Barriers to liver transplant referral in safety net settings: A national provider survey.

Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.

Safety and Efficacy of Vocacapsaicin for Management of Postsurgical Pain: A Randomized Clinical Trial.

BACKGROUND: Nonopioid management of postsurgical pain remains a major unmet need. Few studies have evaluated transient receptor potential vanilloid subfamily member 1 agonists for analgesia after surgery. This study examines intraoperative vocacapsaicin, a novel prodrug of the transient receptor potential vanilloid subfamily member 1 agonist capsaicin, in a validated model of postsurgical pain. METHODS: This was a triple-blinded, randomized, placebo-controlled, dose-ranging trial in patients undergoing bunionectomy. Patients were randomized 1:1:1:1 to surgical site administration of 14 ml of placebo or one of three vocacapsaicin concentrations: 0.30, 0.15, or 0.05 mg/ml. The prespecified primary endpoint was the area-under-the-curve of the numerical rating scale pain score at rest through 96 h for the 0.30 mg/ml group. Prespecified ordered, secondary endpoints for the 0.30 mg/ml group included the percentage of patients who did not require opioids from 0 to 96 h, total opioid consumption through 96 h, and the area-under-the-curve of the numerical rating scale pain score for the first week. RESULTS: The 147 patients were randomized. During the first 96 h, vocacapsaicin (0.30 mg/ml) reduced pain at rest by 33% versus placebo (primary endpoint, 95% CI [10%, 52%], effect size [Cohen's d] = 0.61, P = 0.005). Of patients receiving vocacapsaicin (0.30 mg/ml), 26% did not require postoperative opioids for analgesia (P = 0.025) versus 5% of patients receiving placebo. Vocacapsaicin (0.30 mg/ml) reduced opioid consumption over the first 96 h by 50% versus placebo (95% CI [26%, 67%], effect size = 0.76, P = 0.002). Vocacapsaicin (0.30 mg/ml) reduced pain over the first week by 37% versus placebo (95% CI [12%, 57%], effect size = 0.62, P = 0.004). The treatment effect persisted for at least 2 weeks. All study endpoints showed an administered concentration-versus-response relationship. Vocacapsaicin was well tolerated with no differences between groups in any safety parameter. CONCLUSIONS: A single, local administration of vocacapsaicin during surgery reduced pain and opioid consumption for at least 96 h after surgery compared to control.

An Improved Average Atomic Number Calculation for Estimating Backscatter and Continuum Production in Compounds.

It is often assumed that electron backscatter and continuum (bremsstrahlung) productions emitted from electron-solid interactions during X-ray microanalysis in compounds can be extrapolated from pure element observations by means of the assumption of average atomic number, or Z-bar (Z¯). For pure elements the average Z is equal to the atomic number, but this direct approach fails for compounds. The use of simple atomic fractions yields completely spurious results, and while the commonly used mass fraction Z averaging produces fairly reasonable results, we know from physical considerations that the mass of the neutron plays only a negligible role in such interactions below ∼1 MeV. Therefore, including the mass or atomic weight in such calculations can only introduce further errors in these models. We present an expression utilizing atomic fractions of the atomic numbers of the elements in the compound (Z fraction), with an exponent to account for the variation in nuclear screening as a function of the element Z value.

A New Method for Dead Time Calibration and a New Expression for Correction of WDS Intensities for Microanalysis.

Observed photon count rates must be corrected for detector dead time effects for accurate quantification, especially at high count rates. We present the "constant k-ratio" method, a new approach for calibrating dead time for wavelength dispersive spectrometers by measuring k-ratios as a function of beam current. The method is based on the observation that for a given emission line at a specific take-off angle and electron beam energy, the intensity ratio from two materials containing the element should remain constant as a function of beam current, if the dead time calibration is accurate. The method has the advantage that it does not rely on the linearity of the beam current picoammeter, yet also allows the analyst to evaluate the picoammeter linearity, another critical parameter in EPMA calibration. By simultaneously comparing k-ratios for all spectrometers, one can also ascertain k-ratio consensus, essential for inter-laboratory comparisons. We also introduce improved dead time expressions and provide best practices on how to perform these instrument calibrations using this new "constant k-ratio" method. These improvements enable quantitative analysis of major and minor elements with high accuracy at high beam currents, simultaneously with trace elements with high sensitivity, for point analyses and X-ray mapping.

Operationalizing the Centers for Disease Control and Prevention's Vaccinate With Confidence Framework During the COVID-19 Emergency Response in the United States.

In December 2020, 11 months after identifying the first laboratory-confirmed case of COVID-19 in the United States, the U.S. Food and Drug Administration authorized emergency use of two COVID-19 vaccines. To prepare the public for a large-scale vaccination campaign and build confidence in COVID-19 vaccines, the U.S. Centers for Disease Control and Prevention (CDC) funded more than 200 partners and developed a national Vaccinate with Confidence (VwC) COVID-19 framework to support Americans in their decision to get vaccinated. The evolving nature of the pandemic and highly variable confidence in vaccines across populations has resulted in many unique complexities and challenges to reaching universally high vaccination coverage. Here, we describe how 23 professional health associations and national partner organizations, focused solely on building vaccine confidence, operationalized CDC's VwC COVID-19 framework from February 2021 to March 2022. Capturing how partners deployed and adapted their activities to meet a shifting pandemic landscape, which began with high demand for vaccines that waned over time, is an important first step to understanding how this new strategy was utilized and could be implemented for future surges in COVID-19 cases and other routine immunization efforts. Going forward, evaluation of partner activities should be prioritized to capture learnings and assess VwC program effectiveness.

NIR-Based Intelligent Sensing of Product Yield Stress for High-Value Bioresorbable Polymer Processing.

PLA (polylactide) is a bioresorbable polymer used in implantable medical and drug delivery devices. Like other bioresorbable polymers, PLA needs to be processed carefully to avoid degradation. In this work we combine in-process temperature, pressure, and NIR spectroscopy measurements with multivariate regression methods for prediction of the mechanical strength of an extruded PLA product. The potential to use such a method as an intelligent sensor for real-time quality analysis is evaluated based on regulatory guidelines for the medical device industry. It is shown that for the predictions to be robust to processing at different times and to slight changes in the processing conditions, the fusion of both NIR and conventional process sensor data is required. Partial least squares (PLS), which is the established 'soft sensing' method in the industry, performs the best of the linear methods but demonstrates poor reliability over the full range of processing conditions. Conversely, both random forest (RF) and support vector regression (SVR) show excellent performance for all criteria when used with a prior principal component (PC) dimension reduction step. While linear methods currently dominate for soft sensing of mixture concentrations in highly conservative, regulated industries such as the medical device industry, this work indicates that nonlinear methods may outperform them in the prediction of mechanical properties from complex physicochemical sensor data. The nonlinear methods show the potential to meet industrial standards for robustness, despite the relatively small amount of training data typically available in high-value material processing.

IgG:IgM Ratios of Liver Plasma Cells Reveal Similar Phenotypes of Primary Biliary Cholangitis With and Without Features of Autoimmune Hepatitis.

Within the spectrum of autoimmune liver diseases, there are patients who manifest features of more than one disease, which was previously identified as having overlap syndrome1,2 and is now referred to as variant syndromes. The most common variant syndrome is between primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH). Typically, AIH presents with elevated serum immunoglobulin (Ig) G, whereas PBC is associated with elevated serum IgM.3,4 Previous studies have suggested that plasma cells in liver biopsies of AIH patients are predominantly IgG+, whereas in PBC, there is an abundance of IgM+ cells.5,6 We wanted to determine the immunostaining pattern for IgG and IgM of liver plasma cells among Hispanic patients in Los Angeles with features of both PBC-AIH compared with those with PBC or AIH alone.

Effects of plant growth regulator application on the malting quality of barley.

BACKGROUND: Lodging can negatively affect yield and quality of barley grain. Synthetic plant growth regulators (PGRs) reduce lodging by producing shorter, thicker, and stronger stems. However, the impact of applying PGRs on malting performance of barley is not known. The objective of this work was to assess the effect of application of three PGRs (ethephon, chlormequat chloride, and trinexapac-ethyl) in combination with different seeding rates on the malting quality of barley grown in several locations and years in western Canada. RESULTS: The kernel weight in PGR-treated barley was reduced by 1.7% to 6.5% compared with the nontreated grain. Application of PGRs had no effect on the concentration of proteins and germination energy. Seeding rates significantly affected kernel weight, protein content, and germination index (GI), but no interactions between PGRs and seeding rates were observed. The smaller kernels of ethephon- and trinexapac-treated barley showed good hydration and grain modification during malting, as indicated by high levels of starch-converting enzymes, high Kolbach indices, and low levels of wort ß-glucans. Overall, the fine extract of malt from PGR-treated barley was slightly lower than that of the control malt; however, the extract reduction was statistically significant only for chlormequat- and trinexapac-treated barley. CONCLUSIONS: The application of PGRs had significant effects on kernel plumpness and kernel weight, but the effects of PGR application on the malting quality were generally small and insignificant. The decision of PGRs application on malting barley needs to be considered in combination with potential benefits of PGRs in mitigating lodging and their effects on the agronomic performance of barley. © Her Majesty the Queen in Right of Canada 2019.

High Speed Matrix Corrections for Quantitative X-ray Microanalysis Based on Monte Carlo Simulated K-Ratio Intensities.

Due to recent advances in modeling the production of characteristic X-rays, Monte Carlo simulation of electron-solid interactions can provide improved quantitative estimates of X-ray intensities for both homogeneous and heterogeneous interaction volumes. In the case of homogeneous materials, these modeled X-ray intensities can predict with excellent accuracy, matrix corrections for arbitrary compositions, arbitrary emission lines, and electron energies. By pre-calculating these Monte Carlo X-ray intensities for pure element standards and a range of compositions of binary systems, we can derive matrix corrections for complex compositions in real-time by parameterizing these k-ratios as the so-called alpha factors. This method allows one to perform Monte Carlo-based bulk matrix corrections in seconds for arbitrary and complex compositions (with two or more elements), by combining these binary alpha factors using the so-called beta expression. We are systematically calculating X-ray intensities for 11 compositions from 1 to 99 wt% for binary pairs of all emitters and absorbers in the periodic table, for the main emission lines (Kα, Kß, Lα, Lß, Mα, and Mß) at beam energies from 5 to 50 keV, using Monte Carlo calculations based on a modified PENELOPE electron-photon transport code, although any other Monte Carlo software could also be utilized. Comparison of k-ratios calculated with the proposed method and experimental k-ratios from the Pouchou and Pichoir database suggest improvements over typical φ(ρz) methods. Additional comparisons with k-ratio measurements from more complex compositions would be ideal, but our testing of the additivity of the beta equation suggests that arbitrary compositions can be handled as well, except in cases of extreme fluorescence or absorption.

Multipoint Background Analysis: Gaining Precision and Accuracy in Microprobe Trace Element Analysis.

Electron microprobe trace element analysis is a significant challenge. Due to the low net intensity of peak measurements, the accuracy and precision of such analyses relies critically on background measurements, and on the accuracy of any pertinent peak interference corrections. A linear regression between two points selected at appropriate background positions is a classical approach for electron probe microanalysis (EPMA). However, this approach neglects the accurate assessment of background curvature (exponential or polynomial), and the presence of background interferences, a hole in the background, or an absorption edge can dramatically affect the results if underestimated or ignored. The acquisition of a quantitative wavelength-dispersive spectrometry (WDS) scan over the spectral region of interest remains a reasonable option to determine the background intensity and curvature from a fitted regression of background portions of the scan, but this technique can be time consuming and retains an element of subjectivity, as the analyst has to select areas in the scan which appear to represent background. This paper presents a new multi-point background (MPB) method whereby the background intensity is determined from up to 24 background measurements from wavelength positions on either side of analytical lines. This method improves the accuracy and precision of trace element analysis in a complex matrix through careful regression of the background shape, and can be used to characterize the background over a large spectral region covering several elements to be analyzed. The overall efficiency improves as systematic WDS scanning is not required to assess background interferences. The method is less subjective compared to methods that rely on WDS scanning, including selection of two interpolation points based on WDS scans, because "true" backgrounds are selected through an exclusion method of possible erroneous backgrounds. The first validation of the MPB method involves blank testing to ensure the method can accurately measure the absence of an element. The second validation involves the analysis of U-Th-Pb in several monazite reference materials of known isotopic age. The impetus for the MPB method came from efforts to refine EPMA monazite U-Th-Pb dating, where it was recognized that background errors resulting from interference or strong background curvature could result in errors of several tens of millions of years on the calculated date. Results obtained on monazite reference materials using two different microprobes, a Cameca SX-100 Ultrachron and a JEOL JXA-8230, yield excellent agreement with ages obtained by isotopic methods (Thermal Ionization Mass Spectrometry [TIMS], Sensitive High-Resolution Ion MicroProbe [SHRIMP], or Secondary Ion Mass Spectrometry [SIMS]). Finally, the MPB method can be used to model the background over a large spectrometer range to improve the accuracy of background measurement of minor and trace elements acquired on a same spectrometer, a method called the shared background measurement. This latter significantly improves the accuracy of minor and trace element analysis in complex matrices, as demonstrated by the analysis of Rare Earth Elements (REE) in REE-silicates and phosphates and of trace elements in scheelite.