Virginia Mason Lynnwood Medical Center

The current epidemic of type 2 diabetes (T2D) represents a significant global and national health concern. Globally, the prevalence of diabetes has doubled between 1980 and 2014. In 2014 the World Health Organization estimated that there were 422 million adults living with diabetes worldwide. In the USA, the number of people diagnosed with T2D is estimated to increase to over 70 million by 2050, putting an immense strain on the US healthcare system. Achieving glycemic control is widely acknowledged as the key goal of treatment in T2D and is critical for reducing the onset and progression of diabetes-related complications such as cardiovascular diseases, neuropathies, retinopathies, and nephropathies. Despite the increase in the availability of antihyperglycemic medications and evidence-based treatment guidelines, the proportion of people with T2D who fail to achieve glycemic goals continues to rise. One major contributor is a delay in treatment intensification despite suboptimal glycemic control, referred to as clinical or therapeutic inertia. Clinical inertia prolongs the duration of patients' hyperglycemia which subsequently puts them at increased risk of diabetes-associated complications and reduced life expectancy. Clinical inertia results from a complex interaction between patient, healthcare providers, and healthcare system barriers that need to be addressed together, rather than as separate entities. In this article we provide an overview of clinical inertia in the clinical management of T2D and provide suggestions for overcoming aspects that may have a negative impact on patient care.Funding: Sanofi US, Inc.

In response to the increasing call by professional organizations, journal editors, and statisticians to include not only derived significance levels from quantitative statistical procedures but also measures of effect sizes (ES), this article first provides a rationale for school counseling-related researchers to include these key indices in their studies. We contend that with this information, readers are better able to contextualize and properly interpret research findings and conclusions. Second, the three major ES families and the indices associated with each one are reviewed. Next, the influence of various research designs and differing sample sizes on the size of these effects is discussed, followed by an introduction to ES computation, reporting, and interpretation, particularly as these issues relate to school counseling settings. Practical examples, ES summary tables, and supplementary resources are overviewed as well.

Three comprehensive premarital assessment questionnaires (PAQs) are described, evaluated on their psychometric characteristics, and compared. They include the PREmarital Preparation and Relationship Enhancement (PREPARE) questionnaire, the Facilitating Open Couple Communication, Understanding and Study (FOCCUS) questionnaire, and the RELATionship Evaluation (RELATE). Recommendations for using each PAQ are discussed.

PURPOSE: To measure the influence of best-fit (BF) algorithms (entire dataset, 3 or 6 points landmark-based, or section-based BF) on virtual casts and their alignment discrepancies. MATERIAL AND METHODS: A mandibular typodont was obtained and digitized by using an industrial scanner (GOM Atos Q 3D 12M). A control mesh was acquired. The typodont was digitized by using an intraoral scanner (TRIOS 4). Based on the alignment procedures, four groups were created: BF of the entire dataset (BF group), landmark-based BF using 3 reference points (LBF-3 group), or 6 reference points (LBF-6 group), and section-based BF (SBF group). The root mean square (RMS) error was calculated. One-way ANOVA and post hoc pairwise multi-comparison Tukey were used to analyze the data (α = 0.05). RESULTS: Significant RMS error mean value differences were found across the groups (p < 0.001). Tukey test revealed significant RMS error mean value differences between the BF and LBF-3 groups (p = 0.022), BF and LBF-6 groups (p < 0.001), LB-3 and LB-6 groups (p < 0.001), LBF-3 and SBF groups (p < 0.001), and LBF-6 and SBF groups (p < 0.001). The LBF-6 group had the lowest trueness, while SBF and BF groups obtained the highest trueness values. Furthermore, significant SD differences were revealed across the groups tested (p < 0.001). Tukey test revealed significant SD differences between the BF and LBF-6 groups (p < 0.001), LBF-3 and LB-6 groups (p < 0.001), LBF-3 and SBF groups (p = 0.004), and LBF-6 and SBF groups (p < 0.001). The BF and SBF groups showed equal and highest precision, while the LBF-6 group had the lowest precision. CONCLUSIONS: The best-fit algorithms tested influenced the virtual casts' alignment discrepancy. Entire dataset or section-based best-fit algorithms obtained the highest virtual casts' alignment trueness and precision compared with the landmark-based method.

Purpose To determine experimentally the intrinsic energy response, k bq , of EBT3 GafChromic ® radiochromic film with kilovoltage x rays, 137 Cs, and 60 Co in therapeutic and diagnostic dose ranges through direct measurement with an accompanying mathematical approach to describe the physical processes involved. Methods The EBT3 film was irradiated with known doses using 60 Co, 137 Cs, and 13 NIST‐matched kilovoltage x‐ray beams. Seven dose levels, ranging from 57 to 7002 mGy, were chosen for this work. Monte Carlo methods were used to convert air‐kerma rates to dose rates to the film active layer for each energy. A total of 738 film dosimeters, each measuring (1.2 × 1.2) cm 2 , were cut from three film sheets out of the same lot of the latest version of EBT3 film, to allow for multiple dosimeters to be irradiated by each target dose and beam quality as well as unirradiated dosimeters to be used as controls. Net change in optical density in excess of the unirradiated controls was measured using the UWMRRC Laser Densitometry System (LDS). The dosimeter intrinsic energy response, k bq , for each dose level was determined relative to 60 Co, as the ratio of dosimeter response to each beam quality relative to the absorbed dose to the film active volume at the same dose level. A simplified, single‐hit mathematical model was used to derive a single‐free‐parameter, β , which is a proportionality constant that is dependent on beam quality and describes the microdosimetric interactions within the active layer of film. The response of β for each beam quality relative to 60 Co was also determined. Results k bq was determined for a wide range of doses and energies. The results show a unique variation of k bq as a function of energy, and agree well with results from other investigations. There was no measurable dose dependence for k bq within the 500–7002 mGy range outside of the expanded measurement uncertainty of 3.65% ( k = 2). For doses less than 500 mGy, the signal‐to‐noise ratio was too low to determine k bq accurately. The single‐free‐parameter, β , fit calculations derived from the single‐hit model show a correlation with k bq that suggests that β , at least in part, characterizes the microdosimetric interactions that determine k bq . Conclusions For the beam qualities investigated, a single energy‐dependent k bq correction can be used for doses between 500 and 7002 mGy. Using the single‐hit model with the single‐free‐parameter fit to solve for β shows promise in the determination of the intrinsic energy response of film, with β being the mathematical analog of the measured k bq .

BACKGROUND: We presented the pattern of health care consumption, and the utilization of available resources by describing the ecology of medical care in Beijing on a monthly basis and by describing the socio-demographic characteristics associated with receipt care in different settings. METHODS: A cohort of 6,592 adults, 15 years of age and older were sampled to estimate the number of urban-resident adults per 1,000 who visited a medical facility at least once in a month, by the method of three-stage stratified and cluster random sampling. Separate logistic regression analyses assessed the association between those receiving care in different types of setting and their socio-demographic characteristics. RESULTS: On average per 1,000 adults, 295 had at least one symptom, 217 considered seeking medical care, 173 consulted a physician, 129 visited western medical practitioners, 127 visited a hospital-based outpatient clinic, 78 visited traditional Chinese medical practitioners, 43 visited a primary care physician, 35 received care in an emergency department, 15 were hospitalized. Health care seeking behaviors varied with socio-demographic characteristics, such as gender, age, ethnicity, resident census register, marital status, education, income, and health insurance status. In term of primary care, the gate-keeping and referral roles of Community Health Centers have not yet been fully established in Beijing. CONCLUSIONS: This study represents a first attempt to map the medical care ecology of Beijing urban population and provides timely baseline information for health care reform in China.

This paper addresses the use of combined oral contraceptives in women older than 35 years of age, including the potential risks and benefits, pretreatment assessment, common side effects and their management, appropriate follow-up, and diagnosis of menopause. The case-based discussion also focuses on issues that pertain to women who smoke, have hypertension, or have dyslipidemia.

PURPOSE: To evaluate the chemical composition, flexural strength, and Weibull characteristics of milled and lithography-based additively manufactured (AM) zirconia. MATERIALS AND METHODS: monochrome) milled (M group) and 3Y-TZP zirconia (LithaCon 3Y 210) lithography-based AM (CeraFab System S65 Medical) (AM group) bar specimens (n = 20). The chemical composition of the specimens was determined by using energy dispersive X-ray (EDAX) elemental analysis in a scanning electron microscope. Flexural strength was measured in all specimens using 3-point bend test according to ISO/CD 6872.2 with a universal testing machine (Instron Model 8501). Two-parameter Weibull distribution values were calculated. The Shapiro-Wilk test revealed that the data were normally distributed (p < 0.05). Flexural strength values were analyzed using independent Student's t-test (α = 0.05). RESULTS: There were no major chemical composition differences observed between M and AM groups. The AM specimens (1518.9 ± 253.9 MPa) exhibited a significantly higher flexural strength mean value compared to the milled (980.5 ± 130.3 MPa) specimens (DF = 13, T-value = -5.97, p < 0.001). The Weibull distribution presented the highest shape for M specimens (11.49) compared to those of AM specimens (6.95). CONCLUSIONS: There was no significant difference in the chemical composition of milled and AM zirconia material tested. AM zirconia tested exhibited significantly higher flexural strength compared with the milled zirconia evaluated.

BACKGROUND: Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety. METHODS: Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers' Criteria for medication management and the Cockcroft-Gault formula for estimating glomerular filtration rates (GFR). The "Seniors Medication Alert and Review Technologies" (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed. RESULTS: Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check. CONCLUSION: While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers' Criteria in ambulatory care EMRs.

UNLABELLED: Although iodinated radiopharmaceuticals usually contain a small quantity of unbound iodine, it is difficult to establish the degree to which thyroid activity on scintigraphic images reflects uptake of free radioiodine. The objective of the present study was to examine the effectiveness of thyroid blockade in subjects undergoing (123)I-meta-iodobenzylguanidine (mIBG) imaging and to estimate the relative contribution of bound and unbound radioiodine to imaging findings. METHODS: All subjects were participants in prospective trials of (123)I-mIBG cardiac imaging in which pretreatment with thyroid blockade was optional unless locally required. In a pilot project, 15 subjects (6 blocked) had thyroid uptake measured at 4 h using a probe system. Fifteen-minute (early) and 4-h (late) anterior planar chest images that included the thyroid region were visually scored for thyroid uptake (scale of 0-4) in another group of 152 subjects (98 blocked). Quantitative analysis based on thyroid regions of interest was performed on anterior planar images from a further sample of 669 subjects (442 blocked). For all 3 investigations, quantitative comparisons of thyroid uptake were made between the blocked and nonblocked subjects. RESULTS: There was no statistical difference between probe uptake of the 6 blocked and 9 nonblocked subjects. However, in the second series, mean visual score on the late images was significantly lower for blocked than nonblocked subjects (P < 0.001). In the region-of-interest analyses, net thyroid counts were significantly higher on the late images of nonblocked subjects (P < 0.0001), and compared with early images, 87% of subjects who received blockade showed decreased or unchanged counts whereas 75% of nonblocked subjects had increased net thyroid activity. In nonblocked subjects, an estimated 79% of thyroid counts on late images could be attributed to unbound (123)I. CONCLUSION: On the basis of 3 different methods for assessing thyroid uptake of (123)I, use of thyroid blockade pretreatment in (123)I-mIBG imaging prevents increase of thyroid activity over time because of uptake of unbound (123)I. In most subjects, there is a low level of (123)I-mIBG thyroid activity that probably represents specific uptake in sympathetic nerve terminals.

Volumetric-modulated arc therapy (VMAT) has been shown to be able to deliver plans equivalent to intensity-modulated radiation therapy (IMRT) in a fraction of the treatment time. This improvement is important for patient immobilization/localization compliance due to comfort and treatment duration, as well as patient throughput. Previous authors have suggested commissioning methods for this modality. Here, we extend the methods reported for the Varian RapidArc system (which tested individual system components) to the Elekta linear accelerator, using custom files built using the Elekta iComCAT software. We also extend the method reported for VMAT commissioning of the Elekta accelerator by verifying maximum values of parameters (gantry speed, multileaf collimator (MLC) speed, and backup jaw speed), investigating: 1) beam profiles as a function of dose rate during an arc, 2) over/under dosing due to MLC reversals, and 3) over/under dosing at changing dose rate junctions. Equations for construction of the iComCAT files are given. Results indicate that the beam profile for lower dose rates varies less than 3% from that of the maximum dose rate, with no difference during an arc. The gantry, MLC, and backup jaw maximum speed are internally consistent. The monitor unit chamber is stable over the MUs and gantry movement conditions expected. MLC movement and position during VMAT delivery are within IMRT tolerances. Dose rate, gantry speed, and MLC speed are accurately controlled. Over/under dosing at junctions of MLC reversals or dose rate changes are within clinical acceptability.

In response to the increasing call by professional organizations, journal editors, and statisticians to include not only derived significance levels from quantitative statistical procedures but also measures of effect sizes (ES), this article first provides a rationale for school counseling-related researchers to include these key indices in their studies. We contend that with this information, readers are better able to contextualize and properly interpret research findings and conclusions. Second, the three major ES families and the indices associated with each one are reviewed. Next, the influence of various research designs and differing sample sizes on the size of these effects is discussed, followed by an introduction to ES computation, reporting, and interpretation, particularly as these issues relate to school counseling settings. Practical examples, ES summary tables, and supplementary resources are overviewed as well.

Chlamydia suis has been detected in numerous disease conditions of pigs, particularly in eye infections. This study examined recurring conjunctivitis cases in five commercial pig farms in Japan. 40.5% of the cases were identified as Chlamydia positive using impression cytology of ocular smears and a genus-specific direct fluorescent antibody. C. suis was detected in 59.5% of the samples using PCR tests targeting 16S-23S rRNA intergenic spacer region (ISR) and ompA gene. Genetic analysis of PCR amplicons revealed nine sequence variants of 16S-23S rRNA ISR and 20 sequence variants within ompA gene. Among C. suis-positive conjunctivitis cases, 36.4% showed concurrent infection with 2-4 varied ompA sequence types and 9.1% showed multiple 16S-23S rRNA ISR sequence types of C. suis. Multiple genotypes were found circulating in four of five farms. All 20 detected strains and 25 previously reported C. suis strains were grouped into four clusters. Japanese C. suis strains were closely related to American and European strains indicating wide distribution of these genetically variant strains. This study is the first to show multiple and genetically diverse C. suis strain associations in pig conjunctivitis.

Purpose: Neural mobilization (NM) is often used to treat nerve-related conditions, and its use is reasonable with nerve-related neck and arm pain (NNAP). The aims of this study were to establish the effect of NM on the pain, function, and quality of life (QOL) of patients with NNAP and to establish whether high catastrophizing and neuropathic pain influence treatment outcomes. Method: A randomized controlled trial compared a usual-care (UC; n = 26) group, who received cervical and thoracic mobilization, exercises, and advice, with an intervention (UCNM; n = 60) group, who received the same treatment but with the addition of NM. Soft tissue mobilization along the tract of the nerve was used as the NM technique. The primary outcomes were pain intensity (rated on the Numerical Pain Rating Scale), function (Patient-Specific Functional Scale), and QOL (EuroQol-5D) at 3 weeks, 6 weeks, 6 months, and 12 months. The secondary outcomes were the presence of neuropathic pain (using the Neuropathic Diagnostic Questionnaire) and catastrophizing (Pain Catastrophising Scale). Results: Both groups improved in terms of pain, function, and QOL over the 12-month period ( p &lt; 0.05). No between-groups differences were found at 12 months, but the UCNM group had significantly less pain at 6 months ( p = 0.03). Patients who still presented with neuropathic pain ( p &lt; 0.001) and high pain catastrophizing ( p = 0.02) at 6- and 12-mo follow-ups had more pain. Conclusions: Both groups had similar improvements in function and QOL at 12-month follow-up. The UCNM group had significantly less pain at 6-month follow-up and a lower mean pain rating at 12-month follow-up, although the difference between groups was not significant. Neuropathic pain is common among this population and, where it persisted, patients had more pain and functional limitations at 12-mo follow-up.

A 65-year-old woman presented with intermittent left bundle branch block and angina pectoris. Cardiac catheterization demonstrated bilat eral coronary artery fistulae entering diffusely into the left ventricle with out evidence of major arterial-lumi nar shunt. A surgical procedure to reduce the arterial-to-cameral flow is discussed, and case reports are re viewed and discussed.

Journal of Cataract & Refractive Surgery: January 1993 - Volume 19 - Issue 1 - p 116 doi: 10.1016/S0886-3350(13)80298-2

A new high dose rate (HDR) brachytherapy program was initiated in a community hospital setting, with the goal of using magnetic resonance (MR) images with the implant in place during the planning process. Physics acceptance testing and commissioning was completed for key program components, including multiple applicators. To image new applicators for MRI-based planning prior to use with patients, agar gel doped with copper sulfate was created using simple, MR-safe household materials as a practical and inexpensive alternative to custom-machined precision phantoms. Applicators in-phantom were scanned in a 1.5 T MRI scanner using the same sequences developed for the brachytherapy program, then rigidly registered to high-resolution computed tomography (CT) images to assess distortion, artifact, and geometric displacement. To date, Varian tandem and ring sets, segmented cylinders, cervical probes, endometrial applicators; and third-party plastic needles, tandems, and vaginal guides have been imaged in phantom and are available for use clinically.

Abstract A hands-on learning activity was developed to introduce young learners to concepts and careers in health and medical physics. Inexpensive materials were used to create a work station with learning tools that were designed to be approachable and accessible for this audience. Visitors to a local independent, nonprofit science museum may interact with the activity work station to learn basic information regarding radiation in everyday life and to hear about careers in radiation sciences. Approximately 60 volunteer hours have been contributed associated with the activity. Interested physicists may adapt the lesson plan as a simple and straightforward way to participate in public education efforts in their own communities. A detailed lesson plan, equipment list, and electronic media are available upon request.

INTRODUCTION: Tenapanor is currently seen as a promising treatment for hyperphosphatemia in hemodialysis patients. Although previous meta-analysis has investigated its efficacy and safety, the potential impact of tenapanor remained a topic of further investigation. This meta-analysis aimed to provide an updated and thorough assessment of tenapanor efficacy in reducing serum phosphate levels and its safety in hemodialysis patients, integrating new evidence, and refining the analysis of treatment outcomes. METHODS: In this systematic review and meta-analysis, we searched online databases up to August 2024 for studies evaluating the efficacy and safety of tenapanor in hemodialysis patients. Only short-term randomized controlled trials (4-8 weeks) comparing tenapanor with placebo were included. The primary outcome was the change in serum phosphate levels from baseline. Safety was assessed based on data regarding drug-related adverse effects (AEs), including diarrhea and other gastrointestinal AEs. RESULTS: Among the selected 8 clinical trials with a total of 1,001 patients, tenapanor showed a significant reduction in serum phosphate levels from baseline compared to placebo (mean difference: -1.39 mg/dL; 95% confidence interval [CI]: -1.94, 0.84; p < 0.0001). A greater number of patients in the tenapanor group were able to achieve target serum phosphate levels of ≤5.5 mg/dL (relative risk: 2.80; 95% CI: 1.70, 4.61; p < 0.0001). Drug-related AEs, gastrointestinal AEs, and diarrhea were more severe in the tenapanor group compared to the placebo. CONCLUSION: In summary, the results indicate that tenapanor effectively lowers serum phosphate levels in hemodialysis patients and facilitates achievement of target levels, although drug-related side effects were common. However, these findings are based exclusively on short-term trials (4-8 weeks). Further long-term studies are needed to confirm the sustained efficacy and safety of tenapanor.

Northwest Medical Physics Center (NMPC) is a nonprofit organization that provides clinical physics support to over 35 radiation therapy facilities concentrated in the Pacific Northwest. Although clinical service is the primary function of NMPC, the diverse array of clinical sites and physics expertise has allowed for the establishment of structured education and research programs, which are complementary to the organization's clinical mission. Three clinical training programs have been developed at NMPC: a therapy medical physics residency program accredited by the Commission on Accreditation of Medical Physics Education Programs (CAMPEP), an Applied Physics Technologist (APT) program, and a summer undergraduate internship program. A partnership has also been established with a major radiation oncology clinical vendor for the purposes of validating and testing new clinical devices across multiple facilities. These programs are managed by a dedicated education and research team at NMPC, made up of four qualified medical physicists (QMPs). The education and research work has made a significant contribution to the organization's clinical mission, and it has provided new training opportunities for early-career physicists across many different clinical environments. Education and research can be incorporated into nonacademic clinical environments, improving the quality of patient care, and increasing the number and type of training opportunities available for medical physicists.