Modulation of Structural, Electronic, and Optical Properties of Titanium Nitride Thin Films by Regulated In Situ Oxidation.

Epitaxial titanium nitride (TiN) and titanium oxynitride (TiON) thin films have been grown on sapphire substrates using a pulsed laser deposition (PLD) method in high-vacuum conditions (base pressure <3 × 10-6 T). This vacuum contains enough residual oxygen to allow a time-independent gas phase oxidation of the ablated species as well as a time-dependent regulated surface oxidation of TiN to TiON films. The time-dependent surface oxidation is controlled by means of film deposition time that, in turn, is controlled by changing the number of laser pulses impinging on the polycrystalline TiN target at a constant repetition rate. By changing the number of laser pulses from 150 to 5000, unoxidized (or negligibly oxidized) and oxidized TiN films have been obtained with the thickness in the range of four unit cells to 70 unit cells of TiN/TiON. X-ray photoelectron spectroscopy (XPS) investigations reveal higher oxygen content in TiON films prepared with a larger number of laser pulses. The oxidation of TiN films is achieved by precisely controlling the time of deposition, which affects the surface diffusion of oxygen to the TiN film lattice. The lattice constants of the TiON films obtained by x-ray diffraction (XRD) increase with the oxygen content in the film, as predicted by molecular dynamics (MD) simulations. The lattice constant increase is explained based on a larger electrostatic repulsive force due to unbalanced local charges in the vicinity of Ti vacancies and substitutional O. The bandgap of TiN and TiON films, measured using UV-visible spectroscopy, has an asymmetric V-shaped variation as a function of the number of pulses. The bandgap variation following the lower number of laser pulses (150-750) of the V-shaped curve is explained using the quantum confinement effect, while the bandgap variation following the higher number of laser pulses (1000-5000) is associated with the modification in the band structure due to hybridization of O2p and N2p energy levels.

Granulomatosis With Polyangiitis Presenting as Complete Hearing Loss.

Granulomatosis with Polyangiitis is a rare autoimmune vasculitis that is classically characterized by effects on the upper respiratory tract, lungs, and kidneys. Delay in diagnosis is often attributed to variable and sequential presentation of symptoms rather than concurrent symptomatology. It is important to recognize the wide range of initial presenting symptoms as early diagnosis and treatment is critical in preventing potentially irreversible damage resulting from delayed diagnosis. We present a case of a 29-year-old male with history of mixed sensorineural-conductive hearing loss presumed to be secondary to chronic otitis media who presented to the emergency department with complaint of hematemesis with a subsequent diagnosis of granulomatosis with polyangiitis.

"Opening eyes to real interprofessional education": results of a national faculty development initiative focused on interprofessional education in oncology palliative care.

The purpose of this study was to evaluate participants' feedback related to their experience in the Interprofessional Education Exchange (iPEX) program, a training initiative for faculty development in interprofessional oncology palliative care education. Participants voluntarily submitted a written reflection using a guide. The research team used qualitative content template analysis techniques to determine codes and categories based on the reflections and selected representative quotations (meaning units) from the data. Fifty-three reflections (100%) submitted by those completing the training were included in the analysis. The most appreciated aspects of the training were the opportunity for exchange of ideas and programs and the time allowed during the workshop for each team to work on developing their unique plan for interprofessional education (IPE) in oncology palliative care at their home institution. The iPEX program proved to be feasible, well-accepted, and valued by participants who reported personal, professional, and team growth and expressed appreciation for program support, content, and the exchange of ideas in a face-to-face setting. The results demonstrate that a faculty development program built on recommendations in the literature contributed to successful efforts to plan and initiate IPE in oncology palliative care.

The Interprofessional Education Exchange: The Impact of a Faculty Development Program in Interprofessional Palliative Oncology Education on Trainee Competencies, Skills, and Satisfaction.

Background: The interprofessional education exchange (iPEX) provides education, training, and mentoring to select interprofessional faculty trainee teams for development and implementation of interprofessional education (IPE) in palliative oncology. Objective: To evaluate the impact of the iPEX project on trainees' self-efficacy in IPE skills and IPE competencies. Design: A pre-/post-test design was used to evaluate trainees' progress. Trainees rated project components and developed IPE curricula in palliative oncology. Setting/Subjects: Sixteen United States-based faculty teams consisting of four to five members representing three or more disciplines completed the one-year faculty development project consisting of webinars, online interactive modules, a face-to-face workshop, mentoring, and assistance. The exchange of ideas, means for overcoming obstacles, collaborative teaching techniques, and curriculum development guidelines were integrated into the program. Measurements: Standardized measures of self-efficacy in IPE skills (Interprofessional Facilitation Skills Checklist) and IPE competencies (Core Competencies for Interprofessional Practice Individual Competency Assessment Tool) were used. Trainees rated the effectiveness of the project components on a scale of 1-5 (1 = not at all effective, 5 = extremely effective) and reported their plan for IPE palliative care curricula at their home institution. Results: Pre and post-paired samples t-test scores (n = 78) on both standardized instruments for IPE skills and competencies were significantly different (p < 0.001). Ratings of project components ranged from 3.97 to 4.90. Each team successfully developed a unique plan for IPE in palliative oncology. Conclusions: Multimodal faculty development and mentoring are successful means for improving self-assessed IPE skills and competencies.

Forming Anisotropic Crystal Composites: Assessing the Mechanical Translation of Gel Network Anisotropy to Calcite Crystal Form.

The promise of crystal composites with direction-specific properties is an attractive prospect for diverse applications; however, synthetic strategies for realizing such composites remain elusive. Here, we demonstrate that anisotropic agarose gel networks can mechanically "mold" calcite crystal growth, yielding anisotropically structured, single-crystal composites. Drying and rehydration of agarose gel films result in the affine deformation of their fibrous networks to yield fiber alignment parallel to the drying plane. Precipitation of calcium carbonate within these anisotropic networks results in the formation of calcite crystal composite disks oriented parallel to the fibers. The morphology of the disks, revealed by nanocomputed tomography imaging, evolves with time and can be described by linear-elastic fracture mechanics theory, which depends on the ratio between the length of the crystal and the elastoadhesive length of the gel. Precipitation of calcite in uniaxially deformed agarose gel cylinders results in the formation of rice-grain-shaped crystals, suggesting the broad applicability of the approach. These results demonstrate how the anisotropy of compliant networks can translate into the desired crystal composite morphologies. This work highlights the important role organic matrices can play in mechanically "molding" biominerals and provides an exciting platform for fabricating crystal composites with direction-specific and emergent functional properties.

The Improved Health Outcomes Program (iHOP): A Unique Model to Promote Provider-Driven Research in a Medicaid Population.

We describe an effort to improve the care of Medicaid and uninsured individuals through a three-way partnership between a Medicaid managed care insurer, front-line providers, and an academic university. The project provided annual funding over eleven years, for research, pilot programs, and demonstration projects. Projects were provider-driven in design and methods. The Medicaid-managed care insurer-funded proposals were vetted by a neutral university team experienced in grant writing and community-based research and scored by a community-based review panel. The grant program ran from 2007 to 2018, funding 41 projects, totaling USD 2,097,842. The partnership of an insurer, a university, and frontline providers was not only viable and sustainable for over a decade, but also flexible, free of project selection issues, and well-received by all stakeholders. Funded providers worked in both urban and rural settings and included hospitals, community non-profits, outpatient clinics, academic and community health partnerships, and public health agencies. The projects generally reflected common issues in the Medicaid and uninsured population needs, such as childhood obesity, and they were consistent with the targeted goals of the program. Broad health foci included child and/or maternal health, chronic conditions, mental health, preventive health, screening, system effectiveness, special populations including refugees, Latinos, and rural individuals, and substance use disorders. Details of the awarded grantee goals, the grants management process, and lessons learned from the partnership are presented. The partnership triad model was effective and stable, with each partner adding unique value. The use of the academic institution to administrate the program provided an arms-length relationship between the insurer and the providers in project selection and allowed assistance to less experienced researchers in community settings.

Which Critical Communication Skills Are Essential for Interdisciplinary End-of-Life Discussions?

Conversations about dying and end-of-life (EOL) care are the most challenging of all communication scenarios. These conversations include discussions about diagnosis and prognosis, treatment goals, and EOL wishes, goals of care, and plans for the future. Research has identified critically important skills involved in holding such conversations, and protocols have been established that can assist those discussing these important issues. Often several discussions and professionals from multiple disciplines are needed to ensure that EOL conversations are effective and comprehensive. In this article, we review what is known about the skills and strategies necessary for meaningful and effective EOL conversations and emphasize the valuable role of interdisciplinary approaches to these discussions. Advanced care planning (ACP), which refers to patient decisions about desired care should the patient lose decisional capacity, is included as a type of EOL discussion in this article.

Medicine as It Should Be: Teaching Team and Teamwork during a Palliative Care Clerkship.

BACKGROUND: Interprofessional Education (IPE) is an important component of medical education. Rotations with palliative care interdisciplinary teams (IDTs) provide an optimal environment for IPE and teaching teamwork skills. OBJECTIVE: Our objective was to assess the learning of senior medical students during a palliative care rotation. DESIGN: A constant comparison method based on grounded theory was used in this qualitative study. SETTING/SUBJECTS: Senior medical students completed a semi-structured reflective writing exercise after a required one-week palliative care clerkship. Sixty randomly selected reflective writings were analyzed. MEASUREMENTS: The reflective writings were analyzed to evaluate the student's experiences. RESULTS: Dominant themes identified were related to teams and teamwork. Eight specific themes were identified: value of IDT for team members; value of IDT for patient/family; importance of each team member; reliance on other team members; roles of team members; how teams work; team communication; and interdisciplinary assessment and care planning. Students described exposure to novel experiences and planned to incorporate newly learned behaviors in their future practice. CONCLUSION: By participating in palliative care IDTs, medical students consistently learned about teamwork within healthcare. Additionally, they learned the importance of such teamwork to patients and the team itself. Rotations with palliative care IDTs have a significant role to play in IPE and preparing medical students to practice on teams.

Improving medical graduates' training in palliative care: advancing education and practice.

The needs of an aging population and advancements in the treatment of both chronic and life-threatening diseases have resulted in increased demand for quality palliative care. The doctors of the future will need to be well prepared to provide expert symptom management and address the holistic needs (physical, psychosocial, and spiritual) of patients dealing with serious illness and the end of life. Such preparation begins with general medical education. It has been recommended that teaching and clinical experiences in palliative care be integrated throughout the medical school curriculum, yet such education has not become the norm in medical schools across the world. This article explores the current status of undergraduate medical education in palliative care as published in the English literature and makes recommendations for educational improvements which will prepare doctors to address the needs of seriously ill and dying patients.

Impact of a telehealth intervention on quality of life and symptom distress in patients with head and neck cancer.

BACKGROUND: Patients undergoing treatment for head and neck cancer commonly experience signi•cant changes in quality of life (QoL) and levels of symptom distress. It is not known if a telehealth intervention would mitigate these changes. OBJECTIVE: To evaluate the impact of a telehealth intervention on QoL and symptom burden in patients undergoing initial treatment for head and neck cancers. METHODS: A randomized clinical trial comparing the impact on QoL and symptom distress of telehealth intervention and standard care was conducted with 80 patients (45 treatment, 35 control) who had been diagnosed with head or neck cancer and were receiving 1 or more treatment modalities. Treatment group participants responded daily to symptom management algorithms using a simple telehealth messaging device. QoL was evaluated by the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACTHN) and symptom burden by the Memorial Symptom Assessment Scale (MSAS). Control group participants completed assessments while they received routine care. RESULTS: In the posttreatment phase, the telehealth participants had signi•cantly better scores than the controls for physical well-being (20.6 vs 17.0, P = .02) and trial outcome index (59.9 vs. 50.2, P = .04) on the FACT-HN, and total scores on the MSAS (0.9 vs. 1.2, P = .04). LIMITATIONS: The moderate sample size of 80 patients limits the power to measure more subtle impacts of the intervention. CONCLUSIONS: Using telehealth to provide support to patients with head and neck cancer during the acute phase of treatment improved some aspects of posttreatment QoL and symptom burden.

The Interdisciplinary Curriculum for Oncology Palliative Care Education (iCOPE): meeting the challenge of interprofessional education.

UNLABELLED: Background: Interprofessional education is necessary to prepare students of the health professions for successful practice in today's health care environment. Because of its expertise in interdisciplinary practice and team-based care, palliative care should be leading the way in creating educational opportunities for students to learn the skills for team practice and provision of quality patient-centered care. Multiple barriers exist that can discourage those desiring to create and implement truly interdisciplinary curriculum. DESIGN: An interdisciplinary faculty team planned and piloted a mandatory interdisciplinary palliative oncology curriculum and responded to formative feedback. SETTING/SUBJECTS: The project took place at a large public metropolitan university. Medical, nursing, and social work students and chaplains completing a clinical pastoral education internship participated in the curriculum. MEASUREMENTS: Formative feedback was received via the consultation of an interdisciplinary group of palliative education experts, focus groups from students, and student evaluations of each learning modality. RESULTS: Multiple barriers were experienced and successfully addressed by the faculty team. Curricular components were redesigned based on formative feedback. Openness to this feedback coupled with flexibility and compromise enabled the faculty team to create an efficient, sustainable, and feasible interdisciplinary palliative oncology curriculum. CONCLUSION: Interdisciplinary palliative education can be successful if faculty teams are willing to confront challenges, accept feedback on multiple levels, and compromise while maintaining focus on desired learner outcomes.

"I will never forget": what we learned from medical student reflections on a palliative care experience.

PURPOSE: To use reflective writing to evaluate a new required palliative care experience for third year medical students. METHOD: The authors used a constant comparison method based on grounded theory to conduct a thematic analysis of reflective writings produced by third-year medical students completing a mandatory week-long clinical rotation in palliative care during academic year 2010 at the University of Louisville. RESULTS: Two broad thematic categories were identified: what the students learned and what the students experienced. Student writings revealed learning about palliative care (pain management, family meetings, goals of care, patient-family centered care, timing of palliative care, and delivering bad news); being a doctor (knowledge, communication, presence, empathy, not giving false hope, and person-focused care); the patient (importance of family, the experience of dying, and the uniqueness of each patient); and themselves (need to be non-judgmental, ability to do palliative care, self-limitations, becoming a better physician, and dealing with death). Student reflections centered on encounters with patients and families, internal emotional responses, and self-transformation. CONCLUSIONS: Systematic analysis of reflective writing provides educators with valuable data about students' learning experiences. These results may inform the design and modification of the curriculum.

Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer.

PURPOSE: The purpose of this study was to explore the ability of Distress Thermometer (DT) scores to discern important differences in quality of life scores among women with breast cancer. METHODS: The National Comprehensive Cancer Network's DT, the Functional Assessment of Cancer Therapy-Breast (FACT-B), and a demographic questionnaire were completed by 111 women recently diagnosed with breast cancer. RESULTS: Patients considered moderately to severely distressed (score ≥ 4 on DT) scored significantly lower on FACT-B QOL scales and subscales when compared to those in the group scoring 3 or below. For those scales for which minimally important differences (MIDs) have been established, differences between the two groups were 2-3 and a half times the established MID. CONCLUSIONS: Moderately to severely distressed patients have significantly lower QOL than those with expected or mild distress. The DT provides a quick and easy screening tool to alert the healthcare team to clinically relevant alterations in patients' QOL.

Feasibility and Acceptance of a Telehealth Intervention to Promote Symptom Management during Treatment for Head and Neck Cancer.

Patients undergoing treatment for head and neck cancers have a myriad of distressing symptoms and treatment side effects which significantly alter communication and lower quality of life. Telehealth technology has demonstrated promise in improving patient-provider communication by delivering supportive educational content and guidance to patients in their homes. A telehealth intervention using a simple telemessaging device was developed to provide daily education, guidance, and encouragement for patients undergoing initial treatment of head and neck cancer. The goal of this article is to report the feasibility and acceptance of the intervention using both quantitative and qualitative measures. No eligible patients declined participation based on technology issues. Participants completed the intervention over 86% of the expected days of use. Direct nursing contact was seldom needed during the study period. Satisfaction with the technology and the intervention was very high. In this study a telehealth intervention was shown to be feasible, well accepted, and regularly used by patients experiencing extreme symptom burden and declining quality of life as a result of aggressive treatment for head and neck cancer.

Phase-diverse coherent diffractive imaging: high sensitivity with low dose.

This Letter demonstrates that coherent diffractive imaging (CDI), in combination with phase-diversity methods, provides reliable and artefact free high-resolution images. Here, using x rays, experimental results show a threefold improvement in the available image contrast. Furthermore, in conditions requiring low imaging dose, it is demonstrated that phase-diverse CDI provides a factor of 2 improvement in comparison to previous CDI techniques.

The relationship between weight loss and health-related quality of life in persons treated for head and neck cancer.

PURPOSE: This study explores the relationship between weight loss, health-related quality of life (HRQOL), and symptom burden in patients treated for head and neck cancers. METHODS: Participants completed the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) and the Memorial Symptom Assessment Scale (MSAS) pre-treatment, mid-treatment, and post-treatment. Weights were recorded prior to treatment and at the post-treatment follow-up visit, and percentage weight loss was tabulated. Relationships between weight loss, HRQOL, and symptom burden were evaluated using the nonparametric Spearman rho. A simple linear regression model was developed to examine the influence weight loss has on HRQOL in a predictive manner. RESULTS: Average weight loss per patient was 12 lb with a modal value of 19. Weight loss was found to be significantly correlated with decreases in physical well-being, functional well-being, the Head and Neck specific subscale, and composite QOL scores. No significant correlations were found between weight loss and symptom burden as measured by the MSAS. Linear regression suggested that a 10% decrease in baseline weight resulted in a 19% decrease in the FACT-H&N score. CONCLUSION: The strong association between weight loss and HRQOL supports the importance of efforts to prevent weight loss via patient education, aggressive monitoring, and immediate intervention to stop or reverse weight loss during treatment. New approaches to the weight loss and wasting experienced by patients should be developed and tested.

Palliative care case management: increasing access to community-based palliative care for Medicaid recipients.

PURPOSE: The purpose of this pilot project was to integrate palliative care principles and practices into the day-to-day operations of a Medicaid managed care provider. This was accomplished through the following five activities: (1) employment of an experienced palliative care nurse and social worker to serve as expert role models and consultants to the case management staff; (2) development of a palliative care training curriculum for case managers; (3) provision and evaluation of the training; (4) identification of appropriate patients, provision of palliative care case management (PCCM), and tracking of outcomes; and (5) development of a resource/reference manual for case managers. PRIMARY PRACTICE SETTING: The project involved a managed care organization providing Medicaid services to patients residing in both urban and rural settings. FINDINGS/CONCLUSIONS: Expert staff was hired and modeled effective PCCM. This, as well as the training program, had significant influence on both the palliative care knowledge and attitudes of existing case managers. Involved patients demonstrated improved symptom management and satisfaction with care. Patient scenarios demonstrated desirable outcomes in healthcare utilization, and timely, appropriate hospice referrals were realized. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrating PCCM into the practices of a provider of Medicaid managed care can result in positive patient outcomes, improved utilization of healthcare services, and related savings for the managed care provider. Such a program can increase access to community-based palliative care for Medicaid recipients with life-threatening illnesses. PCCM can address the multiple needs of younger patients with serious illness who are not yet ready to forego curative efforts.

Development of a telehealth intervention for head and neck cancer patients.

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Mark's journey: a study in medicaid palliative care case management.

PURPOSE/OBJECTIVES: Palliative care and managed care share the goals of providing comprehensive patient care in a manner that reflects the goals of the patient while controlling the use of ineffective, costly treatments and arranging for care in the most appropriate treatment setting. The purpose of this case study is to illustrate the integrations of palliative care principles and practices within a managed care organization serving Medicaid patients. The Five Principles of Palliative Care developed by the Last Acts Task Force are used to structure the description of the interventions of the palliative care case management team. PRIMARY PRACTICE SETTING: The practice setting is Passport Health Plan, the managed care provider for the state Medicaid program in Louisville, Kentucky, which serves Jefferson and 15 surrounding Kentucky counties. Care for the patient was provided by a nurse and social worker team specializing in palliative care case management. FINDINGS/CONCLUSIONS: Palliative care principles and practices can be successfully integrated into managed care as a means for providing quality end-of-life care, a cost-effective, yet patient-centered, approach to care, and an alternative when hospice care is not indicated or available. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case management practitioners and organizations and the persons they serve can benefit from incorporating palliative care principles and practices into mainstream case management practice.