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The Geophysical Fluid Dynamics Laboratory (GFDL) has developed a new variable-resolution global model with the ability to represent convective-scale features that serves as a prototype of the Next Generation Global Prediction System (NGGPS). The goal of this prediction system is to maintain the skill in large-scale features while simultaneously improving the prediction skill of convectively driven mesoscale phenomena. This paper demonstrates the new capability of this model in convective-scale prediction relative to the current operational Global Forecast System (GFS). This model uses the stretched-grid functionality of the Finite-Volume Cubed-Sphere Dynamical Core (FV3) to refine the global 13-km uniform-resolution model down to 4-km convection-permitting resolution over the contiguous United States (CONUS), and implements the GFDL single-moment 6-category cloud microphysics to improve the representation of moist processes. Statistics gathered from two years of simulations by the GFS and select configurations of the FV3-based model are carefully examined. The variable-resolution FV3-based model is shown to possess global forecast skill comparable with that of the operational GFS while quantitatively improving skill and better representing the diurnal cycle within the high-resolution area compared to the uniform mesh simulations. Forecasts of the occurrence of extreme precipitation rates over the southern Great Plains are also shown to improve with the variable-resolution model. Case studies are provided of a squall line and a hurricane to demonstrate the effectiveness of the variable-resolution model to simulate convective-scale phenomena.

We present a new global‐to‐regional model, cfvGFS, able to explicitly (without parameterization) represent convection over part of the Earth. This model couples the Geophysical Fluid Dynamics Laboratory Finite‐Volume Cubed‐Sphere Dynamical Core (FV3) to the Global Forecast System physics and initial conditions, augmented with a six‐category microphysics and a modified planetary boundary layer scheme. We examine the characteristics of cfvGFS on a 3‐km continental U. S. domain nested within a 13‐km global model. The nested cfvGFS still has good hemispheric skill comparable to or better than the operational Global Forecast System, while supercell thunderstorms, squall lines, and derechos are explicitly represented over the refined region. In particular, cfvGFS has excellent representations of fine‐scale updraft helicity fields, an important proxy for severe weather forecasting. Precipitation biases are found to be smaller than in uniform‐resolution global models and competitive with operational regional models; the 3‐km domain also improves upon the global models in 2‐m temperature and humidity skill. We discuss further development of cfvGFS and the prospects for a unified global‐to‐regional prediction system. Key Points A global‐to‐regional refined atmosphere model is presented for simultaneous, skillful global and convective‐permitting predictions Springtime forecasts show precipitation skill equal to or better than operational global and regional models Models based on the Finite‐Volume Cubed‐Sphere Dynamical Core show great promise for unifying global and regional prediction systems

A National Science Foundation sponsored educational deployment of a Doppler on Wheels radar called the Hawaiian Educational Radar Opportunity (HERO) was conducted on O‘ahu from 21 October to 13 November 2013. This was the first-ever deployment of a polarimetric X-band (3 cm) research radar in Hawaii. A unique fine-resolution radar and radiosonde dataset was collected during 16 intensive observing periods through a collaborative effort between University of Hawai‘i at Mānoa undergraduate and graduate students and the National Weather Service’s Weather Forecast Office in Honolulu. HERO was the field component of MET 628 “Radar Meteorology,” with 12 enrolled graduate students who collected and analyzed the data as part of the course. Extensive community outreach was conducted, including participation in a School of Ocean and Earth Science and Technology open house event with over 7,500 visitors from local K–12 schools and the public. An overview of the HERO project and highlights of some interesting tropical rain and cloud observations are described. Phenomena observed by the radar include cumulus clouds, trade wind showers, deep convective thunderstorms, and a widespread heavy rain event associated with a cold frontal passage. Detailed cloud and precipitation structures and their interactions with O‘ahu terrain, unique dual-polarization signatures, and the implications for the dynamics and microphysics of tropical convection are presented.

Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the \"Key Driver Implementation Scale\" (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale's psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial. The KDIS items assess a practice's progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options. PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care. The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one.

High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UK-based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053. Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45–116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTN group, participants' systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001), and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference in mRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1): 3 (IQR 2–5; n=420) in the GTN group versus 3 (2–5; n=408) in the sham group, adjusted common odds ratio for poor outcome 1·25 (95% CI 0·97–1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2: 3 [2–5]; n=544, in the GTN group vs 3 [2–5]; n=558, in the sham group; 1·04 [0·84–1·29]; p=0·69). We found no difference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group [p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatment groups. Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patients with presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultra-acute prehospital setting. British Heart Foundation.

Background Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices’ unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure. Methods The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs. Results In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members ( n  = 886 instances) or with practice managers alone ( n  = 670 instances) while relatively few on-site visits were conducted with primary care providers alone ( n  = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices’ percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status. Conclusions PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services. Trial registration NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691.

The absence of agreed methods to diagnose Achilles tendinopathy impedes research and clinical practice. This gap results in heterogeneous and/or poorly described study samples, making it challenging to apply findings in clinical practice. The aim of this Delphi study was to define consensus on (1) diagnostic domains; (2) differential diagnoses; and (3) conditions requiring further medical attention, when assessing for Achilles tendinopathy.We conducted a sequential three-stage process which included: (1) identifying diagnostic domains, differential diagnoses and conditions requiring further medical attention based on existing scoping reviews and clinical practice guidelines; (2) developing Delphi survey questions; and (3) administering a five-round Delphi online survey. Consensus was defined as ≥70% agreement.52 participants completed the surveys. Four diagnostic domains were deemed essential and reached consensus (pain location (93%); pain during activity (97%); tests that provoke pain (87%); palpation to assess pain (83%)). 15 differential diagnoses reached consensus: 2 for both midportion and insertional (partial tear (80%); posterior ankle impingement (78%)), 6 for midportion (plantaris tendinopathy (84%); tibialis posterior or flexor hallucis longus tendinopathy/tenosynovitis (72%); flexor digitorum longus tendinopathy (77%); accessory soleus muscle (74%); paratendinopathy (86%); sural nerve neuropathy (81%)) and 7 for insertional (superficial (88%) and retrocalcaneal bursitis (86%); Haglund’s/calcaneal exostosis (80%), intratendinous calcifications (73%); Sever’s disease (78%); calcaneal stress reaction/fracture (80%); subtalar/ankle pain (71%)). Six conditions requiring further medical attention reached consensus: (Achilles tendon rupture (83%); systemic inflammatory joint disease (86%); metabolic syndrome (75%); familial hypercholesterolaemia (77%); endocrine and hormonal disorders (80%); drug reactions (77%)).This consensus identified essential diagnostic domains, differential diagnoses and conditions requiring further medical attention that should be considered when assessing for Achilles tendinopathy.

Community Geography offers researchers, community groups, and students opportunities to engage in action oriented applied geographical research. Creating and sustaining these research programs can be challenging, programs can involve many partners from both academic and the community, have different goals and purposes, and utilize a variety of methods to perform research. In this paper we offer a framework of three primary overarching principles for implementing CG projects; (1) Who, (2) Why, and (3) How. (1) “Who” describes who is involved in CG, including researchers, community partners, academic institutions, (2) “Why” describes the justifications and benefits of taking this approach. (3) “How” explains how CG borrows methodologies from many disciplines within geography and beyond. Our examples are not exhaustive; rather, they serve as starting points to inspire researchers interested in CG.

Introduction Australia has experienced sustained reductions in hepatitis C testing and treatment and may miss its 2030 elimination targets. Addressing gaps in community-based hepatitis C prescribing in priority settings that did not have, or did not prioritise, hepatitis C testing and treatment care pathways is critical. Methods The Tasmanian Eliminate Hepatitis C Australia Outreach Project delivered a nurse-led outreach model of care servicing hepatitis C priority populations in the community through the Tasmanian Statewide Sexual Health Service, supported by the Eliminating Hepatitis C Australia partnership. Settings included alcohol and other drug services, needle and syringe programs and mental health services. The project provided clients with clinical care across the hepatitis C cascade of care, including testing, treatment, and post-treatment support and hepatitis C education for staff. Results Between July 2020 and July 2022, a total of 43 sites were visited by one Clinical Nurse Consultant. There was a total of 695 interactions with clients across 219 days of service delivery by the Clinical Nurse Consultant. A total of 383 clients were tested for hepatitis C (antibody, RNA, or both). A total of 75 clients were diagnosed with hepatitis C RNA, of which 95% (71/75) commenced treatment, 83% (62/75) completed treatment and 52% (39/75) received a negative hepatitis C RNA test at least 12 weeks after treatment completion. Conclusions Providing outreach hepatitis C services in community-based services was effective in engaging people living with and at-risk of hepatitis C, in education, testing, and care. Nurse-led, person-centred care was critical to the success of the project. Our evaluation underscores the importance of employing a partnership approach when delivering hepatitis C models of care in community settings, and incorporating workforce education and capacity-building activities when working with non-specialist healthcare professionals.