Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine.

BACKGROUND: The gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute. OBJECTIVE: To characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021. MAIN MEASURES: Monthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables. KEY RESULTS: The analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively). CONCLUSIONS: Increased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems.

STUDY OBJECTIVE: People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. METHODS: Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. RESULTS: Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. CONCLUSION: Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Sustainable removal of Cr(VI) using graphene oxide-zinc oxide nanohybrid: Adsorption kinetics, isotherms and thermodynamics.

Metal-based adsorbents are limited for hexavalent chromium [Cr(VI)] adsorption from aqueous solutions because of their low adsorption capacities and slow adsorption kinetics. In the present study, decorated zinc oxide (ZnO) nanoparticles (NPs) on graphene oxide (GO) nanoparticles were synthesized via the solvothermal process. The deposition of ZnO NPs on graphene oxide for the nanohybrid (ZnO-GO) improves Cr(VI) mobility in the nanocomposite or nanohybrid, thereby improving the Cr(VI) adsorption kinetics and removal capacity. Surface deposition of ZnO on graphene oxide was characterized through Fourie Transform Infra-red (FTIR), UV-Visible, X-ray Diffraction (XRD), Field Emission Scanning Electron Microscopy (FESEM), Energy Dispersive Spectroscopy (EDS), and Brunauer-Emmett-Teller (BET) techniques. These characterizations suggest the formation of ZnO-GO nanocomposite with a specific area of 32.95 m2/g and pore volume of 0.058 cm2/g. Batch adsorption analysis was carried to evaluate the influence of operational parameters, equilibrium isotherm, adsorption kinetics and thermodynamics. The removal efficiency of Cr(VI) increases with increasing time and adsorbent dosage. FTIR, FESEM and BET analysis before and after the adsorption studies suggest the obvious changes in the surface functionalization and morphology of the ZnO-GO nanocomposites. The removal efficiency increases from high-acidic to neutral pH and continues to decrease under alkaline conditions as well. Mathematical modeling validates that the adsorption follows Langmuir isotherm and fits well with the pseudo 2nd order kinetics (Type 5) model, indicating a homogeneous adsorption process. The thermodynamics study reveals that Cr(VI) adsorption on ZnO-GO is spontaneous, endothermic, and entropy-driven. A negative value of Gibb's Free Energy represents the thermodynamic spontaneity and feasibility of the sorption process. To the best of our knowledge, this is the first study of Cr(VI) removal from aqueous solution using this hybrid nanocomposite at near-neutral pH. The synthesized nanocomposites prove to be excellent candidates for Cr(VI) removal from water bodies and natural wastewater systems.

Why Do Physicians Depart Their Practice? A Qualitative Study of Attrition in a Multispecialty Ambulatory Practice Network.

BACKGROUND: Physician departure causes considerable disruption for patients, colleagues, and staff. The cost of finding a new physician to replace the loss coupled with lost productivity as they build their practice can cost as much as $1 million per departure. Therefore, we sought to characterize drivers of departure from practice with the goal of informing retention efforts (with a special emphasis on the connection between electronic health record (EHR)-related stress and physician departure). METHODS: This qualitative study of semistructured interviews was conducted between October 2021 and April 2022 among 13 attending physicians who had voluntarily departed their position from 2018 to 2021 in a large multispecialty, productivity-based, ambulatory practice network in the Northeast with a 5% annual turnover rate to understand their reasons for departing practice. RESULTS: Among the 13 participants, 8 were women (61.5%), 3 retired (23.1%), and 6 (46.2%) left for new positions. Major domains surrounding the decision to depart included current features of the health care delivery landscape, leadership/local practice culture, and personal considerations. Major factors within these domains included the EHR, compensation model, emphasis on metrics, leadership support, teamwork/staffing, burnout, and work-life integration. CONCLUSIONS: Opportunities for medical practices to prevent ambulatory physicians' turnover include: (1) addressing workflow by distributing responsibility across team members to better address patient expectations and documentation requirements, (2) ensuring adequate staffing across disciplines and roles, and (3) considering alternative care or payment models.

Trends in the Prescribing of Buprenorphine for Opioid Use Disorder, 2019-2023.

Objective: To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022). Patients and Methods: The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type. Results: Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants. Conclusion: We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.

Understanding the Heterointerfaces in Perovskite Solar Cells via Hole Selective Layer Surface Functionalization.

Interfaces in perovskite solar cells (PSCs) play a pivotal role in determining device performance by influencing charge transport and recombination. Understanding the physical processes at these interfaces is essential for achieving high-power conversion efficiency in PSCs. Particularly, the interfaces involving oxide-based transport layers are susceptible to defects like dangling bonds, excess oxygen, or oxygen deficiency. To address this issue, the surface of NiOx is passivated using octadecylphosphonic acid (ODPA), resulting in improved charge transport across the perovskite hole transport layer (HTL) interface. This surface treatment has led to the development of hysteresis-free devices with an impressive ≈13% increase in power conversion efficiency. Computational studies have explored the halide perovskite architecture of ODPA-treated HTL/Perovskite, aiming to unlock superior photovoltaic performance. The ODPA surface functionalization has demonstrated enhanced device performance, characterized by superior charge exchange capacity. Moreover, higher band-to-band recombination in photoluminescence and electroluminescence indicates presence of lower mid-gap energy states, thereby increasing the effective photogenerated carrier density. These findings are expected to promote the utilization of various phosphonic acid-based self-assembly monolayers for surface passivation of oxide-based transport layers in perovskite solar cells. Ultimately, this research contributes to the realization of efficient halide PSCs by harnessing the favorable architecture of NiOx interfaces.

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol.

INTRODUCTION: The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS: This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION: Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER: NCT04959279; Pre-results.

Predicting physician departure with machine learning on EHR use patterns: A longitudinal cohort from a large multi-specialty ambulatory practice.

Physician turnover places a heavy burden on the healthcare industry, patients, physicians, and their families. Having a mechanism in place to identify physicians at risk for departure could help target appropriate interventions that prevent departure. We have collected physician characteristics, electronic health record (EHR) use patterns, and clinical productivity data from a large ambulatory based practice of non-teaching physicians to build a predictive model. We use several techniques to identify possible intervenable variables. Specifically, we used gradient boosted trees to predict the probability of a physician departing within an interval of 6 months. Several variables significantly contributed to predicting physician departure including tenure (time since hiring date), panel complexity, physician demand, physician age, inbox, and documentation time. These variables were identified by training, validating, and testing the model followed by computing SHAP (SHapley Additive exPlanation) values to investigate which variables influence the model's prediction the most. We found these top variables to have large interactions with other variables indicating their importance. Since these variables may be predictive of physician departure, they could prove useful to identify at risk physicians such who would benefit from targeted interventions.

Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial.

Importance: Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. Objective: To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. Design, Setting, and Participants: This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. Exposures: This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Main Outcomes and Measures: Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. Results: A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. Conclusions and Relevance: In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. Trial Registration: ClinicalTrials.gov Identifier: NCT03658642.

Applicability of new sustainable and efficient green metal-based nanoparticles for removal of Cr(VI): Adsorption anti-microbial, and DFT studies.

Artemisia absinthium leaves were utilized as a reducing agent for green synthesis of Zinc oxide nanoparticles (particle size 17 nm). Synthesized green-ZnO (g-ZnO) were characterized by SEM/EDX, FTIR, XRD, UV, and BET analyses and then further used as an adsorbent to remove Cr(VI) ions from simulated wastewater. Optimal pH, temperature and adsorbent dosage were determined through batch mode studies. High removal efficiency and adsorption capacity were observed at pH 4, 0.25 g L-1 dosage, and 25 mg L-1 concentration of Cr(VI). Experimental data were modelled with different adsorption kinetics (Elovich model, PFO, PSO, IDP model) and isotherms (Langmuir, Freundlich, and Temkin), and it was found the adsorption process was well fitted to Langmuir with an R2 value greater than>0.99. Computational calculation showed that the g-ZnO nanoparticles became ∼14 times more dynamic with delocalized surface states making them a relevant platform to adsorb Cr with greater work function compatibility supporting the experimental findings. The Qmax adsorption capacity of g-ZnO was 315.46 mg g-1 from Langmuir calculations. Thermodynamic calculations reveal that the Cr (VI) adsorption process was spontaneous and endothermic, with a positive ΔS value representing the disorder at the solid-solution interface during the adsorption. In addition, the present study has demonstrated that these g-ZnO nanoparticles show strong antibacterial activities against P. aeruginosa (MTCC 1688) and E. coli (MTCC 1687). Also, the novel g-ZnO adsorbent capacity to remove Cr(VI) from simulated water revealed that it could be reused at least six times with higher removal rates during regeneration experiments. The results obtained from adsorption and antimicrobial activities suggest that g-ZnO nanoparticles could be used effectively in real-time wastewater and agricultural safety applications.

Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study.

BACKGROUND: Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS: We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS: Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION: The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.

National trends in emergency conditions through the Omicron COVID-19 wave in commercial and Medicare Advantage enrollees.

Objective: To evaluate trends in emergency care sensitive conditions (ECSCs) from pre-COVID (March 2018-February 2020) through Omicron (December 2021-February 2022). Methods: This cross-sectional analysis evaluated trends in ECSCs using claims (OptumLabs Data Warehouse) from commercial and Medicare Advantage enrollees. Emergency department (ED) visits for ECSCs (acute appendicitis, aortic aneurysm/dissection, cardiac arrest/severe arrhythmia, cerebral infarction, myocardial infarction, pulmonary embolism, opioid overdose, pre-eclampsia) were reported per 100,000 person months from March 2018 to February 2022 by pandemic wave. We calculated the percent change for each pandemic wave compared to the pre-pandemic period. Results: There were 10,268,554 ED visits (March 2018-February 2022). The greatest increases in ECSCs were seen for pulmonary embolism, cardiac arrest/severe arrhythmia, myocardial infarction, and pre-eclampsia. For commercial enrollees, pulmonary embolism visit rates increased 22.7% (95% confidence interval [CI], 18.6%-26.9%) during Waves 2-3, 37.2% (95% CI, 29.1%-45.8%] during Delta, and 27.9% (95% CI, 20.3%-36.1%) during Omicron, relative to pre-pandemic rates. Cardiac arrest/severe arrhythmia visit rates increased 4.0% (95% CI, 0.2%-8.0%) during Waves 2-3; myocardial infarction rates increased 4.9% (95% CI, 2.1%-7.8%) during Waves 2-3. Similar patterns were seen in Medicare Advantage enrollees. Pre-eclampsia visit rates among reproductive-age female enrollees increased 31.1% (95% CI, 20.9%-42.2%), 23.7% (95% CI, 7.5%,-42.3%), and 34.7% (95% CI, 16.8%-55.2%) during Waves 2-3, Delta, and Omicron, respectively. ED visits for other ECSCs declined or exhibited smaller increases. Conclusions: ED visit rates for acute cardiovascular conditions, pulmonary embolism and pre-eclampsia increased despite declines or stable rates for all-cause ED visits and ED visits for other conditions. Given the changing landscape of ECSCs, studies should identify drivers for these changes and interventions to mitigate them.

Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems.

BACKGROUND: Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood. METHODS: This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity. RESULTS: Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64). CONCLUSIONS: Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings.

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.

Multifunctional nanohybrid for simultaneous detection and removal of Arsenic(III) from aqueous solutions.

Herein, for the adsorption and detection of As (III), multifunctional nanohybrid have been synthesized using a solvothermal approach. Structural and functional characterizations confirmed the impregnation of the ZnO over graphene oxide. Nanohybrid exhibits a remarkable qmax (maximum adsorption capacity) of 8.17 mg/g, at an adsorbent dose of 3 g/L and pH of 8.23. Higher adsorption with nanohybrid was attributed to a large BET surface area of 32.950 m2/g. The chemical nature and adsorption behaviour of As(III) on ZnO-GO were studied by fitting the data with various adsorption isotherms (Langmuir & Freundlich) and kinetics models (six models). It is observed from the findings that removal of As(III) with ZnO-GO nanocomposite appears to be technically feasible with high removal efficiency. The feasibility of the nanocomposite to function as a sensor for the detection of As(III) was also evaluated. The fabricated sensor could detect As(III) with a lower limit of detection of 0.24 µM and linear range up to 80 µM. Overall, this study is significant in nanohybrid as a multifunctional composite for the adsorption and detection of As (III) from wastewater.

Study of nano cellulose-based membrane tailorable biodegradability for use in the packaging application of electronic devices.

With a growing demand for packaging materials and witnessing many landfills and huge garbage islands floating in the Pacific oceans, the need for an alternative material such as bio-degradable plastics has risen. Cellulose-based materials are already in use in several packaging industries. Nanocellulose, a processed cellulose with a specific nanostructure, have several advantages such as high specific strength, modulus, high surface area and unique optical properties. By varying the crosslinking percentages, the kinetics of degradation can be tailored. In this work, extracted cellulose from sugarcane bagasse was hydrolyzed to obtain nanocellulose, which was used to fabricate packaging films (membrane) with PVA as matrix and nanocellulose. Variations of PVA and nanocellulose loadings, and crosslinking agent ratios. In the fabricated films were investigated for chemical, mechanical, optical, thermal, and topographical properties. Results from the degradation tests under appropriate physically simulated environments have suggested that the crosslinking has enhanced the mechanical properties, extent of degradation was dependent on percentages of crosslinking. A real-world device packaging application was demonstrated by encapsulation of perovskite solar cells with the fabricated nanocellulose film revealed that the lifetime of the devices improved which might be indicative of the film having lower permeability for oxygen and moisture.

Pragmatic clinical trial design in emergency medicine: Study considerations and design types.

Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.

A novel CaO nanocomposite cross linked graphene oxide for Cr(VI) removal and sensing from wastewater.

A novel green nanocomposite has been prepared by immobilizing CaO nanoparticles (CaO NPs) on the surface of graphene oxide. Biogenic CaO-NPs were synthesized from Lala clamshells. Morphological and structural characterizations of the nanocomposite were studied extensively. The adsorption capacity (qmax) of the nanocomposite for removing Cr(VI) was 38.04 mg g-1. In addition to this, the adsorption data were adequately simulated with Langmuir, Freundlich, Temkin, and pseudo-second-order models, suggesting that the adsorption process was the combination of external mass transfer and chemisorption. Electrostatic interaction was the dominant mechanism for Cr(VI) removal. In addition, the synthesized nanocomposites also serve as an excellent sensor for Cr(VI) sensing, with a limit of detection (LOD) of 0.02 µM utilizing electrochemical methods. Therefore, this green nanocomposite can simultaneously serve as an adsorbent and sensor for Cr(VI)removal from aqueous solutions.

A systematic study of arsenic adsorption and removal from aqueous environments using novel graphene oxide functionalized UiO-66-NDC nanocomposites.

This study investigates the removal of As(V) from aqueous media using water stable UiO-66-NDC/GO prepared via the solvothermal procedure. The synthesized material was analyzed by Raman spectroscopy, UV-visible, X-ray powder diffraction (XRD), Transmission electron microscopy (TEM), Fourier Transform Infrared spectroscopy (ATR-FTIR), scanning electron microscopy (SEM), and Brunauer-Emmett-Teller (BET) support its applicability as a super-adsorbent for the adsorption of As(V) ions from aqueous solutions. The effect of various parameters, including initial ion concentration, temperature, adsorbent dose, and pH on the adsorption of As(V) was studied to recognize the optimum adsorption conditions. The qmax obtained for this study using Langmuir isotherms was found at 147.06 mg/g at room temperature. Thermodynamic parameters ΔH°, ΔG°, and ΔS° were also calculated and negative values of ΔG° represent that the As(V) adsorption process occurred exothermically and spontaneously. Meanwhile, theoretical density functional simulation findings are accommodated to support these experimental results. It is observed that the dynamic nature of graphene oxide and the UiO-66 NDC nanocomposite system becomes superior for adsorption studies due to delocalized surface states. UiO-66-NDC/GO also showed high reusability for up four regeneration performances using 0.01 M HCl as a regenerant.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial.

OBJECTIVE: To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN: Pragmatic cluster randomized controlled trial (EMBED). SETTING: 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS: 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION: A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES: Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS: 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS: User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658642.