qPCR and qRT-PCR analysis: Regulatory points to consider when conducting biodistribution and vector shedding studies.

Gene and cell therapy fields have experienced remarkable growth during the past decade. Demands for preclinical and clinical safety assessments of these cell and gene therapy test articles (TAs) have effectively increased the necessity for regulated biodistribution, vector shedding, gene expression, and/or pharmacokinetics bioanalysis studies. Guidance documents issued from numerous international regulatory authorities recommend the use of quantitative polymerase chain reaction (qPCR) and/or quantitative reverse transcriptase PCR (qRT-PCR) assays due to their highly sensitive and robust target-specific detection. However, only preclinical biodistribution assay sensitivity is specified in these documents. Criteria such as accuracy, precision, and repeatability are not yet defined. This guidance void has resulted in several conflicting institutional interpretations of essential parameters necessary for the development and validation of robust assays to support safety assessments of gene and cell therapy TAs. There is an urgent need for an ongoing discussion among bioanalytical scientists in this field to generate a "best practice" consensus around preclinical and clinical qPCR/qRT-PCR assay design. With regard to this need, we offer critical points to consider when developing, validating, running sample analysis, and reporting qPCR/qRT-PCR assays.

A pharmacist-led pilot using a performance dashboard to improve psychotropic medication use in a skilled nursing facility.

OBJECTIVES: Inappropriate use of psychotropic medications in the elderly, particularly those with dementia, is a critical safety and quality concern. This pilot quality improvement study used a novel Department of Veterans Affairs (VA) Psychotropic Drug Safety Initiative performance dashboard (PDSI dashboard) to implement a pharmacist-led intervention to improve psychotropic medication prescribing practices in a VA skilled nursing facility (SNF). While clinical dashboard data have become commonplace, literature describing successful implementation for improved clinical care is scant. METHODS: This study took place from November 2015 to February 2016 at a 112-bed VA SNF. A pharmacist used the PDSI dashboard to identify 'actionable' patients with potentially inappropriate psychotropic prescribing and then completed chart reviews to confirm clinical indications. The pharmacist provided recommendations to providers for dose reductions or deprescribing via in-person communication and notes written in the electronic medical record. SNF providers completed anonymous surveys about their experience in receiving recommendations. RESULTS: Over a 5-month period, the PDSI dashboard identified 21 patients with potentially inappropriate psychotropic medication use, with approximately one new patient identified each week. Prescribing recommendations were accepted 66% of the time. All seven SNF providers reported that recommendations were helpful in improving their psychotropic prescribing practices. CONCLUSIONS: The PDSI dashboard was efficient and effective in identifying patients at risk for inappropriate use of psychotropic medications. A clinical pharmacist was essential for implementing and communicating recommendations from the dashboard to providers.

Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation.

BACKGROUND: Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters. OBJECTIVE: To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence. DESIGN: Cross-sectional, observational study of video and event recordings of primary care and specialty consultations. PARTICIPANTS: Thirty-two physicians and 217 patients. MAIN MEASURES: Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence. KEY RESULTS: Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures. CONCLUSIONS: Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

Physician activity during outpatient visits and subjective workload.

We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.

Transcriptional Regulation by ATOH1 and its Target SPDEF in the Intestine.

BACKGROUND & AIMS: The transcription factor atonal homolog 1 (ATOH1) controls the fate of intestinal progenitors downstream of the Notch signaling pathway. Intestinal progenitors that escape Notch activation express high levels of ATOH1 and commit to a secretory lineage fate, implicating ATOH1 as a gatekeeper for differentiation of intestinal epithelial cells. Although some transcription factors downstream of ATOH1, such as SPDEF, have been identified to specify differentiation and maturation of specific cell types, the bona fide transcriptional targets of ATOH1 still largely are unknown. Here, we aimed to identify ATOH1 targets and to identify transcription factors that are likely to co-regulate gene expression with ATOH1. METHODS: We used a combination of chromatin immunoprecipitation and messenger RNA-based high-throughput sequencing (ChIP-seq and RNA-seq), together with cell sorting and transgenic mice, to identify direct targets of ATOH1, and establish the epistatic relationship between ATOH1 and SPDEF. RESULTS: By using unbiased genome-wide approaches, we identified more than 700 genes as ATOH1 transcriptional targets in adult small intestine and colon. Ontology analysis indicated that ATOH1 directly regulates genes involved in specification and function of secretory cells. De novo motif analysis of ATOH1 targets identified SPDEF as a putative transcriptional co-regulator of ATOH1. Functional epistasis experiments in transgenic mice show that SPDEF amplifies ATOH1-dependent transcription but cannot independently initiate transcription of ATOH1 target genes. CONCLUSIONS: This study unveils the direct targets of ATOH1 in the adult intestines and illuminates the transcriptional events that initiate the specification and function of intestinal secretory lineages.

Strategizing EHR use to achieve patient-centered care in exam rooms: a qualitative study on primary care providers.

OBJECTIVE: Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish "patient-centeredness" in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect associated with EHR use. METHODS AND MATERIALS: Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. RESULTS: The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. DISCUSSION AND CONCLUSION: This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing "best" practices to improve patient-centered care in today's highly "wired" health environment. These findings also show that more user-centered EHR design is needed to improve system usability.

EHR use and patient satisfaction: What we learned.

PURPOSE: Few studies have quantitatively examined the degree to which the use of the computer affects patients' satisfaction with the clinician and the quality of the visit. We conducted a study to examine this association. METHODS: Twenty-three clinicians (21 internal medicine physicians, 2 nurse practitioners) were recruited from 4 Veteran Affairs Medical Center (VAMC) clinics located in San Diego, Calif. Five to 6 patients for most clinicians (one patient each for 2 of the clinicians) were recruited to participate in a study of patient-physician communication. The clinicians' computer use and the patient-clinician interactions in the exam room were captured in real time via video recordings of the interactions and the computer screen, and through the use of the Morae usability testing software system, which recorded clinician clicks and scrolls on the computer. After the visit, patients were asked to complete a satisfaction survey. RESULTS: The final sample consisted of 126 consultations. Total patient satisfaction (beta=0.014; P=.027) and patient satisfaction with patient-centered communication (beta=0.02; P=.02) were significantly associated with higher clinician "gaze time" at the patient. A higher percentage of gaze time during a visit (controlling for the length of the visit) was significantly associated with greater satisfaction with patient-centered communication (beta=0.628; P=.033). CONCLUSIONS: Higher clinician gaze time at the patient predicted greater patient satisfaction. This suggests that clinicians would be well served to refine their multitasking skills so that they communicate in a patient-centered manner while performing necessary computer-related tasks. These findings also have important implications for clinical training with respect to using an electronic health record (EHR) system in ways that do not impede the one-on-one conversation between clinician and patient.

Krüpple-like factor 5 is required for proper maintenance of adult intestinal crypt cellular proliferation.

BACKGROUND: Krüpple-like factor 5 (KLF5) is a transcription factor that is highly expressed in the proliferative compartment of the intestinal crypt. There, it is thought to regulate epithelial turnover and homeostasis. AIM: In this study, we sought to determine the role for Klf5 in the maintenance of cellular proliferation, cytodifferentiation, and morphology of the crypt-villus axis. METHODS: Tamoxifen-induced recombination directed by the epithelial-specific Villin promoter (in Villin-CreERT2 transgenic mice) was used to delete Klf5 (in Klf5 (loxP/loxP) mice) from the adult mouse intestine and analyzed by immunostaining and RT-qPCR. Control mice were tamoxifen-treated Klf5 (loxP/loxP) mice lacking Villin-CreERT2. RESULTS: Three days after tamoxifen-induced recombination, the mitosis marker phospho-histone H3 was significantly reduced within the Klf5-mutant crypt epithelium, coincident with increased expression of the apoptosis marker cleaved-caspase 3 within the crypt where cell death rarely occurs normally. We also observed a reduction in Chromagranin A expressing enteroendocrine cells, though no significant change was seen in other secretory or absorptive cell types. To examine the long-term repercussions of Klf5 loss, we killed mice 5, 14, and 28 days post recombination and found reemerging expression of KLF5. Furthermore, we observed restoration of cellular proliferation, though not to levels seen wildtype intestinal crypts. Reduction of apoptosis to levels comparable to the wildtype intestinal crypt was also observed at later time points. Analysis of cell cycle machinery indicated no significant perturbation upon deletion of Klf5; however, a reduction of stem cell markers Ascl2, Lgr5, and Olfm4 was observed at all time points following Klf5 deletion. CONCLUSIONS: These results indicate that Klf5 is necessary to maintain adult intestinal crypt proliferation and proper cellular differentiation. Rapid replacement of Klf5-mutant crypts with wildtype cells and reduction of stem cell markers suggests further that Klf5 is required for self renewal of intestinal stem cells.

Dating violence and interpersonal victimization among a national sample of Latino youth.

PURPOSE: The purpose of this analysis was (1) to provide the rates of dating violence victimization among a national sample of Latino adolescents, (2) to determine the degree to which different forms of dating violence victimization co-occurred for this sample, and (3) to determine how much dating violence victimization overlapped with other forms of non-partner-perpetrated victimization. METHOD: This analysis used data from the Dating Violence Among Latinos Study, which surveyed 1,525 Latino adolescents between the ages of 12 and 18 years about past-year dating violence and non-partner-perpetrated victimization. We calculated victimization rates and relative risk ratios to evaluate the co-occurrence among different forms of dating violence victimization as well as the co-occurrence of dating violence and other forms of victimization. RESULTS: Results show elevated rates of dating violence victimization compared with previous studies, which is primarily accounted for by psychological dating violence. The rate of dating violence appears to precipitously increase starting around ages 13 and 14 years and is consistently higher for boys. Each type of dating violence was significantly associated with other forms of dating violence (e.g., physical and psychological). Dating violence was significantly associated with experiencing conventional crime, peer or sibling victimization, and nonpartner sexual victimization as well as being a polyvictim. CONCLUSIONS: The results support the importance of early prevention efforts with Latino youth and addressing dating violence with both sexes. Furthermore, dating violence should be seen as a potential risk marker for youth who are experiencing multiple forms of victimization.

Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.

OBJECTIVE: The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit. METHODS: Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient. RESULTS: The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower in patient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence. CONCLUSIONS: PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously managing data in the EHR. PRACTICE IMPLICATIONS: EHR activity consumes an increasing proportion of clinicians' time during consultations. To ensure effective communication with their patients, clinicians may benefit from using communication strategies that maintain the flow of conversation when working with the computer, as well as from learning EHR management skills that prevent extended periods of gaze at computer and long periods of silence. Next-generation EHR design must address better usability and clinical workflow integration, including facilitating patient-clinician communication.

The effect of acculturation and immigration on the victimization and psychological distress link in a national sample of Latino women.

Distinct bodies of research have examined the link between victimization and psychological distress and cultural variables and psychological health, but little is known about how cultural variables affect psychological distress among Latino victims. Substantial research has concluded that Latino women are more likely than non-Latino women to experience trauma-related symptoms following victimization. In addition, examination of different types of cultural adaptation has found results supporting the idea that maintaining ties with one's culture of origin may be protective against negative mental health outcomes. The present study evaluates the effect of victimization, immigrant status, and both Anglo and Latino orientation on psychological distress in a national sample of Latino women. Results indicate that along with the total count of victimization experiences, Anglo and/or Latino orientation were strong predictors of all forms of psychological distress. Anglo orientation also functioned as a moderator between victimization and psychological distress measures for anger, dissociation, and anxiety. The results suggest a more nuanced and complex interaction between cultural factors, victimization, and psychological distress.

Improving medical students' success in promoting health behavior change: a curriculum evaluation.

INTRODUCTION: Effective behavior change counseling is an important component of the optimal care of patients, yet only a minority of medical schools currently include such training in their curriculum. AIM: To design and evaluate a formal curriculum to teach medical students the principles of motivational interviewing (MI) that will improve knowledge, skills, and confidence in the area of counseling patients for health behavior change. PARTICIPANTS: Fifty-three 3rd year medical students at the University of California, San Diego. PROGRAM DESCRIPTION: A 4-week curriculum consisting of four 2-h sessions, in a small group format (8-12 students). Educational strategies included a combination of short didactics, video demonstrations, small group role plays, and interactive exercises. PROGRAM EVALUATION: Students completed identical pre- and post-assessments, consisting of a questionnaire measuring confidence and knowledge, and a performance assessment using the Video Assessment of Simulated Encounters-Revised (VASE-R) tool. Knowledge improved significantly (pre-mean: 7.04, post-mean: 11.54; P < 0.001), as did skill development (pre-mean: 7.02, post-mean: 9.47; P < 0.001). Student satisfaction with behavior change counseling training improved from 3.6 to 8.1 (P < 0.001). Students were significantly more confident (P < 0.001) in their abilities to assess a patient's readiness for change and counsel the patient on behavior change after the course. DISCUSSION: Participation in a focused curriculum on the use of motivational interviewing techniques significantly improved 3rd year medical students' knowledge, confidence, and skills in the area of behavior change counseling. These gains may help students succeed in promoting good health habits in their future patients.