The Evolution of Employee Assistance Programs to Best Support Healthcare Organizations.

GOAL: Employee assistance programs (EAPs) have been evolving since they first became prevalent in the 1970s. The important counseling component of EAPs is sometimes lost in discussions about what they do, with many EAPs marketing a broad portfolio of services such as childcare, elder care, legal referral, and other concierge services rather than counseling. The objective of this study was to examine outcomes for the EAP of one organization (Mayo Clinic), compare them to outcomes reported in the literature, and gain insights to help all healthcare organizations best support their employees. METHODS: Consistent with customary EAP practice, data for this study was collected through an anonymous survey link distributed by e-mail to users of individual counseling as well as users of organizational consulting services such as advising leaders and supervisors and leading educational sessions. PRINCIPAL FINDINGS: All (n = 82) individual counseling respondents indicated they would recommend the EAP, none reported worse symptoms, 90% decreased their stress levels, 92% reduced their feelings of anxiety, 88% enjoyed an overall improvement in mood, and 95% developed new skills. If their concern was work-related, 96% agreed the counselor understood the work culture and was able to provide helpful guidance; of the clients who were feeling burned out, 86% agreed they gained strategies to reduce its symptoms. Thematic analysis of individual counseling services indicated that participants highly valued their counselors. Regarding organizational consulting services, respondents (n = 50) indicated EAP services increased their confidence as leaders, supported their work, and provided tangible guidance. They appreciated having an internal EAP counselor. Thematic analysis of organizational consulting services indicated that EAP supported leaders by listening, coaching, and empowering them to normalize issues. PRACTICAL APPLICATIONS: EAPs have evolved into distinct internal, external, and hybrid internal-external models. Internal model counselors are company employees with inside knowledge of company culture, external EAP model counselors are contracted outside of the company, and hybrid models combine a small cadre of internal counselors with the support of outside contractors. Regardless of the model, EAP counselors must collaborate with internal stakeholders, notably the human resources department, to efficiently identify and troubleshoot employee relational issues and allow for customized initiatives to improve mental health. Based upon these findings and the authors' direct experiences with EAP providers, components of an ideal EAP are outlined to show how EAPs can best support employees. Healthcare leaders seeking to add EAP services are advised to focus on offerings that are custom fit to the organization.

Genomic Evaluation of Clinically Ambiguous Pigmented Lesions.

The clinical evaluation of pigmented lesions represents a 'high-stakes' scenario as a missed melanoma can be fatal. Traditional clinical assessment visually sorts pigmented lesions into those that merit a biopsy and those that do not. In our practice there exists a group of lesions judged to not merit biopsy where melanoma, while very unlikely, cannot be excluded with absolute certainty. These ambiguous pigmented lesions (APLs) were often photographed and followed for clinical evolution. This article evaluates the presence of APLs and describes the use of non-invasive genomic testing to sort them. An informal survey using pictures of 10 APLs found that 6 of 8 dermatology providers were unable to identify which were melanomas. Next, our single practice chart review of 1,254 APLs evaluated by non-invasive genomic testing revealed 35 melanomas. All 1,254 were lesions that fell below our biopsy threshold. Non-invasive genomic testing can improve biopsy decisions particularly in clinically indeterminate pigmented lesions.

Vitamin D, melanoma risk, and tumor thickness in PLCO cancer screening trial patients.

OBJECTIVE: The incidence of melanoma is increasing. Other than limiting UV exposure, few factors prevent or reduce the risk of melanoma. The aim of this study is to evaluate the relationship between vitamin D intake and melanoma risk in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. METHODS: A secondary data analysis was performed on PLCO data. More than 1,300 participants developed melanoma. RESULTS: Melanoma risk may be increased among men within the highest quartile of vitamin D intake (HR 1.27, 95% CI 0.99, 1.61). Women in the highest quartile of vitamin D intake had a decreased risk of invasive melanoma (HR 0.63, 95% CI 0.41, 0.96). Higher education and being white corresponded with deeper tumors (P < .001). CONCLUSION: High reported vitamin D intake resulted in an increased risk of melanoma among men. Vitamin D intake yielded a protective effect against invasive melanoma in women.

Mountains of the Mist: A first plant checklist for the Bvumba Mountains, Manica Highlands (Zimbabwe-Mozambique).

The first comprehensive plant checklist for the Bvumba massif, situated in the Manica Highlands along the Zimbabwe-Mozambique border, is presented. Although covering only 276 km2, the flora is rich with 1250 taxa (1127 native taxa and 123 naturalised introductions). There is a high proportion of Orchidaceae and Pteridophyta, with both groups showing a higher richness than for adjacent montane areas, which may be due to the massif's relatively high moisture levels as a result of frequent cloud cover. However, in contrast to other mesic montane regions in southern Africa, there are relatively few near-endemic or range-restricted taxa: there is only one local endemic, Aeranthes africana, an epiphytic forest orchid. This is likely to be an effect of the massif having limited natural grassland compared to forest, the former being the most endemic-rich habitat in southern African mountains outside of the Fynbos Biome. Six other near-endemic taxa with limited distribution in this portion of the Manica Highlands are highlighted. The high number of invasive species is probably a result of diverse human activities in the area. The main species of concern are Acacia melanoxylon, a tree that is invading grassland and previously cultivated land, the forest herb Hedychium gardnerianum which in places is transforming forest understorey with an adverse effect on some forest birds, and the woody herb Vernonanthura polyanthes which invades cleared forest areas after fire. Future botanical work in the massif should focus on a more detailed exploration of the poorly known Serra Vumba on the Mozambican side and on the drier western slopes. This will allow for a more detailed analysis of patterns of endemism across the Manica Highlands.

Gender, financial literacy, and preretirement planning in the UK.

This study uses a two-stage logistic regression model to explore the determinants of retirement planning behavior. A survey of 516 UK women and men of prestate retirement age was used to establish interrelationships between gender, retirement planning, and financial literacy, taking account of attitudinal and expectational variables. Findings confirm lower levels of planning among women, but contrary to previous studies, this study reveals that financial literacy is not significantly related to planning. Furthermore, when attitudinal and expectational variables are incorporated as independent variables, gender becomes statistically insignificant as a determinant of planning.

Rate of Recurrence of Lentigo Maligna Treated With Off-Label Neoadjuvant Topical Imiquimod, 5%, Cream Prior to Conservatively Staged Excision.

Importance: Staged excision of lentigo maligna (LM) often requires multiple stages and can result in significant cosmetic morbidity. Imiquimod cream has been used off-label as monotherapy in the treatment of LM and may be used in the neoadjuvant setting prior to staged excision as a strategy to reduce the size of the surgical margins required to confirm negative histologic margins. Objective: To examine the rate of recurrence of LM in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions. Design, Setting, and Participants: This was a retrospective medical record review of 334 patients with 345 biopsy-confirmed LM tumors from June 2004 to January 2012 who were treated with imiquimod prior to undergoing staged excisions at the University of Utah Medical Center and Huntsman Cancer Institute, large academic hospitals in Salt Lake City. Interventions: Patients were treated with off-label imiquimod, 5%, cream 5 nights per week for 2 to 3 months. Those deemed to have an inadequate inflammatory response were also treated with tazarotene, 0.1%, gel twice weekly. Conservatively staged excisions, beginning with 2-mm margins, were then performed. Main Outcomes and Measures: The rate of recurrence of LM after long-term follow-up. Results: Patients included 235 men (70%) and 99 women (30%) with a mean (SD) age of 67 (13) years. Patients were treated with imiquimod cream for a mean of 2.5 months prior to undergoing conservatively staged excisions. There were 12 local recurrences (a rate of 3.9%) with a mean time to recurrence of 4.3 years and a mean length of follow-up of 5.5 years. Conclusions and Relevance: Neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions for LM allowed for negative histologic margins with a median final margin of 2 mm and a rate of recurrence similar to reported recurrence rates with standard staged excisions by either Mohs surgery or en face permanent sections.

A survey of fellow members of the Society of Dermatology Physician Assistants.

Income and productivity data of physician assistants (PAs) practicing in dermatology were measured by a survey instrument developed by the authors. The median income for PAs in dermatology was $100,000, and the median annual production was $500,000. PAs in dermatology appear to generate adequate revenue to be profitable to a dermatology practice.

Roles and responsibilities of physician assistants practicing in Mohs surgery.

An estimated 30% of members of the American College of Mohs Surgery (ACMS) are using physician assistants (PAs). In Mohs surgery, the surgeon and the pathologist are the same person, so understanding which tasks are being delegated to PAs working in Mohs surgery is important. Our survey explores the number of PAs working with Mohs surgeons and the tasks delegated to PAs in this specialty.

A randomized trial of the off-label use of imiquimod, 5%, cream with vs without tazarotene, 0.1%, gel for the treatment of lentigo maligna, followed by conservative staged excisions.

OBJECTIVE: To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. DESIGN: Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. SETTING: Mohs surgical clinic in an academic institution. PATIENTS: Ninety patients with biopsy-confirmed LM. INTERVENTIONS: Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. MAIN OUTCOME MEASURE: The presence or absence of residual LM at the time of staged excision. RESULTS: Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P=.17). There have been no recurrences to date, with a mean follow-up period of 42 months. CONCLUSIONS: Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

PAs in the ED: do physicians think they increase the malpractice risk?

OBJECTIVE: This study evaluates emergency physicians' perceptions of the malpractice risk posed by utilization of physician assistants (PAs) in emergency departments (EDs) in 2004 and again in 2009. METHODS: A 16-question survey was mailed to a random sample of 1,000 active members of the American College of Emergency Physicians in 2004 and again in 2009. RESULTS: In both 2004 and 2009, 70% of the emergency physicians did not believe that PAs, when properly supervised, are more likely to commit malpractice than any other clinician. In both surveys, 80% of the respondents did not believe PAs were more likely to be sued for malpractice. A significant negative correlation was found between perceived risk of malpractice by PAs and the number of years physicians had worked with PAs or had worked in emergency medicine. From 2004 to 2009, the number of respondents practicing with PAs increased by 26%, the number directly supervising a PA in the ED increased by 19%, the number who thought PAs decreased patient wait times increased by 13%, and the number who reported that PAs increased patient satisfaction increased by 10%. CONCLUSION: As physicians gain clinical experience with PAs, their perceived risk of malpractice tends to decrease. These results may have implications for the utilization of PAs, particularly as EDs become more utilized for noncritical situations.

Use of physician assistants in Mohs micrographic surgery: a survey of fellowship-trained Mohs micrographic surgeons.

BACKGROUND: An increasing number of dermatologists are using physician assistants (PAs) in their practices. A lack of information regarding the use of PAs in Mohs micrographic surgery (MMS) served as the driving force for this research. OBJECTIVES: To quantify the extent to which Mohs surgeons are using PAs in MMS. METHODS: Five hundred seventy-six fellows of the American College of Mohs Surgery were sent surveys in the mail in January 2009. The survey was focused on what percentage of Mohs surgeons are using PAs and how those PAs are being used. RESULTS: One hundred forty-three of the 576 surgeons surveyed (24.8%) responded; 43 of those (30.1%) currently employed one or more PAs; and of those 43, 15 (34.9%) reported that PAs in their practice perform preoperative consults, 25 (58.1%) reported that PAs perform postoperative follow-up, 18 (41.9%) reported that PAs were participating in some aspect of repairs, and 35 (81.4%) reported that PAs were seeing general dermatology patients. CONCLUSION: Mohs surgeons are using PAs for perioperative care, as well as seeing general dermatology patients. A smaller percentage of Mohs surgeons are using PAs to perform portions of MMS or the consequent repairs.

Comparative analysis of total body and dermatoscopic photographic monitoring of nevi in similar patient populations at risk for cutaneous melanoma.

BACKGROUND: Our previous experience monitoring nevi in high-risk patients using serial digital epiluminescence microscopy (DELM) photography achieved low biopsy rates but was limited by melanomas presenting as new lesions or arising from nevi that had not been photographed. OBJECTIVE: To determine whether biopsy rates, efficiency of melanoma detection, and melanoma origin (de novo vs nevus derived) differed in a similar patient population monitored using total body (TB) photography. METHODS: One thousand seventy-six patients (including 187 from a prior cohort) underwent TB photography and were monitored using photographs obtained at the initial visit. Risk factors and median monitoring periods for these patients were comparable with those of patients previously monitored using DELM photography. RESULTS: Two hundred seventy-five biopsies were performed in 467 patients on follow-up visits. Of 12 melanomas detected on follow-up, five were invasive, five presented as changing lesions and two as new lesions, nine arose de novo, and the remainder were nevus derived. CONCLUSIONS: In our experience with both approaches, monitoring patients at risk for melanoma using TB photography was associated with lower biopsy rates and lower nevus-to-melanoma ratios than using DELM and facilitated detection of new and changing lesions. In both cohorts, the majority of melanomas detected on follow-up arose de novo.

Comparison of the predicted structures of loops in the ras-SOS protein bound to a single ras-p21 protein with the crystallographically determined structures in SOS bound to two ras-p21 proteins.

We have previously computed the structures of three loops, residues 591-596, 654-675 and 742-751, in the ras-p21 protein-binding domain (residues 568-1044) of the guanine nucleotide-exchange-promoting SOS protein that were crystallographically undefined when one molecule of ras-p21 (unbound to nucleotide) binds to SOS. Based on our computational results, we synthesized three peptides corresponding to sequences of each of these three loops and found that all three peptides strongly inhibit ras-p21 signaling. More recently, a new crystal structure of SOS has been determined in which this protein binds to two molecules of ras-p21, one unbound to GTP and one bound to GTP. In this structure, the 654-675 loop and residues 742-743 and 750-751 are now crystallographically defined. We have superimposed our energy-minimized structure of the ras-binding domain of SOS bound to one molecule of ras-p21 on the X-ray structure for SOS bound to two molecules of ras-p21. We find that, while the two structures are superimposable, there are large deviations of the residues 673 and 676 and 741 and 752, flanking the two loop segments. This suggests that the binding of the extra ras-p21 molecule, which is far from each of the three loops, induces conformational changes in these domains and further supports their role in signal transduction. In spite of these differences, we have superimposed our computed structures for the loop residues on those from the more recent X-ray structure. Our structure for the 654-675 segment is an anti-parallel beta-sheet with a reverse turn at residues 663-665; in the X-ray structure residues 655-662 adopt an alpha-helical conformation; on the other hand, our computed structure for residues 663-675 superimpose on the X-ray structure for these residues. We further find that our computed structures for residues 742-743 and 750-751 are superimposable on the X-ray structure for these residues.

Comparison of molecular dynamics averaged structures for complexes of normal and oncogenic ras-p21 with SOS nucleotide exchange protein, containing computed conformations for three crystallographically undefined domains, suggests a potential role of these domains in ras signaling.

ras-p21 protein binds to the son-of-sevenless (SOS) guanine nucleotide-exchange promoter that allows it to exchange GDP for GTP. Previously, we performed molecular dynamics calculations on oncogenic (Val 12-) and wild-type ras-p21 bound to SOS. By superimposing the average structures of these two complexes, we identified four domains (residues 631-641, 676-691, 718-729, and 994-1004) in SOS that change conformation and were candidates for being effector domains. These calculations were performed in the absence of three crystallographically undefined loops (i.e., residues 591-596, 654-675, and 742-751). We have now modeled these loops into the SOS structure and have re-performed the dynamics calculations. We find that all three loop domains undergo large changes in conformation that involve mostly changes in their positioning and not their individual conformations. We have also identified another potential effector domain (i.e., residues 980-989). Overall, our current results suggest that SOS interactions with oncogenic ras-p21 may enhance ras-p21 mitogenic signaling through prolonging its activation by maintaining its binding to GTP and by allowing its effector domains to interact with intracellular targets.