A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers - Quadruple Aim -. Reinforcing the recently defined Fifth Aim as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. CONTEXT: Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. METHODS: A conceptual framework to provide additional ethical guardrails for health systems. RESULTS: Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. CONCLUSIONS: As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Inattentional blindness in medicine.

People often fail to notice unexpected stimuli when their attention is directed elsewhere. Most studies of this "inattentional blindness" have been conducted using laboratory tasks with little connection to real-world performance. Medical case reports document examples of missed findings in radiographs and CT images, unintentionally retained guidewires following surgery, and additional conditions being overlooked after making initial diagnoses. These cases suggest that inattentional blindness might contribute to medical errors, but relatively few studies have directly examined inattentional blindness in realistic medical contexts. We review the existing literature, much of which focuses on the use of augmented reality aids or inspection of medical images. Although these studies suggest a role for inattentional blindness in errors, most of the studies do not provide clear evidence that these errors result from inattentional blindness as opposed to other mechanisms. We discuss the design, analysis, and reporting practices that can make the contributions of inattentional blindness unclear, and we describe guidelines for future research in medicine and similar contexts that could provide clearer evidence for the role of inattentional blindness.

How intermolecular charge transfer influences the air-water interface.

The interfacial properties of three water models that allow for intermolecular charge rearrangement were examined with molecular dynamics simulations. They included the TIP4P water model, the TIP4P-FQ water model, which recently were modified to include intermolecular charge transfer [A. J. Lee and S. W. Rick, J. Chem. Phys. 134, 184507 (2011)]. Furthermore, another model with intermolecular charge transfer was developed for this work that was both flexible and polarizable. The effect of including intermolecular charge transfer is modest on most interfacial properties, including surface tension, electrostatic potential, interfacial dipole, and structure. However, a negative charge was found to build up at the air-water interface, but much smaller than has been measured experimentally.

The effects of charge transfer on the properties of liquid water.

A method for treating charge transfer interactions in classical potential models is developed and applied to water. In this method, a discrete amount of charge is transferred for each hydrogen bond formed. It is designed to be simple to implement, to be applicable to a variety of potential models, and to satisfy various physical requirements. The method does not transfer charge at large intramolecular distances, it does not result in a conductive liquid, and it can be easily parameterized to give the correct amount of charge transfer. Two charge transfer models are developed for a polarizable and a non-polarizable potential. The models reproduce many of the properties of liquid water, including the structure, the diffusion constant, and thermodynamic properties over a range of temperatures.

Improving replica exchange using driven scaling.

Replica exchange is a powerful simulation method in which simulations are run at a series of temperatures, with the highest temperature chosen so phase space can be sampled efficiently. In order for swaps to be accepted, the energy distributions of adjacent replicas must have some overlap. This can create the need for many replicas for large systems. In this paper, we present a new method in which the potential energy is scaled by a parameter, which has an explicit time dependence. Scaling the potential energy broadens the distribution of energy and reduces the number of replicas necessary to span a given temperature range. We demonstrate that if the system is driven by the time-dependent potential sufficiently slowly, then equilibrium is maintained and energetic and structural properties are identical to those of conventional replica exchange. The method is tested using two systems, the alanine dipeptide and the trpzip2 polypeptide, both in water.

Separation of Recombinant Therapeutic Proteins Using Capillary Gel Electrophoresis and Capillary Isoelectric Focusing.

Detailed step-by-step methods for protein separation techniques based on capillary electrophoresis (CE) are described in this chapter. Focus is placed on two techniques, capillary gel electrophoresis (CGE) and capillary isoelectric focusing (cIEF). CGE is essentially gel electrophoresis, performed in a capillary, where a hydrogel is used as a sieving matrix to separate proteins or peptides based on size. cIEF separates proteins or peptides based on their isoelectric point (pI), the pH at which the protein or peptide bears no charges. Detailed protocols and steps (including capillary preparation, sample preparation, CE separation conditions, and detection) for both CGE and cIEF presented so that readers can follow the described methods in their own labs.

Characterizing Charge Transfer at Water Ice Interfaces.

Simulations are carried out for the ice/vapor and ice/liquid interfaces using models for water which include intermolecular charge transfer, as well as polarizability. The models transfer a small amount of charge for each hydrogen bond formed, as indicated from electronic structure calculations, from the molecule that accepts the hydrogen bond to the molecule that donates the hydrogen bond. Depending on distance from the interface, molecules can, on average, have more of one type (donor or acceptor) than the other. The asymmetric local environment leads to net charge transfer at the interface, with layers of molecules with small net charges. Molecules at the ice side of the interface tend to be positively charged, while molecules at the vapor or liquid side tend to be negatively charged.