Screening for Quality of Life in a Neurology Tic Clinic Using Quality Improvement Methodology.

BACKGROUND: Tic disorders in children often co-occur with other disorders that can significantly impact functioning. Screening for quality of life (QoL) can help identify optimal treatment paths. This quality improvement (QI) study describes implementation of a QoL measure in a busy neurology clinic to help guide psychological intervention for patients with tics. METHODS: Using QI methodology outlined by the Institute for Healthcare Improvement, this study implemented the PedsQL Generic Core (4.0) in an outpatient medical clinic specializing in the diagnosis and treatment of tic disorders. Assembling a research team to design process maps and key driver diagrams helped identify gaps in the screening process. Conducting several plan-do-study-act cycles refined identification of patients appropriate to receive the measure. Over the three-year study, electronic health record notification tools and data collection were increasingly utilized to capture patients' information during their visit. RESULTS: Over 350 unique patients were screened during the assessment period. Electronic means replaced paper measures as time progressed. The percentage of patients completing the measure increased from 0% to 51.9% after the initial implementation of process improvement, advancing to 91.6% after the introduction of electronic measures. This average completion rate was sustained for 15 months. CONCLUSIONS: Using QI methodology helped identify the pragmatics of implementing a QoL assessment to enhance screening practices in a busy medical clinic. Assessment review at the time of appointment helped inform treatment and referral decisions.

Two self-similar Reynolds-stress transport models with anisotropic eddy viscosity.

Two Reynolds-averaged Navier-Stokes models with full Reynolds-stress transport (RST) and tensor eddy viscosity are presented. These new models represent RST extensions of the k-2L-a-C and k-ϕ-L-a-C models by Morgan [Phys. Rev. E 103, 053108 (2021)10.1103/PhysRevE.103.053108; Phys. Rev. E 105, 045104 (2022)10.1103/PhysRevE.105.045104]. Self-similarity analysis is used to derive constraints on model coefficients required to reproduce expected growth parameters for a variety of canonical flows, including Rayleigh-Taylor (RT) and Kelvin-Helmholtz (KH) mixing layers. Both models are then applied in one-dimensional simulation of RT and KH mixing layers, and the expected self-similar growth rates and anisotropy are obtained. Next, models are applied in two-dimensional simulation of the so-called "tilted rocket rig" inclined RT experiment [J. Fluids Eng. 136, 091212 (2014)10.1115/1.4027587] and in simulation of a shock-accelerated localized patch of turbulence. It is found that RST is required to capture the qualitative growth of the shock-accelerated patch, and an anisotropic eddy viscosity provides substantial improvement over a Boussinesq treatment for the tilted rocket rig problem.

Psychometric properties of the Burnout Assessment Tool across four countries.

BACKGROUND: The Burnout Assessment Tool (BAT) is a new burnout measure developed to replace the Maslach Burnout Inventory (MBI). Studies have supported the psychometric properties and cross-cultural measurement invariance of the BAT. However, some unresolved questions remain. These questions are the appropriate level of score interpretation, convergent validity with the MBI, and measurement invariance using sample groups from countries outside of Europe. METHODS: We used a cross-sectional survey approach to obtain 794 participants from Australia (n = 200), the Netherlands (n = 199), South Africa (n = 197), and the United States (n = 198). In brief, we used bifactor modelling to investigate the appropriate score interpretation and convergent validity with the MBI. Hereafter, we used the Rasch model and ordinal logistic regression to investigate differential item functioning. RESULTS: The bifactor model showed a large general factor and four small group factors, which suggests calculating and interpreting a general burnout score. This model further shows that the BAT and MBI measure the same burnout construct but that the BAT is a more comprehensive burnout measure. Most items fit the Rasch model, and few showed non-negligible differential item functioning. CONCLUSIONS: Our results support the psychometric properties and cross-cultural measurement invariance of the BAT in Australia, the Netherlands, South Africa, and the United States. Furthermore, we provide some clarity on the three previously mentioned unresolved questions.

Large-eddy simulation and Reynolds-averaged Navier-Stokes modeling of three Rayleigh-Taylor mixing configurations with gravity reversal.

High-fidelity large-eddy simulation (LES) is performed of Rayleigh-Taylor (RT) mixing in three different configurations involving gravity reversal. In each configuration, LES results are compared with one-dimensional Reynolds-averaged Navier-Stokes (RANS) results, and a deficiency in a commonly used transport equation for the mass-flux velocity, a_{j}, is identified. In the first configuration, a classical two-component RT mixing layer is allowed to develop before it is subjected to rapid acceleration reversal. In the second configuration, a three-component RT mixing layer with an intermediate density layer is allowed to develop before being subjected to rapid acceleration reversal. Finally, in the third configuration, a light layer is interposed between two heavy layers; in this configuration, only one interface is RT-unstable at a time as it undergoes rapid acceleration reversal. In all cases, a commonly used buoyancy production closure in the a_{j} transport equation is shown to lead to significant over-prediction of mixing layer growth after gravity reversal. An alternative formulation for this closure is then presented which is shown to more accurately capture the stabilization effect of gravity reversal.

Simulation and Reynolds-averaged Navier-Stokes modeling of a three-component Rayleigh-Taylor mixing problem with thermonuclear burn.

Rayleigh-Taylor mixing in the presence of a third component with intermediate density is investigated through three-dimensional large-eddy simulation (LES) with a high-order compact finite-difference code. Two configurations are considered: (1) a symmetric configuration in which the Atwood number between the heavy and intermediate components matches the Atwood number between the intermediate and light components and (2) an asymmetric configuration in which the Atwood number between the heavy and intermediate components is an order of magnitude greater than the Atwood number between the intermediate and light components. Mass fraction covariances are extracted, and proposed Reynolds-averaged Navier-Stokes (RANS) closures for density-specific-volume and density-mass-fraction covariances are evaluated in an a priori fashion. In addition, a multicomponent extension of the k-ϕ-L-a-V RANS model [Morgan, Phys. Rev. E 104, 015107 (2021)2470-004510.1103/PhysRevE.104.015107] is presented which includes model equations for the upper-triangular elements of the mass fraction covariance matrix. This model, referred to as the k-ϕ-L-a-C model, is compared against results from LES and against other RANS models. Profiles of average mass fraction, mass-fraction covariance, and density-specific-volume covariance obtained with the k-ϕ-L-a-C model are found to agree well with LES data. Finally, the impact of three-component turbulent mixing on average reaction rate is investigated in both premixed and nonpremixed cases by heating the mixing layer and allowing it to undergo thermonuclear (TN) burn. A closure model for average reaction rate is proposed for use with the k-ϕ-L-a-C model, and when this model is applied, improved agreement is obtained between LES and RANS in total TN neutron production.

Self-consistent, high-order spatial profiles in a model for two-fluid turbulent mixing.

A Reynolds-averaged Navier-Stokes model is presented with the property that it admits self-consistent, high-order spatial profiles in simulations of two-fluid turbulent mixing layers. Whereas previous models have been limited by the assumption of a linear mixing profile, the present paper relaxes this assumption and, as a result, is shown to achieve much better agreement with experimental profiles. Similarity analysis is presented to derive constraints on model coefficients to enforce desired self-similar growth rates that are fully consistent with the high-order spatial profiles. Through this similarity analysis, it is shown that care must be taken in model construction, as it is possible to construct certain terms in such a way as to leave growth rates unconstrained. This model, termed the k-ϕ-L-a-V model, is then applied in simulations of Rayleigh-Taylor, Richtmyer-Meshkov, and Kelvin-Helmholtz mixing layers. These simulations confirm that the expected growth parameters are recovered and high-order spatial profiles are maintained.

Scalar mixing in a Kelvin-Helmholtz shear layer and implications for Reynolds-averaged Navier-Stokes modeling of mixing layers.

Large-eddy simulation of a temporally evolving Kelvin-Helmholtz (KH) mixing layer is performed with the tenth-order compact difference code miranda to examine the steady-state behavior of a passive scalar in a shear-driven mixing layer. It is shown that the integral behavior of scalar variance in a KH mixing layer behaves similarly to the integral behavior of scalar variance in a Rayleigh-Taylor (RT) mixing layer, and mixedness of the simulated KH shear layer tends towards a value of about 0.8. It is further shown that if the k-L-a-V Reynolds-averaged Navier-Stokes (RANS) model [B. E. Morgan et al., Phys. Rev. E 98, 033111 (2018)2470-004510.1103/PhysRevE.98.033111], calibrated to reproduce steady-state mixing in an RT layer, is applied to simulate a KH mixing layer, the RANS model will significantly overpredict the magnitude of scalar variance in the KH layer. A straightforward addition to the k-L-a-V model is then suggested, and self-similarity analysis is applied to determine constraints on model coefficients. It is shown that with the addition of a buoyancy production term in the model equation for scalar variance, it becomes possible to eliminate the model deficiency and match steady-state mixedness in simulations of both RT and KH mixing layers with a single model calibration.

DRY NEEDLING IN THE MANAGEMENT OF PATIENTS MEETING CLINICAL DIAGNOSTIC CRITERIA FOR SUBACROMIAL PAIN SYNDROME: A CASE SERIES.

BACKGROUND: Physical therapy interventions of exercise and manual therapy provide benefit in treatment of subacromial pain syndrome (SAPS). Dry needling is an emerging technique for treating musculoskeletal conditions; however, conflicting investigative evidence exists regarding the use of dry needling for SAPS. PURPOSE: The purpose of this case series was to describe the use of dry needling, in conjunction with exercise, as a management strategy for patients meeting clinical diagnostic criteria of SAPS and to observe the short- and intermediate-term effects of dry needling with therapeutic exercise in this population. A secondary purpose was to describe a framework of clinical reasoning to guide the pragmatic application of dry needling and exercise in clinical practice. STUDY DESIGN: Case series. METHODS: Twenty-five patients met criteria for SAPS and provided informed consent. Patients received examination-based dry needling for the first two visits with exercises added beginning at the third treatment session to help distinguish treatment effects. The primary outcome measure used in this study was the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) survey assessed at their third clinical visit, at four-weeks after starting intervention and again at a three-month follow up visit. RESULTS: On the Q-DASH survey 21 of 24 patients reported improvement at the third visit (range 4.5 to 38.6 points) and 19 of 22 reported improvement at the 3-month follow-up (range 0.1-54.5 points) relative to baseline. Sixteen of 24 patients at the third visit and 19 of 22 patients at the 3-month follow-up reported Global Rating of Changes scores of +3 or greater. CONCLUSION: This case series provides insight to the observed short- and intermediate-term effects of dry needling combined with exercise for SAPS. Additionally, it discusses the framework of clinical reasoning when applying this intervention. The results are encouraging for dry needling as an adjunct to exercise for treating patients with SAPS. LEVEL OF EVIDENCE: Therapy, level 4.

Direct numerical simulation and Reynolds-averaged Navier-Stokes modeling of the sudden viscous dissipation for multicomponent turbulence.

Simulations of a turbulent multicomponent fluid mixture undergoing isotropic deformations are carried out to investigate the sudden viscous dissipation. This dissipative mechanism was originally demonstrated using simulations of an incompressible single-component fluid [S. Davidovits and N. J. Fisch, Phys. Rev. Lett. 116, 105004 (2016)10.1103/PhysRevLett.116.105004]. By accounting for the convective and diffusive transfer of various species, the current work aims to increase the physical fidelity of previous simulations and their relevance to inertial confinement fusion applications. Direct numerical simulations of the compressed fluid show that the sudden viscous dissipation of turbulent kinetic energy is unchanged from the single-component scenario. More importantly, the simulations demonstrate that the mass fraction variance and covariance for the various species also exhibit a sudden viscous decay. Reynolds-averaged Navier-Stokes simulations were carried out using the k-l model to assess its ability to reproduce the sudden viscous dissipation. Results show that the standard k-l formulation does not capture the sudden decay of turbulent kinetic energy, mass-fraction variance, and mass-fraction covariance for simulations with various compression and expansion rates, or different exponents for the power-law model of viscosity. A new formulation of the k-l model that is based on previous improvements to the k-ε family of models is proposed, which leads to consistently good agreement with the direct numerical simulations for all the isotropic deformations under consideration.

Self-consistent feedback mechanism for the sudden viscous dissipation of finite-Mach-number compressing turbulence.

Previous work [Davidovits and Fisch, Phys. Rev. Lett. 116, 105004 (2016)PRLTAO0031-900710.1103/PhysRevLett.116.105004] demonstrated that the compression of a turbulent field can lead to a sudden viscous dissipation of turbulent kinetic energy (TKE), and that paper suggested this mechanism could potentially be used to design new fast-ignition schemes for inertial confinement fusion (ICF). We expand on previous work by accounting for finite Mach numbers, rather than relying on a zero-Mach-limit assumption as previously done. The finite-Mach-number formulation is necessary to capture a self-consistent feedback mechanism in which dissipated TKE increases the temperature of the system, which in turn modifies the viscosity and thus the TKE dissipation itself. Direct numerical simulations with a tenth-order accurate Padé scheme were carried out to analyze this self-consistent feedback loop for compressing turbulence. Results show that, for finite Mach numbers, the sudden viscous dissipation of TKE still occurs, for both the solenoidal and dilatational turbulent fields. As the domain is compressed, oscillations in dilatational TKE are encountered due to the highly oscillatory nature of the pressure dilatation. An analysis of the source terms for the internal energy shows that the mechanical-work term dominates the viscous turbulent dissipation. As a result, the effect of the suddenly dissipated TKE on temperature is minimal for the Mach numbers tested. Moreover, an analytical expression is derived that confirms the dissipated TKE does not significantly alter the temperature evolution for low Mach numbers, regardless of compression speed. The self-consistent feedback mechanism is thus quite weak for subsonic turbulence, which could limit its applicability for ICF.

Two-length-scale turbulence model for self-similar buoyancy-, shock-, and shear-driven mixing.

The three-equation k-L-a turbulence model [B. Morgan and M. Wickett, Three-equation model for the self-similar growth of Rayleigh-Taylor and Richtmyer-Meshkov instabilities, Phys. Rev. E 91, 043002 (2015)PLEEE81539-375510.1103/PhysRevE.91.043002] is extended by the addition of a second length scale equation. It is shown that the separation of turbulence transport and turbulence destruction length scales is necessary for simultaneous prediction of the growth parameter and turbulence intensity of a Kelvin-Helmholtz shear layer when model coefficients are constrained by similarity analysis. Constraints on model coefficients are derived that satisfy an ansatz of self-similarity in the low-Atwood-number limit and allow the determination of model coefficients necessary to recover expected experimental behavior. The model is then applied in one-dimensional simulations of Rayleigh-Taylor, reshocked Richtmyer-Meshkov, Kelvin-Helmholtz, and combined Rayleigh-Taylor-Kelvin-Helmholtz instability mixing layers to demonstrate that the expected growth rates are recovered numerically. Finally, it is shown in the case of combined instability that the model predicts a mixing width that is a linear combination of Rayleigh-Taylor and Kelvin-Helmholtz mixing processes.

Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy.

Background and Purpose: Clinical reasoning is essential to physical therapist practice. Solid clinical reasoning processes may lead to greater understanding of the patient condition, early diagnostic hypothesis development, and well-tolerated examination and intervention strategies, as well as mitigate the risk of diagnostic error. However, the complex and often subconscious nature of clinical reasoning can impede the development of this skill. Protracted tools have been published to help guide self-reflection on clinical reasoning but might not be feasible in typical clinical settings. Case Description: This case illustrates how the Systematic Clinical Reasoning in Physical Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a physical therapist to search the literature to answer a clinical question and facilitate formal mentorship sessions in postprofessional physical therapist training programs. Outcomes: The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan the examination, query the literature to answer a clinical question, establish a physical therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the mentee's clinical reasoning and provided the mentor insight into the mentee's clinical reasoning. The reliability and validity of the SCRIPT tool have not been formally studied. Discussion: Clinical mentorship is a cornerstone of postprofessional training programs and intended to develop advanced clinical reasoning skills. However, clinical reasoning is often subconscious and, therefore, a challenging skill to develop. The use of a tool such as the SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach to data gathering and making clinical judgments to bring clinical reasoning to the conscious level, facilitate self-reflection, and make a mentored physical therapist's thought processes explicit to his or her clinical mentor.

Three-equation model for the self-similar growth of Rayleigh-Taylor and Richtmyer-Meskov instabilities.

In the present work, the two-equation k-L model [G. Dimonte and R. Tipton, Phys. Fluids 18, 085101 (2006)] is extended by the addition of a third equation for the mass-flux velocity. A set of model constants is derived to satisfy an ansatz of self-similarity in the low Atwood number limit. The model is then applied to the simulation of canonical Rayleigh-Taylor and Richtmyer-Meshkov test problems in one dimension and is demonstrated to reproduce analytical self-similar growth and to recover growth rates used to constrain the model.

Resveratrol improves left ventricular diastolic relaxation in type 2 diabetes by inhibiting oxidative/nitrative stress: in vivo demonstration with magnetic resonance imaging.

Resveratrol is a natural phytophenol that exhibits cardioprotective effects. This study was designed to elucidate the mechanisms by which resveratrol protects against diabetes-induced cardiac dysfunction. Normal control (m-Lepr(db)) mice and type 2 diabetic (Lepr(db)) mice were treated with resveratrol orally for 4 wk. In vivo MRI showed that resveratrol improved cardiac function by increasing the left ventricular diastolic peak filling rate in Lepr(db) mice. This protective role is partially explained by resveratrol's effects in improving nitric oxide (NO) production and inhibiting oxidative/nitrative stress in cardiac tissue. Resveratrol increased NO production by enhancing endothelial NO synthase (eNOS) expression and reduced O(2)(·-) production by inhibiting NAD(P)H oxidase activity and gp91(phox) mRNA and protein expression. The increased nitrotyrosine (N-Tyr) protein expression in Lepr(db) mice was prevented by the inducible NO synthase (iNOS) inhibitor 1400W. Resveratrol reduced both N-Tyr and iNOS expression in Lepr(db) mice. Furthermore, TNF-α mRNA and protein expression, as well as NF-κB activation, were reduced in resveratrol-treated Lepr(db) mice. Both Lepr(db) mice null for TNF-α (db(TNF-)/db(TNF-) mice) and Lepr(db) mice treated with the NF-κB inhibitor MG-132 showed decreased NAD(P)H oxidase activity and iNOS expression as well as elevated eNOS expression, whereas m-Lepr(db) mice treated with TNF-α showed the opposite effects. Thus, resveratrol protects against cardiac dysfunction by inhibiting oxidative/nitrative stress and improving NO availability. This improvement is due to the role of resveratrol in inhibiting TNF-α-induced NF-κB activation, therefore subsequently inhibiting the expression and activation of NAD(P)H oxidase and iNOS as well as increasing eNOS expression in type 2 diabetes.

TEAD-1 overexpression in the mouse heart promotes an age-dependent heart dysfunction.

TEA domain transcription factor-1 (TEAD-1) is essential for proper heart development and is implicated in cardiac specific gene expression and the hypertrophic response of primary cardiomyocytes to hormonal and mechanical stimuli, and its activity increases in the pressure-overloaded hypertrophied rat heart. To investigate whether TEAD-1 is an in vivo modulator of cardiac specific gene expression and hypertrophy, we developed transgenic mice expressing hemagglutinin-tagged TEAD-1 under the control of the muscle creatine kinase promoter. We show that a sustained increase in TEAD-1 protein leads to an age-dependent dysfunction. Magnetic resonance imaging revealed decreases in cardiac output, stroke volume, ejection fraction, and fractional shortening. Isolated TEAD-1 hearts revealed decreased left ventricular power output that correlated with increased betaMyHC protein. Histological analysis showed altered alignment of cardiomyocytes, septal wall thickening, and fibrosis, although electrocardiography displayed a left axis shift of mean electrical axis. Transcripts representing most members of the fetal heart gene program remained elevated from fetal to adult life. Western blot analyses revealed decreases in p-phospholamban, SERCA2a, p-CX43, p-GSK-3alpha/beta, nuclear beta-catenin, GATA4, NFATc3/c4, and increased NCX1, nuclear DYKR1A, and Pur alpha/beta protein. TEAD-1 mice did not display cardiac hypertrophy. TEAD-1 mice do not tolerate stress as they die over a 4-day period after surgical induction of pressure overload. These data provide the first in vivo evidence that increased TEAD-1 can induce characteristics of cardiac remodeling associated with cardiomyopathy and heart failure.

Enhancement of in vivo and in vitro immune functions by a conformationally biased, response-selective agonist of human C5a: implications for a novel adjuvant in vaccine design.

A conformationally biased, agonist of human C5a(65-74) (EP67) was assessed for its adjuvant activities in vitro and in vivo. EP67 induced the release of the inflammatory (Th1) type cytokines from C5a receptor (CD88)-bearing antigen presenting cells (APC). EP67 did not induce the release of these cytokines from splenic APCs obtained from C5a receptor knockouts (CD88(-/-)). Serum from mice immunized with EP67-ovalbumin (OVA) contained high OVA-specific antibody (Ab) titers [IgG1, IgG2a (IGg2c), IgG2b]. Mice receiving OVA alone produced only IgG1 Abs, indicating the ability of EP67 to induce a Th1-like Ab class switch. Spleen cell cultures from wild type mice but not CD88(-/-) mice showed an enhanced OVA-specific proliferative response in vitro. These results indicate the ability of EP67 to drive a Th1-mediated immune response and its potential use as a unique adjuvant.