Distributions of easy axes and reversal processes in patterned MRAM arrays.

The distribution of the easy-axes in an array of MRAM cells is a vital parameter to understand the switching and characteristics of the devices. By measuring the coercivity as a function of applied-field angle, and remaining close to the perpendicular orientation, a classic Stoner-Wohlfarth approximation has been applied to the resulting variation to determine the standard deviation, [Formula: see text], of a Gaussian distribution of the orientation of the easy-magnetisation directions. In this work we have compared MRAM arrays with nominal cells sizes of 20 nm and 60 nm and a range of free layer thicknesses. We have found that a smaller diameter cell will have a wider switching-field distribution with a standard deviation [Formula: see text]. The MRAM arrays consist of pillars produced by etching a multilayer thin film. This value of [Formula: see text] is dominated by pillar uniformity and edge effects controlling the reversal, reinforcing the need for ever-improving etch processes. This is compared to larger pillars, with distributions as low as [Formula: see text]. Furthermore we found that the distribution broadens from [Formula: see text] to [Formula: see text] with free layer thickness in larger pillars and that thinner films had a more uniform easy-axis orientation. For the 20 nm pillars the non-uniform size distribution of the pillars, with a large and unknown error in the free-layer volume, was highlighted as it was found that the activation volume for the reversal of the free layer 930 nm[Formula: see text] was larger than the nominal physical volume of the free layer. However for the 60 nm pillars, the activation volume was measured to be equal to one fifth of their physical volume. This implies that the smaller pillars effectively reverse as one entity while the larger pillars reverse via an incoherent mechanism of nucleation and propagation.

SARS-CoV-2 outbreak among staff and evacuees at Operation Allies Welcome Safe Havens.

We report on five SARS-CoV-2 congregate setting outbreaks at U.S. Operation Allies Welcome Safe Havens/military facilities. Outbreak data were collected, and attack rates were calculated for various populations. Even in vaccinated populations, there was rapid spread, illustrating the importance of institutional prevention and mitigation policies in congregate settings.

The Effects of Humor in Clinical Settings on Medical Trainees and the Implications for Medical Educators: A Scoping Review.

Background: Clinical settings represent the site of patient care and clinical training for medical students and residents. Both processes involve social interaction, and humor is a fundamental component of social interaction that remains underexplored in medical education. This study investigated the impact of humor on medical trainees in the context of the clinical learning environment and examined the implications for medical educators. Methods: Following scoping review methodology, the authors systematically searched six databases and Google Scholar in February 2021 and March 2022. Articles were screened and selected according to inclusion/exclusion criteria, and findings from included articles were synthesized using procedures of metasynthesis. Results: Fifteen articles met inclusion criteria. Six themes emerged relating to the functions and effects of humor in clinical training settings: (1) managing emotions; (2) demarcating insider vs outsider status; (3) facilitating camaraderie; (4) ensuring conformity; (5) negotiating power differentials; and (6) fostering discrimination. Conclusions: The use of humor by medical educators plays an integral role in trainees' everyday experiences. Positive humor helps with coping and communication, while negative humor serves as an indirect medium for communicating ridicule and prejudice. Further research drawing on social psychology theories may identify ways to reduce effects of negative humor and promote well-being and diversity in medical education. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01769-0.

The human RAP1 and GFAPɛ proteins increase γ-secretase activity in a yeast model system.

Alzheimer's disease (AD) is an age-related disorder that results in progressive cognitive impairment and memory loss. Deposition of amyloid ß (Aß) peptides in senile plaques is a hallmark of AD. γ-secretase produces Aß peptides, mostly as the soluble Aß40 with fewer insoluble Aß42 peptides. Rare, early-onset AD (EOAD) occurs in individuals under 60 years of age. Most EOAD cases are due to unknown genetic causes, but a subset is due to mutations in the genes encoding the amyloid precursor protein that is processed into Aß peptides or the presenilins (PS1 and PS2) that process APP. PS1 interacts with the epsilon isoform of glial fibrillary acidic protein (GFAPɛ), a protein found in the subventricular zone of the brain. We have found that GFAPɛ interacts with the telomere protection factor RAP1 (TERF2IP). RAP1 can also interact with PS1 alone or with GFAPɛ in vitro. Our data show that the nuclear protein RAP1 has an extratelomeric role in the cytoplasm through its interactions with GFAPɛ and PS1. GFAPɛ coprecipitated with RAP1 from human cell extracts. RAP1, GFAPɛ, and PS1 all colocalized in human SH-SY5Y cells. Using a genetic model of the γ-secretase complex in Saccharomyces cerevisiae, RAP1 increased γ-secretase activity, and this was potentiated by GFAPɛ. Our studies are the first to connect RAP1 with an age-related disorder.

Global declines in coral reef calcium carbonate production under ocean acidification and warming.

Ocean warming and acidification threaten the future growth of coral reefs. This is because the calcifying coral reef taxa that construct the calcium carbonate frameworks and cement the reef together are highly sensitive to ocean warming and acidification. However, the global-scale effects of ocean warming and acidification on rates of coral reef net carbonate production remain poorly constrained despite a wealth of studies assessing their effects on the calcification of individual organisms. Here, we present global estimates of projected future changes in coral reef net carbonate production under ocean warming and acidification. We apply a meta-analysis of responses of coral reef taxa calcification and bioerosion rates to predicted changes in coral cover driven by climate change to estimate the net carbonate production rates of 183 reefs worldwide by 2050 and 2100. We forecast mean global reef net carbonate production under representative concentration pathways (RCP) 2.6, 4.5, and 8.5 will decline by 76, 149, and 156%, respectively, by 2100. While 63% of reefs are projected to continue to accrete by 2100 under RCP2.6, 94% will be eroding by 2050 under RCP8.5, and no reefs will continue to accrete at rates matching projected sea level rise under RCP4.5 or 8.5 by 2100. Projected reduced coral cover due to bleaching events predominately drives these declines rather than the direct physiological impacts of ocean warming and acidification on calcification or bioerosion. Presently degraded reefs were also more sensitive in our analysis. These findings highlight the low likelihood that the world's coral reefs will maintain their functional roles without near-term stabilization of atmospheric CO2 emissions.

Stony coral populations are more sensitive to changes in vital rates in disturbed environments.

Reef-building corals, like many long-lived organisms, experience environmental change as a combination of separate but concurrent processes, some of which are gradual yet long-lasting, while others are more acute but short-lived. For corals, some chronic environmental stressors, such as rising temperature and ocean acidification, are thought to induce gradual changes in colonies' vital rates. Meanwhile, other environmental changes, such as the intensification of tropical cyclones, change the disturbance regime that corals experience. Here, we use a physiologically structured population model to explore how chronic environmental stressors that impact the vital rates of individual coral colonies interact with the intensity and magnitude of disturbance to affect coral population dynamics and cover. We find that, when disturbances are relatively benign, intraspecific density dependence driven by space competition partially buffers coral populations against gradual changes in vital rates. However, the impact of chronic stressors is amplified in more highly disturbed environments, because disturbance weakens the buffering effect of space competition. We also show that coral cover is more sensitive to changes in colony growth and mortality than to external recruitment, at least in open populations, and that space competition and size structure mediate the extent and pace of coral population recovery following a large-scale mortality event. Understanding the complex interplay among chronic environmental stressors, mass-mortality events, and population size structure sharpens our ability to manage and to restore coral-reef ecosystems in an increasingly disturbed future.

Landscape-scale patterns of nutrient enrichment in a coral reef ecosystem: implications for coral to algae phase shifts.

Nutrient pollution is altering coastal ecosystems worldwide. On coral reefs, excess nutrients can favor the production of algae at the expense of reef-building corals, yet the role of nutrients in driving community changes such as shifts from coral to macroalgae is not well understood. Here we investigate the potential role of anthropogenic nutrient loading in driving recent coral-to-macroalgae phase shifts on reefs in the lagoons surrounding the Pacific island of Moorea, French Polynesia. We use nitrogen (N) tissue content and stable isotopes (δ15 N) in an abundant macroalga (Turbinaria ornata) together with empirical models of nutrient discharge to describe spatial and temporal patterns of nutrient enrichment in the lagoons. We then employ time series data to test whether recent increases in macroalgae are associated with nutrients. Our results revealed that patterns of N enrichment were linked to several factors, including rainfall, wave-driven circulation, and distance from anthropogenic nutrient sources, especially human sewage. Reefs near large watersheds, where inputs of N from sewage and agriculture are high, have been consistently enriched in N for at least the last decade. In many of these areas, corals have decreased and macroalgae have increased, while reefs with lower levels of N input have maintained high cover of coral and low cover of macroalgae. Importantly, these patchy phase shifts to macroalgae have occurred despite substantial island-wide increases in the density and biomass of herbivorous fishes over the time period. Together, these results indicate that nutrient loading may be an important driver of coral-to-macroalgae phase shifts in the lagoons of Moorea even though the reefs harbor an abundant and diverse herbivore assemblage. These results emphasize the important role that bottom-up factors can play in driving coral-to-macroalgae phase shifts and underscore the critical importance of watershed management for reducing inputs of nutrients and other land-based pollutants to coral reef ecosystems.

Epifaunal invertebrate assemblages associated with branching Pocilloporids in Moorea, French Polynesia.

Reef-building corals can harbour high abundances of diverse invertebrate epifauna. Coral characteristics and environmental conditions are important drivers of community structure of coral-associated invertebrates; however, our current understanding of drivers of epifaunal distributions is still unclear. This study tests the relative importance of the physical environment (current flow speed) and host quality (e.g., colony height, surface area, distance between branches, penetration depth among branches, and background partial mortality) in structuring epifaunal communities living within branching Pocillopora colonies on a back reef in Moorea, French Polynesia. A total of 470 individuals belonging to four phyla, 16 families and 39 genera were extracted from 36 Pocillopora spp. colonies. Decapods were the most abundant epifaunal organisms (accounting for 84% of individuals) found living in Pocillopora spp. While coral host characteristics and flow regime are very important, these parameters were not correlated with epifaunal assemblages at the time of the study. Epifaunal assemblages associated with Pocillopora spp. were consistent and minimally affected by differences in host characteristics and flow regime. The consistency in abundance and taxon richness among colonies (regardless of habitat characteristics) highlighted the importance of total habitat availability. With escalating effects of climate change and other localized disturbances, it is critical to preserve branching corals to support epifaunal communities.

Extreme rainfall events pulse substantial nutrients and sediments from terrestrial to nearshore coastal communities: a case study from French Polynesia.

Rainfall mobilizes and transports anthropogenic sources of sediments and nutrients from terrestrial to coastal marine ecosystems, and episodic but extreme rainfall may drive high fluxes to marine communities. Between January 13th and January 22nd, 2017, the South Pacific Island of Moorea, French Polynesia experienced an extreme rainfall event. ~57 cm of rain was delivered over a 10-day storm. We quantified pulsed sediments and nutrients transported to nearshore reefs. We determined the spatial and temporal extent of the sediment pulse with estimates of water transparency. We quantified pulsed nutrients at multiple spatial and temporal scales. To determine if terrestrial nutrients were incorporated into the benthic community, we collected macroalgae over 10 days following the storm and measured tissue nutrient concentrations and δN15. Pulsed sediments impacted water clarity for 6 days following the storm, with greatest impacts closest to the river mouth. Nitrite +nitrate concentrations were >100 times the average while phosphate was >25 times average. Macroalgal tissue nutrients were elevated, and δN15 implicates sewage as the source, demonstrating transported nutrients were transferred to producer communities. Future climate change predictions suggest extreme rainfall will become more common in this system, necessitating research on these pulses and their ramifications on marine communities.

Wrist Injury in Deployed U.S. Marine-How to Maintain the Mission.

Wrist pain commonly affects military members and while most instances are benign, some require urgent orthopedic attention to prevent permanent loss of function. A 27-year-old male Marine while deployed presented with wrist pain after a seemingly benign fall during recreation. Radiographs were initially read as unremarkable and treated as a sprain. Though when reviewed by the Shock Trauma Platoon physicians, a perilunate dislocation was noted. After unsuccessful closed attempts to reduce injury, the Marine was sent to orthopedic surgery and underwent open reduction internal fixation and required a subsequent closed reduction and percutaneous pinning. Perilunate dislocations are uncommon but are among the most severe types of wrist injuries. This case is a reminder that proper evaluation of all injuries is critical. Proper evaluation of wrist injuries includes an attentive physical exam and careful examination of the radiographs; paying close attention to Gilula arcs and collinearity of the radius, lunate, and capitate. Prompt recognition and referral to specialty care for definitive treatment are important to maximize functional outcomes.

Ocean acidification effects on in situ coral reef metabolism.

The Anthropocene climate has largely been defined by a rapid increase in atmospheric CO2, causing global climate change (warming) and ocean acidification (OA, a reduction in oceanic pH). OA is of particular concern for coral reefs, as the associated reduction in carbonate ion availability impairs biogenic calcification and promotes dissolution of carbonate substrata. While these trends ultimately affect ecosystem calcification, scaling experimental analyses of the response of organisms to OA to consider the response of ecosystems to OA has proved difficult. The benchmark of ecosystem-level experiments to study the effects of OA is provided through Free Ocean CO2 Enrichment (FOCE), which we use in the present analyses for a 21-d experiment on the back reef of Mo'orea, French Polynesia. Two natural coral reef communities were incubated in situ, with one exposed to ambient pCO2 (393 µatm), and one to high pCO2 (949 µatm). Our results show a decrease in 24-h net community calcification (NCC) under high pCO2, and a reduction in nighttime NCC that attenuated and eventually reversed over 21-d. This effect was not observed in daytime NCC, and it occurred without any effect of high pCO2 on net community production (NCP). These results contribute to previous studies on ecosystem-level responses of coral reefs to the OA conditions projected for the end of the century, and they highlight potential attenuation of high pCO2 effects on nighttime net community calcification.

Contrasting responses of photosynthesis and photochemical efficiency to ocean acidification under different light environments in a calcifying alga.

Ocean acidification (OA) is predicted to enhance photosynthesis in many marine taxa. However, photophysiology has multiple components that OA may affect differently, especially under different light environments, with potentially contrasting consequences for photosynthetic performance. Furthermore, because photosynthesis affects energetic budgets and internal acid-base dynamics, changes in it due to OA or light could mediate the sensitivity of other biological processes to OA (e.g. respiration and calcification). To better understand these effects, we conducted experiments on Porolithon onkodes, a common crustose coralline alga in Pacific coral reefs, crossing pCO2 and light treatments. Results indicate OA inhibited some aspects of photophysiology (maximum photochemical efficiency), facilitated others (α, the responsiveness of photosynthesis to sub-saturating light), and had no effect on others (maximum gross photosynthesis), with the first two effects depending on treatment light level. Light also exacerbated the increase in dark-adapted respiration under OA, but did not alter the decline in calcification. Light-adapted respiration did not respond to OA, potentially due to indirect effects of photosynthesis. Combined, results indicate OA will interact with light to alter energetic budgets and potentially resource allocation among photosynthetic processes in P. onkodes, likely shifting its light tolerance, and constraining it to a narrower range of light environments.

Nitrogen enrichment offsets direct negative effects of ocean acidification on a reef-building crustose coralline alga.

Ocean acidification (OA) and nutrient enrichment threaten the persistence of near shore ecosystems, yet little is known about their combined effects on marine organisms. Here, we show that a threefold increase in nitrogen concentrations, simulating enrichment due to coastal eutrophication or consumer excretions, offset the direct negative effects of near-future OA on calcification and photophysiology of the reef-building crustose coralline alga, Porolithon onkodes Projected near-future pCO2 levels (approx. 850 µatm) decreased calcification by 30% relative to ambient conditions. Conversely, nitrogen enrichment (nitrate + nitrite and ammonium) increased calcification by 90-130% in ambient and high pCO2 treatments, respectively. pCO2 and nitrogen enrichment interactively affected instantaneous photophysiology, with highest relative electron transport rates under high pCO2 and high nitrogen. Nitrogen enrichment alone increased concentrations of the photosynthetic pigments chlorophyll a, phycocyanin and phycoerythrin by approximately 80-450%, regardless of pCO2 These results demonstrate that nutrient enrichment can mediate direct organismal responses to OA. In natural systems, however, such direct benefits may be counteracted by simultaneous increases in negative indirect effects, such as heightened competition. Experiments exploring the effects of multiple stressors are increasingly becoming important for improving our ability to understand the ramifications of local and global change stressors in near shore ecosystems.

Recruitment Drives Spatial Variation in Recovery Rates of Resilient Coral Reefs.

Tropical reefs often undergo acute disturbances that result in landscape-scale loss of coral. Due to increasing threats to coral reefs from climate change and anthropogenic perturbations, it is critical to understand mechanisms that drive recovery of these ecosystems. We explored this issue on the fore reef of Moorea, French Polynesia, following a crown-of-thorns seastar outbreak and cyclone that dramatically reduced cover of coral. During the five-years following the disturbances, the rate of re-establishment of coral cover differed systematically around the triangular-shaped island; coral cover returned most rapidly at sites where the least amount of live coral remained after the disturbances. Although sites differed greatly in the rate of return of coral, all showed at least some evidence of re-assembly to their pre-disturbance community structure in terms of relative abundance of coral taxa and other benthic space holders. The primary driver of spatial variation in recovery was recruitment of sexually-produced corals; subsequent growth and survivorship were less important in shaping the spatial pattern. Our findings suggest that, although the coral community has been resilient, some areas are unlikely to attain the coral cover and taxonomic structure they had prior to the most recent disturbances before the advent of another landscape-scale perturbation.

Primary Care of Men Who Have Sex With Men in the U.S. Military in the Post-Don't Ask, Don't Tell Era: A Review of Recent Progress, Health Needs, and Challenges.

BACKGROUND: With repeal of "Don't Ask, Don't Tell" (DADT) in 2011 and the Supreme Court decision regarding Section 3 of the Defense of Marriage Act (DOMA) in 2013, military providers are now able to openly address unique health needs of lesbian, gay, and bisexual (LGB) service members and their same-sex spouse beneficiaries. These federal laws created health care barriers, either real or perceived, between providers and patients and often limited medical research involving LGB patients in the Military Health System (MHS). Men who have sex with men (MSM), the largest proportion of LGB service members, represent a segment of the population with the highest risks for disparities in primary care with regard to sexual health and mental health disorders. We provide a review of available research about this military population, in addition to a review of specific health care needs of the MSM patient in order to aid the primary care provider with screening, testing, and counseling. METHODS: A structured literature search was conducted to identify recent literature pertaining to health needs of U.S. military MSM service members. In addition, a review of applicable clinical guidelines, Department of Defense policies, and expert opinion was used to identify areas of particular relevance. FINDINGS: There is little published to characterize the MSM population and their health needs as beneficiaries of the MHS. Only recently have directed assessments of the active-duty MSM patient population been pursued in the post-DADT, DOMA era. Unique needs of the MSM patient identified center around both sexual and mental health, disparities that are paralleled within the nonmilitary MSM population. Population-specific epidemiology driving risk for sexually transmitted illnesses, substance abuse, and mental health disorders are identified and used to inform preventive medicine recommendations for the MSM patient. In addition, resources on MSM health for the health provider are included. DISCUSSION/IMPACT/RECOMMENDATION: The MHS at large now openly serves the MSM population and is making progress toward addressing their unique health needs. Despite ongoing challenges to address remaining disparities, MSM patients, beneficiaries, and primary providers are now more able to have frank, open discussions about specific health needs of this minority segment of the U.S. military without fear of reprisal.

Orbital Cellulitis in a Psoriatic Patient Treated With Adalimumab.

INTRODUCTION: Psoriatic patients on tumor necrosis factor alpha inhibitors (TNFi) may be at increased risk for upper respiratory tract infections, including chronic rhino-sinusitis (CRS). Rarely, CRS can progress to orbital cellulitis (OC), an emergent ophthalmic complication wherein respiratory flora from paranasal sinus disease intrude the retro-orbital space. MATERIALS AND METHODS: Single case report. RESULTS: We report the first case, to our knowledge, of an invasive sinusitis that rapidly evolved into OC in a patient receiving adalimumab treatment for plaque psoriasis and psoriatic arthritis. After TNFi withdrawal and appropriate medical and surgical intervention, the patient fully recovered. However, on resumption of TNFi therapy, symptoms of recalcitrant CRS returned. CONCLUSION: More investigation is needed to explore how TNFi might predispose to chronic, refractory rhino-sinusitis and subsequent progression to OC. Military physicians and other medical providers should be aware of this proposed new disease entity and the potential for rapidly evolving and invasive infections in immunocompromised patients. Screening and monitoring for chronic infectious disease, such as CRS before initiating and during TNFi therapy is warranted.

Transforming Laboratory Utilization Review into Laboratory Stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship.

Appropriate utilization of clinical laboratory services is important for patient care and requires institutional stewardship. Clinical laboratory stewardship programs are dedicated to improving the ordering, retrieval, and interpretation of appropriate laboratory tests. In addition, these programs focus on developing, maintaining, and improving systems to provide proper financial coverage for medically necessary testing. Overall, clinical laboratory stewardship programs help clinicians improve the quality of patient care while reducing costs to patients, hospitals, and health systems. This document, which was created by a new multiinstitutional committee interested in promoting and formalizing laboratory stewardship, summarizes core elements of successful hospital-based clinical laboratory stewardship programs. The core elements will also be helpful for independent commercial clinical laboratories.

Uterine incarceration in a primigravid retroverted bicornuate uterus.

Uterine incarceration is a rare complication that usually occurs after the first trimester of pregnancy. It leads to increased maternal and/or fetal morbidity and mortality. Risk factors include retroversion of uterus and other pelvic abnormalities. Clinical presentation includes severe abdominal and pelvic pain symptoms. Patients can present with concurrent urinary symptoms due to increasing distortion of adjacent structures from the enlarging uterus. A high clinical suspicion of uterine incarceration is confirmed with ultrasound. More advanced imaging such as MRI can be used as an adjunct to ultrasound imaging. Progression from expectant management to intervention is recommended as soon as possible to prevent complications such as uterine rupture and fetal demise. In subsequent pregnancies, close monitoring with serial ultrasounds is warranted to monitor for recurrence of incarceration which has been reported in a few rare cases.

Eplerenone use in primary aldosteronism during pregnancy.

Primary aldosteronism (PA) in pregnancy is rare. Due to pharmacological limitations and risks associated with surgical intervention during pregnancy, clinical decision making in this area is difficult. We report the short-term use of eplerenone in the management of hypertension and hypokalemia due to PA in pregnancy.