MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists

Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRI between 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology (ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated. Clinical significance: More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.

Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients

Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.

Pituitary metastases: a case series and scoping review

PURPOSE

To understand the natural history and optimal treatment strategy for pituitary gland metastasis.

METHODS

We performed both a retrospective chart review of patients treated at our institution and a scoping review of the topic.

RESULTS

The retrospective review identified seven patients with an average age of 59.6 years. Primary histologies included breast cancer (4), melanoma (1), renal cell carcinoma (1), and sarcoma (1). Two patients had anterior pituitary endocrine dysfunction, one of whom was the only patient with visual symptoms. All patients were treated with radiosurgery and two also underwent surgical resection. Overall survival ranged from 6.5 to 117 months. Literature review identified 166 patients from 71 studies. The most common primary cancer was lung (27.7%), followed by breast (18.7%) and renal (14.5%) cancer. 107 presented with endocrine dysfunction, including 41 cases of diabetes insipidus and 55 cases of hypopituitarism. 110 presented with visual compromise. 107 patients received radiotherapy, 96 underwent surgical resection and 44 received systemic chemotherapy/immunotherapy. Surgery was significantly associated with an increased likelihood of vision improvement and a decreased likelihood of endocrine normalization. Radiographic regression predicted visual improvement. Median overall survival was 9.9 months (range: 0.2-96).

CONCLUSIONS

This scoping review showed that both radiosurgery and surgical resection have been frequently used to treat pituitary metastases with good response. Vision improvement is more likely to happen following surgical resection, likely at the expense of endocrine dysfunction. Despite treatment and radiographic response, patient survival remains less than a year.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Gastric Outlet Obstruction and Iron Deficiency Anemia Secondary to Gastric Bezoar: A Case Report

Trichobezoars are an accumulation of undigested hair in the gastrointestinal system. They are a rare finding and are more likely in young females. Diagnosis is largely dependent on history taking and imaging, and treatment involves the removal and psychiatric evaluation.  We describe the case of a 21-year-old female with a history of gastroesophageal reflux disease (GERD) who presented with abdominal pain. Imaging showed a distended stomach with a suspected swallowed foreign substance. The patient subsequently underwent midline laparotomy, gastrotomy, and bezoar extraction. Postoperatively the patient was found to have trichotillomania, trichophagia, anxiety, depression, and symptomatic anemia. Initial management of gastric bezoars includes proper removal, but the additional follow-up needs to include psychiatric evaluation and treatment to prevent reoccurrence. It is also imperative to assess and treat underlying nutritional deficiencies.

The Effect of Derotational Kirschner Wires on Fracture Gap Reduction With Variable-Pitch Headless Screws

PURPOSE

We evaluated the impact of angled derotational Kirschner wires (K-wires) on fracture gap reduction with variable-pitch headless screws.

METHODS

Fully threaded variable-pitch headless screws (20 and 28 mm) were inserted into "normal" bone models of polyurethane blocks. In separate trials, derotational K-wires were inserted at predetermined angles of 0°, 15°, 30°, and 40° and compared with each other, with no K-wire as a control. Fluoroscopic images taken after each screw turn were analyzed. The optimal fracture gap closure, initial screw push-off, and screw back-out gap creation were determined and compared at various derotational K-wire angles.

RESULTS

Initial screw push-off due to screw insertion and screw back-out gap creation were not significantly affected by the angle of the derotational K-wire. With a 20-mm screw, only a 40° derotational K-wire led to significantly less gap closure compared with control and with 0°, 15°, and 30° derotational K-wires. It led to an approximately 60% decrease in gap closure compared with no K-wire. With the 28-mm screw, compared with no K-wire, 15° and 30° derotational K-wires led to statistically significant decreases in gap closure (approximately 25%), whereas a 40° derotational K-wire led to an approximately 60% decrease. With the 28-mm screw, the 40° derotational K-wire also led to a statistically significant smaller gap closure when compared with 0°, 15°, and 30° derotational K-wires.

CONCLUSIONS

A derotational K-wire placed in parallel to the planned trajectory of a headless compression screw does not affect fracture gap closure. With greater angulation of the derotational K-wire, the fracture gap is still closed, but less tightly.

CLINICAL RELEVANCE

Derotational K-wires can help prevent fracture fragment rotation during headless compression screw insertion. At small deviations from parallel (≤30°), fracture gap closure achieved by the screw is minimally affected. At greater angles (ie, 40°), fracture gap closure may be substantially reduced, preventing fracture compression.

Changes in Body Composition in Older Adults after a Technology-Based Weight Loss Intervention

We conducted a post-hoc analysis of a pre/post, single-arm, non-randomized, multicomponent weight loss intervention in older adults. Fifty-three older adults aged ≥65 with a body mass index ≥ 30 kg/m2 were recruited to participate in a six-month, remote monitoring and video-conferencing delivered, prescriptive intervention consisting of individual and group-led registered dietitian nutrition and physical therapy sessions. We assessed weight, height, and body composition using a SECA 514 bioelectrical impedance analyzer. Mean age was 72.9±3.9 years (70% female) and all had ≥2 chronic conditions. Of those with complete data (n=30), we observed a 4.6±3.5kg loss in weight, 6.1±14.3kg (1.9%) loss in fat mass, and 0.78±1.69L loss in visceral fat (all p<0.05). Fat-free mass (-3.4kg±6.8, p=0.19), appendicular lean mass (-0.25±1.83, p=0.22), and grip strength (+3.46±7.89, p=0.56) did not significantly change. These variables were preserved after stratifying by 5% weight loss. Our intervention led to significant body and visceral fat loss while maintaining fat-free and appendicular lean muscle mass.

Lower Extremity Splinting: A Head-to-Head Comparison of A Novel One-Step Spray-on Splint Versus Standard Splinting

INTRODUCTION

Splinting is an essential component of treating many lower extremity musculoskeletal injuries; however, little development has been made in splinting technology. The purpose of this study is to evaluate the efficacy of current immobilization equipment for lower extremity fractures by testing a novel one-step spray-on foam splint (Fast Cast) against structural aluminum malleable (SAM) lower extremity musculoskeletal injuries and 6-inch ACE (3M Corp., Minneapolis, MN, USA) bandage splints.

MATERIALS AND METHODS

Six orthopedic surgical residents and two medical students participated in a prospective analysis of austere splinting techniques and equipment that utilized a cadaveric model with a distal third tibia-fibula shaft fracture. Each participant was observed and scored by three fellowship trained attending orthopedic surgeons. All scoring was independent using a 5-point Likert scale based on 10 splinting criteria (50 total points possible), including quality of radiographic reduction, time to completion, safety, and sustain longitudinal traction. The Likert scale is a set of questions that reflects the respondent's degree of agreement or disagreement with a statement. Each of the 10 questions has a range of 1-5. A score of 50 means the splint performed perfectly. The lowest possible score is a 10. The participants utilized standard equipment that included SAM splints and 6-inch ACE wraps (3M Corp., Minneapolis, MN, USA) in their first attempt. A second immobilization attempt was done with a one-step spray-on foam splint (Fast Cast). After each splinting attempt, the reduction was verified with radiographic imaging. Data analysis was performed using standard descriptive statistics, Student's t-tests, and inter-rater reliability was calculated using Cronbach's alpha scores. This project is Institutional Review Board (IRB) exempt.

RESULTS

The one-step spray-on foam splinting technique was superior (P < .05) in all parameters of the Likert scale, yielding a mean overall score of 45.1 points (±3.8), safety 4.7 points, longitudinal traction 4.5 points, and time 136 seconds (±23). The SAM resulted in a mean overall score of 33.8 points (±7.3), safety 2.8 points, longitudinal traction 4.1 points, and time 170 seconds (±52). Radiographic rating was 4.1 points (±0.7) for the SAM splint and 4.5 (±0.6) for Fast Cast. The differences in time to completion and radiograph rating did not reach statistical significance (P = .12 and P = .07, respectively).

CONCLUSION

A one-step spray-on foam splinting technique demonstrated consistent superiority in reducing fracture motion, potential soft-tissue damage, and sustained longitudinal traction as compared to the standard technique.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

Concomitant Chronic Lymphocytic Leukemia and Mantle Cell Lymphoma Discovered by Flow Cytometry

Casestudy: Chronic lymphocytic leukemia (CLL) accounts for about 30% of all lymphoid neoplasms and is the most common adult blood cancer in the Western world. Mantle cell lymphoma (MCL) accounts for only about 6% of all B-cell lymphomas in Western countries. MCL and CLL are both CD5 positive B-cell lymphoproliferative disorders. It is necessary to distinguish these two entities as MCL is a more aggressive disease, and requires specific treatment. MCL and CLL can occur in one patient at the same time and is often termed a composite lymphoma. We present an 84-year-old female with a history of endometrial cancer who was found to have splenomegaly and lymphadenopathy. Flow cytometry was performed upon her peripheral blood specimen which demonstrated two distinct populations of abnormal light chain restricted B-cell populations. One population demonstrated kappa light chain restriction and was positive for CD45, CD19, CD20, CD5, CD38, FMC-7, and CD22, representing MCL. The other population showed dim lambda light chain restriction that was also positive for CD45, CD19, dim CD20, CD5, and CD23, representing CLL. FISH studies demonstrated t(11;14), and four common deletions or chromosome aneuploidy associated with CLL. These findings confirmed the dual populations of CLL and MCL. This is an interesting case because it is a very rare combination with only a few cases having been reported with two distinct cell populations in one patient at the same time.

Concomitant Chronic Lymphocytic Leukemia and Mantle Cell Lymphoma Discovered by Flow Cytometry

Casestudy: Chronic lymphocytic leukemia (CLL) accounts for about 30% of all lymphoid neoplasms and is the most common adult blood cancer in the Western world. Mantle cell lymphoma (MCL) accounts for only about 6% of all B-cell lymphomas in Western countries. MCL and CLL are both CD5 positive B-cell lymphoproliferative disorders. It is necessary to distinguish these two entities as MCL is a more aggressive disease, and requires specific treatment. MCL and CLL can occur in one patient at the same time and is often termed a composite lymphoma. We present an 84-year-old female with a history of endometrial cancer who was found to have splenomegaly and lymphadenopathy. Flow cytometry was performed upon her peripheral blood specimen which demonstrated two distinct populations of abnormal light chain restricted B-cell populations. One population demonstrated kappa light chain restriction and was positive for CD45, CD19, CD20, CD5, CD38, FMC-7, and CD22, representing MCL. The other population showed dim lambda light chain restriction that was also positive for CD45, CD19, dim CD20, CD5, and CD23, representing CLL. FISH studies demonstrated t(11;14), and four common deletions or chromosome aneuploidy associated with CLL. These findings confirmed the dual populations of CLL and MCL. This is an interesting case because it is a very rare combination with only a few cases having been reported with two distinct cell populations in one patient at the same time.

Use of dual mobility components in total hip arthroplasty: Indications and outcomes

Instability after total hip arthroplasty (THA) can be a problematic complication and remains one of the leading causes of revision surgery in the early post-operative period. Dual mobility (DM) implants decrease dislocation risk after THA but they come with their own set of complications. Selective use of DM implants for THA in high risk groups can confer the advantages of this construct while mitigating the risks. In this paper, we review the current literature to examine the evidence for or against use of DM implants in various clinical scenarios and provide an algorithm for when to consider using DM design construct in THA.

Malignant spinal cord compression

Malignant spinal cord compression (MSCC) is a potentially devastating consequence of cancer. Early recognition of the signs and symptoms of MSCC can allow diagnosis prior to the development of irreversible complications. Information provision to patients and doctors regarding the risk of MSCC and a streamlined pathway for further investigation are both key to improving the outcome for patients developing this condition. Described in this paper is the development of such a pathway at Aberdeen Royal Infirmary.

Impact and Mechanism of Covid-19 on Mental Health and Wellbeing

The Covid-19 pandemic has brought unprecedented pressure to healthcare systems worldwide, resulting in significant and precipitous changes in demand, burden and method of delivery. The psychosocial impact of this crisis is likely to increase over the course of the pandemic, peak later than medical cases and endure for longer thereby significantly exceeding medical morbidity. It will have far reaching impact on the individual, their family and their care providers. Frontline healthcare workers and those with pre-existing mental health difficulties are recognised at increased risk. Now that the initial surge has been expertly curtailed, it is essential that urgent consideration is now directed towards the mental health implications of the current outbreak and ensure that we are as ready for the increased MH needs of the community as we were for the intensive medical care.

No differences in short-term outcomes between patients with anaerobic and aerobic culture positive prosthetic joint infection

BACKGROUND

Prosthetic joint infection (PJI) is a devastation complication of total joint arthroplasty that can result in poor patient outcomes. Anaerobic organisms make up a small proportion of PJI cases and are much less studied. Studies comparing patient outcomes in anaerobic PJI to outcomes in aerobic PJI are sparse. The purpose of this study was to compare the clinical presentation, duration of antibiotics, type of treatment provided, and final outcome between PJI patients with anaerobic infection and those with aerobic infection.

METHODS

This was a retrospective study of 26 patients who underwent treatment for PJI at a tertiary referral center. Eight patients with anaerobic PJI were compared to 18 patients with aerobic PJI in terms of clinical presentation, laboratory values, treatment duration, and functional outcome. Statistical analysis was performed on continuous variables of interest.

RESULTS

The results of our study showed that there are no differences in short term clinical outcomes between PJI patients with cultures positive for anaerobic vs aerobic organisms (38.9% vs 50% successfully treated). Inflammatory markers were higher in the aerobic group and patients in the anaerobic group tended to have fewer medical comorbidities.

CONCLUSION

PJI caused by anaerobic organisms results in poor patient outcomes similar to infection caused by aerobic organisms. There are some differences in clinical presentation between the two groups that can be explained by the fact that anaerobic organisms are of low virulence and result in indolent infections causing longstanding symptoms.

Nuclear Dependence of the Transverse Single-Spin Asymmetry in the Production of Charged Hadrons at Forward Rapidity in Polarized p+p, p+Al, and p+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the nuclear dependence of transverse single-spin asymmetries (TSSAs) in the production of positively charged hadrons in polarized p^{↑}+p, p^{↑}+Al, and p^{↑}+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements have been performed at forward rapidity (1.4<η<2.4) over the range of transverse momentum (1.8<p_{T}<7.0  GeV/c) and Feynman x (0.1<x_{F}<0.2). We observed positive asymmetries for positively charged hadrons in p^{↑}+p collisions, and significantly reduced asymmetries in p^{↑}+A collisions. These results reveal a nuclear dependence of TSSAs for charged-hadron production in a regime where perturbative techniques are applicable. These results provide new opportunities to use p^{↑}+A collisions as a tool to investigate the rich phenomena behind TSSAs in hadronic collisions and to use TSSAs as a new handle in studying small-system collisions.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Coeliac disease in Caucasian and South Asian patients in the North West of England

BACKGROUND

Coeliac disease is an autoimmune enteropathy characterised by mucosal inflammation subsequent to gluten exposure, leading to malabsorption. Treatment is strict dietary control, relying on the patient's ability to maintain lifestyle modifications. The present study aimed to compare clinical presentation and adherence to a gluten-free diet between South Asian and Caucasian patients with coeliac disease in East Lancashire METHODS: In total, 33 South Asian and 113 Caucasian adult patients diagnosed with coeliac disease under the care of the Dietetics Department at East Lancashire Hospitals NHS Trust were selected using a convenience sampling method and then allocated to the South Asian or Caucasian group. A subjective assessment of dietetic notes from follow-up visits within 1 year of the first appointment was undertaken by two investigators who subsequently allocated the patients to one of the three categories: (i) fully-adherent; (ii) partly-adherent; and (iii) non-adherent. Presenting complaint, vitamin D, vitamin B₁₂ , folate and ferritin levels were also compared.

RESULTS

There was a significant difference in adherence to gluten-free diet between the groups, with a larger proportion of Caucasian patients being fully adherent to gluten-free diet compared to South Asian patients (64.6% versus 12.1%, P < 0.001). In addition, a significantly higher proportion of South Asian patients were vitamin D deficient compared with Caucasian patients (70.8% versus 32.8%, P = 0.002).

CONCLUSIONS

The rates of strict adherence to gluten-free diet and vitamin D levels were significantly lower in South Asian patients with coeliac disease compared to the Caucasian coeliac population. Further studies are required to investigate the causes and improve adherence in the South Asian population.

The Effect of Adjunctive Fresh Frozen Plasma Administration on Coagulation Parameters and Survival in a Canine Model of Antivenom-treated Brown Snake Envenoming

This study aimed to assess the effects of dugite envenoming on blood coagulation and platelet count in a canine model, and the efficacy of fresh frozen plasma (FFP) in reversing the clotting disorder after both adequate and inadequate venom neutralization. Following initial dosing and administration studies, an intravenous venom dose of 1μg/kg was administered to eleven dogs. This was followed 30 minutes later by antivenom in either adequate or inadequate doses. A further 30 minutes later, the animals were given either two units of their own FFP or saline. Fibrinogen, aPTT and platelet levels were monitored for eight hours.

Of the six study dogs given antivenom plus FFP, two died at around 60 to 90 minutes post envenoming, at the end of the FFP infusions, and all but one of the survivors had persistent afibrinogenaemia. Of the five study dogs given antivenom and no FFP, all but one had return of detectable fibrinogen at eight hours after envenoming. The platelet count fell in all animals with recovery independent of antivenom dose, administration of FFP, or regeneration of fibrinogen. Post mortem examinations of dogs that died during dosage and administration studies showed massive intracardiac clots.

We conclude that early death from Brown Snake envenoming may be due to massive intravascular clotting. FFP administration was associated with persistent afibrinogenaemia regardless of antivenom dose. In the absence of any evidence for its efficacy, this study suggests that the role of FFP after Brown Snake envenoming should be reconsidered.

Pseudorapidity Dependence of Particle Production and Elliptic Flow in Asymmetric Nuclear Collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200 GeV

Asymmetric nuclear collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200  GeV provide an excellent laboratory for understanding particle production, as well as exploring interactions among these particles after their initial creation in the collision. We present measurements of charged hadron production dN_{ch}/dη in all such collision systems over a broad pseudorapidity range and as a function of collision multiplicity. A simple wounded quark model is remarkably successful at describing the full data set. We also measure the elliptic flow v_{2} over a similarly broad pseudorapidity range. These measurements provide key constraints on models of particle emission and their translation into flow.

Measurements of Multiparticle Correlations in d+Au Collisions at 200, 62.4, 39, and 19.6 GeV and p+Au Collisions at 200 GeV and Implications for Collective Behavior

Recently, multiparticle-correlation measurements of relativistic p/d/^{3}He+Au, p+Pb, and even p+p collisions show surprising collective signatures. Here, we present beam-energy-scan measurements of two-, four-, and six-particle angular correlations in d+Au collisions at sqrt[s_{NN}]=200, 62.4, 39, and 19.6 GeV. We also present measurements of two- and four-particle angular correlations in p+Au collisions at sqrt[s_{NN}]=200  GeV. We find the four-particle cumulant to be real valued for d+Au collisions at all four energies. We also find that the four-particle cumulant in p+Au has the opposite sign as that in d+Au. Further, we find that the six-particle cumulant agrees with the four-particle cumulant in d+Au collisions at 200 GeV, indicating that nonflow effects are subdominant. These observations provide strong evidence that the correlations originate from the initial geometric configuration, which is then translated into the momentum distribution for all particles, commonly referred to as collectivity.

Nuclear Dependence of the Transverse-Single-Spin Asymmetry for Forward Neutron Production in Polarized p+A Collisions at sqrt[s_{NN}]=200 GeV

During 2015, the Relativistic Heavy Ion Collider (RHIC) provided collisions of transversely polarized protons with Au and Al nuclei for the first time, enabling the exploration of transverse-single-spin asymmetries with heavy nuclei. Large single-spin asymmetries in very forward neutron production have been previously observed in transversely polarized p+p collisions at RHIC, and the existing theoretical framework that was successful in describing the single-spin asymmetry in p+p collisions predicts only a moderate atomic-mass-number (A) dependence. In contrast, the asymmetries observed at RHIC in p+A collisions showed a surprisingly strong A dependence in inclusive forward neutron production. The observed asymmetry in p+Al collisions is much smaller, while the asymmetry in p+Au collisions is a factor of 3 larger in absolute value and of opposite sign. The interplay of different neutron production mechanisms is discussed as a possible explanation of the observed A dependence.

Continuous passive motion improves shoulder joint integrity following stroke

Objective: In a pilot study of patients with a first stroke and hemiparesis, we sought to determine whether treatment of the upper limb with continuous passive motion (CPM) that was device delivered would alter impairment, disability or the associated adverse symptoms of shoulder joint instability, pain and tone.

Design: Patients were randomly assigned to receive daily CPM treatments or participate in self-range of motion groups under the supervision of an occupational therapist. All patients received standard daily poststroke therapy for 3.5 h per day. A blinded evaluator at admission and discharge assessed patients using standardized scales of impairment, disability and adverse symptoms.

Setting: Specialized stroke unit of an acute rehabilitation hospital.

Subjects: Two hundred and eighty consecutive patients were screened and 35 of these with a first unilateral stroke, 139-6 days following the acute event, provided informed consent and were randomly assigned to CPM treatment or supervised group self-range exercise.

Main measures: Thirty-two completed the study and were evaluated using standardized measures for motor impairment (Fugl-Meyer, Motor Status Scale and Medical Research Council Motor Power), adverse symptoms (gleno-humeral stability, pain and tone), and disability (Functional Independence Measure).

Results: CPM-treated patients demonstrated positive trends towards improved shoulder joint stability (p =0.06, confidence interval -0.03, 2.3) when compared with patients performing therapist-supervised self-range of motion. There were no significant differences in motor impairment, disability, pain or tone.

Conclusions: Device-delivered continuous passive range of motion may offer an enhanced benefit for some adverse symptom reduction in the hemiplegic arm after stroke over traditional self-range of motion exercise.

Updraft gasification of poultry litter at farm-scale--A case study

Farm and animal wastes are increasingly being investigated for thermochemical conversion, such as gasification, due to the urgent necessity of finding new waste treatment options. We report on an investigation of the use of a farm-scale, auto-thermal gasification system for the production of a heating gas using poultry litter (PL) as a feedstock. The gasification process was robust and reliable. The PL's ash melting temperature was 639°C, therefore the reactor temperature was kept around this value. As a result of the low reactor temperature the process performance parameters were low, with a cold gas efficiency (CGE) of 0.26 and a carbon conversion efficiency (CCE) of 0.44. The calorific value of the clean product gas was 3.39 MJ m(-3)N (LHV). The tar was collected as an emulsion containing 87 wt.% water and the extracted organic compounds were identified. The residual char exceeds thresholds for Zn and Cu to obtain European biochar certification; however, has potential to be classified as a pyrogenic carbonaceous material (PCM), which resembles a high nutrient biochar.

Business Associations, Conservative Networks, and the Ongoing Republican War over Medicaid Expansion

A major component of the Affordable Care Act involves the expansion of state Medicaid programs to cover the uninsured poor. In the wake of the 2012 Supreme Court decision upholding and modifying reform legislation, states can decide whether to expand Medicaid-and twenty states are still not proceeding as of August 2015. What explains state choices about participation in expansion, including governors' decisions to endorse expansion or not as well as final state decisions? We tackle this puzzle, focusing closely on outcomes and battles in predominantly Republican-led states. Like earlier scholars, we find that partisan differences between Democrats and Republicans are central, but we go beyond earlier analyses to measure added effects from two dueling factions within the Republican coalition: statewide business associations and cross-state networks of ideologically conservative organizations. Using both statistical modeling and case studies, we show that GOP-leaning or GOP-dominated states have been most likely to embrace the expansion when organized business support outweighs pressures from conservative networks. Our findings help make sense of ongoing state-level debates over a core part of health reform and shed new light on mounting policy tensions within the Republican Party.

Centrality-Dependent Modification of Jet-Production Rates in Deuteron-Gold Collisions at √[s(NN)]=200 GeV

Jet production rates are measured in p+p and d+Au collisions at sqrt[s_{NN}]=200  GeV recorded in 2008 with the PHENIX detector at the Relativistic Heavy Ion Collider. Jets are reconstructed using the R=0.3 anti-k_{t} algorithm from energy deposits in the electromagnetic calorimeter and charged tracks in multiwire proportional chambers, and the jet transverse momentum (p_{T}) spectra are corrected for the detector response. Spectra are reported for jets with 12<p_{T}<50  GeV/c, within a pseudorapidity acceptance of |η|<0.3. The nuclear-modification factor (R_{dAu}) values for 0%-100% d+Au events are found to be consistent with unity, constraining the role of initial state effects on jet production. However, the centrality-selected R_{dAu} values and central-to-peripheral ratios (R_{CP}) show large, p_{T}-dependent deviations from unity, challenging the conventional models that relate hard-process rates and soft-particle production in collisions involving nuclei.

Measurements of Elliptic and Triangular Flow in High-Multiplicity 3He+Au Collisions at √(s(NN))=200 GeV

We present the first measurement of elliptic (v(2)) and triangular (v(3)) flow in high-multiplicity (3)He+Au collisions at √(s(NN))=200  GeV. Two-particle correlations, where the particles have a large separation in pseudorapidity, are compared in (3)He+Au and in p+p collisions and indicate that collective effects dominate the second and third Fourier components for the correlations observed in the (3)He+Au system. The collective behavior is quantified in terms of elliptic v(2) and triangular v(3) anisotropy coefficients measured with respect to their corresponding event planes. The v(2) values are comparable to those previously measured in d+Au collisions at the same nucleon-nucleon center-of-mass energy. Comparisons with various theoretical predictions are made, including to models where the hot spots created by the impact of the three (3)He nucleons on the Au nucleus expand hydrodynamically to generate the triangular flow. The agreement of these models with data may indicate the formation of low-viscosity quark-gluon plasma even in these small collision systems.

Measurement of Long-Range Angular Correlation and Quadrupole Anisotropy of Pions and (Anti)Protons in Central d+Au Collisions at sqrt[s_{NN}]=200 GeV

We present azimuthal angular correlations between charged hadrons and energy deposited in calorimeter towers in central d+Au and minimum bias p+p collisions at sqrt[s_{NN}]=200 GeV. The charged hadron is measured at midrapidity |η|<0.35, and the energy is measured at large rapidity (-3.7<η<-3.1, Au-going direction). An enhanced near-side angular correlation across |Δη|>2.75 is observed in d+Au collisions. Using the event plane method applied to the Au-going energy distribution, we extract the anisotropy strength v_{2} for inclusive charged hadrons at midrapidity up to p_{T}=4.5 GeV/c. We also present the measurement of v_{2} for identified π^{±} and (anti)protons in central d+Au collisions, and observe a mass-ordering pattern similar to that seen in heavy-ion collisions. These results are compared with viscous hydrodynamic calculations and measurements from p+Pb at sqrt[s_{NN}]=5.02 TeV. The magnitude of the mass ordering in d+Au is found to be smaller than that in p+Pb collisions, which may indicate smaller radial flow in lower energy d+Au collisions.

Cold-nuclear-matter effects on heavy-quark production at forward and backward rapidity in d + Au collisions at √sNN = 200 GeV

The PHENIX experiment has measured open heavy-flavor production via semileptonic decay over the transverse momentum range 1 < p(T) < 6  GeV/c at forward and backward rapidity (1.4 < |y| < 2.0) in d+Au and p + p collisions at √sNN = 200  GeV. In central d+Au collisions, relative to the yield in p + p collisions scaled by the number of binary nucleon-nucleon collisions, a suppression is observed at forward rapidity (in the d-going direction) and an enhancement at backward rapidity (in the Au-going direction). Predictions using nuclear-modified-parton-distribution functions, even with additional nuclear-p(T) broadening, cannot simultaneously reproduce the data at both rapidity ranges, which implies that these models are incomplete and suggests the possible importance of final-state interactions in the asymmetric d + Au collision system. These results can be used to probe cold-nuclear-matter effects, which may significantly affect heavy-quark production, in addition to helping constrain the magnitude of charmonia-breakup effects in nuclear matter.