Use of Direct-to-Consumer Telemedicine to Access Mental Health Services.

BACKGROUND: The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare. OBJECTIVE: To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare. DESIGN: Retrospective cross-sectional study. SETTING: Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018. PARTICIPANTS: Patients and physicians. MAIN MEASURES: Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression. KEY RESULTS: We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits). CONCLUSIONS: As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.

Identifying low-PM2.5 exposure commuting routes for cyclists through modeling with the random forest algorithm based on low-cost sensor measurements in three Asian cities.

Cyclists can be easily exposed to traffic-related pollutants due to riding on or close to the road during commuting in cities. PM2.5 has been identified as one of the major pollutants emitted by vehicles and associated with cardiopulmonary and respiratory diseases. As routing has been suggested to reduce the exposures for cyclists, in this study, PM2.5 was monitored with low-cost sensors during commuting periods to develop models for identifying low exposure routes in three Asian cities: Taipei, Osaka, and Seoul. The models for mapping the PM2.5 in the cities were developed by employing the random forest algorithm in a two-stage modeling approach. The land use features to explain spatial variation of PM2.5 were obtained from the open-source land use database, OpenStreetMap. The total length of the monitoring routes ranged from 101.36 to 148.22 km and the average PM2.5 ranged from 13.51 to 15.40 µg/m³ among the cities. The two-stage models had the standard k-fold cross-validation (CV) R2 of 0.93, 0.74, and 0.84 in Taipei, Osaka, and Seoul, respectively. To address spatial autocorrelation, a spatial cross-validation approach applying a distance restriction of 100 m between the model training and testing data was employed. The over-optimistic estimates on the predictions were thus prevented, showing model CV-R2 of 0.91, 0.67, and 0.78 respectively in Taipei, Osaka, and Seoul. The comparisons between the shortest-distance and lowest-exposure routes showed that the largest percentage of reduced averaged PM2.5 exposure could reach 32.1% with the distance increases by 37.8%. Given the findings in this study, routing behavior should be encouraged. With the daily commuting trips expanded, the cumulative effect may become significant on the chronic exposures over time. Therefore, a route planning tool for reducing the exposures shall be developed and promoted to the public.

Direct Synthesis of Nanosheet-Stacked Hierarchical "Honey Stick-like" MFI Zeolites by an Aromatic Heterocyclic Dual-Functional Organic Structure-Directing Agent.

Soft template designing is the most promising strategy for the synthesis of zeolite nanosheets. MFI nanosheets directed by soft templates (containing long-chain alkyl groups or aromatic groups as hydrophobic component) can be found frequently; however, so far, MFI nanosheets synthesized by soft templates with aromatic heterocycle groups (e. g., s-triazine groups) are rare. Herein, a nanosheet-stacked hierarchical MFI zeolite (NSHM) has been synthesized by using a triply branched s-triazine-based surfactant as a bifunctional organic structure-directing agent. On the basis of a geometrical match relationship, a formation model has been proposed. Synthesized NSHM had abundant mesopores stacked by nanosheets and exhibited a high surface area (430 m2 ⋅ g-1 ). The 1 wt% Pd/NSHM attained a significant increase in yield of cyclohexanol/cyclohexanone mixture (from 66 to 85 %) in the oxidation of cyclohexane compared with Silicalite-1 and SBA-15 as supports.

The Association Between Physician Race/Ethnicity and Patient Satisfaction: an Exploration in Direct to Consumer Telemedicine.

BACKGROUND: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied. OBJECTIVE: To assess differences in patient satisfaction by physician race/ethnicity. DESIGN: A cross-sectional observational study. PARTICIPANTS: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians. MAIN MEASURES: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally. KEY RESULTS: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54-0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53-0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12-2.64), South Asian physicians (aOR 1.77; 95% CI 1.23-2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38-3.20) were more likely to result in patient dissatisfaction. CONCLUSIONS: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction.

Biomimetic fabrication of highly ordered laminae-trestle-laminae structured copper aero-sponge.

Light-weight metallic aero-sponges are highly desirable for electronics, energy storage, catalysis and environmental remediation. Although several fabrication methods have been developed, the mechanical strength and the structural fatigue resistance of the metallic aero-sponges remain unsatisfactory. Loofah sponge is known for its mechanical strength and grease absorption due to its highly ordered hierarchical laminae-trestle-laminae (L-T-L) microstructure. Inspired by this structure-function relationship, we engineered a highly ordered L-T-L structured copper aero-sponge by unidirectional freeze-casting of copper nanowires (CuNWs) and polyvinyl alcohols (PVA). By this approach, water-to-ice crystallization shaped the building blocks into vertically distributed microchannels and horizontally arranged hollow pores. The copper aero-sponge exhibits anisotropic mechanical elasticity with a maximum tolerable compressive stress of 57 kPa, sustainable resilience at a strain of 75% and structure-induced hydrophobicity with a water contact angle more than 130°. The elasticity and hydrophobicity of the copper aero-sponge are also superior to those of the mimicked loofah sponge and copper aero-sponge with disordered pore structure made by the conventional freeze-casting. This work can be extended to manufacture novel bioinspired aero-sponges/aero-gels with hierarchical ordered microstructures.

Multi-Arch-Structured All-Carbon Aerogels with Superelasticity and High Fatigue Resistance as Wearable Sensors.

Compressible and ultralight all-carbon materials are promising candidates for piezoresistive pressure sensors. Although several fabrication methods have been developed, the required elasticity and fatigue resistance of all-carbon materials are yet to be satisfied as a result of energy loss and structure-derived fatigue failure. Herein, we present a two-stage solvothermal freeze-casting approach to fabricate all-carbon aerogel [modified graphene aerogel (MGA)] with a multi-arched structure, which is enabled by the in-depth solvothermal reduction of graphene oxide and unidirectional ice-crystal growth. MGA exhibits supercompressibility and superelasticity, which can resist an extreme compressive strain of 99% and maintain 93.4% height retention after 100 000 cycles at the strain of 80%. Rebound experiments reveal that MGA can rebound the ball (367 times heavier than the aerogel) in 0.02 s with a very fast recovery speed (∼615 mm s-1). Even if the mass ratio between the ball and aerogel is increased to 1306, the ball can be rebound in a relatively short time (0.04 s) with a fast recovery speed (∼535 mm s-1). As a result of its excellent mechanical robustness and electrical conductivity, MGA presents a stable stress-current response (10 000 cycles), tunable linear sensitivity (9.13-7.29 kPa-1), and low power consumption (4 mW). The MGA-based wearable pressure sensor can monitor human physiological signals, such as pulses, sound vibrations, and muscular movements, demonstrating its potential practicability as a wearable device.

Corticosteroid Use for Acute Respiratory Tract Infections in Direct-to-Consumer Telemedicine.

BACKGROUND: Systemic corticosteroids are not indicated for acute respiratory tract infections yet are nonetheless prescribed in outpatient care. Acute respiratory tract infections are the most common diagnosis in direct-to-consumer telemedicine. The objective of this study was to characterize use of corticosteroids for acute respiratory tract infections in this setting and to assess the association between corticosteroid receipt and patient satisfaction. METHODS: Encounters with acute respiratory tract infection patients 18 years and older on a nationwide direct-to-consumer telemedicine platform were conducted by physicians between July 2016 and July 2018. Mixed-effects logistic regression was used to assess differences in the odds of corticosteroid prescription. A second mixed-effects model assessed differences in patient satisfaction by corticosteroid or antibiotic receipt. Adjusted prescribing rates for individual physicians were estimated. Models included diagnoses, patient age and geographic region, physician specialty and geographic region, and antibiotic prescription. RESULTS: Of the 85,972 encounters with 465 physicians, 11% resulted in the physician prescribing corticosteroids. The median physician prescribing rate was 4.0% (range: <1%-81%). Corticosteroid receipt was associated with higher satisfaction versus receiving nothing (odds ratio: 2.54; 95% confidence interval: 2.25-2.87). Patients who received both an antibiotic and a corticosteroid reported the highest satisfaction (odd ratio: 3.91; 95% confidence interval: 3.27-4.68). There was no correlation between individual physicians' corticosteroid and antibiotic prescribing rates. CONCLUSIONS: Corticosteroid receipt was associated with patient satisfaction. Most physicians rarely prescribed corticosteroids, yet a small number prescribed them frequently. Identification of high-prescribing physicians for educational interventions could reduce use of corticosteroids for acute respiratory tract infections.

Management of Urinary Tract Infections in Direct to Consumer Telemedicine.

BACKGROUND: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. OBJECTIVE: To describe management of UTI in a large nationwide DTC telemedicine platform. DESIGN: Cross-sectional observational study. PARTICIPANTS: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. MAIN MEASURES: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. KEY RESULTS: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. CONCLUSIONS: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

Mercury adsorption and re-emission inhibition from actual WFGD wastewater using sulfur-containing activated carbon.

A series of batch experiments were conducted to obtain the optimal adsorption condition for removing aqueous Hg from actual lime-based wet flue gas desulfurization (WFGD) wastewater with sulfur-containing activated carbon (SAC). The experimental results showed that SAC1 had an average 0.32 µg mg-1 larger aqueous Hg adsorption capacity and 21% larger Hg removal than the CS2-treated SAC1 (i.e., SAC2) in all tested pH values, confirming that greater sulfur content associated with effective sulfur functional group (i.e., elemental S) caused the larger Hg adsorption capacity. Furthermore, as increasing pH from 4 to 7, the Hg adsorption capacity of SAC1 decreased by 22% (i.e., 0.27 µg mg-1). The equilibrium Hg adsorption capacity was well fitted with linear and Freundlich adsorption isotherms. Kinetic simulations showed that both pseudo-second order and Elovich equations could well describe the chemisorption behavior of Hg to SAC1. Thermodynamic parameter calculation confirmed that Hg adsorption by SAC1 was thermodynamically spontaneous and exothermic. Re-emission of gaseous Hg markedly decreased by 88% as SO32- addition increased from 0 to 0.01 mM. Notably, by the addition of SAC1, zero re-emission of gaseous Hg was achieved. These experimental results confirm that the capture of aqueous Hg2+ and the inhibition of gaseous Hg0 re-emission can be successfully and simultaneously achieved in actual WFGD wastewater via the addition of SAC.

Nitrogen and Sulfur Co-Doped Graphene Nanosheets to Improve Anode Materials for Sodium-Ion Batteries.

Sodium-ion batteries (SIBs) attract more attention because of sodium's abundant availability, affordable price, and potential to be an effective anode material. Meanwhile, carbon-based materials provide the most promising anode materials. Because of the large radius of sodium ions, SIBs do not exhibit favorable electrochemical performance. Introducing heteroatoms into the carbon-lattice is an effective strategy to enlarge the interlayer space of carbon-based materials which can improve carbon's electrochemical performance. In addition, anode materials with a surface-induced capacitive process can enhance the SIB's electrochemical performance because its capacitive process increases the kinetics of ion diffusion. Here, we describe an SIB's anode material containing nitrogen and sulfur co-doped graphene sheets [denoted as poly(2,5-dimercapto-1,3,4-thiadiazole) (PDMcT)/reduced graphene oxide (RGO)] which are synthesized via carbonization of PDMcT polymerized on the surface of GO. PDMcT/RGO exhibited high capacities (240 mA h g-1 at 500 mA g-1), improved rate performance (144 mA h g-1 at 10 A g-1), and good cycling stability (153 mA h g-1 after 5000 cycles at 5000 mA g-1). These unique results are attributed to the enlarged interlayer spacing and electronic conductivity from the heteroatoms which facilitate the sodium ion's insertion and electron transport. These results represent that PDMcT/RGO is a great potential anode material for SIBs.

Patterns of Use and Correlates of Patient Satisfaction with a Large Nationwide Direct to Consumer Telemedicine Service.

BACKGROUND: Despite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine. OBJECTIVE: To characterize telemedicine patients and physicians and correlates of patient satisfaction DESIGN: Cross-sectional study PARTICIPANTS: Patients and physicians of a large nationwide DTC telemedicine service MAIN MEASURES: Patient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings. KEY RESULTS: The analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor's office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74-3.23) and coupon use (OR 1.47; 95%CI 1.33-1.62). CONCLUSIONS: Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

Promoter effect of heteroatom substituted AlPO-11 molecular sieves in hydrocarbons cracking reaction.

It is important to develop new promoters of fluid catalytic cracking (FCC) catalyst to increase iso-paraffin yield and avoid the decrease of research octane number (RON) caused by olefin saturation in gasoline hydrofining. SAPO-11 and LaAPO-11 molecular sieves were used as promoters to FCC catalyst to increase gasoline RON and were tested in the cracking reaction of n-dodecane on FCC conditions. LaAPO-11 molecular sieve has less and weaker acidity than SAPO-11 molecular sieve. LaAPO-11's metallic sites polarize the CH bonds to form carbenium ions for isomerization reaction and weak acid sites make less contributions to the cracking of iso-paraffin. LaAPO-11 promoter increases the yield of iso-paraffin (C5-9) from 6.4% to 10.2%. Besides that, a high yield of arene (2.0%) is caused by the dehydrogenation activity of LaAPO-11 promoter. The new contributions of this paper are the synthesis of a hydrothermal stable LaAPO-11 molecular sieve with isomerization activity and proposing the reaction routes of iso-paraffin. These new contributions are important for developing more effective RON promoters of FCC catalyst.

Lidar equation inversion methods and uncertainties in measuring fugitive particulate matter emission factors.

Measurements from two field campaigns that employed a micropulse lidar are used to compare the near-end and the far-end lidar equation inversion methods for estimating emission factors (EFs) of particulate matter (PM) from three types of anthropogenic fugitive sources: vehicles moving on unpaved roads, open burning, and open detonation. As optical depth increased from 0 to 2, relative EF uncertainty increased from 54% to 300% using the near-end method and decreased from 69% to 42% using the far-end method. To the best of our knowledge, this research is the first to use field measurements to compare results from these methods for anthropogenic PM plumes and quantify their uncertainties.

Projections of NH3 emissions from manure generated by livestock production in China to 2030 under six mitigation scenarios.

China's rapid urbanization, large population, and increasing consumption of calorie-and meat-intensive diets, have resulted in China becoming the world's largest source of ammonia (NH3) emissions from livestock production. This is the first study to use provincial, condition-specific emission factors based on most recently available studies on Chinese manure management and environmental conditions. The estimated NH3 emission temporal trends and spatial patterns are interpreted in relation to government policies affecting livestock production. Scenario analysis is used to project emissions and estimate mitigation potential of NH3 emissions, to year 2030. We produce a 1km×1km gridded NH3 emission inventory for 2008 based on county-level activity data, which can help identify locations of highest NH3 emissions. The total NH3 emissions from manure generated by livestock production in 2008 were 7.3TgNH3·yr-1 (interquartile range from 6.1 to 8.6TgNH3·yr-1), and the major sources were poultry (29.9%), pigs (28.4%), other cattle (27.9%), and dairy cattle (7.0%), while sheep and goats (3.6%), donkeys (1.3%), horses (1.2%), and mules (0.7%) had smaller contributions. From 1978 to 2008, annual NH3 emissions fluctuated with two peaks (1996 and 2006), and total emissions increased from 2.2 to 7.3Tg·yr-1 increasing on average 4.4%·yr-1. Under a business-as-usual (BAU) scenario, NH3 emissions in 2030 are expected to be 13.9TgNH3·yr-1 (11.5-16.3TgNH3·yr-1). Under mitigation scenarios, the projected emissions could be reduced by 18.9-37.3% compared to 2030 BAU emissions. This study improves our understanding of NH3 emissions from livestock production, which is needed to guide stakeholders and policymakers to make well informed mitigation decisions for NH3 emissions from livestock production at the country and regional levels.

Technical data for concentrated solar power plants in operation, under construction and in project.

This article presents technical data for concentrated solar power (CSP) plants in operation, under construction and in project all over the world in the form of tables. These tables provide information about plants (e.g., name of the CSP plant, country of construction, owner of the plant, aim of the plant) and their technical characteristics (e.g., CSP technology, solar power, area of the plant, presence and type of hybridization system, electricity cost, presence and type of TES, power cycle fluid, heat transfer fluid, operating temperature, operating pressure, type of turbine, type and duration of storage, etc.). Further interpretation of the data and discussions on the current state-of-the-art and future trends of CSP can be found in the associated research article (Pelay et al., 2017) [1].