Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study.

BACKGROUND: Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. OBJECTIVE: The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. METHODS: In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. RESULTS: Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. CONCLUSIONS: Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Implementation of a Work-Related Asthma Screening Questionnaire in Clinical Settings: Multimethods Study.

BACKGROUND: A work-related asthma (WRA) screening questionnaire is currently being validated for implementation in clinical settings. To minimize barriers to integrating tools into clinical practice, a discussion of strategies for the implementation of the questionnaire has begun. OBJECTIVE: This study aimed to understand the benefits, feasibility, barriers, and limitations of implementing the Work-related Asthma Screening Questionnaire-Long version (WRASQ[L]) and asthma e-tools in clinical settings and propose dissemination and implementation strategies for the WRASQ(L). METHODS: This study was conducted in Kingston, Ontario, Canada, from September 2019 to August 2021. A workshop and 2 questionnaires were used to understand the benefits of and barriers to implementing the questionnaire in clinical settings. An expert advisory committee was established to develop the implementation and dissemination strategies. Workshops were semistructured and used thematic qualitative analysis to identify themes that provided an understanding of the benefits and limitations of and barriers to using the WRASQ(L), and e-tools in general, in clinical settings. Workshop participants included patients and health care providers, including physicians, nurses, and asthma educators, who were implementation specialists and expert electronic medical record users. A questionnaire focusing on providers' knowledge and awareness of WRA and another focusing on WRASQ(L) feedback was administered at the workshops. Advisory committee members from relevant stakeholders met 3 times to strategize implementation opportunities. RESULTS: A total of 6 themes were identified in the workshop: involving and addressing patient needs, novel data collection, knowledge translation, time considerations, functional and practical barriers, and human limitations. Questionnaire responses yielded positive feedback on the utility of the WRASQ(L) in clinical settings. All participants agreed that it is an easy way of collecting information on occupational and exposure history and could prompt a discussion between the health care provider and patient on how the workplace and exposures could affect one's asthma, increase awareness of WRA in patients and providers, and increase awareness of exposures in the workplace. Implementation and dissemination strategies were generated with input from the advisory committee. CONCLUSIONS: Stakeholders and workshop participants consider the WRASQ(L) to be a useful tool that satisfies many provider needs in their clinical settings. Once validated, dissemination strategies will include developing educational materials that include the WRASQ(L), linking the questionnaire to stakeholder websites or e-toolkits, translation into other languages, leveraging health care and research networks, conference presentations, and peer-reviewed publications. Implementation strategies will include integration into electronic medical records; designing multifaceted interventions; and targeting nontraditional settings such as workplaces, pharmacies, and research settings. The WRASQ(L) addresses many benefits of and barriers to implementation, as identified in the workshop themes. These themes will guide future implementation and dissemination strategies, noting that human limitations identified in providers and patients will need to be overcome for successful implementation.

Diverse methylotrophic methanogenic archaea cause high methane emissions from seagrass meadows.

Marine coastlines colonized by seagrasses are a net source of methane to the atmosphere. However, methane emissions from these environments are still poorly constrained, and the underlying processes and responsible microorganisms remain largely unknown. Here, we investigated methane turnover in seagrass meadows of Posidonia oceanica in the Mediterranean Sea. The underlying sediments exhibited median net fluxes of methane into the water column of ca. 106 µmol CH4 ⋅ m-2 ⋅ d-1 Our data show that this methane production was sustained by methylated compounds produced by the plant, rather than by fermentation of buried organic carbon. Interestingly, methane production was maintained long after the living plant died off, likely due to the persistence of methylated compounds, such as choline, betaines, and dimethylsulfoniopropionate, in detached plant leaves and rhizomes. We recovered multiple mcrA gene sequences, encoding for methyl-coenzyme M reductase (Mcr), the key methanogenic enzyme, from the seagrass sediments. Most retrieved mcrA gene sequences were affiliated with a clade of divergent Mcr and belonged to the uncultured Candidatus Helarchaeota of the Asgard superphylum, suggesting a possible involvement of these divergent Mcr in methane metabolism. Taken together, our findings identify the mechanisms controlling methane emissions from these important blue carbon ecosystems.

Silicone Wristbands as Passive Samplers in Honey Bee Hives.

The recent decline of European honey bees (Apis mellifera) has prompted a surge in research into their chemical environment, including chemicals produced by bees, as well as chemicals produced by plants and derived from human activity that bees also interact with. This study sought to develop a novel approach to passively sampling honey bee hives using silicone wristbands. Wristbands placed in hives for 24 h captured various compounds, including long-chain hydrocarbons, fatty acids, fatty alcohols, sugars, and sterols with wide ranging octanol-water partition coefficients (Kow) that varied by up to 19 orders of magnitude. Most of the compounds identified from the wristbands are known to be produced by bees or plants. This study indicates that silicone wristbands provide a simple, affordable, and passive method for sampling the chemical environment of honey bees.

Blue boron-bearing diamonds from Earth's lower mantle.

Geological pathways for the recycling of Earth's surface materials into the mantle are both driven and obscured by plate tectonics1-3. Gauging the extent of this recycling is difficult because subducted crustal components are often released at relatively shallow depths, below arc volcanoes4-7. The conspicuous existence of blue boron-bearing diamonds (type IIb)8,9 reveals that boron, an element abundant in the continental and oceanic crust, is present in certain diamond-forming fluids at mantle depths. However, both the provenance of the boron and the geological setting of diamond crystallization were unknown. Here we show that boron-bearing diamonds carry previously unrecognized mineral assemblages whose high-pressure precursors were stable in metamorphosed oceanic lithospheric slabs at depths reaching the lower mantle. We propose that some of the boron in seawater-serpentinized oceanic lithosphere is subducted into the deep mantle, where it is released with hydrous fluids that enable diamond growth10. Type IIb diamonds are thus among the deepest diamonds ever found and indicate a viable pathway for the deep-mantle recycling of crustal elements.

Zintl Ions within Framework Channels: The Complex Structure and Low-Temperature Transport Properties of Na4Ge13.

Single crystals of a complex Zintl compound with the composition Na4Ge13 were synthesized for the first time using a high-pressure/high-temperature approach. Single-crystal diffraction of synchrotron radiation revealed a hexagonal crystal structure with P6/m space group symmetry that is composed of a three-dimensional sp3 Ge framework punctuated by small and large channels along the crystallographic c axis. Na atoms are inside hexagonal prism-based Ge cages along the small channels, while the larger channels are occupied by layers of disordered sixfold Na rings, which are in turn filled by disordered [Ge4]4- tetrahedra. This compound is the same as "Na1-xGe3+z" reported previously, but the availability of single crystals allowed for more complete structural determination with a formula unit best described as Na4Ge12(Ge4)0.25. The compound is the first known example of a guest-host structure where discrete Zintl polyanions are confined inside the channels of a three-dimensional covalent framework. These features give rise to temperature-dependent disorder, as confirmed by first-principles calculations and physical properties measurements. The availability of single-crystal specimens allowed for measurement of the intrinsic low-temperature transport properties of this material and revealed its semiconductor behavior, which was corroborated by theoretical calculations.

Exploring the Therapeutic Affordances of Self-Harm Online Support Communities: An Online Survey of Members.

BACKGROUND: A growing number of online communities have been established to support those who self-harm. However, little is known about the therapeutic affordances arising from engagement with these communities and resulting outcomes. OBJECTIVE: The aim of this study was to explore the presence of therapeutic affordances as reported by members of self-harm online support communities. METHODS: In total, 94 respondents (aged 13-63 years, mean=23.5 years; 94% female) completed an online survey exploring their experiences of engaging with a self-harm online support community. Respondents varied in terms of how long they had been accessing an online community, with 22% (21/94) accessing less than 1 year, 39% (37/94) 1 to 2 years, 14% (13/94) 2 to 3 years, and 24.5% (23/94) more than 3 years. Responses were analyzed using deductive thematic analysis. RESULTS: The results of our analysis describe each of the five therapeutic affordances that were present in the data, namely (1) connection, the ability to make contact with others who self-harm for the purposes of mutual support and in so doing reduce feelings of loneliness and isolation; (2) adaptation, that is, how use of online support varies in relation to the personal circumstances of the individual user; (3) exploration, that is, the ability to learn about self-harm and learn about strategies to reduce or stop self-harming behavior; (4) narration, that is, the ability to share experiences, as well as read about the experiences of others; and (5) self-presentation, that is, how and what users present about themselves to others in the online community. CONCLUSIONS: Our findings suggest that engagement with self-harm online support communities may confer a range of therapeutic benefits for some users, which may serve to minimize the psychosocial burden of self-harm and promote positive coping strategies. In addition, the online nature of the support available may be helpful to those who are unable to access face-to-face support.

Properties of the exotic metastable ST12 germanium allotrope.

The optical and electronic properties of semiconducting materials are of great importance to a vast range of contemporary technologies. Diamond-cubic germanium is a well-known semiconductor, although other 'exotic' forms may possess distinct properties. In particular, there is currently no consensus for the band gap and electronic structure of ST12-Ge (tP12, P43212) due to experimental limitations in sample preparation and varying theoretical predictions. Here we report clear experimental and theoretical evidence for the intrinsic properties of ST12-Ge, including the first optical measurements on bulk samples. Phase-pure bulk samples of ST12-Ge were synthesized, and the structure and purity were verified using powder X-ray diffraction, transmission electron microscopy, Raman and wavelength/energy dispersive X-ray spectroscopy. Optical measurements indicate that ST12-Ge is a semiconductor with an indirect band gap of 0.59 eV and a direct optical transition at 0.74 eV, which is in good agreement with electrical transport measurements and our first-principles calculations.

Large gem diamonds from metallic liquid in Earth's deep mantle.

The redox state of Earth's convecting mantle, masked by the lithospheric plates and basaltic magmatism of plate tectonics, is a key unknown in the evolutionary history of our planet. Here we report that large, exceptional gem diamonds like the Cullinan, Constellation, and Koh-i-Noor carry direct evidence of crystallization from a redox-sensitive metallic liquid phase in the deep mantle. These sublithospheric diamonds contain inclusions of solidified iron-nickel-carbon-sulfur melt, accompanied by a thin fluid layer of methane ± hydrogen, and sometimes majoritic garnet or former calcium silicate perovskite. The metal-dominated mineral assemblages and reduced volatiles in large gem diamonds indicate formation under metal-saturated conditions. We verify previous predictions that Earth has highly reducing deep mantle regions capable of precipitating a metallic iron phase that contains dissolved carbon and hydrogen.

Free Choice and Patient Best Interests.

In medical practice, the doctrine of informed consent is generally understood to have priority over the medical practitioner's duty of care to her patient. A common consequentialist argument for the prioritisation of informed consent above the duty of care involves the claim that respect for a patient's free choice is the best way of protecting that patient's best interests; since the patient has a special expertise over her values and preferences regarding non-medical goods she is ideally placed to make a decision that will protect her interests. In this paper I argue against two consequentialist justifications for a blanket prioritisation of informed consent over the duty of care by considering cases in which patients have imperfect access to their overall best interests. Furthermore, I argue that there are cases where the mere presentation of choice under the doctrine of informed consent is detrimental to patient best interests. I end the paper by considering more nuanced approaches to resolving the conflict between informed consent and the duty of care and consider the option of permitting patients to waive informed consent.

Conference report: interdisciplinary workshop in the philosophy of medicine: parentalism and trust.

On 13 June 2014, the Centre for the Humanities and Health at King's College London hosted a 1-day workshop on 'parentalism and trust'. This workshop was the sixth in a series of workshops whose aim is to provide a new model for high-quality open interdisciplinary engagement between medical professionals and philosophers. This report briefly describes the workshop methodology and the discussions on the day.

Interdisciplinary workshop in the philosophy of medicine: medical knowledge, medical duties.

On 27 September 2013, the Centre for the Humanities and Health (CHH) at King's College London hosted a 1-day workshop on 'Medical knowledge, Medical Duties'. This workshop was the fifth in a series of five workshops whose aim is to provide a new model for high-quality, open interdisciplinary engagement between medical professionals and philosophers. This report identifies the key points of discussion raised throughout the day and the methodology employed.

Elemental compositions of comet 81P/Wild 2 samples collected by Stardust.

We measured the elemental compositions of material from 23 particles in aerogel and from residue in seven craters in aluminum foil that was collected during passage of the Stardust spacecraft through the coma of comet 81P/Wild 2. These particles are chemically heterogeneous at the largest size scale analyzed ( approximately 180 ng). The mean elemental composition of this Wild 2 material is consistent with the CI meteorite composition, which is thought to represent the bulk composition of the solar system, for the elements Mg, Si, Mn, Fe, and Ni to 35%, and for Ca and Ti to 60%. The elements Cu, Zn, and Ga appear enriched in this Wild 2 material, which suggests that the CI meteorites may not represent the solar system composition for these moderately volatile minor elements.