E6 Models from F-theory

F-theory is a non-perturbative formulation of type IIB superstring theory which allows for the decoupling of gravity and for the formulation of GUT theories based on the gauge group E6. In this paper we explore F-theory models in which the low energy supersymmetric theory contains the particle content of three 27 dimensional representations of the underlying E6 gauge group, plus two extra right-handed neutrinos predicted from F and D flatness. The resulting TeV scale effective theory resembles either the E6SSM or the NMSSM+, depending on whether an additional Abelian gauge group does or does not survive. However there are novel features compared to both these models as follows: (i) If the additional Abelian gauge group is unbroken then it can have a weaker gauge coupling than in the E6SSM; (ii) If the additional Abelian gauge group is broken then non-perturbative effects can violate the scale invariance of the NMSSM+ leading to a generalised model; (iii) Unification is achieved not at the field theory level but at the F-theory level since the gauge couplings are split by flux effects, negating the need for any additional doublet states which are usually required; (iv) Proton decay is suppressed by the geometric coupling suppression of a singlet state, a mechanism peculiar to F-theory, which effectively suppresses the coupling of the exotic charge -1/3 colour triplet state D to quarks and leptons; (v) The D bar couples to left-handed leptoquarks, providing characteristic and striking signatures at the LHC.Comment: 31 pages, 7 figure

Gauge Coupling Unification in E6 F-Theory GUTs with Matter and Bulk Exotics from Flux Breaking

We consider gauge coupling unification in E6 F-Theory Grand Unified Theories (GUTs) where E6 is broken to the Standard Model (SM) gauge group using fluxes. In such models there are two types of exotics that can affect gauge coupling unification, namely matter exotics from the matter curves in the 27 dimensional representation of E6 and the bulk exotics from the adjoint 78 dimensional representation of E6. We explore the conditions required for either the complete or partial removal of bulk exotics from the low energy spectrum. In the latter case we shall show that (miraculously) gauge coupling unification may be possible even if there are bulk exotics at the TeV scale. Indeed in some cases it is necessary for bulk exotics to survive to the TeV scale in order to cancel the effects coming from other TeV scale matter exotics which would by themselves spoil gauge coupling unification. The combination of matter and bulk exotics in these cases can lead to precise gauge coupling unification which would not be possible with either type of exotics considered by themselves. The combination of matter and bulk exotics at the TeV scale represents a unique and striking signature of E6 F-theory GUTs that can be tested at the LHC.Comment: 21 pages, 5 figure

Randomized controlled trial of a clinical decision support system for painful polyneuropathy

IntroductionDespite the existence of guidelines, painful neuropathy is often inappropriately treated. We sought to determine the effectiveness of a clinical decision support system on guideline‐recommended medication use.MethodsWe randomized neurology providers, stratified by subspecialty, to a best practice alert (BPA) linked to a Smartset or a BPA alone when seeing patients with neuropathy. The primary outcome was the proportion of patients with uncontrolled nerve pain prescribed a guideline‐recommended medication. Generalized estimating equations were used to assess effectiveness.ResultsSeventy‐five neurology providers (intervention 38, control 37) treated 2697 patients with neuropathy (intervention 1026, control 671). Providers did not acknowledge the BPA in 1928 (71.5%) visits. Only four of eight intervention arm neurologists who treated patients with uncontrolled nerve pain opened the Smartset. The intervention was not associated with guideline‐recommended medication use (odds ratio 0.52, 0.18‐1.48; intervention 52%, control 54.8%).DiscussionOur intervention did not improve prescribing practices for painful neuropathy. Physicians typically ignored the BPAs/Smartset; therefore, future studies should mandate their use or employ alternate strategies.See editorial on pages 552–553 in this issue.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154934/1/mus26774.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154934/2/mus26774_am.pd

Choosing Wisely: Highest‐cost tests in outpatient neurology

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Reply

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Electrodiagnostic tests are unlikely to change management in those with a known cause of typical distal symmetric polyneuropathy

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138297/1/mus25713_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138297/2/mus25713.pd

A questionnaire to identify patellofemoral pain in the community: an exploration of measurement properties

Background Community-based studies of patellofemoral pain (PFP) need a questionnaire tool that discriminates between those with and those without the condition. To overcome these issues, we have designed a self-report questionnaire which aims to identify people with PFP in the community. Methods Study designs: comparative study and cross-sectional study. Study population: comparative study: PFP patients, soft-tissue injury patients and adults without knee problems. Cross-sectional study: adults attending a science festival. Intervention: comparative study participants completed the questionnaire at baseline and two weeks later. Cross-sectional study participants completed the questionnaire once. The optimal scoring system and threshold was explored using receiver operating characteristic curves, test-retest reliability using Cohen’s kappa and measurement error using Bland-Altman plots and standard error of measurement. Known-group validity was explored by comparing PFP prevalence between genders and age groups. Results Eighty-four participants were recruited to the comparative study. The receiver operating characteristic curves suggested limiting the questionnaire to the clinical features and knee pain map sections (AUC 0.97 95 % CI 0.94 to 1.00). This combination had high sensitivity and specificity (over 90 %). Measurement error was less than the mean difference between the groups. Test–retest reliability estimates suggest good agreement (N = 51, k = 0.74, 95 % CI 0.52–0.91). The cross-sectional study (N = 110) showed expected differences between genders and age groups but these were not statistically significant. Conclusion A shortened version of the questionnaire, based on clinical features and a knee pain map, has good measurement properties. Further work is needed to validate the questionnaire in community samples

Amyotrophic Lateral Sclerosis in a Patient with a Family History of Huntington Disease: Genetic Counseling Challenges

Amyotrophic lateral sclerosis (ALS) and Huntington disease (HD) are generally considered to be distinct and easily differentiated neurologic conditions. However, there are case reports of the co‐occurrence of ALS with HD. We present a 57‐year‐old male with a clinical diagnosis of sporadic ALS in the context of a family history of HD. This case adds to the limited literature regarding individuals with a family history of HD who present with features of ALS. There were several genetic counseling challenges in counseling this patient including the diagnostic consideration of two fatal conditions, complex risk information, the personal and familial implications, and the patient’s inability to communicate verbally or through writing due to disease progression. DNA banking effectively preserved the right of our patient and his wife not to learn his HD genetic status during a stressful time of disease progression while providing the option for family members to learn this information in the future if desired. We present lessons learned and considerations for other clinical genetics professionals who are presented with similar challenging issues.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147074/1/jgc40725.pd

Electromyography‐related pain: Muscle selection is the key modifiable study characteristic

Introduction : The aim of this study was to estimate the effects of patient, provider, and study characteristics on electromyography (EMG)‐related pain. Methods : Patients undergoing EMG rated their EMG‐related pain after each muscle was studied on a 100‐point visual analog scale (VAS). Investigators recorded the order in which the muscles were sampled, the total time spent with the needle in each muscle, and whether electrical endplate noise was noted. Results : A total of 1781 muscles were studied in 304 patients. Eleven muscles were associated with significantly more or less pain than the others. Endplate noise was associated with more pain (5.4 mm, 95% CI 2.8–7.0). There was a small, but significant effect from needling time (0.02 mm, 95% CI 0.00–0.04). Conclusions : Among factors that electromyographers can control, muscle selection has the greatest impact on pain. Our data include an extensive list of muscle‐specific EMG‐related pain scores. Provider and other study characteristics have little or no impact on EMG‐related pain. Muscle Nerve 49:570–574, 2014Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106736/1/mus23974.pd

Perceptions of long-term impact and change following a midwife-led biomass smoke education program for mothers in rural Uganda: a qualitative study

Introduction: Women and children in Uganda and other low- and middle-income countries are exposed to disproportionately high levels of household air pollution from biomass smoke generated by smoke-producing cookstoves, especially in rural areas. This population is therefore particularly vulnerable to the negative health effects caused by household air pollution, including negative pregnancy outcomes and other health issues throughout life. The Midwife Project, a collaboration between research and health teams in the UK and Uganda, began in 2016 to implement an education program on lung health for mothers in Uganda, to reduce the health risks to women and children. Education materials were produced to guide midwives in the delivery of health messages across four rural health centres, and mixed-methods results of knowledge questionnaires and interviews demonstrated knowledge acquisition, acceptability and feasibility. This qualitative follow-up study aimed to improve understanding of the longer term impact of this education program from the perspective of midwives, village health team members and mothers, in consideration of rolling the program out more widely in rural Uganda. Methods: Purposive sampling was carried out to recruit consenting antenatal or postnatal women, midwives and village health team members who had been involved in an education session. Individual interviews were conducted with 12 mothers and four village health team members, and four focus groups were conducted with 10 midwives in total. Interviews and focus groups were conducted across all four health centres by two researchers and six translators as appropriate depending on language spoken (English or Lusoga). These were semi-structured and directed by topic guides. Reflective and observational notes were also made. A thematic analysis was carried out by two researchers, along with production of a narrative for each mother, to enrich understanding of each individual story. Results: Midwives and village health teams had continued with the program well past the project end date and all mothers expressed making, or intending to make, changes, suggesting long-term feasibility and acceptability. Main themes generated were ability to change and changes made, ability to change dictated by money, importance of practical education, perceived health improvements, and passing on knowledge. Additional findings were that some education topics seemed to be overlooked, and there was a lack of clarity about the village health team role for the purposes of this program. Some mothers had been motivated to overcome financial barriers, for example by reconstructing cooking areas cheaply themselves. However, information given in the program about building advice and potential financial gains was inconsistent. Conclusion: Recommendations for future biomass smoke education should include explicit building advice, emphasis on financial gains, encouragement to share the knowledge acquired and clarification of the village health team role. These program changes will improve focus and relevancy, optimise impact and, with behaviour change and implementation strategy in mind, could be used for widespread rollout in rural Uganda. Future research should include quantitative data collection to objectively examine surprising perceived health benefits, including reduction in malaria and burns, and further qualitative work on why some education content appears neglected