings suggest that SMC in CN elderly individuals reflects early accumulation of Aβ in the brain. Given the modulating effect of VR on the Aβ–SMC relationship, SMC can be used as a meaningful marker of early Aβ deposition in individuals without VR. Keywords: subjective memory complaints, amyloid beta, vascular risk, Alzheimer’s disease, cognitively normal

BackgroundGraduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied.ObjectiveTo examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care.MethodsFrom 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated.ResultsThe highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable.ConclusionsGME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

We have identified a large expansion of an ATTCT repeat within intron 9 of ATXN10 on chromosome 22q13.31 as the genetic mutation of spinocerebellar ataxia type 10 (SCA10). Our subsequent studies indicated that neither a gain nor a loss of function of ataxin 10 is likely the major pathogenic mechanism of SCA10. Here, using SCA10 cells, and transfected cells and transgenic mouse brain expressing expanded intronic AUUCU repeats as disease models, we show evidence for a key pathogenic molecular mechanism of SCA10. First, we studied the fate of the mutant repeat RNA by in situ hybridization. A Cy3-(AGAAU)(10) riboprobe detected expanded AUUCU repeats aggregated in foci in SCA10 cells. Pull-down and co-immunoprecipitation data suggested that expanded AUUCU repeats within the spliced intronic sequence strongly bind to hnRNP K. Co-localization of hnRNP K and the AUUCU repeat aggregates in the transgenic mouse brain and transfected cells confirmed this interaction. To examine the impact of this interaction on hnRNP K function, we performed RT-PCR analysis of a splicing-regulatory target of hnRNP K, and found diminished hnRNP K activity in SCA10 cells. Cells expressing expanded AUUCU repeats underwent apoptosis, which accompanied massive translocation of PKCdelta to mitochondria and activation of caspase 3. Importantly, siRNA-mediated hnRNP K deficiency also caused the same apoptotic event in otherwise normal cells, and over-expression of hnRNP K rescued cells expressing expanded AUUCU repeats from apoptosis, suggesting that the loss of function of hnRNP K plays a key role in cell death of SCA10. These results suggest that the expanded AUUCU-repeat in the intronic RNA undergoes normal transcription and splicing, but causes apoptosis via an activation cascade involving a loss of hnRNP K activities, massive translocation of PKCdelta to mitochondria, and caspase 3 activation.

We analyse the Planck full-mission cosmic microwave background (CMB) temperature and E-mode polarization maps to obtain constraints on primordial non-Gaussianity (NG). We compare estimates obtained from separable template-fitting, binned, and optimal modal bispectrum estimators, finding consistent values for the local, equilateral, and orthogonal bispectrum amplitudes. Our combined temperature and polarization analysis produces the following final results: flocalNL= -0.9 ± 5.1; fequilNL= -26 ± 47; and forthoNL= -38 ± 24 (68% CL, statistical). These results include low-multipole (4 ≤ ℓ < 40) polarization data that are not included in our previous analysis. The results also pass an extensive battery of tests (with additional tests regarding foreground residuals compared to 2015), and they are stable with respect to our 2015 measurements (with small fluctuations, at the level of a fraction of a standard deviation, which is consistent with changes in data processing). Polarizationonly bispectra display a significant improvement in robustness; they can now be used independently to set primordial NG constraints with a sensitivity comparable to WMAP temperature-based results and they give excellent agreement. In addition to the analysis of the standard local, equilateral, and orthogonal bispectrum shapes, we consider a large number of additional cases, such as scale-dependent feature and resonance bispectra, isocurvature primordial NG, and parity-breaking models, where we also place tight constraints but do not detect any signal. The nonprimordial lensing bispectrum is, however, detected with an improved significance compared to 2015, excluding the null hypothesis at 3.5σ. Beyond estimates of individual shape amplitudes, we also present model-independent reconstructions and analyses of the Planck CMB bispectrum. Our final constraint on the local primordial trispectrum shape is glocalNL= (-5.8 ± 6.5) × 104(68% CL, statistical), while constraints for other trispectrum shapes are also determined. Exploiting the tight limits on various bispectrum and trispectrum shapes, we constrain the parameter space of different early-Universe scenarios that generate primordial NG, including general single-field models of inflation, multi-field models (e.g. curvaton models), models of inflation with axion fields producing parity-violation bispectra in the tensor sector, and inflationary models involving vector-like fields with directionally-dependent bispectra. Our results provide a high-precision test for structure-formation scenarios, showing complete agreement with the basic picture of the CDM cosmology regarding the statistics of the initial conditions, with cosmic structures arising from adiabatic, passive, Gaussian, and primordial seed perturbations.

We analyse the Planck full-mission cosmic microwave background (CMB) temperature and E-mode polarization maps to obtain constraints on primordial non-Gaussianity (NG). We compare estimates obtained from separable template-fitting, binned, and optimal modal bispectrum estimators, finding consistent values for the local, equilateral, and orthogonal bispectrum amplitudes. Our combined temperature and polarization analysis produces the following final results: flocalNL= -0.9 ± 5.1; fequilNL= -26 ± 47; and forthoNL= -38 ± 24 (68% CL, statistical). These results include low-multipole (4 ≤ ℓ < 40) polarization data that are not included in our previous analysis. The results also pass an extensive battery of tests (with additional tests regarding foreground residuals compared to 2015), and they are stable with respect to our 2015 measurements (with small fluctuations, at the level of a fraction of a standard deviation, which is consistent with changes in data processing). Polarizationonly bispectra display a significant improvement in robustness; they can now be used independently to set primordial NG constraints with a sensitivity comparable to WMAP temperature-based results and they give excellent agreement. In addition to the analysis of the standard local, equilateral, and orthogonal bispectrum shapes, we consider a large number of additional cases, such as scale-dependent feature and resonance bispectra, isocurvature primordial NG, and parity-breaking models, where we also place tight constraints but do not detect any signal. The nonprimordial lensing bispectrum is, however, detected with an improved significance compared to 2015, excluding the null hypothesis at 3.5σ. Beyond estimates of individual shape amplitudes, we also present model-independent reconstructions and analyses of the Planck CMB bispectrum. Our final constraint on the local primordial trispectrum shape is glocalNL= (-5.8 ± 6.5) × 104(68% CL, statistical), while constraints for other trispectrum shapes are also determined. Exploiting the tight limits on various bispectrum and trispectrum shapes, we constrain the parameter space of different early-Universe scenarios that generate primordial NG, including general single-field models of inflation, multi-field models (e.g. curvaton models), models of inflation with axion fields producing parity-violation bispectra in the tensor sector, and inflationary models involving vector-like fields with directionally-dependent bispectra. Our results provide a high-precision test for structure-formation scenarios, showing complete agreement with the basic picture of the CDM cosmology regarding the statistics of the initial conditions, with cosmic structures arising from adiabatic, passive, Gaussian, and primordial seed perturbations.

Objectives To evaluate the proficiency of a HIPAA-compliant version of GPT-4 in identifying actionable, incidental findings from unstructured radiology reports of Emergency Department patients. To assess appropriateness of artificial intelligence (AI)-generated, patient-facing summaries of these findings. Materials and Methods Radiology reports extracted from the electronic health record of a large academic medical center were manually reviewed to identify non-emergent, incidental findings with high likelihood of requiring follow-up, further sub-stratified as "definitely actionable" (DA) or "possibly actionable—clinical correlation" (PA-CC). Instruction prompts to GPT-4 were developed and iteratively optimized using a validation set of 50 reports. The optimized prompt was then applied to a test set of 430 unseen reports. GPT-4 performance was primarily graded on accuracy identifying either DA or PA-CC findings, then secondarily for DA findings alone. Outputs were reviewed for hallucinations. AI-generated patient-facing summaries were assessed for appropriateness via Likert scale. Results For the primary outcome (DA or PA-CC), GPT-4 achieved 99.3% recall, 73.6% precision, and 84.5% F-1. For the secondary outcome (DA only), GPT-4 demonstrated 95.2% recall, 77.3% precision, and 85.3% F-1. No findings were "hallucinated" outright. However, 2.8% of cases included generated text about recommendations that were inferred without specific reference. The majority of True Positive AI-generated summaries required no or minor revision. Conclusion GPT-4 demonstrates proficiency in detecting actionable, incidental findings after refined instruction prompting. AI-generated patient instructions were most often appropriate, but rarely included inferred recommendations. While this technology shows promise to augment diagnostics, active clinician oversight via "human-in-the-loop" workflows remains critical for clinical implementation. [ABSTRACT FROM AUTHOR]

IntroductionCompetence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents.MethodsThe PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time.ResultsResidents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores.ConclusionComprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.

Optimization of proton exchange membrane water electrolyzers (PEMWE) has become a focus of researchers looking for a reliable way to generate power. A vital component to PEMWE operation is the porous transport layer (PTL) on the anode side, which is where oxygen is produced. The PTL must allow water access to the catalyst layer and remove oxygen simultaneously. In this work, a previously developed imaging technique is used to generate bilayer PTL structures. A multiscale modeling approach was used to study the effect of a bilayer PTL on oxygen evolution and PEMWE performance. First, a micro scale model was used to predict oxygen transport pathways through different PTL structures. Results showed that the bilayer PTL results in higher oxygen saturation and faster oxygen transport through the PTL. Second, a macro scale model was used to predict performance using bilayer PTLs. Predictions showed potential values between 10 and 20 mV below single layer potential values. This points to the bilayer improving PEMWE operation. Findings from this work show how the addition of a mesoporous layer to a PTL substrate will improve oxygen transport and removal from the catalyst surface, which will improve PEMWE performance. [ABSTRACT FROM AUTHOR]