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ABSTRACT: Physicians are not immune to psychosocial problems but may face unique impediments to attending to them. Self-care among physicians is not a topic generally included as a part of professional training, nor is it a topic that readily receives consideration in professional practice. The stresses of professional practice can exact a great toll, however, and self-neglect can lead to tragic consequences. In some areas, particularly suicide rates, physicians have increased vulnerability, and in other areas problems may be unrecognized (depression, substance abuse, marital problems, and other stress-related concerns). Female physicians show some particular areas of risk. In this paper, we raise questions about how and why physicians may be particularly vulnerable, review the available literature about the extent and nature of such problems in physicians, discuss possible factors related to the development of these problems in physicians, and suggest a variety of solutions to improve physician self-care. [ABSTRACT FROM AUTHOR]

During the first COVID surge, multiple changes in nurse staffing and workflows were made to support care delivery in a resource-constrained environment. We hypothesized that there was a higher rate of inpatient falls during the COVID surge. Furthermore, we predicted that an automated predictive analytic algorithm would perform as well as the Johns Hopkins Fall Risk Assessment. A retrospective review of falls for 3 months before and the first 3 months of the first COVID surge was conducted. We determined the total number of falls and the overall fall rate and examined the distribution of scores and accuracy of fall predictive models for both groups. There was a statistically significant increase in fall rate during the first 3 months of the COVID surge compared with the 3 prior months (2.48/1000 patient-days vs 1.89/1000 patient-days respectively; P = .041). The Johns Hopkins instrument had a greater sensitivity of 78.9% compared with 57.0% for the predictive analytic model. Specificity and accuracy of the predictive analytic model were higher than the Johns Hopkins instrument (71.3% vs 54.1% and 71.2% vs 54.3%, respectively). These findings suggest that the automated predictive analytic model could be used in a resource-constrained environment to accurately classify patients' risk of fall., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

Background: Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness., Objectives: The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals., Research Design: A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results., Subjects: Eight primary care clinics that were engaged in PCMH reform., Measures: We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years., Results: In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03)., Discussion: The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aims of this study were to use cross-sectional optical coherence tomography imaging and custom curve fitting software to evaluate and model the foveal curvature as a spherical surface and to compare the radius of curvature in the horizontal and vertical meridians and test the sensitivity of this technique to anticipated meridional differences., Methods: Six 30-degree foveal-centered radial optical coherence tomography cross-section scans were acquired in the right eye of 20 clinically normal subjects. Cross sections were manually segmented, and custom curve fitting software was used to determine foveal pit radius of curvature using the central 500, 1000, and 1500 μm of the foveal contour. Radius of curvature was compared across different fitting distances. Root mean square error was used to determine goodness of fit. The radius of curvature was compared between the horizontal and vertical meridians for each fitting distance., Results: There radius of curvature was significantly different when comparing each of the three fitting distances (P < .01 for each comparison). The average radii of curvature were 970 μm (95% confidence interval [CI], 913 to 1028 μm), 1386 μm (95% CI, 1339 to 1439 μm), and 2121 μm (95% CI, 2066 to 2183) for the 500-, 1000-, and 1500-μm fitting distances, respectively. Root mean square error was also significantly different when comparing each fitting distance (P < .01 for each comparison). The average root mean square errors were 2.48 μm (95% CI, 2.41 to 2.53 μm), 6.22 μm (95% CI, 5.77 to 6.60 μm), and 13.82 μm (95% CI, 12.93 to 14.58 μm) for the 500-, 1000-, and 1500-μm fitting distances, respectively. The radius of curvature between the horizontal and vertical meridian radii was statistically different only in the 1000- and 1500-μm fitting distances (P < .01 for each), with the horizontal meridian being flatter than the vertical., Conclusions: The foveal contour can be modeled as a sphere with low curve fitting error over a limited distance and capable of detecting subtle foveal contour differences between meridians.

Background: Health reform programs like the patient-centered medical home are intended to improve the triple aim. Previous studies on patient-centered medical homes have shown mixed effects, but high value elements (HVEs) are expected to improve the triple aim., Objective: The aim of this study is to understand whether focusing on HVEs would improve patient experience with care., Methods: Eight clinics were cluster-randomized in a year-long trial. Both arms received practice facilitation, IT-based reporting, and financial incentives. Intervention practices were encouraged to choose HVEs for quality improvement goals. To assess patient experience, 1597 Consumer Assessment of Healthcare Providers and Systems surveys were sent pretrial and posttrial to a stratified random sample of patients. Difference-in-difference multivariate analysis was used to compare patient responses from intervention and control practices, adjusting for confounders., Results: The response rate was 43% (n=686). Nonrespondent analysis showed no difference between arms, although differences were seen by risk status and age. The overall difference in difference was 2.8%, favoring the intervention. The intervention performed better in 9 of 11 composites. The intervention performed significantly better in follow-up on test results (P=0.091) and patients' rating of the provider (P=0.091), whereas the control performed better in access to care (P=0.093). Both arms also had decreases, including 4 of 11 composites for the intervention, and 8 of 11 for the control., Discussion: Practices that targeted HVEs showed significantly more improvement in patient experience of care. However, contemporaneous trends may have affected results, leading to declines in patient experience in both arms.

Objective: To determine the phenotypic spectrum caused by mutations in GRIN1 encoding the NMDA receptor subunit GluN1 and to investigate their underlying functional pathophysiology., Methods: We collected molecular and clinical data from several diagnostic and research cohorts. Functional consequences of GRIN1 mutations were investigated in Xenopus laevis oocytes., Results: We identified heterozygous de novo GRIN1 mutations in 14 individuals and reviewed the phenotypes of all 9 previously reported patients. These 23 individuals presented with a distinct phenotype of profound developmental delay, severe intellectual disability with absent speech, muscular hypotonia, hyperkinetic movement disorder, oculogyric crises, cortical blindness, generalized cerebral atrophy, and epilepsy. Mutations cluster within transmembrane segments and result in loss of channel function of varying severity with a dominant-negative effect. In addition, we describe 2 homozygous GRIN1 mutations (1 missense, 1 truncation), each segregating with severe neurodevelopmental phenotypes in consanguineous families., Conclusions: De novo GRIN1 mutations are associated with severe intellectual disability with cortical visual impairment as well as oculomotor and movement disorders being discriminating phenotypic features. Loss of NMDA receptor function appears to be the underlying disease mechanism. The identification of both heterozygous and homozygous mutations blurs the borders of dominant and recessive inheritance of GRIN1-associated disorders., (© 2016 American Academy of Neurology.)

Objective: To give a comprehensive overview of the phenotypic and genetic spectrum of STXBP1 encephalopathy (STXBP1-E) by systematically reviewing newly diagnosed and previously reported patients., Methods: We recruited newly diagnosed patients with STXBP1 mutations through an international network of clinicians and geneticists. Furthermore, we performed a systematic literature search to review the phenotypes of all previously reported patients., Results: We describe the phenotypic features of 147 patients with STXBP1-E including 45 previously unreported patients with 33 novel STXBP1 mutations. All patients have intellectual disability (ID), which is mostly severe to profound (88%). Ninety-five percent of patients have epilepsy. While one-third of patients presented with Ohtahara syndrome (21%) or West syndrome (9.5%), the majority has a nonsyndromic early-onset epilepsy and encephalopathy (53%) with epileptic spasms or tonic seizures as main seizure type. We found no correlation between severity of seizures and severity of ID or between mutation type and seizure characteristics or cognitive outcome. Neurologic comorbidities including autistic features and movement disorders are frequent. We also report 2 previously unreported adult patients with prominent extrapyramidal features., Conclusion: De novo STXBP1 mutations are among the most frequent causes of epilepsy and encephalopathy. Most patients have severe to profound ID with little correlation among seizure onset, seizure severity, and the degree of ID. Accordingly, we hypothesize that seizure severity and ID present 2 independent dimensions of the STXBP1-E phenotype. STXBP1-E may be conceptualized as a complex neurodevelopmental disorder rather than a primary epileptic encephalopathy., (© 2016 American Academy of Neurology.)

Background: Care management has demonstrated improvements in quality of care for patients with complex care needs. The extent to which these interventions benefit race/ethnic minority populations is unclear., Objectives: To characterize race/ethnic differences in the longitudinal control of clinical outcomes for patients with complex care needs enrolled in Care Management Plus, a health information technology-enabled care coordination intervention., Research Design: Multilevel models of repeated observations from clinical encounters before and after program enrollment for 6 Oregon and California primary care clinics., Subjects: A total of 18,675 clinic patients were examined. We estimated multilevel models for 1481 and 5320 care-managed individuals with repeated hemoglobin A1c and blood pressure measurements, respectively., Measures: Primary outcomes were changes over time for 2 clinical markers of health status for complex care patients: (1) hemoglobin A1c for patients with diabetes; and (2) mid-blood pressure (BP) (average systolic and diastolic blood pressure)., Results: We found significant reductions in A1c for patients with previously uncontrolled A1c (preperiod slope, b=1.03 [0.83, 1.24]; postperiod slope, b=-0.63 [-0.91, -0.35]). For mid-BP we found increasing unconditional preperiod trajectories (b=3.52 [2.39, 4.64]) and decreasing postperiod trajectories (b=-5.21 [-5.70, -4.72]). We also found the trajectories of A1c and mid-BP were not statistically different for black, Latino, and white patients., Conclusions: These analyses demonstrate some promising results for intermediate clinical outcomes for underrepresented patients with complex chronic care needs. It remains to be seen whether these health care system delivery redesigns yield long-term benefits for patients, such as improvements in function and quality of life.

Background: In studies examining the use of human immunodeficiency virus (HIV) health services, researchers often use subjects' self-reported measures. Agreement between a subject's self-reports and medical records in marginalized populations is uncertain, yet important to understand, as this population is disproportionately affected by HIV., Methods: We sought to examine agreement between self-report and medical record health care utilization measures. Using a cross-sectional study, we studied 428 unstably housed HIV-infected adults in New York City. Self-reported data were collected from Audio Computer-Assisted Self-Interviews, and medical record data from health care providers' and facilities' ambulatory medical records. Agreement for a 6-month period was compared for ambulatory visits (0, 1, >or=2), HIV medications (antiretroviral therapy, opportunistic infection prophylaxis), whether CD4 counts and viral loads were performed and their values (CD4: <200, 200-500, >500 cells/mm; Viral load: undetectable, detected)., Results: Agreement between self-report and medical records was 55.2% (kappa=0.12) for visits, and 68.2-79.1% (kappa=0.27-0.48) for medications. Agreement on whether laboratory tests were performed was 62.3-65.7% (kappa=0.11-0.14), whereas agreement on laboratory values was 77.6-79.3% (kappa=0.52-0.70). Most disagreement resulted in greater number of self-reported visits, use of medications, and laboratory tests compared with medical record data., Conclusions: Among HIV-infected marginalized individuals, agreement between self-report and medical records was poor for ambulatory visits, poor to fair for medication use, and poor for laboratory tests performed. However, agreement for CD4 count value was substantially better. These findings have implications on health services research in marginalized populations that relies only on self-report or medical record data. This study underscores the importance of understanding how self-reported and medical record data are correlated in marginalized populations.

Unlabelled: Previously, this laboratory has demonstrated that exhaustive aerobic exercise performance is not subject to significant chronobiological variation between 0800 and 2000 h, but certain physiological responses to maximal aerobic effort do fluctuate significantly within that time frame., Purpose: The purpose of the present investigation was to determine whether muscle performance, and selected physiological responses to resistance exercise, was significantly influenced by time of day effects., Methods: Ten healthy, but untrained, men (21.1+/-0.6 yr, mean +/- SE) volunteered to participate in the study. In a balanced and randomized study design, each subject performed resistance exercise protocols on an isokinetic dynamometer with maximal effort at 0800 h, 1200 h, 1600 h, and 2000 h. Selected physiological and hormonal data were recorded before and immediately following the exercise stimulus., Results: The data demonstrated significant chronobiological oscillation in peak torque, average power, maximal work in a single repetition, and total work per set. Interestingly, this oscillation was manifested only at the fastest velocities of limb movement utilized. Pre- and postexercise rectal temperature exhibited significant time of day fluctuation, as did postexercise blood pressure. Plasma levels of testosterone and cortisol also displayed significant biorhythmicity under both pre- and postexercise conditions. However, exercise-induced responses (pre- to postexercise differences) of those steroid hormones did not exhibit significant biorythmic variation. Although plasma concentrations of both testosterone and cortisol were highest at 0800 h, testosterone to cortisol ratios were greatest at 2000 h., Conclusions: In summary, these data suggest that maximal muscle performance does vary within the segment of the day when exercise typically occurs (0800-2000 h) but that this variation is specific to speed of movement.