Change in Site of Children's Primary Care: A Longitudinal Population-Based Analysis.

PURPOSE: Evidence that fewer children are being seen at family physician (FP) practices has not been confirmed using population-level data. This study examines the proportion of children seen at FP and pediatrician practices over time and the influence of patient demographics and rurality on this trend. METHODS: We conducted a retrospective longitudinal analysis of Vermont all-payer claims (2009-2016) for children aged 0 to 21 years. The sample included 184,794 children with 2 or more claims over 8 years. Generalized estimating equations modeled the outcome of child attribution to a FP practice annually, with covariates for calendar year, child age, sex, insurance, and child Rural Urban Commuting Area (RUCA) category. RESULTS: Over time, controlling for other covariates, children were 5% less likely to be attributed to a FP practice (P <.001). Children had greater odds of attribution to a FP practice as they aged (odds ratio (OR) = 1.11, 95% CI, 1.10-1.11), if they were female (OR = 1.05, 95% CI, 1.03-1.07) or had Medicaid (OR = 1.09, 95% CI, 1.07-1.10). Compared with urban children, those from large rural cities (OR = 1.54, 95% CI, 1.51-1.57), small rural towns (OR = 1.45, 95% CI, 1.42-1.48), or isolated/small rural towns (OR = 1.96, 95% CI, 1.93-2.00) had greater odds of FP attribution. When stratified by RUCA, however, children had 3% lower odds of attending a FP practice in urban areas and 8% lower odds in isolated/small rural towns. CONCLUSIONS: The declining proportion of children attending FP practices, confirmed in this population-based analysis and more pronounced in rural areas, represents a continuing challenge.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Electrically driven reversible insulator-metal phase transition in 1T-TaS2.

In this work, we demonstrate abrupt, reversible switching of resistance in 1T-TaS2 using dc and pulsed sources, corresponding to an insulator-metal transition between the insulating Mott and equilibrium metallic states. This transition occurs at a constant critical resistivity of 7 mohm-cm regardless of temperature or bias conditions and the transition time is significantly smaller than abrupt transitions by avalanche breakdown in other small gap Mott insulating materials. Furthermore, this critical resistivity corresponds to a carrier density of 4.5 × 10(19) cm(-3), which compares well with the critical carrier density for the commensurate to nearly commensurate charge density wave transition. These results suggest that the transition is facilitated by a carrier driven collapse of the Mott gap in 1T-TaS2, which results in fast (3 ns) switching.

Increase in pediatric recurrent fever evaluations during the first year of the COVID-19 pandemic in North America.

The impact of the COVID-19 pandemic on new diagnoses of recurrent fevers and autoinflammatory diseases is largely unknown. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) PFAPA/AID Working Group aimed to investigate the impact of the COVID-19 pandemic on the number of pediatric patients evaluated for recurrent fevers and autoinflammatory diseases in North America. The absolute number of new outpatient visits and the proportion of these visits attributed to recurrent fever diagnoses during the pre-pandemic period (1 March 2019-29 February 2020) and the first year of the COVID-19 pandemic (1 March 2020-28 February 2021) were examined. Data were collected from 27 sites in the United States and Canada. Our results showed an increase in the absolute number of new visits for recurrent fever evaluations in 21 of 27 sites during the COVID-19 pandemic compared to the pre-pandemic period. The increase was observed across different geographic regions in North America. Additionally, the proportion of new visits to these centers for recurrent fever in relation to all new patient evaluations was significantly higher during the first year of the pandemic, increasing from 7.8% before the pandemic to 10.9% during the pandemic year (p < 0.001). Our findings showed that the first year of the COVID-19 pandemic was associated with a higher number of evaluations by pediatric subspecialists for recurrent fevers. Further research is needed to understand the reasons behind these findings and to explore non-infectious triggers for recurrent fevers in children.

Corrigendum: Increase in pediatric recurrent fever evaluations during the first year of the COVID-19 pandemic in North America.

[This corrects the article DOI: 10.3389/fped.2023.1240242.].

Epitaxial graphene transistors: enhancing performance via hydrogen intercalation.

We directly demonstrate the importance of buffer elimination at the graphene/SiC(0001) interface for high frequency applications. Upon successful buffer elimination, carrier mobility increases from an average of 800 cm(2)/(V s) to >2000 cm(2)/(V s). Additionally, graphene transistor current saturation increases from 750 to >1300 mA/mm, and transconductance improves from 175 mS/mm to >400 mS. Finally, we report a 10× improvement in the extrinsic current gain response of graphene transistors with optimal extrinsic current-gain cutoff frequencies of 24 GHz.

Enhanced transport and transistor performance with oxide seeded high-κ gate dielectrics on wafer-scale epitaxial graphene.

We explore the effect of high-κ dielectric seed layer and overlayer on carrier transport in epitaxial graphene. We introduce a novel seeding technique for depositing dielectrics by atomic layer deposition that utilizes direct deposition of high-κ seed layers and can lead to an increase in Hall mobility up to 70% from as-grown. Additionally, high-κ seeded dielectrics are shown to produce superior transistor performance relative to low-κ seeded dielectrics and the presence of heterogeneous seed/overlayer structures is found to be detrimental to transistor performance, reducing effective mobility by 30-40%. The direct deposition of high-purity oxide seed represents the first robust method for the deposition of uniform atomic layer deposited dielectrics on epitaxial graphene that improves carrier transport.

Quantification of Kuramoto Coupling Between Intrinsic Brain Networks Applied to fMRI Data in Major Depressive Disorder.

Organized patterns of system-wide neural activity adapt fluently within the brain to adjust behavioral performance to environmental demands. In major depressive disorder (MD), markedly different co-activation patterns across the brain emerge from a rather similar structural substrate. Despite the application of advanced methods to describe the functional architecture, e.g., between intrinsic brain networks (IBNs), the underlying mechanisms mediating these differences remain elusive. Here we propose a novel complementary approach for quantifying the functional relations between IBNs based on the Kuramoto model. We directly estimate the Kuramoto coupling parameters (K) from IBN time courses derived from empirical fMRI data in 24 MD patients and 24 healthy controls. We find a large pattern with a significant number of Ks depending on the disease severity score Hamilton D, as assessed by permutation testing. We successfully reproduced the dependency in an independent test data set of 44 MD patients and 37 healthy controls. Comparing the results to functional connectivity from partial correlations (FC), to phase synchrony (PS) as well as to first order auto-regressive measures (AR) between the same IBNs did not show similar correlations. In subsequent validation experiments with artificial data we find that a ground truth of parametric dependencies on artificial regressors can be recovered. The results indicate that the calculation of Ks can be a useful addition to standard methods of quantifying the brain's functional architecture.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study.

BACKGROUND: Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers. METHODS: Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use. FINDINGS: Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs. CONCLUSIONS: Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Establishing core domain sets for Chronic Nonbacterial Osteomyelitis (CNO) and Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO): A report from the OMERACT 2020 special interest group.

OBJECTIVE: A working group was established to develop a core domain set (CDS) for Chronic Nonbacterial Osteomyelitis (CNO) and Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) following the OMERACT filter 2.1. METHODS: A scoping review to identify disease-related manifestations was performed, followed by a special interest group (SIG) session at OMERACT2020 to begin the CNO/SAPHO CDS framework. RESULTS: Candidate items were identified from the scoping review and most fell under Life Impact and Pathophysiology Manifestation core areas. A SIG agreed on the need to develop a CDS for CNO and SAPHO (100%) and for children and adults (91%). CONCLUSION: Based on candidate items identified, qualitative research and Delphi surveys will be performed as next steps.

Frequency-Dependent Spatial Distribution of Functional Hubs in the Human Brain and Alterations in Major Depressive Disorder.

Alterations in large-scale brain intrinsic functional connectivity (FC), i.e., coherence between fluctuations of ongoing activity, have been implicated in major depressive disorder (MDD). Yet, little is known about the frequency-dependent alterations of FC in MDD. We calculated frequency specific degree centrality (DC) - a measure of overall FC of a brain region - within 10 distinct frequency sub-bands accessible from the full range of resting-state fMRI BOLD fluctuations (i.e., 0.01-0.25 Hz) in 24 healthy controls and 24 MDD patients. In healthy controls, results reveal a frequency-specific spatial distribution of highly connected brain regions - i.e., hubs - which play a fundamental role in information integration in the brain. MDD patients exhibited significant deviations from the healthy DC patterns, with decreased overall connectedness of widespread regions, in a frequency-specific manner. Decreased DC in MDD patients was observed predominantly in the occipital cortex at low frequencies (0.01-0.1 Hz), in the middle cingulate cortex, sensorimotor cortex, lateral parietal cortex, and the precuneus at middle frequencies (0.1-0.175 Hz), and in the anterior cingulate cortex at high frequencies (0.175-0.25 Hz). Additionally, decreased DC of distinct parts of the insula was observed across low, middle, and high frequency bands. Frequency-specific alterations in the DC of the temporal, insular, and lateral parietal cortices correlated with symptom severity. Importantly, our results indicate that frequency-resolved analysis within the full range of frequencies accessible from the BOLD signal - also including higher frequencies (>0.1 Hz) - reveals unique information about brain organization and its changes, which can otherwise be overlooked.

Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs.

BACKGROUND/OBJECTIVES: People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs. DESIGN: Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers. SETTING: Wisconsin, United States. PARTICIPANTS: Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3). MEASUREMENTS: Demographic characteristics of participants and data from semistructured interviews. FINDINGS: Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD. CONCLUSION: Participants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.

Multiple compliant processes: A reply to Haslam and Reicher on the engaged followership explanation of 'obedience' in Milgram's experiments.

Haslam and Reicher (2018, Br. J. Soc. Psychol., 57, 292-300) offer a thoughtful rejoinder to our critique (Hollander & Turowetz, 2017, Br. J. Soc. Psychol, 56, 655-674) of their theory of engaged followership, currently the most important explanation of 'obedient' behaviour in the Milgram paradigm. Our immersion in Milgram's archived audio recordings has led us to new findings about participants' perspectives, as well as to dissatisfaction with the theory in its present version. Following a brief discussion of our findings, which cast the theory in doubt, we respond to Haslam and Reicher's argument that these data may in fact be consistent with it. Our response identifies three limitations of engaged followership emerging from this debate. Despite the strengths of the theory and these authors' impressive re-analysis of our findings, important reasons remain for scepticism that engaged followership operated in Milgram's experiments in the way, and to the extent, that they claim. Rather, 'obedience' appears amenable to multiple empirically grounded explanations, only one of which is engaged followership.

Improving the ED-to-Home Transition: The Community Paramedic-Delivered Care Transitions Intervention-Preliminary Findings.

OBJECTIVES: To describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the emergency department (ED)-to-home transition. DESIGN: Single-blind randomized controlled trial. SETTING: Three EDs in 2 cities. PARTICIPANTS: Through June 2017, 422 individuals discharged home from the EDs who provided consent and were randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: Median age of participants was 70.7, 241 (57.1%) were female, and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7% of planned telephone follow-up for call 1, 90.9% for call 2, and 85.8% for call 3. We found high levels of acceptability among participants, with most participants (76.2%) and their caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI program in the future. Coaches reported delivering expected services during contact at least 88% of the time. CONCLUSION: Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

Consensus Treatment Plans for Chronic Nonbacterial Osteomyelitis Refractory to Nonsteroidal Antiinflammatory Drugs and/or With Active Spinal Lesions.

OBJECTIVE: To develop standardized treatment regimens for chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis (CRMO), to enable comparative effectiveness treatment studies. METHODS: Virtual and face-to-face discussions and meetings were held within the CNO/CRMO subgroup of the Childhood Arthritis and Rheumatology Research Alliance (CARRA). A literature search was conducted, and CARRA membership was surveyed to evaluate available treatment data and identify current treatment practices. Nominal group technique was used to achieve consensus on treatment plans for CNO refractory to nonsteroidal antiinflammatory drug (NSAID) monotherapy and/or with active spinal lesions. RESULTS: Three consensus treatment plans (CTPs) were developed for the first 12 months of therapy for CNO patients refractory to NSAID monotherapy and/or with active spinal lesions. The 3 CTPs are methotrexate or sulfasalazine, tumor necrosis factor inhibitors with optional methotrexate, and bisphosphonates. Short courses of glucocorticoids and continuation of NSAIDs are permitted for all regimens. Consensus was achieved on these CTPs among CARRA members. Consensus was also reached on subject eligibility criteria, initial evaluations that should be conducted prior to the initiation of CTPs, and data items to collect to assess treatment response. CONCLUSION: Three consensus treatment plans were developed for pediatric patients with CNO refractory to NSAIDs and/or with active spinal lesions. Use of these CTPs will provide additional information on efficacy and will generate meaningful data for comparative effectiveness research in CNO.

Normalizing trust: Participants' immediately post-hoc explanations of behaviour in Milgram's 'obedience' experiments.

We bring an ethnomethodological perspective on language and discourse to a data source crucial for explaining behaviour in social psychologist Stanley Milgram's classic 'obedience' experiments - yet one largely overlooked by the Milgram literature. In hundreds of interviews conducted immediately after each experiment, participants sought to justify their actions, often doing so by normalizing the situation as benign, albeit uncomfortable. Examining 91 archived recordings of these interviews from several experimental conditions, we find four recurrent accounts for continuation, each used more frequently by 'obedient' than 'defiant' participants. We also discuss three accounts for discontinuation used by 'defiant' participants. Contrary to what a leading contemporary theory of Milgramesque behaviour - engaged followership - would predict, 'obedient' participants, in the minutes immediately following the experiment, did not tend to explain themselves by identifying with science. Rather, they justified compliance in several distinct and not entirely consistent ways, suggesting that multiple social psychological processes were at work in producing Milgram's 'obedient' outcome category.

The repertoire of resistance: Non-compliance with directives in Milgram's 'obedience' experiments.

This paper is the first extensive conversation-analytic study of resistance to directives in one of the most controversial series of experiments in social psychology, Stanley Milgram's 1961-1962 study of 'obedience to authority'. As such, it builds bridges between interactionist and experimental areas of social psychology that do not often communicate with one another. Using as data detailed transcripts of 117 of the original sessions representing five experimental conditions, I show how research participants' resistance to experimental progressivity takes shape against a background of directive/response and complaint/remedy conversational sequences--sequence types that project opposing and competing courses of action. In local contexts of competing sequential relevancies, participants mobilize six forms of resistance to the confederate experimenter's directives to continue. These range along a continuum of explicitness, from relatively subtle resistance that momentarily postpones continuation to techniques for explicitly trying to stop the experiment. Although both 'obedient'- and 'defiant'-outcome participants use all six of the forms, evidence is provided suggesting precisely how members of the two groups differ in manner and frequency of resistance.

Tungsten Ditelluride: a layered semimetal.

Tungsten ditelluride (WTe2) is a transition metal dichalcogenide (TMD) with physical and electronic properties that make it attractive for a variety of electronic applications. Although WTe2 has been studied for decades, its structure and electronic properties have only recently been correctly described. We experimentally and theoretically investigate the structure, dynamics and electronic properties of WTe2, and verify that WTe2 has its minimum energy configuration in a distorted 1T structure (Td structure), which results in metallic-like transport. Our findings unambiguously confirm the metallic nature of WTe2, introduce new information about the Raman modes of Td-WTe2, and demonstrate that Td-WTe2 is readily oxidized via environmental exposure. Finally, these findings confirm that, in its thermodynamically favored Td form, the utilization of WTe2 in electronic device architectures such as field effect transistors may need to be reevaluated.