Evaluating the Quality of Virtual Urgent Care: Barriers, Motivations, and Implementation of Quality Measures.

BACKGROUND: Experts estimate virtual urgent care programs could replace approximately 20% of current emergency department visits. In the absence of widespread quality guidance to programs or quality reporting from these programs, little is known about the state of virtual urgent care quality monitoring initiatives. OBJECTIVE: We sought to characterize ongoing quality monitoring initiatives among virtual urgent care programs. APPROACH: Semi-structured interviews of virtual health and health system leaders were conducted using a pilot-tested interview guide to assess quality metrics captured related to care effectiveness and equity as well as programs' motivations for and barriers to quality measurement. We classified quality metrics according to the National Quality Forum Telehealth Measurement Framework. We developed a codebook from interview transcripts for qualitative analysis to classify motivations for and barriers to quality measurement. KEY RESULTS: We contacted 13 individuals, and ultimately interviewed eight (response rate, 61.5%), representing eight unique virtual urgent care programs at primarily academic (6/8) and urban institutions (5/8). Most programs used quality metrics related to clinical and operational effectiveness (7/8). Only one program reported measuring a metric related to equity. Limited resources were most commonly cited by participants (6/8) as a barrier to quality monitoring. CONCLUSIONS: We identified variation in quality measurement use and content by virtual urgent care programs. With the rapid growth in this approach to care delivery, more work is needed to identify optimal quality metrics. A standardized approach to quality measurement will be key to identifying variation in care and help focus quality improvement by virtual urgent care programs.

A Novel Design-Thinking, Hospital Innovation Core Certificate Curriculum for Radiologists and Trainees: Creation, Implementation, and Multiyear Results.

RATIONALE AND OBJECTIVES: Innovation is a crucial skill for physicians and researchers, yet traditional medical education does not provide instruction or experience to cultivate an innovative mindset. This study evaluates the effectiveness of a novel course implemented in an academic radiology department training program over a 5-year period designed to educate future radiologists on the fundamentals of medical innovation. MATERIALS AND METHODS: A pre- and post-course survey and examination were administered to residents who participated in the innovation course (MESH Core) from 2018 to 2022. Respondents were first evaluated on their subjective comfort level, understanding, and beliefs on innovation-related topics using a 5-point Likert-scale survey. Respondents were also administered a 21-question multiple-choice exam to test their objective knowledge of innovation-related topics. RESULTS: Thirty-eight residents participated in the survey (response rate 95%). Resident understanding, comfort and belief regarding innovation-related topics improved significantly (P < .0001) on all nine Likert-scale questions after the course. After the course, a significant majority of residents either agreed or strongly agreed that technological innovation should be a core competency for the residency curriculum, and that a workshop to prototype their ideas would be beneficial. Performance on the course exam showed significant improvement (48% vs 86%, P < .0001). The overall course experience was rated 5 out of 5 by all participants. CONCLUSION: MESH Core demonstrates long-term success in educating future radiologists on the basic concepts of medical technological innovation. Years later, residents used the knowledge and experience gained from MESH Core to successfully pursue their own inventions and innovative projects. This innovation model may serve as an approach for other institutions to implement training in this domain.

Driving Assessment for Persons with Dementia: How and when?

Dementia is a progressive neurodegenerative disease leading to deterioration in cognitive and physical skills. Driving is an important instrumental activity of daily living, essential for independence. However, this is a complex skill. A moving vehicle can be a dangerous tool in the hand of someone who cannot maneuver it properly. As a result, the assessment of driving capacity should be part of the management of dementia. Moreover, dementia comprises of different etiologies and stages consisting of different presentations. As a result, this study aims to identify driving behaviors common in dementia and compare different assessment methods. A literature search was conducted using the PRISMA checklist as a framework. A total of forty-four observational studies and four meta-analyses were identified. Study characteristics varied greatly with regards to methodology, population, assessments, and outcome measures used. Drivers with dementia performed generally worse than cognitively normal drivers. Poor speed maintenance, lane maintenance, difficulty managing intersections and poor response to traffic stimuli were the most common behaviors in drivers with dementia. Naturalistic driving, standardized road assessments, neuropsychological tests, participant self-rating and caregiver rating were the most common driving assessment methods used. Naturalistic driving and on-road assessments had the highest predictive accuracy. Results on other forms of assessments varied greatly. Both driving behaviors and assessments were influenced by different stages and etiologies of dementia at varying degrees. Methodology and results in available research are varied and inconsistent. As a result, better quality research is required in this field.

Deep Neck Contouring With a Focus on Submandibular Gland Vascularity: A Cadaver Study.

BACKGROUND: Opening the neck through a submental incision allows accurate management of deep neck structures and results in exceptional neck contours. OBJECTIVES: The authors aimed to evaluate the distribution of deep neck structures and investigate the detailed vascular anatomy of the submandibular gland. METHODS: A total of 26 fresh frozen cadaver heads (15 female, 11 male) were utilized. The authors evaluated the weights of the excised tissues simulating cosmetic resections, including subcutaneous fat, subplatysmal fat, the anterior belly of the digastric muscle, and submandibular glands. The vascular supply of the submandibular gland and intracapsular vessel diameters were also investigated. RESULTS: Whereas female cadavers had greater mean tissue weight removed from the supraplatysmal plane (mean 20.9 g, 56.6%) than the subplatysmal plane (16 g, 43.4%), male cadavers had higher mean tissue weight removed from the subplatysmal plane (10.5 g, 60.7%) than the supraplatysmal plane (mean 6.8 g, 39.3%). The mean subcutaneous (6.8 g) and subplatysmal (6.4 g) fat weights were almost equal in male cadavers; mean subcutaneous fat weight (20.9 g) was 3 times higher than subplatysmal fat weight (6.8 g) in female cadavers. There was a statistically significant relationship between body mass index and fat removed. The intraglandular vessel diameters increased as resections approached the main feeding vessels located posterosuperior (facial artery) and anterosuperior (submental artery) to the submandibular gland. CONCLUSIONS: The results suggest that to achieve exceptional neck contour the structures deep to the platysma often need to be addressed. The submandibular gland reduction can be safely performed with comprehensive understanding of its vascular anatomy.

The Next Frontier of Remote Patient Monitoring: Hospital at Home.

Remote patient monitoring (RPM) has shown promise in aiding safe and efficient remote care for chronic conditions; however, its use remains more limited within the hospital at home (HaH) model of care despite a significant opportunity to increase patient eligibility, improve safety, and decrease costs. HaH could achieve these goals by further adopting the 3 primary modalities of RPM (ie, vital sign, continuous single-lead electrocardiogram, and fall monitoring). With only 2 in-person vital sign checks required per day, HaH patient eligibility is currently often limited to lower-acuity cases. The use of vital sign RPM within HaH could better match the standard clinical practice of vital sign checks every 4-8 hours and enable safe care for appropriate moderate-acuity medical and surgical floor-level patients not traditionally enrolled in HaH. Robust, efficient collection of more frequent vital signs via RPM could expand patient eligibility for HaH and create a digital health safety net that enables high quality care. Similarly, our experience at Massachusetts General Hospital has demonstrated that appropriate use of continuous single-lead electrocardiogram RPM can also expand HaH enrollment, particularly for patients with acute decompensated heart failure. Through increasing enrollment of patients in HaH, RPM stands to enable more patients to reap the potential safety benefits of home hospitalization, including decreased rates of delirium and hospital-acquired infections, and better avoid aspects of posthospital syndrome. Furthermore, instituting fall detection RPM allows care teams to further HaH patient safety during their episode of acute care and develop enhanced mitigation strategies to avoid falls post home hospitalization. RPM also has the potential to assist HaH in achieving greater economies of scale and decreasing direct variable costs. By expanding HaH eligibility, RPM could enable HaH programs, which have traditionally operated under capacity, to care for a larger census and decrease allocated fixed costs per hospitalization. Additionally, RPM for HaH could further optimize hybrid in-home and remote nurse or physician evaluations, decreasing costs on a per-episode basis by up to an estimated 3.5%. Overall, RPM holds great promise to increase patient eligibility and patient safety while decreasing costs. However, it is in its infancy in achieving its potential to advance the HaH model of care; further research and experience that inform operational and technical as well as policy considerations are needed.

Impact of iodinated contrast allergies on emergency department operations.

OBJECTIVES: Adverse reactions to intravenous (IV) iodinated contrast media are classified by the American College of Radiology (ACR) Manual on Contrast Media as either allergic-like (ALR) or physiologic (PR). Premedication may be beneficial for patients who have prior documented mild or moderate ALR. We sought to perform a retrospective analysis of patients who received computed tomography (CT) imaging in our emergency department (ED) to establish whether listing of an iodinated contrast media allergy results in a delay in care, increases the use of non-contrast studies, and to quantify the incidence of listing iodinated contrast allergies which do not necessitate premedication. METHODS: We performed a retrospective analysis of CT scans performed in our academic medical center ED during a 6-month period. There were 12,737 unique patients of whom 454 patients had a listed iodinated contrast allergy. Of these, 106 received IV contrast and were categorized as to whether premedication was necessary. Descriptive statistics were used to evaluate patient demographics, clinical characteristics, and operational outcomes. A multivariate linear regression model was used to predict time from order to start (OTS time) of CT imaging while controlling for co-variates. RESULTS: Non-allergic patients underwent contrast-enhanced CT imaging at a significantly higher rate than allergic patients (45.9% vs. 23.3%, p < 0.01). The OTS time for allergic patients who underwent contrast-enhanced CT imaging was 360 min and significantly longer than the OTS time for non-allergic patients who underwent contrast-enhanced CT imaging (118 min, p < 0.001). Of the 106 allergic patients who underwent contrast-enhanced CT imaging, 27 (25.5%) did not meet ACR criteria for necessitating premedication. The average OTS time for these 27 patients was 296 min, significantly longer than the OTS for non-allergic patients (118 min, p < 0.01) and did not differ from the OTS time for the 79 patients who did meet premedication criteria (382 min, p = 0.23). A multivariate linear regression showed that OTS time was significantly longer if a contrast allergy was present (p < 0.001). CONCLUSION: A chart-documented iodinated contrast allergy resulted in a significant increase in time to obtain a contrast-enhanced CT study. This delay persisted among patients who did not meet ACR criteria for premedication. Appropriately deferring premedication could potentially reduce the ED length-of-stay by over 4 h for these patients.

Qualitative Evaluation of Quality Measurement Within Emergency Clinician-Staffed Telehealth Programs.

STUDY OBJECTIVE: Emergency clinician-staffed telehealth programs seek to provide equitable, safe, efficient, effective, and patient-centered care. However, early studies show conflicting evidence on whether this aim is accomplished. Furthermore, how programs track the efficacy and safety of their programs remains largely unexplored. We sought to characterize ongoing quality monitoring among emergency clinician-staffed telehealth programs. METHODS: We identified representatives at emergency clinician-staffed telehealth programs through professional networks and published literature. Qualitative interviews were conducted, assessing quality metrics captured as well as motivations for and barriers to quality measurement. We classified quality metric measurement using the National Quality Forum Telehealth Measurement Framework Domains and Subdomains. We developed a codebook from interview transcripts for qualitative analysis to classify motivations for and barriers to quality measurement. RESULTS: We held 8 qualitative interviews with physician representatives at primarily academic (7/8) and urban institutions (5/8). Most widely used quality metrics were related to patient and care team experience (7/8) as well as to access to care (6/8) and effectiveness (6/8). Few programs (2/8) measured finance-related quality metrics. Motivations for quality measurement varied considerably. Common barriers to implementation included technology challenges, data availability, and the lack of quality metric standardization. CONCLUSION: We identified variation in the use and content of quality metrics across emergency clinician-staffed telehealth programs. Most commonly, programs used metrics related to clinical experience; financial metrics were rarely captured. Technology barriers to quality measurement were often cited across programs. Further work is needed to support the standardization and implementation of future quality measurement initiatives.

Organic matter contributions to nitrous oxide emissions following nitrate addition are not proportional to substrate-induced soil carbon priming.

The addition of carbon (C) substrate often modifies the rate of soil organic matter (SOM) decomposition. This is known as the priming effect. Nitrous oxide (N2O) emissions from soil are also linked to C substrate dynamics; however, the relationship between the priming effect and N2O emissions from soil is not understood. This study aimed to investigate the effects of C and N substrate addition on the linkages between SOM priming and N2O emissions. We applied 13C-labelled substrates (acetate, butyrate, glucose; 80 µg C g-1), with water as a control, and 15N-labelled N (300 µg N g-1 soil, potassium nitrate) to three different soils, and, after 3 days, we measured the effects on the priming of SOM and sources of N2O emission. Carbon substrate addition increased both CO2- and SOM-derived N2O emissions in the presence of exogenous N. Emissions of CO2 and N2O from soils with added glucose (mean ± standard deviation, 0.73 ± 0.13 µmol m-2 s-1 and 21.4 ± 12.1 mg N m-2 h-1) were higher (p < 0.05) than those from soils treated with acetate (0.64 ± 0.11 µmol m-2 s-1 and 10.9 ± 6.5 mg N m-2 h-1) or butyrate (0.61 ± 0.11 µmol m-2 s-1 and 11.0 ± 6.6 mg N m-2 h-1), respectively. Acetate addition induced a stronger (p < 0.05) priming effect on soil C (0.07 ± 0.09 µmol C m-2 s-1) than that for glucose (0.02 ± 0.10 µmol C m-2 s-1), while butyrate addition resulted in negative priming (-0.09 ± 0.05 µmol C m-2 s-1). SOM-derived N2O emissions were relatively low from soils with butyrate addition (1.4 ± 1.5 mg N m-2 h-1) compared with acetate (2.9 ± 2.3 mg N m-2 h-1) or glucose (9.2 ± 4.5 mg N m-2 h-1). There was no clear relationship between the priming effect and SOM-derived N2O emissions. The observed priming effect related to the potential electron donor supply of the C substrates was not observed. There is a need to further examine the role of soil priming in relation to soil N2O emissions.

Depth-structuring of multi-kingdom soil communities in agricultural pastures.

The biodiversity and structure of deep agricultural soil communities are poorly understood, especially for eukaryotes. Using DNA metabarcoding and co-occurrence networks, we tested whether prokaryote, fungal, protist, and nematode biodiversity declines with increasing depth (0-0.1,  0.3-0.5,  and 1.1-1.7m) in pastoral soil; whether deep soil organisms are subsets of those at the surface; and whether multi-kingdom networks become more interconnected with increasing depth. Depth-related richness declines were observed for almost all detected fungal classes, protist phyla, and nematode orders, but only 13 of 25 prokaryote phyla, of which nine had increasing richness with depth. Deep soil communities were not simply subsets of surface communities, with 3.8%-12.2% of eukaryotes and 13.2% of prokaryotes detected only in the deepest samples. Eukaryotes mainly occurred in the upper soil layers whereas prokaryotes were more evenly distributed across depths. Plant-feeding nematodes were most abundant in top soil, whereas bacteria feeders were more abundant in deep soil. Co-occurrence network structure differences suggested that deep soil communities are concentrated around scarce niches of resource availability, in contrast to more spatially homogenous and abundant resources at the surface. Together, these results demonstrate effects of depth on the composition, distribution, and structure of prokaryote and eukaryote soil communities.

Soil microbial sensitivity to temperature remains unchanged despite community compositional shifts along geothermal gradients.

Climate warming may be exacerbated if rising temperatures stimulate losses of soil carbon to the atmosphere. The direction and magnitude of this carbon-climate feedback are uncertain, largely due to lack of knowledge of the thermal adaptation of the physiology and composition of soil microbial communities. Here, we applied the macromolecular rate theory (MMRT) to describe the temperature response of the microbial decomposition of soil organic matter (SOM) in a natural long-term warming experiment in a geothermally active area in New Zealand. Our objective was to test whether microbial communities adapt to long-term warming with a shift in their composition and their temperature response that are consistent with evolutionary theory of trade-offs between enzyme structure and function. We characterized the microbial community composition (using metabarcoding) and the temperature response of microbial decomposition of SOM (using MMRT) of soils sampled along transects of increasing distance from a geothermally active zone comprising two biomes (a shrubland and a grassland) and sampled at two depths (0-50 and 50-100 mm), such that ambient soil temperature and soil carbon concentration varied widely and independently. We found that the different environments were hosting microbial communities with distinct compositions, with thermophile and thermotolerant genera increasing in relative abundance with increasing ambient temperature. However, the ambient temperature had no detectable influence on the MMRT parameters or the relative temperature sensitivity of decomposition (Q10 ). MMRT parameters were, however, strongly correlated with soil carbon concentration and carbon:nitrogen ratio. Our findings suggest that, while long-term warming selects for warm-adapted taxa, substrate quality and quantity exert a stronger influence than temperature in selecting for distinct thermal traits. The results have major implications for our understanding of the role of soil microbial processes in the long-term effects of climate warming on soil carbon dynamics and will help increase confidence in carbon-climate feedback projections.

Sequential Laser-Mechanical Drilling of Thick Carbon Fibre Reinforced Polymer Composites (CFRP) for Industrial Applications.

Carbon fibre reinforced polymer composites (CFRPs) can be costly to manufacture, but they are typically used anywhere a high strength-to-weight ratio and a high steadiness (rigidity) are needed in many industrial applications, particularly in aerospace. Drilling composites with a laser tends to be a feasible method since one of the composite phases is often in the form of a polymer, and polymers in general have a very high absorption coefficient for infrared radiation. The feasibility of sequential laser-mechanical drilling for a thick CFRP is discussed in this article. A 1 kW fibre laser was chosen as a pre-drilling instrument (or initial stage), and mechanical drilling was the final step. The sequential drilling method dropped the overall thrust and torque by an average of 61%, which greatly increased the productivity and reduced the mechanical stress on the cutting tool while also increasing the lifespan of the bit. The sequential drilling (i.e., laser 8 mm and mechanical 8 mm) for both drill bits (i.e., 2- and 3-flute uncoated tungsten carbide) and the laser pre-drilling techniques has demonstrated the highest delamination factor (SFDSR) ratios. A new laser-mechanical sequence drilling technique is thus established, assessed, and tested when thick CFRP composites are drilled.

Development of Laser Drilling Strategy for Thick Carbon Fibre Reinforced Polymer Composites (CFRP).

Composites from carbon fibre reinforced polymers (CFRPs) play a significant role in modern manufacturing. They are typically used in aerospace and other industries that require high strength-to-weight ratios. Composite machining, however, remains a challenging job and sometimes is hampered by poor efficiency. Despite considerable research being conducted over the past few years on the machining of composite materials, the material nevertheless suffers from delamination, fibre loss, and imperfect finishing of the fuselage. Laser technology is becoming increasingly popular as an alternative approach to cutting and drilling composites. Experiments have been conducted with a CFRP thickness of 25.4 mm using fibre laser to test the effect of the machining parameters on the primary performance measurements. In this study, different machining criteria are used to assess the fibre laser ability of thick CFRP composites for drilling operation. The experimental findings revealed that a fibre laser is capable of penetrating a thick CFRP to a depth of 22 mm by using a novel drilling procedure.

Augmentation of the Delamination Factor in Drilling of Carbon Fibre-Reinforced Polymer Composites (CFRP).

Carbon fibre-reinforced polymer (CFRP) composite materials play an increasingly important role in modern manufacturing, and they are among the more prominent materials used in aircraft manufacturing today. However, CFRP is highly prone to delamination and other damage when drilled due to it being extremely strong with a good strength-to-weight ratio and high thermal conductivity. Because of this problem and CFRP's growing importance in aircraft manufacture, research has focused on the entry and exit holes as indicators of damage occurrence during drilling of screws, rivets, and other types of holes. The inside of the hole was neglected in past research and a proper way to quantify the internal side of a hole by combining the entry and exit hole should be included. To fill this gap and improve the use of CFRP, this paper reports a novel technique to measure the holes by using the extension of the adjusted delamination factor (SFDSR) for drilling thick CFRP composites in order to establish the influence of machining input variables on key output measures, i.e., delamination and other damages. The experimental results showed a significant difference in interpretation of the damage during the analysis. Improvement was made by providing better perspectives of identifying hole defects.

Evaluation of 5H-Thiazolo[3,2-α]pyrimidin-5-ones as Potential GluN2A PET Tracers.

We describe here our efforts to develop a PET tracer for imaging GluN2A-containing NMDA receptors, based on a 5H-thiazolo[3,2-α]pyrimidin-5-one scaffold. The metabolic stability and overall properties could be optimized satisfactorily, although binding affinities remained a limiting factor for in vivo imaging. We nevertheless identified 7-(((2-fluoroethyl)(3-fluorophenyl)amino)-methyl)-3-(2-(hydroxymethyl)cyclopropyl)-2-methyl-5H-thiazolo-[3,2-α]pyrimidin-5-one ([18 F]7b) as a radioligand providing good-quality images in autoradiographic studies, as well as a tritiated derivative, 2-(7-(((2-fluoroethyl)(4-fluorophenyl)amino)methyl)-2-methyl-5-oxo-5H-thiazolo[3,2-α]pyrimidin-3-yl)cyclopropane-1-carbonitrile ([3 H2 ]15b), which was used for the successful development of a radioligand binding assay. These are valuable new tools for the study of GluN2A-containing NMDA receptors, and for the optimization of allosteric modulators binding to the pharmacophore located at the dimer interface of the GluN1-GluN2A ligand-binding domain.

Rapid growth of large area graphene on glass from olive oil by laser irradiation.

Although homogeneous, high quality graphene can be fabricated on a Cu or Ni sheet using the traditional chemical vapour deposition method at high temperatures (over 1000 °C) under specific atmospheric conditions, their transfer to another substrate is difficult. In this paper a novel method of rapidly (i.e. 3-6 s of laser irradiation) producing a large area (>3 cm2) graphene film from olive oil on a glass surface (pre-coated with a 5-28 nm thick Ni film) with defocused, large area continuous laser irradiation is described. The turbostratic graphene film (6 layers) grown in such a way has shown high electrical conductivity (sheet resistance of around 20 Ω sq-1) and an optical transmittance of 40-50%. With femtosecond laser patterning, 70% optical transparency was demonstrated. Continuous large area graphene was formed at relatively lower temperatures (<250 °C) and without the need for specific atmospheric conditions. The basic process characteristics and mechanisms involved are discussed.