Reporting and conducting patient journey mapping research in healthcare: A scoping review.

AIM: To identify how patient journey mapping is being undertaken and reported. DESIGN: A scoping review of the literature was undertaken using JBI guidance. DATA SOURCES: Databases were searched in July 2021 (16th-21st), including Ovid's Medline, Embase, Emcare and PsycINFO; Scopus; Web of Science Core Collection, the Directory of Open Access Journals; Informit and; ProQuest Dissertations and Theses Global. REVIEW METHODS: Eligible articles included peer-reviewed literature documenting journey mapping methodologies and studies conducted in healthcare services. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full-text articles. A table was used to extract data and synthesize results. RESULTS: Eighty-one articles were included. An acceleration of patient journey mapping research was observed, with 76.5% (n = 62) of articles published since 2015. Diverse mapping approaches were identified. Reporting of studies was inconsistent and largely non-adherent with relevant, established reporting guidelines. CONCLUSION: Patient journey mapping is a relatively novel approach for understanding patient experiences and is increasingly being adopted. There is variation in process details reported. Considerations for improving reporting standards are provided. IMPACT: Patient journey mapping is a rapidly growing approach for better understanding how people enter, experience and exit health services. This type of methodology has significant potential to inform new, patient centred models of care and facilitate clinicians, patients and health professionals to better understand gaps and strategies in health services. The synthesised results of this review alert researchers to options available for journey mapping research and provide preliminary guidance for elevating reporting quality.

Are Male Couples Changing Their Sexual Agreements and Behaviors During the COVID-19 Pandemic?

Sexual agreements are an important element of HIV prevention for many partnered gay, bisexual, and other men who have sex with men (GBMSM). This study describes sexual agreement and sexual behavior changes during the 2020 pandemic among a sample of 215 coupled US GBMSM. Overall, reported behavior shifted towards monogamy. Fifteen percent of respondents developed/ended/changed their agreement during the pandemic; the pandemic factored into 85% of reported changes. Individuals reported fewer outside sexual partners compared to the 3 months pre-pandemic. More research is needed to investigate shifting behavior and associated risk in order to adapt HIV services during the pandemic.

Assessing the Reliability of Self-Reported Sexual Behavior Among Male Couples.

Coupled gay, bisexual, and other men who have sex with men (GBMSM) are at particularly high risk for HIV, and a clear understanding of behavioral risk is key to effective interventions. Accurate behavioral self-reports are a crucial component of valid sexual health research, yet reliability of these data remains understudied. This study aimed to quantify and identify predictors of dyadic discordance in reported 3-month anal intercourse (AI) occurrence and frequency. Using cross-sectional data from 407 male couples in the U.S. (2016-2017), we calculated proportional dyadic concordance and used dyad-level logistic and linear regression to identify demographic, behavioral, and relationship traits associated with the odds of discordant frequency reports and the relative difference between discordant partner reports. Couples had high levels of concordant reports of 3-month anal AI occurrence (97%) but low interpartner agreement in reported frequency (37%). After adjustment, the odds of discordance were significantly associated with dyadic employment and differences on the Communal Coping to Reduce HIV Threat Scale (CCS) (p < .05). Among frequency-discordant couples, the mean relative difference between partner reports was 52.80% ± 35.91% (M ± SD). After adjustment, relative differences between partners' reported AI frequencies were positively associated with interpartner differences in CCS (p < .05). These results indicate that among GBMSM couples in committed partnerships, self-reported sexual behavior data may be impacted by granularity, recall, and relationship characteristics. Further research in this area is warranted to better understand measurement error in self-reported sexual activity data.

The Experiences of Younger Individuals Living With Heart Failure.

BACKGROUND: Heart failure (HF) impacts 1.7 million Americans between the ages of 20 and 59 years, but limited research exists addressing the issues unique to this age group. OBJECTIVE: The aim of this study was to investigate the experiences of younger persons living with HF. METHODS: Semistructured interviews (n = 18) were analyzed using a qualitative thematic analysis. RESULTS: Six themes emerged: (1) role fulfillment: participants who perceived their roles as a parent, caregiver, spouse, employee, and friend have been negatively affected by HF; (2) autonomy: participants frequently linked their well-being to a sense of independence, productivity, and purpose; (3) financial impact: most of the sample expressed financial instability further complicated by existing disability policies; (4) perception of self: recurrent statements revealed participants feeling judged because of their HF diagnosis and younger age; (5) retrospective life changes: participants reflected on past decisions and often blamed themselves for their current health; and (6) symptom burden: participants reported higher levels of psychosocial symptoms, such as depression, anxiety, and fatigue. CONCLUSIONS: Younger individuals living with HF reported overwhelmingly poor health-related quality of life that was linked to the 6 themes identified previously. The effect of HF was seen on numerous life events that traditionally occur earlier in the life course such as establishing a career, meaningful relationships, family, and financial security. This directly impacted health-related quality of life by disrupting what each individual perceived as important to them, which took a toll on their overall mental health. To provide holistic care to younger patients living with HF, interventions that address the heavy burden of psychosocial symptoms and policy changes associated with financial burden and disability laws must be developed.

Pregnancy in the shadow of psychosis: Navigating first-time motherhood with increased likelihood of postpartum psychosis and postnatal depression.

WHAT IS KNOWN ON THE SUBJECT?: New parents who have previously experienced psychosis outside and/or following childbirth have an increased likelihood of experiencing an episode during the postpartum period. The decision to try to conceive can be agonising. Receiving care from a specialist perinatal community mental health team can improve outcomes. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This article offers a first-person insight into the steps the author took to minimise the impact of an episode of postpartum psychosis and/or postnatal depression whilst navigating new motherhood. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This lived experience narrative aligns with the evidence base that demonstrates specialist perinatal community mental health services improve outcomes. It highlights the importance of maternity care providers asking about mental health history to identify any previous episodes or family history and offering referral to a specialist perinatal mental health service if available. ABSTRACT: Introduction Postpartum psychosis is a life-changing but treatable condition that usually occurs in the first few days to weeks after childbirth affecting 1-2 in 1000 pregnancies. Those who have experienced psychosis before, either as a single episode, related or unrelated to childbirth or as part of a long-term mental health condition have a higher likelihood of experiencing an episode in the postnatal period. Aim In this lived experience narrative the author shares personal experience of planning and navigating pregnancy with a higher likelihood of experiencing postpartum psychosis and postnatal depression around this major life transition due to previous episodes. Methods The author utilises a first-person approach to share and reflect on her lived experience. Findings The author shares her experience of receiving care and some of the steps she took to try to manage the impact of pregnancy and birth on her mental health during this major life transition. She describes how care from a specialist perinatal community mental health team and peer support contributed significantly to her family's well-being. Discussion Specialist perinatal community mental health services can improve outcomes for those with a higher likelihood of experiencing postpartum psychosis and postnatal depression by facilitating planning and mitigating some of the risks that could lead to relapse in the perinatal period.

Intimate Partner Violence Perpetration Denial and Underreporting in Cisgender Male Couples.

Intimate partner violence (IPV) perpetrators often deny their actions, limiting opportunities for intervention. Cisgender male couples experience similar IPV rates to mixed-gender couples, yet less is known about how men in same-sex relationships deny or report their IPV behavior. This study aimed to describe perpetration denial across emotional, monitoring/controlling, and physical/sexual IPV, and to identify correlates of perpetration denial, in a convenience sample of male couples (N = 848; United States, 2016-2017). Past-year victimization and perpetration were measured with the IPV-Gay and Bisexual Men (GBM) scale; perpetration deniers were men whose self-reported perpetration contradicted their partner's reported victimization. Individual-, partner-, and dyadic-correlates of perpetration denial, by IPV-type, were identified using actor-partner interdependence models. We identified 663 (78.2%) perpetrators: 527 emotional; 490 monitoring/controlling; 267 physical/sexual. Thirty-six percent of physical/sexual-, 27.7% of emotional-, and 21.43% of monitoring/controlling-perpetrators categorically denied their actions. Depression was negatively associated with denying monitoring/controlling-perpetration (odds ratio 95% confidence interval: 0.91 [0.84, 0.99]) and physical/sexual-perpetration (0.91 [0.83, 0.97]); dyadic differences in depression were associated with emotional-perpetration denial (0.95 [0.90, 0.99]). Recent substance users had 46% lower odds of monitoring/controlling-denial (0.54 [0.32, 0.92]), versus non-users. Partner-race and employment were also significantly associated with emotional perpetration denial. This study highlights IPV denial's complexities, including differences across IPV types. Further investigations into how cisgender men in same-sex couples perceive and report various types of IPV perpetration will provide valuable insight into how an underserved and understudied population experiences IPV.

Los agresores de pareja a menudo niegan sus actos, lo que reduce la posibilidad de intervención. Las parejas de hombres cisgénero presentan índices de violencia de pareja (VP) semejantes a las parejas de distinto género, aunque se sabe menos de cómo niegan la VP los hombres que están en una relación del mismo sexo. El estudio pretende describir la negación de que se ejerce VP en sus variantes emocional, vigilancia/control y física/sexual, así como conocer los correlatos de dicha negación, en una muestra de conveniencia de parejas de hombres (N = 848, EEUU, 2016-2017). Se midió la victimización y la comisión de VP durante el último año por medio de la escala IPV-GBM. Quienes negaban haber ejercido VP eran hombres cuyo comportamiento autoinformado contradecía la victimización que declaraba sufrir su pareja. Se detectaron por tipo de VP los correlatos individuales, de pareja y diádicos de la negación de haber perpetrado VP, mediante modelos de interdependencia actor-pareja. Se detectaron 663 (78.2%) perpetradores: en 527 era emocional, en 490 de vigilancia/control y en 267 física/sexual. El 36% de los que perpetraban violencia física/sexual y el 21.43% de vigilancia/control negaban sus actos categóricamente. La depresión se asociaba negativamente a la negación de haber perpetrado violencia de vigilancia/control (razón de probabilidad, 95% IC: 0.91 [0.84, 0.99]) y física/sexual (0.91 [0.83, 0.97]). Las diferencias diádicas en depresión se asociaban a la negación de haber perpetrado violencia emocional (0.95 [0.90, 0.99]). La probabilidad de los usuarios recientes de sustancias de negar la violencia de vigilancia/control era un 46% menor (0.45 [0.32, 0.92]) que la de quienes no consumían. La raza de su pareja y su empleo se asociaban también significativamente con negar que se hubiera cometido violencia emocional. El estudio destaca las complejidades de negar la violencia de pareja, como las diferencias entre tipos de VP. Seguir investigando en cómo los hombres cisgénero en las parejas del mismo sexo perciben y dan cuenta de los diversos tipos de perpetración de VP aportará un conocimiento valioso sobre cómo experimenta la VP una población minusvalorada y poco estudiada.

Mapping LGBTQ+ Youth Resource Density Across Four High HIV Prevalence Corridors in the US.

Introduction: Studies using geospatial data to understand LGBTQ+-friendly sexual health and wellness resource availability have often focused on services catered to adults. While HIV rates have increased in adolescents in recent years, few studies have explored disparities in resource access for adolescent gay and bisexual men (AGBMSM). Methods: We used geospatial data of resources (collected and verified 2017-2018) from the iReach app to understand disparities in resource access for AGBMSM within and between 4 high HIV prevalence corridors in the US. Results: AGBMSM in non-metro areas had access to fewer resources and some rural counties had no LGBTQ+ -friendly resources. Corridors comprising states with legacies of punitive laws targeting sexual and gender minorities demonstrate stark geographic disparities across the US. Conclusions: Policy-makers must understand the granularity of disparities within regions. Online resources may be able to surmount LGBTQ+ resource deserts. However, physical access to LGBTQ+ -friendly services must be improved as a fundamental strategy for reducing HIV among AGBMSM. Supplementary Information: The online version contains supplementary material available at 10.1007/s13178-021-00660-0.

Intimate Partner Violence Experiences During COVID-19 Among Male Couples.

In addition to the growing morbidity and mortality related to the 2019 novel coronavirus (SAR-CoV-2) pandemic, social distancing measures during the pandemic may result in increased intimate partner violence (IPV). However, it is yet unknown if gay, bisexual, and other men who have sex with men (GBMSM)'s IPV risk has increased during this time. This article describes and analyzes IPV experiences during the COVID-19 pandemic in a sample of coupled-GBMSM in the United States. We hypothesized that pandemic-driven stressors would be associated with increased IPV prevalence and severity. A sample of 214 coupled men living in the US who had previously participated in HIV-related couple studies was surveyed in July-September 2020. Respondents reported demographic, sexual and substance use behaviors, and relationship characteristics. Surveys also collected data on pandemic-related life-changes (employment, substance use, COVID-19 illness). IPV victimization and perpetration were measured with the Gay and Bisexual Men Intimate Partner Violence scale and measured individually experienced or perpetrated violence, sexual, emotional, monitoring, or controlling behaviors, and if a given behavior was new and/or had changed in frequency during the pandemic. Reported prevalence and pandemic-related changes in victimization and perpetration were described. New or more frequent IPV victimization was modeled against employment, substance use changes, COVID-19 illness, and outside sexual partners (modified by a couple's sexual agreement). IPV perpetration prevalence was 15.17%, 34.44% of which was new or more frequent. Victimization prevalence was 14.95%, of which 46.88% was new or more frequent. After adjustment, outside sexual partners were associated with IPV among those with nonmonogamous sexual agreements; each outside sexual partner increased the odds of new or more frequent victimization by 70% (OR = 1.70; 95% CI [1.16, 2.51]). Given this study's documented rise in IPV among a sample of coupled men, additional research into IPV predictors, interventions, and support strategies in GBMSM populations are warranted.

Inter-partner Agreement of Condom Use and Sexual Positioning in Male Couples.

Accurate, reliable self-reports of sexual behavior are a crucial component of valid HIV risk-estimation and behavioral intervention evaluation, yet this data's reliability remains understudied. The goal of this study was to describe interpartner agreement on recent receptive anal intercourse (AI) and condomless receptive AI frequencies, among a sample of male couples. We quantified interpartner agreement on self-reported receptive AI and condomless receptive AI (absolute and relative to AI frequency), and position and condom use during a couple's most recent AI, using cross-sectional data from male partners (US, 2016-2017; N = 718 individuals). Proportional and statistical agreement (intraclass correlation coefficients (ICC), kappa (k)) were assessed. Observed agreement for receptive AI frequency was 49.44% (ICC (95% CI): 0.82(0.79, 0.84)) and for relative receptive frequency, 59.05% (ICC: 0.96 (0.85, 0.96). Agreement on condomless receptive AI was 90.21% (ICC: 0.78 (0.75, 0.82), and for relative condomless receptive AI, 91.15% (ICC: 0.80 (0.77, 0.83). Most recent AI position agreement was 89.42% (k (95% CI): 0.84 (0.80, 0.88)), and condom use, 98.89% (k: 0.82 (0.87, 0.98)). Observed agreement was higher among those who reported consistent positioning and condom use. Further research on self-reported sexual behavior data is needed to improve research validity and intervention effectiveness.

Coping with COVID-19. Work life experiences of nursing, midwifery and paramedic academics: An international interview study.

BACKGROUND: The COVID-19 global pandemic was declared in March 2020. By June 2022, the total deaths worldwide attributed to COVID-19 numbered over 6.3 million. Health professionals have been significantly impacted worldwide primarily those working on the frontline but also those working in other areas including nursing, midwifery, and paramedic higher education. Studies of occupational stress have focused on the clinical health professional roles but scant attention has been drawn to the pressures on university-based academic staff supporting and preparing professionals for frontline health work. DESIGN AND OBJECTIVES: This qualitative study sought to explore the challenges experienced by health academics (nurses, midwives and paramedics), during COVID-19 and identify strategies enlisted. SETTING AND PARTICIPANTS: Six Australian and two United Kingdom universities collaborated, from which 34 health academics were individually interviewed via video or teleconference, using six broad questions. Ethical approval was obtained from the lead site and each participating University. DATA ANALYSIS: Thematic analysis of the data was employed collaboratively across institutions, using Braun and Clarke's method. RESULTS: Data analysis generated four major themes describing academics': Experiences of change; perceptions of organisational responses; professional and personal impacts; and strategies to support wellbeing. Stress, anxiety and uncertainty of working from home and teaching in a different way were reported. Strategies included setting workday routine, establishing physical boundaries for home-working and regular online contact with colleagues. CONCLUSIONS: The ability of nursing, midwifery and, paramedic academic staff to adapt to a sudden increase in workload, change in teaching practices and technology, while being removed from their work environment, and collegial, academic and technological supports is highlighted. It was recognised that these changes will continue post-COVID and that the way academics deliver education is forever altered.

Positive and Negative Impacts of the COVID-19 Pandemic on Relationship Satisfaction in Male Couples.

Little is known about the impact of the coronavirus pandemic and control measures on gay, bisexual, and other men who have sex with men (GBMSM) couples. The goal of this study was to investigate individual-level relationship satisfaction during the COVID-19 pandemic in a sample of 209 coupled GBMSM in the United States. We analyzed reported happiness and feelings about a relationship's future and assessed the odds of changing relationship happiness and investment associated with pandemic-related life changes (pandemic-related employment change; COVID-19 illness; high-risk of severe illness), using logistic and multinomial logit models. Fifty-five percent of participants (N = 114) reported that their relationship happiness had not changed during the pandemic, but 30% (N = 62) reported increased relationship happiness. 25% (N = 53) reported they had become more invested in their relationship's future during the pandemic, and only one participant reported decreased investment. The odds of increased relationship investment was significantly associated with pandemic-related employment change (adjusted odds ratio (aOR), 95% confidence interval (CI): 2.19 [1.04, 4.61]) and increased sex during the pandemic (aOR: 4.38 [1.55, 12.41]). Those with a pandemic-related employment change also had significantly higher odds of increased relationship happiness than those without a change (aOR: 2.10 [1.01, 4.35]). COVID-19 cases that reported being at higher risk of serious COVID-19 disease had higher odds of decreased relationship happiness than high-risk non-cases (aOR: 6.58 [1.10, 39.39]). Additional research in this area is warranted to minimize the long-term impacts of the pandemic on coupled GBMSM.

End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit.

OBJECTIVE: To assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants. STUDY DESIGN: A case-control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36). RESULT: The infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases. CONCLUSION: Continuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.

Widespread closure of HIV prevention and care services places youth at higher risk during the COVID-19 pandemic.

BACKGROUND: Central to measuring the impact of the COVID-19 pandemic on HIV is understanding the role of loss of access to essential HIV prevention and care services created by clinic and community-based organization closures. In this paper, we use a comprehensive list of HIV prevention services in four corridors of the US heavily impacted by HIV, developed as part of a large RCT, to illustrate the potential impact of service closure on LGBTQ+ youth. METHODS: We identified and mapped LGBTQ+ friendly services offering at least one of the following HIV-related services: HIV testing; STI testing; PrEP/PEP; HIV treatment and care; and other HIV-related services in 109 counties across four major interstate corridors heavily affected by HIV US Census regions: Pacific (San Francisco, CA to San Diego, CA); South-Atlantic (Washington, DC to Atlanta, GA); East-North-Central (Chicago, IL to Detroit, MI); and East-South-Central (Memphis, TN to New Orleans, LA). RESULTS: There were a total of 831 LGBTQ+ youth-friendly HIV service providers across the 109 counties. There was a range of LGBTQ+ youth-friendly HIV-service provider availability across counties (range: 0-14.33 per 10,000 youth aged 13-24 (IQR: 2.13), median: 1.09); 9 (8.26%) analyzed counties did not have any LGBTQ+ youth-friendly HIV service providers. The Pearson correlation coefficient for the correlation between county HIV prevalence and LGBTQ+ youth-friendly HIV service provider density was 0.16 (p = 0.09), suggesting only a small, non-statistically significant linear relationship between a county's available LGBTQ+ youth-friendly HIV service providers and their HIV burden. CONCLUSIONS: As the COVID-19 pandemic continues, we must find novel, affordable ways to continue to provide sexual health, mental health and other support services to LGBTQ+ youth.

Multiple neurohumoral modulating agents in systolic dysfunction heart failure: are we lowering blood pressure too much?

BACKGROUND: Disease-modifying drug treatment in heart failure (HF) reduces blood pressure. Titration of these agents is guided by clinic blood pressure readings; however, the impact of such treatment on blood pressure is unknown because diurnal blood pressure patterns remain poorly described. The aim of this study was to examine the impact of additional neurohumoral modulating agents on ambulatory blood pressure monitoring (ABPM) control in patients with systolic HF and examine the relationship between the burden of hypotension and clinical outcomes. METHODS AND RESULTS: In a prospective analysis on 45 patients undergoing initiation and optimization of additional medications (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or beta-blockers), mean daytime systolic (P = .035) and mean daytime and nocturnal diastolic hypotensive episodes (both P < .001) increased significantly posttitration. There was no change in clinic blood pressure before and after titration. In a cross-sectional analysis on 144 patients, those with the most diastolic hypotensive episodes had higher rates of HF readmissions (P = .01) and the composite end point of all-cause mortality and all-cause readmissions (P = .03). CONCLUSIONS: Additional neurohumoral modulating agents could produce significant increases in 24-hour hypotension burden despite reassuring clinic blood pressure readings. The burden of diastolic hypotension is independently predictive of HF readmissions and the composite end point of all-cause mortality and emergency readmissions.

Defining the mechanistic binding of viral particles to a multi-modal anion exchange resin.

A multi-tiered approach to determine the binding mechanism of viral clearance utilizing a multi-modal anion exchange resin was applied to a panel of four viral species that are typically used in validating viral clearance studies (i.e., X-MuLV, MVM, REO3, and PrV). First, virus spiked buffer-only experiments were conducted to evaluate the virus's affinity for single mode and multi-modal chromatography resins under different buffer conditions in a chromatography column setting. From these results we hypothesize that the mechanisms of binding of the viruses involve binding to both the hydrophobic and anionic functional groups. This mechanistic view agreed with the general surface characteristics of the different virus species in terms of isoelectric point and relative hydrophobicity values. This hypothesized mechanistic binding was then tested with commercially relevant, in-process materials, in which competitive binding occurred between the load components (e.g., viruses, target product, and impurities) and the resin. © 2018 American Institute of Chemical Engineers Biotechnol. Prog., 34:1019-1026, 2018.

The step-wise framework to design a chromatography-based hydrophobicity assay for viral particles.

A high-salt, hydrophobic interaction chromatography (HIC) method was developed to measure the relative hydrophobicity of a diverse set of solutes. Through the careful control of buffer pH and salt concentration, this assay was then used to ascertain for the first time the relative hydrophobicity values of three different bacteriophage, four mammalian viruses, and a range of biotech medicinal proteins as benchmarked to protein standards previously characterized for hydrophobicity.

Design and methods of a social network isolation study for reducing respiratory infection transmission: The eX-FLU cluster randomized trial.

BACKGROUND: Social networks are increasingly recognized as important points of intervention, yet relatively few intervention studies of respiratory infection transmission have utilized a network design. Here we describe the design, methods, and social network structure of a randomized intervention for isolating respiratory infection cases in a university setting over a 10-week period. METHODOLOGY/PRINCIPAL FINDINGS: 590 students in six residence halls enrolled in the eX-FLU study during a chain-referral recruitment process from September 2012-January 2013. Of these, 262 joined as "seed" participants, who nominated their social contacts to join the study, of which 328 "nominees" enrolled. Participants were cluster-randomized by 117 residence halls. Participants were asked to respond to weekly surveys on health behaviors, social interactions, and influenza-like illness (ILI) symptoms. Participants were randomized to either a 3-Day dorm room isolation intervention or a control group (no isolation) upon illness onset. ILI cases reported on their isolation behavior during illness and provided throat and nasal swab specimens at onset, day-three, and day-six of illness. A subsample of individuals (N=103) participated in a sub-study using a novel smartphone application, iEpi, which collected sensor and contextually-dependent survey data on social interactions. Within the social network, participants were significantly positively assortative by intervention group, enrollment type, residence hall, iEpi participation, age, gender, race, and alcohol use (all P<0.002). CONCLUSIONS/SIGNIFICANCE: We identified a feasible study design for testing the impact of isolation from social networks in a university setting. These data provide an unparalleled opportunity to address questions about isolation and infection transmission, as well as insights into social networks and behaviors among college-aged students. Several important lessons were learned over the course of this project, including feasible isolation durations, the need for extensive organizational efforts, as well as the need for specialized programmers and server space for managing survey and smartphone data.

Managing your practice's first impression: the process of front-desk reengineering.

Patients must be regarded as consumers. As such, they are increasingly informed, questioning, cost-conscious, technologically savvy, and demanding. Just as health plans have developed defined contribution products that offer consumers more control over how and where their health-care dollars are spent, practice success is linked to reengineering office operations to offer consumers and patients greater choice, control, autonomy, and service. Patients and consumers want practices that deliver clinical and business services that meet the criteria of reliability, effciency, service offerings, patient focus, enthusiasm, customization, and trust. Physician practices must also take care to avoid destructive and disruptive behaviors and conditions such as noise, interference, excessive repetition, long waits, appointment delays, and staff rudeness. A successful patient-focused practice emerges when physicians and office staff begin to look at the clinical and service experience through the patient's eyes.

Cardioembolic stroke secondary to Lambl's excrescence on the aortic valve: a case report.

We report a patient who presented with aphasia and was found to have an embolic cerebral infarction secondary to LE. LE is a rare source of cardioembolic stroke.