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Cyclic oligoadenylates (cOAs) are small second messenger molecules produced by the type III CRISPR-Cas system as part of the prokaryotic immune response. The role of cOAs is to allosterically activate downstream effector proteins that induce dormancy or cell death, and thus abort viral spread through the population. Interestingly, different type III systems have been reported to utilize different cOA stoichiometries (with 3 to 6 adenylate monophosphates). However, so far, their characterization has only been possible in bulk and with sophisticated equipment, while a portable assay with single-molecule resolution has been lacking. Here, we demonstrate the label-free detection of single cOA molecules using a simple protein nanopore assay. It sensitively identifies the stoichiometry of individual cOA molecules and their mixtures from synthetic and enzymatic origin. To achieve this, we trained a convolutional neural network (CNN) and validated it with a series of experiments on mono- and polydisperse cOA samples. Ultimately, we determined the stoichiometric composition of cOAs produced enzymatically by the CRISPR type III-A and III-B variants of Thermus thermophilus and confirmed the results by liquid chromatography-mass spectroscopy (LC-MS). Interestingly, both variants produce cOAs of nearly identical composition (within experimental uncertainties), and we discuss the biological implications of this finding. The presented nanopore-CNN workflow with single cOA resolution can be adapted to many other signaling molecules (including eukaryotic ones), and it may be integrated into portable handheld devices with potential point-of-care applications.

MR1T cells are a recently found class of T cells that recognize antigens presented by the major histocompatibility complex-I-related molecule MR1 in the absence of microbial infection. The nature of the self-antigens that stimulate MR1T cells remains unclear, hampering our understanding of their physiological role and therapeutic potential. By combining genetic, pharmacological, and biochemical approaches, we found that carbonyl stress and changes in nucleobase metabolism in target cells promote MR1T cell activation. Stimulatory compounds formed by carbonyl adducts of nucleobases were detected within MR1 molecules produced by tumor cells, and their abundance and antigenicity were enhanced by drugs that induce carbonyl accumulation. Our data reveal carbonyl-nucleobase adducts as MR1T cell antigens. Recognizing cells under carbonyl stress allows MR1T cells to monitor cellular metabolic changes with physiological and therapeutic implications.

Objectives: We aimed to evaluate thrombotic and hemorrhagic complications with heparin versus bivalirudin use in veno-venous extracorporeal membrane oxygenation (V-V ECMO)., Methods: We performed a retrospective cohort study of adult patients placed on V-V ECMO with intravenous anticoagulation with either heparin or bivalirudin. Time to thrombotic event and major bleed were analyzed in addition to related outcomes., Results: We identified 95 patients placed on V-V ECMO: 61 receiving heparin, 34 bivalirudin. The bivalirudin group had a higher rate of severe COVID-19, higher BMI, and longer ECMO duration. Despite this, bivalirudin was associated with reduced risk of thrombotic event (HR 0.14, 95% CI 0.06-0.32, p < .001) and increased average lifespan of the circuit membrane lung (16 vs. 10 days, p = 0.004). While there was no difference in major bleeding, the bivalirudin group required fewer transfusions of packed red blood cells and platelets per 100 ECMO days (means of 13 vs. 39, p = 0.004; 5 vs. 19, p = .014, respectively). Lastly, the bivalirudin group had improved survival to ECMO decannulation in univariate analysis (median OS 53 vs. 26 days, p = .015)., Conclusions: In this real-world analysis of bivalirudin versus heparin, bivalirudin is a viable option for V-V ECMO and associated with lower risk of thrombotic complications and fewer transfusion requirements., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Importance: The emergence and promise of generative artificial intelligence (AI) represent a turning point for health care. Rigorous evaluation of generative AI deployment in clinical practice is needed to inform strategic decision-making., Objective: To evaluate the implementation of a large language model used to draft responses to patient messages in the electronic inbox., Design, Setting, and Participants: A 5-week, prospective, single-group quality improvement study was conducted from July 10 through August 13, 2023, at a single academic medical center (Stanford Health Care). All attending physicians, advanced practice practitioners, clinic nurses, and clinical pharmacists from the Divisions of Primary Care and Gastroenterology and Hepatology were enrolled in the pilot., Intervention: Draft replies to patient portal messages generated by a Health Insurance Portability and Accountability Act-compliant electronic health record-integrated large language model., Main Outcomes and Measures: The primary outcome was AI-generated draft reply utilization as a percentage of total patient message replies. Secondary outcomes included changes in time measures and clinician experience as assessed by survey., Results: A total of 197 clinicians were enrolled in the pilot; 35 clinicians who were prepilot beta users, out of office, or not tied to a specific ambulatory clinic were excluded, leaving 162 clinicians included in the analysis. The survey analysis cohort consisted of 73 participants (45.1%) who completed both the presurvey and postsurvey. In gastroenterology and hepatology, there were 58 physicians and APPs and 10 nurses. In primary care, there were 83 physicians and APPs, 4 nurses, and 8 clinical pharmacists. The mean AI-generated draft response utilization rate across clinicians was 20%. There was no change in reply action time, write time, or read time between the prepilot and pilot periods. There were statistically significant reductions in the 4-item physician task load score derivative (mean [SD], 61.31 [17.23] presurvey vs 47.26 [17.11] postsurvey; paired difference, -13.87; 95% CI, -17.38 to -9.50; P < .001) and work exhaustion scores (mean [SD], 1.95 [0.79] presurvey vs 1.62 [0.68] postsurvey; paired difference, -0.33; 95% CI, -0.50 to -0.17; P < .001)., Conclusions and Relevance: In this quality improvement study of an early implementation of generative AI, there was notable adoption, usability, and improvement in assessments of burden and burnout. There was no improvement in time. Further code-to-bedside testing is needed to guide future development and organizational strategy.

Background: Despite the ubiquitous utilization of central venous catheters in clinical practice, their use commonly provokes thromboembolism. No prophylactic strategy has shown sufficient efficacy to justify routine use. Coagulation factors FXI (factor XI) and FXII (factor XII) represent novel targets for device-associated thrombosis, which may mitigate bleeding risk. Our objective was to evaluate the safety and efficacy of an anti-FXI mAb (monoclonal antibody), gruticibart (AB023), in a prospective, single-arm study of patients with cancer receiving central line placement., Methods: We enrolled ambulatory cancer patients undergoing central line placement to receive a single dose of gruticibart (2 mg/kg) administered through the venous catheter within 24 hours of placement and a follow-up surveillance ultrasound at day 14 for evaluation of catheter thrombosis. A parallel, noninterventional study was used as a comparator., Results: In total, 22 subjects (n=11 per study) were enrolled. The overall incidence of catheter-associated thrombosis was 12.5% in the interventional study and 40.0% in the control study. The anti-FXI mAb, gruticibart, significantly prolonged the activated partial thromboplastin time in all subjects on day 14 compared with baseline ( P <0.001). Gruticibart was well tolerated and without infusion reactions, drug-related adverse events, or clinically relevant bleeding. Platelet flow cytometry demonstrated no difference in platelet activation following administration of gruticibart. T (thrombin)-AT (antithrombin) and activated FXI-AT complexes increased following central line placement in the control study, which was not demonstrated in our intervention study. CRP (C-reactive protein) did not significantly increase on day 14 in those who received gruticibart, but it did significantly increase in the noninterventional study., Conclusions: FXI inhibition with gruticibart was well tolerated without any significant adverse or bleeding-related events and resulted in a lower incidence of catheter-associated thrombosis on surveillance ultrasound compared with the published literature and our internal control study. These findings suggest that targeting FXI could represent a safe intervention to prevent catheter thrombosis., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04465760., Competing Interests: Disclosures J.J. Shatzel reports receiving consulting fees from Aronora, Inc. C.U. Lorentz, E.I. Tucker, and Oregon Health & Science University (OHSU) have a financial interest in Aronora, Inc, a company that may have a commercial interest in the results of this research and technology. This potential conflict of interest has been reviewed and managed by OHSU. The other authors report no conflicts.

The isolation of biomolecules in a high vacuum enables experiments on fragile species in the absence of a perturbing environment. Since many molecular properties are influenced by local electric fields, here we seek to gain control over the number of charges on a biopolymer by photochemical uncaging. We present the design, modeling, and synthesis of photoactive molecular tags, their labeling to peptides and proteins as well as their photochemical validation in solution and in the gas phase. The tailored tags can be selectively cleaved off at a well-defined time and without the need for any external charge-transferring agents. The energy of a single or two green photons can already trigger the process, and it is soft enough to ensure the integrity of the released biomolecular cargo. We exploit differences in the cleavage pathways in solution and in vacuum and observe a surprising robustness in upscaling the approach from a model system to genuine proteins. The interaction wavelength of 532 nm is compatible with various biomolecular entities, such as oligonucleotides or oligosaccharides., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Although considered "benign," mild blood count abnormalities, genetic factors imparting inconsequential thrombotic risk, and low-risk premalignant blood disorders can have significant psychological and financial impact on our patients. Several studies have demonstrated that patients with noncancerous conditions have increased levels of anxiety with distress similar to those with malignancy. Additionally, referral to a classical hematologist can be a daunting process for many patients due to uncertainties surrounding the reason for referral or misconstrued beliefs in a cancer diagnosis ascribed to the pairing of oncology and hematology in medical practice. If not properly triaged, incidental laboratory abnormalities can trigger extensive and costly evaluation. These challenges are compounded by a lack of consensus guidance and generalizability of modern reference ranges that do not adequately account for common influencing factors. Although often benign, incidental hematologic findings can lead to emotional suffering and careful consideration of the potential psychological and financial duress imparted to an individual must be considered. In this article, we will review the current literature describing the psychological effect of some commonly known hematologic conditions, identify benign causes for variations in hematologic laboratory values, and provide recommendations to reduce psychological toxicity as it pertains to hematologic testing., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Importance: There is increased interest in and potential benefits from using large language models (LLMs) in medicine. However, by simply wondering how the LLMs and the applications powered by them will reshape medicine instead of getting actively involved, the agency in shaping how these tools can be used in medicine is lost., Observations: Applications powered by LLMs are increasingly used to perform medical tasks without the underlying language model being trained on medical records and without verifying their purported benefit in performing those tasks., Conclusions and Relevance: The creation and use of LLMs in medicine need to be actively shaped by provisioning relevant training data, specifying the desired benefits, and evaluating the benefits via testing in real-world deployments.

Objectives: Tertiary and quaternary (TQ) care refers to complex cases requiring highly specialized health services. Our study aimed to compare the ability of a natural language processing (NLP) model to an existing human workflow in predictively identifying TQ cases for transfer requests to an academic health center., Materials and Methods: Data on interhospital transfers were queried from the electronic health record for the 6-month period from July 1, 2020 to December 31, 2020. The NLP model was allowed to generate predictions on the same cases as the human predictive workflow during the study period. These predictions were then retrospectively compared to the true TQ outcomes., Results: There were 1895 transfer cases labeled by both the human predictive workflow and the NLP model, all of which had retrospective confirmation of the true TQ label. The NLP model receiver operating characteristic curve had an area under the curve of 0.91. Using a model probability threshold of ≥0.3 to be considered TQ positive, accuracy was 81.5% for the NLP model versus 80.3% for the human predictions ( P  =   .198) while sensitivity was 83.6% versus 67.7% ( P <.001)., Discussion: The NLP model was as accurate as the human workflow but significantly more sensitive. This translated to 15.9% more TQ cases identified by the NLP model., Conclusion: Integrating an NLP model into existing workflows as automated decision support could translate to more TQ cases identified at the onset of the transfer process., Competing Interests: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To describe the infrastructure, tools, and services developed at Stanford Medicine to maintain its data science ecosystem and research patient data repository for clinical and translational research., Materials and Methods: The data science ecosystem, dubbed the Stanford Data Science Resources (SDSR), includes infrastructure and tools to create, search, retrieve, and analyze patient data, as well as services for data deidentification, linkage, and processing to extract high-value information from healthcare IT systems. Data are made available via self-service and concierge access, on HIPAA compliant secure computing infrastructure supported by in-depth user training., Results: The Stanford Medicine Research Data Repository (STARR) functions as the SDSR data integration point, and includes electronic medical records, clinical images, text, bedside monitoring data and HL7 messages. SDSR tools include tools for electronic phenotyping, cohort building, and a search engine for patient timelines. The SDSR supports patient data collection, reproducible research, and teaching using healthcare data, and facilitates industry collaborations and large-scale observational studies., Discussion: Research patient data repositories and their underlying data science infrastructure are essential to realizing a learning health system and advancing the mission of academic medical centers. Challenges to maintaining the SDSR include ensuring sufficient financial support while providing researchers and clinicians with maximal access to data and digital infrastructure, balancing tool development with user training, and supporting the diverse needs of users., Conclusion: Our experience maintaining the SDSR offers a case study for academic medical centers developing data science and research informatics infrastructure., Competing Interests: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

The success of foundation models such as ChatGPT and AlphaFold has spurred significant interest in building similar models for electronic medical records (EMRs) to improve patient care and hospital operations. However, recent hype has obscured critical gaps in our understanding of these models' capabilities. In this narrative review, we examine 84 foundation models trained on non-imaging EMR data (i.e., clinical text and/or structured data) and create a taxonomy delineating their architectures, training data, and potential use cases. We find that most models are trained on small, narrowly-scoped clinical datasets (e.g., MIMIC-III) or broad, public biomedical corpora (e.g., PubMed) and are evaluated on tasks that do not provide meaningful insights on their usefulness to health systems. Considering these findings, we propose an improved evaluation framework for measuring the benefits of clinical foundation models that is more closely grounded to metrics that matter in healthcare., (© 2023. The Author(s).)

Background: Parkinson disease (PD) is associated with α-synuclein (αS) aggregation within enteric neurons. ENT-01 inhibits the formation of αS aggregates and improved constipation in an open-label study in patients with PD., Objective: To evaluate the safety and efficacy of oral ENT-01 for constipation and neurologic symptoms in patients with PD and constipation., Design: Randomized, placebo-controlled phase 2b study. (ClinicalTrials.gov: NCT03781791)., Setting: Outpatient., Patients: 150 patients with PD and constipation., Intervention: ENT-01 or placebo daily for up to 25 days. After baseline assessment of constipation severity, daily dosing was escalated to the prokinetic dose, the maximum dose (250 mg), or the tolerability limit, followed by a washout period., Measurements: The primary efficacy end point was the number of complete spontaneous bowel movements (CSBMs) per week. Neurologic end points included dementia (assessed using the Mini-Mental State Examination [MMSE]) and psychosis (assessed using the Scale for the Assessment of Positive Symptoms adapted for PD [SAPS-PD])., Results: The weekly CSBM rate increased from 0.7 to 3.2 in the ENT-01 group versus 0.7 to 1.2 in the placebo group ( P  < 0.001). Improvement in secondary end points included SBMs ( P  = 0.002), stool consistency ( P  < 0.001), ease of passage ( P  = 0.006), and laxative use ( P  = 0.041). In patients with dementia, MMSE scores improved by 3.4 points 6 weeks after treatment in the ENT-01 group ( n  = 14) versus 2.0 points in the placebo group ( n  = 14). Among patients with psychosis, SAPS-PD scores improved from 6.5 to 1.7 six weeks after treatment in the ENT-01 group ( n  = 5) and from 6.3 to 4.4 in the placebo group ( n  = 6). ENT-01 was well tolerated, with no deaths or drug-related serious adverse events. Adverse events were predominantly gastrointestinal, including nausea (34.4% [ENT-01] vs. 5.3% [placebo]; P  < 0.001) and diarrhea (19.4% [ENT-01] vs. 5.3% [placebo]; P  = 0.016)., Limitation: Longer treatment periods need to be investigated in future studies., Conclusion: ENT-01 was safe and significantly improved constipation., Primary Funding Source: Enterin, Inc.

The supramolecular dimerization of a ruthenium polypyridyl precursor of a well-developed family of hydrogen-evolving photocatalysts via π-π interactions of the polyheteroaromatic bridging ligand was quantified with concentration-dependent 1 H-NMR spectroscopy. The data sets were analyzed with different calculation and fit methods. A comparison between the results of direct calculation and linear and nonlinear approaches showed that the application of a global nonlinear fit procedure yields the best results. The presented methods are also applicable for dimerization processes in the solution of other molecular moieties., (© 2022 The Authors. Photochemistry and Photobiology published by Wiley Periodicals LLC on behalf of American Society for Photobiology.)

Multiple reporting guidelines for artificial intelligence (AI) models in healthcare recommend that models be audited for reliability and fairness. However, there is a gap of operational guidance for performing reliability and fairness audits in practice. Following guideline recommendations, we conducted a reliability audit of two models based on model performance and calibration as well as a fairness audit based on summary statistics, subgroup performance and subgroup calibration. We assessed the Epic End-of-Life (EOL) Index model and an internally developed Stanford Hospital Medicine (HM) Advance Care Planning (ACP) model in 3 practice settings: Primary Care, Inpatient Oncology and Hospital Medicine, using clinicians' answers to the surprise question ("Would you be surprised if [patient X] passed away in [Y years]?") as a surrogate outcome. For performance, the models had positive predictive value (PPV) at or above 0.76 in all settings. In Hospital Medicine and Inpatient Oncology, the Stanford HM ACP model had higher sensitivity (0.69, 0.89 respectively) than the EOL model (0.20, 0.27), and better calibration (O/E 1.5, 1.7) than the EOL model (O/E 2.5, 3.0). The Epic EOL model flagged fewer patients (11%, 21% respectively) than the Stanford HM ACP model (38%, 75%). There were no differences in performance and calibration by sex. Both models had lower sensitivity in Hispanic/Latino male patients with Race listed as "Other." 10 clinicians were surveyed after a presentation summarizing the audit. 10/10 reported that summary statistics, overall performance, and subgroup performance would affect their decision to use the model to guide care; 9/10 said the same for overall and subgroup calibration. The most commonly identified barriers for routinely conducting such reliability and fairness audits were poor demographic data quality and lack of data access. This audit required 115 person-hours across 8-10 months. Our recommendations for performing reliability and fairness audits include verifying data validity, analyzing model performance on intersectional subgroups, and collecting clinician-patient linkages as necessary for label generation by clinicians. Those responsible for AI models should require such audits before model deployment and mediate between model auditors and impacted stakeholders., Competing Interests: SP is currently employed by Google, with contributions to this work made while at Stanford. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Lu, Sattler, Wang, Khaki, Callahan, Fleming, Fong, Ehlert, Li, Shieh, Ramchandran, Gensheimer, Chobot, Pfohl, Li, Shum, Parikh, Desai, Seevaratnam, Hanson, Smith, Xu, Gokhale, Lin, Pfeffer, Teuteberg and Shah.)

Data on the efficacy and safety of the combination of warfarin and dual-antiplatelet therapy compared with warfarin and mono-antiplatelet therapy (MAPT) in patients with left ventricular assist devices (LVAD) remains scarce. Single-center study of 130 consecutive patients with durable LVAD. Baseline demographics, antithrombotic and antiplatelet regimen, and outcomes were compared between patients receiving warfarin plus dual-antiplatelet therapy (Group 1) and warfarin plus MAPT (Group 2). Antiplatelet therapy was assessed at hospital discharge post-LVAD implant and included aspirin, clopidogrel and dipyridamole. Outcomes at 1-year were assessed in each group. All patients were on aspirin and warfarin. No significant differences with regards to age, gender or ethnicity were noted at baseline between the two groups. Group 1 was more likely to have higher lactate dehydrogenase LDH levels at discharge and a history of stroke. No significant differences in international normalized ratio INR, hemoglobin or hematocrit were noted at discharge. During the study period, 48 patients had gastrointestinal bleeding events: 28 of 68 (41.2%) in Group 1 vs 20 of 62 (32.2%) in Group 2 (P = 0.293). At 1year, no statistically significant differences were noted in gastrointestinal bleeding (Group 1=27.90% vs Group 2 = 25.80, P = 0.784), ischemic stroke (Group 1 = 8.8% vs group 2 = 6.5%, P = 0.612), hemorrhagic stroke (Group 1 = 4.4% vs group 2 = 3.2%, P = 0.725) or mortality (Group 1 = 5.9% vs Group 2 = 1.6%, P = 0.206). Rates of pump thrombosis however were lower in Group 1 (Group 1 = 0% vs Group 2 = 6.5%, P = 0.033). Our study showed a high prevalence of triple-therapy antithrombotic use in LVAD patients with no significant differences in bleeding, stroke or survival. However, the risk for pump thrombosis was lower at 1-year when compared to patient receiving MAPT., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Importance: Various model reporting guidelines have been proposed to ensure clinical prediction models are reliable and fair. However, no consensus exists about which model details are essential to report, and commonalities and differences among reporting guidelines have not been characterized. Furthermore, how well documentation of deployed models adheres to these guidelines has not been studied., Objectives: To assess information requested by model reporting guidelines and whether the documentation for commonly used machine learning models developed by a single vendor provides the information requested., Evidence Review: MEDLINE was queried using machine learning model card and reporting machine learning from November 4 to December 6, 2020. References were reviewed to find additional publications, and publications without specific reporting recommendations were excluded. Similar elements requested for reporting were merged into representative items. Four independent reviewers and 1 adjudicator assessed how often documentation for the most commonly used models developed by a single vendor reported the items., Findings: From 15 model reporting guidelines, 220 unique items were identified that represented the collective reporting requirements. Although 12 items were commonly requested (requested by 10 or more guidelines), 77 items were requested by just 1 guideline. Documentation for 12 commonly used models from a single vendor reported a median of 39% (IQR, 37%-43%; range, 31%-47%) of items from the collective reporting requirements. Many of the commonly requested items had 100% reporting rates, including items concerning outcome definition, area under the receiver operating characteristics curve, internal validation, and intended clinical use. Several items reported half the time or less related to reliability, such as external validation, uncertainty measures, and strategy for handling missing data. Other frequently unreported items related to fairness (summary statistics and subgroup analyses, including for race and ethnicity or sex)., Conclusions and Relevance: These findings suggest that consistent reporting recommendations for clinical predictive models are needed for model developers to share necessary information for model deployment. The many published guidelines would, collectively, require reporting more than 200 items. Model documentation from 1 vendor reported the most commonly requested items from model reporting guidelines. However, areas for improvement were identified in reporting items related to model reliability and fairness. This analysis led to feedback to the vendor, which motivated updates to the documentation for future users.

Introduction: We report the effects of plasma exchange (PE) with albumin replacement on neuropsychological, neuropsychiatric, and quality-of-life (QoL) outcomes in mild-to-moderate Alzheimer's disease (AD) patients in a phase 2b/3 trial (Alzheimer's Management by Albumin Replacement [AMBAR] study)., Methods: Three hundred forty-seven patients were randomized into placebo (sham-PE) and three PE-treatment arms with low/high doses of albumin, with/without intravenous immunoglobulin (IVIG). Specific test measurements were performed at baseline; month 2 (weekly conventional PE); months 6, 9, and 12 (monthly low-volume PE [LVPE]); and month 14., Results: The PE-treated mild-AD cohort improved their language fluency and processing speed versus placebo at month 14 (effect sizes: >100%; P-values: .03 to .001). The moderate-AD cohort significantly improved short-term verbal memory (effect sizes: 94% to >100%; P-values: .02 to .003). The progression of the neuropsychiatric symptoms of PE-treated was similar to placebo. Mild-AD patients showed improved QoL (P-values: .04 to .008)., Discussion: PE-treated AD patients showed improvement in memory, language abilities, processing speed, and QoL-AD. No worsening of their psychoaffective status was observed., (© 2021 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

The molecular apparatus behind biological photosynthesis retains its long-term functionality through enzymatic repair. However, bioinspired molecular devices designed for artificial photosynthesis, consisting of a photocentre, a bridging ligand and a catalytic centre, can become unstable and break down when their individual modules are structurally compromised, halting their overall functionality and operation. Here we report the active repair of such an artificial photosynthetic molecular device, leading to complete recovery of catalytic activity. We have identified the hydrogenation of the bridging ligand, which inhibits the light-driven electron transfer between the photocentre and catalytic centre, as the deactivation mechanism. As a means of repair, we used the light-driven generation of singlet oxygen, catalysed by the photocentre, to enable the oxidative dehydrogenation of the bridging unit, which leads to the restoration of photocatalytic hydrogen formation., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Among 880 healthcare workers with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test, 264 (30.0%) infections were identified following receipt of at least 1 vaccine dose. Median SARS-CoV-2 cycle threshold values were highest among individuals receiving 2 vaccine doses, corresponding to lower viral shedding. Vaccination might lead to lower transmissibility of SARS-CoV-2., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in reduced performance of elective surgeries and procedures at medical centers across the United States. Awareness of the prevalence of asymptomatic disease is critical for guiding safe approaches to operative/procedural services. As COVID-19 polymerase chain reaction (PCR) testing has been limited largely to symptomatic patients, health care workers, or to those in communal care centers, data regarding asymptomatic viral disease carriage are limited., Methods: In this retrospective observational case series evaluating UCLA Health patients enrolled in pre-operative/pre-procedure protocol COVID-19 reverse transcriptase (RT)-PCR testing between April 7, 2020 and May 21, 2020, we determine the prevalence of COVID-19 infection in asymptomatic patients scheduled for surgeries and procedures., Results: Primary outcomes include the prevalence of COVID-19 infection in this asymptomatic population. Secondary data analysis includes overall population testing results and population demographics. Eighteen of 4,751 (0.38%) patients scheduled for upcoming surgeries and high-risk procedures had abnormal (positive/inconclusive) COVID-19 RT-PCR testing results. Six of 18 patients were confirmed asymptomatic and had positive test results. Four of 18 were confirmed asymptomtic and had inconclusive results. Eight of 18 had positive results in the setting of recent symptoms or known COVID-19 infection. The prevalence of asymptomatic COVID-19 infection was 0.13%. More than 90% of patients had residential addresses within a 67-mile geographic radius of our medical center, the median age was 58, and there was equal male/female distribution., Conclusion: These data demonstrating low levels (0.13% prevalence) of COVID-19 infection in an asymptomatic population of patients undergoing scheduled surgeries/procedures in a large urban area have helped to inform perioperative protocols during the COVID-19 pandemic. Testing protocols like ours may prove valuable for other health systems in their approaches to safe procedural practices during COVID-19., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Diagnostic radiology (DxR), having had successful serial co-evolutions with imaging equipment and PACS, is faced with another. With a backdrop termed "globotics transition," it should create an IT and informatics infrastructure capable of integrating artificial intelligence (AI) into current critical communication functions of PACS and incorporating functions currently residing in balkanized products. DxR will face the challenge of adopting sustaining and disruptive AI innovations simultaneously. In this co-evolution, a major selection force for AI will be increasing the flow of information and patients; "increasing" means faster flow over larger areas defined by geography and content. Larger content includes a broader spectrum of imaging and nonimaging information streams that facilitate medical decision making. Evolution to faster flow will gravitate toward a hierarchical IT architecture consisting of many small channels feeding into fewer larger channels, something potentially difficult for current PACS. Smartphone-like architecture optimized for communication and integration could provide a large-channel backbone and many smaller feeding channels for basic functions, as well as those needing to innovate rapidly. New, more flexible architectures stimulate market competition in which DxR could act as an artificial selection force to influence development of faster increased flow in current PACS companies, in disruptors such as consolidated AI companies, or in entirely new entrants like Apple or Google. In this co-evolution, DxR should be able to stimulate design of a modern communication medium that increases the flow of information and decreases the time and energy necessary to absorb it, thereby creating even more indispensable clinical value for itself., (Copyright © 2020 American College of Radiology. All rights reserved.)

Introduction: This phase 2b/3 trial examined the effects of plasma exchange (PE) in patients with mild-to-moderate Alzheimer's disease (AD)., Methods: Three hundred forty-seven patients (496 screened) were randomized (1:1:1:1) into three PE treatment arms with different doses of albumin and intravenous immunoglobulin replacement (6-week period of weekly conventional PE followed by a 12-month period of monthly low-volume PE), and placebo (sham)., Results: PE-treated patients performed significantly better than placebo for the co-primary endpoints: change from baseline of Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL; P = .03; 52% less decline) with a trend for Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog; P = .06; 66% less decline) scores at month 14. Moderate-AD patients (baseline Mini-Mental State Examination [MMSE] 18-21) scored better on ADCS-ADL (P = .002) and ADAS-Cog (P = .05), 61% less decline both. There were no changes in mild-AD patients (MMSE 22-26). PE-treated patients scored better on the Clinical Dementia Rating Sum of Boxes (CDR-sb) (P = .002; 71% less decline) and Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC) (P < .0001; 100% less decline) scales., Discussion: This trial suggests that PE with albumin replacement could slow cognitive and functional decline in AD, although further studies are warranted., (© 2019 The Authors. Alzheimer's & Dementia published by Wiley Periodicals, Inc. on behalf of Alzheimer's Association.)

Background: Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks., Objective: The aim of this study is to investigate whether excess visits where the word "cough" was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years., Methods: A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons., Results: The percentage of patients presenting with an EHR reason for visit containing the word "cough" to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure., Conclusions: A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges., (©Joann G Elmore, Pin-Chieh Wang, Kathleen F Kerr, David L Schriger, Douglas E Morrison, Ron Brookmeyer, Michael A Pfeffer, Thomas H Payne, Judith S Currier. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 10.09.2020.)

Background: Stroke is a leading cause of disability and death in advanced heart failure patients supported with a continuous-flow left ventricular assist system (CF-LVAS). Statins (HMG-CoA reductase inhibitors) reduce the risk of major cardiovascular and neurological events such as stroke, but their impact has not been evaluated in patients implanted with a CF-LVAS. We sought to explore the association between use of statin therapy and subsequent occurrence of neurological events, particularly stroke, following CF-LVAS implantation., Methods: We performed a single center, retrospective, observational cohort study in 200 consecutive adults implanted with a durable CF-LVAS over a 10-year period (2008-2018). We compared patients according to statin use following pump implantation, stratified by an exploratory analysis of pump type (HeartMate II, HeartWare HVAD, and HeartMate 3 [HM3] LVAS)., Results: Overall, 24% of CF-LVAS recipients developed at least 1 neurological event, at a rate of 0.11 events per patient-year (EPPY) among those prescribed statins and 0.22 EPPY among non-users (age-adjusted hazard ratio [HR] 0.46; 95% confidence interval [CI],0.24-0.88; p = 0.019). In the cohort without the HM3 pump, ischemic strokes were 62% lower among statin users (0.05 versus 0.12 EPPY for non-users; age-adjusted HR, 0.38; 95% CI, 0.15-0.99; p = 0.048). The risk of ischemic stroke did not differ significantly when HM3 recipients were included in the analysis (age-adjusted HR, 0.51; 95% CI, 0.22-1.21; p = 0.13). However, ischemic stroke rate in HM3 LVAS recipients was similar to the rate in statin users who received a non-HM3 LVAS (0.06 and 0.05 EPPY, respectively). Rates of hemorrhagic stroke and other safety end points were not significantly different according to statin use., Conclusion: Statin prescription following CF-LVAS is associated with lower rates of neurological events, driven predominantly by a reduction in ischemic strokes. These findings suggest that most patients with a pre-existing indication for statin therapy may continue using statins following CF-LVAS in an effort to decrease the incidence of ischemic stroke., (Copyright © 2020 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a revised guideline on statin therapy initiation. The guideline included a 10-year risk calculation based on regression modeling, which made hand calculation infeasible. Compliance to the guideline has been suboptimal, as many patients were recommended but not prescribed statin therapy. Clinical decision support (CDS) tools may improve statin guideline compliance. Few statin guideline CDS tools evaluated clinical outcome., Objectives: We determined if use of a CDS tool, the statin macro, was associated with increased 2013 ACC/AHA statin guideline compliance at the level of statin prescription versus no statin prescription. We did not determine if each patient's statin prescription met ACC/AHA 2013 therapy intensity recommendations (high vs. moderate vs. low)., Methods: The authors developed a clinician-initiated, EHR-embedded statin macro command ("statin macro") that displayed the 2013 ACC/AHA statin guideline recommendation in the electronic health record documentation. We included patients who had a primary care visit during the study period (January 1-June 30, 2016), were eligible for statin therapy based on the ACC/AHA guideline prior to the study period, and were not prescribed statin therapy prior to the study period. We tested the association of macro usage and statin therapy prescription during the study period using relative risk and mixed effect logistic regression., Results: Subjects included 11,877 patients seen in primary care, who were retrospectively recommended statin therapy at study initiation based on the ACC/AHA guideline, but who had not received statin therapy. During the study period, 125 clinicians used the statin macro command for 389 of the 11,877 patients (3.2%). Of the 389 patients for whom that statin macro was used, 108 patients (28%) had a statin prescribed during the study period. Of the 11,488 for whom the statin macro was not used, 1,360 (13%) patients received a clinician-prescribed statin (relative risk 2.3, p  < 0.001). Controlling for patient covariates and clinicians, statin macro usage was significantly associated with statin therapy prescription (odds ratio 2.86, p  < 0.001)., Conclusion: Although the statin macro had low uptake, its use was associated with a greater rate of statin prescriptions (dosage not determined) for patients whom 2013 ACC/AHA guidelines required statin therapy., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: There is an increasing effort to allow patients open access to their physician notes through electronic medical record portals. However, limited data exist on the impact of such access on oncology patients, and concerns remain regarding potential harms. Therefore, we determined the baseline perceptions and impact of open access to oncology notes on radiation oncology patients., Methods and Materials: Patients receiving radiation therapy were provided instructional materials on accessing oncology notes at the time of their initial evaluation. Patients were prospectively surveyed to evaluate baseline interest and expectations before access and to determine the actual usage and impact at the end of their radiation treatment course., Results: A total of 220 patients were surveyed; 136 (62%) completed the baseline survey, of which 88 (40%) completed the final survey. The majority of participants were age >60 years (n = 83; 61%), and 70 were male (51%). Before accessing the notes, the majority of patients agreed that open access to oncology notes would improve understanding of diagnosis (99%), understanding of treatment side effects (98%), reassurance about treatment goals (96%), and communication with family (99%). All patients who accessed the notes found them to be useful. After accessing the notes, approximately 96%, 94%, and 96% of patients reported an improved understanding of their diagnosis, an improved understanding of treatment side effects, and feeling more reassured about their treatment, respectively. Approximately 11%, 6%, and 4% of patients noted increased worry, increased confusion, and finding information they now regret reading, respectively. Patient age, sex, and specific cancer diagnoses were not predictive of experiencing negative effects from accessing the notes., Conclusions: Radiation oncology patients have a strong interest in open access to their physician notes, and the majority of patients expect and actually report meaningful benefits. These data support strategies to allow more patients with cancer access to their physicians' notes., (Copyright © 2018 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

We conducted a national study to assess the numbers and diversity of applicants for 2016 and 2017 clinical informatics fellowship positions. In each year, we collected data on the number of applications that programs received from candidates who were ultimately successful vs. unsuccessful. In 2017, we also conducted an anonymous applicant survey. Successful candidates applied to an average of 4.2 and 5.5 programs for 2016 and 2017, respectively. In the survey, unsuccessful candidates reported applying to fewer programs. Assuming unsuccessful candidates submitted between 2-5 applications each, the total applicant pool numbered 42-69 for 2016 (competing for 24 positions) and 52-85 for 2017 (competing for 30 positions). Among survey respondents (n=33), 24% were female, 1 was black and none were Hispanic. We conclude that greater efforts are needed to enhance interest in clinical informatics among medical students and residents, particularly among women and members of underrepresented minority groups.

Few opportunities exist for physician trainees to gain exposure to, and training in, the field of clinical informatics, an Accreditation Council for Graduate Medical Education-accredited, recently board-certified specialty. Currently, 21 approved programs exist nationwide for the formal training of fellows interested in pursuing careers in this discipline. Residents and fellows training in medical and surgical fields, however, have few avenues available to gain experience in clinical informatics. An early introduction to clinical informatics brings an opportunity to generate interest for future career trajectories. At University of California Los Angeles (UCLA) Health, we have developed a novel, successful, and sustainable program, the Resident Informaticist Program, with the goals of exposing physician trainees to the field of clinical informatics and its academic nature and providing opportunities to expand the clinical informatics workforce. Herein, we provide an overview of the development, implementation, and current state of the UCLA Health Resident Informaticist Program, with a blueprint for development of similar programs., (© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Given the high-intensity interaction between radiology and IT, radiology leadership should understand IT's new, somewhat conflicting, dual roles. Managing large-scale and small-scale projects concurrently has become an important challenge for leaders of health IT (HIT). Historical parallels of this challenge can be drawn from transportation and communication systems, in which a large-scale mind-set is needed to build the initial network, whereas a small-scale mind-set is more useful to develop the content that will traverse this network. Innovation and creativity is a cornerstone of content small-scale thinking, and in HIT, that is what is needed to extract the value from it. However, unlike the early historical transportation and communication examples, the time between the development of the infrastructure and the follow-on, value-rich content is shortened greatly because it has become nearly simultaneous in HIT. Weaving the ability to concomitantly manage both large- and small-scale projects into the fabric of the organizational HIT culture will be critical for its success., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A molecular photocatalyst consisting of a Ru(II) photocenter, a tetrapyridophenazine bridging ligand, and a PtX2 (X=Cl or I) moiety as the catalytic center functions as a stable system for light-driven hydrogen production. The catalytic activity of this photochemical molecular device (PMD) is significantly enhanced by exchanging the terminal chlorides at the Pt center for iodide ligands. Ultrafast transient absorption spectroscopy shows that the intramolecular photophysics are not affected by this change. Additionally, the general catalytic behavior, that is, instant hydrogen formation, a constant turnover frequency, and stability are maintained. Unlike as observed for the Pd analogue, the presence of excess halide does not affect the hydrogen generation capacity of the PMD. The highly improved catalytic efficiency is explained by an increased electron density at the Pt catalytic center, this is confirmed by DFT studies., (© 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

To develop highly efficient molecular photocatalysts for visible light-driven hydrogen production, a thorough understanding of the photophysical and chemical processes in the photocatalyst is of vital importance. In this context, in situ X-ray absorption spectroscopic (XAS) investigations show that the nature of the catalytically active metal center in a (N^N)MCl2 (M=Pd or Pt) coordination sphere has a significant impact on the mechanism of the hydrogen formation. Pd as the catalytic center showed a substantially altered chemical environment and a formation of metal colloids during catalysis, whereas no changes of the coordination sphere were observed for Pt as catalytic center. The high stability of the Pt center was confirmed by chloride addition and mercury poisoning experiments. Thus, for Pt a fundamentally different catalytic mechanism without the involvement of colloids is confirmed., (© 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Good's syndrome is a relatively rare immunodeficiency condition that presents in the fourth or fifth decade of life and is defined by hypogammaglobulinemia in the setting of a thymoma. The humoral defect may be severe enough to cause an absence in B cells, with a consequent recurrence of sinopulmonary disease, chronic non-infectious diarrhea and opportunistic infections. The prognosis in patients with Good's syndrome appears to be worse than in those with X-linked agammaglobulinemia (XLA) and common variable immune deficiency (CVID). There have only been three cases of Good's syndrome associated with mycobacterium, and only one case with a cavitary lesion in the lungs. We present here a unique case of Good's syndrome with a non-mycobacterial cavitary lesion.

The synthesis and characterisation of two terpyridine based ruthenium/palladium heteronuclear compounds are presented. The photocatalytic behaviour of the Ru/Pd complex containing the linear 2,2':5',2''-terpyridine bridge (1a) and its analogue the non-linear 2,2':6',2''-terpyridine bridge (2a) are compared together with the respective mononuclear complexes 1 and 2. Irradiation of 1a with visible light (e.g., 470 nm) results in the photocatalytic generation of dihydrogen gas. Photocatalysis was not observed with complex 2a by contrast. A comparison with the photocatalytic behaviour of the precursors 1 and 2 indicates, that while for 1a the photocatalysis is an intramolecular process, for the mononuclear precursors it is intermolecular. The photophysical and electrochemical properties of the mono- and heterobinuclear compounds are compared. Raman spectroscopy and DFT calculations indicate that there are substantial differences in the nature of the lowest energy (3)MLCT states of 1a and 2a, from which the contrasting photocatalytic activities of the complexes can be understood.

Purpose: The goal of this study was to identify and validate novel serum markers of human colorectal cancer as potential candidates for noninvasive detection of early colorectal neoplasm., Experimental Design: Employing two-dimensional gel electrophoresis and mass spectrometry, we analyzed 16 matched colorectal cancer and adjacent normal tissue samples. Proteins found to be elevated in cancer tissue were further validated by generating antibodies which were used for immunoblotting of tissue samples and for the development of highly sensitive immunoassays for assessment of serum samples., Results: In total, 735 different proteins were identified in colon tissue. Strong elevation in colorectal cancer for five proteins was confirmed by immunoblot analysis: transforming growth factor-beta induced protein ig-h3 (betaIG-H3), nicotinamide N-methyltransferase (NNMT), nucleoside diphosphate kinase A (nm23-H1), purine nucleoside phosphorylase (PNPH), and mannose-6-phosphate receptor binding protein 1 (M6P1). Elevated levels of NNMT, which is not predicted to be secreted but is known as a cytoplasmic protein, were found in serum from patients with colorectal cancer. Employing a receiver-operating characteristic curve based on the measurement of 109 patients with colorectal cancer and 317 healthy controls, we obtained an area under the curve of 0.84 for NNMT, which was superior to the established tumor marker carcinoembryogenic antigen with an area under the curve of 0.78., Conclusions: It is proposed that NNMT serum levels may have significance in the early detection and in the management of patients with colorectal cancer.

Optimisation of the separation of a synthetic drug mixture by HPLC is performed by changing both continuous variables, i.e. mobile phase composition and temperature, and categorical variables, here the stationary phase. The retention of solutes is described on the basis of a general linear model in which the different columns are modelled by indicator variables. From the solute-specific retention models the global separation optimum is evaluated on the basis of multidimensional window diagrams using relative retentions of all peak pairs as the figure-of-merit.