Network community structure of substorms using SuperMAG magnetometers.

Geomagnetic substorms are a global magnetospheric reconfiguration, during which energy is abruptly transported to the ionosphere. Central to this are the auroral electrojets, large-scale ionospheric currents that are part of a larger three-dimensional system, the substorm current wedge. Many, often conflicting, magnetospheric reconfiguration scenarios have been proposed to describe the substorm current wedge evolution and structure. SuperMAG is a worldwide collaboration providing easy access to ground based magnetometer data. Here we show application of techniques from network science to analyze data from 137 SuperMAG ground-based magnetometers. We calculate a time-varying directed network and perform community detection on the network, identifying locally dense groups of connections. Analysis of 41 substorms exhibit robust structural change from many small, uncorrelated current systems before substorm onset, to a large spatially-extended coherent system, approximately 10 minutes after onset. We interpret this as strong indication that the auroral electrojet system during substorm expansions is inherently a large-scale phenomenon and is not solely due to many meso-scale wedgelets.

An Interdisciplinary Approach to Educating Medical Students About Dementia Assessment and Treatment Planning.

BACKGROUND: Many general practitioners consider dementia care beyond their clinical domain and feel that dementia assessment and treatment should be addressed by specialists, such as geriatricians, geriatric psychiatrists, or neurologists. An urgent need exists to educate all medical trainees in dementia care, regardless of their specialization interests. OBSERVATIONS: We developed a multicomponent, experiential, brief curriculum using team-based learning to expose senior medical students who rotated through the US Department of Veterans Affairs Memory Disorders Clinic at the Central Arkansas Veterans Healthcare System in Little Rock to an interdisciplinary assessment of dementia. The curriculum included didactics, clinical experience, and team-based learning. In pre- and postevaluation, students rated their perception of the role of interdisciplinary team members in assessing and managing dementia, their personal abilities to assess cognition, behavioral problems, caregiver burden, and their perception of the impact of behavioral problems on dementia care. CONCLUSIONS: Dementia knowledge gaps were prevalent in this cohort of senior medical students. Providing interdisciplinary geriatric educational experience improved students perception of their ability to assess for dementia and their recognition of the roles of interdisciplinary team members. Plans are in place to continue and expand the program to other complex geriatric syndromes.

Lessons learned from service design of a trial of a digital mental health service: Informing implementation in primary care clinics.

Implementing a digital mental health service in primary care requires integration into clinic workflow. However, without adequate attention to service design, including designing referral pathways to identify and engage patients, implementation will fail. This article reports results from our efforts designing referral pathways for a randomized clinical trial evaluating a digital service for depression and anxiety delivered through primary care clinics. We utilized three referral pathways: direct to consumer (e.g., digital and print media, registry emails), provider referral (i.e., electronic health record [EHR] order and provider recommendation), and other approaches (e.g., presentations, word of mouth). Over the 5-month enrollment, 313 individuals completed the screen and reported how they learned about the study. Penetration was 13%, and direct to consumer techniques, most commonly email, had the highest yield. Providers only referred 16 patients through the EHR, half of whom initiated the screen. There were no differences in referral pathway based on participants' age, depression severity, or anxiety severity at screening. Ongoing discussions with providers revealed that the technologic implementation and workflow design may not have been optimal to fully affect the EHR-based referral process, which potentially limited patient access. Results highlight the importance of designing and evaluating referral pathways within service implementation, which is important for guiding the implementation of digital services into practice. Doing so can ensure that sustained implementation is not left to post-evaluation bridge-building. Future efforts should assess these and other referral pathways implemented in clinical practice outside of a research trial.

Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies.

BACKGROUND: Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use. OBJECTIVE: The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period. METHODS: The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention. RESULTS: The 3 participants' unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves. CONCLUSIONS: These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages.

Participant and Caregiver Perspectives on Clinical Research During Covid-19 Pandemic.

BACKGROUND/OBJECTIVES: The COVID-19 pandemic has massively disrupted essential clinical research. Many regulatory organizations have rightfully advocated to temporarily halt enrollment and curtail all face-to-face interactions. Views and opinions of patients and their caregivers are seldom considered while making such decisions. The objective was to study older participants' and their caregivers' perspectives to participate in ongoing clinical research during the COVID-19 pandemic. DESIGN: Cross-sectional. SETTING: VISN-16/Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs. PARTICIPANTS: Older participants and their caregivers (N = 51) enrolled in ongoing clinical research studies. MEASUREMENTS: Questions about perceptions of safety to attend research visit, the level of panic among the general public, and medical center's preparedness in handling the pandemic. Other questions identified the source of pandemic information and the preference of a phone or in-person visit. RESULTS: Mean age was 69.3 (±9.4) years, 53% were male, 39% were caregivers, and 65% were Caucasian. Majority (78%) of the participants felt safe/very safe attending the scheduled research appointment; 63% felt that the extra screening made them feel safe/very safe; 82% felt that the medical center was prepared/very prepared for the pandemic. Participants split evenly on their preference for phone versus in-person visits. Family members and television news media were the commonly used sources of pandemic information irrespective of their education. Perceptions were influenced by gender and source of information, not by age or education. Females perceived higher level of panic compared to males (P = .02). Those relying on news media felt safer compared to those that relied on family members (P = .008). CONCLUSION: Even though informants felt that the medical center was prepared to handle the pandemic, only half the participants preferred the in-person visit. Pandemic information was obtained from family members or the television news media. Knowing patients' perspectives may help researchers be better prepared for future pandemics. J Am Geriatr Soc 68:E14-E18, 2020.

Military assistance to the civil authority: medical liaison with the Manchester clinicians after the Arena bombing.

UK Defence Medical Services' personnel have experienced an intense exposure to patients injured during war over the last decade and a half. As some bitter lessons of war surgery were relearned and innovative practices introduced, outcomes for patients impr oved consistently as experience accumulated. The repository of many of the enduring lessons learnt at the Role 4 echelon of care remain at the Queen Elizabeth Hospital Birmingham (QEHB), with the National Health Service and Defence Medical Services personnel who treated the returning casualties. On 22 May 2017, a terrorist detonated an improvised explosive device at the Manchester Arena, killing 22 and wounding 159 people. In the aftermath of the event, QEHB was requested to provide support to the Manchester clinicians and teleconferencing and then two clinical visits were arranged. This short report describes the nature of the visits, outlines the principles of Military Aid to the Civil Authority and looks to the future role of the Defence Medical Services in planning and response to UK terrorism events.

Blunt neck trauma at a level I trauma centre: six-year retrospective case note review.

BACKGROUND: Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic. METHOD: A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017. RESULTS: Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5-70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with 'hot' reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent). CONCLUSION: Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.

Shortening of an existing generic online health-related quality of life instrument for dogs.

OBJECTIVE: Development, initial validation and reliability testing of a shortened version of a web-based questionnaire instrument to measure generic health-related quality of life in companion dogs, to facilitate smartphone and online use. MATERIALS AND METHODS: The original 46 items were reduced using expert judgment and factor analysis. Items were removed on the basis of item loadings and communalities on factors identified through factor analysis of responses from owners of healthy and unwell dogs, intrafactor item correlations, readability of items in the UK, USA and Australia and ability of individual items to discriminate between healthy and unwell dogs. Validity was assessed through factor analysis and a field trial using a "known groups" approach. Test-retest reliability was assessed using intraclass correlation coefficients. RESULTS: The new instrument comprises 22 items, each of which was rated by dog owners using a 7-point Likert scale. Factor analysis revealed a structure with four health-related quality of life domains (energetic/enthusiastic, happy/content, active/comfortable, and calm/relaxed) accounting for 72% of the variability in the data compared with 64% for the original instrument. The field test involving 153 healthy and unwell dogs demonstrated good discriminative properties and high intraclass correlation coefficients. CLINICAL SIGNIFICANCE: The 22-item shortened form is superior to the original instrument and can be accessed via a mobile phone app. This is likely to increase the acceptability to dog owners as a routine wellness measure in health care packages and as a therapeutic monitoring tool.

Prospective, randomised controlled trial comparing intense endoscopic cleaning versus minimal intervention in the early post-operative period following functional endoscopic sinus surgery.

OBJECTIVE: There is currently no standardised management protocol following functional endoscopic sinus surgery. This study assessed frequent endoscopic cleaning versus minimal intervention in the early post-operative period following such surgery. STUDY DESIGN: Prospective, randomised controlled, single-blinded, within-subject trial involving 24 patients with bilateral chronic rhinosinusitis undergoing bilateral functional endoscopic sinus surgery. MAIN OUTCOME MEASURE: The primary outcome measure was ethmoid cavity healing, based on endoscopic appearance, graded using a modified Lund-MacKay endoscopic score. SECONDARY OUTCOME MEASURE: Lund-MacKay symptom score before and after surgery. RESULTS: There was no overall statistically significant difference between the two groups (p = 0.37). Subgroup analysis revealed a significant effect of regular suction clearance on adhesions at three months (p = 0.048), but not on oedema, polyps, granulation, discharge or crusting. CONCLUSION: There is no evidence from this study to support frequent endoscopic cleaning in the early post-operative period after functional endoscopic sinus surgery. Less intensive post-operative management is recommended, resulting in decreased patient morbidity and fewer post-operative follow-up appointments.

Assessing posttraumatic stress disorder using the trauma symptom checklist for young children.

This pilot study assessed the performance of the Trauma Symptom Checklist for Young Children (TSCYC) in correctly classifying the presence or absence of PTSD, as determined by the Diagnostic Interview for children and Adolescents-Parent (DICA-P). Participants included 34 children, ages 4 to 12, referred for outpatient treatment. The 11 PTSD-positive participants scored significantly higher than the 23 PTSD-negative participants on scales assessing intrusive symptoms, arousal symptoms, and total posttraumatic stress (PTS). A model including the PTS-Intrusion, PTS-Avoidance, and PTS-Arousal scales, and the sexual concerns, dissociation, and anger/aggression scales correctly classified 100% of the PTSD-negative and 72.7% of the PTSD-positive participants. These findings suggest that the TSCYC may be used as an economical and time-efficient screening device for PTSD.

Airway and systemic effects of hydrofluoroalkane fluticasone and beclomethasone in patients with asthma.

BACKGROUND: With the transition to hydrofluoroalkane-134a propellants in metered dose inhalers, it is important to consider the efficacy and safety profiles of formulations containing inhaled corticosteroids. We examined the airway and systemic effects of hydrofluoroalkane-134a fluticasone propionate (FLU-HFA) and beclomethasone dipropionate (BEC-HFA) at recommended labelled doses. METHODS: Twenty mild to moderate asthmatics were randomised in crossover fashion to receive 6 weeks of 500 micro g/day followed by 1000 micro g/day FLU-HFA and BEC-HFA. Measurements were made at baseline after placebo run in and washout, and after each randomised treatment. The primary airway outcome for benefit was the dose of methacholine provoking a fall in forced expiratory volume in 1 second (FEV(1)) of 20% or more (methacholine PD(20)) and for systemic adverse effects was overnight urinary cortisol/creatinine (OUCC). RESULTS: For mean responses, both doses of BEC-HFA and FLU-HFA produced significant improvements in PD(20) compared with baseline. The improvement was not significantly greater with 1000 micro g/day FLU-HFA versus BEC-HFA, a 1.69 fold difference (95% CI 0.94 to 3.04). Both doses of BEC-HFA but not FLU-HFA caused significant suppression of OUCC compared with baseline, with significantly (p<0.05) lower values at 1000 micro g/day for BEC-HFA versus FLU-HFA (1.97 fold difference (95% CI 1.28 to 3.02)). CONCLUSION: There was no difference in the airway and systemic effects in patients with mild to moderate asthma between FLU-HFA and BEC-HFA at a dose of 500 micro g/day. At 1000 micro g/day there was increased systemic bioactivity with BEC-HFA compared with FLU-HFA, without any gain in airway efficacy.

A comparison of once daily fexofenadine versus the combination of montelukast plus loratadine on domiciliary nasal peak flow and symptoms in seasonal allergic rhinitis.

BACKGROUND: The combination of montelukast (ML) and loratadine (LT) has previously been shown to be superior to either drug alone in managing seasonal allergic rhinitis (SAR), whilst fexofenadine (FEX) has been shown to be better than LT as monotherapy. OBJECTIVES: We wished to compare ML + LT vs. FEX alone for effects on daily measurements (am/pm) of peak inspiratory flow (PIF) and symptoms. METHODS: Thirty-seven patients with SAR (skin prick positive to grass pollen) were randomised into a single-blind, double-dummy placebo (PL)-controlled cross-over study during the grass pollen season, comparing 2 weeks of once daily treatment with (a) 120mg FEX or (b) 10mg ML + 10mg LT. There was a 7-10 day placebo run-in and washout prior to each randomised treatment. The average of am/pm PIF (the primary outcome variable) was analysed. Patients recorded their symptom scores (from 0 to 3) twice daily, for nasal blockage, discharge, itching and sneezing with; total eye symptoms, ocular cromoglycate use, and daily activity. The total nasal symptom score was calculated as a composite (out of 24). RESULTS: There were no significant differences between baselines after the run-in and washout placebos for any variables. There were significant (P < 0.05, Bonferroni) improvements in all symptoms and PIF compared to pooled placebo with both treatments for all end-points, but no differences between the two treatment regimes (as means and within-treatment 95% confidence intervals): PIF: PL 102 (98-107), FEX 111 (107-116), ML+LT 113 (109-118); total nasal symptoms: PL 7.4 (6.7-2.0), FEX 5.0 (4.3-5.7), ML + LT 4.0 (3.3-4.7). CONCLUSIONS: Once daily FEX as monotherapy was equally effective as the combination of once daily ML + LT in improving nasal peak flow and controlling symptoms in SAR. Further studies are indicated to assess whether ML confers additional benefits to FEX in SAR.

Effects of topical corticosteroid and combined mediator blockade on domiciliary and laboratory measurements of nasal function in seasonal allergic rhinitis.

BACKGROUND: Both domiciliary and laboratory measures of nasal function have been used to evaluate treatment response in allergic airways disease; however, these measures have not been compared. OBJECTIVE: To determine the relationship of domiciliary measures (daily symptoms, peak inspiratory nasal flow, and nasal oral index) and laboratory measures (rhinomanometry, acoustic rhinometry) in assessing treatment response with topical steroids and specific inflammatory mediator blockage. METHODS: Twenty-one patients with seasonal allergic rhinitis and asthma were enrolled into a single-blind, placebo-controlled, crossover study comparing 2 weeks of 1) 400 microg inhaled plus 200 microg intranasal budesonide once daily and 2) 10 mg montelukast plus 10 mg cetirizine once daily. Before each treatment, patients received 7 to 10 days of placebo period. Laboratory measurements were made of nasal resistance by posterior rhinomanometry, and nasal volume between 0 and 5 cm by acoustic rhinometry after both placebo and active treatment periods. Daily domiciliary recordings were made of allergic rhinitis nasal symptoms scores and peak nasal and oral inspiratory flow rate (enabling the calculation of a nasal/oral index) throughout the study. RESULTS: There were significant (P < 0.05) improvements for all allergic rhinitis symptoms with both therapies, after factoring for pollen count. Spearman's rank correlation for comparison among nasal symptoms and the objective responses were: nasal inspiratory flow rate (R = -0.50, P = 0.02); nasal/oral index (R = -0.55 P = 0.01); rhinomanometry (R = 0.24, P = 0.30); and acoustic rhinometry (R = -0.21, P = 0.36). CONCLUSIONS: Both treatments were effective in managing allergic rhinitis symptoms, and patients' symptoms were more closely associated with domiciliary measurements of nasal flow than laboratory measurements of nasal function.

Dose-response for adrenal suppression with hydrofluoroalkane formulations of fluticasone propionate and beclomethasone dipropionate.

AIMS: With the recent introduction of hydrofluoroalkane (HFA) inhalers it is important to know the relative systemic safety profiles of inhaled corticosteroids. We therefore decided to compare systemic bioavailability of HFA-beclomethasone dipropionate (BDP) vs HFA-fluticasone propionate (FP). METHODS: Sixteen healthy volunteers were randomised in placebo-controlled single blind cross-over fashion to receive 3 weeks with HFA-FP or HFA-BDP, given as 1 week cumulative doubling doses (nominal ex-valve) of 500, 1000 and 2000 microg day(-1), with a 1 week placebo run-in and wash-out. Overnight (22.00 h to 08.00 h) and early morning (08.00 h) urinary cortisol/creatinine excretion and 08.00 h serum cortisol were measured after each placebo and dosing period. All data were log-transformed to normalize their distribution. RESULTS: Urine and serum cortisol were suppressed by 2000 microg FP and BDP vs placebo and by 1000 microg BDP vs placebo for urinary cortisol/creatinine (P < 0.05). Overnight urinary cortisol/creatinine ratio (the primary endpoint) was suppressed more by 1000 microg BDP vs 1000 microg FP (P < 0.05), amounting to a geometric mean fold difference (95% CI) of 1.64 (1.04-2.56). There were also more individual low values less than 3 nmol mmol(-1) with BDP than FP at 1000 microg: n = 8/16 vs n = 2/16 (P < 0.05). CONCLUSIONS: There was dose-related suppression of corrected urinary cortisol/creatinine with the HFA formulations of BDP and FP. Suppression of overnight urinary cortisol/creatinine ratio was significantly greater with HFA-BDP than HFA-FP at 1000 microg. This suggests that the greater glucocorticoid potency of HFA-FP may be offset by the greater lung bioavailability of HFA-BDP.

Use of the skeletal survey in the evaluation of child maltreatment.

The radiologic skeletal survey is an important tool for evaluating occult trauma in suspected child abuse. The purposes of this study were: (1) to determine the incidence of clinically unsuspected fractures detected by skeletal survey, and (2) to identify high-risk groups of children who would benefit from skeletal surveys. We retrospectively reviewed the medical records of 203 children admitted over a 30-month period to Children's National Medical Center for alleged physical abuse. Skeletal surveys were ordered based on the treating physicians' clinical suspicions. Patients in whom skeletal surveys were positive for an occult fracture were studied in more detail. There were 96 skeletal surveys performed; of these, 25 were positive for at least 1 clinically unsuspected fracture. Eighty percent of occult fractures were found in children younger than 1 year old. Presenting with a new fracture or an intracranial injury placed the child at higher risk of occult fracture. In contrast, patients with burn injuries had a very low yield of occult fractures. The patient's age and type of suspicious injury can help guide the physician as to when to obtain a skeletal survey.

Effects of monotherapy with intra-nasal corticosteroid or combined oral histamine and leukotriene receptor antagonists in seasonal allergic rhinitis.

BACKGROUND: The combination of a leukotriene receptor antagonist with an antihistamine may have beneficial effects in seasonal allergic rhinitis (SAR). OBJECTIVE: To determine how combined oral mediator blockade compares to monotherapy with intranasal corticosteroid in the treatment of SAR. METHODS: Twenty-two patients with seasonal allergic rhinitis were enrolled in a placebo controlled crossover study comparing 2 weeks therapy of either (a) 200 microg intranasal mometasone furoate (MF) once daily or (b) 10 mg oral montelukast plus 10 mg oral cetirizine once daily (MON/CZ), with a 7-10 day placebo period prior to each treatment period. Domiciliary measures of symptoms and nasal flow were recorded daily. Measurements of posterior rhinomanometry, acoustic rhinometry and nasal nitric oxide were made after all treatment and placebo periods. RESULTS: There were significant (P < 0.05) improvements in domiciliary peak nasal flow (l/min) with both MF (133 (3.8)) and MON/CZ (124 (3.8)) compared to pooled placebo (110 (4.0). Both treatments also showed significant improvement in terms of nasal blockage (units) (PL: 1.1(0.1), MF: 0.5 (0.1), MON/CZ 0.7 (0.1); and total nasal symptoms (units) (PL: 3.5 (0.3), MF 1.6 (0.3), MON/CZ 1.7 (0.3)), although there was no significant difference between the two active treatments. There were no significant differences between placebo and treatment for rhinomanometry, acoustic rhinometry or nitric oxide. CONCLUSIONS: Both intranasal mometasone furoate as monotherapy and oral cetirizine plus montelukast as cotherapy were equally effective for objective and subjective measures of treatment response in SAR. Domiciliary measurements of symptoms and peak flow were more sensitive than laboratory measurements of rhinomanometry, acoustic rhinometry and nasal nitric oxide.

Photosynthesis and the web: 2001.

First, a brief history of the Internet and the World Wide Web is presented. This is followed by relevant information on photosynthesis-related web sites grouped into several categories: (1) large group sites, (2) comprehensive overview sites, (3) specific subject sites, (4) individual researcher sites, (5) kindergarten through high school (K-12) educational sites, (6) books and journals, and, 7) other useful sites. A section on searching the Web is also included. Finally, we have included an appendix with all of the web sites discussed herein as well as other web sites that space did not allow. Readers are requested to send comments, corrections and additions to gov@uiuc.edu.