Clinical and Economic Impact of an Integrated Care Team Model on Targeted, High-Risk Medicare Patients With Type 2 Diabetes.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a referral-based program for managing high-risk patients with type 2 diabetes in California.

Charge Transfer Excitons at van der Waals Interfaces.

The van der Waals interfaces of molecular donor/acceptor or graphene-like two-dimensional (2D) semiconductors are central to concepts and emerging technologies of light-electricity interconversion. Examples include, among others, solar cells, photodetectors, and light emitting diodes. A salient feature in both types of van der Waals interfaces is the poorly screened Coulomb potential that can give rise to bound electron-hole pairs across the interface, i.e., charge transfer (CT) or interlayer excitons. Here we address common features of CT excitons at both types of interfaces. We emphasize the competition between localization and delocalization in ensuring efficient charge separation. At the molecular donor/acceptor interface, electronic delocalization in real space can dictate charge carrier separation. In contrast, at the 2D semiconductor heterojunction, delocalization in momentum space due to strong exciton binding may assist in parallel momentum conservation in CT exciton formation.

Reversible surface electronic traps in PbS quantum dot solids induced by an order-disorder phase transition in capping molecules.

The electronic properties of semiconductor quantum dots (QDs) are critically dependent on the nature of the ligand molecules on their surfaces. Here we show the reversible formation of surface electronic trap states in the model system of solid thin films of PbS QDs capped with thiol molecules. As the temperature was increased from cryogenic to room temperature, we discovered a phase transition in the fluorescence spectra from excitonic emission to trap emission. The critical temperature (T(c)) of the phase transition scales with molecular length and in each case is close to the bulk melting temperature of the capping molecules. We conclude that an order-disorder transition in the molecular monolayer above T(c) introduces surface mobility and the formation of a disordered atomic lead layer at the QD/capping molecule interface, leading to electronic trap formation.

Identifying key roles of the pharmacy technician in primary care settings.

PURPOSE: As the pharmacist's role expands, particularly in primary care practice settings, there is an opportunity for expansion of pharmacy technician duties to aid in administrative and clinical tasks that do not require the pharmacist's professional judgment. Identifying, defining, and expanding the roles of pharmacy technicians has been deemed a key part of the pharmacy practice model. These roles have been shown to enhance pharmacist efficiency and patient outreach; however, examples of the various innovative activities performed by technicians in the primary care setting are lacking in the literature. METHODS: The duties of primary care pharmacy technicians were compiled and defined in 2 different healthcare systems. The role of the technician was separately implemented at each institution, and study designs and protocols were individually created and executed. One institution utilized a 4-round consensus-building process to systematically refine and codify tasks for a dictionary of duties. The second institution utilized a free-text survey, task documentation data in the electronic medical record, and a telephone discussion with the technicians. RESULTS: Despite a lack of methods- and data-sharing between the 2 institutions, similar tasks were identified, including conducting patient outreach, assisting with medication affordability and access, providing patient education, managing referrals, and scheduling appointments. Differences in technician involvement were noted in areas such as prior authorization, care coordination meetings, and quality improvement projects. CONCLUSION: Pharmacy technicians are a helpful, yet underutilized, resource in the primary care setting. Further exploration of technician roles is needed to determine the financial and clinical impact of expanding these roles.

Pre-arrest diversion to addiction treatment by law enforcement: protocol for the community-level policing initiative to reduce addiction-related harm, including crime.

BACKGROUND: Despite evidence that treatment reduces addiction-related harms, including crime and overdose, only a minority of addiction-affected individuals receive it. Linking individuals who committed an addiction-related crime to addiction treatment could improve outcomes. METHODS: The aim of this city-wide, pre-arrest diversion program, Madison Addiction Recovery Initiative (MARI) is to reduce crime and improve health (i.e., reduce the overdose deaths) among adults who committed a minor, non-violent, drug use-related offense by offering them a referral to treatment in lieu of arrest and prosecution of criminal charges. This manuscript outlines the protocol and methods for the MARI program development and implementation. MARI requires its participants to engage in the recommended treatment, without reoffending, during the six-month program, after which the initial criminal charges are "voided" by the law enforcement agency. The project, implemented in a mid-size U.S. city, has involved numerous partners, including law enforcement, criminal justice, public health, and academia. It includes training of the police officer workforce and collaboration with clinical partners for treatment need assessment, treatment placement, and peer support. Program evaluation includes formative, process, outcome (participant-level) and exploratory impact (community-level) assessments. For outcome evaluation, we will compare crime (primary outcome), overdose-related offenses, and incarceration-related data 12 months before and 12 months after the index crime between participants who completed (Group 1), started but not completed (Group 2), and were offered but did not start (Group 3) the program, and adults who would have been eligible should MARI existed (Historical Comparison, Group 4). Clinical characteristics will be compared at baseline between Groups 1-2, and pre-post the program within Group 1. Participant baseline data will be assessed as potential covariates. Surveys of police officers and program completers, and community-level indicators of crime and overdose pre- versus post-program will provide additional data on the program impact. DISCUSSION: By offering addiction treatment in lieu of arrest and prosecution of criminal charges, this pre-arrest diversion program has the potential to disrupt the cycle of crime, reduce the likelihood of future offenses, and promote public health and safety.

Effective enrichment and mass spectrometry analysis of phosphopeptides using mesoporous metal oxide nanomaterials.

Mass spectrometry (MS)-based phosphoproteomics remains challenging due to the low abundance of phosphoproteins and substoichiometric phosphorylation. This demands better methods to effectively enrich phosphoproteins/peptides prior to MS analysis. We have previously communicated the first use of mesoporous zirconium dioxide (ZrO(2)) nanomaterials for effective phosphopeptide enrichment. Here, we present the full report including the synthesis, characterization, and application of mesoporous titanium dioxide (TiO(2)), ZrO(2), and hafnium dioxide (HfO(2)) in phosphopeptide enrichment and MS analysis. Mesoporous ZrO(2) and HfO(2) are demonstrated to be superior to TiO(2) for phosphopeptide enrichment from a complex mixture with high specificity (>99%), which could almost be considered as a "purification", mainly because of the extremely large active surface area of mesoporous nanomaterials. A single enrichment and Fourier transform MS analysis of phosphopeptides digested from a complex mixture containing 7% of alpha-casein identified 21 out of 22 phosphorylation sites for alpha-casein. Moreover, the mesoporous ZrO(2) and HfO(2) can be reused after a simple solution regeneration procedure with comparable enrichment performance to that of fresh materials. Mesoporous ZrO(2) and HfO(2) nanomaterials hold great promise for applications in MS-based phosphoproteomics.

Identification of critical factors for forming collaborative relationships between physicians and pharmacists.

PURPOSE: The purpose of this study was to identify and describe strategies that have successfully achieved collaboration among physicians and pharmacists providing comprehensive medication management (CMM) to support development of CMM services. METHODS: A 2-phase, mixed-methods approach was employed to identify successful strategies for building pharmacist-physician relationships in primary care clinic settings. Phase I used a qualitative approach to identify strategies deemed successful in building relationships with physicians. An advisory group of pharmacists with experience building CMM practices assisted in the development of minimum criteria characterizing pharmacists as having strong collaborative relationships. Semi-structured interviews were conducted with 10 interviewees meeting established criteria. Researchers coded interview transcripts and identified the resulting strategies. Phase II employed a survey instrument to determine how frequently identified strategies are used and evaluate the relative level of perceived impact of each strategy, which was distributed to a national audience of pharmacists practicing in ambulatory care settings. Responses from pharmacists meeting prespecified criteria were included in the analysis. RESULTS: Thirty-three strategies were identified and grouped into 8 themes. In phase II, 104 survey respondents met defined criteria and were eligible to endorse use of identified strategies and rate their relative influence. CONCLUSIONS: Thirty-three strategies were identified and grouped into 8 themes to aid pharmacists practicing CMM in developing stronger collaborative relationships with physician colleagues. A national sampling found many of these strategies were employed by a majority of pharmacists, who had found them to be influential in creating collaborative relationships.

Cyclooxygenase-2 transactivates the epidermal growth factor receptor through specific E-prostanoid receptors and tumor necrosis factor-alpha converting enzyme.

Cyclooxygenase-2 is often highly expressed in epithelial malignancies and likely has an active role in tumor development. But how it promotes tumorigenesis is not clearly defined. Recent evidence suggests that this may involve transactivation of the epidermal growth factor receptor through E-prostanoid receptors, but reports differ about the mechanism by which this occurs. We found that E-prostanoid receptors 2-4, but not 1, transactivated the epidermal growth factor receptor. This required metalloproteinase activity, leading to release of growth factors from the cell surface. Both transforming growth factor-alpha and amphiregulin were released in response to over-expression of cyclooxygenase-2, but betacellulin and heparin-binding EGF-like growth factor were not. The metalloproteinase tumor necrosis factor-alpha converting enzyme was required for proteolytic release of transforming growth factor-alpha. We also found that addition of epidermal growth factor receptor ligands to HEK293 cells induced cyclooxygenase-2 expression, suggesting that by activating epidermal growth factor receptor signaling, cyclooxygenase-2 potentially creates a self-perpetuating cycle of cell growth. Consistent with this, inhibition of cyclooxygenase-2 reduced growth of epidermal growth factor receptor over-expressing MCF-10A breast epithelial cells in three-dimensional culture.

Single-row modified mason-allen versus double-row arthroscopic rotator cuff repair: a biomechanical and surface area comparison.

PURPOSE: The purpose of this study was to compare the time-zero biomechanical strength and the surface area of repair between a single-row modified Mason-Allen rotator cuff repair and a double-row arthroscopic repair. METHODS: Six matched pairs of sheep infraspinatus tendons were repaired by both techniques. Pressure-sensitive film was used to measure the surface area of repair for each configuration. Specimens were biomechanically tested with cyclic loading from 20 N to 30 N for 20 cycles and were loaded to failure at a rate of 1 mm/s. Failure was defined at 5 mm of gap formation. RESULTS: Double-row suture anchor fixation restored a mean surface area of 258.23 +/- 69.7 mm(2) versus 148.08 +/- 75.5 mm(2) for single-row fixation, a 74% increase (P = .025). Both repairs had statistically similar time-zero biomechanics. There was no statistical difference in peak-to-peak displacement or elongation during cyclic loading. Single-row fixation showed a higher mean load to failure (110.26 +/- 26.4 N) than double-row fixation (108.93 +/- 21.8 N). This was not statistically significant (P = .932). All specimens failed at the suture-tendon interface. CONCLUSIONS: Double-row suture anchor fixation restores a greater percentage of the anatomic footprint when compared with a single-row Mason-Allen technique. The time-zero biomechanical strength was not significantly different between the 2 study groups. This study suggests that the 2 factors are independent of each other. CLINICAL RELEVANCE: Surface area and biomechanical strength of fixation are 2 independent factors in the outcome of rotator cuff repair. Maximizing both factors may increase the likelihood of complete tendon-bone healing and ultimately improve clinical outcomes. For smaller tears, a single-row modified Mason-Allen suture technique may provide sufficient strength, but for large amenable tears, a double row can provide both strength and increased surface area for healing.

Determination of anterior labral repair stress during passive arm motion in a cadaveric model.

PURPOSE: The actual forces encountered at the labrum after anterior labral repair have yet to be quantified. The purpose of this study was to determine the amount of force experienced at the glenoid-labrum interface with passive range of motion after an isolated Bankart repair and Bankart repair with capsular shift. METHODS: In 12 fresh-frozen cadaveric shoulders, anterior-inferior labral tears were created and then instrumented with a modified load cell. The labral lesions were repaired with either an anatomic "labral only" technique or a labral repair along with a capsular shift by use of a transglenoid technique. Shoulders were then taken through a series of movements (forward flexion, abduction, external rotation, and abduction and then external rotation) simulating passive range-of-motion rehabilitation while force measurements were taken. Maximum force (in Newtons) on the simulated repairs was recorded. RESULTS: The forces experienced at the labrum showed a statistically significant difference between the group that underwent anatomic "labral only" repair and the group that underwent labral repair with capsular shift. The greatest mean force experienced (17.7 N) was in shoulders undergoing the labral repair with capsular shift with the arm in abduction and external rotation. CONCLUSIONS: In a transglenoid suture repair technique, the forces experienced at the repair site were significantly less than those determined by previous authors to be necessary to result in failure of the Bankart repair. The results of this study show that the forces experienced at the glenoid-labrum interface are higher when a capsular shift is included with a labral repair as opposed to labral repair alone. This difference was statistically significant. CLINICAL RELEVANCE: These data suggest that early postoperative rehabilitation may safely allow greater passive range of motion than is presently accepted.

A biomechanical comparison of the modified Mason-Allen stitch and massive cuff stitch in vitro.

PURPOSE: The suture-tendon interface is generally regarded as the weak link in rotator cuff fixation. High rates of failure in arthroscopic rotator cuff repair have led to a search for strong yet easy-to-perform suture configurations. The goal of this study was to compare the strength of 2 commonly used suture configurations, the modified Mason-Allen stitch and the massive cuff stitch, when suture-anchored into bone. METHODS: Fourteen sheep shoulders were harvested and the infraspinatus tendon isolated. Each infraspinatus tendon was split in half longitudinally along the axis of its fibers to yield 2 tendon-bone specimens per shoulder, for a total of 28 specimens. Each split tendon was then repaired by use of a double-loaded suture anchor with a modified Mason-Allen and simple suture in one specimen and the massive cuff stitch in the other. Each specimen was initially cyclically loaded on a vertical MTS uniaxial load frame (MTS Systems, Eden Prairie, MN) under force control from 5 to 30 N at 0.25 Hz for 20 cycles. Each specimen was then loaded to failure under displacement control at a rate of 1 mm/s. Peak-to-peak displacement, cyclic elongation, ultimate tensile load, stiffness, and mode of failure were recorded. A repeated-measures analysis of variance was performed, with an alpha level of significance set at P < .05. RESULTS: No statistically significant difference was found with regard to ultimate load to failure between the modified Mason-Allen stitch (110.4 +/- 55.1 N) and massive cuff stitch (116.4 +/- 37.9 N). In addition, no statistically significant difference was found with regard to cyclic elongation, peak-to-peak displacement, or initial displacement. The most common mode of failure for both suture configurations was suture pullout. CONCLUSIONS: The modified Mason-Allen stitch and massive cuff stitch yield similar biomechanical profiles when suture-anchored into bone. CLINICAL RELEVANCE: The massive cuff stitch may be a simpler and biomechanically equivalent alternative to the modified Mason-Allen stitch in arthroscopic rotator cuff repair.

Are microsatellite fragment lengths useful for population-level studies? The case of Polygala lewtonii (Polygalaceae).

PREMISE OF THE STUDY: Microsatellites, despite being commonly used population-level markers, contain biases because scoring relies solely on fragment length. Their complexity can lead to homoplasy, the effects of which are poorly understood. We investigated the impact of using fragment lengths, repeats, or flanking region sequences on common population-level analyses. METHODS: Five polymorphic microsatellite markers amplified across the central Florida scrub endemic Polygala lewtonii (Polygalaceae) and its close, widespread congener P. polygama. We genotyped 147 individuals of P. lewtonii and 156 of P. polygama, and sequenced the amplicons of four markers across all individuals. We ran basic statistics, spatial clustering analysis, historical demographics, and migration tests. RESULTS: One population of intermediate morphology was genetically clearly identified as P. polygama, making it the southernmost population of this species. Statistics were comparable between the fragment length and repeat numbers, with some notable differences. Flanking regions exhibited surprisingly high polymorphism between species, and between geographically distant conspecific populations. DISCUSSION: The increasing use of markers developed in one species and amplified in another is only a good practice if precautions are taken, notably the sequencing of the fragments between species and populations. Flanking region sequences are a useful marker at the interspecific level.

Hot electron injection from graphene quantum dots to TiO2.

The Shockley-Queisser limit is the maximum power conversion efficiency of a conventional solar cell based on a single semiconductor junction. One approach to exceed this limit is to harvest hot electrons/holes that have achieved quasi-equilibrium in the light absorbing material with electronic temperatures higher than the phonon temperature. We argue that graphene based materials are viable candidates for hot carrier chromophores. Here we probe hot electron injection and charge recombination dynamics for graphene quantum dots (QDs, each containing 48 fused benzene rings) anchored to the TiO2(110) surface via carboxyl linkers. We find ultrafast electron injection from photoexcited graphene QDs to the TiO2 conduction band with time constant τ(i) < 15 fs and charge recombination dynamics characterized by a fast channel (τ(r1) = 80-130 fs) and a slow one (τ(r2) = 0.5-2 ps). The fast decay channel is attributed to the prompt recombination of the bound electron-hole pair across the interface. The slow channel depends strongly on excitation photon energy or sample temperature and can be explained by a "boomerang" mechanism, in which hot electrons are injected into bulk TiO2, cooled down due to electron-phonon scattering, drifted back to the interface under the transient electric field, and recombine with the hole on graphene QDs. We discuss feasibilities of implementing the hot carrier solar cell using graphene nanomaterials.

Multi component self-assembly: supramolecular organic frameworks containing metal-rotaxane subunits (RSOFs).

A facile, one-pot synthesis of rotaxanated supramolecular organic frameworks (RSOFs) is reported. These systems consist of bis-carboxylate anions threaded through the core of tetraimidazolium macrocycles. Trivalent metal cations, yttrium(III) and smaller lanthanides, are used to "lock" the threaded strut in place. This results in the formation of three-dimensional RSOFs.

Rare-earth cation effects on three-dimensional metal-organic rotaxane framework (MORF) self assembly.

A set of metal-organic rotaxane frameworks (MORFs) are constructed with the use of a tetraimidazolium macrocycle, the terephthalate dianion, and the trivalent lanthanide metal cations Nd(III), Sm(III), Eu(III) or Tb(III) and are reported herein. The specific choice of the metal cation allows for control of the structure and luminescent properties of the resulting molecular frameworks.

Clinical concepts for treatment of the elbow in the adolescent overhead athlete.

Injuries to the adolescent elbow are common because of the repetitive overuse inherent in many overhead sport activities. The management of these patients is greatly facilitated through a greater understanding of the demands placed on the upper extremity kinetic chain during these overhead activities as well as a detailed examination and rehabilitation for the entire upper extremity kinetic chain. Particular emphasis on improving rotator cuff strength and muscular endurance, along with scapular stabilization, is a critical part of elbow rehabilitation in these patients. In addition, the use of a strategic and progressive interval sport return program is necessary to minimize reinjury and return the adolescent overhead athlete to full function.

Apophyseal avulsion fractures of the hip and pelvis.

Apophyseal avulsion fractures of the hip and pelvis are infrequent pediatric fractures. However an increase of adolescent participation in competitive sporting activities and better musculoskeletal imaging techniques has led to an increased awareness of these injuries by the medical community. These fractures can be easily missed. When these fractures are diagnosed and treated appropriately, nonsurgical protocol has bee proposed in the literature. Surgical treatment is usually reserved for certain indications. Complications of these injuries include painful nonunion, exostosis, osteonecrosis, and mechanism of injury and treatment options, these fractures can be successfully diagnosed and treated.

Mesoporous zirconium oxide nanomaterials effectively enrich phosphopeptides for mass spectrometry-based phosphoproteomics.

This work represents the first use of mesoporous zirconium oxide nanomaterials for highly effective and selective enrichment of phosphorylated peptides.