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Host cell damage is a key parameter for research in infection biology, drug testing, and substance safety screening. In this study, we introduce a luciferase reporter system as a new and reliable assay to measure cell damage and validate it with the pathogenic yeast, Candida albicans , as a test case. We transduced human epithelial cell lines with a lentiviral vector to stably express an optimized luciferase enzyme, Nanoluc. Upon cell damage, the release of cytoplasmic luciferase into the extracellular space can be easily detected by a luminometer. We used the luciferase reporter system to investigate the damage caused by C. albicans to different newly generated epithelial reporter cell lines. We found that fungus-induced cell damage, as determined by established methods, correlated tightly with the release of the luciferase. The new luciferase reporter system is a simple, sensitive, robust, and inexpensive method for measuring host cell damage and has a sensitivity comparable to the standard assay, release of lactate dehydrogenase. It is suitable for high-throughput studies of pathogenesis mechanisms of any microbe, for antimicrobial drug screening, and many other applications.IMPORTANCEWe present a quick, easy, inexpensive, and reliable assay to measure damage to mammalian cells. To this end, we created reporter cell lines which artificially express luciferase, an enzyme that can be easily detected in the supernatant when these cells are damaged. We used infections with the well-investigated fungal pathogen of humans, Candida albicans , as a test case of our system. Using our reporter, we were able to recapitulate the known effects of strain variability, gene deletions, and antifungal treatments on host cell damage. This easily adaptable reporter system can be used to screen for damage in infection models with different microbial species, assay cell-damaging potential of substances, discover new non-toxic antibiotics, and many other damage-based applications., Competing Interests: Work from this paper has been used to register the patent "Cytotoxicity assay for detecting cellular damage" (L31002DE) with the Deutsches Patent-und Markenamt authors R.V., M.T., V.T., S.B., and B.H. and Leibniz-HKI as beneficiaries.

Background: Deep brain stimulation (DBS) is a standard treatment for movement disorders, epilepsy, and others, yet its influence on postprocedural sleep quality remains an under-researched topic., Study Objectives: We performed a systematic review and meta-analysis of all DBS effects on sleep., Methods: The use of preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) was utilized. We extracted demographic data, disease type/duration, DBS target, stimulation laterality (unilateral vs bilateral), follow-up lengths, and sleep pre/post-op measurements with polysomnography or across four standard sleep scales. The Cochrane methodology for evaluating RCTs was employed using the risk of bias assessments, data synthesis, and statistical methods, including forest plots (risk ratio; M-H random effects; 95% CI)., Results: Sixty-three studies were included in the overall analysis, representing 3022 patients. In a subgroup meta-analysis of subthalamic nucleus (STN) DBS for Parkinson's disease (PD), patients showed significant sleep improvement at three but not 12 months postoperatively with PDSS, at 12 but not 3 months with Epworth sleep scale, and at 6 months with nonmotor symptom scale. Pittsburgh sleep quality index (PSQI) showed no significant improvement in sleep at any time. Bilateral DBS showed significantly more improvement than unilateral DBS in the PSQI at 6 but not 3 months. Polysomnography showed significant sleep improvement at 1 week but not at 3 or 6 months. Most studies showed no significant sleep improvement for globus pallidus internus, centromedian thalamus, and ventral intermediate nucleus DBS., Conclusions: STN-DBS for PD likely improves sleep; however, significant standardization in sleep scale outcome reporting and follow-up time is needed to effectively determine the target-dependent effects of DBS surgery on sleep., (© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society.)

Magic angle spinning (MAS) dynamic nuclear polarization (DNP) increases the signal intensity of solid-state nuclear magnetic resonance. DNP typically uses continuous wave (CW) microwave irradiation close to the resonance frequency of unpaired electron spins. In this study, we demonstrate that frequency-chirped microwaves improve DNP performance under MAS. By modulating the gyrotron anode potential, we generate a train of microwave chirps with a maximum bandwidth of 310 MHz and a maximum incident power on the spinning sample of 18 W. We characterize the efficiency of chirped DNP using the following polarizing agents: TEMTriPol-1, AsymPolPOK, AMUPol, and Finland trityl. The effects of different chirp widths and periods are analyzed at different MAS frequencies and microwave powers. Furthermore, we show that chirped DNP can be combined with electron decoupling to improve signal intensity by 59%, compared to CW DNP without electron decoupling, using Finland trityl as a polarizing agent.

Competing Interests: Disclosures Dr Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria from Medtronic, AtriCure, EPiEP, and Biotronik. Dr Natale is a consultant for Biosense Webster, Stereotaxis, and Abbott Medical; and has received speaker honoraria/travel from Medtronic, AtriCure, Biotronik, and Janssen. All other authors have no conflicts of interest to disclose.

Background: Electronic health record (EHR)-based patient messages can contribute to burnout. Messages with a negative tone are particularly challenging to address. In this perspective, we describe our initial evaluation of large language model (LLM)-generated responses to negative EHR patient messages and contend that using LLMs to generate initial drafts may be feasible, although refinement will be needed., Methods: A retrospective sample ( n  = 50) of negative patient messages was extracted from a health system EHR, de-identified, and inputted into an LLM (ChatGPT). Qualitative analyses were conducted to compare LLM responses to actual care team responses., Results: Some LLM-generated draft responses varied from human responses in relational connection, informational content, and recommendations for next steps. Occasionally, the LLM draft responses could have potentially escalated emotionally charged conversations., Conclusion: Further work is needed to optimize the use of LLMs for responding to negative patient messages in the EHR., Competing Interests: S.L.B. reports equipment support from Topcon and Optomed, and consulting fees from Topcon, outside the submitted work. C.A.L. reports equity from consulting with Doximity. M.T.-S., M.M., and A.M.S. report no relevant conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Importance: Timely tests are warranted to assess the association between generative artificial intelligence (GenAI) use and physicians' work efforts., Objective: To investigate the association between GenAI-drafted replies for patient messages and physician time spent on answering messages and the length of replies., Design, Setting, and Participants: Randomized waiting list quality improvement (QI) study from June to August 2023 in an academic health system. Primary care physicians were randomized to an immediate activation group and a delayed activation group. Data were analyzed from August to November 2023., Exposure: Access to GenAI-drafted replies for patient messages., Main Outcomes and Measures: Time spent (1) reading messages, (2) replying to messages, (3) length of replies, and (4) physician likelihood to recommend GenAI drafts. The a priori hypothesis was that GenAI drafts would be associated with less physician time spent reading and replying to messages. A mixed-effects model was used., Results: Fifty-two physicians participated in this QI study, with 25 randomized to the immediate activation group and 27 randomized to the delayed activation group. A contemporary control group included 70 physicians. There were 18 female participants (72.0%) in the immediate group and 17 female participants (63.0%) in the delayed group; the median age range was 35-44 years in the immediate group and 45-54 years in the delayed group. The median (IQR) time spent reading messages in the immediate group was 26 (11-69) seconds at baseline, 31 (15-70) seconds 3 weeks after entry to the intervention, and 31 (14-70) seconds 6 weeks after entry. The delayed group's median (IQR) read time was 25 (10-67) seconds at baseline, 29 (11-77) seconds during the 3-week waiting period, and 32 (15-72) seconds 3 weeks after entry to the intervention. The contemporary control group's median (IQR) read times were 21 (9-54), 22 (9-63), and 23 (9-60) seconds in corresponding periods. The estimated association of GenAI was a 21.8% increase in read time (95% CI, 5.2% to 41.0%; P = .008), a -5.9% change in reply time (95% CI, -16.6% to 6.2%; P = .33), and a 17.9% increase in reply length (95% CI, 10.1% to 26.2%; P < .001). Participants recognized GenAI's value and suggested areas for improvement., Conclusions and Relevance: In this QI study, GenAI-drafted replies were associated with significantly increased read time, no change in reply time, significantly increased reply length, and some perceived benefits. Rigorous empirical tests are necessary to further examine GenAI's performance. Future studies should examine patient experience and compare multiple GenAIs, including those with medical training.

Background: Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence., Objective: This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months., Methods: As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later., Results: Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%)., Conclusions: Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan., Trial Registration: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512., International Registered Report Identifier (irrid): RR2-10.2196/30431., (©Cheryl D Stults, Kathleen M Mazor, Michael Cheung, Bernice Ruo, Martina Li, Amanda Walker, Cassandra Saphirak, Florin Vaida, Sonal Singh, Kimberly A Fisher, Rebecca Rosen, Robert Yood, Lawrence Garber, Christopher Longhurst, Gene Kallenberg, Edward Yu, Albert Chan, Marlene Millen, Ming Tai-Seale. Originally published in Journal of Participatory Medicine (https://jopm.jmir.org), 14.03.2024.)

Objective: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout., Materials and Methods: Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors., Results: Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04-1.47), not feeling valued (OR, 3.38; 95% CI, 1.69-7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87-4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63-4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12-2.67)., Discussion: Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support., Conclusion: A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Cryogenic magic angle spinning (MAS) is a standard technique utilized for dynamic nuclear polarization (DNP) in solid-state nuclear magnetic resonance (NMR). Here we describe the optimization and implementation of a stator for cryogenic MAS with 9.5 mm diameter spherical rotors, allowing for DNP experiments on large sample volumes. Designs of the stator and rotor for cryogenic MAS build on recent advancements of MAS spheres and take a step further to incorporate sample insert and eject and a temperature-independent spinning stability of ± 1  Hz. At a field of 7 T and spinning at 2.0 kHz with a sample temperature of 105-107 K, DNP enhancements of 256 and 200 were observed for 124 and 223  µ L sample volumes, respectively, each consisting of 4 M 13 C, 15 N-labeled urea and 20 mM AMUPol in a glycerol-water glassy matrix., Competing Interests: The ETH Zürich has intellectual property protection on the inventions included in this paper. Alexander B. Barnes has patents related to this work filed by Washington University in Saint Louis (62/703,278 filed on 25 July 2018 and 62/672,840 filed on 17 May 2018). The authors declare no other competing interests., (Copyright: © 2023 Lauren E. Price et al.)

Objective: Occupational health (OH) documentation has traditionally been separate from health system electronic health records (EHRs), but this can create patient safety and care continuity challenges. Herein, we describe outcomes and challenges of such integration including how one health system managed compliance with laws, regulations, and ethical principles concerning digital privacy., Methods: Occupational health integration with the enterprise EHR at the University of California San Diego Health was started in June 2021 and completed in December 2021., Results: Integrating with the enterprise EHR allowed for a secure telehealth system, faster visit times, digitization of questionnaires medical clearance forms, and improved reporting capabilities., Conclusions: Integration and interoperability are fundamental building blocks to any OH EHR solution and will allow for evaluation of worker population trends, and targeted interventions to improve worker health status., Competing Interests: Conflicts of interest: K.S. is the owner of MedLaw LLC, employee of the State of Maine, and employee of P&G. He conducts business with LiveWell, WorkWell, and is a consultant for various industries and startup companies. A.S. received compensation from Taylor & Francis media company for a textbook. The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.)

Current remote monitoring of COVID-19 patients relies on manual symptom reporting, which is highly dependent on patient compliance. In this research, we present a machine learning (ML)-based remote monitoring method to estimate patient recovery from COVID-19 symptoms using automatically collected wearable device data, instead of relying on manually collected symptom data. We deploy our remote monitoring system, namely eCOVID, in two COVID-19 telemedicine clinics. Our system utilizes a Garmin wearable and symptom tracker mobile app for data collection. The data consists of vitals, lifestyle, and symptom information which is fused into an online report for clinicians to review. Symptom data collected via our mobile app is used to label the recovery status of each patient daily. We propose a ML-based binary patient recovery classifier which uses wearable data to estimate whether a patient has recovered from COVID-19 symptoms. We evaluate our method using leave-one-subject-out (LOSO) cross-validation, and find that Random Forest (RF) is the top performing model. Our method achieves an F1-score of 0.88 when applying our RF-based model personalization technique using weighted bootstrap aggregation. Our results demonstrate that ML-assisted remote monitoring using automatically collected wearable data can supplement or be used in place of manual daily symptom tracking which relies on patient compliance.

Importance: Physician burnout is an ongoing epidemic; electronic health record (EHR) use has been associated with burnout, and the burden of EHR inbasket messages has grown in the context of the COVID-19 pandemic. Understanding how EHR inbasket messages are associated with physician burnout may uncover new insights for intervention strategies., Objective: To evaluate associations between EHR inbasket message characteristics and physician burnout., Design, Setting, and Participants: Cross-sectional study in a single academic medical center involving physicians from multiple specialties. Data collection took place April to September 2020, and data were analyzed September to December 2020., Exposures: Physicians responded to a survey including the validated Mini-Z 5-point burnout scale., Main Outcomes and Measures: Physician burnout according to the self-reported burnout scale. A sentiment analysis model was used to calculate sentiment scores for EHR inbasket messages extracted for participating physicians. Multivariable modeling was used to model risk of physician burnout using factors such as message characteristics, physician demographics, and clinical practice characteristics., Results: Of 609 physicians who responded to the survey, 297 (48.8%) were women, 343 (56.3%) were White, 391 (64.2%) practiced in outpatient settings, and 428 (70.28%) had been in medical practice for 15 years or less. Half (307 [50.4%]) reported burnout (score of 3 or higher). A total of 1 453 245 inbasket messages were extracted, of which 630 828 (43.4%) were patient messages. Among negative messages, common words included medical conditions, expletives and/or profanity, and words related to violence. There were no significant associations between message characteristics (including sentiment scores) and burnout. Odds of burnout were significantly higher among Hispanic/Latino physicians (odds ratio [OR], 3.44; 95% CI, 1.18-10.61; P = .03) and women (OR, 1.60; 95% CI, 1.13-2.27; P = .01), and significantly lower among physicians in clinical practice for more than 15 years (OR, 0.46; 95% CI, 0.30-0.68; P < .001)., Conclusions and Relevance: In this cross-sectional study, message characteristics were not associated with physician burnout, but the presence of expletives and violent words represents an opportunity for improving patient engagement, EHR portal design, or filters. Natural language processing represents a novel approach to understanding potential associations between EHR inbasket messages and physician burnout and may also help inform quality improvement initiatives aimed at improving patient experience.

Objectives: To improve diabetic retinopathy (DR) screening rates through a primary care-based "teleretina" screening program incorporating clinical informatics tools., Study Design: Quality improvement study at an academic institution., Methods: Existing DR screening workflows using in-person eye examinations were analyzed via a needs assessment. We identified gaps, which clarified the need for expanding DR screening to primary care settings. We developed informatics tools and described associated challenges and solutions. We also longitudinally monitored imaging volume and quality., Results: The needs assessment identified several gaps in baseline DR screening workflows. Health information technology (IT) considerations for the new primary care-based teleretina screening program included integrating the new program with existing information systems, facilitating care coordination, and decreasing barriers to adoption by incorporating automation and other features aimed at decreasing end-user burden. We successfully developed several tools fulfilling these goals, including integration with the ophthalmology picture and archiving communication system, a customized aggregated report in the electronic health record to monitor screenings, automation of billing and health maintenance documentation, and automated results notification to primary care physicians. Of 316 primary care patients screened between October 2020 and July 2021, 73 (23%) were found to have ocular pathology, including DR, glaucoma, age-related macular degeneration, and a range of other eye conditions that were previously undiagnosed., Conclusions: New models of health care delivery, including telemedicine workflows, have become increasingly important for complex diabetic care coordination and require substantial health IT engagement. This program illustrates how clinical informatics tools can make substantial contributions to improving diabetes care.

Objective To detail the implementation, benefits and challenges of onboarding campus-based health services onto a health system's electronic health record. Participants UC San Diego Student Health and Well-Being offers medical services to over 39,000 students. UC San Diego Health is an academic medical center. Methods 20 workstreams and 9 electronic modules, systems, or interfaces were converted to new electronic systems. Results 36,023 student-patient medical records were created. EHR-integration increased security while creating visibility to 19,700 shared patient visits and records from 236 health systems across the country over 6 months. Benefits for the COVID-19 response included access to screening tools, decision support, telehealth, patient alerting system, reporting and analytics, COVID-19 dashboard, and increased testing capabilities. Conclusion Integration of an interoperable EHR between neighboring campus-based health services and an affiliated academic medical center can streamline case management, improve quality and safety, and increase access to valuable health resources in times of need. Pertinent examples during the COVID-19 pandemic included uninterrupted and safe provision of clinical services through access to existing telehealth platforms and increased testing capacity.

Background: Patient-physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient-physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters., Objective: In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient-physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters., Methods: We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit "patient important issue" questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient-staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes., Results: The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient-clinician communication, particularly during the COVID-19 pandemic., Conclusions: EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians' work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians., Trial Registration: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512., International Registered Report Identifier (irrid): DERR1-10.2196/30431., (©Ming Tai-Seale, Rebecca Rosen, Bernice Ruo, Michael Hogarth, Christopher A Longhurst, Lina Lander, Amanda L Walker, Cheryl D Stults, Albert Chan, Kathleen Mazor, Lawrence Garber, Marlene Millen. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.08.2021.)

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic.

Our previous study on nitroxides in o-terphenyl (OTP) revealed two separable decoherence processes at low temperatures, best captured by the sum of two stretched exponentials (SSE) model. Dynamical decoupling (DD) extends both associated dephasing times linearly for 1 to 5 refocusing pulses [Soetbeer et al., Phys. Chem. Chem. Phys., 2018, 20, 1615]. Here we demonstrate an analogous DD behavior of water-soluble nitroxides in water-glycerol glass by using nitroxide and/or solvent deuteration for component assignment. Compared to the conventional Hahn experiment, we show that Carr-Purcell and Uhrig DD schemes are superior in resolving and identifying active dephasing mechanisms. Thereby, we observe a partial coherence loss to intramolecular nitroxide and trityl nuclei that can be alleviated, while the zero field splitting-induced losses for gadolinium labels cannot be refocused and contribute even at the central transition of this spin-7/2 system. Independent of the studied spin system, Uhrig DD leads to a characteristic convex dephasing envelope in both protonated water-glycerol and OTP glass, thus outperforming the Carr-Purcell scheme.

Lead-halide perovskites increasingly mesmerize researchers because they exhibit a high degree of structural defects and dynamics yet nonetheless offer an outstanding (opto)electronic performance on par with the best examples of structurally stable and defect-free semiconductors. This highly unusual feature necessitates the adoption of an experimental and theoretical mindset and the reexamination of techniques that may be uniquely suited to understand these materials. Surprisingly, the suite of methods for the structural characterization of these materials does not commonly include nuclear magnetic resonance (NMR) spectroscopy. The present study showcases both the utility and versatility of halide NMR and NQR (nuclear quadrupole resonance) for probing the structure and structural dynamics of CsPbX 3 (X = Cl, Br, I), in both bulk and nanocrystalline forms. The strong quadrupole couplings, which originate from the interaction between the large quadrupole moments of, e.g., the 35 Cl, 79 Br, and 127 I nuclei, and the local electric-field gradients, are highly sensitive to subtle structural variations, both static and dynamic. The quadrupole interaction can resolve structural changes with accuracies commensurate with synchrotron X-ray diffraction and scattering. It is shown that space-averaged site-disorder is greatly enhanced in the nanocrystals compared to the bulk, while the dynamics of nuclear spin relaxation indicates enhanced structural dynamics in the nanocrystals. The findings from NMR and NQR were corroborated by ab initio molecular dynamics, which point to the role of the surface in causing the radial strain distribution and disorder. These findings showcase a great synergy between solid-state NMR or NQR and molecular dynamics simulations in shedding light on the structure of soft lead-halide semiconductors., Competing Interests: The authors declare no competing financial interest., (Copyright © 2020 American Chemical Society.)

During 2016-2018, San Diego County, California, USA, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades. In close partnership with local healthcare systems, San Diego County Public Health led a public health response to the outbreak that focused on a 3-pronged strategy to vaccinate, sanitize, and educate. Healthcare systems administered nearly half of the vaccinations delivered in San Diego County. At University of California San Diego Health, the use of informatics tools assisted with the identification of at-risk populations and with vaccine delivery across outpatient and inpatient settings. In addition, acute care facilities helped prevent further disease transmission by delaying the discharge of patients with hepatitis A who were experiencing homelessness. We assessed the public health roles that acute care hospitals can play during a large community outbreak and the critical nature of ongoing collaboration between hospitals and public health systems in controlling such outbreaks.

As participants in the California Medicaid 1115 waiver, the University of California San Diego Health (UCSDH) used population health informatics tools to address health disparities. This case study describes a modern application of health informatics to improve data capture, describe health disparities through demographic stratification, and drive reliable care through electronic medical record-based registries. We provide a details in our successful approach using (1) standardized collection of race, ethnicity, language, sexual orientation, and gender identity data, (2) stratification of 8 quality measures by demographic profile, and (3) improved quality performance through registries for wellness, social determinants of health, and chronic disease. A strong population health platform paired with executive support, physician leadership, education and training, and workflow redesign can improve the representation of diversity and drive reliable processes for care delivery that improve health equity., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic., Materials and Methods: Our health system has confirmed prior and current cases of COVID-19. An Incident Command Center was established early in the crisis and helped identify electronic health record (EHR)-based tools to support clinical care., Results: We outline the design and implementation of EHR-based rapid screening processes, laboratory testing, clinical decision support, reporting tools, and patient-facing technology related to COVID-19., Discussion: The EHR is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication, and adoption, and to coordinate the needs of multiple stakeholders while maintaining high-quality, prepandemic medical care., Conclusion: The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: There is a dearth of relevant research on the rapidly evolving epidemic of diabetes mellitus (particularly Type 2 diabetes mellitus) in sub-Saharan Africa. To address some of these issues in the Eritrean context, we conducted a cross-sectional study on glycemic and lipid profiles and associated risk factors., Methods: A total of 309 patients with diabetes mellitus on regular follow-up at the Diabetic and Hypertensive Department at Halibet Regional Referral Hospital, Asmara, were enrolled for the study. Data on specific clinical chemistry and anthropomorphic parameters was collected. Chi-squared ( χ 2 ) test or Fischer's exact test was used to evaluate the relationship between specific variables. Multivariate logistic regression (backward: conditional) was undertaken to identify the factors associated with increased odds of suboptimal values in glucose and specific lipid panel subfractions., Results: High proportions of patients (76.7%) had suboptimal levels of HbA1c with a mean ± SD of 8.6% ± 1.36, respectively. In multivariate regression analysis, the likelihood of HbA1c ≥ 7% was higher in patients with abnormal WHR (AOR = 3.01, 95% CI, 3.01 (1.15-7.92 = 0.024)) and in patients without hypertension (AOR = 1.97, 95% CI (1.06-3.56), p = 0.021). A unit reduction in eGFR was also associated with HbA1c ≥ 7% (AOR = 0.99, 95% CI (0.98-1 = 0.031)). In a separate analysis, the data shows that 80.9% of the patients had dyslipidemia. In particular, 62.1% of the patients had TC ≥ 200 mg/dL (risk factors: sex, hypertension, and HbA1c concentration), 81.6% had LDL-C ≥ 100 mg/dL (risk factors: sex and hypertension), 56.3% had TG ≥ 150 (risk factors: sex, HbA1c, and waist circumference), 62.8% had abnormal HDL-C (risk factors: waist circumference), 78.3% had non-HDL < 130 mg/dL (risk factors: duration of disease, reduced estimated glomerular filtration rate, and HbA1c), and 45.3% had abnormal TG/HDL (risk factors: sex, age of patient, FPG, and waist circumference)., Conclusions: The quality of care, as measured by glycemic and specific lipid targets, in this setting is suboptimal. Therefore, there is an urgent need for simultaneous improvements in both indicators. This will require evidence-based optimization of pharmacological and lifestyle interventions. Therefore, additional studies, preferably longitudinal studies with long follow-up, are required on multiple aspects of DM., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020 Oliver Okoth Achila et al.)

Objective: To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients., Methods: This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR., Results: Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p  = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p  = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use., Conclusion: Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician-patient interactions, these strategies may help alleviate risk of physician burnout., Competing Interests: S.L.B., M.F.C., M.R.H., L.O.-M., and R.E.-K. were supported by grants from National Institutes of Health (T15LM011271, R00LM12238, P30EY10572, P30EY022589, and UL RR031980), the Heed Ophthalmic Foundation fellowship, and by unrestricted departmental grants from Research to Prevent Blindness (RPB). The funding organizations had no role in the design or conduct of this research. M.F.C. is an unpaid member of the Scientific Advisory Board for Clarity Medical Systems (Pleasanton, California, United States), a consultant for Novartis (Basel, Switzerland), and an initial member of InTeleretina, LLC (Honolulu, Hawaii, United States). A.E.H. is a medical specialist at Advanced Clinical (Deerfield, Illinois, United States) and is employed at Verily Life Sciences (South San Francisco, California, United States). The remaining authors do not have any disclosures., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To assess time requirements for patient encounters and estimate after-hours demands of paper-based clinical workflows in ophthalmology., Design: Time-and-motion study with a structured survey., Methods: This study was conducted in a single academic ophthalmology department. A convenience sample consisted of 7 attending ophthalmologists from 6 subspecialties observed during 414 patient encounters for the time-motion analysis and 12 attending ophthalmologists for the survey. Outcome measurements consisted of total time spent by attending ophthalmologists per patient and time spent on documentation, examination, and talking with patients. The survey assessed time requirements of documentation-related activities performed outside of scheduled clinic hours., Results: Among the 7 attending ophthalmologists observed (6 men and 1 woman), mean ± SD age 43.9 ± 7.1 years, during encounters with 414 patients (57.8 ± 24.6 years of age), total time spent per patient was 8.1 ± 4.8 minutes, with 2.8 ± 1.4 minutes (38%) for documentation, 1.2 ± 0.9 minutes (17%) for examination, and 3.3 ± 3.1 minutes (37%) for talking with patients. New patient evaluations required significantly more time than routine follow-up visits and postoperative visits. Higher clinical volumes were associated with less time per patient. Survey results indicated that paper-based documentation was associated with minimal after-hours work on weeknights and weekends., Conclusions: Paper-based documentation takes up a substantial portion of the total time spent for patient care in outpatient ophthalmology clinics but is associated with minimal after-hours work. Understanding paper-based clinical workflows may help inform targeted strategies for improving electronic health record use in ophthalmology., (Published by Elsevier Inc.)

The Harderian gland (HG) is an orbital structure whose proteinaceous secretions pass through the nasolacrimal duct to the vomeronasal organ (VNO). Though these three structures occur in many tetrapod vertebrates, the garter snake (Thamnophis sirtalis) is one of the few vertebrates in which the passage of the proteinaceous secretions have been experimentally shown. Secreted proteins from the HG may function as transporters for chemical signals to the VNO epithelium. To investigate the proteins being produced by the HG of the garter snake, cDNA libraries were constructed from HG mRNA, and several individual cDNAs were analyzed by sequencing, RT-qPCR, and PCR on genomic DNA. Two of the three cDNAs that were characterized are abundantly expressed only in the Harderian gland and contain putative signal sequences for secretion, which makes them candidates for transporter proteins secreted from the HG. One is a member of the large lipocalin family of proteins, based on its similarity to other members of that protein family. Many lipocalins are binding/carrier proteins for a variety of ligands. The other is a family of proteins, with five members identified so far, all of unknown structure and function and present in the garter snake genome but not in other squamate genomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation., Design: Prospective, manual time-motion observations of ophthalmology trainees in 2018., Participants: Eleven ophthalmology residents and fellows observed during 156 patient encounters., Methods: Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models., Main Outcome Measures: Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients., Results: Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011)., Conclusion: Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout., Competing Interests: Conflict of Interest Dr. Chao reports other from Recens Medical, other from Visgenx, other from Dtx Pharma, other from Zilia Health, grants from National Eye Institute, grants from Bright-focus Foundation, outside the submitted work. Dr. Longhurst reports other from null, outside the submitted work. Dr. Chiang reports grants from National Institutes of Health, grants from National Science Foundation, other from Clarity Medical Systems, personal fees from Novartis, other from Inteleretina, LLC, outside the submitted work; In addition, Dr. Chiang has a patent provisional patent for artificial intelligence diagnostic system pending. Dr. Hribar reports grants from National Institutes of Health (Bethesda, MD), during the conduct of the study; grants from National Institutes of Health (Bethesda, MD), outside the submitted work. Dr. Nudleman reports grants from National Institute of Health, outside the submitted work. Dr. Robbins reports grants and personal fees from American Academy of Pediatrics Royalites, Springer Publishing Royalties, Elsevier Publishing Royalties, Department of Health and Human Services Consultant, Prometic Consultant, The Hartwell Foundation Grant, Retrophin Industry sponsored Grant, outside the submitted work. Dr. Baxter reports grants from National Library of Medicine, grants from Heed Ophthalmic Foundation, during the conduct of the study.

The management of invasive fungal disease (IFD) in the haemato-oncology setting remains a challenge. This article reviews recent guidelines relating to IFD for their similarities and differences, as well as applying the Appraisal of Guidelines Research and Evaluation (AGREE) criteria. The guidelines' recommendations on antifungal prophylaxis, empirical and definitive treatment of candidiasis and aspergillosis are summarized; also, minimum standards for diagnosis and follow-up are discussed. This critique of the reviewed guidelines is a practical guide to physicians and commissioners in making local policies for IFD management.

Objective: This paper evaluates gender differences in CD4 cell counts at human immunodeficiency virus (HIV) diagnosis of an African-born population receiving care for HIV infection in a publicly financed clinic setting in Philadelphia, Pennsylvania, in comparison with a non-African, foreign-born cohort in the same setting., Methods: Records of foreign-born individuals receiving HIV care at the Philadelphia city health centers between January 2007 and December 2008 were reviewed. Data abstracted included demographics, country of origin, reason for HIV testing, and baseline CD4 cell count. Associations among baseline CD4 cell count, demographic variables and reason for testing were assessed by gender and by world region of origin (African or non-African)., Results: During the review period, 107 African patients and 127 non-African patients met inclusion criteria. Mean CD4 cell counts at diagnosis were 263 cells/mm3 for African men and 362 cells/mm3 for African women (p = .055). For other foreign-born individuals, mean CD4 cell counts did not vary by gender. African women were more likely than African men to undergo routine testing in the setting of reproductive health care, while there was no gender difference in rates of reproduction-related testing for non-Africans., Conclusions: African men in Philadelphia are diagnosed with HIV at a later stage of disease than African women are. This difference is associated with higher rates of routine testing of African women in reproductive health care settings. Efforts to engage African men in the United States in routine HIV testing are urgently needed as part of the national "test and treat" strategy of HIV testing and linkage to care.