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Background: Patients with ischemic cardiomyopathy, non–left bundle branch block, or QRS duration

Introduction At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force. Materials and Methods The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems. Results This report proposes numerous short- and long-term courses of action in three areas: 1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience. 2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions. 3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership. Conclusion Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS’s top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

The purpose of this retrospective case series was to compare the outcomes of different treatment options for patients diagnosed with hereditary benign intraepithelial dyskeratosis (HBID).The study is designed as a single-institution retrospective chart review of patients who were clinically diagnosed with HBID during their care at the Duke Eye Center. Patient demographics were obtained, and disease course after different therapies was analyzed.Seventeen patients were diagnosed with HBID. 52.9% (9/17) of patients identified with HBID reported Native American ancestry. Medical therapy alone failed to reduce the size or number of corneal lesions in any patient identified in this study. Ten of the 17 patients required surgical intervention. Two eyes received corneal biopsies, 3 eyes received a full conjunctival lesion excision with amniotic membrane grafting, 12 eyes received superficial keratectomy with amniotic membrane grafting, and 1 eye received keratoprosthesis. Lesion recurrence was seen in 9 of the 10 patients treated with surgical excision with an average time to recurrence of 1.5 and 2 months for conjunctival excisions and superficial keratectomy, respectively, when excluding patients who missed scheduled postoperative follow-up appointments.Hereditary benign intraepithelial dyskeratosis is a rare and poorly understood disorder that predominantly affects people with Native American ancestry. Medical therapy only provides symptomatic relief, and patients who receive surgical excision almost always develop recurrence. As a result, we recommend future investigations focus on identifying the optimal surgical technique and timing to limit the morbidity of HBID and improve outcomes.

Left atrial appendage occlusion (LAAO) has emerged as an important therapy for patients with atrial fibrillation at risk for stroke who are not good candidates for long-term oral anticoagulation. Transesophageal echocardiography (TEE) has an important and foundational role in preprocedural left atrial appendage assessment, intraprocedural guidance and device deployment, and post-procedural evaluation in follow-up. Recent studies have evaluated intracardiac echocardiography (ICE) as a primary intraprocedural imaging modality without the need for TEE. The use of ICE offers promise of expedited patient care, reduced procedural complexity, and reduced costs. Observational reports of ICE for LAAO highlight significant variability in procedural technique, including but not limited to ICE catheter placement and position as well as the type and number of intracardiac views. Integration with concomitant electroanatomic mapping provides additional information to the operator regarding the orientation of the ICE catheter to the atrial geometry and can be used to optimize views and avoid perforation. It also allows for more precise near-field delineation of transseptal access. This review characterizes a standardized approach for harnessing ICE based off four anatomic views (aortic, mitral, left superior pulmonary vein, and inferior). These views optimize the unique vantage points of left atrial ICE as opposed to attempting to replicate the transesophageal windows. The focus on complementary and orthogonal angles allows for more precise device placement and assessment for device positioning and peri-device leak.

Clayton Christensen’s theory of “disruptive innovation” describes how smaller firms, with access to far fewer resources, are still able to challenge and displace well-established industry leaders. Uber and Airbnb as startups were able to disrupt the global taxi and hotel industries despite the economic shock of the financial crisis (2007-2008). The COVID-19 pandemic is currently an even more powerful catalyst that is forcing businesses and institutions to define and adapt to the “new normal”. Higher education also finds itself at a critical crossroads where universities around world need to quickly adapt to the changing needs of younger generations, discover the optimal balance between traditional and online learning, find ways to reduce costs and avoid tuition escalation, and become better prepared for future health crises and geopolitical events. The COVID-19 pandemic has already significantly accelerated trends in education and a failure to adapt could spark the disruption in education that Christensen spoke of more than a decade ago. This research utilizes valuable feedback from a diverse group of international students to help educators better understand changes that occurred during COVID-19 and form recommendations regarding how to use technology to maximize learning outcomes.

During the spring 2021 semester, COVID-19 forced most universities around the world to teach exclusively online in a very short time frame. This situation reversed itself, however, during the fall 2021 semester when COVID-19 restrictions were lifted as teachers and students returned to classrooms. This study includes ninety-seven international students who participated in surveys at the beginning and the end of the fall 2021 semester, which included questions related to burnout, self-efficacy, resiliency, home environments, and technical issues. Students were asked to reflect on their educational experiences during the spring 2021 and fall 2021 semesters. The purpose of this study is to identify and examine the most significant changes that occurred between these two semesters. The results indicate a significant shift in student burnout as challenges with home environments were replaced with ones related to returning to the classroom. Even as the concerns about COVID-19 lessen, higher education institutions must understand the magnitude and permanence of its impact.

To examine the effects of chemical composition on thermal expansion in the pyroxene mineral group, X-ray diffraction data have been collected from room temperature to ~925 °C on a chemically diverse group of 13 pyroxenes including four orthorhombic and nine monoclinic samples. Additionally, resulting unit-cell volumes computed from the XRD data have proven to be good tests for a large number of thermal expansion models; the physical model by Kroll and coworkers and the empirical one by Fei have been found to be especially useful. Modeling also has allowed the connection of present data, collected at temperatures above 25 °C, to the volume data of other workers for much lower temperatures, well below 0 °C, and also extrapolation of values for volume and thermal expansion well beyond the measurement range.We have found for orthopyroxenes that Fe2+-Mg2+ substitution has little effect on thermal expansion coefficients for volume. For clinopyroxenes, however, greater thermal expansion occurs in Ca2+-(diopside, augite, hedenbergite, johannsenite) than in Li+-(spodumene) or Na+-bearing members (jadeite, aegirine, kosmochlor). Present data support the observation that differences in volume thermal expansion relate primarily to differences in expansion along the b crystallographic axis. This apparently is due to the greater concentration of M1 polyhedra along the b crystallographic axis, where expansion differences can be related to the shared O1-O1 polyhedral edge and inter-oxygen repulsion that is made easier by divalent, as opposed to trivalent, cation occupancy of the M1 crystallographic site.

Cat's claw creeper, Dolichandra unguis-cati (Bignoniaceae), a perennial woody vine native to tropical America, is a target for biological control in Australia and South Africa. The cat's claw creeper leaf-tying moth Hypocosmia pyrochroma (Lepidoptera: Pyralidae) from tropical South America was released as a biological control agent for cat's claw creeper in Australia from 2007 to 2010. A total of 2,277 adults, 837 pupae and 77,250 larvae were released at 40 sites in Queensland and New South Wales. Releases were made mostly in open fields (85%), and at limited sites (15%) in insect-proof cages erected over naturally occurring cat's claw creeper infestations in the field. Sampling was conducted annually in spring and autumn to monitor the establishment and dispersal of H. pyrochroma. Establishment of H. pyrochroma was first noticed in 2012 at three release sites and since then the number of established sites has increased to 80 in 2020. Establishment was evident on both ‘short-pod’ and ‘long-pod’ forms of cat's claw creeper and was more widespread in sites where releases were made within insect-proof field cages (50%) than in sites with open field releases (9%). The moth was active from late spring to late autumn with peak larval activity in late summer. To date, all field establishments have been in areas predicted by a CLIMEX model as climatically suitable but restricted mostly to riparian environment (93% of establishment), where the moth has continued to spread from 1.5 to 23 km from release sites. In contrast, there is the only limited establishment and spread in non-riparian corridors, highlighting the role of microclimate (riparian) as a limiting factor for establishment and spread. Future efforts will focus on redistribution of the agent to river/creek systems where the moth is currently not present.

During the early phase of an accident with the release of radioactive material to the environment at the local or transboundary scale, a rapid and continuous system of information exchange, including real-time monitoring data to competent authorities and the public, is critical for setting up countermeasures. This information and data exchange must be carried out in a harmonized and consistent manner to facilitate its interpretation and analysis. After the Chernobyl accident in 1986, and in order to avoid the competent authorities being unprepared again for a similar event, the European Commission (EC) defined and put in place a directive (Council Decision 87/600/EURATOM, 1987) which essentially obliges a member state that decides to implement widespread countermeasures to protect its population to notify the European Commission without delay. The same Council Decision also specifies that the results of radiological monitoring must be made available to the European Commission and all potentially affected member states. Over the past 30 years, the European Commission has invested resources in developing and improving a complete system to carry out this delicate task, currently composed of two platforms: the European Community Urgent Radiological Information Exchange (ECURIE) and the European Radiological Data Exchange Platform (EURDEP). This paper aims to increase knowledge of the latter system as a valuable tool for understanding and analysing the radioactivity levels in Europe. Commencing with background information, in this paper, we will describe the EURDEP system in detail, with an emphasis on its status, data availability, and how these data are diffused depending on the audience. Within the scope of this publication, we describe an example of measurements available in the EURDEP system, which to be used for scientific purposes. We provide two complete datasets (air-concentration samples – https://doi.org/10.2905/23CBC7C4-4FCC-47D5-A286-F8A4EDC8215F; De Cort et al., 2019a; and gamma dose rates – https://doi.org/10.2905/0F9F3E2D-C8D7-4F46-BBE7-EACF3EED1560; De Cort et al., 2019b) for the recent radiological release of 106Ru in Europe, which occurred between the end of September and early October 2017. Records stored are publicly accessible through an unrestricted repository called COLLECTION belonging to the JRC Data Public Catalogue (https://data.jrc.ec.europa.eu, last access: 1 July 2019).

Researchers in the US have used supercomputers to gain insights into the origins of the solar wind.

Background: Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these c...

Key Points Question How many people in the US are living with uncorrectable visual acuity loss or blindness? Findings This bayesian meta-analysis generated an estimate that, in 2017, there were 7.08 million people living with visual acuity loss, of whom 1.08 million were living with blindness. Meaning Per this study, uncorrectable visual acuity loss and blindness are even larger drivers of health burden in the US than was previously known., This meta-analysis combines population-based surveys and data from the US Centers for Disease Control and Prevention’s Vision and Eye Health Surveillance System to produce estimates of visual acuity loss and blindness by age, sex, race/ethnicity, and US state., Importance Globally, more than 250 million people live with visual acuity loss or blindness, and people in the US fear losing vision more than memory, hearing, or speech. But it appears there are no recent empirical estimates of visual acuity loss or blindness for the US. Objective To produce estimates of visual acuity loss and blindness by age, sex, race/ethnicity, and US state. Data Sources Data from the American Community Survey (2017), National Health and Nutrition Examination Survey (1999-2008), and National Survey of Children’s Health (2017), as well as population-based studies (2000-2013), were included. Study Selection All relevant data from the US Centers for Disease Control and Prevention’s Vision and Eye Health Surveillance System were included. Data Extraction and Synthesis The prevalence of visual acuity loss or blindness was estimated, stratified when possible by factors including US state, age group, sex, race/ethnicity, and community-dwelling or group-quarters status. Data analysis occurred from March 2018 to March 2020. Main Outcomes or Measures The prevalence of visual acuity loss (defined as a best-corrected visual acuity greater than or equal to 0.3 logMAR) and blindness (defined as a logMAR of 1.0 or greater) in the better-seeing eye. Results For 2017, this meta-analysis generated an estimated US prevalence of 7.08 (95% uncertainty interval, 6.32-7.89) million people living with visual acuity loss, of whom 1.08 (95% uncertainty interval, 0.82-1.30) million people were living with blindness. Of this, 1.62 (95% uncertainty interval, 1.32-1.92) million persons with visual acuity loss are younger than 40 years, and 141 000 (95% uncertainty interval, 95 000-187 000) persons with blindness are younger than 40 years. Conclusions and Relevance This analysis of all available data with modern methods produced estimates substantially higher than those previously published.

Background As secure electronic message exchange increases between patients and clinicians, we must explore and understand how patients and clinicians use those messages to communicate between clinical visits. Objective To present the application of a taxonomy developed specifically to code secure message content in a way that allows for identification of patient and clinician communication functions demonstrated to be associated with patients' intermediate and health outcomes. Method We randomly sampled 1031 patients who sent and received 18 309 messages and coded those messages with codes from our taxonomy. We present the prevalence of each taxon (ie, code) within the sample. Results The most common taxon among initial patient-generated messages were Information seeking (29.09%), followed by Scheduling requests (27.91%), and Prescription requests (23.09%). Over half of subsequent patient-generated messages included responses to clinic staffs' questions (58.31%). Six in 10 clinic staff responses included some form of Information sharing with process-based responses being most common (32.81%). A third of all clinician-generated messages (36.28%) included acknowledgement or some level of fulfilment of a patient's task-oriented request. Clinic staff sought information from patients in 20.54% of their messages. Conclusion This taxonomy is the first step toward examining whether secure messaging communication can be associated with patients' health outcomes. Knowing which content is positively associated with outcomes can support training of, and targeted responses from, clinicians with the goal of generating message content designed to improve outcomes. Patient contribution This study is based on analyses of patient-initiated secure message threads.

Background Good communication has been shown to affect patient outcomes; however, the effect varies according to patient and clinician characteristics. To date, no research has explored the differences in the content of secure messages based on these characteristics. Objective This study aims to explore characteristics of patients and clinic staff associated with the content exchanged in secure messages. Methods We coded 18,309 messages that were part of threads initiated by 1031 patients with hypertension, diabetes, or both conditions, in communication with 711 staff members. We conducted four sets of analyses to identify associations between patient characteristics and the types of messages they sent, staff characteristics and the types of messages they sent, staff characteristics and the types of messages patients sent to them, and patient characteristics and the types of messages they received from staff. Logistic regression was used to estimate the strength of the associations. Results We found that younger patients had reduced odds of sharing clinical updates (odds ratio [OR] 0.77, 95% CI 0.65-0.91) and requesting prescription refills (OR 0.77, 95% CI 0.65-0.90). Women had reduced odds of self-reporting biometrics (OR 0.78, 95% CI 0.62-0.98) but greater odds of responding to a clinician (OR 1.20, 95% CI 1.02-1.42) and seeking medical guidance (OR 1.19, 95% CI 1.01-1.40). Compared with White patients, Black patients had greater odds of requesting preventive care (OR 2.68, 95% CI 1.30-5.51) but reduced odds of requesting a new or changed prescription (OR 0.72, 95% CI 0.53-0.98) or laboratory or other diagnostic procedures (OR 0.66, 95% CI 0.46-0.95). Staff had lower odds of sharing medical guidance with younger patients (OR 0.83, 95% CI 0.69-1.00) and uninsured patients (OR 0.21, 95% CI 0.06-0.73) but had greater odds of sharing medical guidance with patients with public payers (OR 2.03, 95% CI 1.26-3.25) compared with patients with private payers. Staff had reduced odds of confirming to women that their requests were fulfilled (OR 0.82, 95% CI 0.69-0.98). Compared with physicians, nurse practitioners had greater odds of sharing medical guidance with patients (OR 2.74, 95% CI 1.12-6.68) and receiving prescription refill requests (OR 3.39, 95% CI 1.49-7.71). Registered nurses had greater odds of deferred information sharing (OR 1.61, 95% CI 1.04-2.49) and receiving responses to messages (OR 3.93, 95% CI 2.18-7.11) than physicians. Conclusions The differences we found in content use based on patient characteristics could lead to the exacerbation of health disparities when content is associated with health outcomes. Disparities in the content of secure messages could exacerbate disparities in patient outcomes, such as satisfaction, trust in the system, self-care, and health outcomes. Staff and administrators should evaluate how secure messaging is used to ensure that disparities in care are not perpetuated via this communication modality.

BACKGROUND Good communication has been shown to affect patient outcomes; however, the effect varies according to patient and clinician characteristics. To date, no research has explored the differences in the content of secure messages based on these characteristics. OBJECTIVE This study aims to explore characteristics of patients and clinic staff associated with the content exchanged in secure messages. METHODS We coded 18,309 messages that were part of threads initiated by 1031 patients with hypertension, diabetes, or both conditions, in communication with 711 staff members. We conducted four sets of analyses to identify associations between patient characteristics and the types of messages they sent, staff characteristics and the types of messages they sent, staff characteristics and the types of messages patients sent to them, and patient characteristics and the types of messages they received from staff. Logistic regression was used to estimate the strength of the associations. RESULTS We found that younger patients had reduced odds of sharing clinical updates (odds ratio [OR] 0.77, 95% CI 0.65-0.91) and requesting prescription refills (OR 0.77, 95% CI 0.65-0.90). Women had reduced odds of self-reporting biometrics (OR 0.78, 95% CI 0.62-0.98) but greater odds of responding to a clinician (OR 1.20, 95% CI 1.02-1.42) and seeking medical guidance (OR 1.19, 95% CI 1.01-1.40). Compared with White patients, Black patients had greater odds of requesting preventive care (OR 2.68, 95% CI 1.30-5.51) but reduced odds of requesting a new or changed prescription (OR 0.72, 95% CI 0.53-0.98) or laboratory or other diagnostic procedures (OR 0.66, 95% CI 0.46-0.95). Staff had lower odds of sharing medical guidance with younger patients (OR 0.83, 95% CI 0.69-1.00) and uninsured patients (OR 0.21, 95% CI 0.06-0.73) but had greater odds of sharing medical guidance with patients with public payers (OR 2.03, 95% CI 1.26-3.25) compared with patients with private payers. Staff had reduced odds of confirming to women that their requests were fulfilled (OR 0.82, 95% CI 0.69-0.98). Compared with physicians, nurse practitioners had greater odds of sharing medical guidance with patients (OR 2.74, 95% CI 1.12-6.68) and receiving prescription refill requests (OR 3.39, 95% CI 1.49-7.71). Registered nurses had greater odds of deferred information sharing (OR 1.61, 95% CI 1.04-2.49) and receiving responses to messages (OR 3.93, 95% CI 2.18-7.11) than physicians. CONCLUSIONS The differences we found in content use based on patient characteristics could lead to the exacerbation of health disparities when content is associated with health outcomes. Disparities in the content of secure messages could exacerbate disparities in patient outcomes, such as satisfaction, trust in the system, self-care, and health outcomes. Staff and administrators should evaluate how secure messaging is used to ensure that disparities in care are not perpetuated via this communication modality. CLINICALTRIAL

Background The number of electronic messages securely exchanged between clinic staff and patients has risen dramatically over the last decade. A variety of studies explored whether the volume of messages sent by patients was associated with outcomes. None of these studies, however, examined whether message content itself was associated with outcomes. Because secure messaging is a significant form of communication between patients and clinic staff, it is critical to evaluate the context of the communication to best understand its impact on patient health outcomes. Objective To examine associations between patients’ and clinicians’ message content and changes in patients’ health outcomes. Methods We applied a taxonomy developed specifically for secure messages to 14,394 patient- and clinic staff–generated messages derived from patient-initiated message threads. Our study population included 1602 patients, 50.94% (n=816) of whom initiated message threads. We conducted linear regression analyses to determine whether message codes were associated with changes in glycemic (A1C) levels in patients with diabetes and changes in systolic (SBP) and diastolic (DBP) blood pressure in patients with hypertension. Results Patients who initiated threads had larger declines in A1Cs (P=.01) compared to patients who did not initiate threads. Clinic nonresponse was associated with decreased SBP (β=–.30; 95% CI –0.56 to –0.04), as were staffs’ action responses (β=–30; 95% CI –0.58 to –0.02). Increased DBP, SBP, and A1C levels were associated with patient-generated appreciation and praise messages and staff encouragement with effect sizes ranging from 0.51 (A1C) to 5.80 (SBP). We found improvements in SBP associated with patients’ complaints (β=–4.03; 95% CI –7.94 to –0.12). Deferred information sharing by clinic staff was associated with increased SBP (β=1.29; 95% CI 0.4 to 2.19). Conclusions This is the first research to find associations between message content and patients’ health outcomes. Our findings indicate mixed associations between patient message content and patient outcomes. Further research is needed to understand the implications of this work; in the meantime, health care providers should be aware that their message content may influence patient health outcomes.

Corporate managers often pursue voluntary non-GAAP reporting when mandatory reporting is limited, although regulators are concerned with how this reporting is utilized. While the level of flexibility external auditors exhibit during discussions over subjective GAAP reporting choices can influence management's GAAP reporting decisions, it is important to determine if this behavior affects subsequent non-GAAP reporting decisions. Additionally, recent calls for increased audit committee questioning of non-GAAP disclosures may also cause audit committees to influence non-GAAP reporting. In this dissertation, I conduct an experiment to examine how auditor flexibility and audit committee questioning influence non-GAAP preparation and earnings release disclosure choices of senior executives. I predict less flexible auditor behavior will enhance managers' psychological feeling of constraint, while audit committee questioning focused on non-GAAP measures can increase managers' self-assessment of reporting decisions, both of which will translate into more conservative non-GAAP reporting. However, given prior research indicating that corporate governance mechanisms can combine in complex ways, I predict a greater impact of audit committee questioning absent auditor constraint. Results indicate managers make less conservative non-GAAP preparation decisions and disclose more non-GAAP measures in the absence of constraint from inflexible auditors. However, absent this constraint, managers make more conservative non-GAAP preparation choices and present non-GAAP measures less prominently in earnings press releases when the audit committee questions non-GAAP disclosures. These results are driven by a thorough self-assessment of reporting decisions by managers expecting audit committee questioning. This study provides evidence on how external auditors and audit committees influence various voluntary reporting decisions. Doctor of Philosophy Corporate managers can report their company's financial information to investors and other stakeholders in various ways. Some financial information is required to be reported in accordance with a set of formal accounting standards called United States Generally Accepted Accounting Principles (GAAP). Beyond this mandatory reporting, other financial information is disclosed voluntarily when company management believes this extra information is beneficial to investors. These voluntary disclosures— called non-GAAP measures— do not follow a set of accounting standards and can be disclosed with more discretion by company management than GAAP measures. The variation in how non-GAAP measures are prepared and disclosed concerns regulators, such as the Securities and Exchange Commission (SEC). Mandatory GAAP financial reporting is overseen by external auditors from public accounting firms, but auditors typically have very little formal oversight over non-GAAP reporting. Although company management ultimately decides how to disclose GAAP information, external auditors influence these reporting decisions by recommending choices during discussions over subjective GAAP issues. Sometimes auditors exhibit inflexible behavior during these discussions by being unwilling to consider management's reporting choices. This inflexibility limits or constrains the GAAP reporting choices of managers. However, prior research has not studied how this constraint impacts how managers make non-GAAP reporting choices. Further, GAAP reporting choices can also be influenced by the audit committee, which is a subgroup of members of the board of directors that is in charge of overseeing financial reporting and disclosure. Recent calls from regulators have asked for increased audit committee questioning of non-GAAP disclosures, which may also cause audit committees to influence non-GAAP reporting. Non-GAAP measures are often presented in earnings press releases, which are public announcements by a company that disclose information regarding results of operations or financial condition for a given period. Managers can make strategic decisions regarding the preparation of non-GAAP measures and the presentation of this information in earnings releases, both of which can influence investors' decision-making. In this dissertation, I conduct an experiment utilizing senior executives to examine how auditor flexibility and audit committee questioning influence these two types of non-GAAP reporting decisions: how to prepare non-GAAP measures and how to disclose them in earnings press releases. I predict less flexible auditor behavior will enhance managers' psychological feeling of constraint, while audit committee questioning focused on non-GAAP measures will increase managers' self-assessment of reporting decisions, both of which will translate into more conservative non-GAAP reporting. However, prior research indicates that corporate governance mechanisms, which are factors intended to help direct and monitor company management (such as auditors and audit committees), can combine in complex ways. Therefore, I predict a greater impact of audit committee questioning absent auditor constraint. The results indicate managers make less conservative non-GAAP preparation decisions (i.e. are more likely to calculate non-GAAP earnings figures that deviate from their GAAP counterparts) and disclose more non-GAAP measures in the absence of constraint from inflexible auditors. However, absent this constraint, managers make more conservative non-GAAP preparation choices and present non-GAAP measures less prominently in earnings press releases when the audit committee questions non-GAAP disclosures. These results are driven by a thorough self-assessment of reporting decisions by managers expecting audit committee questioning. This study provides evidence on how external auditors and audit committees influence various voluntary reporting decisions. Given the ubiquity of non-GAAP reporting in recent years, this dissertation can provide valuable insights to regulators, investors, and other stakeholders on factors that influence managerial decision-making related to non-GAAP disclosures.

Purpose Despite the potential for adaptive optics scanning light ophthalmoscopy (AOSLO) to quantify retinal disease progression at the cellular level, there remain few longitudinal studies investigating changes in cone density as a measure of disease progression. Here, we undertook a prospective, longitudinal study to investigate the variability of cone density measurements in normal subjects during a 2-year period. Methods Fourteen eyes of nine subjects with no known ocular pathology were imaged both at a baseline and a 2-year follow-up visit by using confocal AOSLO at five retinal locations. Two-year affine-registered images were created to minimize the effects of intraframe distortions. Regions of interest were cropped from baseline, 2-year manually aligned, and 2-year affine-registered images. Cones were identified (graded masked) and cone density was extracted. Results Mean baseline cone density (cones/mm2) was 87,300, 62,200, 45,500, 28,700, and 18,200 at 190, 350, 500, 900, and 1500 μm, respectively. The mean difference (± standard deviation [SD]) in cone density from baseline to 2-year affine-registered images was 1400 (1700), 100 (1800), 300 (800), 400 (800), and 1000 (2400) cones/mm2 at the same locations. The mean difference in cone density during the 2-year period was lower for affine-registered images than manually aligned images. Conclusions There was no meaningful change in normal cone density during a 2-year period. Intervisit variability in cone density measurements decreased when intraframe distortions between time points were minimized. This variability must be considered when planning prospective longitudinal clinical trials using changes in cone density as an outcome measure for assessing retinal disease progression.

BACKGROUND The number of electronic messages securely exchanged between clinic staff and patients has risen dramatically over the last decade. A variety of studies explored whether the volume of messages sent by patients was associated with outcomes. None of these studies, however, examined whether message content itself was associated with outcomes. Because secure messaging is a significant form of communication between patients and clinic staff, it is critical to evaluate the context of the communication to best understand its impact on patient health outcomes. OBJECTIVE To examine associations between patients’ and clinicians’ message content and changes in patients’ health outcomes. METHODS We applied a taxonomy developed specifically for secure messages to 14,394 patient- and clinic staff–generated messages derived from patient-initiated message threads. Our study population included 1602 patients, 50.94% (n=816) of whom initiated message threads. We conducted linear regression analyses to determine whether message codes were associated with changes in glycemic (A1C) levels in patients with diabetes and changes in systolic (SBP) and diastolic (DBP) blood pressure in patients with hypertension. RESULTS Patients who initiated threads had larger declines in A1Cs (P=.01) compared to patients who did not initiate threads. Clinic nonresponse was associated with decreased SBP (β=–.30; 95% CI –0.56 to –0.04), as were staffs’ action responses (β=–30; 95% CI –0.58 to –0.02). Increased DBP, SBP, and A1C levels were associated with patient-generated appreciation and praise messages and staff encouragement with effect sizes ranging from 0.51 (A1C) to 5.80 (SBP). We found improvements in SBP associated with patients’ complaints (β=–4.03; 95% CI –7.94 to –0.12). Deferred information sharing by clinic staff was associated with increased SBP (β=1.29; 95% CI 0.4 to 2.19). CONCLUSIONS This is the first research to find associations between message content and patients’ health outcomes. Our findings indicate mixed associations between patient message content and patient outcomes. Further research is needed to understand the implications of this work; in the meantime, health care providers should be aware that their message content may influence patient health outcomes.