Simple Changes Research Articles

Tuning the DNA binding properties of phenolic hemicyanine dyes for host-guest fluorescent aptasensor applications

Fluorescent dyes that bind specifically to DNA aptamers with turn-on emission serve as powerful tools for biosensor development. DNA three-way junctions (3WJs) consisting of a Y-shaped hydrophobic branch point connecting three double-stranded stems serve as recognition elements for DNA aptasensors for a wide variety of diagnostic applications. Herein, we highlight the tunability of phenolic hemicyanine dyes for host-guest fluorescent aptasensor applications using the cocaine-binding aptamer (MN4) as a representative 3WJ-aptamer substrate. The DNA aptamer MN4 exhibits ligand binding promiscuity and binds the alkaloid quinine with ∼26-fold greater affinity than its intended cocaine target. Combining the cationic N-methylbenzothiazolium (Btz) acceptor with a 2-fluoro-phenolic (FPhO) donor through a vinyl-linkage creates the FPhOBtz hemicyanine as a universal fluorescent turn-on probe for DNA 3WJs. The FPhOBtz dye binds MN4 with higher affinity than cocaine, but with weaker affinity than quinine. Consequently, FPhOBtz displacement from the 3WJ with turn-off fluorescence is effectively mediated by quinine, but not cocaine, resulting in poor detection of cocaine by the dye-displacement assay. Our current results demonstrate superior cocaine detection by replacing the planar cationic Btz group with the non-planar indolenium (Ind) acceptor to afford FPhOInd as the signaling fluorescent probe. This simple change in dye structure strongly diminishes MN4 binding affinity (19-fold) with cocaine now possessing stronger affinity for the 3WJ of MN4 compared to FPhOInd. Consequently, FPhOInd displacement from MN4 is effectively mediated by cocaine to provide a 13-fold improvement in cocaine detection in undiluted urine using the host-guest biosensing platform.

How to introduce interprofessional education (IPE) to cardiac arrest simulations for final year undergraduate medical and nursing students

Healthcare professionals work in a diverse community of different specialities and skills. However, most healthcare professional courses are insular and isolating in their training methods. This results in highly trained individuals, who are unfamiliar with the true multidisciplinary team (MDT) approach in health services [1], leaving them unprepared for working in the NHS. One specific area where teamwork, good communication and appreciation of others’ skills sets are crucial is during medical emergencies and cardiac arrests, where multiple professions (including: Doctors, Nurses, Resuscitation officers, Operating Department Practitioners) work together to achieve the best outcome patients. We aimed to introduce Interprofessional Education (IPE) to cardiac arrest simulations for final year undergraduate medical and nursing students to improve their understanding of working as part of a MDT, to enhance their confidence in dealing with cardiac arrests and prepare them for work in the NHS. Reviewing the literature, there are several key components required to successfully instil IPE including: commitment to IPE, expert facilitation, understanding of roles in different professions, and positive role modelling [2]. When designing the course, we obtained each profession’s learning outcomes for cardiac arrest and planned them into the course; paying particular attention to equal weighting of learning outcomes for both professions and mutual learning outcomes. Furthermore, we identified key skills which we wanted students to demonstrate and designed simulations to incorporate these. For example, nursing students using the defibrillator in manual mode independently and medical students to independently use the defibrillator in automatic mode. To add value to the course we wanted high quality role modelling and profession specific feedback. To do this, we ensured both qualified nurses and doctors with experience in delivering feedback and real-life cardiac arrest cases were present for all sessions. Feedback collated from students and faculty positively supported the introduction of IPE in cardiac arrest simulation, with students specifically commenting on the benefits of teamwork, understanding each other’s competencies, and benefits of workings as an MDT. Due to these simple changes and keeping IPE at the centre of our design and implementation of the cardiac arrest simulation course, we were able to successfully introduce IPE to final year undergraduate medical and nursing students. 1. Choudhury RI, Mathur J, Choudhury SR. How interprofessional education could benefit the future of healthcare–medical students’ perspective. BMC Medical Education. 2020;20(1):1–4. 2. Buring SM, Bhushan A, Broeseker A, Conway S, Duncan-Hewitt W, Hansen L, Westberg S. Interprofessional education: definitions, student competencies, and guidelines for implementation. American journal of pharmaceutical education. 2009;73(4).

중학생의 학교폭력 피해경험과 가해경험 간 관계

Objectives This study selects the school violence victim experience, the perpetrator experience, and the perception of the school climate as major factors, and examines the longitudinal path from the middle school student's school violence victim experience to the perpetrator experience. Most of the studies so far have focused on cross-sectional studies, an aspect of simple change in the relationship between the victim experience and the perpetrator experience and the focus on personal factors. However, not only personal factors but also environmental factors are considered to be important factors in the experience of school violence victimization and the perpetrator experience. Therefore, in this study, the purpose of study was to examine the effect of school factors, in which students spend a relatively large amount of time, on school violence. To this end, we intend to verify the mediating effect of the school violence victimization experience leading to the school violence perpetrator experience through the perception of school climate through longitudinal study data. Methods For this purpose, data from 2013(middle school 1) to 2015(middle school 3) among panel 1 data of the Seoul Education Longitudinal Study 2010 were used. The total number of subjects was 2,411, and the data were analyzed using the autoregressive cross-delay model. Results The victimization experiences and perpetrating experiences of school violence at the previous point affects the victimization experiences and perpetrating experiences of school violence at the next point in time, respectively, and that the previous perception of school climate also affects the perception of next time. In addition, the victimization experience of school violence at the previous point (middle 1) affects the perception of the school climate at the next point (middle 2), and the perception of the school climate at the previous point (middle 2) affects the perpetrating experience of school violence at the next point (middle 3). In other words, the study confirmed that the perception of the school climate had a longitudinal mediating effect in the relationship between the victimization experience and the perpetrating experience. Conclusions These imply that the victimization experience of school violence at the previous point can lead to the perpetrating experience of school violence next time. Also, if a student perceives the school climate negatively in this path, the perpetrating experience of school violence in the future may increase.

Membrane Fusion Mediated by Non-covalent Binding of Re-engineered Cholera Toxin Assemblies to Glycolipids.

Membrane fusion is essential for the transport of macromolecules and viruses across membranes. While glycan-binding proteins (lectins) often initiate cellular adhesion, subsequent fusion events require additional protein machinery. No mechanism for membrane fusion arising from simply a protein binding to membrane glycolipids has been described thus far. Herein, we report that a biotinylated protein derived from cholera toxin becomes a fusogenic lectin upon cross-linking with streptavidin. This novel reengineered protein brings about hemifusion and fusion of vesicles as demonstrated by mixing of fluorescently labeled lipids between vesicles as well as content mixing of liposomes filled with fluorescently labeled dextran. Exclusion of the complex at vesicle-vesicle interfaces could also be observed, indicating the formation of hemifusion diaphragms. Discovery of this fusogenic lectin complex demonstrates that new emergent properties can arise from simple changes in protein architecture and provides insights into new mechanisms of lipid-driven fusion.

Electrocatalytic Energy Release of Norbornadiene-Based Molecular Solar Thermal Systems: Tuning the Electrochemical Stability by Molecular Design.

Molecular solar thermal (MOST) systems, such as the norbornadiene/quadricyclane (NBD/QC) couple, combine solar energy conversion, storage, and release in a simple one-photon one-molecule process. Triggering the energy release electrochemically enables high control of the process, high selectivity, and reversibility. In this work, the influence of the molecular design of the MOST couple on the electrochemically triggered back-conversion reaction was addressed for the first time. The MOST systems phenyl-ethyl ester-NBD/QC (NBD1/QC1) and p-methoxyphenyl-ethyl ester-NBD/QC (NBD2/QC2) were investigated by in-situ photoelectrochemical infrared spectroscopy, voltammetry, and density functional theory modelling. For QC1, partial decomposition (40 %) was observed upon back-conversion and along with a voltammetric peak at 0.6 Vfc , which was assigned primarily to decomposition. The back-conversion of QC2, however, occurred without detectable side products, and the corresponding peak at 0.45 Vfc was weaker by a factor of 10. It was concluded that the electrochemical stability of a NBD/QC couple is easy tunable by simple structural changes. Furthermore, the charge input and, therefore, the current for the electrochemically triggered energy release is very low, which ensures a high overall efficiency of the MOST system.

High-Temperature Fire Resistance and Self-Extinguishing Behavior of Cellular Graphene.

The ability to protect materials from fire is vital to many industrial applications and life safety systems. Although various chemical treatments and protective coatings have proven effective as flame retardants, they provide only temporary prevention, as they do not change the inherent flammability of a given material. In this study, we demonstrate that a simple change of the microstructure can significantly boost the fire resistance of an atomically thin material well above its oxidation stability temperature. We show that free-standing graphene layers arranged in a three-dimensional (3D) cellular network exhibit completely different flammability and combustion rates from a graphene layer placed on a substrate. Covalently cross-linked cellular graphene aerogels can resist flames in air up to 1500 °C for a minute without degrading their structure or properties. In contrast, graphene on a substrate ignites immediately above 550 °C and burns down in a few seconds. Raman spectroscopy, X-ray photoelectron spectroscopy, and thermogravimetric studies reveal that the exceptional fire-retardant and self-extinguishing properties of cellular graphene originate from the ability to prevent carbonyl defect formation and capture nonflammable carbon dioxide gas in the pores. Our findings provide important information for understanding graphene's fire-retardant mechanism in 3D structures/assemblies, which can be used to enhance flame resistance of carbon-based materials, prevent fires, and limit fire damage.

A basic study for the molecular imaging of dual-energy CT in diagnosing anterior cruciate ligament injury of knee joint.

Anterior cruciate ligament (ACL) injury is a common disease in clinical practice that seriously affects the daily life of patients. To explore the molecular imaging basis of "diminution sign on dual-energy colour mapping" for the diagnosis of ACL injury by dual-energy computed tomography (DECT). The hydroxylysine and hydroxyproline reagents were prepared in different concentrations. The grouping was shown as follows: a simple concentration change group of an amino acid (group 1/2); a mixed solution group with the concentration increasing synchronously (group 3); a mixed solution group with the concentration reverse increasing and decreasing (group 4); and a mixed solution group that fix one amino acid with increasing concentration of the other (group 5/6). The samples were scanned by DECT. The solution CT value and image signal-to-noise ratio were analyzed. In group 1/2, the brightness of the dual-energy color mapping of each test tube solution and the CT value increased with increasing the concentration of amino acid. In group 6, there was no significant change in the brightness and brilliance of the dual-energy color mapping and the CT value. The remaining three groups showed an increase in the brightness and brilliance of the dual-energy color mapping and the CT value, and this increase was positively associated with the hydroxylysine concentration. The dual-energy staining of the DECT imaging in "tendon" mode is related to hydroxylysine and hydroxyproline. Moreover, the degree of dual-energy color mapping is positively correlated with the change of CT value.

Revisiting the Rainbow: Culturally Responsive Updates to a Standard Clinical Resource.

Cultural responsivity is essential for efficacious and affirming clinical relationships. This may be especially important with historically marginalized clients, such as transgender and gender-diverse (TGD) people seeking behaviorally based affirming communication services. We recommend modifications to standard tools for diagnostics and training that otherwise might undermine our efforts to create an inclusive and affirming environment. Modifications to the Rainbow Passage, a standardized paragraph utilized for eliciting speech samples in clinical settings, focused on nongendered terminology and the elimination of content with religious connotations. The recommended edits to the Rainbow Passage maintain similar length, cadence, and phonetic balance while considering cultural and health care context for TGD people and other clients. Simple linguistic changes to a standardized paragraph maintain clinical benefits and facilitate SLP efforts toward cultural responsivity, client engagement, and good clinical outcomes.

Silver Dependent Enantiodivergent Gold(I) Catalysed Asymmetric Intramolecular Hydroamination of Alkenes: A Theoretical Study

We report a theoretical study of the first silver-dependent enantiodivergent gold-catalysed reaction. The combination of a single chiral binuclear gold(I) chloride complex and silver perchlorate catalyses the asymmetric intramolecular hydroamination of alkenes and affords both enantiomers of the products by applying a simple solvent change from toluene to methanol. A gold-silver chloride adduct that occurs only in methanol appears to control the enantioinversion. If one gold atom coordinates and activates the alkene moiety, the other gold is included in an adduct with silver chloride, which coordinates a methanol solvent molecule and further interacts with the amine function. If the use of toluene implies free anions and affords (S)-enantiomer, methanol allows a proximal interaction with the amine, leads to an opposite stereodifferentiation of the two diastereomeric intermediates during the final protodeauration step and results in the (R)-enantiomer.

PSUN190 Is Euglycemic Diabetic Ketoacidosis an Underrecognized Risk of SGLT2 Inhibitor Utilization?

Abstract Introduction Sodium-glucose cotransporter-2 (SGLT2) inhibitors were first approved by the FDA in March of 2013 as a promising new medication in the treatment of Type II diabetes mellitus. The mechanism of action of the Sodium-glucose cotransporter-2 is in the convoluted tubule of the nephron and where it inhibits the reabsorption of glucose into the bloodstream. The utilization has increased with promising improvements in congestive heart failure and renal protection. However, as the use of these medications has risen, so have the concerns over their side effects, specifically the frequency of euglycemic diabetic ketoacidosis (euDKA). Initial trials reported an incidence of DKA among patients taking an SGLT2 inhibitor to be between 0.003% and 0.34%. Hypothesis As a quality initiative, we reviewed internal data at a large hospital system to evaluate the rate of euDKA. We hypothesized that the rate of euDKA from SGLT2 was higher than reported. Methods To test this hypothesis, a 5 year retrospective internal quality review was conducted to quantify the number of patients admitted to our institution with DKA while on an SGLT2 inhibitor medication. We used the Epic Database from 4 hospitals in our system and applied the application "Slicer Dicer". We used keywords for diabetic ketoacidosis. We then reviewed the medication lists prior to admission and upon admission for the 4 commercially available SGLT2 agents: empagliflozin, canagliflozin, dapagliflozin. Results 1748 patients were identified with DKA from 2018-2021 were reviewed. Of this population, 164 of them were on SGLT2 medications. The data identified 9.4% of total patients admitted for DKA in our hospital system were taking SGLT2 medications on presentation. Out of this population: 41.5% were on empagliflozin, 27.4% were on canagliflozin, 29.3% were on dapagliflozin, and 1.8% were on ertugliflozin. Out of these same patients, 51.8% were taking a high dosage of SGLT2i medication, whereas 48.2% were taking a low dosage. Conclusion/Discussion This data supports the hypothesis that the incidence of SGLT2 induced euDKA is underreported. There was no correlation between DKA and the use of high versus low dosage of SGLT2i medications. Since DKA is a problem related to dehydration, future educational initiatives should emphasize the importance of educating providers on when to hold medications to prevent DKA. This should include how to plan for sick days and educating patients on the risks presented by their medication. We recommend that ICD codes are updated to include euglycemic DKA and side effects of SGLT2. We believe that these simple changes can reduce the incidence of euDKA in the diabetic population as the indications for therapy expand in vulnerable populations. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Carbohydrate metabolism and lipid profile in patients with Parkinson's disease with subthalamic deep brain stimulation.

Assessment of potential effect of subthalamic nucleus deep brain stimulation (STN-DBS) on glucose metabolism in patients with Parkinson's disease (PD). Although a valuable alternative to pharmacotherapy in advanced PD, STN-DBS is thought to negatively affect the cardiometabolic profile of patients (including body mass, lipid profile). Exacerbation of glucose metabolism dysregulation after DBS could therefore be assumed. Two groups of patients with Parkinson's disease were included: 20 treated pharmacologically (PHT) and 20 newly qualified for STN-DBS (DBS) - with the first assessment prior to surgery, and the second 11 months after surgery on average. Body mass index (BMI), plasma concentrations of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and glucose levels during a three-point oral glucose tolerance test were measured three times (median intervals between visits 12 and 14 months respectively). Significant differences between the two groups were noted with respect to changes in BMI, and serum concentration of TG and HDL-C over the course of the study. In the DBS group, a significant increase in BMI (26.42 vs. 27.24 kg/m2, p = 0.03) and TG level (103.8 vs. 142.8 mg/dL, p < 0.001) with a simultaneous decrease in HDL-C level (54.4 vs. 46 mg/dL, p < 0.01) was observed. Mean glucose level after oral glucose administration was lower in the DBS than in the PHT group (147.4 vs. 120.2 mg/dL, p = 0.03 after one hour and 109.9 vs. 82.3 mg/dL, p < 0.01 after two hours) during the second visit. Also inter-visit changes in fasting glucose levels (8.4 mg/dL in the PHT group and -5.8 mg/dL in the DBS group, p = 0.02) differed over the study duration. Our observations are similar to previous ones indicating less favourable changes in BMI and some lipid fractions in patients treated surgically. Interestingly, such a trend was not observed for glucose metabolism parameters, suggesting that mechanisms other than simple body mass changes are involved in early biochemical changes after STN-DBS in PD patients. The metabolic consequences of DBS require further investigation as an additional factor potentially affecting the outcome of therapy, and routine patient follow-up should not be limited to neurological and psychological assessments.

Auto-detection of necessity for MRI-guided online adaptive replanning using a machine learning classifier.

MRI-guided adaptive radiation therapy (MRgART), particularly daily online adaptive replanning (OLAR) can substantially improve radiation therapy delivery, however, it can be labor-intensive and time-consuming. Currently, the decision to perform OLAR for a treatment fraction is determined subjectively. In this work, we develop a machine learning algorithm based on structural similarity index measure (SSIM) and change in entropy to quickly and objectively determine whether OLAR is necessary for a daily MRI set. A total of 109 daily MRI sets acquired on a 1.5T MR-Linac during MRgART for 22 pancreatic cancer patients each treated with five fractions were retrospectively analyzed. For each daily MRI set, OLAR and reposition (No-OLAR) plans were created and the superior plan with the daily fraction determined per clinical dose-volume criteria. SSIM and entropy maps were extracted from each daily MRI set, with respect to its reference (e.g., dry-run) MRI in the region enclosed by 50-100% isodose surfaces. A total of six common features were extracted from SSIM maps. Pearson's rank correlation coefficient was utilized to rule out redundant SSIM features. A t-test was used to determine significant SSIM features which were combined with the change in entropy to develop anensemble machine classifier with fivefold cross validation. The performance of the classifier was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve. A machine learning classifier model using two SSIM features (mean and full width at half maximum) and change in entropy was determined to be able to significantly discriminate between No-OLAR and OLAR groups. The obtained machine learning ensemble classifier can predict OLAR necessity with a cross validated AUC of 0.93. Misclassification was found primarily for No-OLAR cases with dosimetric plan quality closely comparable to the corresponding OLAR plans, thus, are not a major practical concern. A machine learning classifier based on simple first-order image features, that is, SSIM features and change in entropy, was developed to determine when OLAR is necessary for a daily MRI set with practical acceptable prediction accuracy. This classifier may be implemented in the MRgART process to automatically and objectively determine if OLAR is required following daily MRI.

Modeling Infectious Diseases via Integral Delay Equations

Integral delay equations (IDE) have several applications, they can be found in mathematical models of population and propagation of infectious diseases. Many of these models are sets of non-linear integral delay equations similar to the classical SEIR models, but with the advantage of simplifying the number of equations with a simple change of variable. An alternative equation is the well known renewal equation which can model both demographics and infectious diseases, we focus on the disease model and establish the equivalence between the versions with a single finite delay and the one with multiple delays, both obtained from a histogram of relative frequencies of tracking data of the infected people. We compare their Lyapunov matrices and the stability analysis when the reproductive number is in matrix form.

Application of Electrochemically Reduced Water for New No-Rinse Shampoo: Design and Optimization Using Response Surface Methodology

Coronavirus disease (COVID-19) cases are continuing to rise around the world, with more than 607 million confirmed cases and more than 6.51 million deaths as of September 2022. The World Health Organization (WHO) has emphasized the importance of hygiene in the ongoing COVID-19 pandemic, especially in elderly and bedridden patients. The use of no-rinse shampoo represents a simple change in hair-cleansing products. Daily hospital hair washing for the elderly, bedridden, and ICU patients would be more readily adopted. The objective of this study was to design and optimize a new no-rinse shampoo based on electrochemically reduced water (ERW) using response surface methodology. The relationship between coconut-based surfactant mixtures in a no-rinse shampoo and the resulting physicochemical properties, effectiveness (antibacterial and antifungal activity), and stability of the shampoo was investigated. The vesicle size, size distribution, zeta potential, conductivity, pH, foamability, wetting time, turbidity, and stability of the model formulation were optimized. The optimal formulation with the appropriate physicochemical properties and stability was selected. The effectiveness of the optimal formulation was compared to that of commercially available products. The dry shampoo (DS4) containing 3.5% of the mixed detergent with ERW may prevent infection by Escherichia coli, Staphylococcus epidermidis, Staphylococcus aureus, and Candida albicans. The no-rinse shampoo based on ERW successfully demonstrated good stability in addition to efficacy in terms of antibacterial and antifungal activity. The treated hair fiber was not significantly different from that of the intact hair fiber. Under the scanning electron microscopy (SEM) and the atomic force microscopy (AFM), the cuticle layer of the treated hair fiber was not damaged. Thus, no-rinse shampoos may reduce the time of hair rinsing and improve the quality of life of caregivers.

Therapeutic Application of an Ag-Nanoparticle-PNIPAAm-Modified Eggshell Membrane Construct for Dermal Regeneration and Reconstruction.

Current therapeutic treatments for the repair and/or replacement of damaged skin following disease or traumatic injury is severely limited. The chicken eggshell membrane (ESM) is a unique material: its innate physical and mechanical characteristics offer optimal barrier properties and, as a naturally derived extract, it demonstrates inherent biocompatibility/biodegradability. To further enhance its therapeutic and clinical potential, the ESM can be modified with the thermo-responsive polymer, poly(N-isopropylacrylAmide) (PNIPAAm) as well as the incorporation of (drug-loaded) silver nanoparticles (AgNP); essentially, by a simple change in temperature, the release and delivery of the NP can be targeted and controlled. In this study, ESM samples were isolated using a decellularization protocol, and the physical and mechanical characteristics were profiled using SEM, FT-IR, DSC and DMA. PNIPAAm was successfully grafted to the ESM via amidation reactions and confirmed using FT-IR, which demonstrated the distinctive peaks associated with Amide A (3275 cm−1), Amide B (2970 cm−1), Amide I (1630 cm−1), Amide II (1535 cm−1), CH2, CH3 groups, and Amide III (1250 cm−1) peaks. Confirmation of the incorporation of AgNP onto the stratified membrane was confirmed visually with SEM, qualitatively using FT-IR and also via changes in absorbance at 380 nm using UV-Vis spectrophotometry during a controlled release study for 72 h. The biocompatibility and cytotoxicity of the novel constructs were assessed using human dermal fibroblast (HDFa) and mouse dermal fibroblast (L929) cells and standard cell culture assays. Metabolic activity assessment (i.e., MTS assay), LDH-release profiles and Live/Dead staining demonstrated good attachment and spreading to the samples, and high cell viability following 3 days of culture. Interestingly, longer-term viability (>5 days), the ESM-PNIPAAm and ESM-PNIPAAm (AgNP) samples showed a greater and sustained cell viability profile. In summary, the modified and enhanced ESM constructs were successfully prepared and characterized in terms of their physical and mechanical profiles. AgNP were successfully loaded into the construct and demonstrated a desirable release profile dependent on temperature modulation. Fibroblasts cultured on the extracted ESM samples and ESM-PNIPAAm demonstrated high biocompatibility in terms of high cell attachment, spreading, viability and proliferation rates. As such, this work summarizes the development of an enhanced ESM-based construct which may be exploited as a clinical/therapeutic wound dressing as well as a possible application as a novel biomaterial scaffold for drug development.

S1496 Addressing over Prescription of PPI in an Outpatient Underserved Population

Introduction: Long term use of PPIs has been associated with increased risk of mineral and vitamin deficiencies and in some studies with C. Difficile Colitis. It is estimated that 25%-70% of PPI prescriptions are without an appropriate indication. The aim of this study was to discontinue at least 10% of the patients on PPIs who do not have an appropriate indication for therapy over the course of a 6-week period. Methods: This study took place at a medically underserved resident clinic in Hartford Connecticut. Patients scheduled between 09/16/21 and 10/01/21 were pre-screened using EMR review. Any patient with a PPI on their medication list was included in the data set. Patients were stratified based on clinical need for PPI and potential for tapering using ACG Clinical Guidelines. Providers were educated on the clinical guidelines for PPI therapy. Patients on standard dosing were reduced to 50% dosing for 2 weeks and then discontinued. Patients were provided with as needed H2 Blocker for possible rebound symptoms. A total of 114 patients on PPI with appointments during the time window were identified. On the date of their visit, providers assessed individual patient PPI usage and discontinuation eligibility. Patients eligible for discontinuation of PPI were advised to dose reduce by 50% for 2 weeks and prescribed as needed H2 blocker. Providers also provided education on how to take PPI appropriately. Patients were called 2 weeks later for follow up. At that time if symptoms tolerated, PPI was discontinued. Results: Of the total population, 28% (32/114) were on long term PPI appropriately. Seventy-two percent (82/114) of the patients prescribed PPI lacked a true medical indication. Of these, 44 patients were seen and provided a taper plan. PPI was discontinued successfully in 22% (18/82) of the population of inappropriately prescribed PPI within the 6-week window. Conclusion: The aim of this study to achieve 10% population reduction in inappropriate PPI use was exceeded with roughly 22% discontinuation. Frequent medication reconciliation, patient education on proper PPI use and physician education with ACG Clinical Guidelines were simple changes to successfully improve clinically indicated PPI therapy. Many patients are aware of their triggers and use PPIs as a means of avoiding lifestyle and dietary change. When prescribing PPI, placing a “stop” time on the prescription may further reduce PPI burden.

Reliably mapping low-intensity forest disturbance using satellite radar data

In the last decades tropical forests have experienced increased fragmentation due to a global growing demand for agricultural and forest commodities. Satellite remote sensing offers a valuable tool for monitoring forest loss, thanks to the global coverage and the temporal consistency of the acquisitions. In tropical regions, C-band Synthetic Aperture Radar (SAR) data from the Sentinel-1 mission provides cloud-free and open imagery on a 6- or 12-day repeat cycle, offering the unique opportunity to monitor forest disturbances in a timely and continuous manner. Despite recent advances, mapping subtle forest losses, such as those due to small-scale and irregular selective logging, remains problematic. A Cumulative Sum (CuSum) approach has been recently proposed for forest monitoring applications, with preliminary studies showing promising results. Unfortunately, the lack of accurate in-situ measurements of tropical forest loss has prevented a full validation of this approach, especially in the case of low-intensity logging. In this study, we used high-quality field measurements from the tropical Forest Degradation Experiment (FODEX), combining unoccupied aerial vehicle (UAV) LiDAR, Terrestrial Laser Scanning (TLS), and field-inventoried data of forest structural change collected in two logging concessions in Gabon and Peru. The CuSum algorithm was applied to VV-polarized Sentinel-1 ground range detected (GRD) time series to monitor a range of canopy loss events, from individual tree extraction to forest clear cuts. We developed a single change metric using the maximum of the CuSum distribution, retrieving location, time, and magnitude of the disturbance events. A comparison of the CuSum algorithm with the LiDAR reference map resulted in a 78% success rate for the test site in Gabon and 65% success rate for the test site in Peru, for disturbances as small as 0.01 ha in size and for canopy height losses as fine as 10 m. A correlation between the change metric and above ground biomass (AGB) change was found with R2 = 0.95, and R2 = 0.83 for canopy height loss. From the regression model we directly estimated local AGB loss maps for the year 2020, at 1 ha scale and in percentages of AGB loss. Comparison with the Global Forest Watch (GFW) Tree Cover Loss (TCL) product showed a 61% overlap between the two maps when considering only deforested pixels, with 504 ha of deforestation detected by CuSum vs. 348 ha detected by GFW. Low intensity disturbances captured by the CuSum method were largely undetected by GFW and by the SAR-based Radar for Detecting Deforestation (RADD) Alert System. The results of this study confirm this approach as a simple and reproducible change detection method for monitoring and quantifying fine-scale to high intensity forest disturbances, even in the case of multi-storied and high biomass forests.

Sluggish downloads, lagging video calls: Tips for the remote worker to tame technology

What are the various broadband options to consider when working from home and how can you ensure you’re getting the best from yours? Broadband failures can mean a headache for your clients and you risk looking unprofessional, so having a backup system is vital to continue providing the high-quality service your clients deserve. This article covers what you need to know about IT to either run a successful business from home or work remotely for someone else. If you’ve ever wondered why your system seems to run faster on some days than others, some simple checks and changes to your broadband service will allow you to cope with anything the IT gremlins throw at you.

Rational Origins of Revisionist War

Abstract The rise of China has returned attention to the links between power transitions and war. In this literature, three different causal mechanisms can be confused. This essay disentangles them. Power transitions can lead to three kinds of war: preventive, accidental, and revisionist. Formal models tend to study the first, in which a declining state tries to delay or prevent a rival’s ascent. However, major wars during great power transitions are usually initiated by the rising state, not the declining one. To describe these historical cases, less formal theories, especially neorealism and neoclassical realism, focus on accidental and revisionist wars, but these theories tend to fall back on nonrational mechanisms to connect changing power to the risk of conflict. This leaves a theoretical gap: Why would a rising, rational actor deliberately choose conflict, i.e., start a revisionist war? To suggest an answer, this essay demonstrates how a simple change in standard bargaining models—incorporating a nonzero probability of indecisive war—can ground realist intuitions on rationalist foundations. It further shows how this change leads immediately to an intuitive, formal definition of stability that aligns naturally with existing informal work. Then, contrary to existing realist theory, it shows why the rigorous analysis of realist assumptions leads to a nonmonotonic relationship between the offense/defense balance and war. It thus uses realism to inform and potentially redirect formal scholarship; it also uses formal scholarship to sharpen the logical foundations of realism and, in so doing, derive novel empirical predictions. The essay concludes by applying this synthesis to the rise of China today and indicating directions for deepening the formal/realist synthesis.

Tunable Planar Josephson Junctions Driven by Time-Dependent Spin-Orbit Coupling

Integrating conventional superconductors with common III-V semiconductors provides a versatile platform to implement tunable Josephson junctions (JJs) and their applications. We propose that with gate-controlled time-dependent spin-orbit coupling, it is possible to strongly modify the current-phase relations and Josephson energy and provide a mechanism to drive the JJ dynamics, even in the absence of any bias current. We show that the transition between stable phases is realized with a simple linear change in the strength of the spin-orbit coupling, while the transition rate can exceed the gate-induced electric field GHz changes by an order of magnitude. The resulting interplay between the constant effective magnetic field and changing spin-orbit coupling has direct implications for superconducting spintronics, controlling Majorana bound states, and emerging qubits. We argue that topological superconductivity, sought for fault-tolerant quantum computing, offers simpler applications in superconducting electronics and spintronics.