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In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.

Patient data from the Israeli Ministry of Health demonstrates that a 3rd dose of BNT162b2 is effective in reducing Omicron BA.1/BA.2 severe disease and does not wane over the seven month study period as well as that a fourth dose further improves the protective features of vaccination.

The COVID-19 pandemic has disrupted everyday living and social practices, prompting questions of whether more sustainable consumption patterns are emerging and the likelihood of their long-term retention. To examine these questions, we apply a practice-based approach to a quantitative study of COVID-driven practice changes in the domains of food, material consumption, housing, and mobility conducted in four global North countries (Germany, Italy, Japan, and the United States). We discuss the trends emerging from our analysis from a sustainability perspective and address the role of social practice elements – materials, meanings, competences – in the establishment and discontinuation of sustainable consumption practices. Observed sustainability gains in specific practices and domains (such as a decrease in material consumption and more sustainable food practices and diets), may be offset by other practices, particularly a renewed desire for air travel and larger housing. The uptake and lock-in of sustainable practices are driven by a combination of meaning and material-related practice elements such as the alignment with interests and personal values; the availability of labor, energy, or time; and the ability to routinize practices. However, new policies to support emerging lifestyle shifts, as well as the development of businesses catering to and encouraging low-impact practices, may ultimately determine the formation of a more sustainable “new normal.” We also reflect on the strengths and limitations of using quantitative research methods in studies of sustainable consumption informed by social practice theories.

We analyze the business models of online business-to-consumer (B2C) fashion rental and share challenges and lessons learned from an in-depth case study of a former German fashion-rental company. The firm focused on renting everyday, rather than special occasion, clothing, thus increasing the potential sustainability impact of its offer significantly. We also examine drivers and barriers of both an everyday children’s wear and a women’s wear rental model by incorporating both retailer and consumer perspectives through business data, manager interviews, and consumer surveys with customer and target groups. All data were merged into a single, in-depth analysis of the business models. By combining the complementary viewpoints of retailer and consumers, we were able to more precisely pinpoint the locations of the difficulties in the business models. The main barriers to success were the worsening quality of the company’s inventory and its difficulty acquiring and retaining customers, due both to a lack of familiarity with the concept of fashion rental and the poorly perceived price-performance ratio of fashion rental. These issues suggest that online-fashion rental should begin by focusing on special occasion rentals with more high-end fashion options and should plan a sizeable budget for marketing to raise consumer awareness of alternatives to traditional retail models and alleviate customer concerns. If such a rental model is successful and establishes a stable customer base, everyday fashion-rental options could be explored as a supplement. The article demonstrates the importance of integrating different data sources to obtain a comprehensive understanding of why online-rental models fail or succeed.

We compute the accretion efficiency of small solids, with radii 1 cm ≤ R _s ≤ 10 m, on planets embedded in gaseous disks. Planets have masses 3 ≤ M _p ≤ 20 Earth masses ( M _⊕ ) and orbit within 10 au of a solar mass star. Disk thermodynamics is modeled via 3D radiation-hydrodynamics calculations that typically resolve the planetary envelopes. Both icy and rocky solids are considered, explicitly modeling their thermodynamic evolution. The maximum efficiencies of 1 ≤ R _s ≤ 100 cm particles are generally ≲10%, whereas 10 m solids tend to accrete efficiently or be segregated beyond the planet’s orbit. A simplified approach is applied to compute the accretion efficiency of small cores, with masses M _p ≤ 1 M _⊕ and without envelopes, for which efficiencies are approximately proportional to ${M}_{p}^{2/3}$ . The mass flux of solids, estimated from unperturbed drag-induced drift velocities, provides typical accretion rates dM _p / dt ≲ 10 ^−5 M _⊕ yr ^−1 . In representative disk models with an initial gas-to-dust mass ratio of 70–100 and total mass of 0.05–0.06 M _⊙ , the solids’ accretion falls below 10 ^−6 M _⊕ yr ^−1 after 1–1.5 Myr. The derived accretion rates, as functions of time and planet mass, are applied to formation calculations that compute dust opacity self-consistently with the delivery of solids to the envelope. Assuming dust-to-solid coagulation times of ≈0.3 Myr and disk lifetimes of ≈3.5 Myr, heavy-element inventories in the range 3–7 M _⊕ require that ≈90–150 M _⊕ of solids cross the planet’s orbit. The formation calculations encompass a variety of outcomes, from planets a few times M _⊕ , predominantly composed of heavy elements, to giant planets. The peak luminosities during the epoch of the solids’ accretion range from ≈10 ^−7 to ≈10 ^−6 L _⊙ .

This study compares SARS-CoV-2 infection rates following a recent second or third dose of the BNT162b2 (Pfizer/BioNTech) vaccine. They use data from Israel for 12–14 year olds (second dose) and 16–18 year olds (third dose), and find a 3.7-fold higher risk in the second-dose group.

Background: In common with other service-oriented occupations, teaching is a profession that requires employees to engage in emotional labour. In order to perform their day-to-day roles effectively, teachers are expected to manage and utilise their emotions in nuanced ways, with a high degree of control. As research suggests a complex relationship between emotional labour and occupational burnout, it is essential to examine this further in the context of teaching, so as to better understand the issues associated with teacher burnout. Purpose: This paper aims to explore the literature on emotional labour and burnout, using the lens of sociological research to examine how multiple contexts shape people's experiences in occupations. We present a theoretical discussion on how expectations for emotion displays and management, alongside structural factors, may shape the experiences of teachers. Sources of evidence: We reviewed literature on emotional labour and burnout to examine this relationship within the context of contemporary constraints, including educational policies, accountability and emergent interpersonal dynamics in the everyday lives of school teachers. We focussed mainly on the United States public school system and used search terms including emotional labour, emotion work, emotion management and feeling rules. An inductive analytic strategy was used to identify common themes in the literature. Findings and Conclusion: The thematic analysis of literature suggested that the intertwining of structural- and interactional-level expectations for emotional labour fosters close yet complicated relationships with teacher burnout. In bringing attention to these relationships, we offer suggestions as to the directions education researchers and administrators might take to better comprehend and address teacher burnout.

Malignant pleural mesothelioma (MPM) is a highly lethal cancer of the lining of the chest cavity. To expand our understanding of MPM, we conducted a comprehensive integrated genomic study, including the most detailed analysis of BAP1 alterations to date. We identified histology-independent molecular prognostic subsets, and defined a novel genomic subtype with TP53 and SETDB1 mutations and extensive loss of heterozygosity. We also report strong expression of the immune-checkpoint gene VISTA in epithelioid MPM, strikingly higher than in other solid cancers, with implications for the immune response to MPM and for its immunotherapy. Our findings highlight new avenues for further investigation of MPM biology and novel therapeutic options. SIGNIFICANCE: Through a comprehensive integrated genomic study of 74 MPMs, we provide a deeper understanding of histology-independent determinants of aggressive behavior, define a novel genomic subtype with TP53 and SETDB1 mutations and extensive loss of heterozygosity, and discovered strong expression of the immune-checkpoint gene VISTA in epithelioid MPM.See related commentary by Aggarwal and Albelda, p. 1508.This article is highlighted in the In This Issue feature, p. 1494.

Continuity of care is a challenge in primary care residency teaching clinics. Resident physicians have competing inpatient and outpatient responsibilities and often spend only 1 to 2 half-days per week in the clinic. Their clinic schedules are often pieced together after the needs of inpatient and specialty rotations are met. Similarly, faculty clinicians often balance limited clinic time with teaching, research, or administrative responsibilities. Seeking approaches to improve continuity of care, we visited 23 internal medicine, family medicine, and pediatric residency clinics across the US. This article highlights strategies to optimize continuity of care pioneered by 3 "bright spot" residency teaching clinics with high-continuity performance. The strategies include adopting a strong continuity culture and patient scheduling algorithms that prioritize continuity, appointing a team continuity anchor, and/or reorganizing resident and faculty schedules to maximize continuity. We hope that these perspectives can assist residency teaching practices to improve continuity of care for their patients.

The number of physicians seeing patients part time is growing, an evolution that challenges the primary care pillars of continuity and access. The growth of part-time practice is a response to burnout and to the pressures facing primary care physicians. Physicians who work fewer clinical hours and thereby reduce burnout are more satisfied with their careers, less likely to leave their jobs, and provide a better patient experience. Primary care practices can make a number of adjustments to optimize continuity and access in this era of part-time practice. Moreover, physicians who work fewer clinical hours are equally capable of fostering trusting relationships with patients as physicians seeing patients full time.

We studied 137 primary testicular germ cell tumors (TGCTs) using high-dimensional assays of genomic, epigenomic, transcriptomic, and proteomic features. These tumors exhibited high aneuploidy and a paucity of somatic mutations. Somatic mutation of only three genes achieved significance-KIT, KRAS, and NRAS-exclusively in samples with seminoma components. Integrated analyses identified distinct molecular patterns that characterized the major recognized histologic subtypes of TGCT: seminoma, embryonal carcinoma, yolk sac tumor, and teratoma. Striking differences in global DNA methylation and microRNA expression between histology subtypes highlight a likely role of epigenomic processes in determining histologic fates in TGCTs. We also identified a subset of pure seminomas defined by KIT mutations, increased immune infiltration, globally demethylated DNA, and decreased KRAS copy number. We report potential biomarkers for risk stratification, such as miRNA specifically expressed in teratoma, and others with molecular diagnostic potential, such as CpH (CpA/CpC/CpT) methylation identifying embryonal carcinomas.

Thymic epithelial tumors (TETs) are one of the rarest adult malignancies. Among TETs, thymoma is the most predominant, characterized by a unique association with autoimmune diseases, followed by thymic carcinoma, which is less common but more clinically aggressive. Using multi-platform omics analyses on 117 TETs, we define four subtypes of these tumors defined by genomic hallmarks and an association with survival and World Health Organization histological subtype. We further demonstrate a marked prevalence of a thymoma-specific mutated oncogene, GTF2I, and explore its biological effects on multi-platform analysis. We further observe enrichment of mutations in HRAS, NRAS, and TP53. Last, we identify a molecular link between thymoma and the autoimmune disease myasthenia gravis, characterized by tumoral overexpression of muscle autoantigens, and increased aneuploidy.

Sarcomas are a broad family of mesenchymal malignancies exhibiting remarkable histologic diversity. We describe the multi-platform molecular landscape of 206 adult soft tissue sarcomas representing 6 major types. Along with novel insights into the biology of individual sarcoma types, we report three overarching findings: (1) unlike most epithelial malignancies, these sarcomas (excepting synovial sarcoma) are characterized predominantly by copy-number changes, with low mutational loads and only a few genes (TP53, ATRX, RB1) highly recurrently mutated across sarcoma types; (2) within sarcoma types, genomic and regulomic diversity of driver pathways defines molecular subtypes associated with patient outcome; and (3) the immune microenvironment, inferred from DNA methylation and mRNA profiles, associates with outcome and may inform clinical trials of immune checkpoint inhibitors. Overall, this large-scale analysis reveals previously unappreciated sarcoma-type-specific changes in copy number, methylation, RNA, and protein, providing insights into refining sarcoma therapy and relationships to other cancer types.

Comprehensive multiplatform analysis of 80 uveal melanomas (UM) identifies four molecularly distinct, clinically relevant subtypes: two associated with poor-prognosis monosomy 3 (M3) and two with better-prognosis disomy 3 (D3). We show that BAP1 loss follows M3 occurrence and correlates with a global DNA methylation state that is distinct from D3-UM. Poor-prognosis M3-UM divide into subsets with divergent genomic aberrations, transcriptional features, and clinical outcomes. We report change-of-function SRSF2 mutations. Within D3-UM, EIF1AX- and SRSF2/SF3B1-mutant tumors have distinct somatic copy number alterations and DNA methylation profiles, providing insight into the biology of these low- versus intermediate-risk clinical mutation subtypes.

We performed genomic, epigenomic, transcriptomic, and proteomic characterizations of uterine carcinosarcomas (UCSs). Cohort samples had extensive copy-number alterations and highly recurrent somatic mutations. Frequent mutations were found in TP53, PTEN, PIK3CA, PPP2R1A, FBXW7, and KRAS, similar to endometrioid and serous uterine carcinomas. Transcriptome sequencing identified a strong epithelial-to-mesenchymal transition (EMT) gene signature in a subset of cases that was attributable to epigenetic alterations at microRNA promoters. The range of EMT scores in UCS was the largest among all tumor types studied via The Cancer Genome Atlas. UCSs shared proteomic features with gynecologic carcinomas and sarcomas with intermediate EMT features. Multiple somatic mutations and copy-number alterations in genes that are therapeutic targets were identified.

Cholangiocarcinoma (CCA) is an aggressive malignancy of the bile ducts, with poor prognosis and limited treatment options. Here, we describe the integrated analysis of somatic mutations, RNA expression, copy number, and DNA methylation by The Cancer Genome Atlas of a set of predominantly intrahepatic CCA cases and propose a molecular classification scheme. We identified an IDH mutant-enriched subtype with distinct molecular features including low expression of chromatin modifiers, elevated expression of mitochondrial genes, and increased mitochondrial DNA copy number. Leveraging the multi-platform data, we observed that ARID1A exhibited DNA hypermethylation and decreased expression in the IDH mutant subtype. More broadly, we found that IDH mutations are associated with an expanded histological spectrum of liver tumors with molecular features that stratify with CCA. Our studies reveal insights into the molecular pathogenesis and heterogeneity of cholangiocarcinoma and provide classification information of potential therapeutic significance.

We report a comprehensive molecular characterization of pheochromocytomas and paragangliomas (PCCs/PGLs), a rare tumor type. Multi-platform integration revealed that PCCs/PGLs are driven by diverse alterations affecting multiple genes and pathways. Pathogenic germline mutations occurred in eight PCC/PGL susceptibility genes. We identified CSDE1 as a somatically mutated driver gene, complementing four known drivers (HRAS, RET, EPAS1, and NF1). We also discovered fusion genes in PCCs/PGLs, involving MAML3, BRAF, NGFR, and NF1. Integrated analysis classified PCCs/PGLs into four molecularly defined groups: a kinase signaling subtype, a pseudohypoxia subtype, a Wnt-altered subtype, driven by MAML3 and CSDE1, and a cortical admixture subtype. Correlates of metastatic PCCs/PGLs included the MAML3 fusion gene. This integrated molecular characterization provides a comprehensive foundation for developing PCC/PGL precision medicine.

In the current study, we investigated the ways in which the acquisition and transfer of spatial knowledge were affected by (a) the type of spatial relations predominately experienced during learning (routes determined by walkways vs. straight-line paths between locations); (b) environmental complexity; and (c) the availability of rotational body-based information. Participants learned the layout of a virtual shopping mall by repeatedly searching for target storefronts located in 1 of the buildings. We created 2 novel learning conditions to encourage participants to use either route knowledge (paths on walkways between buildings) or survey knowledge (straight-line distances and directions from storefront to storefront) to find the target, and measured the development of route and survey knowledge in both learning conditions. Environmental complexity was manipulated by varying the alignment of the buildings with the enclosure, and the visibility within space. Body-based information was manipulated by having participants perform the experiment in front of a computer monitor or using a head-mounted display. After navigation, participants pointed to various storefronts from a fixed position and orientation. Results showed that the frequently used spatial knowledge could be developed similarly across environments with different complexities, but the infrequently used spatial knowledge was less developed in the complex environment. Furthermore, rotational body-based information facilitated spatial learning under certain conditions. Our results suggest that path integration may play an important role in spatial knowledge transfer, both from route to survey knowledge (cognitive map construction), and from survey to route knowledge (using cognitive map to guide wayfinding).

PURPOSE: Health coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention. METHODS: We performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures. RESULTS: 290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months. CONCLUSIONS: Results support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

PurposeHealth coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.MethodsWe performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.Results290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.ConclusionsResults support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

Therapy development for adult diffuse glioma is hindered by incomplete knowledge of somatic glioma driving alterations and suboptimal disease classification. We defined the complete set of genes associated with 1,122 diffuse grade II-III-IV gliomas from The Cancer Genome Atlas and used molecular profiles to improve disease classification, identify molecular correlations, and provide insights into the progression from low- to high-grade disease. Whole-genome sequencing data analysis determined that ATRX but not TERT promoter mutations are associated with increased telomere length. Recent advances in glioma classification based on IDH mutation and 1p/19q co-deletion status were recapitulated through analysis of DNA methylation profiles, which identified clinically relevant molecular subsets. A subtype of IDH mutant glioma was associated with DNA demethylation and poor outcome; a group of IDH-wild-type diffuse glioma showed molecular similarity to pilocytic astrocytoma and relatively favorable survival. Understanding of cohesive disease groups may aid improved clinical outcomes.

The current COVID-19 crisis can provide a window of opportunity for promoting sustainability transitions across the globe, but this goal can only be achieved with deliberate planning and carefully designed strategic communication in the public sphere. This policy brief outlines a three-part narrative that discursively connects the COVID-19 pandemic with its potential to facilitate sustainability transitions. We seek to make clear the connection between the coronavirus outbreak and unsustainable behavior, to explain that continuing unsustainable behavior could cause further crises of a similarly debilitating scale, and to frame the current lockdown and standstill as a timely occasion to change direction and to prevent future crises. The policy brief concludes by adapting organizational crisis communication strategies to the current situation and answering questions of how, when, by whom, and at whom communication should take place.

There is substantial heterogeneity among primary prostate cancers, evident in the spectrum of molecular abnormalities and its variable clinical course. As part of The Cancer Genome Atlas (TCGA), we present a comprehensive molecular analysis of 333 primary prostate carcinomas. Our results revealed a molecular taxonomy in which 74% of these tumors fell into one of seven subtypes defined by specific gene fusions (ERG, ETV1/4, and FLI1) or mutations (SPOP, FOXA1, and IDH1). Epigenetic profiles showed substantial heterogeneity, including an IDH1 mutant subset with a methylator phenotype. Androgen receptor (AR) activity varied widely and in a subtype-specific manner, with SPOP and FOXA1 mutant tumors having the highest levels of AR-induced transcripts. 25% of the prostate cancers had a presumed actionable lesion in the PI3K or MAPK signaling pathways, and DNA repair genes were inactivated in 19%. Our analysis reveals molecular heterogeneity among primary prostate cancers, as well as potentially actionable molecular defects.

ObjectivesWe sought to test the hypothesis that training medical assistants to provide health coaching would improve patients' experience of care received and overall satisfaction with their clinic.Study designRandomized controlled trial.MethodsLow-income English- or Spanish-speaking patients aged 18 to 75 years with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were randomized to receive either a health coach or usual care for 12 months. Patient care experience was measured using the Patient Assessment of Chronic Illness Care (PACIC) scale at baseline and at 12 months. Patient overall satisfaction with the clinic was assessed with a single item asking if they would recommend the clinic to a friend or family member. PACIC and satisfaction scores were compared between study arms using generalized estimating equations to account for clustering at the clinician level.ResultsPACIC scores were available from baseline and at 12 months on 366 (76%) of the 441 patients randomized. At baseline, patients receiving health coaching were similar to those in the usual care group with respect to demographic and other characteristics, including mean PACIC scores (3.00 vs 3.06) and the percent who would "definitely recommend" their clinic (73% and 73%, respectively). At 12 months, coached patients had a significantly higher mean PACIC score (3.82 vs 3.13; P < .001) and were more likely to report they would definitely recommend their clinic (85% vs 73%; P = .002).ConclusionsUsing medical assistants trained in health coaching significantly improved the quality of care that low-income patients with poorly controlled chronic disease reported receiving from their healthcare team.

Invasive lobular carcinoma (ILC) is the second most prevalent histologic subtype of invasive breast cancer. Here, we comprehensively profiled 817 breast tumors, including 127 ILC, 490 ductal (IDC), and 88 mixed IDC/ILC. Besides E-cadherin loss, the best known ILC genetic hallmark, we identified mutations targeting PTEN, TBX3, and FOXA1 as ILC enriched features. PTEN loss associated with increased AKT phosphorylation, which was highest in ILC among all breast cancer subtypes. Spatially clustered FOXA1 mutations correlated with increased FOXA1 expression and activity. Conversely, GATA3 mutations and high expression characterized luminal A IDC, suggesting differential modulation of ER activity in ILC and IDC. Proliferation and immune-related signatures determined three ILC transcriptional subtypes associated with survival differences. Mixed IDC/ILC cases were molecularly classified as ILC-like and IDC-like revealing no true hybrid features. This multidimensional molecular atlas sheds new light on the genetic bases of ILC and provides potential clinical options.

PurposeA randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling.MethodsThis paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study.ResultsOf the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches' perceptions of the training.ConclusionsOf low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.

We describe the landscape of genomic alterations in cutaneous melanomas through DNA, RNA, and protein-based analysis of 333 primary and/or metastatic melanomas from 331 patients. We establish a framework for genomic classification into one of four subtypes based on the pattern of the most prevalent significantly mutated genes: mutant BRAF, mutant RAS, mutant NF1, and Triple-WT (wild-type). Integrative analysis reveals enrichment of KIT mutations and focal amplifications and complex structural rearrangements as a feature of the Triple-WT subtype. We found no significant outcome correlation with genomic classification, but samples assigned a transcriptomic subclass enriched for immune gene expression associated with lymphocyte infiltrate on pathology review and high LCK protein expression, a T cell marker, were associated with improved patient survival. This clinicopathological and multi-dimensional analysis suggests that the prognosis of melanoma patients with regional metastases is influenced by tumor stroma immunobiology, offering insights to further personalize therapeutic decision-making.

Primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. The authors developed the 12-item Panel Management Questionnaire (PMQ) measuring 4 domains. Data were assembled from self-administered cross-sectional surveys of 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Staff and clinician PMQ scores in each clinic were correlated. The clinic-level median PMQ score was positively associated with a composite clinic quality measure.