Patient and Provider Satisfaction with Asynchronous Versus Synchronous Telepsychiatry in Primary Care: A Secondary Mixed-Methods Analysis of a Randomized Controlled Trial.

Background: Asynchronous telepsychiatry (ATP) consultations are a novel form of psychiatric consultation. Studies comparing patient and provider satisfaction for ATP with that for synchronous telepsychiatry (STP) do not exist. Methods: This mixed-methods study is a secondary analysis of patients' and primary care providers' (PCPs) satisfaction from a randomized clinical trial of ATP compared with STP. Patients and their PCPs completed satisfaction surveys, and provided unstructured feedback about their experiences with either ATP or STP. Differences in patient satisfaction were assessed using mixed-effects logistic regression models, and the qualitative data were analyzed using thematic analysis with an inductive coding framework. Results: Patient satisfaction overall was high with 84% and 97% of respondents at 6 months reported being somewhat or completely satisfied with ATP and STP, respectively. Patients in the STP group were more likely to report being completely satisfied, to recommend the program to a friend, and to report being comfortable with their care compared with ATP (all p < 0.05). However, there was no difference between the patients in ATP and STP in perceived change in clinical outcomes (p = 0.51). The PCP quantitative data were small, and thus only summarized descriptively. Conclusions: Patients expressed their overall satisfaction with both STP and ATP. Patients in ATP reported more concerns about the process, likely because feedback after ATP was slower than that after STP consultations. PCPs had no apparent preference for STP or ATP, and reported implementing the psychiatrists' recommendations for both groups when such recommendations were made, which supports our previous findings. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

A Comprehensive Analysis of Anion-Quadrupole Interactions in Protein Structures.

The edgewise interactions of anions with phenylalanine (Phe) aromatic rings in proteins, known as anion-quadrupole interactions, have been well studied. However, the anion-quadrupole interactions of the tyrosine (Tyr) and tryptophan (Trp) rings have been less well studied, probably because these have been considered weaker than interactions of anions hydrogen bonded to Trp/Tyr side chains. Distinguishing such hydrogen bonding interactions, we comprehensively surveyed the edgewise interactions of certain anions (aspartate, glutamate, and phosphate) with Trp, Tyr, and Phe rings in high-resolution, nonredundant protein single chains and interfaces (protein-protein, DNA/RNA-protein, and membrane-protein). Trp/Tyr anion-quadrupole interactions are common, with Trp showing the highest propensity and average interaction energy for this type of interaction. The energy of an anion-quadrupole interaction (-15.0 to 0.0 kcal/mol, based on quantum mechanical calculations) depends not only on the interaction geometry but also on the ring atom. The phosphate anions at DNA/RNA-protein interfaces interact with aromatic residues with energies comparable to that of aspartate/glutamate anion-quadrupole interactions. At DNA-protein interfaces, the frequency of aromatic ring participation in anion-quadrupole interactions is comparable to that of positive charge participation in salt bridges, suggesting an underappreciated role for anion-quadrupole interactions at DNA-protein (or membrane-protein) interfaces. Although less frequent than salt bridges in single-chain proteins, we observed highly conserved anion-quadrupole interactions in the structures of remote homologues, and evolutionary covariance-based residue contact score predictions suggest that conserved anion-quadrupole interacting pairs, like salt bridges, contribute to polypeptide folding, stability, and recognition.

Tobacco use by physicians in a physician health program, implications for treatment and monitoring.

The use of tobacco by physicians with substance abuse histories is drastically understudied. A chart review of 1319 physicians enrolled in a physician health program found tobacco use highest for those referred for substance abuse problems (58.1%). Among a subset of currently monitored substance abusers, all those who relapsed during monitoring were using tobacco and had more difficulty maintaining sobriety following initial treatment (p = 0.0137) than non tobacco users. Because tobacco was a risk factor for relapse, reasons why physician health programs should address its use and treatment facilities should establish tobacco-free environments to provide optimum learning and recovery are explored.

Suboptimal pharmacotherapy in a tribal nursing home.

OBJECTIVE: Suboptimal medication use among nursing home (NH) residents is common. NH residents tend to be older, suffer from multiple conditions, and take numerous medications, increasing their risk of serious complications. This article examines pharmacotherapy in a rural, tribally owned NH. DESIGN: Medical records were reviewed and case studies were conducted by a team composed of a medical anthropologist, psychiatrist, and geriatrician. SETTING: A rural, American Indian-owned NH in the US northern plains. PARTICIPANTS: 40 American Indian and 5 EuroAmerican NH residents. MEASUREMENTS: Minimum Data Set assessments, admission records, care plans, social histories, prescription lists, and behavioral consultation reports. RESULTS: Potential underuse affected almost 75% of residents; undertreatment of depressive and psychotic/agitated symptoms was especially common. Potential inappropriate use, especially of analgesics, psychotropics, and antihistamines, affected 30% of residents. A smaller, but still substantial, number of residents (21%) experienced potential overuse, much of which involved anticonvulsants, antibiotics, cardiovascular, and psychotropic agents. The prescription of 10 or more medications was significantly associated with potential drug interactions, as well as underuse, inappropriate medication use, and overuse. CONCLUSIONS: Psychotropic medications were the most potentially problematic medication category, and were strongly implicated in potential underuse, inappropriate use, and overuse. Fewer medications; the discontinuation of drugs known to be potentially problematic for NH residents; modification of psychotropic medication regimens; use of cognitive-enhancing medications where appropriate; implementation of an electronic medical record system; and greater use of nonpharmacological behavioral interventions may have substantially improved residents' treatment regimens.

Screening for alcohol abuse among urban Native Americans in a primary care setting.

The authors examined the rate of and factors associated with alcohol abuse among 754 urban American Indian and Alaska Native primary care patients. Data were collected through a self-administered survey and by abstracting medical records. A total of 423 respondents (56 percent) screened positive for lifetime alcohol abuse, and 202 (27 percent) reported current alcohol abuse. A diagnosis of alcohol abuse was found in the medical records of 68 of the patients who screened positive (16 percent). Logistic regression analysis showed that being male, having been a victim of violence, and feeling depressed were associated with alcohol abuse. Further research is warranted to help clinicians detect and treat alcohol abuse in this special population.