Do we teach critical thinking? A mixed methods study of faculty and student perceptions of teaching and learning critical thinking at three professional schools.

INTRODUCTION: Critical thinking (CT) is an essential set of skills and dispositions for professionals. While viewed as an important part of professional education, approaches to teaching and assessing critical thinking have been siloed within disciplines and there are limited data on whether student perceptions of learning align with faculty perceptions of teaching. MATERIALS AND METHODS: The authors used a convergent mixed methods approach in required core courses in schools of education, government, and medicine at one university in the Northeast United States. Faculty surveys and student focus groups (FG) addressed definitions, strategies, and barriers to teaching CT. RESULTS AND CONCLUSIONS: Sixty-four (51.6%) faculty completed the survey, and 34 students participated in FGs. Among faculty, 54.0% (34/63) reported explicitly teaching CT; but students suggested teaching CT was predominantly implicit. Faculty-reported strategies differed among schools. Faculty defined CT in process terms such as 'analyzing'; students defined CT in terms of viewpoints and biases. Our results reveal a lack of explicit, shared CT mental models between faculty and students and across professional schools. Explicit teaching of CT may help develop a shared language and lead to better understanding and application of the skills and dispositions necessary to succeed in professional life.

Fostering Governance and Information Partnerships for Chronic Disease Surveillance: The Multi-State EHR-Based Network for Disease Surveillance.

CONTEXT: Electronic health records (EHRs) are an emerging chronic disease surveillance data source and facilitating this data sharing is complex. PROGRAM: Using the experience of the Multi-State EHR-Based Network for Disease Surveillance (MENDS), this article describes implementation of a governance framework that aligns technical, statutory, and organizational requirements to facilitate EHR data sharing for chronic disease surveillance. IMPLEMENTATION: MENDS governance was cocreated with data contributors and health departments representing Texas, New Orleans, Louisiana, Chicago, Washington, and Indiana through engagement from 2020 to 2022. MENDS convened a governance body, executed data-sharing agreements, and developed a master governance document to codify policies and procedures. RESULTS: The MENDS governance committee meets regularly to develop policies and procedures on data use and access, timeliness and quality, validation, representativeness, analytics, security, small cell suppression, software implementation and maintenance, and privacy. Resultant policies are codified in a master governance document. DISCUSSION: The MENDS governance approach resulted in a transparent governance framework that cultivates trust across the network. MENDS's experience highlights the time and resources needed by EHR-based public health surveillance networks to establish effective governance.

Predicting Atmospheric Water-Soluble Organic Mass Reversibly Partitioned to Aerosol Liquid Water in the Eastern United States.

Water-soluble organic matter (WSOM) formed through aqueous processes contributes substantially to total atmospheric aerosol, however, the impact of water evaporation on particle concentrations is highly uncertain. Herein, we present a novel approach to predict the amount of evaporated organic mass induced by sample drying using multivariate polynomial regression and random forest (RF) machine learning models. The impact of particle drying on fine WSOM was monitored during three consecutive summers in Baltimore, MD (2015, 2016, and 2017). The amount of evaporated organic mass was dependent on relative humidity (RH), WSOM concentrations, isoprene concentrations, and NOx/isoprene ratios. Different models corresponding to each class were fitted (trained and tested) to data from the summers of 2015 and 2016 while model validation was performed using summer 2017 data. Using the coefficient of determination (R2) and the root-mean-square error (RMSE), it was concluded that an RF model with 100 decision trees had the best performance (R2 of 0.81) and the lowest normalized mean error (NME < 1%) leading to low model uncertainties. The relative feature importance for the RF model was calculated to be 0.55, 0.2, 0.15, and 0.1 for WSOM concentrations, RH levels, isoprene concentrations, and NOx/isoprene ratios, respectively. The machine learning model was thus used to predict summertime concentrations of evaporated organics in Yorkville, Georgia, and Centerville, Alabama in 2016 and 2013, respectively. Results presented herein have implications for measurements that rely on sample drying using a machine learning approach for the analysis and interpretation of atmospheric data sets to elucidate their complex behavior.

Unmet needs with antipsychotic treatment in schizophrenia and bipolar I disorder: patient perspectives from qualitative focus groups.

BACKGROUND: Schizophrenia (SZ) and bipolar I disorder (BD-I) are chronic mental health disorders often treated with antipsychotic medications. This qualitative study sought to better understand disease burden and treatment experiences with oral antipsychotic medications in participants living with SZ or BD-I. METHODS: Six 90-min focus groups were conducted with participants diagnosed with SZ or BD-I. Trained moderators facilitated discussions using a semistructured guide. Participants described symptoms, impacts of disease, and experiences with oral antipsychotic medications, whether favourable or unfavourable. RESULTS: Among participants with SZ (n = 15; 3 groups, 5 per group), 53% were male and 33% were white, with a mean of 18.6 years since diagnosis. Of participants with BD-I (n = 24; 3 groups, 8 per group), 33% were male and 42% were white, with a mean of 13.0 years since diagnosis. Participants described numerous symptoms of their illnesses that impacted relationships and daily life, including effects on emotional health, the ability to work, and encounters with law enforcement. Previous antipsychotic medications were deemed effective by 14/15 (93%) participants with SZ and 12/16 (75%) participants with BD-I. Most participants with SZ (13/15; 87%) or with BD-I (16/24; 67%) reported discontinuing their antipsychotic medication at some point. Side effects were a common reason for discontinuing or switching medications for participants with SZ (8/15; 53%) and for those with BD-I (11/24; 46%). The most common side effects reported in both cohorts were weight gain, drowsiness, sexual problems, and neurologic symptoms. Side effects negatively affected quality of life, leading to serious health problems and issues with self-esteem. CONCLUSIONS: People living with SZ or BD-I cited a range of favourable and unfavourable experiences with oral antipsychotic medications. Most participants reported that their antipsychotics were effective at controlling their symptoms, but multiple side effects impacted their quality of life, caused additional serious health problems, and often led to discontinuation of or switching antipsychotics. Findings from this study contribute to a better understanding of patients' experiences with antipsychotics and highlight a need for new medications with favourable benefit/risk profiles.

"Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication.

Phenomenon: Disrespectful behavior between physicians across departments can contribute to burnout, poor learning environments, and adverse patient outcomes. Approach: In this focus group study, we aimed to describe the nature and context of perceived disrespectful communication between emergency and internal medicine physicians (residents and faculty) at patient handoff. We used a constructivist approach and framework method of content analysis to conduct and analyze focus group data from 24 residents and 11 faculty members from May to December 2019 at a large academic medical center. Findings: We organized focus group results into four overarching categories related to disrespectful communication: characteristics and context (including specific phrasing that members from each department interpreted as disrespectful, effects of listener engagement/disengagement, and the tendency for communication that is not in-person to result in misunderstanding and conflict); differences across training levels (with disrespectful communication more likely when participants were at different training levels); the individual correspondent's tendency toward perceived rudeness; and negative/long-term impacts of disrespectful communication on the individual and environment (including avoidance and effects on patient care). Insights: In the context of predominantly positive descriptions of interdepartmental communication, participants described episodes of perceived disrespectful behavior that often had long-lasting, negative impacts on the quality of the learning environment and clinical work. We created a conceptual model illustrating the process and outcomes of these interactions. We make several recommendations to reduce disrespectful communication that can be applied throughout the hospital to potentially improve patient care, interdepartmental collaboration, and trainee and faculty quality of life.

Using cognitive load theory to evaluate and improve preparatory materials and study time for the flipped classroom.

BACKGROUND: Preclinical medical education is content-dense and time-constrained. Flipped classroom approaches promote durable learning, but challenges with unsatisfactory student preparation and high workload remain. Cognitive load theory defines instructional design as "efficient" if learners can master the presented concepts without cognitive overload. We created a PReparatory Evaluation Process (PREP) to systematically assess and measure improvement in the cognitive-load efficiency of preparatory materials and impact on study time (time-efficiency). METHODS: We conducted this study in a flipped, multidisciplinary course for ~ 170 first year students at Harvard Medical School using a naturalistic post-test design. For each flipped session (n = 97), we assessed cognitive load and preparatory study time by administering a 3-item PREP survey embedded within a short subject-matter quiz students completed before class. Over three years (2017-2019), we evaluated cognitive load- and time- based efficiency to guide iterative revisions of the materials by content experts. The ability of PREP to detect changes to the instructional design (sensitivity) was validated through a manual audit of the materials. RESULTS: The average survey response rate was ≥ 94%. Content expertise was not required to interpret PREP data. Initially students did not necessarily allocate the most study time to the most difficult content. Over time, the iterative changes in instructional design increased the cognitive load- and time-based efficiency of preparatory materials with large effect sizes (p < .01). Furthermore, this increased the overall alignment of cognitive load with study time: students allocated more time to difficult content away from more familiar, less difficult content without increasing workload overall. CONCLUSIONS: Cognitive load and time constraints are important parameters to consider when designing curricula. The PREP process is learner-centered, grounded in educational theory, and works independently of content knowledge. It can provide rich and actionable insights into instructional design of flipped classes not captured by traditional satisfaction-based evaluations.

TP53 mutations in myelodysplastic syndromes and secondary AML confer an immunosuppressive phenotype.

Somatic gene mutations are key determinants of outcome in patients with myelodysplastic syndromes (MDS) and secondary AML (sAML). In particular, patients with TP53 mutations represent a distinct molecular cohort with uniformly poor prognosis. The precise pathogenetic mechanisms underlying these inferior outcomes have not been delineated. In this study, we characterized the immunological features of the malignant clone and alterations in the immune microenvironment in patients with TP53-mutant and wild-type MDS or sAML. Notably, PDL1 expression is significantly increased in hematopoietic stem cells of patients with TP53 mutations, which is associated with MYC upregulation and marked downregulation of MYC's negative regulator miR-34a, a p53 transcription target. Notably, patients with TP53 mutations display significantly reduced numbers of bone marrow-infiltrating OX40+ cytotoxic T cells and helper T cells, as well as decreased ICOS+ and 4-1BB+ natural killer cells. Further, highly immunosuppressive regulatory T cells (Tregs) (ie, ICOShigh/PD-1-) and myeloid-derived suppressor cells (PD-1low) are expanded in cases with TP53 mutations. Finally, a higher proportion of bone marrow-infiltrating ICOShigh/PD-1- Treg cells is a highly significant independent predictor of overall survival. We conclude that the microenvironment of TP53 mutant MDS and sAML has an immune-privileged, evasive phenotype that may be a primary driver of poor outcomes and submit that immunomodulatory therapeutic strategies may offer a benefit for this molecularly defined subpopulation.

Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training.

BACKGROUND: Operating room (OR) fires are rare but devastating events requiring immediate and effective response. Virtual Reality (VR) simulation training can provide a safe environment for practice of skills in such highly stressful situation. This study assessed interprofessional participants' ability to respond to VR-simulated OR fire scenarios, attitudes, numbers of attempt of the VR simulation do participants need to successfully respond to OR fires and does prior experience, confidence level, or professional role predict the number of attempts needed to demonstrate safety and pass the simulation. METHODS: 180 surgical team members volunteered to participate in this study at Beth Israel Deaconess Medical Center, Boston, MA. Each participant completed five VR OR simulation trials; the final two trials incorporated AI assistance. Primary outcomes were performance scores, number of attempts needed to pass, and pre- and post-survey results describing participant confidence and experiences. Differences across professional or training role were assessed using chi-square tests and analyses of variance. Differences in pass rates over time were assessed using repeated measures logistic regression. RESULTS: One hundred eighty participants completed simulation testing; 170 (94.4%) completed surveys. Participants included surgeons (17.2%), anesthesiologists (10.0%), allied health professionals (41.7%), and medical trainees (31.1%). Prior to training, 45.4% of participants reported feeling moderately or very confident in their ability to respond to an OR fire. Eight participants (4.4%) responded safely on the first simulation attempt. Forty-three participants (23.9%) passed by the third attempt (VR only); an additional 97 participants (53.9%) passed within the 4-5th attempt (VR with AI assistance). CONCLUSIONS: Providers are unprepared to respond to OR fires. VR-based simulation training provides a practical platform for individuals to improve their knowledge and performance in the management of OR fires with a 79% pass rate in our study. A VR AI approach to teaching this essential skill is innovative, feasible, and effective.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial.

BACKGROUND: Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia. METHODS: In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated. RESULTS: Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed. CONCLUSIONS: In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Weight gain and comorbidities associated with oral second-generation antipsychotics: analysis of real-world data for patients with schizophrenia or bipolar I disorder.

BACKGROUND: Many second-generation antipsychotics (SGAs) are associated with weight gain and cardiometabolic effects. Antipsychotic-associated weight gain is linked to treatment interruptions, potentially increasing risk of relapse and hospitalization. This retrospective study assessed clinically significant weight gain (CSWG), treatment interruptions, and development of cardiometabolic conditions in patients with schizophrenia (SZ) or bipolar I disorder (BD-I) following initiation of oral SGAs with moderate to high weight gain risk. METHODS: Patients with no prior use of moderate to high weight gain risk oral SGAs were identified from patient-level medical/pharmacy claims and electronic medical records (January 2013-February 2020; OM1 Real-World Data Cloud). Those with ≥ 1 weight measurement in both the 12 months preceding and 3 months after SGA initiation (index date) were analyzed for continuous changes in weight, CSWG (≥ 7% and ≥ 10% increases from baseline), treatment interruptions (switches/discontinuations), and development of cardiometabolic conditions. RESULTS: Median follow-up times in the SZ (n = 8174) and BD-I (n = 9142) cohorts were 153.4 and 159.4 weeks, respectively; 45.5% and 50.7% were obese at baseline. Mean (SD) percent weight increase during treatment was 3.3% (7.2) and 3.7% (7.0) for patients with SZ and BD-I, respectively, and was highest for underweight/normal weight patients (SZ: 4.8% [8.1]; BD-I: 5.5% [8.7]). More than 96% had treatment interruptions during follow-up, primarily discontinuations. CSWG and treatment interruptions occurred within a median of 13 and 14 weeks after treatment initiation, respectively. Of patients with CSWG and treatment interruptions, approximately 75% did not return to baseline weight during follow-up. Among those without baseline cardiometabolic conditions, 14.7% and 11.3% of patients with SZ or BD-I, respectively, developed ≥ 1 condition over 12 months post-index. Incidence was generally highest among those who were overweight/obese at baseline and those who experienced CSWG. CONCLUSIONS: In this analysis of real-world data, both weight gain and treatment interruptions occurred early in treatment for patients with SZ or BD-I. Treatment-associated weight gain persisted despite switching or discontinuing index treatment. Additionally, cardiometabolic morbidity increased within 12 months of treatment initiation. Patients with SZ or BD-I are at greater risk than the general population for cardiometabolic conditions; weight gain associated with SGAs may exacerbate these health risks.

Faculty perspectives on facilitating medical students' longitudinal learning: A mixed-methods study.

INTRODUCTION: Medical students' longitudinal care of patients supports clinical learning and promotes patient-centredness. The literature presents little empirically derived guidance for faculty to facilitate students' longitudinal learning and care. Informed by the conceptual framework of relational learning, this study investigated faculty perspectives about longitudinal teaching, their strategies for facilitating students' longitudinal learning and perceived barriers and enablers. METHODS: Using a convergent mixed-methods approach at a single academic medical centre, the authors conducted a survey and two focus groups in 2018-2019 with faculty members teaching in three longitudinal clinical courses. Quantitative analyses included descriptive statistics and chi-square tests. Qualitative content analysis described deductive categories and identified inductive themes. RESULTS: Forty-three eligible faculty (69%) completed the survey. Ninety-one percent (n = 39) reported that teaching in a longitudinal model enhanced their experience as preceptors. Faculty described activities students performed to provide longitudinal care: spending time with patients independently (n = 38, 88%), making follow-up phone calls (n = 35; 81%) and participating in home- and community-based visits (n = 20, 47%), among others. Twelve faculty participated in two focus groups. Deductive analysis characterised strategies for facilitating students' longitudinal learning and barriers and enablers. Strategies included "encouraging students to follow patients," "faculty adaptability," "offering guidance and setting expectations," and "careful patient selection." Barriers included scheduling limitations, and enablers included student initiative. Inductive analysis identified two themes: faculty goals for students and faculty benefits from teaching. Goals included meaningful engagement with patients and their illness over time. Benefits from teaching included personal gratification, mentorship, and holistic student assessment. DISCUSSION: Our survey and focus group findings demonstrated positive faculty attitudes and experiences, characterised faculty goals and approaches, and identified elements of the educational context that hindered or facilitated longitudinal teaching and learning. This study's faculty perspectives build upon prior investigations of students' and patients' perspectives, offer teaching strategies, and may guide faculty development.

Change in Physician Burnout between 2013 and 2020 in a Major Health System.

OBJECTIVE: Assessing changes in physician burnout over time can offer insight into the causes of burnout. Existing studies are limited by using different samples of physicians at each time point. Our objective was to assess changes in burnout between 2013-2014 and 2019-2020 overall and within a cohort of physicians who took the survey twice. METHODS: This is a longitudinal cohort and cross-sectional study of physicians in a major health system. They were administered the Maslach Burnout Inventory in 2013-2014 and 2019-2020. We separately assessed differences in odds of burnout and its subscales in 2013-2014 and 2019-2020 by physician characteristics and clinical time. We then assessed differences in the odds of reporting burnout and its subscales in 2019-2020 compared with 2013-2014 overall and by physician sex, race, and change in clinical full-time employment. RESULTS: There were 1220 respondents in 2013-2014, 503 in 2019-2020, and 149 who responded at both time points. Burnout increased from 35% to 56%. Compared with 2013-2014, physicians had 2.39 higher odds (95% confidence interval [CI] 1.92-2.98) of burnout in 2019-2020, and this change in burnout was significantly more pronounced for female versus male physicians (odds ratio 1.80; 95% CI 1.57-1.80). Compared with White physicians, non-White physicians had significantly lower odds of burnout at both time points, but their odds increased significantly more over time (odds ratio 1.36; 95% CI 1.05-1.57). CONCLUSIONS: We found a substantial increase in burnout over time, which was particularly pronounced for non-White and female physicians. Assessment over time is essential for understanding problematic trajectories of burnout that may be obscured by cross-sectional studies.

The Harvard Medical School Pathways curriculum: A comprehensive curricular evaluation.

PURPOSE: The Harvard Medical School Pathways curriculum represents a major reform effort. Our goals were to enhance reasoning and clinical skills and improve the learning environment and students' approach to learning via use of collaborative, case-based pedagogy; early clinical exposure; and enhanced approaches to teaching and evaluating clinical skills. We evaluated the impact of Pathways on key outcomes related to these goals. MATERIALS AND METHODS: In this prospective, mixed-methods study, we compared the last prior-curriculum cohort (2014 matriculation, n = 135) and first new-curriculum cohort (2015 matriculation, n = 135). Measures included Likert-type surveys, focus groups, and test scores to assess outcomes. RESULTS: Compared with prior-curriculum students, new-curriculum students reported higher mean preclerkship learning environment ratings (Educational Climate Inventory, 62.4 versus 51.9, p < 0.0001) and greater satisfaction with the quality of their preclerkship education (88% versus 73%, p = 0.0007). Mean USMLE Step-1 and Step-2 scores did not differ between groups. At graduation, new-curriculum students rated their medical school experience higher in 6 of 7 domains, including 'fostering a culture of curiosity and inquiry' (4.3 versus 3.9, p = 0.006) and focus on 'student-centered learning' (3.9 versus 3.4, p = 0.002). CONCLUSIONS: The new curriculum outperformed or was equal to the prior one on most measures of learning environment and perceived quality of education, without a decline in medical knowledge or clinical skills. Robust longitudinal evaluation provided important feedback for ongoing curriculum improvement.

Insight into small molecule binding to the neonatal Fc receptor by X-ray crystallography and 100 kHz magic-angle-spinning NMR.

Aiming at the design of an allosteric modulator of the neonatal Fc receptor (FcRn)-Immunoglobulin G (IgG) interaction, we developed a new methodology including NMR fragment screening, X-ray crystallography, and magic-angle-spinning (MAS) NMR at 100 kHz after sedimentation, exploiting very fast spinning of the nondeuterated soluble 42 kDa receptor construct to obtain resolved proton-detected 2D and 3D NMR spectra. FcRn plays a crucial role in regulation of IgG and serum albumin catabolism. It is a clinically validated drug target for the treatment of autoimmune diseases caused by pathogenic antibodies via the inhibition of its interaction with IgG. We herein present the discovery of a small molecule that binds into a conserved cavity of the heterodimeric, extracellular domain composed of an α-chain and ß2-microglobulin (ß2m) (FcRnECD, 373 residues). X-ray crystallography was used alongside NMR at 100 kHz MAS with sedimented soluble protein to explore possibilities for refining the compound as an allosteric modulator. Proton-detected MAS NMR experiments on fully protonated [13C,15N]-labeled FcRnECD yielded ligand-induced chemical-shift perturbations (CSPs) for residues in the binding pocket and allosteric changes close to the interface of the two receptor heterodimers present in the asymmetric unit as well as potentially in the albumin interaction site. X-ray structures with and without ligand suggest the need for an optimized ligand to displace the α-chain with respect to ß2m, both of which participate in the FcRnECD-IgG interaction site. Our investigation establishes a method to characterize structurally small molecule binding to nondeuterated large proteins by NMR, even in their glycosylated form, which may prove highly valuable for structure-based drug discovery campaigns.

Low-Molecular-Weight Carboxylic Acids in the Southeastern U.S.: Formation, Partitioning, and Implications for Organic Aerosol Aging.

While carboxylic acids are important components in both particle and gas phases in the atmosphere, their sources and partitioning are not fully understood. In this study, we present real-time measurements of both particle- and gas-phase concentrations for five of the most common and abundant low-molecular-weight carboxylic acids (LMWCA) in a rural region in the southeastern U.S. in Fall 2016. Through comparison with secondary organic aerosol (SOA) tracers, we find that isoprene was the most important local precursor for all five LMWCA but via different pathways. We propose that monocarboxylic acids (formic and acetic acids) were mainly formed through gas-phase photochemical reactions, while dicarboxylic acids (oxalic, malonic, and succinic acids) were predominantly from aqueous processing. Unexpectedly high concentrations of particle-phase formic and acetic acids (in the form of formate and acetate, respectively) were observed and likely the components of long-range transport organic aerosol (OA), decoupled from their gas-phase counterparts. In addition, an extraordinarily strong correlation (R2 = 0.90) was observed between a particulate LMWCA and aged SOA, which we tentatively attribute to boundary layer dynamics.

Long-term effect of aripiprazole lauroxil on health-related quality of life in patients with schizophrenia.

BACKGROUND: This post hoc analysis of clinical trial data evaluated long-term, self-reported mental and physical health-related quality of life (HRQoL) scores in schizophrenia patients receiving aripiprazole lauroxil (AL), an atypical long-acting injectable (LAI) antipsychotic approved for the treatment of schizophrenia in adults. METHODS: The study population included 291 stable schizophrenia outpatients enrolled in 2 consecutive long-term safety studies of AL given every 4 weeks for up to 124 weeks. HRQoL was measured using the SF-36v2® Health Survey (SF-36v2) over the course of the follow-up. The primary outcome was change in SF-36v2 mental component summary (MCS) and physical component summary (PCS) scores from baseline to 124 weeks. To contextualize these scores, descriptive analyses were conducted to compare the scores with available scores for the general population as well as for other populations with chronic medical (ie, hypertension and type 2 diabetes) or psychiatric (ie, depression) conditions. RESULTS: Results from this post hoc analysis indicated that the mean MCS score for patients continuing AL improved significantly from baseline over 124 weeks (P < .05, all timepoints), while mean PCS score showed little change over 124 weeks. At baseline, patients had lower (worse) MCS scores than the normed general population, but by week 124, patients had MCS scores comparable to those in the general population. This pattern of change was not observed with PCS scores. Comparison of study MCS scores with those associated with other diseases showed that this schizophrenia cohort had lower scores than those with chronic medical conditions but higher scores than those with depression. PCS scores were higher in the study population than published scores for all reference populations at baseline and week 124. CONCLUSIONS: In this post hoc analysis, outpatients with schizophrenia who continued the LAI antipsychotic AL showed gradual and sustained improvement in self-reported mental HRQoL over several years of follow-up, whereas self-reported physical HRQoL did not change. By the end of follow-up, mental health scores of study patients with schizophrenia were comparable to those of the general population and better than those of patients with depression. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01626456 [trial registration date: June 15, 2012] and NCT01895452 [trial registration date: July 5, 2013]).

Chemical feedbacks weaken the wintertime response of particulate sulfate and nitrate to emissions reductions over the eastern United States.

Sulfate ([Formula: see text]) and nitrate ([Formula: see text]) account for half of the fine particulate matter mass over the eastern United States. Their wintertime concentrations have changed little in the past decade despite considerable precursor emissions reductions. The reasons for this have remained unclear because detailed observations to constrain the wintertime gas-particle chemical system have been lacking. We use extensive airborne observations over the eastern United States from the 2015 Wintertime Investigation of Transport, Emissions, and Reactivity (WINTER) campaign; ground-based observations; and the GEOS-Chem chemical transport model to determine the controls on winter [Formula: see text] and [Formula: see text] GEOS-Chem reproduces observed [Formula: see text]-[Formula: see text]-[Formula: see text] particulate concentrations (2.45 µg [Formula: see text]) and composition ([Formula: see text]: 47%; [Formula: see text]: 32%; [Formula: see text]: 21%) during WINTER. Only 18% of [Formula: see text] emissions were regionally oxidized to [Formula: see text] during WINTER, limited by low [H2O2] and [OH]. Relatively acidic fine particulates (pH∼1.3) allow 45% of nitrate to partition to the particle phase. Using GEOS-Chem, we examine the impact of the 58% decrease in winter [Formula: see text] emissions from 2007 to 2015 and find that the H2O2 limitation on [Formula: see text] oxidation weakened, which increased the fraction of [Formula: see text] emissions oxidizing to [Formula: see text] Simultaneously, NOx emissions decreased by 35%, but the modeled [Formula: see text] particle fraction increased as fine particle acidity decreased. These feedbacks resulted in a 40% decrease of modeled [[Formula: see text]] and no change in [[Formula: see text]], as observed. Wintertime [[Formula: see text]] and [[Formula: see text]] are expected to change slowly between 2015 and 2023, unless [Formula: see text] and NOx emissions decrease faster in the future than in the recent past.

A story half told: a qualitative study of medical students' self-directed learning in the clinical setting.

BACKGROUND: Medical educators have promoted self-directed learning (SDL) as an important means of enabling students to take responsibility for their own learning throughout their training and practice. While SDL has been well-studied in classroom settings, it remains a story half told: barriers to and facilitators of SDL in the clinical setting are not yet well described. The goals of this study were to explicate student experiences of SDL in their clinical training and to identify the roles that local social and cultural contexts play in shaping their experiences of SDL. METHODS: To understand students' conceptualization and experiences of SDL in the clinical setting, we carried out a qualitative study with 15 medical students at Harvard Medical School. The semi-structured interviews were recorded and transcribed. Using an interpretivist approach, data were analyzed both deductively and inductively using the Framework method of content analysis. RESULTS: Participants described patient care activities as primary motivators for engagement in SDL in the clinical setting. Participants' descriptions of SDL aligned with Knowles' steps in SDL, with an additional step of consolidation of learning related to their patients' diagnosis and management. Participants described using a range of cognitive, social-emotional, and peer learning strategies to enhance their SDL. Participants who described a growth mindset appeared to engage in SDL more easily. Learning environments that fostered SDL were those in which faculty and residents demonstrated an educational orientation, promoted psychological safety, and invited student engagement. Teams with perceived excessive work demands were perceived to be less supportive of SDL. CONCLUSIONS: Our study enhances previous classroom-based models of SDL by providing specific, practical implications for both students and faculty in the clinical training setting. Participants described SDL in the clinical setting as patient-centered, and when effectively implemented, SDL appears to support a mastery rather than performance orientation. Our study paves the way for improving medical students' clinical SDL and helping them become lifelong learners in the field of medicine.

Antipsychotic treatment experiences of people with bipolar I disorder: patient perspectives from an online survey.

BACKGROUND: Oral antipsychotic (AP) medications are frequently prescribed to people with bipolar I disorder (BD-I). A cross-sectional online survey examined the experiences of people living with BD-I with a history of recent AP use. METHODS: Adults with self-reported physician-diagnosed BD-I (N = 200) who received oral APs during the prior year completed a survey on AP-related experiences, including side effects and their perceived burden on social functioning, adherence, and work. Items also assessed preferences for trade-offs (balancing symptom management and side effects) when considering a hypothetical new AP. The perceived impact of specific, prevalent side effects on adherence, work, and preferences for a hypothetical AP were also examined. Analyses were descriptive. RESULTS: The survey sample had a mean age of 43.2 (SD = 12.4) years, was 60% female, and 31% nonwhite. Almost all participants (98%) had experienced AP side effects. Common self-reported side effects were feeling drowsy or tired (83%), lack of emotion (79%), anxiety (79%), dry mouth (76%), and weight gain (76%). Weight gain was cited as the most bothersome side effect, rated by most participants (68%) as "very" or "extremely bothersome." Nearly half of participants (49%) reported that AP side effects negatively impacted their job performance; almost all (92%) reported that side effects - most commonly anxiety and lack of emotion - negatively impacted social relationships (e.g., family or romantic partners). The most commonly-reported reason for stopping AP use was dislike of side effects (48%). Side effects most likely to lead to stopping or taking less of AP treatment included "feeling like a 'zombie'" (29%), feeling drowsy or tired (25%), and weight gain (24%). When considering a hypothetical new AP, the most common side effects participants wanted to avoid included AP-induced anxiety (50%), weight gain (48%), and "feeling like a 'zombie'" (47%). CONCLUSIONS: Side effects of APs were both common and bothersome, and impacted social functioning, adherence, and work. Findings highlight the prevailing unmet need for new APs with more favorable benefit-risk profiles.

Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability.

OBJECTIVE: This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND: Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS: We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS: We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION: Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.