Assessment of a Digital Health Coordination Program to Mitigate Telehealth Access Disparities.

Objective: Patients with digital disparity experience challenges with utilizing and accessing virtual care. This study implemented a digital coordination program for patients in outpatient psychiatry. Methods: Clinicians referred patients to a digital health coordinator who provided training to enhance virtual access. Outcomes were patient sociodemographics, barriers to digital health care utilization, change in completed video visits, and clinician satisfaction. Results: The patient cohort included 44 patients with a mean age of 59.8, 75% female, 73% Caucasian, and 84% non-Hispanic. The median household income was less than $25,000. The most common barrier to completing a video visit was difficulty using Zoom. The proportion of completed to scheduled video visits increased in 27% of patients. In such patients, the mean increase in completed visits was 32%. A majority of referring providers (64%) reported increased meaningfulness of work. Conclusion: This pilot proactively identified disparities in virtual care access and mitigated digital literacy barriers, boosting meaningfulness of work for clinicians.

When Compromised Professional Fulfillment Compromises Professionalism.

This Viewpoint highlights the increasing levels of burnout among physicians, discusses how burnout can erode professionalism, and suggests possible steps physicians and health care organizations might take to lessen burnout and maintain professionalism in the setting of burnout.

Understanding Perceived Appreciation to Create a Culture of Wellness.

OBJECTIVE: To fully address physician burnout, academic medical centers need cultures that promote well-being. One observed driver of a culture of wellness is perceived appreciation. The authors identified several contributors to perceived appreciation among faculty at a large, metropolitan academic institution through use of a novel survey. METHODS: The authors surveyed clinical faculty in five departments: psychiatry, emergency medicine, internal medicine, thoracic surgery, and radiology. Two open-ended response questions assessed sources of perceived and lack of perceived appreciation in narrative form. The authors also collected data on gender and department identity. Grounded theory methodology was used to analyze the narrative responses and design thinking to brainstorm specific recommendations based on the main themes identified. RESULTS: A total of 179 faculty respondents filled out the survey for an overall response rate of 29%. Major drivers of perceived appreciation were patient and families (42%); physician, trainee and non-physician colleagues (32.7%); chairs (10%); and compensation (3.3%). Major drivers of perceived lack of appreciation were disrespect for time and skill level, including inadequate staffing (30%); devaluation by a physician colleague, chief of one's service or the chair (29%); poor communication and transparency (13%); and patient and family anger (6%). CONCLUSIONS: Opportunities to improve perceived appreciation include structured communication of patient gratitude, community building programs, top of licensure initiatives and accountability for physician wellness, and inclusivity efforts from organizational leaders.

Diversity, Equity, and Inclusion Committee: An Instrument to Champion Diversity Efforts Within a Large Academic Psychiatry Department.

Diversity, equity, and inclusion (DEI) have become increasingly recognized as essential to the practice of high-quality patient care delivery and the support of members of the clinical environment. A solid understanding of DEI contributes to a better grasp of what drives health care disparities and yields improved clinical outcomes for minority populations. This column discusses how individuals can practically promote DEI by describing the design and implementation of DEI in an academic psychiatry department. The authors highlight the powerful role of departmental initiatives in establishing best practices for DEI and lessons learned through the work of the psychiatry department's DEI committee.

Can Telehealth Advance Professional Equity for Women in Medicine?

Higher rates of burnout among female physicians as compared with male physicians remain a troubling phenomenon. Achieving gender equity in academic advancement is a critical component of addressing this gap. During the timeframe of childbearing and rearing, enhanced control and flexibility are desired workplace changes and offered by telehealth work modalities. This viewpoint explores the role of telehealth and the remote work environment in optimizing control and flexibility, which can increase participation in academic advancement opportunities and improve female physician burnout. Widespread promotion of remote clinical practice and participation in scholarly activities beyond the duration of the COVID-19 pandemic may be a component of the long-term solution to female physician burnout.

Suicidal Behavior Among Hospitalized Adults With Inflammatory Bowel Disease: A United States Nationwide Analysis.

Background: Suicidal behavior in inflammatory bowel disease (IBD) has been minimally explored. We aimed to determine United States (US) nationally representative prevalence estimates of suicidal ideation (SI) and suicide/self-inflicted injury (S/SII) among hospitalized adults with IBD and to examine trends in suicidal behavior over time. Methods: A retrospective cross-sectional study using National (Nationwide) Inpatient Sample data (2006-2011) identified adults with Crohn's disease (CD) or ulcerative colitis (UC), SI or S/SII, and multiple comorbid risk factors for suicidal behavior. Results: We identified 331,777 (estimated 1.64 million) IBD-related hospitalizations (64% CD, 36% UC) and 39,787,239 (estimated 196.08 million) hospitalizations among the general US population. Among IBD-related hospitalizations, 2502 discharges were associated with SI (prevalence 0.76%) and 1104 with S/SII (prevalence 0.33%). Both were significantly greater in CD versus UC (P < 0.001). Relative to the general US population, IBD patients were significantly less likely to demonstrate suicidal behavior: (SI:0.33% versus 0.59%, P < 0.001) (S/SII:0.75% versus 1.04%, P < 0.001). Multivariable logistic regression revealed that IBD was associated with decreased odds of SI (adjusted odds ratio [aOR] 0.62, 95%CI 0.60-0.65) and S/SII (aOR 0.43, 95%CI 0.40-0.45) relative to the general population, and suicidal behavior was lower in IBD compared to disease-related controls with rheumatoid arthritis and systemic lupus erythematosus. Similar increasing trends in suicidal behavior were observed in IBD and non-IBD populations (2006-2011). Conclusion: In this large US database, SI or S/SII occurred in over 1% of the IBD population and was increased in CD versus UC.

Differences Between People Who Use Only Facebook And Those Who Use Facebook Plus Twitter.

Facebook (FB) and Twitter are popular social networking sites. This study examined differences between those who use both sites versus only FB, to test the hypothesis that mono-users differ in their personality characteristics from users active in both websites. Participants were 205 undergraduate students; 96 only used FB, 109 used FB and Twitter. Participants who used both sites reported significantly lower loneliness, higher number of FB friends, and lower number of minutes spent online, as compared to those who only used FB. Loneliness was positively associated with FB use only in those who used FB alone, but was negatively associated with and negatively predicted both FB and Twitter use in those who used both websites. Findings suggest that more intense use of online interactions is more frequently found in mono-users (people using only Facebook) as compared to those using both websites, and it is predicted by increased feelings of loneliness. The current study findings provide additional insights on what personality factors may make some people prone to excessive use of social networking sites.

Drug-drug interactions between warfarin and psychotropics: updated review of the literature.

As the number of psychotropics on the market expands, the likelihood increases that a patient requiring anticoagulation with warfarin will receive concurrent treatment with a psychotropic drug. Because warfarin undergoes hepatic metabolism and is highly protein bound, it is particularly prone to drug interactions; in addition, its relatively narrow therapeutic window places patients at risk of either hemorrhagic or thrombotic complications. Although warfarin's interactions with other drugs have long been studied, the most recent review of the literature of warfarin's interactions with psychotropics was over a decade ago. Thus, we conducted a systematic review of the literature documenting the interaction between warfarin and psychotropics, with a focus on interactions mediated through the cytochrome P450 system and protein binding. A search of the MEDLINE database was performed, and reports of warfarin interactions with psychotropics were identified. The results suggest that interactions between warfarin and psychotropic drugs are important and likely underrecognized. They also have notable implications for both safety and drug compliance. When certain psychotropics are started or discontinued in patients receiving warfarin therapy, or when warfarin is introduced to a patient receiving a stable dose of a psychotropic, clinicians should monitor a patient's international normalized ratio (INR) closely to ensure it remains within therapeutic range. Psychotropics that pose a particular risk of increasing the INR when used with warfarin include fluoxetine, fluvoxamine, quetiapine, and valproic acid. Psychotropics that may significantly decrease the INR when used with warfarin include trazodone, St. John's wort, carbamazepine, and the polycyclic aromatic carbons in tobacco cigarettes; however, nicotine itself, as in nicotine replacement strategies, is not known to alter warfarin's anticoagulant effect. In certain cases, the need for anticoagulation may also necessitate switching to a different psychotropic.

Why Do People Use Facebook?

The social networking site, Facebook, has gained an enormous amount of popularity. In this article, we review the literature on the factors contributing to Facebook use. We propose a model suggesting that Facebook use is motivated by two primary needs: (1) The need to belong and (2) the need for self-presentation. Demographic and cultural factors contribute to the need to belong, whereas neuroticism, narcissism, shyness, self-esteem and self-worth contribute to the need for self presentation. Areas for future research are discussed.

Detrimental effects of divalproex on warfarin therapy following mechanical valve replacement.

Drug interaction between Warfarin and psychiatric agents may have important therapeutic effects for patients undergoing cardiac surgery. We present a case of a patient in whom concurrent treatment with Warfarin and valproic acid resulted in supratherapeutic international normalized ratio values. A discussion of the possible mechanisms for this interaction as well as a review of interactions between Warfarin and other psychiatric medications is the subject of this case report.

Optimization of a mouse recombinant antibody fragment for efficient production from Escherichia coli.

A mutagenized mouse recombinant antibody fragment (rFab) that recognized HIV capsid protein was isolated from Escherichia coli at a level of 12 mg per liter of culture using standard shake flask methods. This is one of the highest yields of a modified antibody fragment obtained using non-fermentor-based methods. Recombinant Fab was isolated directly from the culture medium, which lacked complex materials such as tryptone and yeast extract. Fab isolated from the periplasm was not as homogeneous as that isolated directly from the culture medium. Optimization of the culture medium using recently developed media, the use of E. coli cell lines that contained rare tRNA codons, and mutagenesis of the Fab to improve the stability of the Fab were important factors in producing high-levels of the Fab. An isolation protocol easily adaptable to automation using a thiophilic-sepharose column followed by metal-chelate chromatography and the introduction of a non-traditional metal binding site for metal-chelate purification that bypasses the conventional hexahistidine tag cleavage step (to prevent the purification tag from interfering with crystallization) are additional features of this approach to produce a highly homogenous preparation of rFab. The resulting rFab binds to its antigen, p24, equivalent in character to the monoclonal from which the rFab was originally derived.

Chromosomal duplications and cointegrates generated by the bacteriophage lamdba Red system in Escherichia coli K-12.

BACKGROUND: An Escherichia coli strain in which RecBCD has been genetically replaced by the bacteriophage lambda Red system engages in efficient recombination between its chromosome and linear double-stranded DNA species sharing sequences with the chromosome. Previous studies of this experimental system have focused on a gene replacement-type event, in which a 3.5 kbp dsDNA consisting of the cat gene and flanking lac operon sequences recombines with the E. coli chromosome to generate a chloramphenicol-resistant Lac- recombinant. The dsDNA was delivered into the cell as part of the chromosome of a non-replicating lambda vector, from which it was released by the action of a restriction endonuclease in the infected cell. This study characterizes the genetic requirements and outcomes of a variety of additional Red-promoted homologous recombination events producing Lac+ recombinants. RESULTS: A number of observations concerning recombination events between the chromosome and linear DNAs were made: (1) Formation of Lac+ and Lac- recombinants depended upon the same recombination functions. (2) High multiplicity and high chromosome copy number favored Lac+ recombinant formation. (3) The Lac+ recombinants were unstable, segregating Lac- progeny. (4) A tetracycline-resistance marker in a site of the phage chromosome distant from cat was not frequently co-inherited with cat. (5) Recombination between phage sequences in the linear DNA and cryptic prophages in the chromosome was responsible for most of the observed Lac+ recombinants. In addition, observations were made concerning recombination events between the chromosome and circular DNAs: (6) Formation of recombinants depended upon both RecA and, to a lesser extent, Red. (7) The linked tetracycline-resistance marker was frequently co-inherited in this case. CONCLUSIONS: The Lac+ recombinants arise from events in which homologous recombination between the incoming linear DNA and both lac and cryptic prophage sequences in the chromosome generates a partial duplication of the bacterial chromosome. When the incoming DNA species is circular rather than linear, cointegrates are the most frequent type of recombinant.