Long-term efficacy and safety of baricitinib in patients with severe alopecia areata: 104-week results from BRAVE-AA1 and BRAVE-AA2

BACKGROUND

Efficacy of the Janus kinase (JAK) inhibitor baricitinib for severe alopecia areata (AA) continuously increased over 52 weeks in two Phase 3 trials. There are limited long-term data on JAK inhibitors in AA.

OBJECTIVES

To evaluate efficacy and safety of baricitinib for severe AA through 104 weeks of continuous therapy.

METHODS

Integrated data from the BRAVE-AA1 and BRAVE-AA2 Phase 3 trials included adults with Severity of Alopecia Tool (SALT) scores ≥50 (≥50% scalp hair loss) randomized to and continuously treated with 2-mg or 4-mg baricitinib through Week 104. Patients who qualified to remain on continuous treatment included subjects who achieved SALT score ≤20 at Week 52 (Week-52 responders; 2-mg: N = 65; 4-mg: N = 129) and baricitinib 4-mg-treated patients who had SALT score >20 at Week 52 but achieved SALT score ≤20 at prior visit(s) and/or had significant improvement in eyebrow or eyelash hair growth relative to baseline by Week 52 (Week-52 mixed responders; N = 110). Week-104 outcomes included the proportion of patients achieving SALT score ≤20 (≤20% scalp hair loss). Data were censored after treatment discontinuation.

RESULTS

Among baricitinib 4-mg-treated and baricitinib 2-mg-treated Week-52 responders, 90.7% and 89.2%, respectively, maintained SALT score ≤20 at Week 104. Among Week-52 mixed responders, 39.1% reached SALT score ≤20 by Week 104. Continued improvement in eyebrow and eyelash regrowth was observed across groups. The most frequent treatment-emergent adverse events were COVID-19, upper respiratory tract infection, headache, nasopharyngitis, acne, urinary tract infection and creatine phosphokinase increase.

CONCLUSIONS

Baricitinib demonstrated a high level of maintenance of efficacy over 104 weeks in patients with severe AA. Efficacy increased in Week-52 mixed responders, illustrating that long-term treatment is necessary to observe maximum benefit in some patients. No new safety signals were observed.

Addressing HPSP Learner Needs: A Pilot Study of a "Fundamentals of Military Medicine" Course

INTRODUCTION

Military medicine is uniquely different from civilian medicine, and military physicians in the USA are primarily recruited through the Health Professions Scholarship Program (HPSP) and the Uniformed Services University of the Health Sciences (USUHS). Medical students at the USUHS receive more than 650 hours of military-specific curriculum and spend 21 days engaged in field exercises. HPSP students complete two 4-week officer training sessions during their 4 years of medical school. There is a clear discrepancy in preparation for military medicine between HPSP and USUHS students. The USUHS School of Medicine undertook an initiative to develop a fully online self-paced course on the fundamentals of military medicine topics to help HPSP students bridge the gap in their preparation. This article will describe how the online self-paced course was designed and present feedback from the pilot offering of this course.

MATERIALS AND METHODS

As proof of concept of the effectiveness of an online self-paced course for teaching the fundamentals of military medicine to HPSP students, two chapters from the "Fundamentals of Military Medicine" published by the Borden Institute were transferred to an online format. Each chapter was offered as a module. In addition to the chapters, an introduction and closing module were added to the pilot course. The pilot course was offered over 6 weeks. Data for this study were obtained from module feedback surveys, pre- and post-course quizzes, participant focus groups, and course evaluation surveys. Pre- and post-test scores were analyzed to evaluate content knowledge. The open-ended survey questions on the feedback forms and focus group transcripts were collated and analyzed as textual data.

RESULTS

Fifty-six volunteers enrolled in the study, and 42 completed the pre- and post-course quizzes. This participant pool included HPSP students (79%, n = 44) and military residents in civilian graduate medical education programs (21%, n = 12). The module feedback surveys showed that most participants spent 1 to 3 hours on each of the modules, which they rated as extremely or quite reasonable (Module 1: 64%, Module 2: 86%, Module 3: 83%). There was not much difference between the overall quality of the three modules. The participants found content on application to the military-specific context very valuable. Of the different course elements, video content was rated as the most effective. Participant feedback clearly highlighted that HPSP students want a course that informs them about the fundamentals of military medicine and demonstrates how the information would apply to their lives. Overall, the course was effective. HPSP students showed knowledge gains and self-reported satisfaction with the course's objectives. They were able to locate information easily and understand the course expectations.

CONCLUSIONS

This pilot study has shown that there is a need for a course that provides the fundamentals of military medicine to HPSP students. A fully online self-paced course provides flexibility for the students and improves access.

Large language models and agricultural extension services

Several factors have traditionally hampered the effectiveness of agricultural extension services, including limited institutional capacity and reach. Here we assess the potential of large language models (LLMs), specifically Generative Pre-trained Transformer (GPT), to transform agricultural extension. We focus on the ability of LLMs to simplify scientific knowledge and provide personalized, location-specific and data-driven agricultural recommendations. We emphasize shortcomings of this technology, informed by real-life testing of GPT to generate technical advice for Nigerian cassava farmers. To ensure a safe and responsible dissemination of LLM functionality across farming worldwide, we propose an idealized LLM design process with human experts in the loop.

Stereotactic Cardiac Ablative Radiotherapy (SCAR) for Refractory Ventricular Tachycardia: Western Australia Experience

PURPOSE/OBJECTIVE(S)

Ventricular tachycardia is a potentially life-threatening cardiac condition that is associated with significant morbidity and mortality. Despite advances in medical therapies, implantable cardioverter-defibrillator (ICD) and catheter ablative therapy (CAT), some patients continue to suffer recurrent VT. SCAR is a highly accurate, non-invasive, and novel ablative therapeutic option that has shown promising results in the treatment of refractory VT patients associated with structural heart disease. Early case series and subsequent prospective clinical trials have demonstrated SCAR to be well-tolerated with acceptable safety profiles and consistently decreased VT episodes in VT patients, who failed all conventional antiarrhythmic medications and CAT. The aim of the current study is to report the efficacy and safety/tolerability of SCAR in ICD-dependent patients with refractory VT in Western Australia, Australia.

MATERIALS/METHODS

Seven patients with recurrent refractory VT, deemed high risk or non-suitable for CAT, were referred to GenesisCare at Fiona Stanley Hospital, Western Australia for SCAR between July 2020 and November 2022. Target volume definition and delineation involved interdisciplinary teams by combining all available clinical, electrophysiological mapping and diagnostic/planning cardiac imaging data to generate radiotherapy plans. Patients were treated whilst awake, with a single dose of 25 Gy using VMAT technique on the Synergy Linac with stereotactic X-ray tool capability. Efficacy was assessed by counting the number of episodes of VT and ICD shocks after SCAR. Safety and tolerability were evaluated by treatment related toxicities during follow up.

RESULTS

Of the seven patients referred for SCAR, only five received SCAR as two patients died from their refractory VT before their radiotherapy. For the patients receiving SCAR with at least 6 months follow-up, overall reduction in VT episodes and ICD shocks was 95% and 85%, respectively. No significant treatment-related toxicities were documented during follow-up. Two patients had died. Neither of their deaths were directly attributed to their radiotherapy. One patient died after requesting to cease her antiarrhythmic medications and to have her ICD switched off 2 days after SCAR (against medical advice). The other patient died 431 days after SCAR from aspiration pneumonia after fracturing her cervical spine following a fall at home and was unrelated to her VT.

CONCLUSION

Our data reflects international experience in terms of treatment efficacy and safety profiles of SCAR for patients with refractory VT. SCAR is increasingly recognized as an alternative cardiac ablative option for ICD-dependent VT patients who failed all conventional antiarrhythmic treatments. Nonetheless, careful patient selection and longer-term follow-up are required to ensure the optimal treatment outcomes can be achieved in these patients.

A Rare Case of Severe Burn Injury to the Oropharynx Caused by a Flare Gun

Flare gun injuries are rare, and patients often present with complex trauma that may require multiple operative interventions. Our objective is to explore a case of a 15-year-old male, who presented with second-degree flame burns to the face, left upper extremity and bilateral hands, as well as third-degree burns to the oropharynx and a tongue laceration after a flare gun was discharged into his mouth. The patient underwent multiple debridements of the oral cavity and oropharynx, and his hospital course was complicated by an intra-oral abscess. He eventually made a full recovery and was discharged. This case not only illustrates the need for early operative intervention, but it also underscores the need for awareness campaigns that highlight the dangers of flare guns and similar devices.

Evaluating a Competency-Based Blended Health Professions Education Program: A Programmatic Approach

INTRODUCTION

Competency-based education (CBE) programs usually evaluate student learning outcomes at a course level. However, a more comprehensive evaluation of student achievement of competencies requires evaluation at a programmatic level across all courses. There is currently insufficient literature on accomplishing this type of evaluation. In this article, we present an evaluation strategy adopted by the competency-based master's degree program at the Center for Health Professions Education at the Uniformed Services University of Health Sciences to assess student achievement of competencies. We hypothesized that (1) learners would grow in the competencies through their time in the program and (2) learners would exhibit a behavioristic change as a result of their participation in the program.

MATERIALS AND METHODS

The degree program at the Center for Health Professions Education conducts an annual student self-assessment of competencies using a competency survey. The competency survey data from graduated master's students were collected, providing data from three time points: initial (pre-program survey), middle, and final (end-of-program survey). Open-ended responses from these three surveys were also analyzed. A general linear model for repeated measures was conducted. Significant effects were followed by post hoc tests across time. We also conducted post hoc analysis across domains to better understand the comparative levels of the domains at each time point. The responses to the open-ended prompt were thematically analyzed.

RESULTS

Analysis of the quantitative data revealed that (1) learners reported significant growth across time, (2) learners had different perceptions of their competencies in each of the domains, and (3) not all domains experienced similar changes over time. Analysis of the free responses highlighted the impact of coursework on competency attainment and the behavioristic change in learners.

CONCLUSIONS

This study presents a strategic evaluation tool for course-based CBE programs that follow a traditional credit hour model. Programmatic evaluation of CBE programs should enable the inclusion of the learner's voice and provide evaluation data that go beyond individual course evaluations.

Supporting the Transition to Distance Education During the Pandemic and Beyond

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic affected almost every country around the world, and various forms of lockdown or quarantine measures were implemented. The lockdowns forced medical educators to step beyond traditional educational approaches and adopt distance education technologies to maintain continuity in the curriculum. This article presents selected strategies implemented by the Distance Learning Lab (DLL) at the Uniformed Services University of Health Sciences (USU), School of Medicine (SOM), in transitioning their instruction to an emergency distance education format during the COVID-19 pandemic.

MATERIALS AND METHODS

When moving programs/courses to a distance education format, it is important to recognize that two primary stakeholders are involved in the process: faculty members and students. Therefore, to be successful in transitioning to distance education, strategies must address the needs of both groups and provide support and resources for both.The DLL used two lenses of adult learning and targeted needs assessment to design faculty and student support during the pandemic. The DLL adopted a learner-centered approach to education, focusing on meeting the faculty members and students where they are. This translated into three specific support strategies for faculty: (1) workshops, (2) individualized support, and (3) just-in-time self-paced support. For students, DLL faculty members conducted orientation sessions and provided just-in-time self-paced support.

RESULTS

The DLL has conducted 440 consultations and 120 workshops for faculty members since March 2020, serving 626 faculty members (above 70% of SOM faculty members locally) at USU. In addition, the faculty support website has had 633 visitors and 3,455 pageviews. Feedback comments provided by faculty members have specifically highlighted the personalized approach and the active, participatory elements of the workshops and consultations.Evaluations of the student orientation sessions showed that they felt more confident in using the technologies after the orientation. The biggest increase in confidence levels was seen in the topic areas and technology tools unfamiliar to them. However, even for tools that students were familiar with before the orientation, there was an increase in confidence ratings.

CONCLUSION

Post-pandemic, the potential to use distance education remains. It is important to have support units that recognize and cater to the singular needs of medical faculty members and students as they continue to use distance technologies to facilitate student learning.

The APPD Longitudinal Educational Assessment Research Network's First Decade

ABSTRACT

In 2009, the Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN), a national educational research network, was formed. We report on evaluation of the network after 10 years of operation by reviewing program context, input, processes, and products to measure its progress in performing educational research that advances training of future pediatricians. Historical changes in medical education shaped the initial development of the network. APPD LEARN now includes 74% (148 of 201) of US Pediatric residency programs and has recently incorporated a network of Pediatric subspecialty fellowship programs. At the time of this evaluation, APPD LEARN had approved 19 member-initiated studies and 14 interorganizational studies, resulting in 23 peer-reviewed publications, numerous presentations, and 7 archived sharable data sets. Most publications focused on how and when interventions work rather than whether they work, had high scores for reporting rigor, and included organizational and objective performance outcomes. Member program representatives had positive perceptions of APPD LEARN's success, with most highly valuing participation in research that impacts training, access to expertise, and the ability to make authorship contributions for presentations and publication. Areas for development and improvement identified in the evaluation include adopting a formal research prioritization process, infrastructure changes to support educational research that includes patient data, and expanding educational outreach within and outside the network. APPD LEARN and similar networks contribute to high-rigor research in pediatric education that can lead to improvements in training and thereby the health care of children.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Investigating dilution ventilation control strategies in a modern U.S. school bus in the context of the COVID-19 pandemic

Fresh air ventilation has been identified as a widely accepted engineering control effective at diluting air contaminants in enclosed environments. The goal of this study was to evaluate the effects of selected ventilation measures on air change rates in school buses. Air changes per hour (ACH) of outside air were measured using a well-established carbon dioxide (CO₂) tracer gas decay method. Ventilation was assessed while stationary and while traversing standardized route during late autumn/winter months in Colorado. Seven CO₂ sensors located at the driver's seat and at passenger seats in the front, middle, and rear of the bus yielded similar and consistent measurements. Buses exhibited little air exchange in the absence of ventilation (ACH = 0.13 when stationary; ACH = 1.85 when mobile). Operating the windshield defroster to introduce fresh outside air increased ACH by approximately 0.5-1 ACH during mobile and stationary phases. During the mobile phase (average speed of 23 miles per hour (mph)), the combination of the defroster and two open ceiling hatches (with a powered fan on the rear hatch) yielded an ACH of approximately 9.3 ACH. A mobile phase ACH of 12.4 was achieved by the combination of the defroster, ceiling hatches, and six passenger windows open 2 inches in the middle area of the bus. A maximum mobile phase ACH of 22.1 was observed by using the defroster, open ceiling hatches, driver window open 4 inches, and every other passenger window open 2 inches. For reference, ACHs recommended in patient care settings where patients are being treated for airborne infectious diseases range from 6 to ≥12 ACHs. The results indicate that practical ventilation protocols on school buses can achieve air change rates thought to be capable of reducing airborne viral transmission to the bus driver and student passengers during the COVID-19 pandemic.

Timing of Vaccine Decision-Making Among First-Time Parents

OBJECTIVE

Decreased childhood vaccination can lead to local outbreaks of vaccine-preventable disease. In a pilot study from our group, 72% of parents of newborns reported initiating their vaccine decision-making for that child prior to conception. Since a sound understanding of the timing of parental vaccine decision-making is needed to direct educational efforts, we surveyed a national cohort of first-time parents to extend our preliminary findings.

METHODS

From March 2019 to March 2020, first-time parents of newborns in mother-baby units of the Better Outcomes through Research for Newborns (BORN) network completed the Vaccine Preference Development Survey (VPDS). The VPDS measures intent to vaccinate, timing of vaccine decision-making, and sources of influence. Univariate and multivariate analyses explored associations between intent to vaccinate and timing of vaccine decision-making with demographic variables.

RESULTS

Twenty-three sites provided surveys through site-specific nonrandom systemic sampling; 91% (1393/1524) of surveys were used in the analysis. Most parents planned to fully vaccinate (1191/1380, 86.3%) and started vaccine decision-making prior to conception (850/1378, 61.7%). Maternal age, race and ethnicity, relationship status, and education were all significantly associated with planning to fully vaccinate and preconception decision-making (P < .001). Preconception decision-making correlated strongly with intent to fully vaccinate (P < .001). Parents influenced by personal education, medical professionals, and family/friends were more likely to endorse preconception decision-making; those strongly influenced by internet/social media were less likely to allow all vaccines or start decision-making prior to conception.

CONCLUSIONS

Vaccine decision-making occurs preconception for most new parents. Initiating vaccine discussions during the birth hospitalization may be too late.

Perceived acceptability of partial enteral nutrition (PEN) using oral nutritional supplement drinks in adolescent and adult Crohn's disease outpatients: A feasibility study

BACKGROUND AND AIMS

Studies, mainly in Japanese cohorts, have shown that partial enteral nutrition (PEN) including oral nutritional supplement (ONS) drinks can prolong disease remission and increase drug effectiveness in Crohn's disease (CD). Acceptability is a key feasibility parameter to determine whether PEN is a viable treatment option in UK CD patients. We report the results of a single centre cross-sectional feasibility study carried out to investigate perceived acceptability of PEN using ONS drinks and whether ONS preference varies with sex, nutritional status or phenylthiocarbamide (PTC) sensitivity.

METHODS

Patients with a confirmed CD diagnosis were recruited using convenience sampling from an adult and adolescent gastroenterology outpatient clinic over 3 years. Blind taste testing of 5 polymeric ONS drinks were conducted using a validated 9-point hedonic rating scale followed by completion of an acceptability questionnaire based on the preferred ONS drink. A subset of patients took home the preferred ONS drink for a 7-day ONS study.

RESULTS

105 CD patients (55 males), aged 34.9 (±15.4) years were recruited and 28 patients completed the 7-day ONS study. Overall impression scores did not significantly vary with nutritional status, sex, BMI, handgrip strength (HGS), mid-upper arm circumference (MUAC) or PTC sensitivity. Ensure plus milkshake™ rated highest for overall impression (6.5, p=<0.0001) and all other organoleptic properties (p < 0.0001). The main perceived benefits of using ONS drinks as PEN related to assurance of nutrient intake (89%), convenience (86%), and improvement of gut symptoms (85%). The main perceived barriers related to reduction in pleasure from eating and drinking (56%), struggling with drink storage (54%) having less energy and feeling more tired than if eating 3 solid meals daily (52%). 65% of patients would consider using ONS drinks as PEN as a maintenance treatment option. 81% of patients felt confident-very confident about consuming ONS drinks daily as PEN for three months but this dropped to 64% and 37% at 6 and 12 months, respectively. There was a significant drop in perceived ease of use of ONS drinks as PEN after the 7-day ONS study (P = 0.01).

CONCLUSION

Use of ONS drinks as PEN have high perceived benefits and appear to be a feasible option for short-term use of 3-6 months in CD patients. However, confidence in long-term use of ONS drinks as PEN is low mainly due to the perceived social impact. Future studies should assess longer trial periods and volume of ONS drinks to increase the validity of these findings.

Parenthood and Parental Leave Decisions in Pediatric Residency

OBJECTIVES

The demands of residency training may impact trainees' decision to have children. We examined characteristics of pediatric residents' decisions regarding childbearing, determinants of resident parental leave, and associations with well-being.

METHODS

A survey of 845 pediatric residents at 13 programs was conducted between October 2019 and May 2020. Survey items included demographics, desire for future children, and logistics of parental leave. Outcomes included parental leave length, burnout and depression screening results, satisfaction with duration of breastfeeding, and satisfaction with parental leave and parenthood decisions.

RESULTS

Seventy-six percent (639 of 845) of residents responded to the survey. Fifty-two percent (330) of respondents reported delaying having children during residency, and 29% (97) of those were dissatisfied with their decision to do so. Busy work schedule (89.7%), finances (50.9%), and a desire not to extend residency (41.2%) were the most common reasons for delay. Of respondents, 16% were parents and 4% were pregnant or had pregnant partners. Sixty-one parental leaves were reported, and 67% of parents reported dissatisfaction with leave length. The most frequently self-reported determinant of leave duration was the desire not to extend residency training (74%). Program mean leave length was negatively associated with burnout, measured as a dichotomous outcome (odds ratio = 0.81 [95% confidence interval 0.68-0.98]; P = .02).

CONCLUSIONS

Many pediatric trainees delay parenthood during residency and are not satisfied with their decision to do so. Pediatric resident parental leave remains short and variable in duration, despite the positive association between longer leaves and overall well-being.

The experience of older persons with mental health conditions who interact with healthcare robots and nurse intermediaries: The qualitative case studies

Background

Caring expressions between humans and nonhuman intelligent machines are futuristic prototypes with healthcare robots as major advocates.

Objective

To examine the experience of older persons with mental health conditions, particularly patients with schizophrenia and with dementia in the interaction with healthcare robots and intermediaries in a transactive relational engagement.

Methods

Two qualitative case studies were conducted using sophisticated audio-video technologies to record the conversation and activities that were carefully documented. Following the procedure for qualitative descriptive analysis, a framework based on the Transactive Relationship Theory of Nursing was employed to analyze and interpret the data.

Results

Three themes were revealed, including feelings for the other, inspiring meaningful responses, and demonstrating expressions of joy. The description of the experience of older persons involved in the conversation with humanoid robots was feeling for the other while inspiring meaningful responses in demonstrating expressions of joy.

Conclusion

This study provided initial evidence that the transactive engagements of robots with older persons with schizophrenia and dementia and nurse intermediaries in psychiatric and mental health settings can result in occasions of 'joy' for the patients. These findings suggest that transactive engagements with robots facilitate expressions of joy among older persons with schizophrenia and dementia. However, these findings are not intended to prescribe nursing care actions but to describe the experience of older persons who are in transactive engagements with intelligent machines, indicating the importance and value of healthcare robots in nursing older persons with schizophrenia and with dementia.

Classical Resummation and Breakdown of Strong-Field QED

QED perturbation theory has been conjectured to break down in sufficiently strong backgrounds, obstructing the analysis of strong-field physics. We show that the breakdown occurs even in classical electrodynamics, at lower field strengths than previously considered, and that it may be cured by resummation. As a consequence, an analogous resummation is required in QED. A detailed investigation shows, for a range of observables, that unitarity removes diagrams previously believed to be responsible for the breakdown of QED perturbation theory.

Psychiatric Emergencies: Emergency Department Management of Altered Mental Status

In the United States, encounters related to mental and substance use disorders are common in emergency departments (EDs). Altered mental status (AMS) is a frequent presentation seen in EDs across the country. Individuals may present to the ED with altered thought processes, which may be attributed to intoxication from substances and/or psychoses, conditions that require immediate care and management. Health care providers must always ascertain the etiology of AMS, which may be challenging owing to the various causes of this impairment. The current article provides an overview of the most common disorders associated with AMS, which include underlying medical conditions, substance use, and mental disorders. [Journal of Psychosocial Nursing and Mental Health Services, 59(9), 16-25.].

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

Recognition and Treatment of Psychiatric Emergencies for Health Care Providers in the Emergency Department: Panic Attack, Panic Disorder, and Adverse Drug Reactions

Mental health disorders are common in the United States and may cause significant disturbances in all aspects of a person's life. Individuals with mental health disorders often present to emergency departments for health care. Recognizing and managing common psychiatric emergencies may be challenging for non-mental health providers. The Diagnostic Statistical Manual-5 diagnostic criteria will be discussed and reviewed for panic attack and panic disorder. Both pharmacologic and nonpharmacologic treatment strategies will also be addressed. Adverse drug reactions associated with antipsychotics and selective serotonin reuptake inhibitors are another common psychiatric emergency that will be examined, offering potential management strategies. The objective of this clinical manuscript is to educate emergency health care providers about specific psychiatric emergencies, including panic attack, panic disorder, and adverse drug reactions associated with mental health treatment medications.

The Emergence and Spread of Practice-Based Medical Education Research Networks

Educational research networks leverage shared goals and common infrastructure to overcome traditional barriers to medical education research, including small sample sizes, lack of generalizability, need for expertise in statistical analysis, and limitations on data sharing. The diversity of extant network models today is exciting and provides a set of common options and challenges that newly emerging networks can expect. These include decisions about network focus, organization of data, sampling strategies, funding, and governance. Common challenges include managing authorship, human subjects protection rules, data use agreements, and statistical disclosure control. Medical education research networks both advance the field and develop the researchers who participate in them. The authors repeat the call that they and others have made for the development of networks to promulgate best practices and coordinate multinetwork (multinational, multispecialty, and cross-curriculum) studies.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment

PURPOSE

To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment.

METHOD

A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model.

RESULTS

ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs.

CONCLUSIONS

CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

High-Statistics Measurement of Neutrino Quasielasticlike Scattering at 6 GeV on a Hydrocarbon Target

We measure neutrino charged-current quasielasticlike scattering on hydrocarbon at high statistics using the wideband Neutrinos at the Main Injector beam with neutrino energy peaked at 6 GeV. The double-differential cross section is reported in terms of muon longitudinal (p_{∥}) and transverse (p_{⊥}) momentum. Cross section contours versus lepton momentum components are approximately described by a conventional generator-based simulation, however, discrepancies are observed for transverse momenta above 0.5  GeV/c for longitudinal momentum ranges 3-5 and 9-20  GeV/c. The single differential cross section versus momentum transfer squared (dσ/dQ_{QE}^{2}) is measured over a four-decade range of Q^{2} that extends to 10  GeV^{2}. The cross section turnover and falloff in the Q^{2} range 0.3-10  GeV^{2} is not fully reproduced by generator predictions that rely on dipole form factors. Our measurement probes the axial-vector content of the hadronic current and complements the electromagnetic form factor data obtained using electron-nucleon elastic scattering. These results help oscillation experiments because they probe the importance of various correlations and final-state interaction effects within the nucleus, which have different effects on the visible energy in detectors.

A Reflective Journey of Caring : A Case Study Between A Patient with Schizophrenia and the Interdisciplinary Team

This case study focuses on caring for a patient living with schizophrenia who has been isolated from the community caused by long-term hospitalization in Japan. Using the philosophical perspective of caring, which focuses on nurturing the wholeness and well-being of persons in caring relationship, the case study illuminates the caring, empathy, and courage among the interdisciplinary team. The purpose of this case study is to discuss the interdisciplinary caring process for patients living with schizophrenia using Carper's ways of knowing. Personal knowing is presented through the lens of patients and families and the stigma associated with mental illness. The expression of respect and caring for the patient and their families led by the interdisciplinary team aided in destigmatization of mental illness. Empirical and ethical knowing is demonstrated through the mental health care team's delivery of high quality and clinical excellence with competence, compassion and caring. Aesthetic knowing was offered by the interdisciplinary team focused on the patient's underlying hopes, dreams and aspirations. Through the support of the interdisciplinary team, patients are able to move toward their goals,hopes and dreams, externalizing tasks, as they grow together through mutual caring. J. Med. Invest. 66 : 15-18, February, 2019.

Milestone Ratings and Supervisory Role Categorizations Swim Together, but Is the Water Muddy?

OBJECTIVE

This single-specialty, multi-institutional study aimed to determine 1) the association between milestone ratings for individual competencies and average milestone ratings (AMRs) and 2) the association between AMRs and recommended supervisory role categorizations made by individual clinical competency committee (CCC) members.

METHODS

During the 2015-16 academic year, CCC members at 14 pediatric residencies reported milestone ratings for 21 competencies and recommended supervisory role categories (may not supervise, may supervise in some settings, may supervise in all settings) for residents they reviewed. An exploratory factor analysis of competencies was conducted. The associations among individual competencies, the AMR, and supervisory role categorizations were determined by computing bivariate correlations. The relationship between AMRs and recommended supervisory role categorizations was examined using an ordinal mixed logistic regression model.

RESULTS

Of the 155 CCC members, 68 completed both milestone assignments and supervision categorizations for 451 residents. Factor analysis of individual competencies controlling for clustering of residents in raters and sites resulted in a single-factor solution (cumulative variance: 0.75). All individual competencies had large positive correlations with the AMR (correlation coefficient: 0.84-0.93), except for two professionalism competencies (Prof1: 0.63 and Prof4: 0.65). When combined across training year and time points, the AMR and supervisory role categorization had a moderately positive correlation (0.56).

CONCLUSIONS

This exploratory study identified a modest correlation between average milestone ratings and supervisory role categorization. Convergence of competencies on a single factor deserves further exploration, with possible rater effects warranting attention.

Key Factors in Clinical Competency Committee Members' Decisions Regarding Residents' Readiness to Serve as Supervisors: A National Study

PURPOSE

Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role.

METHOD

CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis.

RESULTS

Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015-2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play.

CONCLUSIONS

CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.

A preliminary trial of an online dissonance-based eating disorder intervention

OBJECTIVE

We conducted a controlled randomized preliminary trial of an expanded online version of the Body Project (n = 46) compared to an assessment-only control condition (n = 36) via a longitudinal design (baseline, postintervention, 2-month follow-up) in a community sample of women (N = 82) with clinical (n = 53) and subclinical (n = 29) eating disorder symptoms.

METHOD

The traditional content of the Body Project was modified to include verbal, written, and behavioral exercises designed to dissuade objectification and maladaptive social comparison and adapted to an online format. Body dissatisfaction, self-esteem, self-objectification, thin-ideal internalization, maladaptive social comparison, trait anxiety, positive affect, negative affect, and eating disorder symptomatology were evaluated in the control and the online expanded Body Project condition at baseline, postintervention, and 2-month follow-up.

RESULTS

A 2 (condition: online expanded Body Project, control) × 3 (time: baseline, postintervention, 2-month follow-up) mixed factorial multivariate analysis of variance (MANOVA) was conducted to examine statistically significant group differences. As predicted, results indicated a statistically significant condition × time interaction.

CONCLUSIONS

Participants in the expanded online Body Project condition showed significant reductions in eating disorder symptoms and several associated psychological risk correlates from baseline to postintervention and follow-up; contrary to predictions, eating disorder symptoms and risk correlates were not significantly lower in the online expanded Body Project condition compared to the waitlist control condition at postintervention or 2-month follow-up.

ALP production through non-linear Compton scattering in intense fields

We derive production yields for massive pseudo-scalar and scalar axion-like-particles (ALPs), through non-linear Compton scattering of an electron in the background of low- and high-intensity electromagnetic fields. In particular, we focus on electromagnetic fields from Gaussian plane wave laser pulses. A detailed study of the angular distributions and effects of the scalar and pseudo-scalar masses is presented. It is shown that ultra-relativistic seed electrons can be used to produce scalars and pseudo-scalars with masses up to the order of the electron mass. We briefly discuss future applications of this work towards lab-based searches for light beyond-the-Standard-Model particles.

Factors Associated With Refusal of Intramuscular Vitamin K in Normal Newborns

BACKGROUND AND OBJECTIVE

Refusal of intramuscular (IM) vitamin K administration by parents is an emerging problem. Our objective was to assess the frequency of and factors associated with refusal of IM vitamin K administration in well newborns in the United States.

METHODS

We determined the number of newborns admitted to well newborn units whose parents refused IM vitamin K administration in the Better Outcomes through Research for Newborns network and, in a nested patient-control study, identified factors associated with refusal of IM vitamin K administration by using a multiple logistic regression model.

RESULTS

Of 102 878 newborns from 35 Better Outcomes through Research for Newborns sites, parents of 638 (0.6%) refused IM vitamin K administration. Frequency of refusal at individual sites varied from 0% to 2.3%. Exclusive breastfeeding (adjusted odds ratio [aOR] = 3.4; 95% confidence interval [CI]: 2.1-5.5), non-Hispanic white race and/or ethnicity (aOR = 1.7; 95% CI: 1.2-2.4), female sex (aOR = 1.6; 95% CI: 1.2-2.3), gestational age (aOR = 1.2; 95% CI: 1.1-1.4), and mother's age (aOR = 1.05; 95% CI: 1.02-1.08) were significantly associated with refusal of IM vitamin K administration. Refusal of the administration of both ocular prophylaxis and hepatitis B vaccine was also strongly associated with refusal of IM vitamin K administration (aOR = 88.7; 95% CI: 50.4-151.9).

CONCLUSIONS

Refusal of IM vitamin K by parents of newborns is a significant problem. Interventions to minimize risks to these newborns are needed.