Toward Efficient, Sustainable, and Scalable Methods of Treatment Characterization: An Investigation of Coding Clinical Practice from Chart Notes.

PURPOSE: Chart notes provide a low-cost data source that could help characterize what occurs in treatment with sufficient precision to improve management of care. This study assessed the interrater reliability of treatment content coded from chart notes and evaluated its concordance with content coded from transcribed treatment sessions. METHOD: Fifty randomly selected and digitally recorded treatment events were transcribed and coded for practice content. Independent coders then applied the same code system to chart notes for these same treatment events. ANALYSIS: We measured reliability and concordance of practice occurrence and extensiveness at two levels of specificity: practices (full procedures) and steps (subcomponents of those procedures). RESULTS: For chart notes, practices had moderate interrater reliability (M k = 0.50, M ICC = 0.56) and steps had moderate (M ICC = 0.74) to substantial interrater reliability (M k = 0.78). On average, 2.54 practices and 5.64 steps were coded per chart note and 4.53 practices and 13.10 steps per transcript. Across sources, ratings for 64% of practices and 41% of steps correlated significantly, with those with significant correlations generally demonstrating moderate concordance (practice M r = 0.48; step M r = 0.47). Forty one percent of practices and 34% of steps from transcripts were also identified in the corresponding chart notes. CONCLUSION: Chart notes provide an accessible data source for evaluating treatment content, with different levels of specificity posing tradeoffs for validity and reliability, which in turn may have implications for chart note interfaces, training, and new metrics to support accurate, reliable, and efficient measurement of clinical practice.

How Do Treatment Protocols Affect the Use of Engagement Practices in Youth Mental Health Services?

PURPOSE: Treatment engagement poses challenges for youth mental health providers. With the expansion of evidence-based treatments (EBTs), providers face complex decisions regarding how to engage youth and families using available information sources. This study investigated how EBT protocols are associated with the selection and delivery of engagement practices. METHOD: Twenty engagement practices were coded in a sample of digital recordings of early treatment sessions (N = 193) from the Child STEPs in California study, a randomized trial testing modular treatment and community-implemented treatment for youth mental health problems. Data were collected on which protocols mental health providers reportedly used to guide their sessions and the protocols in which they had received training. We examined which information sources (i.e., the guiding protocol, other protocols in training history, unspecified source) were associated with observed engagement practices. RESULTS: In sessions guided by a protocol, most observed engagement practices were accounted for by the guiding protocol (p < .001), rather than protocols in training history or unspecified sources (p < .001). In sessions not guided by a protocol, most observed practices were accounted for by training history (p < .001). Practice frequency and extensiveness was generally greater when a protocol guided the session. CONCLUSIONS: Inclusion in protocols is associated with the selection and delivery of engagement practices, but this strategy might be insufficient for supporting the use of the full range of engagement practices supported by evidence. Supports are needed that leverage the engagement evidence base to ensure that selected practices empirically fit the engagement needs of youth and families.

Earlier-born secondary hair follicles exhibit phenotypic plasticity.

The mouse pelage is composed of four distinct hair types. The fact that the follicles that generate these hair types form in successive waves during late embryonic development suggested the model that distinct epigenetic states of the inductive mesenchyme fixed when the follicles are formed specify the distinctive hair morphologies. This model is inconsistent with the observation that many follicles produce different hair types in successive hair cycles. In this study, the characteristics of the hair follicles that switch between the production of different hair types were examined. These follicles were born earlier than those that do not switch between hair types and made longer hairs. They also expressed a higher level of Sox2 in the dermal papilla and had more DP cells per follicle. These observations are consistent with the hypothesis that different birthdates specify the potential of different follicles. However, rather than directly specifying hair type, birthdate correlates with three types: guard hairs, a plastic population that can make awl, auchene or zigzag hairs, and a population that normally makes only zigzag hairs. Although Sox2 expression levels in the DP identify this subset during the morphogenetic cycle, Sox2 expression is not a fixed epigenetic state specified when the follicle is first formed.

Dermal papilla cell number specifies hair size, shape and cycling and its reduction causes follicular decline.

Although the hair shaft is derived from the progeny of keratinocyte stem cells in the follicular epithelium, the growth and differentiation of follicular keratinocytes is guided by a specialized mesenchymal population, the dermal papilla (DP), that is embedded in the hair bulb. Here we show that the number of DP cells in the follicle correlates with the size and shape of the hair produced in the mouse pelage. The same stem cell pool gives rise to hairs of different sizes or types in successive hair cycles, and this shift is accompanied by a corresponding change in DP cell number. Using a mouse model that allows selective ablation of DP cells in vivo, we show that DP cell number dictates the size and shape of the hair. Furthermore, we confirm the hypothesis that the DP plays a crucial role in activating stem cells to initiate the formation of a new hair shaft. When DP cell number falls below a critical threshold, hair follicles with a normal keratinocyte compartment fail to generate new hairs. However, neighbouring follicles with a few more DP cells can re-enter the growth phase, and those that do exploit an intrinsic mechanism to restore both DP cell number and normal hair growth. These results demonstrate that the mesenchymal niche directs stem and progenitor cell behaviour to initiate regeneration and specify hair morphology. Degeneration of the DP population in mice leads to the types of hair thinning and loss observed during human aging, and the results reported here suggest novel approaches to reversing hair loss.

Beta-catenin activity in the dermal papilla of the hair follicle regulates pigment-type switching.

The switch between black and yellow pigment is mediated by the interaction between Melanocortin receptor 1 (Mc1r) and its antagonist Agouti, but the genetic and developmental mechanisms that modify this interaction to obtain different coat color in distinct environments are poorly understood. Here, the role of Wnt/ß-catenin signaling in the regulation of pigment-type switching was studied. Loss and gain of function of ß-catenin in the dermal papilla (DP) of the hair follicle results in yellow and black animals, respectively. ß-Catenin activity in the DP suppresses Agouti expression and activates Corin, a negative regulator of Agouti activity. In addition, ß-catenin activity in the DP regulates melanocyte activity by a mechanism that is independent of both Agouti and Corin. The coordinate and inverse regulation of Agouti and Corin renders pelage pigmentation sensitive to changes in ß-catenin activity in the DP that do not alter pelage structure. As a result, the signals that specify two biologically distinct quantitative traits are partially uncoupled despite their common regulation by the ß-catenin pathway in the same cells.

Conserved Asp-137 imparts flexibility to tropomyosin and affects function.

Tropomyosin (Tm) is an alpha-helical coiled-coil that controls muscle contraction by sterically regulating the myosin-actin interaction. Tm moves between three states on F-actin as either a uniform or a non-uniform semi-flexible rod. Tm is stabilized by hydrophobic residues in the "a" and "d" positions of the heptad repeat. The highly conserved Asp-137 is unusual in that it introduces a negative charge on each chain in a position typically occupied by hydrophobic residues. The occurrence of two charged residues in the hydrophobic region is expected to destabilize the region and impart flexibility. To determine whether this region is unstable, we have substituted hydrophobic Leu for Asp-137 and studied changes in Tm susceptibility to limited proteolysis by trypsin and changes in regulation. We found that native and Tm controls that contain Asp-137 were readily cleaved at Arg-133 with t 1/2 of 5 min. In contrast, the Leu-137 mutant was not cleaved under the same conditions. Actin stabilized Tm, causing a 10-fold reduction in the rate of cleavage at Arg-133. The actin-myosin subfragment S1 ATPase activity was greater for the Leu mutant compared with controls in the absence of troponin and in the presence of troponin and Ca2+. We conclude that the highly conserved Asp-137 destabilizes the middle of Tm, resulting in a more flexible region that is important for the cooperative activation of the thin filament by myosin. We thus have shown a link between the dynamic properties of Tm and its function.