Using Voice Assistant Systems to Improve Dietary Recall among Older Adults: Perspectives of Registered Dietitians.

Dietary assessments are important clinical tools used by Registered Dietitians (RDs). Current methods pose barriers to accurately assess the nutritional intake of older adults due to age-related increases in risk for cognitive decline and more complex health histories. Our qualitative study explored whether implementing Voice assistant systems (VAS) could improve current dietary recall from the perspective of 20 RDs. RDs believed the implementing VAS in dietary assessments of older adults could potentially improve patient accuracy in reporting food intake, recalling portion sizes, and increasing patient-provider efficiency during clinic visits. RDs reported that low technology literacy in older adults could be a barrier to implementation. Our study provides a better understanding of how VAS can better meet the needs of both older adults and RDs in managing and assessing dietary intake.

Rosa Bonheur the Amazon? Equestrianism, female masculinity, and The Horse Fair (1852-1855).

In 1853, Rosa Bonheur first exhibited what would become her most widely celebrated work: The Horse Fair. Although the work's modern setting and animal-focused subject matter do not obviously characterize it as an instance of classical reception, the artist claimed that it was inspired by the Parthenon frieze. A significant amount of feminist and queer scholarship has been dedicated to Rosa Bonheur's life, career, and art practices, all of which reveal the complex ways in which the artist negotiated the gender norms of 19th-century France. These ranged from her decision never to marry, instead living in households with two women, to her officially sanctioned practice of cross-dressing when conducting art studies in public. In view of all these things, one of the most remarkable elements of The Horse Fair is the very probable inclusion of the artist's self-portrait, clad in masculine clothing and riding with legs astride her mount. Taking seriously Bonheur's Parthenonian quotation, how should her self-portrait within the male-dominated arena of the horse market be understood? The author argues that, by classical analogy, Bonheur may be regarded as a gender-bending Amazon of a sort that was radically distinct from the scores of so-called "amazones" promenading about Paris. A comparative consideration of contemporary visualizations of the Amazonian rider trope suggests that Bonheur appropriates and, as it were, refashions this modish, gendered imagery to make a bold statement of women's equality with men.

High-Energy-Density Solid-State Metal-Air Batteries: Progress, Challenges, and Perspectives.

Next-generation batteries have long been considered a transition to more sustainable storage technologies. Among them, metal-air batteries (MABs) with low cost, high safety, and environmental friendliness have shown great potential for future large-scale applications. Motivated by the desirable characteristics, significant progress is made in suppressing serious parasitic reactions, improving electrochemical performance, and increasing the energy density in MABs. Compared to the widely reported liquid electrolyte strategy, solid-state electrolytes (SSEs) can thoroughly solve the volatilization challenges of liquid electrolytes and protect the oxygen electrodes without the formation of diffusion-blocking oxide phases. Notably, SSEs for MABs are still in their infancy, and many thorny challenges still need to be solved. In this review, the main electrochemical mechanism, key challenges, and some important progress are sorted out for solid-state MABs, such as lithium-air, zinc-air, aluminum-air, and magnesium-air batteries. Besides their fundamental significance, these configurations are further compared in terms of energy density, cost, carbon footprint, energy consumption, rate performance, cycle performance, safety, and air stability of prevailing electrolytes.

Generation and characterization of induced pluripotent stem cells from breast cancer patients carrying ATM mutations.

We generated two induced pluripotent stem cell (iPSC) lines from peripheral blood mononuclear cells (PBMCs) of breast cancer patients carrying germline ATM mutations, a gene associated with a 7% prevalence in breast cancer. These iPSC lines displayed typical morphology, expressed pluripotency markers, maintained a stable karyotype, and retained the ability to differentiate into the three germ layers. These patient-specific iPSC lines hold great potential for mechanistic investigations and the development of drug screening strategies aimed at addressing ATM-related cancer.

Feasibility of using the Automated Self-Administered 24-hour (ASA-24) dietary assessment tool in older adults.

Background: Dietary patterns can impact the trajectories of healthy aging. However, dietary assessment tools can be challenging to use. With the increased use of technology in older adults, we aimed to evaluate the feasibility of older adults completing the online, Automated Self-Administered 24-h (ASA-24) dietary assessment tool. Methods: We conducted a randomized, two-period, two-sequence, crossover design of twenty community-dwelling older adults (≥65 years) comparing their preference for completing the ASA-24 alone versus with a research assistant (RA). Participants were recruited via ResearchMatch.com and randomly allocated 1:1 to a sequence of completing both an ASA-24 alone or with an RA, separated by one week. After each session, participants completed an online 11-item feasibility survey (Likert-scale range of 1-5, strongly disagree to strongly agree). Mean and standard deviations were reported for each question. Results: Mean age was 69 ± 3.5 years (90% females), with no differences were observed for sex, age, race, ethnicity, education, or income. Neither group felt a need for RA assistance (p = 0.34). However, both groups felt the system was easier to follow with the help of an RA (RA: 4.4 ± 1.3, vs. SA 4.6 ± 0.5, p = 0.65), particularly when they completed the ASA-24 alone, first (p = 0.04). When conducting the ASA-24 alone, there was less confidence the system could be learned quickly (SA 4.5 ± 0.5→3.4 ± 1.0 vs RA 3.4 ± 1.0→3.4 ± 0.7, p = 0.001). The ASA-24 was thought to be less cumbersome after repeated exposure in those concluding with the RA. Conclusion: While older adults were able to complete the ASA-24 independently, the use of an RA led to improved confidence. Enhancing the sample diversity in a larger number of participants could provide helpful data to improve the science of dietary assessment.

Master clinical teachers and personalised learning.

Clinical history taking and physical examination are two of the most important competencies of physicians. In addition to informing diagnoses, these activities build rapport and establish relationships between caregivers and patients. Despite this, emphasis on the assessment of bedside clinical skills is declining. To prepare our students for clinical work, we began a clinical competency, personalised teaching programme in which students perform a history and physical examination in front of a master clinical teacher (MCT) approximately every 2 weeks throughout their core clerkship year. The MCT works with the student in a clinical encounter, providing personalised bedside instruction on all features of being a clinician including bedside manner, history-taking skills, physical examination skills, and clinical reasoning. The MCT then provides an assessment of student's competency development and gives feedback to the student about what they do well and where they have opportunities for growth. Assessment data are collected and tracked longitudinally across the clerkship phase to ensure that each student is progressing developmentally. With over 6000 observations of student performance, we are able to discern competency development and growth over time. We can identify if a student is not improving as expected during their clerkship phase and intervene by providing extra practice and training. This core clerkship teaching programme has been well received by both students and instructors and has led us to pilot this approach during the post-clerkship phase of our medical training.

Attitudes and Behaviors with Diabetes Technology Use in the Hospital: Multicenter Survey Study in the United States.

Objective: To assess the attitudes, behaviors, and barriers with diabetes technology use in the general medicine hospital wards. Research Design and Methods: The authors developed a nonincentivized web-based anonymous survey that captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) use in the hospital. Setting: Four large hospital systems in the United States. Results: Among 128 survey respondents, 76%, 10%, and 6% were hospitalists, advanced practice providers, and primary care physicians, respectively. The majority of respondents rated the treatment of inpatient hyperglycemia (96%) and the continuation of CSII during the hospital stay (93%) "important." While most respondents (64%) acknowledged knowing the existence of their institution's policies for CSII use, only 84% of those respondents felt somewhat to very familiar with the policy. The most common barrier to CSII use in the inpatient setting was lack of practitioner (70%) and nursing (67%) knowledge of using the device. With regard to CGM use in the hospital, a minority (28%) of respondents were aware of their institution's CGM policies. Less than half of the providers, 43.8%, stated that, when admitting a patient, they reviewed CGM data to guide insulin dosing. Conclusions: In this US multicenter survey, we found that most inpatient practitioners valued glycemic control, but many were not familiar with institutional policies, had lack of knowledge with CSII, and were not reviewing CGM data.

Accuracy of Continuous Glucose Monitors for Inpatient Diabetes Management.

INTRODUCTION: In hospitalized patients, continuous glucose monitoring (CGM) may improve glycemic control, prevent hypoglycemic events, and reduce staff workload compared with point-of-care (POC) capillary glucose monitoring. METHODS: To evaluate CGM accuracy and safety of use in the inpatient setting, two versions of CGM sensors were placed on 43 and 34 adult patients with diabetes admitted to non-intensive care unit (ICU) medical wards, respectively. CGM accuracy relative to POC and safety of use were measured by calculating mean absolute relative difference (MARD) and by Clarke Error Grid (CEG) analysis. RESULTS: CGM version 2 had improved accuracy compared with CGM version 1 with MARD 17.7 compared with 21.4%. CGM accuracy did not change with POC value or with time of sensor wear. On CEG, 98.8% of paired values fell within acceptable zones A and B. CONCLUSION: Despite reduced accuracy compared with the outpatient setting, both versions of CGMs had acceptable safety profiles in the inpatient setting.

Concept Review of a Cloud-Based Smart Battery Management System for Lithium-Ion Batteries: Feasibility, Logistics, and Functionality.

Energy storage plays an important role in the adoption of renewable energy to help solve climate change problems. Lithium-ion batteries (LIBs) are an excellent solution for energy storage due to their properties. In order to ensure the safety and efficient operation of LIB systems, battery management systems (BMSs) are required. The current design and functionality of BMSs suffer from a few critical drawbacks including low computational capability and limited data storage. Recently, there has been some effort in researching and developing smart BMSs utilizing the cloud platform. A cloud-based BMS would be able to solve the problems of computational capability and data storage in the current BMSs. It would also lead to more accurate and reliable battery algorithms and allow the development of other complex BMS functions. This study reviews the concept and design of cloud-based smart BMSs and provides some perspectives on their functionality and usability as well as their benefits for future battery applications. The potential division between the local and cloud functions of smart BMSs is also discussed. Cloud-based smart BMSs are expected to improve the reliability and overall performance of LIB systems, contributing to the mass adoption of renewable energy.

Improving annual albuminuria testing for individuals with diabetes.

BACKGROUND: Annual albuminuria screening detects the early stages of nephropathy in individuals with diabetes. Because early detection of albuminuria allows for interventions that lower the risk of developing chronic kidney disease, guidelines recommend annual testing for all individuals with type 2 diabetes mellitus and for those with type 1 diabetes for at least 5 years. However, at the Eskind Diabetes Clinic at the Vanderbilt University Medical Center, testing occurred less frequently than desired. METHODS: A quality improvement team first analysed the clinic's processes, identifying the lack of a systematic approach to testing as the likely cause for the low rate. The team then implemented two successive interventions in a pilot of patients seen by nurse practitioners in the clinic. In the first intervention, staff used a dashboard within the electronic health record while triaging each patient, pending an albuminuria order if testing had not been done within the past year. In the second intervention, clinic leadership sent daily reminders to the triage staff. A statistical process control chart tracked monthly testing rates. RESULTS: After 6 months, annual albuminuria testing increased from a baseline of 69% to 82%, with multiple special-cause signals in the control chart. CONCLUSIONS: This project demonstrates that a series of simple interventions can significantly impact annual albuminuria testing. This project's success likely hinged on using an existing workflow to systematically determine if a patient was due for testing and prompting the provider to sign a pended order for an albuminuria test. Other diabetes/endocrinology and primary care clinics can likely implement a similar process and so improve testing rates in other settings. When coupled with appropriate interventions to reduce the development of chronic kidney disease, such interventions would improve patient outcomes, in addition to better adhering to an established quality metric.

Heterozygous LMNA mutation-carrying iPSC lines from three cardiac laminopathy patients.

LMNA-related dilated cardiomyopathy (LMNA-DCM) is caused by pathogenic variants in the LMNA gene and is characterized by left ventricular chamber enlargement, reduced systolic function, and arrhythmia. Here, we generated three human induced pluripotent stem cell (iPSC) lines from peripheral blood mononuclear cells (PBMCs) of three DCM patients carrying the same single heterozygous mutation, c.398 G > A, in LMNA. All lines exhibited normal iPSC morphology, expressed high levels of pluripotency markers, showed normal karyotypes, and could differentiate into the three germ layers. These patient-specific iPSC lines can serve as invaluable tools to model in vitro pathological mechanisms of LMNA-DCM.

Intelligent Knowledge Distribution: Constrained-Action POMDPs for Resource-Aware Multiagent Communication.

This article addresses a fundamental question of multiagent knowledge distribution: what information should be sent to whom and when with the limited resources available to each agent? Communication requirements for multiagent systems can be rather high when an accurate picture of the environment and the state of other agents must be maintained. To reduce the impact of multiagent coordination on networked systems, for example, power and bandwidth, this article introduces two concepts for the partially observable Markov decision processes (POMDPs): 1) action-based constraints that yield constrained-action POMDPs (CA-POMDPs) and 2) soft probabilistic constraint satisfaction for the resulting infinite-horizon controllers. To enable constraint analysis over an infinite horizon, an unconstrained policy is first represented as a finite-state controller (FSC) and optimized with policy iteration. The FSC representation then allows for a combination of the Markov chain Monte Carlo and discrete optimization to improve the probabilistic constraint satisfaction of the controller while minimizing the impact on the value function. Within the CA-POMDP framework, we then propose intelligent knowledge distribution (IKD) which yields per-agent policies for distributing knowledge between agents subject to interaction constraints. Finally, the CA-POMDP and IKD concepts are validated using an asset tracking problem where multiple unmanned aerial vehicles (UAVs) with heterogeneous sensors collaborate to localize a ground asset to assist in avoiding unseen obstacles in a disaster area. The IKD model was able to maintain asset tracking through multiagent communications while only violating soft power and bandwidth constraints 3% of the time, while greedy and naive approaches violated constraints more than 60% of the time.

Addressing Patients' Mental Health Needs at a Student-Run Free Clinic.

Student-run free clinics are uniquely positioned to understand the barriers to accessing mental health resources. We abstracted patient demographics and clinical characteristics from 355 patient charts and examined referral patterns for a subset of patients. Seventy-three (21%) of patients were found to have a psychiatric diagnosis and were more likely to have more medical comorbidities (10 versus 6, p < 0.001), total medications (8 versus 6, p < 0.001, and to be English-speaking (odds ratio: 1.97, p < 0.05). Of patients who received a referral, 37 (60%) were referred to specialty treatment, the majority to a single outside agency provider. 15 (25%) of patients were interviewed. Barriers to successful referral included transportation and medical symptoms. A facilitator of successful referral was concern for individual's health. Language, social stigma, and cost were not cited as barriers. This study describes mental health needs at a SRFC and suggests opportunities for improvement.

A Changing Landscape of Mortality for Systemic Light Chain Amyloidosis.

OBJECTIVES: The purpose of this study was to address the overall trends in mortality since the adoption of modern therapies for treatment of systemic amyloidosis, and to reconsider the prognostic significance of individual components of the current staging system. BACKGROUND: Systemic light chain (AL) amyloidosis involves deposition of immunoglobulin light chains in organs throughout the body and is known to have the highest mortality when significant cardiac involvement is present. Survival has historically been poor but may be improving as systemic therapies continue to advance. This study assesses whether recent advancements in light chain directed therapy have led to improved survival in patients with systemic AL amyloidosis. METHODS: We reviewed all cases of patients who were evaluated for a new diagnosis of AL amyloidosis at the Stanford Amyloid Center between 2009 and 2016. Patients' stage at diagnosis was determined according to the most commonly used staging system. Clinical data, overall survival from diagnosis, and the independent influence of each component of the staging system were analyzed. RESULTS: At total of 194 patients were identified with a new diagnosis of systemic AL amyloidosis. Median overall survival was 59 months and 6 months for stage 3 and 4 patients, respectively. Median overall survival was not reached in stage 1 and 2 groups, as survival was >50% by the end of the study. Mean overall survival was 118 months, 76 months, 64 months, and 27 months in Stages 1, 2, 3, and 4 patients, respectively. Although N-terminal pro-B-type natriuretic peptide and troponin I concentrations had large effects on prognosis, differences in serum free light chains (dFLC) on initial staging laboratory results ≥18 mg/dl, part of the current staging system, did not contribute significantly to prognosis for values ≥5 mg/dl. CONCLUSIONS: Survival for patients with systemic AL amyloidosis has improved for patients at all stages of disease in the present era of rapid advancements in light chain-reducing therapies. Cardiac biomarkers at diagnosis, but not baseline dFLC ≥18 mg/dl, continue to provide important prognostic information.

Short-term outcomes of en bloc combined heart and liver transplantation in the failing Fontan.

Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2-41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end-diastolic pressure was 18/12 mm Hg, respectively. Median Model for End-Stage Liver Disease excluding International Normalized Ratio score was 10 (7-26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178-307) and 287 (227-396) minutes, respectively. Median intensive care and hospital stay were 19 (5-96) and 29 (13-197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post-transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.

Serial Cardiac FDG-PET for the Diagnosis and Therapeutic Guidance of Patients With Cardiac Sarcoidosis.

BACKGROUND: Cardiac fluorodeoxyglucose positron-emission tomography (FDG-PET) has emerged as a standard imaging modality for the diagnosis of cardiac sarcoidosis (CS); however, there is a scarcity of data on the use of serial FDG-PET to guide immunosuppressive therapy. The aim of this work was to report our experience using serial FDG-PET for the diagnosis and management of patients with CS, focusing on its utility in ongoing immunosuppression management. METHODS AND RESULTS: We studied consecutive patients with CS managed at Stanford University from 2010 to 2017. We evaluated our experience using FDG-PET for diagnosis and guidance of immunosuppressive therapy titration in CS. Among 34 patients diagnosed with CS, 16 (47%), 12 (35%) and 14(41%) presented with heart block, heart failure, and ventricular arrhythmias, respectively. FDG-PET proved beneficial in the initial diagnosis in 21 patients (62%). A total of 128 FDG-PET scans were performed (median 3 per patient). Ninety-four FDG-PET scans (73%) resulted in a change in therapy, with 42FDG-PET scans (33%) instrumental for tapering prednisone. Among patients who were initiated on prednisone, the mean dose of prednisone at 1 year was 9.5mg/d. Over a median follow-up of 2.3years, 48% of patients were successfully weaned from prednisone completely, and 20% were weaned to a maintenance dosage of 5-10mg/d. During the follow-up period, transplant-free survival was 88%. CONCLUSIONS: The use of serial cardiac FDG-PET for the diagnosis and management of CS was critical for guiding immunosuppression management and resulted in low chronic steroid doses and good disease control within 1 year of diagnosis.

Ultrasensitive Electrochemical Methane Sensors Based on Solid Polymer Electrolyte-Infused Laser-Induced Graphene.

Methane is a potent greenhouse gas, with large emissions occurring across gas distribution networks and mining/extraction infrastructure. The development of inexpensive, low-power electrochemical sensors could provide a cost-effective means to carry out distributed sensing to identify leaks for rapid mitigation. In this work, we demonstrate a simple and cost-effective strategy to rapidly prototype ultrasensitive electrochemical gas sensors. A room-temperature methane sensor is evaluated which demonstrates the highest reported sensitivity (0.55 µA/ppm/cm2) with a rapid response time (40 s) enabling sub-ppm detection. Porous, laser-induced graphene (LIG) electrodes are patterned directly into commercial polymer films and imbibed with a palladium nanoparticle dispersion to distribute the electrocatalyst within the high surface area support. A pseudo-solid-state ionic liquid/polyvinylidene fluoride electrolyte was painted onto the flexible cell yielding a porous electrolyte, within the porous LIG electrode, simultaneously facilitating rapid gas transport and enabling the room temperature electro-oxidation pathway for methane. The performance of the amperometric sensor is evaluated as a function of methane concentration, relative humidity, and tested against interfering gases.

Framing Medicine as a Moral Practice: An Introductory Medical School Course.

PROBLEM: The transition into medical school represents a time of profound professional development for medical students. Many medical schools manage this transition with brief orientations followed by abrupt moves into the anatomy laboratory. Recognizing that early introduction of key humanistic concepts could have a lasting impact on students' attitudes, faculty at the Vanderbilt University School of Medicine created the Foundations of the Profession (FoP) course to frame medicine as a moral practice. APPROACH: The FoP course, offered annually since 2012, occurs during the first week of medical school. Using coronary artery disease with a chief complaint of angina as a core example, teams of students create variations of five hypothetical patients and walk them through potential care episodes. This allows students to compare the impact of many factors on a provider's ability to uphold fundamental professional obligations. Students engage in readings, lectures, small-group discussions, clinic visits, and research on insurance plans. Faculty engage with students in small groups and establish a safe environment for discussion of challenging moral dilemmas. OUTCOMES: From 2013 to 2016, 356 (97%) of the 368 first-year medical students who took the course submitted summative course evaluations. Of the respondents, 349 (98%) indicated they believed the course contributed to their professional development and supported their learning. NEXT STEPS: Future iterations of this course may include increased exposure to key educational faculty to solidify the formation of a moral scaffold on which to build subsequent knowledge.

The Effect of a Student-Run Free Clinic on Hospital Utilization.

Student-run free clinics (SRFCs) serve uninsured patients and offer unique educational opportunities. However, the impact of these clinics on hospital utilization is unclear. In this pre-post observational study, we used multivariable modeling to test the hypothesis that patients of Shade Tree Clinic, the SRFC affiliated with Vanderbilt University Medical Center (VUMC), would have decreased hospital utilization after joining the clinic. To evaluate the relationship between STC and VUMC, we conducted a sub-analysis of patients referred to Shade Tree from VUMC using univariate Wilcoxon signed-rank tests. Multivariable analysis showed patients were less likely to be hospitalized after joining Shade Tree (p=.04). Univariate analysis showed differences in hospitalizations among patients referred from VUMC (p=.02). These results suggest that Shade Tree does not result in an additional burden on the health care system and may reduce hospital utilization. Additional research with control populations may further highlight the effect of SRFCs on health care utilization.