Riverview Hospital

The opportunity for new biomarker-based tests to predict treatment response and the appropriate use of emerging rheumatoid arthritis (RA) therapies may depend on patients' prior treatment history. We examined rheumatoid arthritis (RA) treatment sequences and biologic/JAKi initiation overall and by line of therapy (LoT) to estimate the size of the eligible RA patient population in the U.S. for a new predictive treatment response test using a population-based RA inception cohort. We utilized an augmented health plan claims database to create an inception cohort of RA patients and estimated the rate of advanced treatment (biologic or JAKi) addition or switch. Results were stratified by advanced treatment naïve vs. treatment-experienced status and also described specific RA treatment sequences and combinations over time. Among 37,656 RA patients, 59,557 new RA treatment initiations were identified. Most patients (85.2%) initiated biologics; the remainder initiated JAKi. Of these, 40.2% used biologics/JAKi as monotherapy. The overall biologic/JAKi addition/switch rate was 25.7 per 100 patient-years (22.7/100py in biologic-naïve patients, and >30/100py in treatment-experienced patients). Rates varied substantially between prescribers, with an observed add/switch rate in the practices of prescribers in the highest decile (53.8/100py) more than 4-fold greater than rates in the practice of prescribers in the lowest decile (12.1/100py). These findings highlight the size and characteristics of the eligible RA population in the U.S. initiating a new RA biologic or JAKi treatment each year, thus providing valuable insights for stakeholders developing or marketing new RA therapies or biomarker-based diagnostic tests to predict future treatment response.

Repetitive Transcranial Magnetic Stimulation (rTMS) has been applied as an investigational therapy for Alzheimer's Disease (AD). The recent largest (N = 135) double-blind study with 6 months post-treatment follow-up investigating rTMS efficacy as a treatment for AD found about 72% of participants in each group of active and sham were positively responsive to rTMS (using Magstim AirFilm active and sham coils). Since the used sham coil produced about 25.3% of the peak active stimulus, it was hypothesized it could evoke a measurable response in AD patients. This study looks at the details of the above study's sham responses to determine why and how such a response might occur and how cerebrovascular symptomatology may have impacted that response. In the above-mentioned study, 90 and 45 patients were randomly assigned to active and sham groups, respectively. Those with modified Hachinski Ischemic Scores (HIS) below and above 2 were labeled AD2 and ADcvd2, respectively. Analysis of the primary outcome measure ADAS-Cog score change from baseline to post-treatment and follow-ups showed the ADcvd2 in the sham group had a significantly (p = .034) greater improvement or less decline at post-treatment and follow-up sessions compared to the ADcvd2 in the active group. Additionally, the improvement of the ADcvd2 sham compared to those in the active group persisted longer. Also, there was a significant (p = .036) improvement for AD2 individuals in the active compared to AD2 sham stimulation group at 2-months post-treatment. Overall, the sham rTMS stimulus did evoke a measurable response which was more effective for ADcvd2 in sham than ADcvd2 in active support of a vascular mechanism likely linked to the shallower sham stimulus penetration.

Introduction Ultrasound guidance for the delivery of regional anesthesia in the emergency department (ED) is an area of increasing interest. However, in order to perform a regional nerve block, one must first be able to correctly identify the specific nerve on ultrasound. Therefore, the primary purpose of this study is to investigate the number of supervised ultrasound examinations required for an emergency medicine (ED) physician to gain proficiency in accurately identifying the nerves of the lower extremity at the level of the femoral and popliteal nerves. Methods The proficiency outcome was defined as the number of attempts a resident needed to locate and correctly identify the femoral and popliteal nerves for 10 consecutive examinations. Didactic education was provided via a one-hour lecture and two supervised hands-on ultrasound examinations for each region prior to testing.Count data are summarized using percentages or medians and ranges. Random effects negative binomial regression was used for modeling panel count data, with the results summarized as an incidence rate ratio (95% confidence interval) and P-values <0.05 considered statistically significant. Results Complete data for the number of attempts, confidence, gender, and years in practice was available for 31 residents. The median number of attempts and range for popliteal and femoral nerves were 0 (0-11) and 0 (0-11), respectively. The median level of confidence and range for popliteal and femoral nerves were 3.5 (1-5) and 3 (1-5), respectively. There was a significant association between confidence and proficiency (P=0.009) and between years in practice and proficiency (P=0.010). Conclusion The findings of this small data set would suggest that proficiency can be quickly obtained in identifying the femoral and popliteal nerves with ultrasound after only a few proctored examinations. A significant association was found between years in practice and proficiency. This suggests that physicians with previous ultrasound scanning experience may require fewer supervised examinations when learning how to identify the femoral and popliteal nerves.

ABSTRACT “Bly in Blackwell’s: A Turning Point for Mental Health and Journalism” tells the story of Nellie Bly, a Pennsylvania-born investigative journalist. In 1887, Bly was set with the task of writing and reporting on an infamous insane asylum in New York—The Lodge on Blackwell’s Island. To do this, Bly acted “insane” and was sent to the institution as a patient so she could report on its inhumane conditions and expose it firsthand. After over a week of work in a terrifying environment, Bly was able to leave and wrote a two-part article for The New York World that was later published as Ten Days in a Mad-House. By making this brave effort, Nellie Bly changed the course of journalism and mental health, especially for women. This historical article shares the steps of Bly’s journey and shows just how much of an effect this plucky young writer had on our world.

ObjectiveThe effect of the COVID‐19 pandemic on community‐based rheumatology care and the use of telehealth is unclear. We undertook this study to investigate the impact of the pandemic on rheumatology care delivery in a large community practice–based network.MethodsUsing a community practice–based rheumatologist network, we examined trends in in‐person versus telehealth visits versus canceled visits in 3 time periods: pre–COVID‐19, COVID‐19 transition (6 weeks beginning March 23, 2020), and post–COVID‐19 transition (May‐August). In the transition period, we compared patients who received in‐person care versus telehealth visits versus those who cancelled all visits. We used multivariable logistic regression to identify factors associated with canceled or telehealth visits.ResultsPre–COVID‐19, there were 7,075 visits/week among 60,002 unique rheumatology patients cared for by ~300 providers practicing in 92 offices. This number decreased substantially (24.6% reduction) during the COVID‐19 transition period for in‐person visits but rebounded to pre–COVID‐19 levels during the post–COVID‐19 transition. There were almost no telehealth visits pre–COVID‐19, but telehealth increased substantially during the COVID‐19 transition (41.4% of all follow‐up visits) and slightly decreased during the post–COVID‐19 transition (27.7% of visits). Older age, female sex, Black or Hispanic race/ethnicity, lower socioeconomic status, and rural residence were associated with a greater likelihood of canceling visits. Most factors were also associated with a lower likelihood of having telehealth versus in‐office visits. Patients living further from the rheumatologists’ office were more likely to use telehealth.ConclusionCOVID‐19 led to large disruptions in rheumatology care; these disruptions were only partially offset by increases in telehealth use and disproportionately affected racial/ethnic minorities and patients with lower socioeconomic status. During the COVID‐19 era, telehealth continues to be an important part of rheumatology practice, but disparities in access to care exist for some vulnerable groups.

General rules for determining the internal forces in case of fixed loads, which act on the rod structures and known to reader from the course Mechanics of Materials, are reminded. Concepts of influence lines and direct/indirect load application are introduced. All influence lines for simplest structures (one span simply supported and cantilevered beams) are constructed using analytical expressions for required factor. Applications of influence lines for fixed and moving loads are discussed.

Abstract This chapter deals with some simplest nonlinear problems of the statics, stability, and vibrations of deformable systems.Compressed rods with lateral loading. The peculiarity of this type of problems: despite the initial linear relations and the classical assumptions, the obtained solutions satisfy the superposition principle only partially; thus, the combination of axial and transversal loads leads to nonlinear results.Static nonlinearity. “Restrained” free transverse vibration of the one-span uniform beam with both immovable supports are considered. In this case the axial force is not active force but reaction occurs due to free vibrations. This axial force induced by the deflection of a beam is the source of the static nonlinearity in the problem.Physical nonlinearity. Free vibration of the simply supported uniform beam is considered; the material of the beam does not obey to Hooke’s law. Assumed the relationship normal stress-strain is weakly nonlinear.Geometrical nonlinearity. Stability analysis of a simply supported uniform flexible rod with large deflections is considered. It is assumed that the compressing force retains orientation in the process of deforming the rod.For all the above problems the exact differential equations are derived and detailed mathematical analysis is presented. Rejecting the classical assumptions of structural mechanics leads to a new mathematical model of the object.KeywordsDesign diagramAssumptionsTypes of nonlinearitiesStabilityVibrationLarge deformation“Restrained” vibrationAxial forceSuperposition principleP-Δ analysisTransversal vibration

ABSTRACTConservation biologists need to effectively monitor species given resource limitations and the inherent challenges of assessing long‐term demographic processes. We assessed gopher tortoise (Gopherus polyphemus) abundance at a landscape scale and at the scale of 3 local populations within the Conecuh National Forest (CNF), Alabama, USA, between 1991 and 2017. We collected landscape‐level data from line transect distance sampling arranged uniformly across the CNF during a single season (2011); we obtained data for local populations from long‐term mark‐recapture of individuals at 3 sites selected based on prior knowledge of high density at each. At a landscape scale, we estimated 5,242 (95% CI = 3,538–7,768) tortoises occurred across the approximately 34,000‐ha forest, yielding a density of 0.14–0.32 tortoises/ha. These low densities across the landscape suggest that, on average, management activities across the property have not allowed tortoise populations to retain the social structure needed for long‐term persistence. The 3 local populations, however, contained 25–60 individuals and densities of 1.9–6.9 tortoises/ha. Over the study period, populations at 2 sites were stable and the third experienced significant population growth. Mean annual survival of individuals was 0.89 and invariant across size classes. Overall, line transect distance sampling is important for assessing landscape‐scale abundance of tortoises but may fail to detect local clusters of high‐density sites important for population persistence. Our mark‐recapture efforts at the local scale revealed that small populations on these high‐density sites can exhibit long‐term stability or growth even though they do not meet current established criteria for viability. Improved models that incorporate immigration and emigration and better reflect the dynamics of peripheral populations would assist in determining how such populations best contribute to species recovery and regional conservation targets. © 2020 The Wildlife Society.