Assembling Adjustment: Parergasia, Paper Technologies, and the Revision of Recovery.

Drawing from research on 'paper technologies' conducted by medical historians Volker Hess and Andrew Mendelsohn, among others, this article explores how Adolf Meyer (1866-1950) and his staff at the Phipps Psychiatric Clinic used customized punch cards to develop an alternative conceptualization of schizophrenia: 'parergasia.' It begins by examining 'dementia praecox,' the conceptual precursor to both schizophrenia and parergasia, to explain how earlier paper technologies used to track patients transferred to asylums generated prognostic assumptions that precluded deinstitutionalization and community-based care. It then describes how Meyer's staff modified these technologies to define parergasia in opposition to dementia praecox and other diagnoses that resulted in prolonged hospitalization, primarily by conducting follow-up studies on discharged patients that correlated outcomes with various social factors. After demonstrating how the standardized forms used in these studies limited the possible metrics of recovery, it concludes by suggesting how Meyer's research influenced leaders of the community mental health movement, and prefigured later trends in psychiatric services.

Perceptions of Oncologists About Sharing Clinic Notes with Patients.

In a large survey (n = 809) conducted to understand how oncologists differ from nononcologists regarding routinely sharing visit notes with patients, oncologists were less likely to agree patient safety would improve (p = .03) or that patients would be offended after reading notes (p = .01); however, they agreed with nononcologists that sharing notes would lead to less candid documentation (69% vs. 73%; p = .39). Oncologists share a high level of worry about the impact of sharing notes on documentation practices, a concern that will need to be addressed as the practice of sharing visit notes expands to cancer care.

Awareness and Use of the After-Visit Summary Through a Patient Portal: Evaluation of Patient Characteristics and an Application of the Theory of Planned Behavior.

BACKGROUND: Patient portals are being used to provide a clinical summary of the office visit or the after-visit summary (AVS) to patients. There has been relatively little research on the characteristics of patients who access the AVS through a patient portal and their beliefs about the AVS. OBJECTIVE: The aim was to (1) assess the characteristics of patients who are aware of and access the AVS through a patient portal and (2) apply the Theory of Planned Behavior (TPB) to predict behavioral intention of patients toward accessing the AVS provided through a patient portal. METHODS: We developed a survey capturing the components of TPB (beliefs, attitude, perceived norm, and perceived behavioral control). Over a 6-month period, patients with a patient portal account with an office visit in the previous week were identified using our organization's scheduling system. These patients were sent an email about the study and a link to the survey via their portal account. We applied univariate statistical analysis (Pearson chi-square and 1-way ANOVA) to assess differences among groups (aware/unaware of AVS and accessed/did not access AVS). We reported means and standard deviations to depict belief strengths and presented correlations between beliefs and attitude, perceived norm, and perceived behavioral control. We used hierarchical regression analysis to predict behavioral intention toward accessing the AVS through the patient portal. RESULTS: Of the 23,336 patients who were sent the survey, 5370 responded for a response rate of 23.01%. Overall, 76.52% (4109/5370) were aware that the AVS was available through the patient portal and 54.71% of those (2248/4109) accessed the AVS within 5 days of the office visit. Patients who accessed the AVS had a greater number of sessions with the portal (mean 119, SD 221.5) than those who did not access the AVS (mean 79.1, SD 123.3, P<.001); the difference was not significant for awareness of the AVS. The strongest behavioral beliefs with accessing the AVS were being able to track visits and tests (mean 2.53, SD 1.00) followed by having medical information more readily accessible (mean 2.48, SD 1.07). In all, 56.7% of the variance in intention to access the AVS through the portal was accounted for by attitude, perceived norm, and perceived behavioral control. CONCLUSIONS: Most users of a patient portal were aware that the AVS was accessible through the portal. Patients had stronger beliefs about accessing the AVS with the goal of timely and efficient access of information than with engaging in their health care. Interventions to improve patient access of the AVS can focus on providers promoting patient beliefs about the value of the AVS for tracking tests and visits, and timely and efficient access of information.

Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use.

OBJECTIVE: The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS: This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends. RESULTS: The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1)/6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends. CONCLUSION: Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders.

Mutations in a guanylate cyclase GCY-35/GCY-36 modify Bardet-Biedl syndrome-associated phenotypes in Caenorhabditis elegans.

Ciliopathies are pleiotropic and genetically heterogeneous disorders caused by defective development and function of the primary cilium. Bardet-Biedl syndrome (BBS) proteins localize to the base of cilia and undergo intraflagellar transport, and the loss of their functions leads to a multisystemic ciliopathy. Here we report the identification of mutations in guanylate cyclases (GCYs) as modifiers of Caenorhabditis elegans bbs endophenotypes. The loss of GCY-35 or GCY-36 results in suppression of the small body size, developmental delay, and exploration defects exhibited by multiple bbs mutants. Moreover, an effector of cGMP signalling, a cGMP-dependent protein kinase, EGL-4, also modifies bbs mutant defects. We propose that a misregulation of cGMP signalling, which underlies developmental and some behavioural defects of C. elegans bbs mutants, may also contribute to some BBS features in other organisms.

Provider Perceptions of an Electronic Health Record Prostate Cancer Screening Tool.

OBJECTIVES: We conducted a focus group to assess the attitudes of primary care physicians (PCPs) toward prostate-specific antigen (PSA)-screening algorithms, perceptions of using decision support tools, and features that would make such tools feasible to implement. METHODS: A multidisciplinary team (primary care, urology, behavioral sciences, bioinformatics) developed the decision support tool that was presented to a focus group of 10 PCPs who also filled out a survey. Notes and audio-recorded transcripts were analyzed using Thematic Content Analysis. RESULTS: The survey showed that PCPs followed different guidelines. In total, 7/10 PCPs agreed that engaging in shared decision-making about PSA screening was burdensome. The majority (9/10) had never used a decision aid for PSA screening. Although 70% of PCPs felt confident about their ability to discuss PSA screening, 90% still felt a need for a provider-facing platform to assist in these discussions. Three major themes emerged: (1) confirmatory reactions regarding the importance, innovation, and unmet need for a decision support tool embedded in the electronic health record; (2) issues around implementation and application of the tool in clinic workflow and PCPs' own clinical bias; and (3) attitudes/reflections regarding discrepant recommendations from various guideline groups that cause confusion. CONCLUSION: There was overwhelmingly positive support for the need for a provider-facing decision support tool to assist with PSA-screening decisions in the primary care setting. PCPs appreciated that the tool would allow flexibility for clinical judgment and documentation of shared decision-making. Incorporation of suggestions from this focus group into a second version of the tool will be used in subsequent pilot testing.

Primary Care Physician Preferences Regarding Communication from Orthopaedic Surgeons.

BACKGROUND: Musculoskeletal consultations constitute a growing portion of primary care physician (PCP) referrals. Optimizing communication between PCPs and orthopaedists can potentially reduce time spent in the electronic medical record (EMR) as well as physician burnout. Little is known about the preferences of PCPs regarding communication from orthopaedic surgeons. Hence, the present study investigated, across a large health network, the preferences of PCPs regarding communication from orthopaedists. METHODS: A total of 175 PCPs across 15 practices within our health network were surveyed. These providers universally utilized Epic as their EMR platform. Five-point, labeled Likert scales were utilized to assess the PCP-perceived importance of communication from orthopaedists in specific clinical scenarios. PCPs were further asked to report their preferred method of communication in each scenario and their overall interest in communication from orthopaedists. Logistic regression analyses were performed to determine whether any PCP characteristics were associated with the preferred method of communication and the overall PCP interest in communication from orthopaedists. RESULTS: A total of 107 PCPs (61.1%) responded to the survey. PCPs most commonly rated communication from orthopaedists as highly important in the scenario of an orthopaedist needing information from the PCP. In this scenario, PCPs preferred to receive an Epic Staff Message. Scenarios involving a recommendation for surgery, hospitalization, or a major clinical change were also rated as highly important. In these scenarios, an Epic CC'd Chart rather than a Staff Message was preferred. Increased after-hours EMR use was associated with diminished odds of having a high interest in communication from orthopaedists (odds ratio, 0.65; 95% confidence interval, 0.48 to 0.88; p = 0.005). Ninety-three PCPs (86.9%) reported spending 1 to 1.5 hours or more per day in Epic after normal clinical hours, and 27 (25.2%) spent >3 hours per day. Forty-six PCPs (43.0%) reported experiencing ≥1 symptom of burnout. CONCLUSIONS: There were distinct preferences among PCPs regarding clinical communication from orthopaedic surgeons. There was also evidence of substantial burnout and after-hours work effort by PCPs. These results may help to optimize communication between PCPs and orthopaedists while reducing the amount of time that PCPs spend in the EMR.

A Provider-Facing Decision Support Tool for Prostate Cancer Screening in Primary Care: A Pilot Study.

OBJECTIVES: Our objective was to pilot test an electronic health record-embedded decision support tool to facilitate prostate-specific antigen (PSA) screening discussions in the primary care setting. METHODS: We pilot-tested a novel decision support tool that was used by 10 primary care physicians (PCPs) for 6 months, followed by a survey. The tool comprised (1) a risk-stratified algorithm, (2) a tool for facilitating shared decision-making (Simple Schema), (3) three best practice advisories (BPAs: <45, 45-75, and >75 years), and (4) a health maintenance module for scheduling automated reminders about PSA rescreening. RESULTS: All PCPs found the tool feasible, acceptable, and clear to use. Eight out of ten PCPs reported that the tool made PSA screening conversations somewhat or much easier. Before using the tool, 70% of PCPs felt confident in their ability to discuss PSA screening with their patient, and this improved to 100% after the tool was used by PCPs for 6 months. PCPs found the BPAs for eligible (45-75 years) and older men (>75 years) more useful than the BPA for younger men (<45 years). Among the 10 PCPs, 60% found the Simple Schema to be very useful, and 50% found the health maintenance module to be extremely or very useful. Most PCPs reported the components of the tool to be at least somewhat useful, with 10% finding them to be very burdensome. CONCLUSION: We demonstrated the feasibility and acceptability of the tool, which is notable given the marked low acceptance of existing tools. All PCPs reported that they would consider continuing to use the tool in their clinic and were likely or very likely to recommend the tool to a colleague.

Virtual Scribes and Physician Time Spent on Electronic Health Records.

Importance: Time on the electronic health record (EHR) is associated with burnout among physicians. Newer virtual scribe models, which enable support from either a real-time or asynchronous scribe, have the potential to reduce the burden of the EHR and EHR-related documentation. Objective: To characterize the association of use of virtual scribes with changes in physicians' EHR time and note and order composition and to identify the physician, scribe, and scribe response factors associated with changes in EHR time upon virtual scribe use. Design, Setting, and Participants: Retrospective, pre-post quality improvement study of 144 physicians across specialties who had used a scribe for at least 3 months from January 2020 to September 2022, were affiliated with Brigham and Women's Hospital and Massachusetts General Hospital, and cared for patients in the outpatient setting. Data were analyzed from November 2022 to January 2024. Exposure: Use of either a real-time or asynchronous virtual scribe. Main Outcomes: Total EHR time, time on notes, and pajama time (5:30 pm to 7:00 am on weekdays and nonscheduled weekends and holidays), all per appointment; proportion of the note written by the physician and team contribution to orders. Results: The main study sample included 144 unique physicians who had used a virtual scribe for at least 3 months in 152 unique scribe participation episodes (134 [88.2%] had used an asynchronous scribe service). Nearly two-thirds of the physicians (91 physicians [63.2%]) were female and more than half (86 physicians [59.7%]) were in primary care specialties. Use of a virtual scribe was associated with significant decreases in total EHR time per appointment (mean [SD] of 5.6 [16.4] minutes; P < .001) in the 3 months after vs the 3 months prior to scribe use. Scribe use was also associated with significant decreases in note time per appointment and pajama time per appointment (mean [SD] of 1.3 [3.3] minutes; P < .001 and 1.1 [4.0] minutes; P = .004). In a multivariable linear regression model, the following factors were associated with significant decreases in total EHR time per appointment with a scribe use at 3 months: practicing in a medical specialty (-7.8; 95% CI, -13.4 to -2.2 minutes), greater baseline EHR time per appointment (-0.3; 95% CI, -0.4 to -0.2 minutes per additional minute of baseline EHR time), and decrease in the percentage of the note contributed by the physician (-9.1; 95% CI, -17.3 to -0.8 minutes for every percentage point decrease). Conclusions and Relevance: In 2 academic medical centers, use of virtual scribes was associated with significant decreases in total EHR time, time spent on notes, and pajama time, all per appointment. Virtual scribes may be particularly effective among medical specialists and those physicians with greater baseline EHR time.

A Prospective Intervention to Reduce Burnout Among Academic Radiologists.

RATIONALE AND OBJECTIVES: Few studies have examined what constitutes effective interventions to reduce burnout among radiologists. We compared self-reported burnout among academic medical center radiologists before and after a series of departmental initiatives intended to increase wellbeing and professional satisfaction. MATERIALS AND METHODS: This Institutional Review Board-approved, prospective study took place 2017-2019 in a tertiary academic medical center. In pre- (2017) and post-intervention (2019) periods, we administered the previously-validated Stanford Physician Wellness Survey to faculty in our 11-division radiology department. Faculty rated their burnout level across 8 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, organizational/personal values alignment, perceived quality of supervisory leadership). Between the two surveys, departmental initiatives focusing on culture, team building, work-life balance, and personal well-being were implemented (e.g., electronic medical record training, shorter work hours). Pre- and post-survey results were compared, using Whitney-Mann U test to calculate Z scores. RESULTS: Faculty members rated lower professional fulfillment (Z-3.04, p=0.002), higher emotional exhaustion (Z=2.52, p=0.012), increased sleep-related impairment (Z=2.38, p=0.012), and reduced organizational/personal values alignment (Z=-4.10, p<0.0001) between the two surveys. No significant differences were identified associated with interpersonal disengagement (Z=1.82, p=0.069), self-compassion (Z=1.39, p=0.164), negative impact of work on personal relationship (Z=0.89, p=0.372) and perceived supervisory leadership quality (Z=0.07, p=0.942). CONCLUSION: Despite numerous departmental initiatives intended to improve culture, workplace efficiency, work-life balance, and personal wellness, self-reported burnout was unchanged or worsened over time.Physician and employee wellness embedded into institutional culture maybe more effective than departmental improvement initiatives.

Frequency and Clinical Utility of Alerts for Intra-Institutional Radiologist Discrepant Opinions.

OBJECTIVE: Determine the rate of documented notification, via an alert, for intra-institutional discrepant radiologist opinions and addended reports and resulting clinical management changes. METHODS: This institutional review board-exempt, retrospective study was performed at a large academic medical center. We defined an intra-institutional discrepant opinion as when a consultant radiologist provides a different interpretation from that formally rendered by a colleague at our institution. We implemented a discrepant opinion policy requiring closed-loop notification of the consulting radiologist's second opinion to the original radiologist, who must acknowledge this alert within 30 days. This study included all discrepant opinion alerts created December 1, 2019, to December 31, 2021, of which two radiologists and an internal medicine physician performed consensus review. Primary outcomes were degree of discrepancy and percent of discrepant opinions leading to change in clinical management. Secondary outcome was report addendum rate compared with an existing peer learning program using Fisher's exact test. RESULTS: Of 114 discrepant opinion alerts among 1,888,147 reports generated during the study period (0.006%), 58 alerts were categorized as major (50.9%), 41 as moderate (36.0%), and 15 as minor discrepancies (13.1%). Clinical management change occurred in 64 of 114 cases (56.1%). Report addendum rate for discrepant opinion alerts was 4-fold higher than for peer learning alerts at our institution (66 of 315 = 21% versus 432 of 8,273 =5.2%; P < .0001). DISCUSSION: Although discrepant intra-institutional radiologist second opinions were rare, they frequently led to changes in clinical management. Capturing these discrepancies by encouraging alert use may help optimize patient care and document what was communicated to the referring or consulting care team by consulting radiologists.

A Multiyear Survey Evaluating Clinician Electronic Health Record Satisfaction.

OBJECTIVES: We assessed how clinician satisfaction with a vendor electronic health record (EHR) changed over time in the 4 years following the transition from a homegrown EHR system to identify areas for improvement. METHODS: We conducted a multiyear survey of clinicians across a large health care system after transitioning to a vendor EHR. Eligible clinicians from the first institution to transition received a survey invitation by email in fall 2016 and then eligible clinicians systemwide received surveys in spring 2018 and spring 2019. The survey included items assessing ease/difficulty of completing tasks and items assessing perceptions of the EHR's value, usability, and impact. One item assessing overall satisfaction and one open-ended question were included. Frequencies and means were calculated, and comparison of means was performed between 2018 and 2019 on all clinicians. A multivariable generalized linear model was performed to predict the outcome of overall satisfaction. RESULTS: Response rates for the surveys ranged from 14 to 19%. The mean response from 3 years of surveys for one institution, Brigham and Women's Hospital, increased for overall satisfaction between 2016 (2.85), 2018 (3.01), and 2019 (3.21, p < 0.001). We found no significant differences in mean response for overall satisfaction between all responders of the 2018 survey (3.14) and those of the 2019 survey (3.19). Systemwide, tasks rated the most difficult included "Monitoring patient medication adherence," "Identifying when a referral has not been completed," and "Making a list of patients based on clinical information (e.g., problem, medication)." Clinicians disagreed the most with "The EHR helps me focus on patient care rather than the computer" and "The EHR allows me to complete tasks efficiently." CONCLUSION: Survey results indicate room for improvement in clinician satisfaction with the EHR. Usability of EHRs should continue to be an area of focus to ease clinician burden and improve clinician experience.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke.

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

Self-reported Burnout: Comparison of Radiologists to Nonradiologist Peers at a Large Academic Medical Center.

RATIONALE AND OBJECTIVES: Relatively little data exist on factors associated with radiologists' burnout versus other medical specialties. We compared self-reported burnout among academic medical center radiologists versus nonradiologist peers to inform initiatives to increase wellbeing and professional satisfaction. MATERIALS AND METHODS: In 2017, our large urban academic medical center administered the Stanford Physician Wellness Survey to faculty in fifteen clinical departments (fourteen academic, one community-based). Faculty rated burnout via Likert scale (0-no burnout; 1-occasional stress/no burnout; 2-one or more burnout symptoms; 3-persistent burnout symptoms; 4-completely burned out); burnout defined as >=2. Responses in 11 domains (professional fulfillment, emotional exhaustion, interpersonal disengagement, sleep difficulties, self-compassion, negative work impact on personal relations, perceived appreciation, control over schedule, organizational/personal values alignment, electronic health record, perceived quality of supervisory leadership) compared radiologists versus nonradiologists for association with burnout, using Whitney-Mann U test to calculate Z scores. RESULTS: There was no significant difference in overall self-reported burnout between radiologists and nonradiologists, nor in self-rating for emotional exhaustion, interpersonal disengagement, self-compassion, control over schedule, organizational/personal values alignment, or electronic health record experience. Radiologists had significantly lower self-rating for work happiness (Z = -2.669, p = 0.0076), finding work meaningful (Z = -2.77351, p = 0.0055), perceiving physicians as highly valued (Z = -2.5486, p = 0.0108), and believing leadership treated them with respect and dignity (Z = -3.44149, p = 0.0006). CONCLUSION: Compared to nonradiologist colleagues, radiologists were less likely to find work meaningful and more likely to feel unhappy and undervalued in the workplace and by leadership. Initiatives to increase perceived appreciation, leadership relationships, and meaningfulness of work for radiologists may reduce burnout.

Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care.

Importance: Physicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear. Objective: To characterize measures of EHR use and ambulatory care quality performance among PCPs. Design, Setting, and Participants: A cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women's Hospital and Massachusetts General Hospital during calendar year 2021. Exposures: Independent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review). Main Outcomes and Measures: Outcome variables were ambulatory quality measures (year-end, PCP panel-level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening). Results: The sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease. Conclusions and Relevance: This cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.

An essential role for DYF-11/MIP-T3 in assembling functional intraflagellar transport complexes.

MIP-T3 is a human protein found previously to associate with microtubules and the kinesin-interacting neuronal protein DISC1 (Disrupted-in-Schizophrenia 1), but whose cellular function(s) remains unknown. Here we demonstrate that the C. elegans MIP-T3 ortholog DYF-11 is an intraflagellar transport (IFT) protein that plays a critical role in assembling functional kinesin motor-IFT particle complexes. We have cloned a loss of function dyf-11 mutant in which several key components of the IFT machinery, including Kinesin-II, as well as IFT subcomplex A and B proteins, fail to enter ciliary axonemes and/or mislocalize, resulting in compromised ciliary structures and sensory functions, and abnormal lipid accumulation. Analyses in different mutant backgrounds further suggest that DYF-11 functions as a novel component of IFT subcomplex B. Consistent with an evolutionarily conserved cilia-associated role, mammalian MIP-T3 localizes to basal bodies and cilia, and zebrafish mipt3 functions synergistically with the Bardet-Biedl syndrome protein Bbs4 to ensure proper gastrulation, a key cilium- and basal body-dependent developmental process. Our findings therefore implicate MIP-T3 in a previously unknown but critical role in cilium biogenesis and further highlight the emerging role of this organelle in vertebrate development.

Potential effects of dams on migratory fish in the Mekong River: lessons from salmon in the Fraser and Columbia Rivers.

We compared the effects of water resource development on migratory fish in two North American rivers using a descriptive approach based on four high-level indicators: (1) trends in abundance of Pacific salmon, (2) reliance on artificial production to maintain fisheries, (3) proportion of adult salmon that are wild- versus hatchery-origin, and (4) number of salmon populations needing federal protection to avoid extinction. The two rivers had similar biological and physical features but radically different levels of water resource development: the Fraser River has few dams and all are located in tributaries, whereas the Columbia River has more than 130 large mainstem and tributary dams. Not surprisingly, we found substantial effects of development on salmon in the Columbia River. We related the results to potential effects on migratory fish in the Mekong River where nearly 200 mainstem and tributary dams are installed, under construction, or planned and could have profound effects on its 135 migratory fish species. Impacts will vary with dam location due to differential fish production within the basin, with overall effects likely being greatest from 11 proposed mainstem dams. Minimizing impacts will require decades to design specialized fish passage facilities, dam operations, and artificial production, and is complicated by the Mekong's high diversity and productivity. Prompt action is needed by governments and fisheries managers to plan Mekong water resource development wisely to prevent impacts to the world's most productive inland fisheries, and food security and employment opportunities for millions of people in the region.

Evaluation of a rapid biosensor tool for measuring PAH availability in petroleum-impacted sediment.

Decades of research have shown that the concentration of freely dissolved PAH (Cfree) in sediment correlates with PAH bioavailability and toxicity to aquatic organisms. Passive sampling techniques and models have been used for measuring and predicting Cfree, respectively, but these techniques require weeks for analytical chemical measurements and data evaluation. This study evaluated the performance of a portable, field-deployable antibody-based PAH biosensor method that can provide measurements of PAH Cfree within a matter of minutes using a small volume of mechanically-extracted sediment porewater. Four sediments with a wide range of PAHs (ΣPAH 2.4 to 307 mg/kg) derived from petroleum, creosote, and mixed urban sources, were analyzed via three methods: 1) bulk chemistry analysis; 2) ex situ sediment passive sampling; and 3) biosensor analysis of mechanically-extracted sediment porewater. Mean ΣPAH Cfree determined by the biosensor for the four sediments (3.1 to 55 µg/L) were within a factor of 1.1 (on average) compared to values determined by the passive samplers (2.0 to 52 µg/L). All mean values differed by a factor of 3 or less. The biosensor was also useful in identifying sediments that are likely to be non-toxic to benthic invertebrates. In two of the four sediments, biosensor results of 20 and 55 µg/L exceeded a potential risk-based screening level of 10 µg/L, indicating toxicity could not be ruled out. PAH Toxic Units (ΣTU) measured in these two sediments using the passive sampler Cfree results were also greater than the ΣTU threshold of 1 (6.7 and 5.8, respectively), confirming the conclusions reached with the biosensor. In contrast, the other two sediments were identified as non-toxic by both the biosensor (3.1 and 4.3 µg/L) and the passive sampler (ΣTUs of 0.34 and 0.039). These results indicate that the biosensor is a promising tool for rapid screening of sediments potentially-impacted with PAHs.