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Serum cryoglobulins were found in nineteen out of twenty patients with infectious endocarditis. The cryoglobulins were of the `mixed type' consisting of IgG. IgM and IgA. C3 and fibrinogen were present in some specimens. The concentration of the cryoglobulins tended to will with therapy and clinical improvement of the patients. Serum antibodies to the offending bacterial organism were not preferentially concentrated in the cryoglobulins. In contrast, IgM rheumatoid factor was present in the cryoglobulins, though undetectable in the corresponding serum. These findings are consistent with the view that cryoglobulins represent circulating immune complexes which may be important in the pathogenesis of immunological sequelae sometimes found in patients with infectious endocarditis. [ABSTRACT FROM AUTHOR]

Distribution of viral antibodies was examined by the indirect fluorescent antibody technique in specimens from rheumatoid arthritis and from systemic lupus erythematosus patients. Titres in sera from rheumatoid arthritis patients were usually equal to, or greater than, those in joint fluids. Viral antibodies were found in whole cryoprecipitates from joint fluids and in the IgG fractions of the cryoprecipitates. Anti-herpes simplex antibodies were most frequently found in cryoprecipitates and were at highest titre in sera and joint fluids. Anti-respiratory syncytial virus anti- bodies were next in frequency and in titre. No evidence was presented to support the concept of localized viral antibody synthesis in joints of rheumatoid arthritis patients. Serum antibody titres in systemic lupus erythematosus patients were similar to those in rheumatoid arthritis patients; however, viral antibodies were not found in the serum cryoprecipitates of systemic lupus erytheniatosus patients. [ABSTRACT FROM AUTHOR]

The Medicare Annual Wellness Visit (AWV) screens for risk factors of functional decline in older adults. However, the extent to which internal medicine resident physicians ("residents") perform the AWV and feel confident in addressing its clinical topics has not been formally assessed. The number of AWVs completed by 47 residents and 15 general internists in a primary care clinic were calculated for June 2020 through May 2021. In June 2021, the residents were surveyed about their knowledge, skills, and confidence regarding the AWV. Residents averaged four completed AWVs, whereas general internists averaged 54 completed AWVs. 85% of residents responded to the survey; 67% of these resident respondents felt somewhat confident or confident that they understood the purpose of the AWV, and 53% felt similarly confident explaining the AWV to patients. Residents felt somewhat confident or confident treating depression/anxiety (95%), substance use (90%), falls (72%), and completing an advance directive (72%). The topics fewer residents felt somewhat confident or confident addressing were fecal incontinence (50%), IADLs (45%), and physical/emotional/sexual abuse (45%). By better understanding topics where residents are least confident, we identify opportunities for curriculum development in geriatric care and potentially increase the utility of the AWV as a screening tool.

Background: Primary care in Rhode Island is in crisis. The dearth of primary care providers is already affecting access to services and the situation is likely to worsen unless major steps are taken. There are inadequate numbers of trainees in primary care medical residencies, nurse practitioner (NP) and physician assistant (PA) training programs who plan to practice primary care in our state. The Care Transformation Collaborative of RI (CTC-RI) has assembled a broadly representative task force of physicians, NPs, PAs, and others to build a strong and robust primary care delivery system across the state that recruits, trains, retains, and sustains primary care providers. Study Methods and Design: Program directors from all primary care medical residencies, NP, and PA programs were asked to provide data on their programs, including the number of new trainees per year, total enrollment, and information on recent year graduates, including the total number, the number entering primary care, and the number entering primary care who plan to practice in RI., Primary Results: Of the 106 graduates from primary care residencies in RI in academic year 2002-23, only 15 (14%) planned to provide primary care in Rhode Island. Similarly, of the 144 NP and PA graduates in primary care programs, only 48 (33%) planned to provide primary care in the state., Principal Conclusions: Given the high rate of primary care provider burnout, reduction in patient care hours, and retirement, primary care access will be further eroded unless major steps are taken. The CTC-RI Task Force on Primary Care Provider Workforce has produced a strategic roadmap to address these issues.

Introduction: With growing freight operations throughout the world, there is a push for transportation systems to accommodate trucks during loading and unloading operations. Currently, many urban locations do not provide loading and unloading zones, which results in trucks parking in places that obstruct bicyclist's roadway infrastructure (e.g., bicycle lanes)., Method: To understand the implications of these truck operations, a bicycle simulation experiment was designed to evaluate the impact of commercial vehicle loading and unloading activities on safe and efficient bicycle operations in a shared urban roadway environment. A fully counterbalanced, partially randomized, factorial design was chosen to explore three independent variables: commercial vehicle loading zone (CVLZ) sizes with three levels (i.e., no CVLZ, Min CVLZ, and Max CVLZ), courier position with three levels (i.e., no courier, behind the truck, beside the truck), and with and without loading accessories. Bicyclist's physiological response and eye tracking were used as performance measures. Data were obtained from 48 participants, resulting in 864 observations in 18 experimental scenarios using linear mixed-effects models (LMM)., Results: Results from the LMMs suggest that loading zone size and courier position had the greatest effect on bicyclist's physiological responses. Bicyclists had approximately two peaks-per-minute higher when riding in the condition that included no CVLZ and courier on the side compared to the base conditions (i.e., Max CVLZ and no courier). Additionally, when the courier was beside the truck, bicyclist's eye fixation durations (sec) were one (s) greater than when the courier was located behind the truck, indicating that bicyclists were more alert as they passed by the courier. The presence of accessories had the lowest influence on both bicyclists' physiological response and eye tracking measures., Practical Applications: These findings could support better roadway and CVLZ design guidelines, which will allow our urban street system to operate more efficiently, safely, and reliable for all users., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 National Safety Council and Elsevier Ltd. All rights reserved.)

Crashes caused by problems with bus drivers' physical and mental health have increased in frequency in recent years. Insomnia, a common type of sleep problem, has significant positive relationships with both crash risk and mental health problems, especially anxiety and depression, which are themselves associated with driving behavior. However, few studies have conducted analysis on sleep-related problems and mental health exclusively on bus drivers, nor on how these problems influence driving performance. Thus, this study explored the effect of insomnia and mental health on bus drivers' risky driving behavior and evaluated the interaction of four variables: insomnia, anxiety, depression, and risky driving behavior. The survey-based investigation was conducted in a bus company in Suzhou, China, with 1,295 bus drivers participating. Insomnia, anxiety, and depression were self-reported based on professional mental health scales and risky driving behaviors were measured by the Driver Behavior Questionnaire. Two mediation models and a chain mediation model were developed to examine relationships among the bus drivers' insomnia, anxiety, depression, and risky driving behavior. Results revealed that (a) bus drivers less than 31 years old, drivers with more than 11 years' experience driving buses, and those with crash and violation involvement within three years demonstrated more severe degrees of insomnia, anxiety, depression, and risky driving behavior; (b) there were significant positive correlations and interactions among the four variables. Results specifically related to the interaction among variables include findings that (a) anxiety mediated between insomnia and risky driving behavior; (b) depression mediated between insomnia and risky driving behavior; and (c) anxiety affected bus drivers' risky driving behavior primarily though depression. The findings in this study indicate the importance of regular physical and mental health examination of bus drivers and suggest that interventions focused on insomnia and mental health problems may be helpful to reduce risky driving behaviors of bus drivers both directly and indirectly., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

The Manchester Driver Behavior Questionnaire (DBQ) is a widely used self-reported measure of aberrant driving behaviors. It provides a standardized way of evaluating drivers' safety awareness and motivation, but the effectiveness of the DBQ's application in different regions can be influenced by culture, social norms, and time period. Several studies have adjusted DBQ items to reflect driver behavior native to particular regions or times, but few have used objective measurements to make proper adjustments. A naturalistic driving study (NDS) provides vehicle kinematic data and in-vehicle videos that objectively capture actual driving behaviors. The gender, age, and driving experience characteristics of aberrant driving behaviors were analyzed, and, based on comparisons between the DBQ self-reported driving behaviors and those observed in the Shanghai, China, NDS, the existing items from the Manchester DBQ were subsequently adjusted. Sixty-two types of real-world aberrant driving behaviors were extracted from 490 valid crash and near crash events observed in the Shanghai NDS. Aberrant driving behavior rates were calculated for individual characteristics (gender, age, and driving experience), and factor rates were calculated based on the three DBQ factor types of violation, error, and lapse. Results revealed that (a) male drivers, drivers in their thirties, and those with three to five years of driving experience demonstrated higher rates of aberrant driving behaviors; and (b) there were weak correlations between observed NDS factor rates and self-reported DBQ scores, and only slight differences among drivers divided by factor rate level (e.g., high violation rate). The questionnaire calibrated for Chinese drivers includes 23 items. Five of the original 24 DBQ items were modified, eight were left unchanged, eleven were deleted, and ten field-observed combined behaviors were added. In addition to the importance of adjusting the DBQ for today's Chinese drivers, this study provides a method for objectively modifying DBQ items in the future in accord with observed driving behaviors in an NDS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Bicyclist safety at urban intersections is a critical element for encouraging an increase in bicycle commuting. With cyclist injury and fatality rates rising due to collisions with vehicles at signalized intersections, increasing the safety of riders continues to be an important consideration when promoting this mode of transportation. Previous research has addressed crash causality and helped to develop several roadway treatments to improve bicyclist safety, but little has been done to compare and contrast the benefits of the various treatment types. This bicycling simulator study examined the impacts of three different intersection treatments (i.e., bike box, mixing zone, and bicycle signals) to better understand their influence on bicyclists' comfort, levels of stress, and riding behaviors. This improved understanding allowed researchers to make recommendations for which of the three designs proved to be most effective for reducing the risk of vehicle-bicycle collisions at signalized intersections. Forty participants successfully completed the study by responding to twenty-four scenarios while riding in the Oregon State University Bicycling Simulator. Time-space measurements revealed that the mixing zone treatment correlated with the most unpredictable riding behaviors. Analysis of the participants' eye-movements revealed a lower rate of recognizing the conflict vehicle when traversing the bicycle signal treatments. Galvanic Skin Response measurements were used to measure participants stress levels but found no statistically significant results, although it was found that the mixing zone elicited slightly larger stress responses. Researchers found the bike box design to be the most versatile, providing a balance of increased safety while also requiring the participant to perceive potential danger and be ready to respond accordingly. The results of this research can provide a better understanding of how to best implement these intersection treatments to increase bicyclists' safety at signalized intersections., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Garden-based nutrition programs are used to address food access and nutrition in low-income communities. In urban immigrant communities, food-growing practices may be shaped by environmental and cultural factors, and may not reflect the assumptions behind these curricula. Built-environment research was adapted to develop a protocol for assessing a community's gardening practices. A random sample of census blocks was generated and mapped, observational protocols developed, iteratively tested and refined, then fieldworkers trained and deployed. Daily debriefings were conducted to identify challenges in field implementation. Nearly all (93%) sampled blocks contained evidence of food cultivation. Garden structures, land-use patterns, and plant choices reflected cultural preferences, differing substantively from USDA home gardening curricula. This tool successfully identified food-growing practices within an urban immigrant Asian and Pacific Islander community, and provides a replicable methodology for community assessment. Results support the need to culturally-tailor garden-based nutrition programs for urban immigrant populations.

Background: Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique., Objective: To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance., Methods: A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients., Results: Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts., Conclusion: Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction: Rhode Island has received national recognition as a leader in statewide, multipayer, multistakeholder initiatives that focus on investments in primary care as a strategy to build a strong delivery system foundation that delivers high-quality, affordable health care., Method: For this case study we summarize key structural, process and outcomes factors and lessons learned from internal and external evaluations and project based and stakeholder-engaged quality improvement efforts that helped Rhode Island become the most improved U.S. health system over the past 5 years., Results: Rhode Island's Office of the Insurance Commissioner through a collaborative process contractually established per-member, per-month payments to practices that engaged in the statewide transformation program to the patient-centered medical home model of care and paid incentives for achieving quality, patient experience, and hospital utilization targets., Discussion: Critical lessons learned include the importance of engaging stakeholders in systems change, measuring and monitoring primary care spending, and continuous learning and best-practice sharing. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.

Cut-in maneuvers, when vehicles change lane and move closely in front of a vehicle in the adjacent lane, are very common but adversely affect roadway capacity and traffic safety. Yet little research has comprehensively explored cut-in behavior, particularly in China, which has a challenging driving environment and is often used for connected and autonomous vehicle testing. This study developed an extraction algorithm to retrieve 5608 cut-in events from the Shanghai Naturalistic Driving Study. The data were used to identify cut-in characteristics, including motivation, turn signal usage, duration, urgency, and impact. Results showed that almost half of drivers did not use a turn signal when cutting in, and that cut-ins had a shorter time to collision (TTC) than other lane changing. A lognormal distribution was found to produce the best fit for cut-in duration, which varied from 0.7 s to 12.4 s. As characteristics were found to vary by roadway type and motivation, multilevel mixed-effects linear models were developed to examine the influencing factors of cut-in gap acceptance. Acceptance of lead and lag gaps was significantly affected by environmental variables, vehicle type, and kinematic parameters, which has important implications for microsimulation, as does the large variance in duration that makes specifying duration essential when setting scenarios. Improvement in safety education is warranted by the high degrees of risk and aggression shown by TTC and turn signal usage; but the ability of drivers, who needed to yield to the cut-in, to predict danger and adopt safe, suitable, and timely strategies suggests that advanced driver assistance systems and connected and autonomous vehicles can learn similar responses., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: The purpose of this study was to assess the degree of behavioral health (BH) integration change in patient-centered medical homes (PCMHs) when using a practice facilitator (PF) specially trained in implementing integrated care and how a quasi-experimental design assists in this process., Method: Twelve PCMHs, 8 Federally Qualified Health Centers and 4 private practices, with varying degrees of BH services participated in this study. The degree of BH integration was assessed with a quasi-experimental design using the Maine Health Access Foundation's Site Self Assessment (MeHAF SSA) at baseline and after implementing site-specific BH services. The sites tracked completion of unique objectively measured goals being implemented using the Goal Attainment Scale (GAS) score., Results: At the conclusion of the study, sites saw a statistically significant increase in the level of BH integration from a baseline of 2.73 (SD = 0.44) to a postintervention score of 3.49 (SD = 0.22) with improvements from mild-moderate overall integration to moderate-advanced overall integration (p < .001). In addition, 10 out of the 12 sites achieved successful implementation of unique goals with assistance from the PF., Discussion: This study provides the first quasi-experimental/pretest-posttest evidence utilizing real-world data that the practice facilitation method is an effective solution toward increasing the degree of BH integration. This paper describes the real-world efforts to evaluate the degree of BH integration change in PCMHs when using a PF with content expertise in BH integration within primary care. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Southern Hemisphere humpback whales (Megaptera novaeangliae) generally undertake annual migrations from polar summer feeding grounds to winter calving and nursery grounds in subtropical and tropical coastal waters. Evidence for such migrations arises from seasonality of historic whaling catches by latitude, Discovery and natural mark returns, and results of satellite tagging studies. Feeding is generally believed to be limited to the southern polar region, where Antarctic krill (Euphausia superba) has been identified as the primary prey item. Non-migrations and / or suspended migrations to the polar feeding grounds have previously been reported from a summer presence of whales in the Benguela System, where feeding on euphausiids (E. lucens), hyperiid amphipods (Themisto gaudichaudii), mantis shrimp (Pterygosquilla armata capensis) and clupeid fish has been described. Three recent research cruises (in October/November 2011, October/November 2014 and October/November 2015) identified large tightly-spaced groups (20 to 200 individuals) of feeding humpback whales aggregated over at least a one-month period across a 220 nautical mile region of the southern Benguela System. Feeding behaviour was identified by lunges, strong milling and repetitive and consecutive diving behaviours, associated bird and seal feeding, defecations and the pungent "fishy" smell of whale blows. Although no dedicated prey sampling could be carried out within the tightly spaced feeding aggregations, observations of E. lucens in the region of groups and the full stomach contents of mantis shrimp from both a co-occurring predatory fish species (Thyrsites atun) and one entangled humpback whale mortality suggest these may be the primary prey items of at least some of the feeding aggregations. Reasons for this recent novel behaviour pattern remain speculative, but may relate to increasing summer humpback whale abundance in the region. These novel, predictable, inter-annual, low latitude feeding events provide considerable potential for further investigation of Southern Hemisphere humpback feeding behaviours in these relatively accessible low-latitude waters.