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All sourcesNASA NTRSDOE OSTI
DOE OSTI2021

Rapid Cis–Trans Coevolution Driven by a Novel Gene Retroposed from a Eukaryotic Conserved CCR4–NOT Component in Drosophila

Young, or newly evolved, genes arise ubiquitously across the tree of life, and they can rapidly acquire novel functions that influence a diverse array of biological processes. Previous work identified a young regulatory duplicate gene in Drosophila, Zeus that unexpectedly diverged rapidly from its parent, Caf40, an extremely conserved component in the CCR4–NOT machinery in post-transcriptional and post-translational regulation of eukaryotic cells, and took on roles in the male reproductive system. This neofunctionalization was accompanied by differential binding of the Zeus protein to loci throughout the Drosophila melanogaster genome. However, the way in which new DNA-binding proteins acquire and coevolve with their targets in the genome is not understood. Here, by comparing Zeus ChIP-Seq data from D. melanogaster and D. simulans to the ancestral Caf40 binding events from D. yakuba, a species that diverged before the duplication event, we found a dynamic pattern in which Zeus binding rapidly coevolved with a previously unknown DNA motif, which we term Caf40 and Zeus-Associated Motif (CAZAM), under the influence of positive selection. Interestingly, while both copies of Zeus acquired targets at male-biased and testis-specific genes, D. melanogaster and D. simulans proteins have specialized binding on different chromosomes, a pattern echoed in the evolution of the associated motif. Using CRISPR-Cas9-mediated gene knockout of Zeus and RNA-Seq, we found that Zeus regulated the expression of 661 differentially expressed genes (DEGs). Our results suggest that the evolution of young regulatory genes can be coupled to substantial rewiring of the transcriptional networks into which they integrate, even over short evolutionary timescales. Our results thus uncover dynamic genome-wide evolutionary processes associated with new genes.

59 BASIC BIOLOGICAL SCIENCES↗
DOE OSTI2020

Laboratory Infection of Novel Akhmeta Virus in CAST/EiJ Mice

Akhmeta virus is a zoonotic Orthopoxvirus first identified in 2013 in the country of Georgia. Subsequent ecological investigations in Georgia have found evidence that this virus is widespread in its geographic distribution within the country and in its host-range, with rodents likely involved in its circulation in the wild. Yet, little is known about the pathogenicity of this virus in rodents. We conducted the first laboratory infection of Akhmeta virus in CAST/EiJ Mus musculus to further characterize this novel virus. We found a dose-dependent effect on mortality and weight loss (p < 0.05). Anti-orthopoxvirus antibodies were detected in the second- and third-highest dose groups (5 × 104 pfu and 3 × 102 pfu) at euthanasia by day 10, and day 14 post-infection, respectively. Anti-orthopoxvirus antibodies were not detected in the highest dose group (3 × 106 pfu), which were euthanized at day 7 post-infection and had high viral load in tissues, suggesting they succumbed to disease prior to mounting an effective immune response. In order of highest burden, viable virus was detected in the nostril, lung, tail, liver and spleen. All individuals tested in the highest dose groups were DNAemic. Akhmeta virus was highly pathogenic in CAST/EiJ Mus musculus, causing 100% mortality when ≥3 × 102 pfu was administered.

59 BASIC BIOLOGICAL SCIENCES↗
NASA NTRS2014

Proteins with Novel Structure, Function and Dynamics

Recently, a small enzyme that ligates two RNA fragments with the rate of 10(exp 6) above background was evolved in vitro (Seelig and Szostak, Nature 448:828‐831, 2007). This enzyme does not resemble any contemporary protein (Chao et al., Nature Chem. Biol. 9:81‐83, 2013). It consists of a dynamic, catalytic loop, a small, rigid core containing two zinc ions coordinated by neighboring amino acids, and two highly flexible tails that might be unimportant for protein function. In contrast to other proteins, this enzyme does not contain ordered secondary structure elements, such as alpha‐helix or beta‐sheet. The loop is kept together by just two interactions of a charged residue and a histidine with a zinc ion, which they coordinate on the opposite side of the loop. Such structure appears to be very fragile. Surprisingly, computer simulations indicate otherwise. As the coordinating, charged residue is mutated to alanine, another, nearby charged residue takes its place, thus keeping the structure nearly intact. If this residue is also substituted by alanine a salt bridge involving two other, charged residues on the opposite sides of the loop keeps the loop in place. These adjustments are facilitated by high flexibility of the protein. Computational predictions have been confirmed experimentally, as both mutants retain full activity and overall structure. These results challenge our notions about what is required for protein activity and about the relationship between protein dynamics, stability and robustness. We hypothesize that small, highly dynamic proteins could be both active and fault tolerant in ways that many other proteins are not, i.e. they can adjust to retain their structure and activity even if subjected to mutations in structurally critical regions. This opens the doors for designing proteins with novel functions, structures and dynamics that have not been yet considered.

Proteins↗
NASA NTRSDate not supplied

Reducing OCO-2 regional biases through novel 3D cloud, albedo, and meteorology estimation

This ROSES project tests the addition of novel 3D cloud, albedo fine structure, temperature and water vapor profile to the OCO-2 retrieved system. All new parameters have been added to the ReFRACtor / TROPESS system for testing. Currently, we are comparing 3d-cloud retrievals from OCO-2 radiances to the MODIS-derived EAR3T cloud properties. The water and temperature profile retrievals have been implemented and result in improved XCO2 comparisons to TCCON, and now are implementing principal-component analysis (PCA) to reduce the number of parameters added. We are also studying ECOSTRESS spectral library, AVIRIS-ng, OCO-2 spectral residuals, and albedo retrievals with additional parameters to determine the appropriate characterization of albedo. We find that the current albedo parametrization (2nd order polynomial) is adequate for ocean and vegetation, but not adequate for soil and rock observations.

Reducing OCO-2↗
NASA NTRS2022

Acoustic Modeling of Novel Over-The-Rotor Acoustic Liner Concepts Using COMSOL Multiphysics Simulation Software

This paper presents simulation predictions of novel over-the-rotor acoustic liner configurations compared with experimental data. This is a follow on to the investigation on the effect of grazing flow on grooved over-the-rotor casing treatments. The purpose of this modeling investigation stems from the determination that traditional liner modeling techniques are inadequate for nontraditional internal liner cavity geometries. A series of these expansion chamber type liner design concepts were previously developed by Glenn Research Center and tested using the Langley Research Center Normal Incidence Tube. The measured normalized impedance and absorption coefficient is compared with that obtained from the COMSOL Multiphysics® simulation. Additionally, using a parametric case study, another series of simulations were conducted to determine what additional benefits, if any, this genre of liner has to offer the acoustics community. A total of 53 permutations of this concept was investigated. The results indicate that with longer internal fins, the resonance is sifted to lower frequencies.

Acoustics↗
DOE OSTI2022

Use of Novel Diglycolamide Extractants in Liquid-liquid Separations of Light Rare Earths

Creation of a novel extractant that can improve rare earth separations both economically and environmentally will be pivotal for industry progression. Diglycolamide (DGA) extractants provide chemistries that support this goal by serving as an extractant with high affinity for lanthanides and improved separation factors for light rare earths as compared to current extractants like PC88A. Initial organic phase loading capacity and phase dispersion tests performed with various modified DGAs generated results that were unfavorable for industrial processing, but further modification of the DGA alkyl chain substituents have resulted in new structures with promising results. Dispersion time measurements taken in small scale batch contacts of the extractant with a simulated leach liquor containing La, Ce, Nd, and Pr support implementation in both mixer-settlers and centrifugal contactors for larger scale separations. Furthermore, this confirmation allowed for preliminary flowsheet design using extraction equilibria at various organic to aqueous flow ratios (O/A) for extraction, scrubbing, and stripping stages. These values along with expected product/effluent compositions for each section aid in the testing for specific distribution ratios and final flowsheet design. Implementation of the DGA extractant into solvent extraction equipment will provide essential information for the next steps of this project and how this extractant may be optimized for future applications.

42 ENGINEERING↗
DOE OSTI2022

Identification of Novel, Replicable Genetic Risk Loci for Suicidal Thoughts and Behaviors Among US Military Veterans

Importance: Suicide is a leading cause of death; however, the molecular genetic basis of suicidal thoughts and behaviors (SITB) remains unknown. Objective: To identify novel, replicable genomic risk loci for SITB. Design, Setting, and Participants: This genome-wide association study included 633 778 US military veterans with and without SITB, as identified through electronic health records. GWAS was performed separately by ancestry, controlling for sex, age, and genetic substructure. Cross-ancestry risk loci were identified through meta-analysis. Study enrollment began in 2011 and is ongoing. Data were analyzed from November 2021 to August 2022. Main Outcome and Measures: SITB. Results: A total of 633 778 US military veterans were included in the analysis (57 152 [9%] female; 121 118 [19.1%] African ancestry, 8285 [1.3%] Asian ancestry, 452 767 [71.4%] European ancestry, and 51 608 [8.1%] Hispanic ancestry), including 121 211 individuals with SITB (19.1%). Meta-analysis identified more than 200 GWS (P < 5 × 10 -8 ) cross-ancestry risk single-nucleotide variants for SITB concentrated in 7 regions on chromosomes 2, 6, 9, 11, 14, 16, and 18. Top single-nucleotide variants were largely intronic in nature; 5 were independently replicated in ISGC, including rs6557168 in ESR1, rs12808482 in DRD2, rs77641763 in EXD3, rs10671545 in DCC, and rs36006172 in TRAF3. Associations for FBXL19 and AC018880.2 were not replicated. Gene-based analyses implicated 24 additional GWS cross-ancestry risk genes, including FURIN, TSNARE1, and the NCAM1-TTC12-ANKK1-DRD2 gene cluster. Cross-ancestry enrichment analyses revealed significant enrichment for expression in brain and pituitary tissue, synapse and ubiquitination processes, amphetamine addiction, parathyroid hormone synthesis, axon guidance, and dopaminergic pathways. Seven other unique European ancestry–specific GWS loci were identified, 2 of which (POM121L2 and METTL15/LINC02758) were replicated. Two additional GWS ancestry-specific loci were identified within the African ancestry (PET112/GATB) and Hispanic ancestry (intergenic locus on chromosome 4) subsets, both of which were replicated. Further, no GWS loci were identified within the Asian ancestry subset; however, significant enrichment was observed for axon guidance, cyclic adenosine monophosphate signaling, focal adhesion, glutamatergic synapse, and oxytocin signaling pathways across all ancestries. Within the European ancestry subset, genetic correlations (r > 0.75) were observed between the SITB phenotype and a suicide attempt-only phenotype, depression, and posttraumatic stress disorder. Additionally, polygenic risk score analyses revealed that the Million Veteran Program polygenic risk score had nominally significant main effects in 2 independent samples of veterans of European and African ancestry.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2020

A Novel NASICON‐Type Na 4 MnCr(PO 4 ) 3 Demonstrating the Energy Density Record of Phosphate Cathodes for Sodium‐Ion Batteries

Abstract Sodium‐ion batteries (SIBs) have attracted incremental attention as a promising candidate for grid‐scale energy‐storage applications. To meet practical requirements, searching for new cathode materials with high energy density is of great importance. Herein, a novel Na superionic conductor (NASICON)‐type Na 4 MnCr(PO 4 ) 3 is developed as a high‐energy cathode for SIBs. The Na 4 MnCr(PO 4 ) 3 nanoparticles homogeneously embedded in a carbon matrix can present an extraordinary reversible capacity of 160.5 mA h g −1 with three‐electron reaction at ≈3.53 V during the Na + extraction/insertion process, realizing an unprecedentedly high energy density of 566.5 Wh kg −1 in the phosphate cathodes for SIBs. It is intriguing to reveal the underlying mechanism of the unique Mn 2+ /Mn 3+ , Mn 3+ /Mn 4+ , and Cr 3+ /Cr 4+ redox couples via X‐ray absorption near‐edge structure spectroscopy. The whole electrochemical reaction undergoes highly reversible single‐phase and biphasic transitions with a moderate volume change of 7.7% through in situ X‐ray diffraction and ex situ high‐energy synchrotron X‐ray diffraction. Combining density functional theory (DFT) calculations with the galvanostatic intermittent titration technique, the superior performance is ascribed to the low ionic‐migration energy barrier and desirable Na‐ion diffusion kinetics. The present work can offer a new insight into the design of multielectron‐reaction cathode materials for SIBs.

Zhang, Jian↗
DOE OSTI2021

Novel Ultrabright and Air-Stable Photocathodes Discovered from Machine Learning and Density Functional Theory Driven Screening

The high brightness, low emittance electron beams achieved in modern X-ray free-electron lasers (XFELs) have enabled powerful X-ray imaging tools, allowing molecular systems to be imaged at picosecond time scales and sub-nanometer length scales. One of the most promising directions for increasing the brightness of XFELs is through the development of novel photocathode materials. Whereas past efforts aimed at discovering photocathode materials have typically employed trial-and-error-based iterative approaches, this work represents the first data-driven screening for high brightness photocathode materials. Through screening over 74 000 semiconducting materials, a vast photocathode dataset is generated, resulting in statistically meaningful insights into the nature of high brightness photocathode materials. This screening results in a diverse list of photocathode materials that exhibit intrinsic emittances that are up to 4x lower than currently used photocathodes. In a second effort, multiobjective screening is employed to identify the family of M 2 O (M = Na, K, Rb) that exhibits photoemission properties that are comparable to the current state-of-the-art photocathode materials, but with superior air stability. This family represents perhaps the first intrinsically bright, visible light photocathode materials that are resistant to reactions with oxygen, allowing for their transport and storage in dry air environments.

36 MATERIALS SCIENCE↗
DOE OSTI2023

Permeability of Single–Layer–Free–Standing Meshes at Varying Capillary Pressure via a Novel Method

The permeability of mesh wicks is important for various applications, including two–phase heat transfer. However, the understanding of the permeability of single–layer, free–standing mesh wicks, with liquid–gas interfaces on both sides, is limited. A novel and simpler method is presented to determine the permeability of a free–standing wick and apply it to a representative mesh. This method involves modifying the capillary pressure via elevation and simultaneously measuring the permeability to determine the permeability–capillary pressure relationship. When applied to a copper mesh with plain weave having undergone surface cleaning, the permeability is found to decrease as capillary pressure for deionized water increases. A dimensional analysis is presented to generalize this data for other mesh sizes with similar weaves and fluids. The behavior of mesh in application is modeled, based on the integration of Darcy's law with an analytic function fit to measured data, and parametric studies are conducted to investigate the superficial velocity of liquids through the mesh under varying driving pressures, transport lengths, and liquid viscosity, based on the obtained capillary pressure–permeability relationship. This study provides valuable insights into the transport properties of mesh wicks, with potential applications in fields such as electronics cooling, electrochemical devices, and fluid purification technologies.

36 MATERIALS SCIENCE↗
DOE OSTI2024

Novel Fast Cure Silicone Inks for Single-Step, Support-Free 3D Printing of Tall, Overhanging, and High Aspect Ratio Structures

Silicone elastomers have a broad variety of applications, such as soft robotics, biomedical devices, and structural metamaterials. The extrusion-based method known as direct ink write (DIW) has enabled the production of additively manufactured silicone structures. However, this method is limited to manufacturing mostly planar or pseudo-3D structures. Due to the low self-supporting capabilities of extruded strands for traditional silicone-based “inks,” obtaining tall or overhanging structures, or structures comprised by thin walls is not feasible. Here, in this study, a novel Fast Cure silicone-based ink is demonstrated that enables manufacturing of complex 3D structures. The Fast Cure ink is a two-part mixture and silicone structures are produced by inline mixing and coextrusion of a part containing a catalyst (part A) and a part containing a crosslinker (part B). By the virtue of crosslinking, the extruded strands rapidly rigidize, increasing their self-supportive capacity. Hence, structures can be obtained with superior shape retention and previously unobtainable parts are realized that are tall, with aspect ratios higher than 3, and have overhanging features, achieving inclination angles smaller than 35° with respect to the printing plane. These minimal sag parts are achieved without requiring extra curing or mechanisms, support structures, or suspension baths.

36 MATERIALS SCIENCE↗
DOE OSTI2024

Novel Mito-Nuclear Combinations Facilitate the Global Invasion of a Major Agricultural Crop Pest

A fundamental understanding of the underlying mechanisms involved in biological invasions is crucial to developing effective risk assessment and control measures against invasive species. The fall armyworm (FAW), Spodoptera frugiperda, is a highly invasive pest that has rapidly spread from its native Americas into much of the Eastern Hemisphere, with a highly homogeneous nuclear genetic background. However, the exact mechanism behind its rapid introduction and propagation remains unclear. Here, a systematic investigation is conducted into the population dynamics of FAW in China from 2019 to 2021 and found that FAW individuals carrying “rice” mitochondria (FAW-mR) are more prevalent (>98%) than that with “corn” mitochondria (FAW-mC) at the initial stage of the invasion and in newly-occupied non-overwintering areas. Further fitness experiments show that the two hybrid-strains of FAW exhibit different adaptions in the new environment in China, and this may have been facilitated by amino acid changes in mitochondrial-encoded proteins. FAW-mR used increases energy metabolism, faster wing-beat frequencies, and lower wing loadings to drive greater flight performance and subsequent rapid colonization of new habitats. In contrast, FAW-mC individuals adapt with more relaxed mitochondria and shuttle energetics into maternal investment, observed as faster development rate and higher fecundity. The presence of two different mitochondria types within FAW has the potential to significantly expand the range of damage and enhance competitive advantage. Overall, the study describes a novel invasion mechanism displayed by the FAW population that facilitates its expansion and establishment in new environments.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2022

Insight into the Fast-Rechargeability of a Novel Mo 1.5 W 1.5 Nb 14 O 44 Anode Material for High-Performance Lithium-Ion Batteries

Wadsley–Roth phased niobates are promising anode materials for lithium-ion batteries, while their inherently low electrical conductivity still limits their rate-capability. Herein, a novel doped Mo 1.5 W 1.5 Nb 14 O 44 (MWNO) material is facilely prepared via an ionothermal-synthesis-assisted doping strategy. The detailed crystal structure of MWNO is characterized by neutron powder diffraction and aberration corrected scanning transmission electron microscope, unveiling the full occupation of Mo 6+ -dopant at the t1 tetrahedral site. In half-cells, MWNO exhibits enhanced fast-rechargeability. In this work, the origin of the improved performance is investigated by ultraviolet–visible diffuse reflectance spectroscopy, density functional theory (DFT) computation, and electrochemical impedance spectroscopy, revealing that bandgap narrowing improves the electrical conductivity of MWNO. Furthermore, operando X-ray diffraction elucidates that MWNO exhibits a typical solid-solution phase conversion-based lithium-ion insertion/extraction mechanism with reversible structural evolution during the electrochemical reaction. The boosted lithium-ion diffusivity of MWNO, due to the Mo 6+ /W 6+ doping effect, is confirmed by a galvanostatic intermittent titration technique and DFT. With the simultaneously enhanced electrical conductivity and lithium-ion diffusivity, MWNO successfully demonstrates its fast-rechargeability and practicality in the LiNi 0.5 Mn 1.5 O 4 -coupled full-cells. Therefore, this work illustrates the potential of ionothermal synthesis in energy storage materials and provides a mechanistic understanding of the doping effect on improving material's electrochemical performance.

25 ENERGY STORAGE↗
DOE OSTI2025

Novel Zwitterionic Polyurethane-in-Salt Electrolytes with High Ion Conductivity, Elasticity, and Adhesion for High-Performance Solid-State Lithium Metal Batteries

This study presents a novel polymer-in-salt (PIS) zwitterionic polyurethane-based solid polymer electrolyte (zPU-SPE) that offers high ionic conductivity, strong interaction with electrodes, and excellent mechanical and electrochemical stabilities, making it promising for high-performance all solid-state lithium batteries (ASSLBs). The zPU-SPE exhibits remarkable lithium-ion (Li+) conductivity (3.7 × 10⁻⁴ S cm−1 at 25 °C), enabled by exceptionally high salt loading of up to 90 wt.% (12.6 molar ratio of Li salt to polymer unit) without phase separation. It addresses the limitations of conventional SPEs by combining high ionic conductivity with a Li+ transference number of 0.44, achieved through the incorporation of zwitterionic groups that enhance ion dissociation and transport. The high surface energy (338.4 J m−2) and elasticity ensure excellent adhesion to Li anodes, reducing interfacial resistance and ensuring uniform Li+ flux. When tested in Li||zPU||LiFePO₄ and Li||zPU||S/C cells, the zPU-SPE demonstrated remarkable cycling stability, retaining 76% capacity after 2000 cycles with the LiFePO4 cathode, and achieving 84% capacity retention after 300 cycles with the S/C cathode. Molecular simulations and a range of experimental characterizations confirm the superior structural organization of the zPU matrix, contributing to its outstanding electrochemical performance. The findings strongly suggest that zPU-SPE is a promising candidate for next-generation ASSLBs.

Wang, Kun↗
DOE OSTI2023

A Novel High‐Performance Electrolyte for Extreme Fast Charging in Pilot Scale Lithium‐Ion Pouch Cells

Realizing extreme fast charging (XFC) in lithium-ion batteries for electric vehicles is still challenging due to the insufficient lithium-ion transport kinetics, especially in the electrolyte. Herein, a novel high-performance electrolyte (HPE) consisting of lithium bis(fluorosulfonyl)imide (LiFSI), lithium hexafluorophosphate (LiPF 6 ) and carbonates is proposed and tested in pilot-scale, 2-Ah pouch cells. Moreover, the origin of improved electrochemical performance is comprehensively studied via various characterizations, suggesting that the proposed HPE exhibits high ionic conductivity and excellent electrochemical stability at high charging rate of 6-C. Furthermore, the HPE-based pouch cells deliver improved discharge specific capacity and excellent long-term cyclability up to 1500 cycles under XFC conditions, which is superior to the conventional state-of-the-art baseline electrolyte.

25 ENERGY STORAGE↗
DOE OSTI2023

Novel Co 5 Cluster Based Triazole Bridged Cobalt-Fluorophosphate: Synthesis, Structure, Magnetic and Heterogeneous Catalytic Epoxidation Studies

A novel triazole bridged cobalt fluorophosphate coordination polymer with the formula {Co 5 (1,2,4-triazole) 2 (OH) 2 (PO 3 F) 4 } n has been synthesized. Single crystal X-ray studies reveal that the compound comprises of Co 5 clusters which ultimately build the whole framework, here all cobalt centers are in octahedral geometry established from continuous shape analysis. All the cobalt centers are in Co(II) oxidation state and the results are supported by the bond valence sum (BVS) calculation. The sample has been characterized by single crystal X-ray, powder X-ray, FTIR and TGA analysis. The compound was tested for olefin catalysis performance and magnetism. Magnetization measurements reveal overall antiferromagnetic interactions among the Co(II) ions. The compound is very active in the catalytic transformation of olefins to their corresponding epoxides. In conclusion, catalytic epoxidation studies reveal that cyclohexene and styrene can be converted up to 97% with almost 65% selectivity of products with higher TON numbers.

37 INORGANIC, ORGANIC, PHYSICAL, AND ANALYTICAL CH↗
DOE OSTI2022

A novel methodology to integrate outcomes regarding perioperative pain experience into a composite score: Prediction model development and validation

Abstract Background An integrated score that globally assesses perioperative pain experience and rationally weights each component has not yet been developed. Methods A development dataset specific to adult Chinese patients undergoing orthopaedic surgery was obtained from PAIN OUT (1985 qualified patients of 2244). A more recent validation dataset obeying the same conditions was obtained from the Chinese Anaesthesia Shared‐database Platform (1004 qualified patients of 1032). Outcomes were assessed using the International Pain Outcomes Questionnaire (IPO‐Q), which comprises key patient‐level outcomes of perioperative pain management, including pain experience and perceptions of care. Using principal component analysis and regression models, a composite score (CS) was inferred to integrate pain experience. The discrimination of the CS for dissatisfaction and desire for more pain treatment was compared with that of the worst pain score. Results A CS was developed from the 12 items of the IPO‐Q regarding pain experience. The weight for calculating the CS was worst pain 11, least pain 17, time spent in severe pain 11, interference with activity in bed 9, interference with breathing deeply or coughing 10, interference with sleep 9, anxiety 12, helplessness 12, nausea 0, drowsiness 2, itch 5 and dizziness 2. In external validation, the CS indicated superior discrimination to the worst pain in predicting dissatisfaction ( p < 0.001) and desire for more pain treatment ( p < 0.001). Conclusions This study introduced a methodology to integrate outcomes regarding perioperative pain experience into a CS, which was based on the weight of each item. Significance This novel methodology sheds additional light on the riveting issue of carefully integrating several measures into a composite endpoint, which may be useful for quality improvement purposes when addressing the impact of a change in clinical practice.

Jiang, Bailin↗