Revisiting the effects of state anesthesia policy interventions: A comprehensive look at certified registered nurse anesthetist service provision in U.S. hospitals from 2010 to 2021.

AIMS: Rural hospitals in the United States often rely on nonphysician providers such as advanced practice nurses to care for their patients. One important role that is served by advanced practice nurses is that of anesthesia provider (certified registered nurse anesthetist or CRNA). In 2001, Centers for Medicare & Medicaid Services (CMS) passed an opt-out law affording state governors the right to loosen physician supervision requirements on CRNAs in their respective states, thus potentially improving access in targeted areas. Since then, 24 states have adopted these opt-out provisions. We aim to understand the extent to which the CMS opt-out law has resulted in increased CRNA service provision in hospitals, especially in rural areas. DESIGN: The study used a longitudinal design. We compiled 2010-2021 American Hospital Association data, which includes 4,464 unique U.S. hospitals observed an average of 8 times annually (35,863 total hospital-year observations). METHODS: We model CRNA services provision at the hospital level using longitudinal mixed effects generalized linear models that incorporate state, county, and hospital control variables. RESULTS: Using descriptive statistics and mixed effects generalized linear models, we discovered that adopting opt-out provisions does not universally result in increased CRNA service provision in U.S. hospitals. Notably, opt-out provisions do not improve access in rural counties. However, in supplemental analysis, we discover some of the conditions under which the likelihood of CRNA service provision is influenced. CONCLUSIONS: Hospitals often utilize CRNAs to staff their hospitals. However, many hospitals use both CRNAs and physician anesthesiologists; this can be a potential source of contention and confusion, given the lack of uniformity in the scope of practice policies. We offer some suggestions with regard to the effects of state interventions into the field, and how they might impact this dispute. Lastly, policymakers should consider additional measures to address rural access limitations, as the opt-out policy does not seem to be working as intended.

Opt-out HIV screening in adults attending the Emergency Department of a London teaching hospital.

BACKGROUND: Opt-out Emergency Department blood borne virus (EDBBV) screening was introduced at the Royal Free Hospital under the NHSEI (NHS England and NHS Improvement) programme to expand opt-out testing in local authority areas with high HIV prevalence. This initiative was part of the "Toward Zero" policy towards ending HIV transmission in England by 2030. METHODS: All patients attending the Royal Free Hospital Emergency Department (ED) aged 16 and over were screened for blood borne viruses (HIV/HBV/HCV) unless they opted out. We looked at HIV data from patients seen in ED between the initiation of EDBBV testing on the 12th of April and 12th of August 2022. Hepatitis B and C data was reviewed in a separate study. OUTCOME: A total of 12,208 samples from 10,641 patients were screened for HIV. Amongst these samples there were 88 which were positive, giving a seroprevalence of 0.84 %. There were 48 patients who were already known to local HIV services, 35 were known to HIV services outside of our Trust and 5 were new diagnoses. CONCLUSION: Our results confirmed our local HIV prevalence to be very high, as per the UK Health Security Agency and supports the need for HIV testing. Opt-out ED BBV screening has been a highly effective method for identifying people living with HIV who are unaware of their status.

When does metacognition evolve in the opt-out paradigm?

Metacognition (awareness of one's own knowledge) is taken for granted in humans, but its evolution in non-human animals is not well understood. While there is experimental evidence of seemingly metacognitive judgements across species, studies rarely focus on why metacognition may have evolved. To address this, I present an evolutionary model of the opt-out paradigm, a common experiment used to assess animal's metacognition. Individuals are repeatedly presented with a task or problem and must decide between opting-out and receiving a fixed payoff or opting-in and receiving a larger reward if they successfully solve the task. Two evolving traits - bias and metacognition - jointly determine whether individuals opt-in. The task's reward, the mean probability of success and the variability in success across trials, and the cost of metacognition were varied. Results identify two scenarios where metacognition evolves: (1) environments where success variability is high; and (2) environments where mean success is low, but rewards are high. Overall, the results support predictions implicating uncertainty in the evolution of metacognition but suggest metacognition may also evolve in conditions where metacognition can be used to identify cases where an otherwise inaccessible high payoff is easy to acquire.

Ethical, Psychological and Social Un/certainties in the Face of Deemed Consent for Organ Donation in England.

Deemed consent legislation for deceased organ donation was introduced in England in 2020, and is considered a vital part of the new UK NHS Blood and Transplant's 10-year strategy to increase consent for organ donation. Despite the legislation containing safeguards to protect the public, the introduction of deemed consent creates ethical, psychological and social un/certainties for healthcare professionals in their practice. In this paper, we offer insights into healthcare professionals' perspectives on deemed consent, drawn from interview data with 24 healthcare professionals in an NHS Trust in England, prior to the introduction of the legislation. Whilst participants supported deemed consent in principle, they were concerned that it would present a threat to the nature of donation as a 'gift'; the notion of informed consent (or non-consent); and the autonomy of donors, their relatives, and their own roles as health professionals, posing dilemmas for practice. We argue that healthcare professionals present themselves as guardians of potential (non)donors and thus as having ethics and integrity in their own practice. We draw conclusions around the values and principles that matter to healthcare professionals when contemplating consent in deceased donation which will be useful for organ donation committees and ethics forums.

Does implementing opt-out solve the organ shortage problem? Evidence from a synthetic control approach.

In light of the persistent shortage of organ donations needed to save precious human lives, several countries have modified their organ donation laws by introducing an opt-out system, making every deceased a potential organ donor unless the person has objected. This study examines the impact of adopting opt-out on organ donation rates. Using a panel dataset covering a 21-year period, I apply a synthetic control approach to focus on countries that changed their prevailing organ donation legislation from opt-in to opt-out. I compare them to a synthetic counterfactual from countries that have kept their legislation the same since 1999. Synthetic control estimates show that Argentina and Wales achieved substantially higher organ donation rates with the shift from an opt-in to an opt-out system than without the reform taking place. My findings suggest that as one strategy among others, implementing opt-out cannot solve the organ shortage problem entirely but effectively contributes to reducing it considerably.

HPV self-sampling in organized cervical cancer screening program: A randomized pilot study in Estonia in 2021.

BACKGROUND: Cervical cancer incidence in Estonia ranks among the highest in Europe, but screening attendance has remained low. This randomized study aimed to evaluate the impact of opt-in and opt-out human papillomavirus (HPV) self-sampling options on participation in organized screening. METHODS: A random sample of 25,591 women were drawn from the cervical cancer screening target population who were due to receive a reminder in autumn 2021 and thereafter randomly allocated to two equally sized intervention arms (opt-out and opt-in) receiving a choice between HPV self-sampling or clinician sampling. In the opt-out arm, a self-sampler was sent to home address by regular mail; the opt-in arm received an e-mail containing a link to order a self-sampler online. The remaining 30,102 women in the control group received a standard reminder for conventional screening. Participation by intervention arm, age and region of residence was calculated; a questionnaire was used to assess self-sampling user experience. RESULTS: A significant difference in participation was seen between opt-out (41.7%) (19.8% chose self-sampling and 21.9% clinician sampling), opt-in (34.1%) (7.9% self-sampling, 26.2% clinician sampling) and control group (29.0%, clinician sampling only). All age groups and regions in the intervention arms showed higher participation compared to the control group, but the size of the effect varied. Among self-sampling users, 99% agreed that the device was easy to use and only 3.5% preferred future testing at the clinic. CONCLUSION: Providing women with a choice between self-sampling and clinician sampling significantly increased participation in cervical cancer screening. Opt-in and opt-out options had a different effect across age groups, suggesting the need to adapt strategies.

A 25-year scoping review of the organ donation system in Malaysia: past, present, and future.

Organ donation and transplantation are integral components of modern medicine. This scoping review thoroughly explores the historical evolution, current status, and future prospects of organ donation and transplantation in Malaysia. Historically, Malaysia faced significant challenges in establishing a robust organ transplantation system, with various factors hindering organ donation efforts. Currently, Malaysia continues to struggle with stagnant donation rates despite collaborative efforts from various sectors. There is an urgent need to amend the 50-year-old Human Tissue Act to strengthen the legal framework for organ donation and address ethical concerns. Looking to the future, Malaysia could adopt a soft opt-out system and prioritize advancements in organ preservation techniques by exploring new sources of organs through the donation after circulatory death program. Continued efforts are necessary to enhance education programs for professionals and the public, dispelling myths about organ donation and effectively educating on the concepts of brain death. Malaysia strives to create a more accessible future for organ transplantation, aligning with the Sustainable Development Goals to reduce the burden of organ failure and improve the population's health and well-being.

Ethical Issues in Implementation Science: A Qualitative Interview Study of Participating Clinicians.

BACKGROUND: Implementation science presents ethical issues not well addressed by traditional research ethics frameworks. There is little empirical work examining how clinicians whose work is affected by implementation studies view these issues. Accordingly, we interviewed clinicians working at sites participating in an implementation study seeking to improve patient handoffs to the intensive care unit (ICU). METHODS: We performed semi-structured interviews with 32 clinicians working at sites participating in an implementation study aiming to improve patient handoffs from the operating room to the ICU. We analyzed the interviews using an iterative coding process following a conventional content analysis approach. RESULTS: Clinicians' greatest concern about involvement was possible damage to interpersonal relations with more senior clinicians. They were divided about whether informed consent from clinicians was necessary but were satisfied with the study's approach of sending out mass communications about the study. They did not think opting out of the implementation portion of the study was feasible but saw this inability to opt out as unproblematic because they equated the study with routine quality improvement. Those clinicians who helped launch the study at their sites recounted several different ways of doing so beyond simply facilitating access. CONCLUSIONS: The risks that clinicians identified stemmed more from their general status as employees than their specific work as clinicians. Implementation researchers should be attuned to the ethical ramifications of involving employees of varying ranks. Implementation researchers using hybrid designs should also be sensitive to the possibility that practitioners affected by a study will equate it with quality improvement and overlook its research component. Finally, the interactions that go into facilitating an implementation study are more various than the "gatekeeping" typically discussed by research ethicists. More research is needed on the ethics of the myriad interactions that are involved in making implementation studies happen.

A new decision-support tool in a multi-center randomized trial for personalized, optimized, and simplified fertility treatment in non-PCOS patients.

Abstract: This study aimed to evaluate the effectiveness of a clinical decision support tool, Opt-IVF, in achieving the following outcomes: reducing the total cumulative dosage of Gonadotropins (Gns) used during controlled ovarian stimulation cycles and reducing the repeated ultrasonograms (USG) for monitoring follicular growth without compromising the number of good quality blastocysts obtained. The study design employed a multi-center randomized trial. The study enrolled 115 women aged 25-45 years undergoing IVF. Among the participants, 55 were randomly assigned to the intervention group (Opt-IVF), and 60 were randomly assigned to the control group. The intervention involved using a clinical decision support tool, Opt-IVF, to guide Gn dosing and trigger dates. The participants in the intervention group required significantly lower cumulative Gn dosage. The intervention group had higher numbers of oocytes retrieved and M2 retrieved than the control group. The number of good-quality blastocysts, the good-quality blastocyst rate, the ovarian sensitivity index (OSI), and the pregnancy rate in the intervention group were significantly higher than in the control group. The utilization of the clinical decision support tool led to several positive outcomes, including eliminating the need for ultrasound exams after day 5, reducing the dosage of Gn required, and yielding significantly higher numbers of high-quality blastocysts and higher pregnancy rates. Thus, Opt-IVF can successfully provide a personalized, optimized, and simplified approach to superovulation. Opt-IVF consistently outperformed the clinical teams in most of the outcomes. Clinical trials registration: ClinicalTrials.gov (ID - NCT05811065). Date of Registration: 15 March 2023. Date of enrollment of the first subject: 20 March 2023. Lay Summary: The high cost of IVF is a result of costly drugs, fixed prices for infrastructure, extensive testing required, and labor costs for physicians and other healthcare personnel. Superovulation, which involves the drug-induced release of multiple eggs needed for IVF, accounts for a significant share of these costs. Current approaches to superovulation involve almost daily monitoring of follicle development using ultrasound and/or blood tests. The daily dosage of stimulatory hormones is then prescribed by physicians based on empirical data and clinical experience. However, the dose is not optimized for each patient, and overstimulation complications can occur. The cost of testing and drugs makes this stage very expensive. To overcome the shortcomings of this system, we have developed a decision support tool (Opt-IVF) that can provide a personalized model-optimized dosage profile for each patient. The clinical results show that Opt-IVF optimizes and personalizes dosage, reduces testing, and provides better outcomes for patients.

Opt-out vaccination in school and daycare: Reconciling parental authority and obligations.

An increasing vaccine hesitancy among parents, which has resulted in insufficient rates of immunization, provides reason to reconsider childhood vaccination practices. Studies suggest that parents' decision-making process concerning whether to vaccinate their child is highly influenced by cognitive biases. These biases can be utilized to increase vaccination uptake via changes in the choice context. This article considers childhood vaccination programmes, which involve children being vaccinated in school or daycare unless their parents actively 'opt out'. We suggest that such programmes reconcile parents' decisional authority and vaccination duties. First, opt-out childhood vaccination based in schools or daycare centres are not disrespectful of parental authority. Second, the programme aligns the default setting with a moral obligation to vaccinate one's child that most parents have.

Citizen Views on an Opt-Out Approach to National Electronic Health Records in Germany: A Small-Scale Qualitative Study.

Objectives: Electronic health records (German: elektronische Patientenakte - ePA) are an important healthcare tool. However, in Germany, current participation remains low for their national ePA. To rectify this, the German government recently adopted an opt-out approach to their national ePA system. The objective of this study is to investigate and provide a brief overview of German public attitudes towards this approach to inform policymakers with evidence-based insights. Methods: Four public focus groups were conducted with 12 German citizens to discuss their opinions on the German governments new opt-out approach to the ePA. Results: Three major thematic categories were identified (Contributors to Opt-Out Implementation, Barriers to Opt-Out Implementation, and Contingent Factors) to describe citizen views on the opt-out approach for the ePA. Conclusion: The public is generally supportive of an opt-out approach to ePAs in Germany, as they see the benefits ePAs can provide to German society; but they are skeptical on how successful this approach might be due to extant issues that policymakers must be aware of in order to successfully implement an opt-out approach for Germany's national ePA system.

Qualitative Content and Discourse Analysis Comparing the Current Consent Systems for Deceased Organ Donation in Spain and England.

England switched to an opt-out system of consent in 2020 aiming to increase the number of organs available. Spain also operates an opt-out system yet has almost twice the organ donations per million population compared with England. We aimed to identify both differences and similarities in the consent policies, documents and procedures in deceased donation between the two countries using comparative qualitative content and discourse analysis. Spain had simpler, locally tailored documents, the time taken for families to review and process information may be shorter, there were more pathways leading to organ donation in Spain, and more robust legal protections for the decisions individuals made in life. The language in the Spanish documents was one of support and reassurance. Documents in England by comparison appeared confusing, since additions were designed to protect the NHS against risk and made to previous document versions to reflect the law change rather than being entirely recast. If England's ambition is to achieve consent rates similar to Spain this analysis has highlighted opportunities that could strengthen the English system-by giving individuals' decisions recorded on the organ donor register legal weight, alongside unifying and simplifying consent policies and procedures to support families and healthcare professionals.

CDR1, a DUF946 domain containing protein, positively regulates cadmium tolerance in Arabidopsis thaliana by maintaining the stability of OPT3 protein.

Industrial and agricultural production processes lead to the accumulation of cadmium (Cd) in soil, resulting in crops absorb Cd from contaminated soil and then transfer it to human body through the food chain, posing a serious threat to human health. Thus, it is necessary to explore novel genes and mechanisms involved in regulating Cd tolerance and detoxification in plants. Here, we found that CDR1, a DUF946 domain containing protein, localizes to the plasma membrane and positively regulates Cd stress tolerance. The cdr1 mutants exhibited Cd sensitivity, accumulated excessive Cd in the seeds and roots, but decreased in leaves. However, CDR1-OE transgenic plants not only showed Cd tolerance but also significantly reduced Cd in seeds and roots. Additionally, both in vitro and in vivo assays demonstrated an interaction between CDR1 and OPT3. Cell free protein degradation and OPT3 protein level determination assays indicated that CDR1 could maintain the stability of OPT3 protein. Moreover, genetic phenotype analysis and Cd content determination showed that CDR1 regulates Cd stress tolerance and affect the distribution of Cd in plants by maintaining the stability of OPT3 protein. Our discoveries provide a key candidate gene for directional breeding to reduce Cd accumulation in edible seeds of crops.

#consented - A semantic consent code to facilitate consistent documentation and implementation of consent in collaborative medical research.

INTRODUCTION: In German and international research networks different approaches concerning patient consent are applied. So far it is time-consuming to find out to what extent data from these networks can be used for a specific research project. To make the contents of the consents queryable, we aimed for a permission-based approach (Opt-In) that can map both the permission and the withdrawal of consent contents as well as make it queryable beyond project boundaries. MATERIALS AND METHODS: The current state of research was analysed in terms of approach and reusability. Selected process models for defining consent policies were abstracted in a next step. On this basis, a standardised semantic terminology for the description of consent policies was developed and initially agreed with experts. In a final step, the resulting code was evaluated with regards to different aspects of applicability. RESULTS: A first and extendable version for a Semantic Consent Code (SCC) based on 3-axis (CLASS, ACTION, PURPOSE) was developed, consolidated und published. The added value achieved by the SCC was illustrated using the example of real consents from large national research associations (Medical Informatics Initiative and NUM NAPKON/NUKLEUS). The applicability of the SCC was successfully evaluated in terms of the manual semantic mapping of consents by briefly trained personnel and the automated interpretability of consent policies according to the SCC (and vice versa). In addition, a concept for the use of the SCC to simplify consent queries in heterogeneous research scenarios was presented. CONCLUSIONS: The Semantic Consent Code has already successfully undergone initial evaluations. As the published 3-axis code SCC is an essential preliminary work to standardising initially diverse consent texts and contents and can iteratively be extended in multiple ways in terms of content and technical additions. It should be extended in cooperation with the potential user community.

Who declines "opt-out" HIV/HCV testing? Experience of an internal medicine resident continuity clinic serving a predominantly Black adult population in South Carolina.

BACKGROUND: Universal "opt-out" human immunodeficiency virus (HIV) or hepatitis C virus (HCV) testing involves testing individuals for HIV or HCV regardless of symptoms, unless they decline. Little is known about the characteristics of individuals who decline. METHODS: We conducted a retrospective, medical record review of adults evaluated at an outpatient clinic in South Carolina. "Opt-out" HIV/HCV testing was implemented in Feb 2019; we reviewed medical records of individuals evaluated in May - July 2019. We excluded individuals who did not meet age-based screening criteria (HIV: 18-65 years; HCV: 18-74 years), had a prior HIV/HCV diagnosis, were tested for HIV/HCV within the preceding 12 months, and whose "opt-out" decision was not documented. We used multivariable logistic regression to estimate adjusted odds ratios (aOR) and 95 % confidence intervals (CI) for "opt-out" decision, with age, sex, race/ethnicity, insurance status, visit type, and genitourinary vs. non-genitourinary chief complaints as predictors. RESULTS: The final analyses included 706 individuals for HIV and 818 for HCV. Most individuals were non-Hispanic Black (77 % and 78 %) and female (66 % and 64 %). The mean ages were 49.1 (±11.9) and 51.9 (±13.2). Nearly one-third of individuals declined HIV and HCV testing (31 % and 30 %). Black males were more likely to decline HIV and HCV testing than Black females (aOR = 1.61 [95 % CI. 1.08 - 2.40] and aOR = 1.50 [95 %CI. 1.04 - 2.16]). CONCLUSION: Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status. MAIN POINT: Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status.

A Grey Wolf Optimizer Algorithm for Multi-Objective Cumulative Capacitated Vehicle Routing Problem Considering Operation Time.

In humanitarian aid scenarios, the model of cumulative capacitated vehicle routing problem can be used in vehicle scheduling, aiming at delivering materials to recipients as quickly as possible, thus minimizing their wait time. Traditional approaches focus on this metric, but practical implementations must also consider factors such as driver labor intensity and the capacity for on-site decision-making. To evaluate driver workload, the operation times of relief vehicles are typically used, and multi-objective modeling is employed to facilitate on-site decision-making. This paper introduces a multi-objective cumulative capacitated vehicle routing problem considering operation time (MO-CCVRP-OT). Our model is bi-objective, aiming to minimize both the cumulative wait time of disaster-affected areas and the extra expenditures incurred by the excess operation time of rescue vehicles. Based on the traditional grey wolf optimizer algorithm, this paper proposes a dynamic grey wolf optimizer algorithm with floating 2-opt (DGWO-F2OPT), which combines real number encoding with an equal-division random key and ROV rules for decoding; in addition, a dynamic non-dominated solution set update strategy is introduced. To solve MO-CCVRP-OT efficiently and increase the algorithm's convergence speed, a multi-objective improved floating 2-opt (F2OPT) local search strategy is proposed. The utopia optimum solution of DGWO-F2OPT has an average value of two fitness values that is 6.22% lower than that of DGWO-2OPT. DGWO-F2OPT's average fitness value in the algorithm comparison trials is 16.49% less than that of NS-2OPT. In the model comparison studies, MO-CCVRP-OT is 18.72% closer to the utopian point in Euclidean distance than CVRP-OT.

Revealing misattributed parentage through the integration of genetic information into the electronic health record.

The integration of genetic information (GI) into the electronic health record (EHR) seems inevitable as the mainstreaming of genomics continues. Such newly provided accessibility to GI could be beneficial for improving health care, as well as for supporting clinical decision-making and health management. Notwithstanding these promising benefits, the automatic integration of GI into the EHR, allowing unrestricted access to one's GI through patient portals, carries various knowledge-related risks for patients. This article is focused on the potential case of inadvertently revealing misattributed parentage through such practice. The article aims to identify key clinical and ethical implications of such revelation for adult patients. Clinical implications include, for example, altering the physician-patient interaction and the need to enhance physician's genetic literacy to improve genetic-information-specific communication skills. Ethical implications yield arguments supporting disclosure of MP, such as autonomy, individuals' right to know medical information pertaining to them, and the right to know one's genetic origins. Arguments opposing disclosure of MP centre on the right not to know GI and concerns for post-disclosure family relationships. Following the clinical and ethical analyses of these respective implications, we consider how such integration of GI into the EHR ought to be carried out, ethically. We therefore suggest a solution, featuring an autonomy-based approach, built around EHR users' right not to know. Our solution of nuanced consent options (including a 'genetic ignorance option') is designed to enable patients' informed exposure to GI through the EHR, allowing them some control over their self- and familial narrative.

Perspectives on the currently available pharmacotherapy for wet macular degeneration.

INTRODUCTION: Wet age-related macular degeneration (w-AMD) is a leading cause of visual impairment globally, with its prevalence expected to rise alongside increasing life expectancy. The current standard treatment involves frequent intravitreal injections of anti-VEGF agents, which although revolutionary, pose significant burdens on both patients and healthcare services. AREAS COVERED: This review explores current and emerging pharmaceutical treatments for w-AMD, focusing on their pharmacokinetics, pharmacodynamics, efficacy, and safety. Promising developments include extending treatment intervals with newer anti-VEGF agents like brolucizumab and faricimab, biosimilars offering cost-effective options, and exploring innovative drug delivery methods such as subretinal gene therapy. Combination therapies, gene therapies, and novel agents like KSI-301 and OPT-302 show potential for improving treatment outcomes and reducing treatment burden. EXPERT OPINION: While current treatments for w-AMD have significantly advanced with the advent of anti-VEGF therapies, their limitations in terms of treatment burden and incomplete responses have spurred research into diverse alternative approaches. These innovative strategies offer hope for improving patient outcomes and reducing healthcare burdens, suggesting a promising future for w-AMD management.

The stomatal response to vapor pressure deficit drives the apparent temperature response of photosynthesis in tropical forests.

As temperature rises, net carbon uptake in tropical forests decreases, but the underlying mechanisms are not well understood. High temperatures can limit photosynthesis directly, for example by reducing biochemical capacity, or indirectly through rising vapor pressure deficit (VPD) causing stomatal closure. To explore the independent effects of temperature and VPD on photosynthesis we analyzed photosynthesis data from the upper canopies of two tropical forests in Panama with Generalized Additive Models. Stomatal conductance and photosynthesis consistently decreased with increasing VPD, and statistically accounting for VPD increased the optimum temperature of photosynthesis (Topt) of trees from a VPD-confounded apparent Topt of c. 30-31°C to a VPD-independent Topt of c. 33-36°C, while for lianas no VPD-independent Topt was reached within the measured temperature range. Trees and lianas exhibited similar temperature and VPD responses in both forests, despite 1500 mm difference in mean annual rainfall. Over ecologically relevant temperature ranges, photosynthesis in tropical forests is largely limited by indirect effects of warming, through changes in VPD, not by direct warming effects of photosynthetic biochemistry. Failing to account for VPD when determining Topt misattributes the underlying causal mechanism and thereby hinders the advancement of mechanistic understanding of global warming effects on tropical forest carbon dynamics.

A medida que aumenta la temperatura, disminuye la absorción neta de carbono en los bosques tropicales, sin embargo, aún no se conocen bien los mecanismos que la subyacen. Las altas temperaturas pueden limitar la fotosíntesis directamente, por ejemplo, reduciendo la eficiencia de los procesos bioquímicos, pero también de forma indirecta a través del aumento del déficit de presión de vapor (DPV) que resulta en el cierre estomático. Para explorar los efectos independientes de la temperatura y el DPV en la fotosíntesis, analizamos datos de la absorción neta de carbono del dosel de dos bosques tropicales en Panamá utilizando modelos aditivos generalizados. La conductancia estomática y la fotosíntesis disminuyó consistentemente con el aumento de DPV, y considerando el DPV en modelas estadísticas, la temperatura óptima de la fotosíntesis (Topt) aumentó, de un Topt aparente influida por la DVP de c. 30­31°C a un Topt independiente del DPV de c. 33­36°C. Los árboles y las lianas mostraron respuestas similares a la temperatura y a la DVP en ambos bosques, a pesar de la diferencia de 1500 mm en la precipitación media anual. La fotosíntesis en los bosques tropicales está limitada en gran medida por los efectos indirectos del aumento de la temperatura, a través de cambios en el DPV y no por los efectos directos en los procesos bioquímicos. Si no se tiene en cuenta el DPV al determinar el Topt, se atribuye erróneamente el mecanismo causal subyacente y, por lo tanto, se obstaculiza el avance en la comprensión de los efectos del calentamiento global en la dinámica del carbono.

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France.

BACKGROUND: Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria. METHODS: A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021. RESULTS: Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR. CONCLUSION: Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term. PRACTICAL IMPLICATIONS: Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.