Statewide Initiative to Reduce Patient Radiation Doses During Percutaneous Coronary Intervention.

BACKGROUND: Improved radiation safety practices are needed across hospitals performing percutaneous coronary intervention (PCI). This study was performed to assess the temporal trend in PCI radiation doses concurrent with the conduct of a statewide radiation safety initiative. METHODS: A statewide initiative to reduce PCI radiation doses was conducted in Michigan between 2017 and 2021 and included focused radiation safety education, reporting of institutional radiation doses, and implementation of radiation performance metrics for hospitals. Using data from a large statewide registry, PCI discharges between July 1, 2016, and July 1, 2022, having a procedural air kerma (AK) recorded were analyzed for temporal trends. A multivariable regression analysis was performed to determine whether declines in procedural AK over time were attributable to changes in known predictors of radiation doses. RESULTS: Among 131 619 PCI procedures performed during the study period, a reduction in procedural AK was observed over time, from a median dose of 1.46 (0.86-2.37) Gy in the first year of the study to 0.97 (0.56-1.64) Gy in the last year of the study (P<0.001). The proportion of cases with an AK ≥5 Gy declined from 4.24% to 0.86% over the same time period (P<0.0001). After adjusting for variables known to impact radiation doses, a 1-year increase in the date of PCI was associated with a 7.61% (95% CI, 7.38%-7.84%) reduction in procedural AK (P<0.0001). CONCLUSIONS: Concurrent with the conduct of a statewide initiative to reduce procedural radiation doses, a progressive and significant decline in procedural radiation doses was observed among patients undergoing PCI in the state of Michigan.

Ecological validity of the Meyers Neuropsychological Battery.

Neuropsychologists are increasingly being asked to apply neuropsychological test results to real world functioning; however, neuropsychological tests are not usually constructed to do so, but instead are more concerned with diagnostic accuracy than with prediction of daily functioning. Using samples of 5,460 patients that did self-ratings and 2791 patients that had family ratings plus the Meyers Neuropsychological Battery (MNB), it was found that the family ratings were better predicted by neuropsychological test data than were self-ratings on the 38 item Patient Competency Rating Scale (PCRS). The R values for family ratings on the 36 regression equations ranged from .236 to .763. The results show that the ratings given patients by family members could be predicted by the neuropsychological test results. These findings can help the clinician to make broad statements regarding likely real-life functioning and also support the ecological validity of the tests that make up the MNB.

Objective methods for matching neuropsychological patterns: Formulas and comparisons.

INTRODUCTION: Objective neuropsychology test score pattern matching methods can help to identify data similarities and differences with comparison groups which can help the clinician in diagnosis and in identifying treatment options. MATERIALS AND METHODS: The current study examines five methods of matching a data set: Correlation, Configuration, Kullback-Leibler (KL) Divergence, Pooled Effect Size (Cohen's d), and a new method called MNB (Meyers Neuropsychological Battery) Code. Thirty data sets diagnosed with Traumatic Brain Injury (TBI) were compared with four Comparison Group data sets consisting of TBI, Depression, Anxiety and Attention Deficit/Hyperactivity Disorder. RESULTS: The Correlation Method was correct 90% (27/30) and Configuration was correct 86% (26/30). The KL Divergence was correct 76% (23/30) and the MNB Code was correct 73% (22/30). The Effect Size Method was correct 70% (21/30). When using a simple majority of all the matching methods, the classification rate was 90+ percent. CONCLUSIONS: The results of this study demonstrate that there are statistical methods that can identify patterns of cognitive strengths and weaknesses. Multiple matching methods and a simple majority of agreement between the different comparisons suggests the best matching profile for diagnosis. In some cases, more than one pattern may be present.

Physician norms for the Automated Neuropsychological Assessment Metrics (ANAM).

INTRODUCTION: The development of population specific norms for the Automated Neuropsychological Assessment Metrics (ANAM) is to help expand the utility for use with other population groups. Currently, normative data are available for general military, special operations, athletic, and community populations. The current study provides normative reference values for use in assessing physicians. MATERIALS AND METHODS: Retrospective data from a sample of 2,288 physicians who completed the ANAM were examined. The data were gathered from practicing civilian physicians serving in the National Guard or Reserves who completed the assessment as part of the mandated Department of Defense clinical testing policy. The effects of age and sex on performance were examined for all subtests. Normative tables were stratified by age (23-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-79) and sex. Base rates of low scores among the physician population were also examined. RESULTS: Older age was associated with lower performance on all subtests with small-to-medium effect sizes. A mixed pattern of performance was observed as a factor of sex with females scoring better on one subtest and males scoring better on three subtests. However, effects sizes associated with sex were small and likely of minimal clinical significance. A total of 11.3% of the physician sample scored below average on two or more tests in the battery. CONCLUSIONS: This study provides normative data for practicing physicians that can be used to help inform clinical decision-making.

A Validity Measure for the Automated Neuropsychological Assessment Metrics.

The Automated Neuropsychological Assessment Metrics (ANAM) is one of the most widely used and validated neuropsychological instruments for assessing cognition. The ANAM Test System includes a reporting tool, the ANAM Validity Indicator Report that generates scores for the embedded effort measure, the ANAM Performance Validity Index (APVI). The current study seeks to develop a proxy for the APVI, using raw subtest summary test scores. This would be useful for situations where the APVI score is unavailable (e.g., validity report not generated at the time of the assessment) or when the item level data needed to generate this score are inaccessible. ANAM scores from a large data set of 1,000,000+ observations were used for this retrospective analysis. Results of linear regression analysis suggest that the APVI can be reasonably estimated from the raw subtest summary test scores that are presented on the ANAM Performance Report. Clinically, this means that an important step in the interpretation process, checking the validity of test data, can still be performed even when the APVI is not available.

Microstructural evidence of the toughening mechanisms of polyurethane reinforced with halloysite nanotubes under high strain-rate tensile loading.

In this study, we have investigated the relationship between the spherulitic morphology and the dynamic tensile response of polyurethane reinforced with Halloysite nanotubes (HNTs). The polyurethane prepolymer is partially silane end-capped and filled with only 0.8 wt.% of acid-treated Halloysite nanotubes. The resultant nanocomposite material presents a 35% higher spall strength compared to the neat polyurethane and 21% higher fracture toughness. We show evidence that the HNTs are not the toughening phase in the nanocomposite, but rather it is their influence on the resultant spherulitic structures which alters the polymer microstructure and leads to a tougher dynamic response. Microstructural characterization is performed via Scanning Electron Microscopy, Atomic Force Microscopy and Field Emission Scanning Electron Microscopy, and crystallinity examination via X-ray diffraction. The spherulitic structures present a brittle fracture character, while the interspherulitic regions are more ductile and show large deformation. The nanocomposite presents a finer and more rigid spherulitic structure, and a more energy dissipative fracture mechanism characterized by a rougher fracture surface with highly deformed interspherulitic regions.

Synthesis and characterization of partially silane-terminated polyurethanes reinforced with acid-treated halloysite nanotubes for transparent armour systems.

In the present work, nanocomposites based on the partially silane-terminated polyurethanes reinforced with sulfuric acid-treated halloysite nanotubes were synthesized and evaluated as a potential candidate for transparent blast resistant configurations. The polyurethane must present high tensile ductility at high strain rates to be able to contain fragments and increase the survivability of the system. Gas-gun spall experiments were conducted to measure the dynamic tensile strength (spall strength) and fracture toughness of the nanocomposite and neat polyurethane. The nanocomposite presented a 35% higher spall strength and 21% higher fracture toughness compared to the neat polyurethane while maintaining transparency. The recovered samples following the spall tests were analysed via scanning electron microscope fractographies. The nanocomposite and neat polyurethane samples were chemically characterized via Fourier transform infrared spectroscopy and melting behaviour via differential scanning calorimetry. The improved properties can be attributed, in large part, to the presence of more rigid spherulitic structures, and a rougher fracture surface constituting of several micro-cracks within the nanocomposite.

Premorbid estimates of neuropsychological functioning for diverse groups.

One of the basic tasks performed by a neuropsychologist is to identify the difference between current performance and the premorbid expected performance. Baseline expected performance for Intellectually Impaired (n = 21), Developmentally Delayed (n = 40), Attention Deficit Disorder (n = 98), Learning Disability (n = 42), and "Normal" groups (n = 75) were developed along with a demographically corrected prediction of premorbid functioning and a word reading based prediction of premorbid functioning. We utilized a subset of this data pool for development (n = 107) and validation (n = 108) of premorbid functioning estimates. Findings show that a combination of three methods (baseline, demographic, and reading) were superior to any individual method. The effect size (Cohen's d) calculations show that differences in the prediction of domain level performances were small and likely not clinically meaningful, indicating that the premorbid estimates would be usable as a prediction of expected performance at the domain level. However, the motor domains were not well predicted.

Mass Spectrometry-Based Biomarkers in Drug Development.

Advances in mass spectrometry, proteomics, protein bioanalytical approaches, and biochemistry have led to a rapid evolution and expansion in the area of mass spectrometry-based biomarker discovery and development. The last decade has also seen significant progress in establishing accepted definitions, guidelines, and criteria for the analytical validation, acceptance and qualification of biomarkers. These advances have coincided with a decreased return on investment for pharmaceutical research and development and an increasing need for better early decision making tools. Empowering development teams with tools to measure a therapeutic interventions impact on disease state and progression, measure target engagement and to confirm predicted pharmacodynamic effects is critical to efficient data-driven decision making. Appropriate implementation of a biomarker or a combination of biomarkers can enhance understanding of a drugs mechanism, facilitate effective translation from the preclinical to clinical space, enable early proof of concept and dose selection, and increases the efficiency of drug development. Here we will provide descriptions of the different classes of biomarkers that have utility in the drug development process as well as review specific, protein-centric, mass spectrometry-based approaches for the discovery of biomarkers and development of targeted assays to measure these markers in a selective and analytically precise manner.

Differential Diagnosis of Complicated Bone Stress Injury in a Female Collegiate Swimmer.

An 18-year-old woman presented to a direct-access military physical therapy clinic after a fall directly onto the knee, with subsequent medial knee pain. The history and examination of the patient led the physical therapist to order radiographs, which revealed a pre-existing metaphyseal fibrous defect. On the same day, an orthopaedic consultation recommended magnetic resonance imaging and computed tomography, which showed a progression from a benign cortical defect to disruption of the posterior femur and surrounding bone marrow edema consistent with bone stress injury. J Orthop Sports Phys Ther 2018;48(10):823. doi:10.2519/jospt.2018.7731.

Pseudohyperphosphatemia in a patient with incidentally identified progression of smoldering myeloma.

BACKGROUND: Pseudohyperphosphatemia is a rare laboratory finding in MM, especially in patients with smoldering myeloma (SMM) progressing to symptomatic multiple myeloma (MM). Laboratorians and clinicians should be aware of this phenomenon and take necessary actions to avoid misdiagnosis. METHODS: Specimens from a monoclonal IgG kappa SMM patient with extremely high serum phosphorus concentrations measured by the Roche phosphomolybdate assay were re-evaluated using serial dilutions and the ORTHO VITROS assay free from monoclonal gammaglobulin interference. Serum free kappa/lambda chain ratio was also assessed. RESULTS: Both serial dilutions and the ORTHO VITROS assay normalized serum phosphorus concentrations, suggesting the extremely high serum phosphorus concentrations measured by the Roche assay is due to interference from monoclonal gammaglobulin. Additionally, the patient's serum free kappa/lambda ratio was >100. Based on serum free kappa/lambda ratio, disease progression from SMM to MM was diagnosed. CONCLUSIONS: Prompt and appropriate laboratory investigations ensure correct diagnosis of pseudohyperphosphatemia and help clinicians properly manage patients. To our knowledge, this patient is the first reported case of pseudohyperphosphatemia in patients with progression from SMM to MM.

Molecular dynamics at constant Cauchy stress.

The Parrinello-Rahman algorithm for imposing a general state of stress in periodic molecular dynamics simulations is widely used in the literature and has been implemented in many readily available molecular dynamics codes. However, what is often overlooked is that this algorithm controls the second Piola-Kirchhoff stress as opposed to the true (Cauchy) stress. This can lead to misinterpretation of simulation results because (1) the true stress that is imposed during the simulation depends on the deformation of the periodic cell, (2) the true stress is potentially very different from the imposed second Piola-Kirchhoff stress, and (3) the true stress can vary significantly during the simulation even if the imposed second Piola-Kirchhoff is constant. We propose a simple modification to the algorithm that allows the true Cauchy stress to be controlled directly. We then demonstrate the efficacy of the new algorithm with the example of martensitic phase transformations under applied stress.

Is Co-norming Required?

Researchers who have been responsible for developing test batteries have argued that competent practice requires the use of a "fixed battery" that is co-normed. We tested this assumption with three normative systems: co-normed, meta-regressed norms and a system of these two methods. We analyzed two samples: 330 referred patients and 99 undergraduate volunteers. The T scores generated for referred patients using the three systems were highly associated with one another and quite similar in magnitude, with an Overall Test Battery Means (OTBMs) using the co-normed, hybrid, and meta-regressed scores equaled 43.8, 45.0, and 43.9, respectively. For volunteers, the OTBMs equaled 47.4, 47.5, and 47.1, respectively. The correlations amongst these OTBMs across systems were all above .90. Differences among OTBMs across normative systems were small and not clinically meaningful. We conclude that co-norming for competent clinical practice is not necessary.

Normative Data for the Neurobehavioral Symptom Inventory.

The demographically diverse populations served by large health care systems (Veterans Affairs, Department of Defense, Medicare, Medicaid) are routinely screened with the Neurobehavioral Symptom Inventory (NSI). The extent to which a patient's report of symptoms either initially and/or across time is affected by demographic variables-gender, ethnicity, age, or education-has not been investigated despite widespread use of the NSI. In practice, the effectiveness of this tool might be improved with demographically based norms. A large data set of normal community-dwelling individuals was collected using the NSI. Emphasis was made to collect data from individuals of diverse ethnic backgrounds. It was hypothesized that ethnic/cultural backgrounds would have an impact on NSI scores. The results provide normative data for the NSI applicable to a wide variety of individuals of various ages and ethnic backgrounds. An analysis of variance indicated there was no significant difference in NSI responses based on ethnic/cultural background; however, age and gender were found to contribute significantly to the variance associated with symptom endorsement. The NSI appears to be a reliable measure of self-report postconcussive symptoms. Age is a variable associated with differential symptom endorsement on the NSI. Follow-up studies are needed to provide a measure of the sensitivity and specificity of this measure.

Toward innovative, cost-effective, and systemic solutions to improve outcomes and well-being of military families affected by autism spectrum disorder.

The burdens faced by military families who have a child with autism are unique. The usual challenges of securing diagnostic, treatment, and educational services are compounded by life circumstances that include the anxieties of war, frequent relocation and separation, and a demand structure that emphasizes mission readiness and service. Recently established military autism-specific health care benefits set the stage for community-viable and cost-effective solutions that can achieve better outcomes for children and greater well-being for families. Here we argue for implementation of evidence-based solutions focused on reducing age of diagnosis and improving access to early intervention, as well as establishment of a tiered menu of services, individualized to the child and family, that fit with the military ethos and system of health care. Absence of this new model of care could compromise the utility and sustainability of the autism-specific benefit.

Rbm24a and Rbm24b are required for normal somitogenesis.

We recently demonstrated that the gene encoding the RNA binding motif protein 24 (RBM24) is expressed during mouse cardiogenesis, and determined the developmental requirement for its zebrafish homologs Rbm24a and Rbm24b during cardiac development. We demonstrate here that both Rbm24a and Rbm24b are also required for normal somite and craniofacial development. Diminution of rbm24a or rbm24b gene products by morpholino knockdown resulted in significant disruption of somite formation. Detailed in situ hybridization-based analyses of a spectrum of somitogenesis-associated transcripts revealed reduced expression of the cyclic muscle pattering genes dlc and dld encoding Notch ligands, as well as their respective target genes her7, her1. By contrast expression of the Notch receptors notch1a and notch3 appears unchanged. Some RBM-family members have been implicated in pre-mRNA processing. Analysis of affected Notch-pathway mRNAs in rbm24a and rbm24b morpholino-injected embryos revealed aberrant transcript fragments of dlc and dld, but not her1 or her7, suggesting the reduction in transcription levels of Notch pathway components may result from aberrant processing of its ligands. These data imply a previously unknown requirement for Rbm24a and Rbm24b in somite and craniofacial development. Although we anticipate the influence of disrupting RBM24 homologs likely extends beyond the Notch pathway, our results suggest their perturbation may directly, or indirectly, compromise post-transcriptional processing, exemplified by imprecise processing of dlc and dld.

Mass spectrometry-based biomarkers in drug development.

Advances in mass spectrometry, proteomics, protein bioanalytical approaches, and biochemistry have led to a rapid evolution and expansion in the area of mass spectrometry-based biomarker discovery and development. The last decade has also seen significant progress in establishing accepted definitions, guidelines, and criteria for the analytical validation, acceptance, and qualification of biomarkers. These advances have coincided with a decreased return on investment for pharmaceutical research and development and an increasing need for better early decision making tools. Empowering development teams with tools to measure a therapeutic interventions impact on disease state and progression, measure target engagement, and to confirm predicted pharmacodynamic effects is critical to efficient data-driven decision making. Appropriate implementation of a biomarker or a combination of biomarkers can enhance understanding of a drugs mechanism, facilitate effective translation from the preclinical to clinical space, enable early proof of concept and dose selection, and increase the efficiency of drug development. Here we will provide descriptions of the different classes of biomarkers that have utility in the drug development process as well as review specific, protein-centric, mass spectrometry-based approaches for the discovery of biomarkers and development of targeted assays to measure these markers in a selective and analytically precise manner.

Emotional distress affects attention and concentration: the difference between mountains and valleys.

The current study tests the hypothesis that the "mountains and valleys pattern" (MVP) observed within the Attention and Concentration domain of the Meyers Neuropsychological Battery reflects the interference of emotional distress/anxiety on the patient's cognitive test performance. First, the MVP was objectively quantified using a formula that took into account both increased and decreased scores, rather than canceling them out through averaging. Using a total sample of 787 subjects, the Minnesota Multiphasic Personality Inventory-Second Edition Restructured Form (MMPI-2-RF) profile scores of cases with and without this pattern were then compared using an extensive database followed by a smaller, matched-groups design. The presence of the MVP was related to MMPI-2-RF test performance. In particular, this pattern was related to emotional distress/anxiety scales but was not related to scales reflecting neurological or cognitive complaints. The degree of emotional distress experienced may affect attention and concentration test performance in a way that sometimes heightens focus and at other times disrupts focus. The MVP may be used to assess the effects of emotional distress on the consistency of an individual patient's attention and concentration test performance.