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Abstract Background Digital harm-reduction interventions typically focus on people with severe drug-use problems, yet these interventions have moderate effectiveness on drug-users with lower levels of risk of harm. The difference in effectiveness may be explained by differences in behavioural patterns between the two groupings. Harnessing behavioural theories to understand what is at the core of drug-use behaviours and mapping the content of new interventions, may improve upon the effectiveness of interventions for lower-risk drug-users. To the best of our knowledge, this is the first study to systematically apply the Behaviour Change Wheel (BCW) approach to understand the components, influencing capabilities, opportunities, and motivations (COM-B) of higher education students to change their drug-use behaviors. It is also the first study which identifies specific patterns of behaviours that are more responsive to harm reduction practices through the use of the Theoretical Domain Framework (TDF). Methods We employed an explanatory sequential mix-method design. We first conducted an on-line survey and a Delphi exercise to understand the factors influencing COM-B components of higher education students to change their drug-use. Subsequently, we mapped all evidence onto the COM-B components and the TDF domains to identify clusters of behaviours to target for change, using a pattern-based discourse analysis. Finally, a series of multidisciplinary group meetings identified the intervention functions—the means by which the intervention change targeted behaviours and the Behavioural Change Techniques (BCTs) involved using the behaviour change technique taxonomy (v.1). Results Twenty-nine BCTs relevant to harm-reduction practices were identified and mapped across five intervention functions (education, modelling, persuasion, incentivization, and training) and five policy categories (communication/marketing, guidelines, regulation, service provision, and environmental/social planning). These BCTs were distributed across eight identified saturated clusters of behaviours MyUSE intervention attempts to change. Conclusions The BCTs, identified, will inform the development of a digitally delivered behaviour change intervention that focuses on increasing mindful decision-making with respect to drug-use and promotes alternatives to drug-use activities. The findings can also inform implementation scientists in applying context-specific harm-reduction practices in higher education. We present examples of how the eight identified clusters of target behaviours are mapped across the COM-B components and the TDF, along with suggestions of implementation practices for harm reduction at student population level.

The preservation of DNA in biological samples is important for forensic testing, as samples can be tested years or even decades after collection. Generally, the DNA within biological evidence is stable over shorter time frames but can degrade over extended periods. In this work, we evaluated accelerated aging as a method to reduce the duration of studies examining the stability of DNA in forensic evidence-type samples. Evaluation of the DNA extracted from cells stored at 37 and 50°C for 194 or 79 days, respectively, showed similar quality metrics to cells stored at 25°C for 548 days.

ABSTRACT Bones and teeth can provide a lasting resource to identify human remains following decomposition. Bone can support dynamic communities of micro- and macroscopic scavengers and incidental taxa, which influence the preservation of bone over time. Previously we identified key microbial taxa associated with survivability of DNA in bones of surface-decomposed human remains, observing high intra- and interindividual variation. Here we characterized the postmortem bone microbiome of skeletal remains in a multi-individual burial to better understand subsurface bone colonization and preservation. To understand microbial community origins and assembly, 16S rRNA amplicon sequences from 256 bone and 27 soil samples were compared to bone from individuals who decomposed on the ground surface, and human gut sequences from the American Gut Project. Untargeted metabolomics was applied to a subset of 41 bone samples from buried remains to examine potential microbe–metabolite interactions and infer differences related to community functionality. Results show that postmortem bone microbial communities are distinct from those of the oxic surface soils and the human gut. Microbial communities from surface-deposited bone and shallow buried bone were more similar to those from soils, while bones recovered from saturated areas deeper in the grave showed increased similarity with human gut samples with higher representation of anaerobic taxa, suggesting that the depositional environment affected the established bone microbiome. Correlations between metabolites and microbes indicate that phosphate solubilization is likely an important mechanism of microbially mediated skeletal degradation. This research expands our knowledge of microbial bone colonizers, including colonizers important in a burial environment. IMPORTANCE Understanding the microbes that colonize and degrade bone has important implications for preservation of skeletal elements and identification of unknown human remains. Current research on the postmortem bone microbiome is limited and largely focuses on archaeological or marine contexts. Our research expands our understanding of bone microbiomes in buried remains by characterizing the taxonomic and metabolic diversity of microbes that are colonizing bone after a 4-year postmortem burial interval and examines the potential impact of microbial colonization on human skeletal DNA preservation. Our results indicate that the postmortem bone microbiome is distinct from the human gut and soil. Evidence from combined metabolomic and amplicon sequencing analysis suggests that Pseudomonas and phosphate solubilization likely play a role in skeletal degradation. This work provides important insight into the types and activities of microbes controlling the preservation of buried skeletal remains.

With increased warming and open water due to climate change, the frequency and intensity of storm surges is expected to increase. Although studies have shown that strong storms can negatively impact Arctic ecosystems, the impact of storms on Arctic marine mammals is relatively unknown. In July 2016, an unusually large storm occurred in the Mackenzie Delta while instrumented seabed moorings equipped with hydrophones and oceanographic sensors were in place to study environmental drivers of beluga habitat use during their summer aggregation. The storm lasted up to 88 h, with maximum wind speeds reaching 60 km/h; historical wind data from Tuktoyaktuk revealed a storm of similar duration has not occurred in July in at least the past 28 years. This provided a unique opportunity to study the impacts of large storms on oceanographic conditions, beluga habitat use, and the traditional subsistence hunt that occurs annually in the delta. The storm resulted in increased water levels and localized flooding as well as a significant drop in water temperature (∼10 °C) and caused belugas to leave the area for 5 days. Although belugas returned after the storm ended, the subsistence hunt was halted resulting in the lowest beluga harvest between 1978 and 2017.

Probiotics are considered to have multiple beneficial effects on the human gastrointestinal tract, including immunomodulation, pathogen inhibition, and improved host nutrient metabolism. However, extensive characterization of these properties is needed to define suitable clinical applications for probiotic candidates. Lactobacillus johnsonii 456 (LBJ 456) was previously demonstrated to have anti-inflammatory and anti-genotoxic effects in a mouse model. Here, we characterize its resistance to gastric and bile acids as well as its ability to inhibit gut pathogens and adhere to host mucosa. While bile resistance and in vitro host attachment properties of LBJ 456 were comparable to other tested probiotics, LBJ 456 maintained higher viability at lower pH conditions compared to other tested strains. LBJ 456 also altered pathogen adhesion to LS 174T monolayers and demonstrated contact-dependent and independent inhibition of pathogen growth. Genome analyses further revealed possible genetic elements involved in host attachment and pathogen inhibition. Importantly, we show that ingestion of Lactobacillus johnsonii 456 over a one week yogurt course leads to persistent viable bacteria detectable even beyond the period of initial ingestion, unlike many other previously described probiotic species of lactic acid bacteria.

There are important differences in the risk of SARS-CoV-2 infection and death depending on occupation. Infections in healthcare workers have received the most attention, and there are clearly increased risks for intensive care unit workers who are caring for COVID-19 patients. However, a number of other occupations may also be at an increased risk, particularly those which involve social care or contact with the public. A large number of data sets are available with the potential to assess occupational risks of COVID-19 incidence, severity, or mortality. We are reviewing these data sets as part of the Partnership for Research in Occupational, Transport, Environmental COVID Transmission (PROTECT) initiative, which is part of the National COVID-19 Core Studies. In this report, we review the data sets available (including the key variables on occupation and potential confounders) for examining occupational differences in SARS-CoV-2 infection and COVID-19 incidence, severity and mortality. We also discuss the possible types of analyses of these data sets and the definitions of (occupational) exposure and outcomes. We conclude that none of these data sets are ideal, and all have various strengths and weaknesses. For example, mortality data suffer from problems of coding of COVID-19 deaths, and the deaths (in England and Wales) that have been referred to the coroner are unavailable. On the other hand, testing data is heavily biased in some periods (particularly the first wave) because some occupations (e.g. healthcare workers) were tested more often than the general population. Random population surveys are, in principle, ideal for estimating population prevalence and incidence, but are also affected by non-response. Thus, any analysis of the risks in a particular occupation or sector (e.g. transport), will require a careful analysis and triangulation of findings across the various available data sets.

To grow, survive and reproduce under anthropogenic-induced changes, individuals must respond quickly and favourably to the surrounding environment. A species that feeds on a wide variety of prey types (i.e. generalist diet) may be comprised of generalist individuals, specialist individuals that feed on different prey types, or a combination of the two. If individuals within a population respond differently to an environmental change, population-level responses may not be detectable. By tracking foraging movements of great black-backed gulls (Larus marinus), a generalist species, we compared group-level and individual-level responses to an increase in prey biomass (capelin; Mallotus villosus) during the breeding season in coastal Newfoundland, Canada. As hypothesized, shifts in prey availability resulted in significantly different individual responses in foraging behaviour and space use, which was not detectable when data from individuals were combined. Some individuals maintained similar foraging areas, foraging trip characteristics (e.g., trip length, duration) and habitat use with increased capelin availability, while others shifted foraging areas and habitats resulting in either increased or decreased trip characteristics. We show that individual specialization can be non-contextual in some gulls, whereby these individuals continuously use the same feeding strategy despite significant change in prey availability conditions. Findings also indicate high response diversity among individuals to shifting prey conditions that a population- or group-level study would not have detected, emphasizing the importance of examining individual-level strategies for future diet and foraging studies on generalist species.

BackgroundDigital interventions have been identified as a possible tool for reducing the harm caused by illicit drug use among students attending higher education (ie, college students). However, the success of interventions in this area has been hampered by a lack of user involvement and behavior change theory in their design. The My Understanding of Substance use Experiences (MyUSE) project combines a rigorous user-centered design (UCD) methodology and a robust behavioral change framework to develop a digitally delivered harm reduction intervention for illicit drug use among students in higher education. ObjectiveThis project aims to design and develop a digital intervention that targets drug use–related harm among students in higher education. MethodsThe MyUSE project will take place over 3 phases. The first phase was exploratory in nature, involving 3 systematic reviews, a large survey, and student workshops to gather a comprehensive evidence base to guide the project. The second phase is the development stage of the project, involving the use of the Behavior Change Wheel theoretical framework to determine the behavior change techniques of the intervention and the use of the UCD methodology to guide the development of the digital intervention. The third phase is the evaluation stage, whereby the intervention will undergo a 5-stage evaluation process to comprehensively evaluate its impacts. ResultsThe exploratory phase 1 of the MyUSE project was completed in December 2018. Phase 2 is currently underway, and phase 3 is due to begin in September 2020. ConclusionsHigher education institutions (HEIs) are ideally placed to intervene and support students in the area of illicit drug use but are constrained by limited resources. Current digital interventions in this area are sparse and have several weaknesses. The MyUSE project combines a UCD approach with a robust behavior change framework to develop a digitally delivered intervention that is economically viable, effective in changing behavior, usable and acceptable to students, and able to sustain long-term implementation in HEIs. International Registered Report Identifier (IRRID)DERR1-10.2196/17829

Identifying natal origins of animals is key to determining the relative productivity of natal habitats, dispersal of individuals among local populations (i.e., connectivity), and, ultimately, metapopulation dynamics. As marine fish larvae have a high potential for dispersal, natural tags such as otolith chemistry are often used to determine natal origins. Trace elements may be incorporated into embryonic otoliths while larvae are developing in the egg, resulting in chemical signatures in the pre-hatch region of the otolith that reflect the natal habitat. Our goal was to determine whether the natal origins of 1- to 3-day-old larval capelin (Mallotus villosus), a key forage fish in many northern marine ecosystems, could be determined using otolith chemistry. We sampled larvae from five Newfoundland regions (i.e., embayments: Placentia Bay, St. Mary’s Bay, Witless Bay, Trinity Bay, and Notre Dame Bay) during July–August 2019 to quantify regional differences in otolith chemistry. Additionally, eggs/larvae were field-reared within two regions over multiple years (Notre Dame Bay: 2014, 2015, 2018, and 2019; Trinity Bay: 2018 and 2019) to quantify interannual variation in region-specific otolith chemistry. Multielemental otolith signatures (i.e., Mg, Mn, Zn, Sr, and Ba), as determined by laser ablation inductively coupled plasma–mass spectrometry (LA ICP–MS), differed significantly among regions, with individuals classified into their natal region with 78% success (region-specific success: 68–100%). Classification success into natal region remained high (67–76%) despite interannual variation in otolith trace element concentrations within regions. Characterizing region-specific otolith chemical signatures that reflect natal origins of capelin larvae is the first step in determining the productivity and relative contributions of different regions of coastal Newfoundland to capelin recruitment.

Microbial colonization of bone is an important mechanism of postmortem skeletal degradation. However, the types and distributions of bone and tooth colonizing microbes are not well characterized. It is unknown if microbial communities vary in abundance or composition between bone element types, which could help explain differences in human DNA preservation. The goals of the present study were to (1) identify the types of microbes capable of colonizing different human bone types and (2) relate microbial abundances, diversity, and community composition to bone type and human DNA preservation. DNA extracts from 165 bone and tooth samples from three skeletonized individuals were assessed for bacterial loading and microbial community composition and structure. Random forest models were applied to predict operational taxonomic units (OTUs) associated with human DNA concentration. Dominant bacterial bone colonizers were from the phyla Proteobacteria, Actinobacteria, Firmicutes, Bacteroidetes, and Planctomycetes. Eukaryotic bone colonizers were from Ascomycota, Apicomplexa, Annelida, Basidiomycota, and Ciliophora. Bacterial loading was not a significant predictor of human DNA concentration in two out of three individuals. Random forest models were minimally successful in identifying microbes related to human DNA concentration, which were complicated by high variability in community structure between individuals and body regions. This work expands on our understanding of the types of microbes capable of colonizing the postmortem human skeleton and potentially contributing to human skeletal DNA degradation.

Dopamine receptor agonists are used for the treatment of various psychiatric diseases. Here, the authors screen approximately three million compounds and identify a novel class of D1R agonists that do not have a catechol scaffold and possess promising pharmacokinetic properties.

ABSTRACT: Objective: Obesity is a predictor of adverse outcomes in patients undergoing adrenalectomy. Pre-adrenalectomy weight reduction is becoming an increasingly common challenge in view of the rising prevalence of obesity. This case report describes the clinical course of a morbidly obese gentleman who underwent bariatric surgery prior to pheochromocytoma resection.Methods: A morbidly obese man with a body mass index of 43 kg/m2 had an incidental finding of an 8.5 cm right-sided pheochromocytoma. Dietary and pharmacologic methods of weight loss lead to a 6 kg weight loss over a 12-month period. Multidisciplinary discussion concluded that weight loss and tumor resection were priority and the patient proceeded to laparoscopic sleeve gastrectomy with appropriate peri-operative alpha- and beta-blockade.Results: Laparoscopic sleeve gastrectomy proceeded without complication and lead to a further 23 kg of weight loss and the pheochromocytoma was resected 2 months later.Conclusion: Bariatric surgery for pre-operative weight loss in medically prepared patients with pheochromocytoma should be considered for morbidly obese patients in whom nonsurgical weight loss is unsuccessful.Abbreviations: BMI = body mass index

Objective: To provide a nontraditional source of data to university policymakers regarding student, faculty, and staff approval of university smoke/tobacco-free policies, as published through campus newspaper articles. Methods: From January to April 2016, a total of 2523 articles were retrieved concerning campus smoking/tobacco at 4-year, public universities. Of these, 54 articles met the inclusion factors, which described 30 surveys about campus approval of tobacco-free policies and 24 surveys about smoke-free policies. Results: In all, the surveys included more than 130 000 respondents. With the exception of 4 surveys, all reported that the most of the respondents approved a tobacco/smoke-free campus policy. Conclusions: Although the study had several limitations, the findings provide a synthesis from a nontraditional data source that is consistent with findings from the peer-reviewed literature, in which most of the students, faculty, and staff on university campuses approve of smoke/tobacco-free campus policies.

Decomposing vertebrates, including humans, result in pronounced changes in surrounding soil biogeochemistry, particularly nitrogen (N) and carbon (C) availability, and alter soil micro- and macrofauna. However, the impacts of subsurface human decomposition, where oxygen becomes limited and microbial biomass is generally lower, are far less understood. The goals of this study were to evaluate the impact of human decomposition in a multi-individual, shallow (~70 cm depth) grave on soil biogeochemistry and soil microbial and nematode communities. Three individuals were interred and allowed to decay for four years. Soils were collected from two depths (0‒5 and 30‒35 cm) along linear transects radiating from the grave as well as from within and below (85‒90 cm depth) the grave during excavation to assess how decomposition affects soil properties. Along radiating surface transects, several extracellular enzymes rates and nematode richness increased with increasing distance from the grave, and likely reflect physical site disruption due to grave excavation and infill. There was no evidence of carcass-sourced C and N lateral migration from the grave, at least at 30‒35 cm depth. Within the grave, soils exhibited significant N-enrichment (e.g., ammonium, dissolved organic N), elevated electrical conductivity, and elevated respiration rates with depth. Soil biogeochemistry within the grave, particularly in the middle (30‒35 cm) and base (70‒75 cm depth), was significantly altered by human decomposition. Mean microbial gene abundances changed with depth in the grave, demonstrating increased microbial presence in response to ongoing decomposition. Human-associated Bacteroides were only detected at the base of the grave where anoxic conditions prevailed. Nematode community abundance and richness were reduced at 70‒75 cm and not detectable below 85‒90 cm. Further, we identified certain Plectus spp. as potential indicators of enrichment due to decomposition. Here we demonstrate that human decomposition influences soil biogeochemistry, microbes, and microfauna up to four years after burial.

Abstract Introduction Graduate medical education programs and academic health systems have long struggled with providing sufficient training in the regulatory and business aspects of health care. Needs assessments confirm that medical students, medical residents, surgical residents, and faculty all rank the topic of billing and coding as an area of curricular need. Indeed, data demonstrates that incorrect coding by academic medical center learners leads to large financial losses and that educational content is needed to address the financial needs of academic institutions. Nationally, internal medicine curricular milestones have recognized the understanding of coding and reimbursement principles as a curricular milestone toward development of competence in systems-based practice. Superimposed upon these chronic concerns, the national transition to ICD-10 coding increases the need for immediately available teaching content on the importance of diagnosis coding. Methods In response, Diagnosis Coding for Clinicians: Core Knowledge and Transition to ICD-10 provides succinct educational content that can be individually reviewed by graduate medical and continuing medical learners. The content is specifically designed to assist training programs and learners with the transition to ICD-10 coding in a manner that supports accurate and specific medical coding practices. The content is provided as an interactive audiovisual presentation that automatically launches on standard personal computers or handheld devices. The presentation can be loaded on learning management systems or provided on a training website. An accompanying examination may be used to document minimum knowledge achievement for inclusion in a learning portfolio. Results Diagnosis Coding for Clinicians: Core Knowledge and Transition to ICD-10 is now mandatory for all billing physicians, house officers, and midlevel providers at the University of Michigan Health System, where each mandated learner must pass a content exam with a minimum 80% correct score. Discussion The content has been peer-reviewed and approved by a series of physician leaders, hospital executives, and coding specialists at the University of Michigan Health System. Focus groups of learners have found the information clear, relevant, appropriately succinct, and engaging.

Abstract Introduction Caring with Compassion provides core background information to support clinical care for homeless, underserved, uninsured, and at-risk populations. It was designed by an interdisciplinary team of educators from the fields of medicine, nursing, and social services. The team identified practical knowledge objectives using an iterative, expert consensus approach. Content validity was addressed by incorporating national internal medicine milestones and feedback from national educational leaders. This content is designed for graduate medical learners, advanced medical students, and nurse practitioners. Methods Caring with Compassion is divided into two major content domains: Domain 1 provides an overview of US public health care systems; Domain 2 presents the bio-psychosocial model of health care and special care needs of underserved populations. This submission includes the content for Domain 1: U.S. Public Healthcare Systems. Domain 2 is separately published by MedEdPORTAL. Results Nationally, over 350 learners have registered for the online version of the curriculum, and feedback has been highly positive. Preliminary quantitative outcome data demonstrates highly significant improvement in multiple choice examination scores following exposure to the modules for all assessed content areas [n, pretest, posttest, t test p value]: epidemiology of populations in need (42, 49%, 81%, p < .0001); public health insurance (30, 52%, 80%, p < .0001); health care delivery systems knowledge (19, 53%, 67%, p < .002). Discussion This content has benefited from continual revisions based on learner and faculty feedback, including results of the formal focus groups as detailed above. Expansion of content is ongoing based on requests from faculty users nationally. Further plans include expansion of faculty development tools and continual content revisions based on new research and curricular feedback.

Abstract Introduction The Caring with Compassion series provides core background information to support bio-psychosocial clinical care for homeless, underserved, uninsured, and at-risk populations. At the University of Michigan Medical School, this content serves as a core resource for a fourth-year medical student clinical elective regarding care of the underserved. At the University of Michigan School of Nursing, it is a core resource for advance nurse practitioner clinical rotations in underserved settings. For graduate medical learners, the content is available as an independent learning resource. This resource is the second domain in a two-domain series. The first domain provides an overview of US public health care systems, while this domain presents the bio-psychosocial model of health care and special care needs of underserved populations. Methods In this module, case-based materials are provided to address the topics of biomedical conditions among the homeless, social determinants of health, the biopsychosocial model of health, and interdisciplinary team care. A multiple-choice test and answer key are provided for each topic. Results Nationally, over 300 learners from multiple medical and nursing training programs have registered as learners, and feedback has been highly positive. Through the use of t tests, preliminary quantitative outcome data demonstrated significant improvement in multiple-choice examination scores following exposure to the modules for all assessed content areas: epidemiology of populations in need (n = 42, pretest = 49%, posttest = 81%, p < .0001); health care delivery systems knowledge (n = 19, pretest = 53%, posttest = 67%, p < .002); homelessness and disease (n = 20, pretest = 59%, posttest = 82%, p < .0001); public health insurance (n = 30, pretest = 52%, posttest = 80%, p < .0001); team care (n = 14, pretest = 45%, posttest = 64%, p < .001); social determinants (n = 29, pretest = 51%, posttest = 56%, p = .022). Additionally, comments from users included: “This is incredible and I am going through it slowly — realize how much I need to learn,” “A great tool for everyone not only to raise awareness but hopefully inspire people to take an active role in the care of the underserved.” Discussion Most training programs find it easiest to utilize this resource then encourage application in clinical settings. For programs with residents providing continuity care in federally qualified health care centers, the content may be used for ambulatory case conference discussions.

Abstract Coding 101 is a modular, self-study curriculum addressing knowledge necessary to code and bill for physician-provided services. Coding 101 was designed for internal medicine residents, but is suitable for all clinical learners from advanced medical students through faculty. The curriculum is designed to allow adult learners to independently engage with the learning components at their own pace. A learner's guide is provided to assist independent study, and a teacher's guide is provided for residency faculty who wish to use Coding 101 as a springboard for program implementation. A summative exam is provided to allow portfolio documentation of minimum knowledge achievement. A previous limited version of Coding 101, comprising only 3 videos with limited suggested online links, was Accepted with Acclamation in 2007 as MedEdPORTAL #436. The current version of Coding 101 has been extensively rewritten, reformatted, and expanded; it now includes 8 video modules, formative quizzes, case study examples, a summative examination, and expanded supplementary resources. The audiovisual modules are provided as individual mp4 videos. Formative quizzes are provided in interactive PowerPoint format. A summative examination is provided in a document that faculty can implement on their own tracking systems; access to an online version (not MedEdPORTAL peer reviewed) is provided via reference URL in the Instructor's Guide. This content has been successfully implemented by numerous internal medicine residency programs. At the University of Michigan, the content is provided to learners for optional review and self-study, and is well-received by learners. Due to benefit perceived by the central billing office, the University of Michigan Health System now uses the site for orientation of new faculty as well as residents. Feedback from national users of Coding 101 has been highly positive. In 2010, the Association of Program Directors in Internal Medicine E-Learning Task Force endorsed the curriculum as a highly rated educational site. The American College of Physicians (ACP) has selected Coding 101 as a resource for the ACP Center for Practice Improvement and Innovation website, under “Running a Practice/Payment and Coding/Coding”. Institutions ranging from commercial coding audit companies to VA hospitals to university training programs are active users of Coding 101 for training of their employees and learners. Most residency programs find it easiest to simply make the content available and encourage application of the content in clinical learning settings. Residents have demonstrated self-motivation to review the content when it is made available, because it relates to future payment. Programs who wish to document minimal knowledge achievement require successful completion of the provided summative knowledge examination.

Abstract Coding 101 is an online curriculum designed for residents. The curriculum includes three audiovisual modules and suggested supplementary online resources. While the audiovisual modules can be viewed in any order, they are designed for progressive learning in a suggested viewing order. Each module contains learning objectives for systems-based practice, an Accreditation Council for Graduate Medical Education general competency. Within each module, learning points are identified for PGY1-PGY3 progressive learning. For residents to best learn coding rules, the three modules should be viewed during PGY1, preferably during an ambulatory block experience when residents can focus on learning and applying coding principles. Residents should review the suggested resources after the related topics are introduced in the audiovisual modules. Clinic preceptors must also complete the modules, as many will need to learn the material as well. The first module, Coding Fundamentals, provides an overview of International Classification of Diseases, Current Procedural Terminology, Healthcare Common Procedure Coding System, and medical necessity rules. The second module, EM Coding, provides guided examples of outpatient evaluation and management coding using 1995 and 1997 rules. The third module, Beyond the Basics, introduces Modifier -25, Teaching Modifiers GE/GC, coding for counseling time, preventive care coding, and other miscellaneous topics. Supplementary suggested content allows learners to link to the Medicare 1995/1997 documents, the Centers for Medicare & Medicaid Services Evaluation and Management Services Guide, and other coding resources. The overall curriculum is appropriate for residents, fourth-year ambulatory students, fellows, and even faculty.

Background: Medical nutrition therapy is fundamental for diabetes management, however there is a lack of evidence supporting an ideal recommended carbohydrate intake for maintaining optimal glycaemia in individuals living with type 1 diabetes (T1D). Adults with T1D are increasingly drawn to very low carbohydrate (≤ 50 g/day or < 10% total energy intake) and low carbohydrate diets (< 130 g/day or < 26% total energy intake) because of the reported positive impact on both physical health and psychological well-being. Current evidence regarding the effectiveness on glycaemia and the lived experience by adults with T1D when using these diets is limited. This mixed methods systematic review was undertaken to examine the effectiveness of very low and low carbohydrate diets on HbA1c and explore the lived experience of adults with T1D who have followed these dietary regimens., Methods: Seven databases (MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Informit Health Collection, Web of Science, and PsycInfo) were searched from inception to 1 October 2023. Quality assessment of the included studies was undertaken using the JBI's critical appraisal checklists. Separate quantitative and qualitative synthesis was performed, and findings were integrated for the purpose of comparison and complementarity., Results: Seventeen studies of varying methodologies were included. Findings from quantitative research were inconclusive in determining the effectiveness of very low and low carbohydrate diets on HbA1c levels. Qualitative data synthesis identified four themes [1) Motivation to follow the diet, 2) Health benefits of the diet, 3) Challenges of the diet, and 4) Limited information (participants knowledge, information sources) about the diet] that influenced adherence to very low and low carbohydrate diets. Through the integration of results from selected studies, it was evident that there were conflicting outcomes between quantitative and qualitative studies., Conclusions: There is little evidence to indicate that very low and low carbohydrate diets improve HbA1c in adults with T1D. However, this goes against the reported lived experiences of participants. This review highlights the insufficiency of robust evidence on this topic. Future research involving larger participant samples over longer durations are needed to provide more definitive evidence in relation to the efficacy of these diets and into the enablers and barriers experienced when using a very low or low carbohydrate diet in order to provide support to adults with T1D. Systematic review registration PROSPERO CRD42023482800., (© 2024. Crown.)

Background: The contributions of the gut microbiota to obesity and metabolic disease represent a potentially modifiable factor that may explain variation in risk between individuals. This study aimed to explore relationships among microbial composition and imputed functional attributes, a range of soluble metabolic and immune indices, and gene expression markers in males with or without evidence of metabolic dysregulation (MetDys)., Methods: This case-control study included healthy males (n=15; 41.9±11.7 years; body mass index [BMI], 22.9±1.2 kg/m 2 ) and males with evidence of MetDys (n=14; 46.6±10.0 years; BMI, 35.1±3.3 kg/m 2 ) who provided blood and faecal samples for assessment of a range of metabolic and immune markers and microbial composition using 16S rRNA gene sequencing. Metagenomic functions were imputed from microbial sequence data for analysis., Results: In addition to elevated values in a range of traditional metabolic, adipokine and inflammatory indices in the MetDys group, 23 immunomodulatory genes were significantly altered in the MetDys group. Overall microbial diversity did not differ between groups; however, a trend for a higher relative abundance of the Bacteroidetes ( P =0.06) and a lower relative abundance of the Verrucomicrobia ( P =0.09) phyla was noted in the MetDys group. Using both family- and genera-level classifications, a partial least square discriminant analysis revealed unique microbial signatures between the groups., Conclusion: These findings confirm the need for ongoing investigations in human clinical cohorts to further resolve the relationships between the gut microbiota and metabolic and immune markers and risk for metabolic disease.

Introduction: Second-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas., Materials and Methods: A longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework., Results: 2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],p<0.001), and a 77% per (two-to-three-year) time-interval increase in initiation (OR = 1.77,[95% CI:1.30-2.43],p = <0.001) of 'new' medications compared to sulphonylureas. 'New' medications were prescribed less for non-English-speaking patients. There was some regional variation in prescribing., Conclusion: Registrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Patsan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To examine if there is an association between a low-carbohydrate diet (LCD), glycemic control, and quality of life (QoL) in Australian adults with type 1 diabetes., Methods: This single-group, pre-post, mixed methods (quantitative and qualitative) study was conducted in an outpatient tertiary hospital. Eligible participants were those aged ≥18 years, with type 1 diabetes for ≥1 year, and using multiple daily insulin injections. Participants followed a 12-week individualized LCD (<100 g/d). Daily glucose levels were monitored using a continuous glucose monitor. Glycated hemoglobin (HbA1c) and QoL were measured preintervention and postintervention. A post-hoc exploratory regression analysis determined whether changes in carbohydrate intake was associated with changes in HbA1c and QoL. Qualitative data collected postintervention explored participants' perceptions relating to a LCD, glycemic control, and QoL., Results: Participants (n = 22) completed the 12-week LCD intervention. An LCD provided a statistically, significant improvement in HbA1c 0.83% (95% CI 0.32%-1.33%), P = .003 but did not impact QoL: estimated change 1.14 units (95% CI: -5.34 to 7.61); P = .72. The post-hoc exploratory regression analysis showed that participants with poorer baseline glycemic control were more likely to respond to an LCD resulting in significant reductions in HbA1c. Participant perceptions relating to the study variables were mixed., Conclusions: An LCD (<100 g/d) is a potentially effective and safe strategy to improve glycemic control without negatively effecting QoL in Australian adults with type 1 diabetes., (Copyright © 2022 AACE. Published by Elsevier Inc. All rights reserved.)

Background: Globally, the prevalence of type 1 diabetes mellitus (T1DM) is rising. In 2020, a total of 124,652 Australians had T1DM. Maintaining optimal glycemic control (hemoglobin A 1c ≤7.0%, ≤53 mmol/mol) on a standard carbohydrate diet can be a challenge for people living with T1DM. The Diabetes Complications and Control Trial established that macrovascular and microvascular complications could be reduced by improving glycemic control. Recent studies have found that a very low or low carbohydrate diet can improve glycemic control. However, the overall evidence relating to an association between a very low or low carbohydrate diet and glycemic control in people living with T1DM is both limited and mixed. In addition, research has suggested that a reduced quality of life due to anxiety and depression adversely influences glycemic control. Despite a potential link between a very low or low carbohydrate diet and optimal glycemic control, to our knowledge, no research has examined an association between a low carbohydrate diet, quality of life, and glycemic control, making this study unique in its approach., Objective: The study aims to develop a validated diabetes-specific quality of life questionnaire for use in Australian adults with T1DM and to determine if an association exists between a low carbohydrate diet, quality of life, and glycemic control in Australian adults living with T1DM., Methods: This cross-sectional study will be conducted in a tertiary hospital outpatient setting and will consist of 3 phases: phase 1, online Australian diabetes-specific quality of life questionnaire development and piloting (25-30 adults with T1DM); phase 2, questionnaire validation (364 adults with T1DM); and phase 3, a 12-week dietary intervention to determine if an association exists between a low carbohydrate diet, quality of life, and glycemic control in adults with T1DM (16-23 adults with T1DM). The validation of the study-developed Australian diabetes-specific quality of life questionnaire, and changes in hemoglobin A 1c and quality of life in adults with T1DM while undertaking a low carbohydrate diet over 12 weeks will be the primary outcomes of this study., Results: Phase 1 of the study is currently open for recruitment and has recruited 12 participants to date. It is anticipated that the first results will be submitted for publication in November 2021. Presently, no results are available., Conclusions: This study is the first of its kind in that it will be the first to generate a new validated instrument, which could be used in evidence-based practice and research to understand the quality of life of Australian adults with T1DM. Second, the low carbohydrate dietary intervention outcomes could be used to inform clinicians about an alternative approach to assist T1DM adults in improving their quality of life and glycemic control. Finally, this study could warrant the development of an evidence-based low carbohydrate dietary guideline for adults living with T1DM with the potential to have a profound impact on this population., Trial Registration: ClinicalTrials.gov NCT04213300; https://clinicaltrials.gov/ct2/show/NCT04213300., International Registered Report Identifier (irrid): PRR1-10.2196/25085., (©Janine Paul, Rati Jani, Peter Davoren, Catherine Knight-Agarwal. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 26.03.2021.)

Aim: To report the first study of temelimab, a monoclonal antibody neutralizing the pathogenic human endogenous retrovirus type W envelope, in patients with type 1 diabetes (T1D)., Materials and Methods: This double-blind, placebo-controlled, randomized clinical trial recruited adult patients with T1D within 4 years postdiagnosis and remaining C-peptide secretion. Sixty-four patients were randomized (2:1) to monthly temelimab 6 mg/kg or placebo during 24 weeks followed by a 24-week, open-label extension, during which all patients received temelimab. The primary objective was the safety and tolerability of temelimab. The secondary objective was to assess the pharmacodynamics response such as C-peptide levels, insulin use, HbA1c, hypoglycaemia and autoantibodies., Results: Temelimab was well tolerated without any group difference in the frequency or severity of adverse events. Concerning exploratory endpoints, there was no difference in the levels of C-peptide, insulin use or HbA1c between treatment groups at weeks 24 and 48. The frequency of hypoglycaemia events was reduced with temelimab (P = 0.0004) at week 24 and the level of anti-insulin antibodies was lower with temelimab (P < 0.01); the other autoantibodies did not differ between groups., Conclusions: Temelimab appeared safe in patients with T1D. Pharmacodynamics signals (hypoglycaemia and anti-insulin antibodies) under temelimab were observed. Markers of β-cell functions were not modified by treatment. These results need to be further explored in younger patients with T1D with earlier disease onset., (© 2020 John Wiley & Sons Ltd.)

Background: The incidence of thyroid cancer is increasing worldwide without a simultaneous rise in mortality. It is thought that the incidence of non-clinically significant thyroid cancers are on the rise as a result of more sensitive diagnostic imaging., Aim: To determine the number of inappropriate requests for thyroid ultrasound (US), the quality of radiology reporting for thyroid nodules based on accepted guidelines and the resultant number of thyroid cancers identified because of these investigations., Methods: Electronic medical records of patients who underwent thyroid US imaging and thereafter referred to the Endocrine Department at Gold Coast University Hospital, Queensland, between July 2014 and July 2017 were reviewed. Data for 251 patients who had thyroid US were analysed and the final 201 patients who were found to have thyroid nodules were evaluated using descriptive statistics. Indications for thyroid US imaging among referring clinicians were assessed and we compared both clinical management and radiology reporting practices of thyroid nodules to the published 2009 and 2015 American Thyroid Association (ATA) guidelines., Results: There were 50.2% of patients with initial thyroid US imaging deemed outside of expert recommendations where 42% of these patients required further surveillance imaging and 25.4% required fine needle aspiration of their thyroid nodules. A definite recommendation whether to evaluate thyroid nodules further was provided in 44.8% of radiology reports. There were no radiology reports that described thyroid nodules findings based on patterns as recommended by the 2015 ATA guidelines. Two cases of thyroid cancer were detected including one patient with prior history of thyroid cancer and a second patient with hypothyroidism., Conclusion: Routine use of US thyroid imaging outside expert recommendation is common. There is lack of standardised reporting when assessing thyroid nodules on US. Limiting the initial use of US in cases of palpable neck lumps and the use of systematic reporting according to the 2017 guidelines published by the American College of Radiology Thyroid Imaging Reporting and Data System may reduce unnecessary investigations for thyroid nodules in the future., (© 2019 Royal Australasian College of Physicians.)

Exercise is an important element to optimize health and well-being, though navigating exercise safely can be challenging for exercise specialists working with people with diabetes. Measuring glucose levels before an exercise session assists in the determination of whether exercise is safe for a person with diabetes. A number of organizations have recently developed guidelines to provide exercise and diabetes recommendations based on glucose levels and other relevant factors. However, there are limited easy-to-use resources to assist exercise specialists to determine whether exercise should be started and continued by people with diabetes. The type of diabetes, pre-exercise glucose level, medications and their timing, recent food intake and general sense of wellness all warrant consideration when determining the approach to each exercise session. An expert group was convened to review the published literature and develop resources to guide exercise specialists in assessing the safety of an adult with diabetes starting exercise, and indications to cease exercise, based upon glucose levels and other factors. Contraindications to people with diabetes starting or continuing exercise are (1) glucose < 4.0 mmol/L; (2) glucose > 15.0 mmol/L with symptoms of weakness/tiredness, or with ketosis; (3) hypoglycaemic event within the previous 24 h that required assistance from another person to treat and (4) feeling unwell. To optimize diabetes and exercise safety, recommendations (stratified by pre-exercise glucose level) are provided regarding carbohydrate ingestion, glucose monitoring and medication adjustment.

Aim: Relationships between the intestinal microbiota, intestinal permeability and inflammation in the context of risk for obesity-associated disease continue to be of interest. The aim of the study was to examine the associations between intestinal permeability and type 2 diabetes (T2D)., Methods: A total of 130 individuals with T2D (age: 57.5±6.2 years (mean±SD); BMI: 30.4±3.2; 45% female) and 161 individuals without T2D (age: 37.4±12.5 years; BMI: 25.1±3.9; 65% female) were included in the study. Assessment of intestinal permeability included measurement of circulating lipopolysaccharide (LPS), LPS-binding protein (LBP) and intestinal fatty acid binding protein (iFABP) concentrations, which were used for calculation of a derived permeability risk score (PRS). Associations between permeability measures and T2D status were assessed using logistic regression models., Results: LBP (∼34%, P<0.001), iFABP (∼46%, P<0.001) and the PRS (∼24% P<0.001) were all significantly higher in the T2D affected individuals. Individuals with a PRS in the upper tertile were 5.07 times more likely (CI: 1.72-14.95; P=0.003) to have T2D when models were adjusted for age, sex and BMI. There was a trend towards improved prediction when including the PRS in models containing age, sex and BMI (AUC: 0.954 versus 0.962; P=0.06)., Conclusion: These data demonstrate differences in measures of intestinal permeability between individuals with and without T2D. The utility of using intestinal permeability measures as a tool for predicting T2D risk in at risk individuals should be further investigated., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: There is an increasing array of medicines available to improve blood glucose control in type 2 diabetes. Finding the best combination for an individual patient requires an assessment of the patient's characteristics and understanding the mechanism of action for each drug., Objective: The aim of this article is to provide a rational approach for choosing between the various blood glucose-lowering medicines available for treatment of patients with type 2 diabetes mellitus., Discussion: Metformin is the first choice of glucose-lowering medicines for most patients with type 2 diabetes. Sulphonylureas have proven benefits in long-term trials. Insulin is required in patients with symptoms of insulin deficiency. Glucagon-like peptide 1 agonists and sodium-glucose co-transporter 2 inhibitors provide some assistance in weight loss as well as improving blood glucose control. Dipeptidyl peptidase 4 inhibitors provide an alternative to metformin and sulphonylureas, especially when side effects of those drugs limit their use. Re-assessing blood glucose control after an appropriate trial period before deciding on continuing use is appropriate.

Objective: To report a case of prolonged hypoglycemia after acute tramadol poisoning., Methods: We describe a patient's clinical presentation and outcome with prolonged hypoglycemia attributable to acute tramadol poisoning. In addition, the possible mechanism for the hypoglycemia is discussed, and a brief review of the pertinent literature is presented., Results: A 54-year-old woman had previously undergone a partial hepatectomy because of involvement of her liver by a gastrointestinal stromal tumor. After ingestion of 3,000 mg of tramadol with suicidal intent, she developed prolonged hypoglycemia that necessitated treatment with continuous intravenous glucose infusion for 24 hours. Reports in the literature have described central nervous system depression, nausea, vomiting, tachycardia, seizures, and even death from tramadol overdoses., Conclusion: This report alerts clinicians to the potential danger of severe hypoglycemia in tramadol poisoning.

Background: The male Atlantic salmon generally matures in fresh water upon returning after one or several years at sea. Some fast-growing male parr develop an alternative life strategy where they sexually mature before migrating to the oceans. These so called 'precocious' parr or 'sneakers' can successfully fertilise adult female eggs and so perpetuate their line. We have used a custom-built cDNA microarray to investigate gene expression changes occurring in the salmon gonad and brain associated with precocious maturation. The microarray has been populated with genes selected specifically for involvement in sexual maturation (precocious and adult) and in the parr-smolt transformation., Results: Immature and mature parr collected from a hatchery-reared stock in January were significantly different in weight, length and condition factor. Changes in brain expression were small - never more than 2-fold on the microarray, and down-regulation of genes was much more pronounced than up-regulation. Significantly changing genes included isotocin, vasotocin, cathepsin D, anamorsin and apolipoprotein E. Much greater changes in expression were seen in the testes. Among those genes in the testis with the most significant changes in expression were anti-Mullerian hormone, collagen 1A, and zinc finger protein (Zic1), which were down-regulated in precocity and apolipoproteins E and C-1, lipoprotein lipase and anti-leukoproteinase precursor which were up-regulated in precocity. Expression changes of several genes were confirmed in individual fish by quantitative PCR and several genes (anti-Mullerian hormone, collagen 1A, beta-globin and guanine nucleotide binding protein (G protein) beta polypeptide 2-like 1 (GNB2L1) were also examined in adult maturing testes. Down-regulation of anti-Mullerian hormone was judged to be greater than 160-fold for precocious males and greater than 230-fold for November adult testes in comparison to July testes by this method. For anti-Mullerian hormone and guanine nucleotide binding protein beta polypeptide 2-like 1 expression changes in precocious males mirrored mature adults (November) but for collagen 1A and beta-globin the pattern was more complex., Conclusions: Expression changes in the fish brain during the process of precocious sexual maturation were small compared to those in the testes. Microarray analysis suggested down-regulation of housekeeping functions and up-regulation of a small number of specific processes. Transcriptional changes in the testes were much more pronounced with anti-Mullerian hormone playing a major role. Expression profiles for mature parr and maturing adult testes indicate subtle differences in gene expression between these two related groups.

A 44-year-old man presented with extreme hypernatraemia. The case is unique in three respects: the patient's plasma sodium concentration was 208mmol/L; the aetiology was multifactorial, including essential hypernatraemia, hypodipsia and high ambient temperature; and the patient survived with full neurological recovery. We briefly review various disorders of thirst and osmorecepters.

Elevated circulating plasma nonesterified fatty acids (NEFA) may contribute to the insulin resistance and hyperglycemia of non-insulin-dependent diabetes mellitus (NIDDM), and decreasing plasma NEFA could provide a therapeutic benefit. A sustained-release preparation of acipimox, a lipolysis inhibitor, was used in an attempt to decrease circulating plasma NEFA levels long-term, and the effects on glycemic control, insulin resistance, and serum lipids were measured. Sixty NIDDM patients (43 males and 17 females) took part in a randomized controlled trial of acipimox or placebo for 12 weeks. Fasting plasma NEFA levels did not change in acipimox-treated patients (baseline v 12 weeks, 0.84 +/- 0.35 v 0.88 +/- 0.55 mmol x L(-1), mean +/- SD). Fasting blood glucose was unchanged (mean difference v placebo, -0.5 mmol x L(-1); 95% confidence interval [CI], -1.4 to 0.3 mmol x L[-1]), but serum fructosamine decreased (mean difference v placebo, -26 micromol x L(-1); 95% CI, -51 to 0 mmol x L[-1]), as did the standardized hemoglobin A1 ([HbA1] mean difference v placebo, -1.4%; 95% CI, -3.0% to -0.1%). Insulin resistance measured as steady-state plasma glucose during an insulin-dextrose infusion test was unchanged (mean difference v placebo, -1.4 mmol x L(-1); 95% CI, -3.2 to 0.5 mmol x L[-1]). Serum total cholesterol (mean difference v placebo, -0.4 mmol x L(-1); 95% CI, -0.6 to -0.1 mmol x L[-1]), serum apolipoprotein B ([apo B] mean difference v placebo, -0.19 g x L(-1); 95% CI, -0.3 to -0.1 g x L[-1]), and serum triglycerides (mean difference v placebo for pretreatment v posttreatment ratio, 0.59; 95% CI, 0.40 to 0.88) were all lower with acipimox. Serum high-density lipoprotein (HDL) cholesterol (mean difference v placebo, 0.10 mmol x L(-1); 95% CI, -0.05 to 0.3 mmol x L[-1]), serum apo A1 (mean difference v placebo, 0.03 g x L(-1); 95% CI, -0.04 to 0.1 g x L[-1]), and serum lipoprotein(a) ([Lp(a)] acipimox v placebo, 154 (0 to 1,574) v 71 (0 to 1,009), median and range) were unchanged. Despite the lack of change in fasting plasma NEFA levels, acipimox caused a modest beneficial improvement in overall glycemic control and plasma lipids in NIDDM patients and could be a useful agent in the treatment of dyslipidemic NIDDM patients.