Decisional Regret Surrounding Dialysis Initiation: A Comparative Analysis.

Rationale & Objective: Dialysis comes with a substantial treatment burden, so patients must select care plans that align with their preferences. We aimed to deepen the understanding of decisional regret with dialysis choices. Study Design: This study had a mixed-methods explanatory sequential design. Setting & Participants: All patients from a single academic medical center prescribed maintenance in-center hemodialysis or presenting for home hemodialysis or peritoneal dialysis check-up during 3 weeks were approached for survey. A total of 78 patients agreed to participate. Patients with the highest (15 patients) and lowest decisional regret (20 patients) were invited to semistructured interviews. Predictors: Decisional regret scale and illness intrusiveness scale were used in this study. Analytical Approach: Quantitatively, we examined correlations between the decision regret scale and illness intrusiveness scale and sorted patients into the highest and lowest decision regret scale quartiles for further interviews; then, we compared patient characteristics between those that consented to interview in high and low decisional regret. Qualitatively, we used an adapted grounded theory approach to examine differences between interviewed patients with high and low decisional regret. Results: Of patients invited to participate in the interviews, 21 patients (8 high regret, 13 low regret) agreed. We observed that patients with high decisional regret displayed resignation toward dialysis, disruption of their sense of self and social roles, and self-blame, whereas patients with low decisional regret demonstrated positivity, integration of dialysis into their identity, and self-compassion. Limitations: Patients with the highest levels of decisional regret may have already withdrawn from dialysis. Patients could complete interviews in any location (eg, home, dialysis unit, and clinical office), which may have influenced patient disclosure. Conclusions: Although all patients experienced disruption after dialysis initiation, patients' approach to adversity differs between patients experiencing high versus low regret. This study identifies emotional responses to dialysis that may be modifiable through patient-support interventions.

As part of a quality improvement initiative in our dialysis practice, a patient stated, "I wish I never started dialysis." This quote served as the catalyst for embarking on a research project with the aim to understand why patients living with end-stage kidney disease have regret about starting and continuing dialysis, a lifesaving but time-intensive measure. We surveyed and interviewed patients on the topic and learned that patients experiencing regret had a disrupted sense of self and blamed themselves for their need of dialysis. Patients with little to no regret demonstrated positivity and self-compassion. These findings will help health care professionals as they work with patients considering dialysis or having newly started dialysis.

Congenital Syphilis in the Medicaid Program: Assessing Challenges and Opportunities Through the Experiences of Seven Southern States.

INTRODUCTION: Rates of congenital syphilis cases are increasing, particularly among lower socioeconomic populations within the southern United States. Medicaid covers a significant portion of these births, which provides an opportunity to improve birth outcomes. This project sought to collect information from key stakeholders to assess facilitators of and barriers to Medicaid funding of prenatal syphilis screening and to provide insight into improving screening and lowering incidence through the Medicaid program. METHODS: Seven southern states (Alabama, Georgia, Kentucky, Louisiana, North Carolina, South Carolina, and Tennessee) were identified for this assessment. Researchers conducted a legal and policy analysis for each state to gather information on factors affecting congenital syphilis prevention, identify knowledge gaps, and inform the development of interview guides. Seventeen structured interviews with 29 participants were conducted to gather information on facilitators and barriers to receiving timely prenatal syphilis screening through the Medicaid program. Interview transcripts were analyzed and compared to identify key themes. RESULTS: Barriers to timely prenatal syphilis screening include varied laws among the states on the timing of screening, Medicaid reimbursement policies that may not adequately incentivize testing, Medicaid enrollment issues that affect both enrollment and continuity of care, and lack of clear understanding among providers on recommended testing. CONCLUSION: This work provides insight into systemic issues that may be affecting rates of prenatal syphilis screening and incidence among Medicaid enrollees and others in the U.S. South. To address rising congenital syphilis cases, policymakers should consider requiring third trimester syphilis screening, adopting policies to enhance access to prenatal care, adapting Medicaid payment and incentive models, and promoting collaboration between Medicaid and public health agencies.

Navigating the Intersection of PrEP and Medicaid.

The proposed national PrEP program would serve people who are uninsured as well as those enrolled in Medicaid. In this article, the authors propose a set of recommendations for the proposed program's implementers as well as state Medicaid agencies and Medicaid managed care organizations to ensure PrEP access for people enrolled in Medicaid, addressing gaps without undermining the important role of the Medicaid program in covering and promoting PrEP.

Combinatorial PCR Method for Efficient, Selective Oligo Retrieval from Complex Oligo Pools.

With the rapidly decreasing cost of array-based oligo synthesis, large-scale oligo pools offer significant benefits for advanced applications including gene synthesis, CRISPR-based gene editing, and DNA data storage. The selective retrieval of specific oligos from these complex pools traditionally uses polymerase chain reaction (PCR). Designing a large number of primers to use in PCR presents a serious challenge, particularly for DNA data storage, where the size of an oligo pool is orders of magnitude larger than other applications. Although a nested primer address system was recently developed to increase the number of accessible files for DNA storage, it requires more complicated lab protocols and more expensive reagents to achieve high specificity, as well as more DNA address space. Here, we present a new combinatorial PCR method that has none of those drawbacks and outperforms in retrieval specificity. In experiments, we accessed three files that each comprised 1% of a DNA prototype database that contained 81 different files and enriched them to over 99.9% using our combinatorial primer method. Our method provides a viable path for scaling up DNA data storage systems and has broader utility whenever one must access a specific target oligo and can design their own primer regions.

Getting SET for Student Success: Foundations for a Student Education Team.

BACKGROUND: Family medicine clinical education poses logistic issues that we sought to address with the Student Education Team model. METHODS: The model combined team-based, patient-centered care with student experiences in a sustainable precepting model. Four learners successfully underwent precepting simultaneously. Schedulers booked patients in the team schedule, and the patients knew they would see a student and a faculty team member. RESULTS: The Student Education Team model increased the learner to preceptor ratio compared to traditional precepting models. Use of the team increased the number of learners completing rotations. The team schedule nearly eliminated patients refusing student involvement and enhanced throughput because patients saw the most readily available staff. DISCUSSION: The team offered clinicians and learners a model for incorporating learning into clinicians' schedules.

An Empirical Comparison of Preservation Methods for Synthetic DNA Data Storage.

Synthetic DNA has recently risen as a viable alternative for long-term digital data storage. To ensure that information is safely recovered after storage, it is essential to appropriately preserve the physical DNA molecules encoding the data. While preservation of biological DNA has been studied previously, synthetic DNA differs in that it is typically much shorter in length, it has different sequence profiles with fewer, if any, repeats (or homopolymers), and it has different contaminants. In this paper, nine different methods used to preserve data files encoded in synthetic DNA are evaluated by accelerated aging of nearly 29 000 DNA sequences. In addition to a molecular count comparison, the DNA is also sequenced and analyzed after aging. These findings show that errors and erasures are stochastic and show no practical distribution difference between preservation methods. Finally, the physical density of these methods is compared and a stability versus density trade-offs discussion provided.

Molecular-level similarity search brings computing to DNA data storage.

As global demand for digital storage capacity grows, storage technologies based on synthetic DNA have emerged as a dense and durable alternative to traditional media. Existing approaches leverage robust error correcting codes and precise molecular mechanisms to reliably retrieve specific files from large databases. Typically, files are retrieved using a pre-specified key, analogous to a filename. However, these approaches lack the ability to perform more complex computations over the stored data, such as similarity search: e.g., finding images that look similar to an image of interest without prior knowledge of their file names. Here we demonstrate a technique for executing similarity search over a DNA-based database of 1.6 million images. Queries are implemented as hybridization probes, and a key step in our approach was to learn an image-to-sequence encoding ensuring that queries preferentially bind to targets representing visually similar images. Experimental results show that our molecular implementation performs comparably to state-of-the-art in silico algorithms for similarity search.

Quantifying molecular bias in DNA data storage.

DNA has recently emerged as an attractive medium for archival data storage. Recent work has demonstrated proof-of-principle prototype systems; however, very uneven (biased) sequencing coverage has been reported, which indicates inefficiencies in the storage process. Deviations from the average coverage in the sequence copy distribution can either cause wasteful provisioning in sequencing or excessive number of missing sequences. Here, we use millions of unique sequences from a DNA-based digital data archival system to study the oligonucleotide copy unevenness problem and show that the two paramount sources of bias are the synthesis and amplification (PCR) processes. Based on these findings, we develop a statistical model for each molecular process as well as the overall process. We further use our model to explore the trade-offs between synthesis bias, storage physical density, logical redundancy, and sequencing redundancy, providing insights for engineering efficient, robust DNA data storage systems.

Author Correction: Probing the physical limits of reliable DNA data retrieval.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Probing the physical limits of reliable DNA data retrieval.

Synthetic DNA is gaining momentum as a potential storage medium for archival data storage. In this process, digital information is translated into sequences of nucleotides and the resulting synthetic DNA strands are then stored for later retrieval. Here, we demonstrate reliable file recovery with PCR-based random access when as few as ten copies per sequence are stored, on average. This results in density of about 17 exabytes/gram, nearly two orders of magnitude greater than prior work has shown. We successfully retrieve the same data in a complex pool of over 1010 unique sequences per microliter with no evidence that we have begun to approach complexity limits. Finally, we also investigate the effects of file size and sequencing coverage on successful file retrieval and look for systematic DNA strand drop out. These findings substantiate the robustness and high data density of the process examined here.

Random access in large-scale DNA data storage.

Synthetic DNA is durable and can encode digital data with high density, making it an attractive medium for data storage. However, recovering stored data on a large-scale currently requires all the DNA in a pool to be sequenced, even if only a subset of the information needs to be extracted. Here, we encode and store 35 distinct files (over 200 MB of data), in more than 13 million DNA oligonucleotides, and show that we can recover each file individually and with no errors, using a random access approach. We design and validate a large library of primers that enable individual recovery of all files stored within the DNA. We also develop an algorithm that greatly reduces the sequencing read coverage required for error-free decoding by maximizing information from all sequence reads. These advances demonstrate a viable, large-scale system for DNA data storage and retrieval.