Duluth Clinic

This chapter focuses on designing and building scalable and resilient architectures on Google Cloud Platform (GCP). The chapter begins by introducing the principles of scalable and resilient design, including fault tolerance, elasticity, and scalability. You will learn about the key components of scalable and resilient architectures on GCP, including load balancing, autoscaling, and distributed databases. The chapter also covers best practices for building scalable and resilient architectures on GCP, including using managed services, designing for failure, and monitoring and alerting. Overall, this chapter provides a comprehensive guide to building scalable and resilient architectures on GCP, with practical examples and real-world use cases.

In this chapter, you will learn about Google App Engine (GAE), a fully managed platform for developing and deploying web applications and services. GAE allows developers to focus on writing code without worrying about the underlying infrastructure and about scaling the application as traffic increases. The chapter covers the key features of GAE, including the programming languages and frameworks supported, storage options, and deployment methods. You will also learn about scaling and optimizing GAE applications to handle changes in traffic and improve performance. Finally, the chapter covers security considerations and best practices for deploying and managing GAE applications. By the end of this chapter, you will have a comprehensive understanding of Google App Engine and how to use it to develop and deploy web applications.

Recent studies have compared brain function in individuals with video gaming disorder as compared to healthy controls. This chapter reviews preliminary findings in reward circuitry, emotional memory and cognitive function. Also discussed are the criteria constituting an addictive disorder, as described by the American Psychiatric Association. Finally, future directions of possible scholarship in these areas are addressed.

Introduction: With more widespread anticoagulant use, anticoagulation-associated intracerebral hemorrhage (ICH) represents an increasing proportion of all ICH. We hypothesized that c ombining ischemic and hemorrhagic stroke risk estimation can guide treatment decisions, with more precision than ischemic risk estimation alone. Methods: We enrolled consecutive patients with anticoagulation-associated ICH in 15 centers in USA, Europe and Asia from 2015-2017. Each patient was assigned annual baseline ischemic stroke and hemorrhage risk based on their CHA 2 DS 2 -VASc and HAS-BLED scores without and with index ICH taken into account. We computed a net risk by subtracting the hemorrhagic from the ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative an “Unfavorable”. We compared clinical and neuroimaging characteristics between the two groups. Results: Our cohort comprised 357 patients (59% male, median age 76 [68-82] years). 69% used vitamin-K antagonists (VKA), 31 % Non vitamin K antagonist (NOAC). 191 (53.5%) of patients had a favorable indication for anticoagulation prior to their ICH event; the rest 166 (46.5%) had an unfavorable indication. Those with an unfavorable indication were younger (72[66-80] vs 78[73-84] years, p=0.001, had a lower CHA 2 DS 2 -VASc score (3[3-4] vs 5[4-6], p<0.001) and higher HAS-BLED score (3[2-4] vs 2[2-3], p=0.025). Those with favorable indication had a significantly higher prevalence of all major cardiovascular risk factors and were more likely to use NOAC (35% vs 25%, p=0.045). After including ICH into the HAS-BLED score estimation, 77 of the 191 patients with favorable profile were rendered unfavorable; leaving 114 patients (32% of the cohort) with favorable profile. Conclusions: In this anticoagulation-associated ICH cohort, baseline hemorrhage risk exceeded ischemic risk in ~50% of patients. This finding highlights the need for careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining ~ 50% suffered an ICH although their baseline risk of ischemia exceeded that of hemorrhage which stresses the need for imaging, serum or other biomarkers to allow more precise estimation of hemorrhagic complication risk.

Subjectivity is a slippery entity for psychology for which a conceptual framework is, subsequently, undeveloped. Subjectivity processes include evolving experience episodes and its unifying thinking core. The inquiry presented in this study targeted the structure of experience, its relation to an I, its relation to thinking, and its intersubjective nature. A proposed outline of the processes of subjectivity presented are derived from William James, Hector Neri Castaneda, and Lynne Rudder Baker. The resulting subjectivity structure is empirically developed from linguistic indexical references which are used to map processes with which a person receives experience and intersubjectively shares it. Experience and thinking are shown to be entwined in a stream of experience by an internal reflexivity of first-person perspective which constitutes a person and a corresponding system of I-strands. Experience is tied to a doxastic matrix, mind in an other vocabulary, in a relation that integrates an experience-thinking episode to the accretions of past experiences and beliefs which prepares continuing thinking and action. It is proposed that a noumenal I outside the world constructs the world from internal experience to counter Cartesian radical doubt which makes the sensory world uncertain and in which only one’s experience is reliably one’s own.

A pediatrician’s approach to newborn screening (NBS) impacts patient care. Some physicians have reported not being well prepared to inform families about a positive NBS and recommend further follow-up. The knowledge and approach of categorical pediatric residents (RES) in the United States regarding NBS is not known. They were anonymously surveyed via listserv maintained by American Academy of Pediatrics. A total of 655 responses were analyzed. The mean composite knowledge score (CKS) was 17.7 (SD 1.8), out of maximum 21. Training level (p = 0.001) and completing NICU rotation (p < 0.001) predicted higher CKS. Most RES agreed that NBS is useful and pediatricians play an important role in the NBS process, however, only 62% were comfortable with counseling. Higher level RES were more likely to follow NBS results in clinic (p = 0.0027) and know the contact agency for results (p < 0.001). Most RES wanted more NBS training during residency and were not aware of clinical algorithms like ACTion sheets developed by American College of Medical Genetics. We concluded that although RES have sufficient knowledge about NBS, there is a need for earlier RES education on available tools for NBS to enhance their comfort level and improve practices such as educating parents about the NBS process.

Study Design:Systematic literature review.Objectives:The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis.Methods:A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed.Results:Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference −0.61, CI −0.90 to −0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P < .001), but was subject to heterogeneity among studies (I2 = 56%, P = .13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients.Conclusion:Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.

Adolescent and young adult (AYA) survivors of cancer and central nervous system (CNS) tumors endure major life disruptions with their diagnosis, treatment, and the burden of emerging learning difficulties. Survivors and their parents often struggle to obtain more academic support as survivors transition through school. This study explored the knowledge and experience survivors and their parents need as they progress through school to college. This cross-sectional study examined childhood cancer and CNS tumor survivors, aged 11 to 21 years, with a known learning difficulty (Individual Education Plan, 504 Plan) and their parents. We assessed participants' knowledge of and experience with transition planning for postsecondary education and independent living. Ninety-two AYA survivors and parents (45 survivors, 47 parents) completed the survey. High school-aged survivors described their learning difficulties better than middle school-aged survivors. Survivors estimated their abilities higher than did their parents. Despite a majority of survivors expecting to attend college, 68.5% of survivors and 57.9% of parents were not certain how to get special accommodations for standardized college entrance exams. Only 20.8% of survivors were aware of what a transition plan includes. Parents understood the transition planning process and when it should begin better than the students (P=0.001), but many parents (40.0%) were still unsure. AYA survivors and parents lack knowledge necessary to successfully transition to their goals after high school. Greater education is needed.