Ab Initio Calculations of Quantum Light-Matter Interactions in General Electromagnetic Environments.

The emerging field of strongly coupled light-matter systems has drawn significant attention in recent years because of the prospect of altering both the physical and chemical properties of molecules and materials. Because this emerging field draws on ideas from both condensed-matter physics and quantum optics, it has attracted the attention of theoreticians from both fields. While the former often employ accurate descriptions of the electronic structure of the matter, the description of the electromagnetic environment is often oversimplified. In contrast, the latter often employs sophisticated descriptions of the electromagnetic environment while using oversimplified few-level approximations of the electronic structure. Both approaches are problematic because the oversimplified descriptions of the electronic system are incapable of describing effects such as light-induced structural changes in the electronic system, while the oversimplified descriptions of the electromagnetic environments can lead to unphysical predictions because the light-matter interactions strengths are misrepresented. In this work, we overcome these shortcomings and present the first method which can quantitatively describe both the electronic system and general electromagnetic environments from first principles. We realize this by combining macroscopic QED (MQED) with Quantum Electrodynamical Density-Functional Theory. To exemplify this approach, we consider the example of an absorbing spherical cavity and study the impact of different parameters of both the environment and the electronic system on the transition from weak-to-strong coupling for different aromatic molecules. As part of this work, we also provide an easy-to-use tool to calculate the cavity coupling strengths for simple cavity setups. Our work is a significant step toward parameter-free ab initio calculations for strongly coupled quantum light-matter systems and will help bridge the gap between theoretical methods and experiments in the field.

A Rare Case of Losartan-Induced Visceral Angioedema.

The following describes a case of isolated visceral angioedema related to an angiotensin II receptor blocker (ARB) medication. Additionally, we discuss the pathophysiology of drug-induced angioedema, various presentations that can be encountered, and the leading theorized mechanisms of how renin-angiotensin-aldosterone system (RAAS) blocking medications lead to angioedema. The goal of sharing this case is to help increase awareness of the possibility of ARB-induced angioedema and to recommend keeping visceral angioedema as part of the differential diagnosis when presented with a patient who is taking an angiotensin converting enzyme inhibitor (ACEI) or ARB medication that is experiencing gastrointestinal symptoms of unclear etiology.

Combining experiments on luminescent centres in hexagonal boron nitride with the polaron model and ab initio methods towards the identification of their microscopic origin.

The two-dimensional material hexagonal boron nitride (hBN) hosts luminescent centres with emission energies of ∼2 eV which exhibit pronounced phonon sidebands. We investigate the microscopic origin of these luminescent centres by combining ab initio calculations with non-perturbative open quantum system theory to study the emission and absorption properties of 26 defect transitions. Comparing the calculated line shapes with experiments we narrow down the microscopic origin to three carbon-based defects: C2CB, C2CN, and VNCB. The theoretical method developed enables us to calculate so-called photoluminescence excitation (PLE) maps, which show excellent agreement with our experiments. The latter resolves higher-order phonon transitions, thereby confirming both the vibronic structure of the optical transition and the phonon-assisted excitation mechanism with a phonon energy ∼170 meV. We believe that the presented experiments and polaron-based method accurately describe luminescent centres in hBN and will help to identify their microscopic origin.

Indirect Band Gap Semiconductors for Thin-Film Photovoltaics: High-Throughput Calculation of Phonon-Assisted Absorption.

Discovery of high-performance materials remains one of the most active areas in photovoltaics (PV) research. Indirect band gap materials form the largest part of the semiconductor chemical space, but predicting their suitability for PV applications from first-principles calculations remains challenging. Here, we propose a computationally efficient method to account for phonon-assisted absorption across the indirect band gap and use it to screen 127 experimentally known binary semiconductors for their potential as thin-film PV absorbers. Using screening descriptors for absorption, carrier transport, and nonradiative recombination, we identify 28 potential candidate materials. The list, which contains 20 indirect band gap semiconductors, comprises well-established (3), emerging (16), and previously unexplored (9) absorber materials. Most of the new compounds are anion-rich chalcogenides (TiS3 and Ga2Te5) and phosphides (PdP2, CdP4, MgP4, and BaP3) containing homoelemental bonds and represent a new frontier in PV materials research. Our work highlights the previously underexplored potential of indirect band gap materials for optoelectronic thin-film technologies.

Momentum-Dependent Oscillator Strength Crossover of Excitons and Plasmons in Two-Dimensional PtSe2.

The 1T-phase layered PtX2 chalcogenide has attracted widespread interest due to its thickness dependent metal-semiconductor transition driven by strong interlayer coupling. While the ground state properties of this paradigmatic material system have been widely explored, its fundamental excitation spectrum remains poorly understood. Here we combine first-principles calculations with momentum (q) resolved electron energy loss spectroscopy (q-EELS) to study the collective excitations in 1T-PtSe2 from the monolayer limit to the bulk. At finite momentum transfer, all the spectra are dominated by two distinct interband plasmons that disperse to higher energy with increasing q. Interestingly, the absence of long-range screening in the two-dimensional (2D) limit inhibits the formation of long wavelength plasmons. Consequently, in the small-q limit, excitations in monolayer PtSe2 are exclusively of excitonic nature, and the loss spectrum coincides with the optical spectrum. The qualitatively different momentum dependence of excitons and plasmons enables us to unambiguously disentangle their spectral fingerprints in the excited state spectrum of layered 1T-PtSe2. This will help to discern the charge carrier plasmon and locally map the optical conductivity and trace the layer-dependent semiconductor to metal transition in 1T-PtSe2 and other 2D materials.

WSe2 as Transparent Top Gate for Infrared Near-Field Microscopy.

Independent control of carrier density and out-of-plane displacement field is essential for accessing novel phenomena in two-dimensional (2D) material heterostructures. While this is achieved with independent top and bottom metallic gate electrodes in transport experiments, it remains a challenge for near-field optical studies as the top electrode interferes with the optical path. Here, we characterize the requirements for a material to be used as the top-gate electrode and demonstrate experimentally that few-layer WSe2 can be used as a transparent, ambipolar top-gate electrode in infrared near-field microscopy. We carry out nanoimaging of plasmons in a bilayer graphene heterostructure tuning the plasmon wavelength using a trilayer WSe2 gate, achieving a density modulation amplitude exceeding 2 × 1012 cm-2. The observed ambipolar gate-voltage response allows us to extract the energy gap of WSe2, yielding a value of 1.05 eV. Our results provide an additional tuning knob to cryogenic near-field experiments on emerging phenomena in 2D materials and moiré heterostructures.

The Effects of Cannabinoids on Sleep.

The use of cannabis products to help with sleep and various other medical conditions by the public has increased significantly in recent years. Withdrawal from cannabinoids can lead to sleep disturbance. Here, we describe a patient who developed significant insomnia leading to worsening anxiety, mood, and suicidal ideation in the setting of medical cannabis withdrawal, prompting presentation to the Emergency Department and inpatient admission. There is a limited evidence base for the use of cannabis products for sleep. We provide a comprehensive review evaluating the literature on the use of cannabis products on sleep, including an overview of cannabis and related psychoactive compounds, the current state of the law as it pertains to the prescribing and use of these substances, and potential side effects and drug interactions. We specifically discuss the impact of cannabis products on normal sleep and circadian sleep-wake rhythms, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias, and restless legs syndrome. We also describe the effects of cannabis withdrawal on sleep and how this increases relapse to cannabis use. Most of the studies are observational but the few published randomized controlled trials are reviewed. Our comprehensive review of the effects of cannabis products on normal sleep and sleep disorders, relevant to primary care providers and other clinicians evaluating and treating patients who use these types of products, shows that cannabis products have minimal to no effects on sleep disorders and may have deleterious effects in some individuals. Further research examining the differential impact of the various types of cannabinoids that are currently available on each of these sleep disorders is required.

Improving Immunization Rates During the 2019 Measles Outbreak.

In 2019, there were multiple outbreaks of measles in the United States. In the context of the public awareness of these outbreaks, we performed an intervention with the intent to improve the rate of measles immunization in our pediatric population. Pediatric patients that were lacking adequate measles immunization were identified by electronic medical record (EMR) survey. Charts were reviewed and updated if records were found to be incomplete. Parents of the remaining children were sent a letter, personally signed by the child's primary care provider, encouraging measles immunization. A measles fact sheet, produced by the United States Center for Disease Control, was also included with the letter. There were 44 patients in the study group whose parents received a letter and measles fact sheet. As a result, 5 of these children were brought in for a measles, mumps, and rubella (MMR) immunization. The 44 patients whose parents received a letter included 20 patients whose parents had previously expressed intent to not vaccinate their children as documented in the EMR. None of these children received an MMR immunization. Although small in scope, this project provides a glimpse into the importance of personal provider guidance to parents who are inclined to immunize their children. Unfortunately, it also demonstrated that provider advice did not change the opinions of parents who had already taken a stance against vaccination, even in the context of an urgent public health situation that had garnered widespread coverage in the lay press and social media.

Pre-Anesthetic Medical Evaluations: Criteria Considerations for Telemedicine Alternatives to Face to Face Visits.

BACKGROUND: The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. METHODS: A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019-June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. RESULTS: 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% (n = 89) of visits resulted in medication adjustments and 76.7% (n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing (P < .05). CONCLUSIONS: This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.

Getting SET for Student Success: Foundations for a Student Education Team.

BACKGROUND: Family medicine clinical education poses logistic issues that we sought to address with the Student Education Team model. METHODS: The model combined team-based, patient-centered care with student experiences in a sustainable precepting model. Four learners successfully underwent precepting simultaneously. Schedulers booked patients in the team schedule, and the patients knew they would see a student and a faculty team member. RESULTS: The Student Education Team model increased the learner to preceptor ratio compared to traditional precepting models. Use of the team increased the number of learners completing rotations. The team schedule nearly eliminated patients refusing student involvement and enhanced throughput because patients saw the most readily available staff. DISCUSSION: The team offered clinicians and learners a model for incorporating learning into clinicians' schedules.

Prevention of Neonatal Hypoglycemia With Oral Glucose Gel for High-Risk Newborns.

BACKGROUND: Neonatal hypoglycemia (glucose <47) is the most common metabolic problem in newborns (incidence 5% - 15%) and can cause adverse outcomes, even in the absence of noticeable symptoms. Oral glucose gel (OGG) is safe and effective for treatment of neonatal hypoglycemia. In order to reduce interventions such as intravenous (IV) dextrose administration and neonatal intensive care unit (NICU) transfer, in October 2017, we implemented a protocol in our Level 1 rural community hospital to identify newborns with asymptomatic hypoglycemia based on risk factors and treat them with OGG. Risk factors include large or small size for gestational age, maternal gestational diabetes, preterm and late preterm birth, and newborns requiring resuscitation. METHODS: Chart review was performed for all infants born at our hospital from October 1, 2016 through September 30, 2018. Data for year 1-the period before protocol implementation (October 2016- September 2017)-was compared to post implementation data from year 2 (October 2017-September 2018). RESULTS: There was a significant risk reduction in newborns requiring interventions due to hypoglycemia after protocol implementation (P = 0.029, Student t test). In year one, 7 of 310 total newborns required IV dextrose or NICU transfer related to neonatal hypoglycemia. In year two, 108 out of 250 total newborns were tested for asymptomatic hypoglycemia based on risk factors identified in the protocol. Of those tested, 31 newborns demonstrated hypoglycemia and received OGG. None of the 250 newborns required further associated interventions. CONCLUSION: Protocol-based hypoglycemia testing based on risk factors with subsequent OGG administration was effective in reducing the need for IV dextrose and NICU transfer from our Level 1 rural community hospital.

Combining density functional theory with macroscopic QED for quantum light-matter interactions in 2D materials.

A quantitative and predictive theory of quantum light-matter interactions in ultra thin materials involves several fundamental challenges. Any realistic model must simultaneously account for the ultra-confined plasmonic modes and their quantization in the presence of losses, while describing the electronic states from first principles. Herein we develop such a framework by combining density functional theory (DFT) with macroscopic quantum electrodynamics, which we use to show Purcell enhancements reaching 107 for intersubband transitions in few-layer transition metal dichalcogenides sandwiched between graphene and a perfect conductor. The general validity of our methodology allows us to put several common approximation paradigms to quantitative test, namely the dipole-approximation, the use of 1D quantum well model wave functions, and the Fermi's Golden rule. The analysis shows that the choice of wave functions is of particular importance. Our work lays the foundation for practical ab initio-based quantum treatments of light-matter interactions in realistic nanostructured materials.

Gynecomastia in a Patient Taking Meloxicam-A Case Report.

Gynecomastia is benign enlargement of glandular tissue in the male breast. It occurs due to an imbalance of estrogen and testosterone. It may be unilateral or bilateral. Physiologic gynecomastia commonly occurs in infants and during puberty and is self-limited. Gynecomastia may affect up to 50% of adult men over age 50 years old and can be related to underlying medical illness or caused by certain medications. Known causative agents include anti-androgenic and estrogenic drugs. Probable agents include alcohol and anti-ulcer, psychoactive, and antiretroviral medications. Non-steroidal anti-inflammatory drugs (NSAIDs) are not commonly associated with the development of gynecomastia. This case presents an instance in which the NSAID, meloxicam, was the only identified variable in a patient who developed unilateral gynecomastia. His breast tenderness and abnormal exam resolved spontaneously within 4 weeks of cessation of meloxicam therapy.

Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice.

Opioid use disorder (OUD) is a cause of significant morbidity and mortality in the United States. Although efforts are being made to limit access to prescription opioids, the use of heroin and synthetic opioids as well as death due to opioid overdose has increased. Medication-assisted treatment (MAT) is the pairing of psychosocial intervention with a Food and Drug Administration (FDA)-approved medication (methadone, buprenorphine plus naltrexone) to treat OUD. MAT has resulted in reductions in overdose deaths, criminal activity, and infectious disease transmission. Access to MAT in rural areas is limited by shortages of addiction medicine-trained providers, lack of access to comprehensive addiction programs, transportation, and cost-related issues. Rural physicians express concern about lack of mentorship and drug diversion as reasons to avoid MAT. The prescribing of MAT with buprenorphine requires a Drug Enforcement Agency (DEA) waiver that can easily be obtained by Family Medicine providers. MAT can be incorporated into the outpatient practice, where patient follow-up rates and number needed to treat to effect change are similar to that of other chronic medical conditions. We describe a case of opioid overdose and a suggested protocol for the induction of MAT with buprenorphine/naloxone (Suboxone) for OUD in a rural family medicine outpatient practice. Treatment access is facilitated by utilizing the protocol, allowing office staff work to the extent allowed by their licensure, promoting teamwork and minimizing physician time commitment. We conclude that improved access to MAT can be accomplished in a rural family medicine outpatient clinic by staff that support and mentor one another through use of a MAT protocol.

Provider Approachability: An All-Staff Survey Approach to Creating a Culture of Safety.

OBJECTIVES: A culture-of-safety survey of our hospital staff revealed fear-based reluctance to question those in authority. We aimed to examine provider approachability (words and actions that promote trust and reduce or eliminate fear of interaction). METHODS: Providers and staff completed an anonymous facility-wide survey (survey 1) regarding perceptions of provider approachability. Results were safely communicated to providers, and improvement resources were offered. A follow-up survey (survey 2 [S2]) was performed. RESULTS: The survey participation rate was 59% (389/658). Eighty-four percent of providers had improved scores in S2. Mean top-box scores improved from 0.63 to 0.76 (P < .001). Providers deemed less approachable by nonprovider staff were also deemed less approachable by their peers (r = 0.82; survey 1). Forty-four percent reported improvement in the safety culture in S2. Twenty-eight percent of providers reported making efforts to improve how they were perceived by others. CONCLUSIONS: Provider approachability surveys are a safe, effective method of assessing and encouraging positive interactions that promote trust and influence positive communication. The process created an opportunity to identify and assist providers who were less approachable.

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care.

OBJECTIVE: To describe the steps taken and results obtained by a rural primary care practice to effectively implement opioid prescribing guidelines. PATIENTS AND METHODS: Between December 1, 2014, and May 30, 2017, a quality improvement project was undertaken. Elements included prescribing registries, a nurse coordinator, and an Opioid Use Review Panel. Clinic workflow was redesigned to more consistently incorporate these and other guideline recommendations into practice. The effect on opioid prescribing was measured as well as patient outcomes. RESULTS: There were 462 patients meeting inclusion criteria before implementation. At the conclusion, 16 patients (3%) had died, 9 patients (2%) were no longer seeing clinicians participating in the project, and 2 patients (0.4%) had transitioned to hospice or long-term care facilities. Of the remaining 435 patients, 96 (22.1%; 95% CI, 18.4-26.2) had decreased prescribing below the threshold for inclusion or were no longer receiving opioid prescriptions. Originally, 64 patients (13.9%; 95% CI, 11.0-17.3) were using average daily doses equal to or greater than 90 morphine milligram equivalents. After implementation, 54 of 435 patients (12.4%; 95% CI, 9.6-15.8) were still using equal to or greater than 90 morphine milligram equivalents per day after accounting for death or loss to follow-up. CONCLUSION: A change in clinic process to implement guidelines for prescribing of chronic opioid therapy was completed. It was associated with a decrease in the number of patients using chronic opioid therapy, primarily at lower doses. This was accomplished in a rural practice with very limited resources in pain medicine, psychiatry, and addiction medicine.

Collaborative Care Management Associated With Improved Depression Outcomes in Patients With Personality Disorders, Compared to Usual Primary Care.

BACKGROUND: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer treatment outcomes for MDD. Our study seeks to examine the differences in MDD treatment outcomes for patients with comorbid PD when using a CCM approach rather than usual care (UC). METHODS: In our retrospective cohort study, we reviewed the records of 9614 adult patients enrolled in our depression registry with the clinical diagnosis MDD and the diagnosis of PD (Yes/No). Clinical outcomes for depression were measured with Patient Health Questionnaire-9 (PHQ-9) scores at 6 months. RESULTS: In our study cohort, 59.4% of patients (7.1% of which had comorbid PD) were treated with CCM, as compared with 40.6% (6.8% with PD) treated with UC. We found that the presence of a PD adversely affected clinical outcomes of remission within both groups, however, at 6 months patients with PD had significantly lower MDD remission rates when treated with UC as compared with those treated with CCM (11.5% vs 25.2%, P = .002). Patients with PD in the UC group were also noted to have an increased rate of persistent depressive symptoms (PHQ-9 score ≥10) at 6 months as compared with those in the CCM group (67.7% vs 51.7%, P = .004). CONCLUSIONS: In patients with comorbid MDD and PD, clinical outcomes at 6 months were significantly improved when treated with CCM compared with UC. This finding is encouraging and supports the idea that CCM is an effective model for caring for patients with behavioral concerns, and it may be of even greater benefit for those patients being treated for comorbid behavioral health conditions.

How Preferences for Continuity and Access Differ Between Multimorbidity and Healthy Patients in a Team Care Setting.

INTRODUCTION: Team-based care has become an essential part of modern medical practice. Patient-centered medical homes often struggle to balance the dual competing goals of acute access and continuity of care. Multimorbidity patients may value continuity more than healthy patients, and thus may prefer to wait to see their primary care physician (PCP). METHODS: A total of 1700 randomly selected healthy adults and multimorbidity patients were asked to rate satisfaction with care and presented with 4 acute and 4 chronic scenarios to choose an access and continuity preference in an anonymous mailed survey. RESULTS: In all, 770 responses were obtained. All respondents preferred to be seen 2.5 days sooner for acute appointments. Multimorbidity patients preferred to wait 0.28 days longer for acute issues to see their PCP. Patients who were not satisfied with their care team preferred to wait 0.75 days to see their PCP. Those not satisfied with their PCP choose to be seen 0.38 days sooner by their care team or any physician. CONCLUSIONS: All patients prefer continuity of care with their PCP for chronic disease management and value quick access to care for acute problems. For acute visits, multimorbidity patients prefer to wait longer to see their PCP than healthy adults. Satisfaction also plays an important role in patients' willingness to wait for an appointment with their PCP.

A Systematic Approach to Clinical Peer Review in a Critical Access Hospital.

PURPOSE: Clinical provider peer review (CPPR) is a process for evaluating a patient's experience in encounters of care. It is part of ongoing professional practice evaluation and focused professional practice evaluation-important contributors to provider credentialing and privileging. Critical access hospitals are hindered in CPPR by having a limited number of providers, shortages of staff resources, and relationships among staff members that make unbiased review difficult. Small departments within larger institutions may face similar challenges. METHODS: A CPPR process created at Mayo Clinic Health System is described. It involved a case review questionnaire built on the Institute of Medicine "Six Aims for Changing the Health Care System," a standardized intervention algorithm and tracking tool. OUTCOMES: During 2007 through 2014, a total of 994 cases were reviewed; 31% led to provider dialog and education or intervention. Findings were applied to core measure processes with success rate going from 87% to 97%. Changes were adopted in end-of-life care, contributing to a 50% reduction in all-cause mortality rate. CONCLUSIONS: Providing peer review tools to a critical access hospital can keep peer review within a group with knowledge of the individual provider's practice and can make process improvement the everyday work of those involved.