Endostructural and periosteal growth of the human humerus.

The growth and development of long bones are of considerable interests in the fields of comparative anatomy and palaeoanthropology, as evolutionary changes and adaptations to specific physical activity patterns are expected to be revealed during bone ontogeny. Traditionally, the cross-sectional geometry of long bones has been examined at discrete locations usually placed at set intervals or fixed percentage distances along the midline axis of the bone shaft. More recently, the technique of morphometric mapping has enabled the continuous analysis of shape variation along the shaft. Here we extend this technique to the full sequence of late fetal and postnatal development of the humeral shaft in a modern human population sample, with the aim of establishing the shape changes during growth and their relationship with the development of the arm musculature and activity patterns. A sample of modern human humeri from individuals of age ranging from 24 weeks in utero to 18 years was imaged using microtomography at multiple resolutions and custom Matlab scripts. Standard biomechanical properties, cortical thickness, surface curvature, and pseudo-landmarks were extracted along radial vectors spaced at intervals of 1° at each 0.5% longitudinal increment measured along the shaft axis. Heat maps were also generated for cortical thickness and surface curvature. The results demonstrate that a whole bone approach to analysis of cross-sectional geometry is more desirable where possible, as there is a continuous pattern of variation along the shaft. It is also possible to discriminate very young individuals and adolescents from other groups by relative cortical thickness, and also by periosteal surface curvature.

Primary Care Behavioral Health Integration and Care Utilization: Implications for Patient Outcome and Healthcare Resource Use.

BACKGROUND: Behavioral health (BH) integration in primary care (PC) can potentially improve outcomes and reduce cost of care. While different models of integration exist, evidence from real-world examples is needed to demonstrate the effectiveness and value of integration. This study aimed to evaluate the outcomes of six PC practice sites located in Western New York that implemented a primary care behavioral health (PCBH) integration model. OBJECTIVE: To assess the impact of PCBH on all-cause healthcare utilization rates. DESIGN: A retrospective observational study based on historical multi-payer health insurance claims data. Claims data were aggregated on a per-member-per-month basis to compare utilization rates among the patients in the PC practice sites that had implemented PCBH to those in the sites that had not yet done so. PARTICIPANTS: The sample included 6768 unique adult health plan members between October 2015 and June 2017 with at least one BH diagnosis code who were attributed to one of the six newly integrated PC practice sites. INTERVENTIONS: Under the PCBH integration model, BH specialists were embedded in PC practice sites to treat a wide range of BH conditions. MAIN MEASURES: Rates of all-cause ED visits and hospital admissions, along with rates of PC provider and BH provider visits. KEY RESULTS: PCBH implementation was associated with reductions in the rates of outpatient ED visits (14.2%; p < 0.001) and PC provider visits (12.0%; p < 0.001), as well as with an increased rate of BH provider visits (7.5%; p = 0.018). CONCLUSIONS: PCBH integration appears to alter the treatment patterns among patients with BH conditions by shifting patient visits away from ED and PC providers toward BH providers who specialize in treatment of such patients.

Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control.

Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings. We investigated whether physicians' perceptions of autonomy support and job control significantly moderate the relationship between practice satisfaction and guideline adherence in a pay-for-performance context. We performed secondary analysis of a study dataset created by merging prospective information on clinical services provided by Rochester (NY)-based primary physicians (N = 156) during the years 2001-2004 with census data on specific characteristics of their ambulatory-care populations, claims-sourced information on attributes of their primary care practices, and survey data on their work-related attitudes. Greater job satisfaction had a significant multivariate association with lower adherence (ß = -0.139; p=<.0001) among physicians that perceived low autonomy support from the market-dominant payer organization. For physicians experiencing high autonomy support, a positive satisfaction-adherence association existed (ß = 0.105; p=<.0001). Low job control was a negative moderator (ß = -0.103; p=<.0001), and high control a positive moderator (ß = 0.071; p=<.0001), of the influence of job satisfaction on guideline adherence. Given the limitations of this study, such as the cross-sectional survey data and potential for unmeasured confounding variables, the validity of our findings should be tested by future research. We conclude that payers attempting to over-direct partner physicians can demotivate the satisfied physicians from achieving top-level guideline adherence, thereby squandering opportunities for intrinsic satisfaction to improve guideline adherence. To optimize the potential for job satisfaction to motivate greater guideline adherence, it may be important for payers to be perceptibly more supportive of physicians' autonomy and sense of job control.

A volumetric technique for fossil body mass estimation applied to Australopithecus afarensis.

Fossil body mass estimation is a well established practice within the field of physical anthropology. Previous studies have relied upon traditional allometric approaches, in which the relationship between one/several skeletal dimensions and body mass in a range of modern taxa is used in a predictive capacity. The lack of relatively complete skeletons has thus far limited the potential application of alternative mass estimation techniques, such as volumetric reconstruction, to fossil hominins. Yet across vertebrate paleontology more broadly, novel volumetric approaches are resulting in predicted values for fossil body mass very different to those estimated by traditional allometry. Here we present a new digital reconstruction of Australopithecus afarensis (A.L. 288-1; 'Lucy') and a convex hull-based volumetric estimate of body mass. The technique relies upon identifying a predictable relationship between the 'shrink-wrapped' volume of the skeleton and known body mass in a range of modern taxa, and subsequent application to an articulated model of the fossil taxa of interest. Our calibration dataset comprises whole body computed tomography (CT) scans of 15 species of modern primate. The resulting predictive model is characterized by a high correlation coefficient (r2 = 0.988) and a percentage standard error of 20%, and performs well when applied to modern individuals of known body mass. Application of the convex hull technique to A. afarensis results in a relatively low body mass estimate of 20.4 kg (95% prediction interval 13.5-30.9 kg). A sensitivity analysis on the articulation of the chest region highlights the sensitivity of our approach to the reconstruction of the trunk, and the incomplete nature of the preserved ribcage may explain the low values for predicted body mass here. We suggest that the heaviest of previous estimates would require the thorax to be expanded to an unlikely extent, yet this can only be properly tested when more complete fossils are available.

The Moderating Effect of Job Satisfaction on Physicians' Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines.

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling. Results show that attitudes motivated, while norms suppressed, adherence to guidelines among discontented physicians. Separate models for satisfied versus discontented physicians revealed motivational differences. Satisfied physicians disregarded intrinsic and extrinsic influences and biases. Discontented physicians, alienated by social pressure, favored personal inclinations. To improve adherence to guidelines among discontented physicians, incentives should align with personal attitudes and incorporate promotional campaigns countering resentment of peer and organizational pressure.

Convex-hull mass estimates of the dodo (Raphus cucullatus): application of a CT-based mass estimation technique.

The external appearance of the dodo (Raphus cucullatus, Linnaeus, 1758) has been a source of considerable intrigue, as contemporaneous accounts or depictions are rare. The body mass of the dodo has been particularly contentious, with the flightless pigeon alternatively reconstructed as slim or fat depending upon the skeletal metric used as the basis for mass prediction. Resolving this dichotomy and obtaining a reliable estimate for mass is essential before future analyses regarding dodo life history, physiology or biomechanics can be conducted. Previous mass estimates of the dodo have relied upon predictive equations based upon hind limb dimensions of extant pigeons. Yet the hind limb proportions of dodo have been found to differ considerably from those of their modern relatives, particularly with regards to midshaft diameter. Therefore, application of predictive equations to unusually robust fossil skeletal elements may bias mass estimates. We present a whole-body computed tomography (CT) -based mass estimation technique for application to the dodo. We generate 3D volumetric renders of the articulated skeletons of 20 species of extant pigeons, and wrap minimum-fit 'convex hulls' around their bony extremities. Convex hull volume is subsequently regressed against mass to generate predictive models based upon whole skeletons. Our best-performing predictive model is characterized by high correlation coefficients and low mean squared error (a = - 2.31, b = 0.90, r (2) = 0.97, MSE = 0.0046). When applied to articulated composite skeletons of the dodo (National Museums Scotland, NMS.Z.1993.13; Natural History Museum, NHMUK A.9040 and S/1988.50.1), we estimate eviscerated body masses of 8-10.8 kg. When accounting for missing soft tissues, this may equate to live masses of 10.6-14.3 kg. Mass predictions presented here overlap at the lower end of those previously published, and support recent suggestions of a relatively slim dodo. CT-based reconstructions provide a means of objectively estimating mass and body segment properties of extinct species using whole articulated skeletons.

An enantioselective formal synthesis of montelukast sodium.

A formal synthesis of the antiasthma drug montelukast sodium is described, wherein the key chiral diol intermediate was accessed with greater convergence of the C-C bond-forming steps as compared to previous routes. Improved synthetic efficiency was achieved by deploying homogeneous metal-based catalysis in two pivotal steps. In the first, a tandem Mizoroki-Heck reaction and double-bond isomerization between a previously known allyl alcohol intermediate and a hindered 2-(2-halophenyl)propan-2-ol secured direct access to the 3-(2-(2-hydroxypropan-2-yl)phenyl)-1-phenylpropan-1-one moiety in the product. In the second step, asymmetric hydrogenation of the ketone functionality in the Mizoroki-Heck reaction product provided a convenient method to introduce the benzylic alcohol chiral center and obtain the desired chiral diol precursor of montelukast sodium. A detailed catalyst screening led to the identification of ((R)-Xyl-BINAP)((R,R)-DPEN)RuCl2 as a catalyst that afforded an enantioselectivity of 99% ee in the hydrogenation step on a multigram lab scale at a molar substrate:catalyst loading of 5000:1.

Rhodium/phospholane-phosphite catalysts give unusually high regioselectivity in the enantioselective hydroformylation of vinyl arenes.

Using the phospholane-phosphite ligand, BOBPHOS, almost perfect regioselectivities and high enantioselectivities (up to 92% ee) are observed in Rh catalysed enantioselective hydroformylation of vinyl arenes. This can be achieved under solvent-free conditions.

Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.

Current strategies for addressing health care costs stress physician performance measurement and commonly use an efficiency index (EI). During seven years of conducting individual practitioner pay-for-performance (P4P), we found that using EIs hindered our work on reducing overuse of services. This paper offers an alternative approach through the identification of variation in key cost drivers. As proof of concept, we apply this model to hypertension care. We then describe a project that decreased apparent overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Focusing directly on reducing overuse improves cost efficiency without the barriers imposed by EI methodology.