Prediction of gestational diabetes mellitus at the first trimester: machine-learning algorithms.

PURPOSE: Short- and long-term complications of gestational diabetes mellitus (GDM) involving pregnancies and offspring warrant the development of an effective individualized risk prediction model to reduce and prevent GDM together with its associated co-morbidities. The aim is to use machine learning (ML) algorithms to study data gathered throughout the first trimester in order to predict GDM. METHODS: Two independent cohorts with forty-five features gathered through first trimester were included. We constructed prediction models based on three different algorithms and traditional logistic regression, and deployed additional two ensemble algorithms to identify the importance of individual features. RESULTS: 4799 and 2795 pregnancies were included in the Xinhua Hospital Chongming branch (XHCM) and the Shanghai Pudong New Area People's Hospital (SPNPH) cohorts, respectively. Extreme gradient boosting (XGBoost) predicted GDM with moderate performance (the area under the receiver operating curve (AUC) = 0.75) at pregnancy initiation and good-to-excellent performance (AUC = 0.99) at the end of the first trimester in the XHCM cohort. The trained XGBoost showed moderate performance in the SPNPH cohort (AUC = 0.83). The top predictive features for GDM diagnosis were pre-pregnancy BMI and maternal abdominal circumference at pregnancy initiation, and FPG and HbA1c at the end of the first trimester. CONCLUSION: Our work demonstrated that ML models based on the data gathered throughout the first trimester achieved moderate performance in the external validation cohort.

Two-dimensional ferroelectricity in a single-element bismuth monolayer.

Ferroelectric materials are fascinating for their non-volatile switchable electric polarizations induced by the spontaneous inversion-symmetry breaking. However, in all of the conventional ferroelectric compounds, at least two constituent ions are required to support the polarization switching1,2. Here, we report the observation of a single-element ferroelectric state in a black phosphorus-like bismuth layer3, in which the ordered charge transfer and the regular atom distortion between sublattices happen simultaneously. Instead of a homogenous orbital configuration that ordinarily occurs in elementary substances, we found the Bi atoms in a black phosphorous-like Bi monolayer maintain a weak and anisotropic sp orbital hybridization, giving rise to the inversion-symmetry-broken buckled structure accompanied with charge redistribution in the unit cell. As a result, the in-plane electric polarization emerges in the Bi monolayer. Using the in-plane electric field produced by scanning probe microscopy, ferroelectric switching is further visualized experimentally. Owing to the conjugative locking between the charge transfer and atom displacement, we also observe the anomalous electric potential profile at the 180° tail-to-tail domain wall induced by competition between the electronic structure and electric polarization. This emergent single-element ferroelectricity broadens the mechanism of ferroelectrics and may enrich the applications of ferroelectronics in the future.

Modeling Family Medicine Provider Care Team Design to Improve Patient Care Continuity.

BACKGROUND AND OBJECTIVES: Continuity of care is an integral aspect of high-quality patient care in primary care settings. In the Department of Family Medicine at Mayo Clinic, providers have multiple responsibilities in addition to clinical duties or panel management time (PMT). These competing time demands limit providers' clinical availability. One way to mitigate the impact on patient access and care continuity is to create provider care teams to collectively share the responsibility of meeting patients' needs. METHODS: This study presents a descriptive characterization of patient care continuity based on provider types and PMT. Care continuity was measured by the percentage of patient a ppointments s een by a provider in their o wn c are t eam (ASOCT) with the aim of reducing the variability of provider care team continuity. The prediction method is iteratively developed to illustrate the importance of the individual independent components. An optimization model is then used to determine optimal provider mix in a team. RESULTS: The ASOCT percentage in current practice among care teams ranges from 46% to 68% and the per team number of MDs varies from 1 to 5 while the number of nurse practitioners and physician assistants (NP/PAs) ranges from 0 to 6. The proposed methods result in the optimal provider assignment, which has an ASOCT percentage consistently at 62% for all care teams and 3 or 4 physicians (MDs) and NP/PAs in each care team. CONCLUSIONS: The predictive model combined with assignment optimization generates a more consistent ASOCT percentage, provider mix, and provider count for each care team.

Convolutional Neural Networks for Classifying Cervical Cancer Types Using Histological Images.

Cervical cancer is the most common cancer among women worldwide. The diagnosis and classification of cancer are extremely important, as it influences the optimal treatment and length of survival. The objective was to develop and validate a diagnosis system based on convolutional neural networks (CNN) that identifies cervical malignancies and provides diagnostic interpretability. A total of 8496 labeled histology images were extracted from 229 cervical specimens (cervical squamous cell carcinoma, SCC, n = 37; cervical adenocarcinoma, AC, n = 8; nonmalignant cervical tissues, n = 184). AlexNet, VGG-19, Xception, and ResNet-50 with five-fold cross-validation were constructed to distinguish cervical cancer images from nonmalignant images. The performance of CNNs was quantified in terms of accuracy, precision, recall, and the area under the receiver operating curve (AUC). Six pathologists were recruited to make a comparison with the performance of CNNs. Guided Backpropagation and Gradient-weighted Class Activation Mapping (Grad-CAM) were deployed to highlight the area of high malignant probability. The Xception model had excellent performance in identifying cervical SCC and AC in test sets. For cervical SCC, AUC was 0.98 (internal validation) and 0.974 (external validation). For cervical AC, AUC was 0.966 (internal validation) and 0.958 (external validation). The performance of CNNs falls between experienced and inexperienced pathologists. Grad-CAM and Guided Gard-CAM ensured diagnoses interpretability by highlighting morphological features of malignant changes. CNN is efficient for histological image classification tasks of distinguishing cervical malignancies from benign tissues and could highlight the specific areas of concern. All these findings suggest that CNNs could serve as a diagnostic tool to aid pathologic diagnosis.

Balancing Clinician Workload Through Strategic Patient Panel Designs.

BACKGROUND AND OBJECTIVES: Clinician workload is a key contributor to burnout and well-being as well as overtime and staff shortages, particularly in the primary care setting. Appointment volume is primarily driven by the size of patient panels assigned to clinicians. Thus, finding the most appropriate panel size for each clinician is essential to optimization of patient care. METHODS: One year of appointment and panel data from the Department of Family Medicine were used to model the optimal panel size. The data consisted of 82 881 patients and 105 clinicians. This optimization-based modeling approach determines the panel size that maximizes clinician capacity while distributing heterogeneous appointment types among clinician groups with respect to their panel management time (PMT), which is the percent of clinic work. RESULTS: The differences between consecutive PMT physician groups in total annual appointment volumes per clinician for the current practice range from 176 to 348. The optimization-based approach for the same PMT physician group results in having a range from 211 to 232 appointments, a relative reduction in variability of 88%. Similar workload balance gains are also observed for advanced practice clinicians and resident groups. These results show that the proposed approach significantly improves both patient and appointment workloads distributed among clinician groups. CONCLUSION: Appropriate panel size has valuable implications for clinician well-being, patients' timely access to care, clinic and health system productivity, and the quality of care delivered. Results demonstrate substantial improvements with respect to balancing appointment workload across clinician types through strategic use of an optimization-based approach.

Epitaxial Growth of Single-Layer Kagome Nanoflakes with Topological Band Inversion.

The kagome lattice has attracted intense interest with the promise of realizing topological phases built from strongly interacting electrons. However, fabricating two-dimensional (2D) kagome materials with nontrivial topology is still a key challenge. Here, we report the growth of single-layer iron germanide kagome nanoflakes by molecular beam epitaxy. Using scanning tunneling microscopy/spectroscopy, we unravel the real-space electronic localization of the kagome flat bands. First-principles calculations demonstrate the topological band inversion, suggesting the topological nature of the experimentally observed edge mode. Apart from the intrinsic topological states that potentially host chiral edge modes, the realization of kagome materials in the 2D limit also holds promise for future studies of geometric frustration.

Coordination of Intraoperative Neurophysiologic Monitoring Technologist and Surgery Schedules.

Resource coordination in surgical scheduling remains challenging in health care delivery systems. This is especially the case in highly-specialized settings such as coordinating Intraoperative Neurophysiologic Monitoring (IONM) resources. Inefficient coordination yields higher costs, limited access to care, and creates constraints to surgical quality and outcomes. To maximize utilization of IONM resources, optimization-based algorithms are proposed to effectively schedule IONM surgical cases and technologists and evaluate staffing needs. Data with 10 days of case volumes, their surgery durations, and technologist staffing was used to demonstrate method effectiveness. An iterative optimization-based model that determines both optimal surgery and technologist start time (operational scenario 4) was built in an Excel spreadsheet along with Excel's Solver settings. It was compared with current practice (operational scenario 1) and optimization solution on only surgery start time (operational scenario 2) or technologist start time (operational scenario 3). Comparisons are made with respect to technologist overtime and under-utilization time. The results conclude that scenario 4 significantly reduces overtime by 74% and under-utilization time by 86% as well as technologist needs by 10%. For practices that do not have flexibility to alter surgeon preference on surgery start time or IONM technologist staffing levels, both scenarios 2 and 3 also result in substantial reductions in technologist overtime and under-utilization. Moreover, IONM technologist staffing options are discussed to accommodate technologist preferences and set constraints for surgical case scheduling. All optimization-based approaches presented in this paper are able to improve utilization of IONM resources and ultimately improve the coordination and efficiency of highly-specialized resources.

Room Temperature Ferromagnetism of Monolayer Chromium Telluride with Perpendicular Magnetic Anisotropy.

The realization of long-range magnetic ordering in 2D systems can potentially revolutionize next-generation information technology. Here, the successful fabrication of crystalline Cr3 Te4 monolayers with room temperature (RT) ferromagnetism is reported. Using molecular beam epitaxy, the growth of 2D Cr3 Te4 films with monolayer thickness is demonstrated at low substrate temperatures (≈100 °C), compatible with Si complementary metal oxide semiconductor technology. X-ray magnetic circular dichroism measurements reveal a Curie temperature (Tc ) of v344 K for the Cr3 Te4 monolayer with an out-of-plane magnetic easy axis, which decreases to v240 K for the thicker film (≈7 nm) with an in-plane easy axis. The enhancement of ferromagnetic coupling and the magnetic anisotropy transition is ascribed to interfacial effects, in particular the orbital overlap at the monolayer Cr3 Te4 /graphite interface, supported by density-functional theory calculations. This work sheds light on the low-temperature scalable growth of 2D nonlayered materials with RT ferromagnetism for new magnetic and spintronic devices.

Coronavirus Disease 2019-Related Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis.

BACKGROUND: This study aimed to describe the clinical symptoms, laboratory findings, treatment, and outcomes of coronavirus disease 2019-related multisystem inflammatory syndrome in children to provide a reference for clinical practice. METHODS: We employed a literature search of databases such as PubMed, Web of Science, EMBASE, and Johns Hopkins University for articles on COVID-19-related multisystem inflammatory syndrome in children published between April 1, 2020, and January 15, 2021. High-quality articles were selected for analysis on the basis of their quality standard scores. Using R3.6.3 software, meta-analyses of random- or fixed-effects models were used to determine the prevalence of comorbidities. Subgroup analysis was also performed to determine heterogeneity. RESULTS: A total of 57 articles (2,290 pediatric patients) were included in the study. Clinical Manifestations. :ncidences of fever, gastrointestinal symptoms, respiratory symptoms, and musculoskeletal symptoms (myalgias or arthralgias) were 99.91% (95% CI: 99.67-100%), 82.72% (95% CI: 78.19-86.81%), 53.02% (45.28-60.68%), and 14.16% (95% CI: 8.4-21.12%), respectively. The incidences of rash, conjunctival injection, lymphadenopathy, dry cracked lips, neurologic symptoms (headache, altered mental status, or confusion), swollen hands and feet, typical Kawasaki disease, and atypical Kawasaki disease were 59.34% (95% CI: 54.73-63.87%), 55.23% (95% CI: 50.22-60.19%), 27.07% (95% CI: 19.87-34.93%), 46.37% (95% CI: 39.97-52.83%), 28.87% (95% CI: 22.76-35.40%), 28.75% (95% CI: 21.46-36.64%), 17.32% (95% CI: 15.44-19.29%), and 36.19% (95% CI: 21.90-51.86%), respectively. The incidences of coronary artery dilation, aneurysm, pericardial effusion, myocarditis, myocardial dysfunction, high troponin, and N-terminal pro-B-type natriuretic peptide were 17.83%, 6.85%, 20.97%, 35.97%, 56.32%, 76.34%, and 86.65%, respectively. The incidences of reduced lymphocytes, thrombocytopenia, hypoalbuminemia, elevated C-reactive protein, ferritin, LDH, interleukin-6, PCT, and FIB were 61.51%, 26.42%, 77.92%, 98.5%, 86.79%, 80.59%, 89.30%, 85.10%, and 87.01%, respectively. PICU Hospitalization Rate and Mortality. The incidences of PICU hospitalization or with shock were 72.79% and 55.68%, respectively. The mortality rate was 1.00%. Conclusion and Relevance. PICU hospitalization and shock rates of multisystem inflammatory syndrome in children associated with COVID-19 were high, and its cumulative multiorgans and inflammatory indicators are increased, but if treated in time, the mortality rate was low.

Diverse Structures and Magnetic Properties in Nonlayered Monolayer Chromium Selenide.

Thickness-dependent magnetic behavior has previously been observed in chemical vapor deposition-grown chromium selenide. However, the low-dimensional structure in nonlayered chromium selenide, which plays a crucial role in determining the low-dimensional magnetic order, needs further study. Here, we report the structure-dependent magnetic properties in monolayer CrSe2 and Cr2Se3 grown by molecular beam epitaxy. In the monolayer CrSe2, 1T-CrSe2 with a lattice constant of 3.3 Å has a metallic character, coexisting with the 1T″ phase with 2 × 2 surface periodicity. Monolayer CrSe2 can be transformed into Cr2Se3 with a lattice constant of 3.6 Å by annealing at 300 °C. X-ray magnetic circular dichroism (XMCD) measurements combined with DFT calculations reveal that while the MBE-grown monolayer CrSe2 is antiferromagnetic, monolayer Cr2Se3 is ferromagnetic with a Curie temperature of ∼200 K. This work demonstrates the structural diversity in nonlayered chromium selenide and the critical effect of different structures on its electronic and magnetic properties.

Reduce Patient Treatment wait time in a Proton Beam Facility - A Gatekeeper Approach.

Patient wait time can negatively impact treatment quality in a proton therapy center, where multiple treatment rooms share one proton beam. Wait time increases patient discomfort that can lead to patient motion, dissatisfaction, and longer treatment delay. This study was to develop a patient call-back model that reduced patient wait while efficiently utilizing the proton beam. A "Gatekeeper" logic allowing therapists to adjust the time of a patient's call-back to the treatment room was developed. It uses a two-pronged approach to minimize overlap of long treatment and the possibility of excessive wait in the queue to receive the proton beam. The goal was to reduce the maximum wait time to less than eight minutes per field for a four-room facility. The effectiveness of this logic was evaluated through simulation, and five scenarios were compared. Four scenarios implementing various levels of gatekeeper logic were compared with the original scenario without the logic. The best performing model provided a reduction of the maximum field wait by 26% and met the predefined goal. Adjusting call-back extended the treatment day length by an average of 6 min and a maximum of 12 min in total. The use of this gatekeeper logic significantly reduces patient field wait with minimal impact on treatment day length for a four-room proton facility. A sample interface that adopts this logic for therapists to make informed decision on patient call-back time is demonstrated.

Ketogenic Diet Suppressed T-Regulatory Cells and Promoted Cardiac Fibrosis via Reducing Mitochondria-Associated Membranes and Inhibiting Mitochondrial Function.

Ketogenic diet (KD) is popular in diabetic patients but its cardiac safety and efficiency on the heart are unknown. The aim of the present study is to determine the effects and the underlined mechanisms of KD on cardiac function in diabetic cardiomyopathy (DCM). We used db/db mice to model DCM, and different diets (regular or KD) were used. Cardiac function and interstitial fibrosis were determined. T-regulatory cell (Treg) number and functions were evaluated. The effects of ketone body (KB) on fatty acid (FA) and glucose metabolism, mitochondria-associated endoplasmic reticulum membranes (MAMs), and mitochondrial respiration were assessed. The mechanisms via which KB regulated MAMs and Tregs were addressed. KD improved metabolic indices in db/db mice. However, KD impaired cardiac diastolic function and exacerbated ventricular fibrosis. Proportions of circulatory CD4+CD25+Foxp3+ cells in whole blood cells and serum levels of IL-4 and IL-10 were reduced in mice fed with KD. KB suppressed the differentiation to Tregs from naive CD4+ T cells. Cultured medium from KB-treated Tregs synergically activated cardiac fibroblasts. Meanwhile, KB inhibited Treg proliferation and productions of IL-4 and IL-10. Treg MAMs, mitochondrial respiration and respiratory complexes, and FA synthesis and oxidation were all suppressed by KB while glycolytic levels were increased. L-carnitine reversed Treg proliferation and function inhibited by KB. Proportions of ST2L+ cells in Tregs were reduced by KB, as well as the production of ST2L ligand, IL-33. Reinforcement expressions of ST2L in Tregs counteracted the reductions in MAMs, mitochondrial respiration, and Treg proliferations and productions of Treg cytokines IL-4 and IL-10. Therefore, despite the improvement of metabolic indices, KD impaired Treg expansion and function and promoted cardiac fibroblast activation and interstitial fibrosis. This could be mainly mediated by the suppression of MAMs and fatty acid metabolism inhibition via blunting IL-33/ST2L signaling.

An Algorithm for Pairing Interventionalists and Surgeons for the TAVR Procedure.

The Transcatheter Aortic Valve Replacement (TAVR) procedure requires an initial consultation and a subsequent procedure by an interventionalist (IC) and surgeon. The IC-surgeon pair coordination is extremely challenging, especially at Mayo Clinic due to provider time commitments distributed across practice, research, and education activities. Current practice aims to establish the coordination manually, resulting in a scheduling process that is cumbersome and time consuming for the schedulers. We develop an algorithm for pairing ICs and surgeons that minimizes the lead time (days elapsed between the clinic consult and procedure). As compared to current practice, this algorithm is able to reduce average lead time by 59% and increase possible IC-surgeon pairs by 7%. The proposed algorithm is shown to be flexible enough to incorporate practice variations such as lead time upper bound and two procedure days for a single consult day. Algorithm alternatives are also presented for practices who may find the proposed algorithm infeasible for their practice.

The effect of moiré superstructures on topological edge states in twisted bismuthene homojunctions.

Creating and controlling the topological properties of two-dimensional topological insulators is essential for spintronic device applications. Here, we report the successful growth of bismuth homostructure consisting of monolayer bismuthene and single-layer black phosphorus-like Bi (BP-Bi) on the HOPG surface. Combining scanning tunneling microscopy/spectroscopy with noncontact atomic force microscopy, moiré superstructures with twist angles in the bismuth homostructure and the modulation of topological edge states of bismuthene were observed and studied. First-principles calculations reproduced the moiré superlattice and indicated that the structure fluctuation is ascribed to the stacking modes between bismuthene and BP-Bi, which induce spatially distributed interface interactions in the bismuth homostructure. The modulation of topological edge states is directly related to the variation of interlayer interactions. Our results suggest a promising pathway to tailor the topological states through interfacial interactions.

Can Reconstructed Se-Deficient Line Defects in Monolayer VSe2 Induce Magnetism?

There have been several recent conflicting reports on the ferromagnetism of clean monolayer VSe2 . Herein, the controllable formation of 1D defect line patterns in vanadium diselenide (VSe2 ) monolayers initiated by thermal annealing is presented. Using scanning tunneling microscopy and q-plus atomic force microscopy techniques, the 1D line features are determined to be 8-member-ring arrays, formed via a Se deficient reconstruction process. The reconstructed VSe2 monolayer with Se-deficient line defects displays room-temperature ferromagnetism under X-ray magnetic circular dichroism and magnetic force microscopy, consistent with the density functional theory calculations. This study possibly resolves the controversy on whether ferromagnetism is intrinsic in monolayer VSe2 , and highlights the importance of controlling and understanding the atomic structures of surface defects in 2D crystals, which could play key roles in the material properties and hence potential device applications.

High-Energy Gain Upconversion in Monolayer Tungsten Disulfide Photodetectors.

Photodetectors usually operate in the wavelength range with photon energy above the bandgap of channel semiconductors so that incident photons can excite electrons from valence band to conduction band to generate photocurrent. Here, however, we show that monolayer WS2 photodetectors can detect photons with energy even lying 219 meV below the bandgap of WS2 at room temperature. With the increase of excitation wavelength from 620 to 680 nm, photoresponsivity varies from 551 to 59 mA/W. This anomalous phenomenon is ascribed to energy upconversion, which is a combination effect of one-photon excitation and multiphonon absorption through an intermediate state created most likely by sulfur divacancy with oxygen adsorption. These findings will arouse research interests on other upconversion optoelectronic devices, photovoltaic devices, for example, of monolayer transition metal dichalcogenides (TMDCs).

Selective self-assembly of 2,3-diaminophenazine molecules on MoSe2 mirror twin boundaries.

The control of the density and type of line defects on two-dimensional (2D) materials enable the development of new methods to tailor their physical and chemical properties. In particular, mirror twin boundaries (MTBs) on transition metal dichacogenides have attracted much interest due to their metallic state with charge density wave transition and spin-charge separation property. In this work, we demonstrate the self-assembly of 2,3-diaminophenazine (DAP) molecule porous structure with alternate L-type and T-type aggregated configurations on the MoSe2 hexagonal wagon-wheel pattern surface. This site-specific molecular self-assembly is attributed to the more chemically reactive metallic MTBs compared to the pristine semiconducting MoSe2 domains. First-principles calculations reveal that the active MTBs couple with amino groups in the DAP molecules facilitating the DAP assembly. Our results demonstrate the site-dependent electronic and chemical properties of MoSe2 monolayers, which can be exploited as a natural template to create ordered nanostructures.

Point Defects and Localized Excitons in 2D WSe2.

Identifying the point defects in 2D materials is important for many applications. Recent studies have proposed that W vacancies are the predominant point defect in 2D WSe2, in contrast to theoretical studies, which predict that chalcogen vacancies are the most likely intrinsic point defects in transition metal dichalcogenide semiconductors. We show using first-principles calculations, scanning tunneling microscopy (STM), and scanning transmission electron microscopy experiments that W vacancies are not present in our CVD-grown 2D WSe2. We predict that O-passivated Se vacancies (OSe) and O interstitials (Oins) are present in 2D WSe2, because of facile O2 dissociation at Se vacancies or due to the presence of WO3 precursors in CVD growth. These defects give STM images in good agreement with experiment. The optical properties of point defects in 2D WSe2 are important because single-photon emission (SPE) from 2D WSe2 has been observed experimentally. While strain gradients funnel the exciton in real space, point defects are necessary for the localization of the exciton at length scales that enable photons to be emitted one at a time. Using state-of-the-art GW-Bethe-Salpeter-equation calculations, we predict that only Oins defects give localized excitons within the energy range of SPE in previous experiments, making them a likely source of previously observed SPE. No other point defects (OSe, Se vacancies, W vacancies, and SeW antisites) give localized excitons in the same energy range. Our predictions suggest ways to realize SPE in related 2D materials and point experimentalists toward other energy ranges for SPE in 2D WSe2.

Evidence of Spin Frustration in a Vanadium Diselenide Monolayer Magnet.

Monolayer VSe2 , featuring both charge density wave and magnetism phenomena, represents a unique van der Waals magnet in the family of metallic 2D transition-metal dichalcogenides (2D-TMDs). Herein, by means of in situ microscopy and spectroscopic techniques, including scanning tunneling microscopy/spectroscopy, synchrotron X-ray and angle-resolved photoemission, and X-ray absorption, direct spectroscopic signatures are established, that identify the metallic 1T-phase and vanadium 3d1 electronic configuration in monolayer VSe2 grown on graphite by molecular-beam epitaxy. Element-specific X-ray magnetic circular dichroism, complemented with magnetic susceptibility measurements, further reveals monolayer VSe2 as a frustrated magnet, with its spins exhibiting subtle correlations, albeit in the absence of a long-range magnetic order down to 2 K and up to a 7 T magnetic field. This observation is attributed to the relative stability of the ferromagnetic and antiferromagnetic ground states, arising from its atomic-scale structural features, such as rotational disorders and edges. The results of this study extend the current understanding of metallic 2D-TMDs in the search for exotic low-dimensional quantum phenomena, and stimulate further theoretical and experimental studies on van der Waals monolayer magnets.