RNA in axons, dendrites, synapses and beyond.

In neurons, a diverse range of coding and non-coding RNAs localize to axons, dendrites, and synapses, where they facilitate rapid responses to local needs, such as axon and dendrite extension and branching, synapse formation, and synaptic plasticity. Here, we review the extent of our current understanding of RNA subclass diversity in these functionally demanding subcellular compartments. We discuss the similarities and differences identified between axonal, dendritic and synaptic local transcriptomes, and discuss the reported and hypothesized fates and functions of localized RNAs. Furthermore, we outline the RNA composition of exosomes that bud off from neurites, and their implications for the biology of neighboring cells. Finally, we highlight recent advances in third-generation sequencing technologies that will likely provide transformative insights into splice isoform and RNA modification diversity in local transcriptomes.

Rethinking Measures and Mortality Attribution in Health Care: The ENT Example.

National performance metrics ultimately enhance patient decision-making and promote meaningful improvements in health care delivery, which makes having valid and reliable measures essential. This study examined US News and World Report metrics from 2019 to 2012 and used electronic health record data, combined with detailed chart review across 3 in-system hospitals, to assess the provision of care compared to the attribution of patients assigned to the ear, nose, and throat (ENT) mortality group. Of the initial 47 ENT-attributed deaths, 23 of those were verified, dimensioning the mortality rate from 1.7% to just 0.8%. These results underscore the necessity of rethinking measures and mortality attribution methodologies to be more accurate. Current methods use Medicare Severity Diagnosis Related Group billing coding to map the attribution. We suggest transitioning away from specialty ranking approaches and towards a procedure and condition "rating" approach to ensure that these ranking types capture data about the provision of care within a given encounter.

Improving the timeliness of birth registration in Fiji through a financial incentive.

Background: Fiji is a Pacific Island nation with the predominant ethnic groups indigenous Fijians (iTaukei) (62 %) and Fijians of Indian descent (31 %). This study reports on the effect of a Parental Assistance Payment Program (PAPP) tied to on-time birth registration, available in Fiji from August 2018 to July 2020. Methods: Unit record birth registration data (n = 117,829) for children born during 2016-22 were used to calculate mean birth-to-registration intervals and the likelihood of on-time birth registration (within 365 days) before the PAPP (January 2016-July 2018) compared to during the PAPP (August 2018-July 2020), by population disaggregations (sex, ethnicity, age, marital status). Results: During the PAPP, mean birth-to-registration intervals declined sharply by 81 %, from 665 days (95 %CI: 658-671) to 124 days (121-127). The largest declines were among i-Taukei children (803 to 139 days, 83 %) compared to non-iTaukei (283 to 76 days, 73 %); mothers aged 10-19 years (880 to 134 days, 85 %) compared to ≥20 years (653 to 123 days, 81 %); and single mothers (983 to 145 days, 85 %) compared to married mothers (570 to 115 days, 80 %). On-time birth registration increased from 57 % to 93 %, and the adjusted hazard ratio showed children born during the PAPP were 2.3 times more likely (95 %CI: 2.2-2.4) to have their birth registered on-time compared to children born before the PAPP. When the PAPP was discontinued in August 2020, the birth-to-registration interval increased sharply in all population groups. Conclusions: During the two-year period the PAPP was available, it was highly effective at improving the timeliness of birth registration, particularly among iTaukei children, young mothers, and single mothers. After the PAPP was discontinued, the timeliness of birth registration deteriorated sharply. Longer post-PAPP follow-up time (≠5 years) is required to determine whether the timeliness of birth registration has deteriorated to levels similar to those during the pre-PAPP period.

Dead reckoning of protist viability with propidium monoazide (PMA)-quantitative PCR; a case study using Neoparamoeba perurans.

The ability to distinguish between viable and non-viable protozoan parasites is central to improved human and animal health management. While conceptually simple, methods to differentiate cell viability in situ remain challenging. Amoebic gill disease, caused by Neoparamoeba perurans is a parasitic disease impacting Atlantic salmon aquaculture globally. Although commercial freshwater treatments alleviate AGD, viable amoebae remain on gills or in used treatment water. Existing PCR-based assays are able to quantify N. perurans abundance but cannot discriminate amoeba viability. We investigated the use of propidium monoazide (PMA) application, prior to real-time PCR, to distinguish between alive and dead cells. We demonstrate that 200 µM PMA can significantly reduce amplification from non-viable (isopropanol treated) cultured amoebae across at least three logs of cell concentrations. Using a serial dilution of viable and non-viable cells, we show that non-PMA PCR amplifies both viable and non-viable amoebae, while PMA exposure suppresses (but does not completely inhibit) amplification from non-viable amoebae. The effect of freshwater treatment on N. perurans viability was assessed using the PMA-PCR. Following PMA exposure, amplification from freshwater treated amoebae was reduced by approximately 94-97 %. Taken together this study demonstrates that PMA combined with traditional real-time PCR can estimate amoeba viability.

Tubulointerstitial nephropathy is the predominant finding in men in a review of more than 3000 renal biopsies over a 10-year period from Sri Lanka.

BACKGROUND: Chronic kidney disease (CKD) is a significant clinical challenge in Sri Lanka. The present study presents histopathological diagnoses from native renal biopsies in Kandy District, 2011-2020. METHODS: Reports of 5,014 renal biopsies principally performed at Kandy Teaching Hospital over 2011-2020 were reviewed. After exclusions for post-kidney transplant biopsies (1,572) and those without evident pathology (347), 3,095 biopsies were included. The predominant histopathological entities were grouped and categorised according to diagnosis and stratified by age and sex. RESULTS: The main histopathological entities (all biopsies) were tubulointerstitial nephropathy (TIN) 25% (n = 760), glomerulonephritis (GN) 15% (467), lupus nephropathy 14% (429), focal segmental glomerular sclerosis (FSGS) 10% (297), and IgA nephropathy (IgAN) 8% (242). For adult women ≥ 15 years, the main histopathological entities were lupus nephropathy 24% (325), TIN 17% (228), and GN 16% (217). For adult men ≥ 15 years, the main histopathological entities were TIN 34% (449), GN 14% (180), and IgAN 10% (125). The proportion of TIN in the present study was higher than international studies of a similar size. CONCLUSION: This is the largest study of renal biopsies reported from Sri Lanka to date. TIN was the most common diagnosis in adults ≥ 15 years at 25%. Notable sex differences showed TIN was the most common histopathology in men (34%) but not in women (17%). No previously published similar study of this size has found TIN as the predominant diagnosis amongst renal biopsies in men. Further research is required into the possible causes of these observations in Sri Lanka. CLINICAL TRIAL NUMBER: Not applicable.

Characterization of the impact of dietary immunostimulant CpG on the expression of mRNA biomarkers involved in the immune responses in Atlantic salmon (Salmo salar).

Infectious diseases have significantly impacted Atlantic salmon aquaculture worldwide. Modulating fish immunity with immunostimulant-containing functional feeds could be an effective strategy in mitigating disease problems. Previously, we characterized the impact of polyriboinosinic polyribocytidylic acid (pIC) and formalin-killed typical Aeromonas salmonicida bacterin on miRNA expression in Atlantic salmon fed a commercial diet with and without immunostimulant CpG. A set of miRNA biomarkers of Atlantic salmon head kidney responding to pIC and/or bacterin immune stimulations was identified (Xue et al., 2019) [1]. Herein, we report a complementary qPCR study that investigated the impact of the pIC, bacterin and dietary CpG on the expression of immune-relevant mRNAs (n = 31) using the same samples as in the previous study (Xue et al., 2019) [1]. Twenty-six of these genes were predicted target transcripts of the pIC- and/or bacterin-responsive miRNAs identified in the earlier study. The current data showed that pIC and/or bacterin stimulations significantly modulated the majority of the qPCR-analyzed genes involved in various immune pathways. Some genes responded to both stimulations (e.g. tnfa, il10rb, ifng, irf9, cxcr3, campb) while others appeared to be stimulation specific [e.g. irf3, irf7a, il1r1, mxa, mapk3 (pIC only); clra (bacterin only)]. A. salmonicida bacterin stimulation produced a strong inflammatory response (e.g. higher expression of il1b, il8a and tnfa), while salmon stimulated with pIC showed robust interferon responses (both type I and II). Furthermore, the current data indicated significant down-regulation of immune-relevant transcripts (e.g. tlr9, irf5, il1r1, hsp90ab1, itgb2) by dietary immunostimulant CpG, especially among pre-injection and PBS-injected fish. Together with our prior miRNA study, the present research provided complementary information on Atlantic salmon anti-viral and anti-bacterial immune responses and on how dietary CpG may modulate these responses.

Adult mortality from non-communicable diseases in Fiji's major ethnic groups 2013-17.

Background: Sustainable Development Goal 3.4.1 (SDG3.4.1) targets a one-third reduction in non-communicable disease (NCD) mortality in ages 30-69-years by 2030 (relative to 2015). Directing interventions to achieve this aim requires reliable estimates of underlying cause of death (UCoD). This may be problematic when both cardiovascular diseases (CVD) and diabetes are present due to a lack of consistency in certification of such deaths. We estimate empirically 2013-17 NCD mortality in Fiji, by sex and ethnicity, from CVD, diabetes, cancer, and chronic lower respiratory diseases (CRD), and aggregated as NCD4. Methods: UCoD was determined from Medical Certificates of Cause-of-Death (MCCD) from the Fiji Ministry of Health after pre-processing of mortality data where diabetes and/or hypertension were present in order to generate internationally comparable UCoD. If no potentially fatal complications from diabetes or hypertension accompanied these causes in Part I (direct cause) of the MCCD, these conditions were re-assigned to Part II (contributory cause). The probability of a 30-year-old dying before reaching age 70-years (PoD30-70), by cause, was calculated. Findings: The PoD30-70 from NCD4 over 2013-17 differed by sex and ethnicity: in women, it was 36% (95%CI 35-37%) in i-Taukei and 27% (26-28%) in Fijians of Indian descent (FID); in men, it was 41% (40-42%) in both i-Taukei and FID.PoD30-70 from CVD, diabetes, cancer and CRD in women was: 18%, 10%, 13% and 1·0% in i-Taukei; 13%, 10%, 5·6% and 1·1% in FID; in men was: 28%, 8.4%, 7·6% and 2·2% in i-Taukei; 31%, 8.3%, 3.5% and 3·1% in FID. Interpretation: To achieve SDG3.4.1 goals in Fiji by 2030, effective population wide and ethnic-specific interventions targeting multiple NCDs are required to reduce PoD30-70 from NCD4: from 36% to 24% in i-Taukei, and 27% to 18% in FID women; and from 41% to 27% in i-Taukei and FID men. Funding: Not applicable.

Patient-Representing Population's Perceptions of GPT-Generated Versus Standard Emergency Department Discharge Instructions: Randomized Blind Survey Assessment.

BACKGROUND: Discharge instructions are a key form of documentation and patient communication in the time of transition from the emergency department (ED) to home. Discharge instructions are time-consuming and often underprioritized, especially in the ED, leading to discharge delays and possibly impersonal patient instructions. Generative artificial intelligence and large language models (LLMs) offer promising methods of creating high-quality and personalized discharge instructions; however, there exists a gap in understanding patient perspectives of LLM-generated discharge instructions. OBJECTIVE: We aimed to assess the use of LLMs such as ChatGPT in synthesizing accurate and patient-accessible discharge instructions in the ED. METHODS: We synthesized 5 unique, fictional ED encounters to emulate real ED encounters that included a diverse set of clinician history, physical notes, and nursing notes. These were passed to GPT-4 in Azure OpenAI Service (Microsoft) to generate LLM-generated discharge instructions. Standard discharge instructions were also generated for each of the 5 unique ED encounters. All GPT-generated and standard discharge instructions were then formatted into standardized after-visit summary documents. These after-visit summaries containing either GPT-generated or standard discharge instructions were randomly and blindly administered to Amazon MTurk respondents representing patient populations through Amazon MTurk Survey Distribution. Discharge instructions were assessed based on metrics of interpretability of significance, understandability, and satisfaction. RESULTS: Our findings revealed that survey respondents' perspectives regarding GPT-generated and standard discharge instructions were significantly (P=.01) more favorable toward GPT-generated return precautions, and all other sections were considered noninferior to standard discharge instructions. Of the 156 survey respondents, GPT-generated discharge instructions were assigned favorable ratings, "agree" and "strongly agree," more frequently along the metric of interpretability of significance in discharge instruction subsections regarding diagnosis, procedures, treatment, post-ED medications or any changes to medications, and return precautions. Survey respondents found GPT-generated instructions to be more understandable when rating procedures, treatment, post-ED medications or medication changes, post-ED follow-up, and return precautions. Satisfaction with GPT-generated discharge instruction subsections was the most favorable in procedures, treatment, post-ED medications or medication changes, and return precautions. Wilcoxon rank-sum test of Likert responses revealed significant differences (P=.01) in the interpretability of significant return precautions in GPT-generated discharge instructions compared to standard discharge instructions but not for other evaluation metrics and discharge instruction subsections. CONCLUSIONS: This study demonstrates the potential for LLMs such as ChatGPT to act as a method of augmenting current documentation workflows in the ED to reduce the documentation burden of physicians. The ability of LLMs to provide tailored instructions for patients by improving readability and making instructions more applicable to patients could improve upon the methods of communication that currently exist.

Intermediate vs. High Oxygen Saturation Targets in Preterm Infants: A National Cohort Study.

INTRODUCTION: Optimal oxygen saturation targets remain unknown for extremely preterm infants. METHODS: Cohort analysis of eligible preterm infants born <29 weeks' gestation admitted between 2011 and 2018 to centers submitting data to the Canadian Neonatal Network (CNN) database. Site questionnaires to determine saturation targets, alarm settings, and date of change, allowed assignation of centers to intermediate (88-93%) or high (90-95%) saturation targets. A 6-month washout period was applied to sites which switched targets during the study period. Our primary outcome was survival free of major morbidity. Secondary outcomes were death, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity, and evidence of brain injury during admission. Generalized estimating equations were applied to compensate for demographic differences and site practices. RESULTS: There were 2,739 infants in the high (mean gestational age [GA] 26 ± 1.6 weeks) and 6,813 infants in the intermediate (mean GA 26.2 ± 1.6 weeks) saturation target group. Survival without morbidity was higher in the intermediate target group (adjusted odds ratio [aOR] 1.59; 95% CI: 1.04, 2.45). There was no difference in mortality between groups (aOR 0.81; 95% CI: 0.59, 1.11), in NEC, treated retinopathy, or brain injury. On subgroup analysis, restricting data to sites which switched targets during the study, intermediate saturation targets were associated with lower rates of BPD (aOR 0.45; 95% CI: 0.28, 0.72). CONCLUSION: For neonates <29 weeks' gestation, intermediate saturation target was associated with higher odds of survival without major morbidity compared to higher oxygen saturation target.

Evolution of Retinal Neuron Fractality When Interfacing with Carbon Nanotube Electrodes.

Exploring how neurons in the mammalian body interact with the artificial interface of implants can be used to learn about fundamental cell behavior and to refine medical applications. For fundamental and applied research, it is crucial to determine the conditions that encourage neurons to maintain their natural behavior during interactions with non-natural interfaces. Our previous investigations quantified the deterioration of neuronal connectivity when their dendrites deviate from their natural fractal geometry. Fractal resonance proposes that neurons will exhibit enhanced connectivity if an implant's electrode geometry is matched to the fractal geometry of the neurons. Here, we use in vitro imaging to quantify the fractal geometry of mouse retinal neurons and show that they change during interaction with the electrode. Our results demonstrate that it is crucial to understand these changes in the fractal properties of neurons for fractal resonance to be effective in the in vivo mammalian system.

The commoditization of civil nuclear power.

The commoditization of nuclear power through the factory production of sealed micro-power units within a digitally enabled holistic assurance framework is described. This would revolutionize nuclear power-plant design, construction, operation and decommissioning through a paradigm shift to manufacture-operate-remove-recycle (MORR). The potential impact of recent research on an integrated nuclear digital environment for large bespoke nuclear power plants and the design, build and operation of fusion power plants using such a digital environment is explored. These strands are interwoven to discuss the technical, economic and socio-political implications of MORR in the context of micro-reactors and to consider the potential evolution of safeguarding issues based on a digital assurance framework that leads to type approvals. Commoditization of nuclear power would lower costs in line with offshore wind and the output from a single production line in a factory could replace a third of current fossil fuel-based electricity generation in the UK over a 15-year period, making a significant contribution to achieving zero greenhouse gas emissions. The challenges associated with the changes in culture, both in the nuclear industry and in society, as well as the technology gaps, that need to be addressed in realizing this paradigm shift are identified and discussed.

Using machine learning to distinguish between authentic and imitation Jackson Pollock poured paintings: A tile-driven approach to computer vision.

Jackson Pollock's abstract poured paintings are celebrated for their striking aesthetic qualities. They are also among the most financially valued and imitated artworks, making them vulnerable to high-profile controversies involving Pollock-like paintings of unknown origin. Given the increased employment of artificial intelligence applications across society, we investigate whether established machine learning techniques can be adopted by the art world to help detect imitation Pollocks. The low number of images compared to typical artificial intelligence projects presents a potential limitation for art-related applications. To address this limitation, we develop a machine learning strategy involving a novel image ingestion method which decomposes the images into sets of multi-scaled tiles. Leveraging the power of transfer learning, this approach distinguishes between authentic and imitation poured artworks with an accuracy of 98.9%. The machine also uses the multi-scaled tiles to generate novel visual aids and interpretational parameters which together facilitate comparisons between the machine's results and traditional investigations of Pollock's artistic style.

2023 Society for Academic Emergency Medicine Consensus Conference on Precision Emergency Medicine: Development of a policy-relevant, patient-centered research agenda.

OBJECTIVES: Precision medicine is data-driven health care tailored to individual patients based on their unique attributes, including biologic profiles, disease expressions, local environments, and socioeconomic conditions. Emergency medicine (EM) has been peripheral to the precision medicine discourse, lacking both a unified definition of precision medicine and a clear research agenda. We convened a national consensus conference to build a shared mental model and develop a research agenda for precision EM. METHODS: We held a conference to (1) define precision EM, (2) develop an evidence-based research agenda, and (3) identify educational gaps for current and future EM clinicians. Nine preconference workgroups (biomedical ethics, data science, health professions education, health care delivery and access, informatics, omics, population health, sex and gender, and technology and digital tools), comprising 84 individuals, garnered expert opinion, reviewed relevant literature, engaged with patients, and developed key research questions. During the conference, each workgroup shared how they defined precision EM within their domain, presented relevant conceptual frameworks, and engaged a broad set of stakeholders to refine precision EM research questions using a multistage consensus-building process. RESULTS: A total of 217 individuals participated in this initiative, of whom 115 were conference-day attendees. Consensus-building activities yielded a definition of precision EM and key research questions that comprised a new 10-year precision EM research agenda. The consensus process revealed three themes: (1) preeminence of data, (2) interconnectedness of research questions across domains, and (3) promises and pitfalls of advances in health technology and data science/artificial intelligence. The Health Professions Education Workgroup identified educational gaps in precision EM and discussed a training roadmap for the specialty. CONCLUSIONS: A research agenda for precision EM, developed with extensive stakeholder input, recognizes the potential and challenges of precision EM. Comprehensive clinician training in this field is essential to advance EM in this domain.

Real-Time Electronic Patient Portal Use Among Emergency Department Patients.

Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

Vegetable omega-3 and omega-6 fatty acids differentially modulate the antiviral and antibacterial immune responses of Atlantic salmon.

The immunomodulatory effects of omega-3 and omega-6 fatty acids are a crucial subject of investigation for sustainable fish aquaculture, as fish oil is increasingly replaced by terrestrial vegetable oils in aquafeeds. Unlike previous research focusing on fish oil replacement with vegetable alternatives, our study explored how the omega-6 to omega-3 polyunsaturated fatty acid (PUFA) ratio in low-fish oil aquafeeds influences Atlantic salmon's antiviral and antibacterial immune responses. Atlantic salmon were fed aquafeeds rich in soy oil (high in omega-6) or linseed oil (high in omega-3) for 12 weeks and then challenged with bacterial (formalin-killed Aeromonas salmonicida) or viral-like (polyriboinosinic polyribocytidylic acid) antigens. The head kidneys of salmon fed high dietary omega-3 levels exhibited a more anti-inflammatory fatty acid profile and a restrained induction of pro-inflammatory and neutrophil-related genes during the immune challenges. The high-omega-3 diet also promoted a higher expression of genes associated with the interferon-mediated signaling pathway, potentially enhancing antiviral immunity. This research highlights the capacity of vegetable oils with different omega-6 to omega-3 PUFA ratios to modulate specific components of fish immune responses, offering insights for future research on the intricate lipid nutrition-immunity interplay and the development of novel sustainable low-fish oil clinical aquaculture feeds.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition.

BACKGROUND: The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. METHODS: This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. RESULTS: A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. CONCLUSIONS: Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

Common and disparate clinical presentations and mechanisms in different eosinophilic gastrointestinal diseases.

Eosinophilic gastrointestinal diseases (EGIDs) are a group of diseases characterized by selective eosinophil infiltration of the gastrointestinal (GI) tract in the absence of other causes of eosinophilia. These diseases are generally driven by type 2 inflammation, often in response to food allergen exposure. Among all EGIDs, the clinical presentation often includes a history of atopic disease with a variety of GI symptoms. EGIDs are traditionally separated into eosinophilic esophagitis (EoE) and non-EoE EGIDs. EoE is relatively better understood and now associated with clinical guidelines and 2 US Food and Drug Administration-approved treatments, whereas non-EoE EGIDs are rarer and less well-understood diseases without US Food and Drug Administration-approved treatments. Non-EoE EGIDs are further subclassified by the area of the GI tract that is involved; they comprise eosinophilic gastritis, eosinophilic enteritis (including eosinophilic duodenitis), and eosinophilic colitis. As with other GI disorders, the disease presentations and mechanisms differ depending on the involved segment of the GI tract; however, the differences between EoE and non-EoE EGIDs extend beyond which GI tract segment is involved. The aim of this article is to summarize the commonalities and differences between the clinical presentations and disease mechanisms for EoE and non-EoE EGIDs.

Project EPIC (Empowering People to Independence in COPD): Study protocol for a hybrid effectiveness-implementation pilot randomized controlled trial of telephonic, geriatrics-palliative care nurse-coaching in older adults with COPD and their family caregivers.

BACKGROUND: EPIC (Empowering People to Independence in COPD) is a geriatric-palliative care telephonic, nurse coach intervention informed by Baltes' Theory of Successful Aging and adapted from the ENABLE (Educate, Nurture, Advise, Before Life Ends) intervention. EPIC, focused on improving independence, mobility, well-being, and COPD symptoms, has undergone formative and summative evaluation for adults with COPD. METHODS: The primary study aim is to assess the refined EPIC intervention's feasibility and acceptability via a pilot hybrid effectiveness-implementation randomized control trial in community-dwelling older adults with moderate to severe COPD and their family caregivers. The secondary aim is to explore the impact of EPIC on patient and caregiver outcomes. Older adults with COPD and their family caregivers (target N = 60 dyads) will be randomized to EPIC (intervention) or usual COPD care (control). EPIC includes six patient and four family caregiver weekly, telephone-based nurse coach sessions using a manualized curriculum (Charting Your Course), plus three monthly follow-up calls. Feasibility will be measured as completion of EPIC intervention and trial components (e.g., recruitment, retention, data collection). Acceptability will be evaluated using satisfaction surveys and post-study feedback interviews. A blinded data collector will assess exploratory outcomes (e.g., Life-Space mobility, quality of life, caregiver burden, emotional symptoms, loneliness, cognitive impairment, functional status, healthcare utilization) at baseline, 12, and 24 weeks. DISCUSSION: This intervention fills a gap in addressing the geriatrics and palliative care needs and equity for adults with COPD and their family caregivers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05040386.

Fractal Fluency: Processing of Fractal Stimuli Across Sight, Sound, and Touch.

People are continually exposed to the rich complexity generated by the repetition of fractal patterns at different size scales. Fractals are prevalent in natural scenery and also in patterns generated by artists and mathematicians. In this chapter, we will investigate the powerful significance of fractals for the human senses. In particular, we propose that fractals with mid-range complexity play a unique role in our visual experiences because the visual system has adapted to these prevalent natural patterns. This adaptation is evident at multiple stages of the visual system, ranging from data acquisition by the eye to processing of this data in the higher visual areas of the brain. Based on these results, we will discuss a fluency model in which the visual system processes mid-complexity fractals with relative ease. This fluency optimizes the observer's capabilities (such as enhanced attention and pattern recognition) and generates an aesthetic experience accompanied by a reduction in the observer's physiological stress levels. In addition to reviewing people's responses to viewing fractals, we will compare these responses to recent research focused on fractal sounds and fractal surface textures. We will extend our fractal fluency model to allow for stimuli across multiple senses.