Increasing Rates of Urine Albumin Creatinine Ratio Ordering by Providers in Diabetics in Adult Primary Care: A Quality Improvement Initiative

Background: The rising incidence of diabetes within the United States and worldwide has led to increased diabetes related morbidity and mortality. As the leading cause of end stage renal disease (ESRD), more attention needs to be placed on increasing rates of diabetic nephropathy screening. The vast majority of diabetics are treated in primary care, positioning primary care as a center focus for diabetes related screening and treatment. Local problem: Low rates of diabetic nephropathy screening were noted at an academic medical center affiliated primary care clinic. A quality improvement initiative was elicited to increase the number of urine microalbumin creatine ratio tests ordered by primary care providers. Methods: Using the Plan-Do-Study-Act (PDSA) framework, a pre-visit planning intervention aimed at reducing missed opportunities during primary care visits was enacted over a 2 month period. The specific aim of this quality improvement initiative was to increase the number of ordered uACR screening tests in patients with type 1 and type 2 between the ages 18 and 75 who had not had a test completed within the past year. Interventions: A report was generated the day prior to scheduled visit encounters for those diabetic patients overdue for a diabetic nephropathy screening. uACR orders were queued and pended for provider signature within the upcoming visit encounter. The pending order flagged the medical assistant (MA) to prepare a specimen cup. The provider handed the patient the specimen cup at the conclusion of the visit for the urine to be collected. Results: Of the 91 diabetic patients seen during the intervention, 87 patients had an order for a uACR signed during the visit encounter. This demonstrates an order compliance rate of 95.6%, an improvement by 26.7 percentage points when compared to the to the pre-intervention data. Conclusions: This quality improvement initiative underscored the importance of avoiding missed opportunities and taking advantage of all patient contact to perform diabetes follow up as a team. The increased number of signed uACR orders during the intervention brings to light the potential advantages of a pre-charting to avoid missing vital recommended screening tests

Volume Comparison for Hypersurfaces in Lorentzian Manifolds and Singularity Theorems

We develop area and volume comparison theorems for the evolution of spacelike, acausal, causally complete hypersurfaces in Lorentzian manifolds, where one has a lower bound on the Ricci tensor along timelike curves, and an upper bound on the mean curvature of the hypersurface. Using these results, we give a new proof of Hawking's singularity theorem.Comment: 15 pages, LaTe

Saffron (Crocus sativus L.) in ocular diseases:a narrative review of the existing evidence from clinical studies

Saffron (Crocus sativus L.) and its main constituents, i.e., crocin and crocetin, are natural carotenoid compounds, which have been reported to possess a wide spectrum of properties and induce pleiotropic anti-inflammatory, anti-oxidative, and neuroprotective effects. An increasing number of experimental, animal, and human studies have investigated the effects and mechanistic pathways of these compounds in order to assess their potential therapeutic use in ocular diseases (e.g., in age related macular degeneration, glaucoma, and diabetic maculopathy). This narrative review presents the key findings of published clinical studies that examined the effects of saffron and/or its constituents in the context of ocular disease, as well as an overview of the proposed underlying mechanisms mediating these effects

Rate theory for correlated processes: Double-jumps in adatom diffusion

We study the rate of activated motion over multiple barriers, in particular the correlated double-jump of an adatom diffusing on a missing-row reconstructed Platinum (110) surface. We develop a Transition Path Theory, showing that the activation energy is given by the minimum-energy trajectory which succeeds in the double-jump. We explicitly calculate this trajectory within an effective-medium molecular dynamics simulation. A cusp in the acceptance region leads to a sqrt{T} prefactor for the activated rate of double-jumps. Theory and numerical results agree

Simpson's aggregation paradox in nonparametric statistical analysis: Theory, computation, and susceptibility in public health data

This study establishes sufficient conditions for observing instances of Simpson's (data aggregation) Paradox under rank sum scoring (RSS), as used, e.g., in the Wilcoxon-Mann-Whitney (WMW) rank sum test. The WMW test is a primary nonparametric statistical test in FDA drug product evaluation and other prominent medical settings. Using computational nonparametric statistical methods, we also establish the relative frequency with which paradox-generating Simpson Reversals occur under RSS when an initial data sequence is pooled with its ordinal replicate. For each 2-sample, n-element per sample or 2 x n case of RSS considered, strict Reversals occurred for between 0% and 1.74% of data poolings across the whole sample space, roughly similar to that observed for 2 x 2 x 2 contingency tables and considerably less than that observed for path models. The Reversal rate conditional on observed initial sequence is highly variable. Despite a mode at 0%, this rate exceeds 20% for some initial sequences. Our empirical application identifies clusters of Simpson Reversal susceptibility for publicly-released mobile phone radiofrequency exposure data. Simpson Reversals under RSS are not simply a theoretical concern but can reverse nonparametric or parametric biostatistical results even in vitally important public health settings. Conceptually, Paradox incidence can be viewed as a robustness check on a given WMW statistical test result. When an instance of Paradox occurs, results constituting this instance are found to be data-scale dependent. Given that the rate of Reversal can vary substantially by initial sequence, the practice of calculating this rate conditional on observed initial sequence represents a potentially important robustness check upon a result

Pediatric Phantom Dosimetry of Kodak 9000 Cone-beam Computed Tomography

Purpose: The purpose of the study was to evaluate the radiation dose of the Kodak 9000 cone-beam computed tomography (CBCT) device for different anatomical areas using a pediatric phantom. Methods: Absorbed doses resulting from maxillary and mandibular region three by five cm CBCT volumes of an anthropomorphic 10-year-old child phantom were acquired using optical stimulated dosimetry. Equivalent doses were calculated for radiosensitive tissues in the head and neck area, and effective dose for maxillary and mandibular examinations were calculated following the 2007 recommendations of the International Commission on Radiological Protection (ICRP). Results: Of the mandibular scans, the salivary glands had the highest equivalent dose (1,598 microsieverts [μSv]), followed by oral mucosa (1,263 μSv), extrathoracic airway (pharynx, larynx, and trachea; 859 μSv), and thyroid gland (578 μSv). For the maxilla, the salivary glands had the highest equivalent dose (1,847 μSv), followed closely by oral mucosa (1,673 μSv), followed by the extrathoracic airway (pharynx, larynx, and trachea; 1,011 μSv) and lens of the eye (202 μSv). Conclusion: Compared to previous research of the Kodak 9000, completed with the adult phantom, a child receives one to three times more radiation for mandibular scans and two to 10 times more radiation for maxillary scans

An open reproducible framework for the study of the iterated prisoner's dilemma

The Axelrod library is an open source Python package that allows for reproducible game theoretic research into the Iterated Prisoner's Dilemma. This area of research began in the 1980s but suffers from a lack of documentation and test code. The goal of the library is to provide such a resource, with facilities for the design of new strategies and interactions between them, as well as conducting tournaments and ecological simulations for populations of strategies. With a growing collection of 139 strategies, the library is a also a platform for an original tournament that, in itself, is of interest to the game theoretic community. This paper describes the Iterated Prisoner's Dilemma, the Axelrod library and its development, and insights gained from some novel research.Comment: 11 pages, Journal of Open Research Software 4.1 (2016

Mitochondrial Ca(2+) uptake by the voltage-dependent anion channel 2 regulates cardiac rhythmicity.

Tightly regulated Ca(2+) homeostasis is a prerequisite for proper cardiac function. To dissect the regulatory network of cardiac Ca(2+) handling, we performed a chemical suppressor screen on zebrafish tremblor embryos, which suffer from Ca(2+) extrusion defects. Efsevin was identified based on its potent activity to restore coordinated contractions in tremblor. We show that efsevin binds to VDAC2, potentiates mitochondrial Ca(2+) uptake and accelerates the transfer of Ca(2+) from intracellular stores into mitochondria. In cardiomyocytes, efsevin restricts the temporal and spatial boundaries of Ca(2+) sparks and thereby inhibits Ca(2+) overload-induced erratic Ca(2+) waves and irregular contractions. We further show that overexpression of VDAC2 recapitulates the suppressive effect of efsevin on tremblor embryos whereas VDAC2 deficiency attenuates efsevin\u27s rescue effect and that VDAC2 functions synergistically with MCU to suppress cardiac fibrillation in tremblor. Together, these findings demonstrate a critical modulatory role for VDAC2-dependent mitochondrial Ca(2+) uptake in the regulation of cardiac rhythmicity