Developing Strategies of Organizational Sustainability for Solo and Small Business Medical Practices

Recent trends point toward a decline in solo and small business medical practices, yet, the need and demand still exists for this model of health care. The purpose of this case study was to explore effective approaches to help physicians in solo practice and small medical group primary care practitioners (PCPs) retain their small business medical practices. The study included purposive sampling and face-to-face interviews: 11 physicians, predominately primary care practitioners, in the Baltimore-Washington metropolitan region, were interviewed until data saturation was reached. A component of systems theory (strategic thinking) and the dynamic capabilities concept were used to frame the study. Audio recordings were transcribed and analyzed to identify themes regarding effective competitive approaches to help small medical group physicians retain their practices. Four major themes emerged: need for flexibility and adaptability, need for higher levels of business acumen, need to fully embrace automation, and a focus on pursuing financial stability before pursuing growth and expansion of the medical practice. Results may benefit society by preserving and strengthening a source of patient-centered, effective, affordable health care for communities served by small business medical practices. Implications for social change include presenting methods to enhance stability and organizational sustainability of small business medical practices

Biola Hour Highlights, 1974 - 08

A Christian Says \u27Thank You\u27 by Gerald Griffiths The Four Suppers of the New Testament by Al Sanders The Revelation of Jesus Christ by Lloyd Anderson Panel Discussions with Richard Chase, Vern Lewis, and Norman Wrighthttps://digitalcommons.biola.edu/bhhs/1007/thumbnail.jp

Biola Hour Highlights, 1974 - 09

How to Win Over Worry by Gerald Griffiths Psalm 37: The Psalm of Serenity by Al Sanders The Revelation of Jesus Christ by Lloyd Anderson Panel Discussions with Richard Chase, Charles Feinberg, and Samuel Sutherlandhttps://digitalcommons.biola.edu/bhhs/1008/thumbnail.jp

Evidence from diatom-bound nitrogen isotopes for subarctic Pacific stratification during the last ice age and a link to North Pacific denitrification changes

Author Posting. © American Geophysical Union, 2007. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Paleoceanography 22 (2007): PA1215, doi:10.1029/2005PA001205.In a piston core from the central Bering Sea, diatom microfossil-bound N isotopes and the concentrations of opal, biogenic barium, calcium carbonate, and organic N are measured over the last glacial/interglacial cycle. Compared to the interglacial sections of the core, the sediments of the last ice age are characterized by 3‰ higher diatom-bound δ 15N, 70 wt % lower opal content and 1200 ppm lower biogenic barium. Taken together and with constraints on sediment accumulation rate, these results suggest a reduced supply of nitrate to the surface due to stronger stratification of the upper water column of the Bering Sea during glacial times, with more complete nitrate consumption resulting from continued iron supply through atmospheric deposition. This finding extends the body of evidence for a pervasive link between cold climates and polar ocean stratification. In addition, we hypothesize that more complete nutrient consumption in the glacial age subarctic Pacific contributed to the previously observed ice age reduction in suboxia and denitrification in the eastern tropical North Pacific by lowering the nutrient content of the intermediate-depth water formed in the subpolar North Pacific. In the deglacial interval of the Bering Sea record, two apparent peaks in export productivity are associated with maxima in diatom-bound and bulk sediment δ 15N. The high δ 15N in these intervals may have resulted from greater surface nutrient consumption during this period. However, the synchroneity of the deglacial peaks in the Bering Sea with similar bulk sediment δ 15N changes in the eastern Pacific margin and the presence of sediment lamination within the Bering Sea during the deposition of the productivity peaks raise the possibility that both regional and local denitrification worked to raise the δ 15N of the nitrate feeding Bering Sea surface waters at these times.Financial support for this work was provided by NSF grants OCE-0136449, OCE-9981479, ANT-0453680, by BP and Ford Motor Company through the Princeton Carbon Migration Initiative, and by a NDSEG fellowship to B.G.B. Work conducted aboard the USCG Healy (Healy 0202) was funded by grant OPP-9912122

Replacement reactions and deformation by dissolution and precipitation processes in amphibolites

The deformation of the middle to lower crust in collisional settings occurs via deformation mechanisms that vary with rock composition, fluid content, pressure, and temperature. These mechanisms are responsible for the accommodation of large tectonic transport distances during nappe stacking and exhumation. Here, we show that fracturing and fluid flow triggered coupled dissolution–precipitation and dissolution–precipitation creep processes, which were responsible for the formation of a mylonitic microstructure in amphibolites. This fabric is developed over a crustal thickness >500 m in the Lower Seve Nappe (Scandinavian Caledonides). Amphibolites display a mylonitic foliation that wraps around albite porphyroclasts appearing dark in panchromatic cathodoluminescence (CL). The albite porphyroclasts were dissected and fragmented by fractures preferentially developed along the (001) cleavage planes and display lobate edges with embayments and peninsular features. Two albite/oligoclase generations, bright in CL, resorbed and overgrew the porphyroclasts, sealing the fractures. Electron backscattered diffraction shows that the two albite/oligoclase generations grew both pseudomorphically and topotaxially at the expense of the albite porphyroclasts and epitaxially around them. These two albite/oligoclase generations also grew as neoblasts elongated parallel to the mylonitic foliation. The amphibole crystals experienced a similar microstructural evolution, as evidenced by corroded ferrohornblende cores surrounded by ferrotschermakite rims that preserve the same crystallographic orientation of the cores. Misorientation maps highlight how misorientations in amphibole are related to displacement along fractures perpendicular to its c-axis. No crystal plasticity is observed in either mineral species. Plagioclase and amphibole display a crystallographic preferred orientation that is the result of topotaxial growth on parental grains and nucleation of new grains with a similar crystallographic orientation. Amphibole and plagioclase thermobarometry constrains the mylonitic foliation development to the epidote amphibolite facies (˜600°C, 0.75–0.97 GPa). Our results demonstrate that at middle to lower crustal levels, the presence of H2O-rich fluid at grain boundaries facilitates replacement reactions by coupled dissolution–precipitation and favours deformation by dissolution–precipitation creep over dislocation creep in plagioclase and amphibole

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead