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Non-valvular atrial fibrillation (NVAF) is the most common cause of cardioembolic stroke. The left atrial appendage (LAA) is the major source of cardiac emboli in patients with NVAF. Anticoagulation (AC) is the standard of care for stroke prevention in atrial fibrillation (AF), but many patients are intolerant of AC. Surgical exclusion of the LAA may result in incomplete closure and is associated with an increased risk of embolism. We report a case of a woman in her 50s with a history of persistent AF, mitral valve prolapse s/p repair with surgical LAA exclusion, and multifocal haemorrhagic stroke presented for elective LAA closure who underwent a Watchman placement successfully. This case demonstrates that a percutaneous approach for occlusion of the LAA when surgical exclusion was incomplete may be feasible with appropriate planning. Clinical outcome data for this patient group are needed.

Objectives. To provide adjusted rates of self-reported receipt of the influenza vaccine in the 2018–2019 flu season among adults in large metropolitan, medium and small metropolitan, and nonmetropolitan areas of the United States by age group, gender, and race. Methods. We queried the 2019 National Health Interview Survey for respondents aged 18 years and older. To provide national estimates of influenza vaccination coverage, we performed sample-weighted multivariable logistic regressions and predicted marginal modeling while adjusting for age, gender, race/ethnicity, and urban–rural household designation. Results. After weighting, 48.1%, 46.2%, and 43.6% of adults from large metropolitan, small and medium metropolitan, and nonmetropolitan areas, respectively, received the influenza vaccine. Additionally, there was a trend toward declining influenza vaccination status from large metropolitan to rural areas in all age groups, both genders, and multiple racial/ethnic groups. Conclusions. Self-reported influenza vaccination rates were lower in rural than in urban areas among adults of all age groups and both genders. Using community leaders for health promotion, augmentation of the community health care workforce, and provision of incentives for providers to integrate influenza vaccination in regular visits may expand influenza vaccine coverage. (Am J Public Health. 2022;112(2):304–307. https://doi.org/10.2105/AJPH.2021.306575 )

We study health-care provider agency and optimal payments, considering an expensive medication for dialysis patients. Using Medicare claims data we estimate a structural model of treatment decisions, in which providers differ in their altruism and marginal costs, and this heterogeneity is unobservable to the government. In a novel application of nonlinear pricing methods, we empirically characterize the optimal contracts in this environment. The optimal contracts eliminate medically excessive dosages and reduce expenditures, resulting in approximately $300 million in annual gains from better contracting. This approach could be applied to a broad class of problems in health-care payment policy. (JEL D64, D86, H51, I11, I13, J33, L21)

Androgen deprivation therapy (ADT), a backbone treatment for advanced prostate cancer (PC), is known to have a variety of metabolic side effects. We conducted an updated meta-analysis to quantify the metabolic risks of ADT.We searched PubMed, Web of Science, and Scopus in May of 2022 for studies investigating the risk of metabolic syndrome (MetS), diabetes, and hypertension from ADT in PC patients using keywords. Only full-length studies with a control group of PC patients not on ADT were included. All results compatible with each outcome domain in each included study were sought. For included studies, relative risk (RR) was pooled using a random effects model and a trim-fill approach was used to adjust for publication bias.1,846 records were screened, of which 19 were found suitable for data extraction. Five studies, including 891 patients, were evaluated for MetS as an outcome, with the random effects model showing a pooled RR of 1.60 ([95% Confidence Interval (CI), 1.06-2.42]; P=0.03) for patients on ADT while twelve studies, including 336,330 patients, examined diabetes as an outcome, and the random effects model showed a RR of 1.43 ([95% CI, 1.28-1.59]; P0.01). After adjustment for publication bias, ADT was associated with a 25% increased risk for diabetes but was not associated with MetS. 4 studies, including 7,051 patients, examined hypertension as an outcome, and the random effects model showed a RR of 1.30 ([95% CI, 1.08-1.55]; P=0.18) in ADT patients.In patients with PC, ADT was not associated with MetS and the association with diabetes was not as strong as previously reported. Our novel meta-analysis of hypertension showed that ADT increased the risk of hypertension by 30%. These results should be understood in the context of collaborating care between a patient's oncologist and primary care provider to optimize care.

This study used carbon rods from spent zinc-carbon batteries as a source of exfoliated graphite (EG) to produce conductive filament composites for fused deposition modeling 3D printing. The EG filler was prepared through microwave irradiation, while the resulting 3D printable electroconductive EG composites were prepared using polylactic acid (PLA) and polyethylene glycol (PEG) as the polymer matrix and compatibilizer, respectively, via a sonication-assisted solution blending and melt extrusion process. A two-level full factorial design was employed to fully investigate the influence of filament production parameters such as EG loading, PEG:PLA ratio, and sonication time on the resistivity (i.e., conductivity-1) of the prepared composites. Analysis of variance showed that both EG loading and sonication time had significant effects on the resistivity of the composites. The optimum electrical resistivity of the new EG filament composites was found to be 916.418 Ω-cm (maximum conductivity = 1.091 x10-3 S/cm) at EG loading = 45 % w/w, PEG:PLA ratio = 1:10, and sonication time = 2 hours. The conductivity of the 3D printed composites was also correlated with EG amount by the power law model of percolation theory, resulting in an electrical percolation threshold at around 35 % w/w of EG. Our filament composites enable the fabrication of high-value conductive materials from waste resources for sustainable additive manufacturing in the electronics industry.

The field of wildlife conservation is comprised of a variety of players with different contexts and approaches. Zoos and aquariums, historically largely focused on public entertainment, are shifting more towards conservation-minded missions and can play a unique role in wildlife conservation by leveraging their distinct assets. The Minnesota Zoo is an AZA-accredited institution and an agency of the State of Minnesota that has been conducting wildlife conservation for over 40 years. Here, we review our current portfolio of local field projects, including initiatives targeting pollinators, native mussels, turtles, and bison, using several considerations to structure and better understand how our unique context has shaped our work. Our designation as a state agency has impacted our initiatives by necessitating a focus on local efforts and has facilitated many partnerships with other government agencies. Indeed, partnerships have been vital to our success and have shaped our programs significantly since their inception. All of the Zoo’s conservation initiatives are built on a bedrock of sound science, and we continue to contribute to the field through research, utilizing the expertise of department staff. In addition, the various funding streams that support our programs have dramatically shaped our work and have created some siloing of staff within the department. However, grant funding can serve as a buffer against the impacts of economic uncertainty, as evidenced during the COVID-19 pandemic. Lastly, our programs have expanded and our objectives have pivoted over the years in response to changing needs and opportunities; such flexibility—and increased flexibility for our staff—is imperative to the future success of these efforts. The Minnesota Zoo’s narrative is unique and helps us understand how we can continue to most effectively carry out local conservation efforts. As we work to protect habitats and save species from extinction, it is important to utilize the distinct assets that each organization can contribute in order to have the greatest collective impact.

Background: The Beers Criteria identifies potentially inappropriate medications (PIMs) that should be avoided in older adults living with dementia. Objective: The aim of this study was to provide estimates of the prevalence and persistence of PIM use among community-dwelling older adults living with dementia in 2011-2017. Methods: Medicare claims data were used to create an analytic dataset spanning from 2011 to 2017. The analysis included community-dwelling Medicare fee-for-service beneficiaries aged 65 and older who were enrolled in Medicare Part D plans, had diagnosis for dementia, and were alive for at least one calendar year. Dementia status was determined using Medicare Chronic Conditions Date Warehouse (CCW) Chronic Condition categories and Charlson Comorbidity Index. PIM use was defined as 2 or more prescription fills with at least 90 days of total days-supply in a calendar year. Descriptive statistics were used to report the prevalence and persistence of PIM use. Results: Of 1.6 million person-year observations included in the sample, 32.7% used one or more PIMs during a calendar year in 2011-2017. Breakdown by drug classes showed that 14.9% of the sample used anticholinergics, 14.0% used benzodiazepines, and 11.0% used antipsychotics. Conditional on any use, mean annual days-supply for all PIMs was 270.6 days (SD = 102.7). The mean annual days-supply for antipsychotic use was 302.7 days (SD = 131.2). Conclusion: Significant proportion of community-dwelling older adults with dementia used one or more PIMs, often for extended periods of time. The antipsychotic use in the community-dwelling older adults with dementia remains as a significant problem.

There is substantial evidence of the connection between career development and mental health. Executive processing, including associated feelings and thoughts, has been found to significantly impact career decision making and problem solving. This has implications for career practitioners tasked with addressing these complex concerns. Utilizing comprehensive frameworks that account for this connection is essential. Cognitive Information Processing theory (CIP; Sampson et al., 2020; Sampson et al., 2004) accounts for the interconnected elements of career and mental health, and specific dimensions of executive processing. Interventions derived from CIP as well as other approaches offer a structure in which to address executive processing elements influencing career development. Being intentional in assessing and addressing career-related thoughts and feelings enables a career practitioner to effectively and efficiently support those in need.

Cure rates now exceed 90% in many contemporary trials for children with B-cell acute lymphoblastic leukemia (B-ALL). However, treatment remains suboptimal, and therapy is toxic for all patients. New treatment options potentially offer the chance to reduce both treatment resistance and toxicity. Here, we review recent advances in ALL diagnostics, chemotherapy, and immunotherapy. In addition to describing recently published results, we also attempt to project the impact of these new developments into the future to imagine what B-ALL therapy may look like in the next few years.

Background: Cognitive decline is among the most feared aspects of growing old. Assessing cognitive functioning is important in determining the level of impairment. Montreal Cognitive Assessment Test (MoCA) has been used as a rapid screening tool to assess cognitive function. Objective: This study was conducted to establish normative data in the adult population of Mumbai (40-60 years of age) using the MoCA scale. Materials and methods: The Institutional Ethics Committee (IEC) approval was obtained and a cross-sectional study was conducted in a metropolitan city in India, from November 2022 to December 2022. Adults were screened using The Saint Louis University Mental Status Examination (SLUMS) out of which 107 participants were recruited, ranging from 40-60 years of age. Montreal cognitive assessment test (MoCA) was used to capture normative data on the age, gender, and education demographics. Results: The composite mean score of MoCA was found as 24.12 with a standard deviation of ±3.525 giving a range of 20.595 - 27.645. There was no significant difference in despite of scores between the two age groups and the gender variant. However, education had an impactful difference. The mean score on MoCA for graduates and primary education was 25.39 and 21.80 respectively. It showed a statistically highly significant difference with higher values in graduates. Conclusion: The MoCA scores were directly correlated with educational status. Hence, this study helped us to understand the subtle cognitive impairments in early adulthood. Population-based normative data is essential for early screening and diagnosis. Key words: Montreal cognitive assessment test MoCA, Normative data, Middle-aged adults, cognitive assessment.

We use young clusters and giant molecular clouds (GMCs) in the galaxies M33 and M31 to constrain temporal and spatial scales in the star formation process. In M33, we compare the PHATTER catalogue of 1214 clusters with ages measured via colour-magnitude diagram (CMD) fitting to 444 GMCs identified from a new 35 pc resolution ALMA $^{12}$CO(2-1) survey. In M31, we compare the PHAT catalogue of 1249 clusters to 251 GMCs measured from a CARMA $^{12}$CO(1-0) survey with 20 pc resolution. Through two-point correlation analysis, we find that young clusters have a high probability of being near other young clusters, but correlation between GMCs is suppressed by the cloud identification algorithm. By comparing the positions, we find that younger clusters are closer to GMCs than older clusters. Through cross-correlation analysis of the M33 cluster data, we find that clusters are statistically associated when they are $\leq$10 Myr old. Utilizing the high precision ages of the clusters, we find that clusters older than $\approx 18$ Myr are uncorrelated with the molecular ISM. Using the spatial coincidence of the youngest clusters and GMCs in M33, we estimate that clusters spend $\approx$4-6 Myr inside their parent GMC. Through similar analysis, we find that the GMCs in M33 have a total lifetime of $\approx 11$-15 Myr. We also develop a drift model and show that the above correlations can be explained if the clusters in M33 have a 5-10 km s$^{-1}$ velocity dispersion relative to the molecular ISM., Comment: 14 pages, 13 figures, 1 tables, accepted for publication at MNRAS

Background and Objectives: Cognitive benefits of longitudinal curricula and interleaving have been demonstrated in several disciplines. However, most residency curricula are structured in a block format. There is no consensus definition as to what constitutes a longitudinal program, making comparative research on curricular efficacy a challenge. The objective of our study was to arrive at a consensus definition of Longitudinal Interleaved Residency Training (LIRT) in family medicine. Methods: A national workgroup was convened and utilized a Delphi method between October 2021 and March 2022 to arrive at a consensus definition. Results: Twenty-four invitations were sent, and 18 participants initially accepted. The final workgroup (n=13) was representative of the nationwide diversity of family medicine residency programs in terms of geographic location (P=.977) and population density (P=.123). The following definition was approved: “LIRT is a curricular design and program structure that offers graduated, concurrent clinical experiences in the core competencies of the specialty. LIRT models the comprehensive scope of practice and continuity that defines the specialty; applies training methods that enhance long-term retention of knowledge, skills, and attitudes across all dimensions and locations of care delivery; and accomplishes program objectives through employment of longitudinal curricular scheduling and interleaving with spaced repetition.” Additional technical criteria and definitions of terms are elucidated in the body of this article. Conclusions: A representative national workgroup crafted a consensus definition of Longitudinal Interleaved Residency Training (LIRT) in family medicine, a program structure with a basis in emerging evidence-based cognitive science.

H-Net's Past-President Seth Offenbach and Vice President of Research and Publications Niels Eichhorn introduce the inaugural volume of the Proceedings of the H-Net Teaching Conference.

Introduction Digital technology designed to improve care for patients with inflammatory bowel disease has received increased attention in recent years. In the UK, technology in this area has been developed and preliminary reports of pilot programs have shown promising results. When considering the range of designs and purposes that technology can incorperate, the concept of a ‘digital consultation’ has become a crucial factor. To develop digital solutions effectively in clinical practice for inflammatory bowel disease services, it is essential to understand the existing published evidence base on what a ‘digitally enhanced’ consultation may entail. Methods A literature search was conducted by searching the Embase, CINAHL and Medline databases using the following search terms: ‘inflammatory bowel disease’, ‘gastroenterology’, ‘chronic disease’, ‘e-health’, ‘digital health’ and ‘outpatient consultations’. The search was limited to articles written in English. Initially, 313 articles were retrieved. To refine the results and focus on web portals/mobile apps that enhance a consultation, abstracts were reviewed and irrelevant articles were removed. A date range of 2016–2021 was applied, which resulted in 13 relevant research articles. Results A total of 10 technologies were described and five themes emerged; ‘disease activity’, ‘quality of life’, ‘quality of care’, ‘healthcare utilisation’ and ‘test of change’. The retrieved articles were critically evaluated. Conclusions Inflammatory bowel disease services must decide what they wish to achieve by using digital technology. Some centres may wish to improve access, while others aim to improve the quality of the care that they provide. This review illustrates variation in both aim, design and construct, which has led to a difference in results.