A decentralized, patient-centered approach to diabetes disease management in the primary care setting

Although many disease management programs have been developed for diabetes, no single design has proved best for all providers and patient populations. Cost effectiveness is especially relevant to diabetes programs because significant costs of the disease may come from complications that occur later in life, while the costs of the program are incurred immediately. For this reason, diabetes disease management programs with positive outcomes and low implementation costs are of particular importance. We report here on the outcomes of a pilot test of the Steps to Health program developed by Abbott Laboratories. The Steps to Health program was designed to improve patients\u27 compliance for their diabetes care by increasing their knowledge and understanding of diabetes. The pilot test format utilized a decentralized approach to implement the Steps to Health program and included assessments of clinical, process, and quality-of-life outcomes. The study used a prospective, observational, pre-post design. Patients were assessed at enrollment and at 6 months. The primary clinical outcome was glycemic control, as measured by HbA1c. For the 70 patients (18% of enrollment) with complete baseline and endpoint data, mean decrease in HbA1c was 1.7% (p \u3c 0.0001). Clinical process measures of preventive diabetes care showed minor changes in rates between the pre- and postenrollment periods. There was also significant improvement in patient satisfaction regarding their knowledge of diabetes, overall ability to take care of diabetes, and helpfulness of the information received. These results suggest that a diabetes disease management program that is relatively inexpensive and easy to implement, centered on patient education in self-management, can achieve clinically significant improvements in glycemic control for a specific period of time (6 months) and result in a high level of patient satisfaction

Metastatic tumors to the jaws : A report of eight new cases

Purpose: The purpose of the article is to present 8 new cases of metastatic tumors occurring in the jawbones, their clinical features , diagnostic workup and management. Patients and methods: The records of 8 patients with metastatic jaw lesions were reviewd. Demographic data, presenting symptoms, primary tumor site, radiographic findings, bone scintigraphy , histopathology and clinical management were analyzed. Results: The patients , ranged in age from 44 to 80 years, with a mean of 64.5 years. The primary malignant sites were: the lung , the breast , the rectum, the thyroid, the uterus and the parotid gland . The mandible was the site of oral involvement in seven cases and the maxilla in one. There was no gender difference with respect to the oral site affected. The clinical jaw presentations were: exophytic soft tissue mass, paresthesia of the lower lip and a periapical lesion The provided treatment protocols were: chemotherapy , radiotherapy and chemotherapy, surgery and chemotherapy and supportive care only. In one case the jaw lesion was the first indication of an unknown malignancy at a distant primary site. Conclusions: Metastatic jaw lesions are uncommon. Paresthesia of the lower lip and the chin is a sinister sign for patients with a metastatic jaw lesion. In view of these cases it can be said that meticulous work-up of of jaw lesions suspected of being metastatic, may be life saving or extend the patient?s survival period

Demand driven salt clean-up in a molten salt fast reactor – Defining a priority list

<div><p>The PUREX technology based on aqueous processes is currently the leading reprocessing technology in nuclear energy systems. It seems to be the most developed and established process for light water reactor fuel and the use of solid fuel. However, demand driven development of the nuclear system opens the way to liquid fuelled reactors, and disruptive technology development through the application of an integrated fuel cycle with a direct link to reactor operation. The possibilities of this new concept for innovative reprocessing technology development are analysed, the boundary conditions are discussed, and the economic as well as the neutron physical optimization parameters of the process are elucidated. Reactor physical knowledge of the influence of different elements on the neutron economy of the reactor is required. Using an innovative study approach, an element priority list for the salt clean-up is developed, which indicates that separation of Neodymium and Caesium is desirable, as they contribute almost 50% to the loss of criticality. Separating Zirconium and Samarium in addition from the fuel salt would remove nearly 80% of the loss of criticality due to fission products. The theoretical study is followed by a qualitative discussion of the different, demand driven optimization strategies which could satisfy the conflicting interests of sustainable reactor operation, efficient chemical processing for the salt clean-up, and the related economic as well as chemical engineering consequences. A new, innovative approach of balancing the throughput through salt processing based on a low number of separation process steps is developed. Next steps for the development of an economically viable salt clean-up process are identified.</p></div

Strong partnerships make good partners: Insights about physician-hospital relationships from a study of physician executives

While physicians are likely to respond favorably in concept to hospital-based disease management and other clinical programs, they are less likely to accept their structural and functional characteristics. Because of their role at the hospital-physician interface, hospital physician executives are often tasked with implementing such programs. Given the challenges involved, a deeper understanding of the role of these executives in building the hospital-physician relationship will therefore be an important contribution. To this end, we surveyed senior physician executives at hospitals and health systems (n = 326), to assess their view of the hospital-physician relationship at their institutions, focusing especially on the role of medical staff cohesion. This article presents several of our key findings, in particular that (1) many physician executives identified their medical staff as having relatively low cohesion and (2) the perceived level of medical staff cohesion correlated strongly with the level of physician support for organizational priorities, the degree of constructive physician involvement, and success in improving the physician-hospital relationship. In light of these findings, we conclude by offering concrete recommendations for physician executives and others seeking to build medical staff cohesion in the service of clinical improvement

Establishment of the first humpback whale fibroblast cell lines and their application in chemical risk assessment

This paper reports the first successful derivation and characterization of humpback whale fibroblast cell lines. Primary fibroblasts were isolated from the dermal connective tissue of skin biopsies, cultured at 37°C and 5% CO in the standard mammalian medium DMEM/F12 supplemented with 10% fetal bovine serum (FBS). Of nine initial biopsies, two cell lines were established from two different animals and designated HuWa1 and HuWa2. The cells have a stable karyotype with 2n=44, which has commonly been observed in other baleen whale species. Cells were verified as being fibroblasts based on their spindle-shaped morphology, adherence to plastic and positive immunoreaction to vimentin. Population doubling time was determined to be ~41h and cells were successfully cryopreserved and thawed. To date, HuWa1 cells have been propagated 30 times. Cells proliferate at the tested temperatures, 30, 33.5 and 37°C, but show the highest rate of proliferation at 37°C. Short-term exposure to para,para'-dichlorodiphenyldichloroethylene (p,p'-DDE), a priority compound accumulating in southern hemisphere humpback whales, resulted in a concentration-dependent loss of cell viability. The effective concentration which caused a 50% reduction in HuWa1 cell viability (EC value) was approximately six times greater than the EC value for the same chemical measured with human dermal fibroblasts. HuWa1 exposed to a natural, p,p'-DDE-containing, chemical mixture extracted from whale blubber showed distinctively higher sensitivity than to p,p'-DDE alone. Thus, we provide the first cytotoxicological data for humpback whales and with establishment of the HuWa cell lines, a unique in vitro model for the study of the whales' sensitivity and cellular response to chemicals and other environmental stressors

Automated CT and MRI Liver Segmentation and Biometry Using a Generalized Convolutional Neural Network.

PurposeTo assess feasibility of training a convolutional neural network (CNN) to automate liver segmentation across different imaging modalities and techniques used in clinical practice and apply this to enable automation of liver biometry.MethodsWe trained a 2D U-Net CNN for liver segmentation in two stages using 330 abdominal MRI and CT exams acquired at our institution. First, we trained the neural network with non-contrast multi-echo spoiled-gradient-echo (SGPR)images with 300 MRI exams to provide multiple signal-weightings. Then, we used transfer learning to generalize the CNN with additional images from 30 contrast-enhanced MRI and CT exams.We assessed the performance of the CNN using a distinct multi-institutional data set curated from multiple sources (n = 498 subjects). Segmentation accuracy was evaluated by computing Dice scores. Utilizing these segmentations, we computed liver volume from CT and T1-weighted (T1w) MRI exams, and estimated hepatic proton- density-fat-fraction (PDFF) from multi-echo T2*w MRI exams. We compared quantitative volumetry and PDFF estimates between automated and manual segmentation using Pearson correlation and Bland-Altman statistics.ResultsDice scores were 0.94 ± 0.06 for CT (n = 230), 0.95 ± 0.03 (n = 100) for T1w MR, and 0.92 ± 0.05 for T2*w MR (n = 169). Liver volume measured by manual and automated segmentation agreed closely for CT (95% limit-of-agreement (LoA) = [-298 mL, 180 mL]) and T1w MR (LoA = [-358 mL, 180 mL]). Hepatic PDFF measured by the two segmentations also agreed closely (LoA = [-0.62%, 0.80%]).ConclusionsUtilizing a transfer-learning strategy, we have demonstrated the feasibility of a CNN to be generalized to perform liver segmentations across different imaging techniques and modalities. With further refinement and validation, CNNs may have broad applicability for multimodal liver volumetry and hepatic tissue characterization

Acute hepatitis in three patients with systemic juvenile idiopathic arthritis taking interleukin-1 receptor antagonist

<p>Abstract</p> <p>Purpose</p> <p>We investigated the etiology of acute hepatitis in three children with systemic Juvenile Idiopathic Arthritis (sJIA) taking Interleukin-1 receptor antagonist (IL1RA).</p> <p>Methods</p> <p>Laboratory and clinical data for three children with sJIA diagnosed at ages 13 months to 8 years who developed acute hepatitis during treatment with IL1RA were reviewed for evidence of sJIA flare, infection, macrophage activation syndrome (MAS), malignancy, and drug reaction.</p> <p>Results</p> <p>In all patients, hepatitis persisted despite cessation of known hepatotoxic drugs and in absence of known infectious triggers, until discontinuation of IL1RA. Liver biopsies had mixed inflammatory infiltrates with associated hepatocellular injury suggestive of an exogenous trigger. At the time of hepatitis, laboratory data and liver biopsies were not characteristic of MAS. In two patients, transaminitis resolved within one week of discontinuing IL1RA, the third improved dramatically in one month.</p> <p>Conclusions</p> <p>Although sJIA symptoms improved significantly on IL1RA, it appeared that IL1RA contributed to the development of acute hepatitis. Hepatitis possibly occurred as a result of an altered immune response to a typical childhood infection while on IL1RA. Alternatively, hepatitis could have represented an atypical presentation of MAS in patients with sJIA taking IL1RA. Further investigation is warranted to determine how anti-IL1 therapies alter immune responsiveness to exogenous triggers in patients with immune dysfunction such as sJIA. Our patients suggest that close monitoring for hepatic and other toxicities is indicated when treating with IL1RA.</p

The use of a length-structured multispecies model fitted directly to data in near-real time as a viable tool for advice

Fish communities are multispecies assemblages, so ideally multispecies models should be used directly for assessing this resource. However, progress in this direction has been slow, partly because these models are often more complex and take longer to fit, rendering them too slow to demonstrate near-real-time utility, and thus creating a perception that they are opaque to stakeholders. In this study we implemented a multispecies assessment for the Irish Sea, fitting a model of eight key stocks directly to catch and survey data. Two novel features of our approach allowed the multispecies model to be fitted within a few hours. Firstly, by using size-based theory and life-history invariants to specify many of the required properties of stocks, we reduced the number of general parameters that needed to be fitted directly to a more manageable 25. Secondly, by using state-of-the-art fitting methods, we found acceptable solutions quickly enough to provide assessments within the timescale of an advisory meeting. The outcomes were compared with the standard single species assessments of the same eight species. Model fits were generally good for either catch or at least one of the surveys, but not for all data sources at the same time, illustrating the challenges of fitting multiple stocks to different data sources simultaneously. Estimates of SSB and F agreed qualitatively with the assessments for most stocks with the exception of whiting. Estimates of natural mortality showed modest year to year variability, suggesting that single species assessments may be appropriate for short term tactical management. This method shows great promise for making multispecies assessments as a complement to existing assessments because of the rapid turnaround time and ability to respond at meetings to the requests of stakeholders. In addition, because these models avoid our current dependence on existing single species models they can be used to provide boundary conditions in natural mortality for standard assessment models and check for internal consistency in the assessment process. Furthermore, they are easily accessible because they are based upon freely available code

Book Reviews

Book reviews of: Song of My Life: A Biography of Margaret Walker. By Carolyn J. Brown Jackson: University Press of Mississippi, 2014. Author’s note, afterword, acknowledgements, illustrations, appendices, notes, bibliography, index. Pp. xi, 147. $20.00 cloth. ISBN: 9781628461473. Searching for Freedom after the Civil War: Klansman, Carpetbagger, Scalawag, and Freedman. By G. Ward Hubbs. (Tuscaloosa: The University of Alabama Press, 2015. List of illustrations, preface, prologue, appendices, notes, bibliography, index. Pp. ix, 223.$34.95 cloth, $34.95 ebook. ISBN: 978-0-8173-1860-4.) Choctaw Resurgence in Mississippi: Race, Class, and Nation Building in the Jim Crow South, 1830-1977. By Katherine M. B. Osburn. (Lincoln: University of Nebraska Press, 2014. Acknowledgements, illustrations, maps, notes, index. Pp. 342.$65 Cloth, $25 Paper. ISBN: 0803240445.) Stennis: Plowing a Straight Furrow. By Don H. Thompson (Oxford: Triton Press, 2015. Acknowledgments, illustrations, notes. Pp. 176.$35 cloth. $14.95 paper. ISBN: 1936946467.) Corazón de Dixie: Mexicanos in the U. S. South since 1910. By Julie M. Weise. (Chapel Hill: University of North Carolina Press, 2015. Acknowledgments, appendix, notes, bibliography, index. Pp. 358.$32.50 paper, $29.99 e-book. ISBN: 9781469624969.) The Great Melding: War, the Dixiecrat Rebellion, and the Southern Model for America’s New Conservatism. By Glenn Feldman. (Tuscaloosa: University of Alabama Press, 2015. Acknowledgements, notes, index. Pp. x, 388.$59.95 cloth, $59.95 ebook. ISBN 978-0-8173-1866-6.) Baptists in America: A History. By Thomas S. Kidd and Barry Hankins. (New York: Oxford University Press, 2015. Preface, acknowledgements, notes, index. pp. xii, 329.$29.95 cloth. ISBN: 9780199977536.) One Nation Under God: How Corporate America Invented Christian America. By Kevin M. Kruse. (New York: Basic Books, 2015. Acknowledgements, notes, index. Pp. xvi, 352. $29.99. ISBN: 9780465049493.) Confederate Generals in the Trans-Mississippi: Essays on America’s Civil War, Vol. 1, Edited by Lawrence Lee Hewitt with Arthur W. Bergeron, Jr., and Thomas E. Schott. (Knoxville: University of Tennessee Press, 2013. Acknowledgments, illustrations, maps, notes, index. Pp. xxiii, 302.$54.95 cloth. ISBN: 9781572338661.) Agriculture and the Confederacy: Policy, Productivity, and Power in the Civil War South. By R. Douglas Hurt. (Chapel Hill: The University of North Carolina Press, 2015. Acknowledgements, maps, tables, notes, index. Pp. xi, 349. $45 paper. ISBN: 1469620006.) Womanpower Unlimited and the Black Freedom Struggle in Mississippi. By Tiyi M. Morris. (Athens: University of Georgia Press, 2015. Acknowledgements, illustrations, notes index. Pp. xvi, 237.$69.95 cloth, $24.95 paper. ISBN: 0820347302.

Commentary: Combining ecosystem and single-species modeling to provide ecosystem-based fisheries management advice within current management systems

A Commentary on: 'Combining Ecosystem and Single-Species Modeling to Provide Ecosystem-Based Fisheries Management Advice Within Current Management Systems' by Howell, D., Schueller, A. M., Bentley, J. W., Buchheister, A., Chagaris, D., Cieri, M., Drew, K., Lundy, M. G., Pedreschi, D., Reid, D. G., and Townsend, H. (2021). Front. Mar. Sci. 7:607831. doi: 10.3389/fmars.2020.60783