Culture

March 18, 2020 - For patients with fragility fractures related to underlying bone weakness, a dedicated fracture liaison service (FLS) can lower the risk of subsequent fractures, suggests a study in the March 18, 2020 issue of The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

Patients receiving FLS care have high rates of evaluation and treatment for osteoporosis, leading to improved bone quality and function, according to the follow-up study by Julio C. Fernandes, MD, FRCSC, PhD, MBA, and colleagues of Université de Montréal. "These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective," the researchers write.

New Data on Two-Year Outcomes of FLS Care for Fragility Fractures

Fragility fractures are those resulting from minimal trauma, such as a fall from standing height or less, and commonly occur in the hip, spine, or wrist. The FLS approach has emerged as a means to improve the identification and care of fragility fractures, including those related to osteoporosis.

Dr. Fernandes and colleagues report on their experience with FLS care in 532 patients. The average patient age was 63 years, and 86 percent were women. Rates of recommended evaluation and management of fragility fractures were analyzed, along with subsequent fractures and other key outcomes after a two-year follow-up.

Patients managed with use of FLS had high rates of recommended care. Eighty-nine percent of patients underwent measurement of bone mineral density, and 87 percent were started on treatment for osteoporosis. Overall, 84 percent of patients made at least one follow-up visit.

A total of 23 subsequent fractures occurred in 21 patients over nearly 900 person-years, with a rate of 2.6 percent per 100 person-years. That rate was lower than those suggested by past studies of patients with fragility fractures in the general population, which have ranged from 4 to 10 per 100 person-years.

Laboratory tests showed significant improvements bone metabolism during FLS care, including a slower rate of bone turnover. Standard measures of functional capacity and disability improved, while pain scores decreased.

Despite its growing popularity, there are still limited data on the effectiveness of the FLS approach. While previous "real world" studies of FLS care have reported high rates of testing and treatment, this new study is one of the first to include the results of systematic follow-up, including subsequent fracture rates.

The results suggest real benefits of FLS care for patients with fragility fractures, including testing, treatment, and follow-up participation rates over 80 percent. This study also suggests that FLS care is associated with a low rate of subsequent fractures, with reduced bone turnover and improved functional capacity.

Although this new analysis doesn't include a comparison group of patients not receiving FLS care, historical data from previous studies support their findings. "A randomized controlled trial with a larger sample and a longer follow-up period would better quantify the yield of improvement over the usual care," Dr. Fernandes and colleagues conclude.

Texas is one of a handful of states operating under a Medicaid 1115 Transformation Waiver that allows the expansion of Medicaid managed care while simultaneously maintaining hospital funding. Under the waiver, Texas receives supplemental payments from the federal government through the Delivery System Reform Incentive Payment (DSRIP) program, which allows health care providers in the state to receive such payments when they establish programs that improve patient access and outcomes. Additional payments can then be earned as the provider meets certain milestones related to the implementation and performance of those DSRIP programs.

Past studies have indicated that patients with low socioeconomic status are among the most likely to lack a primary care provider, causing them to receive lower quality health care and be readmitted to the hospital at a higher rate. These factors also contribute to a higher rate of emergency room visits and an increased risk of all-cause readmissions and death after discharge for these patients.

Armed with this information, an interdisciplinary research team from the Texas Tech University Health Sciences Center (TTUHSC) recently completed a study to determine if an interprofessional patient navigation program (PNP) created using DSRIP guidelines can help decrease emergency room visits and hospital admissions for these high consumers of health care.

The Journal of Healthcare Management published the study, "An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System," in its January 2020 issue. Charles F. Seifert, Pharm.D., FCCP, BCPS, from the TTUHSC Jerry H. Hodge School of Pharmacy, and Barbara Cherry, DNSc, RN, NEA-BC, from the TTUHSC School of Nursing were the study's co-principal investigators.

Other TTUHSC team members included pharmacotherapy resident Taylor J. Horyna, Pharm.D., BCPS, from the TTUHSC Jerry H. Hodge School of Pharmacy; Dolores Buscemi, MD, FACP, from the TTUHSC School of Medicine; and Rosalinda Jimenez, Ed.D., APRN, FNP-BC, PMHNP-BC, and Linda McMurry, DNP, RN, NEA-BC, from the TTUHSC School of Nursing.

To plan the study, Seifert said the team looked at results generated by 11 Medicare Coordinated Care Demonstration programs, which showed that coordinated patient care resulted in an 8%-33% decrease in hospitalization among high-risk Medicare patients. Two common threads that appeared to be woven into each successful program included face-to-face interactions between care coordinators and patients and the use of evidence-based patient education interventions.

Based upon those results, Seifert said the initial idea for TTUHSC's PNP study was to have patient navigators work with people 65 years of age and older to bring down hospital utilization. They eventually lowered the age to 50 and expanded their search for eligible patients beyond Lubbock's University Medical Center by accepting patient referrals from TTUHSC's Department of Internal Medicine and the university's Larry Combest Community Health & Wellness Center. These steps significantly increased the number of patients participating in the study.

"Once the program was up and fully running, we had four patient navigators at any given time and they were working to navigate an average of 150 total patients," Seifert said.

All patients enrolled in the study were required to host one home visit where they made face-to-face contact with the patient navigator. During home visits, patient navigators checked blood pressure, conducted medication adherence checks and performed a home environment scan.

"Another requirement for the patients when they got their medication was a pharmacy review," Seifert added. "If the navigator determined the patient didn't understand what they were taking and why they were taking it, the navigator would pass the information to a nurse practitioner, who would assign a resident to visit the home with the patient navigator to help educate the patient."

The median age of the 364 patients enrolled in the study was 59 years. Seifert said the vast majority of patients were indigent and 229 (62.9%) were female. The patients enrolled in the program represented a much higher percentage of minorities than that of the Lubbock County census, and estimated more than 70% had mental health issues. Though 75% had Medicaid or Medicare, most relied on a hospital emergency room for their primary care because they believed the best doctors worked at a hospital or because cultural influences caused them to be skeptical of health care provided outside a hospital.

"You have to get down to where the patients live to really understand the issues," Seifert said. "We were fortunate in that several of our patient navigators were minorities and they better understood the culture. One of our navigators was an amputee and just about all of our amputees we referred to her. It was interesting because when a patient saw a person like them, they trusted them a whole lot more."

When the study ended, the results showed the PNP program produced a significant reduction in emergency room visits among participants, down from 3.1 to 1.13 visits per year. In addition, annual hospital admissions dropped from 1.53 to 0 and total hospital utilization declined from 4.95 to 2.36 visits per year. Seifert said decreases in total hospital and emergency room utilization were noted in 74.9% of the participants and were not significantly impacted by any particular patient navigator, the type of insurance a patient used or the presence of a primary care physician.

During the three years the PNP was studied, personnel expenses averaged $312,302 per year and included a 2% annual raise for each patient navigator. Operating costs ($15,059 per year) and administrative overhead ($77,393 per year) brought the annual average expense for implementing the PNP to $404,754.

Seifert said the reduction in emergency room visits (1.97 fewer visits per patient at an estimated cost of $2,394 per visit) resulted in a $707,427 annual cost avoidance for the PNP (1.97 fewer visits/year x 150 patients x $2,394 per visit). The reduction in total annual hospital admissions, estimated at $4,200 per admission, produced an additional annual cost avoidance of $963,900 (1.53 fewer visits/year x $4,200/visit x 150 patients), which adds up to a total annual cost avoidance of $1,671,327.

When the estimated average annual expenses ($404,754) were subtracted from the estimated annual cost avoidance ($1,671,327), the PNP produced an estimated total annual cost avoidance of $1,266,573. Seifert said that factoring in a 20% sensitivity variable showed the PNP still resulted in an annual cost avoidance of more than $1 million ($1,013,258.40). Multiplied over the three-year duration of the study, he said the interprofessional PNP cost an estimated $1,214,262 to implement and produced an estimated overall cost avoidance of $3,799,719.

"This study shows that in three years you can more than pay for the program and I think it would be good for somebody to take this model and utilize it in their practice," Seifert said. "Ideally what I would like to see is hospitals and other health care institutions, whether it's a clinic or medical home health provider, taking the model and utilizing it to improve patient care. I think if the population is selected correctly, it can be beneficial in any situation."

It's balloon art on steroids: a pneumatic, shape-changing soft robot capable of navigating its environment without requiring a tether to a stationary power source.

Developed by researchers in UC Santa Barbara mechanical engineering professor Elliot Hawkes' group, it's also a major step in the effort to bring soft robots to human environments, where their characteristics are uniquely suited for interaction with and around people.

"The main challenge that we're trying to address is to make a human-scale soft robot," said Hawkes, whose paper appears in the journal Science Robotics. Most soft robots to date tend to be small, and often are tethered to the wall for power or compressed air, he explained. But what if they could create a soft robot large enough and strong enough to perform human-scale interactions and independent enough to navigate diverse, unstructured environments, such as disaster zones?

Enter the isoperimetric soft robot, a roughly four-foot-tall pneumatic robot that can move by deforming its soft, air-filled fabric tubes -- while keeping its perimeter constant.

"The idea is that you can change the shape of the soft robot by using simple motors that drive along the tubes, instead of using the slow, inefficient pumps that are normally used," said Hawkes, who conducted research for this paper while at Stanford University.

The isoperimetric robot is actually a combination of concepts from three distinct robotic areas -- soft robotics, truss robots and collective robots -- that together create new capabilities. The soft fabric tubes allow the robot to traverse irregular surfaces and deform as needed, and are light while being strong. The motors also can connect to each other via three-degree-of-freedom universal joints to create truss-like structures that can support weight and allow locomotion in three dimensions. And the motor "nodes" that allow the tubes to bend are themselves small, simple collective robots that together roll along the fabric tube and pinch to form joints of varying angles.

Perhaps the most notable thing about the robot is that it doesn't require inflation and deflation to move, doing away with the need for a connection to an external, stationary source of air or an unwieldy, bulky onboard pump. The motors are powered by small batteries.

"We were looking at ways to make it untethered, and we realized that we didn't need to pump air in and out; what we really needed to do was to move the air around," Hawkes said. This was, in fact, one of the group's major design challenges.

"It turns out that when you have air, even at relatively low pressure, there are huge forces that it applies," he said, so much of the engineering actually went into creating the nodes that roll along the tube and pinch to create joints. The advantage here, Hawkes added, is that the robot's operation is quicker and more seamless than it would be if it had to inflate and deflate in the process.

The researchers envision many uses for this type of robot. In a collapsed building scenario, for instance, it could crawl flat into tight spaces and reconfigure into a three-dimensional truss to create space and support weight. For planetary exploration, it packs light and can navigate uncertain terrain. It can pick up and even manipulate loads, and its soft nature allows it to work alongside humans. Its simple, modular construction allows students and other robot-builders to create a variety of their own robots in different shapes for diverse purposes.

Taken together, the robot's size, freedom of movement, strength and utility in real-world scenarios represent the type of focus that Hawkes and his group think will be beneficial. Soft robot research is new and exciting, Hawkes said, and it's taking off.

"But as a field, we need to think critically about what contributions each research project offers, what problems it solves or how it advances the field," he said, "as opposed to just making another cool gizmo."

WASHINGTON - A research team led by Children's National Hospital faculty was able to "rescue" a pre-clinical model of fetal alcohol spectrum disorder (FASD) in juvenile models, reversing motor skill deficits with the help of a novel drug derived from scorpion venom. The finding, in the Nature Neuroscience, could offer hope to an estimated 119,000 children born with this condition worldwide each year.

FASD, caused by alcohol consumption during pregnancy, causes numerous learning disabilities, including cognitive and intellectual deficits. Motor skills problems can be an early indicator for these other issues, explains study leader Kazue Hashimoto-Torii, Ph.D., a principal investigator at the Center for Neuroscience Research at the Children's National Research Institute. Many parents and caregivers first notice a problem when babies show delays in achieving motor developmental milestones. Although these effects are well documented, Hashimoto-Torii adds, it's been unclear what molecular mechanisms cause these deficits.

Hashimoto-Torii has been studying these effects ever since her postdoctoral training when, pregnant herself; she became interested in the consequences of environmental exposures on development. Over the past several years, she and colleagues have published a series of papers toward understanding FASD's molecular mechanisms.

In the most current paper, her team worked with a pre-clinical model of FASD in which gestating fetuses were exposed to alcohol at embryonic days 16 and 17, a period in which brain cells grow predominantly in the upper cortex, a brain region that plays a key role in motor abilities. This embryonic period corresponds to early mid-gestation in human fetuses.

When the researchers tested these pre-clinical models 30 days after birth--in two exams designed to assess both large-- and small-muscle motor skills--they showed significant deficits in both areas. Searching for the molecular differences that might underlie this diminished performance, the researchers found that prenatal alcohol exposure immediately activated a signaling pathway known as "heat shock," which causes cells to produce protective proteins. These heat shock proteins were produced randomly in some cells, rather than uniformly throughout the cell population.

Using a pre-clinical model that allowed them to track the descendants of these rapidly dividing neurons, the team found differences in the expression of 93 genes. One gene in particular, known as Kcnn2, which encodes a calcium-activated potassium channel, was over-expressed in the cells that produced heat shock proteins. This gene already has been implicated as playing an important role in learning and memory. Cells in which Kcnn2 was over-expressed showed abnormal firing patterns.

When the researchers administered a drug that blocks this channel, known as Tamapin and derived from Indian red scorpion venom, the affected cells' firing patterns reverted to normal. More importantly, pre-clinical models that received this drug at 30 days of life showed marked improvements in both large- and small-muscle motor skills. The fact that the pre-clinical models could still show improvements long after the initial damage suggests that treatment for children with FASD with a similar agent might also be effective, says Hashimoto-Torii. To that end, she and colleagues have launched a biotech company to further investigate this drug to see if it might hold promise in humans.

"Usually investigators looking for the molecular mechanisms behind disease stop there, but we want to move forward to have a real impact on public health," she says. "We really want to give patients the hope of having a better life through treating the neurodevelopmental problems caused by FASD."

PLYMOUTH MEETING, PA [March 18, 2020] — Experts from the Seattle Cancer Care Alliance (SCCA)—a Member Institution of the National Comprehensive Cancer Network® (NCCN®)—are sharing insights and advice on how to continue providing optimal cancer care during the novel coronavirus (COVID-19) pandemic. SCCA includes the Fred Hutchinson Cancer Research Center and the University of Washington, which are located in the epicenter of the COVID-19 outbreak in the United States. The peer-reviewed article sharing best practices is available for free online-ahead-of-print via open access at JNCCN.org.

“Responding quickly and confidently to the COVID-19 crisis is the health care challenge of our generation,” said co-lead author F. Marc Stewart, MD, Medical Director, SCCA. “Our overarching goal is to keep our cancer patients and staff safe while continuing to provide compassionate, high-quality care under circumstances we’ve never had to face before. We are working around the clock to develop new guidelines and policies to address situations that we couldn’t have imagined several weeks ago. When the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity.”

“The COVID-19 pandemic is impacting every facet of our global and domestic societies and health care systems in unprecedented fashion,” said Robert W. Carlson, MD, Chief Executive Officer, NCCN. “People with cancer appear to be at increased risk of COVID-19, and their outcomes are worse than individuals without cancer. The NCCN Member Institutions are rapidly gaining experience in preventing and managing COVID-19. As is the nature of the NCCN Member Institutions, they are sharing their experience in organizing and managing institutional and care systems responses and best practices in this rapidly evolving global effort.”

The article stresses the importance of keeping channels of communication open between administrators and staff, patients, caregivers, and the general public. The authors recommend forming an Incident Command Structure (as illustrated below) to provide early coordination of institution-wide efforts and to rapidly respond to changing information. They highlight the need to remain flexible and ready for unexpected challenges.

Some of the anticipated challenges include:

Staff shortages due to potential exposure and/or school closings
Limitations of resources such as hospital beds, mechanical ventilation, and other equipment
Impact on treatment from travel bans, including reduced access to international donors for allogeneic stem cell transplantation

The authors recommend mitigating some of these concerns through proactive measures that include:

Providing patient information via handouts, signs, web-based communication, and a dedicated phone line for questions and triage
Rescheduling “well” visits and elective surgeries, and deferring second opinion consultations (where care is already appropriately established)
Increasing hours of general hospital operations to reduce the unnecessary use of emergency department resources
Reinforcing a strict “stay at home when ill” policy and insuring staff have access to testing
Restricting travel and enabling work-from-home wherever possible
Prioritizing the use of soap and water over hand gel
Limiting the number of team members who enter patients’ rooms
Considering lower thresholds for blood transfusions
Moving some procedures from inpatient to outpatient
Adopting a no visitor policy with rare exceptions such as end-of-life circumstances
Having upfront, proactive palliative and end-of-life conversations with cancer patients who may become infected with COVID-19

The article also addresses the importance of self-care within and beyond the medical community. The authors call for the prioritization of measures to protect health and frontline staff and assure a safe work environment in order to prevent provider burnout. Those measures include compensation policies, reassignments to administrative roles for immunocompromised staff, and the creation of a back-up labor pool.

NCCN is also gathering documents and links from the leading cancer centers that comprise the nonprofit alliance, and sharing them all online at NCCN.org/covid-19. These include print outs for patient information, screening tools, visitation policies, and other essential forms. Hospitals worldwide are free to use or adapt these resources immediately. The site will be continuously updated as new resources become available.

The entire article can be read at https://jnccn.org/page/COVID-19/special-feature-on-covid19, or via a link at NCCN.org/covid-19.

# # #

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of 28 leading cancer centers devoted to patient care, research, and education. NCCN is dedicated to improving and facilitating quality, effective, efficient, and accessible cancer care so patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. By defining and advancing high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers around the world.

DOI

10.6004/jnccn.2020.7560

Children's National Hospital researchers for the first time have isolated bacterial extracellular vesicles from the blood of healthy donors, a critical step to better understanding the way gut bacteria communicate with the rest of the body via the bloodstream.

For decades, researchers considered circulating bacterial extracellular vesicles as bothersome flotsam to be jettisoned as they sought to tease out how bacteria that reside in the gut whisper messages to the brain.

There is a growing appreciation that extracellular vesicles - particles that cells naturally release - actually facilitate intracellular communication.

"In the past, we thought they were garbage or noise," says Robert J. Freishtat, M.D., MPH, associate director, Center for Genetic Medicine Research at Children's National Research Institute. "It turns out what we throw away is not trash."

Kylie Krohmaly, a graduate student in Dr. Freishtat's laboratory, has isolated from blood, extracellular vesicles from Escherichia coli and Haemophilus influenzae, common bacteria that colonize the gut, and validated the results via electron microscopy.

"The images are interesting because they look like they have a bit of a halo around them or penumbra," Krohmaly says.

The team theorizes that the solar eclipse lookalikes contain important signaling proteins and chromatin, DNA from the human host.

"It's the first time anyone has pulled them out of blood. Detecting them is one thing. Pulling them out is a critical step to understanding the language the microbiome uses as it speaks with its human host," Dr. Freishtat adds.

Krohmaly's technique is so promising that the Children's National team filed a provisional patent.

The Children's research team has devised a way to gum up the cellular works so that bacteria no longer become antibiotic resistant. Targeted bacteria retain the ability to make antibiotic-resistance RNA, but like a relay runner dropping rather than passing a baton, the bacteria are thwarted from advancing beyond that step. And, because that gene is turned off, the bacteria are newly sensitive to antibiotics - instead of resistant bacteria multiplying like clockwork these bacteria get killed.

"Our plan is to hijack this process in order to turn off antibiotic-resistance genes in bacteria," Dr. Freishtat says. "Ultimately, if a child who has an ear infection can no longer take amoxicillin, the antibiotic would be given in tandem with the bacteria-derived booster to turn off bacteria's ability to become antibiotic resistant. This one-two punch could become a novel way of addressing the antibiotic resistance process."

New research from the University of Cincinnati shows an increased rate of sudden episodes of kidney failure or damage in women who are hospitalized during pregnancy.

The increased rates of acute kidney injury (or AKI) in hospitalized pregnant women were even more likely to occur among those with diabetes and showed a higher likelihood of maternal mortality with pregnancy-related AKI. The study, published in the American Journal of Nephrology, finds those higher rates could be due to increased awareness of the disease, and that awareness may produce protocols to reduce the impact of AKI on pregnant women.

Silvi Shah, assistant professor in the Division of Nephrology, Kidney Clinical Advancement, Research and Education Program at UC, says the research found an overall acute kidney injury rate of 0.08% in pregnancy-related hospitalizations. Compared to white women, black women had a 52% higher likelihood and Native American women had a 45% higher likelihood for AKI during pregnancy-related hospitalizations, according to the study.

"Kidney injury during pregnancy is associated with significant maternal and fetal morbidity and mortality," says Shah, lead author of the study. "Since data is so scarce for clinical outcomes with AKI during pregnancy, we examined the rates, racial differences, mortality and health care utilization associated with pregnancy-related AKI hospitalizations."

The study examined more than 42 million pregnancy-related hospitalizations between Jan. 1, 2006, and Dec. 31, 2015, using data from the Nationwide Inpatient Sample. The rate of AKI during pregnancy-related hospitalization was 0.08% and the rate increased from 0.04% in 2006 to 0.12% in 2015. Factors associated with a higher likelihood of AKI during pregnancy included older age, black and Native American race and ethnicity and diabetes. Hospitalizations with pregnancy-related AKI had a 14-fold higher adjusted risk of inpatient mortality and a 16-fold higher adjusted risk of cardiovascular events.

"AKI, defined as sudden deterioration in kidney function potentially leading to kidney failure, is not uncommon and strikingly increases the risk of morbidity and mortality," says Charuhas Thakar, division director of nephrology and professor of medicine at UC and senior author of the study. "AKI incidence has increased with the total number of AKI hospitalizations rising from just under one million in 2000 to nearly four million in 2014. Identifying specific clinical settings and co-morbid and other risk factors of AKI may provide opportunities to improve survival and reduce long-term consequences of this devastating condition."

Shah says this study is unique in that it addresses a comprehensive racial group of patients from 2005-16 from a national database to better understand the incidence of AKI during pregnancy and factors associated with it among women of child-bearing age. She says the study further considered patients with all pregnancy-related hospitalizations, thus avoiding the potential shortfalls of registries dependent on voluntary reporting or patient recall.

"Our findings suggest a high burden of AKI during pregnancy in women especially those with history of diabetes and of black and Native American race and ethnicity," says Shah. "We speculate that increased awareness and detection of AKI during pregnancy have contributed to the increasing rates of AKI during pregnancy-related hospitalizations in recent years in the United States, but further research is needed. I encourage clinicians to routinely check patient kidney panels during inpatient hospitalizations. This study suggests that implementation of specific interventions for the prevention, diagnosis and management of AKI in pregnant women may reduce the burden of AKI during hospitalizations in the United States."

Molybdenum-99 (Mo-99) is an important medical isotope used to help radiologists detect heart disease, bone decay and some types of hard-to-find cancers. Scientists at the U.S. Department of Energy’s (DOE) Argonne National Laboratory have discovered a novel way to squeeze even more out of it.

Enriched molybdenum, from which Mo-99 can be made, is expensive, costing about $1,000 per gram. Commercial producers lacked an easy, cost-effective way to recycle the enriched material — until now. (Note that Mo-99 decays into technetium-99m, which radiologists then use to develop the actual pharmaceuticals used in medical procedures.)

For the first time in the U.S., Argonne scientists have scaled up the recycling of isotopically enriched molybdenum, Mo-98 or 100, to engineering scale using new 3D printed parts. This new approach makes the laboratory’s recycling method — pioneered in 2015 by Mo-99 program manager Peter Tkac and others — faster, more reliable and more cost effective.

Unlocking the benefits of 3D printing

When Tkac and colleagues first discovered how to recycle enriched molybdenum, the process proved tedious. The team converted the used enriched molybdenum, along with other chemicals, to an acidic solution. They then purified the enriched molybdenum in multiple stages using funnels and test tubes.

“Our original method would have been very difficult to automate,” said Tkac.

A year later, Tkac began working with Peter Kozak and others to automate the process, which relies on corrosive chemicals. The team replaced funnels and test tubes with 3D-printed acrylic contactors, which spin and separate chemicals using centrifugal force. The researchers said these contactors are what make recycling enriched molybdenum cheaper and more efficient.

“We printed each contactor as one piece with streamlined features and fewer external connections,” said Kozak. “This allows us to push the liquid through the system as quickly and reliably as possible.”

The new process effectively separated the enriched molybdenum from potassium and other contaminants, as described in a December 26 article in the Journal of Solvent Extraction and Ion Exchange.

Yet, a problem arose. The hydrochloric acid corroded the 3D-printed plastic after about 15 hours of operation.

“Our experiment was successful,” said Kozak. “But if you want to move into full production, you need material that will survive a lot longer than that.”

Looking for PEEK performance

Kozak and Tkac soon found a more durable material called polyether ether ketone (PEEK). PEEK is a better choice because it resists the recycling method’s mineral acids and many organic solvents.

But PEEK material, the team found, also shrinks as is it printed, causing the material to warp. To compensate, Kozak tweaked the printer’s fan speed and temperature, which helped him print PEEK materials that are stronger and more flexible than the original acrylic plastic. With PEEK material, the team found the best of both worlds: efficient, quick, and cost-effective recycling of enriched molybdenum that is strong enough to hold up against the chemicals that separate molybdenum from other materials.

HOUSTON - (March 18, 2020) - Working blacks who believe racism has a major impact on their lives are more likely to seek self-employment than those who feel less strongly about its effects, according to new research from Rice University.

"Belief in Systemic Racism and Self-Employment Status among Working Blacks" will appear in an upcoming volume of Ethnic and Racial Studies. Rice researchers Asia Bento, a sociology graduate student, and Tony Brown, a professor of sociology, analyzed data from 600 black respondents to the 2012 Outlook on Life Surveys for the research.

"Many people think self-employment can be a road to success," Brown said. "There are many, many stories told about people who are self-employed and 'do very well.' But we found ourselves wondering what role racism plays in a black person's decision to become self-employed."

Bento and Brown found that working black adults with "racial capital," or high awareness of the systemic nature of racism, were seven times more likely to pursue self-employment than those with low awareness.

"We feel that these individuals might seek self-employment to evade racism or at least minimize its influence on their careers," Bento said.

But the researchers were quick to note that self-employment did not necessarily translate into great financial success. In fact, they found self-employed black survey respondents were generally in worse financial situations than those working for somebody else. Those self-employed respondents were also less likely to have a college education.

The researchers said the survey responses suggest people might change jobs or make other financial decisions based on their belief in "how the world works" -- in other words, that racism is intertwined with capitalism and unavoidable in a traditional workplace.

"Self-employed or not, racism still undermines their career and financial success," Bento said.

The researchers hope their study will encourage future work examining racial capital among other groups, including Latinos and black immigrants.

What The Study Did: Nontrauma center hospitals were the nearest hospitals to most of the mass shootings (five or more people injured or killed by a gun) that happened in the U.S. in 2019. This study examined distances to trauma centers and nontrauma center hospitals for 187 mass shootings.

Authors: Michael L. Nance, M.D., of the Children's Hospital of Philadelphia, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamasurg.2020.0095)

Editor's Note: The article includes conflict of interest and funding/support disclosures. Please see the articles for additional information, including other authors, author contributions and affiliations, conflicts of interest and financial disclosures, and funding and support.

Philadelphia, March 18, 2020--In an analysis of 2019 mass shootings and hospital locations, researchers at Children's Hospital of Philadelphia (CHOP) found that the closest hospital to more than 70% of mass shootings was a non-trauma center, where sudden, high casualty loads were more likely to overwhelm capacity and trauma-specific care options may have been limited. They also found that in more than half of mass shooting events, the nearest pediatric trauma center was more than 10 miles away.

The findings were published today in a research letter in JAMA Surgery.

"The large number of serious injuries caused by mass shootings requires coordinated, high-level initial care, which is most commonly found in a trauma center," said Sage R. Myers, MD, MSCE, an attending physician in the Emergency Department at CHOP, Director of Trauma and Resuscitation for the Emergency Department, and co-author of the letter. "Yet in the vast majority of events we studied, a non-trauma center was the closest hospital and thus was likely the primary patient-transport destination. Given that mass shootings are unfortunately commonplace, all hospitals - regardless of trauma center status - should expect and prepare for the eventuality of a mass casualty event involving both adults and children."

The researchers used the Gun Violence Archive to analyze all 2019 mass shootings, defined as five or more injuries or deaths by firearm, and found a total of 187 mass shooting events. Those events led to 1,250 injuries, 23.8% of which resulted in death - more than double the 10% mortality rate of wounds sustained in military combat.

They then used Google Maps to calculate the driving distance from the address of the event to the nearest hospital, noting whether the facility was a non-trauma center, an adult level 1 or 2 trauma center, or a pediatric level 1 or 2 trauma center. Their analysis revealed that for 133 of the 187 events (71.1%), a non-trauma hospital was the nearest hospital.

Of the 187 mass shooting events in 2019, nearly 30% involved children. Yet 50.8% of all events occurred more than 10 miles from a pediatric trauma center, creating a challenge in caring for children injured in mass shootings.

"Children with injuries place a great stress on the system because many non-pediatric centers have limited child-specific resources, such as appropriately sized tracheal tubes and IVs, personnel trained in pediatric care, and pediatric-focused triage and transport policies," said Michael L. Nance, MD, Director of CHOP's Pediatric Trauma Program and a Fellow with CHOP's Violence Prevention Initiative. "Until we are able to reduce the frequency of mass shooting events, all hospitals must be ready to function similarly to a military field unit, with resources to treat trauma injuries in patients of all ages."

Cyclic molecules are everywhere, and everything around us stems from the way they are assembled: not just taste, colour and smell but also (for example) pharmaceutical drugs. Nature by itself forms molecular rings of different sizes and chains of rings of varying lengths that scientists are able to reproduce artificially. Chemists from the University of Geneva (UNIGE) have now devised a new technique for creating these chains of molecular rings that do not use standard chemical interactions but contact with large molecular surfaces that are electron-poor and do not exist in nature. Unlike with standard procedures, this new technique works by autocatalysis - the rarest, but also the most ambitious, type of transformation that exists in chemistry. The results of this research, published in the journal Angewandte Chemie, open up new prospects for molecular cyclization and also provide the first part of the answer to an old contradiction in classical chemistry.

The molecules that surround us are often arranged in the shape of cycles, forming steroids, sugars, perfumes or also drugs, for example. In organic chemistry, these molecular rings can be created using the technique of catalysis: the selected molecule, called a substrate, is placed in contact with the molecule that realizes the transformation - the catalyst - usually through hydrogen bonds. But with this single method of interaction, the creative possibilities are reduced. Incorporating new ways of interaction would convert them differently, thereby creating new materials with the potential to solve scientific and societal problems that are intractable with conventional methods.

Stefan Matile is a professor in the Department of Organic Chemistry in the School of Chemistry and Biochemistry of UNIGE's Faculty of Sciences. He is also a member of the NCCR Chemical Biology and the NCCR Molecular Systems Engineering. "Our laboratory has specialised in implementing new contacts between molecules, one of them based on very large molecular surfaces, known as aromatics, which are poor in highly-delocalised electrons." Professor Matile adds that contacts with these large, empty molecular plains, which are absent in nature, seemed promising for the cyclization of molecular rings that are chained to each other. But what are the consequences?

Chains of molecular rings produced by autocatalysis

The aims of the Geneva chemists were: to reproduce cycles of different sizes, i.e. consisting of a number of defined atoms (steroids, for instance, are formed from three cycles of six atoms plus one of five); and to link several cycles together without using the hydrogen bonds but a molecular surface low in delocalised electrons (known as anion-π interactions). "The main characteristic of this molecular plain is the empty space it provides for molecules to assemble", says Miguel Paraja, a researcher in UNIGE's Department of Organic Chemistry. On contact with this new, spacious and electron-deficient surface, the molecules formed cycles of different sizes (4 to 8 atoms) and various sequences. "But the big news was the way the transformations occurred!" adds the Geneva-based chemist.

All these cyclizations took place autocatalytically. "With a conventional catalyst, the cyclizations are fast at the start, and then - since there is less and less substrate - they increasingly slow down, explains Xiaoyu Hao, a researcher in the same laboratory. But with autocatalysis, it's the very opposite that happens!" Indeed, the molecular transformations accelerate on a massive scale. "Although this autocatalysis is a very rare transformation phenomenon in chemistry, it is also the most astonishing, says professor Matile. "It's based on mutual aid between molecules: the first molecules transformed help the next to transform, which isn't the case during normal catalysis, which decelerates rather than accelerates."

The first step in answering an old contradiction of classical chemistry

This discovery helps answer one of the oldest contradictions in classical chemistry. "There is a very well-known chain of molecular rings, called a brevetoxin, which is found in the red tide and which has the effect of killing fish", explains professor Matile. It was discovered by a towering figure in organic chemistry, Koji Nakanishi, who put forward an explanation for the possible construction of this extraordinary chain formed from eleven consecutive molecular rings in a single reaction. But this hypothesis did not agree with Jack Baldwin, a famous chemist who produced the rules explaining the formation of cycles that are now accepted as the basis of classical chemistry. The "Nakanishi hypothesis" violates these rules for every of the eleven rings. "Our rings can be formed according to Baldwin's rules if we want them to, reports Paraja. More importantly, we can also break the Baldwin rules on demand with our new catalysts and create those forbidden rings that Koji Nakanishi dreamed of." "The key to success, explains Hao, is the large empty space offered by our new catalysts."

Professor Matile continues that: "With the discovery of autocatalysis in forming cyclic molecules, our anion-π contacts have helped us understand the most subtle way to transform the molecules that exists in chemistry. And this will help us create new chains of molecular rings." The chemists will be able to influence and direct the nature of the transformation of the next substrate, creating new materials, one of the main objectives also of the NCCR Molecular Systems Engineering. "Most solutions to scientific problems, be they about food, medicine or environment, involve molecules and new contacts that can be created among them", says the Geneva-based chemist.

Hundreds of Aboriginal men who became native mounted police in colonial Australia carried a significant burden of responsibility for law and order for white settlers in Queensland and other settlements.

A long-running ARC-funded archaeology project has turned the lens on the recruitment to the Queensland Native Mounted Police and their part in the violent 'frontier wars' - which created long-term traumatic impacts on the lives of the Indigenous people involved.

"We argue that the massacres, frontier violence, displacement, and the ultimate dispossession of land and destruction of traditional cultural practices resulted in both individual and collective inter-generational trauma for Aboriginal peoples," says Flinders University Professor Heather Burke in a new article published in the Journal of Genocide Research

"Despite the Australian frontier wars taking place over a century ago, their impacts continue to reverberate today in a range of different ways, many of which are as yet only partially understood."

Professor Burke, and Queensland researchers, say official records show of the history of the Queensland Mounted Police in terms of its development, its white officers, some day-to-day operations of the force, and how many people were killed during the frontier wars.

The article looks at the ongoing psychological impacts of the historical dispossession and frontier violence.

Based on more than four years of research, the Archaeology of the Queensland Native Mounted Police project combined historical records, oral and historical evidence from a range of sites across central and northern Queensland to understand more fully the activities, lives and legacies of the native police.

It strives to present an alternative perspective on the nature of frontier conflict during Australian settlement, in order to initiative new understandings of the Aboriginal and settler experience, and contribute to global studies of Indigenous responses to colonialism.

The article 'Betwixt and Between: Trauma, Survival and the Aboriginal Troopers of the Queensland Native Mounted Police' (March, 2020) by Heather Burke, Bryce Barker, Lynley Wallis, Sarah Craig and Michelle Combo has been published in the Journal of Genocide Research (Taylor & Francis Online) DOI: 10.1080/14623528.2020.1735147

Background:

The Queensland Native Mounted Police was organised along paramilitary lines, consisting of detachments of Aboriginal troopers led by white officers. It covered the whole of Queensland, including 170 camps, and was explicitly constituted to protect the lives, livelihoods and property of settlers and to prevent (and punish) any Aboriginal aggression or resistance.

This was often accomplished through violence in many forms, leading Australian historian Henry Reynolds to characterise the NMP as "the most violent organisation in Australian history".

The project's new publicly available national database covers the 50-year history of the Queensland Native Mounted Police (1849-1904) and stories of many of the 800 troopers and 400 officers. It is the only publicly available historical and archaeological dataset of their lives and activities. The excavations conducted over the past four years were the first archaeological investigations of any native police force operating anywhere in Australia.
https://youtu.be/5AIqN_-1Dpk

Separation anxiety in dogs should be seen as a symptom of underlying frustrations rather than a diagnosis, and understanding these root causes could be key to effective treatment, new research by animal behaviour specialists suggests.

Many pet owners experience problem behaviour in their dogs when leaving them at home. These behaviours can include destruction of household items, urinating or defecating indoors, or excessive barking and are often labelled as 'separation anxiety' as the dog gets anxious at the prospect of being left alone.

Treatment plans tend to focus on helping the dog overcome the 'pain of separation', but the current work indicates dealing with various forms of frustration is a much more important element of the problem.

Animal behaviour researchers have now identified four key forms of separation anxiety, and suggest that animal behaviourists should consider these underlying reasons as the issue that needs treating, and not view 'separation anxiety' as a diagnosis.

The team, led by scientists from the University of Lincoln, UK, identified four main forms of distress for dogs when separated from their owners. These include a focus on getting away from something in the house, wanting to get to something outside, reacting to external noises or events, and a form of boredom.

More than 2,700 dogs representing over 100 breeds were included in the study.

Daniel Mills, Professor of Veterinary Behavioural Medicine in the School of Life Sciences at the University of Lincoln, said: "Until now, there has been a tendency to think of this as a single condition, ie "My dog has got separation anxiety" and then to focus on the dependence on the owner and how to make them more independent. However, this new work indicates that having separation anxiety is more like saying "My dog's got an upset tummy" which could have many causes and take many forms, and so both assessment and treatment need to be much more focussed.

"If your dog makes themselves ill by chewing something it shouldn't, you would need to treat it very differently to if it has picked up an infection. One problem might need surgery and the other antibiotics.

"Labelling the problem of the dog who is being destructive, urinating or defecating indoors or vocalising when left alone as separation anxiety is not very helpful. It is the start of the diagnostic process, not the end. Our new research suggests that frustration in its various forms is very much at the heart of the problem and we need to understand this variety if we hope to offer better treatments for dogs."

The new study, published in the academic journal Frontiers in Veterinary Science, highlights how different emotional states combine to produce problem behaviours in dogs. Although it is first triggered by the owner's departure, the unwanted behaviour arises because of a combination of risk factors that may include elements of the dog's temperament, the type of relationship it has with the owner and how the two of them interact.

The research team will soon be building on the latest study to examine in greater detail the influence the dog-owner relationship has on problem behaviours triggered by separation. It is hoped the research will open up new, more specific treatment programmes for owners.

An excessive amount of carbon dioxide is the main cause of climate change. One of the best approaches is to capture and convert carbon dioxide (CO2) into fuel such as methane. On the other hand, a sustainable way to solve the energy problem is to generate alternative energy source, however, challenges related to the storage of renewable electricity are preventing the development of these technologies. Thus, CO2 conversion to methane using renewable hydrogen has the great potential to provide a solution to these two problems of excessive CO2 levels, and the temporal mismatch between renewable electricity production and demand as well as hydrogen storage.

Best-known catalysts for CO2 methanation are supported nanoparticles of metals. However, most of them suffer from the issue of stability as well as selectivity towards methane over CO. Best way to resolve the issue of catalyst stability is by replacing active sites (metal nanoparticles) with metal-free active sites which are catalytic as well as stable even in an air environment at high temperatures.

In this work, researchers at TIFR have developed the magnesiothermic defect engineering protocol to design a new catalyst system where metal nanoparticle active sites were replaced with defects as catalytically active sites.

This is the first metal-free-ligand-free catalyst for CO2 conversion. The defects in nanosilica convert CO2 to methane with excellent productivity and selectivity. Furthermore, metal nanoparticles were not required, and the defect sites alone acted as catalytic sites for carbon dioxide activation and hydrogen dissociation and their cooperative action converted CO2 to methane.

The catalyst is recyclable and stable for more than 200 h with 10000 μmoles g-1 h-1 of productivity for methane. Notably, unlike expensive metal catalysts, the catalytic activity for methane production increased significantly after every regeneration cycle, reaching more than double the methane production rate after eight regeneration cycles as compared to the initial catalyst performance.

The spectroscopy studies gave atomistic insights into the various defect sites (Si radical centers, O-vacancy, and non-bridging oxygen hole centres) in terms of their concentrations, proximity, and cooperativity. In-Situ spectroscopy study provided mechanistic insights at a molecular level, indicating possible pathways for CO2 conversion to methane and carbon monoxide, which was further confirmed by computational study in collaboration with Prof. Ayan Datta of Indian Association of Cultivation Science (IACS), Kolkata.