Favorable outcomes with reduced steroid use in juvenile dermatomyositis

BACKGROUND: High-intensity glucocorticoid regimens are commonly used to induce and maintain remission in Juvenile Dermatomyositis but are associated with several adverse side-effects. Evidence-based treatment guidelines from North American and European pediatric rheumatology research societies both advocate induction with intravenous pulse steroids followed by high dose oral steroids (2 mg/kg/day), which are then tapered. This study reports the time to disease control with reduced glucocorticoid dosing. METHODS: We retrospectively reviewed the records at a single tertiary-care children\u27s hospital of patients diagnosed with Juvenile Dermatomyositis between 2000 and 2014 who had a minimum of 2 years of follow-up. The primary outcome measure was time to control of muscle and skin disease. Additional outcome measures included glucocorticoid dosing, effect of treatment on height, frequency of calcinosis, and complications from treatment. RESULTS: Of the 69 patients followed during the study period, 31 fulfilled inclusion criteria. Median length of follow-up was 4.58 years, (IQR 3-7.5). Myositis control was achieved in a median of 7.1 months (IQR 0.9-63.4). Cutaneous disease control was achieved in a median of 16.7 months (IQR 4.3-89.5). The median starting dose of glucocorticoids was 0.85 mg/kg/day, (IQR 0.5-1.74). The median duration of steroid treatment was 9.1 months, (IQR 4.7-17.4), while the median duration of any pharmacotherapy was 29.2 months (IQR 10.4 to 121.3). Sustained disease control off medications was achieved in 21/31 (68%) patients by the end of review. Persistent calcinosis was identified in only one patient (3%). CONCLUSION: Current accepted treatment paradigms for Juvenile Dermatomyositis include oral glucocorticoids beginning at 2 mg/kg/day and reduced over a prolonged time period. However, our results suggest that treatment using reduced doses and duration with early use of steroid-sparing agents is comparably effective in achieving favorable outcomes in Juvenile Dermatomyositis

Adverse childhood experiences, support, and the perception of ability to work in adults with disability

Objective To examine the impact of adverse childhood experiences (ACEs) and support on self-reported work inability of adults reporting disability. Participants Adults (ages 18–64) who participated in the Behavioral Risk Factor Surveillance System in 2009 or 2010 and who reported having a disability (n = 13,009). Design and Main Outcome Measures The study used a retrospective cohort design with work inability as the main outcome. ACE categories included abuse (sexual, physical, emotional) and family dysfunction (domestic violence, incarceration, mental illness, substance abuse, divorce). Support included functional (perceived emotional/social support) and structural (living with another adult) support. Logistic regression was used to adjust for potential confounders (age, sex and race) and to evaluate whether there was an independent effect of ACEs on work inability after adding other important predictors (support, education, health) to the model. Results ACEs were highly prevalent with almost 75% of the sample reporting at least one ACE category and over 25% having a high ACE burden (4 or more categories). ACEs were strongly associated with functional support. Participants experiencing a high ACE burden had a higher adjusted odds ratio (OR) [95% confidence interval] of 1.9 [1.5–2.4] of work inability (reference: zero ACEs). Good functional support (adjusted OR 0.52 [0.42–0.63]) and structural support (adjusted OR 0.48 [0.41–0.56]) were protective against work inability. After adding education and health to the model, ACEs no longer appeared to have an independent effect. Structural support remained highly protective, but functional support only appeared to be protective in those with good physical health. Conclusions ACEs are highly prevalent in working-age US adults with a disability, particularly young adults. ACEs are associated with decreased support, lower educational attainment and worse adult health. Health care providers are encouraged to screen for ACEs. Addressing the effects of ACEs on health and support, in addition to education and retraining, may increase ability to work in those with a disability

Combining microscopic and macroscopic probes to untangle the single-ion anisotropy and exchange energies in an S=1 quantum antiferromagnet

The magnetic ground state of the quasi-one-dimensional spin-1 antiferromagnetic chain is sensitive to the relative sizes of the single-ion anisotropy (D) and the intrachain (J) and interchain (J') exchange interactions. The ratios D/J and J'/J dictate the material's placement in one of three competing phases: a Haldane gapped phase, a quantum paramagnet and an XY-ordered state, with a quantum critical point at their junction. We have identified [Ni(HF)2(pyz)_2]SbF6, where pyz = pyrazine, as a rare candidate in which this behavior can be explored in detail. Combining neutron scattering (elastic and inelastic) in applied magnetic fields of up to 10~tesla and magnetization measurements in fields of up to 60~tesla with numerical modeling of experimental observables, we are able to obtain accurate values of all of the parameters of the Hamiltonian [D = 13.3(1)~K, J = 10.4(3)~K and J' = 1.4(2)~K], despite the polycrystalline nature of the sample. Density-functional theory calculations result in similar couplings (J = 9.2~K, J' = 1.8~K) and predict that the majority of the total spin population resides on the Ni(II) ion, while the remaining spin density is delocalized over both ligand types. The general procedures outlined in this paper permit phase boundaries and quantum-critical points to be explored in anisotropic systems for which single crystals are as yet unavailable

Use of graded responsibility and common entrustment considerations among United States emergency medicine residency programs

Purpose The Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to provide increasing autonomy as residents progress through training, known as graded responsibility. However, there is little guidance on how to implement graded responsibility in practice and a paucity of literature on how it is currently implemented in emergency medicine (EM). We sought to determine how EM residency programs apply graded responsibility across a variety of activities and to identify which considerations are important in affording additional responsibilities to trainees. Methods We conducted a cross-sectional study of EM residency programs using a 23-question survey that was distributed by email to 162 ACGME-accredited EM program directors. Seven different domains of practice were queried. Results We received 91 responses (56.2% response rate) to the survey. Among all domains of practice except for managing critically ill medical patients, the use of graded responsibility exceeded 50% of surveyed programs. When graded responsibility was applied, post-graduate year (PGY) level was ranked an “extremely important” or “very important” consideration between 80.9% and 100.0% of the time. Conclusion The majority of EM residency programs are implementing graded responsibility within most domains of practice. When decisions are made surrounding graded responsibility, programs still rely heavily on the time-based model of PGY level to determine advancement

Why do supply chain technologies sometimes fail to improve a firm’s performance?

Successful implementation depends on the reason why the technology was adopted in the first place, write Zhongzhi Liu, Daniel Prajogo, and Adegoke Ok

Invisibility as a structural determinant: Mortality outcomes of Asians and Pacific Islanders experiencing homelessness

IntroductionAsians and Pacific Islanders (APIs) who are experiencing homelessness are situated in a social intersection that has rendered them unrecognized and therefore vulnerable. There has been increasing attention to racial disparities in homelessness, but research into API homelessness is exceedingly rare, despite rapidly growing populations. The purpose of this study is to examine the causes of death among APIs who died while homeless in Santa Clara County (SCC) and compare these causes to other racial groups.Materials and methodsWe report on data obtained from the SCC Medical Examiner-Coroner's Office on unhoused people's deaths that occurred between 2011 and 2021 (n = 1,394), including data on deaths of APIs experiencing homelessness (n = 87).ResultsAPIs comprised 6.2% of total deaths of unhoused people. APIs died less often of causes related to drug/alcohol use than all other racial groups (24.1, compared to 39.3%), and there was a trend toward more API deaths from injuries or illnesses. When APIs were disaggregated into sub-groups (East/Southeast Asian, South Asian, Pacific Islander), there were notable mortality differences in cause of death, age, and sex.DiscussionWe argue that invisibility is a structural determinant of health that homeless APIs face. Though relatively small in numbers, APIs who are invisible may experience increased social isolation and, subsequently, specific increased mortality risks. To understand the health outcomes of unhoused APIs, it is essential that researchers and policymakers recognize API homelessness and gather and report disaggregated races and ethnicities

Contemporary practices of strength and conditioning coaches in professional soccer

This study describes the contemporary practices of strength and conditioning coaches in professional soccer. Fifty-two strength and conditioning coaches from professional leagues across 18 countries completed an online survey, consisting of 45 questions, with eight sections: (a) background information, (b) muscular strength and power development, (c) speed development, (d) plyometrics, (e) flexibility development, (f) physical testing, (g) technology use, and (h) programing. A frequency analysis was used to assess and report responses to fixed response questions, and thematic-analysis used for open-ended questions to create clear, identifiable and distinct themes. All strength and conditioning coaches were educated to degree level or higher, 65% held strength and conditioning certifications and 54% held soccer coaching certifications. Concentric (100%) and eccentric (98%) modes of resistance were the most commonly prescribed, whereas the squat (including variations) (52%) was deemed the most important exercise for soccer players. Hang clean (33%) and multiple hops/lunges (89%) were the most programed Olympic weightlifting and plyometric exercises. Global Positioning Systems (94%) were the most utilized technology-based equipment. Time, scheduling and fixtures were the biggest issues faced, which made it difficult to periodize training programs and apply appropriate training loads. Furthermore, strength and conditioning coaches would like to further integrate technology to comprehensively monitor and test players, while also believing that technology will continue to be developed and integrated in the future. Strength and conditioning coaches from professional soccer can use the information from this study to review current practices and also provide ideas for diversifying or modifying future practices

Modelling hurricane track memory

It has been observed that hurricanes that are close in time often follow similar paths. If this can be shown to be statistically significant, it could have implications for how insurance premiums are calculated in areas of the US prone to hurricanes. We developed two independent path distance metrics and while one suggested that sequential storms within a given hurricane season are more likely to follow each other than any other pair of storms within that season, this conclusion was not supported by the other metric. Some considerations of how local and large scale air pressure gradients might affect hurricane paths were considered. A point vortex model in the presence of a steering flow field was developed and used to simulate the path of two time displaced vortices. In order for the vortices to follow each other they had to be relatively weak compared to the steering flow field. At realistic vortex strength, the trajectories became chaotic. In summary, our metrics provided conflicting evidence towards the no- tion of hurricane track memory. A large-scale steering flow field did not appear to provide sufficient explanation for hurricanes following each other, though this does not preclude hurricane track memory being due to localised physical changes following a large storm

The redshift and mass dependence on the formation of the Hubble sequence at z > 1 from CANDELS/UDS

In this paper we present a detailed study of the structures and morphologies of a sample of 1188 massive galaxies with M-* >= 10(10) M-circle dot between redshifts z = 1 and 3 within the Ultra Deep Survey (UDS) region of the Cosmic Assembly Near-infrared Deep Extragalactic Legacy Survey (CANDELS) field. Using this sample we determine how galaxy structure and morphology evolve with time, and investigate the nature of galaxy structure at high redshift. We visually classify our sample into discs, ellipticals and peculiar systems and correct for redshift effects on these classifications through simulations. We find significant evolution in the fractions of galaxies at a given visual classification as a function of redshift. The peculiar population is dominant at z > 2 with a substantial spheroid population, and a negligible disc population. We compute the transition redshift, z(trans), where the combined fraction of spheroidal and disc galaxies is equal to that of the peculiar population, as z(trans) = 1.86 +/- 0.62 for galaxies in our stellar mass range. We find that this transition changes as a function of stellar mass, with Hubble-type galaxies becoming dominant at higher redshifts for higher mass galaxies (z(trans) = 2.22 +/- 0.82), than for the lower mass galaxies (z(trans) = 1.73 +/- 0.57). Higher mass galaxies become morphologically settled before their lower mass counterparts, a form of morphological downsizing. We furthermore compare our visual classifications with the Sersic index, the concentration, asymmetry and clumpiness (CAS) parameters, star formation rate and rest-frame U - B colour. We find links between the colour of a galaxy, its star formation rate and how extended or peculiar it appears. Finally, we discuss the negligible z > 2 disc fraction based on visual morphologies and speculate that this is an effect of forming disc appearing peculiar through processes such as violent disc instabilities or mergers. We conclude that to properly define and measure high-redshift morphology and structure a new and more exact classification scheme is needed