Patient experience in a remote patient monitoring program for hypertension: A qualitative study.

BACKGROUND: Remote patient monitoring (RPM), which includes out-of-office blood pressure (BP) measurement, coupled with interventions including telehealth and team-based care, is recommended for hypertension (HTN) management. We aimed to assess participant experience with RPM for HTN (RPM-HTN) to understand barriers and facilitators to implementing RPM-HTN in a primary care population where health disparities and social inequities are prevalent. METHODS: This is a qualitative implementation study of participants' experiences with an RPM-HTN program for primary care patients with uncontrolled HTN at an academic health system. We recruited participants with high and low levels of engagement (≥16 or <16 days of transmitted BP readings per month). Semi-structured interviews were conducted, and descriptive statistics and rapid qualitative analysis were used to identify factors affecting the implementation of RPM-HTN, specifically adoption, acceptability, appropriateness, and feasibility. RESULTS: Multiple themes emerged from interviews with 14 participants. A doctor's recommendation and wanting help with BP management were facilitators for engagement, while work conflicts and forgetfulness were barriers to engagement. Participants enjoyed the format and content of nurse and clinical pharmacist phone calls and forming a relationship with the team; expressed improved understanding of HTN and BP management; and appreciated the convenience of remote monitoring. CONCLUSIONS: Participants found RPM-HTN acceptable and appropriate, highlighting the team-based and out-of-office approach to care. This study provides actionable targets to overcome feasibility barriers to implementation. In order to increase engagement, RPM policies and procedures should take into account barriers including the quantity of required BP measurements and mechanisms of telehealth communication.

Morphological and Mechanical Tube Feet Plasticity among Populations of Sea Urchin (Strongylocentrotus purpuratus).

Sea urchins rely on an adhesive secreted by their tube feet to cope with the hydrodynamic forces of dislodgement common in nearshore, high wave-energy environments. Tube feet adhere strongly to the substrate and detach voluntarily for locomotion. In the purple sea urchin, Strongylocentrotus purpuratus, adhesive performance depends on both the type of substrate and the population of origin, where some substrates and populations are more adhesive than others. To explore the source of this variation, we evaluated tube foot morphology (disc surface area) and mechanical properties (maximum disc tenacity and stem breaking force) of populations native to substrates with different lithologies: sandstone, mudstone, and granite. We found differences among populations, where sea urchins native to mudstone substrates had higher disc surface area and maximum disc tenacity than sea urchins native to sandstone substrates. In a lab-based reciprocal transplant experiment, we attempted to induce a plastic response in tube foot morphology. We placed sea urchins on nonnative substrates (i.e., mudstone sea urchins were placed on sandstone and vice versa), while keeping a subgroup of both populations on their original substrates as a control. Instead of a reciprocal morphological response, we found that all treatments, including the control, reduced their disc area in laboratory conditions. The results of this study show differences in morphology and mechanical properties among populations, which explains population differences in adhesive performance. Additionally, this work highlights the importance of considering the impact of phenotypic plasticity in response to captivity when interpreting the results of laboratory studies.

Los erizos de mar utilizan una secreción adhesiva en sus pies ambulacrales para adherirse al sustrato y resistir fuerzas hidrodinámicas. Los pies ambulacrales se adhieren fuertemente, pero pueden despegarse voluntariamente para moverse. En el erizo morado, Strongylocentrotus purpuratus, el desempeño del sistema de adhesión depende del tipo de sustrato y la población de origen donde algunas poblaciones y sustratos tienen mejor desempeño adhesivo que otros. Para explicar el origen de esta variación, evaluamos la morfología (área del disco) del pie ambulacral y las propiedades mecánicas (tenacidad máxima del disco y fuerza necesaria para romper el tubo que conecta el disco con el animal) de poblaciones que se encuentran adheridas a sustratos con diferentes litologías: arenisca, lodolitas, y granito. Encontramos diferencias entre las poblaciones donde erizos de la población que vive en lodolitas tienen tenacidad del disco más alta y discos más grandes que erizos que viven en arenisca. En un experimento de laboratorio, intentamos inducir una respuesta plástica en la morfología del pie ambulacral. Para esto, pusimos erizos en sustratos diferentes a los que normalmente se adhieren (erizos que en encuentran en lodolita los pusimos en arenisca y viceversa) y dejamos erizos en su sustrato original como control. Sin embargo, en lugar de una respuesta plástica en la morfología del pie ambulacral, encontramos que todos los tratamientos, incluido los controles, redujeron el área del disco en condiciones de laboratorio. Los resultados de este estudio muestran diferencias en morfología y propiedades mecánicas entre las poblaciones, lo que explica diferencias en el desempeño del sistema de adhesión. Además, este estudio demuestra la importancia de considerar el impacto de plasticidad fenotípica al momento de interpretar estudios de laboratorio.

Grief and loss in old age: Exploration of the association between grief and depression.

BACKGROUND: The proportion of older adults is increasing due to demographic changes. Depression belongs to the most common mental disorders in late life. The loss of an emotionally significant person is a risk factor for the development of depression. The aim of this study is to analyze the association between depression and grief burden resulting from loss. Based on prior evidence, we examined loneliness as a possible mediator and social support as possible moderator of this association. METHODS: The cross-sectional analyses are based on a sample (N = 863) of study participants aged 75+ (M = 81.4 years, SD = 4.4, 62.2% female) with loss experience deriving from the multicenter prospective German cohort study AgeMooDe. Regression analyses (moderated mediation) were performed. RESULTS: With increasing age (ß = 0.10, p = .005) and grief burden (ß = 0.33, p <. 001) depression severity increased. There was an indirect mediating effect of loneliness on the correlation of grief burden and depression (b = 0.04, CI [0.03, 0.05]), but no moderating effect of social support on the correlation of grief burden and loneliness. People living alone had a significantly higher risk of depression, increased loneliness and lack of social support. LIMITATIONS: Assessments were based on self-reporting and recorded dimensionally. The cross-sectional design limits conclusions about directions and causality of associations. Sampling bias cannot be completely excluded. CONCLUSION: The study provides empirical evidence and a better understanding of the association between grief and depression among the very old and the mediating role of loneliness.

Postnatally acquired CMV meningitis diagnosed via BioFire FilmArray: A case report.

Postnatally acquired cytomegalovirus (CMV) is commonly acquired via breast milk, with premature infants more frequently developing symptoms of CMV infection in comparison to term infants. Meningitis is a rare clinical manifestation of CMV infection. The diagnosis of meningitis is difficult to make in infants, particularly those who are preterm. Consequentially, broad-spectrum empiric antimicrobial coverage is often administered for several days while waiting for current gold standard CSF testing to result. The BioFire FilmArray (BFA) simultaneously tests for 14 different pathogens, including CMV, allowing for quicker diagnosis and shorter time to definitive treatment. Here, we report a very low birth weight infant with postnatally acquired CMV meningitis, the first to our knowledge to be diagnosed using the BioFire FilmArray.

Subjective speckle suppression for 3D measurement using one-dimensional numerical filtering.

Laser speckle projection is a reliable method to generate statistical illumination patterns for 3D reconstruction purposes as in stereo photogrammetry. This type of pattern has several advantages compared to incoherent methods. However, the biggest disadvantage is given by the coherent noise, the so-called "subjective speckles," developing when a coherently illuminated surface is imaged by a lens system. Some experimental techniques have been published already, being costly in measurement time or leading to loss in light intensity and/or depth of field. In this work we want to present numerical one-dimensional filtering techniques that reduce this kind of noise and increase the performance of 3D reconstruction, while no experimental changes to the classical speckle projection technique have to be made. Therefore, a model describing the expectable contrast reduction is derived, the dependency between filter orientation and setup geometry is investigated, and results from simulations and real experiments are shown. It is found that for small filter sizes the results can be improved independent of the filter, but that in the general case a vertical orientation of the filter towards the setup geometry is most useful.

Stress-controlled decomposition routes in cubic AlCrN films assessed by in-situ high-temperature high-energy grazing incidence transmission X-ray diffraction.

The dependence of decomposition routes on intrinsic microstructure and stress in nanocrystalline transition metal nitrides is not yet fully understood. In this contribution, three Al0.7Cr0.3N thin films with residual stress magnitudes of -3510, -4660 and -5930 MPa in the as-deposited state were in-situ characterized in the range of 25-1100 °C using in-situ synchrotron high-temperature high-energy grazing-incidence-transmission X-ray diffraction and temperature evolutions of phases, coefficients of thermal expansion, structural defects, texture as well as residual, thermal and intrinsic stresses were evaluated. The multi-parameter experimental data indicate a complex intrinsic stress and phase changes governed by a microstructure recovery and phase transformations taking place above the deposition temperature. Though the decomposition temperatures of metastable cubic Al0.7Cr0.3N phase in the range of 698-914 °C are inversely proportional to the magnitudes of deposition temperatures, the decomposition process itself starts at the same stress level of ~-4300 MPa in all three films. This phenomenon indicates that the particular compressive stress level functions as an energy threshold at which the diffusion driven formation of hexagonal Al(Cr)N phase is initiated, provided sufficient temperature is applied. In summary, the unique synchrotron experimental setup indicated that residual stresses play a decisive role in the decomposition routes of nanocrystalline transition metal nitrides.

Influences on students' empathy in medical education: an exploratory interview study with medical students in their third and last year.

BACKGROUND: Empathy is beneficial for patients and physicians. It facilitates treatment and improves physical and psychosocial outcomes. The therapeutic relevance of empathy emphasizes the need to help medical students develop their empathic abilities. Our study aimed to identify factors which promote or hinder the development and expression of empathy in medical students during the course of their studies. METHODS: We interviewed 24 medical students (six male and six female students in their 6th semester as well as six male and six female students in their final clinical year) using semi-structured interviews. The interviews were recorded, transcribed verbatim and analyzed using Braun & Clarke's thematic analysis. RESULTS: We identified four main themes influencing the development and expression of empathy. 1) Course of studies: hands-on-experience, role models, science and theory, and emphasis on the importance of empathy; 2) students: insecurities and lack of routine, increasing professionalism, previous work experiences, professional distance, mood, maturity, and personal level of empathy; 3) patients: "easy" and "difficult" patients including their state of health; and 4) surrounding conditions: time pressure/stress, work environment, and job dissatisfaction. CONCLUSIONS: The development and use of empathy could be promoted by increasing: hands-on-experiences, possibilities to experience the patient's point of view and offering patient contact early in the curriculum. Students need support in reflecting on their actions, behavior and experiences with patients. Instructors need time and opportunities to reflect on their own communication with and treatment of patients, on their teaching behavior, and on their function as role models for treating patients empathically and preventing stress. Practical experiences should be made less stressful for students. The current changes implemented in some medical school curriculums (e.g., in Germany) seem to go in the right direction by integrating patient contact early on in the curriculum and focusing more on teaching adequate communication and interaction behaviors.

Fast molecular outflow from a dusty star-forming galaxy in the early Universe.

Galaxies grow inefficiently, with only a small percentage of the available gas converted into stars each free-fall time. Feedback processes, such as outflowing winds driven by radiation pressure, supernovae, or supermassive black hole accretion, can act to halt star formation if they heat or expel the gas supply. We report a molecular outflow launched from a dust-rich star-forming galaxy at redshift 5.3, 1 billion years after the Big Bang. The outflow reaches velocities up to 800 kilometers per second relative to the galaxy, is resolved into multiple clumps, and carries mass at a rate within a factor of 2 of the star formation rate. Our results show that molecular outflows can remove a large fraction of the gas available for star formation from galaxies at high redshift.

The programmable shunt-system Codman Medos Hakim: A clinical observation study and review of literature.

OBJECTIVES: Hydrocephalus can be defined as clinically symptomatic dilatation of the internal ventricular system at the expense of brain and blood volume. Shunt insertion is the mainstay of therapy for communicating hydrocephalus. One of the most frequently used valves is the programmable Codman Medos Hakim valve which enables the pressure level to be adjusted from 30 to 200 mmH2O. The problem of functional over- or underdrainage and the associated complications should be significantly reduced if not excluded. Especially in the clinical application of the Codman Medos Hakim Shunt System in hydrocephalus of other etiology only a few studies can be found. This study aims to increase knowledge of both the safety of Codman Medos valves with SiphonGuard in the clinical application as well as the correct choice of the pressure level for different indications. PATIENTS AND METHODS: In this retrospective study, 101 patients were included who underwent surgery with the adjustable "Codman Medos Hakim" valve with "SiphonGuard" between January 2010 and July 2013. We analyzed the patient files and imaging (CCT, cMRT) data. The statistical examinations were performed using the WINStat program for Excel. RESULTS: Our results show that an initial pressure level of 120mmH2O proved to be suitable in all subgroups. After optimization of the initial pressure level 70.3% of the valves (71 valves) had a pressure level of 120mmH2O. Importantly, only in the SAH subgroup the clinical improvement was correlated with a reduction in the measured indices. But in all subgroups a clinical deterioration was associated with an increased ventricular size. CONCLUSION: Overall, the clinical data show that an initial pressure level of 120mmH2O seems to be appropriate for most patients treated in this series. Measured indices from the cranial imaging can provide valuable indications for the presence of a suboptimal valve setting for the individual patient.

Author Correction: A massive core for a cluster of galaxies at a redshift of 4.3.

Change history: In this Letter, the Acknowledgements section should have included the following sentence: "The National Radio Astronomy Observatory is a facility of the National Science Foundation operated under cooperative agreement by Associated Universities, Inc.". This omission has been corrected online.

A massive core for a cluster of galaxies at a redshift of 4.3.

Massive galaxy clusters have been found that date to times as early as three billion years after the Big Bang, containing stars that formed at even earlier epochs1-3. The high-redshift progenitors of these galaxy clusters-termed 'protoclusters'-can be identified in cosmological simulations that have the highest overdensities (greater-than-average densities) of dark matter4-6. Protoclusters are expected to contain extremely massive galaxies that can be observed as luminous starbursts 7 . However, recent detections of possible protoclusters hosting such starbursts8-11 do not support the kind of rapid cluster-core formation expected from simulations 12 : the structures observed contain only a handful of starbursting galaxies spread throughout a broad region, with poor evidence for eventual collapse into a protocluster. Here we report observations of carbon monoxide and ionized carbon emission from the source SPT2349-56. We find that this source consists of at least 14 gas-rich galaxies, all lying at redshifts of 4.31. We demonstrate that each of these galaxies is forming stars between 50 and 1,000 times more quickly than our own Milky Way, and that all are located within a projected region that is only around 130 kiloparsecs in diameter. This galaxy surface density is more than ten times the average blank-field value (integrated over all redshifts), and more than 1,000 times the average field volume density. The velocity dispersion (approximately 410 kilometres per second) of these galaxies and the enormous gas and star-formation densities suggest that this system represents the core of a cluster of galaxies that was already at an advanced stage of formation when the Universe was only 1.4 billion years old. A comparison with other known protoclusters at high redshifts shows that SPT2349-56 could be building one of the most massive structures in the Universe today.

Parenting style impacts cognitive and behavioural outcomes of former preterm infants: A systematic review.

We sought to evaluate published evidence in aggregate regarding the impact of parenting style on the cognitive and behavioural outcomes of former preterm infants. We searched 5 databases using germane MeSH terms. Parenting style was defined as any descriptor of parenting using ≥2 dimensions on published parenting axes. We evaluated studies for quality of evidence and strength of recommendations using standardized tools and categorized summative recommendations by parenting axis and child outcome. Twenty-seven articles met our inclusion criteria. Parental responsivity is the only parenting axis strongly associated with both improved child cognition and behaviour. Parental demandingness is associated only with improved child cognition, and parental warmth and rejection are associated only with child behaviour. Parental coercion is not associated with subsequent child outcomes. Parental responsivity may be essential in optimizing neurodevelopment in former preterm infants. More targeted studies are needed to inform this relationship and identify opportunities for intervention.

Atypical Cowpox Virus Infection in a Series of Cats.

Within 4 weeks, five cats with skin lesions affecting the hindlimbs and mainly consisting of oedema, hyperaemia and plaque-like alterations were presented to the same veterinary clinic. The cats were suffering from lameness, trauma, renal insufficiency or complicated tail amputation. Although the lesions seemed unusual for a poxvirus infection, microscopical examination of biopsy samples or specimens taken during necropsy examination revealed ballooning degeneration of keratinocytes with eosinophilic, cytoplasmic inclusion bodies indicative of an orthopoxvirus infection. Cowpox virus infection was verified using immunohistochemistry and virus isolation. Molecular analysis revealed identical haemagglutinin gene sequences in four cases and spatiotemporal circumstances in some cases pointed to hospital-acquired transmission. Unusual manifestations of feline cowpox may have an unexpected risk for human infection.

Galaxy growth in a massive halo in the first billion years of cosmic history.

According to the current understanding of cosmic structure formation, the precursors of the most massive structures in the Universe began to form shortly after the Big Bang, in regions corresponding to the largest fluctuations in the cosmic density field. Observing these structures during their period of active growth and assembly-the first few hundred million years of the Universe-is challenging because it requires surveys that are sensitive enough to detect the distant galaxies that act as signposts for these structures and wide enough to capture the rarest objects. As a result, very few such objects have been detected so far. Here we report observations of a far-infrared-luminous object at redshift 6.900 (less than 800 million years after the Big Bang) that was discovered in a wide-field survey. High-resolution imaging shows it to be a pair of extremely massive star-forming galaxies. The larger is forming stars at a rate of 2,900 solar masses per year, contains 270 billion solar masses of gas and 2.5 billion solar masses of dust, and is more massive than any other known object at a redshift of more than 6. Its rapid star formation is probably triggered by its companion galaxy at a projected separation of 8 kiloparsecs. This merging companion hosts 35 billion solar masses of stars and has a star-formation rate of 540 solar masses per year, but has an order of magnitude less gas and dust than its neighbour and physical conditions akin to those observed in lower-metallicity galaxies in the nearby Universe. These objects suggest the presence of a dark-matter halo with a mass of more than 100 billion solar masses, making it among the rarest dark-matter haloes that should exist in the Universe at this epoch.

A tailored automated nutrition screening tool for rapid identification of risk in acute-care hospital settings.

Malnourishment is prevalent in hospitalized patients and associated with adverse medical outcomes. Thus, nutrition screening to identify high-risk patients is widespread. However, no single universal tool has been shown to be suitable for all hospital departments. To address this challenge, a novel, tailored, electronic tool for nutritional screening was developed and evaluated. The Rambam Automated Nutrition Computerized Screening tool efficiently screens all newly admitted patients and does not rely on self-reported height and weight estimates. Validation was carried out in medical wards (n=94), and compared to the Malnutrition Universal Screening Tool, length of stay and an independent assessment by a professional dietician. Results from this research support the use of automated, flexible tools that instantaneously incorporate relevant available data from the electronic health record. Tools that are adaptable to meet the needs of individual hospital departments, can save valuable time and ensure full screening of all admitted patients.

Increasing F2-isoprostanes in the first month after birth predicts poor respiratory and neurodevelopmental outcomes in very preterm infants.

OBJECTIVE: This study examined the association between increased early oxidative stress, measured by F2-isoprostanes (IsoPs), and respiratory morbidity at term equivalent age and neurological impairment at 12 months of corrected age (CA). STUDY DESIGN: Plasma samples were collected from 136 premature infants on days 14 and 28 after birth. All participants were infants born at ⩽28 weeks of gestational age enrolled into the Prematurity and Respiratory Outcomes Program (PROP) study. Respiratory morbidity was determined at 40 weeks of postmenstrual age (PMA) by the Respiratory Severity Index (RSI), a composite measure of oxygen and pressure support. Neurodevelopmental assessment was performed using the Developmental Assessment of Young Children (DAYC) at 12 months of CA. Multivariable logistic regression models estimated associations between IsoP change, RSI and DAYC scores. Mediation analysis was performed to determine the relationship between IsoPs and later outcomes. RESULTS: Developmental data were available for 121 patients (90% of enrolled) at 12 months. For each 50-unit increase in IsoPs, regression modeling predicted decreases in cognitive, communication and motor scores of -1.9, -1.2 and -2.4 points, respectively (P<0.001). IsoP increase was also associated with increased RSI at 40 weeks of PMA (odds ratio=1.23; P=0.01). RSI mediated 25% of the IsoP effect on DAYC motor scores (P=0.02) and had no significant impact on cognitive or communication scores. CONCLUSIONS: In the first month after birth, increases in plasma IsoPs identify preterm infants at risk for respiratory morbidity at term equivalent age and worse developmental outcomes at 12 months of CA. Poor neurodevelopment is largely independent of respiratory morbidity.

Documentation of the dietetic care process: developing a sectoral, tailored system.

Use of electronic health records necessitates a systematic approach for documentation of the Dietetic Care Process (DCP). However, no standardized system exists in Israel. The authors propose a novel documentation system developed by an expert advisory committee and tailored to a specific patient population. In this pilot study, 12 experienced Israeli Registered Dietitians (RDs) (median years of practice=23.0; s.d.=8.8; practice in geriatric populations median=13.0; s.d.=8.5) were recruited to evaluate the new tool for DCP documentation. Participants completed an explanatory short course online and evaluated the utility of the tool. There was full agreement that the proposed tool is necessary and an effective method for documenting the DCP within geriatric populations in clinical practice. In conclusion, a novel, tailored and sectoral tool designed for standardized documentation of dietetic care was recommended for implementation by an experienced group of RDs with substantive clinical experience in geriatric populations.