Preserving Patient Privacy During Computation over Shared Electronic Health Record Data.

Patient Electronic Health Records (EHRs) contain valuable clinical data that is useful for medical research and public health inquires. However, patient privacy regulation and improper resource sharing risks limit access to EHR medical data for research and public health purposes. In this paper, we introduce an end-to-end security solution that addresses both concerns and facilitates the sharing of patient EHR data over an unsecured third-party server using a leveled homomorphic encryption (LHE) scheme. Time testing for aggregating queries and linear computations was carried out using an HPE ProLiant DL580 Gen 10 server with an Intel Xeon Platinum 8280 Processor.

The Emergency Medicine Resident Retreat: Creating and Sustaining a Transformative and Reflective Experience.

Introduction  Burnout rates for emergency medicine residents are high. One intervention and initiative to enhance wellness and address burnout is the resident retreat. Retreats have multiple formats and are often designed with an emphasis on social events. This longitudinal retreat curriculum for a three-year residency training program was designed emphasizing rest, a step away from what is familiar, and reflection.  Methods Individual resident retreats were designed for each year of postgraduate training. The agenda for each is organized and intentional. Activities focused on personal well-being, self-reflection, team building, professional development, and physical activities are coupled with topics unique to class year roles and responsibilities. Retreats are held away from the hospital establishing a separation from the workplace. Results The retreat program has been sustainable for almost decades with trainees evaluating it highly. Faculty and residents enthusiastically participate in the program and consider it a fundamental part of the residency; 93.75% of residents surveyed strongly agreed that the retreats benefit their training while 94.2% strongly agreed that retreats increased their enthusiasm for training. Conclusions An emergency medicine resident retreat program focusing on unique elements for each post-graduate year is achievable and sustainable in an emergency medicine residency program. Over time, the retreat has become an integral part of the residency experience with positive experiences for both faculty and trainees.

Patients as team members: Factors affecting involvement in treatment decisions from the perspective of patients with a chronic condition.

BACKGROUND: Active patient involvement in treatment decisions is seen as a feature of patient-centred care that will ultimately lead to better healthcare services and patient outcomes. Although many factors have been identified that influence patient involvement in treatment decisions, little is known about the different views that patients have on which factors are most important. OBJECTIVE: This study explores the views of patients with a chronic condition on factors influencing their involvement in treatment decisions. DESIGN: Q-methodology was used to study the views of patients. Respondents were asked to rank a set of 42 statements from the least important to the most important for active patient involvement in treatment decision-making. The set of 42 statements was developed based on a literature search and a pilot in which two external researchers, 15 patients and four healthcare professionals participated. A total of 136 patients with one of three major chronic conditions were included: diabetes types 1 and 2, respiratory disease (i.e., chronic obstructive pulmonary disease and asthma) and cancer (i.e., breast cancer and prostate cancer). Data were collected in a face-to-face interview setting in the Netherlands. RESULTS: Four distinct views on the factors influencing active patient involvement were identified among patients with a chronic condition. (1) Enabled involvement: the extent to which patients are facilitated and empowered to participate will lead to patient involvement. (2) Relationship-driven involvement: the relationship between patients and healthcare professionals drives patient involvement. (3) Disease impact-driven involvement: the severity of disease drives patient involvement. (4) Cognition-driven involvement: knowledge and information drive patient involvement. DISCUSSION AND CONCLUSION: From the patients' perspective, this study shows that there is no one-size-fits-all approach to involving patients more actively in their healthcare journey. Strategies aiming to enhance active patient involvement among patients with a chronic condition should consider this diversity in perspectives among these patients. PATIENT CONTRIBUTION: Patients are the respondents as this study researches their perspective on factors influencing patient involvement. In addition, patients were involved in pilot-testing the statement set.

Cultivating Patient-Physician Communication About Vaccination Through Vaccine Metaphors.

The ease of access to misinformation online leaves patients vulnerable to poor decision-making and perplexed as to who serves as a reliable authority in the dissemination of health-related truths. Of prominent concern in twenty-first century medicine, is the communication between physicians and patients regarding vaccines. This cultural circumstance presents a challenge to physicians to be effective and trustworthy communicators, a challenge that entails the development of crucial skills at the earliest stages of medical education. We describe a pedagogical intervention through which medical students are given the educational experience of metaphorical construction to communicate the importance of vaccination.

Data from a pre-publication independent replication initiative examining ten moral judgement effects.

We present the data from a crowdsourced project seeking to replicate findings in independent laboratories before (rather than after) they are published. In this Pre-Publication Independent Replication (PPIR) initiative, 25 research groups attempted to replicate 10 moral judgment effects from a single laboratory's research pipeline of unpublished findings. The 10 effects were investigated using online/lab surveys containing psychological manipulations (vignettes) followed by questionnaires. Results revealed a mix of reliable, unreliable, and culturally moderated findings. Unlike any previous replication project, this dataset includes the data from not only the replications but also from the original studies, creating a unique corpus that researchers can use to better understand reproducibility and irreproducibility in science.

Achieving Coordinated Care for Patients With Complex Cases of Cancer: A Multiteam System Approach.

Patients with cancer with multiple chronic conditions pose a unique challenge to how primary care and specialty care teams provide well-coordinated, patient-centered care. Effectiveness of these care teams in providing optimal health care depends on the extent to which they coordinate their goals and knowledge as components of a multiteam system (MTS). This article outlines challenges of care coordination in the context of an MTS, illustrated through the care experience of "Mr Fuentes," a patient in the Dallas County integrated safety-net system, Parkland. As a continuing patient with chronic illnesses, the patient being discussed is managed through one of the Parkland community-oriented primary care clinics. However, a cancer diagnosis triggered an additional need for augmented coordination between his different provider teams. Further research and practice should investigate the relationships of MTS coordination for shared care management, transfer to and from specialty care, treatment compliance, barriers to care, and health outcomes of chronic comorbid conditions, as well as cancer control and surveillance.

Resident Supervision and Patient Safety: Do Different Levels of Resident Supervision Affect the Rate of Morbidity and Mortality Cases?

BACKGROUND: In our academic emergency department, our senior residents lead their own patient care team, known as the red team (RT). Attending physicians are responsible for managing their own team (AT) and precepting the senior resident's cases. OBJECTIVE: We hypothesized that the RT would have the same number of morbidity and mortality (M&M) cases and similar numbers of adverse outcomes as the AT. We also hypothesized that there would be no increase in M&M cases during the first quarter of every academic year. METHODS: We obtained data from M&M cases from 2009-2013, including month and year of patient visit, standard of care code (SoCC), and whether the patient was seen by the RT or an AT. Data were analyzed using a χ(2) test comparing expected outcomes with observed outcomes. RESULTS: There was a total of 117 M&M cases during the study period with a SoCC ≥ 3; 76 cases were AT and 41 cases were RT. There was no statistically significant difference between expected and observed number of cases. Mean RT and AT SoCCs were 4.03 and 4.23, respectively. There was no statistically significant difference between the two groups for SoCC. Mean SoCC was not significantly different for the first quarter of the year. CONCLUSIONS: We found that our patient care model did not lead to an increased number of M&M cases and RT cases were not associated with worse outcomes overall. Additionally, there was no increased rate of M&M cases in the beginning of the academic year.

Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force's process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge.

Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best-practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision-making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired. We present two cases that illustrate key insights into a best-practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients.

Team knowledge representation: a network perspective.

OBJECTIVE: We propose a network perspective of team knowledge that offers both conceptual and methodological advantages, expanding explanatory value through representation and measurement of component structure and content. BACKGROUND: Team knowledge has typically been conceptualized and measured with relatively simple aggregates, without fully accounting for differing knowledge configurations among team members. Teams with similar aggregate values of team knowledge may have very different team dynamics depending on how knowledge isolates, cliques, and densities are distributed across the team; which members are the most knowledgeable; who shares knowledge with whom; and how knowledge clusters are distributed. METHOD: We illustrate our proposed network approach through a sample of 57 teams, including how to compute, analyze, and visually represent team knowledge. RESULTS: Team knowledge network structures (isolation, centrality) are associated with outcomes of, respectively, task coordination, strategy coordination, and the proportion of team knowledge cliques, all after controlling for shared team knowledge. CONCLUSION: Network analysis helps to represent, measure, and understand the relationship of team knowledge to outcomes of interest to team researchers, members, and managers. Our approach complements existing team knowledge measures. APPLICATION: Researchers and managers can apply network concepts and measures to help understand where team knowledge is held within a team and how this relational structure may influence team coordination, cohesion, and performance.

Whole-genome comparison of leucine-rich repeat extensins in Arabidopsis and rice. A conserved family of cell wall proteins form a vegetative and a reproductive clade.

We have searched the Arabidopsis and rice (Oryza sativa) genomes for homologs of LRX1, an Arabidopsis gene encoding a novel type of cell wall protein containing a leucine-rich repeat (LRR) and an extensin domain. Eleven and eight LRX (LRR/EXTENSIN) genes have been identified in these two plant species, respectively. The LRX gene family encodes proteins characterized by a short N-terminal domain, a domain with 10 LRRs, a cysteine-rich motif, and a variable C-terminal extensin-like domain. Phylogenetic analysis performed on the conserved domains indicates the existence of two major clades of LRX proteins that arose before the eudicot/monocot divergence and then diversified independently in each lineage. In Arabidopsis, gene expression studies by northern hybridization and promoter::uidA fusions showed that the two phylogenetic clades represent a specialization into "reproductive" and "vegetative" LRXs. The four Arabidopsis genes of the "reproductive" clade are specifically expressed in pollen, whereas the seven "vegetative" genes are predominantly expressed in various sporophytic tissues. This separation into two expression classes is also supported by previous studies on maize (Zea mays) and tomato (Lycopersicon esculentum) LRX homologs and by information on available rice ESTs. The strong conservation of the amino acids responsible for the putative recognition specificity of the LRR domain throughout the family suggests that the LRX proteins interact with similar ligands.

Spinal epidural hematoma complicating thrombolytic therapy with tissue plasminogen activator--a case report.

Patients who receive thrombolytic therapy are at risk of central nervous system (CNS) hemorrhage, and this diagnosis must be sought in any patient who develops neurologic complaints after thrombolysis and anticoagulation. Early imaging and neurosurgical consultation are essential to improve outcome after hemorrhage occurs. We describe a patient who developed spinal epidural hematoma (SEH) after thrombolysis and anticoagulation for acute myocardial infarction. Delay in diagnosis and management may have contributed to a poor outcome. The literature on SEH is reviewed, and approaches to improve the prognosis of patients suffering CNS hemorrhage after thrombolysis are discussed.

Substantive and operational issues of response bias across levels of analysis: an example of climate-satisfaction relationships.

Two studies tested whether method variance is present at multiple levels of analysis and whether methodological procedures can minimize its impact. In Study 1, 8,052 employees from 71 hotels completed measures of climate, work environment characteristics, and satisfaction. A comparison of correlations at the individual level, cross-level, cross-level split, aggregate level, and aggregate-split level of analysis revealed that response bias was present across multiple levels. Results suggest that samples should be split in half when cross-level and aggregate correlations are computed to ameliorate response bias problems that arise from individual-level method variance. In Study 2, results indicated that the temporal spacing of measures of climate and satisfaction influenced response bias. Implications and recommendations for future research are discussed.